Publications

Late after surgical repair of complex congenital heart disease, atrial arrhythmias are a major cause of morbidity, and ventricular arrhythmias and sudden cardiac death are a major cause of mortality. The six cases in this article highlight common challenges in the management of arrhythmias in the adult congenital heart disease population.

OBJECTIVE

We examined the association between childhood adversity and cumulative biological risk for a variety of chronic diseases in adulthood, and whether this association varied by neighborhood affluence.

METHODS

Data were drawn from the Chicago Community Adult Health Study (2001-2003), a cross-sectional probability sample that included interviews and blood collection (n = 550 adults). A childhood adversity score was calculated from eight items. Neighborhood affluence was defined using Census data. An index to reflect cumulative biological risk was constructed as a count of eight biomarkers above clinically established thresholds, including systolic and diastolic blood pressure, resting heart rate, C-reactive protein, waist circumference, hemoglobin A1c, and total and high-density lipoprotein cholesterol. Generalized linear models with a Poisson link function were used to estimate incident rate ratios (IRRs).

RESULTS

A 1-standard-deviation increase in the childhood adversity score was associated with a 9% increase in cumulative biological risk, after adjustment for demographic and behavioral characteristics (IRR = 1.09, 95% confidence interval (CI) = 1.02-1.17). This association was modified by neighborhood affluence (IRR = 0.92, 95% CI = 0.86, 0.99). Stratified models indicated that childhood adversity was associated with elevated cumulative biological risk only among individuals who resided in low-affluence (bottom tertile) neighborhoods (IRR = 1.16, 95% CI = 1.05, 1.28); there was no association in high-affluence (top tertile) neighborhoods (IRR = 0.97, 95% CI = 0.83, 1.14).

CONCLUSIONS

Childhood adversity is associated with elevated cumulative biological risk in adulthood, and neighborhood affluence may buffer this association. Results demonstrate the importance of neighborhood characteristics for associations between childhood adversity and disease risk, even after accounting for adult socioeconomic status.

A self-administered, street intercept survey was conducted in order to examine the relation of stigma and shame associated with sexually transmitted infections (STI) to STI testing practices, partner notification, and partner-delivered treatment among young African American men (n=108) in a low-income, urban community in San Francisco with high STI burden. Multivariate logistic regression revealed that increasing STI-related stigma was significantly associated with a decreased odds of STI testing, such that every standard deviation increase in stigma score was associated with 0.62 decreased odds of having been tested (aOR: 0.62, 95% CI: 0.38-1.00), controlling for age. STI stigma was also significantly associated with a decreased willingness to notify non-main partners of an STI (aOR: 0.64 95% CI: 0.41-0.99). Participants with higher levels of stigma and shame were also significantly less likely to be willing to deliver STI medication to a partner (stigma aOR: 0.57, 95% CI: 0.37-0.88; shame aOR 0.53 95% CI: 0.34-0.83). Findings suggest that STI-related stigma and shame, common in this population, could undermine STI testing, treatment, and partner notification programs. The medical establishment, one of the institutional factors to have reinforced this culture of stigma, must aid efforts to reduce its effects through providing integrated services, reframing sexual health in campaigns, educating clients, and providing wider options to aid disclosure and partner notification practices.

Owing to the improved longevity afforded by combination antiretroviral therapy (cART), HIV-infected individuals are developing several non-AIDS-related comorbid conditions. Consequently, medical management of the HIV-infected population is increasingly complex, with a growing list of potential drug-drug interactions (DDIs). This article reviews some of the most relevant and emerging potential interactions between antiretroviral medications and other agents. The most common DDIs are those involving protease inhibitors or non-nucleoside reverse transcriptase inhibitors, which alter the cytochrome P450 enzyme system and/or drug transporters such as p-glycoprotein. Of note are the new agents for the treatment of chronic hepatitis C virus infection. These new classes of drugs and others drugs that are increasingly used in this patient population represent a significant challenge with regard to achieving the goals of effective HIV suppression and minimization of drug-related toxicities. Awareness of DDIs and a multidisciplinary approach are imperative in reaching these goals.

BACKGROUND

Manual cigarette lighter refilling with butane/propane admixed liquefied petroleum gas (LPG) is a common low-income occupation in India. This practice may cause adverse health effects from LPG exposure among such workers.

OBJECTIVE

To assess respiratory status among LPG-exposed workers and non-exposed controls.

METHODS

We quantified the exposure and evaluated respiratory symptoms and lung function among 113 LPG refilling workers (aged 41.9±9.9 years) and 79 controls (aged 40.8±7.2 years). We used multiple linear regression analysis to estimate the LPG exposure response within the group of refilling workers, adjusting for age, height and smoking status.

RESULTS

Compared to the controls, the LPG-exposed lighter refillers manifested a 190 ml decrement in 1-second forced expiratory volume (FEV1) (2.55±0.4 vs. 2.26±0.3 l) and a 6% decrement in FEV1/forced vital capacity (FVC) (both P < 0.05). We found a significantly negative exposure response among the LPG workers: for FVC and FEV1, 44 ml per ml of reported daily LPG use in refilling (P < 0.05).

CONCLUSION

Likely heavy exposure to LPG through manually refilling cigarette lighters is associated with airflow decrements. This adverse effect may be relevant to other occupational groups heavily exposed to volatile hydrocarbons, especially those in marginal employment sectors.

PURPOSE

We aimed to approximate the annual clinical work that is performed during facial trauma coverage and analyze the economic incentives for subspecialty surgeons providing the coverage.

METHODS

A retrospective, clinical productivity data analysis of 6 consecutive years of facial trauma coverage at an American College of Surgeons-verified Level I trauma center was performed by the use of a trauma database and relative value unit (RVU) data. A payer mix analysis also was completed. SPSS V19 was used for analysis.

RESULTS

Between 2006 and 2011, 526 patients were treated for facial injuries. The annual nonoperative RVUs ranged from 371 to 539, whereas the annual operative RVUs range was 235-426. Trend analysis displayed that most of the annual RVUs were nonoperative until the year 2011, when the operative RVUs surpassed the nonoperative. Payer mix analysis revealed that commercial insurance coverage was the most common (range 21-54%, median 41%) followed by self-pay coverage (18-32%, median 29%). This finding was a consistent phenomenon except in the year 2009, when self-pay covered the majority of the RVUs (32%). Nasal bone fractures (24%) and mandibular fractures (16%) were the two most common diagnoses. Open reduction and internal fixation of mandibular fractures (17%), open reduction and internal fixation orbital bone fractures (15%), and complex facial repair (12%) constituted the most common operative procedures. Facial trauma consultations were obtained 22% (16-24%) of covered days. The percent of days requiring emergency procedures was (0.5-1%).

CONCLUSION

The infrequency of subspecialty consultations and operative interventions, and significant payer mix differences between facial trauma patients relative to the current ambulatory surgery population of the covering subspecialties poses economical challenges for both the hospitals and providers that use the traditional coverage models.

BACKGROUND

Improving childhood tuberculosis (TB) evaluation and care is a global priority, but data on performance at community health centers in TB endemic regions are sparse.

OBJECTIVE

To describe the current practices and quality of TB evaluation for children with cough ≥2 weeks' duration presenting to community health centers in Uganda.

METHODS

Cross-sectional analysis of children (<15 years) receiving care at five Level IV community health centers in rural Uganda for any reason between 2009-2012. Quality of TB care was assessed using indicators derived from the International Standards of Tuberculosis Care (ISTC).

RESULTS

From 2009-2012, 1713 of 187,601 (0.9%, 95% CI: 0.4-1.4%) children presenting to community health centers had cough ≥ 2 weeks' duration. Of those children, only 299 (17.5%, 95% CI: 15.7-19.3%) were referred for sputum microscopy, but 251 (84%, 95% CI: 79.8-88.1%) completed sputum examination if referred. The yield of sputum microscopy was only 3.6% (95% CI: 1.3-5.9%), and only 55.6% (95% CI: 21.2-86.3%) of children with acid-fast bacilli positive sputum were started on treatment. Children under age 5 were less likely to be referred for sputum examination and to receive care in accordance with ISTC. The proportion of children evaluated in accordance with ISTC increased over time (4.6% in 2009 to 27.9% in 2012, p = 0.03), though this did not result in increased case-detection.

CONCLUSION

The quality of TB evaluation was poor for children with cough ≥2 weeks' duration presenting for health care. Referrals for sputum smear microscopy and linkage to TB treatment were key gaps in the TB evaluation process, especially for children under the age of five.