Jeffrey E. Korte

Prevention of gonorrhea and chlamydia through behavioral intervention: Results of a two-year controlled randomized trial in minority women

Background: Sexually transmitted disease (STD), including AIDS, disproportionately affects African-American and Hispanic women. Goal: To evaluate efficacy of standard and enhanced (addition of optional support groups) gender- and culture-specific, small-group behavioral interventions, compared to interactive STD counseling, in high risk minority women for two years. Methods: Women with a non-viral STD were treated and enrolled in a randomized trial. Follow-up screens and interviews occurred at 6 months, 1 year, 18 months (short interview, optional exam) and 2 years. The primary outcome was subsequent infection with chlamydia and/or gonorrhea. Secondary outcomes included risky sexual behaviors. We employed logistic regression based on intention-to-treat. Results: Data from 775 women were included; the retention rate was 91%. Adjusted infection rates were higher in the controls in Year 1 (26.8%), Year 2 (23.1%), and cumulatively (39.8%) than in the enhanced (15.4%, P = 0.004; 14.8%, P < 0.03; 23.7%, P < 0.001, respectively) and standard (15.7%, P = 0.006; 14.7%, P = 0.03; 26.2%, P < 0.008, respectively) intervention arms at these time points. Enhanced-intervention women who opted to attend support groups (attendees) had the lowest adjusted infection rates in Year 1 (12.0%) and cumulatively (21.8%). Intervention women in general, but particularly attendees, were significantly less likely than controls to have repeat infections. Multiple partners and unprotected sex with an untreated or incompletely treated partner helped explain group differences in infection. Conclusions: Risk-reduction interventions significantly decreased both single and multiple infective episodes with chlamydia and/or gonorrhea and risky sexual behaviors in the two-year study period. Support-group attendance appeared to contribute additional risk reduction in Year 1.

Behaviors changed by intervention are associated with reduced STD recurrence: the importance of context in measurement.

Background Evaluations of STD/HIV interventions incorporating behavioral and biologic outcomes have not reported strong correspondence. Goal The goal of the study was to demonstrate that behaviors, measured comprehensively, are associated with infection and to delineate the behaviors responsible for reduced infection rates in Project SAFE (Sexual Awareness For Everyone). Study Design Follow-up data from an intervention trial were analyzed to determine: (1) study versus control differences in complex risk behaviors and (2) the overall relationship between these behaviors and infection status (chlamydia and/or gonorrhea), with use of multiple logistic regression. Results Lower infection rates among 249 women who received intervention (compared with 228 controls) were explained by reduced-risk status in 5 modifiable behaviors. The 0 to 12–month logistic regression model (including sex with untreated partner [OR = 5.6], lack of mutual monogamy [OR = 2.4], unsafe sex [OR = 1.9], rapid partner turnover [OR = 2.7], and douching after sex [OR = 1.9]) correctly predicted infection status for 75.3% of participants (71.8% of infected, 76.2% of uninfected). Women in nonmutually monogamous unions who had sex with partners who were untreated or incompletely treated were 13 times more likely to be infected than those who were monogamous and avoided sex with an untreated/incompletely treated partner. Conclusion This intervention reduced infection rates by maintaining low-risk behaviors and changing high-risk behaviors. We elucidated the complex relationship between behavior and infection by incorporating context into variable conceptualization and considering several behaviors simultaneously.

Diagnostic Assessment of Mycoplasma genitalium in Culture-Positive Women

ABSTRACT Detection of Mycoplasma genitalium-mediated, chlamydia-negative nongonococcal urethritis and other M. genitalium-linked infectious etiologies has been very challenging. Although M. genitalium is considered a leading cause of genitourinary symptoms in men and women, extreme difficulties in its cultivation due to its highly fastidious nature and the lack of routine and effective diagnostic tests have slowed the generation of clinical data which directly implicate the presence of M. genitalium in disease pathogenesis. In this study, we compared enzyme-linked immunosorbent assays (ELISAs) and immunoblot and PCR assays in M. genitalium culture-positive women over 1 to 3 years of clinical visits to determine the usefulness of independent diagnostic strategies. Furthermore, the value of combinatorial diagnostic assessments is described, which provides insights into the dynamics of M. genitalium-host interactions. Overall, we show that neither ELISA nor PCR, alone or in combination, provides the sensitivity required to confidently predict the existence of viable M. genitalium organisms in cervical and vaginal samples. Additionally, culture-positive women exhibited a range of antibody responsiveness to M. genitalium based upon ELISA and immunoblot assessments, indicating immune diversity among this high-risk population.

Cervicitis and genitourinary symptoms in women culture positive for Mycoplasma genitalium.

Problem  Mycoplasma genitalium has been associated with male urethritis. We sought to relate M. genitalium to genitourinary signs and symptoms in women.

Predictors of long-acting reversible contraception use among unmarried young adults

OBJECTIVE The objective of the study was to improve the understanding of long-acting reversible contraception (LARC) use patterns among unmarried, young adults at risk of unintended pregnancy. STUDY DESIGN We performed a secondary data analysis of a national survey conducted by Guttmacher Institute of unmarried women and men aged 18-29 years. LARC is defined as an intrauterine device (IUD) or implant. Predictors of LARC use and IUD knowledge among those at risk for unintended pregnancy (n = 1222) were assessed using χ(2) analysis and logistic regression models. RESULTS LARC use was associated with older age, high IUD knowledge, and earlier onset of sexual activity. Respondents with high IUD knowledge were 6 times more likely to be current LARC users (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.4-28.8). Sociodemographic variables did not predict use. Respondents with lower education (OR, 1.76; 95% CI, 1.0-3.0), an external locus of control (OR, 1.6; 95% CI, 1.1-2.3), male sex (OR, 2.8; 95% CI, 1.9-4.1), and foreign language had less knowledge of IUD. CONCLUSION Increasing knowledge of IUD among certain groups may improve LARC use among young, unmarried adults and in turn decrease unintended pregnancy.

An Association Between Trichomonas vaginalis and High-Risk Human Papillomavirus in Rural Tanzanian Women Undergoing Cervical Cancer Screening

OBJECTIVE The goal of this study was to determine the prevalence of vaginitis and its association with high-risk human papillomavirus (HR HPV) in women undergoing cervical cancer screening in rural Tanzania. METHODS For the purpose of cervical cancer screening, cytology and HR HPV polymerase chain reaction data were collected from 324 women aged between 30 and 60 years. Microscopy and gram stains were used to detect yeast and bacterial vaginosis. Cervical nucleic acid amplification test specimens were collected for the detection of Trichomonas vaginalis (TV), Chlamydia trachomatis, and Neisseria gonorrhoeae. RESULTS The majority of women were married (320 of 324) and reported having a single sexual partner (270 of 324); the median age of participants was 41 years. HR HPV was detected in 42 participants. Forty-seven percent of women had vaginitis. Bacterial vaginosis was the most common infection (32.4%), followed by TV (10.4%), and yeast (6.8%). In multivariable logistic regression analysis, TV was associated with an increased risk of HR HPV (odds ratio, 4.2 [95% CI, 1.7-10.3]). Patients with TV were 6.5 times more likely to have HPV type 16 than patients negative for TV (50% vs 13.3%) (odds ratio, 6.5 [95% CI, 1.1-37]). CONCLUSIONS Among rural Tanzanian women who presented for cervical cancer screening, Trichomonas vaginitis was significantly associated with HR HPV infection (specifically type 16).

Adjunctive triple chronotherapy (combined total sleep deprivation, sleep phase advance, and bright light therapy) rapidly improves mood and suicidality in suicidal depressed inpatients: An open label pilot study

Previous studies have demonstrated that combined total sleep deprivation (Wake therapy), sleep phase advance, and bright light therapy (Triple Chronotherapy) produce a rapid and sustained antidepressant effect in acutely depressed individuals. To date no studies have explored the impact of the intervention on unipolar depressed individuals with acute concurrent suicidality. Participants were suicidal inpatients (N = 10, Mean age = 44 ± 16.4 SD, 6F) with unipolar depression. In addition to standard of care, they received open label Triple Chronotherapy. Participants underwent one night of total sleep deprivation (33-36 h), followed by a three-night sleep phase advance along with four 30-min sessions of bright light therapy (10,000 lux) each morning. Primary outcome measures included the 17 item Hamilton depression scale (HAM17), and the Columbia Suicide Severity Rating Scale (CSSRS), which were recorded at baseline prior to total sleep deprivation, and at protocol completion on day five. Both HAM17, and CSSRS scores were greatly reduced at the conclusion of the protocol. HAM17 scores dropped from a mean of 24.7 ± 4.2 SD at baseline to a mean of 9.4 ± 7.3 SD on day five (p = .002) with six of the ten individuals meeting criteria for remission. CSSRS scores dropped from a mean of 19.5 ± 8.5 SD at baseline to a mean of 7.2 ± 5.5 SD on day five (p = .01). The results of this small pilot trial demonstrate that adjunctive Triple Chronotherapy is feasible and tolerable in acutely suicidal and depressed inpatients. Limitations include a small number of participants, an open label design, and the lack of a comparison group. Randomized controlled studies are needed.

Relationship of abuse and pelvic inflammatory disease risk behavior in minority adolescents

Purpose Little is known about the relationship between minority adolescents experiences of sexual or physical abuse and the pathology of gynecological symptoms that might have an impact on the diagnosis of sexually transmitted disease (STD) or risk for pelvic inflammatory disease (PID). The objective of this study was to determine the relationship of sexual or physical abuse to the pathology of genitourinary symptoms that impact diagnoses of STD and risk for PID among Mexican American and African American adolescent women with a current STD. Methods Mexican American and African American adolescent women (n = 373) with an STD underwent a targeted physical exam and questioning regarding sexual or physical abuse, current genitourinary symptomatology, and risk behaviors known to be associated with PID to determine the relationship of sexual or physical abuse to the pathology of genitourinary symptoms that impact diagnoses of STD and risk for PID. Results Bivariate comparisons found that abused adolescents (n = 232) reported more behaviors associated with increased risk for PID, including earlier coitus, more sex partners, higher STD recurrence, and delayed health‐seeking behavior. Multivariate comparisons found that abused adolescents were more likely to report pathologic genitourinary symptomatology than those who were not abused. Clinicians reported more abnormal physical exams but did not make any more presumptive diagnoses of PID for abused than nonabused adolescents. Conclusions Delayed treatment for PID dramatically worsens future fertility and chronic pelvic pain. These findings demonstrate that abused adolescent women are at high risk for PID. Because of its considerable impact on risk for PID, an assessment for abuse is essential in clinical management of adolescent women with STD and diagnosis of PID.

Sexual problems among women with multiple sclerosis.

BACKGROUND Sexual problems are prevalently experienced by women with multiple sclerosis (MS) and have been investigated in several studies. The nature of sexual changes in MS is best defined as primary, secondary, and tertiary. OBJECTIVES The aim of this study was to investigate three levels of sexual problems (SP) in female patients with MS and to examine their relationship with various clinical and demographic variables. METHODS A total of 132 women with MS completed two questionnaires; demographic and clinical history, and Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19). Fatigue was evaluated by Fatigue (energy) sub-scale of Multiple Sclerosis Quality of Life-54 (MSQOL-54) questionnaire. General physical ability and frequency of sexual intercourse were also evaluated. RESULTS One hundred and fifteen patients (87.1%) reported primary SP. The most frequent symptoms of primary, secondary and tertiary sexual problems were delayed orgasm, spasticity and concern about partners sexual satisfaction, respectively. The MSISQ-19 total score was correlated with age(p=0.002), disease duration(p=0.010), marriage duration(p=0.001), fatigue(p<0.001), number of children(p=0.006), physical ability(p<0.001), education(p=0.006), economic status(p=0.002), number of times having sexual intercourse(p=0.007) and number of times approached by spouse for intercourse(p=0.012) in the last 30 days. CONCLUSIONS Sexual problems were prevalent among our participants. Appropriate management of SP depends on understanding the disturbed level.

Some Considerations for Excess Zeroes in Substance Abuse Research

Background: Count data collected in substance abuse research often come with an excess of “zeroes,” which are typically handled using zero-inflated regression models. However, there is a need to consider the design aspects of those studies before using such a statistical model to ascertain the sources of zeroes. Objectives: We sought to illustrate hurdle models as alternatives to zero-inflated models to validate a two-stage decision-making process in situations of “excess zeroes.” Methods: We use data from a study of 45 cocaine-dependent subjects where the primary scientific question was to evaluate whether study participation influences drug-seeking behavior. The outcome, “the frequency (count) of cocaine use days per week,” is bounded (ranging from 0 to 7). We fit and compare binomial, Poisson, negative binomial, and the hurdle version of these models to study the effect of gender, age, time, and study participation on cocaine use. Results: The hurdle binomial model provides the best fit. Gender and time are not predictive of use. Higher odds of use versus no use are associated with age; however once use is experienced, odds of further use decrease with increase in age. Participation was associated with higher odds of no-cocaine use; once there is use, participation reduced the odds of further use. Conclusion: Age and study participation are significantly predictive of cocaine-use behavior. Scientific Significance: The two-stage decision process as modeled by a hurdle binomial model (appropriate for bounded count data with excess zeroes) provides interesting insights into the study of covariate effects on count responses of substance use, when all enrolled subjects are believed to be “at-risk” of use.