Mediterranean and Dietary Approaches to Stop Hypertension dietary patterns and risk of sudden cardiac death in postmenopausal women

BACKGROUND

The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets are characterized by higher intake of fruit, vegetables, whole grains, and unsaturated fatty acids. All of these foods and nutrients may affect cholesterol, inflammation, the development of atherosclerosis, and, therefore, risk of cardiac death.

OBJECTIVE

Our objective was to examine the association between the Mediterranean and DASH dietary patterns and risk of sudden cardiac death (SCD) in women.

DESIGN

We used a prospective cohort of 93,122 postmenopausal women enrolled in the Women's Health Initiative study between 1993 and 1998 and followed for an average of 10.5 y. Women completed a food-frequency questionnaire (FFQ) twice during follow-up. We scored their diets according to how closely the reported diet resembled each dietary pattern. SCD was defined as death that occurred within 1 h of symptom onset.

RESULTS

A higher Mediterranean diet score was associated with lower risk of SCD (HR: 0.64; 95% CI: 0.43, 0.94) when women in the highest quintile were compared with women in the lowest quintile after adjustment for age, total energy, race, income, smoking, and physical activity. After adjustment for potential mediators, the association was similar (HR: 0.67; 95% CI: 0.46, 0.99). A higher DASH diet score was not associated with risk of SCD. However, sodium intake, which is a crucial component of the DASH dietary pattern, was not well characterized by the FFQ.

CONCLUSION

The Mediterranean dietary pattern may be associated with lower risk of SCD in women. This trial was registered at clinicaltrials.gov as NCT00000611.

Accuracy of brief screening tools for identifying postpartum depression among adolescent mothers

OBJECTIVE

To evaluate the accuracy of the Edinburgh Postnatal Depression Scale (EPDS) and 3 subscales for identifying postpartum depression among primiparous adolescent mothers.

METHODS

Mothers enrolled in a randomized controlled trial to prevent postpartum depression completed a psychiatric diagnostic interview and the 10-item EPDS at 6 weeks, 3 months, and 6 months postpartum. Three subscales of the EPDS were assessed as brief screening tools: 3-item anxiety subscale (EPDS-3), 7-item depressive symptoms subscale (EPDS-7), and 2-item subscale (EPDS-2) that resemble the Patient Health Questionnaire-2. Receiver operating characteristic curves and the areas under the curves for each tool were compared to assess accuracy. The sensitivities and specificities of each screening tool were calculated in comparison with diagnostic criteria for a major depressive disorder. Repeated-measures longitudinal analytical techniques were used.

RESULTS

A total of 106 women contributed 289 postpartum visits; 18% of the women met criteria for incident postpartum depression by psychiatric diagnostic interview. When used as continuous measures, the full EPDS, EPDS-7, and EPDS-2 performed equally well (area under the curve >0.9). Optimal cutoff scores for a positive depression screen for the EPDS and EPDS-7 were lower (≥ 9 and ≥ 7, respectively) than currently recommended cutoff scores (≥ 10). At optimal cutoff scores, the EPDS and EPDS-7 both had sensitivities of 90% and specificities of >85%.

CONCLUSIONS

The EPDS, EPDS-7, and EPDS-2 are highly accurate at identifying postpartum depression among adolescent mothers. In primary care pediatric settings, the EPDS and its shorter subscales have potential for use as effective depression screening tools.

The association between epilepsy and autism symptoms and maladaptive behaviors in children with autism spectrum disorder

Epilepsy is common in children with autism spectrum disorder (ASD) but little is known about how seizures impact the autism phenotype. The association between epilepsy and autism symptoms and associated maladaptive behaviors was examined in 2,645 children with ASD, of whom 139 had epilepsy, from the Simons Simplex Collection. Children with ASD and epilepsy had significantly more autism symptoms and maladaptive behaviors than children without epilepsy. However, after adjusting for IQ, only hyperactivity symptoms remained significantly increased (13% higher) in the epilepsy group. Among children with ASD without co-occurring intellectual disability, children with epilepsy had significantly more irritability (20% higher) and hyperactivity (24% higher) symptoms. This is the largest study to date comparing the autism phenotype in children with ASD with and without epilepsy. Children with ASD and epilepsy showed greater impairment than children without epilepsy, which was mostly explained by the lower IQ of the epilepsy group. These findings have important clinical implications for patients with ASD.

Cumulative exposure to paternal seminal fluid prior to conception and subsequent risk of preeclampsia

A growing body of literature suggests that prior and prolonged exposure to paternal antigens in seminal fluid induces maternal tolerance to the allogeneic fetus, protecting it from rejection and facilitating successful implantation and placentation. In this case-control study of nulliparous women, we test the hypothesis that increased exposure to paternal seminal fluid via the vaginal or oral route will confer a reduced risk of preeclampsia. Preeclampsia cases (n=258) and normotensive controls (n=182) were selected from live births to Iowa women over the period August 2002 to April 2005. Disease status was verified by medical chart review. Seminal fluid exposure indexes incorporated information on type and frequency of sexual practices, contraceptive use, and ingestion practices prior to conception with the baby's father. Preeclampsia risk decreased significantly with increasing vaginal exposure to paternal semen (test for trend p<0.05). Women in the highest 10th percentile of vaginal exposure had a 70% reduced odds of preeclampsia relative to women in the lowest 25th percentile of exposure (aOR=0.3; 95% CI: 0.1-0.9). Oral seminal fluid exposure was not associated with a reduced risk of preeclampsia. These findings are congruent with the immune maladaptation hypothesis of preeclampsia causation and indicate that paternal antigen exposure via the vaginal mucosa may facilitate immune tolerance to paternal HLA. Thus, advising nulliparous women to decrease their use of barrier contraceptive methods and to increase vaginal sexual intercourse prior to conceiving may reduce their risk of preeclampsia.

Clinical characteristics of children with autism spectrum disorder and co-occurring epilepsy

Objectives

To estimate the prevalence of epilepsy in children with Autism Spectrum Disorder (ASD) and to determine the demographic and clinical characteristics of children with ASD and epilepsy in a large patient population.

Methods

Cross-sectional study using four samples of children with ASD for a total of 5,815 participants with ASD. The prevalence of epilepsy was estimated from a population-based sample. Children with and without epilepsy were compared on demographic and clinical characteristics. Multivariate logistic regression was used to examine the association between demographic and clinical characteristics and epilepsy.

Results

The average prevalence of epilepsy in children with ASD 2–17 years was 12.5%; among children aged 13 years and older, 26% had epilepsy. Epilepsy was associated with older age, lower cognitive ability, poorer adaptive and language functioning, a history of developmental regression and more severe ASD symptoms. The association between epilepsy and the majority of these characteristics appears to be driven by the lower IQ of participants with epilepsy. In a multivariate regression model, only age and cognitive ability were independently associated with epilepsy. Children age 10 or older had 2.35 times the odds of being diagnosed with epilepsy (p<.001) and for a one standard deviation increase in IQ, the odds of having epilepsy decreased by 47% (p<.001).

Conclusion

This is among the largest studies to date of patients with ASD and co-occurring epilepsy. Based on a representative sample of children with ASD, the average prevalence of epilepsy is approximately 12% and reaches 26% by adolescence. Independent associations were found between epilepsy and older age and lower cognitive ability. Other risk factors, such as poor language and developmental regression, are not associated with epilepsy after controlling for IQ. These findings can help guide prognosis and alert clinicians to patients with ASD who are at increased risk for epilepsy.

Long-term alcohol and caffeine intake and risk of sudden cardiac death in women

BACKGROUND

Alcohol and caffeine intakes may play a role in the development of sudden cardiac death (SCD) because of their effects on cholesterol, blood pressure, heart rate variability, and inflammation.

OBJECTIVE

Our objective was to examine the association between long-term alcohol and caffeine intakes and risk of SCD in women.

DESIGN

We examined 93,676 postmenopausal women who participated in the Women's Health Initiative Observational Study. Women were enrolled between 1993 and 1998 and were followed until August 2009. Women completed a food-frequency questionnaire at baseline and again at year 3. We modeled exposure to alcohol 3 ways: by using baseline intake only, a cumulative average of baseline and year 3 intake, and the most recent reported intake (a simple time-varying analysis).

RESULTS

Intake of 5-15 g alcohol/d (about one drink) was associated with a nonsignificantly reduced risk of SCD compared with 0.1-5 g/d of baseline intake (HR: 0.64; 95% CI: 0.40, 1.02), of cumulative average intake (HR: 0.69; 95% CI: 0.43, 1.11), and of most recent intake (HR: 0.58; 95% CI: 0.35, 0.96), with adjustment for age, race, income, smoking, body mass index, physical activity, hormone use, and total energy. No association was found between SCD and total caffeine intake (mg/d) or cups of caffeinated coffee, decaffeinated coffee, and caffeinated tea.

CONCLUSIONS

Our results suggest that about one drink per day (or 5.1-15 g/d) may be associated with a reduced risk of SCD in this population; however, this association was only statistically significant for a model using the most recent alcohol intake. Total caffeine, regular coffee, decaffeinated coffee, and regular tea intake were not associated with the risk of SCD. This trial was registered at clinicaltrials.gov as NCT00000611.

Exploring the role of antithrombin replacement for the treatment of preeclampsia: a prospective randomized evaluation of the safety and efficacy of recombinant antithrombin in very preterm preeclampsia (PRESERVE-1)

PROBLEM

Antithrombin (AT) replacement has been described in patients with hereditary AT deficiency undergoing delivery; however, the kinetics of AT replacement in preeclampsia is not adequately understood. Therefore, the Prospective Randomized Evaluation of the Safety and Efficacy of Recombinant Antithrombin in Very Preterm Preeclampsia (PRESERVE-1) study has been proposed.

METHODS

Sixty women aged≥18 years at 24 0/7-28 0/7 weeks' gestation and with hypertension and proteinuria will be enrolled and randomly assigned to receive recombinant human AT or placebo until fetal and/or maternal indications cause cessation of expectant management or until 34 0/7 weeks' gestation. The primary endpoint is the increase in gestational age from randomization to delivery. Safety assessments and laboratory assays will also be performed.

RESULTS

PRESERVE-1 study enrollment will begin during the second half of 2013.

CONCLUSION

The PRESERVE-1 study will provide further insight into the pharmacokinetic activity and safety of AT therapy in preeclampsia.

Implementing provider-based sampling for the National Children's Study: opportunities and challenges

BACKGROUND

The National Children's Study (NCS) was established as a national probability sample of births to prospectively study children's health starting from in utero to age 21. The primary sampling unit was 105 study locations (typically a county). The secondary sampling unit was the geographic unit (segment), but this was subsequently perceived to be an inefficient strategy.

METHODS AND RESULTS

This paper proposes that second-stage sampling using prenatal care providers is an efficient and cost-effective method for deriving a national probability sample of births in the US. It offers a rationale for provider-based sampling and discusses a number of strategies for assembling a sampling frame of providers. Also presented are special challenges to provider-based sampling pregnancies, including optimising key sample parameters, retaining geographic diversity, determining the types of providers to include in the sample frame, recruiting women who do not receive prenatal care, and using community engagement to enrol women. There will also be substantial operational challenges to sampling provider groups.

CONCLUSION

We argue that probability sampling is mandatory to capture the full variation in exposure and outcomes expected in a national cohort study, to provide valid and generalisable risk estimates, and to accurately estimate policy (such as screening) benefits from associations reported in the NCS.

Correction of systematic bias in ultrasound dating in studies of small-for-gestational-age birth: an example from the Iowa Health in Pregnancy Study

The authors examined whether early ultrasound dating (≤20 weeks) of gestational age (GA) in small-for-gestational-age (SGA) fetuses may underestimate gestational duration and therefore the incidence of SGA birth. Within a population-based case-control study (May 2002-June 2005) of Iowa SGA births and preterm deliveries identified from birth records (n = 2,709), the authors illustrate a novel methodological approach with which to assess and correct for systematic underestimation of GA by early ultrasound in women with suspected SGA fetuses. After restricting the analysis to subjects with first-trimester prenatal care, a nonmissing date of the last menstrual period (LMP), and early ultrasound (n = 1,135), SGA subjects' ultrasound GA was 5.5 days less than their LMP GA, on average. Multivariable linear regression was conducted to determine the extent to which ultrasound GA predicted LMP dating and to correct for systematic misclassification that results after applying standard guidelines to adjudicate differences in these measures. In the unadjusted model, SGA subjects required a correction of +1.5 weeks to the ultrasound estimate. With adjustment for maternal age, smoking, and first-trimester vaginal bleeding, standard guidelines for adjudicating differences in ultrasound and LMP dating underestimated SGA birth by 12.9% and overestimated preterm delivery by 8.7%. This methodological approach can be applied by researchers using different study populations in similar research contexts.

Genome-wide association study identifies a maternal copy-number deletion in PSG11 enriched among preeclampsia patients

Background

Specific genetic contributions for preeclampsia (PE) are currently unknown. This genome-wide association study (GWAS) aims to identify maternal single nucleotide polymorphisms (SNPs) and copy-number variants (CNVs) involved in the etiology of PE.

Methods

A genome-wide scan was performed on 177 PE cases (diagnosed according to National Heart, Lung and Blood Institute guidelines) and 116 normotensive controls. White female study subjects from Iowa were genotyped on Affymetrix SNP 6.0 microarrays. CNV calls made using a combination of four detection algorithms (Birdseye, Canary, PennCNV, and QuantiSNP) were merged using CNVision and screened with stringent prioritization criteria. Due to limited DNA quantities and the deleterious nature of copy-number deletions, it was decided a priori that only deletions would be selected for assay on the entire case-control dataset using quantitative real-time PCR.

Results

The top four SNP candidates had an allelic or genotypic p-value between 10^-5 and 10^-6, however, none surpassed the Bonferroni-corrected significance threshold. Three recurrent rare deletions meeting prioritization criteria detected in multiple cases were selected for targeted genotyping. A locus of particular interest was found showing an enrichment of case deletions in 19q13.31 (5/169 cases and 1/114 controls), which encompasses the PSG11 gene contiguous to a highly plastic genomic region. All algorithm calls for these regions were assay confirmed.

Conclusions

CNVs may confer risk for PE and represent interesting regions that warrant further investigation. Top SNP candidates identified from the GWAS, although not genome-wide significant, may be useful to inform future studies in PE genetics.

Association of variants in innate immune genes with asthma and eczema

BACKGROUND

The innate immune pathway is important in the pathogenesis of asthma and eczema. However, only a few variants in these genes have been associated with either disease. We investigate the association between polymorphisms of genes in the innate immune pathway with childhood asthma and eczema. In addition, we compare individual associations with those discovered using a multivariate approach.

METHODS

Using a novel method, case control based association testing (C2BAT), 569 single nucleotide polymorphisms (SNPs) in 44 innate immune genes were tested for association with asthma and eczema in children from the Boston Home Allergens and Asthma Study and the Connecticut Childhood Asthma Study. The screening algorithm was used to identify the top SNPs associated with asthma and eczema. We next investigated the interaction of innate immune variants with asthma and eczema risk using Bayesian networks.

RESULTS

After correction for multiple comparisons, 7 SNPs in 6 genes (CARD25, TGFB1, LY96, ACAA1, DEFB1, and IFNG) were associated with asthma (adjusted p-value<0.02), while 5 SNPs in 3 different genes (CD80, STAT4, and IRAKI) were significantly associated with eczema (adjusted p-value < 0.02). None of these SNPs were associated with both asthma and eczema. Bayesian network analysis identified 4 SNPs that were predictive of asthma and 10 SNPs that predicted eczema. Of the genes identified using Bayesian networks, only CD80 was associated with eczema in the single-SNP study. Using novel methodology that allows for screening and replication in the same population, we have identified associations of innate immune genes with asthma and eczema. Bayesian network analysis suggests that additional SNPs influence disease susceptibility via SNP interactions.

CONCLUSION

Our findings suggest that innate immune genes contribute to the pathogenesis of asthma and eczema, and that these diseases likely have different genetic determinants.

Sexual risk behaviors among HIV-infected South African men and women with their partners in a primary care program: implications for couples-based prevention

We studied 1163 sexually-active HIV-infected South African men and women in an urban primary care program to understand patterns of sexual behaviors and whether these behaviors differed by partner HIV status. Overall, 40% reported a HIV-positive partner and 60% a HIV-negative or status unknown partner; and 17.5% reported >2 sex acts in the last 2 weeks, 16.4% unprotected sex in the last 6 months, and 3.7% >1 sex partner in the last 6 months. Antiretroviral therapy (ART) was consistently associated with decreased sexual risk behaviors, as well as with reporting a HIV-negative or status unknown partner. The odds of sexual risk behaviors differed by sex; and were generally higher among participants reporting a HIV-positive partner, but continued among those with a HIV-negative or status unknown partner. These data support ART as a means of HIV prevention. Engaging in sexual risk behaviors primarily with HIV-positive partners was not widely practiced in this setting, emphasizing the need for couples-based prevention.

Spatial and temporal modeling of daily pollen concentrations

Accurate assessments of pollen counts are valuable to allergy sufferers, the medical industry, and health researchers; however, monitoring stations do not exist in most areas. In addition, the degree of spatial reliability provided by the limited number of monitoring stations is poorly understood. We developed and compared spatial models to estimate pollen concentrations in locations without monitoring stations. Daily Acer, Quercus, and overall tree, grass, and weed pollen counts, in grains/m(3), were obtained from 14 aeroallergen monitoring stations located in the northeastern and mid-Atlantic region of the United States from 2003 to 2006. Pollen counts were spatially interpolated using ordinary kriging. Mixed effects and generalized estimating equations incorporating daily and seasonal weather characteristics, pollen season characteristics and land-cover information were also developed to estimate daily pollen concentrations. We then compared observed values from a monitoring station to model estimates for that location. Observed counts and kriging estimates for tree pollen differed (p = 0.04), but not when peak periods were removed (p = 0.29). No differences between observed and kriging estimates of Acer (p = 0.46), Quercus (p = 0.24), grass (p = 0.31) or weed pollen (p = 0.29) were found. Estimates from longitudinal models also demonstrated good agreement with observed counts, except for the extremes of pollen distributions. Our results demonstrate that spatial interpolation techniques as well as regression methods incorporating both weather and land-cover characteristics can provide reliable estimates of daily pollen concentrations in areas where monitors do not exist for all but periods of extremely high pollen.

Effects of endotoxin exposure on childhood asthma risk are modified by a genetic polymorphism in ACAA1

Background

Polymorphisms in the endotoxin-mediated TLR4 pathway genes have been associated with asthma and atopy. We aimed to examine how genetic polymorphisms in innate immunity pathways interact with endotoxin to influence asthma risk in children.

Methods

In a previous analysis of 372 children from the Boston Home Allergens and the Connecticut Childhood Asthma studies, 7 SNPs in 6 genes (CARD15, TGFB1, LY96, ACAA1, DEFB1 and IFNG) involved in innate immune pathways were associated with asthma, and 5 SNPs in 3 genes (CD80, STAT4, IRAK2) were associated with eczema. We tested these SNPs for interaction with early life endotoxin exposure (n = 291), in models for asthma and eczema by age 6.

Results

We found a significant interaction between endotoxin and a SNP (rs156265) in ACAA1 (p = 0.0013 for interaction). Increased endotoxin exposure (by quartile) showed protective effects for asthma in individuals with at least one copy of the minor allele (OR = 0.39 per quartile increase in endotoxin, 95% CI 0.15 to 1.01). Endotoxin exposure did not reduce the risk of asthma in children homozygous for the major allele.

Conclusion

Our findings suggest that protective effects of endotoxin exposure on asthma may vary depending upon the presence or absence of a polymorphism in ACAA1.

Effect of robot-assisted versus conventional body-weight-supported treadmill training on quality of life for people with multiple sclerosis

This study describes the effect of body-weight-supported treadmill training (BWSTT) on quality of life (QoL) for multiple sclerosis (MS) patients. Thirteen individuals with MS and gait impairment randomly received two blocks of six biweekly training sessions: (1) robot-assisted BWSTT then BWSTT alone (R-T) or (2) BWSTT alone then robot-assisted BWSTT (T-R). No statistically significant differences were found between robot-assisted BWSTT and unassisted BWSTT for improving QoL outcome measures. The change in Physical Component Summary scores from baseline to the end of the 12 training sessions improved significantly more in the R-T than the T-R group. Within-participant longitudinal changes in QoL for all participants from both groups combined showed significant improvements in 5 of the 13 QoL measures. The results of this pilot study suggest that both types of BWSTT may improve QoL for people with gait dysfunction secondary to MS.

Growth of infants born to HIV-infected women in South Africa according to maternal and infant characteristics

OBJECTIVE

To evaluate growth parameters assessed by weight and length in HIV-infected and HIV-uninfected infants born to HIV-infected mothers in South Africa from birth to 6 months of age.

METHODS

We calculated z-scores for weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length (WLZ) among a cohort of 840 mother-infant dyads. Multivariable Cox proportional hazards models with time-varying covariates were used to estimate the risk of falling <-2 z-scores for WAZ, LAZ, and WLZ as a function of infant and maternal characteristics.

RESULTS

By 6 months after birth, a fifth of infants had WAZ <-2, 19% had an LAZ <-2, and 29% had a WLZ <-2. WLZ and WAZ were significantly lower in HIV-infected infants than in uninfected infants by 3 months of age and LAZ by 6 months of age (P<0.001). The risk of WAZ falling <-2 was associated with decreasing maternal CD4 cell count (adj. HR for CD4 cell count <200 cells/μl: 1.64; 95% CI: 1.10-2.43), premature birth (adj. HR: 2.82; 95% CI: 2.06-3.86) and formula feeding (adj. HR: 3.35; 95% CI: 1.64-6.85). The risk of LAZ falling <-2 was associated with increasingly lower maternal age (adj. HR for<20 years: 0.54; 95% CI: 0.31-0.96), lower maternal CD4 cell count (adj. HR for CD4 cell count <200 cells/μl: 1.72; 95% CI: 1.14-2.59), premature birth (adj. HR: 2.37; 95% CI: 1.70-3.30) and formula feeding (adj. HR: 4.22; 95% CI: 1.85-9.62). The risk of WLZ falling <-2 was significantly associated with infant HIV infection (adj. HR: 1.64; 95% CI: 1.16-2.32) and formula feeding (adj. HR: 1.78; 95% CI: 1.11-2.83). The risk of WAZ and LAZ falling <-2 was more than two times greater for HIV-infected infants than for uninfected infants with gastrointestinal infections.

CONCLUSIONS

HIV-infected infants were more likely to be stunted and wasted than uninfected infants, which often occurred within 3 months after birth. Infants who were born to mothers with advanced HIV disease, formula-fed and co-infected with HIV and gastrointestinal infections were at greater risk for growth disturbances. Further interventions are needed to promptly initiate both HIV-infected mothers and infants on appropriate antiretroviral therapy and nutritional supplementation.

Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery

The current study examines sexual behaviors among HIV-infected Indians in primary care, where access to highly active antiretroviral therapy (HAART) has recently increased. Between January and April 2008, we assessed the sexual behaviors of 247 HIV-infected South Indians in care. Multivariable logistic regression models were used to determine predictors of being in a HIV-seroconcordant primary relationship, being sexually active, and reporting unprotected sex. Over three-fourths (80%) of participants were HAART-experienced. Among the 58% of participants who were currently in a seroconcordant relationship, one-third were serodiscordant when enrolling into care. Approximately two-thirds (63.2%) of participants were sexually active; 9.0% reported unprotected sex. In the multivariable analyses, participants who were in a seroconcordant primary relationship were more likely to have children, use alcohol, report unprotected sex, and have been enrolled in care for >12 months. Sexually active participants were more likely to be on HAART, have a prior tuberculosis diagnosis, test Herpes simplex type 2 antibody seropositive, and have low general health perceptions. Participants who reported unprotected sex were more likely to be in a seroconcordant relationship, be childless, want to have a child, and use alcohol. We did not document an association between HAART and unprotected sex. Among HIV-infected Indians in primary care, predictors of unprotected sex included alcohol use and desire for children. Prevention interventions for Indian couples should integrate reproductive health and alcohol use counseling at entry into care.

Morbidity and mortality among infants born to HIV-infected women in South Africa: implications for child health in resource-limited settings

BACKGROUND

We examined correlates of infant morbidity and mortality within the first 3 months of life among HIV-exposed infants receiving post-exposure antiretroviral prophylaxis in South Africa.

METHODS

We conducted a prospective cohort study of 848 mother-child dyads. Multivariable Cox proportional hazards models were used.

RESULTS

The main causes of infant morbidity were gastrointestinal and respiratory infections. Morbidity was higher with infant HIV infection (HR: 2.61; 95% CI: 1.40-4.85; p = 0.002) and maternal plasma viral load (PVL) >100,000 copies ml⁻¹ (HR: 1.87; 95% CI: 1.01-3.48; p = 0.048), and lower with maternal age < 20 years (HR: 0.25; 95% CI: 0.07-0.88; p = 0.031). Mortality was higher with infant HIV infection (HR: 4.10; 95% CI: 1.18-14.31; p = 0.027) and maternal PVL >100,000 copies ml⁻¹ (HR: 6.93; 95% CI: 1.64-29.26; p = 0.008). Infant feeding status did not influence the risk of morbidity nor mortality.

CONCLUSIONS

Future interventions that minimize pediatric HIV infection and reduce maternal viremia, which are the main predictors of child health soon after birth, will impact positively on infant health outcomes.

Prenatal factors for childhood blood pressure mediated by intrauterine and/or childhood growth?

OBJECTIVE

Some prenatal factors may program an offspring's blood pressure, but existing evidence is inconclusive and mechanisms remain unclear. We examined the mediating roles of intrauterine and childhood growth in the associations between childhood systolic blood pressure (SBP) and 5 potentially modifiable prenatal factors: maternal smoking during pregnancy; prepregnancy BMI; pregnancy weight gain; chronic hypertension; and preeclampsia-eclampsia.

METHODS

The sample contained 30 461 mother-child pairs in the Collaborative Perinatal Project. Prenatal data were extracted from obstetric forms, and children's SBP was measured at 7 years of age. Potential mediation by intrauterine growth restriction (IUGR) and childhood growth was examined by the causal step method.

RESULTS

Heavy maternal smoking during pregnancy was significantly associated with higher offspring SBP (adjusted mean difference versus nonsmoking: 0.73 mm Hg [95% confidence interval (CI): 0.32-1.14]), which attenuated to null (0.13 [95% CI: -0.27-0.54]) after adjustment for changes in BMI from birth to 7 years of age. Prepregnancy overweight-obesity was significantly associated with higher offspring SBP (versus normal weight: 0.89 mm Hg [95% CI: 0.52-1.26]), which also attenuated to null (-0.04 mm Hg [95% CI: -0.40-0.31]) after adjustment for childhood BMI trajectory. Adjustment for BMI trajectory augmented the association between maternal pregnancy weight gain and offspring SBP. Adjustment for childhood weight trajectory similarly changed these associations. However, all these associations were independent of IUGR.

CONCLUSIONS

Childhood BMI and weight trajectory, but not IUGR, may largely mediate the associations of maternal smoking during pregnancy and prepregnancy BMI with an offspring's SBP.

Predictors of nonadherence to highly active antiretroviral therapy among HIV-infected South Indians in clinical care: implications for developing adherence interventions in resource-limited settings

In light of the increasing availability of generic highly active antiretroviral therapy (HAART) in India, further data are needed to examine variables associated with HAART nonadherence among HIV-infected Indians in clinical care. We conducted a cross-sectional analysis of 198 HIV-infected South Indian men and women between January and April 2008 receiving first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based HAART. Nonadherence was defined as taking less than 95% of HAART doses in the last 1 month, and was examined using multivariable logistic regression models. Half of the participants reported less than 95% adherence to HAART, and 50% had been on HAART for more than 24 months. The median CD4 cell count was 435 cells per microliter. An increased odds of nonadherence was found for participants with current CD4 cell counts greater than 500 cells per microliter (adjusted odds ratio [AOR]: 2.22 [95% confidence interval {CI}: 1.04-4.75]; p = 0.038), who were on HAART for more than 24 months (AOR: 3.07 [95% CI: 1.35-7.01]; p = 0.007), who reported alcohol use (AOR: 5.68 [95%CI: 2.10-15.32]; p = 0.001), who had low general health perceptions (AOR: 3.58 [95%CI: 1.20-10.66]; p = 0.021), and who had high distress (AOR: 3.32 [95%CI: 1.19-9.26]; p = 0.022). This study documents several modifiable risk factors for nonadherence in a clinic population of HIV-infected Indians with substantial HAART experience. Further targeted culturally specific interventions are needed that address barriers to optimal adherence.

Association between placental morphology and childhood systolic blood pressure

We tested hypotheses that disproportionately large placental size and vascular lesions were associated with high systolic blood pressure (SBP); and these associations might be more evident with age. The sample included 13 273 of 40 666 full-term singletons in the Collaborative Perinatal Project. Placentas were examined by pathologists blinded of pregnancy courses and outcomes. The 4-month and 7-year SBPs were measured with palpation and auscultation methods, respectively. We found that placental weight (adjusted mean difference corresponding to an increase by 1 SD 0.50 [95% CI, 0.33 to 0.68]) and placenta-fetus weight ratio (0.37 [95% CI, 0.19 to 0.54]) was positively associated with 7-year SBP but not associated with 4-month SBP. Placental largest and smallest diameters and area were negatively associated with 4-month SBP but positively with 7-year SBP. Placental thickness was negatively associated with 4-month SBP only. Placental volume was negatively associated with 4-month SBP (-0.60 [95% CI, - 0.85 to -0.35]) but positively associated with 7-year SBP (0.48 [95% CI, 0.30 to 0.67]). Thrombi in cord vessels (adjusted mean difference versus absence 2.73 [95% CI, - 0.03 to 5.50]) and decidual vessels (2.58 [95% CI, 0.24 to 4.91]), villous microinfarcts (1.63 [95% CI, 0.71 to 2.55]), necrosis at the decidual margin (1.57 [95% CI, 0.54 to 2.59]), and basalis (3.44 [95% CI, 1.55 to 5.32]) were associated with higher 4-month SBP only. We conclude that placental inefficiency, reflected by disproportionately large weight and size, predicts long-term blood pressure, whereas vascular resistance and lesions may only influence short-term blood pressure.

Decreased sexual risk behavior in the era of HAART among HIV-infected urban and rural South Africans attending primary care clinics

OBJECTIVE

In light of increasing access to HAART in sub-Saharan Africa, we conducted a longitudinal study to assess the impact of HAART on sexual risk behaviors among HIV-infected South Africans in urban and rural primary care clinics.

DESIGN

Prospective observational cohort.

METHODS

We conducted a cohort study at rural and urban primary care HIV clinics in South Africa consisting of 1544 men and 4719 women enrolled from 2003 to 2010, representing 19703 clinic visits. The primary outcomes were being sexually active, unprotected sex, and more than one sex partner and were evaluated at 6 monthly intervals. Generalized estimated equations assessed the impact of HAART on sexual risk behaviors.

RESULTS

Among 6263 HIV-infected men and women, over a third (37.2%) initiated HAART during study follow-up. In comparison to pre-HAART follow-up, visits while receiving HAART were associated with a decrease in those reporting being sexually active [adjusted odds ratio: 0.86 (95% confidence interval: 0.78-0.95)]. Unprotected sex and having more than one sex partner were reduced at visits following HAART initiation compared to pre-HAART visits [adjusted odds ratio: 0.40 (95% confidence interval: 0.34-0.46) and adjusted odds ratio: 0.20 (95% confidence interval: 0.14-0.29), respectively].

CONCLUSION

Sexual risk behavior significantly decreased following HAART initiation among HIV-infected South African men and women in primary care programs. The further expansion of antiretroviral treatment programs could enhance HIV prevention efforts in Africa.

Does chocolate intake during pregnancy reduce the risks of preeclampsia and gestational hypertension?

PURPOSE

Chocolate consumption is associated with favorable levels of blood pressure and other cardiovascular disease risk markers. We analyzed a prospective cohort study to determine whether regular chocolate intake during pregnancy is associated with reduced risks of preeclampsia and gestational hypertension (GH).

METHODS

Subjects were recruited from 13 prenatal care practices in Connecticut (1988-1991). In-person interviews were administered at <16 weeks' gestation to ascertain risk factors for adverse pregnancy outcomes. Hospital delivery and prenatal records were abstracted to classify preeclampsia (n = 58), GH (n = 158), and normotensive pregnancies (n = 2351). Chocolate consumption (servings/week) during the first and third trimesters was ascertained at initial interview and immediately postpartum, respectively. Consumers of less than 1 serving/week comprised the referent group. Adjusted odds ratios (aORs) were estimated by the use of logistic regression.

RESULTS

Chocolate intake was more frequent among normotensive (80.7%) than preeclamptic (62.5%) or GH women (75.8%), and associated with reduced odds of preeclampsia (first trimester: aOR, 0.55; 95% confidence interval [95% CI], 0.32-0.95; third trimester: aOR, 0.56; 95% CI, 0.32-0.97). Only first trimester intake was associated with reduced odds of GH (aOR,0.65; 95% CI, 0.45-0.87).

CONCLUSIONS

These findings provide additional evidence of the benefits of chocolate. Prospective studies are needed to confirm and delineate protective effects of chocolate intake on risk of preeclampsia.

Mortality of mothers from cardiovascular and non-cardiovascular causes following pregnancy complications in first delivery

The combined effects of preterm delivery, small-for-gestational-age offspring, hypertensive disorders of pregnancy, placental abruption and stillbirth on early maternal death from cardiovascular causes have not previously been described in a large cohort. We investigated the effects of pregnancy complications on early maternal death in a registry-based retrospective cohort study of 782 287 women with a first singleton delivery in Denmark 1978-2007, followed for a median of 14.8 years (range 0.25-30.2) accruing 11.6 million person-years. We employed Cox proportional hazard models of early death from cardiovascular and non-cardiovascular causes following preterm delivery, small-for-gestational-age offspring and hypertensive disorders of pregnancy. We found that preterm delivery and small-for-gestational-age were both associated with subsequent death of mothers from cardiovascular and non-cardiovascular causes. Severe pre-eclampsia was associated with death from cardiovascular causes only. There was a less than additive effect on cardiovascular mortality hazard ratios with increasing number of pregnancy complications: preterm delivery 1.90 [95% confidence intervals 1.49, 2.43]; preterm delivery and small-for-gestational-age offspring 3.30 [2.25, 4.84]; preterm delivery, small-for-gestational-age offspring and pre-eclampsia 3.85 [2.07, 7.19]. Thus, we conclude that, separately and combined, preterm delivery and small-for-gestational-age are strong markers of early maternal death from both cardiovascular and non-cardiovascular causes, while hypertensive disorders of pregnancy are markers of early death of mothers from cardiovascular causes.