Prevalence of chlamydial and gonococcal infections among young adults in the United States

Context  Chlamydial and gonococcal infections are important causes of pelvic inflammatory disease, ectopic pregnancy, and infertility. Although screening for Chlamydia trachomatis is widely recommended among young adult women, little information is available regarding the prevalence of chlamydial and gonococcal infections in the general young adult population. Objective  To determine the prevalence of chlamydial and gonoccoccal infections in a nationally representative sample of young adults living in the United States. Design, Setting, and Participants  Cross-sectional analyses of a prospective cohort study of a nationally representative sample of 14 322 young adults aged 18 to 26 years. In-home interviews were conducted across the United States for Wave III of The National Longitudinal Study of Adolescent Health (Add Health) from April 2, 2001, to May 9, 2002. This study sample represented 66.3% of the original 18 924 participants in Wave I of Add Health. First-void urine specimens using ligase chain reaction assay were available for 12 548 (87.6%) of the Wave III participants. Main Outcome Measures  Prevalences of chlamydial and gonococcal infections in the general young adult population, and by age, self-reported race/ethnicity, and geographic region of current residence. Results  Overall prevalence of chlamydial infection was 4.19% (95% confidence interval [CI], 3.48%-4.90%). Women (4.74%; 95% CI, 3.93%-5.71%) were more likely to be infected than men (3.67%; 95% CI, 2.93%-4.58%; prevalence ratio, 1.29; 95% CI, 1.03-1.63). The prevalence of chlamydial infection was highest among black women (13.95%; 95% CI, 11.25%-17.18%) and black men (11.12%; 95% CI, 8.51%-14.42%); lowest prevalences were among Asian men (1.14%; 95% CI, 0.40%-3.21%), white men (1.38%; 95% CI, 0.93%-2.03%), and white women (2.52%; 95% CI, 1.90%-3.34%). Prevalence of chlamydial infection was highest in the south (5.39%; 95% CI, 4.24%-6.83%) and lowest in the northeast (2.39%; 95% CI, 1.56%-3.65%). Overall prevalence of gonorrhea was 0.43% (95% CI, 0.29%-0.63%). Among black men and women, the prevalence was 2.13% (95% CI, 1.46%-3.10%) and among white young adults, 0.10% (95% CI, 0.03%-0.27%). Prevalence of coinfection with both chlamydial and gonococcal infections was 0.030% (95% CI, 0.18%-0.49%). Conclusions  The prevalence of chlamydial infection is high among young adults in the United States. Substantial racial/ethnic disparities are present in the prevalence of both chlamydial and gonococcal infections.      

Untreated gonococcal and chlamydial infection in a probability sample of adults

Context  The prevalence and distribution of gonococcal and chlamydial infections in the general population are poorly understood. Development of nucleic acid amplification tests, such as the ligase chain reaction assay, provides new opportunities to estimate the prevalence of untreated infections in the population. Objective  To estimate the overall prevalence of untreated gonococcal and chlamydial infections and to describe patterns of infection within specific demographic subgroups of the young adult population in Baltimore, Md. Design and Setting  Cross-sectional behavioral survey based on a probability sample of Baltimore households with collection of urine specimens between January 1997 and September 1998. Participants  A total of 728 adults aged 18 to 35 years completed the interview portion of the study, and 579 of these respondents also provided a urine specimen adequate for testing. Main Outcome Measure  Prevalence of untreated infection, as measured by the percentage of specimens testing positive for gonococcal and chlamydial infection by ligase chain reaction, weighted to reflect variations in probabilities of sample selection from the population. Alternate estimates of the prevalence of recent treated infection were derived from clinically diagnosed cases reported to the Baltimore City Health Department and by diagnoses reported by participants in the survey. Results  An estimated 5.3% (SE, 1.4%) of the population aged 18 to 35 years has an untreated gonococcal infection, and 3.0% (SE, 0.8%) is estimated to have an untreated chlamydial infection. While 7.9% (SE, 1.6%) of the population is estimated to have either an untreated gonococcal or chlamydial infection, estimated prevalence is substantially higher among black women (15.0%; SE, 3.7%). Few participants with untreated infections reported dysuria or discharge during the 6 months preceding testing. The estimated number of untreated gonococcal infections in the population (9241; SE, 2441) substantially exceeds both the number of such infections diagnosed among Baltimore adults aged 18 to 35 years and reported to the Baltimore City Health Department during 1998 (4566), and the estimated number of diagnoses derived using participants' reports for the 12 months prior to the survey (4708 [SE, 1918] to 5231 [SE, 2092]). The estimated number of untreated chlamydial infections (5231; SE, 1395) is also greater than the number of cases reported to the health department in 1998 (3664) but is slightly less than the estimated number of diagnoses derived using participants' reports of chlamydial infections diagnosed during the 12 months prior to the survey (5580 [SE, 1918] to 6975 [SE, 2441]). Conclusion  In 1997-1998, the estimated number of undiagnosed gonococcal and chlamydial infections prevalent in the population of Baltimore adults aged 18 to 35 years approached or exceeded the number of infections that were diagnosed and treated annually.      

Effect of nonoxynol-9 gel on urogenital gonorrhea and chlamydial infection: a randomized controlled trial

Context  Nonoxynol-9 has been suggested as a vaginal microbicide to protect against common sexually transmitted infections. Objective  To compare nonoxynol-9 gel and condom use (gel group) vs condom use alone (condom group) for the prevention of male-to-female transmission of urogenital gonococcal and chlamydial infection. Design and Setting  Randomized controlled trial conducted at 10 community clinics and 10 pharmacies in Yaoundé, Cameroon, between October 1998 and September 2000, with 6 months of follow-up. Participants  High-risk population of 1251 women (excluding sex workers) being treated for or who had symptoms of sexually transmitted infections. Three were excluded from the gel group (0.5%) and 7 from the condom group (1%) because of no follow-up data. Interventions  Nonoxynol-9 gel (100 mg) and condoms or condoms only. Main Outcome Measure  A positive test result for gonococcal or chlamydial infection by the ligase chain reaction assay; secondary outcome measure was a positive test result for human immunodeficiency virus (HIV). Results  The rate ratio (RR) for new urogenital infections was 1.2 for the gel group vs condom group (95% confidence interval [CI], 0.9-1.6; P = .21). The gel group had 116 diagnosed gonococcal infections, chlamydial infections, or both for a rate of 43.6 per 100 person-years, and the condom group had 100 infections for a rate of 36.6 per 100 person-years. The RR for gonococcal infection in the gel group vs the condom group was 1.5 (95% CI, 1.0-2.3) and for chlamydial infection was 1.0 (95% CI, 0.7-1.4). There were 5 new cases of HIV infections in the gel group and 4 in the condom group. Three women in each group became pregnant during the study. Conclusion  Nonoxynol-9 gel did not protect against urogenital gonococcal or chlamydial infection.      

Feasibility of eliminating ocular Chlamydia trachomatis with repeat mass antibiotic treatments

Context  Mass antibiotic administrations for ocular chlamydial infection play a key role in the World Health Organization's trachoma control program. Mathematical models suggest that it is possible to eliminate trachoma locally with repeat mass treatment, depending on the coverage level of the population, frequency of mass treatments, and rate that infection returns into a community after each mass treatment. Precise estimates of this latter parameter have never been reported. Objective  To determine the rate at which chlamydial infection returns to a population after mass treatment and to estimate the treatment frequency required for elimination of ocular chlamydia from a community. Design, Setting, and Participants  Longitudinal cohort study of 24 randomly selected villages from the Gurage Zone in Ethiopia conducted February 2003 to October 2003. A total of 1332 children aged 1 to 5 years were monitored for prevalence of ocular chlamydial infection pretreatment and 2 and 6 months posttreatment. Interventions  All individuals older than 1 year were eligible for single-dose oral azithromycin treatment. Pregnant women were offered tetracycline eye ointment. Main Outcome Measures  Prevalence of ocular chlamydial infection, measured by polymerase chain reaction, in children aged 1 to 5 years, in each of 24 villages at each time point was used to estimate the rate of return of infection and the treatment frequency necessary for elimination. Results  The prevalence of infection was 56.3% pretreatment (95% confidence interval [CI], 47.5%-65.1%), 6.7% 2 months posttreatment (95% CI, 4.2%-9.2%), and 11.0% 6 months posttreatment (95% CI, 7.3%-14.7%). Infection returned after treatment at an exponential rate of 12.3% per month (95% CI, 4.6%-19.9% per month). The minimum treatment frequency necessary for elimination was calculated to be once every 11.6 months (95% CI, 7.2-30.9 months), given a coverage level of 80%. Thus, biannual treatment, already being performed in some areas, was estimated to be more than frequent enough to eventually eliminate infection. Conclusion  The rate at which ocular chlamydial infection returns to a community after mass treatment suggests that elimination of infection in a hyperendemic area is feasible with biannual mass antibiotic administrations and attainable coverage levels.      

Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials

Context  Aspirin therapy reduces the risk of cardiovascular disease in adults who are at increased risk. However, it is unclear if women derive the same benefit as men. Objective  To determine if the benefits and risks of aspirin treatment in the primary prevention of cardiovascular disease vary by sex. Data Sources and Study Selection  MEDLINE and the Cochrane Central Register of Controlled Trials databases (1966 to March 2005), bibliographies of retrieved trials, and reports presented at major scientific meetings. Eligible studies were prospective, randomized controlled trials of aspirin therapy in participants without cardiovascular disease that reported data on myocardial infarction (MI), stroke, and cardiovascular mortality. Six trials with a total of 95 456 individuals were identified; 3 trials included only men, 1 included only women, and 2 included both sexes. Data Extraction  Studies were reviewed to determine the number of patients randomized, mean duration of follow-up, and end points (a composite of cardiovascular events [nonfatal MI, nonfatal stroke, and cardiovascular mortality], each of these individual components separately, and major bleeding). Data Synthesis  Among 51 342 women, there were 1285 major cardiovascular events: 625 strokes, 469 MIs, and 364 cardiovascular deaths. Aspirin therapy was associated with a significant 12% reduction in cardiovascular events (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.79-0.99; P = .03) and a 17% reduction in stroke (OR, 0.83; 95% CI, 0.70-0.97; P = .02), which was a reflection of reduced rates of ischemic stroke (OR, 0.76; 95% CI, 0.63-0.93; P = .008). There was no significant effect on MI or cardiovascular mortality. Among 44 114 men, there were 2047 major cardiovascular events: 597 strokes, 1023 MIs, and 776 cardiovascular deaths. Aspirin therapy was associated with a significant 14% reduction in cardiovascular events (OR, 0.86; 95% CI, 0.78-0.94; P = .01) and a 32% reduction in MI (OR, 0.68; 95% CI, 0.54-0.86; P = .001). There was no significant effect on stroke or cardiovascular mortality. Aspirin treatment increased the risk of bleeding in women (OR, 1.68; 95% CI, 1.13-2.52; P = .01) and in men (OR, 1.72; 95% CI, 1.35-2.20; P<.001). Conclusions  For women and men, aspirin therapy reduced the risk of a composite of cardiovascular events due to its effect on reducing the risk of ischemic stroke in women and MI in men. Aspirin significantly increased the risk of bleeding to a similar degree among women and men.      

Risk factors for parvovirus B19 infection in pregnancy

Context  Parvovirus B19 infection during pregnancy has been associated with fetal death. However, the incidence of and risk factors for infection in pregnant women have not been well studied. Objectives  To estimate a pregnant woman's risk of infection with parvovirus B19 in epidemic and endemic situations and to study risk factors for infection. Design  Population-based cohort study conducted between November 1992 and June 1994. Setting  Three regions in Denmark. Participants  A total of 30,946 pregnant women from a consecutive and population-based screening. Main Outcome Measures  Specific IgG antibodies in serum samples obtained in the first trimester of pregnancy and from the newborn infant to assess past infection and seroconversion. Information on family structure, educational background, socioeconomic status, and pregnancy outcome was obtained from national registers. Results  Based on 30,946 serum samples, 65.0% of pregnant women had evidence of past infection. Annual seroconversion rates among susceptible women during endemic and epidemic periods were 1.5% (95% confidence interval [CI], 0.2%-1.9%) and 13.0% (95% CI, 8.7%-23.1%), respectively. Baseline seropositivity was significantly correlated with increasing number of siblings, having a sibling of the same age, number of own children, and occupational exposure to children. Risk of acute infection increased with the number of children in the household as follows: 0 children odds ratio (OR), 1 (reference); 1 child OR, 3.17 (95% CI, 2.24-4.49); 2 children OR, 5.47 (95% CI, 3.55-8.45); 3 or more children OR, 7.54 (95% CI, 3.80-14.94). Having children aged 6 to 7 years resulted in the highest rate of seroconversion among mothers (6.8%; OR, 4.07; 95% CI, 1.89-8.73). Compared with other pregnant women, nursery school teachers had a 3-fold increased risk of acute infection (OR, 3.09; 95% CI, 1.62-5.89). Population-attributable risk of seroconversion was 55.4% for number of own children and 6.0% for occupational exposure. Conclusions  The risk of infection is high for susceptible pregnant women during epidemics and associated with the level of contact with children. Nursery school teachers have the highest occupational risk, but most infections seem to be the result of exposure to the woman's own children.      

Women's susceptibility to tobacco carcinogens and survival after diagnosis of lung cancer

Context  It has been hypothesized that women are more susceptible to tobacco carcinogens than men, but after diagnosis of lung cancer, they have better survival rates than men. Objective  To add to the evidence on the lung cancer risk of women who smoke and their survival after diagnosis of lung cancer, conditional on other prognostic indicators and compared with men of the same age who smoke. Design, Setting, and Participants  Nonexperimental, etiologic study with prospective collection of data based on baseline computed tomographic screening for lung cancer and follow-up of diagnosed cases of lung cancer in North America in 1993-2005. A total of 7498 women and 9427 men were screened, all of whom were asymptomatic, aged at least 40 years, and had a history of cigarette smoking. Main Outcome Measures  Comparing women with men, the prevalence odds ratio (OR) for screen-detectable lung cancer (conditional on age and smoking history) and the hazard ratio of fatal outcome of lung cancer (conditional on smoking history, disease stage, tumor cell type, and resection). Results  Lung cancer was diagnosed in 156 women and 113 men (rates of 2.1% and 1.2%, respectively).The prevalence OR comparing women with men was 1.9 (95% confidence interval [CI], 1.5-2.5). The hazard ratio of fatal outcome of lung cancer comparing women with men was 0.48 (95% CI, 0.25-0.89). Conclusion  Women appear to have increased susceptibility to tobacco carcinogens but have a lower rate of fatal outcome of lung cancer compared with men.      

Blood lead,blood pressure,and hypertension in perimenopausal and postmenopausal women

Context  Lead exposures have been shown to be associated with increased blood pressure and risk of hypertension in older men. In perimenopausal women, skeletal lead stores are an important source of endogenous lead exposure due to increased bone demineralization. Objective  To examine the relationship of blood lead level with blood pressure and hypertension prevalence in a population-based sample of perimenopausal and postmenopausal women in the United States. Design, Setting, and Participants  Cross-sectional sample of 2165 women aged 40 to 59 years, who participated in a household interview and physical examination, from the Third National Health and Nutrition Examination Survey conducted from 1988 to 1994. Main Outcome Measures  Associations of blood lead with blood pressure and hypertension, with age, race and ethnicity, cigarette smoking status, body mass index, alcohol use, and kidney function as covariates. Results  A change in blood lead levels from the lowest (quartile 1: range, 0.5-1.6 µg/dL) to the highest (quartile 4: range, 4.0-31.1 µg/dL) was associated with small statistically significant adjusted changes in systolic and diastolic blood pressures. Women in quartile 4 had increased risks of diastolic (>90 mm Hg) hypertension (adjusted odds ratio [OR], 3.4; 95% confidence interval [CI], 1.3-8.7), as well as moderately increased risks for general hypertension (adjusted OR, 1.4; 95% CI, 0.92-2.0) and systolic (>140 mm Hg) hypertension (adjusted OR, 1.5; 95% CI, 0.72-3.2). This association was strongest in postmenopausal women, in whom adjusted ORs for diastolic hypertension increased with increasing quartile of blood lead level compared with quartile 1 (adjusted OR, 4.6; 95% CI, 1.1-19.2 for quartile 2; adjusted OR, 5.9; 95% CI, 1.5-23.1 for quartile 3; adjusted OR, 8.1; 95% CI, 2.6-24.7 for quartile 4). Conclusions  At levels well below the current US occupational exposure limit guidelines (40 µg/dL), blood lead level is positively associated with both systolic and diastolic blood pressure and risks of both systolic and diastolic hypertension among women aged 40 to 59 years. The relationship between blood lead level and systolic and diastolic hypertension is most pronounced in postmenopausal women. These results provide support for continued efforts to reduce lead levels in the general population, especially women.      

Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction: a meta-analysis

Michelle O’Donoghue, MD; William E. Boden, MD; Eugene Braunwald, MD; Christopher P. Cannon, MD; Tim C. Clayton, MSc; Robbert J. de Winter, MD, PhD; Keith A. A. Fox, MB, ChB; Bo Lagerqvist, MD, PhD; Peter A. McCullough, MD, MPH; Sabina A. Murphy, MPH; Rudolf Spacek, MD, PhD; Eva Swahn, MD, PhD; Lars Wallentin, MD, PhD; Fons Windhausen, MD; Marc S. Sabatine, MD, MPH

JAMA. 2008;300(1):71-80.

Context  Although an invasive strategy is frequently used in patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS), data from some trials suggest that this strategy may not benefit women.

Objective  To conduct a meta-analysis of randomized trials to compare the effects of an invasive vs conservative strategy in women and men with NSTE ACS.

Data Sources  Trials were identified through a computerized literature search of the MEDLINE and Cochrane databases (1970-April 2008) using the search terms invasive strategy, conservative strategy, selective invasive strategy, acute coronary syndromes, non-ST-elevation myocardial infarction, and unstable angina.

Study Selection  Randomized clinical trials comparing an invasive vs conservative treatment strategy in patients with NSTE ACS.

Data Extraction  The principal investigators for each trial provided the sex-specific incidences of death, myocardial infarction (MI), and rehospitalization with ACS through 12 months of follow-up.

Data Synthesis  Data were combined across 8 trials (3075 women and 7075 men). The odds ratio (OR) for the composite of death, MI, or ACS for invasive vs conservative strategy in women was 0.81 (95% confidence interval [CI], 0.65-1.01; 21.1% vs 25.0%) and in men was 0.73 (95% CI, 0.55-0.98; 21.2% vs 26.3%) without significant heterogeneity between sexes (P for interaction = .26). Among biomarker-positive women, an invasive strategy was associated with a 33% lower odds of death, MI, or ACS (OR, 0.67; 95% CI, 0.50-0.88) and a nonsignificant 23% lower odds of death or MI (OR, 0.77; 95% CI, 0.47-1.25). In contrast, an invasive strategy was not associated with a significant reduction in the triple composite end point in biomarker-negative women (OR, 0.94; 95% CI, 0.61-1.44; P for interaction = .36) and was associated with a nonsignificant 35% higher odds of death or MI (OR, 1.35; 95% CI, 0.78-2.35; P for interaction = .08). Among men, the OR for death, MI, or ACS was 0.56 (95% CI, 0.46-0.67) if biomarker-positive and 0.72 (95% CI, 0.51-1.01) if biomarker-negative (P for interaction = .09).

Conclusions  In NSTE ACS, an invasive strategy has a comparable benefit in men and high-risk women for reducing the composite end point of death, MI, or rehospitalization with ACS. In contrast, our data provide evidence supporting the new guideline recommendation for a conservative strategy in low-risk women.

     

HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women

Context  Sex trafficking of girls and women is widespread across South Asia and is recognized as both a violent gender-based crime and major human rights violation. Inadequate empirical data exist to characterize this phenomenon and its related health consequences, such as human immunodeficiency virus (HIV) infection. Objective  To determine the prevalence of HIV infection among repatriated sex-trafficked Nepalese girls and women and to identify trafficking-related predictors of such infection. Design  Medical and case records of 287 repatriated girls and women reporting being trafficked from Nepal for sexual exploitation and receiving rehabilitative services between January 1997 and December 2005 at a major nongovernmental organization were systematically reviewed in January 2006. Setting  Major Nepalese nongovernmental organization providing shelter and care to repatriated survivors of sex trafficking. Main Outcome Measures  Prevalence of and risk for HIV based on demographic characteristics and on trafficking- and prostitution-related experiences. Results  Among 287 repatriated Nepalese sex-trafficked girls and women, 109 (38.0%) tested positive for HIV. Among those with complete documentation of trafficking experiences (n = 225), median age at time of trafficking was 17.0 years, with 33 (14.7%) trafficked prior to age 15 years. Compared with those trafficked at 18 years or older, girls trafficked prior to age 15 years were at increased risk for HIV (adjusted odds ratio [AOR], 3.70; 95% confidence interval [CI], 1.32-10.34), with 20 of 33 (60.6%) infected among this youngest age group. Additional factors associated with HIV positivity included being trafficked to Mumbai (AOR, 4.85; 95% CI, 2.16-10.89) and longer duration of forced prostitution (AOR, 1.02; 95% CI, 1.01-1.03; indicating increased risk per additional month of brothel servitude). In post hoc analyses, girls trafficked prior to age 15 years had increased odds of having been detained in multiple brothels (odds ratio [OR], 5.03; 95% CI, 1.96-12.93) and in brothels for a duration of 1 year or more (OR, 2.67; 95% CI, 1.12-6.33) vs those trafficked at 18 years or older. Conclusions  In this study, repatriated Nepalese sex-trafficked girls and women were found to have a high prevalence of HIV infection, with increased risk among those trafficked prior to age 15 years. Present findings demonstrate the need for greater attention to reducing and intervening in sex trafficking in South Asia, particularly among the very young.      

Prevalence of HPV infection among females in the United States

Context  Human papillomavirus (HPV) infection is estimated to be the most common sexually transmitted infection. Baseline population prevalence data for HPV infection in the United States before widespread availability of a prophylactic HPV vaccine would be useful. Objective  To determine the prevalence of HPV among females in the United States. Design, Setting, and Participants  The National Health and Nutrition Examination Survey (NHANES) uses a representative sample of the US noninstitutionalized civilian population. Females aged 14 to 59 years who were interviewed at home for NHANES 2003-2004 were examined in a mobile examination center and provided a self-collected vaginal swab specimen. Swabs were analyzed for HPV DNA by L1 consensus polymerase chain reaction followed by type-specific hybridization. Demographic and sexual behavior information was obtained from all participants. Main Outcome Measures  HPV prevalence by polymerase chain reaction. Results  The overall HPV prevalence was 26.8% (95% confidence interval [CI], 23.3%-30.9%) among US females aged 14 to 59 years (n = 1921). HPV prevalence was 24.5% (95% CI, 19.6%-30.5%) among females aged 14 to 19 years, 44.8% (95% CI, 36.3%-55.3%) among women aged 20 to 24 years, 27.4% (95% CI, 21.9%-34.2%) among women aged 25 to 29 years, 27.5% (95% CI, 20.8%-36.4%) among women aged 30 to 39 years, 25.2% (95% CI, 19.7%-32.2%) among women aged 40 to 49 years, and 19.6% (95% CI, 14.3%-26.8%) among women aged 50 to 59 years. There was a statistically significant trend for increasing HPV prevalence with each year of age from 14 to 24 years (P<.001), followed by a gradual decline in prevalence through 59 years (P = .06). HPV vaccine types 6 and 11 (low-risk types) and 16 and 18 (high-risk types) were detected in 3.4% of female participants; HPV-6 was detected in 1.3% (95% CI, 0.8%-2.3%), HPV-11 in 0.1% (95% CI, 0.03%-0.3%), HPV-16 in 1.5% (95% CI, 0.9%-2.6%), and HPV-18 in 0.8% (95% CI, 0.4%-1.5%) of female participants. Independent risk factors for HPV detection were age, marital status, and increasing numbers of lifetime and recent sex partners. Conclusions  HPV is common among females in the United States. Our data indicate that the burden of prevalent HPV infection among females was greater than previous estimates and was highest among those aged 20 to 24 years. However, the prevalence of HPV vaccine types was relatively low.      

Gender disparities in the receipt of home care for elderly people with disability in the United States

Context  Projected demographic shifts in the US population over the next 50 years will cause families, health care practitioners, and policymakers to confront a marked increase in the number of people with disabilities living in the community. Concerns about the adequacy of community support are particularly salient to women, who make up a disproportionate number of disabled elderly people and who may be particularly vulnerable because they are more likely to live alone with limited financial resources. Objective  To address gender differences in receipt of informal and formal home care. Design, Setting, and Participants  Nationally representative survey conducted in 1993 among 7443 noninstitutionalized people (4538 women and 2905 men) aged 70 years or older. Main Outcome Measure  Number of hours per week of informal (generally unpaid) and formal (generally paid) home care received by survey participants who reported any activity of daily living (ADL) or instrumental activity of daily living (IADL) impairment (n = 3109) compared by gender and living arrangement and controlling for other factors. Results  Compared with disabled men, disabled women were much more likely to be living alone (45.4% vs 16.8%, P<.001) and much less likely to be living with a spouse (27.8% vs 73.6%, P<.001). Overall, women received fewer hours of informal care per week than men (15.7 hours; 95% confidence interval [CI], 14.5-16.9 vs 21.2 hours; 95% CI, 19.7-22.8). Married disabled women received many fewer hours per week of informal home care than married disabled men (14.8 hours; 95% CI, 13.7-15.8 vs 26.2 hours; 95% CI, 24.6-27.9). Children (>80% women) were the dominant caregivers for disabled women while wives were the dominant caregivers of disabled men. Gender differences in formal home care were small (2.8 hours for women; 95% CI, 2.5-3.1 vs 2.1 hours for men; 95% CI, 1.7-2.4). Conclusion  Large gender disparities appear to exist in the receipt of informal home care for disabled elderly people in the United States, even within married households. Programs providing home care support for disabled elderly people need to consider these large gender disparities and the burden they impose on families when developing intervention strategies in the community.      

Obesity, weight gain, and the risk of kidney stones

Context  Larger body size may result in increased urinary excretion of calcium, oxalate, and uric acid, thereby increasing the risk for calcium-containing kidney stones. It is unclear if obesity increases the risk of stone formation, and it is not known if weight gain influences risk. Objective  To determine if weight, weight gain, body mass index (BMI), and waist circumference are associated with kidney stone formation. Design, Setting, and Participants  A prospective study of 3 large cohorts: the Health Professionals Follow-up Study (N = 45 988 men; age range at baseline, 40-75 years), the Nurses’ Health Study I (N = 93 758 older women; age range at baseline, 34-59 years), and the Nurses’ Health Study II (N = 101 877 younger women; age range at baseline, 27-44 years). Main Outcome Measures  Incidence of symptomatic kidney stones. Results  We documented 4827 incident kidney stones over a combined 46 years of follow-up. After adjusting for age, dietary factors, fluid intake, and thiazide use, the relative risk (RR) for stone formation in men weighing more than 220 lb (100.0 kg) vs men less than 150 lb (68.2 kg) was 1.44 (95% confidence interval [CI], 1.11-1.86; P = .002 for trend). In older and younger women, RRs for these weight categories were 1.89 (95% CI, 1.52-2.36; P<.001 for trend) and 1.92 (95% CI, 1.59-2.31; P<.001 for trend), respectively. The RR in men who gained more than 35 lb (15.9 kg) since age 21 years vs men whose weight did not change was 1.39 (95% CI, 1.14-1.70; P = .001 for trend). Corresponding RRs for the same categories of weight gain since age 18 years in older and younger women were 1.70 (95% CI, 1.40-2.05; P<.001 for trend) and 1.82 (95% CI, 1.50-2.21; P<.001 for trend). Body mass index was associated with the risk of kidney stone formation: the RR for men with a BMI of 30 or greater vs those with a BMI of 21 to 22.9 was 1.33 (95% CI, 1.08-1.63; P<.001 for trend). Corresponding RRs for the same categories of BMI in older and younger women were 1.90 (95% CI, 1.61-2.25; P<.001 for trend) and 2.09 (95% CI, 1.77-2.48; P<.001 for trend). Waist circumference was also positively associated with risk in men (P = .002 for trend) and in older and younger women (P<.001 for trend for both). Conclusions  Obesity and weight gain increase the risk of kidney stone formation. The magnitude of the increased risk may be greater in women than in men.      

Risk of subsequent fracture after low-trauma fracture in men and women

Context  There are few published long-term data on absolute risk of subsequent fracture (refracture) following initial low-trauma fracture in women and fewer in men. Objective  To examine long-term risk of subsequent fracture following initial osteoporotic fracture in men and women. Design, Setting, and Participants  Prospective cohort study (Dubbo Osteoporosis Epidemiology Study) in Australia of 2245 community-dwelling women and 1760 men aged 60 years or older followed up for 16 years from July 1989 through April 2005. Main Outcome Measure  Incidence of first (initial) fracture and incidence of subsequent fracture according to sex, age group, and time since first fracture. Relative risk was determined by comparing risk of subsequent fracture with risk of initial fracture. Results  There were 905 women and 337 men with an initial fracture, of whom 253 women and 71 men experienced a subsequent fracture. Relative risk (RR) of subsequent fracture in women was 1.95 (95% confidence interval [CI], 1.70-2.25) and in men was 3.47 (95% CI, 2.68-4.48). As a result, absolute risk of subsequent fracture was similar in women and men and at least as great as the initial fracture risk for a woman 10 years older. Thus, women and men aged 60 to 69 years had absolute refracture rates of 36/1000 person-years (95% CI, 26-48/1000) and 37/1000 person-years (95% CI, 23-59/1000), respectively. The increase in absolute fracture risk remained for up to 10 years, by which time 40% to 60% of surviving women and men experienced a subsequent fracture. All fracture locations apart from rib (men) and ankle (women) resulted in increased subsequent fracture risk, with highest RRs following hip (RR, 9.97; 95% CI, 1.38-71.98) and clinical vertebral (RR, 15.12; 95% CI, 6.06-37.69) fractures in younger men. In multivariate analyses, femoral neck bone mineral density, age, and smoking were predictors of subsequent fracture in women and femoral neck bone mineral density, physical activity, and calcium intake were predictors in men. Conclusion  After an initial low-trauma fracture, absolute risk of subsequent fracture was similar for men and women. This increased risk occurred for virtually all clinical fractures and persisted for up to 10 years.      

Drug-resistant tuberculosis, clinical virulence, and the dominance of the Beijing strain family in Russia

Context  Tuberculosis and multidrug-resistant tuberculosis is a serious public health problem in Russia. Objective  To address the extent of "Beijing strain" transmission in the prison/civil sectors and the association of drug resistance, clinical, and social factors with the Beijing genotype. Design and Setting  Cross-sectional population-based molecular epidemiological study of all civilian and penitentiary tuberculosis facilities in the Samara region, Russia. Patients  Consecutively recruited patients with bacteriologically proven tuberculosis (n = 880). Main Outcome Measure  Proportion of Beijing strains and association with drug resistance, human immunodeficiency virus infection, imprisonment, radiological, clinical, and other social factors. Results  Beijing-family strains (identified by spoligotyping and composed of 2 main types by mycobacterial interspersed repetitive unit analysis) were predominant: 586/880 (66.6%; 95% confidence interval [CI], 63.4%-69.7%) with a significantly higher prevalence in the prison population (rate ratio [RR], 1.3; 95% CI, 1.2-1.5) and those aged younger than 35 years (RR, 1.2; 95% CI, 1.0-1.3). Comparable proportions were co-infected with the human immunodeficiency virus (10%), concurrent hepatitis B and C (21.6%), drank alcohol (90%), smoked (90%), and had a similar sexual history. Drug resistance was nearly 2-fold higher in patients infected with Beijing strains compared with non-Beijing strains: multidrug resistance (RR, 2.4; 95% CI, 1.9-3.0), for isoniazid (RR, 1.8; 95% CI, 1.5-2.1), for rifampicin (RR, 2.2; 95% CI, 1.7-2.7), for streptomycin (RR, 1.9; 95% CI, 1.5-2.3), and for ethambutol (RR, 2.2; 95% CI, 1.6-3.2). Univariate analysis demonstrated that male sex (odds ratio [OR], 1.5; 95% CI, 1.1-1.9), advanced radiological abnormalities (OR, 3.3; 95% CI, 1.3-8.4), homelessness (OR, 5.6; 95% CI, 1.1-6.3), and previous imprisonment (OR, 2.0; 95% CI, 1.5-2.7) were strongly associated with Beijing-strain family disease. Multivariate analysis supported previous imprisonment to be a risk factor (OR, 2.0; 95% CI, 1.4-3.3) and night sweats to be less associated (OR 0.7; 95% CI, 0.5-1.0) with Beijing-strain disease. Conclusions  Drug resistance and previous imprisonment but not human immunodeficiency virus co-infection were significantly associated with Beijing-strain infection. There was evidence that Beijing isolates caused radiologically more advanced disease.      

Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies

Context  Trial of labor after previous cesarean delivery is associated with increased risk of uterine rupture. However, no reliable data exist on the effect of a trial of labor on the risk of perinatal death in otherwise uncomplicated term pregnancies. Objective  To determine the risk of intrapartum stillbirth or neonatal death not related to congenital abnormality among women with uncomplicated term pregnancies who had a trial of labor after previous cesarean delivery, compared with women having a planned repeat cesarean delivery, and multiparous and nulliparous women at term not delivered by planned cesarean method. Design and Setting  Population-based, retrospective cohort study of data from the linked Scottish Morbidity Record and Stillbirth and Neonatal Death Enquiry encompassing births in Scotland between January 1, 1992, and December 31, 1997. Population  A total of 313 238 singleton births between 37 and 43 weeks' gestational age in which the fetus was in a cephalic presentation. Main Outcome Measure  Delivery-related perinatal death, defined as intrapartum stillbirth or neonatal death unrelated to congenital anomaly, compared among the 4 groups. Results  Among women who had a trial of labor following previous cesarean delivery (n = 15 515), the overall rate of delivery-related perinatal death was 12.9 (95% confidence interval [CI], 7.9-19.9) per 10 000 women. This was approximately 11 times greater (odds ratio [OR], 11.6; 95% CI, 1.6-86.7) than the risk associated with planned repeat cesarean delivery (n = 9014), more than twice (OR, 2.2; 95% CI, 1.3-3.5) the risk associated with other multiparous women in labor (n = 151 549), and similar to the risk among nulliparous women in labor (n = 137 160; OR, 1.3; 95% CI, 0.8-2.1). The associations were not explained by differences in maternal height, smoking status, socioeconomic status, age, fetal growth, or week of gestation at delivery. Among women having a trial of labor, the rate of death due to mechanical causes, including uterine rupture, was 4.5 (95% CI, 1.8-9.3) per 10 000 women. This was more than 8 times greater than other multiparous women (OR, 8.5; 95% CI, 3.2-22.3) and nulliparous women (OR, 8.8; 95% CI, 3.2-24.2). Conclusions  The absolute risk of perinatal death associated with trial of labor following previous cesarean delivery is low. However, in our study, the risk was significantly higher than that associated with planned repeat cesarean delivery, and there was a marked excess of deaths due to uterine rupture compared with other women in labor.      

Sex differences in the use of implantable cardioverter-defibrillators for primary and secondary prevention of sudden cardiac death

Context  Previous studies of sex differences in the use of implantable cardioverter-defibrillators (ICDs) predate recent expansions in Medicare coverage and did not provide patient follow-up over multiple years. Objective  To examine sex differences in ICD use for primary and secondary prevention of sudden cardiac death. Design, Setting, and Participants  Analysis of a 5% national sample of research-identifiable files obtained from the US Centers for Medicare & Medicaid Services for the period 1991 through 2005. Patients were those aged 65 years or older with Medicare fee-for-service coverage and diagnosed with acute myocardial infarction and either heart failure or cardiomyopathy but no prior cardiac arrest or ventricular tachycardia (ie, the primary prevention cohort [n = 65 917 men and 70 504 women]), or with cardiac arrest or ventricular tachycardia (ie, the secondary prevention cohort [n = 52 252 men and 47 411 women]), from 1999 through 2005. Main Outcome Measures  Receipt of ICD therapy and all-cause mortality at 1 year. Results  In the 2005 primary prevention cohort, 32.3 per 1000 men and 8.6 per 1000 women received ICD therapy within 1 year of cohort entry. In multivariate analyses, men were more likely than women to receive ICD therapy (hazard ratio [HR], 3.15; 95% confidence interval [CI], 2.86-3.47). Among men and women alive at 180 days after cohort entry, the hazard of mortality in the subsequent year was not significantly lower among those who received ICD therapy (HR, 1.01; 95% CI, 0.82-1.23). In the 2005 secondary prevention cohort, 102.2 per 1000 men and 38.4 per 1000 women received ICD therapy. Controlling for demographic variables and comorbid conditions, men were more likely than women to receive ICD therapy (HR, 2.44; 95% CI, 2.30-2.59). Among men and women alive at 30 days after cohort entry, the hazard of mortality in the subsequent year was significantly lower among those who received ICD therapy (HR, 0.65; 95% CI, 0.60-0.71). Conclusion  In the Medicare population, women are significantly less likely than men to receive ICD therapy for primary or secondary prevention of sudden cardiac death.      

Effect of a single mass antibiotic distribution on the prevalence of infectious trachoma

Context  The World Health Organization recommends mass antibiotic distributions in its strategy to eliminate blinding trachoma as a public health concern. Some hypothesize that a single distribution is sufficient to control the ocular strains of chlamydia that cause trachoma. Others believe infection will inevitably return and periodic treatments or other measures are essential. Objective  To determine whether ocular chlamydial infection returns to the community up to 24 months after a single mass antibiotic distribution in a hyperendemic region of Ethiopia. Design, Setting, and Participants  Longitudinal cohort study conducted March 2003 to March 2005 in the Gurage Zone of Ethiopia. Eight randomly selected villages were assessed for ocular chlamydial infection. Fifteen untreated villages were randomly chosen at 12 months to allow assessment of a secular trend. Intervention  A single dose of oral azithromycin was offered to all residents of the 8 selected villages who were aged 1 year or older. Main Outcome Measure  Prevalence of ocular chlamydial infection in all children aged 1 to 5 years from each intervention village prior to treatment and 2, 6, 12, 18, and 24 months after mass antibiotic treatment, and also in untreated villages enrolled at 12 months. Results  Five hundred fifteen children were examined for ocular chlamydial infection at baseline. For the follow-up examinations, the mean participation rate was 83%. The mean prevalence of infection in children aged 1 to 5 years decreased from 43.5% (95% confidence interval [CI], 35.0%-52.0%) to 5.1% (95% CI, 1.1%-9.2%) after treatment. On average, infection returned gradually over 24 months to 11.3% (95% CI, 4.5%-18.1%; P = .001). In 7 of 8 villages, infection was higher at 24 months than at 2 months. In the remaining village, no infection could be identified at any point after treatment. Villages enrolled at 12 months had significantly fewer infections than those enrolled 12 months earlier, suggesting a secular trend (P<.001). Conclusions  Ocular chlamydial infection was not eliminated in children aged 1 to 5 years after a single mass azithromycin distribution; it slowly returned over 24 months, although not to baseline levels. Repeated treatments or other effective measures will be necessary for elimination.