Retinal vascular function and cardiovascular risk factors

The current platform of conventional cardiovascular risk assessments tends to forsake the importance of endothelial function - a key biological mechanism by which cardiovascular risk factors exert their propensity for adverse vascular events. Moreover, the presence and severity of endothelial dysfunction in ‘low-risk’ individuals suggests considerable variability in pre-clinical risk that could potentially be detected well before the onset of disease. The aim of the present thesis was to investigate the presence and impact of retinal vascular dysfunction, as a barometer of endothelial function, in otherwise healthy individuals with one or more cardiovascular risk factors, but low to moderate cardiovascular risk. Systemic circulatory influences on retinal vascular function were also evaluated. The principle sections and findings of this work are: 1. Ageing effect on retinal vascular function • In low-risk individuals, there are age differences in retinal vascular function throughout the entire functional response curve for arteries and veins. Gender differences mainly affect the dilatory phase and are only present in young individuals. 2. Retinal vascular function in healthy individuals with a family history of cardiovascular disease • In low-risk individuals with a family history of cardiovascular disease, impairments in microvascular function at the retinal level correlate with established plasma markers for cardiovascular risk. 3. Ethnic differences in retinal vascular function • When compared to age-matched White Europeans, in low-risk middle-aged South Asians, there are impairments in retinal vascular function that correlate with established cardiovascular risk indicators. 4. Systemic circulatory influences on retinalµvascular function • Systemic antioxidant capacity (redox index) and plasma markers for cardiovascular risk (lipids) influence retinal microvascular function at both arterial and venous levels. 5. Retinal vascular function in individuals with obstructive sleep apnoea: a preliminarystudy • Patients with moderate to severe sleep apnoea exhibit attenuated retinal vascular function.

A comparative analysis of school satisfaction and dropout risk of middle school students attending programs for students with emotional handicaps, severe emotional disturbance and general education students attending center schools and satellite schools

This study evaluated school satisfaction as an indicator of dropout risk of students with Emotional Handicaps (EH) and students with Severe Emotional Disturbance (SED). The students attended two different kinds of middle schools in a largely urban school district in South Florida. One hundred eight students in grade 8 (ages 13-16) participated in this study. Participants were administered the National Dropout Prevention Assessment (NDPA). Forty participants with EH and SED attended a special center school. Thirty-one participants with EH and SED attended satellite programs in a regular middle school. Thirty-seven general education participants attended the same regular middle school. Overall school satisfaction scores were generated, as well as three primary factors (school, environment and personal) and 16 subscales (school atmosphere, future income, difficulty level of classwork, teacher relationships, peer relationships, intrinsic interest in classwork, school hours, classwork stress, general attitude towards school, family influence, perceived opportunity for career, future goals, travel distance, leisure time, self-appraisal of performance, and self-esteem).^ Comparison of students with EH and SED revealed that both groups of students were rated at "low risk" of becoming dropouts on the Environmental factor and the Difficulty of Schoolwork subscale. Students with EH were rated at "caution risk" risk on the Travel Distance subscale. Students with SED were rated at "high risk" on this subscale.^ There were no significant differences in school satisfaction and dropout risk between different program delivery models. There were also no significant differences for category of students (EH, SED) by school type (center school, satellite program). All students were rated at "low risk" of dropping out of school.^ There were significant differences between general education students and students with EH and SED attending satellite programs. Students with EH and SED were rated at "caution risk" for dropping out on the Travel Distance and the Leisure Time subscales. Discussion of results, implications for practice and recommendations for further research are included. ^

Social support, risk, and adjustment of immigrant preadolescents

The current study was designed to explore the salience of social support, immigrant status, and risk in middle childhood and early adolescence across two time periods as indicated by measures of school adjustment and well-being. Participants included 691 children of public elementary schools in grades 4 and 6 who were interviewed in 1997 (Time 1) and reinterviewed two years later (Time 2); 539 were U.S.-born, and 152 were foreign-born. ^ Repeated measures multivariate analyses of variance (MANOVA's) were conducted to assess the effects of immigrant status and risk on total support, well-being, and school adjustment from Time 1 to Time 2. Follow-up analyses, including Student-Newman-Keuls post hoc tests, were used to test the significance of the differences among the means of support categories (low and high), immigrant status (U.S. born and non-U.S. born), risk (low and high) and time (time 1 and time 2). ^ Results showed that immigrant participants in the high risk group reported significantly lower levels of support than their peers. Further, children of low risk at Time 2 indicated the highest levels of support. Second, immigrant preadolescents, preadolescents who reported low levels of social support, and preadolescents of the high risk reported lower levels of emotional well-being. There was also an interaction of support by risk by time, indicating that children who are at risk and had low levels of social support reported more emotional problems at Time 1. Finally, preadolescents who are at risk and preadolescents who reported lower levels of support were more likely to show school adaptation problems. Findings from this study highlight the importance of a multivariable approach to the study of support, emotional adjustment, and academic adjustment of immigrant preadolescents. ^

Predictors of safer sex behaviors of midlife and older women

Heterosexual transmission of the human immunodeficiency virus (HIV) in midlife and older women is increasing, yet little is known about the safer sex practices of these women. Identification of HIV risk and protective factors necessitates understanding of the influences of individual, interpersonal, and socio-environmental factors on the sexual behaviors of this understudied, at-risk population. The purpose of this study was to determine the influence of self esteem, sensation seeking, self silencing, sexual assertiveness, and HIV-stigma on the safer sex behaviors of women aged 50 and older. ^ This study was guided by the ecological perspective which emphasizes the multilevel factors affecting health behaviors within individual, interpersonal, and socio-environmental contexts. A community-based, ethnically diverse sample of 572 women aged 50 to 93 (M = 63.6 years, SD = 10.5) completed a 128-item anonymous questionnaire. This study used a cross-sectional, correlational research design. The data were analyzed using Pearson correlation coefficients and multiple regression analysis. ^ Results from the regression analysis with the predictors (i.e., ethnicity, education, self esteem, sensation seeking, self silencing, sexual assertiveness, and HIV stigma) indicated the model significantly predicted safer sex behaviors (p < .001). Self silencing (β = -.115, p < .05) was a significant predictor. The lower the self silencing scores, the higher the safer sex behavior scores. Further exploration of the data revealed that the greater the age of the woman, the more likely she is to engage in safer sex behaviors (β = .173, p < .001). While the data showed this model was statistically significant, its practical significance may be limited due to the low proportion of variance explained by age and self silencing. HIV/AIDS prevention interventions that are socially anchored, age-appropriate, and gender-specific are discussed and recommendations for socially meaningful strategies to reduce the number of new cases of HIV/AIDS in midlife and older women are presented. ^

Comparison of Cardiovascular Disease Risk Factors between Single and Partnered Mothers: Data from the 2006 Health Survey of Adults and Children in Bermuda

Women are a high-risk population for cardiovascular diseases (CVD); however relationships between CVD and subpopulations of mothers are sparse. A secondary data analysis of the 2006 Health Survey of Adults and Children in Bermuda was conducted to compare the prevalence of CVD risk factors in single (n=77) and partnered (n=241) mothers. A higher percentage of single mothers were Black (p25 kg/m2 (p=0.01) and reported high blood pressure (p=0.004) and high cholesterol (0.017). Single mothers were nearly three times (OR=2.66) more likely to experience high blood pressure and two times (OR= 2.22) more likely to have high cholesterol. Single mothers may benefit from nutrition education programs related to lowering CVD risk.

Análise do perfil de encaminhamento da atenção primária para pré-natal de alto risco: desafios para o ensino de competências em saúde materno-infantil

OBJECTIVE: to identify a profile of the main causes of inappropriate referrals from primary care to specialized services, as strategy for the curriculum development of core competencies related to maternal health. METHODS: a cross-sectional study was performed using document analysis of all referrals of pregnant women from primary care to the high-risk pregnancy service, state of Rio Grande do Norte, Brazil. All pregnant women referred from June to December 2014 (n = 771) were included. According to their causes the referrals were categorized as adequate, inadequate or inconclusive. RESULTS: a total of 188 referrals were classified as inadequate (24.4%) and 93 inconclusive (12.1%) totalizing 36.5% of inappropriate referrals. The main causes identified in these inappropriate referrals were: low-risk pregnancy (12.8%), unconfirmed hypertension (12.1%), risk of abortion (8.9%), teenage pregnancy (7.1%) , toxoplasmosis (5.3%), Rh incompatibility (4.6%) and urinary tract infection (4.3%). These data contributed to the formulation of the following products: 1) a continuing education program for health professionals working in primary care, undergraduate students and residents; and 2) development of a virtual platform to support professionals who need to refer patients to high-risk pregnancy service. CONCLUSION: the results of this study are relevant in the current context of education of health professionals, with potential for positively impact not only in the development of skills related to maternal health in undergraduate and graduate education, as well as contributing for improvement of the health care of the population.

Characterization of the Galactic White Dwarf Population in the Next Generation Virgo Cluster Survey

Halo white dwarfs remain one of the least studied stellar populations in the Milky Way because of their faint luminosities. Recent work has uncovered a population of hot white dwarfs which are thought to be remnants of low-mass Population II stars. This thesis uses optical data from the Next Generation Virgo Cluster Survey (NGVS) and ultravoilet data from the GALEX Ultraviolet Virgo Cluster Survey (GUViCS) to select candidates which may belong to this population of recently formed halo white dwarfs. A colour selection was used to separate white dwarfs from QSOs and main-sequence stars. Photometric distances are calculated using model colour-absolute magnitude relations. Proper motions are calculated by using the difference in positions between objects from the Sloan Digital Sky Survey and the NGVS. The proper motions are combined with the calculated photometric distances to calculate tangential velocities, as well as approximate Galactic space velocities. White dwarf candidates are characterized as belonging to either the disk or the halo using a variety of methods, including calculated scale heights (z> 1 kpc), tangential velocities (vt >200 km/s), and their location in (V,U) space. The 20 halo white dwarf candidates which were selected using Galactic space velocities are analyzed, and their colours and temperatures suggest that these objects represent some of the youngest white dwarfs in the Galactic halo.

A novel framework for predicting patients at risk of readmission

Uncertainty in decision-making for patients’ risk of re-admission arises due to non-uniform data and lack of knowledge in health system variables. The knowledge of the impact of risk factors will provide clinicians better decision-making and in reducing the number of patients admitted to the hospital. Traditional approaches are not capable to account for the uncertain nature of risk of hospital re-admissions. More problems arise due to large amount of uncertain information. Patients can be at high, medium or low risk of re-admission, and these strata have ill-defined boundaries. We believe that our model that adapts fuzzy regression method will start a novel approach to handle uncertain data, uncertain relationships between health system variables and the risk of re-admission. Because of nature of ill-defined boundaries of risk bands, this approach does allow the clinicians to target individuals at boundaries. Targeting individuals at boundaries and providing them proper care may provide some ability to move patients from high risk to low risk band. In developing this algorithm, we aimed to help potential users to assess the patients for various risk score thresholds and avoid readmission of high risk patients with proper interventions. A model for predicting patients at high risk of re-admission will enable interventions to be targeted before costs have been incurred and health status have deteriorated. A risk score cut off level would flag patients and result in net savings where intervention costs are much higher per patient. Preventing hospital re-admissions is important for patients, and our algorithm may also impact hospital income.

Common polygenic variation enhances risk prediction for Alzheimer's disease.

The identification of subjects at high risk for Alzheimer’s disease is important for prognosis and early intervention. We investigated the polygenic architecture of Alzheimer’s disease and the accuracy of Alzheimer’s disease prediction models, including and excluding the polygenic component in the model. This study used genotype data from the powerful dataset comprising 17 008 cases and 37 154 controls obtained from the International Genomics of Alzheimer’s Project (IGAP). Polygenic score analysis tested whether the alleles identified to associate with disease in one sample set were significantly enriched in the cases relative to the controls in an independent sample. The disease prediction accuracy was investigated in a subset of the IGAP data, a sample of 3049 cases and 1554 controls (for whom APOE genotype data were available) by means of sensitivity, specificity, area under the receiver operating characteristic curve (AUC) and positive and negative predictive values. We observed significant evidence for a polygenic component enriched in Alzheimer’s disease (P = 4.9 × 10−26). This enrichment remained significant after APOE and other genome-wide associated regions were excluded (P = 3.4 × 10−19). The best prediction accuracy AUC = 78.2% (95% confidence interval 77–80%) was achieved by a logistic regression model with APOE, the polygenic score, sex and age as predictors. In conclusion, Alzheimer’s disease has a significant polygenic component, which has predictive utility for Alzheimer’s disease risk and could be a valuable research tool complementing experimental designs, including preventative clinical trials, stem cell selection and high/low risk clinical studies. In modelling a range of sample disease prevalences, we found that polygenic scores almost doubles case prediction from chance with increased prediction at polygenic extremes.

The effectiveness of community-based interventions to improve maternal and infant health in the Northeast of Brazil

EMOND, Alan et al. The effectiveness of community-based interventions to improve maternal and infant health in the Northeast of Brazil. Revista Panamericana de Salud Pública/ Pan American Journal of Public Health , v.12, n.2, p.101-110, 2002

EULAR Recommendations for Women's Health and the Management of Family Planning, Assisted Reproduction, Pregnancy and Menopause in Patients with Systemic Lupus Erythematosus and/or Antiphospholipid Syndrome

OBJECTIVES: Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). METHODS: Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus. RESULTS: Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease. CONCLUSIONS: Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.

Mémoire de source, propension à halluciner et psychose : identification de marqueurs cognitifs et cliniques chez une population à haut risque génétique

Les déficits cognitifs sont centraux à la psychose et sont observables plusieurs années avant le premier épisode psychotique. L’atteinte de la mémoire épisodique est fréquemment identifiée comme une des plus sévères, tant chez les patients qu’avant l’apparition de la pathologie chez des populations à risque. Chez les patients psychotiques, l’étude neuropsychologique des processus mnésiques a permis de mieux comprendre l’origine de cette atteinte. Une altération des processus de mémoire de source qui permettent d’associer un souvenir à son origine a ainsi été identifiée et a été associée aux symptômes positifs de psychose, principalement aux hallucinations. La mémoire de source de même que la présence de symptômes sous-cliniques n’ont pourtant jamais été investiguées avant l’apparition de la maladie chez une population à haut risque génétique de psychose (HRG). Or, leur étude permettrait de voir si les déficits en mémoire de source de même que le vécu d’expériences hallucinatoires sont associés à l’apparition de la psychose ou s’ils en précèdent l’émergence, constituant alors des indicateurs précoces de pathologie. Afin d’étudier cette question, trois principaux objectifs ont été poursuivis par la présente thèse : 1) caractériser le fonctionnement de la mémoire de source chez une population HRG afin d’observer si une atteinte de ce processus précède l’apparition de la maladie, 2) évaluer si des manifestations sous-cliniques de symptômes psychotiques, soit les expériences hallucinatoires, sont identifiables chez une population à risque et 3) investiguer si un lien est présent entre le fonctionnement en mémoire de source et la symptomatologie sous-clinique chez une population à risque, à l’instar de ce qui est documenté chez les patients. Les résultats de la thèse ont permis de démontrer que les HRG présentent une atteinte de la mémoire de source ciblée à l’attribution du contexte temporel des souvenirs, ainsi que des distorsions mnésiques qui se manifestent par une fragmentation des souvenirs et par une défaillance de la métacognition en mémoire. Il a également été observé que les expériences hallucinatoires sous-cliniques étaient plus fréquentes chez les HRG. Des associations ont été documentées entre certaines distorsions en mémoire et la propension à halluciner. Ces résultats permettent d’identifier de nouveaux indicateurs cliniques et cognitifs du risque de développer une psychose et permettent de soulever des hypothèses liant l’attribution de la source interne-externe de l’information et le développement de la maladie. Les implications empiriques, théoriques, méthodologiques et cliniques de la thèse sont discutées.

The effectiveness of community-based interventions to improve maternal and infant health in the Northeast of Brazil

EMOND, Alan et al. The effectiveness of community-based interventions to improve maternal and infant health in the Northeast of Brazil. Revista Panamericana de Salud Pública/ Pan American Journal of Public Health , v.12, n.2, p.101-110, 2002

Estimating glomerular filtration rate in acute coronary syndromes: Different equations, different mortality risk prediction

AIMS: Renal dysfunction is a powerful predictor of adverse outcomes in patients hospitalized for acute coronary syndrome. Three new glomerular filtration rate (GFR) estimating equations recently emerged, based on serum creatinine (CKD-EPIcreat), serum cystatin C (CKD-EPIcyst) or a combination of both (CKD-EPIcreat/cyst), and they are currently recommended to confirm the presence of renal dysfunction. Our aim was to analyse the predictive value of these new estimated GFR (eGFR) equations regarding mid-term mortality in patients with acute coronary syndrome, and compare them with the traditional Modification of Diet in Renal Disease (MDRD-4) formula. METHODS AND RESULTS: 801 patients admitted for acute coronary syndrome (age 67.3±13.3 years, 68.5% male) and followed for 23.6±9.8 months were included. For each equation, patient risk stratification was performed based on eGFR values: high-risk group (eGFR<60ml/min per 1.73m2) and low-risk group (eGFR⩾60ml/min per 1.73m2). The predictive performances of these equations were compared using area under each receiver operating characteristic curves (AUCs). Overall risk stratification improvement was assessed by the net reclassification improvement index. The incidence of the primary endpoint was 18.1%. The CKD-EPIcyst equation had the highest overall discriminate performance regarding mid-term mortality (AUC 0.782±0.20) and outperformed all other equations (ρ<0.001 in all comparisons). When compared with the MDRD-4 formula, the CKD-EPIcyst equation accurately reclassified a significant percentage of patients into more appropriate risk categories (net reclassification improvement index of 11.9% (p=0.003)). The CKD-EPIcyst equation added prognostic power to the Global Registry of Acute Coronary Events (GRACE) score in the prediction of mid-term mortality. CONCLUSION: The CKD-EPIcyst equation provides a novel and improved method for assessing the mid-term mortality risk in patients admitted for acute coronary syndrome, outperforming the most widely used formula (MDRD-4), and improving the predictive value of the GRACE score. These results reinforce the added value of cystatin C as a risk marker in these patients.

Prevalencia de genotipos del papiloma virus humano en mujeres de la provincia del Azuay, Ecuador

Los principales objetivos de la investigación fueron detectar en función con la edad, la prevalencia de los genotipos de alto y bajo riesgo oncogénico de virus del papiloma humano (VPH) en muestras cervicales de las mujeres en los catorce cantones de la provincia de Azuay. El proyecto abarcó el diagnóstico histopatológico de las lesiones cervicales intraepiteliales y la relación de los genotipos encontrados, con los factores de riesgo y las vacunas existentes que se utilizan como medida de prevención de cáncer de cuello uterino. Fueron examinadas muestras de frotis cervicales de una población aleatoria de 500 mujeres con la prueba de Papanicolaou (Pap), usando la reacción en cadena de la polimerasa en tiempo real (PCR). El estudio reveló una prevalencia de VPH de 25.6%; 4.8% genotipos oncogénicos de bajo riesgo y el 20.8% genotipos oncogénicos de alto riesgo respectivamente, y sólo en el grupo de edad de 20 a 29 años, una significativa prevalencia mayor de los genotipos de alto riesgo 31 y 66 (p<0.05). Las células escamosas atípicas de significado indeterminado (ASCUS) representan el 7% y la lesión intraepitelial escamosas de bajo grado (LIEBG) 1.8%. Por otra parte no se identificaron lesiones escamosas intraepiteliales de alto grado. De la población encuestada 2.8% de las mujeres poseen genotipos virales que son tratables por las vacunas distribuidas por el Ministerio de Salud Pública (MSP).