Cathy Lally

Medical, reproductive and psychosocial experiences of women diagnosed with von Willebrand's disease receiving care in haemophilia treatment centres: a case–control study

Summary. Objective:  To assess the medical, gynaecological and reproductive experiences of women with von Willebrands disease (VWD) and to evaluate the impact of VWD on mental health and life activities.

Predictors of PFOA Levels in a Community Surrounding a Chemical Plant

Background Perfluorooctanoic acid (PFOA) is considered a probable human carcinogen by the U.S. Environmental Protection Agency. It does not exist in nature but has been used widely since World War II. It is present in the serum of most Americans at about 4–5 ng/mL, although the routes of exposure remain unknown. Objectives We examined predictors of PFOA in mid-Ohio Valley residents living near a chemical plant that until recently released large quantities of PFOA into the environment, contaminating drinking water. Methods We studied 69,030 residents in six contaminated water districts who participated in a 2005–2006 survey involving a questionnaire and blood tests. Of these, 64,251 had complete data on PFOA and covariates. We also analyzed a subset (71%) for whom we had occupational history. We ran linear regression models to determine serum PFOA predictors. Results Mean PFOA serum level was 83.0 ng/mL (median, 28.2). The most important predictors were current (median for all districts, 38.4; highest district, 224.1) and past (median, 18.6) residence in contaminated water districts, and current (median, 147.8) and past (median, 74.9) employment at the chemical plant (R2 model = 0.55). PFOA was higher for males, those consuming local vegetables, and those using well water rather than public water, and lower for those using bottled water. PFOA was higher at younger and older ages. Conclusions PFOA levels in this population varied with distance of residence from the plant and employment at the plant. Effects of age and sex reflected prior findings. Effects of other demographic and lifestyle covariates were relatively weak.

Parity and coronary heart disease among women in the American Cancer Society CPS II population.

Four of five cohort studies have shown an increase in cardio-vascular disease with increased parity, after control for a number of cardiovascular risk factors. The effect has been observed primarily in categories of four or more livebirths. To analyze this issue further, we conducted an analysis of 585,445 women from the American Cancer Society Cancer Prevention Survey II (CPS II). There were 4,787 deaths from coronary heart disease (International Classification of Diseases Codes 410-414) among these women during the follow-up period from 1981 to 1989. After controlling for a number of cardiovascular risk factors, we found no increased trend in heart disease with increased parity. Rare ratios for women with no live births or 1, 2, 3, 4, 5, and 6 or more livebirths were 1.00, 0.95, 0.89, 0.82, 0.94, 0.98, 0.94, respectively. Without control over confounders, however, we observed an increased risk for the highest party category (rate ratio = 1.18; 95% confidence interval = 1.04-1.34). Positive findings for parity to date have been found primarily in cohort studies representative of the general population, whereas our own data and another earlier negative study among nurses came from more select populations likely to be relatively homogeneous for socioeconomic variables. Positive findings in the literature may be due, at least in part, to confounding by unmeasured variables related to socioeconomic status.

The Role of the t-PA I/D and PAI-1 4G/5G Polymorphisms in African-American Adults With a Diagnosis of Myocardial Infarction or Venous Thromboembolism

To determine whether or not the PAI-1 4G/5G and t-PA I/D polymorphisms in African-Americans were linked to cardiovascular disease, the association of these polymorphisms to disease expression was analyzed in a recently completed case-control study of myocardial infarction or venous thromboembolism among African-Americans. All African-Americans patients with a history of venous thromboembolism attending an anticoagulant clinic, and patients with a history of a MI attending a cardiology clinic at a large local urban public hospital were eligible for inclusion as cases in the study. In this study it was observed that there was a statistically significant association between the D allele of the t-PA I/D polymorphism and venous thromboembolism and a nonsignificant association between the D allele and myocardial infarction among African-Americans. t-PA antigen levels were statistically significantly higher among both myocardial infarction and venous thromboembolism cases compared with control subjects. The genotypes were unrelated to t-PA plasma levels. There was no association between either myocardial infarction or venous thromboembolism and the 4G/5G PAI-1 genotype. It was also found that genotype frequencies for both PAI-1 4G/5G and t-PA I/D polymorphisms in African-American adults were different from those reported for both U.S. Causcians and Europeans.

A Survey of Gynecologists Concerning Menorrhagia: Perceptions of Bleeding Disorders as a Possible Cause

We sought to determine perceptions and practices of American gynecologists when treating with a woman complaining of menorrhagia, specifically with regard to an underlying bleeding disorder as a potential cause. A mail survey of Georgia members of the American College of Obstetricians and Gynecologists was conducted. The survey response was 52%, and the analysis includes 376 physicians who reported seeing at least one gynecological patient per week. On average, respondents were in practice 20 years and reported that 8% of their patient population complain of menorrhagia. Virtually all physicians reported employing a menstrual history as a starting point for the workup for menorrhagia, and 95% order a hemoglobin/hematocrit determination. About 50% of physicians considered saturating three tampons/pads per 4 hours as excessive, although the criterion varied widely (range 0-24 per 4 hours, SD = 3). The diagnoses considered most likely among reproductive age women were anovulatory bleeding or benign lesions or that the heavy bleeding was within normal limits. Only 4% of physicians would consider von Willebrand disease (VWD) for this age group (women of reproductive age). Among girls near menarche, physicians overwhelmingly consider anovulatory bleeding or bleeding within normal limits the likely diagnoses, and 16% would consider VWD in this age group. Only rarely (3%) do surveyed physicians refer menorrhagia patients to other specialists. Most respondents believe that most menorrhagia is caused by anovulation or is within normal limits. Bleeding disorders are believed to be a rare cause of menorrhagia.

New gene variants associated with venous thrombosis: a replication study in White and Black Americans

Summary.  Background: We evaluated 10 single‐nucleotide polymorphisms (SNPs) identified in three European case–control studies as risk factors for venous thrombosis. Objectives: We sought to replicate the positive findings from this report among Whites and to evaluate the association of these SNPs with venous thrombosis for the first time among Blacks. Patient/methods: These SNPs were evaluated in a case–control study of deep vein thrombosis and pulmonary embolism that included 1076 cases and 1239 controls. About 50% of subjects were African Americans. We measured plasma factor (F) XI on a subset of subjects. Results: Among Whites, positive findings for rs13146272 in the CYP4V2 gene, for rs3087505 in the KLKB1 gene and for rs3756008 and rs2036914 in the F11 gene were found. We did not find significant associations for rs2227589 in the SERPINC1 gene and for rs1613662 in the GP6 gene. Among Blacks, rs2036914 in F11 and rs670659 in RGS7 were related to venous thrombosis, but the study had limited statistical power for many SNPs. Among Blacks, plasma FXI was related to two SNPs and the OR relating to the 90th percentile of the control distribution of plasma FXI was 2.6 (95% CI, 1.4, 5.0). Conclusions: Our study supports the finding that genetic variants in the F11 gene are risk factors for venous thrombosis among both Whites and Blacks, although the findings in Blacks require confirmation. A meta‐analysis of five case–control studies indicates that rs2227589 in the SERPINC1 gene, rs13146272 in the CYP4V2 gene and rs1613662 in the GP6 gene are risk factors for venous thrombosis among Whites.

Hormonal contraception, sickle cell trait, and risk for venous thromboembolism among African American women

OBJECTIVE We evaluated the effect of oral and other hormonal contraceptive (HC) use on venous thromboembolism risk among African American women and investigated whether the association was modified by the sickle cell trait. STUDY DESIGN We report the findings of a case-control study that included 60 African American women with an idiopathic, first episode of venous thromboembolism and 196 African American controls. RESULTS The odds of current HC use compared with noncurrent use contrasting cases and controls is 3.8 (95% confidence interval [CI], 1.7-8.1; P < .001). Among subjects with sickle cell trait, the odds ratio is higher (odds ratio [OR], 6.7; 95% CI, 1.0-43) than the odds ratio among subjects without sickle cell trait (OR, 2.6; 95% CI, 1.1-6.2), but the difference is not statistically significant. CONCLUSION This study provides persuasive evidence that hormonal contraceptive use increases venous thromboembolism risk among African American women and that the increase in risk may be larger among women with sickle cell trait.

The impact of co-morbid conditions on family history of venous thromboembolism in Whites and Blacks

INTRODUCTION Our objectives were to compare the magnitude of family history as a risk factor for venous thromboembolism (VTE) risk between Blacks and Whites, and to assess the impact of co-morbid conditions on familial risk for VTE. MATERIALS AND METHODS We used data from the Genetic Attributes Thrombosis Epidemiology (GATE) study, a matched case-control study which enrolled Blacks and Whites aged 18-70years in Atlanta, Georgia. A total of 1,094 case patients with a deep vein thrombosis (DVT) or pulmonary embolism (PE) and 1,264 control patients were interviewed about their family history. RESULTS Family history of VTE was a statistically significant risk factor for VTE among Blacks (odds ratio (OR)=2.9, 95% confidence interval (CI) 2.0-4.1; P value<0.0001) and among Whites (OR=2.7, 95% CI 1.9-3.7; P value<0.0001); among Blacks and Whites who were obese or had hypertension; among Blacks who had diabetes mellitus or cancer; as well as among males and females, and across all age categories. Family history of VTE increased the risk of VTE among Blacks with cancer by about 6-fold, whereas among Blacks without cancer the increased risk due to a positive family history was about 3-fold; a 2-fold relative difference. In addition, family history was a risk factor for VTE among case patients with DVT only or with PE only. The effect of family history generally was stronger among those with recurrent episodes of VTE compared with a first episode of VTE. For example, family history of any VTE was a strong risk factor among Black females with recurrent VTE compared with Black females with first VTE (OR=3.9, 95% CI 2.0-7.5; P value<0.0001). CONCLUSION Our study indicated that the adjusted attributable fraction for VTE was 16.9% among Blacks vs. 18.3% among Whites, and certain co-morbid conditions could further increase the risk of VTE associated with a positive family history of VTE.

Randomized Trial of an Integrated Behavioral Health Home: The Health Outcomes Management and Evaluation (HOME) Study

OBJECTIVE Behavioral health homes provide primary care health services to patients with serious mental illness treated in community mental health settings. The objective of this study was to compare quality and outcomes of care between an integrated behavioral health home and usual care. METHOD The study was a randomized trial of a behavioral health home developed as a partnership between a community mental health center and a Federally Qualified Health Center. A total of 447 patients with a serious mental illness and one or more cardiometabolic risk factors were randomly assigned to either the behavioral health home or usual care for 12 months. Participants in the behavioral health home received integrated medical care on-site from a nurse practitioner and a full-time nurse care manager subcontracted through the health center. RESULTS Compared with usual care, the behavioral health home was associated with significant improvements in quality of cardiometabolic care, concordance of treatment with the chronic care model, and use of preventive services. For most cardiometabolic and general medical outcomes, both groups demonstrated improvement, although there were no statistically significant differences between the two groups over time. CONCLUSIONS The results suggest that it is possible, even under challenging real-world conditions, to improve quality of care for patients with serious mental illness and cardiovascular risk factors. Improving quality of medical care may be necessary, but not sufficient, to improve the full range of medical outcomes in this vulnerable population.

Use of mobile technology in a community mental health setting.

Introduction mHealth holds promise in transforming care for people with serious mental illness (SMI) and other disadvantaged populations. However, information about the rates of smartphone ownership and usage of mobile health apps among people with SMI is limited. The objective of this research is to examine the current ownership, usage patterns, and existing barriers to mobile health interventions for people with SMI treated in a public sector community mental health setting and to compare the findings with national usage patterns from the general population. Methods A survey was conducted to determine rates of ownership of smartphone devices among people with SMI. Surveys were administered to 100 patients with SMI at an outpatient psychiatric clinic. Results were compared with respondents to the 2012 Pew Survey of mobile phone usage. Results A total of 85% of participants reported that they owned a cell phone; of those, 37% reported that they owned a smartphone, as compared with 53% of respondents to the Pew Survey and 44% of socioeconomically disadvantaged respondents to the Pew Survey. Discussion While cell phone ownership is common among people with SMI, their adoption of smartphone technology lags behind that of the general population primarily due to cost barriers. Efforts to use mHealth in these populations need to recognize current mobile ownership patterns while planning for anticipated expansion of new technologies to poor populations as cost barriers are reduced in the coming years.