Home Screening for Bacterial Vaginosis to Prevent Sexually Transmitted Diseases

BACKGROUND

Longitudinal studies have consistently found a significant association between bacterial vaginosis (BV) and acquisition of sexually transmitted diseases. However, there are limited prospective data to confirm these findings.

METHODS

We conducted a prospective, randomized, open-label trial of home screening and treatment of young women with asymptomatic BV who were also at high risk for sexually transmitted diseases. These women were screened every 2 months for 12 months and randomized to treatment with oral metronidazole 500 mg twice daily for 7 days or observation alone. The primary outcome was the incidence of gonorrhea and/or chlamydia.

RESULTS

A total of 1365 subjects were enrolled in the study across 10 sites. Adherence with mailing specimens obtained at home was excellent in both groups (84%-88%). The incidence of gonorrhea and/or chlamydia was 19.1 per 100 person-years (95% confidence interval, 15.1-22.1) for the treatment group and 18.5 per 100 person-years (15.1-22.8) for the observation arm, a difference that was not statistically significant.

CONCLUSIONS

Young women were very amenable to home screening for BV, gonorrhea, and chlamydia. Treatment of asymptomatic BV with 1 week of oral metronidazole did not decrease the incidence of gonorrhea and/or chlamydia.

CLINICAL TRIALS REGISTRATION

NCT00667368.

Women's Perceptions of Provider Empathy in the Context of Healthcare Disparities

An issue in addressing racial healthcare disparities is the need to reduce, often unconscious, provider bias. Provider empathy can overcome such bias. Patient perceptions of provider empathy were explored to identify which provider behaviors patients perceived as conveying empathy and how perceived provider empathy influenced patient-provider interactions. In this qualitative study utilizing in-depth interviews and medical records, interviewers conducted in-depth interviews with 23 patients from three clinics. Patients reported that the following influenced perceptions of provider empathy: Taking time, patient engagement, valuing the patient, clear communication, and the healthcare system. Subtle racial differences existed. This information contributes to research on empathy and patient-provider interaction and provides preliminary evidence for racial differences.

Randomized Trial of Periodic Presumptive Treatment With High-Dose Intravaginal Metronidazole and Miconazole to Prevent Vaginal Infections in HIV-negative Women

BACKGROUND

Vaginal infections are common, frequently recur, and may increase women's risk for sexually transmitted infections (STIs). We tested the efficacy of a novel regimen to prevent recurrent vaginal infections.

METHODS

Human immunodeficiency virus (HIV)-negative women 18-45 years old with 1 or more vaginal infections, including bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), or Trichomonas vaginalis (TV), were randomly assigned to receive vaginal suppositories containing metronidazole 750 mg plus miconazole 200 mg or matching placebo for 5 consecutive nights each month for 12 months. Primary endpoints, evaluated every 2 months, were BV (Gram stain) and VVC (positive wet mount and culture).

RESULTS

Participants (N = 234) were randomly assigned to the intervention (N = 118) or placebo (N = 116) arm. Two hundred seventeen (93%) women completed an end-of-study evaluation. The intervention reduced the proportion of visits with BV compared to placebo (21.2% vs 32.5%; relative risk [RR] 0.65, 95% confidence interval [CI] .48-.87). In contrast, the proportion of visits with VVC was similar in the intervention (10.4%) versus placebo (11.3%) arms (RR 0.92, 95% CI .62-1.37).

CONCLUSIONS

Monthly treatment with intravaginal metronidazole plus miconazole reduced the proportion of visits with BV during 12 months of follow-up. Further study will be important to determine whether this intervention can reduce women's risk of STIs.

Fully integrated e-services for prevention, diagnosis, and treatment of sexually transmitted infections: results of a 4-county study in California

OBJECTIVES

We examined the acceptability, feasibility, and cost of a fully integrated online system (eSTI) for sexually transmitted infection (STI) testing, treatment, and linkage to care with 4 Northern California health departments.

METHODS

In April 2012, we implemented the eSTI system, which provided education; testing of self-collected vaginal swabs for chlamydia, gonorrhea, and trichomoniasis; e-prescriptions; e-partner notification; and data integration with clinic electronic health records. We analyzed feasibility, acceptability, and cost measures.

RESULTS

During a 3-month period, 217 women aged 18 to 30 years enrolled; 67% returned the kit. Of these, 92% viewed their results online. STI prevalence was 5.6% (chlamydia and trichomoniasis). All participants with STIs received treatment either the same day at a pharmacy (62%) or within 7 days at a clinic (38%). Among participants completing follow-up surveys, 99% would recommend the online eSTI system to a friend, and 95% preferred it over clinic-based testing within a study.

CONCLUSIONS

The fully integrated eSTI system has the potential to increase diagnosis and treatment of STIs with higher patient satisfaction at a potentially lower cost.

Examination of costs for a lay health educator-delivered translation of the Diabetes Prevention Program in senior centers

OBJECTIVE

Older adults in the U.S. have high rates of obesity. Despite the demonstrated efficacy of lifestyle interventions among older adults, lifestyle interventions are not widely implemented in community settings. Program delivery by lay health educators (LHEs) might support greater dissemination because of lower delivery cost and greater accessibility. We examined the costs of a LHE-delivered translation of the Diabetes Prevention Program (DPP) evidence-based lifestyle intervention for older adults in Arkansas senior centers.

METHODS

This examination of costs used data from a cluster randomized control trial (conducted 2008-2010) in which 7 senior centers (116 participants) were randomized to implement a LHE-delivered 12-session translation of the DPP lifestyle intervention. We compiled direct lifestyle intervention implementation costs, including training, recruitment, materials, and ongoing intervention implementation support. Weight loss data (at 4-month follow-up) were collected from participants.

RESULTS

Participant weight loss averaged 3.7kg at 4-months. The total estimated cost to implement the lifestyle intervention is $2731 per senior center, or $165 per participant. The implementation cost per kilogram lost is $45.

CONCLUSIONS

A LHE-delivered DPP translation in senior centers is effective in achieving weight loss at low cost and offers promise for the dissemination of this evidence-based intervention.

Smoking restrictions in the homes of children with cancer

OBJECTIVES

To examine smoking restrictions in households of children with cancer and their effect on biological measures of children's secondhand smoke exposure (SHSe).

METHODS

A sample of 135 parents of nonsmoking children with cancer who lived with a smoker completed structured interviews.

RESULTS

Approximately 43% of families prohibited smoking in the home. Children living in homes that prohibited smoking had median cotinine levels that were 71% and 52% lower than did those from homes with no and partial restrictions.

CONCLUSIONS

Parents should be directed to completely ban all smoking from the home and car to best protect their children from SHSe.

A randomized trial of a community-based cognitive intervention for obese senior adults

OBJECTIVE

To determine whether a cognitive intervention delivered by lay health educators (LHEs) in senior centers was effective in improving cognition in obese older adults.

METHODS

This cluster randomized trial was conducted in 16 senior centers from which 228 senior adults were recruited. The centers were randomized to either the cognitive intervention or a control, weight-loss intervention. The primary outcome variable, cognitive function, was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

Analyses of RBANS indices as continuous variables did not indicate significant differences between arms. However, after adjusting for baseline delayed memory, gender, and baseline body mass index, seniors in the cognitive intervention arm had a 2.7 times higher odds of a reliable improvement (clinically significant) in delayed memory from baseline as compared to those in the control intervention (95% CI, 1.3-5.6, p = .011). The intervention effect was not significant for the proportion showing reliable improvement in immediate memory or in attention. Attendance at the 12-session program was high with an average of 83% (67%-92%) sessions attended and 87% of participants in the cognitive arm indicating they would recommend the program.

DISCUSSION

Cognitive interventions can be effectively delivered in the community by LHEs.

Parental psychosocial predictors of secondhand smoke exposure (SHSe) for children with cancer

Children with cancer are at greater risk for the negative consequences of secondhand smoke exposure, making the identification of predictors of exposure critical. The current study investigated the impact of parents' psychosocial variables (perceived stress and vulnerability, self-efficacy), as well as health-related and demographic variables, on children's current exposure levels. Data were from 135 families whose children (M = 8.6 years old) lived with a smoker and were being treated for cancer. Self-efficacy was the consistent significant psychosocial predictor of exposure and the time since a child's diagnosis was indicative of lower exposure when limiting the sample to only smoking parents (n = 95). Both predictors of exposure have implications on motivation for behavioral change and may be suggestive of a teachable moment. Interventions may profit from tailoring programs to families based on these predictors of exposure, in particular for tobacco-based interventions for parents of medically compromised children, such as children with cancer.

Training of lay health educators to implement an evidence-based behavioral weight loss intervention in rural senior centers

PURPOSE OF THE STUDY

Lay health educators (LHEs) offer great promise for facilitating the translation of evidence-based health promotion programs to underserved areas; yet, there is little guidance on how to train LHEs to implement these programs, particularly in the crucial area of empirically validated obesity interventions.

DESIGN AND METHODS

This article describes experiences in recruiting, training, and retaining 20 LHEs who delivered a 12-month evidence-based behavioral lifestyle intervention (based on the Diabetes Prevention Program) in senior centers across a rural state. A mixed method approach was used which incorporated collecting the folllowing: quantitative data on sociodemographic characteristics of LHEs; process data related to training, recruitment, intervention implementation, and retention of LHEs; and a quantitative program evaluation questionnaire, which was supplemented by a qualitative program evaluation questionnaire. Descriptive statistics were calculated for quantitative data, and qualitative data were analyzed using content analysis.

RESULTS

The training program was well received, and the LHEs effectively recruited participants and implemented the lifestyle intervention in senior centers following a structured protocol.

IMPLICATIONS

The methods used in this study produced excellent long-term retention of LHEs and good adherence to intervention protocol, and as such may provide a model that could be effective for others seeking to implement LHE-delivered health promotion programs.

Outcome of patients with relapsed/refractory acquired immune deficiency syndrome-related lymphoma diagnosed 1999-2008 and treated with curative intent in the AIDS Malignancy Consortium

No comparative studies exist for relapsed/refractory (rel/rfr) acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL). To determine practices over the last decade and to assess the outcomes of salvage chemotherapy with curative intent and autologous stem cell transplant (ASCT), we retrospectively evaluated treatment outcomes in patients with rel/rfr ARL who were treated in 13 national AIDS Malignancy Consortium (AMC) sites between 1999 and 2008 (n = 88). The most commonly used second-line therapies were ICE (ifosfamide/carboplatin/etoposide, n = 34), dose adjusted EPOCH (etoposide/prednisone/vincristine/cyclophosphamide/doxorubicin, n = 17) and ESHAP (etoposide/methylprednisolone/cytarabine/cisplatin, n = 11). The odds of achieving a response were lower for those with non-Hodgkin lymphoma (NHL) than for those with HL and for those with primary refractory disease than for those with relapse. Overall survival (OS) was significantly longer for those with relapsed disease compared to those with refractory disease and for those with non-Burkitt NHL compared to those with Burkitt. OS was longer in patients who underwent ASCT compared to those who did not (1-year OS: 63.2% vs. 37.2%). However, among 32 patients (36%) who achieved a complete or partial response (CR/PR) after second-line therapy, 1-year OS was not different between the two groups (87.5% for ASCT vs. 81.8% for non-ASCT). Long-term survival in some patients with rel/rfr ARL may be possible without transplant, although transplant remains the standard of care for chemotherapy sensitive disease.

Intervention to reduce secondhand smoke exposure among children with cancer: a controlled trial

OBJECTIVE

This randomized controlled trial tested the efficacy of parent-based behavioral counseling for reducing secondhand smoke exposure (SHSe) among children with cancer. It also examined predictors of smoking and SHSe outcomes.

METHODS

Participants were 135 parents or guardians of nonsmoking children with cancer, <18 years, at least 30 days postdiagnosis, and living with at least one adult smoker. Parents were randomized to either a standard care control group or an intervention consisting of six counseling sessions delivered over 3 months. Parent-reported smoking and child SHSe levels were obtained at baseline, 3, 6, 9, and 12 months. Children provided urine samples for cotinine analyses.

RESULTS

Reductions in parent-reported smoking and exposure were observed in both the intervention and control conditions. There was a significantly greater reduction in parent-reported smoking and child SHSe at 3 months for the intervention group compared with the control group. Child SHSe was significantly lower at 12 months relative to baseline in both groups. Children's cotinine levels did not show significant change over time in either group. Exposure outcomes were influenced by the number of smokers at home, smoking status of the parent participating in the trial, and the child's environment (home versus hospital) the day before the assessment.

CONCLUSIONS

Children's SHSe can be reduced by advising parents to protect their child from SHSe, combined with routine reporting of their child's exposure and cotinine testing, when delivered in the context of the pediatric cancer setting. More intensive interventions may be required to achieve greater reductions in SHSe.

Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis infections in men with nongonococcal urethritis: predictors and persistence after therapy

BACKGROUND

Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), and Trichomonas vaginalis (TV) are sexually transmitted infections (STIs) associated with nongonococcal urethritis (NGU). We assessed their predictors and persistence after treatment.

METHODS

We analyzed data from an NGU treatment trial among symptomatic heterosexual men aged 16-45 years from STI clinics. Nucleic acid amplification tests detected CT, MG, and TV at baseline and at 1 and 4 weeks after therapy. Associations between variables and STI detection were investigated.

RESULTS

Among 293 participants, 44% had CT, 31% had MG, and 13% had TV at baseline. In multivariate analysis, CT infection was associated with young age and STI contact. Young age was also associated with MG, and having ≥ 1 new partner was negatively associated with TV. We detected persistent CT in 12% and MG in 44% of participants at 4 weeks after therapy, which were associated with signs and symptoms of NGU. Persistent CT was detected in 23% of participants after azithromycin treatment vs 5% after doxycycline treatment (P = .011); persistent MG was detected in 68% of participants after doxycycline vs 33% after azithromycin (P = .001). All but 1 TV infection cleared after tinidazole.

CONCLUSIONS

Persistent CT and MG after treatment of NGU are common, and were associated with clinical findings and drug regimen.

Down-regulation of the serotonin transporter in hyperreactive platelets counteracts the pro-thrombotic effect of serotonin

An elevated plasma concentration of serotonin ([5-HT]) is a common feature of cardiovascular disease often associated with enhanced platelet activation and thrombosis. Whether elevated in vivo plasma 5-HT per se represents an independent risk factor for platelet hyperreactivity or only is an epiphenomenon of cardiovascular disease is poorly understood. We examined in vitro and in vivo platelet function following a 24h elevation of plasma [5-HT] in mice. In vivo administration of 5-HT using osmotic minipumps increased plasma [5-HT] in treated mice compared to control mice instrumented with saline loaded pumps. 5-HT infusion did not increase systolic blood pressure, but markers of platelet activation including P-selectin and (PE)Jon/A staining were increased and these findings coincided with the enhanced aggregation of isolated platelets in response to type I fibrillar collagen. Tail bleeding times and the time to occlusion following chemical damage to the carotid artery were shortened in 5-HT-infused mice. 5-HT-infused mice were treated with paroxetine (Prx) to block 5-HT uptake via the serotonin transporter (SERT). Prx lowered platelet [5-HT] and attenuated platelet activation and aggregation. These results and our biochemical indices of enhanced 5-HT intracellular signaling in the platelets of 5-HT-infused mice reveal a mechanistic link between elevated plasma [5-HT], abnormal intracellular 5-HT signaling and accentuated platelet aggregation. Although a down-regulation of the serotonin transporter (SERT) on the platelet surface may counteract the pro-thrombotic influence of elevated plasma [5HT], this compensatory mechanism may fail to prevent the increased thrombotic risk caused by elevated plasma [5-HT].

Lay health educators translate a weight-loss intervention in senior centers: a randomized controlled trial

BACKGROUND

Older adults have high obesity rates and respond well to evidence-based weight-loss programs, such as the Diabetes Prevention Program (DPP) Lifestyle intervention. The goal of this study was to determine whether a translation of the DPP Lifestyle program delivered by lay health educators and conducted in senior centers is effective in promoting weight loss among older adults.

DESIGN

An RCT with older adults nested within senior centers. Senior centers identified lay health educators to receive training and deliver the intervention program at the senior center. Senior centers were randomized to DPP Lifestyle program or an attention control intervention (cognitive training).

SETTING/PARTICIPANTS

Senior centers (N=15) located throughout Arkansas. Participants (N=228) were obese (BMI=34.5±4.9) older (aged 71.2±6.6 years) adults able to engage in moderate exercise. Follow-up data were collected at 4 months on 93% of the original cohort between February 2009 and July 2010.

INTERVENTIONS

A 12-session translation of the Diabetes Prevention Program Lifestyle behavioral weight-control program delivered in group sessions by trained lay health educators.

MAIN OUTCOME MEASURES

Body weight was assessed by digital scale. Percentage weight loss from baseline and proportion achieving ≥5% and ≥7% weight loss were examined. Analyses were completed in March 2011.

RESULTS

Participants attending senior centers randomized to Lifestyle lost a significantly greater percentage of baseline weight (3.8%, 95% CI=2.9%, 4.6%) than those in the control senior centers (0.2%, 95% CI= -0.6%, -0.9%) after adjusting for baseline BMI and gender (p<0.001). Among participants attending senior centers offering the Lifestyle program, 38% lost ≥5% of baseline weight compared with 5% in the control arm (p<0.001). Similarly, significantly more participants (24%) in Lifestyle senior centers lost ≥7% than did control participants (3%, p=0.001).

CONCLUSIONS

A behavioral lifestyle weight-loss intervention delivered by a lay health educator offers a promising vehicle for translation of evidence-based obesity treatment programs in underserved areas.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.govNCT01377506.

Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens--a randomized clinical trial

BACKGROUND

Nongonococcal urethritis (NGU) is a common chlamydia-associated syndrome in men; however, Trichomonas vaginalis and Mycoplasma genitalium are associated with its etiology and should be considered in approaches to therapy. We sought to determine whether the addition of tinidazole, an anti-trichomonal agent, to the treatment regimen would result in higher cure rates than those achieved with treatment with doxycycline or azithromycin alone. A secondary aim was to compare the efficacy of doxycycline therapy and with that of azithromycin therapy.

METHODS

Randomized, controlled, double-blinded phase IIB trial of men with NGU. Participants were randomized to receive doxycycline plus or minus tinidazole or azithromycin plus or minus tinidazole and were observed for up to 45 days.

RESULTS

The prevalences of Chlamydia trachomatis, M. genitalium, and T. vaginalis were 43%, 31%, and 13%, respectively. No pathogens were identified in 29% of participants. Clinical cure rates at the first follow-up visit were 74.5% (111 of 149 patients) for doxycycline-containing regimens and 68.6% (107 of 156 patients) for azithromycin-containing regimens. By the final visit, cure rates were 49% (73 of 149 patients) for doxycycline-containing regimens and 43.6% (68 of 156 patients) for azithromycin-containing regimens. There were no significant differences in clinical response rates among the treatment arms. However, the chlamydia clearance rate was 94.8% (55 of 58 patients) for the doxycycline arm and 77.4% (41 of 53 patients) for the azithromycin arm (P = .011), and the M. genitalium clearance rate was 30.8% (12 of 39 patients) for the doxycycline arm and 66.7% (30 of 45 patients) for the azithromycin arm (P = .002).

CONCLUSIONS

Addition of tinidazole to the treatment regimen did not result in higher cure rates but effectively eradicated trichomonas. Clinical cure rates were not significantly different between patients treated with doxycycline and those treated with azithromycin; however, doxycycline had significantly better efficacy against Chlamydia, whereas azithromycin was superior to doxycycline for the treatment of M. genitalium.

Establishing the predictive validity of intentions to smoke among preadolescents and adolescents surviving cancer

PURPOSE

A significant proportion of adults surviving childhood cancer are smokers. Although these estimated rates of smoking are slightly lower than those in the US population, they remain alarmingly high for this high-risk group. The purpose of this study was to examine the predictive validity of adolescent self-reported smoking intentions for later smoking among childhood cancer survivors.

PATIENTS AND METHODS

Baseline tobacco intentions were collected from 119 nonsmoking cancer survivors, age 10 to 18 years, who participated in a tobacco-based clinical trial during the late 1990s. Follow-up smoking status was systematically collected annually up to 10 years postintervention (median follow-up, 6.0 years; interquartile range, 3.0 to 6.9 years) as part of clinical survivorship care.

RESULTS

Twenty-seven participants (22.7%) subsequently initiated tobacco use within 5 years of study enrollment. The 5-year cumulative incidence was 29.8% +/- 6.0% for those who were susceptible to smoking compared with 12.8% +/- 5.4% for those who were committed never smokers (P = .022). Past use (P < .001) and having friends who smoked (P = .038) were also associated (univariate model) with tobacco initiation, and there was a trend for an association for older adolescents (P = .073). Every unit increase on the intentions scale was associated with a 17% increase in the risk for tobacco initiation (P = .002) after adjusting for age group and past tobacco use in a multivariable model.

CONCLUSION

Because early intentions to smoke are predictive of later tobacco use, survivors as young as 10 years of age who waver in their commitment to remain tobacco abstinent should be targeted for tobacco prevention interventions.

A comparison of tobacco-related risk factors between preadolescents with and without cancer

INTRODUCTION

To compare preadolescents with and without cancer on current smoking status, future intentions to smoke, and tobacco-related risk factors, as well as to explore the relationship between cancer status and tobacco-related variables with intentions.

PROCEDURE

Ninety-four preadolescents undergoing treatment for cancer and a matched comparison sample of 190 participants without cancer, ages 8 to 11 years, completed questionnaires about their smoking habits, intentions to smoke and tobacco-related psychosocial risk factors.

RESULTS

No preadolescents with cancer and only two preadolescents without cancer reported current smoking. Compared to healthy nonsmoking preadolescents, nonsmokers with cancer were approximately one-half as likely to report future intentions to smoke. Intention to smoke was better predicted by variables most proximal to smoking including older age, being male, not having cancer, having close friends who smoke, parental smoking, and lower perceived vulnerability for tobacco-related illnesses. In the model examining distal variables, preadolescents who were more rebellious, older, and without cancer were more likely to report future smoking intentions.

DISCUSSION/CONCLUSIONS

Although future intentions to smoke differed according to cancer status, the relationship between tobacco-related risk factors and future smoking intentions appeared to be similar among preadolescents with and without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Smoking prevention and tobacco-related health risk education should begin during the elementary years, a time prior to smoking initiation and the development of solidified smoking attitudes. The diagnosis and treatment of pediatric cancer may provide an excellent opportunity for health care providers to begin communicating anti-smoking messages and health risk counseling to their young patients and families.

Anti-Smoking Communication to Preadolescents with and without a Cancer Diagnosis: Parents and Healthcare Providers as Important Communicators

A cancer diagnosis does not prevent smoking among pediatric oncology patients, and anti-smoking communications among parents and health care providers have been proposed as influencing smoking outcomes in this group. Anti-smoking communications were compared among 93 preadolescents with cancer and 402 controls. After adjusting for demographics and covariates, preadolescents with cancer were less likely than control participants to report receipt of anti-smoking messages from physicians and parents, and recalled more messages >/= 4 months post-diagnosis as compared to 1-3 months. Should anti-tobacco communications prove to influence smoking outcomes, parents and physicians may be uniquely positioned to provide smoking prevention interventions to these patients.