Fatigue among HIV-infected patients in the era of highly active antiretroviral therapy

OBJECTIVE

To describe the prevalence of operationally defined fatigue in an ethnically diverse HIV-infected population in south London, and to examine the association of fatigue with demographic characteristics, stage of disease, antiretroviral therapy and psychological factors.

METHODS

A descriptive comparative cross-sectional study of HIV-infected patients attending a London HIV clinic over a 5-month period in 2002 was performed. Demographic and clinical data were obtained from the local database. Participants completed four self-administered questionnaires-the Chalder Fatigue Scale (CFS), a measure of physical and mental fatigue; the General Health Questionnaire (GHQ-12) to detect anxiety and depression; the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to measure functional status, and the Illness Perception Questionnaire (IPQ). Fatigue 'cases' were defined as those scoring at least 4 on the CFS. Multivariate logistic regression was used to identify factors associated with the presence of fatigue.

RESULTS

Two hundred and five patients were approached and 148 (72%) agreed to participate. Overall, 65% of patients were defined as fatigued. Significant psychological distress on the GHQ-12, functional impairment on the SF-36 and a higher CD4 count were all independently associated with the presence of fatigue. There was no association with use of antiretroviral therapy or demographic characteristics.

CONCLUSIONS

The presence of fatigue in HIV-infected patients is most strongly associated with psychological factors and not with more advanced HIV disease or the use of highly active antiretroviral therapy. This highlights the importance of investigation and management of underlying depression and anxiety in patients presenting with fatigue.

Use of depression rating scales in chronic fatigue syndrome

OBJECTIVE

The aim of this study was to examine the performance of three commonly used depression rating scales in a hospital sample of patients with chronic fatigue syndrome (CFS).

METHODS

Sixty-one patients with CDC criteria for CFS completed the General Health Questionnaire (GHQ), the Hamilton Depression Scale (HAM-D) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D). Current psychiatric status was assessed using the Structured Clinical Interview for DSM-III-R. DISORDERS: Patient version (SCID-P). Receiver operating curves were drawn for each of the depression rating scales.

RESULTS

Thirty-one percent of the patients were depressed according to the SCID-P. Using the standard cut-offs, both GHQ and HAM-D overestimated the number of depressed patients, whilst the HADS-D underestimated the number. The receiver operating curves suggest that the optimum cut-offs for GHQ, HAM-D and HADS-D in this population are 7/8, 13/14 and 8/9, respectively.

CONCLUSIONS

Standard cutoffs may not be appropriate when using depression rating scales in CFS patients in a tertiary care setting.

Schizophrenia-like psychosis arising de novo following a temporal lobectomy: timing and risk factors

OBJECTIVES

To clarify risk factors for the development of schizophrenia-like psychotic disorders following temporal lobectomy, and to explore the possibility that the early postoperative period is a time of high risk for the onset of such chronic psychotic disorders.

METHODS

Patients who developed schizophrenia-like psychosis were identified from a series of 320 patients who had a temporal lobectomy for medically intractable epilepsy. The relationship of their disorders to both the operation and subsequent seizure activity was examined. Using a retrospective case-control design, risk factors for the development of schizophrenia-like psychosis were established.

RESULTS

Eleven patients who developed schizophrenia-like psychosis postoperatively were identified and compared with 33 control subjects who remained free of psychosis postoperatively. The onset of de novo psychotic symptoms was typically in the first year following the operation. No clear relationship between postoperative seizure activity and fluctuations in psychotic symptoms emerged. Compared with the controls, patients who become psychotic had more preoperative bilateral electroencephalogram (EEG) abnormalities, pathologies other than mesial temporal sclerosis in the excised lobe and a smaller amygdala on the unoperated side.

CONCLUSIONS

Temporal lobectomy for medically intractable epilepsy may precipitate a schizophrenia-like psychosis. Patients with bilateral functional and structural abnormalities, particularly of the amygdala, may be at particular risk for the development of such psychoses.

Oral glutamine in paediatric oncology patients: a dose finding study

OBJECTIVE

The purpose of this study was to determine the most appropriate dose of oral glutamine to use in a further clinical study in paediatric oncology patients.

DESIGN

This was a phase I, pharmokinetic study.

SETTING

The study was carried out at The Yorkshire Regional Centre for Paediatric Oncology and Haematology, St James's University Hospital, Leeds, UK.

SUBJECTS

Thirteen patients undergoing treatment for paediatric malignancy participated in this study. All 13 completed the study.

INTERVENTIONS

The most appropriate dose was determined by patient acceptability and by plasma glutamine and ammonia levels measured at timed intervals after ingestion of a single glutamine dose.

RESULTS

Doses of 0.35, 0.5 and 0.65 g/kg were well tolerated with no untoward plasma glutamine and ammonia levels. One patient was recruited to a higher dose of 0.75 g/kg, but the plasma glutamine and ammonia levels peaked at 2601 and 155 micro mol/l, respectively. The ammonia level was greater than the acceptable upper limit. It was difficult to disperse the glutamine adequately at this dose, resulting in the suspension being found to be unpalatable and therefore no further patients were recruited at this dose.

CONCLUSION

It was concluded that 0.65 g/kg is a safe dose of glutamine to use in a clinical study in paediatric oncology patients.

Typical and atypical Carney's triad presenting with malignant hypertension and papilledema

This report encourages clinicians to consider a diagnosis of Carney's triad in patients with multifocal gastric stromal sarcoma, extraadrenal paraganglioma (predominantly mediastinal), or pulmonary chondroma. The authors conducted a retrospective 20-year survey at the Hospital for Sick Children and identified two children with Carney's triad. One child, presenting atypically with papilledema and fundal hemorrhages from malignant hypertension and benign intracranial hypertension from chronic iron-deficiency anemia, is the second patient ever to date be described with the complete Carney's triad of neoplasms at diagnosis. Another child presented more typically with gastric stromal sarcoma and pulmonary chondroma without paraganglioma. Carney's triad is a rare differential diagnosis for "idiopathic" hypertension or iron-deficiency anemia from chronic gastrointestinal bleeding. If missed, patients with Carney's triad may have the debilitating physical and mental consequences of chronic iron deficiency and may die of untreated prolonged hypertension and metastatic leiomyosarcoma.

Oregon's Toxic Household Products Law

In 1991, Oregon became the first state in the U.S. to require the addition of an aversive agent to ethylene glycol-containing antifreeze and methanol-containing windshield wiper fluid. This new law, entitled "Toxic Household Products (THP) Act," was designed to reduce pediatric and animal poisonings from accidental ingestion of these two potentially lethal consumer automotive products. While not the stated intention of the law, addition of aversive agents to consumer automotive products could also reduce adult poisonings associated with intentional (suicides or alcoholics ingesting methanol-containing windshield wiper fluid) or accidental exposures. This law went into effect April 30, 1995, following settlement of a lawsuit brought by the Chemical Manufacturing Specialties Association (CSMA), a trade group representing the five largest manufacturers of ethylene glycol-based antifreeze in the U.S. This paper discusses the major policy issues that arose following the passage of Oregon's THP Act. Major provisions of the law are provided along with a discussion of CSMA's opposition to the Act's implementation. A description of the eventual settlement that was reached with CSMA as well as the major components of Oregon Health Division's (OHD) enforcement program are also highlighted. Data are presented for 1987 through 1998 on the number of exposures and severity of effects for pediatric cases (children < 6 years old) following exposure to both of these potentially lethal automotive products. However, because of the low incidence of exposures each year, these data are insufficient to draw any conclusions on the impact of the THP Act.

Misuse of antimicrobials in children with asthma and bronchiolitis: a review

Of 200 children hospitalized because of asthma or bronchiolitis, 100 received antibiotics inappropriately.

Factors affecting the measurement of energy expenditure during energy balance studies in preterm infants

Our objective was to examine factors that affect the accuracy of energy expenditure measurements (EE), when using flow-through indirect calorimetry (IC), to determine the minimum length of time needed to measure 24- and 48-h EE and to compare cross-over and parallel designs as methods of investigation during energy balance collections (EB) in preterm infants. A baby doll manikin was used to determine equilibration times and to compare VCO(2) and VO(2) as measured by flow meter and indirect calorimetry under different study conditions, one of which simulated an EB. "Continuous" EE was measured to determine the minimum length of time needed to accurately reflect 24- and 48-h EE and to compare parallel and cross-over studies as methods of study design in a group of "normal" enterally fed preterm infants. The mean (+/-SD) errors between flow meter and indirect calorimetry determinations for VCO(2) and VO(2) were -1.9 +/- 2.5 and -1.8 +/- 4.3% under conditions that simulated an EB. Cumulative 6-h EE accurately predicted 24- and 48-h EE. Expressed in absolute terms (kcal/d), EE did not change on a day-to-day basis but did increase over the 2-wk study period. Expressed on body weight basis (kcal/kg/d), EE did not change on a day-to-day or week-to-week basis. The variance in EE due to biologic variability; i.e. the parallel design, was approximately 6 times greater than that due to age, weight, and weight gain; i.e. the cross-over design. Indirect calorimetry, therefore, accurately measures EE in conditions simulating an energy balance collection. Six-hour EE determinations are valid estimate of EE during a 48-h balance collection, while cross-over studies may be the preferred method of study design during short-term studies of EE in preterm infants.

Shear bond strength to moist and dry dentin of four dentin bonding systems

PURPOSE

To compare the shear bond strength of four single-bottle adhesive systems (Prime & Bond NT, Single Bond, Gluma Comfort Bond, Gluma Comfort Bond + Desensitizer) bonded to moist and dry dentin.

MATERIALS AND METHODS

A column of resin-based composite was bonded to human dentin using the dentin bonding systems following manufacturers' directions (n= 12). For half the specimens, the dentin was dried completely after acid etching (air dried for 10 s). For the remaining specimens, the dentin was left moist (glistening appearance with no puddles) after acid etching. All specimens were thermocycled for 1,000 cycles at 6-60 degrees C, placed in a fixture on an MTS machine and loaded in shear until failure.

RESULTS

Statistical analysis revealed that dentin condition (moist or dry) was significant for Prime & Bond NT, Single Bond, and Gluma Comfort Bond. Bonding to moist dentin produced higher bond strengths than bonding to dry dentin. For Gluma Comfort Bond + Desensitizer, no statistical difference was found between bonding to moist vs. dry dentin. Over all, Single Bond and Gluma Comfort Bond bonded to moist dentin produced significantly higher bond strengths than all other groups.

Care of the dying in long-term care settings

A team of caregivers provides health care in nursing homes. This team is led by a nurse and includes a physician, nursing assistants, and other nursing home staff. Given the future demand for palliative care in this setting, the roles of all caregivers need to be supported with meaningful training, improved working conditions, and respect for each caregiver's contribution.

Interaction between Burkholderia pseudomallei and Acanthamoeba species results in coiling phagocytosis, endamebic bacterial survival, and escape

Burkholderia pseudomallei causes melioidosis, a potentially fatal disease whose clinical outcomes include rapid-onset septicemia and relapsing and delayed-onset infections. Like other facultative intracellular bacterial pathogens, B. pseudomallei is capable of survival in human phagocytic cells, but unlike mycobacteria, Listeria monocytogenes, and Salmonella serovar Typhimurium, the species has not been reported to survive as an endosymbiont in free-living amebae. We investigated the consequences of exposing Acanthamoeba astronyxis, A. castellani, and A. polyphaga to B. pseudomallei NCTC 10276 in a series of coculture experiments. Bacterial endocytosis was observed in all three Acanthamoeba species. A more extensive range of cellular interactions including bacterial adhesion, incorporation into amebic vacuoles, and separation was observed with A. astronyxis in timed coculture experiments. Amebic trophozoites containing motile intravacuolar bacilli were found throughout 72 h of coculture. Confocal microscopy was used to confirm the intracellular location of endamebic B. pseudomallei cells. Transmission electron microscopy of coculture preparations revealed clusters of intact bacilli in membrane-lined vesicles inside the trophozoite cytoplasm; 5 x 10(2) CFU of bacteria per ml were recovered from lysed amebic trophozoites after 60 min of coculture. Demonstration of an interaction between B. pseudomallei and free-living acanthamebae in vitro raises the possibility that a similar interaction in vivo might affect environmental survival of B. pseudomallei and subsequent human exposure. Endamebic passage of B. pseudomallei warrants further investigation as a potential in vitro model of intracellular B. pseudomallei infection.