Immunonutrition in the surgical patient.

Both malnutrition and the physical injury related to trauma and surgery increase the expression of T-helper 2 (Th2) lymphocytes which cause impaired cell mediated immunity. Activation of the hypothalamic-pituitary-adrenal axis and sympathoadrenal system with the release of cortisol and catecholamines drive the development of Th2 cells. Th2 cytokines result in the accumulation of arginase-1 expressing myeloid-derived suppressor cells in lymphoid tissue. The myeloid-derived suppressor cells cause an arginine deficient state resulting in impaired lymphocyte function. Prostaglandin-E2 released following trauma plays a synergetic role with cortisol and catecholamines in driving these pathways. There is now increasing evidence that immunomodulating enteral formulas supplemented with arginine and omega-3 fatty acids can reverse many of the immune mediated changes and decrease the number of adverse outcomes after major surgery and trauma. These immunomodulating enteral formulas should be strongly considered in surgical patients undergoing major surgery and following severe trauma.

Field test results of an automated exposure assessment tool, the local positioning system (LPS).

A user-friendly environmental monitoring system that collects real time data has been developed. Flash card memory logs exposure data from multiple sensors along with corresponding times and positions. Optional use of telemetry repeaters and a reference station allows central monitoring of data to assess exposure and to initiate intervention when safe levels are exceeded. A software analysis package allows researchers to identify exposure hot spots and direct control efforts, with the ultimate goal being to reduce injury and disease. Preliminary field test results document position accuracy and system performance in harsh environments.

Mechanism of action of thiazolidinediones.

Type 2 diabetes is associated with multiple metabolic abnormalities including insulin resistance and the procoagulant state. Thiazolidenediones are an emerging class of insulin sensitizers which have the potential to mitigate many of the complications of diabetes. Mechanisms of action of the thiazolidenediones are discussed together with their possible pitfalls. Presently, evidence to clearly define the role of thiazolidenedionesfor the treatment of type 2 diabetes is lacking.

Toward a new understanding of Whipple's disease.

Since the first successful antibiotic treatment of Whipple's disease in 1952, many breakthroughs have occurred in the diagnosis and treatment of this disease that was once thought fatal. This article provides a historic overview and highlights recent encouraging discoveries regarding this underdiagnosed disease, including the use of polymerase chain reaction techniques and the recent cultivation of the Tropheryma whippelii bacterium.

Evidence-based therapy for type 2 diabetes. The best and worst of times.

Type 2 diabetes, which is increasing in prevalence, is a multifaceted disease that presents a challenge to the primary care physician. In this article, Drs Flemmer and Vinik review the significant findings of several important clinical trials and present a method of comprehensive staged management to improve the quality of patient care.

Deep venous thrombosis: prediction by D-dimer?

The utility of D-dimer as an inexpensive, noninvasive method of diagnosing deep venous thrombosis (DVT) is debated. We sought to determine whether a qualitative D-dimer assay would have a high correlation with DVT in 65 hospitalized patients who were randomly referred for diagnosis of DVT by venous duplex and duplex Doppler ultrasonography. Patients were excluded from the study if they had any inflammatory, infectious, or malignant condition associated with elevation of D-dimer. The mean level of D-dimer in patients with DVT (16 of 65 patients) was 5,141 ng/mL, compared with 3,024 ng/mL in those without DVT, but there was considerable overlap between the two groups. No patients with a D-dimer level < 2,000 ng/mL had DVT. We conclude that the qualitative D-dimer assay is an excellent exclusionary test for DVT at levels less than 2,000 ng/mL. Limitations of the D-dimer assay and cost-effective issues are discussed.

Attitudes and observations about nonverbal communication in the psychotherapeutic greeting situation.

A survey of 209 licensed, psychotherapists was conducted to investigate attitudes towards and observations of nonverbal communication in a reference situation. Background factors such as gender, years of psychotherapeutic experience, hours of therapy practiced each month, and theoretical approach were used to examine relationships. The psychotherapeutic greeting situation, i.e., the first time a therapist and patient meet in a waiting room, was chosen as the reference situation. Female psychotherapists believed that nonverbal communication was more important than male psychotherapists. Psychotherapists with 16 years or more experience supported items that constitute the greeting phase and items on active observation significantly more often than psychotherapists with less experience. Hours of psychotherapeutic practice and frames of reference were not significantly related to any item within the questionnaire. Belief in nonverbal communication was not significantly related to items that involve preparing to meet a patient for the first time.

Acute retroviral disease masquerading as bacterial sepsis: the "bands" play on.

We describe a case of acute human immunodeficiency virus infection that initially appeared to be bacterial sepsis. A marked increase in band forms was seen in the peripheral blood of our patient, with no increase in atypical lymphocytes. Having reviewed the most recent literature, we find this to be common, particularly in the first few days of acute retroviral illness. We suggest that the absence of atypical lymphocytes in the peripheral blood can be misleading in some cases and may militate against the primary diagnosis of acute retroviral disease.