19 research outputs found
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Neuropsychologic Impairment in Early HIV Infection: A Risk Factor for Work Disability
Objective: To explore the functional significance of incident neuropsychologic impairment among initially asymptomatic subjects infected with human immunodeficiency virus. Design: Prospective, observational cohort study of homosexual and bisexual men to examine the incidence of work disability related to the onset of neuropsychologic impairment. Setting: A university clinical and behavioral research site in New York City. Participants: Sample of 207 homosexual and bisexual men; 123 were seropositive and 84 were seronegative. Principal Outcome Measures: Incident work disability in the course of 4.5 years of follow-up, with disability defined as a persistent (≥24 months) change in work hours (from 20 or more to less than 20 h/wk). Results: Compared with seronegative control subjects (n=72), the relative risk of work disability among initially asymptomatic seropositive men (n=44) was 2.76 (95% confidence interval, 1.2 to 6.5), nearly a threefold increase. Proportional hazards models show that this increased risk is attributable to the development of major neuropsychologic impairment in a subset (eight of 44) of the initially asymptomatic men, which is significantly associated with incident work disability (6/8 [75%]). Adjusting for symptom status and CD4+ cell count at the time of disability did not eliminate the increased risk associated with neuropsychologic impairment. Conclusions: In this cohort, the increased risk of work disability among initially asymptomatic human immunodeficiency virus—positive men was related to incident neuropsychologic impairment; such impairment predicted work disability independently of symptom status and CD4+ cell count over the follow-up period. Neuropsychologic impairment in the course of human immunodeficiency virus infection may indicate increased risk for poor outcomes over and above that associated with systemic disease
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Neuropsychological Changes in a Prospectively Followed Cohort of Homosexual and Bisexual Men With and Without HIV Infection
We evaluated neuropsychological test performance of 168 homosexual and bisexual men with and without human immunodeficiency virus (HIV) infection (113 HIV+ subjects and 55 HIV- controls) over 4.5 years of semiannual follow-up. Analyses of the longitudinal data were performed by applying generalized estimating equations (GEEs) to regression analyses with repeated measures. Compared with the HIV- men, the HIV+ subjects performed more poorly on memory testing. Performance on all tests tended to improve over time, but this improvement was attenuated or eliminated in the HIV+ group for tests of language and attention. Within the HIV+ subjects, improvement over time in tests of memory, executive function, language, and attention was attenuated or eliminated in patients with lower CD4 levels; more advanced HIV disease was associated with poorer memory and executive function and with attenuated or reduced learning effects for memory, motor speed, and language tests. Clinically significant neurologic findings were associated with worse memory and orientation and with attenuated or reversed learning effects for memory, language, and attention tests. There were 33 deaths in the HIV+ group. In the men who died, there was more rapid decline in executive, language, and attentional test performance. These observations remained significant after controlling for HIV disease severity. We conclude that HIV infecting the CNS results in progressive cognitive change that is closely associated with neurologic findings. In addition, our findings suggest a relation between more rapid cognitive progression and death
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Neurologic Signs and Symptoms in a Cohort of Homosexual Men Followed for 4.5 Years
We traced the development of neurologic impairment in 207 homosexual men (123 human immunodeficiency virus [HIV]-positive and 84 HIV-negative controls) over 4.5 years of follow-up. We applied generalized estimating equations to logistic regression analyses with repeated measures to examine the differences between HIV-positive and HIV-negative subjects with respect to the likelihood of developing six neurologic outcomes derived from a factor analysis, significant neurologic impairment (modified Kurtzke disability score of ≥3), or significant neuropsycholog-ical impairment. We found that, over time, HIV-positive subjects were more likely to develop clinically significant ex-trapyramidal signs and frontal release signs than HIV-negative subjects. Controlling for age or education, as CD4 count declined, the odds of developing significant extrapyramidal signs, abnormalities in alternating movements, frontal release signs, and a Kurtzke score ≥3 increased. HIV-positive subjects were almost five times as likely (odds ratio [OR], 4.6; 95% CI, 1.6 to 13.4) as HIV-negative subjects to stay the same or worsen neurologically on the next visit, and those with CD4 ≥200 were 4.8 times as likely (OR, 4.8; 95% CI, 2.2 to 10.7) to maintain or worsen neurologically relative to those with higher CD4 counts. We conclude that neurologic impairment becomes increasingly apparent over time in HIV-infected men, especially in those with low CD4 counts
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Cerebral Single-Photon Emission Computed Tomography Abnormalities in Human Immunodeficiency Virus Type 1-Infected Gay Men without Cognitive Impairment
Objective: To determine whether technetium Tc 99m exametazime single-photon computed emission tomography (SPECT) can distinguish gay human immunodeficiency virus (HIV)—positive subjects, both with and without mild cognitive impairment, from gay HIV-negative control subjects. Design: Twenty HIV-positive subjects (12 without cognitive impairment and eight with mild cognitive impairment) and 10 HIV-negative subjects underwent neurological, neuropsychological, magnetic resonance imaging, and technetium Tc 99m exametazime SPECT examinations. Setting: Subjects were recruited from a natural history study of gay men with HIV infection. Patients: Subjects from the cohort who had previously participated in a magnetic resonance imaging study were selected for the SPECT study. Main Outcome Measures: The SPECT scans were rated as abnormal if focal defects, confirmed by a horizontal profile analysis, were seen. Results: Sixty-seven percent of HIV-positive subjects without cognitive impairment, 88% of HIV-positive subjects with mild cognitive impairment, and 20% of HIV-negative subjects had abnormal SPECT scans (P<.05 for both HIV-positive groups when each group was compared with HIV-negative subjects). Conclusion: Compared with gay HIV-negative control subjects, focal SPECT defects are seen with an increased frequency in HIV-positive gay men without cognitive impairment and in HIV-positive gay men with mild cognitive impairment
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A Prospective Controlled Study of Magnetic Resonance Imaging of the Brain in Gay Men and Parenteral Drug Users with Human Immunodeficiency Virus Infection
To detect the earliest structural changes in the brain in human immunodeficiency virus (HIV) infection, 118 gay men and 115 parenteral drug users enrolled in a study of the natural history of HIV infection underwent magnetic resonance imaging evaluations. Routine T2-weighted and heavily T2-weighted scans for quantification of brain water were obtained, blinded to HIV serostatus. Atrophy and foci of increased signal did not correlate with any medical, immunologic, neurologic, or neuropsychologic parameters in the group as a whole, or in the gay men or parenteral drug user subgroups. Three subjects had progressive multifocal leukoencephalopathy and one had central nervous system lymphoma. In a subgroup in whom intracranial water percent was calculated, correlations were found with CD4 counts and CD4/CD8 ratios. We conclude that standard magnetic resonance imaging of the brain does not differentiate asymptomatic and mildly symptomatic HIV-positive individuals from HIV-negative individuals, regardless of risk group. However, intracranial water percent may distinguish HIV-positive from HIV-negative individuals because it correlates with raw CD4 counts and CD4/CD8 ratios
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A Comparison of Cerebral Spect Abnormalities in Hiv-Positive Homosexual Men with and without Cognitive Impairment
Objective: To determine whether technetium Tc 99m exametazime (HMPAO) single-photon emission computed tomography (SPECT) can distinguish between human immunodeficiency virus (HIV)-positive homosexual men with normal neuropsychologic test results and HIV-positive homosexual men with abnormal neuropsychologic test results. Design: Neurologic, neuropsychologic, magnetic resonance imaging, and Tc 99m HMPAO SPECT examinations were performed on 10 HIV-positive homosexual men without cognitive impairment and five HIV-positive homosexual men with cognitive impairment. Patients: Human immunodeficiency virus—positive homosexual men from New York City were recruited for the study. Main Outcome Measures: Findings on SPECT scans were evaluated qualitatively for focal defects, heterogeneity of the cortical margin, white matter hypoperfusion, and decreased global cortical uptake. All SPECT focal defects were coregistered with magnetic resonance images; SPECT heterogeneity and global cortical uptake were also measured quantitatively. Results: Coregistration with magnetic resonance imaging revealed that 63% of the focal SPECT defects corresponded to brain gyri and 37% corresponded to sulci. There was no significant difference in the frequency of qualitative or quantitative SPECT abnormalities between HIV-positive homosexual men with and without cognitive impairment. However, after examining individual neuropsychologic test factors, impaired motor speed performance was associated with decreased quantitative global cerebral uptake. Conclusions: Qualitative SPECT abnormalities are not increased in frequency in HIV-positive homosexual men with global cognitive impairment compared with those in HIV-positive homosexual men without cognitive impairment. Impaired motor speed performance may be associated with decreased quantitative global cerebral uptake
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Risk of Human Immunodeficiency Virus Type 1-Related Neurologic Disease in a Cohort of Intravenous Drug Users
Background: Although the proportion of cases of acquired immunodeficiency syndrome related to intravenous drug use has increased dramatically over the past decade, there has been no longitudinal examination of primary neurologic disease in this group. Objective: To study the development of neurologic disease in human immunodeficiency virus (HIV)—negative and HIV-positive men and women who were intravenous drug users over a 3.5-year period. Design: Prospective observational cohort study. Setting: Subjects were recruited from an infectious disease clinic at a New York City Hospital or from a methadone maintenance program. Participants: Ninety-nine HIV-negative (62 men and 37 women) and 124 HIV-positive (85 men and 39 women) intravenous drug users volunteered. Main Outcome Measure: The development of clinically significant manifestations in six neurologic domains. Results: With multivariate adjustment for current and past substance abuse, age, education, and head injury, we examined the odds of developing HIV-related neurologic disease. Extrapyramidal signs and reduced motor ability became increasingly apparent over time in HIV-infected men as their CD4 cell count declined and as the subjects developed the acquired immunodeficiency syndrome. Fewer neurologic signs were seen in the women. Conclusions: The impact of HIV infection among intravenous drug users parallels that in homosexual men and is independent of alcohol and other drug use
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Neuropsychological Changes in a Prospectively Followed Cohort of Intravenous Drug Users with and without HIV
We followed a cohort of 223 intravenous drug users (99 HIV and 124 HIV+) for up to 3.5 years, examining change in performance over time as a function of HIV status, disease severity, and neurological signs and symptoms. Analyses were performed by applying generalized estimating equations (GEE) to regression analyses with repeated measures, and controlled for age, education, and length of substance use. None of the subjects had AIDS at baseline. There were 147 men (85 HIV+ and 62 HIV) and 76 women (39 HIV+ and 37 HIV). Memory performance was worse in the HIV+ than HIV− women. In the men, performance on the memory, executive, language, and attention factors improved significantly overtime, but this improvement was attenuated in the HIV men for the attention and orientation factors. In the HIV+ women. AIDS was associated with worsening performance on attention tests. The presence or onset of clinically significant neurological findings was associated with poorer language and motor speed performance. In the HIV+ men, memory performance was worse when the CD4 count fell below 200: it declined over time in men with AIDS but not in those without. A learning effect for language was attenuated in men who developed AIDS. The presence or development of a clinically significant neurological sign was associated with poorer memory, executive, language, attention, and motor speed performance. Our findings parallel those that we previously reported in a prospectively followed cohort of gay men. In combination, our studies of gay men and IDU cohorts suggest that (a) HIV can affect cognition early, even when the patient is medically asymptomatic; (b) cognitive difficulties worsen as the severity of HIV infection increases; and (c) the advent of clinically significant neurologic signs is associated with progression to more severe cognitive deficits. Our data suggest that the neurological and neuropsychological changes are both manifestations of the central effect of HIV on the CNS
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Neurologic and Neuropsychological Manifestations of Human Immunodeficiency Virus Infection in Intravenous Drug Users without Acquired Immunodeficiency Syndrome. Relationship to Head Injury
We examined 99 human immunodeficiency virus (HIV)—negative and 122 HIV-positive intravenous drug users (IVDUs) without acquired immunodeficiency syndrome (AIDS) to determine whether HIV-positive IVDUs had more neurologic and neuropsychological impairment than their HIV-negative counterparts. Controlling for age, education, drug use, history of head injury, and interactions between head injury and HIV status and drug use, HIV-positive subjects had more extrapyramidal signs and frontal release signs. These findings persisted when asymptomatic HIV-positive subjects without systemic signs of infection and HIV-negative subjects were compared. Neurologic findings were more severe in those with more systemic illness. Among those reporting a history of head injury with loss of consciousness, neuropsychological performance was significantly worse in the HIV-positive subjects, and this increased with severity of illness. This was not true in the group without head injury, suggesting an interaction between history of head injury and the seropositive state. No relationship was noted between head injury and either drug use or HIV state. Therefore, subtle neurologic and neuropsychological abnormalities may precede clinical evidence of AIDS in IVDUs and may be more evident in those with head injury
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Multidisciplinary Baseline Assessment of Homosexual Men with and without Human Immunodeficiency Virus Infection. I. Overview of Study Design
Although much is known about the virus believed by most experts to be the cause of the acquired immunodeficiency syndrome and about its pathogenic actions, major areas of ignorance remain. Among these are the reasons for the varying time between infection with human immunodeficiency virus and development of acquired imunodeficiency syndrome, the relationship between neurologic and medical aspects of the disease, the time course of neuropsychological findings, and the prevalence of psychiatric morbidity. We assessed 124 homosexual men who were positive for human immunodeficiency virus and 84 who were negative for the virus. In this article we describe the study design, method of recruitment, and medical and demographic characteristics of the cohort, which will be followed up for 5 years