Anindya K. De

FAMILY EDUCATION AND SUPPORT INTERVENTIONS IN HEART FAILURE: A PILOT STUDY

BACKGROUND Self-management of dietary sodium restriction by persons with heart failure (HF) is difficult and usually occurs within the home setting and within a family context. OBJECTIVE To compare a patient and family education (EDUC) intervention with a combined education and family partnership intervention (EDUC + FPI) for effects on improving dietary sodium self-management in persons with HF. METHODS Patients with HF and a family member (FM) were randomized to EDUC (n = 29 dyads) or EDUC + FPI (n = 32 dyads). Participants with HF were primarily White males with a mean age of 61 years (+/-12). The FMs were primarily women and spouses and had a mean age of 54 years (+/-17). Self-reported dietary sodium (Diet NA) intake and 24-hr urinary sodium (Urine NA) were measured at baseline (BL) and 3 months (3M) after intervention. Data were analyzed with descriptive statistics, generalized least squares regression, paired t test, and chi-square test. RESULTS Groups did not differ by age, gender, or clinical variables; however, family functioning (Family APGAR) scores were slightly higher in the EDUC + FPI group at BL. Both groups decreased Diet NA and Urine NA from BL to 3M; the EDUC + FPI group showed greater decrease in Urine NA and had a greater percentage of those who decreased Urine NA by at least 15% (p = .04). Regression analysis to predict Urine NA revealed a significant Group x Time interaction (p = .03) when accounting for time-varying measures of body mass index (p = .001). DISCUSSION A family-focused intervention may be useful in reducing dietary sodium intake in persons with HF. The Urine NA results support the importance of incorporating family-focused education and support interventions into HF care.

Detection of Recent HIV-1 Infection Using a New Limiting-Antigen Avidity Assay: Potential for HIV-1 Incidence Estimates and Avidity Maturation Studies

Background Accurate and reliable laboratory methods are needed for estimation of HIV-1 incidence to identify the high-risk populations and target and monitor prevention efforts. We previously described a single-well limiting-antigen avidity enzyme immunoassay (LAg-Avidity EIA) to detect recent HIV-1 infection. Methods We describe here further optimization and characterization of LAg-Avidity EIA, comparing it to the BED assay and a two-well avidity-index (AI) EIA. Specimen sets included longitudinal sera (n = 393), collected from 89 seroconverting individuals from 4 cohorts representing 4 HIV-1 subtypes, and sera from AIDS patients (n = 488) with or without TB co-infections from 3 different cohorts. Ninety seven HIV-1 positive specimens were purchased commercially. The BED assay, LAg-Avidity EIA, AI-EIA and HIV serology were performed, as needed. Results Monitoring quality control specimens indicated high reproducibility of the LAg-Avidity EIA with coefficient of variation of <10% in the dynamic range. The LAg-Avidity EIA has an overall mean duration of recency (ω) of 141 days (95% CI 119–160) at normalized optical density (ODn) cutoff of 1.0, with similar ω in different HIV-1 subtypes and populations (132 to 143 days). Antibody avidity kinetics were similar among individuals and subtypes by both the LAg-Avidity EIA and AI-EIA compared to the HIV-IgG levels measured by the BED assay. The false recent rate among individuals with AIDS was 0.2% with the LAg-Avidity EIA, compared to 2.9% with the BED assay. Western blot profiles of specimens with increasing avidity confirm accurate detection of recent HIV-1 infections. Conclusions These data demonstrate that the LAg-Avidity EIA is a promising assay with consistent ω in different populations and subtypes. The assay should be very useful for 1) estimating HIV-1 incidence in cross-sectional specimens as part of HIV surveillance, 2) identifying risk factors for recent infections, 3) measuring impact of prevention programs, and 4) studying avidity maturation during vaccine trials.

Keepin' it R.E.A.L.!: results of a mother-adolescent HIV prevention program.

Background: The concern that adolescents may be placing themselves at risk for contracting HIV has led to widespread public and parental support for HIV prevention programs. Several programs on increasing communication between parents and teenagers have been tested, but the study of the impact of these programs on resulting sexual behavior is lacking. Objective: To test the efficacy of two interventions for mothers and their adolescents in delaying initiation of sexual intercourse for youth who are not sexually active and encouraging the use of condoms among sexually active youth. Methods: Employed were a control group and two treatment groups: one based on social cognitive theory (SCT) and the other a life skills program (LSK) based on problem behavior theory. Assessments were conducted before the intervention (baseline) and at 4, 12, and 24 months after the baseline assessment. Results: Adolescents and their mothers (total N = 582) enrolled in the trial. At baseline, the adolescents ranged in age 11-14 years and were mostly male and African American. The mean age of the mothers was 37.9 years, and most were African American and single. The primary analyses showed no difference among groups in abstinence rates for adolescents. However, adolescents in the LSK group demonstrated an increase in the condom use rate, and those in the SCT and control groups scored higher on human immunodeficiency virus (HIV) knowledge than those in the LSK group. Mothers showed substantial increases over time in comfort talking about sex and self-efficacy. For HIV knowledge, mothers in the SCT group scored significantly higher than those in the LSK and control groups. Conclusion: The results of this study are comparable to previous studies that have included mothers in the HIV education of their adolescents. Although the program did not demonstrate a substantial effect on abstinence rates, increases were observed in condom use among adolescents and in mothers sex-based discussions and comfort in talking about sexual issues.

Vaccine effectiveness during a varicella outbreak among schoolchildren : Utah, 2002-2003

Objectives. In the context of a chickenpox outbreak involving 2 Utah elementary schools, we conducted an investigation to assess vaccine effectiveness, describe illness severity, and examine risk factors for breakthrough varicella (ie, varicella in those who have been vaccinated). Methods. All parents were asked to complete a questionnaire about their child’s medical history. Parents of children with recent varicella were interviewed, and vaccination records were verified. Lesions were submitted for polymerase chain reaction testing. Results. Questionnaires were returned for 558 (93%) of 597 students in school A and 924 (97%) of 952 students in school B. A total of 83 schoolchildren (57 unvaccinated and 26 vaccinated) had varicella during the October 2002 through February 2003 outbreak period. An additional 17 cases occurred among household contacts, including infants and adults. Polymerase chain reaction analysis recovered wild-type varicella. Vaccine effectiveness was 87%. With 1 notable exception, vaccinated children tended to have milder illness. Risk factors for breakthrough varicella included eczema, vaccination ≥5 years before the outbreak, and vaccination at ≤18 months of age. Restricting analysis to children vaccinated ≥5 years before the outbreak, those vaccinated at ≤18 months of age were more likely to develop breakthrough varicella (relative risk: 9.3; 95% confidence interval: 1.3–68.9). Conclusions. The vaccine, administered by >100 health care providers to 571 children during a 7-year time period, was effective. Risk factors for breakthrough varicella suggest some degree of biological interaction between age at vaccination and time since vaccination.

Multiple Imputation by Fully Conditional Specification for Dealing with Missing Data in a Large Epidemiologic Study

Missing data commonly occur in large epidemiologic studies. Ignoring incompleteness or handling the data inappropriately may bias study results, reduce power and efficiency, and alter important risk/benefit relationships. Standard ways of dealing with missing values, such as complete case analysis (CCA), are generally inappropriate due to the loss of precision and risk of bias. Multiple imputation by fully conditional specification (FCS MI) is a powerful and statistically valid method for creating imputations in large data sets which include both categorical and continuous variables. It specifies the multivariate imputation model on a variable-by-variable basis and offers a principled yet flexible method of addressing missing data, which is particularly useful for large data sets with complex data structures. However, FCS MI is still rarely used in epidemiology, and few practical resources exist to guide researchers in the implementation of this technique. We demonstrate the application of FCS MI in support of a large epidemiologic study evaluating national blood utilization patterns in a sub-Saharan African country. A number of practical tips and guidelines for implementing FCS MI based on this experience are described.

Recalibration of the Limiting Antigen Avidity EIA to Determine Mean Duration of Recent Infection in Divergent HIV-1 Subtypes

Background Mean duration of recent infection (MDRI) and misclassification of long-term HIV-1 infections, as proportion false recent (PFR), are critical parameters for laboratory-based assays for estimating HIV-1 incidence. Recent review of the data by us and others indicated that MDRI of LAg-Avidity EIA estimated previously required recalibration. We present here results of recalibration efforts using >250 seroconversion panels and multiple statistical methods to ensure accuracy and consensus. Methods A total of 2737 longitudinal specimens collected from 259 seroconverting individuals infected with diverse HIV-1 subtypes were tested with the LAg-Avidity EIA as previously described. Data were analyzed for determination of MDRI at ODn cutoffs of 1.0 to 2.0 using 7 statistical approaches and sub-analyzed by HIV-1 subtypes. In addition, 3740 specimens from individuals with infection >1 year, including 488 from patients with AIDS, were tested for PFR at varying cutoffs. Results Using different statistical methods, MDRI values ranged from 88–94 days at cutoff ODn = 1.0 to 177–183 days at ODn = 2.0. The MDRI values were similar by different methods suggesting coherence of different approaches. Testing for misclassification among long-term infections indicated that overall PFRs were 0.6% to 2.5% at increasing cutoffs of 1.0 to 2.0, respectively. Balancing the need for a longer MDRI and smaller PFR (<2.0%) suggests that a cutoff ODn = 1.5, corresponding to an MDRI of 130 days should be used for cross-sectional application. The MDRI varied among subtypes from 109 days (subtype A&D) to 152 days (subtype C). Conclusions Based on the new data and revised analysis, we recommend an ODn cutoff = 1.5 to classify recent and long-term infections, corresponding to an MDRI of 130 days (118–142). Determination of revised parameters for estimation of HIV-1 incidence should facilitate application of the LAg-Avidity EIA for worldwide use.

The Seattle angina questionnaire: reliability and validity in women with chronic stable angina.

Angina pectoris causes substantial psychological and functional disability and adversely effects health-related quality of life, particularly in women. Studies of cardiac disease-specific quality of life in women with coronary artery disease and angina are limited because little reliability and validity data for these instruments exist for women. Therefore, the purpose of this study was to examine reliability and validity of the Seattle Angina Questionnaire (SAQ), a cardiac disease-related quality-of-life measure, in a sample of women with chronic stable angina. A secondary analysis was performed on SAQ data from 175 women with a confirmed diagnosis of CAD and angina pectoris. The majority of the women were older, white, living with their spouse, had a previous acute myocardial infarction, and had undergone revascularization. The Cronbach alpha was used to assess reliability of the SAQs five subscales, and factor analysis was used to assess the SAQs validity. Results suggest that the SAQ is a reliable and valid quality-of-life measure in women with CAD. The physical limitations subscale factored into two separate factors, suggesting that the subscale measures two domains of physical function: self-care and exercise tolerance/mobility. Future research is needed to determine whether examining different combinations of SAQ items might provide a more sensitive assessment of cardiac disease-specific quality of life in women.

Identifying risk factors for underimmunization by using geocoding matched to census tracts: a statewide assessment of children in Hawaii.

OBJECTIVE. Obtaining childhood immunization coverage data for small geographic areas is difficult and resource-intensive, especially in the absence of comprehensive immunization registries. To identify factors that are associated with delayed immunization, we collected school-entry immunization records statewide and used geocoding to link to publicly available census tract sociodemographic data. METHODS. Immunization records were reviewed for children who were enrolled in all public and private school kindergarten programs in Hawaii in the 2002–2003 school year; immunization status at the time of the second birthday was determined. The main outcome variable was up-to-date status for the 4:3:1:3:3 vaccination series (4 doses of diphtheria-tetanus-pertussis, 3 doses of polio, 1 dose of measles-mumps-rubella, 3 doses of Haemophilus influenzae type b, and 3 doses of hepatitis B vaccines). Childrens home addresses were geocoded to census tracts; coverage rates by tract were mapped, and sociodemographic data from Census 2000 files were used to identify factors that were associated with delays in immunization. RESULTS. Records were obtained for 15275 of 15594 children registered in Hawaii kindergartens. Overall, 78% had completed their 4:3:1:3:3 series by their second birthday. Risk factors for delayed immunization included delayed immunization at 3 months of age, living in Maui County, living in a neighborhood where a low proportion of adults had postsecondary education, and living in a neighborhood where a high proportion of households spoke a language other than English at home. The majority (80%) of underimmunized children would have required only 1 additional visit to bring them up-to-date. CONCLUSIONS. Retrospective review of kindergarten-entry immunization data revealed geographic areas with lower immunization coverage, and geocoding to census tracts identified associated sociodemographic risk factors. This is a practical method for state or city health departments to identify pockets of need and to direct resources appropriately.

Risk factors for pediatric invasive pneumococcal disease in the Intermountain West, 1996-2002.

PURPOSE In response to concerns that the epidemiology of pediatric invasive pneumococcal disease (IPD) in the Intermountain West (i.e., Utah, Idaho, Wyoming, Montana, and parts of Arizona and Nevada) was poorly understood and might differ from elsewhere in the United States, a case-control study was undertaken to determine factors associated with IPD during 1996-2002. METHODS A telephone questionnaire was administered to parents of children comprising 120 cases identified through hospital records and to parents of 156 age-matched controls located by random-digit dialing. The unit of analysis was each matched case-control set. RESULTS Underlying chronic illness was reported for 32 (27%) of the cases. For previously healthy children, breastfeeding had a protective benefit (adjusted odds ratio: 0.2; 95% confidence interval [CI], 0.1-0.6), while a history of tympanostomy tube surgery was a risk factor (adjusted odds ratio: 12.6; 95% CI, 1.5-107.3). CONCLUSIONS The presence of an underlying chronic illness was the strongest risk factor for IPD. Except for a history of tympanostomy tube surgery, the factors associated with IPD in this investigation were similar to those reported from other geographic regions. Tympanostomy surgery might serve as a surrogate indicator for predisposition to recurrent otitis media or decreased ability to clear pneumococcal infection, raising risk for invasive disease. Pediatric clinicians should continue to encourage breastfeeding, and continued emphasis on pneumococcal vaccination should help prevent IPD.

Estimating Tanzania's National Met and Unmet Blood Demand From a Survey of a Representative Sample of Hospitals

Estimating blood demand to determine collection goals challenges many low-income countries. We sampled Tanzanian hospitals to estimate national blood demand. A representative sample based on probability proportional to size sampling of 42 of 273 (15%) Tanzanian transfusing hospitals was selected. Blood bank registers, patient medical records, and blood component disposition records were reviewed prospectively from June to September 2013 to determine the number of components requested and the number and proportion issued, not issued due to nonavailability, and not issued for other reasons. Data were estimated for an annual national estimate. Of an estimated 278 371 components requested in 2013, 6648 (2.4%) were not issued due to nonavailability, 34 591 (12.4%) were not issued for other reasons, and 244 535 (87.8%) were issued. Of these 278 371 components, 86 753 (31.2%) were requested by adult medical, 74 499 (26.8%) by pediatric medical, and 57 312 (20.6%) by obstetric units. In these 3 units, the proportion of units not issued due to nonavailability was 1.8%. Private (4.1%) and large (6%) hospitals had the largest proportion of units not issued because of nonavailability. Of 244 535 issued components, 91 690 (37.5%) were collected, tested, and issued from blood banks that are not part of the Tanzania National Blood Transfusion Services (TNBTS). Nearly 98% of blood component demand was met. However, a large portion of the blood supply for the hospitals came from non-TNBTS blood banks. TNBTS could increase availability of safe blood through assuring the quality of donor selection and donation testing at non-TNBTS blood banks.