Delayed medical care after diagnosis in a US national probability sample of persons infected with human immunodeficiency virus.

OBJECTIVE: To identify health care and patient factors associated with delayed initial medical care for human immunodeficiency virus (HIV) infection. DESIGN: Survey of a national probability sample of persons with HIV in care. SETTING: Medical practices in the contiguous United States. PATIENTS: Cohort A (N = 1540) was diagnosed by February 1993 and was in care within 3 years; cohort B (N = 1960) was diagnosed by February 1995 and was in care within 1 year of diagnosis. MAIN OUTCOME MEASURE: More than 3- or 6-month delay. RESULTS: Delay of more than 3 months occurred for 29% of cohort A (median, 1 year) and 17% of cohort B. Having a usual source of care at diagnosis reduced delay, with adjusted odds ratios (ORs) of 0.61 (95% confidence interval [CI], 0.48-0.77) in cohort A and 0. 70 (95% CI, 0.50-0.99) in cohort B. Medicaid coverage at diagnosis showed lower adjusted ORs of delay compared with private insurance (cohort A: adjusted OR, 0.52; 95% CI, 0.30-0.92; cohort B: adjusted OR, 0.48; 95% CI, 0.27-0.85). Compared with whites, Latinos had 53% and 95% higher adjusted ORs of delay (P<.05) in cohorts A and B, respectively, and African Americans had a higher adjusted OR in cohort A (1.56; 95% CI, 1.19-2.04). The health care factors showed similar effects on delay of greater than 6 months. CONCLUSIONS: Medicaid insurance and a usual source of care were protective against delay after HIV diagnosis. After full adjustment, delay was still greater for Latinos and, to a lesser extent, African Americans compared with whites.

Psoriasis and the risk of cancer.

To test the validity of the common hypothesis that patients with psoriasis have an inherently lower susceptibility to cancer, we prospectively studied 1367 patients with severe psoriasis who enrolled in a clinical trial of oral methoxsalen photochemotherapy for treatment of psoriasis for an average of 3.2 yr. The incidence of non-cutaneous cancers and the number of deaths from such cancers were slightly but not significantly higher than that expected for the general population (relative risk = 1.1; standard mortality ratio = 1.3). Among 318 patients (23%) in this cohort who were over 35 yr of age and who lacked appreciable exposure to suspected cutaneous carcinogens, the observed incidence for cutaneous carcinoma was 1.4 times that expected, based on rates for the general population (90% confidence interval = .8 to 2.7). These data suggest that patients with psoriasis have a risk of systemic and cutaneous cancer that is comparable to the risk for the general population.

Risk factors for retrolental fibroplasia: experience with 3,025 premature infants. National Collaborative Study on Patent Ductus Arteriosus in Premature Infants.

The rate of retrolental fibroplasia in relation to prenatal and neonatal characteristics was explored on the basis of a cohort of 3,025 neonates with birth weight less than 1,750 g. The overall rate of retrolental fibroplasia of any degree at hospital discharge was 11%, varying from 43% for those with birth weight between 500 and 749 g to 3% for those in the 1,500- to 1,750-g category. Among the potential determinants, the main interest was in nonhyperoxic characteristics, conditional on measures of prematurity and oxygen supplementation. Maternal diabetes and antihistamine use during the last 2 weeks of pregnancy were associated with significantly higher rates of retrolental fibroplasia, whereas toxemia was associated with lower rates. Frequent apneic spells, bronchopulmonary dysplasia, and sepsis in the neonate were also associated with significantly higher rates. On the other hand, the data indicate no independent role of low Apgar score, intraventricular hemorrhage, exchange transfusion, patent ductus arteriosus, or certain other characteristics previously postulated as risk factors.

Electrocardiogram of the premature infant at 1 year of age.

ECGs were examined from 461 premature infants at 1 year of age. Data from those without a history of bronchopulmonary dysplasia were generally similar to published norms for healthy 1-year old infants. History and persistence of residual lung disease were reflected in the ECG by a high prevalence of findings suggestive of right ventricular hypertrophy. Clinically significant patent ductus arteriosus during the neonatal period did not influence the 1-year ECG findings. The data expand the published experience with follow-up ECGs from premature infants and suggest that the ECG may be a useful tool in follow-up of chronic residual lung disease in this population.

Type of disinfectant in drinking water and patterns of mortality in Massachusetts.

Chlorination has been the major strategy for disinfection of drinking water in the United States. Concern about the potential health effects of the reaction by-products of chlorine has prompted use of alternative strategies. One such method is chloramination, a treatment process that does not appear to have carcinogenic by-products, but may have less potent biocidal activity than chlorination. We examined the patterns of mortality of residents in Massachusetts who died between 1969 and 1983 and lived in communities using drinking water that was disinfected either by chlorine or chloramine. Comparison of type of disinfectant among 51,645 cases of deaths due to selected cancer sites and 214,988 controls who died from cardiovascular, cerebrovascular, or pulmonary disease, or from lymphatic cancer showed small variation in the patterns of mortality. Bladder cancer was moderately associated with residence at death in a chlorinated community (mortality odds ratio = 1.7, 95% confidence interval = 1.3-2.2) in a logistic regression analysis using controls who died from lymphatic cancer. A slight excess of deaths from pneumonia and influenza was observed in communities whose residents drank chloraminated water compared to residents from chlorinated communities, as well as to all Massachusetts residents (standardized mortality ratio = 118, 95% confidence interval = 116-120 for chloraminated communities, and standardized mortality ratio = 98, 95% confidence interval = 95-100 for chlorinated communities). These results are intended to be preliminary and crude descriptions of the relationship under study.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical closure of patent ductus arteriosus in 268 preterm infants.

Over a 2 year period ending in April, 1981, 268 premature infants with birth weight below 1,750 gm underwent operation for a "hemodynamically significant" patent ductus arteriosus. Operations were performed in 13 centers participating in a collaborative study, which was primarily designed to evaluate the role of indomethacin in the management of patent ductus arteriosus. No patient died during the operations, which were done at a median age of 10 days. Eight infants (3%) died within 36 hours after operation. In only one was the death directly attributable to the operative procedure. Hospital mortality (23%) and postoperative morbidity, which included bronchopulmonary dysplasia, pneumothorax, and sepsis, were unrelated to birth weight, age at operation, and degree of preexisting pulmonary disease or preoperative treatment of the infant with indomethacin. Results indicate that surgical ligation is a safe and effective procedure for treating patent ductus arteriosus with large left-to-right shunting in small premature infants.

Increased prevalence of atopic dermatitis in Kawasaki disease.

Atopic dermatitis is associated with immunoregulatory abnormalities similar to those observed in acute Kawasaki disease. We investigated whether the prevalence of atopic dermatitis is increased among children who acquire Kawasaki disease. In a case-control telephone survey 83 Kawasaki disease patients and 83 children with innocent heart murmurs were matched for age and time between clinic visit and interview. The interviewer was blinded to the hypothesis of the study. Nine (11%) Kawasaki disease patients but only one (1%) unaffected child had atopic dermatitis; the incidence of atopic dermatitis among children with Kawasaki disease was 9 times greater than that of controls (95% confidence limits, 1.6 to 49.4). Serum immunoglobulin E concentrations were significantly higher (P = 0.02, Mann-Whitney) in 44 unselected Kawasaki disease patients (median, 22; range, less than or equal to 4 to 900 IU/ml) studied 6 to 12 months after onset than in 27 children of similar age (median, less than or equal to 4; range, less than or equal to 4 to 164 IU/ml). We observed that there is a strong association between atopic dermatitis and Kawasaki disease.

Chemical quality of maternal drinking water and congenital heart disease.

We undertook a case-control study to investigate the association between chemicals in maternal drinking water consumed during pregnancy and congenital heart disease in the offspring. Two hundred and seventy affected children and 665 healthy children were enrolled in the study. Information on contaminant levels in maternal drinking water was available from records of routine water analysis of samples taken from public taps in the communities where the mothers resided during pregnancy. Mothers provided information during a telephone interview on their health, pregnancy management, and demographic characteristics. Nine inorganic metals were analysed for detection of an association with congenital heart disease. The chemical exposures of particular interest were arsenic, lead, mercury and selenium. None of the chemicals was associated materially with an increase in the frequency of congenital heart disease overall. Arsenic exposure at any detectable level was associated with a threefold increase in occurrence of coarctation of the aorta (prevalence odds ratio = 3.4, 95% confidence interval = 1.3-8.9). Detectable traces of selenium in drinking water were associated with a lower frequency of any congenital heart disease than was observed among children exposed to drinking water not containing detectable levels of selenium (prevalence odds ratio = 0.62, 95% confidence limits = 0.40-0.97). A dose-response effect was observed over four levels of selenium exposure. Non-differential errors in the measurement and classification of exposure to contaminants routinely monitored in drinking water could account for lack of positive findings. In addition, most of the contaminant levels were below the maximum levels set by the Environmental Protection Agency, so that lack of evidence of effect may have been due to the low exposure levels in this population.

Maternal drugs and congenital heart disease.

Congenital heart disease comprises one-third of all major birth defects. Prevalence estimates depend on the definition of the disease and the postnatal period when the disease is diagnosed. The studies with the longest follow-up estimate that 0.9% of infants are afflicted. The cause of these cardiac defects is largely unknown. The effect of embryonic exposure to maternal drugs during cardiogenesis has been widely studied, and the evidence suggests that maternal use of ethanol, anticonvulsants, lithium, and exogeneous female hormones may increase the risk of congenital heart disease. An antiemetic agent containing doxylamine has been implicated in the courts. This review offers an analysis of the epidemiologic evidence of the occurrence of congenital heart disease in relation to maternal drug use during pregnancy. The evidence indicates that the vast majority of heart malformations cannot be attributed to these pharmacologic agents.

Battering in pregnancy: an assessment of two screening methods.

OBJECTIVE: To compare two different screening techniques for identifying women with a history of domestic violence or battering in the current pregnancy. METHODS: The five-question Abuse Assessment Screen was incorporated into routine social service interviews and applied prospectively to all registrants for routine prenatal care at Women & Infants' Hospital during an initial social service evaluation from September 7 through October 29, 1993. This group (N = 143) was compared to a historical control group of all new registrants from July 12 through September 3, 1993 (N = 191) who had routine interviews by social services. Demographic and medical data were compared, as well as the specific information addressed by the screen, including history of domestic violence, physical or sexual violence within the last year, violence during the current pregnancy, recent sexual abuse, and fear of partner. RESULTS: The median age of the study population was 23 years old, 50% were white, 63% were single, and 42% had no insurance. There was a higher detection of violence in all categories using the Abuse Assessment Screen compared with the standard interview--any history: 41 versus 14% (relative risk [RR] 3.0, 95% confidence interval [CI] 2.0-4.5); recent history: 15 versus 3% (RR 5.6, CI 2.2-14.5); during pregnancy: 10 versus 1% (RR 9.3, CI 2.2-40.5); recent sexual abuse: 4 versus 0% (P = .006); and fear of abuser: 6 versus 3% (RR 1.8, CI 0.6-5.0). CONCLUSION: Use of a structured screen improves detection rates of battering both before and during pregnancy, enabling clinicians to have a greater opportunity to intervene.

Perinatal risk assessment for patent ductus arteriosus in premature infants.

Data from 2107 inborn premature infants monitored for hemodynamically significant patent ductus arteriosus were used to develop means for clinically assessing at birth the risk of developing patent ductus arteriosus during the first 30 days of life. The overall 30-day incidence rates in birth weight categories 500 to 999, 1000 to 1499 g, and 1500 to 1750 g were 41, 17, and 7%, respectively. At-birth risk estimates obtainable from the derived multivariate functions ranged from 0 to 78% for the 500 to 999 and 1000- to 1499-g categories, and from 0 to 20% for the 1500- to 1750-g category. The derived risk functions provide for enhanced selectivity in the application of measures for the prevention of patent ductus arteriosus.

Sexual violence against women living with or at risk for HIV infection.

OBJECTIVES: This study investigates factors associated with sexual violence against adult women living with and at risk for HIV infection. METHODS: Women at least 18 years old and living in Rhode Island or southeast Massachusetts enrolled from 1987 to 1992 in a cohort study of heterosexual HIV risk. A total of 408 women provided interviews on lifetime experiences of rape and HIV-related risk exposures. Data are presented on 96 women reporting experiences with rape as adults, and 231 women who reported never experiencing rape or forced sex. RESULTS: Lifetime prevalence of sexual abuse was 43%. Over half occurred during adulthood. Thirty-five percent of women with HIV were raped as adults. Among women with HIV, adult rape experiences were associated with earlier age of first sex, more sexual partners, unprotected sex involving drugs, earlier age of injection drug use, teen pregnancy, STDs, and serious gynecologic surgery than those reporting they were never raped (prevalence odds ratios ranged from 2.8 to 11.2). Among women without HIV, adult rape was associated with similar experiences, although with some exception, the relative odds estimates were less pronounced. Women engaged in sex work were more likely to report rape. CONCLUSION: The high prevalence of rape reported in this cohort of mostly economically poor women living with and at risk for HIV infection is consistent with other studies. Economic and social vulnerability that frames HIV risk and subsequent infection in women includes rape. Clinicians caring for women with HIV and counseling women at risk for infection need to screen routinely for sexual abuse.

Lifetime socioeconomic position in relation to onset of perimenopause.

STUDY OBJECTIVE: To assess the association between lifetime socioeconomic position and onset of perimenopause. DESIGN: Prospective cohort study. SETTING: Boston, Massachusetts. PARTICIPANTS: 603 premenopausal women aged 36-45 years at baseline who completed a cross sectional survey on childhood and adult socioeconomic position. MAIN OUTCOME MEASURES: Time to perimenopause, defined as time in months from baseline interview to a woman's report of (1) an absolute change of at least seven days in menstrual cycle length from baseline or subjective report of menstrual irregularity; (2) a change in menstrual flow amount or duration; or (3) cessation of periods for at least three months, whichever came first. MAIN RESULTS: Incidence of perimenopause was 1.75 times higher (95%CI 1.10 to 2.79) and median age at onset was 1.2 years younger (44.7 v 45.9 years) for women reporting childhood and adult economic distress compared with women reporting no lifetime economic distress. After adjustment for age, race/ethnicity, age at menarche, parity, oral contraceptive use, family history of early menopause, depression, smoking, and body mass index, the association weakened (incidence rate ratio (IRR)=1.59; 95%CI 0.97 to 2.61). Inverse associations were observed for most, but not all, measures of educational level. Measures of current household income were not associated with risk of perimenopause. CONCLUSIONS: This study suggests that adverse socioeconomic conditions across the lifespan, when measured in terms of economic hardship and low educational attainment, may be associated with an increased rate of entry into perimenopause.

Entangled epidemics: cocaine use and HIV disease.

Over the past decade, two epidemics have had a severe impact on public health in this country. These health problems involve cocaine abuse and AIDS (or HIV disease). The processes of these two conditions are clearly not independent of each other and may be quite complex. Understanding of this relationship has been hampered by a myriad of social, biological and behavioral variables that are entangled with the basic cocaine-HIV association. This article presents a paradigm for discussion of the interaction between cocaine exposure and HIV disease based on three mechanisms: the relationship between cocaine exposure and increased opportunity for HIV exposure, the direct role that cocaine plays in altering susceptibility to HIV infection, and the influence that cocaine use has on the progression of HIV disease. The goal of this structured approach is to enhance conceptual understanding of the cocaine-HIV relationship while recognizing the complexity of the issue and the limitations of current research efforts. This model will serve as a framework for the discussion of implications for future research, clinical practice, and public policy.

Quality of community drinking water and the occurrence of spontaneous abortion.

To investigate the relationship between community drinking water quality and spontaneous abortion, we compared trace element levels in the drinking water of 286 women having a spontaneous abortion through 27 wk gestation with that of 1,391 women having livebirths. Trace element levels were gathered from routine analyses of public tap water supplies from the communities where the women resided during pregnancy. After adjustment for potential confounders, an increase in the frequency of spontaneous abortion was associated with detectable levels of mercury; high levels of arsenic, potassium, and silica; moderately hard water, and surface water. In contrast, a decrease in the frequency of spontaneous abortion was associated with high levels of alkalinity and sulfate, and any detectable level of nitrate. These results require further corroboration because there is a paucity of data investigating this issue.

Quality of community drinking water and the occurrence of late adverse pregnancy outcomes.

The relationship between community drinking water quality and the occurrence of late adverse pregnancy outcomes was investigated by conducting a case-control study among women who delivered infants during August 1977 through March 1980 at Brigham and Women's Hospital in Massachusetts. The water quality indices were compared among 1,039 congenital anomaly cases, 77 stillbirth cases, 55 neonatal death cases, and 1,177 controls. Trace element levels were gathered from routine analyses of public water supplies from the communities in which the women resided during pregnancy. It was observed that, after adjustment for confounding, the frequency of stillbirths was increased for women exposed to chlorinated surface water (OR 2.6 95% CI 0.9-7.5) and for women exposed to detectable lead levels (OR 2.1; 95% CI 0.6-7.2); the frequency of cardiovascular defects was increased relative to detectable lead levels (OR 2.2, 95% CI 0.9-5.7); and the frequency of central nervous system defects was increased relative to the highest tertile of potassium (OR 6.3, 95% CI 1.1-37.3). The frequency of ear, face, and neck anomalies was increased in relation to detectable silver levels (OR 3.3, 95% CI 0.9-12.2), but the frequency decreased relative to high potassium levels (OR 0.2, 95% CI 0.1-0.7). The frequency of neonatal deaths was decreased relative to detectable fluoride levels (OR 0.4, 95% CI 0.2-1.0), and the frequency of musculoskeletal defects was decreased relative to detectable chromium levels (OR 0.4, 95% CI 0.2-1.0). The majority of these associations were not stable statistically. Further research is needed to corroborate these findings.

Bladder cancer in Massachusetts related to chlorinated and chloraminated drinking water: a case-control study.

Consumers of chlorinated drinking water have a small excess of bladder cancer. Risk may have been underestimated because of confounding and misclassification of exposure status. To address these problems, we undertook a case-control study. Detailed residential histories were obtained by telephone interviews with informants of 614 individuals who died of primarily bladder cancer and 1,074 individuals who died of other causes. Their surface water has been disinfected with chlorine or a combination of chlorine and ammonia (cloramine) since 1938. The mortality ratio for bladder cancer among individuals who resided only in communities supplied with drinking water disinfected with chlorine, relative to individuals who resided only in communities supplied with drinking water disinfected with chloramine, was 1.6 (95% confidence interval = 1.2-2.1), using all controls; when the comparison group was restricted to individuals who died of lymphoma, the mortality odds ratio was 2.7 (95% confidence interval = 1.7-4.3).

Causes of retinopathy of prematurity: an epidemiologic perspective.

This chapter presents a strategy for integration of the current thinking about the causes of ROP. Application of these concepts assumes that results of any etiologic study are derived from valid methods. Discussion of principles of validity in epidemiologic studies is beyond the scope of this paper. However, reference was made to two sources of invalidity in studies of the causes of ROP: 1) the empirical or operational definition and measurement of the conceptual cause, and 2) confounding by degree of immaturity of retinal vasculatures, particularly with regard to interpretation of duration of ventilatory support as a cause of ROP. The distinction was made between an agent that initiates or promotes disease mechanism and a cause. Failure to appreciate this distinction has contributed to the confusion about the role of oxygen in the pathogenesis of retinopathy. Apart from settings of oxygen mismanagement, oxygen per se is part of the mechanism for development of disease. Certainly there are other biochemical requirements in addition to oxygen that set the stage for full-blown disease. Factors that are associated with the disruption of normal development of retinal vasculature and are susceptible to manipulation (either by reduction or elimination) during the prenatal and postnatal period may be more useful component causes to investigate.