Influenza and human immunodeficiency virus infection: absence of HIV progression after acute influenza infection.

Influenza is a major cause of morbidity for people with significant underlying disease, but the impact of influenza on people infected with human immunodeficiency virus (HIV) remains unclear. We studied a population of HIV-infected adults during the 1998-1999 influenza season to see whether influenza had any adverse effects on the course of HIV infection. During 5 months of follow-up, we found no unique clinical manifestations or negative impact on CD4(+) cell count, virus load, or clinical progression of HIV disease. Although half of our cohort received antibiotic therapy, none received specific anti-influenza therapy and none required hospitalization. Acute influenza does not appear to be a risk for progression of HIV disease.

Special problems with children and adolescents with diabetes.

Treatment of children and adolescents with insulin-dependent diabetes mellitus (type 1) is different in many ways than it is for adults. Physical, cognitive, and emotional development changes affect therapeutic goals and modalities. Neonatal, early childhood, school-age, and adolescent patients all have unique needs. Further, diabetes can affect psychosocial maturation and the likelihood of difficulties with mood.

Using telecommunication technology to manage children with diabetes: the Computer-Linked Outpatient Clinic (CLOC) Study.

The purpose of this study was to evaluate the efficacy of using a telecommunication system to assist in the outpatient management of pediatric patients with insulin-dependent diabetes. Metabolic control, patients' psychosocial status, family functioning, perceived quality of life, patterns of parental/child responsibility for daily diabetes maintenance, and nursing time-on-task were evaluated. One hundred six pediatric patients (mean age = 13.3 years) were randomly assigned to an experimental or control outpatient clinic for 1 year. Experimental subjects transmitted self-monitoring blood glucose data by modem to the hospital every 2 weeks. Transmitted data were reviewed by nurse practitioners who telephoned subjects to discuss regimen adjustments. Control subjects received standard care with regimen adjustments made by physicians. There were no significant between-group differences for metabolic control, rates of hospitalization or emergency-room visits, psychological status, general family functioning, quality of life, or parent-child responsibility. A significant decrease was noted in nursing time-on-task for experimental subjects.

Cytomegalovirus vasculitis. Case reports and review of the literature.

Cytomegalovirus (CMV) infection is a substantial cause of morbidity and mortality among immunocompromised patients. It may present with a mild, self-limited syndrome, retinitis, colitis, or invasive disease with pneumonitis, hepatitis, and bone marrow suppression. We review another, less common manifestation of CMV disease: CMV-associated vasculitis. CMV may productively infect vascular endothelial cells (25), causing a local vasculitis (3, 14, 19) and ischemia. Alternatively, the host immune response to cells expressing viral antigen may be the stimulus for vasculitis (12, 53). Since there are no pathognomonic appearances to mucosal or cutaneous lesions, biopsy of accessible sites is critical for diagnosis and expeditious initiation of appropriate antiviral therapy. The CMV-associated vasculitides represent a broad spectrum of diseases, with GI vasculitis in nontransplant recipients having the best prognosis. Cutaneous vasculitis associated with CMV seems to be a more fulminant disease, with the majority of cases having a fatal outcome. These differences likely reflect the degree of viral burden and the state of immune competence. Additionally, since the virus itself is immunosuppressive, host defenses may be further compromised by the infection. Although a large collective experience assessing the impact of ganciclovir and foscarnet is not currently available, both the prompt initiation of antiviral treatment and a concurrent reduction in any immunosuppressive regimen, including steroids, should be undertaken since these therapeutic strategies have clearly improved outcome for other CMV syndromes (22, 34, 55). As the number of recipients rises and the HIV pandemic spreads we are likely to see an increase in the number of cases of vasculitis associated with CMV infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of resident participation in a multidisciplinary diabetes team.

OBJECTIVE: To determine the impact of participation in a multidisciplinary diabetes team on pediatric residents' perceptions of team members' roles. RESEARCH DESIGN AND METHODS: Pediatric residents were assigned to a traditional diabetes clinical rotation (n = 34) or to an ambulatory multidisciplinary diabetes team within their continuity clinic (n = 21). The residents and a small sample of practicing pediatricians (n = 46) completed a Likert-type instrument at the completion of the 18-mo study. RESULTS: Multidisciplinary diabetes team residents were significantly more positive about the roles for endocrinological evaluation in monitoring compliance, for the nurse educator/certified diabetes educator in assisting with sick-day management and school behavioral problems, and for the dietician in helping with cholesterol problems. They were significantly more like practicing pediatricians in their perceptions of pediatric roles in teaching sick-day management, implementing weight reduction, assisting with conflict resolution about diabetes, screening for microvascular complications, and developing behavioral strategies for metabolic control than residents in the traditional rotation. The groups did not differ in their beliefs about patient empowerment. CONCLUSIONS: Multidisciplinary diabetes team participation may be useful in modifying specific role perceptions of pediatric residents about diabetes care. It does not appear to alter perceptions favoring greater patient empowerment.

Using nontraditional methods to teach pediatric residents about insulin-dependent diabetes mellitus.

The purpose of this study was to examine the effect of a training experience on the attitudes and beliefs of pediatric residents concerning insulin-dependent diabetes mellitus (IDDM), persons with diabetes, and the use of a multidisciplinary team to empower patients/families. The resident training experience consisted of three days of diabetes lifestyle simulation including attending an educational program designed for newly-diagnosed patients and their families. Residents' attitudes, beliefs, and team function attitudes were measured at preinstruction, postinstruction, and 6 months following instruction. There was no significant change in beliefs about diabetes. Attitudes about persons with diabetes became more positive after the training experience, but did not continue after six months. Residents also expressed a change in team attitudes, specifically, in their acceptance of having the certified diabetes educator (CDE) nurse and the patient/family adjust insulin and manage insulin during illness.

Activation of human immunodeficiency virus by herpes simplex virus.

Heterologous viruses have been examined for their ability to accelerate the course of infection with the human immunodeficiency virus (HIV) type 1. In this study, ACH-2 cells persistently infected with HIV-1 exhibited augmented HIV-1 replication as a result of superinfection with herpes simplex virus (HSV) type 1. Using HSV-1 mutants with deletions in the genes encoding immediate-early proteins ICP0, ICP4, and ICP27, it was found that ICP0 and ICP27, but not ICP4, were essential for up-regulation of HIV replication. Northern blot analysis showed that this activation of HIV was characterized by an initial rise in the level of the small, subgenomic (2.0 and 4.3 kb) mRNA species, followed by an increase in the level of unspliced genomic (9.2 kb) mRNA. Such a shift in transcriptional phase recapitulates the early-to-late transition seen in single-step growth curves of acute HIV-1 infection. Thus, HSV can activate HIV-1 from latency in ACH-2 cells, this activation of HIV is independent of productive HSV replication since the delta ICP4 deletion mutant is replication-incompetent, and this activation is evident as an increase in the steady-state levels of HIV transcripts.

Twice-daily humulin ultralente insulin decreases morning fasting hyperglycemia.

OBJECTIVE: To test whether a two-injection regimen of HUL/R would improve FBG and metabolic control in pediatric IDDM patients with a dawn rise in FBG compared with our standard twice-daily therapy, HL/R. RESEARCH DESIGN AND METHODS: Seventy-seven patients with fasting hyperglycemia (prebreakfast mean FBG greater than or equal to 8.3 mM (150 mg/dl) during the preceding 2 wk) were evaluated with twice-weekly midsleep (0230-0330) FBG for 2 wk. Forty-seven patients (61%) had a mean dawn rise between midsleep and prebreakfast of greater than or equal to 2.8 mM (50 mg/dl). Patients continued on HL/R for an additional 4 wk, after which 31 patients were then randomized into a double-blind 12-wk trial of either HUL/R (n = 14) or HL/R (n = 17) administered before breakfast and the evening meal. Midsleep FBG was obtained twice weekly with weekly insulin adjustment as needed to optimize glycemic control. FBG was monitored and verified with memory glucometers (Glucometer M). HbA1c levels were measured at the time of physician visits at 0, 6, and 12 wk. RESULTS: Prebreakfast FBG was lower in the HUL/R-treated patients (10.6 +/- 0.6 vs. 12.6 +/- 0.6 mM [191 +/- 6.4 vs. 227 +/- 11.2 mg/dl], P less than 0.02). The dawn rise was diminished in the HUL/R patients (0.5 +/- 0.5 vs. 2.6 +/- 0.7 mM [9 +/- 8.3 vs. 46 +/- 11.7 mg/dl], P less than 0.02). FBG at lunch, dinner, bedtime, and midsleep were similar in both groups, and HbA1c did not differ between groups or change significantly in either group during the 12-wk trial. Insulin dose, percentage R, day-night dosage split, and episodes of hypoglycemia (FBG less than 3.3 mM [60 mg/dl]) were similar in both groups. CONCLUSIONS: A 12-wk trial of twice-daily HUL/R improved fasting glycemia in pediatric patients with a dawn rise but did not improve metabolic control as measured by HbA1c.

Diabetes care in schools: benefits and pitfalls of Public Law 94-142.

The implementation of the Education for All Handicapped Children Act of 1975 (Pub L No. 94-142) has brought significant changes in educational services for health-impaired children. Health-related services are one of many important services available to children under Pub L No. 94-142. For some children with IDDM, specific diabetes-related care is essential for continued progress in school. However, barriers exist that impede access to related health support services, including lack of agreement about the applicability for Pub L No. 94-142 to children with IDDM, lack of consensus as to who should provide services, and concern about liability of school personnel. This paper describes those barriers and suggests approaches to overcome them. One such approach is an Indiana State legislative amendment that provides schools with immunity from civil liability for diabetes-related care.

Pediatrics residents' attitudes about insulin-dependent diabetes mellitus and children with diabetes.

Nationwide, pediatricians provide a substantial portion of the health care of children with diabetes. Their beliefs and attitudes about diabetes and children with the illness have an important influence on their treatment decisions. The attitudes and beliefs of a 1988 sample of pediatrics residents were compared with data from a 1987 national survey of practicing pediatricians' beliefs and attitudes about children with insulin-dependent diabetes mellitus and about the disease itself. Pediatrics residents in their second and third years of training were considerably more negative about diabetes and diabetic children than were either the members of the national sample of practicing pediatricians or the residents' first-year colleagues.

Management of diabetes in pediatric resident continuity clinics.

General pediatricians provide comprehensive care for many children with insulin-dependent diabetes mellitus. To assess and improve our ambulatory training program, we first evaluated diabetes-specific care behaviors by residents in their continuity clinics and then introduced a structured visit encounter form. Based on established guidelines provided to the residents, a chart audit indicated appropriate measurement of glycosylated hemoglobin 40% of the time, cholesterol 90% of the time, urine protein 50% of the time, and thyroxine 66.7% of the time. Height was plotted 23% of the time, blood pressure was noted 66% of the time, and ophthalmologic referrals were documented 60% of the time. Requests for assistance from nonphysician members of a multidisciplinary diabetes team were minimal. After introduction of the structured visit encounter form, care behaviors did not improve. New training approaches to prepare general pediatric residents to provide excellent diabetes care are needed.

Pediatric endocrinologic recommendations, pediatric practice, and current pediatric training regarding care of children with diabetes.

Many pediatric diabetes patients are cared for by community-based pediatricians. Training for pediatricians in optimal diabetes care should be based on both the recommendations of pediatric endocrinologists regarding optimal care and the practices of general pediatricians. Pediatric endocrinologists, general pediatricians, and pediatric residency coordinators were surveyed to assess the consonance of current recommendations, practices, and training in pediatric diabetes care. Not surprisingly, pediatric endocrinologists recommended more subspecialty care than pediatricians reported practicing. A major difference between endocrinologists and pediatricians emerged in the area of psychosocial support. A total of 85% of endocrinologists answered that there should be a mental health diabetes team member, but only 37% of pediatricians reported often or sometimes working with one to develop care plans. Pediatricians who provide complete diabetes care for most of their patients measure frequent glycosylated hemoglobin levels, obtain yearly lipid measurements marginally less often, and use urinary glucose measurements more often than recommended by pediatric endocrinologists. According to the descriptions of most pediatric residency training programs, multidisciplinary teams include a pediatrician, an endocrinologist, and a dietician. However, 25% do not include a social worker or nurse and 70% do not include a psychologist. Although most training programs operate on the assumption that their trainees will ultimately share responsibility with a subspecialist for diabetes care, in 26% of programs residents saw no diabetics in their continuity clinics. Most residents do not participate in providing diabetes education.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of computer-assisted self-monitoring of blood glucose system.

The Glucometer M Diabetes Management System includes a glucose-reflectance meter with memory that can interface with a microcomputer for data manipulation and analysis. We evaluated the system in a short-term randomized control trial to determine its impact on metabolic control, self-monitoring of blood glucose (SMBG) testing behaviors, regimen self-adjustment, understanding of insulin-dependent diabetes mellitus (IDDM) treatment, attitudes about SMBG, and perceived quality of patient-physician interaction. Twenty-nine adolescent subjects (experimental) with IDDM were randomly assigned the Glucometer M system for 4 mo. Twenty-eight control subjects used meters without memory. All subjects returned twice to the clinic at 2-mo intervals during the study. At clinic visits, both groups reviewed their SMBG data with their physician. Reviews on experimental subjects were conducted with computer-generated data formats. Control subject reviews used traditional logbooks. Both groups showed a significant drop in glycosylated hemoglobin during the study period (P less than .001); however, there were no between-group differences. There were also no differences in SMBG testing behavior or self-reported regimen self-adjustment between groups or within groups compared with baseline. Compared with control subjects, experimental subjects indicated a significant increase in self-reported understanding of IDDM treatment (P = .002), perceived importance of testing (P = .006), and the quality of interaction with their physician (P less than .001). These data suggest that use of computer-assisted SMBG systems in the outpatient setting does not improve metabolic control over 4 mo. It may, however, contribute to improving communication between the patient and health-care providers.

Longitudinal relationship of asymptomatic hypoglycemia to cognitive function in IDDM.

Early-onset insulin-dependent diabetes mellitus (IDDM) is linked to subsequent learning deficits. To investigate the relationship of learning deficits to metabolic control, 23 children with IDDM (age at testing 71 +/- 21 mo, age at diagnosis 35 +/- 15 mo) diagnosed before 5 yr of age were followed for periods of 6-78 mo. Mean glycosylated hemoglobin (HbA1), episodes of severe hypoglycemia, and frequency of self-monitoring blood glucose (SMBG) measurements less than 2.8 mM (50 mg/dl, asymptomatic hypoglycemia) were recorded every 3 mo. Six subjects entered the study 12.3 +/- 6.7 mo after diagnosis, and only severe hypoglycemia was present before entry. For the remaining 17 subjects, HbA1 and severe and asymptomatic hypoglycemia were present from the time of diagnosis of diabetes. Mean HbA1 level was 10.1 +/- 1.0%, and mean severe hypoglycemic episodes per patient was 2.9, but the frequency was highly skewed; one patient had 37 episodes, and 14 had none. The mean percentage of SMBG readings less than 2.8 mM was 2.4 +/- 2.1. On the revised Stanford-Binet Intelligence Scale there was no correlation between any subscale and severe hypoglycemia. However, the relative frequency of asymptomatic hypoglycemia correlated with scores on the abstract/visual reasoning scale (r = -.39, P = .037). This relationship was primarily accounted for by the relationship of asymptomatic hypoglycemia to performance on the copying subscale (r = -.42, P = .022). Children with frequent asymptomatic hypoglycemic episodes had lower mean copying scores and abstract reasoning scores than those with infrequent episodes.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving compliance with exercise in adolescents with insulin-dependent diabetes mellitus: results of a self-motivated home exercise program.

In this project we investigated the impact of a 12-week at-home aerobic fitness program on aerobic capacity and metabolic control of ten adolescents (four girls and six boys 12 to 14 years of age) with insulin-dependent diabetes mellitus. The adolescents had no prior experience with exercise training. The 45-minute program, designed by a physical therapist, consisted of a stretching, calisthenics, and "cool-down" routine set to popular music. It was taught to the youngsters in group sessions. Each adolescent was given audio- and videocassettes of the routine for home use that emphasized self-motivation in maintaining training. The youngsters were asked to exercise three times per week and were also taught how to adjust their insulin and diet for exercise. Aerobic fitness was determined by maximal oxygen uptake following a vigorous, continuous progressive cycling test; metabolic control was measured by glycosylated hemoglobin values. All of the adolescents reported greater than 85% completion of the program. The youngsters displayed a correspondingly significant increase in aerobic fitness as measured by maximal oxygen uptake: 40.39 +/- 8.87 v 44.86 +/- 12.89 mL/kg/min. Glycosylated hemoglobin levels (mean +/- SD) for the entire group were significantly reduced after the program (11.41 +/- 4.47% v 10.01 +/- 3.21%). Results of this study indicate that nonathletic adolescents with insulin-dependent diabetes mellitus can engage in self-motivated exercise training at home. If properly designed, such programs can improve aerobic fitness and may contribute to improvement in diabetes control.