Faroque A. Khan

Nutritional Treatment for Acquired Immunodeficiency Virus-Associated Wasting Using β-Hydroxy β-Methylbutyrate, Glutamine, and Arginine: A Randomized, Double-Blind, Placebo-Controlled Study

BACKGROUND The current study was designed to examine whether a combination of three nutrients, consisting of beta-hydroxy-beta-methylbutyrate (HMB), a metabolite of leucine, L-glutamine (Gln) and L-arginine (Arg), each of which has been previously shown to slow muscle proteolysis, could synergistically alter the course of muscle wasting in patients with established acquired immunodeficiency syndrome (AIDS). METHODS Sixty-eight human immunodeficiency virus (HIV)-infected patients with a documented weight loss of at least 5% in the previous 3 months were recruited from the HIV clinic at Nassau County Medical Center. The subjects were randomly assigned in a double-blind fashion to receive either placebo containing maltodextrin or the nutrient mixture (HMB/Arg/Gln) containing 3 g HMB, 14 g L-glutamine, and 14 g L-arginine given in two divided doses daily for 8 weeks. Body weights (BW) were recorded weekly and lean body mass (LBM) and fat mass (FM) were measured by air displacement plethysmography and by a single computerized tomography (CT) slice through the thigh at 0, 4, and 8 weeks. RESULTS Forty-three subjects completed the 8-week protocol, (placebo, n = 21; HMB/Arg/Gln, n = 22). At 8 weeks, the subjects consuming the HMB/Arg/Gln mixture gained 3.0 +/- 0.5 kg of BW while those supplemented with the placebo gained 0.37 +/- 0.84 kg (p = .009). The BW gain in the HMB/Arg/Gln-treated subjects was predominantly LBM (2.55 +/- 0.75 kg) compared with the placebo-supplemented subjects who lost lean mass (-0.70 +/- 0.69 kg, p = .003). No significant change in FM gain was observed (0.43 +/- 0.83 kg for the group receiving HMB/Arg/Gln and 1.07 +/- 0.64 kg for the group receiving the placebo, p > .20). Similar percentage changes in muscle mass and fat mass were observed with CT scans. Immune status was also improved as evident by an increase in CD3 and CD8 cells and a decrease in the HIV viral load with HMB/Arg/Gln supplementation. CONCLUSIONS The data indicate that the HMB/Arg/Gln mixture can markedly alter the course of lean tissue loss in patients with AIDS-associated wasting.

Ciliary Dyskinesia Associated With Hydrocephalus and Mental Retardation in a Jordanian Family

OBJECTIVE To describe the presentation and genetic transmission of ciliary dyskinesia syndrome associated with hydrocephalus and mental retardation in 3 generations of a family. PATIENTS AND METHODS A large Jordanian family included 9 individuals in 3 generations with recurrent pulmonary infections; 4 male siblings have been diagnosed as having mental retardation, and a maternal uncle was believed to have been similarly affected. Chromosome analysis of the family showed a normal karyotype. RESULTS Electron microscopy of the nasal cilia from 3 affected siblings showed features of primary ciliary dyskinesia. Computed tomographic scans of the brains of all 4 affected siblings showed hydrocephalus. CONCLUSIONS The recurrent pulmonary infections and hydrocephalus in this large Jordanian family are likely related to ciliary dyskinesia, which appears to follow an autosomal recessive mode of inheritance. The unusual presentation of ciliary dyskinesia, hydrocephalus, and mental retardation may be due to a new genetic mutation.

Effects of Continuous Positive Airway Pressure in Acute Asthma

We studied flow changes, airway pressures, breathing patterns and subjective sensation during tidal breathing on continuous positive airway pressure (CPAP) in 21 acutely ill asthmatic patients and 19 controls. The measurements obtained at various levels of CPAP were compared to the value at zero end-expiratory pressure. The fractional inspiratory time (TI/TTOT) was significantly reduced in both the patients and the control group (p less than 0.01). Patients noticed the best sensation of comfort at CPAP of 5.3 +/- (SD) 2.8 and the control group at 1.6 +/- 2.5. We noted a reduction in peak tidal expiratory flow and an increase in late-phase expiratory flow during tidal breathing in both groups although these changes were not statistically significant. There was improvement in sensation of comfort during low to medium levels of CPAP in acutely ill asthmatics. We conclude that low to medium levels of CPAP may be beneficial in acute asthma by assisting inspiratory muscles. As CPAP is increased, the beneficial effects of increased end-expiratory flow rate may be offset by the reduction in peak tidal expiratory flow rates.

Enlarging Intratracheal Tube Cuff Diameter: A Quantitative Roentgenographic Study of Its Value in the Early Prediction of Serious Tracheal Damage

A prospective study to radiographically document impending tracheal damage in patients on continuous mechanical ventilation was done in 135 intubated adult patients over an eighteen month period. The previously unrecognized enlarging cuff/trachea ratio over 150% was seen in 18 patients. Five of 9 patients who died with C/T ratio over 150% were autopsied; all had severe tracheal damage at the cuff site. Four of 5 patients who were decannulated/extubated developed tracheal stenosis at the cuff site, necessitating tracheal resection in 3 patients. Thus a C/T ratio over 150% is a reliable clinical indicator of tracheal damage. Some thoughts as to prevention of this iatrogenic disease are presented.

Renal involvement in the systemic inflammatory reaction syndrome

Uncontrolled infection quite often leads to systemic inflammatory reaction syndrome (SIRS) and multiorgan dysfunction (MOD) syndrome. Thirty-five consecutive patients (19 males) fulfilling strict diagnostic criteria for SIRS were enrolled in two multicenter prospective double-blind trials involving new therapies for SIRS. The patients were followed prospectively up to day 28 after the enrollment. In the 35 patients with SIRS, males predominated in the age group below 40 (10/12, 83%) compared to the older group (nine males out of 23, 39%). Out of 16 females presenting with SIRS, only two were below the age of 40. This distribution was statistically different than our general MICU population. The serum albumin in these patients was uniformly low, with a mean of 22.5 gm/L. The bulk of SIRS patients (22/35; 63%) went on to develop acute renal failure (ARF). Although statistically not different, skin and peritoneal infections were more common in ARF group while pulmonary infections in non-ARF group. The majority of blood-cultures grew gram-positive organisms. Resolution of SIRS occurred within first 3 days in greater number of non-ARF survivors than ARF survivors (6/9, 66.7% vs. 6/16, 37.5%). Of the 22 ARF patients, 17 showed improvement in their renal function; the five who did not, died before day 28. The overall mortality (about 32%) was similar in both groups. Patients who developed both ARF and ARDS did not survive. In conclusion. SIRS occurs mostly in elderly patients, almost always in patients with low albumin levels. Premenopausal women seem to be protected. Blood cultures isolated a gram-positive organism in the majority of cases. Improvement in serum creatinine suggests good prognosis. The mortality in ARF and non-ARF groups is similar.

Psychological aspects of weaning from mechanical ventilation

Abstract The authors discuss the role of the psychiatrist in the management of patients whose emotional problems impede successful weaning from mechanical ventilation. Although the authors find it impossible to establish predictive criteria, they suggest that a significant recent object loss or past psychiatric treatment should alert the staff to the possibility of difficulty in weaning. They present two case studies and offer suggestions for management.

ROLE OF BRONCHOSCOPY IN AIDS

The differential diagnosis of pulmonary disorders in the HIV-infected individual is broad. Clinical features and chest radiographs may point towards a diagnosis but cannot reliably establish one. It is important to know the conditions in which bronchoscopy, BAL, and TBB are likely to be diagnostic, just as it is to know when other invasive or noninvasive procedures may be more useful. Finally, the incidence of transmission of infections such as tuberculosis during bronchoscopy and cross-contamination of patients with an improperly sterilized bronchoscope, cannot be overemphasized.

Branhamella infections. An increasingly common respiratory illness.

Branhamella catarrhalis is an important cause of acute sinusitis and otitis media in children and of acute tracheobronchitis in older persons with underlying chronic lung disease or a suppressed immune system. Clinical presentation of B catarrhalis infection varies from a mild, self-limiting disease to severe pneumonia, but most cases are mild to moderate in severity. Infection occurs sporadically, and endogenous spread from the oropharynx is the likely mechanism. The keys to diagnosis are a high index of clinical suspicion, correct interpretation of Grams stain of sputum, and subsequent confirmation on culture. Because most strains of B catarrhalis produce beta lactamase, antibiotics that resist beta-lactamase production, eg, amoxicillin-clavulanic acid (Augmentin), erythromycin, ciprofloxacin (Cipro), are recommended. Mild infections can be self-limiting and may not require antibiotic therapy.

Acquired immune deficiency syndrome. A deadly new disease.

The acquired immune deficiency syndrome (AIDS) represents a new epidemic of major proportions. Risk factors include homosexuality, intravenous drug abuse, Haitian descent, and multiple transfusion in the presence of hemophilia A. The etiology of AIDS remains unknown, but there is increasing evidence implicating a transmissible infectious agent and/or multiple antigenic exposures inducing a loss of immunoregulation. In a high-risk patient, the features of weight loss, generalized lymphadenopathy, and fever should arouse suspicion of AIDS. Diagnostic confirmation includes demonstration of reduced numbers of T lymphocytes with reversal of helper-suppressor T-lymphocyte ratio, presence of unusual opportunistic infections, and a progressive downhill course. The most common infection in AIDS is Pneumocystis carinii pneumonia. Treatment failures with trimethoprim-sulfamethoxazole (Bactrim, Septra) are common; pentamidine isethionate (Lomidine) may be more effective in eradicating the infection. In spite of initial improvement, recurrences of P carinii pneumonia and other opportunistic infections are common. In addition, other protozoan, viral, fungal, and atypical mycobacterial infections are frequent in patients with AIDS. Finally, rare neoplasms such as Kaposis sarcoma and B-cell lymphoma, including primary lymphoma of the brain, are also being recognized as complications. At present there is no specific therapy for AIDS, and the disease is usually fatal. Continued research will hopefully result in immunomodulation techniques and specific vaccines to combat this serious epidemic.

Addison's disease due to metastatic carcinoma: The value of CT scan

A case of Addisons disease secondary to bilateral adrenal metastasis is reported. The adrenal metastasis were secondary to bronchogenic carcinoma and the diagnosis was made on the basis of the CT scan. The role of CT in the diagnosis of adrenal disease as well as the importance of including the adrenals in the chest CT scan for preoperative staging of bronchogenic carcinoma is discussed.