ContextModifiable behavioral risk factors are leading causes of mortality in
the United States. Quantifying these will provide insight into the effects
of recent trends and the implications of missed prevention opportunities.ObjectivesTo identify and quantify the leading causes of mortality in the United
States.DesignComprehensive MEDLINE search of English-language articles that identified
epidemiological, clinical, and laboratory studies linking risk behaviors and
mortality. The search was initially restricted to articles published during
or after 1990, but we later included relevant articles published in 1980 to
December 31, 2002. Prevalence and relative risk were identified during the
literature search. We used 2000 mortality data reported to the Centers for
Disease Control and Prevention to identify the causes and number of deaths.
The estimates of cause of death were computed by multiplying estimates of
the cause-attributable fraction of preventable deaths with the total mortality
data.Main Outcome MeasuresActual causes of death.ResultsThe leading causes of death in 2000 were tobacco (435 000 deaths;
18.1% of total US deaths), poor diet and physical inactivity (400 000
deaths; 16.6%), and alcohol consumption (85 000 deaths; 3.5%). Other
actual causes of death were microbial agents (75 000), toxic agents (55 000),
motor vehicle crashes (43 000), incidents involving firearms (29 000),
sexual behaviors (20 000), and illicit use of drugs (17 000).ConclusionsThese analyses show that smoking remains the leading cause of mortality.
However, poor diet and physical inactivity may soon overtake tobacco as the
leading cause of death. These findings, along with escalating health care
costs and aging population, argue persuasively that the need to establish
a more preventive orientation in the US health care and public health systems
has become more urgent.

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Actual causes of death in the United States, 2000.

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333.

/pdf/sexually-transmitted-diseases-treatment-guidelines-4zaqk3joit.pdf

Sexually transmitted diseases treatment guidelines.

SUMMARY The availability of an increasing number of antiretroviral agents and the rapid evolution of new information has introduced extraordinary complexity into the treatment of HIV-infected persons. In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for the clinical management of HIV-infected adults and adolescents. This report recommends that care should be supervised by an expert, and makes recommendations for laboratory monitoring including plasma HIV RNA, CD4 cell counts and HIV drug resistance testing. The report also provides guidelines for antiretroviral therapy, including when to start treatment, what drugs to initiate, when to change therapy, and therapeutic options when changing therapy. Special considerations are provided for adolescents and pregnant women. As with treatment of other chronic conditions, therapeutic decisions require a mutual understanding between the patient and the health care provider regarding the benefits and risks of treatment. Antiretroviral regimens are complex, have major side effects, pose difficulty with adherence, and carry serious potential consequences from the development of viral resistance due to non-adherence to the drug regimen or suboptimal levels of antiretroviral agents. Patient education and involvement in therapeutic

/pdf/guidelines-for-the-use-of-antiretroviral-agents-in-hiv-3wuv1pwax4.pdf

Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents

Background: Combination antiretroviral therapy with protease inhibitors has transformed HIV infection from a terminal condition into one that is manageable. However, the complexity of regimens makes adherence to therapy difficult. Objective: To assess the effects of different levels of adherence to therapy on virologic, immunologic, and clinical outcome; to determine modifiable conditions associated with suboptimal adherence; and to determine how well clinicians predict patient adherence. Design: Prospective, observational study. Setting: HIV clinics in a Veterans Affairs medical center and a university medical center. Patients: 99 HIV-infected patients who were prescribed a protease inhibitor and who neither used a medication organizer nor received their medications in an observed setting (such as a jail or nursing home). Measurements: Adherence was measured by using a microelectronic monitoring system. The adherence rate was calculated as the number of doses taken divided by the number prescribed. Patients were followed for a median of 6 months (range, 3 to 15 months). Results: During the study period, 45 397 doses of protease inhibitor were monitored in 81 evaluable patients. Adherence was significantly associated with successful virologic outcome (P < 0.001) and increase in CD4 lymphocyte count (P 5 0.006). Virologic failure was documented in 22% of patients with adherence of 95% or greater, 61% of those with 80% to 94.9% adherence, and 80% of those with less than 80% adherence. Patients with adherence of 95% or greater had fewer days in the hospital (2.6 days per 1000 days of follow-up) than those with less than 95% adherence (12.9 days per 1000 days of follow-up; P 5 0.001). No opportunistic infections or deaths occurred in patients with 95% or greater adherence. Active psychiatric illness was an independent risk factor for adherence less than 95% (P 5 0.04). Physicians predicted adherence incorrectly for 41% of patients, and clinic nurses predicted it incorrectly for 30% of patients. Conclusions: Adherence to protease inhibitor therapy of 95% or greater optimized virologic outcome for patients with HIV infection. Diagnosis and treatment of psychiatric illness should be further investigated as a means to improve adherence to therapy.

Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.

https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.21178

Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection

To the Editor: Palella et al. (March 26 issue)1 reported that the use of more intensive antiretroviral therapies is responsible for declines in both morbidity and mortality in patients with AIDS. We conducted a study to evaluate the impact of protease inhibitors on the rates of selected opportunistic processes and mortality and found similar results. Our study population came from a public human immunodeficiency virus (HIV) outpatient clinic in New Orleans. All subjects and data were from the Adult Spectrum of Disease study, a prospective study funded by the Centers for Disease Control and Prevention examining the natural history of . . .

https://www.nejm.org/doi/pdf/10.1056/NEJM199808063390612

Declining Morbidity and Mortality among Patients with Advanced Human Immunodeficiency Virus Infection

Collection of sensitive data with the use of video-enhanced, computer-assisted, self-administered interviews (V-CASI) has the potential to reduce interview bias and improve the validity of the study. The purpose of this study was to compare responses to sensitive questions elicited by V-CASI and by face-to-face interview (FTFI) methods. Women attending a New Orleans, Louisiana, public family planning or sexually transmitted disease clinic from July 1995 to July 1996, diagnosed with a Chlamydia trachomatis infection responded to eight close-ended behavioral questions (four socially undesirable, two socially desirable, and two neutral behaviors) using both FTFI and V-CASI techniques in a randomized crossover design. Of the 280 women included, the mean age was 23 years, 95 percent were African American, and 71 percent felt comfortable using computers. While kappa scores indicated good-to-excellent agreement between interview techniques, women tended to admit to socially undesirable behaviors more often on V-CASI compared with FTFI. Thirty percent of the women gave a discrepant response between V-CASI and FTFI toward social desirability. Women who reported a socially undesirable behavior in V-CASI (i.e., more than two sex partners and infrequent condom usage) were more likely to have a discrepant response. Utilization of the same logistic regression model to predict condom use yielded different results when data from V-CASI were used compared with data from FTFI. The V-CASI technique can reduce social desirability bias and improve validity in research requiring information on sensitive sexual behaviors.

/pdf/application-of-computer-assisted-interviews-to-sexual-2g2a2xn0sw.pdf

Application of Computer-assisted Interviews to Sexual Behavior Research

Trichomonas vaginalis (TV) is likely the most common non-viral sexually transmitted infection (STI) in the world. It is as an important source of reproductive morbidity, a facilitator of HIV transmission and acquisition, and thus it is an important public health problem. Despite its importance in human reproductive health and HIV transmission, it is not a reportable disease and surveillance is not generally done. This is problematic since most persons infected with TV are asymptomatic. Metronidazole (MTZ) has been the treatment of choice for women for decades, and single dose has been considered the first line of therapy. However, high rates of retest positive are found among TV infected persons after single dose MTZ treatment. This has not been explained by drug resistance since in vitro resistance is only 2–5 %. Treatment failure can range from 7–10 % and even higher among HIV+ women. Treatment efficacy may be influenced by vaginal ecology. The origins of repeat positives need further explanation and better treatment options are needed.

/pdf/trichomonas-vaginalis-a-review-of-epidemiologic-clinical-and-51coiwhqu0.pdf

Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues

BackgroundRepeated infection with Chlamydia trachomatis increases the risk for serious sequelae: pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain. A substantial proportion of women treated for C trachomatis infection are reinfected by an untreated male sex partner

/pdf/patient-delivered-partner-treatment-with-azithromycin-to-s6wxa8mqq7.pdf

Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial.

Objectives To describe the patterns and correlates of discontinuation of the initial highly active antiretroviral therapy (HAART) regimen in an urban, outpatient cohort of antiretroviral-naive patients. Design Retrospective cohort of 345 randomly selected antiretroviral-naive patients who initiated HAART on 6 selected regimens between January 1997 and May 2001 in New Orleans, LA. Methods An investigator reviewed medical records to collect information on concurrent medications, symptoms/diagnoses, staging indicators, and reasons for HAART discontinuation. Proportional hazards regression methods were used to identify predictors of discontinuation. Results After a median follow-up of 8.1 months, 61% of patients changed or discontinued their initial HAART regimen; 24% did so because of an adverse event. The events most commonly cited as the cause for discontinuation were nausea, vomiting, and diarrhea. A detectable viral load was associated with discontinuation at any time, while reporting nausea/vomiting or dizziness at the previous visit were associated with discontinuation during the first 3 months on HAART. Nausea/vomiting and not having AIDS at the time of HAART initiation were associated with discontinuation due to an adverse event at any time, while a high viral load, and dizziness or anorexia/weight loss at the previous visit were associated with discontinuation due to an adverse event in the first 3 months on HAART. Conclusions Gastrointestinal adverse events of HAART are the most frequently cited reason for discontinuation of HAART. An effort should be made to educate patients about these events and to encourage continued adherence. Additionally, appropriate prophylaxes for these events are warranted.

Patricia Kissinger

Papers

Declining Morbidity and Mortality among Patients with Advanced Human Immunodeficiency Virus Infection

Application of Computer-assisted Interviews to Sexual Behavior Research

Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues

Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial.

Patterns and correlates of discontinuation of the initial HAART regimen in an urban outpatient cohort.