Ultraviolet radiation intensity predicts the relative distribution of dermatomyositis and anti-Mi-2 autoantibodies in women.

OBJECTIVE: Because studies suggest that ultraviolet (UV) radiation modulates the myositis phenotype and Mi-2 autoantigen expression, we conducted a retrospective investigation to determine whether UV radiation may influence the relative prevalence of dermatomyositis and anti-Mi-2 autoantibodies in the US. METHODS: We assessed the relationship between surface UV radiation intensity in the state of residence at the time of onset with the relative prevalence of dermatomyositis and myositis autoantibodies in 380 patients with myositis from referral centers in the US. Myositis autoantibodies were detected by validated immunoprecipitation assays. Surface UV radiation intensity was estimated from UV Index data collected by the US National Weather Service. RESULTS: UV radiation intensity was associated with the relative proportion of patients with dermatomyositis (odds ratio [OR] 2.3, 95% confidence interval [95% CI] 0.9-5.8) and with the proportion of patients expressing anti-Mi-2 autoantibodies (OR 6.0, 95% CI 1.1-34.1). Modeling of these data showed that these associations were confined to women (OR 3.8, 95% CI 1.3-11.0 and OR 17.3, 95% CI 1.8-162.4, respectively) and suggests that sex influences the effects of UV radiation on autoimmune disorders. Significant associations were not observed in men, nor were UV radiation levels related to the presence of antisynthetase or anti-signal recognition particle autoantibodies. CONCLUSION: This first study of the distribution of myositis phenotypes and UV radiation exposure in the US showed that UV radiation may modulate the clinical and immunologic expression of autoimmune disease in women. Further investigation of the mechanisms by which these effects are produced may provide insights into pathogenesis and suggest therapeutic or preventative strategies.

Mechanism of dendritic epidermal T cell-mediated tolerance induction and inhibition of proliferation

Dendritic epidermal T cells (DETC) comprise a unique population of T cells that reside in mouse epidermis and whose function remains unclear. Most DETC express a $\gamma\delta$ TCR, although some, including our DETC line, AU16, express an $\alpha\beta$ TCR. Additionally, AU16 cells express CD3, Thy-1, CD45, CD28, B7, and AsGM-1. Previous studies in our laboratory demonstrated that hapten-conjugated AU16 could induce specific immunologic tolerance in vivo and inhibit T cell proliferation in vitro. Both these activities are antigen-specific, and the induction of tolerance is non-MHC-restricted. In addition, AU16 cells are cytotoxic to a number of tumor cell lines in vitro. These studies suggested a role for these cells in immune surveillance. The purpose of my studies was to test the hypothesis that these functions of DETC (tolerance induction, inhibition of T cell proliferation, and tumor cell killing) were mediated by a cytotoxic mechanism. My specific aims were (1) to determine whether AU16 could prevent or delay tumor growth in vivo; and (2) to determine the mechanism whereby AU16 induce tolerance, using an in vitro proliferation assay. I first showed that AU16 cells killed a variety of skin tumor cell lines in vitro. I then demonstrated that they prevented melanoma growth in C3H mice when both cell types were mixed immediately prior to intradermal (i.d.) injection. Studies using the in vitro proliferation assay confirmed that DETC inhibit proliferation of T cells stimulated by hapten-bearing, antigen-presenting cells (FITC-APC). To determine which cell was the target, $\gamma$-irradiated, hapten-conjugated AU16 were added to the proliferation assay on d 4. They profoundly inhibited the proliferation of naive T cells to $\gamma$-irradiated, FITC-APC, as measured by ($\sp3$H) TdR uptake. This result strongly suggested that the T cell was the target of the AU16 activity because no APC were present by d 4 of the in vitro culture. In contrast, the addition of FITC-conjugated splenic T cells (SP-T) or lymph node T cells (LN-T) was less inhibitory. Preincubation of the T cells with FITC-AU16 cells for 24 h, followed by removal of the AU16 cells, completely inhibited the ability of the T cells to proliferate in response to FITC-APC, further supporting the conclusion that the T cell was the target of the AU16. Finally, AU16 cells were capable of killing a variety of activated T cells and T cell lines, arguing that the mechanism of proliferation inhibition, and possibly tolerance induction is one of cytotoxicity. Importantly, $\gamma\delta$ TCR$\sp+$ DETC behaved, both in vivo and in vitro like AU16, whereas other T cells did not. Therefore, these results are consistent with the hypothesis that AU16 cells are true DETC and that they induce tolerance by killing T cells that are antigen-activated in vivo. ^

Development and evaluation of a cervical cancer screening program for Chinese women

Despite of the proven efficacy of the Pap test, Asian populations still have low Pap screening compliance. The purpose of this dissertation was to investigate factors that influencing women's decision to obtain a Pap test, and to describe the development and evaluation of a cervical cancer educational program promoting the Pap screening behavior among women in Taiwan. ^ The first study examined factors associated with Pap screening compliance. Psychometric properties of measurement instruments were also assessed. The scale reliabilities were as the follows: Cronbach alpha 0.70 for knowledge scale, 0.88 for pros scale, 0.68 for cons scale, and 0.72 for perceived norms scale. Results from multiple logistic regression analysis, after adjusted for marital status, showed women who compliant to Pap screening guidelines had significantly higher knowledge, higher perceived benefits (pros), lower perceived barriers (cons), and higher perceived norms to receive a Pap test. ^ The second study described the development of a program called “Love yourself before you take care of your family”, designed to increase Pap screening behavior among women in Taiwan. The development of this program was guided by Intervention Mapping (IM), an innovative process of intervention design. The program used methods such as information transmission, modeling, persuasion, and facilitation. Strategies included direct mail campaigns, role model stories with women's testimonials, and phone intervention. ^ The third study examined the effectiveness of a randomized trial of the carefully-designed intervention (N = 424). Participants were female family members of inpatients admitted to one of the major teaching hospitals in Taiwan during August and September 1999. Women in the intervention group reported a higher rate of receiving a Pap test than women in the control group (50% versus 32%) after a three-month intervention (p = 0.002). Women in the intervention group showed increased knowledge (p = .016), perceived pros (p = 0.008), and susceptibility (p = .011) between baseline and follow-up. They also showed higher perceived pros of Pap tests than women in control group at follow-up (p = .031). This result suggested that program development based on theories and evidences could maximize the intervention impact for a specific target population. ^

The identification of child abuse in Harris County in 1998

Characteristics of child abuse cases are not well known. In this study I collected data on 70 child abuse cases that were reported to Children's Protective Services in Harris County in 1998. The purpose of this study was to determine the factors in Harris County that lead to the identification of physical and sexual abuse. In order to answer the questions of who, what, where and when relative to the discovery of abuse I applied the same questionnaire (see Appendix) to each of 35 Sexual Abuse case reports and to each of 35 Physical Abuse/Neglect case reports. Answers to the first four questions were arranged by frequency distribution to show the predominant reporter, the 10 most common indicators, the most common locale, and the most frequent timing. Tables of the age, sex, and ethnicity of the children indicate the identity of those whose victimization was most reported. In addition the relationship between the form questions and the characteristics of the children was explored. A comparison of Sexual Abuse cases with Physical Abuse/Neglect cases was conducted and the results were analyzed and recorded in the Tables. ^ Child maltreatment often has negative short and long term effects on children's mental health and development. Suicide, violence, delinquency, drug and alcohol abuse and other forms of criminality are frequently child abuse related. Early detection and treatment helps to alleviate the myriad mental and physical ailments that untreated victims present as adults. This translates into medical dollar savings. ^ The long term objectives of my research were to reduce the number of undetected and unreported child abuse cases in Harris County by formulating better educational programs and literature for medical professionals and other personnel who are in contact with children. ^

Maternal factors, fetal parameters and the risk of shoulder dystocia

Introduction. Shoulder dystocia is a serious complication of vaginal birth, with an incidence ranging from 0.15% to 2.1% of all births. There are approximately 4 million births per year in the United States and shoulder dystocia will be experienced by approximately 20,000 women each year. Although studies have been reported on shoulder dystocia, few studies have addressed both maternal and fetal risk factors. The purpose of this study was to identify maternal and fetal risk factors for shoulder dystocia while proposing factors that could be used to predict impending shoulder dystocia. ^ Material and methods. Articles were reviewed from Medline Pubmed using the search phrase "Risk factors of shoulder dystocia" and Medline Ovid using the search words "Dystocia", "Shoulder" and "Risk factors". Rigorous selection criteria were used to identify articles to be included in the study. Data collected from identified articles were transferred to STATA 10 software for trend analysis of the incidence of shoulder dystocia and the year of publication and a pair wise correlation was also determined between these two variables. ^ Results. Among a total of 343 studies identified, only 20 met our inclusion criteria and were retained for this review. The incidence of shoulder dystocia ranged from 0.07% to 2% and there was no particular trend or correlation between the incidence of shoulder dystocia and year of publication between 1985 and 2007. Pre-gestational and gestational diabetes, postdatism, obesity, birth weight > 4000g and fundal height at last visit > 40cm were identified as major risk factors in our series of studies. ^ Conclusion. Future strategies to predict shoulder dystocia should focus on pre-gestational and gestational diabetes mellitus, postdatism, obesity, birth weight > 4000g and fundal height at last visit > 40cm. ^

The determinants of sexually transmitted infection screening uptake among African American young adults: A systematic review

Objective. To conduct a systematic review of literature to determine the factors associated with STI including HIV screening uptake among African American young adults in the United States. ^ Methods. The electronic databases OVID Medline and OVID PsycINFO were systematically searched to identify potentially relevant articles. Ninety-six articles were initially identified, five of which were included in the final review. ^ Results. The results of this review were inconclusive. There was no definitive evidence to suggest which determinants were predictive of screening uptake. ^ Conclusions. There is a limited body of literature examining the demographic and behavioral risk factors associated with uptake or non-uptake of STI including HIV screening among African American young adult populations. This finding points to the need for more quality research to be conducted in this area. ^

Geographic variation of the etiology of travelers' diarrhea

Introduction. Traveler's Diarrhea is an important public health program in travelers from industrialized nations to the developing world with a prevalence rate of between 13 and 60%. Although studies are found on the etiology of traveler's diarrhea, these studies have not described the etiology over different regions of the world. The objective of this study was to identify the frequency of specific etiology of traveler's diarrhea by geographic area of the world. In addition to this, it was also examined whether there are any regional differences in the isolation rate of ETEC and conventional pathogens and variation, if any, in frequency of these pathogens in different regions over time.^ Material and methods. This is a systematic review of the studies on the etiology of traveler's diarrhea by geographic regions. The search databases used were Medline Pubmed and Medline Ovid and key words used for the search were Etiology of traveler's diarrhea, travelers' diarrhea and acute diarrhea of travelers. The articles were selected according to the inclusion and exclusion criteria and relevant data was extracted which was statistically analyzed.^ Results. Out of 110 studies from 1970 to 2004, 52 studies were included and 58 were excluded from the review. All the 52 studies were grouped according to the geographic regions of interest. Latin America (25 studies), Asia (7 studies), Africa (9 studies), and others/Mixed (11 studies), were the 4 major groups of regions studied. The overall most common pathogen was ETEC (29.10%) in this study and other common pathogens were EAEC (14.42%), norovirus (10.95%), EPEC (6%) and rotavirus (5.23%). ETEC and Shigella show a decreasing trend in Latin America & Caribbean but increasing trend in Asia.^ Conclusion. ETEC is the single most common cause of travelers' diarrhea in the world. Potent vaccines against ETEC are required to prevent travelers' diarrhea and thus reduce the attack rate. Also, PCR based studies are required to identify the causes of pathogen negative diarrhea. ^

A review of cataract in stable and conflict zones in Africa

Aim. To review and explore cataract prevalence in stable and unstable countries by examining published and unpublished ocular literature about Africa from 1980 onwards.^ Methods. Searches using OVID, Proquest Dissertations, WHO, and Ebsco Host were done. The review was restricted to articles utilizing WHO definitions of blindness and low vision. Random cluster sampling technique with a minimum sample size of 1,500, and reporting causes of blindness categorized by age and gender were inclusion considerations in the selected articles. ^ Results. Blindness and low vision increased with conflict. Women and the elderly were more likely to have vision impairing cataract. Cataract was the leading cause of blindness; the prevalence range was 22%–81% for the reviewed nations.^ Conclusion. Instability was connected to higher cataract prevalence and worse visual outcome across all characteristics examined except cataract surgical rates. ^

Comparison of hand hygiene evaluations: A literature review

Background. Because our hands are the most common mode of transmission for bacteria causing hospital acquired infections, hand hygiene practices are the most effective method of preventing the spread of these pathogens, limiting the occurrence of healthcare-associated infections and reducing transmission of multi-drug resistant organisms. Yet, compliance rates are below 40% on the average. ^ Objective. This culminating experience project is primarily a literature review on hand hygiene to help determine the barriers to hand hygiene compliance and offer solutions on improving these rates and to build on a hand hygiene evaluation performed during my infection control internship completed at Memorial Hermann Hospital during the fall semester of 2005. ^ Method. A review of peer-reviewed literature using Ovid Medline, Ebsco Medline and PubMed databases using keywords: hand hygiene, hand hygiene compliance, alcohol based handrub, healthcare-associated infections, hospital-acquired infections, and infection control. ^ Results. A total of eight hand hygiene studies are highlighted. At a children's hospital in Seattle, hand hygiene compliance rates increases from 62% to 81% after five periods of interventions. In Thailand, 26 nurses dramatically increased compliance from 6.3% to 81.2% after just 7 months of training. Automated alcohol based handrub dispensers improved compliance rates in Chicago from 36.3% to 70.1%. Using education and increased distribution of alcohol based handrubs increased hand hygiene rates from 59% to 79% for Ebnother, from 54% to 85% for Hussein and from 32% to 63% for Randle. Spartanburg Regional Medical Center increased their rates from 72.5% to 90.3%. A level III NICU achieved 100% compliance after a month long educational campaign but fell back down to its baseline rate of 89% after 3 months. ^ Discussion. The interventions used to promote hand hygiene in the highlighted studies varied from low tech approaches such as printed materials to advanced electronic gadgets that alerted individuals automatically to perform hand hygiene. All approaches were effective and increased compliance rates. Overcoming hand hygiene barriers, receiving and accepting feedback is the key to maintaining consistently high hand hygiene adherence. ^

A systematic review of community-based colorectal cancer screening randomized controlled trials with multi-ethnic groups

Background. The CDC estimates that 40% of adults 50 years of age or older do not receive time-appropriate colorectal cancer screening. Sixty percent of colorectal cancer deaths could be prevented by regular screening of adults 50 years of age and older. Yet, in 2000 only 42.5% of adults age 50 or older in the U.S. had received recommended screening. Disparities by health care, nativity status, socioeconomic status, and race/ethnicity are evident. Disparities in minority, underserved populations prevent us from attaining Goal 2 of Healthy People 2010 to “eliminate health disparities.” This review focuses on community-based screening research among underserved populations that includes multiple ethnic groups for appropriate disparities analysis. There is a gap in the colorectal cancer screening literature describing the effectiveness of community-based randomized controlled trials. ^ Objective. To critically review the literature describing community-based colorectal cancer screening strategies that are randomized controlled trials, and that include multiple racial/ethnic groups. ^ Methods. The review includes a preliminary disparities analysis to assess whether interventions were appropriately targeted in communities to those groups experiencing the greatest health disparities. Review articles are from an original search using Ovid Medline and a cross-matching search in Pubmed, both from January 2001 to June 2009. The Ovid Medline literature review is divided into eight exclusionary stages, seven electronic, and the last stage consisting of final manual review. ^ Results. The final studies (n=15) are categorized into four categories: Patient mailings (n=3), Telephone outreach (n=3), Electronic/multimedia (n=4), and Counseling/community education (n=5). Of 15 studies, 11 (73%) demonstrated that screening rates increased for the intervention group compared to controls, including all studies (100%) from the Patient mailings and Telephone outreach groups, 4 of 5 (80%) Counseling/community education studies, and 1 of 4 (25%) Electronic/multimedia interventions. ^ Conclusions. Patient choice and tailoring education and/or messages to individuals have proven to be two important factors in improving colorectal cancer screening adherence rates. Technological strategies have not been overly successful with underserved populations in community-based trials. Based on limited findings to date, future community-based colorectal cancer screening trials should include diverse populations who are experiencing incidence, survival, mortality and screening disparities. ^

The influence of socioeconomic status on the relationship between diabetes and amputations: A systematic review of the literature

This paper synthesizes the current knowledge available regarding the impact of socioeconomic status on diabetes and amputations. In September 2009, searches in the OVID Medline and PubMed databases were performed using keywords associated with race/ethnicity, educational level, insurance status, veteran status, low income, diabetes, and lower extremity amputation. Articles published between 1996 and the search date were used. The pertinent articles were analyzed, summarized, and synthesized. ^ The majority of the articles agreed that African American, American Indian, and Latino minorities experience significantly higher rates of diabetes-related lower extremity amputation (LEA) when compared to whites. Few articles suggested that the disparity experienced by minorities and others of low SES was due to biology; most articles link it to a combination of lower income, lower educational attainment, uninsured or underinsured status, and a greater prevalence of detrimental health behaviors such as smoking. These, in turn, are linked to decreased knowledge of self-care, delayed health care seeking, delayed diagnoses and treatment, discrimination, and low quality health care. Interventions focused on patient education, established regimens of treatment, foot care, and control of diabetes have been shown to be effective, although none have lowered the rate of diabetes-related LEA to rates found in the general population.^

Systematic review of worksite-based behavior change programs that target metabolic syndrome risk factors

Approximately one-third of US adults have metabolic syndrome, the clustering of cardiovascular risk factors that include hypertension, abdominal adiposity, elevated fasting glucose, low high-density lipoprotein (HDL)-cholesterol and elevated triglyceride levels. While the definition of metabolic syndrome continues to be much debated among leading health research organizations, the fact is that individuals with metabolic syndrome have an increased risk of developing cardiovascular disease and/or type 2 diabetes. A recent report by the Henry J. Kaiser Family Foundation found that the US spent $2.2 trillion (16.2% of the Gross Domestic Product) on healthcare in 2007 and cited that among other factors, chronic diseases, including type 2 diabetes and cardiovascular disease, are large contributors to this growing national expenditure. Bearing a substantial portion of this cost are employers, the leading providers of health insurance. In lieu of this, many employers have begun implementing health promotion efforts to counteract these rising costs. However, evidence-based practices, uniform guidelines and policy do not exist for this setting in regard to the prevention of metabolic syndrome risk factors as defined by the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III). Therefore, the aim of this review was to determine the effects of worksite-based behavior change programs on reducing the risk factors for metabolic syndrome in adults. Using relevant search terms, OVID MEDLINE was used to search the peer-reviewed literature published since 1998, resulting in 23 articles meeting the inclusion criteria for the review. The American Dietetic Association's Evidence Analysis Process was used to abstract data from selected articles, assess the quality of each study, compile the evidence, develop a summarized conclusion, and assign a grade based upon the strength of supporting evidence. The results revealed that participating in a worksite-based behavior change program may be associated in one or more improved metabolic syndrome risk factors. Programs that delivered a higher dose (>22 hours), in a shorter duration (<2 years) using two or more behavior-change strategies were associated with more metabolic risk factors being positively impacted. A Conclusion Grade of III was obtained for the evidence, indicating that studies were of weak design or results were inconclusive due to inadequate sample sizes, bias and lack of generalizability. These results provide some support for the continued use of worksite-based health promotion and further research is needed to determine if multi-strategy, intense behavior change programs targeting multiple risk factors are able to sustain health improvements in the long-term.^

A systematic review of literature to compare the fertility desires among HIV positive women and cancer survivors

Background. Decision-making on reproductive issues is influenced by an interplay of individual, familial, medical, religious and socio-cultural factors. Women with chronic medical illnesses such an HIV infection and cancers are often fraught with decisional conflicts about child-bearing. With increase in the incidence of these illnesses as well as improvement in survival rates, there is a need to pay due attention to the issue of reproductive decision-making. Examining the prevalence and determinants of fertility desires in the two groups in a comparative manner would help bring to light perception of the medical community and the society in general on the two illnesses and the issue of motherhood. ^ Methods. Systematic literature search was undertaken using databases such as MEDLINE (PubMED), MEDLINE (Ovid), PsycInfo and Web of Science. Articles published in English and English language abstracts for foreign articles were included. Studies that explore ‘fertility desires’ as the outcome variable were included. Quantitative studies which have assessed the prevalence of fertility desires as well as qualitative studies which have provided a descriptive understanding of factors governing reproductive desires were included in the review. ^ Results. A total of 34 articles (29 studies examining HIV and 5 studies examining cancer in relation to fertility desires). Variables such as age, stage of illness, support of spouse and family, perception of the medical community and one’s own view of motherhood were key determinants among both groups. ^ Conclusion. There is a need for uniform, systematic research in this field. It is important that health care workers acknowledge these decisional conflicts, include them as part of the medical care of these patients and provide guidance with the right balance of information, practicality and compassion.^

Sexual initiation of U.S. Latino and Colombian high school students: Toward a new theory of adolescent sexuality and implications for sexual health prevention and promotion

The general research question for this dissertation was: do the data on adolescent sexual experiences and sexual initiation support the explicit or implicit adolescent sexuality theories informing the sexual health interventions currently designed for youth? To respond to this inquiry, three different studies were conducted. The first study included a conceptual and historical analysis of the notion of adolescence introduced by Stanley Hall, the development of an alternative model based on a positive view of adolescent sexuality, and the rationale for introducing to adolescent sexual health prevention programs the new definitions of sexual health and the social determinants of health approach. The second one was a quantitative study aimed at surveying not only adolescents' risky sexual behaviors but also sexual experiences associated with desire/pleasure which have been systematically neglected when investigating the sexual and reproductive health of the youth. This study was conducted with a representative sample of the adolescents attending public high schools in the State of Caldas in the Republic of Colombia. The third study was a qualitative analysis of 22 interviews conducted with male and female U.S. Latino adolescents on the reasons for having had or having not had vaginal sex. The more relevant results were: most current adolescent sexual health prevention programs are still framed in a negative approach to adolescent sexuality developed a century ago by Stanley Hall and Sigmund Freud which do not accept the adolescent sexual experience and propose its sublimation. In contrast, the Colombian study indicates that, although there are gender differences, adolescence is for males and females a normal period of sexual initiation not limited to coital activity, in which sexual desire/pleasure is strongly associated with sexual behavior. By the same token, the study about the reasons for having had or not had initiated heterosexual intercourse indicated that curiosity, sexual desire/pleasure, and love are basic motivations for deciding to have vaginal sexual intercourse for the first time and that during adolescence, young women and men reach the cognitive development necessary for taking conscious decisions about their sexual acts. The findings underline the importance of asking pertinent questions about desire/pleasure when studying adolescent sexuality and adopting an evidence-based approach to sexual health interventions.^