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1.  Teaching Health Literacy Using Popular Television Programming: A Qualitative Pilot Study 
Teaching of health and medical concepts in the K-12 curriculum may help improve health literacy.
The purpose of this project was to determine acceptability and preliminary efficacy of pilot implementation of a health literacy curriculum using brief clips from a popular television program.
Participants included 55 ninth-grade students in a low-income school with a high proportion of minority students. The curriculum used three brief interspersed segments from the television show ER to teach basic topics in cardiology. After the 30-minute experimental curriculum, students completed open-ended surveys which were coded qualitatively.
The most common codes described “enjoyment” (N=28), “acquisition of new knowledge” (N=28), “informative” (N=15), “interesting” (N=12), and “TV/video” (N=10). We found on average 2.9 examples of medical content per participant. Of the 26 spontaneously-generated verifiable statements, 24 (92.3%) were judged as accurate by two independent coders (κ=0.70, P=.0002).
Use of brief segments of video material contributed to the acceptability of health education curricula without detracting from students’ acquisition of accurate information.
Translation to Health Education Practice
Health education practitioners may wish to include brief clips from popular programming to motivate students and provide context for health-related lessons.
PMCID: PMC3757562  PMID: 23998135
2.  Association of Race and Ethnicity With Management of Abdominal Pain in the Emergency Department 
Pediatrics  2013;132(4):e851-e858.
To determine if race/ethnicity-based differences exist in the management of pediatric abdominal pain in emergency departments (EDs).
Secondary analysis of data from the 2006–2009 National Hospital Ambulatory Medical Care Survey regarding 2298 visits by patients ≤21 years old who presented to EDs with abdominal pain. Main outcomes were documentation of pain score and receipt of any analgesics, analgesics for severe pain (defined as ≥7 on a 10-point scale), and narcotic analgesics. Secondary outcomes included diagnostic tests obtained, length of stay (LOS), 72-hour return visits, and admission.
Of patient visits, 70.1% were female, 52.6% were from non-Hispanic white, 23.5% were from non-Hispanic black, 20.6% were from Hispanic, and 3.3% were from “other” racial/ethnic groups; patients’ mean age was 14.5 years. Multivariate logistic regression models adjusting for confounders revealed that non-Hispanic black patients were less likely to receive any analgesic (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.43–0.87) or a narcotic analgesic (OR: 0.38; 95% CI: 0.18–0.81) than non-Hispanic white patients (referent group). This finding was also true for non-Hispanic black and “other” race/ethnicity patients with severe pain (ORs [95% CI]: 0.43 [0.22–0.87] and 0.02 [0.00–0.19], respectively). Non-Hispanic black and Hispanic patients were more likely to have a prolonged LOS than non-Hispanic white patients (ORs [95% CI]: 1.68 [1.13–2.51] and 1.64 [1.09–2.47], respectively). No significant race/ethnicity-based disparities were identified in documentation of pain score, use of diagnostic procedures, 72-hour return visits, or hospital admissions.
Race/ethnicity-based disparities exist in ED analgesic use and LOS for pediatric abdominal pain. Recognizing these disparities may help investigators eliminate inequalities in care.
PMCID: PMC4074647  PMID: 24062370
abdominal pain; disparities; emergency department; racial difference
3.  Evaluation of VA Women’s Health Fellowships: Developing Leaders in Academic Women’s Health 
The Department of Veterans Affairs (VA) instituted the VA Women’s Health Fellowship (VAWHF) Program in 1994, to accommodate the health needs of increasing numbers of female veterans and to develop academic leaders in women’s health. Despite the longevity of the program, it has never been formally evaluated.
To describe the training environments of VAWHFs and career outcomes of female graduates.
Cross-sectional web-based surveys of current program directors (2010–2011) and VAWHF graduates (1995–2011).
Responses were received from six of seven program directors (86 %) and 42 of 74 graduates (57 %). The mean age of graduates was 41.2 years, and mean time since graduation was 8.5 years. Of the graduates, 97 % were female, 74 % trained in internal medicine, and 64 % obtained an advanced degree. Those with an advanced degree were more likely than those without an advanced degree to pursue an academic career (82 % vs. 60 %; P < 0.01). Of the female graduates, 76 % practice clinical women’s health and spend up to 66 % of their time devoted to women’s health issues. Thirty percent have held a VA faculty position. Seventy–nine percent remain in academics, with 39 % in the tenure stream. Overall, 94 % had given national presentations, 88 % had received grant funding, 79 % had published in peer-reviewed journals, 64 % had developed or evaluated curricula, 51 % had received awards for teaching or research, and 49 % had held major leadership positions. At 11 or more years after graduation, 33 % of the female graduates in academics had been promoted to the rank of associate professor and 33 % to the rank of full professor.
The VAWHF Program has been successful in training academic leaders in women’s health. Finding ways to retain graduates in the VA system would ensure continued clinical, educational, and research success for the VA women veteran’s healthcare program.
PMCID: PMC3682043  PMID: 23435766
VA women’s health; fellowship; academic productivity; female leadership; women in academic medicine
4.  Short-Term Perioperative All-Cause Mortality and Cardiovascular Events in Women with Systemic Lupus Erythematosus 
Arthritis care & research  2013;65(6):986-991.
Persons with systemic lupus erythematosus (SLE) are at increased risk of cardiovascular disease (CVD) events, but this excess CVD burden in the perioperative setting is yet to be determined. We aimed to determine the risk of perioperative short-term all-cause mortality and CVD events among women with SLE compared to those without SLE.
Methods and Results
We conducted a cross-sectional analysis of pooled hospital discharge data from years 1998 to 2002 of the Nationwide Inpatient Sample. We abstracted diseases and procedures using International Classification of Diseases, Ninth Revision (ICD-9-CM) codes. The principal procedure was categorized into either a low, intermediate, or high risk level. Survey logistic regression adjusting for potential confounders provided estimates for stratum-specific odds of adverse events in women with SLE relative to those without SLE for each procedure risk level. All-cause mortality was significantly greater among women with SLE having a low (Odds Ratio [OR] 1.54; 95% Confidence Interval [CI] 1.00-2.37) or a high risk principal procedure (OR 2.52; 95% CI 1.34-4.75) relative to women without SLE, but did not differ significantly among persons with intermediate risk procedures. Women with SLE with a low risk procedure were also more likely to experience a composite CVD event relative to women without SLE (OR 1.40; 95% CI 1.04-1.87).
Women with SLE are at increased risk for short-term perioperative adverse events. These results highlight a need for greater scrutiny during perioperative evaluation and management of women with SLE.
Significance and Innovation
The perioperative setting represents a time of heightened risk for morbidity and mortality, especially in individuals at increased risk of cardiovascular disease. Women with SLE are at increased risk of premature morbidity and mortality attributed to atherosclerotic disease. The results of our study which revealed an increased risk of adverse perioperative events in women with SLE indicates a need for greater scrutiny in perioperative clinical care also in addition to further investigation as to the non-cardiovascular causes of increased perioperative mortality observed in women with SLE.
PMCID: PMC3674177  PMID: 23213026
5.  Effect of hospital level variation in the use of carotid artery stenting versus carotid endarterectomy on perioperative stroke and death in asymptomatic patients 
Journal of vascular surgery  2013;57(3):627-634.
Perioperative stroke and death (PSD) is more common after carotid artery stenting (CAS) than after carotid endarterectomy (CEA) in symptomatic patients, but it is unclear if this is also true in asymptomatic patients. Further, use of both CEA and CAS varies geographically, suggesting possible variation in outcomes. We compared odds of PSD after CAS and CEA in asymptomatic patients to determine the impact of this variation.
Design of Study
We identified CAS and CEA procedures and hospitals where they were performed in 2005–2009 California hospital discharge data. Preoperative symptom status and medical comorbidities were determined using administrative codes. We compared PSD rates after CAS and CEA using logistic regression and propensity score matching. We quantified hospital level variation in the relative utilization of CAS by calculating hospital-specific probabilities of CAS use among propensity score matched patients. We then calculated a weighted average for each hospital and used this as a predictor of PSD.
We identified 6,053 CAS and 36,524 CEA procedures that treated asymptomatic patients in 278 hospitals. PSD occurred in 250 CAS and 660 CEA patients, yielding unadjusted PSD rates of 4.1% and 1.8%, respectively (P<.001). Compared with CAS patients, CEA patients were more likely to be older than 70 (66% vs. 62%, P<.001), but less likely to have 3 or more Elixhauser comorbidities (37% vs. 39%, P<.001). Multivariate models demonstrated that CAS was associated with increased odds of PSD (OR 1.865, 95% CI 1.373–2.534, P<.001). Estimation of average treatment effects based on propensity scores also demonstrated 1.9% increased probability of PSD with CAS (P<.001). The average probability of receiving CAS across all hospitals and strata was 13.8%, but the inter-quartile range was 0.9%–21.5%, suggesting significant hospital level variation. In univariate analysis, patients treated at hospitals with higher CAS utilization had higher odds of PSD as compared to patients in hospitals that performed CAS less (OR 2.141, 95% CI 1.328–3.454, P=.002). Multivariate analysis did not demonstrate this effect, but again demonstrated higher odds of PSD after CAS (OR 1.963, 95% CI 1.393–2.765, P<.001).
CEA has lower odds of PSD compared to CAS in asymptomatic patients. Increased utilization of CAS at the hospital level is associated with increased odds of PSD among asymptomatic patients, but this effect appears to be related to generally worse outcomes after CAS as compared to CEA.
PMCID: PMC3692978  PMID: 23312937
6.  Unhealthy Alcohol and Illicit Drug Use are Associated with Decreased Quality of HIV Care 
HIV-infected patients with substance use experience suboptimal health outcomes, possibly to due to variations in care.
To assess the association between substance use and the quality of HIV care (QOC) received.
Research Design
Retrospective cohort study.
HIV-infected patients enrolled in the Veterans Aging Cohort Study.
We collected self-report substance use data and abstracted 9 HIV quality indicators (QIs) from medical records. Independent variables were unhealthy alcohol use (AUDIT-C score ≥4) and illicit drug use (self-report of stimulants, opioids, or injection drug use in past year). Main outcome was the percentage of QIs received, if eligible. We estimated associations between substance use and QOC using multivariable linear regression.
The majority of the 3,410 patients were male (97.4%) and Black (67.0%) with a mean age of 49.1 years (SD 8.8). Overall, 25.8% reported unhealthy alcohol use, 22% illicit drug use, and participants received 81.5% (SD=18.9) of QIs. The mean percentage of QIs received was lower for those with unhealthy alcohol use vs. not (59.3% vs. 70.0%, p<.001) and those using illicit drugs vs. not (57.8% vs. 70.7%, p<.001). In multivariable models, unhealthy alcohol use (adjusted β −2.74; 95% CI −4.23, −1.25) and illicit drug use (adjusted β −3.51 95% CI −4.99, −2.02) remained inversely associated with the percentage of QIs received.
Though the overall QOC for these HIV-infected Veteran patients was high, gaps persist for those with unhealthy alcohol and illicit drug use. Interventions that address substance use in HIV-infected patients may improve the QOC received.
PMCID: PMC3460799  PMID: 22820808
Alcohol; Quality of Health Care; HIV; Quality Indicators; Health Care; Opioid-Related Disorders
7.  Perioperative All-Cause Mortality and Cardiovascular Events in Patients with Rheumatoid Arthritis: Comparison with Unaffected Controls and Persons with Diabetes Mellitus 
Arthritis and rheumatism  2012;64(8):2429-2437.
Rheumatoid arthritis (RA) is associated with an increased cardiovascular (CV) burden similar to that of diabetes mellitus (DM). This risk may warrant pre-operative CV assessment as is performed for patients with DM. We aimed to determine if the risk of perioperative mortality and CV events among patients with RA differed from those of unaffected patients and those with DM.
We used 1998 to 2002 Nationwide Inpatient Sample of the Healthcare Cost Utilization Project (HCUP-NIS) data to identify elective hospitalizations of patients undergoing non-cardiac surgery. Surgical procedures were categorized as low risk, intermediate risk, and high risk of CV events using established guidelines. Logistic models provided the adjusted odds of study endpoints in RA, DM, or both relative to neither condition.
Among 7,756,570 patients with a low risk, intermediate risk, or high risk non-cardiac procedure, 2.34%, 0.51%, and 2.12% had a composite CV event, respectively, and death occurred in 1.47%, 0.50%, 2.59% respectively. Among those with an intermediate risk procedure, death was less likely in RA than DM patients (0.30% vs. 0.65%; p <0.001), but the difference in mortality among those with low risk or high risk procedures was not significant. Patients with RA were less likely to have a CV event than patients with DM with procedures of low risk (3.38% vs. 5.30%; p <0.001) and intermediate risk (0.34% vs. 1.07%; p <0.001). In adjusted models, RA was not independently associated with an increased risk of perioperative mortality or CV event.
RA was not associated with adverse perioperative CV or mortality risk, suggesting a lack of need for a change from current perioperative clinical care.
PMCID: PMC3442932  PMID: 22354534
8.  The Risk of Incident Coronary Heart Disease Among Veterans with and without HIV and Hepatitis C 
Whether hepatitis C (HCV) confers additional coronary heart disease (CHD) risk among Human Immunodeficiency Virus (HIV) infected individuals is unclear. Without appropriate adjustment for antiretroviral therapy, CD4 count, and HIV-1 RNA, and substantially different mortality rates among those with and without HIV and HCV infection, the association between HIV, HCV, and CHD may be obscured.
Methods and Results
We analyzed data on 8579 participants (28% HIV+, 9% HIV+HCV+) from the Veterans Aging Cohort Study Virtual Cohort who participated in the 1999 Large Health Study of Veteran Enrollees. We analyzed data collected on HIV and HCV status, risk factors for and the incidence of CHD, and mortality from 1/2000–7/2007. We compared models to assess CHD risk when death was treated as a censoring event and as a competing risk. During the median 7.3 years of follow-up, there were 194 CHD events and 1186 deaths. Compared with HIV−HCV− Veterans, HIV+ HCV+ Veterans had a significantly higher risk of CHD regardless of whether death was adjusted for as a censoring event (adjusted hazard ratio (HR)=2.03, 95% CI=1.28–3.21) or a competing risk (adjusted HR=2.45, 95% CI=1.83–3.27 respectively). Compared with HIV+HCV− Veterans, HIV+ HCV+ Veterans also had a significantly higher adjusted risk of CHD regardless of whether death was treated as a censored event (adjusted HR=1.93, 95% CI=1.02–3.62) or a competing risk (adjusted HR =1.46, 95% CI=1.03–2.07).
HIV+HCV+ Veterans have an increased risk of CHD compared to HIV+HCV−, and HIV−HCV− Veterans.
PMCID: PMC3159506  PMID: 21712519
viruses; coronary disease; mortality; multi morbidity
9.  A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center 
Unhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients.
We conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting.
A total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features.
RCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients.
PMCID: PMC3533719  PMID: 23186245
Alcohol consumption; Alcoholism; Inpatients; Nursing; Nurses; Implementation; Screening; Counseling; Qualitative research; Focus groups
11.  Patterns of drug use and abuse among aging adults with and without HIV: A latent class analysis of a US Veteran cohort* 
Drug and alcohol dependence  2010;110(3):208-220.
This study characterized the extent and patterns self-reported drug use among aging adults with and without HIV, assessed differences in patterns by HIV status, and examined pattern correlates. Data derived from 6351 HIV infected and uninfected adults enrolled in an eight-site matched cohort, the Veterans Aging Cohort Study (VACS). Using clinical variables from electronic medical records and sociodemographics, drug use consequences, and frequency of drug use from baseline surveys, we performed latent class analyses (LCA) stratified by HIV status and adjusted for clinical and socio-demographic covariates. Participants were, on average, age 50 (range 22–86), primarily male (95%) and African-American (64%). Five distinct patterns emerged: non-users, past primarily marijuana users, past multidrug users, current high consequence multidrug users, and current low consequence primarily marijuana users. HIV status strongly influenced class membership. Non -users were most p revalent among HIV uninfected (36.4%) and current high consequence multidrug users (25.5%) were most prevalent among HIV infected. While problems of obesity marked those not currently u sing drugs, current users experienced higher prevalences of medical or mental health disorders. Multimorbidity was highest among past and current multidrug users. HIV-infected participants were more likely than HIV-uninfected participants to be current low consequence primarily marijuana users. In this sample, active drug use and abuse were common. HIV infected and uninfected Veterans differed on extent and patterns of drug use and on important characteristics within identified classes. Findings have the potential to inform screening and intervention efforts in aging drug users with and without HIV.
PMCID: PMC3087206  PMID: 20395074
aging; Veterans; HIV; substance-related disorders; latent class analysis; illicit drugs; cohort studies
American journal of hypertension  2009;22(11):1212-1218.
Moderate alcohol consumption is associated with a reduced risk of total mortality among Caucasian women. Whether moderate alcohol consumption is associated with a reduced risk of total mortality among African American or hypertensive women is unclear.
We conducted a prospective study among 10,576 black and 105,610 white post-menopausal women from the Women’s Health Initiative, without a history of cancer or cardiovascular disease, who completed the baseline examinations in 1994–1998.
During the mean 8 years of follow-up, 5608 women died. Moderate drinking (1–<7 drinks/week) was associated with a lower risk of total mortality among Caucasians (hazard ratio (HR) =0.81, 95% CI=0.72–0.91) and hypertensives (HR=0.76, 95% CI=0.65–0.87) as compared with lifetime abstention from alcohol. Among African American moderate drinkers the risk of total mortality was HR=0.94, 95% CI=0.67–1.3. Current drinking (<1 drink/month or greater) was associated with a lower risk of mortality among Caucasians, including hypertensives and non-hypertensives, and hypertensive African Americans (HR=0.74, 95% CI=0.54–0.99) but not among non-hypertensive African Americans (HR=1.31, 95% CI=0.79–2.16). The stratified comparisons among African Americans were affected by the low prevalence of moderate drinking (14.6%) and the low mortality rate (37.5/10,000) among the non-hypertensive lifetime abstainers.
Moderate drinking is associated with a lower risk of total mortality among Caucasian women. Current drinking is associated with a lower risk of total mortality among Caucasians, regardless of hypertensive status, and hypertensive but not non-hypertensive African American women. The latter observation was affected by the low mortality rate among the African American non-hypertensive lifetime abstainers.
PMCID: PMC3104852  PMID: 19730413
alcohol; hypertension; mortality; women; race/ethnicity
13.  Exposure to Cannabis in Popular Music and Cannabis Use among Adolescents 
Addiction (Abingdon, England)  2009;105(3):515-523.
Cannabis use is frequently referenced in American popular music, yet it remains uncertain whether exposure to these references is associated with actual cannabis use. We aimed to determine if exposure to cannabis in popular music is independently associated with current cannabis use in a cohort of urban adolescents.
We surveyed all 9th grade students at three large U.S. urban high schools. We estimated participants’ exposure to lyrics referent to cannabis with overall music exposure and content analyses of their favorite artists’ songs. Outcomes included current (past 30 day) and ever use of cannabis. We used multivariable regression to assess independent associations between exposures and outcomes while controlling for important covariates.
Each of the 959 participants was exposed to an estimated 40 cannabis references per day (standard deviation = 104). Twelve percent (N = 108) were current cannabis users and 32% (N=286) had ever used cannabis. Compared with those in the lowest tertile of total cannabis exposure in music, those in the highest tertile of exposure were almost twice as likely to have used cannabis in the past 30 days (odds ratio = 1.83; 95% confidence interval = 1.04, 3.22), even after adjusting for sociodemographic variables, personality characteristics, and parenting style. As expected, however, there was no significant relationship between our cannabis exposure variable and a sham outcome variable of alcohol use.
This study supports an independent association between exposure to cannabis in popular music and early cannabis use among urban American adolescents.
PMCID: PMC2881613  PMID: 20039860
Cannabis; adolescence; music; popular music; mass media; iPod; radio
14.  Erectile Dysfunction Drug Receipt, Risky Sexual Behavior and Sexually Transmitted Diseases in HIV-infected and HIV-uninfected Men 
Health care providers may be concerned that prescribing erectile dysfunction drugs (EDD) will contribute to risky sexual behavior.
To identify characteristics of men who received EDD prescriptions, determine whether EDD receipt is associated with risky sexual behavior and sexually transmitted diseases (STDs), and determine whether these relationships vary for certain sub-groups.
Cross-sectional study.
Two thousand seven hundred and eighty-seven sexually-active, HIV-infected and HIV-uninfected men recruited from eight Veterans Health Affairs outpatient clinics. Data were obtained from participant surveys, electronic medical records, and administrative pharmacy data.
EDD receipt was defined as two or more prescriptions for an EDD, risky sex as having unprotected sex with a partner of serodiscordant or unknown HIV status, and STDs, according to self-report.
Overall, 28% of men received EDD in the previous year. Eleven percent of men reported unprotected sex with a serodiscordant/unknown partner in the past year (HIV-infected 15%, HIV-uninfected 6%, P < 0.001). Compared to men who did not receive EDD, men who received EDD were equally likely to report risky sexual behavior (11% vs. 10%, p = 0.9) and STDs (7% vs 7%, p = 0.7). In multivariate analyses, EDD receipt was not significantly associated with risky sexual behavior or STDs in the entire sample or in subgroups of substance users or men who had sex with men.
EDD receipt was common but not associated with risky sexual behavior or STDs in this sample of HIV-infected and uninfected men. However, risky sexual behaviors persist in a minority of HIV-infected men, indicating ongoing need for prevention interventions.
PMCID: PMC2837496  PMID: 19921112
HIV infection; risky sexual behavior; STDs; men; phosphodiesterase inhibitors
15.  Media Exposure and Marijuana and Alcohol Use Among Adolescents 
Substance use & misuse  2009;44(5):722-739.
We aimed to determine which media exposures are most strongly associated with marijuana and alcohol use among adolescents. In 2004, we surveyed 1,211 students at a large high school in suburban Pittsburgh regarding substance use, exposure to entertainment media, and covariates. Of the respondents, 52% were female, 8% were non-White, 27% reported smoking marijuana, and 60% reported using alcohol. They reported average exposure to 8.6 hr of media daily. In adjusted models, exposure to music was independently associated with marijuana use, but exposure to movies was independently associated with alcohol use. Implications, limitations, and suggestions for further research are discussed.
PMCID: PMC3008330  PMID: 19306219
alcohol; marijuana; mass media; entertainment media; adolescence; music; movies; television; video games; books
16.  Focus on the Heart: Alcohol Consumption, HIV Infection, and Cardiovascular Disease 
Alcohol Research & Health  2010;33(3):237-246.
With the advent of effective antiretroviral therapy, people infected with HIV have a longer life expectancy and, consequently, are likely to develop other chronic conditions also found in noninfected people, including cardiovascular disease (CVD). Alcohol consumption, which is common among HIV-infected people, may influence the risk of CVD. In noninfected adults, moderate alcohol consumption can reduce the risk of coronary heart disease (CHD), heart attacks, and the most common type of stroke, whereas heavy drinking increases the risk of these cardiovascular events. These relationships can be partially explained by alcohol’s effects on various risk factors for CVD, including cholesterol and other lipid levels, diabetes, or blood pressure. In HIV-infected people, both the infection itself and its treatment using combination antiretroviral therapy may contribute to an increased risk of CVD by altering blood lipid levels, inducing inflammation, and impacting blood-clotting processes, all of which can enhance CVD risk. Coinfection with the hepatitis C virus also may exacerbate CVD risk. Excessive alcohol use can further enhance CVD risk in HIV-infected people through either of the mechanisms described above. In addition, excessive alcohol use (as well as HIV infection) promote microbial translocation—the leaking of bacteria or bacterial products from the intestine into the blood stream, where they can induce inflammatory and immune reactions that damage the cardiovascular system.
PMCID: PMC3860509  PMID: 23584065
Alcohol consumption; alcohol use disorder; heavy drinking; alcohol and other drug effects and consequences; human immunodeficiency virus; antiretroviral therapy; combination antiretroviral therapy; cardiovascular disease; coronary heart disease; stroke
17.  Update in Addiction Medicine for the Primary Care Clinician 
Journal of General Internal Medicine  2008;23(12):2112-2116.
PMCID: PMC2596507  PMID: 18830761
substance-related disorders; primary health care; review literature
18.  Cost-Effectiveness of Screening for Unhealthy Alcohol Use with %Carbohydrate Deficient Transferrin: Results From a Literature-Based Decision Analytic Computer Model 
The %carbohydrate deficient transferrin (%CDT) test offers objective evidence of unhealthy alcohol use but its cost-effectiveness in primary care conditions is unknown.
Using a decision tree and Markov model, we performed a literature-based cost-effectiveness analysis of 4 strategies for detecting unhealthy alcohol use in adult primary care patients: (i) Questionnaire Only, using a validated 3-item alcohol questionnaire; (ii) %CDT Only; (iii) Questionnaire followed by %CDT (Questionnaire-%CDT) if the questionnaire is negative; and (iv) No Screening. For those patients screening positive, clinicians performed more detailed assessment to characterize unhealthy use and determine therapy. We estimated costs using Medicare reimbursement and the Medical Expenditure Panel Survey. We determined sensitivity, specificity, prevalence of disease, and mortality from the medical literature. In the base case, we calculated the incremental cost-effectiveness ratio (ICER) in 2006 dollars per quality-adjusted life year ($/QALY) for a 50-year-old cohort.
In the base case, the ICER for the Questionnaire-%CDT strategy was $15,500/QALY compared with the Questionnaire Only strategy. Other strategies were dominated. When the prevalence of unhealthy alcohol use exceeded 15% and screening age was <60 years, the Questionnaire-%CDT strategy costs less than $50,000/QALY compared to the Questionnaire Only strategy.
Adding %CDT to questionnaire-based screening for unhealthy alcohol use was cost-effective in our literature-based decision analytic model set in typical primary care conditions. Screening with %CDT should be considered for adults up to the age of 60 when the prevalence of unhealthy alcohol use is 15% or more and screening questionnaires are negative.
PMCID: PMC2758076  PMID: 19426168
Carbohydrate Deficient Transferring; Alcohol Use; Primary Care
19.  Factors Associated with Alcohol Use, Depression, and Their Co-occurrence during Pregnancy 
Alcohol use and depression each adversely affect birth outcomes, but the impact of their co-occurrence among pregnant women is not well understood. In this study, we examined factors associated with alcohol use, depression, and their co-occurrence during pregnancy.
We analyzed datasets from 2 longitudinal studies conducted nearly 20 years apart in the same outpatient prenatal clinic of an urban women’s hospital. Participants included 278 women recruited from 1982 to 1985 for the Maternal Health Practices and Child Development (MHPCD) Study and 209 women recruited from 2000 to 2002 for the Health Outcomes from Prenatal Education (HOPE) Study. Both studies selected women on the basis of their level of alcohol use early in pregnancy. We used multinomial logistic regression models to test multiclassification prediction of alcohol use, depression, and their co-occurrence during pregnancy.
In the second and third trimesters, more MHPCD participants than HOPE participants consumed alcohol (67% vs. 20%), experienced depression (85% vs. 34%), and had co-occurring drinking and depression (56% vs. 10%) (p<0.001 for each). For the MHPCD cohort, smoking predicted alcohol use. There were no significant predictors for depression alone or the co-occurrence. For the HOPE cohort, older age and smoking were predictors of alcohol use; smoking and less education were predictors of depression; and illicit drug use was a predictor of the co-occurrence of alcohol use and depression (p<0.05 for all relationships).
Smoking, older age, lower education, and illicit substance use predicted alcohol and/or probable depression in the second and third trimesters among women who drank in the first trimester.
PMCID: PMC2746640  PMID: 18540924
alcohol use; depression; co-occurrence; pregnancy; risk factors
20.  The association between hepatitis C infection and prevalent cardiovascular disease among HIV-infected individuals 
AIDS (London, England)  2007;21(2):193-197.
To examine the association between hepatitis C and prevalent cardiovascular disease (CVD) among HIV-infected individuals.
A cross-sectional analysis of data from the HIV–Longitudinal Interrelationships of Viruses and Ethanol (HIV–LIVE) cohort, a prospective cohort of HIV-infected individuals with current or past alcohol problems.
We analysed health questionnaire and laboratory data from 395 HIV-infected individuals (50.1% co-infected with hepatitis C) using logistic regression to estimate the odds ratio (OR) for the prevalence of CVD among those co-infected with hepatitis C and HIV compared with those infected with HIV alone.
The prevalence of CVD was higher among those co-infected with hepatitis C compared with those with HIV alone (11.1 versus 2.5%, respectively). After adjusting for age, the OR for the prevalence of CVD was significantly higher among those with hepatitis C co-infection (adjusted OR 4.65, 95% confidence interval 1.70–12.71). The relationship between hepatitis C and CVD persisted when adjusting for age and other sociodemographic characteristics, substance use, and cardiovascular risk factors in separate regression models.
Co-infection with hepatitis C among a cohort of HIV-infected individuals was associated with a higher age-adjusted odds for the prevalence of CVD. These data suggest that hepatitis C infection may be associated with an increased risk of CVD among those co-infected with HIV.
PMCID: PMC1805683  PMID: 17197810
Cardiovascular disease; cardiovascular risk factors; hepatitis C; HIV; myocardial infarction; substance abuse
21.  Decreased Alcohol Consumption in Outpatient Drinkers Is Associated with Improved Quality of Life and Fewer Alcohol-related Consequences 
This study's objective was to determine whether changes in alcohol consumption are associated with changes in quality of life and alcohol-related consequences in an outpatient sample of drinkers. Two hundred thirteen subjects completed the Short Form 36-item (SF-36) Health Survey and the Short Inventory of Problems at baseline, 6 months, and 12 months. Subjects who sustained a 30% or greater decrease in drinks per month reported improvement in SF-36 Physical Component Summary (P = .058) and Mental Component Summary (P = .037) scores and had fewer alcohol-related consequences (P < .001) when compared to those with a <30% decrease. These findings suggest another benefit of alcohol screening and intervention in the primary care setting.
PMCID: PMC1495050  PMID: 12047737
alcohol drinking; alcohol dependence; alcohol abuse; quality of life; health status

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