Publications

Abstract

OBJECTIVE: Twin studies suggest that heritability of moderate-severe bronchopulmonary dysplasia (BPD) is 53% to 79%, we conducted a genome-wide association study (GWAS) to identify genetic variants associated with the risk for BPD. METHODS: The discovery GWAS was completed on 1726 very low birth weight infants (gestational age = 250-296/7 weeks) who had a minimum of 3 days of intermittent positive pressure ventilation and were in the hospital at 36 weeks' postmenstrual age. At 36 weeks' postmenstrual age, moderate-severe BPD cases (n = 899) were defined as requiring continuous supplemental oxygen, whereas controls (n = 827) inhaled room air. An additional 795 comparable infants (371 cases, 424 controls) were a replication population. Genomic DNA from case and control newborn screening bloodspots was used for the GWAS. The replication study interrogated single-nucleotide polymorphisms (SNPs) identified in the discovery GWAS and those within the HumanExome beadchip. RESULTS: Genotyping using genomic DNA was successful. We did not identify SNPs associated with BPD at the genome-wide significance level (5 3 1028) and no SNP identified in previous studies reached statistical significance (Bonferroni-corrected P value threshold .0018). Pathway analyses were not informative. CONCLUSIONS: We did not identify genomic loci or pathways that account for the previously described heritability for BPD. Potential explanations include causal mutations that are genetic variants and were not assayed or are mapped to many distributed loci, inadequate sample size, race ethnicity of our study population, or case-control differences investigated are not attributable to underlying common genetic variation. Pediatrics 2013;132:290-297

Abstract

The data discussed represent the findings from a study by the NIH-funded Hispanic Health Disparities Research Center, exploring the influence of institutional and psychosocial factors on adherence to antiretroviral medications by Mexican-origin persons living with AIDS on the US-Mexico Border. A qualitative approach was utilized consisting of clinic observations, baseline and follow-up interviews with patients (N = 113), key informant interviews (N = 9) and focus groups (5) with patients and health providers. Findings include the social-normative, institutional and geo-political factors affecting treatment and service delivery as well as individual variation and culturally patterned behaviors. ARV adherence and retention were found to depend on complex interactions and negotiation of co-occurring factors including the experience of medications and side-effects, patient/provider relationships, cultural norms and the changing dynamics of international borders. We note effects of drug-related violence which created border-crossing obstacles influencing mobility, access to services and adherence.

Abstract

Background: The Detection of Ischemia in Asymptomatic Diabetics (DIAD) study demonstrated a low 5-year hard cardiac event rate. We hypothesized that a blunted heart rate response (HRR, maximum percent change) to adenosine, a simple marker of cardiac autonomic neuropathy, will identify a cohort at higher cardiac risk. Methods: In DIAD, 518 participants were randomized to screening adenosine myocardial perfusion imaging (MPI) and had available data. HRR < 20% was considered abnormal. The primary endpoint was a composite of nonfatal myocardial infarction and cardiac death. Results: During 4.7 ± 0.9 years of follow-up 15 (3%) participants experienced the primary outcome. Participants with lower HRR experienced more events than those with higher HRR (8%, 3%, 1%, for HRR < 20% (n = 79), 20-39% (n = 182) and ≥ 40% (n = 257), respectively, p = 0.01). In a Cox proportional regression model that included MPI abnormalities and HRR, both were independently associated with cardiac events (p for model < 0.001). HRR < 20% was associated with 9-fold increased risk (p = 0.007) and moderate/large abnormal MPI was associated with 6-fold increased risk (p = 0.004). Participants with both abnormal MPI and HRR (n = 8) were at highest risk for cardiac events (38%) whereas those with HRR ≥ 40%, irrespective of MPI abnormalities (n = 234), were at extremely low risk (≤ 1%, log-rank p < 0.001). Conclusions: In DIAD, abnormal HRR to adenosine infusion is an independent predictor of cardiac events. This easily obtained marker of cardiac autonomic neuropathy identifies asymptomatic patients with type 2 diabetes mellitus at increased risk, particularly when associated with abnormal MPI, who may warrant further testing and more aggressive cardiovascular risk factor management.

Abstract

Objectives: To evaluate the prevalence of hepatitis B virus (HBV) infection, exposure, and immunity among Asian American college students as a basis for evaluating HBV screening and vaccination policy. Participants and Methods: Self-identified Asian American college students aged 18 years or older were examined. Serological tests of HBV surface antigens, antibodies to HBV core antigens (anti-HBc), and antibodies to HBV surface antigens (anti-HBs) were used to determine HBV infection and immunization prevalence. Results: Among US-born students (n = 66), none was infected with HBV, 68% (n = 45) had immunity from vaccination, and 1 student had evidence of past exposure to HBV. Among foreign-born students (n = 142), 4% (n = 5) had evidence of chronic HBV infection, 62% (n = 88) had immunity from vaccination, and 19% (n = 27) had results indicating past exposure to HBV. Asian American college students showed very little knowledge of HBV vaccination; 43% reported that they had received vaccination, whereas 50% did not know whether they had received it or not. Conclusions: The prevalence of current and past HBV infection among foreign-born Asian American college students is significantly higher (p <.01), than US-born students. The lack of awareness of their HBV-infected status points out the importance of routine HBV screening of high-risk populations such as Asian students.

Abstract

Spots of blood are routinely collected from newborn babies onto filter paper called Guthrie cards and used to screen for metabolic and genetic disorders. The archived dried blood spots are an important and precious resource for genomic research. Whole genome amplification of dried blood spot DNA has been used to provide DNA for genome-wide SNP genotyping. Here we describe a 96 well format procedure to extract DNA from a portion of a dried blood spot that provides sufficient unamplified genomic DNA for genome-wide single nucleotide polymorphism (SNP) genotyping. We show that SNP genotyping of the unamplified DNA is more robust than genotyping amplified dried blood spot DNA, is comparable in cost, and can be done with thousands of samples. This procedure can be used for genome-wide association studies and other large-scale genomic analyses that require robust, high-accuracy genotyping of dried blood spot DNA.

Abstract

OVERVIEW: Despite the decline in the incidence of central nervous system disease associated with HIV, distal sensory peripheral (DSP) neuropathy continues to be prevalent in this population, causing debilitating symptoms and affecting quality of life. Patients typically present with numbness, tingling, burning pain, and loss of sensation in the toes and soles of their feet. Although this complication causes loss of protective function and puts patients at elevated risk for injury, infection, and falls, foot care for people with HIV is often overlooked. This article reviews what is known about DSP neuropathy in HIV and discusses relevant foot care guidelines, adopted from the literature on other conditions associated with neuropathic foot disorders.

Abstract

OBJECTIVE: HIV infection and illicit drug use are each associated with diminished cognitive performance. This study examined the separate and interactive effects of HIV and recent illicit drug use on verbal memory, processing speed, and executive function in the multicenter Women's Interagency HIV Study. METHODS: Participants included 952 HIV-infected and 443 HIV-uninfected women (mean age = 42.8, 64% African-American). Outcome measures included the Hopkins Verbal Learning Test - Revised and the Stroop test. Three drug use groups were compared: recent illicit drug users (cocaine or heroin use in past 6 months, n = 140), former users (lifetime cocaine or heroin use but not in past 6 months, n = 651), and nonusers (no lifetime use of cocaine or heroin, n = 604). RESULTS: The typical pattern of recent drug use was daily or weekly smoking of crack cocaine. HIV infection and recent illicit drug use were each associated with worse verbal learning and memory (P < 0.05). Importantly, there was an interaction between HIV serostatus and recent illicit drug use such that recent illicit drug use (compared with nonuse) negatively impacted verbal learning and memory only in HIV-infected women (P < 0.01). There was no interaction between HIV serostatus and illicit drug use on processing speed or executive function on the Stroop test. CONCLUSIONS: The interaction between HIV serostatus and recent illicit drug use on verbal learning and memory suggests a potential synergistic neurotoxicity that may affect the neural circuitry underlying performance on these tasks.

Abstract

OBJECTIVE: The Met allele of the catechol-O-methyltransferase (COMT) Val158Met polymorphism is associated with increased cortical dopamine and risk behaviors including illicit drug use and unprotected sex. Therefore, we examined whether or not the distribution of the Val158Met genotype differed between HIV-infected and HIV-uninfected women. DESIGN: Cross-sectional analysis using data from the Women's Interagency HIV Study (WIHS), the largest longitudinal cohort study of HIV in women. METHODS: We conducted an Armitage-Cochran test and logistic regression to compare genotype frequencies between 1848 HIV-infected and 612 HIV-uninfected women in WIHS. RESULTS: The likelihood of carrying one or two Met alleles was greater in HIV-infected women (61%) compared to HIV-uninfected women (54%), Z = -3.60, P <0.001. CONCLUSION: We report the novel finding of an association between the Val158Met genotype and HIV serostatus that may be mediated through the impact of dopamine function on propensity for risk-taking.

Abstract

Background: Provisions of the Affordable Care Act that increase hospitals' financial accountability for preventable readmissions have heightened interest in identifying system-level interventions to reduce readmissions. Objectives: To determine the relationship between hospital nursing; that is, nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Method and Design: Analysis of linked data from California, New Jersey, and Pennsylvania that included information on the organization of hospital nursing (ie, work environment, patient-to-nurse ratios, and proportion of nurses holding a BSN degree) from a survey of nurses, as well as patient discharge data, and American Hospital Association Annual Survey data. Robust logistic regression was used to estimate the relationship between nursing factors and 30-day readmission. Results: Nearly 1 quarter of heart failure index admissions [23.3% (n = 39,954)], 19.1% (n = 12,131) of myocardial infarction admissions, and 17.8% (n = 25,169) of pneumonia admissions were readmitted within 30 days. Each additional patient per nurse in the average nurse's workload was associated with a 7% higher odds of readmission for heart failure [odds ratio (OR) = 1.07; confidence interval CI, 1.05-1.09], 6% for pneumonia patients (OR = 1.06; CI, 1.03-1.09), and 9% for myocardial infarction patients (OR = 1.09; CI, 1.05-1.13). Care in a hospital with a good versus poor work environment was associated with odds of readmission that were 7% lower for heart failure (OR = 0.93; CI, 0.89-0.97), 6% lower for myocardial infarction (OR = 0.94; CI, 0.88-0.98), and 10% lower for pneumonia (OR = 0.90; CI, 0.85-0.96) patients. Conclusions: Improving nurses' work environments and staffing may be effective interventions for preventing readmissions.

Abstract

Background: Provisions of the Affordable Care Act that increase hospitals' financial accountability for preventable readmissions have heightened interest in identifying system-level interventions to reduce readmissions. OBJECTIVES: To determine the relationship between hospital nursing; that is, nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Method and Design: Analysis of linked data from California, New Jersey, and Pennsylvania that included information on the organization of hospital nursing (ie, work environment, patient-to-nurse ratios, and proportion of nurses holding a BSN degree) from a survey of nurses, as well as patient discharge data, and American Hospital Association Annual Survey data. Robust logistic regression was used to estimate the relationship between nursing factors and 30-day readmission. Results: Nearly 1 quarter of heart failure index admissions [23.3% (n=39,954)], 19.1% (n=12,131) of myocardial infarction admissions, and 17.8% (n=25,169) of pneumonia admissions were readmitted within 30 days. Each additional patient per nurse in the average nurse's workload was associated with a 7% higher odds of readmission for heart failure [odds ratio (OR)=1.07; confidence interval CI, 1.05-1.09], 6% for pneumonia patients (OR=1.06; CI, 1.03-1.09), and 9% for myocardial infarction patients (OR=1.09; CI, 1.05-1.13). Care in a hospital with a good versus poor work environment was associated with odds of readmission that were 7% lower for heart failure (OR=0.93; CI, 0.89-0.97), 6% lower for myocardial infarction (OR=0.94; CI, 0.88-0.98), and 10% lower for pneumonia (OR=0.90; CI, 0.85-0.96) patients. Conclusions: Improving nurses' work environments and staffing may be effective interventions for preventing readmissions.

Abstract

The objective of this study was to analyze hospital staff nurses' shift length, scheduling characteristics, and nurse reported safety and quality. A secondary analysis of a large nurse survey linked with hospital administrative data was conducted. More than 22 000 registered nurses' reports of shift length and scheduling characteristics were examined. Extended shift lengths were associated with higher odds of reporting poor quality and safety. Policies aimed at reducing the use of extended shifts may be advisable.

Abstract

Proteinuria is associated with adverse clinical outcomes in HIV infection. Here we evaluated whether APOL1 risk alleles, previously associated with advanced kidney disease, are independently associated with proteinuria in HIV infection in a cross-sectional study of HIV-infected women in the Women's Interagency HIV Study. We estimated the percent difference in urine protein excretion and odds of proteinuria (≥200 mg/g) associated with two versus one or no APOL1 risk allele using linear and logistic regression, respectively. Of 1285 women successfully genotyped, 379 carried one and 80 carried two risk alleles. Proteinuria was present in 124 women, 78 of whom had proteinuria confirmed on a second sample. In women without prior AIDS, two risk alleles were independently associated with a 69% higher urine protein excretion (95% confidence interval (CI): 36, 108) and five-fold higher odds of proteinuria (95% CI: 2.45, 10.37) as compared with one or no risk allele. No association was found in women with prior AIDS. Analyses in which women with impaired kidney function were excluded and proteinuria was confirmed by a second urine sample yielded similar estimates. Thus, APOL1 risk alleles are associated with significant proteinuria in HIV-infected persons without prior clinical AIDS, independent of clinical factors traditionally associated with proteinuria. Trials are needed to determine whether APOL1 genotyping identifies individuals who could benefit from earlier intervention to prevent overt renal disease.

Abstract

Sources related to demand for nurses data are more difficult to find, and also more difficult to interpret relative to supply. When people talk about the "demand" for nurses, they can have multiple concepts in mind. Even if the concept is well-defined, the data may not clearly align with the intended concept. As with data on RN supply, the relative value of different data sources on RN demand depends on the goals of the data collection and analysis. To measure the current demand for nurses, employer surveys are ideal. Such surveys can explicitly obtain information about vacant positions to measure the total demand for nurses.

Abstract

Objective:: The aims of this study were to describe the shift lengths of pediatric nurses and to measure the association of shift length with nurse job outcomes, nurse-reported patient outcomes, and nurse-assessed safety and quality of care in hospitals. Background:: Long work hours have been linked with poor patient outcomes in adult patient populations, but little is known about the relationship in pediatric settings. Methods:: A secondary analysis of cross-sectional nurse survey data was conducted. Our analysis focused on 3710 registered nurses who worked in 342 acute care hospitals that treated children. Results:: Most pediatric nurses worked 12-hour shifts, especially in intensive care settings. Nurses who worked extended shifts of more than 13 hours reported worse job outcomes and lower quality and safety for patients compared with nurses who worked 8-hour shifts. Conclusions:: Allocating resources to nursing to improve working hours may be a productive strategy for administrators to improve the health and well-being of pediatric patients and nurses.

Abstract

Objectives: Depression is very common in patients with heart failure (HF). However, little is known about how depression influences self-care (ie, adherence to diet, medication and symptom management behaviors) in ethnic minority patients with HF. The purpose of this study was to explore the meaning of depression and how depressive symptoms affect self-care in an ethnic minority Black population with HF. Design: In this mixed methods study, 30 Black patients (mean age 59.63 SD 615 years; 60% male) participated in in-depth interviews about HF self-care and mood; and completed standardized instruments measuring self-care, depression, and physical functioning. Thematic content analysis was used to explore the meaning of depression and elicit themes about how depressive symptoms affect daily self-care practices. Qualitative and quantitative data were integrated in the final analytic phase. Results: Self-care was very poor in the sample. Forty percent of the sample had evidence of depressive symptoms (PHQ-9≥10; mean 7.59 ± 6 5.29, range 0 to 22). Individuals with depressive symptoms had poorer self-care (P=.029). In the qualitative data, individuals described depressive mood as "feeling blue⋯ like I failed." "Overwhelming" sadness and fatigue influenced self-care and resulted in treatment delays. For many, spirituality was central to coping with sadness. Few discussed depressive feelings with health care providers. Conclusions: Depression in ethnic minority patients with HF may be difficult to assess. Research to develop and test culturally sensitive interventions is critically needed, since depression influences self-care and minority populations continue to experience poorer outcomes.

Abstract

We studied how older people describe others with cognitive impairment. Forty-two focus groups represented African Americans, American Indians, Chinese Americans, Latinos, Vietnamese Americans, and Whites other than Latinos (Whites) (N=396, ages 50+), in nine locations in the United States of America. Axial coding connected categories and identified themes. The constant comparison method compared themes across ethnic groups. African Americans, American Indians and Whites emphasised memory loss. African Americans, American Indians, Latinos and Whites stressed withdrawal, isolation and repetitive speech. African Americans, American Indians, Vietnamese Americans and Whites emphasised 'slow thinking'. Only Whites described mood swings and personality changes. Many participants attributed dementia to stress. Terms describing others with dementia included 'Alzheimer's', 'dementia', 'senile' and 'crazy'. Euphemisms were common ('senior moment', 'old timer's disease'). Responses focused on memory, with limited mention of other cognitive functions. Differences among ethnic groups in descriptions of cognitive health and cognitive impairment underscore the need to tailor public health messages about cognitive health to ways that people construe its loss, and to their interest in maintaining it, so that messages and terms used are familiar, understandable and relevant to the groups for which they are designed. Health promotion efforts should develop ethnically sensitive ways to address the widely held misperception that even serious cognitive impairment is a normal characteristic of ageing and also to address stigma associated with cognitive impairment.