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1.  Asian and Pacific Islander Populations Have Higher Rates of Short Interpregnancy Intervals 
A short interpregnancy interval (IPI) is associated with poor maternal and neonatal outcomes. There is currently little known about rates of IPIs in Asian and Pacific Islander populations. We sought to determine rates of IPIs among Pacific Islanders and Asian subgroups in California.
Data from all birth records in California between 1999 and 2004 were linked with hospital discharge data. For women with a first birth in 1999–2000 and a second birth before the end of the study period, IPIs were calculated as the interval between the first birth and conception of the next pregnancy. We use bivariate and multivariable modeling to determine whether specific Asian ethnicities are associated with greater risk of short IPIs (< 6 months, 6–18 months).
Our sample included 178,000 women. In multivariable analyses adjusted for maternal demographic, social, and clinical factors, Pacific Islanders and all other Asian subgroups were more likely to have an IPI <6 months than were white women (Pacific Islanders: OR 3.31 (95% CI [2.7, 4.1]); Filipinas: OR1.51 (95% CI [1.33, 1.71]); Southeast Asians: 1.93 (95% CI [1.73, 2.1]); East Asians: OR 1.65 (95% CI [1.48, 1.84]); Other Asians: OR 2.04 (95% CI [1.70, 2.4])). Other risk factors for shorter IPIs included young maternal age, lower educational attainment, public insurance, and prior preterm birth. Similar findings were noted for IPIs of 6–18 months.
There were significantly higher rates of IPI < 6 months compared to > 18 months in the Pacific Islander group and Asian sub groups. In addition, there were higher rates of IPI 6–18 months compared to > 18 months in the Pacific Islander and Southeast Asian groups. More work should focus on rates of adverse maternal and neonatal outcomes associated with a short IPI in these populations. A better understanding of whether short intervals are the result of intended or unintended pregnancies will be critical in informing effective interventions.
PMCID: PMC4175939
2.  The Relationship between Body Mass Index and Mental Health Among Iraq and Afghanistan Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):563-570.
Obesity is a growing public health concern and is becoming an epidemic among veterans in the post-deployment period.
To explore the relationship between body mass index (BMI) and posttraumatic stress disorder (PTSD) in a large cohort of Iraq and Afghanistan veterans, and to evaluate trajectories of change in BMI over 3 years.
Retrospective, longitudinal cohort analysis of veterans’ health records
A total of 496,722 veterans (59,790 female and 436,932 male veterans) whose height and weight were recorded at the Department of Veterans Affairs (VA) healthcare system at least once after the end of their last deployment and whose first post-deployment outpatient encounter at the VA was at least 1 year prior to the end of the study period (December 31, 2011).
BMI, mental health diagnoses.
Seventy-five percent of Iraq and Afghanistan veterans were either overweight or obese at baseline. Four trajectories were observed: “stable overweight” represented the largest class; followed by “stable obese;” “overweight/obese gaining;” and “obese losing.” During the 3-year ascertainment period, those with PTSD and depression in particular were at the greatest risk of being either obese without weight loss or overweight or obese and continuing to gain weight. Adjustment for demographics and antipsychotic medication attenuated the relationship between BMI and certain mental health diagnoses. Although BMI trajectories were similar in men and women, some gender differences were observed. For example, the risk of being in the persistently obese class in men was highest for those with PTSD, whereas for women, the risk was highest among those with depression.
The growing number of overweight or obese returning veterans is a concerning problem for clinicians who work with these patients. Successful intervention to reduce the prevalence of obesity will require integrated efforts from primary care and mental health to treat underlying mental health causes and assist with engagement in weight loss programs.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2374-8) contains supplementary material, which is available to authorized users.
PMCID: PMC3695271  PMID: 23807066
women’s health; veteran; mental health; obesity
3.  Gender Differences in Health Service Utilization Among Iraq and Afghanistan Veterans with Posttraumatic Stress Disorder 
Journal of Women's Health  2012;21(6):666-673.
Little is known about gender differences in healthcare use among newly returning veterans with posttraumatic stress disorder (PTSD). We investigated gender differences in Veterans Affairs (VA) medical center health service use among Iraq and Afghanistan veterans with PTSD with and without comorbid depression and alcohol use disorders (AUD).
Using VA administrative data, bivariate and multivariate statistics were used to examine gender differences in health service use among 159,705 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with PTSD seeking VA healthcare from October 7, 2001, to December 31, 2010.
Female veterans with PTSD were more likely to be black and single and to have higher mental health, primary care, and emergency care use compared to men with PTSD. Men were more likely to have higher mental health inpatient use compared to women. Women and men with comorbid PTSD and depression or comorbid PTSD and AUD were more likely to have higher use in all domains compared to their counterparts with PTSD without these comorbid disorders. Women with comorbid PTSD and depression were 12.5 times more likely to have a mental health inpatient hospitalization compared to their female counterparts without depression and twice as likely to have a mental health hospitalization compared to men with comorbid PTSD and depression.
Women with PTSD had higher use than men in almost all areas, as did all veterans with comorbid PTSD and depression and comorbid PTSD and AUD, regardless of gender. Better understanding these health service use differences will allow for targeted evaluation and integrated treatment interventions in veterans with PTSD.
PMCID: PMC3366102  PMID: 22313026
4.  Adipose Tissue and Metabolic Factors Associated with Steatosis in HIV/HCV coinfection: Histology versus Magnetic Resonance Spectroscopy 
Hepatic steatosis is common in persons with HIV and hepatitis C virus (HCV); yet biopsy measurement of steatosis is prone to sampling error. We compared magnetic resonance spectroscopy (MRS) measurement of steatosis to histology in HIV/HCV-coinfected patients, and explored the associated adipose tissue and metabolic factors.
Cross-sectional analysis of 42 HIV/HCV-coinfected men and women. Logistic regression analysis identified factors [MRI-measured visceral adipose tissue (VAT) and abdominal subcutaneous adipose tissue (SAT) and Homeostasis Model Assessment (HOMA) estimated insulin resistance] associated with histologic steatosis (≥5% of hepatocytes with fat) and MRS steatosis (≥5% of hepatic fat).
MRS steatosis was strongly associated with histologic steatosis, when measured continuously [odds ratio: 10.2 per doubling of MRS-measured hepatic fat; 95% confidence interval (CI):2.9, 69.3] and dichotomously (Kappa coefficient=0.52; p=0.0007). Four of the 10 with MRS-measured steatosis did not have histologic steatosis; 3 of 9 with histologic steatosis did not have MRS-measured steatosis (67% sensitivity; 88% specificity). Associations of VAT and abdominal SAT were associated with both histologic and MRS-measured steatosis. Insulin resistance was also associated with both.
When compared to histology, MRS was similarly associated with adipose tissue and metabolic factors. MRS is a useful non-invasive alternative to biopsy in HIV/HCV coinfection.
PMCID: PMC2943991  PMID: 20512045
Steatosis; Magnetic Resonance Spectroscopy; HIV; HCV; Adipose tissue; Insulin Resistance
5.  Association of Antiretroviral Therapy with Fibrinogen Levels in HIV Infection 
AIDS (London, England)  2008;22(6):707-715.
PMCID: PMC3156620  PMID: 18356600
fibrinogen; HIV; protease inhibitors; non-nucleoside reverse transcriptase inhibitors
6.  Screening Prevalence and Incidence of Colorectal Cancer Among American Indian/Alaskan Natives in the Indian Health Service 
Digestive Diseases and Sciences  2011;56(7):2104-2113.
Studies on colorectal cancer (CRC) screening and incidence among American Indian/Alaska Natives (AI/AN) are few.
Our aim was to determine CRC screening prevalence and to calculate CRC incidence among AI/AN receiving care within the Indian Health Service (IHS).
A retrospective cohort study of AI/AN who utilized IHS from 1996 to 2004. AI/AN who were average-risk for CRC and received primary care within IHS were identified by searching the IHS Resource Patient Management System for selected ICD-9/CPT codes (n = 142,051). CRC screening prevalence was calculated and predictors of screening were determined for this group. CRC incidence rates were ascertained for the entire AI/AN population ages 50–80 who received IHS medical care between 1996 and 2004 (n = 283,717).
CRC screening was performed in 4.0% of average-risk AI/AN. CRC screening was more common among women than men (RR = 1.6, 95% CI 1.4–1.7) and among AI/AN living in the Alaska region compared to the Pacific Coast region (RR = 2.5, 95% CI 2.2–2.8) while patients living in the Northern Plains (RR = 0.4, 95% CI 0.3–0.4) were less likely to have been screened. CRC screening was less common among patients with a greater number of primary care visits. The age-adjusted CRC incidence among AI/AN ages 50–80 was 227 cancers per 100,000 person-years.
CRC was common among AI/AN receiving medical care within IHS. However, CRC screening prevalence was far lower than has been reported for the U.S. population.
PMCID: PMC3112488  PMID: 21234688
Screening; Incidence; Colonoscopy; Health disparity

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