Psychosocial Factors Associated with Adaptation in HIV-Infected Mothers

Factors associated with the mental health of 40 HIV-infected mothers were examined in a sample of primarily African-American and Latina, socioeconomically disadvantaged single mothers with histories of substance use recruited from pediatric HIV clinics. Structured questionnaires on stress, social support, family functioning, psychiatric disorder, psychological distress, and substance abuse were individually administered. Different dimensions of stressful experiences (particularly losses due to death and victimization), social support, and family functioning combined in different ways to influence the mother's mental health. The combined influence of stress and social support accounted for at least half the variance in both psychiatric symptoms and psychological distress. This study supports models of stress and protective factors in understanding the mental health of HIV+ mothers, particularly models that examine stress in different life domains and different positive and negative components of social support and family functioning.     

Contractile leg fatigue after cycle exercise: a factor limiting exercise in patients with chronic obstructive pulmonary disease

We evaluated whether contractile fatigue of the quadriceps occurs after cycling exercise in patients with chronic obstructive pulmonary disease (COPD) and whether it could contribute to exercise limitation. Eighteen COPD patients performed two constant work-rate cycling exercises up to exhaustion. These tests were preceded by nebulization of placebo or 500 microg of ipratropium bromide. Muscle fatigue was defined as a postexercise reduction in quadriceps twitch force of more than 15% of the resting value. There was an increase in endurance time postipratropium compared with placebo nebulization (440 +/- 244 seconds vs. 322 +/- 188 seconds, p = 0.06). Nine patients developed contractile fatigue after placebo exercise. In these patients, ipratropium did not increase the endurance time (394 +/- 220 seconds with placebo vs. 400 +/- 119 seconds with ipratropium) despite an 11% improvement in FEV1. In the nine patients who did not fatigue after placebo exercise, endurance time increased from 249 +/- 124 seconds with placebo to 479 +/- 298 seconds with ipratropium (p < 0.05). There was a significant correlation between the improvement in endurance time with ipratropium and quadriceps twitch force at 10 minutes after placebo exercise (r = 0.59, p = 0.01). The occurrence of contractile fatigue during exercise may explain why bronchodilation fails to improve exercise tolerance in some COPD patients.     

Visceral larva migrans mimicking lymphoma

We report a case of visceral larva migrans in an adult with fever, night sweats, weight loss, hilar and mediastinal lymphadenopathy, bilateral pleural effusion, and eosinophilia-mimicking lymphoma. Visceral larva migrans was diagnosed subsequently because of negative findings for malignancy and positive serologic test result for Toxocara canis. Progressive improvement was observed with albendazole therapy.     

Acetylcysteine, coronary procedure and prevention of contrast-induced worsening of renal function: which benefit for which patient?

OBJECTIVES: This study was designed to determine whether acetylcysteine could provide a protective effect on renal function in a population of patients with normal renal function or mild to moderate chronic renal failure, usually referred for a coronary procedure. BACKGROUND: Contrast-induced nephropathy is a well-recognized complication of coronary angiography. Recent studies suggest that saline hydration and acetylcysteine reduce the incidence of contrast-induced worsening of renal function in patients with pre-existing chronic renal failure who are undergoing computed tomography examinations. METHODS: One hundred eight patients were blindly and randomly assigned to receive either acetylcysteine or placebo before and after administration of contrast agent in association with a moderate hydration protocol. Serum creatinine and urea nitrogen were measured before and 24 hours after coronary procedure. RESULTS: The mean serum creatinine concentration remained unchanged 24 hours after contrast agent administration in both groups: from 1.04 +/- 0.26 to 1.03 +/- 0.29 mg/dl in the acetylcysteine group and from 1.16 +/- 1.1 to 1.06 +/- 0.41 mg/dl in the control group (p = 0.29, for the comparison between two groups, NS). We divided the population into 3 subgroups according to their creatinine clearance: no significant change of serum creatinine concentration was observed in patients with normal renal function nor in patients with pre-existing mild to moderate chronic renal failure in both groups. There was no significant difference for the incidence of contrast-induced nephropathy between both groups (2 of the 53 patients in the acetylcysteine group and 3 of the 51 patients in the placebo group, p = 0.98, NS). CONCLUSIONS: Our data do not support the systematic use of acetylcysteine before a coronary procedure in patients with normal renal function or mild to moderate chronic renal failure, to prevent contrast-induced nephropathy.     

Bioavailability and pharmacokinetics of dehydroepiandrosterone in the cynomolgus monkey

We have studied the pharmacokinetics of dehydroepiandrosterone (DHEA) administered orally (PO), i.v., and during a continuous i.v. infusion in ovariectomized cynomolgus monkeys under suppression of adrenal DHEA secretion with dexamethasone. The glucocorticoid induced a rapid suppression of serum cortisol, DHEA, and DHEA-sulfate (DHEA-S) as well as their metabolites, thus permitting to use this model to study the pharmacokinetic parameters of DHEA and its metabolites without significant interference by endogenous steroid levels. After a single 10 mg i.v. dose of DHEA, the metabolic clearance rate and terminal half-life of DHEA were 99.9 +/- 9.1 liter/d and 4.5 +/- 0.3 h, respectively. Following a 50-mg DHEA PO dose, systemic availability was only 3.1 +/- 0.4%. As shown by their high conversion ratios, the major circulating metabolites of DHEA are DHEA-S, androsterone glucuronide, and androstane-3 alpha,17 beta-diol-glucuronide. The conversion ratios of androst-5-ene-3 beta,17 beta-diol, testosterone, dihydrotestosterone, and androstenedione are, in comparison, small. No transformation to estrogens could be detected in the circulation after either i.v. or PO DHEA administration. The present data indicate that DHEA is transformed predominantly into androgens in peripheral tissues in ovariectomized cynomolgus monkeys with minimal (androgens) or no (estrogens) release of the bioactive steroids in the circulation. Furthermore, the present study supports the importance of measuring circulating androgen glucuronide derivatives to assess hormonal exposure of peripheral tissues to androgens after DHEA administration.     

Deactivation of alveolar macrophages in septic neutropenic ARDS

STUDY OBJECTIVES: Neutrophils often have been involved in the pathophysiology of ARDS. However, authentic ARDS has been described in patients with severe neutropenia, suggesting the presence of other potential mechanisms that are responsible of this syndrome. Alveolar macrophages (AMs) could be involved in the development of ARDS, and so we decided to study AM activation in neutropenic patients. PATIENTS: We designed a prospective study and enrolled two subgroups of consecutive patients (group A, 18 patients; group B, 22 patients) with septic ARDS. In the first period, 7 of 18 patients were neutropenic, and in the second period 10 of 22 patients were neutropenic. All neutropenic patients were treated with granulocyte colony-stimulating factor (G-CSF). Measurements and results: In group A, BAL fluid samples were analyzed for differential and total cell counts, and alveolar activation marker expression (ie, human leukocyte antigen [HLA]-DR locus) was determined. Basal and lipopolysaccharide (LPS)-stimulated production of tumor necrosis factor, interleukin (IL)-1 beta, IL-6, and IL-10 was evaluated in group B. In neutropenic patients, the BAL fluid total cell count and the neutrophil absolute count was significantly lower compared to those in nonneutropenic patients (p = 0.029 and p = 0.046, respectively). HLA-DR expression on AMs was significantly decreased (p = 0.016), and the percentage of AMs expressing HLA-DR was also significantly lower (p = 0.041). In neutropenic patients, the mean percentage of AMs expressing HLA-DR was significantly lower in deceased patients compared to survivors (30 +/- 7 vs 43 +/- 1, respectively; p = 0.047). Basal AMs released cytokines was comparable between the two groups; however, LPS stimulation yielded a deactivation of AMs in neutropenic patients. CONCLUSION: These results suggest a deactivation and/or hypoactivation of AMs in septic ARDS patients. This deactivation/hypoactivation could be linked to the use of G-CSF as this molecule has been shown to generate a down-regulation of HLA-DR expression.     

Mutations in the adiponectin gene in lean and obese subjects from the Swedish obese subjects cohort

Adiponectin (also called AdipoQ, gelatin-binding protein 28, Acrp30) DNA sequence variants were determined in 96 unrelated female subjects with severe obesity (mean body mass index [BMI], 42.3 kg/m2) and in 96 non-obese female controls (mean BMI, 23.0 kg/m2) from the Swedish Obese Subjects (SOS) cohort. A single base substitution (T45G) at codon 15 of exon 2 resulting in no change in amino acid (Gly15Gly) was found in equal frequencies among obese and control subjects. However, this polymorphism was associated with serum cholesterol and waist circumference (P=.023 and.043, respectively) in the obese group. A IVS2 + G62T sequence variation was also identified, but had similar prevalence rates in obese and control subjects. Blood glucose was highest in the obese female subjects who were homozygotes for the G allele (GG) of the IVS2 + G62T polymorphism (N=56; P=.033) and all the diabetics (n=6) in this sample were in this group. IVS2 + G62T polymorphism was also associated with BMI (P=.014), diastolic blood pressure (P=.009), and sagittal diameter (P=.032). A missense point mutation at codon 111 (Tyr111His) was not associated with any obesity-related phenotypes. In conclusion, adiponectin DNA sequence variations might play a role in the complications of morbid obesity and should be further investigated.     

Current epidemiology of septic shock: the CUB-Réa Network

To update the epidemiology of septic shock we analyzed clinical, microbiologic, and outcome variables from 100,554 intensive care unit admissions on the Collège des Utilisateurs de Bases de données en Réanimation (CUB-Réa) database, collected from 22 hospitals over a 8-year period, 1993 to 2000. The overall frequency of septic shock was 8.2 per 100 admissions (i.e., 8,251 stays). It increased from 7.0 (in 1993) to 9.7 per 100 admissions (in 2000). The distribution analysis of the sites of infection and of the types of pathogens showed an increase in the rate of pulmonary infection (p = 0.001) and of multiresistant bacteria-related septic shock (p = 0.001). The crude mortality was 60.1% and declined from 62.1% (in 1993) to 55.9 (in 2000) (p = 0.001). As compared with matched intensive care unit admissions without sepsis, the excess risk of death due to septic shock was 25.7 (95% confidence interval, 24.0-27.3) and the matched odds ratio of death was 3.9 (95% confidence interval, 3.5-4.3). The frequency of septic shock is increasing with more multiresistant strains. Its crude mortality rate is decreasing, but patients with septic shock still have a high excess risk of death than critically ill patients who are nonseptic.     

Noninvasive ventilation during exercise training improves exercise tolerance in patients with chronic obstructive pulmonary disease

PURPOSE: In patients with chronic obstructive pulmonary disease, pulmonary rehabilitation has been demonstrated to increase exercise capacity and reduce dyspnea. In the most disabled patients, the intensity of exercise during the training sessions is limited by ventilatory pump capacity. This study therefore evaluated the beneficial effect of noninvasive ventilation (NIV) support during the rehabilitation sessions on exercise tolerance. METHODS: This study included 14 patients with stabilized chronic obstructive pulmonary disease, ages 63 +/- 7 years, with a forced expiratory volume in 1 second (FEV(1)) 31.5% +/- 9.2% of predicted value. All 14 patients participated in an outpatient pulmonary rehabilitation program. Seven of the patients trained with NIV during the exercise sessions (NIV group), whereas the remaining seven patients breathed spontaneously (control group). Exercise tolerance was evaluated during an incremental exercise test and during constant work rate exercise at 75% of peak oxygen consumption (VO(2)) before and after the training program. RESULTS: The application of noninvasive ventilation increased exercise tolerance, reduced dyspnea, and prevented exercise-induced oxygen desaturation both before and after training. The pressure support was well tolerated by all the patients during the course of the training program. In the NIV group, training induced a greater improvement in peak VO(2) (18% vs 2%; P <.05) and a reduced ventilatory requirement for maximal exercise, as compared with the control group. The constant work rate exercise duration increased similarly in both groups (116% vs 81%, nonsignificant difference), and posttraining blood lactate was decreased at isotime (P <.05 in both groups), but not at the end of the exercise. CONCLUSION: In this pilot study, exercise training with noninvasive ventilation support was well tolerated and yielded further improvement in the increased exercise tolerance brought about by pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. This improved exercise tolerance is partly explained by a better ventilatory adaptation during exercise.