Faculty Bibliography

RATIONALE & OBJECTIVE:Pneumococcal vaccine is recommended for adults 65 years and older and those younger than 65 years with clinical indications (eg, diabetes, lung/heart disease, kidney failure, and nephrotic syndrome). Its cost-effectiveness in less severe chronic kidney disease (CKD) is uncharacterized. STUDY DESIGN:Cost-effectiveness analysis. SETTING & POPULATION:) or nephrotic-range albuminuria (urinary albumin-creatinine ratio≥2,000mg/g). Data sources were the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004, Centers for Disease Control and Prevention, and the Atherosclerosis Risk in Communities (ARIC) Study. INTERVENTION(S):Vaccination compared to no vaccination. OUTCOMES:Incremental cost-effectiveness ratios based on US dollars per quality-adjusted life-year (QALY). MODEL, PERSPECTIVE, & TIMEFRAME:Markov model, US health sector perspective, and lifetime horizon. RESULTS:The prevalence of pneumococcal vaccination in NHANES 1999 to 2004 was 56.6% (aged 65-79 years), 28.5% (aged 50-64 years with an indication), and 9.7% (aged 50-64 years without an indication), with similar prevalences across CKD risk status. Pneumococcal vaccination was overall cost-effective (<US $100,000/QALY) for adults aged 65 to 79 years (US $15,000/QALY) and 50 to 64 years (US $38,000/QALY). Among those aged 50 to 64 years, incremental cost-effectiveness ratios were lowest for kidney failure or nephrotic-range albuminuria (US $1,000/QALY), followed by CKD with high risk (US $17,000/QALY), CKD with moderate risk (US $25,000/QALY), and no CKD (US $43,000/QALY). Pneumococcal vaccination was cost-effective among adults aged 50 to 64 years with CKD even when assuming the lowest vaccine efficacy or 50% higher vaccine costs. LIMITATIONS:Some model parameters were based on data from the general population. Analysis did not consider costs associated with kidney disease progression. CONCLUSIONS:Uptake of pneumococcal vaccination should be improved in general. Our results also suggest the cost-effectiveness of expanding its indication to younger adults with CKD less severe than kidney failure or nephrotic syndrome.

BACKGROUND:The diagnosis of posttraumatic stress disorder (PTSD) is usually based on clinical interviews or self-report measures. Both approaches are subject to under- and over-reporting of symptoms. An objective test is lacking. We have developed a classifier of PTSD based on objective speech-marker features that discriminate PTSD cases from controls. METHODS:Speech samples were obtained from warzone-exposed veterans, 52 cases with PTSD and 77 controls, assessed with the Clinician-Administered PTSD Scale. Individuals with major depressive disorder (MDD) were excluded. Audio recordings of clinical interviews were used to obtain 40,526 speech features which were input to a random forest (RF) algorithm. RESULTS:The selected RF used 18 speech features and the receiver operating characteristic curve had an area under the curve (AUC) of 0.954. At a probability of PTSD cut point of 0.423, Youden's index was 0.787, and overall correct classification rate was 89.1%. The probability of PTSD was higher for markers that indicated slower, more monotonous speech, less change in tonality, and less activation. Depression symptoms, alcohol use disorder, and TBI did not meet statistical tests to be considered confounders. CONCLUSIONS:This study demonstrates that a speech-based algorithm can objectively differentiate PTSD cases from controls. The RF classifier had a high AUC. Further validation in an independent sample and appraisal of the classifier to identify those with MDD only compared with those with PTSD comorbid with MDD is required.

OBJECTIVE:We sought to examine associations in older adults among diabetes, glycemic control, diabetes duration, and biomarkers of hyperglycemia with incident mild cognitive impairment (MCI) and incident dementia. RESEARCH DESIGN AND METHODS:, fructosamine, glycated albumin, and 1,5-anhydroglucitol. RESULTS:and fructosamine were also associated with incident MCI. CONCLUSIONS:Diabetes status, poor glycemic control, and longer diabetes duration were associated with worse cognitive outcomes over a median follow-up of 5 years.

Rationale: Air quality improvements are increasingly difficult to come by as modern pollution control technologies and measures have been widely implemented in the United States. Although there have been dramatic improvements in air quality over the last several decades, it is important to evaluate changes in the health impacts of air pollution for a more recent time period to better understand the current trajectory of air quality improvements. Objectives: To provide county-level estimates of annual air pollution-related health outcomes across the United States and to evaluate these trends from 2008 to 2017, presented as part of the annual American Thoracic Society (ATS)/Marron Institute "Health of the Air" report. Methods: Daily air pollution values were obtained from the U.S. Environmental Protection Agency's Air Quality System for monitors in the United States from 2008 to 2017. Concentration-response functions used in the ATS/Marron Institute "Health of the Air" report were applied to the pollution increments corresponding to differences between the rolling 3-year design values (reported as the third year) and ATS-recommended levels for annual particulate matter less than or equal to 2.5 μm in aerodynamic diameter (PM_2.5; 11 μg/m³), short-term PM_2.5 (25 μg/m³), and ozone (O₃; 60 ppb). Health impacts were estimated at the county level in locations with valid monitor data. Results: Annual excess mortality in the United States due to air pollution levels greater than recommended by the ATS decreased from approximately 12,600 (95% confidence interval [CI], 5,470-21,040) in 2010 to 7,140 (95% CI, 2,290-14,040) in 2017. This improvement can be attributed almost entirely to reductions in PM_2.5-related mortality, which decreased by approximately 60% (reduced from 8,330 to 3,260 annual deaths), whereas O₃-related mortality remained largely unchanged, other than year-to-year variability, over the same time period (reduced from 4,270 to 3,880 annual deaths). Conclusions: Improvements in health impacts attributable to ambient PM_2.5 concentrations have been observed across most regions of the United States over the last decade, although the rate of these improvements has leveled off in recent years. Despite two revisions of the National Ambient Air Quality Standards strengthening the standard for O₃ in 2008 and 2015, there has not yet been a substantial improvement in the health impacts attributable to O₃ during this time period. In many U.S. cities, an increase in the exposed population over the last decade has outpaced the improvements in ambient O₃ concentrations, resulting in a net increase in O₃-related health impacts over time.

Background Understanding the relationships between demographic, healthcare-related and psychosocial factors with STI vulnerability will provide information that can guide development of STI prevention efforts tailored to the lived realities of YMSM. Methods Between 2009-2011, n=600 YMSM were enrolled at age 18 in a prospective cohort study examining psychosocial and physical health during semi-annual visits conducted over a 36-month period. Reports of recent STIs were collected by self-report and a composite outcome variable was created: self-report of any STI (CT, GC, and/or syphilis) in the prior 90 days (hereafter called STI diagnoses). Bivariate analysis was conducted to examine relationships between STI diagnoses and 3 domains of covariates: demographic factors, psychosocial factors, and healthcare system related factors. Generalized estimating equations (GEE) with link logit was used to model factors from each domain associated with STI diagnoses. Results Over the course of the study period, these 597 participants contributed a total of 2,765 visits and self-reported n=205 STI diagnoses (composite variable detailed above). Increased age was associated with increased likelihood of STI diagnoses (aOR=1.22 per year, 95% CI 1.04-1.43) after adjustment for SES, race, #insertive/receptive anal intercourse acts, type of healthcare obtained (private clinic, public clinic, VA), and insurance status. Black/African YMSM were more likely to self-report an STI (aOR=2.90, 95% CI 1.50-5.61), compared to White (non-hispanic) peers (adjusted for age, SES, #sex acts, clinic type, and insurance). Participants receiving healthcare at public clinics (aOR= 1.89, 95% CI 1.30- 2.77) and VA facilities (aOR= 4.13 95% CI 2.24-7.60) were more likely to report STI diagnoses than those attending private clinics (adjusted for age, race, SES, #sex acts, insurance). Depression score, gay-related stigma, internalized homophobia were not associated with STI diagnoses. Conclusion Older black/african YMSM were more likely to self-report an STI, perhaps because they participant in a different core mixing group of sexual contacts than other participants

OBJECTIVES/OBJECTIVE:To characterize bone scan use, and potential overuse, after radical prostatectomy using a large, national integrated delivery system. Overuse of imaging is well documented in the setting of newly diagnosed prostate cancer, but whether overuse persists following radical prostatectomy remains unknown. MATERIALS AND METHODS/METHODS:We identified 12,269 prostate cancer patients treated with radical prostatectomy between 2005-2008 using the Veterans Administration Central Cancer Registry. We used administrative and laboratory data to examine rates of bone scan use, including preceding PSA levels, and receipt of adjuvant or salvage therapy. We then performed multivariable logistic regression to identify factors associated with post-prostatectomy bone scan use. RESULTS:At a median follow up of 6.8 years, one in five men (22%) underwent a postoperative bone scan at a median PSA of 0.2 ng/mL. Half of bone scans (48%) were obtained in men who did not receive further treatment with androgen deprivation (ADT) or radiation therapy. After adjustment, post-prostatectomy bone scan was associated with a prior bone scan (adjusted Odds Ratio (aOR) 1.55, 95% Confidence Interval (CI) 1.32 - 1.84), positive surgical margin (aOR 1.68, 95% CI 1.40 - 2.01), preoperative PSA (aOR 1.02, 95% CI 1.01 - 1.03) as well as Hispanic ethnicity, black race, and increasing D'Amico risk category, but not with age or comorbidity. CONCLUSION/CONCLUSIONS:We found a substantial rate of bone scan utilization after radical prostatectomy. The majority was performed for PSA <1ng/mL where the likelihood of a positive test is low. More judicious use of imaging appears warranted in the post-prostatectomy setting.

Adolescents are an important population to represent in biobanks. Inclusion of biospecimens from adolescents advances our understanding of the long-term consequences of pediatric disease and allows the discovery of methods to prevent adult diseases during childhood. Consent for biobanking is complex, especially when considering adolescent participation, as it brings up issues that are not present with general clinical research. The development and successful implementation of an adolescent capacity assessment tool applied specifically to biobanking can potentially provide researchers and clinicians with contextualized information on participants' understanding, appreciation, reasoning, and voluntary choice for biobanks. This tool would enhance current studies looking at the role of shared decision-making in biobanking, as well as provide a formal measurement when considering decisions around pediatric and adolescent biobanking participation. This study adapted the MacCAT-CR for use with a hypothetical adolescent biobank study and examines predictors of MacCAT-CR scores on healthy and chronically ill adolescents.

Low perception of HIV risk is a challenge to PrEP implementation. We analyzed associations between perceptions of PrEP candidacy, behavioral indications for PrEP, and sexual behaviors. We recruited a sample of 580 MSM from a geosocial-networking smartphone application in Paris, France. A modified Poisson regression model was conducted to examine associations between perceived candidacy for PrEP and behavioral indications for PrEP, and relationships among engagement in group sex, transactional sex, HIV test history, and indications for PrEP. Adjusted risk ratios (aRR) and 95% confidence intervals (CIs) were calculated. For the outcome of perceived candidacy for PrEP, a multinomial logistic regression was performed, and adjusted relative risk ratios (aRRR) were calculated. Multivariate analyses were adjusted for socio-demographics. Respondents who considered themselves PrEP candidates were more likely to meet PrEP eligibility criteria compared to those who did not consider themselves candidates (aRR 1.65; 95% CI 1.34-2.03). Those who had engaged in group or transactional sex were more likely to have behavioral indications for PrEP (aRR 1.27; 95% CI 1.07-1.50, aRR 1.32; 95% CI 1.13-1.56, respectively), whereas HIV test history was not significantly associated with behavioral indications for PrEP. Respondents who had engaged in group sex or transactional sex were more likely to perceive themselves as candidates for PrEP (aRRR 2.24; 95% CI 1.21-4.16, aRRR 2.58; 95% CI 1.09-6.13, respectively), although those never tested for HIV were less likely to perceive themselves as candidates for PrEP (aRRR 0.18; 95% CI 0.03-0.91). The elucidation of candidacy perceptions and risk behaviors is key to furthering the effective implementation of PrEP engagement interventions.

Background Transgender and gender non-binary people have unique sexual health needs and rates of HIV and other sexually transmissible infections that outstrip the general population. Very little is known, however, about their experiences of sexual health care, including how those experiences might affect sexual health screening practices. Methods Using data collected via a national survey of transgender and non-binary people in Australia (n=1,636), responses to four items on sexual health care experiences were summed to create a scale from 0 (gender-sensitive) to 4 (gender-insensitive). Bivariate and multivariate analyses compared scale scores and assessed associations with sexual health screening. Results In total, 50% of trans and non-binary participants were uncomfortable disclosing their gender during sexual health care, 68% reported that intake paperwork did not allow accurate gender descriptions, 74% felt staff made assumptions about their bodies or sex lives, and 40% did not receive sexual health care that was sensitive to their needs. On average, non-binary participants experienced the greatest degree of gender-insensitivity (M=2.3) compared with transgender men (M=1.8) and women (M=1.6, p<0.001). Gender insensitivity was most common in hospitals (M=2.9) followed by general practice clinics (M=2.1) and least common in sexual health clinics (M=1.6) and community-lead sexual health services (M=1.3, p<0.001). Among sexually active participants, 51% had received a sexual health screen in the previous year. After controlling for confounders (age, education, income, monogamy, condom use), transgender and non-binary people with more gender-insensitive experiences of sexual health care were less likely to report a recent sexual health screen (adjusted odds ratio=1.3, 95% confidence interval:1.1- 1.5, p<0.001). Conclusion Transgender and, in particular, non-binary people experience gender insensitivity when receiving sexual health care, most notably in hospital settings. This insensitivity is associated with delaying sexual health screens among the sexually active. Educating health providers on gender sensitive sexual health care could improve screening uptake