Viruses are a common cause of central nervous system (CNS) infections with many host, agent, and environmental factors influencing the expression of viral diseases. Viruses can be responsible for CNS disease through a variety of mechanisms including direct infection and replication within the CNS resulting in encephalitis, infection limited to the meninges, or immune-related processes such as acute disseminated encephalomyelitis. Common pathogens including herpes simplex virus, varicella zoster, and enterovirus are responsible for the greatest number of cases in immunocompetent hosts. Other herpes viruses (eg, cytomegalovirus, John Cunningham virus) are more common in immunocompromised hosts. Arboviruses such as Japanese encephalitis virus and Zika virus are important pathogens globally, but the prevalence varies significantly by geographic region and often season. Early diagnosis from radiographic evidence and molecular (eg, rapid) diagnostics is important for targeted therapy. Antivirals may be used effectively against some pathogens, although several viruses have no effective treatment. This article provides a review of epidemiology, diagnostics, and management of common viral pathogens in CNS disease.
Introduction Testosterone (T) administration to men increases T, estradiol (E2), dihydrotestosterone (DHT), and fat-free mass (FFM), and decreases fat mass (FM) but does not consistently improve insulin sensitivity (IS). Aim The aim of this study was to examine the effects of T administration in obese, nondiabetic men on body composition and IS, and to determine if inhibition (i) of metabolism of T to E2 with anastrazole or to DHT with dutasteride alters these effects. Methods This was a 98-day randomized, double-blind, parallel group, placebo-controlled trial of 57 men, 24–51 year, free T in the lower 25% of normal range (<0.33 nmol/L), body mass index ≥30.0 kg/m2. Subjects were randomized to one of four groups: (i) placebo: gel, pills, and injection; (ii) T/DHT/iE2: T gel, anastrazole, and acyline (gonadotropin releasing-hormone antagonist to suppress endogenous T); (iii) T/iDHT/E2: T gel, dutasteride, and acyline; (iv) T/DHT/E2: T gel, placebo pills, and acyline. Main Outcome Measures Main outcome measures are insulin sensitivity as percent change (%Δ) in glucose disposal rates (GDR) from a two-step euglycemic clamp (GDR1 and 2), and %FM and %FFM by dual X-ray absorptiometry scan. Results Insulin Sensitivity: %Δ GDR1 differed across groups (P = 0.02, anova) and was significantly higher in the dutasteride (T/iDHT/E2) compared with the placebo and T gel (T/DHT/E2) groups. %ΔGDR2 was higher in the dutasteride (T/iDHT/E2) compared with the anastrazole (T/DHT/iE2) group. Body Composition: T gel alone (T/DHT/E2) or with dutasteride (T/iDHT/E2) significantly increased %FFM (P < 0.05) and decreased %FM (P < 0.05). There was no change in %FFM or %FM after placebo or anastrazole (T/DHT/iE2). Conclusions The combination of T plus dutasteride improved body composition and IS while T alone improved body composition but not IS, suggesting that when T is administered to men, reduction to DHT attenuates the beneficial effects of aromatization to E2 on IS but not body composition.
Background The impact of clinician specialty on cardiovascular disease risk factor outcomes among persons with HIV (PWH) is unclear. Methods PWH receiving care at 3 Southeastern US academic HIV clinics between January 2014 and December 2016 were retrospectively stratified into five groups based on specialty of clinician managing their hypertension or hyperlipidemia. Patients were followed until first ASCVD event, death, or end of study. Outcomes of interest were meeting 8 th Joint National Commission’s (JNC 8) blood pressure (BP) goals and National Lipid Association (NLA) non high-density lipoprotein (HDL) goals for hypertension and hyperlipidemia respectively. Point estimates for associated risk factors were generated using modified Poisson regression with robust error variance. Results Of 1667 PWH in the analysis, 965 had hypertension, 205 had hyperlipidemia and 497 had both diagnoses. At study start, median patient age was 52 years, 66% were Black and 65% identified as male. Among persons with hypertension, 24% were managed by an infectious diseases (ID) clinician alone, 5% were co-managed by an ID clinician and a primary care clinician (PCC). Persons managed by an ID clinician were less likely to meet JNC 8 hypertension targets at the end of observation than the rest of the cohort (relative risk (RR) 0.84, 95% confidence interval 0.75-0.95), but when mean study blood pressure was considered there was no difference between persons managed by ID and the rest of the cohort (RR 0.96. 95% CI 0.88-1.05). There was no significant association between ID clinician managing hyperlipidemia and meeting NLA non-HDL goals (RR 0.89, 95% CI 0.68-1.15). Conclusions Clinician specialty may play a role in suboptimal hypertension outcomes in persons with HIV.
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