Cumulative Burden of Depression and All-Cause Mortality in Women Living With Human Immunodeficiency Virus.

Background: Research linking depression to mortality among people living with human immunodeficiency virus (PLWH) has largely focused on binary "always vs never" characterizations of depression. However, depression is chronic and is likely to have cumulative effects on mortality over time. Quantifying depression as a cumulative exposure may provide a better indication of the clinical benefit of enhanced depression treatment protocols delivered in HIV care settings. Methods: Women living with HIV (WLWH), naive to antiretroviral therapy, from the Women's Interagency HIV Study were followed from their first visit in or after 1998 for up to 10 semiannual visits (5 years). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. An area-under-the-curve approach was used to translate CES-D scores into a time-updated measure of cumulative days with depression (CDWD). We estimated the effect of CDWD on all-cause mortality using marginal structural Cox proportional hazards models. Results: Overall, 818 women contributed 3292 woman-years over a median of 4.8 years of follow-up, during which the median (interquartile range) CDWD was 366 (97-853). Ninety-four women died during follow-up (2.9 deaths/100 woman-years). A dose-response relationship was observed between CDWD and mortality. Each additional 365 days spent with depression increased mortality risk by 72% (hazard ratio, 1.72; 95% confidence interval, 1.34-2.20). Conclusions: In this sample of WLWH, increased CDWD elevated mortality rates in a dose-response fashion. More frequent monitoring and enhanced depression treatment protocols designed to reduce CDWD may interrupt the accumulation of mortality risk among WLWH.

Do black lives matter in public health research and training?

OBJECTIVE: To examine whether investments made in public health research align with the health burdens experienced by white and black Americans. METHODS: In this cross-sectional study of all deaths in the United States in 2015, we compared the distribution of potential years of life lost (PYLL) across 39 causes of death by race and identified key differences. We examined the relationship between cause-of-death-specific PYLL and key indicators of public health investment (federal funding and number of publications) by race using linear spline models. We also compared the number of courses available at the top schools of public health relevant to the top causes of death contributor to PYLL for black and white Americans. RESULTS: Homicide was the number one contributor to PYLL among black Americans, while ischemic heart disease was the number one contributor to PYLL among white Americans. Firearm-related violence accounted for 88% of black PYLL attributed to homicide and 71% of white PYLL attributed to homicide. Despite the high burden of PYLL, homicide research was the focus of few federal grants or publications. In comparison, ischemic heart disease garnered 341 grants and 594 publications. The number of public health courses available relevant to homicide (n = 9) was similar to those relevant to ischemic heart disease (n = 10). CONCLUSIONS: Black Americans are disproportionately affected by homicide, compared to white Americans. For both black and white Americans, the majority of PYLL due to homicide are firearm-related. Yet, homicide research is dramatically underrepresented in public health research investments in terms of grant funding and publications, despite available public health training opportunities. If left unchecked, the observed disproportionate distribution of investments in public health resources threatens to perpetuate a system that disadvantages black Americans.

Training needs in operative obstetrics for maternal-fetal medicine fellows.

OBJECTIVE: To define residual operative obstetric training needs for first-year maternal-fetal medicine (MFM) fellows. METHODS: We administered a web-based survey to all 100 first-year fellows. We used descriptive statistics to report frequency data for 13 procedures, and logistic regression to estimate odds ratios for comfort in doing and teaching selected procedures. RESULTS: Response rate was 86% (n = 86). Fellows who completed residency in the Northeast/Midatlantic (n = 26) were less likely to report comfort doing or teaching low forceps deliveries (OR 0.21, 95% CI 0.05, 0.78; and 0.20, 95% CI 0.04, 0.85, respectively), while those completing fellowship in the West (n = 13), reported more comfort performing breech extraction of a second twin (OR 6.84, 95% CI 1.24, 51.50); fellows completing residency in the Southeast formed the referent group. Fellows reporting completion of the three selected procedures >5 times each during residency were significantly more likely to report comfort doing and teaching them as fellows. Type of residency program (community/academic) was not significantly associated with reported comfort. CONCLUSION: The wide range of operative obstetric experience fellows reported gaining in residency varies by region. Additional research is needed to understand competency and teaching ability for procedural skills, and many MFM fellows may need additional procedural experience.