Publications

Abstract

Objective: The objective of this study was to test the hypothesis that sexual risk behavior would increase following initiation of antiretroviral therapy (ART) in Kenyan female sex workers (FSWs). Design: Prospective cohort study. Setting: FSW cohort in Mombasa, Kenya, 1993-2008. Subjects: Eight hundred and ninety-eight women contributed HIV-1-seropositive follow-up visits, of whom 129 initiated ART. Intervention: Beginning in March 2004, ART was provided to women qualifying for treatment according to Kenyan National Guidelines. Participants received sexual risk reduction education and free condoms at every visit. Main Outcome Measures: Main outcome measures included unprotected intercourse, abstinence, 100% condom use, number of sexual partners, and frequency of sex. Outcomes were evaluated at monthly follow-up visits using a 1-week recall interval. Results: Compared with non-ART-exposed follow-up, visits following ART initiation were not associated with an increase in unprotected sex [adjusted odds ratio (AOR) 0.86, 95% confidence interval (CI) 0.62-1.19, P = 0.4]. There was a nonsignificant decrease in abstinence (AOR 0.81, 95% CI 0.65-1.01, P = 0.07), which was offset by a substantial increase in 100% condom use (AOR 1.54, 95% CI 1.07-2.20, P = 0.02). Numbers of sex partners and frequency of sex were similar before versus after starting ART. A trend for decreased sexually transmitted infections following ART initiation provides additional support for the validity of the self-reported behavioral outcomes (AOR 0.67, 95% CI 0.44-1.02, P = 0.06). Conclusion: In the setting of ongoing risk reduction education and provision of free condoms, initiation of ART was not associated with increased sexual risk behavior in this cohort of Kenyan FSWs.

Abstract

BACKGROUND: Whether triglyceride-mediated pathways are causally relevant to coronary heart disease is uncertain. We studied a genetic variant that regulates triglyceride concentration to help judge likelihood of causality.METHODS: We assessed the -1131T>C (rs662799) promoter polymorphism of the apolipoprotein A5 (APOA5) gene in relation to triglyceride concentration, several other risk factors, and risk of coronary heart disease. We compared disease risk for genetically-raised triglyceride concentration (20,842 patients with coronary heart disease, 35,206 controls) with that recorded for equivalent differences in circulating triglyceride concentration in prospective studies (302 430 participants with no history of cardiovascular disease; 12,785 incident cases of coronary heart disease during 2.79 million person-years at risk). We analysed -1131T>C in 1795 people without a history of cardiovascular disease who had information about lipoprotein concentration and diameter obtained by nuclear magnetic resonance spectroscopy.FINDINGS: The minor allele frequency of -1131T>C was 8% (95% CI 7-9). -1131T>C was not significantly associated with several non-lipid risk factors or LDL cholesterol, and it was modestly associated with lower HDL cholesterol (mean difference per C allele 3.5% [95% CI 2.6-4.6]; 0.053 mmol/L [0.039-0.068]), lower apolipoprotein AI (1.3% [0.3-2.3]; 0.023 g/L [0.005-0.041]), and higher apolipoprotein B (3.2% [1.3-5.1]; 0.027 g/L [0.011-0.043]). By contrast, for every C allele inherited, mean triglyceride concentration was 16.0% (95% CI 12.9-18.7), or 0.25 mmol/L (0.20-0.29), higher (p=4.4x10(-24)). The odds ratio for coronary heart disease was 1.18 (95% CI 1.11-1.26; p=2.6x10(-7)) per C allele, which was concordant with the hazard ratio of 1.10 (95% CI 1.08-1.12) per 16% higher triglyceride concentration recorded in prospective studies. -1131T>C was significantly associated with higher VLDL particle concentration (mean difference per C allele 12.2 nmol/L [95% CI 7.7-16.7]; p=9.3x10(-8)) and smaller HDL particle size (0.14 nm [0.08-0.20]; p=7.0x10(-5)), factors that could mediate the effects of triglyceride.INTERPRETATION: These data are consistent with a causal association between triglyceride-mediated pathways and coronary heart disease.FUNDING: British Heart Foundation, UK Medical Research Council, Novartis.

Abstract

Background. Antiretroviral scale-up is increasing in resource-constrained settings. To date, few studies have explored the barriers and facilitators of adherence to ART in these settings. Facilitators and barriers of antiretroviral adherence in Peru are not completely understood. Methods. At two clinics that serve a large number of HIV-positive individuals in Lima, Peru, 31 in-depth interviews were carried out in 2006 with adult HIV-positive individuals receiving ART. Purposive sampling was used to recruit the participants. Interviews were transcribed and coded using two Spanish-speaking researchers and a content analysis approach to identify themes in the data. Results. Among the participants, 28/31 (90%) were male, 25/31 (81%) were self-identified as mestizo, and 19/31 (61%) had an education above high school. The most frequently discussed barriers to adherence included side effects, simply forgetting, inconvenience, dietary requirements, being away from home, and fear of disclosure/stigma. The most frequently discussed facilitators to adherence included having a fixed routine, understanding the need for compliance, seeing positive results, treatment knowledge, and faith in treatment. Conclusions. Overall, these findings were similar to the facilitators and challenges experienced by individuals on ART in other resource constrained settings. Further treatment support tools and networks should be developed to decrease the challenges of ART adherence for HIV-positive individuals in Lima, Peru.

Abstract

In view of their role in licensing opioid treatment programs (OTPs), state opioid treatment authorities (SOTAs) are in a unique position to influence how OTPs address their patients' alcohol abuse. Using data from a telephone survey of SOTAs from the District of Columbia and states that have at least one OTP (n = 46), this study examines the extent to which SOTAs address alcohol abuse in their respective state policies and guidelines for OTPs. Findings indicate that 27 states have overall measures on how to address patients' problematic alcohol use, 23 states require or recommend alcohol education to be provided to all patients, and 17 states have stipulations that address specific actions to be taken if patients present at daily dosing under the influence of alcohol. Although SOTAs generally rate alcohol of at least moderate importance in formulating regulations, many of their policies and guidelines do not deal with various alcohol-related services and issues.

Abstract

We sought to identify factors associated with delayed diagnosis of human immunodeficiency virus (HIV; testing HIV-seropositive 6 months or more after HIV seroconversion), by comparing delayed testers to non-delayed testers (persons who were diagnosed within 6 months of HIV seroconversion), in King County, Washington among men who have sex with men (MSM). Participants were recruited from HIV testing sites in the Seattle area. Delayed testing status was determined by the Serologic Testing Algorithm for Recent HIV Seroconversion or a self-reported previous HIV- negative test. Quantitative data on sociodemographic characteristics, health history, and drug-use and sexual behaviors were collected via computer-assisted self-interviews. Qualitative semi-structured interviews regarding testing and risk behaviors were also conducted. Multivariate analysis was used to identify factors associated with delayed diagnosis. Content analysis was used to establish themes in the qualitative data. Out of the 77 HIV-seropositive MSM in this sample, 39 (51%) had evidence of delayed diagnosis. Factors associated with delayed testing included being African-American, homeless, "out" to 50% or less people about male-male sex, and having only one sex partner in the past 6 months. Delayed testers often cited HIV-related sickness as their reason for testing and fear and wanting to be in denial of their HIV status as reasons for not testing. Delayed testers frequently did not identify as part of the MSM community, did not recognize that they were at risk for HIV acquisition, and did not feel a responsibility to themselves or others to disclose their HIV status. This study illustrates the need to further explore circumstances around delayed diagnosis in MSM and develop outreach methods and prevention messages targeted specifically to this potentially highly marginalized population in order to detect HIV infections earlier, provide HIV care, and prevent new infections.

Abstract

Abusive head trauma (AHT) has greater mortality and morbidity than any other form of physical abuse. Therefore, early recognition and accurate diagnosis are essential for comprehensive investigation and appropriate treatment of infants who present with this devastating traumatic injury. Advanced practice nurses need to have a thorough understanding of AHT in order to promptly and accurately assess and manage these infants. Using a case-based approach, the epidemiology, pathophysiology, mechanisms of injury, clinical presentation, diagnosis, and treatment of AHT are described. This article also discusses AHT prevention and implications for advanced practice nurses caring for these patients.

Abstract

The purpose of this descriptive phenomenological study was to describe homeless adolescent mothers' experiences of caring for their children while living in a shelter. Eight homeless adolescent mothers participated in the study. Data were analyzed using Colaizzi [Colaizzi, P. (1978). Psychological research as the phenomenologist views it. In R. S. Valle & M. King (Eds.) Existential Foundations of Psychology (chapter 3). New York, NY: Oxford University Press]. Five themes were generated: (a) tough and troubling times, (b) acting out, (c) wishing it undone, (d) hostile encounters, and (e) steering clear. Nurses working with homeless families may help these young mothers cope with the demands of shelter living while keeping in mind that distinctive support needs may arise during different times of the homeless experience.

Abstract

Forced sex is a public health issue affecting many college women. Despite physical and mental health consequences, and multiple prevention programs on college campuses, most sexual violence goes unreported (Fisher, Daigle, Cullen, & Turner, 2003). The purpose of this research was to determine the significant attitudes and beliefs that are associated with reporting of forced sexual experiences. Guided by the Theory of Planned Behavior (TPB), the study used a predictive exploratory design to explore the association of intention to report forced sex with attitudes and beliefs (Ajzen, 1991). A convenience sample of 144 African-American women who were attending a private college in the south completed a survey. Women who expressed more favorable attitudes towards reporting, perceived reporting as being supported by important referents, and perceived more control over reporting, reported stronger intentions to report forced sex. The analysis supported the utility of TPB in predicting the intention to report forced sex by African-American college women. Theoretically significant and clinically relevant prevention strategies should incorporate important referents, address salient beliefs, and determine ways to increase perceived behavioral control.

Abstract

Objectives: To investigate the arachidonate 5-lipoxygenase-activating protein (ALOX5AP) gene as a potential modifier gene for coronary heart disease (CHD) in patients with familial hypercholesterolemia (FH). Background: The ALOX5AP gene is required for the synthesis of leukotrienes, a protein family involved in inflammatory responses. Recently, genetic variation in this gene was shown to be associated with myocardial infarction in an Icelandic and British population. Since FH is characterized by severely increased levels of plasma low-density lipoprotein (LDL) cholesterol levels, chronic inflammation of the arterial wall, and subsequent premature CHD, the ALOX5AP gene could be an important modifier gene for CHD in FH. Methods: In a cohort of 1817 FH patients, we reconstructed two four-marker haplotypes, previously defined in Icelandic (HapA) and British (HapB) individuals. The haplotypes were inferred with PHASE and the associations between the haplotypes and CHD were analyzed with a Cox proportional hazards model, adjusted for year of birth, sex, and smoking. Results: HapB had a frequency of 6.9% and 8.2% in the group without and with CHD, respectively, conferring a hazard ratio of 1.48 (95% CI 1.17-1.89, p = 0.001). This association was predominantly found in patients with LDL cholesterol levels above the median (HR 1.82, 95% CI 1.20-2.76, p = 0.005). HapA was not associated with CHD. Conclusion: We conclude that genetic variation in the ALOX5AP gene contributes to CHD risk in patients with FH. Our findings emphasize the important role of inflammation in the pathogenesis of early CHD in this disorder, particularly in patients with more severely raised LDL cholesterol levels.

Abstract

Objective: Heart failure (HF) self-care requires both knowledge and skill, but little attention has been given to identify how to improve skill in HF self-care. The objective was to assess what self-care skills patients with HF perceive that they need and how they developed the skills needed to perform self-care. Methods: Data from 85 adults with chronic HF enrolled in 3 prior studies were analyzed using qualitative descriptive meta-analysis techniques. Themes were reexamined using within study and across-study analyses and translated to create a broader and more complete understanding of the development of skill in HF self-care. Results: Tactical and situational skills are needed to perform adequate self-care. Skill in self-care evolves over time and with practice as patients learn how to make self-care practices fit into their daily lives. Proficiency in these skills was acquired primarily through input from family and friends. Health care professionals rarely made significant contributions to the learning of essential skills. Conclusion: Traditional patient education does not support self-care skill development in patients with HF. New patient teaching strategies are needed that support the development of tactical and situational skills, foster coherence, and use trusted resources. Research testing coaching interventions that target skill-building tactics, such as role-playing in specific situations, are needed.

Abstract

Objective: To evaluate the relationships between the amount and type of dietary fat and intermediate age-related macular degeneration (AMD). Design: Women aged 50 to 79 years with high and low lutein intake from 3 sites of the Women's Health Initiative Observational Study were recruited into the Carotenoids in Age-Related Eye Disease Study. Fat intake from 1994 through 1998 was estimated using food frequency questionnaires, and AMD was assessed photographically from 2001 through 2004. Results: Intakes of ω-6 and ω-3 polyunsaturated fatty acids, which were highly correlated (r=0.8), were associated with approximately 2-fold higher prevalence of intermediate AMD in high vs low quintiles. However, monounsaturated fatty acid intake was associated with lower prevalence. Age interactions were often observed. In women younger than 75 years (n=1325), total fat and saturated fatty acid intakes were associated with increased prevalence of AMD (multivariate adjusted odds ratios [95% confidence interval] for intermediate AMD, 1.7 [1.0-2.7] for quintile 5 vs quintile 1 for total fat [P=.10 for trend] and 1.6 [0.7-3.6] for saturated fatty acids [P=.23 for trend]). The associations were reversed in older women. Conclusions: These results support a growing body of evidence suggesting that diets high in several types of fat may contribute to the risk of intermediate AMD and that diets high in monounsaturated fatty acids may be protective.

Abstract

Background: Transforming growth factor ß (TGFß) signaling has been shown to promote myocardial fibrosis and remodeling with coronary artery disease (CAD), and previous studies show a major role for fibrosis in the initiation of malignant ventricular arrhythmias (VA) and sudden cardiac arrest (SCA). Common single nucleotide polymorphisms (SNPs) in TGFß pathway genes may be associated with SCA. Objective: We examined the association of common SNPs among 12 candidate genes in the TGFß pathway with the risk of SCA. Methods: SNPs (n = 617) were genotyped in a case-control study comparing 89 patients with CAD and SCA caused by VA to 520 healthy control subjects. Results: Nineteen SNPs among 5 genes (TGFB2, TGFBR2, SMAD1, SMAD3, SMAD6) were associated with SCA after adjustment for age and sex. After permutation analysis to account for multiple testing, a single SNP in TGFBR2 (rs9838682) was associated with SCA (odds ratio: 1.66, 95% confidence interval: 1.08 to 2.54, P = .02). Conclusion: We show an association between a common TGFBR2 polymorphism and risk of SCA caused by VA in the setting of CAD. If validated, these findings support the role of genetic variation in TGFß signaling in SCA susceptibility.

Abstract

Purpose:To examine perceptions about aging well in the context of cognitive health among a large and diverse group of older adults.Design and Methods:Forty-two focus groups were conducted with older adults living in the community (N = 396; White, African American, American Indian, Chinese, Vietnamese, and Hispanic). Participant descriptions of "someone who you think is aging well" were analyzed. Constant comparison methods examined themes by race/ethnicity.Results:There were notable race/ethnicity differences in perceptions of aging well. Compared with other racial/ethnic groups Chinese participants were more likely to emphasize relationships between mental outlook and physical abilities, Vietnamese participants were less likely to emphasize independent living. American Indians did not relate aging well to diet or physical activity. Important themes that emerged about aging well for all racial/ethnic groups were as follows: living to advanced age, having good physical health, having a positive mental outlook, being cognitively alert, having a good memory, and being socially involved.Implications:To promote cognitive health among diverse populations, communication strategies should focus on shared perceptions of aging well, such as living to an advanced age with intact cognitive function, having a positive attitude, and being mobile. Health promotions may also create a range of culturally sensitive messages, targeted to views that are more salient among some racial/ethnic groups.

Abstract

Context Coronary artery disease (CAD) is the major cause of mortality and morbidity in patients with type 2 diabetes. But the utility of screening patients with type 2 diabetes for asymptomatic CAD is controversial. Objective To assess whether routine screening for CAD identifies patients with type 2 diabetes as being at high cardiac risk and whether it affects their cardiac outcomes. Design, Setting, and Patients The Detection of Ischemia in Asymptomatic Diabetics (DIAD) study is a randomized controlled trial in which 1123 participants with type 2 diabetes and no symptoms of CAD were randomly assigned to be screened with adenosine-stress radionuclide myocardial perfusion imaging (MPI) or not to be screened. Participants were recruited from diabetes clinics and practices and prospectively followed up from August 2000 to September 2007. Main Outcome Measure Cardiac death or nonfatal myocardial infarction (MI). Results The cumulative cardiac event rate was 2.9% over a mean (SD) follow-up of 4.8 (0.9) years for an average of 0.6% per year. Seven nonfatal MIs and 8 cardiac deaths (2.7%) occurred among the screened group and 10 nonfatal MIs and 7 cardiac deaths (3.0%) among the not-screened group (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.44-1.88; P=.73). Of those in the screened group, 409 participants with normal results and 50 with small MPI defects had lower event rates than the 33 with moderate or large MPI defects; 0.4% per year vs 2.4% per year (HR, 6.3; 95% CI, 1.9-20.1; P=.001). Nevertheless, the positive predictive value of having moderate or large MPI defects was only 12%. The overall rate of coronary revascularization was low in both groups: 31 (5.5%) in the screened group and 44 (7.8%) in the unscreened group (HR, 0.71; 95% CI, 0.45-1.1; P=.14). During the course of study there was a significant and equivalent increase in primary medical prevention in both groups. Conclusion In this contemporary study population of patients with diabetes, the cardiac event rates were low and were not significantly reduced by MPI screening for myocardial ischemia over 4.8 years. Trial Registration clinicaltrials.gov Identifier: NCT00769275