R. Morgan

Specific nutrient abnormalities in asymptomatic HIV-1 infection.

ObjectiveTo determine whether specific nutrient abnormalities occur in earlier stages of HIV-1 infection, thereby preceding the marked wasting and malnutrition that accompany later stages of the infection. DesignA longitudinal investigation to determine biological, psychological and social factors thought to influence the progression and outcome of HIV-1 infection. Nutritional status was assessed using biochemical measurement of nutrient levels, dietary history, anthropometry and clinical examination for the signs and symptoms of nutritional deficiency or excess. SettingThe study was performed on an outpatient basis at the University of Miami School of Medicine. ParticipantsOne hundred homosexual men, aged between 20 and 55 years, who were asymptomatic other than persistent generalized lymphadenopathy (Centers for Disease Control stage III) and 42 age-matched homosexual men demonstrated to be free of HIV-1 infection at two 6-month intervals. Main outcome measuresBiochemical measurement of nutrient status, dietary history, anthropometry, clinical signs or symptoms of nutritional excess or deficiency were obtained for all participants. ResultsDespite few differences in mean blood levels of specific nutrients, prevalence of specific nutrient abnormalities was widespread among HIV-1-infected subjects, compared with non-infected male homosexual controls. Overtly and marginally low blood levels of vitamins A (18%), E (27%), riboflavin (26%), B6 (53%), and B12 (23%), together with copper (74%) and zinc (50%) were documented in HIV-1-seropositive subjects. With the exception of riboflavin, zinc, and copper, a similar prevalence of abnormalities among HIV-1-seronegative controls was not observed. ConclusionSpecific nutrient abnormalities occur with relative frequency in asymptomatic HIV-1 infection and may contribute to the rate and form of HIV-1 disease progression.

The Medicare-HMO Revolving Door — The Healthy Go in and the Sick Go Out

BACKGROUND Enrollment in Medicare health maintenance organizations (HMOs) is encouraged because of the expectation that HMOs can help slow the growth of Medicare costs. However, Medicare HMOs, which are paid 95 percent of average yearly fee-for-service Medicare expenditures, are increasingly believed to benefit from the selective enrollment of healthier Medicare recipients. Furthermore, whether sicker patients are more likely to disenroll from Medicare HMOs, thus raising average fee-for-service costs, is not clear. METHODS We used Medicare enrollment and inpatient billing records for southern Florida from 1990 through 1993 to examine differences in the use of inpatient medical services by 375,406 beneficiaries in the Medicare fee-for-service system, 48,380 HMO enrollees before enrollment, and 23,870 HMO enrollees after disenrollment. We also determined whether these differences were related to demographic characteristics and whether the pattern of use after disenrollment persisted over time. RESULTS The rate of use of inpatient services in the HMO-enrollment group during the year before enrollment was 66 percent of the rate in the fee-for-service group, whereas the rate in the HMO-disenrollment group after disenrollment was 180 percent of that in the fee-for-service group. Beneficiaries who disenrolled from HMOs re-enrolled at about the time that their level of use dropped to that in the fee-for-service group. CONCLUSIONS These data show marked selection biases with respect to HMO enrollment and disenrollment. These biases undermine the effectiveness of the Medicare managed-care system and highlight the need for longitudinal and population-based studies.

A stress-moderator model of distress in early HIV-1 infection: Concurrent analysis of life events, hardiness and social support

A stress moderator framework was employed to investigate the relationship of negative life events, hardiness and social support to psychological distress among 67 asymptomatic HIV-1 seropositive gay males. Both main effects and stress moderator (interaction) models were evaluated. Main effects were found for negative life events and social support but not hardiness (either as commitment or overall hardiness); no moderator effects emerged. Results were the same whether events were quantified as negative impact or as number of events, and were in the predicted direction--life events associated with greater distress, social support with less distress. The present study replicates for early HIV-1 infection findings obtained in non-HIV-infected samples about the influence on psychological distress of negative life events and social support. Methodological limitations, possible explanations for the absence of stress moderator effects, and clinical implications of the findings are discussed.

A psychological assessment of chronic fatigue syndrome/chronic epstein-barr virus patients

Abstract Chronic Fatigue Syndrome (CFS), the current name for a malady most recently known as Chronic Epstein Barr Virus (CEBV), is a medical puzzle that now is a focus of intense research interest. Although the literature is sparse and studies are either anecdotal or based on small samples, psychological and psychiatric symtoms are frequently reported for patients with symptoms suggestive of CFS/CEBV. Cognitive impairment in this population has been frequently noted but has also received little systematic attention in CFS/CEBV research. Consequently, the aim of this study was twofold: (1) to broaden understanding of the psychological aspects of CFS/CEBV, including cognition, and (2) to place this understanding on a firmer empirical basis by use of a more comprehensive battery and a larger sample than typifies previous research. Twenty-four subjects exhibiting both serological profile and clinical symptomatology indicative of CEBV/CFS infection were investigated. Multiple measures were employed to tap per...

A psychosocial model of distress over time in early hiv-1 infection: The role of life stressors, social support and coping

Abstract This study tested whether a psychosocial model-consisting of life event stressors, social support and coping strategy-was associated with distress over time in 40 homosexual men with asymptomatic HIV-1 infection. With prior distress controlled, changes in distress were associated with changes in negatively rated life events and social support (replicating our cross-sectional findings) and with coping strategy (disengagement/denial, venting emotions and religion). Stringent tests that ruled out spurious moderator effects yielded significant stress moderator interactions for social support and active coping, as well as evidence for nonlinear relationships for both main effects and interactions. These findings confirm that the psychosocial model is associated with distress over time during asymptomatic HIV-1 infection. The model thus provides a framework for screening to identify patients who would benefit from clinical interventions while simultaneously identifying the areas most needing intervention.

Do Medicare HMOs and Medicare FFS differ in their use of the Medicare hospice benefit

This study compares use of the hospice benefit in Medicare fee-for-service (FFS) and Medicare risk-health maintenance organization (HMO) options in South Florida in 1992. A higher percentage of deaths occurred in hospice in the HMO option than in the FFS option. Compared to individuals in the FFS option, HMO-enrolled hospice users had longer lengths of hospice stay, lower 7-day mortality and higher 180-day (6 month) survival. These differences are consistent with the physicians financial incentives associated with the two programs.

Emotional distress, stress-related disruption and coping among healthy HIV-positive gay males

Abstract Although emotional distress is extensive both when HIV seropositivity is first determined and during symptomatic stages of the infection, it is not known if distress also characterizes the often lengthy asymptomatic period. To ascertain if it does, a sample (N=45) of asymptomatic HIV seropositive gay males was assessed on emotional distress, stressors, and coping styles. Data were compared with available normative data as well as with a small control sample (N=13) of seronegative gay males. On emotional distress indices, the majority of seropositive participants scored below the norms for psychiatric patient groups, resembling more the norms for non-patients, although there was a distressed subset. Despite evidence of considerable event-related stress, the moderate levels of currently-perceived stress among the seropositives indicated that as a whole they were not feeling overwhelmed. Coping styles did not appear to be disrupted in that they were nearly identical to normative data. In comparison ...

Immune function and anti-HTLV-I/II status in anti-HIV-1-negative intravenous drug users receiving methadone

PURPOSE The study objective was to evaluate the effects of long-term methadone use and human T-cell leukemia virus (HTLV) types I and II seropositivity on the distribution of lymphocyte subsets and on lymphocyte function as measured in vitro in intravenous drug users seronegative for human immunodeficiency virus type 1 (HIV-1). PATIENTS AND METHODS Anti-HIV-1-negative intravenous drug users receiving methadone maintenance therapy (n = 24) were studied in a Veterans Administration drug abuse treatment center. These subjects were compared to 38 age- and sex-matched control subjects who did not abuse drugs. HIV-1 and HTLV serostatus was determined by repetitive enzyme-linked immunosorbent assay and confirmed by immunoblot. Lymphocyte subsets were determined by two-color flow cytometry. Lymphocyte function was measured by proliferative response to plant mitogens and by natural killer (NK) cell-mediated cytotoxicity to a tumor cell target. RESULTS Significant differences were seen in lymphocyte phenotype in the methadone-treated group, with elevations in the T-cell helper subset CD4+CD26+; in CD8 and CD8+I2+ cells, suppressor/cytotoxic T lymphocytes, and activated suppressor/cytotoxic T cells; and in CD2+CD26+ cells and activated total T lymphocytes. Lymphocyte function was suppressed in the methadone group, with poor responses to pokeweed mitogen and phytohemagglutinin in culture. Moreover, NK-cell cytotoxicity was significantly reduced in the methadone group. None of these immunologic differences were attributable to HTLV serostatus. CONCLUSION The immune abnormalities seen suggest that a clinically significant degree of immune impairment exists in methadone-treated intravenous drug users. However, these abnormalities could not be explained by the presence of other retroviruses in this HIV-1-negative study group, as there was no significant difference in immune function when HTLV-seropositive patients were compared to HTLV-seronegative subjects treated with methadone.

Ethnicity, Emotional Distress, Stress-Related Disruption, and Coping among HIV Seropositive Gay Males

Differences in psychosocial factors that impact immune function and which, therefore, are relevant to HIV infection have been reported between Hispanics and non-Hispanic whites in the cross-cultural literature. To determine whether there were differences between Hispanic and non-Hispanic white HIV-seropositive homosexual males on life stressors, coping style, social support, and emotional distress, a sample (Hispanics = 27, non-Hispanic whites = 49) of participants in a five-year longitudinal study of HIV disease progression was assessed on relevant measures. Hispanics in this sample were not found to evidence psychosocial deficits as compared to non-Hispanic whites. Although not more stressed overall, Hispanics reportedhigher severity of stress on daily interactions related to their homosexual lifestyle than did their non-Hispanic white counterparts. Level ofacculturation isproposedas apossible explanation forthe striking similarities along most other psychosocial parameters.

Use of Veterans Affairs Medical Care by Enrollees in Medicare HMOs

To the Editor: Older people in the United States who use the medical services of the Veterans Health Administration are frequently also entitled to health care through Medicare. Although most do no...