Body shape and composition in HIV-infected women: an urban cohort.

OBJECTIVES: Alterations in body shape and composition are associated with HIV/AIDS. Wasting remains prevalent; increasingly, lipodystrophy is reported. Obesity is also epidemic in the USA. In this study, we sought to characterize the body changes reported by women attending a US urban clinic, and to evaluate contributing factors using inexpensive methods that are readily available in clinical practice. METHODS: In an urban Maryland clinic, a cross-section of HIV-infected women were evaluated by self report, anthropomorphic measurements, bioelectric impedance analysis (BIA) and chart review; they were categorized as no change, lipodystrophy, weight loss/wasting or weight gain/obesity. RESULTS: One hundred and sixty-one women were evaluated: 144 (89%) were African-American; 100 (62%) had used intravenous drugs and 40 (25%) were actively injecting drugs, while 39 (24%) smoked crack. Ninety-five (59%) were on highly active antiretroviral therapy (HAART) for a median period of 11.7 months [interquartile range (IQR)=4.5-24.2]. Since starting current HAART or in the previous year, 12 (7.4%) reported lipodystrophy changes, 85 (52.8%) weight gain, 27 (16.8%) overall weight loss, and 37 (23.0%) no change. Lipodystrophy was associated with higher CD4 percentage (P=0.03), lower frequency of crack use (P=0.04) and higher educational level (P=0.03). Weight loss correlated with longer duration of infection (P=0.01), select BIA results and increased rate of crack use (P=0.005). Weight gain was associated with higher fat mass (P=0.005), higher peak viral load (P=0.02), and lower rate of intravenous drug use (P=0.03). CONCLUSIONS: Self-reported changes in body shape were common. Obesity and complications of illicit drug use were more prevalent than lipodystrophy in this inner-city population of HIV-positive women.

Introduction of evidence-based medicine into an ambulatory clinical clerkship.

Evidence-based medicine (EBM) has emerged has a critical clinical competency in the 21st century. Medical schools usually introduce students to critical appraisal in the preclinical years, but there have been few evaluated interventions in teaching EBM in the clinical years. We describe a strategy to encourage students to practice EBM during a required ambulatory medicine clerkship. During this clerkship, our students are required to submit an EBM report, which is prompted by an individual case, and structured with a 5-step approach. One small-group session is devoted to modeling this approach with a case of chest pain. Using a checklist to grade 216 consecutive EBM reports, we found that students were quite successful with the exercise, achieving on average 89.6% of possible checklist points. Students who followed the structure of the exercise closely were more likely to extend their discussions beyond that required and to suggest potential further areas of investigation or design.

Gonadal hormone levels in injection drug users.

Levels of serum sex hormones, particularly testosterone, luteinizing hormone, and follicle-stimulating hormone, have been shown to change in various disease states. Hypogonadism has been well-documented in patients with HIV infection. As HIV infection and injection drug use are closely linked, we examined whether injection drug users (IDU's) exhibit hormone abnormalities. We evaluated men participating in the ALIVE study (AIDS Linked to Intravenous Experiences), a large cohort study conducted in Baltimore, MD. We found that 20% of 40 IDU subjects (20 HIV+, 20 HIV-) with a mean age 41.5+/-0.9, had low serum total testosterone concentration. We were unable to detect a direct correlation between drug use and hormone levels. Further study is needed on the hormonal milieu of the IDU patient.

The use of a transscrotal testosterone delivery system in the treatment of patients with weight loss related to human immunodeficiency virus infection.

PURPOSE: Weight loss is a strong predictor of morbidity and mortality in human immunodeficiency virus (HIV)-infected patients. Men with acquired immunodeficiency syndrome (AIDS) lose body cell mass. Hypogonadism is also common. This study tested the efficacy of a testosterone transscrotal patch (6 mg/day) in improving body cell mass and treating hypogonadism in these patients. SUBJECTS AND METHODS: This multicenter, randomized, double-blinded, placebo-controlled trial was conducted from August 1995 to October 1996 in 133 men, 18 years of age and older, who had AIDS, 5% to 20% weight loss, and either a low morning serum total testosterone level (<400 ng/dL) or a low free testosterone level (<16 pg/mL). Outcomes included weight, body cell mass as measured using bioelectrical impedance analysis, quality of life, and morning measurements of serum testosterone and dihydrotestosterone levels, lymphocyte subsets, and HIV quantification. RESULTS: There were no significant differences in baseline weight, CD4 cell counts, or HIV serum viral quantification between treatment arms. Morning total and free testosterone levels increased in those treated with testosterone, but not with placebo. Following 12 weeks of treatment there were no differences (testosterone-placebo) in mean weight change (-0.3 kg [95% confidence interval (CI): -1.4 to 0.8]) or body cell mass (-0.2 kg [95% CI: -1.0 to 0.6]) in the two groups. There were also no changes in quality of life in either group. CONCLUSION: Hypogonadal men with AIDS and weight loss can achieve adequate morning serum sex hormone levels using a transscrotal testosterone patch. However, this system of replacement does not improve weight, body cell mass, or quality of life.

Treatment of HIV related weight loss.

AIDS: Weight loss is a significant problem with HIV and AIDS patients. The definition of wasting syndrome is provided. Men and women do not lose weight and body mass in the same way; the differences between the genders are reviewed. Treatment includes insuring an adequate oral intake of calories, correcting malabsorption problems, and using anabolic steroids to rebuild body mass. Resistance exercises may also be helpful.^ieng

Testosterone replacement treatment options for HIV-infected men.

Hypogonadism is well documented in HIV-infected men, particularly as they progress to AIDS and in those with symptoms of wasting. Testosterone deficiency can be diagnosed with simple laboratory tests, and various treatment options exist. The benefits of androgen replacement are well documented from a large body of literature and experience with hypogonadal men without HIV infection. Hypogonadal men who are given testosterone replacement have improved sexual thoughts and functioning, more energy, and improved mood. Generally, quality of life improves with such therapy. Testosterone replacement tends to maintain or improve lean body mass. The benefit, dose, and timing of testosterone replacement treatment for men with HIV infection, however, are less clear and require further study. Appropriate history and a high degree of clinical suspicion, coupled with relatively simple laboratory measurements, can confirm the diagnosis of hypogonadism in men with HIV. Various options for testosterone replacement, including injections of testosterone esters and the use of transcutaneous patches, are discussed, as are the uses of pharmacologic doses of testosterone, primarily for its potential anabolic effect.

Promotion criteria for clinician-educators in the United States and Canada. A survey of promotion committee chairpersons.

CONTEXT: Clinician-educators have concerns about their ability to be promoted and the criteria used by medical school promotion committees. OBJECTIVE: To discover the criteria and methods that medical school promotion committees use to make decisions about the promotion of clinician-educators. METHODS: In June 1996 we mailed a questionnaire to chairpersons of all medical school promotion committees in the United States and Canada. RESULTS: Of 142 schools surveyed, 115 (81%) responded; 45% of respondents had a clinician-educator promotion track. On a scale from 1 (minimally important) to 7 (extremely important), the mean importance ratings of aspects of clinician-educators' performance were the following: teaching skills (6.3), clinical skills (5.8), mentoring (5.7), academic administration (5.3), developing educational programs (5.3), nonresearch scholarship (5.1), clinical research (4.8), service coordination (4.7), and education research (4.5). Methods to evaluate each aspect of performance were rated by respondents for importance and frequency of use. The 4 most important methods for evaluating teaching were awards, peer evaluation, learner evaluation, and teaching portfolio; 70% or more of schools used these frequently or always. The 4 most important methods of evaluating clinical skills were peer evaluation, awards, trainee evaluation, and objective measures, which were used frequently or always by 78%, 65%, 58%, and 29% of schools, respectively. Clinician-educators were expected to have fewer peer-reviewed publications to be promoted than investigators (5.7 vs 10.6, P<.001). Schools with separate clinician-educator tracks differed little in survey responses from schools without such tracks. CONCLUSION: Most, but not all, promotion committees now assign high importance to the special contributions of clinician-educators and use a variety of methods to assess these, regardless of whether they have a separate clinician-educator promotion track.