Mieke H. Godfried

Increased resting energy expenditure in human immunodeficiency virus-infected men

Even in the absence of anorexia and malabsorption, weight loss is frequently observed in patients with acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC). To investigate whether increased resting energy expenditure (REE) might be responsible for this weight loss, indirect calorimetry was performed in 18 human immunodeficiency virus (HIV)-infected men free of clinically active opportunistic infections for at least 2 months. Patients with AIDS (n = 11) or ARC (n = 7) had 9% higher rates of REE when compared with 11 healthy volunteers (P less than .05) with similar food intake and of the same body composition. The results obtained from patients with AIDS or ARC were identical. As no differences were found between patients and controls in plasma concentrations of catecholamines, thyroid hormones, cortisol, or tumor necrosis factor, except for lower concentrations of norepinephrine in the patients (mean +/- SD, 233 +/- 111 v 367 +/- 125 ng/L, patients v controls, P less than .01), this hypermetabolism is not explained by higher levels of these catabolic hormones. The results indicate that even in the absence of acute concomitant infections, increased REE may contribute to the weight loss in patients with AIDS or ARC.

The AmRo study: pregnancy outcome in HIV-1-infected women under effective highly active antiretroviral therapy and a policy of vaginal delivery.

Objective  To explore pregnancy outcome in HIV‐1‐positive and HIV‐negative women, and mother‐to‐child transmission (MTCT) according to mode of delivery under effective highly active antiretroviral therapy (HAART).

Satisfaction with the outpatient encounter: a comparison of patients' and physicians' views.

AbstractOBJECTIVE: To compare patients’ and physicians’ visit-specific satisfaction in an internal medicine outpatient setting, and to explain their respective views. DESIGN: Patients’ and physicians’ background characteristics were assessed prior to outpatient encounters. Immediately after the encounter, both patients and physicians completed a questionnaire assessing satisfaction with the visit. SETTING: The outpatient division of an academic teaching hospital. PARTICIPANTS: Thirty residents and specialists in general internal medicine, rheumatology, and gastroenterology, and 330 patients having a follow-up appointment with one of these physicians. MEASUREMENTS AND MAIN RESULTS: Patients’ and physicians’ visit-specific satisfaction was assessed using 5 Visual Analogue Scales (0 to 100). Patients’ overall satisfaction was higher than physicians’ satisfaction (mean 81 vs. 66), and correlation of patients’ and physicians’ overall satisfaction with the specific visit was medium sized (r=.28, P<.001). Patients’ satisfaction ratings were associated with their previsit self-efficacy in communicating with their physician (P<.001) and with visiting a female physician (P<.01). Physicians’ satisfaction was associated with patients’ higher educational level (P<.05), primary language being Dutch (P<.001), better mental health (P<.05), and preference for receiving less than full information (P<.05). CONCLUSIONS: In an outpatient setting, patients’ visit-specific satisfaction ratings were substantially higher than, and only moderately associated with, physicians’ ratings of the same visit. The dissimilar predictors explaining patients’ and physicians’ satisfaction suggest that patients and physicians form their opinion about a consultation in different ways. Hence, when evaluating outpatient encounters, physicians’ satisfaction has additional value to patients’ satisfaction in establishing quality of care.

Soluble receptors for tumour necrosis factor: a putative marker of disease progression in HIV infection.

OBJECTIVE To assess the value of concentrations of soluble receptors for tumour necrosis factor (sTNFR) as markers for disease progression in HIV infection. DESIGN We measured concentrations of sTNFR in the serum of 32 HIV-infected male patients in various stages of disease and in 12 healthy male control subjects. Correlations between the levels of sTNFR and CD4+ lymphocyte counts were calculated. RESULTS Serum levels of sTNFR p55 and p75 were elevated in parallel with severity of clinical stage. sTNFR p55 levels were higher at later stages of HIV infection (Centers for Disease Control stage IV) with or without concurrent illness, whereas sTNFR p75 was already elevated in asymptomatic carriers, compared with controls. There was an inverse correlation between sTNFR concentrations and CD4+ lymphocyte counts. CONCLUSIONS Our results suggest that sTNFR concentrations could be potential markers for disease progression in HIV infection.

Haematological parameters of HIV-1-uninfected infants born to HIV-1-infected mothers

Aim: To investigate haematological parameters in infants born to HIV‐1‐infected mothers and exposed to combination antiretroviral therapy (ART) used to prevent mother‐to‐child transmission (MTCT).

Decreased glucose oxidation during short-term starvation

Prolonged fasting (for days or weeks) decreases glucose production and oxidation. The effects of short-term starvation (ie, less than 24 hours) on glucose metabolism are not known. To evaluate this issue, glucose oxidation and glucose turnover were measured after 16-hour and subsequently after 22-hour fasting. Glucose oxidation was calculated by indirect calorimetry in 12 healthy men (age 22 to 44 years); glucose turnover was measured by primed, continuous infusion of 3-3H-glucose in eight of these 12 volunteers. After 16-hour fasting net glucose oxidation was 0.59 +/- 0.17 mg x kg-1 x min-1 and glucose tissue uptake 2.34 +/- 0.12 mg x kg-1 x min-1. No correlation was found between net glucose oxidation and glucose tissue uptake. Prolonging fasting with an additional 6 hours resulted in decreases of respiratory quotient (0.77 +/- 0.01 v 0.72 +/- 0.01) (P less than .005), plasma glucose concentration (4.7 +/- 0.1 v 4.6 +/- 0.1 mmol/L) (P less than .05), glucose tissue uptake (2.10 +/- 0.12 mg x kg-1 x min-1) (P less than .05), net glucose oxidation (0.09 +/- 0.04 mg x kg-1 x min-1) (P less than .005), and plasma insulin concentration (8 +/- 1 v6 +/- 1 mU/L) (P less than .005). Net glucose oxidation expressed as a percentage of glucose tissue uptake decreased from 22% +/- 8% to 2% +/- 1% (P less than .05). There was no net glucose oxidation in seven of 12 controls after 22-hour fasting.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical specialists' patient-centered communication and patient-reported outcomes.

Background:Physicians’ patient-centered communication in the medical consultation is generally expected to improve patient outcomes. However, empirical evidence is contradictory so far, and most studies were done in primary care. Objective:We sought to determine the association of specialists’ patient-centered communication with patient satisfaction, adherence, and health status. Methods:Residents and specialists in internal medicine (n = 30) and their patients (n = 323) completed a questionnaire before a (videotaped) follow-up encounter. Patients’ satisfaction was assessed immediately after the consultation and their self-reported treatment adherence, symptoms, and distress 2 weeks later. Specialists’ patient-centered communication was assessed by coding behaviors that facilitate or rather inhibit patients to express their perspective. Patient participation was assessed by determining their relative contribution to the conversation and their active participation behavior. Outcomes were assessed using standard questionnaires. Analyses accounted for relevant patient, visit and physician characteristics. Results and Conclusions:Medical specialists’ facilitating behavior was associated with greater satisfaction in patients who were less confident in communicating with their doctor. Patient-centered communication was not associated with patients’ health status or adherence in general, but facilitating behavior was positively related to the adherence of patients with a foreign primary language. In general, patients appeared to be more satisfied after an encounter with a more-facilitating and a less-inhibiting physician, but these associations diminished when controlling for background characteristics. We conclude that the absence of strong associations between patient-centered communication and patient-reported outcomes may be explained by medical specialists being responsive to patients’ characteristics.

Nelfinavir Plasma Concentrations Are Low during Pregnancy

Plasma nelfinavir concentration ratios (CRs) were calculated for all pregnant (n=27) and nonpregnant (n=48) human immunodeficiency virus type 1-infected women receiving the drug who visited our outpatient clinic. In pregnant women, mean and median nelfinavir CRs were significantly lower (P=.02 and P=.04, respectively), and 51% of the CRs were below the clinically relevant threshold of 0.90, compared with 35% of the CRs in nonpregnant women. After we adjusted for confounders, we found that the mean nelfinavir CR was 34% lower in pregnant women (P=.02). With targeted interventions, subsequent CRs in pregnant women showed a significant increase (median increase, 0.31; P=.01).

Soluble receptors for tumor necrosis factor are markers for clinical course but not for major metabolic changes in human immunodeficiency virus infection.

Tumor necrosis factor alpha (TNF) is a potential mediator of the metabolic changes in human immunodeficiency virus type 1 (HIV) infection. Soluble TNF receptor types I and II (sTNFR-I and -II) presumably reflect TNF activity. To examine the relationship between s TNFRs and host metabolism, resting energy expenditure (REE), body composition, and transferrin, albumin, triglyceride, retinol-binding protein, and sTNFR concentrations were measured in 12 asymptomatic and 18 symptomatic HIV-infected male subjects and 15 male control subjects. sTNFRs were increased in parallel with disease severity. REE was elevated approximately 8% in HIV-infected subjects (P = .005). REE correlated positively with fat free mass (FFM) and the presence of HIV infection, but not with sTNFRs. Inverse correlations existed between sTNFR-I or -II and albumin concentration (r = -.48, P = .007, and r = -.49, P = .006, respectively), between sTNFR-II and transferrin concentration (r = -.53, P = .003), and between In(sTNFR-II) and percent body fat (r = -.37, P < .05), but not between sTNFRs and triglyceride or retinol-binding protein. Thus, sTNFRs are markers for clinical course but not for major metabolic changes in HIV infection.

Low levels of specific T cell activation marker CD27 accompanied by elevated levels of markers for non-specific immune activation in the cerebrospinal fluid of patients with AIDS dementia complex.

Concentrations of soluble receptors for tumor necrosis factor (sTNFR-p55 and sTNFR-p75) and soluble T cell antigens CD25 and CD27 (sCD25 and sCD27) were measured in paired serum/cerebrospinal fluid (CSF) samples of 15 patients with AIDS dementia complex (ADC) and 15 HIV-infected control subjects (11 with other central nervous system (CNS) infections and four without CNS infection). In this study levels of sTNFR-p55, sTNFR-p75 and sCD25 were elevated in the CSF of ADC patients and of the 11 patients with other CNS infections, whereas CSF-levels of the specific T cell marker sCD27 were lower in patients with ADC as compared to the control subjects with and without other CNS infections. This pattern suggests a relative failure of eliciting a T cell-mediated immune response intrathecally in patients with ADC.