Characterising a syndemic among black women at risk for HIV: the role of sociostructural inequity and adverse childhood experiences.

Objectives Black women disproportionately experience STIs (including HIV/AIDS), gender-based violence, substance misuse and mental health conditions. Addressing a gap in syndemic research, we characterised comorbidity overlap within the context of sociostructural inequities and adverse childhood experiences (ACEs) among black women in Baltimore, Maryland. Methods Between 2015 and 2018, black women (n=305) were recruited from STI clinics in Baltimore, Maryland. Among those with complete survey data (n=230), we conducted a latent class analysis to differentiate women based on their profile of the following syndemic comorbidities: STIs, adult sexual victimisation, substance misuse and mental health disorders. We then examined the association between ACEs and syndemic latent class membership. Results Thirty-three percent of women experienced three to nine ACEs before age 18 years, and 44% reported four to six comorbidities. The two-class latent class solution demonstrated the best fit model, and women were categorised in either class 1 (past-year STI; 59%) or class 2 (syndemic comorbidities; 41%). Women in class 2 were more likely to report unstable housing (10% vs 3%) and identify as bisexual/gay (22% vs 10%) than women in class 1. ACEs were significantly associated with an increased likelihood of class 2 membership. Conclusions This study reinforces the importance of screening for ACEs and offering trauma-informed, integrated care for black women with syndemic comorbidities. It also highlights the critical nature of tailoring interventions to improve sociostructural equity, preventing and reducing syndemic development.

Association of Pre-ESRD Serum Bicarbonate with Post-ESRD Mortality in Patients with Incident ESRD.

BACKGROUND: Serum bicarbonate or total carbon dioxide (CO2) concentrations decline as chronic kidney disease (CKD) progresses and rise after dialysis initiation. While metabolic acidosis accelerates the progression of CKD and is associated with higher mortality among patients with end stage renal disease (ESRD), there are scarce data on the association of CO2 concentrations before ESRD transition with post-ESRD mortality. METHODS: A historical cohort from the Transition of Care in CKD (TC-CKD) study includes 85,505 veterans who transitioned to ESRD from October 1, 2007, through March 31, 2014. After 1,958 patients without follow-up data, 3 patients with missing date of birth, and 50,889 patients without CO2 6 months prior to ESRD transition were excluded, the study population includes 32,655 patients. Associations between CO2 concentrations averaged over the last 6 months and its rate of decline during the 12 months prior to ESRD transition and post-ESRD all-cause, cardiovascular (CV), and non-CV mortality were examined by using hierarchical adjustment with Cox regression models. RESULTS: The cohort was on average 68 ± 11 years old and included 29% Black veterans. Baseline concentrations of CO2 were 23 ± 4 mEq/L, and median (interquartile range) change in CO2 were -1.8 [-3.4, -0.2] mEq/L/year. High (≥28 mEq/L) and low (<18 mEq/L) CO2 concentrations showed higher adjusted mortality risk while there was no clear trend in the middle range. Consistent associations were observed irrespective of sodium bicarbonate use. There was also a U-shaped association between the change in CO2 and all-cause, CV, and non-CV mortality with the lowest risk approximately at -2.0 and 0.0 mEq/L/year among sodium bicarbonate nonusers and users, respectively, and the highest mortality was among patients with decline in CO2 >4 mEq/L/year. CONCLUSION: Both high and low pre-ESRD CO2 levels (≥28 and <18 mEq/L) during 6 months prior to dialysis transition and rate of CO2 decline >4 mEq/L/year during 1 year before dialysis initiation were associated with greater post-ESRD all-cause, CV, and non-CV mortality. Further studies are needed to determine the optimal management of CO2 in patients with advanced CKD stages transitioning to ESRD.

Feminine gender norms and syndemic harmful drinking, sexual violence, and sexually transmitted infections among Black women at risk for HIV.

BACKGROUND: This study examined the associations between feminine gender ideologies (i.e., socially constructed attitudes and beliefs of women's appropriate behavior and roles) and the syndemic comorbidities of harmful alcohol use, sexual violence, and sexually transmitted infections (STI), which disproportionately affect Black women. METHODS: Black women, aged 18-44 (n = 305) were recruited from STI clinics in Baltimore, MD into a retrospective cohort study. A survey assessed feminine gender ideologies using a measure of hyperfemininity and sexual hyperfemininity (subscale of sexual domains), harmful drinking (AUDIT), lifetime STI (Y/N and count), and syndemic burden (no burden [0-1 morbidity] and syndemic burden [2-3 comorbidities]). Multivariable regression models identified correlates of harmful drinking, STI, and syndemic burden. The analytic sample included (n = 231) women with complete data. RESULTS: Nearly half of our sample reported high hyperfemininity and high sexual hyperfemininity, 23% reported harmful drinking, 39% experienced sexual violence as an adult, and 74% reported a lifetime STI. High sexual hyperfemininity (Adjusted Odds Ratio [AOR] = 1.94, 95% Confidence Interval [CI]: 1.00-3.76) and sexual violence (AOR = 2.82, 95%CI: 1.43-5.58) were associated with greater odds of harmful drinking. Experiencing sexual violence in adulthood was associated with an increased count of lifetime STIs (Adjusted Incidence Rate Ratio [AIRR] = 1.33, 95%CI: 1.06-1.68). Syndemic burden affected 41% of our sample. High sexual hyperfemininity was associated with experiencing syndemic burden in unadjusted models (OR = 1.98, 95%CI: 1.16-3.37), but was not significant after controlling for confounders. CONCLUSIONS: Interventions to reduce harmful drinking and STIs among Black women in the U.S. should address sexual gender ideologies and sexual violence.

Perceived stress and mental health: The mediating roles of social support and resilience among black women exposed to sexual violence.

BACKGROUND: Black women disproportionately suffer from violence and its subsequent mental health outcomes. Increasing levels of perceived stress are associated with greater symptoms of depression and post-traumatic stress disorder (PTSD). Social support and resilience can potentially mediate the negative consequences of perceived stress on women's mental health. This study assesses the association between perceived stress and mental health outcomes among Black women. In addition, this study examines social support and resilience as mediators of association between perceived stress and mental health. METHODS: Black women residing in Baltimore, MD (n = 310) were recruited from STD clinics into a retrospective cohort study (2013-2018) on sexual assault and HIV risk. Social support and resilience served as coping variables and were assessed as mediators in the associations between perceived stress and mental health. Analyses were stratified by exposure to sexual violence in adulthood. RESULTS: Almost half of our sample (46%) experienced severe depression and about one-third (27%) experienced severe PTSD. Resilience partially mediated the association between perceived stress and severe depressive symptoms among exposed women. Social support partially mediated the association between perceived stress and severe PTSD symptoms among exposed women. LIMITATIONS: Since this is a cross-sectional analysis, we are unable to determine the temporal relationship between outcome and exposure variables. The CES-D-10 and NSESSS are scales that measure the severity of depressive and PTSD symptoms, respectively, and are not clinical diagnoses. CONCLUSION: There is a critical need to develop interventions focused on reducing the burden of stress on mental health.

Serum uric acid, protein intake and mortality in hemodialysis patients.

BACKGROUND: The association between serum uric acid (SUA) and mortality has been conflicting among studies using hemodialysis (HD) patients. Given the close link between purine and protein in foods, we hypothesized that normalized protein catabolic rate (nPCR), a dietary protein intake surrogate, modifies the SUA-mortality association in the HD population. METHODS: We identified 4298 patients who initiated HD and had one or more SUA measurement in a contemporary cohort of HD patients over 5 years (1 January 2007-31 December 2011), and examined survival probability according to the first uric acid measurement, adjusting for dialysis vintage, case-mix and malnutrition-inflammation complex-related variables. RESULTS: Mean SUA concentration was 6.6 ± 1.8 mg/dL. There was a consistent association of higher SUA with better nutritional status and lower all-cause mortality irrespective of adjusted models (Ptrend < 0.001). In the case-mix adjusted model, the highest SUA category (≥8.0 mg/dL) compared with the reference group (>6.0-7.0 mg/dL) showed no significant mortality risk [hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.72-1.13], while the lowest category (<5.0 mg/dL) was associated with higher mortality (HR 1.42, 95% CI 1.16-1.72). The hypouricemia-mortality association was significantly modified by nPCR (Pinteraction = 0.001). Mortality risk of low SUA (<5.0 mg/dL) persisted among patients with low nPCR (<0.9 g/kg/day; HR 1.73, 95% CI 1.42-2.10) but not with high nPCR (≥0.9 g/kg/day; HR 0.99, 95% CI 0.74-1.33). CONCLUSIONS: SUA may be a nutritional marker in HD patients. Contrary to the general population, low but not high SUA is associated with higher all-cause mortality in HD patients, especially in those with low protein intake. Nutritional features of SUA warrant additional studies.