Faculty Bibliography

INTRODUCTION/BACKGROUND:Evidence from low-resource settings indicates that economic insecurity is a major barrier to HIV treatment adherence. Economic empowerment (EE) interventions have the potential to improve adherence outcomes among adolescents living with HIV (ALWHIV) by mitigating the effects of poverty. This study aims to assess the efficacy and cost-effectiveness of a savings-led family-based EE intervention, Suubi + Adherence, aimed at improving antiretroviral therapy (ART) adherence outcomes ALWHIV in Uganda. METHODS:Adolescents (mean age 12 years at enrolment; 56% female) receiving ART for HIV at 39 health centres were randomized to Suubi + Adherence intervention (n = 358) or bolstered standard of care (BSOC; n = 344). A difference-in-differences analysis was employed to assess the change in the proportion of virally suppressed adolescents (HIV RNA viral load <40 copies/mL) over 24 months. The cost-effectiveness analysis examined how much the intervention cost to virally suppress one additional adolescent relative to BSOC from the healthcare provider perspective. RESULTS:At 24 months, the intervention was associated with an 8.85-percentage point [95% confidence interval (CI) 0.80 to 16.90 percentage points] increase in the proportion of virally suppressed adolescents between the study arms (p = 0.032). Per-participant costs were US$177 and US$263 for the BSOC and intervention groups respectively. The incremental cost of virally suppressing one additional adolescent was estimated at US$970 [95% CI, US$508 to 10,725] over two years. CONCLUSIONS:Our results support the integration of family-based EE interventions into adherence-support strategies as part of routine HIV care in low-resource settings to address the underlying economic drivers of poor ART adherence among ALWHIV. Moreover, per-participant costs to achieve viral suppression do not seem prohibitive compared to other community-based adherence interventions targeted at ALWHIV in low-resource settings. Further research on combination interventions at the nexus of economic security and HIV treatment and care is needed to inform the development of feasible and scalable HIV policies and programmes.

OBJECTIVE:Retrieval practice, often using electronic flashcards, is increasingly utilized among medical students for self-study. In this study, the authors evaluated usage and satisfaction with electronic flashcards based on a medical school psychiatry curriculum. METHODS:First-year medical students at one institution consented to participate and received access to a set of pre-made flashcards. Surveys were distributed that collected demographic information along with measures of prior performance, test anxiety, and prior experience with electronic flashcards. The total number of flashcard reviews and time spent on the platform for each student were collected using statistics internally generated by the platform. Each student's final exam score was also collected. RESULTS:A total of 114 of 129 first year medical students (88%) consented to participate, and 101 students were included in the final analysis. Fifty-eight (56%) were flashcard users with a median of 660 flashcards studied over 2.95 h. A total of 87% of flashcard users found the flashcards to be helpful, and 83% of flashcard users would recommend the flashcards to someone else. Flashcard usage was not associated with final exam scores. CONCLUSIONS:This novel electronic study resource was well-received by first-year medical students for psychiatric instruction in medical school, though usage was not associated with higher exam scores.

Functional abdominal pain (FAP) is one of the most common childhood medical complaints, associated with significant distress and impairment. Little is known about how children understand their pain. Do they attribute it to personal weakness? Do they perceive pain as having global impact, affecting a variety of activities? How do they cope with pain? We explored the pain beliefs of 5- to 9-year-old children with FAP using a novel Teddy Bear Interview task in which children answered questions about a Teddy bear's pain. Responses were analyzed quantitatively and qualitatively. Results indicate that the majority of young children with FAP are optimistic about pain outcomes. Children generated many types of coping strategies for Teddy's pain and adjusted their calibration of Teddy's pain tolerance dependent on the activity being performed. Early warning signs also emerged: a subset of children were pessimistic about Teddy's pain, and several children identified coping strategies that, while developmentally appropriate, could lead to excessive help seeking if not intervened upon (e.g., physician consultation and shot). The Teddy Bear Interview allows children to externalize their pain, making it a useful tool to access cognitive pain constructs in younger children. Thus, these findings highlight the importance of early intervention for childhood FAP.

BACKGROUND:The advent of next-generation sequencing (NGS) techniques in clinical practice led to a significant advance in gene discovery. We aimed to describe diagnostic yields of a "dynamic" exome-based approach in a cohort of patients with epilepsy associated with neurodevelopmental disorders. METHODS:We conducted a retrospective, observational study on 72 probands. All patients underwent a first diagnostic level of a 135 gene panel, a second of 297 genes for inconclusive cases, and finally, a whole-exome sequencing for negative cases. Diagnostic yields at each step and cost-effectiveness were the objects of statistical analysis. RESULTS:<< 0.001). The cost-effectiveness plane indicated that our exome-based "dynamic" approach was better in terms of cost savings and higher diagnostic rate. CONCLUSIONS:Our findings suggested that "dynamic" NGS techniques applied to well-phenotyped individuals can save both time and resources. In patients with unexplained epilepsy comorbid with NDDs, our approach might maximize the number of diagnoses achieved.

Alcohol consumption is mediated by several important neuromodulatory systems, including the endocannabinoid and neuropeptide Y (NPY) systems in the limbic brain circuitry. However, molecular mechanisms through which cannabinoid-1 (CB1) receptors regulate alcohol consumption are still unclear. Here, we investigated the role of the CB1 receptor-mediated downstream regulation of NPY via epigenetic mechanisms in the amygdala. Alcohol drinking behavior was measured in adult male C57BL/6J mice treated with a CB1 receptor neutral antagonist AM4113 using a two-bottle choice paradigm while anxiety-like behavior was assessed in the light-dark box (LDB) test. The CB1 receptor-mediated changes in the protein levels of phosphorylated cAMP-responsive element binding protein (pCREB), CREB binding protein (CBP), H3K9ac, H3K14ac and NPY, and the mRNA levels of Creb1, Cbp, and Npy were measured in amygdaloid brain structures. Npy-specific changes in the levels of acetylated histone (H3K9/14ac) and CBP in the amygdala were also measured. We found that the pharmacological blockade of CB1 receptors with AM4113 reduced alcohol consumption and, in an ethanol-naïve cohort, reduced anxiety-like behavior in the LDB. Treatment with AM4113 also increased the mRNA levels of Creb1 and Cbp in the amygdala as well as the protein levels of pCREB, CBP, H3K9ac and H3K14ac in the central and medial nucleus of amygdala, but not in the basolateral amygdala. Additionally, AM4113 treatment increased occupancy of CBP and H3K9/14ac at the Npy gene promoter, leading to an increase in both mRNA and protein levels of NPY in the amygdala. These novel findings suggest that CB1 receptor-mediated CREB signaling plays an important role in the modulation of NPY function through an epigenetic mechanism and further support the potential use of CB1 receptor neutral antagonists for the treatment of alcohol use disorder.

Within the autistic spectrum, there is remarkable variability in the etiology, presentation, and treatment response. This prospective study was designed to identify, through cluster analysis, subgroups of individuals with ASD without intellectual disability (ID) based on the severity of the core symptoms in childhood. The secondary aim was to explore whether these subgroups and a group with typical development (TD) differ in cognitive, adaptive, and social aspects measured in adolescence. The sample at baseline was comprised of 52 children with ASD without ID and 37 children with TD, aged 7-11. Among the ASD group, three clusters were identified. Cluster 1 (40%), 'high severity', presented high symptom severity on the DSM-5 criteria and the Social Communication Questionnaire. Cluster 2 (34%) showed 'moderate severity' on most of the scores. Cluster 3 (25%) corresponded to 'low severity', showing moderate social impairment and low restrictive, repetitive patterns of behavior, interests and activities. At 5-year follow-up, 45 adolescents with ASD without ID and 27 adolescents with TD were assessed. All clusters had significantly more difficulties in EF, ToM, socialization and adaptive behavior compared to TD. Social and adaptive trajectories between the ASD subgroups were relatively different; Cluster 3 showed poorer socialization and daily living skills than the other two subgroups. These findings highlight the importance of fully assessing social, cognitive, and adaptive profiles to develop care plans tailored to specific needs.

INTRODUCTION/BACKGROUND:Violence risk assessment is one of the most frequent reasons for child and adolescent psychiatry consultation with adolescents in the pediatric emergency department (ED). Here we provide a systematic review of risk factors for violence in adolescents using the risk factor categories from the MacArthur Violence Risk Assessment study. Further, we provide clinical guidance for assessing adolescent violence risk in the pediatric ED. METHODS:For this systematic review, we used the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2009 checklist. We searched PubMed and PsycINFO databases (1966-July 1, 2020) for studies that reported risk factors for violence in adolescents. RESULTS:Risk factors for adolescent violence can be organized by MacArthur risk factor categories. Personal characteristics include male gender, younger age, no religious affiliation, lower IQ, and Black, Hispanic, or multiracial race. Historical characteristics include a younger age at first offense, higher number of previous criminal offenses, criminal history in one parent, physical abuse, experiencing poor child-rearing, and low parental education level. Among contextual characteristics, high peer delinquency or violent peer-group membership, low grade point average and poor academic performance, low connectedness to school, truancy, and school failure, along with victimization, are risk factors. Also, firearm access is a risk factor for violence in children and adolescents. Clinical characteristics include substance use, depressive mood, attention deficit hyperactivity disorder, antisocial traits, callous/unemotional traits, grandiosity, and justification of violence. CONCLUSION/CONCLUSIONS:Using MacArthur risk factor categories as organizing principles, this systematic review recommends the Structured Assessment of Violence Risk in Youth (SAVRY) risk- assessment tool for assessing adolescent violence risk in the pediatric ED.

Though notable progress has been made in protections for LGBTQ people in the United States, they are still disproportionately victims of discrimination and harassment. Activism efforts on behalf of LGBTQ communities by heterosexual, cisgender people-known as cishet allies-are critical to maintaining and gaining civil rights. Social justice praxis encourages people with privileged identities, such as heterosexuals, to act on behalf of and in coalition with LGBTQ communities. The current study conducted a thematic qualitative content analysis of open-ended self-report data about activist behaviors and beliefs of 249 self-identified cishet allies. Results describe: types of activism, events that sparked activism, motivators for activism, and barriers to activism. Findings show that educating self and others are key activist behaviors while social media usage may mitigate barriers, such as perceived lack of social support and time. Findings are discussed in context of sample limitations and future research directions are outlined.