Romina Kee

Cerebrospinal Fluid Abnormalities in Patients with Syphilis: Association with Clinical and Laboratory Features

OBJECTIVE To define clinical and laboratory features that identify patients with neurosyphilis. METHODS Subjects (n=326) with syphilis but no previous neurosyphilis who met 1993 Centers for Disease Control and Prevention criteria for lumbar puncture underwent standardized history, neurological examination, venipuncture, and lumbar puncture. Neurosyphilis was defined as a cerebrospinal fluid (CSF) white blood cell count >20 cells/ microL or reactive CSF Venereal Disease Research Laboratory (VDRL) test result. RESULTS Sixty-five subjects (20.1%) had neurosyphilis. Early syphilis increased the odds of neurosyphilis in univariate but not multivariate analyses. In multivariate analyses, serum rapid plasma reagin (RPR) titer > or =1 : 32 increased the odds of neurosyphilis 10.85-fold in human immunodeficiency virus (HIV)-uninfected subjects and 5.98-fold in HIV-infected subjects. A peripheral blood CD4+ T cell count < or =350 cells/ microL conferred 3.10-fold increased odds of neurosyphilis in HIV-infected subjects. Similar results were obtained when neurosyphilis was more stringently defined as a reactive CSF VDRL test result. CONCLUSION Serum RPR titer helps predict the likelihood of neurosyphilis. HIV-induced immune impairment may increase the risk of neurosyphilis.

Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults: A Randomized Trial

CONTEXT Homeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services. OBJECTIVE To assess the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical illnesses. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial conducted at a public teaching hospital and a private, nonprofit hospital in Chicago, Illinois. Participants were 407 social worker-referred homeless adults with chronic medical illnesses (89% of referrals) from September 2003 until May 2006, with follow-up through December 2007. Analysis was by intention-to-treat. INTERVENTION Housing offered as transitional housing after hospitalization discharge, followed by placement in long-term housing; case management offered on-site at primary study sites, transitional housing, and stable housing sites. Usual care participants received standard discharge planning from hospital social workers. MAIN OUTCOME MEASURES Hospitalizations, hospital days, and emergency department visits measured using electronic surveillance, medical records, and interviews. Models were adjusted for baseline differences in demographics, insurance status, prior hospitalization or emergency department visit, human immunodeficiency virus infection, current use of alcohol or other drugs, mental health symptoms, and other factors. RESULTS The analytic sample (n = 405 [n = 201 for the intervention group, n = 204 for the usual care group]) was 78% men and 78% African American, with a median duration of homelessness of 30 months. After 18 months, 73% of participants had at least 1 hospitalization or emergency department visit. Compared with the usual care group, the intervention group had unadjusted annualized mean reductions of 0.5 hospitalizations (95% confidence interval [CI], -1.2 to 0.2), 2.7 fewer hospital days (95% CI, -5.6 to 0.2), and 1.2 fewer emergency department visits (95% CI, -2.4 to 0.03). Adjusting for baseline covariates, compared with the usual care group, the intervention group had a relative reduction of 29% in hospitalizations (95% CI, 10% to 44%), 29% in hospital days (95% CI, 8% to 45%), and 24% in emergency department visits (95% CI, 3% to 40%). CONCLUSION After adjustment, offering housing and case management to a population of homeless adults with chronic medical illnesses resulted in fewer hospital days and emergency department visits, compared with usual care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00490581.

Acceptability of human papillomavirus immunization.

The purpose of this study was to examine the attitudes about hypothetical human papillomavirus (HPV) vaccines in two groups of women in clinical settings. Twenty adolescent women attending an urban community adolescent health clinic and 20 adult women attending a city health department sexually transmitted disease (STD) clinic were recruited to participate in individual interviews. Adolescents were 14-18 years of age (mean 15.6), 75% nonHispanic white, and 75% sexually experienced. Adults were 20-50 years of age (mean 33.6), 95% African American, and all were sexually experienced. As part of the interview, participants ranked nine hypothetical HPV vaccines in order of acceptability. Each vaccine was uniquely defined as a function of cost (

Human papillomavirus, genital warts, Pap smears, and cervical cancer: Knowledge and beliefs of adolescent and adult women

150,

Etiology of Genital Ulcers and Prevalence of Human Immunodeficiency Virus Coinfection in 10 US Cities

50, or free), efficacy (50% or 90%), disease targeted (genital warts, cervical cancer, or both), and physician recommendation (not mentioned by a physician or specifically recommended). Rankings by adolescents and adults were highly concordant (Spearman rho = 0.9). Efficacy, physicians recommendation, and cost influenced rankings most strongly. Ranking decisions were often based on complex decision making, in which all characteristics were considered simultaneously. These findings suggest that certain features of an HPV vaccine might significantly affect vaccine acceptability. Vaccine efficacy, physician endorsement, and cost were particularly salient issues.

Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter?

The high prevalence of genital warts, human papillomavirus (HPV), and the viruss cancer-causing potential warrant that women be well informed about these conditions and measures to prevent them. The purpose of this descriptive study was to examine womens knowledge and beliefs about genital warts, HPV, cervical cancer, and Pap tests. We interviewed 40 women recruited from health clinics in Chicago (20 adults) and Indianapolis (20 adolescents) about these issues. Audiotapes of the interviews were transcribed and analyzed. Among both the adults and adolescents there was a good deal of misunderstanding about symptoms associated with genital warts, about the purpose of Pap smears, and about the association of genital HPV with abnormal Pap smears and cervical cancer. The gaps in womens understanding about this potentially deadly infection suggest the need for more comprehensive education about preventing genital HPV, the infections possible sequelae, and the significance of Pap screening for cancer detection and prevention.The high prevalence of genital warts, human papillomavirus (HPV), and the viruss cancer-causing potential warrant that women be well informed about these conditions and measures to prevent them. The purpose of this descriptive study was to examine womens knowledge and beliefs about genital warts, HPV, cervical cancer, and Pap tests. We interviewed 40 women recruited from health clinics in Chicago (20 adults) and Indianapolis (20 adolescents) about these issues. Audiotapes of the interviews were transcribed and analyzed. Among both the adults and adolescents there was a good deal of misunderstanding about symptoms associated with genital warts, about the purpose of Pap smears, and about the association of genital HPV with abnormal Pap smears and cervical cancer. The gaps in womens understanding about this potentially deadly infection suggest the need for more comprehensive education about preventing genital HPV, the infections possible sequelae, and the significance of Pap screening for cancer detection and prevention.

The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized Controlled Trial

To determine the etiology of genital ulcers and to assess the prevalence of human immunodeficiency virus (HIV) infection in ulcer patients in 10 US cities, ulcer and serum specimens were collected from approximately 50 ulcer patients at a sexually transmitted disease clinic in each city. Ulcer specimens were tested using a multiplex polymerase chain reaction assay to detect Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV); sera were tested for antibody to HIV. H. ducreyi was detected in ulcer specimens from patients in Memphis (20% of specimens) and Chicago (12%). T. pallidum was detected in ulcer specimens from every city except Los Angeles (median, 9% of specimens; range, 0%-46%). HSV was detected in >/=50% of specimens from all cities except Memphis (42%). HIV seroprevalence in ulcer patients was 6% (range by city, 0%-18%). These data suggest that chancroid is prevalent in some US cities and that persons with genital ulcers should be a focus of HIV prevention activities.

Effect of Screening for Partner Violence on Women's Quality of Life: A Randomized Controlled Trial

To identify factors that affect normalization of laboratory measures after treatment for neurosyphilis, 59 subjects with neurosyphilis underwent repeated lumbar punctures and venipunctures after completion of therapy. The median duration of follow-up was 6.9 months. Stepwise Cox regression models were used to determine the influence of clinical and laboratory features on normalization of cerebrospinal fluid (CSF), white blood cells (WBCs), CSF protein concentration, CSF Venereal Disease Research Laboratory (VDRL) reactivity, and serum rapid plasma reagin (RPR) titer. Human immunodeficiency virus (HIV)-infected subjects were 2.5 times less likely to normalize CSF-VDRL reactivity than were HIV-uninfected subjects. HIV-infected subjects with peripheral blood CD4+ T cell counts of < or =200 cells/ mu L were 3.7 times less likely to normalize CSF-VDRL reactivity than were those with CD4+ T cell counts of >200 cells/ mu L. CSF WBC count and serum RPR reactivity were more likely to normalize but CSF-VDRL reactivity was less likely to normalize with higher baseline values. Future studies should address whether more intensive therapy for neurosyphilis is warranted in HIV-infected individuals.

Effect of Screening for Partner Violence on Women's Quality of Life

OBJECTIVES We assessed the health impact of a housing and case management program, the Chicago Housing for Health Partnership, for homeless people with HIV. METHODS HIV-positive homeless inpatients at a public hospital (n = 105) were randomized to usual care or permanent housing with intensive case management. The primary outcome was survival with intact immunity, defined as CD4 count > or = 200 and viral load < 100,000. Secondary outcomes were viral loads, undetectable viral loads, and CD4 counts. RESULTS Outcomes were available for 94 of 105 enrollees (90%). Of 54 intervention participants, 35 (65%) reached permanent housing in program housing agencies. After 1 year, 55% of the intervention and 34% of the usual care groups were alive and had intact immunity (P = .04). Seventeen intervention (36%) and 9 usual care (19%) participants had undetectable viral loads (P = .051). Median viral loads were 0.89 log lower in the intervention group (P = .03). There were no statistical differences in CD4 counts. CONCLUSIONS Homelessness is a strong predictor of poor health outcomes and complicates the medical management of HIV. This housing intervention improved the health of HIV-positive homeless people.

Improving asthma self-efficacy: Developing and testing a pilot community-based asthma intervention for African American adults

CONTEXT Although partner violence screening has been endorsed by many health organizations, there is insufficient evidence that it has beneficial health outcomes. OBJECTIVE To determine the effect of computerized screening for partner violence plus provision of a partner violence resource list vs provision of a partner violence list only on womens health in primary care settings, compared with a control group. DESIGN, SETTING, AND PARTICIPANTS A 3-group blinded randomized controlled trial at 10 primary health care centers in Cook County, Illinois. Participants were enrolled from May 2009-April 2010 and reinterviewed 1 year (range, 48-56 weeks) later. Participants were English- or Spanish-speaking women meeting specific inclusion criteria and seeking clinical services at study sites. Of 3537 women approached, 2727 were eligible, 2708 were randomized (99%), and 2364 (87%) were recontacted 1 year later. Mean age of participants was 39 years. Participants were predominantly non-Latina African American (55%) or Latina (37%), had a high school education or less (57%), and were uninsured (57%). INTERVENTION Randomization into 3 intervention groups: (1) partner violence screen (using the Partner Violence Screen instrument) plus a list of local partner violence resources if screening was positive (n = 909); (2) partner violence resource list only without screen (n = 893); and (3) no-screen, no-partner violence list control group (n=898). MAIN OUTCOME MEASURES Quality of life (QOL, physical and mental health components) was the primary outcome, measured on the 12-item Short Form (scale range 0-100, mean of 50 for US population). RESULTS At 1-year follow-up, there were no significant differences in the QOL physical health component between the screen plus partner violence resource list group (n = 801; mean score, 46.8; 95% CI, 46.1-47.4), the partner violence resource list only group (n = 772; mean score, 46.4; 95% CI, 45.8-47.1), and the control group (n = 791; mean score, 47.2; 95% CI, 46.5-47.8), or in the mental health component (screen plus partner violence resource list group [mean score, 48.3; 95% CI, 47.5-49.1], the partner violence resource list only group [mean score, 48.0; 95% CI, 47.2-48.9], and the control group [mean score, 47.8; 95% CI, 47.0-48.6]). There were also no differences between groups in days unable to work or complete housework; number of hospitalizations, emergency department, or ambulatory care visits; proportion who contacted a partner violence agency; or recurrence of partner violence. CONCLUSIONS Among women receiving care in primary care clinics, providing a partner violence resource list with or without screening did not result in improved health. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00526994.