Matthias Schrappe

Clinical risk factors for malnutrition in HIV-1-infected patients

Objective:To estimate the influence of fever, diarrhoea, stage of HIV disease, opportunistic infection and anorexia on malnutrition in HIV-infected patients we analysed data of patients undergoing a nutritional counselling programme from November 1989 to April 1992. Patients and methods:Our study group comprised 104 HIV-infected patients (98 homosexual men, 15 asymptomatics, 30 AIDS-related complex patients, 59 AIDS patients). Nutritional status was measured by previous weight loss, bioelectrical impedance analysis and prospective intake protocol. Results:Patients had lost 10 ± 8.7% of body weight. Compared with controls, body mass index was lower (P< 0.001), and extracellular/body cell mass ratio (ECM/BCM) was higher (P< 0.001). BCM was reduced proportionately to weight loss, percentage of body fat was lower compared with controls (P< 0.001), even in patients with stable weight. Clinical risk factors for malnutrition were identified as fever in 31, diarrhoea in 26, acute infections in 42 and anorexia in 73 out of 104 patients. One single risk factor was predominant in 63 patients: fever in five, diarrhoea in 14, acute infections in 17 and anorexia in 27 patients. Weight loss was not linearly correlated to CD4 count or to time since AIDS diagnosis. Food intake was highly variable (39–165% of calculated needs) without correlation to weight loss. Conclusions:Loss of body fat was found even in the earlier stages of HIV infection and was more severe than loss of BCM. Important risk factors for malnutrition are anorexia (most frequent), diarrhoea and fever (most severe). Most patients have combined risk factors. Treatment strategies and pathophysiologic studies should consider the heterogeneity of HIV-associated malnutrition.

Seroprevalence and disease association of antineutrophil cytoplasmic autoantibodies and antigens in HIV infection.

SummaryThis prospective study was designed to determine the role of antineutrophil cytoplasmic autoantibodies (ANCA) in HIV-infected patients. Immunofluorescence tests (IFT) and enzyme-linked immunosorbent assays (ELISA) were applied to sera of 199 consecutive outpatients. In the IFT 20% were positive. An atypical ANCA pattern was demonstrated in 67% of these, 33% revealed a perinuclear staining (pANCA). Specific ELISA revealed proteinase 3 (n=2), myeloperoxidase (n=1), lysozyme (n=2), lactoferrin (n=1), cathepsin G (n=1), and human leukocyte elastase (HLE, n=6). The target antigen remained unidentified in 26 patients. Perinuclear ANCA-positive patients showed atypical antigens in eight of 13 cases; all six patients with anti-HLE revealed a pANCA pattern. The antigens of atypical ANCA-positive patients remained unidentified in 21 of 26 (81%) cases. No signs of vasculitis were present in the ANCA-positive patients. ANCA are frequently found in the sera of HIV-positive patients. They bind to a variety of antigens. No correlation was found between ANCA positivity and autoimmune or opportunistic diseases.

Resting energy expenditure, weight loss, and altered body composition in HIV infection

Failure to downregulate resting energy expenditure (REE) as an adaption to anorexia or malabsorption is often stated as the major cause of weight loss in individuals with AIDS. In a prospective study, REE was compared with weight changes in HIV-infected patients. The impact of altered body composition on REE was reassessed by critical review of the literature. Patients were 65 male HIV-infected patients, 28 with recent weight loss (WL), and 37 who were weight stable (WS); 50/65 patients had AIDS, and 29/65 had acute infections; 29 male healthy persons served as controls. Indirect calorimetry, prospective intake protocol, and bioelectrical impedance analysis were performed. Absolute REE was lower in WL patients than in controls (1459 +/- 309 versus 1711 +/- 151 kcal/d, p < 0.001) and in WS patients (1625 +/- 402 kcal/d, p < 0.05). REE/kg body cell mass (BCM) was higher in WL and WS than in controls (both p < 0.01) due to lower BCM in both patient groups (p < 0.001). REE (%Harris-Benedict) was not different among the three groups. Weight changes around the measurement were not correlated to REE (r2 = 0.0008, p = 0.82). REE was independent of diarrhea, acute infection, fever, or caloric intake. REE had a stronger correlation to body weight and to Harris-Benedicts prediction than to fat-free mass or BCM. REE explains < 1% of weight changes. Many patients can downregulate REE as an adaption to anorexia and/or malabsorption. Higher REE/kg BCM does not signify hypermetabolism at the cellular level but can be explained by the maintenance of energy-consuming visceral tissue within the BCM during BCM loss.

CMV-antigenemia in peripheral blood for the diagnosis of CMV disease in HIV-infected patients

In a prospective study of HIV patients with suspected cytomegalovirus (CMV) disease (n = 144; 140 men, four women; aged 23-69 years, median 38 years; CD4 cells 0-400, median 20/microliters), 242 blood samples were examined for the presence of CMV-pp65 antigen in peripheral blood polymorphonuclear leucocytes by use of monoclonal antibodies and alkaline phosphatase-anti-alkaline phosphatase staining. All patients were thoroughly examined for existing CMV disease at first visit and during follow-up (at least 2 months or until death: 0-24 months, median 14 months). In 43/486 samples of patients with CMV disease, the antigen-test was positive and in 179/194 samples of patients without CMV disease the test was negative, resulting in a sensitivity of 90% and a specificity of 93% for the presence of CMV disease in HIV-infected patients.

Evaluation of nutritional counselling in HIV-associated malnutrition

In HIV-infected patients, the outcome of counselling as the first step of a nutritional intervention programme was evaluated, in order to identify clinical and nutritional predictors for its efficacy. 75 HIV-infected patients were investigated, most with advanced disease. Nutritional status was determined by body weight, bioelectrical impedance and 7-day food intake record. Prior mean weight loss was 10% (range = +4% to -31%). Counselling facilitated weight gain in 40 75 patients (1-4 months later, overall mean difference +1.4 +/- 6.2%) and in 14 34 patients (8-11 months later, overall mean difference -1.4 +/- 9.0%). Weight changes correlated with changes in body cell mass (r(2) = .69, p < .001) and in body fat (r(2) = .29, p < 0.05), but not extracellular mass. Underlying conditions such as AIDS definition, fever, and diarrhoea correlated to prior weight loss (p < .001) but not to the outcome of counselling. Low energy intake (before counselling, < 31.5 kcal/kg) did not correlate to prior weight loss but it predicted further weight loss (p < 0.05 towards normal intake). High energy intake (> 38.5 kcal/kg) correlated (p < 0.05) with more prior weight loss but not with further weight changes. Nutritional counselling may be an effective first-line intervention for malnourished HIV infected patients. More than half of patients gain weight without other nutritional treatment. Whereas the severity of malnutrition is influenced by the underlying disease, fever, and diarrhoea, the course of weight change after nutritional intervention is not. Counselling may reduce the nutritional impact of these risk factors. In patients with low spontaneous intake, efficacy of counselling alone is limited, but it may help to identify those who require more invasive nutritional treatment.

Are administrative data valid when measuring patient safety in hospitals? A comparison of data collection methods using a chart review and administrative data

OBJECTIVE To evaluate the validity and reliability of German Diagnosis Related Group administrative data to measure indicators of patient safety in comparison to clinical records. DESIGN A cross-sectional study was conducted using chart review (CR) as gold standard and screening of associated administrative data based on DRG coding. SETTING Three German somatic acute care hospitals for adults. PARTICIPANTS A total of 3000 cases treated between May and December, 2010. MAIN OUTCOME MEASURES Eight indicators were used to analyse the incidence of associated adverse events (AEs): pressure ulcers, catheter-related infections, respiratory failure, deep vein thromboses, hospital-acquired pneumonia, acute renal failure, acute myocardial infarction and wound infections. We calculated sensitivity, specificity, positive predictive value (PPV) and Cohens Kappa with 95% confidence intervals. RESULTS Screening of administrative data identified 171 AEs and 456 were identified by CR. A number of 135 identical events were identified by both methods. Sensitivities for the detection of AEs using administrative data ranged from 6 to 100%. Specificities ranged from 99 to 100%. PPV were 33 to 100% and reliabilities were 12 to 85%. CONCLUSIONS Indicators based on German administrative data deviate widely from indicators based on clinical data. Therefore, hospitals should be cautious to use indicators based on administrative data for quality assurance. However, some might be useful for case findings and quality improvement. The precision of the evaluated indicators needs further development to detect AEs by the valid use of administrative data.

Intestinal microsporidiosis with Septata intestinalis in a patient with AIDS—response to albendazole

Microsporidiosis is a common finding in HIV-infected patients who have diarrhoea. The species most commonly causing gastrointestinal disease is Enterocytozoon bieneusi. Recently Septata intestinalis has been described as a cause of diarrhoea and disseminated infection in patients with AIDS. A 44-year-old homosexual man with severe immunodeficiency (CD4 cell count 40/microliters) had a history of watery diarrhoea for 2 weeks. Microsporidian spores measuring 1.2 to 1.5 x 2.5 to 3.0 microns were found in stool samples. Electron microscopy of duodenal biopsies confirmed the diagnosis of intestinal microsporidiosis and showed parasitophorous vacuoles with the typical ultrastructure of S. intestinalis. The patient was treated with albendazole (400 mg twice daily) and became asymptomatic within 4 days. No spores could be detected in stool samples after a treatment period of 14 days. About 25 infections with S. intestinalis have been reported to date, and the case presented here is the first in a German patient.

Versorgungsforschung — Konzept, Methoden und Herausforderungen

Die Versorgungsforschung (VF) als 4. Saule der Forschung untersucht die Umsetzung der Ergebnisse der klinischen Forschung in der Praxis der Gesundheitsversorgung hinsichtlich ihrer Wirkung auf Qualitat und Effizienz in individueller und soziookonomischer Perspektive. Die zentralen Ziele sind, Patientenorientierung, Qualitat und Wirtschaft lichkeit der Versorgung in moglichst gleichem Mase zu erreichen. Die Fragestellungen lassen sich entlang der funf Hauptfunktionen von Forschung, der Beschreibung, Erklarung, Gestaltung, Intervention und Evaluation festmachen. Methodisch muss sich die VF an den fur die klinische Forschung etablierten Qualitatsmerkmalen der evidenzbasierten Medizin orientieren, wobei sowohl Methoden der klinischen Epidemiologie als auch der empirischen Sozialforschung (quantitativ und qualitativ) zum Einsatz kommen. Die VF steht vor neuen Herausforderungen; sie muss valide Methoden in praxisnaher Form anwenden, qualitative und quantitative Methoden in sinnvoller Kombination einsetzen, neue Versorgungsforschungsmethoden entwickeln und diese hinsichtlich ihrer Wirksamkeit in der Praxis uberprufen.

Intestinal Microsporidiosis in Patients with Acquired Immunodeficiency Syndrome - Report of Three More German Cases

SummaryIntestinal microsporidiosis withEnterocytozoon bieneusi was diagnosed in three of 18 HIV-infected patients with chronic diarrhoea. In two cases all known stages of the life cycle ofE. bieneusi (merogonial plasmodia, sporogonial plasmodia, sporoblasts, spores) were found in duodenal biopsies by electron microscopical examination, whereas in the third case only merogonial and sporogonial stages were seen. Spores were also visible by light microscopy in semithin sections. Two patients were treated with albendazole (2×400 mg/day for 4 weeks) but showed no response. These findings underline the concept of the worldwide distribution of this parasite and verify that it is also frequent in Germany.ZusammenfassungEine intestinale Microsporidiose mitEnterocytozoon bieneusi konnte bei drei von 18 HIV-infizierten Patienten mit chronischem Durchfall durch elektronenmikroskopische Untersuchungen diagnostiziert werden. In zwei Fällen wurden alle bekannten Stadien des Entwicklungszyklus vonE. bieneusi in duodenalen Biopsien gefunden (Meronten, Sporonten, Sporoblasten, Sporen) wohingegen in einem Fall nur Meronten und Sporonten gesehen wurden. Die Sporen waren auch lichtmikroskopisch in Semidünnschnitten sichtbar. Zwei Patienten wurden mit Albendazol behandelt (2×400 mg/Tag für 4 Wochen), besserten sich jedoch nicht in ihrer Symptomatik. Diese drei Fälle einer intestinalen Microsporidiose unterstreichen das Konzept der weltweiten Verbreitung dieser Parasiten und belegen, daß sie auch in Deutschland häufiger vorkommen.

Foscarnet and ganciclovir combination therapy for CMV disease in HIV-infected patients

SummaryAn open prospective trial of combined ganciclovir and foscarnet therapy for 3 weeks was initiated in 14 episodes of severe CMV-disease in 13 HIV-infected patients (all CDC class IV, age 30–42, median 34 years, CD4+ cell count 0–80, median 10/µl). In seven episodes of gastrointestinal disease (five colitis, two esophagitis) remission of symptoms and mucosal changes was achieved in five. In seven episodes of retinitis, scarring was achieved in six. Renal toxicity was seen in two patients, moderate hematologic toxicity in eight patients. Overall efficacy was comparable to monotherapy; no new toxicities were seen with the combination of these two drugs.ZusammenfassungIn 14 Episoden einer CMV-Erkrankung bei 13 HIV-infizierten Patienten wurde eine Kombinationstherapie mit Ganciclovir und Foscarnet in einer offenen, prospektiven, nicht randomisierten Studie durchgeführt. Alle Patienten (n=13, Alter 30–42, Median 34 Jahre; CD4+Lymphozyten 0–80, Median 10/µl; alle Stadium IV CDC) wurden über 3 Wochen mit 2 × 5 mg/kg/d Ganciclovir und 2 × 90 mg/kg/d Foscarnet behandelt. In sieben Episoden einer gastrointestinalen CMV-Erkrankung (Colitis fünf, Ösophagitis zwei) wurde eine Remission in fünf Episoden erzielt, bei CMV-Retinitis in sechs von sieben Fällen. Nephrotoxizität trat bei zwei Patienten auf, mäßige Hämatotoxizität bei acht Patienten, sämtlich reversibel. Die Wirksamkeit der Therapie ist ähnlich der Monotherapie, die Nebenwirkungen sind additiv.