Publications

OBJECTIVE

The purpose of this study was to evaluate attitudes of primary care providers toward barriers to metabolic monitoring and to characterize their beliefs about providers' responsibility for monitoring and reducing cardiovascular risk for people with severe mental illness.

METHODS

An anonymous survey was administered to 214 primary care providers working in 23 public community health clinics in San Francisco.

RESULTS

The response rate was 77% (164 of 214). Nearly 40% of primary care providers were unaware of consensus guidelines for metabolic monitoring of people who take second-generation antipsychotic medications. Responses showed variation in providers' beliefs about who should monitor patients' metabolic risk. The major barriers to metabolic monitoring were severity of psychiatric illness, difficulty collaborating with psychiatrists, and difficulty arranging psychiatric follow-up.

CONCLUSIONS

Primary care providers believed that better communication between primary care providers and psychiatrists would facilitate metabolic monitoring and promote better treatment for patients with severe mental illness who are taking antipsychotic medications.

Housing instability, a growing public health problem, may be an independent environmental risk factor for hypertension, but limited prospective data exist. We sought to determine the independent association of housing instability in early adulthood (year 5, 1990-1991) and incident hypertension over the subsequent 15 years of follow-up (years 7, 10, 15, and 20) in the Coronary Artery Risk Development in Young Adults (CARDIA) study (N = 5,115). Because causes of inadequate housing and its effects on health are thought to vary by race and sex, we hypothesized that housing instability would exert a differential effect on incident hypertension by race and sex. At year 5, all CARDIA participants were asked about housing and those free of hypertension were analyzed (N = 4,342). We defined housing instability as living in overcrowded housing, moving frequently, or living doubled up. Of the 4,342 participants, 8.5 % were living in unstable housing. Across all participants, housing instability was not associated with incident hypertension (incidence rate ratio (IRR), 1.1; 95 % CI, 0.9-1.5) after adjusting for demographics, socioeconomic status, substance use, social factors, body mass index, and study site. However, the association varied by race and sex (p value for interaction, <0.001). Unstably housed white women had a hypertension incidence rate 4.7 times (IRR, 4.7; 95 % CI, 2.4-9.2) that of stably housed white women in adjusted analysis. There was no association among white men, black women, or black men. These findings suggest that housing instability may be a more important risk factor among white women, and may act independently or as a marker for other psychosocial stressors (e.g., stress from intimate partner violence) leading to development of hypertension. Studies that examine the role of these psychosocial stressors in development of hypertension risk among unstably housed white women are needed.

One- half of women in the United States do not meet the weekly dose of physical activity recommended by the Centers for Disease Control. Many women could benefit tremendously if they were to adopt a more active lifestyle. Health benefits from exercise include lowering the risk for cardiovascular disease, slowing the rate of bone loss in osteoporosis, and improving mood during pregnancy. In this article, we review the health benefits that women may gain from physical activity and the recommendations for physical activity for adults in the United States. We offer evidence supporting use of the exercise prescription, discuss how to write an exercise prescription, and how to tailor the exercise prescription for women with particular medical problems.

In rodent models, undercarboxylated osteocalcin (ucOC) acts as a hormone that promotes insulin sensitivity and secretion. If ucOC plays a similar role in humans, then antiresorptive therapies, which reduce ucOC levels, may increase the risk of insulin resistance and diabetes. We tested whether antiresorptive therapies result in higher fasting glucose, increased weight, or greater diabetes incidence in post hoc analyses of three randomized, placebo-controlled trials in postmenopausal women: Fracture Intervention Trial (FIT) (N = 6151) of alendronate (4 years), Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly Pivotal Fracture Trial (HORIZON-PFT) (N = 7113) of zoledronic acid (3 years), and Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM) trial (N = 7076) of denosumab (3 years). Fasting glucose was measured annually in FIT and HORIZON in a subset of women, and every 6 months in FREEDOM in all participants. Weight was measured annually in all trials. Incident diabetes was identified from adverse event reports, initiation of diabetes medication, or elevated fasting glucose. Differences in fasting glucose changes from randomization to trial conclusion between treatment and placebo groups were not statistically significant: -0.47 mg/dL in FIT, 0.20 mg/dL in HORIZON-PFT, and 0.09 mg/dL in FREEDOM, all p > 0.6. Weight change differed between treatment and placebo groups in FIT (0.32 kg, p = 0.003) and FREEDOM (0.31 kg, p = 0.023) but not in HORIZON-PFT (0.15 kg, p = 0.132). In the three trials combined, diabetes occurred in 203 and 225 women assigned to treatment or placebo, respectively. Diabetes incidence was not increased in any of the treatment groups or in the pooled estimate (pooled relative risk [RR] = 0.90; 95% confidence interval [CI] 0.74-1.10). Antiresorptive therapy does not have a clinically important effect on fasting glucose, weight, or diabetes risk in postmenopausal women. Contrary to predictions from mouse models, reduced bone turnover does not appear to play a significant role in glucose metabolism in humans.

Food insecurity is common among HIV-infected populations in resource-rich and resource-poor countries. We hypothesized that food insecurity would be associated with risky sexual behaviors. We examined this hypothesis among all sexually active participants (n = 154) in the Research on Access to Care in the Homeless (REACH) cohort in San Francisco. The outcomes were unprotected vaginal or anal sex and multiple sexual partners during the prior 90 days. Associations were examined using repeated measures multivariable logistic regression analyses. Food insecurity was independently associated with unprotected sexual activity (AOR = 2.01 for each five point increase in HFIAS scale, 95 % CI 1.31-3.10) and multiple sexual partners (AOR = 1.54 for each five-point increase in HFIAS scale, 95 % CI 1.05-2.29). Food insecurity is a risk factor for unprotected sexual activity and multiple sexual partners among homeless and marginally housed HIV-infected individuals in San Francisco. Measures to alleviate food insecurity may play a role in decreasing secondary HIV transmission.

Early receipt of HIV care and ART is essential for improving treatment outcomes, but is dependent first upon HIV testing. Heavy alcohol consumption is common in sub-Saharan Africa, a barrier to ART adherence, and a potential barrier to HIV care. We conducted a population-based study of 2,516 adults in southwestern Uganda from November-December 2007, and estimated the relative risk of having never been tested for HIV using sex-stratified Poisson models. More men (63.9 %) than women (56.9 %) had never been tested. In multivariable analysis, compared to women who had not consumed alcohol for at least 5 years, women who were current heavy drinkers and women who last drank alcohol 1-5 years prior, were more likely to have never been tested. Alcohol use was not associated with prior HIV testing among men. HIV testing strategies may thus need to specifically target women who drink alcohol.

OBJECTIVE

To test the feasibility of measuring household ventilation and evaluate whether ventilation is associated with tuberculosis (TB) in household contacts in Kampala, Uganda.

DESIGN

Adults with pulmonary TB and their household contacts received home visits to ascertain social and structural household characteristics. Ventilation was measured in air changes per hour (ACH) in each room by raising carbon dioxide (CO₂) levels using dry ice, removing the dry ice, and measuring changes in the natural log of CO₂ (lnCO2) over time. Ventilation was compared in homes with and without co-prevalent TB.

RESULTS

Members of 61 of 66 (92%) households approached were enrolled. Households averaged 5.4 residents/home, with a median of one room/home. Twelve homes (20%) reported co-prevalent TB in household contacts. Median ventilation for all rooms was 14 ACH (interquartile range [IQR] 10-18). Median ventilation was 12 vs. 15 ACH in index cases' sleeping rooms in households with vs. those without co-prevalent TB (P = 0.12). Among smear-positive indexes not infected by the human immunodeficiency virus (HIV), median ventilation was 11 vs. 17 ACH in index cases' sleeping rooms in homes with vs. those without co-prevalent TB (P = 0.1).

CONCLUSION

Our findings provide evidence that a simple CO₂ decay method used to measure ventilation in clinical settings can be adapted to homes, adding a novel tool and a neglected variable, ventilation, to the study of household TB transmission.

A 2012 American Association of Occupational Health Nurses, Inc. (AAOHN) web-based membership survey of 5,138 members was designed to identify occupational health and safety issues facing members. A total of 2,123 members responded to the survey (41% response rate). Of the AAOHN members who responded to this survey, 61% reported health risk appraisal (HRA) priorities for 2012. HRA priority areas are identified among various subgroups of the AAOHN responders in this article. The top three HRA priority areas identified were weight management/nutrition/healthy eating, physical activity, and mental health/stress management. These priority areas were consistent across three industry sectors, three occupational health nurse job titles, and the smallest and largest employers. These results suggest that occupational health nurses should consider prioritizing their employee wellness efforts in these areas.