Heather J. Hoffman

Hookworm, Ascaris lumbricoides infection and polyparasitism associated with poor cognitive performance in Brazilian schoolchildren.

Objective  To investigate the relationship between hookworm and Ascaris lumbricoides infection and performance on three subsets of the Wechsler Intelligence Scale for Children – third edition (WISC‐III) (Digit Span, Arithmetic and Coding) and Raven Colored Progressive Matrices.

Is Frequent CD4+ T-Lymphocyte Count Monitoring Necessary for Persons With Counts ≥300 Cells/µL and HIV-1 Suppression?

Among patients infected with human immunodeficiency virus (HIV), those with HIV-1 RNA <200 copies/mL and CD4 counts ≥300 cells/µL had a 97.1% probability of maintaining durable CD4 ≥200 cells/µL for 4 years. When non-HIV causes of CD4 lymphopenia were excluded, the probability rose to 99.2%. Our data support less frequent CD4 monitoring during viral suppression.

Patient Navigation Significantly Reduces Delays in Breast Cancer Diagnosis in the District of Columbia

Background: Patient Navigation (PN) originated in Harlem as an intervention to help poor women overcome access barriers to timely breast cancer treatment. Despite rapid, nationally widespread adoption of PN, empirical evidence on its effectiveness is lacking. In 2005, National Cancer Institute initiated a multicenter PN Research Program (PNRP) to measure PN effectiveness for several cancers. The George Washington Cancer Institute, a project participant, established District of Columbia (DC)-PNRP to determine PNs ability to reduce breast cancer diagnostic time (number of days from abnormal screening to definitive diagnosis). Methods: A total of 2,601 women (1,047 navigated; 1,554 concurrent records-based nonnavigated) were examined for breast cancer from 2006 to 2010 at 9 hospitals/clinics in DC. Analyses included only women who reached complete diagnostic resolution. Differences in diagnostic time between navigation groups were tested with ANOVA models including categorical demographic and treatment variables. Log transformations normalized diagnostic time. Geometric means were estimated and compared using Tukey–Kramer P value adjustments. Results: Average—geometric mean [95% confidence interval (CI)]—diagnostic time (days) was significantly shorter for navigated, 25.1 (21.7, 29.0), than nonnavigated women, 42.1 (35.8, 49.6). Subanalyses revealed significantly shorter average diagnostic time for biopsied navigated women, 26.6 (21.8, 32.5) than biopsied nonnavigated women, 57.5 (46.3, 71.5). Among nonbiopsied women, diagnostic time was shorter for navigated, 27.2 (22.8, 32.4), than nonnavigated women, 34.9 (29.2, 41.7), but not statistically significant. Conclusions: Navigated women, especially those requiring biopsy, reached their diagnostic resolution significantly faster than nonnavigated women. Impact: Results support previous findings of PNs positive influence on health care. PN should be a reimbursable expense to assure continuation of PN programs. Cancer Epidemiol Biomarkers Prev; 21(10); 1655–63. ©2012 AACR.

Relation of Vitamin D Level to Maximal Oxygen Uptake in Adults

Low cardiorespiratory fitness and low serum 25-hydroxy vitamin D (25[OH]D) levels are associated with increased cardiovascular and all-cause mortality, but whether low 25(OH)D is independently associated with cardiorespiratory fitness in healthy adults is not known. We examined 25(OH)D levels and fitness in 200 healthy adults participating in a double-blind clinical trial investigating statins and muscle performance (STOMP study). Maximal aerobic exercise capacity (Vo₂(max)) was measured using metabolic gas analysis during graded treadmill exercise to exhaustion. 25(OH)D was measured using an enzyme-linked immunosorbent assay. Daily physical activity was assessed using the Paffenbarger Physical Activity Questionnaire. Serum 25(OH)D concentration was positively related to Vo₂(max) (r = 0.29, p = 0.0001), even after adjusting for relevant predictors (e.g., age, gender, and body mass index). There was also a significant interaction between 25(OH)D level and self-reported hours of moderate to vigorous physical activity (MVPA; p < 0.02). With each SD increase in 25(OH)D, Vo₂(max) increased by 2.6 ml/kg/min (p = 0.0001) when MVPA was low (16 hours/week) and 1.6 ml/kg/min (p <0.0004) when MVPA was moderate (35 hours/week) but only 0.01 ml/kg/min (p = 0.9) when MVPA was high (64 hours/week). In conclusion, serum 25(OH)D levels predict Vo₂(max) in adults; the effect is greatest in those with low levels of physical activity.

Introduction of rapid syphilis testing within prevention of mother-to-child transmission of HIV programs in Uganda and Zambia: a field acceptability and feasibility study.

Background:Given that integration of syphilis testing into prevention of mother-to-child transmission of HIV (PMTCT) programs can prevent adverse pregnancy outcomes, this study assessed feasibility and acceptability of introducing rapid syphilis testing (RST) into PMTCT services. Methods:RST was introduced into PMTCT programs in Zambia and Uganda. Using a pre–post intervention design, HIV and syphilis testing and treatment rates during the intervention were compared with baseline. Results:In Zambia, comparing baseline and intervention, 12,761 of 15,967 (79.9%) and 11,460 of 11,985 (95.6%) first-time antenatal care (ANC) attendees were tested for syphilis (P < 0.0001), 523 of 12,761 (4.1%) and 1050 of 11,460 (9.2%) women tested positive (P < 0.0001); and 267 of 523 (51.1%) and 1000 of 1050 (95.2%) syphilis-positive women were treated (P < 0.0001), respectively. Comparing baseline and intervention, 7479 of 7830 (95.5%) and 11,151 of 11,409 (97.7%) of ANC attendees were tested for HIV (P < 0.0001) and 1303 of 1326 (98.3%) and 2036 of 2034 (100.1%) of those testing positive received combination antiretroviral drugs or single-dose nevirapine prophylaxis (P < 0.0001). In Uganda, 13,131 of 14,540 (90.3%) women were tested for syphilis during intervention, with 690 of 13,131 (5.3%) positive and 715 of 690 (103.6%) treated. Syphilis baseline data were collected, but not included in analysis, as ANC syphilis testing before the study was not consistently practiced. Comparing baseline and intervention, 6479 of 6776 (95.6%) and 11,192 of 11,610 (96.4%) ANC attendees were tested for HIV (P = 0.0009) and 570 of 726 (78.5%) and 964 of 1153 (83.6%) received combination or single-dose prophylaxis (P = 0.007). In Zambia, 254 of 1050 (24.2%) syphilis-positive pregnant women were HIV-positive and 99 of 690 (14.3%) in Uganda. Conclusions:Integrating RST in PMTCT programs increases screening and treatment for syphilis among HIV-positive pregnant women and does not compromise HIV services.

Alcohol Withdrawal Pharmacotherapy for Inpatients with Medical Comorbidity

Abstract Studies show that symptom-triggered dosing is best for treatment of alcohol withdrawal in patients on chemical dependence wards without other illness. On general medical hospital wards, withdrawal may be affected by comorbid medical illness. A clinical trial was undertaken to determine whether there is a difference between symptom-triggered (ST) and fixed-schedule (FS) dosing of lorazepam in patients hospitalized on general medical wards at a university medical center. One hundred eighty-three subjects were assessed by their nurses with the Revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Subjects in the ST arm received lorazepam doses based on CIWA-Ar score. Subjects in the FS arm received scheduled lorazepam with tapering over 4 days. Symptom-triggered dosing for alcohol withdrawal for general medicine inpatients results in less lorazepam given with similar reduction in CIWA-Ar scores for the first 2 days, but a higher proportion of protocol errors.

Obesity and Outcomes Among Patients With Established Atrial Fibrillation

Atrial fibrillation (AF) and obesity have reached epidemic proportions. The impact of obesity on clinical outcomes in patients with established AF is unknown. We analyzed 2,492 patients in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study. Body mass index (BMI) was evaluated as a categorical variable (normal 18.5 to <25 kg/m(2), overweight 25 to <30 kg/m(2), obese >or=30 kg/m(2)). Rate of death from any cause was higher in the normal BMI group (5.8 per 100 patient-years) than in the overweight and obese groups (3.9 and 3.7, respectively). Cardiovascular death rate was highest in the normal BMI group (3.1 per 100 patient-years), lowest in the overweight group (1.5 per 100 patient-years), and intermediate in the obese group (2.1 per 100 patient-years). After adjustment for baseline factors, differences in risk of death from any cause were no longer significant. However, overweight remained associated with a lower risk of cardiovascular death (hazard ratio 0.47, p = 0.002). Obese patients were more likely to have an uncontrolled heart rate at rest, but rhythm-control strategy success was similar across BMI categories. In each BMI category, risk of death from any cause was similar for patients randomized to a rhythm- or rate-control strategy. In conclusion, in patients with established AF, overweight and obesity do not adversely affect overall survival. Obesity does not appear to affect the relative benefit of a rate- or rhythm-control strategy.

Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the District of Columbia.

Delays in follow‐up after breast cancer screening contribute to disparities in breast cancer outcomes. The objective of this research was to determine the impact of race/ethnicity and health insurance on diagnostic time, defined as number of days from suspicious finding to diagnostic resolution.

Provision of services and care for HIV-exposed infants: A comparison of maternal and child health clinic and HIV comprehensive care clinic models.

Objective:Prevention of Mother-to-Child Transmission of HIV programs require follow-up of HIV-exposed infants (HEI) for infant feeding support, prophylactic medicines, and HIV diagnosis for at least 18 months. Retention in care and receipt of HIV services are challenging in resource-limited settings. This study compared infant follow-up results when HEI services were provided within Maternal and Child Health (MCH) clinics or in specialized HIV Comprehensive Care Clinics (CCCs) in Kenya. Methods:This observational prospective cohort study enrolled HEI at 6–8 weeks of age in 2 purposively selected hospitals with similar characteristics but different models of service delivery. In the CCC model, HEI received immunization and growth monitoring in MCH but cotrimoxazole prophylaxis and infant HIV testing in the CCC. In the MCH model, all services were provided in the MCH. Data were collected at enrollment, 14 weeks, and 6, 9, and 12 months. Results:From April 2008 to April 2009, 184 HEI were enrolled in the CCC cohort and 179 in the MCH cohort. Infants in MCH were 1.14, 1.42, 1.95, and 1.29 times more likely to attend 14-week, 6-, 9-, and 12-month postnatal visits, respectively, and 2.24 times (95% confidence interval: 1.57 to 3.18) more likely to attend all 4 visits. Although infants in MCH were 1.33 times (95% confidence interval: 1.10 to 1.62) more likely to have HIV antibody testing at 1 year than CCC, there were no differences for polymerase chain reaction test or cotrimoxazole initiation at 6–8 weeks. Conclusions:HIV services integrated in MCH yield better follow-up of HEI than CCC.

High HIV incidence in the postpartum period sustains vertical transmission in settings with generalized epidemics: a cohort study in Southern Mozambique

Acute infection with HIV in the postpartum period results in a high risk of vertical transmission through breastfeeding. A study was done to determine the HIV incidence rate and associated risk factors among postpartum women in Southern Mozambique, where HIV prevalence among pregnant women is 21%.