Effect of angiotensin-converting enzyme inhibition in HIV-associated nephropathy.

Angiotensin-converting enzyme inhibition (ACEI) delays progression of diabetic and nondiabetic renal disease. This study examined the effect of fosinopril, 10 mg by mouth daily, in HIV-associated nephropathy (HIV-AN). Twenty patients with HIV-AN were studied. Of 11 patients with non-nephrotic-range proteinuria, 7 received treatment and 4 did not. Average baseline creatinine (mg/dl) for treated and nontreated patients was 1.3 +/- 0.24 and 1.0 +/- 0.25, respectively (P = 0.07). At 24 wk, creatinine of treated and nontreated patients was 1.5 +/- 0.34 and 4.9 +/- 2.4 (P = 0.006). Average baseline 24-h urine protein excretion (g/d) for treated and nontreated patients was 1.6 +/- 0.68 and 0.78 +/- 0.39, respectively (P = 0.02). At 24 wk, 24-h protein excretion of treated and non-treated patients was 1.25 +/- 0.86 and 8.5 +/- 1.4 (P = 0.006). Of nine patients with nephrotic-range proteinuria, five were treated and four were not. Average baseline creatinine for treated and nontreated patients was 1.7 +/- 0.46 and 1.9 +/- 0.42, respectively (P = 0.4). At 12 wk, creatinine for treated and nontreated patients was 2.0 +/- 1.0 and 9.2 +/- 2.0 (P = 0.02). The baseline 24-h protein excretion for treated and nontreated patients was 5.4 +/- 1.6 and 5.2 +/- 0.97 (P = 0.9). At 12 wk, 24-h protein excretion for treated and nontreated was 2.8 +/- 1.0 and 10.5 +/- 3.5 (P = 0.008). These preliminary data suggest that treatment with ACEI may stabilize serum creatinine and 24-h protein excretion for up to 24 wk in patients with non-nephrotic-range proteinuria and for up to 12 wk in patients with nephrotic-range proteinuria when initial serum creatinine is < or = 2.0 mg/dl. Furthermore, the renin-angiotensin system may play a role in HIV-AN, and early treatment with ACEI may be beneficial in HIV-AN.

Accuracy of IgM immunoblotting to confirm the clinical diagnosis of early Lyme disease.

BACKGROUND: A 2-test approach for the serologic diagnosis of Lyme disease has recently been proposed. A positive or equivocal result on a first-stage test (eg, an enzyme immunoassay) is followed by a Western immunoblot test. For a sample to be considered seropositive for Lyme disease, the immunoblot result must be positive. OBJECTIVES: To assess the accuracy of IgM immunoblotting for detection of early Lyme disease and to establish interpretative criteria for a commercially available immunoblot assay. METHODS: Serum samples from 44 patients with erythema migrans were tested by an IgM immunoblot assay. All patients were culture-positive for Borrelia burgdorferi. Serum samples from 2 different control groups were also tested. Interpretative criteria were developed using receiver operating characteristic curves. RESULTS: The presence of any 2 IgM bands was found to be the optimal criterion for a positive test result, and in patients with illness of less than 7 days' duration, this was significantly more sensitive than the criterion of any 2 of the 3 specific bands defined by the Centers for Disease Control and Prevention/Association of State and Territorial Public Health Laboratory Directors Lyme Disease Workgroup (P < .05). Specificity of the criterion of any 2 bands was 100% for 1 group of controls but only 96% for the more clinically relevant control group; this small difference had a large impact on the positive predictive value in populations at low risk for Lyme disease. CONCLUSIONS: Using a commercially available immunoblot test kit, the presence of any 2 IgM bands is proposed as a positive result. The predictive value of a positive IgM immunoblot result, however, is poor in patients with minimal clinical evidence for Lyme disease.

Effect of garlic on total serum cholesterol. A meta-analysis.

OBJECTIVE: To assess the size and consistency of garlic's effect on total serum cholesterol in persons with cholesterol levels greater than 5.17 mmol/L (200 mg/dL). DATA SOURCES: Clinical trials were identified by a computerized literature search of MEDLINE and by an assessment of the bibliographies of published studies and reviews. STUDY SELECTION: Trials were selected if they were randomized and placebo-controlled and if at least 75% of their patients had cholesterol levels greater than 5.17 mmol/L (200 mg/dL). Studies were excluded if they did not provide enough data to compute effect size. Five of 28 studies were selected for review. DATA EXTRACTION: Details of study design, patient characteristics, interventions, duration of therapy, and cholesterol measurements were extracted by one author and were verified by another. DATA SYNTHESIS: Study quality was evaluated by multiple reviewers using a closed-ended questionnaire. Patients treated with garlic consistently showed a greater decrease in total cholesterol levels compared with those receiving placebo. Meta-analysis of homogeneous trials estimated a net cholesterol decrease attributable to garlic of 0.59 mmol/L (95% CI, 0.44 to 0.74) (23 mg/dL [CI, 17 to 29]) (P < 0.001). CONCLUSIONS: Meta-analysis of the controlled trials of garlic to reduce hypercholesterolemia showed a significant reduction in total cholesterol levels. The best available evidence suggests that garlic, in an amount approximating one half to one clove per day, decreased total serum cholesterol levels by about 9% in the groups of patients studied.

Improving the autopsy rate at a university hospital.

PURPOSE: Although the autopsy is widely recognized as an invaluable tool for medical education, as well as the gold standard by which the accuracy of diagnoses are measured, there has been a steady decline in the autopsy rate over the last 20 years. At Westchester County Medical Center, a university hospital of New York Medical College, we observed an alarming drop in our autopsy rate. We realized that the methods used to obtain consent from the family of the deceased were haphazard and often left to the junior houseofficer available. We hypothesized that we could increase the autopsy rate by explicitly involving senior housestaff in the task of obtaining autopsy consent after giving them formal instruction in the technique of asking for consent and by having them record information regarding their encounters with families. PATIENTS AND METHODS: Data concerning the frequency of autopsies at Westchester County Medical Center were collected for a 3-month period in 1990. A corresponding period in 1991 was designated the study period during which our intervention was initiated. All medical examiner's cases were excluded for both periods since autopsy consent for these patients is not at the discretion of the family. At the start of the study period and each month thereafter, formal instruction regarding obtaining permission for autopsy was given to all senior residents assigned to direct patient care duty. The senior resident was required to complete a data form regarding autopsy request on each patient who died. RESULTS: Nine autopsies among 89 deaths (10%) were obtained during the study period in 1990, compared with 31 autopsies among 116 deaths (27%) in 1991 (p less than 0.01). In 1991, autopsies were more likely to be obtained when death was unexpected (p less than 0.05). CONCLUSION: The institution of a formal program to educate and involve the senior resident staff in obtaining autopsy consent can significantly improve the autopsy rate at a university hospital.

Incidence and prevalence of Lyme disease in a suburban Westchester County community.

This study was designed to determine the incidence and prevalence of Lyme disease in a section of Chappaqua, NY, a residential community in which Lyme disease is epidemic, and to identify risk factors for this disease. On the basis of clinical history and baseline serologic testing, the overall prevalence of Lyme disease for 114 persons entering the study was 8.8%. The incidence during the 5-month study period of May through September 1989 was 2.6%; all three incident cases had erythema migrans (EM). Hours outdoors per week in play or exercise correlated with the occurrence of Lyme disease.

Effect of New York State's do-not-resuscitate legislation on in-hospital cardiopulmonary resuscitation practice.

PURPOSE: On April 1, 1988, New York State enacted legislation governing the withholding of cardiopulmonary resuscitation (CPR). Suggestions that the mandated protocol for withholding CPR is too cumbersome and will result in an increase in CPR attempts led us to study the effect of the new law on in-hospital resuscitation practice. PATIENTS AND METHODS: We retrospectively reviewed the charts of 245 adult in-patients at a county teaching hospital who died during three-month periods before and after the law took effect. RESULTS: There was a statistically nonsignificant decline in the frequency of CPR attempts at the time of death, from 59 (50%) of 119 patients in 1987 to 57 (45%) of 126 patients in 1988. Use of explicit written "do-not-resuscitate" (DNR) orders increased significantly from 13 (22%) of 60 patients who died without CPR in 1987 to 64 (93%) of 69 patients in 1988. Patient and family involvement in decisions to withhold CPR was common before the law and did not change significantly. CONCLUSION: Although changing the way DNR decisions are documented, the legislation resulted in no significant change either in the frequency of CPR or in the degree to which patients are involved in these decisions.

Predictive value of a screening test for antibodies to HTLV-III.

A test for the detection of antibodies to HTLV-III is available and will be widely used to screen donated blood to prevent transfusion-associated acquired immunodeficiency syndrome (AIDS). Based upon the sensitivity and specificity, the authors calculated the expected predictive values for different groups of asymptomatic individuals using Bayes' theorem. The prevalence of HTLV-III infection has great impact upon the positive and negative predictive values of the test. For a member of the general population there is a less than 3% chance that a positive test represents a true positive. High-risk patients, such as hemophiliacs, with a positive test will have a greater than 95% chance of actually having antibodies to HTLV-III, but the negative predictive value of the test in this group is less than ideal. The authors recommend that all positive tests for HTLV-III be confirmed by more specific methods when obtained in low-risk people. Members of high-risk groups for AIDS should continue to refrain from donating blood, despite the availability of the screening test.

Persistence of multiply antibiotic-resistant Campylobacter jejuni in a patient with the acquired immune deficiency syndrome.

Chronic diarrhea due to Campylobacter jejuni has been described in patients with hypogammaglobulinemia. A patient with the acquired immune deficiency syndrome (AIDS) and normal total serum immunoglobulins had persistent diarrhea and C. jejuni on stool culture for seven and a half months despite repeated antibiotic therapy. Antibiotic sensitivity studies revealed the C. jejuni to be multiply antibiotic-resistant. Evaluation of the mechanism of resistance showed the organism harbored a conjugative plasmid capable of transferring resistance to tetracycline, but not to other antibiotics. It is concluded that C. jejuni infection may rarely result in chronic diarrhea in patients with AIDS. The combination of an immune deficiency state including abnormal B cell function previously described in AIDS and multiple antibiotic resistance may have contributed to the persistence of the organism in this case.

Late appearance of pneumothorax after subclavian venipuncture.

Pneumothorax is a well-recognized complication of subclavian vein catheterization. Chest radiography is advised soon after the procedure. Implied here is that when pneumothorax occurs, it will do so shortly after attempted subclavian venipuncture. Two cases of late pneumothorax are reported, one of which became clinically apparent four days after the procedure. If undetected, this may present a hazard in preoperative patients.