Temporal trends in healthcare utilization following primary melanoma diagnosis among Medicare beneficiaries.

BACKGROUND: Little is known about the impact of primary melanoma diagnosis on healthcare utilization and changes in utilization over time. OBJECTIVES: To evaluate population-based temporal trends in healthcare utilization following primary melanoma diagnosis. METHODS: We conducted a before-and-after multiple time series study of Medicare beneficiaries aged ≥ 66 years with primary melanoma diagnoses between 2000 and 2009 using the Surveillance, Epidemiology, and End Results Medicare database. Primary exposure was time from primary melanoma diagnosis at 3-6 months and 6-24 months postdiagnosis. Covariates included tumour-, patient- and geographical-level characteristics and healthcare utilization in the 6 months before diagnosis. Poisson regression was used to estimate population-based risk-adjusted utilization rates for skin biopsies, benign skin excisions, internal medicine office visits and dermatology office visits. RESULTS: The study population included 56 254 patients with first diagnoses of primary melanoma. Most patients were ≥ 75 years old (56·8%), male (62·1%), and had in situ melanoma (42·4%) or localized invasive melanoma (45·9%). From 2000 to 2009, risk-adjusted skin biopsy rates 24 months postdiagnosis increased from 358·3 to 541·3 per 1000 person-years (P < 0·001), and dermatology visits increased from 989·0 to 1535·6 per 1000 person-years (P < 0·001). Benign excisions and internal medicine visits remained stable. In 2000, risk-adjusted skin biopsy rates 6 months postdiagnosis increased by 208·5 relative to the 6 months before diagnosis (148·7 vs. 357·2) compared with an observed absolute increase of 272·5 (290·9 vs. 563·1) in 2009. Trends in dermatology visits were similar. CONCLUSIONS: Utilization of skin biopsies and dermatology office visits following primary melanoma diagnosis has increased substantially over time. These results may inform optimization of care delivery for melanoma within the Medicare population.

Skin biopsy utilization and melanoma incidence among Medicare beneficiaries.

BACKGROUND: Melanoma incidence has increased in recent decades in the U.S.A. Uncertainty remains regarding how much of this increase is attributable to greater melanoma screening activities, potential detection bias and overdiagnosis. OBJECTIVES: To use a cross-sectional ecological analysis to evaluate the relationship between skin biopsy and melanoma incidence rates over a more recent time period than prior reports. METHODS: Examination of the association of biopsy rates and melanoma incidence (invasive and in situ) in SEER-Medicare data (including 10 states) for 2002-2009. RESULTS: The skin biopsy rate increased by approximately 50% (6% per year) throughout this 8-year period, from 7012 biopsies per 100 000 persons in 2002 to 10 528 biopsies per 100 000 persons in 2009. The overall melanoma incidence rate increased approximately 4% (< 1% per year) over the same time period. The incidence of melanoma in situ increased approximately 10% (1% per year), while the incidence of invasive melanoma increased from 2002 to 2005 then decreased from 2006 to 2009. Regression models estimated that, on average, for every 1000 skin biopsies performed, an additional 5·2 (95% confidence interval 4·1-6·3) cases of melanoma in situ were diagnosed and 8·1 (95% confidence interval 6·7-9·5) cases of invasive melanoma were diagnosed. When considering individual states, some demonstrated a positive association between biopsy rate and invasive melanoma incidence, others an inverse association, and still others a more complex pattern. CONCLUSIONS: Increased skin biopsies over time are associated with increased diagnosis of in situ melanoma, but the association with invasive melanoma is more complex.

Influence of menopause on mood: a systematic review of cohort studies.

OBJECTIVE: This systematic evidence review evaluates the independent influence of the menopausal transition on mood including depression, anxiety, and other psychological symptoms. METHODS: Community-based, prospective cohort studies of mid-life women transitioning through menopause that assessed at least one mood symptom on two or more occasions were identified by searches of MEDLINE (1966-2007) and PsycINFO (1974-2007) databases. Articles were selected based on predetermined inclusion and exclusion criteria. Each study was quality-rated by three authors; poor quality studies were excluded. RESULTS: Nine studies met inclusion criteria. They varied broadly in design, outcome measures, statistical methodology, and in consideration of and adjustment for important confounders. Five found no association between the menopausal transition and depression, negative mood, major depressive disorder, other psychological symptoms, and general mental health. Three found that women entering or completing the menopausal transition were more likely than premenopausal women to be depressed. One found that well-being increased from the early to late menopausal transition. CONCLUSION: There is no demonstrated pattern of an adverse independent influence of the menopausal transition on mood symptoms in mid-life women. However, the available studies are too methodologically diverse to be definitive.

Oregon physicians' attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act.

CONTEXT: The Oregon Death with Dignity Act, passed by ballot measure in 1994 and enacted in October 1997, legalized physician-assisted suicide for competent, terminally ill Oregonians, but little is known about the effects of the act on clinical practice or physician perspective. OBJECTIVE: To examine Oregon physicians' attitudes toward and practices regarding care of dying patients since the passage of the Death with Dignity Act. DESIGN, SETTING, AND PARTICIPANTS: A self-administered questionnaire was mailed in February 1999 to Oregon physicians eligible to prescribe under the act. Of 3981 eligible physicians, 2641 (66%) returned the questionnaire by August 1999. MAIN OUTCOME MEASURES: Physicians' reports of their efforts to improve care for dying patients since 1994, their attitudes, concerns, and sources of information about participating in the Death with Dignity Act, and their conversations with patients regarding assisted suicide. RESULTS: A total of 791 respondents (30%) reported that they had increased referrals to hospice. Of the 2094 respondents who cared for terminally ill patients, 76% reported that they made efforts to improve their knowledge of the use of pain medications in the terminally ill. Nine hundred forty-nine responding physicians (36%) had been asked by a patient if they were potentially willing to prescribe a lethal medication. Seven percent of all survey participants reported that 1 or more patients became upset after learning the physician's position on assisted suicide, and 2% reported that 1 or more patients left their care after learning the physician's position on assisted suicide. Of the 73 physicians who were willing to write a lethal prescription and who had received a request from a patient, 20 (27%) were not confident they could determine when a patient had less than 6 months to live. CONCLUSION: Most Oregon physicians who care for terminally ill patients report that since 1994 they have made efforts to improve their ability to care for these patients and many have had conversations with patients about assisted suicide.

Screening for chlamydial infection.

OBJECTIVES: To examine data on the effectiveness of screening for chlamydial infection by a physician or other health care professional. Specifically, we examine the evidence that early treatment of chlamydial infection improves health outcomes, as well as evidence of the effectiveness of screening strategies in nonpregnant women, pregnant women, and men, and the accuracy of tests used for screening. This review updates the literature since the last recommendation of the U.S. Preventive Services Task Force published in 1996. SEARCH STRATEGY: We searched the topic of chlamydia in the MEDLINE, HealthSTAR, and Cochrane Library databases from January 1994 to July 2000, supplemented by reference lists of relevant articles and from experts in the field. Articles published prior to 1994 and research abstracts were cited if particularly important to the key questions or to the interpretation of included articles. SELECTION CRITERIA: A single reader reviewed all English abstracts. Articles were selected for full review if they were about Chlamydia trachomatis genitourinary infections in nonpregnant women, pregnant women, or men and were relevant to key questions in the analytic framework. Investigators read the full-text version of the retrieved articles and applied additional eligibility criteria. For all topics, we excluded articles if they did not provide sufficient information to determine the methods for selecting subjects and for analyzing data. DATA COLLECTION AND ANALYSIS: We systematically reviewed three types of studies about screening in nonpregnant women that relate to three key questions: (1) studies about the effectiveness of screening programs in reducing prevalence rates of infection, (2) studies about risk factors for chlamydial infection in women, and (3) studies about chlamydial screening tests in women. Our search found too few studies on pregnant women to systematically review, although pertinent studies are described. We systematically reviewed two types of studies about screening in men: (1) studies about prevalence rates and risk factors for chlamydial infection in men and (2) studies about chlamydial screening tests in men. MAIN RESULTS: Nonpregnant women. The results of a randomized controlled trial conducted in a large health maintenance organization indicate that screening women selected by a set of risk factors reduces the incidence of pelvic inflammatory disease (PID) over a 1-year period. Changes in population prevalence rates have not been well documented because few studies have employed a representative population sample. Age continues to be the best predictor of chlamydial infection in women, with most studies evaluating cut-offs at age younger than 25 years. Other risk factors may be useful predictors, but these are likely to be population specific. To determine the accuracy of screening tests for women, we retrieved and critically reviewed 34 articles on test performance. Results indicate that endocervical swab specimens and first-void urine specimens have similar performance when using DNA amplification tests and have better sensitivity than endocervical culture. Recurrent chlamydial infections in women have been associated with increased risks for PID and ectopic pregnancies. Pregnant women. The Second Task Force recommendations for screening pregnant women were based on two major studies demonstrating improved pregnancy outcomes following treatment of chlamydial infection. We identified no recent studies on this topic in our literature search. Very few studies describe risk factors for chlamydial infection in pregnant women. Nonculture testing techniques appear to perform well in pregnant women, although studies are limited. Men. No studies described the effectiveness of screening or early treatment for men in reducing transmission to women or in preventing acute infections or complications in men. Studies of prevalence rates and risk factors for chlamydial infection in men are limited. Age lower than 25 years is the strongest known risk factor cited so far. Results of urethral swab specimens compared to first-void urine specimens were similar for DNA amplification tests. DNA amplification techniques are more sensitive than culture. CONCLUSIONS: Screening women for Chlamydia trachomatis reduces the incidence of PID, and it is associated with reductions in prevalence of infection in uncontrolled studies. No studies were found to determine whether screening asymptomatic men would reduce transmission or prevent acute infections or complications. Age is the strongest risk factor for men and women. A variety of tests can detect chlamydial infection with acceptable sensitivity and specificity, including new DNA amplification tests that use either endocervical swabs in women, urethral swabs in men, or first-void urine specimens from men and women.

Hormone replacement therapy and cognition: systematic review and meta-analysis.

CONTEXT: Some observational data suggest that hormone replacement therapy (HRT) may reduce the risk of cognitive decline and dementia but results have been conflicting. OBJECTIVE: To review and evaluate studies of HRT for preventing cognitive decline and dementia in healthy postmenopausal women. DATA SOURCES: Studies with English-language abstracts identified in MEDLINE (1966-August 2000), HealthSTAR (1975-August 2000, PsychINFO (1984-August 2000); Cochrane Library databases; and articles listed in reference lists of key articles. STUDY SELECTION: Randomized controlled trials and cohort studies were reviewed for the effects of HRT on cognitive decline; cohort and case-control studies were reviewed for dementia risk. No randomized controlled trials regarding dementia risk were identified. DATA EXTRACTION: Twenty-nine studies met inclusion criteria and were rated. Two reviewers rated study quality independently and 100% agreement was reached on Jadad scores and 80% agreement was reached on US Preventive Services Task Force quality scores. A final score was reached through consensus if reviewers disagreed. DATA SYNTHESIS: Studies of cognition were not combined quantitatively because of heterogeneous study design. Women symptomatic from menopause had improvements in verbal memory, vigilance, reasoning, and motor speed, but no enhancement of other cognitive functions. Generally, no benefits were observed in asymptomatic women. A meta-analysis of observational studies suggested that HRT was associated with a decreased risk of dementia (summary odds ratio, 0.66; 95% confidence interval, 0.53-0.82). However, possible biases and lack of control for potential confounders limit interpretation of these studies. Studies did not contain enough information to assess adequately the effects of progestin use, various estrogen preparations or doses, or duration of therapy. CONCLUSIONS: In women with menopausal symptoms, HRT may have specific cognitive effects, and future studies should target these effects. The meta-analysis found a decreased risk of dementia in HRT users but most studies had important methodological limitations.

Contributions of general internal medicine teaching units: a national survey.

OBJECTIVE: To identify and describe general internal medicine teaching units and their educational activities. DESIGN: A cross-sectional mailed survey of heads of general internal medicine teaching units affiliated with U.S. internal medicine training programs who responded between December 1996 and December 1997. MEASUREMENTS AND MAIN RESULTS: Responses were received from 249 (61%) of 409 eligible programs. Responding and nonresponding programs were similar in terms of university affiliation, geographic region, and size of residency program. Fifty percent of faculty received no funding from teaching units, 37% received full-time (50% or more time), and 13% received part-time (under 50% time) funding from units. Only 23% of faculty were primarily located at universities or medical schools. The majority of faculty were classified as clinicians (15% or less time spent in teaching) or clinician-educators (more than 15% time spent in teaching), and few were clinician-researchers (30% or more time spent in research). Thirty-six percent of faculty were internal medicine subspecialists. All units were involved in training internal medicine residents and medical students, and 21% trained fellows of various types. Half of the units had teaching clinics located in underserved areas, and one fourth had teaching clinics serving more than 50% managed care patients. Heads of teaching units reported that 54% of recent graduating residents chose careers in general internal medicine. CONCLUSIONS: General internal medicine teaching units surveyed contributed substantial faculty effort, much of it unfunded and located off-campus, to training medical students, residents, and fellows. A majority of their graduating residents chose generalist careers.

Physicians' experiences with the Oregon Death with Dignity Act.

BACKGROUND: Physician-assisted suicide was legalized in Oregon in October 1997. There are data on patients who have received prescriptions for lethal medications and died after taking the medications. There is little information, however, on physicians' experiences with requests for assistance with suicide. METHODS: Between February and August 1999, we mailed a questionnaire to physicians who were eligible to prescribe lethal medications under the Oregon Death with Dignity Act. RESULTS: Of 4053 eligible physicians, 2649 (65 percent) returned the survey. Of the respondents, 144 (5 percent) had received a total of 221 requests for prescriptions for lethal medications since October 1997. We received information on the outcome in 165 patients (complete information for 143 patients and partial for on an additional 22). The mean age of the patients was 68 years; 76 percent had an estimated life expectancy of less than six months. Thirty-five percent requested a prescription from another physician. Twenty-nine patients (18 percent) received prescriptions, and 17 (10 percent) died from administering the prescribed medication. Twenty percent of the patients had symptoms of depression; none of these patients received a prescription for a lethal medication. In the case of 68 patients, including 11 who received prescriptions and 8 who died by taking the prescribed medication, the physician implemented at least one substantive palliative intervention, such as control of pain or other symptoms, referral to a hospice program, a consultation, or a trial of antidepressant medication. Forty-six percent of the patients for whom substantive interventions were made changed their minds about assisted suicide, as compared with 15 percent of those for whom no substantive interventions were made (P<0.001). CONCLUSIONS: Our data indicate that in Oregon, physicians grant about 1 in 6 requests for a prescription for a lethal medication and that 1 in 10 requests actually result in suicide. Substantive palliative interventions lead some--but not all--patients to change their minds about assisted suicide.

Does estrogen adequately protect postmenopausal women against osteoporosis: an iconoclastic perspective.

In sum, the skeletal benefits provided by hormone replacement therapy are important, and estrogen should be justifiably considered one of the fundamentals of menopausal management. However, its efficacy in the prevention of osteoporotic fractures should not be overstated. Low bone mass and fractures remain serious threats in older postmenopausal women, even in the presence of hormone replacement. With the recognition of that reality comes a variety of challenges to clinicians and investigators. Clinicians should use estrogen to its best advantage, though, at the same time, remain vigilant of its limitations. Older postmenopausal women who are, or who have been, taking estrogen should not be a priori considered adequately protected against fracture. The same careful clinical evaluation recommended for the protection of those at increased fracture risk, including bone mass measures, should be available to estrogen-taking women in the later postmenopausal period. Recognizing this need, the National Osteoporosis Foundation has recently recommended bone mineral density testing in older women, regardless of estrogen status, and HCFA reimbursement has become available for this indication. In the presence of low bone density, estrogen-taking women should be afforded appropriate levels of diagnostic and therapeutic attention, with the intent to further reduce fracture risk. Once estrogen therapy has been elected, patients and their clinicians should be aware that bone loss can still be expected in the later postmenopausal years. Periodic reevaluations of bone density and other risks for fracture (e.g. falls) may be appropriate. In the face of continued good health, those reevaluations can be infrequent, but women who have medical conditions associated with adverse skeletal effects should be followed more closely despite their estrogen therapy. If we are to build on the value of estrogen to improve our approach to osteoporosis, additional data are needed. When fracture risk has been considered in complex models that adjust for account other medical and lifestyle variables, a greater protective effect of estrogen has emerged (12), suggesting that there are factors whose actions attenuate those of estrogen. Prominent candidates include genetics, tobacco and alcohol use, medications, body composition, and propensity to fall. There are undoubtedly others yet unidentified. These should be further defined, and the basic mechanisms for interactions between them and estrogen should be examined. It would be clinically advantageous to use these factors to accurately identify not only the women who would benefit from estrogen replacement but also those who would not. Because estrogen has important beneficial effects, an essential research objective should be the development of therapeutic strategies that combine the advantages of estrogen with other modalities (pharmacological or otherwise), to maximally protect the many estrogen-taking women who may be considered at continued risk for fracture. To whit, the initial reports of combination therapy with bisphosphonates are encouraging (13, 14). Other important skeletal agents can be anticipated to interact with estrogen in as-of-yet unforeseen ways. On another front, it can be anticipated that selective estrogen receptor modulators will be subject to estrogen-like limitations when used for osteoporosis prevention/therapy, and their effects will be influenced by a similar, but distinct, array of covariates. Our vision of the role of hormone replacement in the reduction of osteoporotic fracture risk should be considerably sharpened. At one time, estrogen was the lone best hope for the avoidance of fracture, but no longer should we be satisfied with that imperfect solution. The development of much more efficient and effective methods for osteoporosis risk assessment, prevention, and treatment now provides a chance to surpass previous expectations. (ABSTRACT TRUNCATED)

Managed care, attitudes, and career choices of internal medicine residents.

The influence of managed care on internal medicine residents' attitudes and career choices has not yet been determined and could be substantial. In a survey of 1,390 third-year internal medicine residents, 21% believed that managed care was the best model of health care for the United States, and 31% stated they would be satisfied working in a managed care system. Those from high managed care communities (>30% penetration) were only slightly more accepting of managed care, but were more likely to choose general internal medicine as a career (54%, p = .0009) than those from communities with lower managed care penetration.

Oregon emergency physicians' experiences with, attitudes toward, and concerns about physician-assisted suicide.

OBJECTIVE: To determine emergency physicians' (EPs') attitudes toward physician-assisted suicide (PAS), factors associated with those attitudes, current experiences with attempted suicides in terminally ill persons, and concerns about the impact of legalizing PAS on emergency medicine practice. METHODS: A cross-sectional, anonymous mailed survey was taken of EPs in the state of Oregon. RESULTS: Of 356 eligible physicians, 248 (70%) returned the survey. Of the respondents, 69% indicated that PAS should be legal, 65% considered PAS consistent with the physician's role, and 19% believed that it is immoral. The respondents were concerned that patients might feel pressure if they perceived themselves to be either a care burden on others (82%) or a financial stress to others (69%). Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons. Support for legalization was not associated with gender, age, or practice location. Respondents with no religious affiliation were most supportive of PAS (p < 0.001), and Catholic respondents were least suppportive (p = 0.03). A majority (58%) had treated at least 1 terminally ill patient after an apparent overdose. Most respondents (97%) indicated at least 1 circumstance for which they would sometimes be willing to let a terminally ill patient die without resuscitation after PAS if the Oregon initiative becomes law: if verified with an advance directive from the patient (81%), with documentation in writing from the physician (73%), after speaking to the primary physician (64%), if a competent patient verbally confirmed intent (60%), or if the family verbally confirmed intent (52%). CONCLUSIONS: Although the majority of Oregon EPs favor the concept of legalization of PAS, most have concerns that safeguards in the Oregon initiative are inadequate to protect vulnerable patients. These physicians would consider not resuscitating terminally ill patients who have attempted suicide under the law's provisions, only in the setting of documentation of the patient's intent.

Substance-impaired physicians probationary and voluntary treatment programs compared.

We compared the characteristics and treatment outcomes of substance-impaired physicians monitored by two different programs in Oregon: a probationary program administered by the Oregon Board of Medical Examiners and the confidential, voluntary Diversion Program for Health Professionals. Demographic, substance use, and treatment outcome variables were obtained by a retrospective medical record review from 41 physicians monitored by the Oregon board and 56 physicians monitored by the diversion program during a 3-year study period. Compared with physicians monitored by the Oregon board, physicians in the diversion program were younger, more likely to be in training programs and less likely to be in hospital-based practice settings, more often reported by immediate rather than third-party contacts, more likely to choose in-state inpatient treatment than out-of-state treatment, and less likely to have concurrent mental illness diagnoses (P < .05 for all comparisons). Short-term relapse rates did not differ statistically between the groups (22.0% for the Oregon board group, 14.3% for the diversion program group). The higher number of younger physicians and physicians in training and tendency toward increased reporting by immediate contacts in the diversion program suggested earlier intervention than in the Oregon board group.

Legalizing assisted suicide--views of physicians in Oregon.

BACKGROUND: Since the Oregon Death with Dignity Act was passed in November 1994, physicians in Oregon have faced the prospect of legalized physician-assisted suicide. We studied the attitudes and current practices of Oregon physicians in relation to assisted suicide. METHODS: From March to June 1995, we conducted a cross-sectional mailed survey of all physicians who might be eligible to prescribe a lethal dose of medication if the Oregon law is upheld. Physicians were asked to complete and return a confidential 56-item questionnaire. RESULTS: Of the 3944 eligible physicians who received the questionnaire, 2761 (70 percent) responded. Sixty percent of the respondents thought physician-assisted suicide should be legal in some cases, and nearly half (46 percent) might be willing to prescribe a lethal dose of medication if it were legal to do so; 31 percent of the respondents would be unwilling to do so on moral grounds. Twenty-one percent of the respondents have previously received requests for assisted suicide, and 7 percent have complied. Half the respondents were not sure what to prescribe for this purpose, and 83 percent cited financial pressure as a possible reason for such requests. The respondents also expressed concern about complications of suicide attempts and doubts about their ability to predict survival at six months accurately. CONCLUSIONS: Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States. A sizable minority of physicians in Oregon objects to legalization and participation on moral grounds. Regardless of their attitudes, physicians had a number of reservations about the practical applications of the act.

Smoking, alcohol, and neuromuscular and physical function of older women. Study of Osteoporotic Fractures Research Group.

OBJECTIVE: To determine the associations of current and lifetime smoking and alcohol use with physical function in an older population. DESIGN: Survey. SETTING: Four clinic centers in the United States. PARTICIPANTS: A total of 9704 community-dwelling, ambulatory white women 65 years or older recruited from four areas of the United States. MAIN OUTCOME MEASURES: Twelve performance tests of muscle strength, agility and coordination, gait and balance, and self-reported functional status. RESULTS: Compared with women who never smoked, current smokers had significantly poorer function on all of the performance measures except grip strength after adjusting for age, history of stroke, body mass index, clinic site, physical activity, and alcohol use (P < .05). This decrease in function was 50% to 100% as great as that associated with a 5-year increase in age, and most measures worsened with increasing numbers of pack-years. Compared with current moderate drinkers, nondrinkers had significantly poorer function on all of the performance measures except tandem walk (P < .05). Evaluation of a dose effect with alcohol was limited by the small number of heavy drinkers in the study. CONCLUSIONS: In this population, women who currently smoke are weaker and have poorer balance and poorer performance on measures of integrated physical function than nonsmokers. Smoking is associated with a decline in physical function. Current moderate drinkers have better physical function compared with nondrinkers, but associations of function with heavy drinkers could not be assessed.

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.

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.