Effectiveness of dietary intervention in children and adolescents with elevated blood pressure

Hypertension is a known risk factor for cardiovascular disease in adults. Essential hypertension in children and adolescents is increasing in prevalence in the United States, and hypertension in children may track into adulthood. This increasing prevalence is attributed to the trends of increasing overweight and obese children and adolescents. Family history and being of African-American/black descent may predispose youth to elevated blood pressure. Interventions targeted to reduce and treat hypertension in youth include non-pharmaceutical interventions such as weight reduction, increased physical activity, and dietary changes and pharmaceutical treatment when indicated. The effectiveness of non-pharmaceutical interventions is well documented in adults, but there are limited studies with regards to children and adolescents, specifically in the arena of dietary interventions. Lifestyle modifications such as dietary interventions are the mainstay of recommended treatment for those children and adolescents with prehypertension or stage 1 hypertension. Given the association of being overweight and hypertension, efficacy of dietary interventions are of interest because of reduced cost, easy implementation and potential for multiple beneficial outcomes such as reduced weight and reduction of other metabolic or cardiovascular derangements. Barriers to dietary interventions often include socioeconomic status, ethnicity, personal, and external factors. The goal of this systematic review of the literature is to identify interventions targeted to children and adolescents that focus on recommended dietary changes related to blood pressure. Dietary interventions found for this review mostly focused on a particular nutrient or food group with the one notable exception that focused on the DASH pattern of eating. The effects of the interventions on blood pressure varied, but overall dietary modifications can be achieved in youth and can serve a role in producing positive outcomes on blood pressure. Increasing potassium and following a DASH diet seemed to provide the most clinically significant results. Further studies are still needed to evaluate long-term effectiveness and to contribute more supporting evidence for particular modifications in these age cohorts.^

Spatial analysis of cardiovascular disease mortality and air pollution in Harris County, Texas

The association between fine particulate matter air pollution (PM2.5) and cardiovascular disease (CVD) mortality was spatially analyzed for Harris County, Texas, at the census tract level. The objective was to assess how increased PM2.5 exposure related to CVD mortality in this area while controlling for race, income, education, and age. An estimated exposure raster was created for Harris County using Kriging to estimate the PM2.5 exposure at the census tract level. The PM2.5 exposure and the CVD mortality rates were analyzed in an Ordinary Least Squares (OLS) regression model and the residuals were subsequently assessed for spatial autocorrelation. Race, median household income, and age were all found to be significant (p<0.05) predictors in the model. This study found that for every one μg/m3 increase in PM2.5 exposure, holding age and education variables constant, an increase of 16.57 CVD deaths per 100,000 would be predicted for increased minimum exposure values and an increase of 14.47 CVD deaths per 100,000 would be predicted for increased maximum exposure values. This finding supports previous studies associating PM2.5 exposure with CVD mortality. This study further identified the areas of greatest PM2.5 exposure in Harris County as being the geographical locations of populations with the highest risk of CVD (i.e., predominantly older, low-income populations with a predominance of African Americans). The magnitude of the effect of PM2.5 exposure on CVD mortality rates in the study region indicates a need for further community-level studies in Harris County, and suggests that reducing excess PM2.5 exposure would reduce CVD mortality.^

Changes in sexual behaviors associated with crack cocaine cessation among African Americans in Houston, Texas

Aim To examine the association between the crack cocaine cessation and risky sexual behaviors. Design and setting Between June 2002 and March 2005, a sample of African-American residents of Houston, Texas who were using crack at the time of enrollment participated in a cohort study to evaluate per outreach interventions to reduce HIV risk behaviors. The sample for this study consisted of 351 women and men who completed structured surveys at baseline and at six months about socio-demographic characteristics, drug use, and sexual behaviors. Multivariate logistic regression was used to analyze the association between crack cessation and risky sexual behaviors at follow-up, while controlling for confounding characteristics. Measurements Crack cessation was defined as reporting no crack use in the 30 days prior to the follow-up interview. Possible associated factors included unprotected sex, having multiple sex partners, trading sex for money/drugs, crack use, and socio-demographic variables. Findings At the six-month follow-up interview, 21% of participants reported that they had not used crack in the previous 30 days. For women, crack cessation was significantly associated with having only one sex partner at follow-up; for men, crack cessation was significantly associated with being single, separated, or divorced at baseline, having only one sex partner at follow-up, and initiating protected sex by follow-up. Conclusion These findings support previous research indicating that crack use is associated with unprotected sex and multiple sexual partners, as men and women who ceased crack use were less likely to engage in these risky sexual behaviors. Findings demonstrate that treatment for crack use could have a meaningful effect on risky sexual behaviors and HIV/STI prevention.^

Preserving Family: Themes from a Qualitative Study of Kin Caregivers

This article presents themes from a qualitative study of 58 African American female kinship caregivers in San Francisco. Core concepts that emerged describe various paths along which children move into kin homes, and caregivers' mixed emotional reactions to becoming surrogate parents. Women also discussed multiple family roles they assumed after taking in children. Responses highlight three primary reasons for becoming caregivers that center on providing for and protecting these children—particularly from the perceived threat of the public foster care system—and ultimately preserving the family unit. Paradoxically, caregivers' reasons mirror the stated goals of the public foster care system, which they view as a threat to family stability. We discuss the problems of implementing practice and policy recommendations for permanency and family preservation and how to bridge the gap between the deeply held negative beliefs of African American caregivers towards the public system and begin to build trust.

Risk and protective factors associated with depression among racial and ethnic mothers of adolescents

The central paradigm linking disadvantaged social status and mental health has been the social stress model (Horwitz, 1999), the assumption being that individuals residing in lower social status groups are subjected to greater levels of stress not experienced by individuals from higher status groups. A further assumption is that such individuals have fewer resources to cope with stress, in turn leading to higher levels of psychological disorder, including depression (Pearlin, 1989). Despite these key assumptions, there is a dearth of literature comparing the social patterning of stress exposure (Hatch & Dohrenwend, 2007; Meyer, Schwartz, & Frost, 2008; Kessler, Mickelson, & Williams, 1999; Turner & Avison, 2003; Turner & Lloyd, 1999; Turner, Wheaton, & Lloyd, 1995), and the distribution and contribution of protective factors, posited to play a role in the low rates of depression found among African- and Latino-Americans (Alegria et al., 2007; Breslau, Aguilar-Gaxiola, Kendler, Su, Williams, & Kessler, 2006; Breslau, Borges, Hagar, Tancredi, Gilman, 2009; Gavin, Walton, Chae, Alegria, Jackson, & Takeuchi, 2010; Williams, & Neighbors, 2006). Thus, this study sought to describe both the distribution and contribution of risk and protective factors in relation to depression among a sample of African-, European-, and Latina-American mothers of adolescents, including testing a hypothesized mechanism through which social support, an important protective factor specific to women and depression, operates. ^ Despite the finding that the levels of depression were not statistically different across all three groups of women, surprising results were found in describing the distribution of both risk and protective factors, in that results reported among all women who were mothers when analyzed masked differences within each ethnic group when SES was assessed, a point made explicit by Williams (2002) regarding racial and ethnic variations in women's health. In the final analysis, while perceived social support was found to partially mediate the effect of social isolation on depression, among African-Americans, the direct effect of social isolation and depression was lower among this group of women, as was the indirect effect of social isolation and perceived social support when compared to European- and Latina-American mothers. Or, put differently, higher levels of social isolation were not found to be as associated with more depression or lower social support among African-American mothers when compared to their European- and Latina-American counterparts. ^ Women in American society occupy a number of roles, i.e., that of being female, married or single, mother, homemaker or employee. In addition, to these roles, ethnicity and SES also come into play, such that the intersection of all these roles and the social contexts that they occupy are equally important and must be taken into consideration when making predictions drawn from the social stress model. Based on these findings, it appears that the assumptions of the social stress model need to be revisited to include the variety of roles that intersect among individuals from differing social groups. More specifically, among women who are mothers and occupy a myriad of other roles, i.e., that of being female, married or single, African- or Latina-American, mother, homemaker or employee, the intersection of all the roles and the social contexts that women occupy are equally important and must be taken into consideration when looking at both the types and distribution of stressors across women. Predictions based on simple, mutually exclusive categories of social groups may lead to erroneous assumptions and misleading results.^

Time to renal disease and end-stage renal disease in PROFILE: a multiethnic lupus cohort.

BACKGROUND: Renal involvement is a serious manifestation of systemic lupus erythematosus (SLE); it may portend a poor prognosis as it may lead to end-stage renal disease (ESRD). The purpose of this study was to determine the factors predicting the development of renal involvement and its progression to ESRD in a multi-ethnic SLE cohort (PROFILE). METHODS AND FINDINGS: PROFILE includes SLE patients from five different United States institutions. We examined at baseline the socioeconomic-demographic, clinical, and genetic variables associated with the development of renal involvement and its progression to ESRD by univariable and multivariable Cox proportional hazards regression analyses. Analyses of onset of renal involvement included only patients with renal involvement after SLE diagnosis (n = 229). Analyses of ESRD included all patients, regardless of whether renal involvement occurred before, at, or after SLE diagnosis (34 of 438 patients). In addition, we performed a multivariable logistic regression analysis of the variables associated with the development of renal involvement at any time during the course of SLE.In the time-dependent multivariable analysis, patients developing renal involvement were more likely to have more American College of Rheumatology criteria for SLE, and to be younger, hypertensive, and of African-American or Hispanic (from Texas) ethnicity. Alternative regression models were consistent with these results. In addition to greater accrued disease damage (renal damage excluded), younger age, and Hispanic ethnicity (from Texas), homozygosity for the valine allele of FcgammaRIIIa (FCGR3A*GG) was a significant predictor of ESRD. Results from the multivariable logistic regression model that included all cases of renal involvement were consistent with those from the Cox model. CONCLUSIONS: Fcgamma receptor genotype is a risk factor for progression of renal disease to ESRD. Since the frequency distribution of FCGR3A alleles does not vary significantly among the ethnic groups studied, the additional factors underlying the ethnic disparities in renal disease progression remain to be elucidated.

Candidate gene identification following linkage: Search for hypertension susceptibility genes

Following up genetic linkage studies to identify the underlying susceptibility gene(s) for complex disease traits is an arduous yet biologically and clinically important task. Complex traits, such as hypertension, are considered polygenic with many genes influencing risk, each with small effects. Chromosome 2 has been consistently identified as a genomic region with genetic linkage evidence suggesting that one or more loci contribute to blood pressure levels and hypertension status. Using combined positional candidate gene methods, the Family Blood Pressure Program has concentrated efforts in investigating this region of chromosome 2 in an effort to identify underlying candidate hypertension susceptibility gene(s). Initial informatics efforts identified the boundaries of the region and the known genes within it. A total of 82 polymorphic sites in eight positional candidate genes were genotyped in a large hypothesis-generating sample consisting of 1640 African Americans, 1339 whites, and 1616 Mexican Americans. To adjust for multiple comparisons, resampling-based false discovery adjustment was applied, extending traditional resampling methods to sibship samples. Following this adjustment for multiple comparisons, SLC4A5, a sodium bicarbonate transporter, was identified as a primary candidate gene for hypertension. Polymorphisms in SLC4A5 were subsequently genotyped and analyzed for validation in two populations of African Americans (N = 461; N = 778) and two of whites (N = 550; N = 967). Again, SNPs within SLC4A5 were significantly associated with blood pressure levels and hypertension status. While not identifying a single causal DNA sequence variation that is significantly associated with blood pressure levels and hypertension status across all samples, the results further implicate SLC4A5 as a candidate hypertension susceptibility gene, validating previous evidence for one or more genes on chromosome 2 that influence hypertension related phenotypes in the population-at-large. The methodology and results reported provide a case study of one approach for following up the results of genetic linkage analyses to identify genes influencing complex traits. ^

Racial disparities in patient survival after liver transplantation in the United States

Background. Racial disparities in healthcare span such areas as access, outcomes after procedures, and patient satisfaction. Previous work suggested that minorities experience less healthcare and worse survival rates. In adult orthotopic liver transplantation (OLT) mixed results have been reported, with some showing African-American recipients having poor survival compared to Caucasians, and others finding no such discrepancy. ^ Purpose. This study’s purpose was to analyze the most recent United Network for Organ Sharing (UNOS) data, both before and after the implementation of the Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) scoring system, to determine if minority racial groups still experience poor outcomes after OLT. ^ Methods. The UNOS dataset for 1992-2001 (Era I) and 2002-2007 (Era II) was used. Patient survival rates for each Era and for adult and pediatric recipients were analyzed with adjustment. A separate multivariate analysis was performed on African-American adult patients in Era II in order to identify unique predictors for poor patient survival. ^ Results. The overall study included 66,118 OLT recipients. The majority were Caucasian (78%), followed by Hispanics (13%) and African-Americans (9%). Hispanic and African-American adults were more likely to be female, have Hepatitis C, to be in the intensive care unit (ICU) or ventilated at time of OLT, to have a MELD score ≥23, to have a lower education level, and to have public insurance when compared to Caucasian adults (all p-values < 0.05). Hispanic and African-American pediatric recipients were more likely have public insurance and less likely to receive a living donor OLT than were Caucasian pediatric OLT recipients (p <0.05). There was no difference in the likelihood of having a PELD score ≥21 among racial groups (p >0.40). African-American adults in Era I and Era II had worse patient survival rates than both Caucasians and Hispanic (pair-wise p-values <0.05). This same disparity was seen for pediatric recipients in Era I, but not in Era II. Multivariate analysis of African-American recipients revealed no unique predictors of patient death. ^ Conclusions. African-American race is still a predictor of poor outcome after adult OLT, even after adjustment for multiple clinical, demographic, and liver disease severity variables. Although African-American and Hispanic subgroups share many characteristics previously thought to increase risk of post-OLT death, only African-American patients have poor survival rates when compared to Caucasians. ^

For health's sake: Cervical and breast cancer screening

African-Americans make up twelve percent of the United States population, yet they experience morbidity and mortality at a rate that, in some cases, is disproportionate to their numbers. There are numerous health areas, including cancer, in which disparities exist. There are also numerous reasons which have been suggested to explain the high rates of cancer morbidity and mortality experienced by African-Americans. Among the reasons given to explain these differences are lack of knowledge and lack of access to medical care (1). This study sought to increase the knowledge, attitudes, and behavioral intentions of African-American women attending a Baptist church in Houston with regard to cervical cancer, breast cancer, Pap smear, and mammography. It was hypothesized that a church-based cancer education program would produce the desired change in knowledge, attitudes, and behavioral intentions.^ The quasi-experimental design of the study was untreated control group with pretest and posttest and untreated control group with posttest only. Female members of Mount Ararat Baptist Church took part in an eight-week, cancer education program based on social cognitive theory. Baseline data were collected before the start of the program at Mount Ararat and at Solid Rock Baptist Church, control group one. At the end of the program, the follow-up survey was administered at the program church, control church one, and in a third church, Damascus Missionary Baptist Church, which served as the posttest only group. The data were analyzed by Fisher's exact and paired t-test to determine if the program supported the project's hypotheses.^ Results of data analyses supported the major study hypotheses, the exception being behavioral intention to have Pap smear performed. Although the program appeared to have generally influenced changes in the desired direction, the results are limited due to the quasi-experimental design and small sample size. Longer term studies with larger sample sizes are needed to more fully develop and evaluate programs which impact the health of African-Americans. ^

Genetic variants associated with metastatic prostate cancer

Introduction. Distant metastasis remains the leading cause of death among prostate cancer patients. Several genetic susceptibility loci associated with Prostate cancer have been identified by the Genome Wide Association Studies (GWAS). To date, few studies have explored the ability of these SNPs to identify metastatic prostate cancer. Based on the identification of genetic variants as predictors of aggressive disease, a case comparison study of prostate cancer patients was designed to explore the association of 96 GWAS single nucleotide polymorphisms (SNPs) with metastatic disease. ^ Method. 1242 histologically confirmed prostate cancer patients, with and without metastatic disease, were enrolled into the study. Data were collected from personal interviews, hospital database and abstraction of medical records. Ninety six SNPs identified from GWAS studies based on their associations with prostate cancer risk were genotyped in the study population. Univariate and multivariate logistic regression analyses were used to explore the relationships of the variants with metastatic prostate cancer in Whites and African American men. ^ Results. Four SNPs showed independent associations with metastatic prostate cancer (rs721048 in EHBP1 (2p15), rs3025039 in VEGF (6p12), rs11228565 in Intergenic(11q13.2) and rs2735839 in KLK3(19q13.33)) in the White population. For SNP rs2735839 in KLK3, genotype GA was 1.71 times as likely to be associated with metastatic prostate cancer diagnosis as genotype AA after adjusting for other significant SNPs and covariates (95% CI, 1.12-2.60; p=0.012). In men of African descent, three SNPs: rs1512268 in NKX3-1(8p21.2), rs12155172 in intergenic (7p15.3) & rs10486567 in JAZF1 (7p15.2) were positively associated with metastatic disease in the multivariate analysis. The strongest SNP was rs1512268 heterozygous genotype AG in NKX3-1(8p21.2) which was associated with 3.97-fold increased risk of metastatic prostate cancer diagnosis (95% CI, 1.69-9.34; p =0.002). ^ Conclusion. Genetic variants associated with metastatic prostate cancer were different in Whites and African American men. Given the high mortality rate recorded in men diagnosed with metastatic prostate tumor, further studies are needed to validate associations and establish their clinical application.^

Weight-for-age percentile and its association to community acquired methicillin resistant Staphylococcus aureus among pediatric patients in Houston, TX

BACKGROUND: Weight has been implicated as a risk factor for symptomatic community-acquired methicillin resistant Staphylococcus Aureus (CA-MRSA). Information from Texas Children's Hospital (TCH) in Houston, TX was used to implement a case-control study to assess weight-for-age percentile (WFA), race and seasonal exposure as risk factors. ^ METHODS: A retrospective chart review to collect data from TCH was conducted covering the time period January 1st, 2008 to May 31st, 2011. Cases were confirmed and identified by the infectious disease department and were matched on a 1:1 ratio to controls that were seen by the emergency department for non-infected fractures from June 1st, 2008 to May 31st, 2011. Data abstraction was performed using TCH's electronic medical records (EMR) system (EPIC ®). ^ RESULTS: Of 702 CA-MRSA identified cases, ages 9 to 16.99, 564 (80.3%) had the variable `weight' present in their EMR, were not duplicates and not determined to be outliers. Cases were randomly matched to a pool of available controls (n=1864) according to age and gender, yielding 539 1:1 matched pairs (95.5% case matching success) with a total study sample size, N=1078. Case median age was 13.38 years with the majority being White (66.05%) and male (59.4%). Adjusted conditional logistic regression analysis of the matched pairs identified the following risk factors to presenting with CA-MRSA infection among pediatric patients, ages 9 to 16.99 years: a) Individual weight in the highest (75th-99.9th) WFA quartile (OR=1.36; 95% confidence interval [CI]=1.06-1.74; P= 0.016), b) Infection during summer months (OR: 1.69; 95% CI=1.2-2.38; P= 0.003), c) patients of African American race/ethnicity (OR= 1.48; 95% CI=1.13-1.95; P= 0.004). ^ CONCLUSIONS: Pediatric patients, 9 to 16.99 years of age, in the highest WFA quartile (75th-99.9th), or of African-American race had an associated increased risk of presenting with CA-MRSA infection. Furthermore, children in this population were at a higher risk of contracting CA-MRSA infection during the summer season.^

Adherence to HIV /AIDS therapies among low -literacy populations: The ALP project

Adherence to HIV/AIDS therapies has been an important health problem since the early 1980s when AZT was first prescribed as a therapy for HIV/AIDS. It became particularly important between 1995 and 1997 with the advent of protease inhibitors (Chesney, Ickovics, Hecht, Sikipa, & Rabkin J., 1999) and became even more significant as persons with HIV/AIDS began to develop resistance to medications. Low-literacy populations have poorer health (Brez & Taylor, 1997) and higher AIDS rates (Simon, Hu, Diaz, & Kerndt, 1995), than their higher literacy counterparts due to delayed treatment (Baker, Parker, Williams, Clark, & Nurss, 1997), shame of literacy skills (Parikh, 1996), and poor access to care (Williams, et al., 1995). Poorer health and higher AIDS rates can also be attributed to poor patient-provider relationships (Crespo-Fierro, 1997; Eldred, Wu, Chaisson, & Moore, 1998) to a poorer understanding of medical protocols (Murphy, 1997), and inadequate patient education (Ungvarski, 1997; Davis, Michielutte, Askov, Williams, & Weiss, 1998, Doak, Doak, & Root, 1996). ^ The ALP intervention was developed for HIV positive low-literacy populations of African American women in Houston, Texas. The intervention was based on a needs assessment, using the PRECEDE model, an innovative process referred to as Intervention Mapping, and validated using formative evaluation methods with 54 individuals. The needs assessment resulted in a list of behavioral, environmental, predisposing, enabling, and reinforcing determinants of adherence. The Intervention Mapping framework was used to refine these determinants and develop a list of objectives describing what must be learned or changed to for the target population to adhere to HIV/AIDS therapies. Methods and strategies, were developed using theoretical constructs from the Health Belief Model (Rosenstock, 1974) and Social Cognitive Theory (Bandura, 1986). These theories, empirical evidence, and information from the target population indicated that perceived susceptibility, perceived severity, outcome expectations, and self-efficacy were important and changeable determinants of adherence to HIV/AIDS therapies for this population. ^ These components were brought together in the form of a theory-based color cartoon book and 10-minute cassette tape. The book was developed for people with 2.9 years of U.S. education as measured with the Flesch-Kincaid Grade Level method and the script was recorded onto a cassette tape to make it suitable for populations with even lower-literacy skills. A formative evaluation was conducted to ensure that the content and structure were accurate, clear, realistic, readable, appropriate, and likely to be used as intended. ^