Types of Stroke among People Living with HIV in the United States

Background: Most studies of stroke in people living with HIV (PLWH) do not use verified stroke diagnoses, are small, and/or do not differentiate stroke types and subtypes.Setting: CNICS, a U.S. multisite clinical cohort of PLWH in care.Methods: We implemented a centralized adjudication stroke protocol to identify stroke type, subtype, and precipitating conditions identified as direct causes including infection and illicit drug use in a large diverse HIV cohort.Results: Among 26,514 PLWH, there were 401 strokes, 75% of which were ischemic. Precipitating factors such as sepsis or same-day cocaine use were identified in 40% of ischemic strokes. Those with precipitating factors were younger, had more severe HIV disease, and fewer traditional stroke risk factors such as diabetes and hypertension. Ischemic stroke subtypes included cardioembolic (20%), large vessel atherosclerosis (13%), and small vessel (24%) ischemic strokes. Individuals with small vessel strokes were older, were more likely to have a higher current CD4 cell count than those with cardioembolic strokes and had the highest mean blood pressure of the ischemic stroke subtypes.Conclusion: Ischemic stroke, particularly small vessel and cardioembolic subtypes, were the most common strokes among PLWH. Traditional and HIV-related risk factors differed by stroke type/subtype. Precipitating factors including infections and drug use were common. These results suggest that there may be different biological phenomena occurring among PLWH and that understanding HIV-related and traditional risk factors and in particular precipitating factors for each type/subtype may be key to understanding, and therefore preventing, strokes among PLWH

Integrating data systems to improve HIV care engagement in King County, WA

Thesis (Ph.D.)--University of Washington, 2019Continuous engagement in HIV care and treatment is crucial for the health of persons living with HIV (PLWH) and for preventing HIV transmission to others. However, in the United States (US), care engagement, or retention in care, represents the biggest drop off in the HIV care continuum, which maps out the care process from HIV testing and diagnosis, linkage to and retention in HIV care, and ultimately achievement of viral suppression. Many health departments in the US use HIV surveillance data to facilitate HIV care engagement activities, a process known as data to care. While Data to Care programs have had some success, their effectiveness is hindered by the completeness and timeliness of HIV surveillance data. A novel approach to Data to Care uses real-time data exchange between HIV surveillance with external data sources, such as emergency department (ED) and inpatient (IP) hospitalization data and jail booking rosters, to improve the signal of Data to Care investigations, and provide a setting and an opportunity to re-engage PLWH in HIV care. Since real-time data exchange involves linking data sources that don’t often have a shared unique person identifier, these programs should also consider the accuracy of the record linkage algorithms they utilize, in order to maximize their reach and efficiency. We investigated the effect of the use of real-time data exchange on HIV care engagement outcomes in two settings: emergency department and inpatient hospitals and in jails. First, we evaluated the impact of an existing ED/hospital-based health information exchange on HIV care outcomes. We compared the proportion of patients that had a viral load test in the 3 months and viral suppression in the 6 months after an alert-eligible ED visit/inpatient admission in the pre-intervention (01/20/13-01/20/15) and post-intervention (07/20/15-07/20/17) periods. To assess whether our pre/post results could be due to secular trends, we compared the difference between patients with an alert-eligible ED visit/IP admission to patients who had a visit outside of the alert window in both the pre-intervention and post-intervention periods. Next, we developed a new automated, real-time data exchange between public health HIV surveillance and county jail data to identify incarcerated PLWH and facilitate post-incarceration HIV care engagement efforts. A team of public health relinkage specialists and jail release planners used this data exchange to guide case conferences about patients who were virally unsuppressed or out-of-care and jointly developed a plan for re-engagement in care and treatment. We compared viral load testing within 3 months and viral suppression within 6 months after release from jail among PLWH released in the post-intervention period (04/01/18-11/01/18) to those released in the pre-intervention period (10/01/16-10/01/17) using Cox proportional hazards models. Finally, we compared the performance of record linkage algorithms commonly used by data exchanges commonly used in public health practice. We compared five deterministic algorithms and two probabilistic record linkage algorithms using simulations and a real-world scenario. We simulated pairs of datasets while varying the number of erroneous fields per record and overlap between these datasets. We matched datasets using each algorithm and calculated their recall (sensitivity) and precision (positive predictive value). In a real-world scenario, HIV and STD surveillance data from King County, WA were matched to identify PLWH who had a syphilis diagnosis. We used manual review to define a gold standard and calculate recall and precision. In our evaluation of an ED/hospital-based health information exchange, patients in the post-intervention period were 1.08 times more likely to have a viral load test within 3 months after an ED visit/IP admission (95% CI: 0.97, 1.20) and 1.50 times more likely to achieve viral suppression within 6 months after an ED visit/IP admission (95% CI: 1.27, 1.76). However, there was a similar pre/post increase in both HIV care engagement (DID: 1.00, 95% CI: 0.84, 1.18) and viral suppression (DID: 1.01, 95% CI: 0.84, 1.20) among patients with visits outside of the alert window. After implementation of a real-time data exchange between HIV surveillance and jail booking data coupled with HIV care coordination between health department and jail release planners, viral load testing within 3 months after release from jail increased by 35% (95% CI: 0.84, 2.18) and viral suppression within 6 months after release from jail increased by 37% (95% CI: 0.82, 2.30), but these differences were not statistically significant. In our simulation study, we found that probabilistic algorithms maintained a high recall at nearly all data quality levels, while being comparable to deterministic algorithms in terms of precision. Deterministic algorithms typically failed to identify matches in scenarios with low data quality. In the real-world scenario, probabilistic algorithms had the lowest trade-off between recall and precision. The results of this dissertation indicate that ED/hospital-based data exchange provides substantial opportunities to interact with PLWH who are poorly engaged in HIV care. However, the observed increase in HIV re-engagement and viral suppression after implementation of this data exchange may reflect secular trends resulting from diverse interventions of which this program was only one. Real-time health information exchange with emergency departments and hospitals can identify PLWH who are inadequately engaged with care and facilitate D2C efforts, but more efforts are needed to improve the effectiveness of reengagement interventions linked to real-time D2C. Implementation of a real-time data exchange between HIV surveillance and jail booking rosters resulted in a trend towards improved post-incarceration HIV care outcomes for incarcerated PLWH who are virally unsuppressed/out-of-care in King County. Real-time data exchange between health departments and county jails is a promising strategy for identifying incarcerated PLWH to support care coordination and improving post-incarceration HIV care engagement. Finally, in our simulation study on record linkage algorithms, we found that probabilistic algorithms maximize the number of true matches identified, while still maintaining high precision. Public health activities that rely on the integration of multiple data sources to target intervention delivery should utilize probabilistic algorithms to reduce gaps in the coverage of interventions and maximize their reach

An Inexpensive Paper-Based Aluminum-Air Battery

Paper-based batteries are an alternative to traditional batteries due to their low cost, portability, and simplicity to operate. In the present work, we demonstrate an improved and inexpensive paper-based aluminum-air battery employing KOH as the electrolyte with sufficient energy to power small devices. The dimensions of the device, electrode size, and electrolyte concentration were optimized with respect to amperage and reproducibility. The maximum amperage of 17.4 mA and maximum power of 3.0 mW was achieved with a 9 cm2 battery with anode and cathode electrode areas of 5.1 cm2 and 3.75 cm2 respectively, using 1.5 M potassium hydroxide (KOH). In a series configuration, the batteries generate sufficient energy to power light-emitting diodes (LEDs), a flashlight, a glucometer, and a pregnancy test

Easily Fabricated Microfluidic Devices Using Permanent Marker Inks for Enzyme Assays

In this communication, we describe microfluidic paper analytical devices (μPADs) easily fabricated from commercially available Sharpie ink permanent markers on chromatography paper to colorimetrically detect glucose using glucose oxidase (GOx). Here, solutions of horseradish peroxidase (HRP), GOx, and potassium iodide (KI)were directly spotted onto the center of the μPAD and flowed into samples of glucose that were separately spotted on the μPAD. Using an XY plotter (Roland DGA Corporation, Irvine, CA USA), several ink marks drawn in the paper act as the hydrophobic barriers, thereby, defining the hydrophilic fluid flow paths of the solutions. Two paper devices are described that act as independent assay zones. The glucose assay is based on the enzymatic oxidation of iodide to iodine whereby a color change from clear to brownish-yellow is associated with the presence of glucose. In these experiments, two designs are highlighted that consist of circular paper test regions fabricated for colorimetric and subsequent quantification detection of glucose. The use of permanent markers for paper patterning is inexpensive and rapid and does not require special laboratory equipment or technical skill

Correction: Genetic Ancestry and Asthma and Rhinitis Occurrence in Hispanic Children: Findings from the Southern California Children's Health Study.

Asthma and rhinitis are common childhood health conditions. Being an understudied and rapidly growing population in the US, Hispanic children have a varying risk for these conditions that may result from sociocultural (including acculturative factors), exposure and genetic diversities. Hispanic populations have varying contributions from European, Amerindian and African ancestries. While previous literature separately reported associations between genetic ancestry and acculturation factors with asthma, whether Amerindian ancestry and acculturative factors have independent associations with development of early-life asthma and rhinitis in Hispanic children remains unknown. We hypothesized that genetic ancestry is an important determinant of early-life asthma and rhinitis occurrence in Hispanic children independent of sociodemographic, acculturation and environmental factors.Subjects were Hispanic children (5-7 years) who participated in the southern California Children's Health Study. Data from birth certificates and questionnaire provided information on acculturation, sociodemographic and environmental factors. Genetic ancestries (Amerindian, European, African and Asian) were estimated based on 233 ancestry informative markers. Asthma was defined by parental report of doctor-diagnosed asthma. Rhinitis was defined by parental report of a history of chronic sneezing or runny or blocked nose without a cold or flu. Sample sizes were 1,719 and 1,788 for investigating the role of genetic ancestry on asthma and rhinitis, respectively.Children had major contributions from Amerindian and European ancestries. After accounting for potential confounders, per 25% increase in Amerindian ancestry was associated with 17.6% (95% confidence interval [CI]: 0.74-0.99) and 13.6% (95% CI: 0.79-0.98) lower odds of asthma and rhinitis, respectively. Acculturation was not associated with either outcome.Earlier work documented that Hispanic children with significant contribution from African ancestry are at increased asthma risk; however, in Hispanic children who have little contribution from African ancestry, Amerindian ancestry was independently associated with lower odds for development of early-childhood asthma and rhinitis

Multivariate Association between Amerindian Genetic Ancestry and Asthma.

<p>^a Odds ratios (ORs) are adjusted for the variables with ORs shown under each model plus age and community of residence. Also models that included Amerindian ancestry (i.e., models 2 and 4) are further adjusted for African and Asian genetic ancestries. Statistically significant ORs are in <b>bold</b>.</p><p>^bThe OR for Amerindian ancestry is scaled to 25% increases in Amerindian ancestry.</p><p>Multivariate Association between Amerindian Genetic Ancestry and Asthma.</p

Flow Chart of Study Population and Sample Size.

<p>The figure shows the number of Hispanic children available in the Children’s Health Study in 2003, subjects excluded for not having birth certificate or genetic ancestry data, and final sample size available for analyzing the associations of genetic ancestry on asthma (N = 1,719) and rhinitis (N = 1,788).</p