HIV Infection and Falls: Epidemiology and Risk Assessment

描述（由申请人提供）：候选人：作为护理耶鲁大学的助理教授，我非常适合从护理研究的国家研究所K 01指导研究科学家职业发展奖。我的近期目标/培训需求是：1）发展我对衰老和老年综合征的理解，特别是福尔斯; 2）发展更高级的信息提取和统计分析技能; 3）获得定性方法的经验; 4）发展临床干预研究技能。我的长期目标是：1）在老年综合征和艾滋病毒领域成为一名独立和富有成效的研究者，特别是在福尔斯和使用基于电子病历的观察队列方面的专业知识; 2）开发针对艾滋病毒感染人群的福尔斯评估和预防干预措施; 3）使用这种方法探索其他 HIV感染背景下的老年综合征。这个项目汇集了来自多个学科的导师，他们致力于我作为独立研究人员的发展。以目标为导向的培训活动解决了我的直接目标/培训需求，包括教学法，强化研讨会，持续参与研讨会，特别是在老龄化和生物统计学方面，研究项目本身的工作，以及准备R 03，这将启动我职业生涯的下一步。环境：耶鲁大学和退伍军人健康管理局（VHA）康涅狄格州提供的设施和资源是无与伦比的。耶鲁大学护理学院为开展临床研究的教师提供广泛支持。耶鲁大学医学信息学中心支持信息学的培训和研究资源，特别是在信息提取领域。大部分的工作，告知我们的理解福尔斯在老年人和福尔斯预防干预措施来自耶鲁大学的老龄化计划。这个跨学科的计划提供了广泛的教育机会，以及获得个人从广泛的学科谁纳入老龄化作为其临床和研究工作的重点。VHA康涅狄格州是退伍军人老龄化队列研究（VACS）的所在地，该研究为该项目提供了数据，并拥有广泛的计算机资源，使大型数据集（如VACS）的探索变得可行。调研：这项研究将探讨严重的福尔斯（SF），福尔斯是严重到值得访问的医疗保健提供，在艾滋病毒感染和未感染的个人年龄> 40岁。有证据表明，福尔斯是艾滋病毒感染者的一个问题。然而，这一人群与一般老年人群之间存在的差异突出表明，简单地对艾滋病毒感染者实施老年人有效的福尔斯预防干预措施是不适当的。直立和视力丧失在老年人中很常见，但不是艾滋病毒感染者的主要健康问题。HIV特异性因素如较低的CD 4计数、较高的病毒载量、使用依法韦仑和使用利托那韦也可能导致福尔斯跌倒风险。我提出了以下具体目标：1）确定SF的发病率，频率，后遗症和发病年龄; 2）阐明SF的传统和HIV特异性危险因素; 3）在HIV感染者中发生严重跌倒，描述导致跌倒的因素，以及他们随后跌倒的风险。在SA 1中，有三个因变量：首次严重跌倒（SF）、复发性SF和严重跌倒后遗症。严重福尔斯将使用跌倒相关的E代码进行识别。此外，我将使用信息提取来识别放射学报告和门诊进展记录中的严重福尔斯。HIV状态是主要的预测变量。SF的后遗症将通过诊断代码识别。自变量是艾滋病毒状况。我将使用泊松回归、分段逻辑回归和考克斯回归模型来检验假设。在SA 2中，严重福尔斯是主要结局，并将在SA 1中确定。主要自变量是艾滋病毒状况。在第一个模型中，将结合联合收割机艾滋病毒感染和未感染的退伍军人，我将探讨传统的危险因素的贡献，一个严重的下降的风险。我将测试是否多种物质滥用有更大的关联性与SF在HIV感染者包括多种物质滥用和HIV状态之间的相互作用，包括传统的RF。在一个仅限于HIV感染者的单独模型中，我将测试HIV特异性风险因素，特别是CD 4计数和依法韦仑使用，以及传统风险因素对严重福尔斯风险的贡献。我将使用纵向分段logitic回归并估计每个RF的纵向平均可归因分数。将从当地招募的有严重跌倒史的HIV感染患者样本中探索SA 3。 这是一个定性目标，将使用半结构化的面对面访谈。解释性描述方法将指导数据分析。从电子病历中收集的数据将提供有关参与者病史以及在急诊室或诊所对跌倒的评估的具体信息。总之，这些目标将为我提供必要的信息，以制定一个福尔斯预防干预措施，是针对艾滋病毒感染者遇到的具体风险，并开始建立在艾滋病毒感染的背景下老年综合征的职业生涯。

DESCRIPTION (provided by applicant): Candidate: As an Assistant Professor at the Yale School of Nursing, I am ideally suited for a K01 Mentored Research Scientist Career Development Award from the National Institute of Nursing Research. My immediate goals/training needs are: 1) to develop my understanding of aging and geriatric syndromes, falls in particular; 2) to develop more advanced skills in information extraction and statistical analysi; 3) to gain experience in qualitative methods; and 4) To develop skills in clinical intervention research. My long-term goals are: 1) to be an independent and productive investigator in the field of geriatric syndromes and HIV, with particular expertise in falls and the use of electronic medical record-based observational cohorts; 2) to develop a falls assessment and prevention intervention tailored to the HIV infected populations; and 3) to use this approach to explore other geriatric syndromes in the context of HIV infection. This project brings together mentors from multiple disciplines who are committed to my development as an independent researcher. The goal-directed training activities address my immediate goals/training needs and include didactics, intensive workshops, ongoing participation in seminars, particularly in aging and biostatistics, work on the research project itself, and preparation of an R03 that will launch the next step in my career. Environment: The facilities and resources provided by Yale and the Veterans Health Administration (VHA) Connecticut are unparalleled. The Yale School of Nursing provides extensive support to faculty conducting clinical research. The Yale Center for Medical Informatics supports resources for training and research in informatics, particularly in the area o information extraction. Much of the work that informs our understanding of falls in the elderly and falls prevention interventions comes from the Yale Program on Aging. This cross- disciplinary program provides extensive educational opportunities as well as access to individuals from a broad range of disciplines who incorporate aging as a focus of their clinical and research work. The VHA Connecticut is the home of the Veterans Aging Cohort Study (VACS) which provides the data for this project and has extensive computer resources that make the exploration of large datasets, such as VACS, feasible. Research: The research will explore serious falls (SF), falls that are serious enough to merit a visit to a health care provide, among HIV infected and uninfected individuals aged > 40 years. There is evidence that falls are a problem among HIV infected individuals. However, the differences that exist between this population and the general elderly population highlight the inappropriateness of simply imposing falls prevention interventions that work in the elderly on HIV infected individuals. Orthostasis and vision loss are common in the elderly, but are not central health concerns for HIV infected individuals. HIV specific factors such as lower CD4 count, higher viral load, efavirenz use, and ritonavir use may also contribute to falls risk. I propose the following specific aims: 1) To determine the incidence, frequency, sequelae, and age of onset of SF; 2) To elucidate traditional and HIV-specific risk factors for SF; 3) In HIV infected individuals who have had a serious fall, to describe the factors that contributed to the fall, as well as their risk for a subsequent fall. In SA1, there are three dependent variables: first serious fall (SF), recurrent SFs, and serious fall sequelae. Serious falls will be identified using falls-related E-codes. In addition, I will use information extraction to identify serious falls in radiology reports and in outpatient progress notes. HIV status is the primary predictor variable. Sequelae of SFs will be identified by diagnostic codes. The independent variable is HIV status. I will use Poisson regression, piecewise logistic regression, and Cox regression models to test the hypotheses. In SA2, serious falls are the primary outcome and will be identified as in SA1. The primary independent variable is HIV status. In the first model that will combine HIV infected and uninfected Veterans, I will explore the contribution of traditional risk factors to the risk of a serious fall. I will test whether polysubstance abuse has a greater association with SF in HIV infected individuals by inclusion of an interaction between polysubstance abuse and HIV status and include traditional RFs. In a separate model restricted to HIV infected individuals, I will tes the contribution of HIV specific risk factors, particularly CD4 count and efavirenz use, in additio to traditional risk factors, to the risk of serious falls. I will use a longitudinal piecewise logitic regression and estimate the longitudinal average attributable fraction of each RF. SA3 will be explored from a sample of locally recruited HIV infected patients with a history of a serious fall. This is a qualitative aim that will use semi-structured, face-to-face interviews. An interpretive descriptive approach will guide data analysis. Data collected from the electronic medical record will provide specific information about the participants' medical history and about the evaluation of the fall in the emergency room or in the clinic. Together, these aims will provide me with the information necessary to develop a falls prevention intervention that is tailored to the specific risks encountered by HIV infected individuals and to begin to build a career in geriatric syndromes in the context of HIV infection.