RESUMO
BACKGROUND: Substance use is common among people living with human immunodeficiency virus (PLWH) and a barrier to achieving viral suppression. Among PLWH who report illicit drug use, we evaluated associations between HIV viral load (VL) and reduced use of illicit opioids, methamphetamine/crystal, cocaine/crack, and marijuana, regardless of whether or not abstinence was achieved. METHODS: This was a longitudinal cohort study of PLWH from 7 HIV clinics or 4 clinical studies. We used joint longitudinal and survival models to examine the impact of decreasing drug use and of abstinence for each drug on viral suppression. We repeated analyses using linear mixed models to examine associations between change in frequency of drug use and VL. RESULTS: The number of PLWH who were using each drug at baseline ranged from n = 568 (illicit opioids) to n = 4272 (marijuana). Abstinence was associated with higher odds of viral suppression (odds ratio [OR], 1.4-2.2) and lower relative VL (ranging from 21% to 42% by drug) for all 4 drug categories. Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with VL suppression (OR, 2.2, 1.6, respectively). Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with lower relative VL (47%, 38%, respectively). CONCLUSIONS: Abstinence was associated with viral suppression. In addition, reducing use of illicit opioids or methamphetamine/crystal, even without abstinence, was also associated with viral suppression. Our findings highlight the impact of reducing substance use, even when abstinence is not achieved, and the potential benefits of medications, behavioral interventions, and harm-reduction interventions.
Assuntos
Infecções por HIV , Drogas Ilícitas , Transtornos Relacionados ao Uso de Substâncias , HIV , Infecções por HIV/prevenção & controle , Humanos , Estudos Longitudinais , Transtornos Relacionados ao Uso de Substâncias/complicações , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Carga ViralRESUMO
BACKGROUND: The pediatric reproductive organs are optimally imaged with a full bladder. The filling of the bladder, however, often leads to significant delay in diagnosis and can subject the patient to invasive bladder catheterization. As the key imaging feature in ovarian torsion is unilateral ovarian enlargement, we suspected that a torsed ovary is large enough to be visualized even if the bladder is not well distended. OBJECTIVE: The purpose of this study was to retrospectively investigate if clinically suspected adnexal torsion can be excluded based on non-visualization of the ovaries on transabdominal ultrasound (US) with a non-distended bladder in pediatric patients. MATERIALS AND METHODS: This retrospective study comprised 349 girls (1-19 years old) between Jan. 1, 2013, and July 30, 2018. Three hundred and forty-one of the girls were referred to transabdominal US to assess for adnexal torsion and/or appendicitis, and the ovaries were initially not visualized on US. Their bladders were subsequently filled and rescanned with a distended bladder showing the ovaries. Ovarian volumes and time between US scans were documented. The ratio of the volume of the larger ovary to the smaller one was calculated. Nine girls had surgically proven adnexal torsion and a preoperative transabdominal US with a non-distended bladder. There was an overlap of one girl between the two groups. The negative predictive value (NPV), positive predictive value (PPV), and sensitivity and specificity for exclusion of adnexal torsion based on non-visualization of the ovaries on US with a non-distended bladder were calculated. RESULTS: One of the girls (1/341) who had a US study done with a non-distended bladder in which the ovaries were not visualized had a positive diagnosis of adnexal torsion. In eight of the nine girls who had surgically proven adnexal torsion, the torted ovary was identified with a non-distended bladder. The NPV and PPV for exclusion of adnexal torsion with a non-distended bladder was 1.0 and 0.8, respectively. The specificity and sensitivity were 99.4% and 88.9%, respectively. The mean and median time difference between the initial scan and the scan after bladder filling was 105.1 min (standard deviation [SD] -65.8) and 89.0 min (interquartile range [IQR]- 59.0, 130.5), respectively. CONCLUSION: Non-visualization of the ovaries with a non-distended bladder on transabdominal US study can help exclude clinically suspected adnexal torsion, alleviating the need for bladder filling and prolonging the wait time in the emergency department. Inclusion of non-visualization of the ovaries as one of the features in a predictive score for adnexal torsion should be considered.
Assuntos
Doenças dos Anexos/diagnóstico por imagem , Anormalidade Torcional/diagnóstico por imagem , Ultrassonografia/métodos , Anexos Uterinos/diagnóstico por imagem , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Ovário/diagnóstico por imagem , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
BACKGROUND: Current guidelines suggest treatment for many individuals who may never develop a stroke. We hypothesized that a combination of coronary artery calcification (CAC) and carotid artery intima-media thickness (C IMT) data could better individualize risk assessment for ischemic stroke and transient ischemic attack events. METHODS: A total of 4720 individuals from the Multi-Ethnic Study of Atherosclerosis were evaluated for ischemic stroke and transient ischemic attack. Cox proportional hazards models for time to incident ischemic stroke/transient ischemic attack were used to examine CAC and CIMT as ischemic stroke/transient ischemic attack predictors in addition to traditional risk factors. We calculated the 10-year number needed to treat by applying the benefit observed in ASCOT-LLA to the observed event rates within CAC and CIMT strata. RESULTS: Median follow-up was 13.1 years. Compared with individuals with no CAC and with CIMT ≤ 75th percentile, stroke/transient ischemic attack risk increased progressively with each CAC category (0, 1-100, >100) among individuals with CIMT > 75th percentile. Among participants eligible for statin therapy based on the 2013 atherosclerotic cardiovascular disease (ASCVD) guidelines (ASCVD risk of >5%), 739/2906 (25%) had no CAC and CIMT ≤ 75th percentile and an observed ischemic stroke/transient ischemic attack rate of 2.49 per 1000 person-years. The predicted 10-year number needed to treat was 292 for no CAC and CIMT ≤ 75th percentile and 57 for CAC > 100 and CIMT > 75th percentile. CONCLUSION: The combination of CIMT and CAC could serve to further refine risk calculation for ischemic stroke/transient ischemic attack prevention and may prioritize those in most need of statin therapy to reduce ischemic stroke/transient ischemic attack risk.
Assuntos
Doença da Artéria Coronariana/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Ataque Isquêmico Transitório/prevenção & controle , Prevenção Primária/métodos , Acidente Vascular Cerebral/prevenção & controle , Calcificação Vascular/tratamento farmacológico , Idoso , Espessura Intima-Media Carotídea , Tomada de Decisão Clínica , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/etnologia , Feminino , Humanos , Ataque Isquêmico Transitório/etnologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Prevalência , Fatores de Proteção , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etnologia , Fatores de Tempo , Estados Unidos/epidemiologia , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/etnologiaRESUMO
PURPOSE: Substance use is linked with poor outcomes among people living with HIV (PLWH) and is associated with mental health disorders. This analysis examines the impact of decreasing substance use, even without abstinence, on depressive symptoms among PLWH. METHODS: Data are from PLWH enrolled in the Centers for AIDS Research Network of Integrated Clinical Sites cohort. Participants completed longitudinal assessments of substance use (modified ASSIST) and depressive symptoms (PHQ-9). Changes in substance use frequency were categorized as abstinence, reduced use, and nondecreasing use. Adjusted linear mixed models with time-updated change in substance use frequency and depressive symptom scores were used to examine associations between changes in the use of individual substances and depressive symptoms. Analyses were repeated using joint longitudinal survival models to examine associations with a high (PHQ-9 ≥10) score. RESULTS: Among 9905 PLWH, 728 used cocaine/crack, 1016 used amphetamine-type substances (ATS), 290 used illicit opiates, and 3277 used marijuana at baseline. Changes in ATS use were associated with the greatest improvements in depressive symptoms: stopping ATS led to a mean decrease of PHQ-9 by 2.2 points (95% CI: 1.8 to 2.7) and a 61% lower odds of PHQ-9 score ≥10 (95% CI: 0.30 to 0.52), and decreasing ATS use led to a mean decrease of 1.7 points (95% CI: 1.2 to 2.3) and a 62% lower odds of PHQ-9 score ≥10 (95% CI: 0.25 to 0.56). Stopping and reducing marijuana and stopping cocaine/crack use were also associated with improvement in depressive symptoms. CONCLUSIONS: We demonstrated that both substance use reduction and abstinence are associated with improvements in depressive symptoms over time.
Assuntos
Depressão/patologia , Uso de Medicamentos/estatística & dados numéricos , Infecções por HIV/complicações , Drogas Ilícitas/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND: Illicit drug use (DU) and hazardous drinking (HD) among marginalized populations may be associated with greater barriers to care. METHODS: We used baseline data on the participants of the Seek, Test, Treat, and Retain data harmonization initiative. DU includes use of any illicit drugs within the past 6 months. HD was defined as scores ≥8 for men and ≥ 7 for women on Alcohol Use Disorders Identification Test within the past 12 months. Social support scores were assigned by summing scores from individual questions related to social support. Two outcomes for multivariable regression models and mediation analysis were perceived access to care and perceived barriers to care scores, calculated from summated points from individual questions within each domain. All models were adjusted for age, gender, race/ethnicity, and social support and stratified by HIV status. RESULTS: Among 1403 illicit drug users and 4984 non-drug users, the mean age was 39.6 ± 12.2 years old, 71% were male, 57% African Americans, and 39% Hispanic/Latinos. Over 25% reported difficulties in covering medical costs and finding transportation to health care facilities and greater proportions of drug users and hazardous drinkers reported these issues than non-DU/non-HD. In multivariable models, DU and HD were both independently associated with having greater barriers to care (ß: 0.49 (95% confidence interval: 0.19 to 0.79) p < 0.01; 0.31 (0.18 to 0.45) < 0.01) in HIV-negative participants. Neither DU nor HD was strongly associated with barriers to care for HIV-positive participants. Social support was associated with better perceived access to care and fewer barriers to care in the HIV-negative participants. CONCLUSION: The current study found that financial burdens of care, logistical difficulties in accessing care, and low social support were common challenges among individuals using illicit drugs and/or drinking hazardously. Addressing structural barriers and strengthening social support may be important strategies to improve health care among marginalized populations, regardless of HIV status.
Assuntos
Consumo de Bebidas Alcoólicas/psicologia , Atitude Frente a Saúde , Comportamento Perigoso , Usuários de Drogas/psicologia , Acessibilidade aos Serviços de Saúde , Drogas Ilícitas , Adulto , Consumo de Bebidas Alcoólicas/terapia , Usuários de Drogas/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
BACKGROUND: Biomarkers to predict the presence and severity of subclinical cardiovascular disease (CVD) in nonalcoholic fatty liver disease (NAFLD) are lacking. METHODS: 3876 participants from the Multi-Ethnic Study of Atherosclerosis (MESA), without known chronic liver disease underwent baseline non-contrast cardiac CT, with NAFLD defined by validated liver:spleen ratio (L:S)â¯<â¯1.0, and subclinical CVD defined by coronary artery calcium (CAC) scoreâ¯>â¯0. Randomly-selected subgroups underwent detailed inflammatory marker testing, including LpPLA2 mass (Nâ¯=â¯2951), activity (Nâ¯=â¯3020), high-sensitivity C-reactive protein (hsCRP; Nâ¯=â¯3849), and interleukin-6 (IL-6; Nâ¯=â¯3764). Among those with NAFLD, we estimated the prevalence of CACâ¯>â¯0 and CACâ¯>â¯100 for each SD biomarker increase, using multivariable log-binomial regression models adjusted for cardiometabolic risk factors. RESULTS: Seventeen percent (Nâ¯=â¯668) of participants met the criteria for NAFLD. NAFLD participants were younger (mean age 61⯱â¯10 vs. 63⯱â¯10â¯years, pâ¯<â¯.0001) but more likely to have an elevated BMI (mean 31.1⯱â¯5.5 vs. 28.0⯱â¯5.2â¯kg/m2, pâ¯<â¯.0001), diabetes (22% vs. 11%, pâ¯<â¯.0001), and increased inflammatory biomarkers, including LpPLA2 activity, hsCRP and IL-6 (all pâ¯<â¯.0001). Among NAFLD participants, IL-6 was the only biomarker independently associated with prevalent CACâ¯>â¯0 (PRâ¯=â¯1.06 [1.00-1.11]), or CACâ¯>â¯100 (PRâ¯=â¯1.09 [1.02-1.17]). In contrast, circulating LpPLA2 mass/activity and hsCRP were not associated with either the prevalence or severity of subclinical CVD (all pâ¯>â¯.05). CONCLUSION: In a large, multi-ethnic population with NAFLD, IL-6 is independently associated with the prevalence and severity of subclinical atherosclerosis. Further research into the longitudinal effects of NAFLD on progressive CVD will determine whether IL-6 is a marker or mediator of NAFLD-related atherosclerosis.
Assuntos
Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/etnologia , Interleucina-6/sangue , Hepatopatia Gordurosa não Alcoólica/sangue , Hepatopatia Gordurosa não Alcoólica/etnologia , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Estudos de Coortes , Etnicidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND: Atherosclerosis and its clinical sequelae represent the leading cause of mortality among patients with nonalcoholic fatty liver disease (NAFLD). While epidemiologic data support the hepatoprotective benefits of coffee in NAFLD, whether coffee improves NAFLD-associated CVD risk is unknown. METHODS: We examined 3710 ethnically-diverse participants from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort, without history of known liver disease, and with available coffee data from a validated 120-item food frequency questionnaire. All participants underwent baseline non-contrast cardiac CT from which NAFLD was defined by liver:spleen ratio (L:S<1.0), and subclinical CVD was defined by coronary artery calcium (CAC)>0. Major CVD events were defined by the first occurrence of myocardial infarction, cardiac arrest, angina, stroke, or CVD death. We used log-binomial regression to calculate the adjusted prevalence ratio (PR) for CAC>0 by coffee intake and NAFLD status, and events were compared between groups using frequency of events within adjusted Cox proportional hazard regression models. RESULTS: Seventeen percent (N=637) of participants met criteria for NAFLD. NAFLD participants were more likely to have elevated BMI (mean 31.1±5.5kg/m2 vs. 28.0±5.2kg/m2, p<0.0001), and diabetes (22% vs. 11%, p<0.0001), but did not differ in daily coffee consumption (p=0.97). Among NAFLD participants, coffee consumption was not associated with prevalent, baseline CAC>0 (PR=1.02 [0.98-1.07]). Over 12.8years of follow-up, 93 NAFLD and 415 non-NAFLD participants experienced a CV event. However, coffee intake was not associated with incident CVD events, in either NAFLD (HR=1.05 [0.91-1.21]) or non-NAFLD participants (HR=1.03 [0.97-1.11]). CONCLUSION: In a large, population-based cohort, coffee consumption was not associated with the prevalence of subclinical CVD, nor did coffee impact the future risk of major CVD events, regardless of underlying NAFLD status.
Assuntos
Doenças Cardiovasculares , Café/efeitos adversos , Hepatopatia Gordurosa não Alcoólica/complicações , Idoso , Aterosclerose , Doenças Cardiovasculares/etiologia , Etnicidade , Seguimentos , Humanos , Pessoa de Meia-Idade , Análise de RegressãoRESUMO
We present a model for longitudinal measures of fetal weight as a function of gestational age. We use a linear mixed model, with a Box-Cox transformation of fetal weight values, and restricted cubic splines, in order to flexibly but parsimoniously model median fetal weight. We systematically compare our model to other proposed approaches. All proposed methods are shown to yield similar median estimates, as evidenced by overlapping pointwise confidence bands, except after 40 completed weeks, where our method seems to produce estimates more consistent with observed data. Sex-based stratification affects the estimates of the random effects variance-covariance structure, without significantly changing sex-specific fitted median values. We illustrate the benefits of including sex-gestational age interaction terms in the model over stratification. The comparison leads to the conclusion that the selection of a model for fetal weight for gestational age can be based on the specific goals and configuration of a given study without affecting the precision or value of median estimates for most gestational ages of interest.