Publications

BACKGROUND

The Raloxifene Use for The Heart (RUTH) trial showed that raloxifene, a selective estrogen receptor modulator, had no overall effect on the incidence of coronary events in women with established coronary heart disease or coronary heart disease risk factors. We provide detailed results of the effect of raloxifene on coronary outcomes over time and for 24 subgroups (17 predefined, 7 post hoc).

METHODS AND RESULTS

Postmenopausal women (n=10 101; mean age, 67 years) were randomized to raloxifene 60 mg/d or placebo for a median of 5.6 years. Coronary outcomes were assessed by treatment group in women with coronary heart disease risk factors and those with established coronary heart disease. Raloxifene had no effect on the incidence of coronary events in any subgroup except in the case of a post hoc age subgroup analysis using age categories defined in the Women's Health Initiative randomized trials. The effect of raloxifene on the incidence of coronary events differed significantly by age (interaction P=0.0118). The incidence of coronary events in women <60 years of age was significantly lower in those assigned raloxifene (50 events) compared with placebo (84 events; hazard ratio, 0.59; 95% confidence interval, 0.41 to 0.83; P=0.003; absolute risk reduction, 36 per 1000 women treated for 1 year). No difference was found between treatment groups in the incidence of coronary events in women > or =60 and <70 or > or =70 years of age.

CONCLUSIONS

In postmenopausal women at increased risk of coronary events, the overall lack of benefit of raloxifene was similar across the prespecified subgroups.

Among hepatitis C patients, lack of cirrhosis and sustained virologic response (SVR) reduce the risk of hepatocellular carcinoma (HCC). Japanese studies document multiple cases of HCC among these patients, but only one case has been reported outside of Asia. We identified five patients with hepatitis C in our university-based hepatology practice who developed HCC despite SVR and lack of cirrhosis on their pretreatment liver biopsy. At the time of HCC diagnosis, two remained noncirrhotic, one had clearly progressed to cirrhosis, and two lacked repeat histology. We present these patients in a case series format and discuss several important implications of their cases. Physicians often base screening and treatment decisions on an initial liver biopsy performed years earlier. As fibrosis may advance, and because SVR and lack of cirrhosis do not fully protect against HCC, future study should further evaluate the risk of HCC among hepatitis C patients after sustained virologic response.

GOAL

In San Francisco, coinciding with increases in the western United States, we observed substantial gonorrhea increases among young heterosexuals during 2003-2005. We conducted a case-control study to identify intervention strategies for prevention and control.

STUDY DESIGN

We interviewed case patients with gonorrhea during February-July, 2006 and control subjects at the local Department of Motor Vehicles. We included sexually active heterosexuals aged 15 to 35 years in sex-stratified analyses.

RESULTS

We interviewed 225 persons: 24 male and 28 female case patients and 98 male and 75 female control subjects. In multivariable analysis adjusting for black race and multiple partners among men, black race [adjusted odds ratio (AOR), 5.1; 95% confidence interval (CI), 1.7-15.0], having had multiple partners (AOR, 3.1; 95% CI, 1.1-8.5), having had an anonymous partner (AOR, 6.4; 95% CI, 1.9-21.4), and a long-term partnership (AOR, 0.3; 95% CI, 0.1-0.9) were associated with gonococcal infection. Among women, after adjustment for age, multiple partners, and black race (subject or partner), being black or having a black partner (AOR, 6.9; 95% CI, 2.2-21.8), having had a recently incarcerated partner (AOR, 6.2; 95% CI, 1.0-38.4), or meeting partners on the street (AOR, 19.0; 95% CI, 2.0-179.0) were associated with gonococcal infection.

CONCLUSIONS

Demographic and behavioral factors increase risk for gonorrhea among heterosexuals in San Francisco with partner characteristics being particularly important. Prevention and control efforts are focusing on blacks and incarcerated populations using street-based outreach and expanded screening and treatment.

BACKGROUND

Young adults entering jail are at increased risk for sexually transmitted diseases (STD) such as chlamydia, are released quickly, and are unlikely to be tested for STDs elsewhere. San Francisco jails performed targeted chlamydia screening and treatment since 1996.

GOAL

To determine this program's impact on chlamydia positivity among females attending neighborhood medical clinics.

STUDY DESIGN

During 1997-2004, jail testing density, a measure of the proportion of persons from year 2000 census blocks that were tested in jail, was compared by neighborhood. Chlamydia positivity among females aged 15 to 25 years were compared at 2 clinics serving areas with different jail testing densities.

RESULTS

Of persons offered screening at intake, 89% accepted. A total of 42,952 tests were performed among 23,561 persons in jail (45% black, 73% male). A total of 2765 (6.4%) tests were positive for chlamydia; 81% of chlamydial infections were treated. Jail testing density significantly correlated with neighborhood female chlamydia rates. Mean jail testing density at Clinic S, calculated by using the residence of persons tested for chlamydia, was 7 times greater than that at Clinic O. Chlamydia positivity declined at Clinic S from 16.1% to 7.8% (Ptrend <0.001). No significant change occurred at Clinic O in chlamydia (4.7% in 1997 and 2004, Ptrend = 0.81).

CONCLUSIONS

In San Francisco, screening young adults in jail focused testing on persons from neighborhoods with high chlamydia rates. Jail screening started immediately before chlamydia declines among young females at a clinic serving neighborhoods with high jail testing density. These programs might help reduce community prevalence and racial/ethnic disparities in STDs.

BACKGROUND

Obesity is an established and modifiable risk factor for urinary incontinence, but conclusive evidence for a beneficial effect of weight loss on urinary incontinence is lacking.

METHODS

We randomly assigned 338 overweight and obese women with at least 10 urinary-incontinence episodes per week to an intensive 6-month weight-loss program that included diet, exercise, and behavior modification (226 patients) or to a structured education program (112 patients).

RESULTS

The mean (+/-SD) age of the participants was 53+/-11 years. The body-mass index (BMI) (the weight in kilograms divided by the square of the height in meters) and the weekly number of incontinence episodes as recorded in a 7-day diary of voiding were similar in the intervention group and the control group at baseline (BMI, 36+/-6 and 36+/-5, respectively; incontinence episodes, 24+/-18 and 24+/-16, respectively). The women in the intervention group had a mean weight loss of 8.0% (7.8 kg), as compared with 1.6% (1.5 kg) in the control group (P<0.001). After 6 months, the mean weekly number of incontinence episodes decreased by 47% in the intervention group, as compared with 28% in the control group (P=0.01). As compared with the control group, the intervention group had a greater decrease in the frequency of stress-incontinence episodes (P=0.02), but not of urge-incontinence episodes (P=0.14). A higher proportion of the intervention group than of the control group had a clinically relevant reduction of 70% or more in the frequency of all incontinence episodes (P<0.001), stress-incontinence episodes (P=0.009), and urge-incontinence episodes (P=0.04).

CONCLUSIONS

A 6-month behavioral intervention targeting weight loss reduced the frequency of self-reported urinary-incontinence episodes among overweight and obese women as compared with a control group. A decrease in urinary incontinence may be another benefit among the extensive health improvements associated with moderate weight reduction. (ClinicalTrials.gov number, NCT00091988.)