The influence of stress on the menstrual cycle among newly incarcerated women

OBJECTIVE

We sought to estimate the association of stressful life events on menstrual function in incarcerated women.

METHODS

Project CONNECT is a study of reproductive health needs of incarcerated women conducted between June 2002 and December 2003. This analysis examines menstrual function in 446 women from this cohort who were under the age of 45. Regularity was defined as menses between 26 and 35 days long. Amenorrhea was defined as > or =90 days since last menstruation. Measures included stressful experiences and deprivation (e.g., physical or sexual abuse, stressful living conditions, exchanging sex for drugs or money, or having had an incarcerated parent).

RESULTS

Menstrual dysfunction was common in this population. Nine percent reported amenorrhea, and 33% reported menstrual irregularity. A number of stressors were associated with menstrual irregularity, including having a parent with history of alcohol or drug problems (relative risk [RR] = 1.34; 95% confidence interval [CI], 1.00-1.80), childhood physical or sexual abuse (RR = 1.48; 95% CI, 1.03-2.13), or any sexual abuse (RR = 1.49; 95% CI, 1.03-2.14) after adjusting for age, race/ethnicity, smoking status, and recent drug use. These effects were attenuated somewhat when excluding women who had reported any hormonal contraceptive use in the past 3 months.

CONCLUSION

Incarcerated women have high rates of amenorrhea and menstrual irregularity and the prevalence may be associated with certain stresses. Further research on the causes and consequences of menstrual dysfunction in this underserved population is needed.

Public health surveillance of fatal child maltreatment: analysis of 3 state programs

OBJECTIVES

We sought to describe approaches to surveillance of fatal child maltreatment and to identify options for improving case ascertainment.

METHODS

Three states--California, Michigan, and Rhode Island--used multiple data sources for surveillance. Potential cases were identified, operational definitions were applied, and the number of maltreatment deaths was determined.

RESULTS

These programs identified 258 maltreatment deaths in California, 192 in Michigan, and 60 in Rhode Island. Corresponding maltreatment fatality rates ranged from 2.5 per 100,000 population in Michigan to 8.8 in Rhode Island. Most deaths were identified by child death review teams in Rhode Island (98%), Uniform Crime Reports in California (56%), and child welfare agency data in Michigan (44%). Compared with the total number of cases identified, child welfare agency (the official source for maltreatment reports) and death certificate data underascertain child maltreatment deaths by 55% to 76% and 80% to 90%, respectively. In all 3 states, more than 90% of cases ascertained could be identified by combining 2 data sources.

CONCLUSIONS

No single data source was adequate for thorough surveillance of fatal child maltreatment, but combining just 2 sources substantially increased case ascertainment. The child death review team process may be the most promising surveillance approach.

Young incarcerated men's perceptions of and experiences with HIV testing

We analyzed incarcerated men's perceptions of and experiences with HIV testing. Interviews were conducted with 105 men, aged 18 to 29 years, in 4 states. Most men had received an HIV test while incarcerated because it was convenient or free or because they thought it was mandatory. At most sites, men believed they were HIV-negative because they never received test results. Some men did not know the diseases for which they had been tested. Some men avoided HIV testing outside prison because they lacked time, lacked resources, feared knowing the results, or perceived themselves to not be at risk. HIV testing programs for young men inside or outside prison should address barriers to HIV testing, communicate the meaning and extent of testing, and improve notification of those with HIV-negative results.

Pharmacist-led cardiac risk reduction model

The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated care model that incorporates the 4 major modifiable risk factors into a single treatment program. The authors aimed to assess the effectiveness of the CRRC model by comparing the Framingham point score before and after CRRC intervention. Retrospective data between 2001 and 2002 were analyzed for 375 veterans (age 65+/-10 years) with diabetes (88.8%) or coronary artery disease (44%) referred to the CRRC for intensive cardiac risk management. Total Framingham point score decreased from 14.5 at baseline to 13.6 after CRRC intervention (mean change 0.9+/-0.3). When considering only the patients not at target goals at baseline (n=200), significant improvements in guideline adherence was observed in low-density lipoprotein cholesterol, systolic blood pressure, hemoglobin A1c, and smoking. The CRRC model reduces the risk of cardiovascular events as assessed by Framingham point score in patients with established coronary artery disease and/or diabetes.

Dietary supplement use and nutrient intake in HIV-infected persons

Dietary supplement use was assessed in 368 HIV-infected patients enrolled in the Nutrition for Healthy Living cohort. The objective was to describe the dietary, demographic, and health characteristics of the HIV-infected persons who use different types of dietary supplements. Each patient was categorized in 1 of 4 dietary supplement groups. Extremes in intake of micronutrients were common. Men and women who consumed no supplements reported inadequate intakes of a number of micronutrients. Men using nonvitamin/nonmineral (NVNM) supplements had diets higher in fiber, protein, and 13 of 14 vitamins and minerals. Almost 90% of male NVNM supplement users ingested 1 or more vitamins or minerals in amounts above the tolerable upper limit. Male NVNM supplement users were more likely to be white, well educated, and receiving highly active antiretroviral therapy and more likely to have higher annual incomes, higher CD4 counts, and lower HIV RNA levels. HIV-infected women who were using NVNM supplements exhibited similar trends. Micronutrient inadequacy and excess are relatively common in persons living with HIV infection. Practitioners need to judiciously address optimal nutrient intake from both diet and dietary supplements in this population.

Children's mental health and family functioning in Rhode Island

OBJECTIVES

Our objectives were to (a) estimate the prevalence of children's mental health problems, (b) assess family functioning, and (c) investigate the relationship between children's mental health and family functioning in Rhode Island.

METHODS

From the 2003 National Survey of Children's Health, Rhode Island data for children 6 to 17 years of age were used for the analyses (N = 1326). Two aspects of family functioning measures, parental stress and parental involvement, were constructed and were examined by children's mental health problems, as well as other child and family characteristics (child's age, gender, race/ethnicity, special needs, parent's education, income, employment, family structure, number of children, and mother's general and mental health). Bivariate analyses and multivariate logistic regression were used to investigate the relationship.

RESULTS

Among Rhode Island children, nearly 1 (19.0%) in 5 had mental health problems, 1 (15.6%) in 6 lived with a highly stressed parent, and one third (32.7%) had parents with low involvement. Bivariate analyses showed that high parental stress and low parental involvement were higher among parents of children with mental health problems than parents of children without those problems (33.2% vs 11.0% and 41.0% vs 30.3%, respectively). In multivariate logistic regression, parents of children with mental health problems had nearly 4 times the odds of high stress compared with parents of children without those problems. When children's mental health problems were severe, the odds of high parental stress were elevated. However, children's mental health was not associated with parental involvement.

CONCLUSIONS

Children's mental health was strongly associated with parental stress, but it was not associated with parental involvement. The findings indicate that when examining the mental health issues of children, parental mental health and stress must be considered.

A statewide assessment of tuberculin skin testing of preschool children enrolled in medicaid managed care

OBJECTIVES

This study examined tuberculosis screening among preschool children enrolled in a statewide Medicaid managed care program.

METHODS

A random sample of 2,000 was selected from 19 to 35 month old children who were continuously enrolled in Rhode Island's Medicaid managed care program for 1 year. Sociodemographic data were obtained from computerized administrative databases. Medical record audits were performed to obtain the dates and results of tuberculosis tests.

RESULTS

Data from the medical record audits were available for 1,988 of the study children. For 1,215 of the study children (1,215/1,988 = 61%) a tuberculin skin test had been performed, but a reading was only documented for 736 children (60% of children who received a tuberculin skin test) and only one child tested positive (0.1%).

CONCLUSIONS

A majority of preschool children in this population in which the prevalence of risk factors for tuberculosis is likely to be relatively high did have a tuberculosis test performed. However, in many cases the tuberculin skin test was either not read or the results not documented. The low rate of positivity is consistent with current AAP guidelines for selective tuberculin skin testing.

A success story: HIV prevention for injection drug users in Rhode Island

Background

New HIV diagnoses related to injection drug use (IDU) have declined in the United States. Access to clean syringes and decreasing HIV transmission among injection drug users have been HIV prevention priorities of the Rhode Island (RI) HIV community. To examine trends in IDU-related new HIV diagnoses in RI, we performed a retrospective analysis of new HIV diagnoses according to HIV risk factor from 1990–2003.

Results

There has been an 80% absolute reduction in IDU-related new HIV diagnoses in RI coincident with IDU-specific prevention efforts.

Conclusion

There has been a greater decline in IDU-related new HIV diagnoses in Rhode Island compared to national data reported by the Centers for Disease Control and Prevention. We hypothesize that this dramatic decline in Rhode Island is related to extensive HIV prevention efforts targeting IDUs. Further research is needed to examine the impact of specific HIV prevention interventions for injection drug users.

Antimicrobial Resistance of Community-acquired Bloodstream Isolates of Viridans Group Streptococci

Infections due to antimicrobial-resistant viridans group streptococci are increasing. The present study was done to determine the frequency of antibiotic resistance among community-acquired viridans group streptococci isolated from blood cultures and to identify the risk factors associated with acquiring antibiotic-resistant viridans group streptococci. Twenty-eight community-acquired viridans group streptococcal isolates were recovered from 27 patients, of which 89%, 86%, 79%, 61%, and 39% were susceptible to ceftriaxone, clindamycin, tetracycline, penicillin, and erythromycin, respectively; 100% were susceptible to levofloxacin and vancomycin. Among the patients with previous antibiotic use, 73% had penicillin non-susceptible viridans group streptococci, compared with 18% who did not receive prior antibiotics (p = 0.006). Patients with and without prior antibiotic use, 27% and 0%, respectively, had ceftriaxone non-susceptible viridans group streptococci isolates, respectively (p = 0.05). Patients with and without prior antibiotic use, 45% and 6%, respectively, had tetracycline non-susceptible viridans group streptococci isolates, respectively (p = 0.02). No other risk factors for isolation of non-susceptible viridans group streptococci were identified.

Atypical squamous cells of undetermined significance, human papillomavirus, and cervical intraepithelial neoplasia 2 or 3 in adolescents: ASC-US, age, and high-grade cervical neoplasia

OBJECTIVE

To determine rates of and factors associated with cervical intraepithelial neoplasia (CIN) 2 or 3 among women with atypical squamous cells of undetermined significance (ASC-US) and oncogenic human papillomavirus (HPV) infection.

MATERIALS AND METHODS

This is a retrospective review of 357 women with ASC-US and known high-risk HPV infection. To be eligible for inclusion, patients had to have subsequently undergone colposcopic-directed cervical biopsy and/or endocervical sampling. Univariate and multivariable regression analyses were used to estimate crude and adjusted odds ratios of CIN 2 or 3 by risk factors associated with HPV and CIN.

RESULTS

Thirty-three of 215 (15%) women with ASC-US and oncogenic HPV who underwent histological sampling demonstrated CIN 2 or 3. In the adjusted model, only nulliparity (adjusted odds ratio = 2.2, 95% CI = 1.0-4.8) retained a marginal association with the outcome. No significant age-related differences in the prevalence of high-grade disease emerged. The high-grade lesions seen in adolescents consisted of single, small lesions.

CONCLUSIONS

In the light of these findings, and in conjunction with the high rate of oncogenic HPV infection among adolescents with ASC-US, both reflex HPV testing and immediate colposcopy do not appear to be of benefit in the initial management of teenagers with this cytological diagnosis.

A novel approach to T classification in tumor-node-metastasis staging of breast cancer

BACKGROUND

The aim of this study was to examine the effect of measurement bias in breast cancer and to create a more rational T-size categorization in tumor-node-metastasis staging in response to smaller, screen-detected cancers and measurement bias.

METHODS

From 1987 to 2003, 10,853 invasive nonmetastatic breast cancers enlisted in the Rhode Island Cancer Registry with a known dimension were reviewed. Data analyzed by proposed classifications included the rate of lymph node metastases and the mortality rate from breast cancer.

RESULTS

The median diameter was 16 mm. Cancer measurements reflected the bias in pathologists' dimension recording, which is centered strongly about whole- and half-centimeter sizes. A new T classification is proposed with the following sizes and frequencies in the Rhode Island Cancer Registry: 1 to 2 mm = T1 mic (3% of registered cases); 3 to 7 mm = T1a (11%); 8 to 12 mm = T1b (23%); 13 to 17 mm = T1c (18%); 18 to 22 mm = T2a (17%); 23 to 27 mm = T2b (8%); 28 to 32 mm = T2c (8%); 33 to 42 mm = T3a (6%); 43 to 52 mm = T3b (3%), and greater than 52 mm = T3c (4%). The unadjusted odds ratio for the probability of node metastases was 1.43 (confidence interval, 1.40-1.46; P < .001) with each increase in proposed grouping. The range in the lymph node metastatic rate was 5.5% for tumors 1 to 2 mm to 64% for cancers greater than 52 mm. By Cox proportional hazard, the unadjusted hazard ratio for death from breast cancer for each increase in proposed grouping was 1.33 (confidence interval, 1.29-1.37; P < .001). The 10-year survival rate ranged from 98.3% for tumors 1 to 2 mm to 70.3% for cancers greater than 52 mm.

CONCLUSIONS

A more rational T category for use in tumor-node-metastasis staging is presented to reflect the much smaller invasive breast cancers encountered by screening and to account for the dimension recording bias of pathologists. This new T category shows a clinically and statistically significant linear relationship for both incidence of lymph node metastases and hazard ratio of death.

Psychological resources protect health: 5-year survival and immune function among HIV-infected women from four US cities

OBJECTIVE

Guided by Cognitive Adaptation Theory, the aim was to determine whether psychological resources (positive affect, positive expectancy regarding health outcomes, finding meaning in challenging circumstances) protect against HIV-related mortality and decline in CD4 lymphocyte counts among women with HIV.

DESIGN

The HIV Epidemiologic Research Study, a longitudinal prospective cohort study, with semi-annual interview, physical examination and laboratory assays.

METHODS

A total of 773 HIV-seropositive women aged 16 to 55 years were recruited from four academic medical centers in Baltimore, Maryland; Bronx, New York; Providence, Rhode Island; and Detroit, Michigan. Semi-annually for up to 5 years, the women were interviewed, underwent physical examination, medical record abstraction, and venipuncture. Primary outcomes for these analyses included HIV-related mortality and CD4 cell count slope decline over 5 years.

RESULTS

Psychological resources were inversely associated with HIV-related mortality and time to death, beyond the effects of potential confounding variables such as clinical status (e.g., HIV viral load, symptoms, antiretroviral therapy), sociodemographic characteristics (e.g. age, race), and depression at study entry (P < 0.05). Psychological resources also were inversely associated with CD4+ cell count decline (P < 0.01), serving as a possible mechanism linking resources to mortality.

CONCLUSIONS

Psychological resources may protect against HIV-related mortality and immune system decline. Findings have implications for understanding individual variability in HIV disease progression. Moreover, because psychological resources are potentially amenable to change, results can be applied to clinical interventions aimed at improving the health of women with HIV.

Disentangling depressive personality disorder from avoidant, borderline, and obsessive-compulsive personality disorders

Several studies have found that 3 personality disorders (PDs) tend to share moderate rates of comorbidity with depressive PD: avoidant, borderline, and obsessive-compulsive. This study sought to evaluate the diagnostic criteria of each disorder in an effort to understand where areas of overlap may occur and to modify criteria sets where reasonable to reduce any degree of overlap. One thousand two hundred psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality Disorders. The highest degree of comorbidity was observed between avoidant PD and depressive PD. Logistic regression analyses indicated that 2 criteria-avoidant criterion 5 and depressive criterion 2-could be removed from the diagnostic criteria sets and reduce the rates of overlap by as much as 15%. A factor analysis of the criteria of all 4 PDs indicated that there is a common clustering of many of the symptoms of avoidant, borderline, depressive, and obsessive-compulsive PDs and that borderline symptoms tend to cluster together most consistently. Avoidant and obsessive-compulsive personality symptoms clustered in ways that may reflect a problem of how to engage with others, suggestive of an approach-avoidance conflict. Depressive PD symptoms clustered in a way suggestive of problems with anger that is directed toward oneself and others. The factor analysis results suggest that an organization of symptoms around themes of conflict may provide useful ways of understanding the personality patterns of these 4 disorders.

Prevalence and Diagnostic Correlates of DSM-IV Pathological Gambling in Psychiatric Outpatients

Studies of the prevalence of pathological gambling (PG) in psychiatric and substance abusing patients suggest that the disorder is not rare. Most studies have been of substance abusers in treatment, and the rate of PG has been found to be several times higher than the rate found in community based epidemiological surveys. However, only one study has examined the prevalence of PG in a heterogeneous sample of patients, and this was a study of psychiatric inpatients. We are not aware of any prior study of the prevalence of PG in a psychiatric outpatient sample. In the present report from the Rhode Island Methods to Improve Diagnosis and Services (MIDAS) project we examined the current and lifetime prevalence of PG in 1,709 psychiatric outpatients interviewed with a semi-structured diagnostic interview that included a module to diagnose DSM-IV PG. Forty (2.3%) patients had a lifetime history of DSM-IV PG, all of whom had at least one other DSM-IV axis I disorder. Patients with PG had significantly more axis I disorders than patients without PG, and had significantly higher rates of bipolar disorder, social phobia, panic disorder with agoraphobia, alcohol use disorder, and other impulse control disorders. Possible reasons for the low prevalence of PG in our sample are discussed.