The changing management of chylothorax in the modern era.

Initial conservative therapy is applied to all cases of chylothorax (CTx) with expected excellent outcomes. The indication for aggressive surgical treatment of early CTx remains uncertain and requires rigorous scientific scrutiny. Lymphangiography and lymphoscintigraphy are useful to localize the leak and assess thoracic duct patency as well as to differentiate partial from complete thoracic duct transection. The aetiology of the CTx, flow rate and patient condition dictate the preferred management. Octreotide/somatostatin and etilefrine therapy is highly efficacious in the conservative management of CTx. For patients in whom conservative management fails, those who are good surgical candidates, and those in whom the site of the leak is well identified, surgical repair and/or ligation using minimally invasive techniques is highly successful with limited adverse outcomes. Similarly, if the site of the chylous effusion cannot be well visualized, a thoracic duct ligation via video-assisted thoracic surgery is the gold standard approach. A pleuroperitoneal or less often a pleurovenous shunt is a final option and may be curative in some patients.

Discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting.

The nature of discomfort and level of exertion associated with wearing respiratory protection in the health care workplace are not well understood. Although a few studies have assessed these topics in a laboratory setting, little is known about the magnitude of discomfort and the level of exertion experienced by workers while they deliver health care to patients for prolonged periods. The purpose of this study was to determine the magnitude of discomfort and level of exertion experienced by health care workers while wearing respiratory protection for periods up to 8 hr when performing their typical occupational duties. This project was a multiple cross-over field trial of 27 health care workers, aged 24-65, performing their typical, hospital-based occupational duties. Each participant served as his/her own control and wore one of seven respirators or a medical mask for 8 hr (or as long as tolerable) with interposed doffing periods every 2 hr. Self-perceived discomfort and exertion were quantified before each doffing: self-perceived level of discomfort using a visual analog scale, and self-perceived level of exertion using a Borg scale. Overall, and as would be expected, discomfort increased over time with continual respirator use over an 8-hr period. Interestingly, exertion increased only marginally over the same time period. The relatively low level of exertion associated with eight respiratory protective devices, including models commonly used in the U.S. health care workplace, is not likely to substantially influence workers' tolerability or occupational productivity. However, the magnitude of discomfort does appear to increase significantly over time with prolonged wear. These results suggest that respirator-related discomfort, but not exertion, negatively influences respirator tolerance over prolonged periods. Discomfort may also interfere with the occupational duties of workers.

Emotional bonds and social support exchange between men living with HIV infection and their mothers.

Men infected with HIV are often faced with caregiving responsibilities of aging, ill parents, while simultaneously looking for support from their parents in dealing with their own health problems. Unfortunately, the reciprocal roles of HIV-positive adult sons and aging mothers as caregivers have not been examined. To address this gap in the literature, HIV-positive men (n = 118) answered open-ended questions about the support they exchanged with their mothers, completed the Depth of Relationships Inventory, and rated the importance of health-related assistance between themselves and their mothers. The men viewed themselves as important providers of both instrumental and emotional support to their mothers. Men perceived their mothers to be significant providers of emotional support but only moderately important in providing instrumental support. About a third of the men responded that the help they provided and received from the mothers in managing each other's health and staying healthy was extremely important. Men regarded their relationships with their mothers as one of their most important social relationships. Non-White men rated the quality of their mother-son relationships more highly, exchanged more instrumental support, and provided more emotional support to their mothers than White men. Men who disclosed their HIV-positive status to their mothers rated the importance of the help they received from their mothers in managing their illnesses higher than men who had not disclosed.

Diminished speech intelligibility associated with certain types of respirators worn by healthcare workers.

This study sought to determine the level of communication interference associated with commonly used disposable and reusable respirators and surgical masks worn by healthcare workers. Speech intelligibility was assessed using the modified rhyme test in an intensive care unit environment. Respirators decreased speech intelligibility by a range of 1% to 17%, although not all were statistically significant. Differences in speech intelligibility associated with surgical masks and disposable filtering facepiece respirators (without exhalation valves) were not statistically significant compared with controls. Wearing half-face elastomeric respirators with voice augmentation equipment was associated with higher speech intelligibility than models without this equipment (OR = 2.81). Hearing clarity while wearing a powered air-purifying respirator (PAPR) was 79% compared with 90% with no PAPR (OR = 0.40). While some respirators appear to have little or no effect on speech intelligibility, interference with speech intelligibility associated with certain types of respirators commonly worn by U.S. healthcare workers may be substantial.

Nutritional formula improved immune profiles of seniors living in nursing homes.

OBJECTIVES: To assess whether an experimental nutritional formula (EXP) supports immune function in seniors living in long-term care facilities. DESIGN: Prospective, randomized, double-blind, controlled trial conducted September 2002 through January 2003. SETTING: North central Florida nursing homes. PARTICIPANTS: Subjects aged 65 and older (n = 157). INTERVENTION: Subjects received 240 mL/d of EXP or standard liquid nutrition (CON) for 4 weeks before and 6 weeks after an influenza vaccination. MEASUREMENTS: Influenza vaccine antibody responses, immunophenotyping, lymphocyte activation, cytokines, and clinical measures (fever, number of prescribed antibiotics). RESULTS: Ninety-two subjects (n = 40, CON; n = 52, EXP) completed the study. Geometric mean antibody titers were similar between groups, yet the percentage of subjects with H1N1 antibody titers greater than 100 postvaccination was higher in the EXP group than in the CON group (43% vs 23%, P=.047). Similar trends were found for the percentage of subjects (intent to treat) with fourfold increases against the B/Hong Kong component (64% vs 46%, P = .09) or with H3N2 antibody titers of 40 or more (97% vs 89%, P=.06). EXP subjects had higher levels of influenza-activated lymphocytes (CD69+ and CD25+). Cytokine production after mitogen activation was lower in EXP than CON subjects (interleukin (IL)-6: 20+/-3 vs 29+/-3 ng/mL, P = .045; IL-10: 310+/-60 vs 603+/-140 pg/mL, P = .06). Fewer EXP subjects were treated for fever (5% vs 16%, P = .02) or prescribed antibiotics (7 vs 11 new antibiotics/100 days of study, P = .06). CONCLUSION: Seniors consuming the EXP formula demonstrated enhanced immune function, indicated by increased influenza vaccine response and lymphocyte activation, less fever, and fewer newly prescribed antibiotics than those consuming a standard ready-to-drink nutritional supplement.

Oxidative stress and antioxidant capacity in smoking and nonsmoking men with HIV/acquired immunodeficiency syndrome.

BACKGROUND: Past studies document decreased levels of antioxidants and selenium and increased levels of oxidative stress in people living with HIV/acquired immunodeficiency syndrome (AIDS). Cigarette smoking is another source of oxidative stress. Excessive oxidative stress can induce HIV replication, resulting in disease progression. The purpose of this study was to determine whether subjects with HIV/AIDS who smoke cigarettes have increased oxidative stress and decreased antioxidant status compared with nonsmokers with HIV/AIDS. METHODS: Thirty-one men with HIV/AIDS (adhering to highly active antiretroviral therapy for the previous 3 months) were recruited during regular visits to a Veterans Affairs Medical Center Infectious Disease Clinic in a southeastern US city. Plasma was obtained from a 1-time blood draw for this comparison study. Plasma lipid peroxide (LPO) was used as a marker of oxidative stress. Indicators of antioxidant capacity included plasma glutathione peroxidase (GPx, the functional indicator of selenium status), vitamin C, and antioxidant potential (AOP). RESULTS: Fifteen smokers and 10 nonsmokers with HIV/AIDS were enrolled. Median plasma LPO level was above the normal range of 0-1.3 micromol/L in both nonsmokers (2.5 [0-23.4] micromol/L, median [range]) and smokers (4.0 [0-47.5] micromol/L), but there was no difference between groups. Plasma GPx concentration was significantly lower in smokers (169 [118-295] mumol/min/L) compared with nonsmokers (197 [149-414] micromol/min/L). Vitamin C and AOP levels were not different between groups. CONCLUSIONS: This pilot study suggests that effects of smoking on oxidative stress are not additive, as no striking differences were observed in oxidative stress or antioxidant capacity between clinically stable smoking and nonsmoking men with HIV/AIDS.

Arginine supplementation enhances mitogen-induced splenocyte proliferation but does not affect in vivo indicators of antigen-specific immunity in mice.

Arginine is a conditionally essential amino acid with many physiologic roles. Its role in immune function has been one of major focus with conflicting results. Early in vitro immune studies demonstrated increased mitogen-induced lymphocyte proliferation with dietary arginine supplementation; however, not all studies confirmed this effect. Even less is known about the effect of arginine supplementation on in vivo immune responses. To test whether arginine supplementation enhances in vivo indicators of immune function, young female BALB/c mice were fed either the AIN-93G rodent diet (6.4 g arginine/kg diet) or the same diet with 20 g total arginine/kg diet for 15 d before delayed-type hypersensitivity (DTH) testing with 2,4-dinitrofluorobenzene (n = 16-18/diet group). The same mice were challenged with influenza virus A/Port Chalmers/1/73 (H3N2) 15 d later. Mice were killed 3, 6, or 31 d postinfluenza challenge (5-6/diet group on each day). Mitogen-induced splenocyte proliferation, body weight, anti-influenza serum antibody, lung viral titers, and serum arginine were measured. DTH did not differ between diet groups. On d 6 and 31 postchallenge, mitogen-induced proliferation of splenocytes from mice fed the arginine diet was >1.5-fold that of mice fed the control diet (P < 0.05). Body weight and influenza lung viral and serum antibody titers did not differ between diet groups. These data suggest that despite significant enhancement of in vitro mitogen-induced splenocyte proliferation, arginine supplementation does not have a biologically significant effect on antigen-specific in vivo indicators of immune function in this model.

HIV and older adults: clinical outcomes in the era of HAART.

As the human immunodeficiency virus (HIV) epidemic enters its third decade, nurses are caring for increasing numbers of older adults with HIV who are on complicated medication regimens or highly active antiretroviral therapy (HAART). Although HAART has revolutionized HIV and acquired immunodeficiency syndrome (AIDS) care, little is known about how older adults respond to the new therapies. A review of the medical records of 19 older (> or = 50 years) and 18 younger (< 40 years) adults initiated on their first HAART regimen revealed both older and younger adults had similar positive clinical outcomes. Nurses need to individualize their care to patients of all ages rather than develop specific clinical guidelines for older adults with HIV.

Nutritional formula enhanced immune function and reduced days of symptoms of upper respiratory tract infection in seniors.

OBJECTIVES: To assess whether an experimental nutritional formula, given as a supplement, would reduce days of symptoms of upper respiratory tract infection (URTI) and affect antibody and lymphocyte proliferative responses to influenza vaccine. DESIGN: A prospective, randomized, double-blind, controlled trial was conducted between October 1999 and April 2000. SETTING: Assisted- and independent-living facilities in North Central Florida. PARTICIPANTS: Sixty-six individuals, aged 65 and older. INTERVENTION: Subjects received 8 oz/d of an experimental formula containing antioxidants, zinc, selenium, fermentable oligosaccharides, and structured triacylglycerol or an isoenergetic, isonitrogenous control formula for 183 days. MEASUREMENTS: Subjects recorded daily symptoms of URTI. Antibody titers and lymphocyte proliferation to three influenza vaccine components were measured on Days 57 and 183. RESULTS: Eighteen subjects in the control group and 16 subjects in the experimental group consumed an average of 7 ounces of formula daily and completed the 183-day study. Median days of symptoms of URTI were 3 (range 0-69, total days=156) and 0 (range 0-49, total days=78) for the control and experimental groups, respectively (P=.049). On Day 57, seven of 17 (41%) subjects in the control group and 13 of 15 (87%) subjects in the experimental group achieved a fourfold or greater increase in serum antibody titer to A/Beijing (P=.012). Lymphocyte proliferation to influenza vaccine components was greater in the experimental (median=1,365 cpm, range=0-14,955 cpm) than the control group (median=136 cpm, range=0-4,270 cpm) (P=.013). CONCLUSION: Subjects consuming an experimental nutritional formula experienced enhanced immune function and fewer days of URTI symptoms.

Infectious disease risk in the elderly.

Older persons suffer excessively from infectious diseases such as pneumonia and urinary tract infections. This article discusses some of the reasons for this additional morbidity and mortality, including the anatomical and physiological changes with aging, impairment of immune function, presence of co-morbid diseases, and delays in diagnosis and initiation of therapy.

Overexpression of CRIP in transgenic mice alters cytokine patterns and the immune response.

Cysteine-rich intestinal protein (CRIP), which contains a double zinc finger motif, is a member of the Group 2 LIM protein family. Our results showed that the developmental regulation of CRIP in neonates was not influenced by conventional vs. specific pathogen-free housing conditions. Thymic and splenic CRIP expression was not developmentally regulated. A line of transgenic (Tg) mice that overexpress the rat CRIP gene was created. When challenged with lipopolysaccharide, the Tg mice lost more weight, exhibited increased mortality, experienced greater diarrhea incidence, and had less serum interferon-gamma (IFN-gamma) and more interleukin (IL)-6 and IL-10. Similarly, splenocytes from the Tg mice produced less IFN-gamma and IL-2 and more IL-10 and IL-6 upon mitogen stimulation. Delayed-type hypersensitivity response was less in the Tg mice. Influenza virus infection produced greater weight loss in the Tg mice, which also showed delayed viral clearance. The observed responses to overexpression of the CRIP gene are consistent with a role for this LIM protein in a cellular pathway that produces an imbalance in cytokine pattern favoring Th2 cytokines.