Supriya D. Mehta

Potential factors affecting adherence with HIV therapy

A greatly increased level and duration of suppression of HIV replication has become possible with the use of protease inhibitors in combination with nucleoside analogues as antiretroviral therapy [1,2]. The long-term effectiveness of protease inhibitors, and other antiretroviral medications, is dependent upon strict adherence to the prescribed regimen, since HIV resistance to these drugs can develop with subtherapeutic doses [3,4]. Consequences of poor adherence include not only diminished outcome for the patient, but also the public health threat of multidrug-resistant HIV, and widespread transmission of drug-resistant virus, similar to that seen with multidrug-resistant tuberculosis [5].

Factors Associated With Parental Readiness to Make Changes for Overweight Children

Objective. The prevalence of childhood obesity is increasing in the United States. However, it has been difficult to help children successfully lose weight and maintain weight loss. Parental involvement in this effort is important. Currently, little is known about parents’ readiness to make behavior changes to help their children lose weight. The objective of this study was to describe demographic factors and parental perceptions associated with parents’ readiness to make weight-reducing lifestyle changes for their overweight and at-risk-for-overweight children. Methods. A total of 151 parents of children who were aged 2 to 12 years and had BMIs ≥85th percentile for age and gender completed a 43-item self-administered questionnaire. Parental stage of change, defined as precontemplation stage, contemplation stage, and preparation/action stage, was determined using an algorithm involving current parental practices and future intentions. Parents in the preparation/action stage were considered to be ready to make behavior changes to help their child lose weight. Maximum-likelihood multinomial logistic regression was used to identify demographics and perceptions associated with parental stage of change. Results. Sixty-two percent of the children had a BMI ≥95th percentile. Their mean age was 7.5 years, and 53% were male. Of the 151 parents, 58 (38%) were in the preparation/action stage of change, 26 (17%) were in the contemplation stage, and 67 (44%) were in the precontemplation stage. Factors associated with being in the preparation/action stage of change were having overweight or older (≥8 years) children, believing that their own weight or child’s weight was above average, and perceiving that their child’s weight was a health problem. After controlling for multiple factors, having an older child (odds ratio [OR]: 2.99; 95% confidence interval [CI]: 1.18–7.60), believing that they themselves were overweight (OR: 3.45; 95% CI: 1.36–8.75), and perceiving that their child’s weight was a health problem (OR: 9.75; 95% CI: 3.43–27.67) remained significantly associated with being in the preparation/action stage of change. Conclusions. Several demographic factors and personal perceptions are associated with a parent’s readiness to help his or her child lose weight. Knowledge of these factors may be beneficial to providers and program developers when addressing pediatric overweight with parents and initiating new interventions.

Association between Vitamin D Deficiency and Primary Cesarean Section

BACKGROUND At the turn of the 20th century, women commonly died in childbirth due to rachitic pelvis. Although rickets virtually disappeared with the discovery of the hormone vitamin D, recent reports suggest vitamin D deficiency is widespread in industrialized nations. Poor muscular performance is an established symptom of vitamin D deficiency. The current U.S. cesarean birth rate is at an all-time high of 30.2%. We analyzed the relationship between maternal serum 25-hydroxyvitamin D [25(OH)D] status, and prevalence of primary cesarean section. METHODS Between 2005 and 2007, we measured maternal and infant serum 25(OH)D at birth and abstracted demographic and medical data from the maternal medical record at an urban teaching hospital (Boston, MA) with 2500 births per year. We enrolled 253 women, of whom 43 (17%) had a primary cesarean. RESULTS There was an inverse association with having a cesarean section and serum 25(OH)D levels. We found that 28% of women with serum 25(OH)D less than 37.5 nmol/liter had a cesarean section, compared with only 14% of women with 25(OH)D 37.5nmol/liter or greater (P = 0.012). In multivariable logistic regression analysis controlling for race, age, education level, insurance status, and alcohol use, women with 25(OH)D less than 37.5 nmol/liter were almost 4 times as likely to have a cesarean than women with 25(OH)D 37.5 nmol/liter or greater (adjusted odds ratio 3.84; 95% confidence interval 1.71 to 8.62). CONCLUSION Vitamin D deficiency was associated with increased odds of primary cesarean section.

Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey

Objectives. The objectives of this study were to analyze all available breastfeeding data from US Baby-Friendly hospitals in 2001 to determine whether breastfeeding rates at Baby-Friendly designated hospitals differed from average US national, regional, and state rates in the same year and to determine prime barriers to implementation of the Baby-Friendly Hospital Initiative. Methods. In 2001, 32 US hospitals had Baby-Friendly designation. Using a cross-sectional design with focused interviews, this study surveyed all 29 hospitals that retained that designation in 2003. Demographic data, breastfeeding rates, and information on barriers to becoming Baby-Friendly were also collected. Simple linear regression was used to assess factors associated with breastfeeding initiation. Results. Twenty-eight of 29 hospitals provided breastfeeding initiation rates: 2 from birth certificate data and 26 from the medical record. Sixteen provided in-hospital, exclusive breastfeeding rates. The mean breastfeeding initiation rate for the 28 Baby-Friendly hospitals in 2001 was 83.8%, compared with a US breastfeeding initiation rate of 69.5% in 2001. The mean rate of exclusive breastfeeding during the hospital stay (16 of 29 hospitals) was 78.4%, compared with a national mean of 46.3%. In simple linear regression analysis, breastfeeding rates were not associated with number of births per institution or with the proportion of black or low-income patients. Of the Ten Steps to Successful Breastfeeding the 3 described as most difficult to meet were Steps 6, 2, and 7. The reason cited for the problem with meeting Step 6 was the requirement that the hospital pay for infant formula. Conclusion. Baby-Friendly designated hospitals in the United States have elevated rates of breastfeeding initiation and exclusivity. Elevated rates persist regardless of demographic factors that are traditionally linked with low breastfeeding rates.

Maternal Birthplace and Breastfeeding Initiation Among Term and Preterm Infants: A Statewide Assessment for Massachusetts

OBJECTIVES. Among premature infants, formula feeding increases the risk for necrotizing enterocolitis, delayed brainstem maturation, decreased scoring on cognitive and developmental tests, and delayed visual development. With this in mind, many interventions are designed to increase breast milk consumption in preterm infants. Breastfeeding initiation rates among US premature infants are not collected nationally, however, and published data on breastfeeding rates in this population are limited. In addition, national surveys calculate breastfeeding rates among term infants according to maternal race/ethnicity, but maternal birthplace is not recorded. This is likely to be important, because breastfeeding is the cultural norm in the countries of origin for many non–US-born US residents. Massachusetts has a diverse racial/ethnic population, including many non–US-born women. The goals of this study were to compare breastfeeding initiation rates among preterm and term infants in Massachusetts in 2002 and to determine the effect of maternal race/ethnicity and birthplace on breastfeeding initiation rates among term and preterm infants. METHODS. Massachusetts Community Health Information Profile, an online public health database that was created by the Massachusetts Department of Public Health, includes breastfeeding initiation data that are obtained from the electronic birth certificate, which we used to compare breastfeeding rates among preterm and term infants. Birth-linked demographics and data that also were accessed were maternal age, race/ethnicity, birthplace, and health insurance (public or private) as an indicator of socioeconomic status and infants gestational age. We assessed the association between breastfeeding initiation and maternal birthplace, as well as race/ethnicity and the other potential confounders, using logistic regression. RESULTS. There were 80624 births in Massachusetts in 2002, and 8.2% (6611) of newborns had a gestational age <37 weeks. The states overall breastfeeding initiation rate was 74.6%. We excluded records of mothers who were younger than 15 years and older than 39 years, nonsingleton births, infants with a gestational age <24 weeks and >42 weeks, and records with missing data. Of the total births in Massachusetts, 67884 (84%) met inclusion criteria for this study. Breastfeeding initiation rates were lowest among preterm infants of the youngest gestational ages. Breastfeeding initiation was 76.8% among term infants born at 37 to 42 weeks, 70.1% among infants born at 32 to 36 weeks, and 62.9% among infants born at 24 to 31 weeks. In univariate analysis, among preterm infants, a lower proportion of US-born black, Asian, and Hispanic mothers initiated breastfeeding than US-born white mothers; non–US-born black and non–US-born Hispanic mothers had the highest breastfeeding initiation rates. Among term infants, US-born black mothers had the lowest initiation rates, and non–US-born black and non–US-born Hispanic mothers had the highest. In multivariate logistic regression, however, after controlling for mothers age, race, birthplace, and insurance, US-born white mothers were least likely to breastfeed either term or preterm infants when compared with any other racial/ethnic group, including US-born black mothers. The likelihood that non–US-born Hispanic mothers would breastfeed was almost 8 times greater than that for US-born white mothers for a preterm infant and almost 10 times greater for a term infant. In multivariate logistic regression analysis stratified by gestational age for both preterm and term infants, older mothers and mothers with private health insurance were most likely to breastfeed. CONCLUSIONS. In Massachusetts, preterm infants were less likely to receive breast milk than term infants, and the likelihood of receiving breast milk was lowest among the youngest preterm infants. In multivariate logistic regression, mothers who were born outside the United States were more likely than US-born mothers to breastfeed either term or preterm infants in all racial and ethnic groups. In an unexpected finding, US-born white mothers were less likely to breastfeed term or preterm infants than US-born black mothers or mothers of any other racial or ethnic group.

Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: A critical population for STD control intervention

Background Urban emergency departments (EDs) providing services to patients at high risk for sexually transmitted infection may be logical sites for intervention. Goal To determine the prevalence of gonorrhea (GC) and chlamydia (CT) in an adult ED patient population, and to assess risk factors for infection. Study Design Cross-sectional study of patients aged 18 to 44 in an urban ED, seeking care of any medical nature. Main outcome was positive for GC or CT by urine ligase chain reaction assay. Results Test results for GC and/or CT were positive in 13.6% of 434 18 to 31 year-olds and in 1.8% of 221 32 to 44 year-olds. Of 63 infected individuals identified by the study, 15 (23.8%) were treated at the ED visit. Age ≤31 detected 88% of infections. Among 18- to 31-year-old patients, predictive risk factors by multivariate analysis included age <25, >1 sex partner in the past 90 days, and a history of sexually transmitted disease. Conclusion This study identified a high prevalence of GC and CT in patients seeking ED services. Many of these infections were clinically unsuspected. These data demonstrate that the ED is a high-risk setting and may be an appropriate site for routine GC and CT screening in 18- to 31-year-old patients.

Widespread Vitamin D Deficiency in Urban Massachusetts Newborns and Their Mothers

OBJECTIVE: To determine vitamin D status and associated factors in a cohort of newly delivered infants and their mothers in Boston, Massachusetts. PATIENTS AND METHODS: Enrollment in this cross-sectional study took place from 2005 to 2007 in an urban Boston teaching hospital with 2500 births per year. A questionnaire and medical-record data were used to identify variables that are potentially associated with vitamin D deficiency (25-hydroxyvitamin D [25(OH)D] < 20 ng/mL). Infant and maternal blood was obtained by venipuncture within 72 hours of birth. The main outcome measure was infant and maternal 25(OH)D status, assessed by competitive protein binding. RESULTS: We enrolled 459 healthy mother/infant pairs. After subsequent exclusions, analyses were performed on 376 newborns and 433 women. The median infant 25(OH)D level was 17.2 ng/mL (95% confidence interval [CI]: 16.0–18.8; range: <5.0 to 60.8 ng/mL). The median maternal 25(OH)D level was 24.8 ng/mL (95% CI: 23.2–25.8; range: <5.0 to 79.2 ng/mL). Overall, 58.0% of the infants and 35.8% of the mothers were vitamin D deficient (25[OH]D < 20 ng/mL); 38.0% of the infants and 23.1% of the mothers were severely deficient (25[OH]D < 15 ng/mL). Risk factors for infant vitamin D deficiency included maternal deficiency (adjusted odds ratio [aOR]: 5.28 [95% CI: 2.90–9.62]), winter birth (aOR: 3.86 [95% CI: 1.74–8.55]), black race (aOR: 3.36 [95% CI: 1.37–8.25]), and a maternal BMI of ≥35 (aOR: 2.78 [95% CI: 1.18–6.55]). Maternal prenatal-vitamin use throughout the second and third trimesters was protective against infant deficiency (aOR: 0.30 [95% CI: 0.16–0.56]). Similarly, prenatal-vitamin use of ≥5 times per week in the third trimester was protective for mothers (aOR: 0.37 [95% CI: 0.20–0.69]). Despite this, >30% of the women who took prenatal vitamins were still vitamin D deficient at the time of birth. CONCLUSIONS: A high proportion of infants and their mothers in New England were vitamin D deficient. Prenatal vitamins may not contain enough vitamin D to ensure replete status at the time of birth.

Adult Male Circumcision Does Not Reduce the Risk of Incident Neisseria gonorrhoeae, Chlamydia trachomatis, or Trichomonas vaginalis Infection: Results from a Randomized, Controlled Trial in Kenya

BACKGROUND We examined the effect of male circumcision on the acquisition of 3 nonulcerative sexually transmitted infections (STIs). METHODS We evaluated the incidence of STI among men aged 18-24 years enrolled in a randomized trial of circumcision to prevent human immunodeficiency virus (HIV) infection in Kisumu, Kenya. The outcome was first incident nonulcerative STI during 2 years of follow-up. STIs examined were laboratory-detected Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis infection. RESULTS There were 342 incident infections among 2655 men followed up. The incidences of infection due to N. gonorrhoeae, C. trachomatis, and T. vaginalis were 3.48, 4.55, and 1.32 cases per 100 person-years, respectively. The combined incidence of N. gonorrhoeae and C. trachomatis infection was 7.26 cases per 100 person-years (95% confidence interval, 6.49-8.13 cases per 100 person-years). The incidences of these STIs, individually or combined, did not differ by circumcision status as a time-dependent variable or a fixed variable based on assignment. Risks for incident STIs in multivariate analysis included an STI at enrollment, multiple sex partners within <30 days, and sexual intercourse during menses in the previous 6 months; condom use was protective. CONCLUSIONS Circumcision of men in this population did not reduce their risk of acquiring these nonulcerative STIs. Improved STI control will require more-effective STI management, including partner treatment and behavioral risk reduction counseling.

Cost-effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients.

Background Previous studies have shown screening for gonorrhea and chlamydia to be cost-effective for limiting the sequelae of infection and the associated costs of management. Goal To evaluate the cost-effectiveness of enhanced screening for gonorrhea and chlamydia in an emergency department (ED) setting. Study Design Five strategies were compared with use of decision analysis for theoretical cohorts of 10,000 female and 10,000 male ED patients aged 18 years to 31 years: standard ED practice, three enhanced screening strategies, and mass treatment. Main outcome measures were untreated gonorrhea or chlamydia cases and their sequelae, transmission to a partner, congenital outcomes, and cost to prevent a case. This analysis, from the perspective of the healthcare sector, included medical case costs expressed in US dollars (1999), discounted at an annual rate of 3%. Results Mass treatment was the most cost-effective strategy among women and men. Of the screening strategies for women, universal screening combined with standard practice was the most cost-effective; it was used for treating 499 more cases of gonorrhea and chlamydia than was standard practice, saving

Breastfeeding Duration Rates and Factors Affecting Continued Breastfeeding Among Infants Born at an Inner-City US Baby-Friendly Hospital:

95.70 per case treated. Standard ED practice remained the most cost-effective strategy for men under a variety of circumstances. Conclusion The authors recommend urine ligase chain reaction screening for gonorrhea and chlamydia in women aged 18 years to 31 years in the ED, in conjunction with standard ED practice, to decrease the occurrence of the sequelae and costs associated with infection.