Bonnie Faigeles

Statin Use During Ischemic Stroke Hospitalization Is Strongly Associated With Improved Poststroke Survival

Background and Purpose— Statins reduce infarct size in animal models of stroke and have been hypothesized to improve clinical outcomes after ischemic stroke. We examined the relationship between statin use before and during stroke hospitalization and poststroke survival. Methods— We analyzed records from 12 689 patients admitted with ischemic stroke to any of 17 hospitals in a large integrated healthcare delivery system between January 2000 and December 2007. We used multivariable survival analysis and grouped-treatment analysis, an instrumental variable method that uses treatment differences between facilities to avoid individual patient-level confounding. Results— Statin use before ischemic stroke hospitalization was associated with improved survival (hazard ratio, 0.85; 95% CI, 0.79–0.93; P<0.001), and use before and during hospitalization was associated with better rates of survival (hazard ratio, 0.59; 95% CI, 0.53–0.65; P<0.001). Patients taking a statin before their stroke who underwent statin withdrawal in the hospital had a substantially greater risk of death (hazard ratio, 2.5; 95% CI, 2.1–2.9; P<0.001). The benefit was greater for high-dose (>60 mg/day) statin use (hazard ratio, 0.43; 95% CI, 0.34–0.53; P<0.001) than for lower dose (<60 mg/day) statin use (hazard ratio, 0.60; 95% CI, 0.54–0.67; P<0.001; test for trend P<0.001), and earlier treatment in-hospital further improved survival. Grouped-treatment analysis showed that the association between statin use and survival cannot be explained by patient-level confounding. Conclusions— Statin use early in stroke hospitalization is strongly associated with improved poststroke survival, and statin withdrawal in the hospital, even for a brief period, is associated with worsened survival.

Reducing Postrelease HIV Risk among Male Prison Inmates A Peer-Led Intervention

Male prison inmates within 2 weeks of release were recruited to evaluate a prerelease HIV prevention intervention. A total of 414 inmates were randomly assigned to receive the intervention or to a comparison group. All participants completed a face-to-face survey at baseline; high rates of preincarceration at-risk behavior were reported. Follow-up telephone surveys were completed with 43% of participants; results support the effectiveness of the prerelease intervention. Men who received the intervention were significantly more likely to use a condom the first time they had sex after release from prison and also were less likely to have used drugs, injected drugs, or shared needles in the first 2 weeks after release from prison. Implications for the development, implementation, and evaluation of prison-based HIV prevention programs are discussed.

Collaborative Research to Prevent HIV among Male Prison Inmates and Their Female Partners

Despite the need for targeted HIV prevention interventions for prison inmates, institutional and access barriers have impeded development and evaluation of such programs. Over the past 6 years, the authors have developed a unique collaborative relationship to develop and evaluate HIV prevention interventions for prison inmates. The collaboration includes an academic research institution (the Center for AIDS Prevention Studies at the University of California, San Francisco), a community-based organization (Centerforce), and the staff and inmate peer educators inside a state prison. In this ongoing collaboration, the authors have developed and evaluated a series of HIV prevention interventions for prison inmates and for women who visit prison inmates. Results of these studies support the feasibility and effectiveness of HIV prevention programs for inmates and their partners both in prison and in the community. Access and institutional barriers to HIV intervention research in prisons can be overcome through the development of collaborative research partnerships.

Sex in the New World: An Empowerment Model for HIV Prevention in Latina Immigrant Women

In 1996, nearly 60% of U.S. AIDS cases among Latinas were attributed to unprotected sex with men. Economic disadvantage, language barriers, and strong cultural gender norms regarding sex exacerbate the risk for HIV infection among Latina immigrant women. Through a collaboration among scientists and providers, this study was designed to evaluate the impact of a multifaceted empowerment program for Latina immigrant women on HIV risk behaviors. Women (N = 74) were followed for the first 6 months of their participation and attended up to nine distinct types of activities (e.g., information meetings, friendship circles, and workshops). Although the program was not developed to specifically target HIV risk behaviors, women showed significant increases in sexual communication comfort, were less likely to maintain traditional sexual gender norms, and reported changes in decision-making power. Targeting broader sociocultural issues may increase the necessary skills for Latina women to prevent HIV infection from their sexual partners. Successful collaborations between scientists and providers are critical in developing effective, community-relevant interventions.

A simple protocol to prevent external ventricular drain infections.

BACKGROUND External ventricular drains (EVDs) are associated with high rates of infection, and EVD infections cause substantial morbidity and mortality. OBJECTIVE To determine whether the introduction of an evidence-based EVD infection control protocol could reduce the rate of EVD infections. METHODS This was a retrospective analysis of an EVD infection control protocol introduced in a tertiary care neurointensive care unit. We compared rates of cerebrospinal fluid culture positivity and ventriculitis for the 3 years before and 3 years after the introduction of an evidence-based EVD infection control protocol. A total of 262 EVD placements were analyzed, with a total of 2499 catheter-days. RESULTS The rate of cerebrospinal fluid culture positivity decreased from 9.8% (14 of 143; 11.43 per 1000 catheter-days) at baseline to 0.8% (1 of 119; 0.79 per 1000 catheter-days) in the EVD infection control protocol period (P = .001). The rate of ventriculitis decreased from 6.3% (9 of 143; 7.35 per 1000 catheter-days) to 0.8% (1 of 119; 0.79 per 1000 catheter-days; P = .02). CONCLUSION The introduction of a simple, evidence-based infection control protocol was associated with a dramatic reduction in the risk of EVD infection.

The Effectiveness of Peer HIV Education For Male Inmates Entering State Prison

Abstract Prisons and jails present an opportunity for HIV education because at-risk individuals who are underserved with HIV education and prevention services in the community are concentrated there. To be effective in changing risk behavior, however, HIV education within prisons must be appropriate and accessible to inmates, the majority of whom are members of ethnic minority groups. The purpose of this study was to describe the HIV-related knowledge, attitudes, and behavior of inmates entering a large state prison, and to evaluate the effectiveness of an HIV prevention intervention conducted by an HIV+ inmate peer educator compared to an intervention conducted by a professional HIV educator. The intervention was designed to educate inmates entering the prison about how the virus is transmitted and how infection can be prevented. Overall 2,295 male inmates participated in the evaluation. The two intervention groups had similar outcomes, both outperforming the no intervention group in intention to use con...

Data from the National AIDS Behavioral Surveys. I. Sexual risk for human immunodeficiency virus infection among women in high-risk cities.

Data from 3,482 women aged 18-49 living in 23 urban areas of the United States who participated in the 1990-1991 National AIDS Behavioral Surveys show that in the preceding year, approximately 15% engaged in sexual behavior that might expose them to the human immunodeficiency virus (HIV). Risk behaviors include having multiple sexual partners, having a risky main sexual partner or having both multiple partners and a risky main partner. An additional 17% of women with no other risk factor report that they do not know their main partners HIV risk status. Predictors of risk factors vary by ethnicity, and having multiple partners and having a risky main partner appear to have distinct sets of predictors. Single women are more likely than others to have multiple partners, and among white women, those with more than 12 years of education are more likely to have multiple partners. Among blacks and Hispanics, younger women are more likely than older women to have multiple partners. Among Hispanic women, married respondents and those with more than 12 years of education are more likely than others to have a risky main sexual partner; the latter pattern is reversed among white women, however, with those having less than 12 years of education being more likely to have a risky main sexual partner. In general, women with a risky main partner are the least likely to use condoms consistently.

Rapid Warfarin Reversal in the Setting of Intracranial Hemorrhage: A Comparison of Plasma, Recombinant Activated Factor VII, and Prothrombin Complex Concentrate

OBJECTIVE To compare the safety and effectiveness of three methods of reversing coagulopathic effects of warfarin in patients with potentially life-threatening intracranial hemorrhage. METHODS A retrospective electronic medical record review of 63 patients with warfarin-related intracranial hemorrhage between 2007 and 2010 in an integrated health care delivery system was conducted. The three methods of rapid warfarin reversal were fresh-frozen plasma (FFP), activated factor VII (FVIIa; NovoSevenRT [Novo Nordisk, Bagsværd, Denmark]), and prothrombin complex concentrate (PCC; BebulinVH [Baxter, Westlake Village, California, USA], ProfilnineSD [Grifols, North Carolina, USA]), each used adjunctively with vitamin K (Vit K, phytonadione). We determined times from reversal agent order to laboratory evidence of warfarin reversal (international normalized ratio [INR]) in the first 48 hours and compared INR rebound rates and complications in the first 48 hours. RESULTS Reversal with FFP took more than twice as long compared with FVIIa or PCC. To reach an INR of 1.3, mean (±SD) reversal times were 1933 ± 905 minutes for FFP, 784 ± 926 minutes for FVIIa, and 980 ± 1021 minutes for PCC (P < 0.001; P < 0.01 between FFP and FVIIa, P < 0.05 between FFP and PCC). INR rebound occurred in 0 of 31 patients for FFP, 4 of 8 for FVIIa, and 0 of 7 for PCC (P = 0.001). Complications were uncommon. FVIIa was 15 and 3.5 times as expensive as FFP and PCC, respectively. CONCLUSION As an adjunct to Vit K for rapid warfarin reversal, FVIIa and PCC appear more effective than FFP. Either FVIIa or PCC are reasonable options for reversal, but FVIIa is considerably more expensive and may have greater risk of INR rebound.

Smoking and Socioeconomic Status in a Population-Based Inner City Sample of African-Americans, Latinos and Whites

Objective To examine patterns of cigarette smoking among individuals of different socioeconomic status (SES) and ethnicity. Design A cross-sectional and longitudinal community-based random household sample. Methods Unmarried African-American, Latino and white men and women, aged 20–44 years, living in San Francisco in 1988–9 and in 1989–90, were surveyed regarding prior and current smoking. Evaluation of behaviors was based on responses to an interviewer reading questions related to the variables of interest. SES was primarily based on educational attainment. Results Overall, 40% of respondents smoked, with an inverse association in univariate analysis between smoking and educational attainment in each gender/ethnic subgroup, except for Latino men. After controlling for other variables, ethnicity and education predicted smoking: With Latinos as referent, whites [odds ratio (OR) = 3.2] and African-Americans (OR = 2.7) were more likely to smoke, and there was a consistent graded inverse association between educational attainment and smoking (P < 0.0001). Of smokers, after controlling for other variables, heavy smokers (≥ 1 pack/day compared with < 1 pack/day) were more likely to be older (P < 0.0001) and white (OR = 7.1) than African-American (OR = 1.8) or Latino (OR = 1.0), and there was a trend toward heavy smokers being less educated (P = 0.06). One year later, 1422 (80%) of the original participants were resurveyed. Of 563 baseline smokers, 96 (17%) reported having quit, with African-Americans less likely to quit than whites or Latinos (P < 0.05). Of 859 baseline nonsmokers, 34 (4%) had started to smoke 1 year later. Conclusions In a population-based inner city sample, the prevalence of smoking was considerable and there was a strong inverse association between smoking and educational attainment in almost all ethnic and gender subgroups. Further studies are needed to explore the possible reasons for these differences so that culturally sensitive risk factor interventions may be developed and tested.

Inpatient statin use predicts improved ischemic stroke discharge disposition

Objective: To determine whether statin use is associated with improved discharge disposition after ischemic stroke. Methods: We used generalized ordinal logistic regression to analyze discharge disposition among 12,689 patients with ischemic stroke over a 7-year period at 17 hospitals in an integrated care delivery system. We also analyzed treatment patterns by hospital to control for the possibility of confounding at the individual patient level. Results: Statin users before and during stroke hospitalization were more likely to have a good discharge outcome (odds ratio [OR] for discharge to home = 1.38, 95% confidence interval [CI] 1.25–1.52, p < 0.001; OR for discharge to home or institution = 2.08, 95% CI 1.72–2.51, p < 0.001). Patients who underwent statin withdrawal were less likely to have a good discharge outcome (OR for discharge to home = 0.77, 95% CI 0.63–0.94, p = 0.012; OR for discharge to home or institution = 0.43, 95% CI 0.33–0.55, p < 0.001). In grouped-treatment analysis, an instrumental variable method using treatment patterns by hospital, higher probability of inpatient statin use predicted a higher likelihood of discharge to home (OR = 2.56, 95% CI 1.71–3.85, p < 0.001). In last prior treatment analysis, a novel instrumental variable method, patients with a higher probability of statin use were more likely to have a good discharge outcome (OR for each better level of ordinal discharge outcome = 1.19, 95% CI 1.09–1.30, p = 0.001). Conclusions: Statin use is strongly associated with improved discharge disposition after ischemic stroke.