A trial of testosterone therapy for HIV-associated weight loss.

OBJECTIVE: Weight loss in HIV-infected patients is extremely common and is associated with increased morbidity and mortality. Decreased testosterone concentrations occur commonly in patients with HIV disease and are associated with weight loss. This study assessed the effect of testosterone therapy on HIV associated weight loss in patients with AIDS. METHODS: Forty HIV-seropositive patients with CD4+ counts of < 2 x 10(5)/l and weight loss greater than 5% of usual body weight were randomized in a double-blind manner to receive 200 mg of testosterone cypionate of placebo intramuscularly every 2 weeks for 3 months. Patients were then crossed to receive the alternate treatment for the next 3 months. Outcome variables included weight, skin fold measurement, a quality-of-life questionnaire, Karnofsky score, T-cell subset analysis, complete blood count, routine blood chemistry measurements and free testosterone concentration. RESULTS: Thirty-nine patients entered the study. Of these, 35 completed the first 3-month period (18 on placebo, 17 on testosterone) and 23 completed the whole 6 month trial. Analysis of these 23 patients did not show any significant differences between testosterone and placebo treatment. Analysis of the first 3 months only for the 35 patients who completed it did not show any significant difference between the effects of testosterone and placebo treatment on weight gain. Patients treated with testosterone reported improved overall well-being (P = 0.03) and a trend towards increased muscle strength (P = 0.08). There was no difference between the two groups in terms of side-effects or other effects on hematopoetic, liver, renal, or immune function. CONCLUSIONS: Treatment with testosterone cypionate compared with placebo did not result in significant weight gain. Testosterone supplementation did appear to produce an improved overall sense of well-being and possibly some increases in muscle strength. This randomized, double-blinded study does not confirm the results of other recent studies which show potential benefits of testosterone and its analogs when used as a treatment for weight loss in HIV-positive patients.

Beta-carotene in HIV infection: an extended evaluation.

OBJECTIVE: Several small short-term intervention studies have suggested that beta-carotene supplementation in HIV-infected patients can increase the number of various immune cells including CD4 cells. This prospective double-blinded study was designed to investigate whether beta-carotene supplementation would result in this immuno-enhancement in a larger number of patients over a longer time period. METHODS: HIV-positive patients were randomly assigned to receive either 60 mg beta-carotene orally three times daily or a matched placebo. In addition, all patients received a multivitamin supplement. Patients were evaluated at baseline, 1 month, and 3 months for T-cell quantitative subsets, natural killer cells, HIV p24 antigen, beta-carotene levels, complete blood counts and chemistry batteries. Body weights and Karnofsky scores were evaluated at each visit. RESULTS: Seventy-two patients signed informed consent forms and entered the study. Except for serum beta-carotene concentration, there were no statistically significant differences (P < 0.05) between the treatment (60 mg beta-carotene three times daily and multivitamins) and placebo (placebo and multivitamins) groups at baseline or after either 1 or 3 months of treatment. DISCUSSION: Earlier studies suggesting that beta-carotene supplementation increased levels of immune cells in HIV-infected patients were not replicated in this study. The addition of a multivitamin supplement to both arms of this study may have masked any difference between the two groups. However, on the basis of the results of this study, we would not recommend supplementation with high doses of beta-carotene for HIV-infected patients.

A prolonged use of granulocyte colony stimulating factor in Felty's syndrome.

Current treatment for Felty's syndrome, a triad of rheumatoid arthritis, splenomegaly and neutropenia, is often unsuccessful. Felty's syndrome may be related to decreased production of hematopoietic growth factors. We treated a patient with Felty's syndrome, profound neutropenia and a history of multiple complicated hospitalization for severe infections, with granulocyte colony stimulating factor (GCSF) for 18 months. After initiation of GCSF, the patient's neutrophil count has remained in the normal range for 18 months. After 2 easily treated infections at the start of therapy, she had only one episode of cellulitis occurring after 18 months when her GCSF dose was reduced to every 3rd day. She has been infection-free since then on every other day therapy. GCSF may be a cost effective longterm therapy for selected patients with Felty's syndrome and may reduce both patients' morbidity and overall medical costs.

The HIV wasting syndrome: a review.

The HIV wasting syndrome and other HIV-associated weight loss is a major problem in HIV-infected patients. The available data strongly suggest that wasting is associated with decreased survival. It may also further impair immune function. A variety of etiologies probably contribute to this wasting, including hypermetabolism, alterations in metabolism, lessened oral intake, malabsorption, cytokine effects, and endocrine dysfunction. The relative contributions of each of these etiologies to wasting probably varies considerably from patient to patient. Successful treatment calls for identification of possible etiologies of wasting in the individual patient with AIDS. Further treatment may include treating underlying conditions and controlling such symptoms as diarrhea, nausea, or fever. Nutritional support, including both parenteral and enteral nutrition, has shown some promise of efficacy, and a variety of drugs appears to be helpful. Future treatment to reverse wasting may include the use of several of these agents in combination. Currently, there is much that clinicians can do to evaluate and treat the HIV wasting syndrome, with significant potential benefits to their patients.

Endocrine function in the HIV wasting syndrome.

We compared endocrine function in patients with the HIV wasting syndrome with other HIV-positive patients without wasting to determine associations between endocrine dysfunction and wasting. Sixty-six HIV-seropositive patients were evaluated by thyroid, gonadal, and adrenal function tests. Fourteen of these patients met the clinical definition of wasting. Total and free testosterone levels were significantly lower in patients with wasting compared with patients without wasting with both similar and higher mean CD4 counts. Prolactin levels were significantly higher, and cortisol levels were higher with borderline significance in patients with wasting compared with patients with similar CD4 counts without wasting. These findings suggest that endocrine function in the HIV wasting syndrome differs from that of HIV-infected patients without wasting, which may have implications about the pathogenesis and treatment of the HIV wasting syndrome.

Micronutrient concentrations in the HIV wasting syndrome.

OBJECTIVE: We measured micronutrient values in patients with the HIV wasting syndrome and in other HIV-seropositive patients to determine whether specific micronutrient deficiencies were associated with the wasting syndrome. METHODS: Serum from 47 HIV-seropositive patients was evaluated for concentrations of vitamin A, B6, B12, C, D, E, folate, the mineral zinc, carotene and glutathione. Comparisons were made between groups stratified by CD4 cell count and wasting/non-wasting status. RESULTS: Mean serum levels were significantly lower for vitamin A (P = 0.04), folate (P = 0.04) and carotene (P = 0.06) in patients with the HIV wasting syndrome than in non-wasting patients with comparable CD4 cell counts. Values of vitamins A, B6, C, D, carotene and glutathione were below the normal range in over 10% of HIV-seropositive patients in this study. CONCLUSION: Decreased micronutrient concentrations are common in HIV-infected patients and occur more frequently in patients with the wasting syndrome. Clinicians may wish to evaluate HIV-seropositive patients with wasting for individual micronutrient deficiencies, although they should note that particular deficiencies may be only part of the larger picture of malabsorption and undernutrition.

Internal medicine training in ambulatory gynecology. A house of staff survey.

OBJECTIVES: Practicing internists commonly provide gynecologic care, yet internists receive little formal training in ambulatory gynecology. To evaluate current residency training, we surveyed house staff perceptions of their training in gynecology. METHODS: Data were collected from house staff at five Portland, Ore, internal medicine training programs by questionnaire using a Likert scale about training in 24 gynecologic and five nongynecologic internal medicine problems. Responses were compared by level of training, institution, and gender. RESULTS: Responses were received from 195 (89%) of 221 residents. House staff reported less than adequate training in gynecology, particularly in the areas of family planning and medical complications of pregnancy, while reporting much superior training in the traditional medicine problems. CONCLUSIONS: House staff in internal medicine report little training in the diagnosis and treatment of gynecologic problems. Training in family planning may be particularly deficient. Residency programs must seek effective teaching strategies to address this deficiency.

A checklist for evaluation of HIV-infected patients.

To aid in making care of HIV-infected patients part of your office routine, Dr Coodley presents here a checklist that combines the various clinical aspects of initial management. Covering the steps from the history to plans for follow-up, this article should allay anxiety and promote confidence in your entire staff by explaining the necessary basics in a simple-to-read format.

Beta-carotene in HIV infection.

beta-Carotene has been reported to have an immunostimulatory effect. Recent studies suggest that beta-carotene supplementation can increase CD4 counts in HIV-infected patients. Our double-blind, placebo-controlled clinical trial was designed to test the efficacy of beta-carotene in raising CD4 counts in HIV-infected patients. Twenty-one HIV-seropositive patients were randomized to receive either beta-carotene, 180 mg/day or placebo for 4 weeks, and then crossed over to receive the alternative treatment for the following 4 weeks. beta-Carotene resulted in a statistically significant increase in total WBC count (p = 0.01), % change in CD4 count (p = 0.02), and % change in CD4/CD8 ratios (p = 0.02) compared to placebo. The absolute CD4 count, absolute CD4/CD8 ratio, and total and B-lymphocytes all increased on carotene and fell during placebo, but these differences did not reach statistical significance. No toxicity was observed on either treatment. beta-Carotene appears to have an immunostimulatory effect in HIV-infected patients. Further studies are needed to demonstrate whether beta-carotene has a role as adjunct therapy in treatment of HIV-infected patients.

Internal medicine training in ambulatory gynecology.

OBJECTIVE: To assess internists' perceptions of their training in the management of common problems in ambulatory gynecology and to compare these perceptions with their clinical practice experiences. METHODS: We surveyed 325 internists in the Portland, Oregon, metropolitan area about their residency training and practice experiences in the diagnosis and management of 25 clinical problems in ambulatory gynecology and five nongynecologic problems. RESULTS: Responses were received from 159 internists (48.5%). Overall, the internists reported relatively little residency training in the management of many common gynecologic disorders. Women internists managed gynecologic problems more than did their male counterparts, independent of the number of women patients in their practices. CONCLUSIONS: Internal medicine residency programs need to expand training in ambulatory gynecology to better prepare graduates for clinical practice.