Developing a Spinal CSF Leak Program in a Multihospital Network.

OBJECTIVE: Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare and challenging to diagnose and treat. Patients may present to a variety of physicians, and many patients are often referred to a specialized center with a dedicated spinal CSF leak program and expertise in this condition. To our knowledge, there are no reported publications on how to create such a program. CONCLUSION: In this article, we describe the specific steps we took to develop a spinal CSF leak program, which we have implemented over a multihospital network.

Carotid intimal medial thickness in human immunodeficiency virus-infected women: effects of protease inhibitor use, cardiac risk factors, and the metabolic syndrome.

CONTEXT: Little is known regarding carotid intimal medial thickness (IMT) in HIV-infected women and the risk factors for subclinical atherosclerosis in this population, including antiretroviral therapy and the metabolic syndrome. OBJECTIVE: Our objective was to assess carotid IMT in relationship to HIV status and antiretroviral therapy in HIV-infected women in comparison with healthy age- and body mass index (BMI)-matched control subjects. SETTING AND SUBJECTS: The study took place at an academic medical center and included 97 HIV-infected women compared with 86 age- and BMI-matched healthy control subjects. MAIN OUTCOME MEASURES: We assessed carotid IMT, metabolic syndrome, and risk factors for increased IMT. RESULTS: Carotid IMT was not increased in HIV-infected women [0.62 mm (0.57-0.68); median (IQR)] compared with non-HIV-infected women [0.61 mm (0.55-0.68)] matched for age and BMI (P = 0.07) but was increased significantly among HIV patients receiving a protease inhibitor (PI) [0.65 (0.59-0.71) mm] vs. non-PI-treated patients [0.61 (0.57-0.66) mm] (P < 0.05) and vs. control subjects [0.61 (0.55-0.68) mm] (P < 0.05). The prevalence of metabolic syndrome was significantly increased among the HIV-infected women compared with control subjects and particularly in PI- vs. non-PI-treated HIV patients (45 vs. 19%, P = 0.001). Metabolic syndrome score correlated with IMT among non-HIV patients but not among the HIV group. Individual risk factors most strongly associated with IMT in multivariate regression modeling in the control group were age and waist-to-hip ratio, and among the HIV group age and waist circumference. CONCLUSIONS: These data demonstrate increased carotid IMT in HIV-infected women receiving PI therapy, which may be due to associated metabolic abnormalities related to PI therapy or more direct effects of this medication class on the vasculature. Additional studies of the mechanisms by which PI uses results in subclinical atherosclerosis are needed.

Effects of a supervised home-based aerobic and progressive resistance training regimen in women infected with human immunodeficiency virus: a randomized trial.

BACKGROUND: Women infected with human immunodeficiency virus (HIV) increasingly demonstrate abnormalities in fat distribution and metabolism; however, the effects of a home-based exercise regimen in this group have not been investigated. METHODS: We conducted a 16-week randomized intervention study of a supervised home-based progressive resistance training and aerobic exercise program in 40 HIV-infected women with increased waist-hip ratio and self-reported fat redistribution. Cross-sectional muscle area and muscle attenuation were measured by computed tomography. Cardiorespiratory fitness was determined by calculated maximum oxygen consumption (VO2max) and strength by 1-repetition maximum. RESULTS: Cardiorespiratory fitness (VO2max) was markedly lower at baseline (median [95% confidence interval], 15.4 [8.3-25.2] mL x kg(-1) x min(-1)) than reported values for healthy female subjects (26-35 mL x kg(-1) x min(-1)). Subjects randomized to exercise had significant improvement in mean +/- SEM VO2max (1.5 +/- 0.8 vs -2.5 +/- 1.6 mL x kg(-1) x min(-1); P<.001) and endurance (1.0 +/- 0.3 vs -0.6 +/- 0.3 minute; P<.001). Strength increased at the knee extensors, pectoralis, knee flexors, shoulder abductors, ankle plantar flexors, and elbow flexors (all P<.001). Total muscle area (6 +/- 1 vs 2 +/- 1 cm2; P = .02) and attenuation (2 +/- 1 vs -1 +/- 1 Hounsfield unit; P = .03) increased in the exercise group. No significant difference was seen in lipid levels, blood pressure, or abdominal visceral fat between the groups, but subjects randomized to exercise reported improved energy and appearance. CONCLUSIONS: A 16-week, supervised, home-based exercise regimen improved measures of physical fitness in HIV-infected women. The effects on strength were most significant, but improvements in cardiorespiratory fitness, endurance, and body composition were also seen.

Longitudinal analysis of bone density in human immunodeficiency virus-infected women.

OBJECTIVES: The objective of the study was to investigate change in bone mineral density (BMD) over time in HIV-infected women in comparison with healthy control subjects similar in age, race, and body mass index (BMI). DESIGN: This was a prospective cohort study. METHODS: BMD was measured by dual-energy x-ray absorptiometry in 100 HIV-infected females and 100 healthy controls similar in age (41 +/- 1 vs. 41 +/- 1 yr, P = 0.57), BMI (26.1 +/- 0.5 vs. 27.2 +/- 0.4 kg/m(2), P = 0.12), and race (60 vs. 65% non-Caucasian, P = 0.47, HIV-infected vs. controls). Changes in BMD were determined every 6 months over 24 months. RESULTS: At baseline, HIV-infected subjects had lower BMD at the lumbar spine (1.01 +/- 0.01 vs. 1.07 +/- 0.01 g/cm(2), P = 0.001), hip (0.94 +/- 0.01 vs. 0.98 +/- 0.01 g/cm(2), P = 0.02), and femoral neck (0.83 +/- 0.01 vs. 0.87 +/- 0.01 g/cm(2), P = 0.02). Historical low weight, duration of nucleoside reverse transcriptase inhibitor use, and FSH were significantly associated with lumbar BMD, whereas duration of HIV, BMI, historical low weight, smoking pack-years, N-telopeptide of type 1 collagen, viral load, 25 hydroxyvitamin D, and osteocalcin were associated with hip BMD at baseline. In mixed model longitudinal analyses, BMD remained lower in HIV-infected subjects than in controls over 24 months of follow-up (P = 0.001 for the spine, P = 0.04 for the hip, and P = 0.02 for the femoral neck). These differences remained significant controlling for age, race, BMI, and menstrual function. In contrast, rates of change for the spine (P = 0.79), hip (P = 0.44), and femoral neck (P = 0.34) were not different between the HIV and control groups over 2 yr. In the HIV group, longitudinal changes in BMD were not associated with current protease inhibitor, nucleoside reverse transcriptase inhibitor, or non-nucleoside reverse transcriptase inhibitor use but were associated with CD4 count, weight, FSH, N-telopeptide of type 1 collagen, and baseline BMD. CONCLUSIONS: BMD is reduced at the spine, hip, and femoral neck among women with HIV in relationship to low weight, duration of HIV, smoking, and increased bone turnover. Over 2 yr of follow-up, BMD remained stable but lower in HIV-infected women, compared with control subjects.

Effects of obesity, body composition, and adiponectin on carotid intima-media thickness in healthy women.

CONTEXT: Increased common carotid intima-media thickness (IMT) is predictive of coronary artery disease and stroke. OBJECTIVE: In this study, we investigated common carotid IMT by obesity category in a cohort of healthy women without previously known cardiovascular disease. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES: One hundred healthy women (aged 24-59 yr) from the general community enrolled in an observational study conducted at an academic medical center participated in the study. B-mode ultrasound imaging of the common carotid arteries was used to measure common carotid IMT in 99 subjects. Fat distribution was determined by computed tomography. Hormonal and inflammatory parameters related to cardiovascular disease and obesity were measured. RESULTS: IMT was higher in obese [body mass index (BMI) >or= 30 kg/m(2)], compared with overweight women (BMI >or= 25 and < 30 kg/m(2)) [0.69 mm, interquartile range (IQR) 0.60-0.75 mm] vs. 0.62 mm [IQR 0.56-0.68 mm), P = 0.044] and in comparison with lean women (BMI < 25 kg/m(2)) [0.69 mm (IQR 0.60-0.75 mm) vs. 0.59 mm (IQR 0.54-0.67 mm), P = 0.016]. In multivariate modeling, age (beta = 0.0050 mm change in IMT per year of age, P = 0.003), smoking (beta = 0.0044 mm change in IMT per pack-year, P = 0.046), and sc abdominal adiposity (beta = 0.00026 mm change in IMT per square centimeter, P = 0.010) were positively associated with IMT, whereas adiponectin (beta = -0.0042 mm change in IMT per milligram per liter, P = 0.045) was negatively associated with IMT. Visceral adiposity (beta = 0.00048 mm change in IMT per square centimeter, P = 0.092) was not significantly associated with IMT after adjusting for age, race, smoking, sc abdominal adiposity, and adiponectin. CONCLUSIONS: Obesity is associated with increased common carotid IMT in young and middle-aged women. Adiponectin and sc abdominal adiposity are associated with carotid IMT in this population.