Clinical assessment of HIV-associated lipodystrophy in an ambulatory population.

OBJECTIVE: To identify clinical factors associated with prevalence of fat atrophy (lipoatrophy) and fat accumulation (lipoaccumulation) in HIV-1 infected patients. DESIGN: Evaluation of HIV-1 infected patients seen for routine care between 1 October and 31 December 1998 in the eight HIV Outpatient Study (HOPS) clinics. SETTING: Eight clinics specializing in the care of HIV-1 infected patients. PATIENTS: A total of 1077 patients were evaluated for signs of fat maldistribution. INTERVENTIONS: A standardized set of questions and specific clinical signs were assessed. Demographic, clinical and pharmacological data for each patient were also included in the analysis. MAIN OUTCOME MEASURES: Demographic, immunologic, virologic, clinical, laboratory, and drug treatment factors were assessed in stratified and multivariate analyses for their relationship to the presence and severity of fat accumulation and atrophy. RESULTS: Independent factors for moderate/severe lipoatrophy for 171 patients were increasing age, any use of stavudine, use of indinavir for longer than 2 years, body mass index (BMI) loss, and measures of duration and severity of HIV disease. Independent risk factors for moderate/severe fat accumulation for 104 patients were increasing age, BMI gain, measures of amount and duration of immune recovery, and duration of antiretroviral therapy (ART). The number of non-drug risk factors substantially increased the likelihood of lipoatrophy. If non-drug risk factors were absent, lipoatrophy was unusual regardless of the duration of drug use. CONCLUSIONS: HIV-associated lipodystrophy is associated with several host, disease, and drug factors. While prevalence of lipoatrophy increased with the use of stavudine and indinavir, and lipoaccumulation was associated with duration of ART, other non-drug factors were strongly associated with both fat atrophy and accumulation.

Women's responses to a mailed hormone replacement therapy workbook.

OBJECTIVE: Effectively communicating information about the complex decisions that face women at midlife, including whether to use hormone replacement therapy (HRT), is an ongoing challenge. Although numerous decision-making tools exist, few have been evaluated. The objective of this study was to examine women's use of a workbook designed to promote informed HRT decision-making. DESIGN: We developed a workbook to prepare women to discuss HRT, osteoporosis, heart disease, and breast cancer with their providers. To evaluate the workbook, women aged 45-65 years were randomly assigned to one of three groups: (1) workbook plus baseline and 6-month surveys, (2) workbook and 6-month survey, or (3) no workbook with both surveys. Results are based on the responses of 580 women in groups 1 and 2 (response rate, 84.2%). RESULTS: At 6 months, 79% of women recalled receiving the workbook, of whom 51% read all or most of it, 35% skimmed or read part of it, and 14% did not read it. The percentages of women completing self-assessments were 55% osteoporosis; 56% heart disease; 58% breast cancer; 57% advantages and disadvantages of HRT; and 52% personal preferences about HRT. As a result of the workbook, 10% made an appointment with their providers, and 12% had a discussion about HRT with their providers. Use of the workbook was not associated with menopause symptoms, attitudes about or use of HRT, hysterectomy, or provider discussions about menopause and HRT. CONCLUSION: This simple approach of using a mailed workbook holds promise as a successful mechanism to prepare women to discuss HRT and other related health issues with their providers.

Understanding attitudes of older women toward hormone replacement therapy.

BACKGROUND: Counseling women facing the decision to initiate, continue, or discontinue hormone replacement therapy represents a major challenge for providers. Women's attitudes deserve careful consideration in this context, because attitudes may influence hormone replacement therapy use and patients' satisfaction with decision-making. Little is known about factors that may explain different attitudes. METHODS: To evaluate the association between char acteristics of peri- and postmenopausal women and their attitudes toward hormone replacement therapy, we conducted a population-based, computer-assisted telephone survey of 1,076 randomly selected women, ages 50-80, at a staff-model health maintenance organization. Women with a positive or neutral attitude were compared to those with a negative attitude. We exam ined associations between attitudes and demographic and clinical characteristics, self-rated health status, physical function, personal and family history of condi tions affected by hormone replacement therapy, gyne cologic visits, provider characteristics, interactions with provider, and sources of information about hor mone replacement therapy. RESULTS: The perception of being adequately informed about the benefits of hormone replacement therapy by one's provider was associated with a tripling of the likelihood of having a positive attitude toward hormone replacement therapy. Additional fac tors associated with positive attitudes included past hormone replacement therapy use, younger age, a higher level of physical functioning, and personal history of heart disease. Relationships between these vari ables and attitudes varied among current hormone replacement therapy users and nonusers. CONCLUSIONS: The study findings reinforce the critical role of provider counseling in shaping women's atti tudes about hormone replacement therapy.

Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia.

OBJECTIVES: The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia. METHODS: Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology. RESULTS: Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners. CONCLUSIONS: Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.

Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators.

BACKGROUND AND METHODS: National surveillance data show recent, marked reductions in morbidity and mortality associated with the acquired immunodeficiency syndrome (AIDS). To evaluate these declines, we analyzed data on 1255 patients, each of whom had at least one CD4+ count below 100 cells per cubic millimeter, who were seen at nine clinics specializing in the treatment of human immunodeficiency virus (HIV) infection in eight U.S. cities from January 1994 through June 1997. RESULTS: Mortality among the patients declined from 29.4 per 100 person-years in the first quarter of 1995 to 8.8 per 100 in the second quarter of 1997. There were reductions in mortality regardless of sex, race, age, and risk factors for transmission of HIV. The incidence of any of three major opportunistic infections (Pneumocystis carinii pneumonia, Mycobacterium avium complex disease, and cytomegalovirus retinitis) declined from 21.9 per 100 person-years in 1994 to 3.7 per 100 person-years by mid-1997. In a failure-rate model, increases in the intensity of antiretroviral therapy (classified as none, monotherapy, combination therapy without a protease inhibitor, and combination therapy with a protease inhibitor) were associated with stepwise reductions in morbidity and mortality. Combination antiretroviral therapy was associated with the most benefit; the inclusion of protease inhibitors in such regimens conferred additional benefit. Patients with private insurance were more often prescribed protease inhibitors and had lower mortality rates than those insured by Medicare or Medicaid. CONCLUSIONS: The recent declines in morbidity and mortality due to AIDS are attributable to the use of more intensive antiretroviral therapies.

Patterns of prenatal care initiation in Georgia, 1980-1992.

OBJECTIVE: To determine whether characteristics in a woman's first pregnancy were associated with the trimester in which she initiated prenatal care in her second pregnancy. METHODS: Data for white and black women whose first and second pregnancies resulted in singleton live births between 1980 and 1992 were obtained from Georgia birth certificates (n = 177,041). Adjusted relative risks (RRs) for early prenatal care in the second pregnancy were computed by logistic regression models that included trimester of prenatal care initiation, infant outcomes, or maternal conditions in the woman's first pregnancy as the exposure and controlled for maternal age, education, child's year of birth, interval between first and second pregnancy, presence of father's name on the birth certificate, and the interaction between prenatal care and education. Models were stratified by race. RESULTS: Women of both races who initiated prenatal care in the first trimester of their first pregnancies were more likely than those with delayed care to initiate prenatal care in the first trimester of their second pregnancies (RR = 1.25 and 1.63 for white and black women educated beyond high school, respectively). Both white and black women who delivered a baby with very low birth weight (RR = 1.06 and 1.15, respectively) or who suffered an infant death (RR = 1.09 and 1.31, respectively) in their first pregnancies were more likely than those who did not experience these events to begin prenatal care in the first trimester of their second pregnancies. CONCLUSION: Women with some potentially preventable adverse infant outcomes tend to obtain earlier care in their next pregnancy. Unfortunately, women who delayed prenatal care in their first pregnancy frequently delay prenatal care in their next.

The relationship of interpregnancy interval to infant birthweight and length of gestation among low-risk women, Georgia.

To examine the association between interpregnancy interval and low birthweight (< 2500 g), preterm delivery (< 37 weeks' gestation), and inadequate fetal growth, we studied a population-based sample of 23,388 white and 4885 black women at low risk for adverse pregnancy outcomes who delivered their first and second infants in Georgia from 1980 to 1992. We used fetal death and livebirth certificates. The interpregnancy interval was the time from delivery to the woman's next conception. For each pregnancy outcome, we stratified by race and used logistic regression to assess the association between interpregnancy interval and outcome, while controlling for confounders. Intervals < 6 months were observed for 3.7% of white women and 7.0% of black women and intervals > or = 48 months were seen for 16.8% of white women and 24.8% of black women. Results from logistic regression showed that, for both races, interpregnancy interval was associated with low birthweight and preterm delivery. Nearly all of the increased risk occurred in intervals < 6 months or > or = 48 months. The magnitude of the increase in risk associated with these intervals ranged from modest to moderate and was similar for black and white women. Because short interpregnancy intervals are rare and are weak risk factors among low-risk women, efforts to lengthen interpregnancy intervals are unlikely to reduce substantially their rates of adverse pregnancy outcomes.

Sensitivity of antinociceptive tests to opioid agonists and partial agonists.

There is considerable variation in the potency of opioids across different animal models of antinociceptive activity. In the less sensitive tests the partial agonist analgesics behave as antagonists. The activity of opioids in antinociceptive tests appears to be dependent on both the intensity of the noxious stimulus and the intrinsic activity of the drug.