Faculty Bibliography

BACKGROUND:Children in Sub-Saharan Africa (SSA) comprise half of the total regional population, yet existing mental health services are severely under-equipped to meet their needs. Although effective interventions for the treatment of disruptive behavioral disorders (DBDs) in youth have been tested in high-poverty and high-stress communities in developed countries, and are relevant for widespread dissemination in low- and middle-income countries (LMICs), most of these evidence-based practices (EBPs) have not been utilized in SSA, a region heavily impacted by poverty, diseases including HIV/AIDS, and violence. Thus, this paper presents a protocol for a scale-up longitudinal experimental study that uses a mixed-methods, hybrid type II, effectiveness implementation design to test the effectiveness of an EBP, called Multiple Family Group (MFG) aimed at improving child behavioral challenges in Uganda while concurrently examining the multi-level factors that influence uptake, implementation, sustainment, and youth outcomes. METHODS:The MFG intervention will be implemented and tested via a longitudinal experimental study conducted across 30 public primary schools located in both semi-urban and rural communities. The schools will be randomly assigned to three study conditions (n = 10 per study condition): (1) MFG delivered by trained family peers; (2) MFG delivered by community health workers; or; (3) comparison: usual care comprising mental health care support materials, bolstered with school support materials. A total of 3000 children (ages 8 to 13 years; grades 2 to 7) and their caregivers (N = 3000 dyads); 60 parent peers, and 60 community health workers will be recruited. Each study condition will comprise of 1000 child-caregiver dyads. Data will be collected at baseline, 8 and 16 weeks, and 6-month follow-up. DISCUSSION/CONCLUSIONS:This project is the first to test the effectiveness of the MFG intervention while concurrently examining multi-level factors that influence overall implementation of a family-based intervention provided in schools and aimed at reaching the large child population with mental health service needs in Uganda. Moreover, the study draws upon an EBP that has already been tested for delivery by parent peers and community facilitators, and hence will take advantage of the advancing science behind task-shifting. If successful, the project has great potential to address global child mental health needs. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov, ID: NCT03081195 . Registered on 16 March 2017.

Importance/UNASSIGNED:Prostate cancer imaging rates appear to vary by health care setting. With the recent extension of the Veterans Access, Choice, and Accountability Act, the government has provided funds for veterans to seek care outside the Veterans Health Administration (VA). It is important to understand the difference in imaging rates and subsequent differences in patterns of care in the VA vs a traditional fee-for-service setting such as Medicare. Objective/UNASSIGNED:To assess the association between prostate cancer imaging rates and a VA vs fee-for-service health care setting. Design, Setting, and Participants/UNASSIGNED:This cohort study included data for men who received a diagnosis of prostate cancer from January 1, 2004, through March 31, 2008, that were collected from the VA Central Cancer Registry, linked to administrate claims and Medicare utilization records, and the Surveillance, Epidemiology, and End Results Program database. Three distinct nationally representative cohorts were constructed (use of VA only, use of Medicare only, and dual use of VA and Medicare). Men older than 85 years at diagnosis and men without high-risk features but missing any tumor risk characteristic (prostate-specific antigen, Gleason grade, or clinical stage) were excluded. Analysis of the data was completed from March 2016 to February 2018. Exposures/UNASSIGNED:Patient utilization of different health care delivery systems. Main Outcomes and Measures/UNASSIGNED:Rates of prostate cancer imaging were analyzed by health care setting (Medicare only, VA and Medicare, and VA only) among patients with low-risk prostate cancer and patients with high-risk prostate cancer. Results/UNASSIGNED:Of 98 867 men with prostate cancer (77.4% white; mean [SD] age, 70.26 [7.48] years) in the study cohort, 57.3% were in the Medicare-only group, 14.5% in the VA and Medicare group, and 28.1% in the VA-only group. Among men with low-risk prostate cancer, the Medicare-only group had the highest rate of guideline-discordant imaging (52.5%), followed by the VA and Medicare group (50.9%) and the VA-only group (45.9%) (P < .001). Imaging rates for men with high-risk prostate cancer were not significantly different among the 3 groups. Multivariable analysis showed that individuals in the VA and Medicare group (risk ratio [RR], 0.87; 95% CI, 0.76-0.98) and VA-only group (RR, 0.79; 95% CI, 0.67-0.92) were less likely to receive guideline-discordant imaging than those in the Medicare-only group. Conclusions and Relevance/UNASSIGNED:The results of this study suggest that patients with prostate cancer who use Medicare rather than the VA for health care could experience more utilization of health care services without an improvement in the quality of care.

OBJECTIVE:Even though safe and effective treatments for depression are available, many individuals with a diagnosis of depression do not obtain treatment. This study aimed to develop a tool to identify persons who might not initiate treatment among those who acknowledge a need. METHODS:Data were aggregated from the 2008-2014 U.S. National Survey on Drug Use and Health (N=391,753), including 20,785 adults given a diagnosis of depression by a health care provider in the 12 months before the survey. Machine learning was applied to self-report survey items to develop strategies for identifying individuals who might not get needed treatment. RESULTS:A derivation cohort aggregated between 2008 and 2013 was used to develop a model that identified the 30.6% of individuals with depression who reported needing but not getting treatment. When applied to independent responses from the 2014 cohort, the model identified 72% of those who did not initiate treatment (p<.01), with a balanced accuracy that was also significantly above chance (71%, p<.01). For individuals who did not get treatment, the model predicted 10 (out of 15) reasons that they endorsed as barriers to treatment, with balanced accuracies between 53% and 65% (p<.05 for all). CONCLUSIONS:Considerable work is needed to improve follow-up and retention rates after the critical initial meeting in which a patient is given a diagnosis of depression. Routinely collected information about patients with depression could identify those at risk of not obtaining needed treatment, which may inform the development and implementation of interventions to reduce the prevalence of untreated depression.

BACKGROUND:The Dietary Approaches to Stop Hypertension (DASH) dietary pattern is recommended for cardiovascular disease risk reduction. Assessment of dietary intake has been limited to subjective measures and a few biomarkers from 24-h urine collections. OBJECTIVE:The aim of the study was to use metabolomics to identify serum compounds that are associated with adherence to the DASH dietary pattern. DESIGN:We conducted untargeted metabolomic profiling in serum specimens collected at the end of 8 wk following the DASH diet (n = 110), the fruit and vegetables diet (n = 111), or a control diet (n = 108) in a multicenter, randomized clinical feeding study (n = 329). Multivariable linear regression was used to determine the associations between the randomized diets and individual log-transformed metabolites after adjustment for age, sex, race, education, body mass index, and hypertension. Partial least-squares discriminant analysis (PLS-DA) was used to identify a panel of compounds that discriminated between the dietary patterns. The area under the curve (C statistic) was calculated as the cumulative ability to distinguish between dietary patterns. We accounted for multiple comparisons with the use of the Bonferroni method (0.05 of 818 metabolites = 6.11 × 10-5). RESULTS:Serum concentrations of 44 known metabolites differed significantly between participants randomly assigned to the DASH diet compared with both the control diet and the fruit and vegetables diet, which included an amino acid, 2 cofactors and vitamins (n = 2), and lipids (n = 41). With the use of PLS-DA, component 1 explained 29.4% of the variance and component 2 explained 12.6% of the variance. The 10 most influential metabolites for discriminating between the DASH and control dietary patterns were N-methylproline, stachydrine, tryptophan betaine, theobromine, 7-methylurate, chiro-inositol, 3-methylxanthine, methyl glucopyranoside, β-cryptoxanthin, and 7-methylxanthine (C statistic = 0.986). CONCLUSIONS:An untargeted metabolomic platform identified a broad array of serum metabolites that differed between the DASH diet and 2 other dietary patterns. This newly identified metabolite panel may be used to assess adherence to the DASH dietary pattern. This trial was registered at http://www.clinicaltrials.gov as NCT03403166.

BACKGROUND:Chronic kidney disease (CKD) afflicts many older adults and increases the risk for medication-related adverse events. OBJECTIVE:The aim of this study was to assess the prevalence and associated morbidity and mortality of polypharmacy (use of several medications concurrently), and potentially inappropriate medication (PIM) use in older adults, looking for differences by CKD status. METHODS:) by level of estimated glomerular filtration rate (eGFR) for participants aged 65 years or older attending a baseline study visit in the Atherosclerosis Risk in Communities study (n =6392). We used zero-inflated negative binomial and Cox proportional hazards regressions to assess the relationship between baseline polypharmacy, PIM use, and subsequent hospitalization and death. RESULTS:. Over a median of 2.6 years, more concurrent medications were associated with higher risk of hospitalization and death, but PIM use was not. While those with CKD had higher absolute risks, there was no difference in the relative risks associated with greater numbers of medications by CKD status. CONCLUSION:Polypharmacy and PIM use were common, with greater numbers of medications associated with higher risk of hospitalization and death; relative risks were similar for those with and without CKD.

PURPOSE OF REVIEW/OBJECTIVE:The social networks of people who inject drugs (PWID) have long been studied to understand disease transmission dynamics and social influences on risky practices. We illustrate how PWID can be active agents promoting HIV, HCV, and overdose prevention. RECENT FINDINGS/RESULTS:We assessed drug users' connections and interactions with others at risk for HIV/HCV in three cities: New York City (NYC), USA (n = 539); Pereira, Colombia (n = 50); and St. Petersburg, Russia (n = 49). In all three cities, the majority of participants' network members were of a similar age as themselves, yet connections across age groups were also present. In NYC, knowing any opioid user(s) older than 29 was associated with testing HCV-positive. In NYC and St. Petersburg, a large proportion of PWID engaged in intravention activities to support safer injection and overdose prevention; in Pereira, PWID injected, had sex, and interacted with other key groups at risk. People who use drugs can be active players in HIV/HCV and overdose risk- reduction; their networks provide them with ample opportunities to disseminate harm reduction knowledge, strategies, and norms to others at risk. Local communities could augment prevention programming by empowering drug users to be allies in the fight against HIV and facilitating their pre-existing health-protective actions.

Incarceration is strongly associated with post-release STI/HIV risk. One pathway linking incarceration and STI/HIV risk may be incarceration-related dissolution of protective network ties. Among African American men released from prison who were in committed partnerships with women at the time of incarceration (N = 207), we measured the association between committed partnership dissolution during incarceration and STI/HIV risk in the 4 weeks after release. Over one-quarter (28%) experienced incarceration-related partnership dissolution. In adjusted analyses, incarceration-related partnership dissolution was strongly associated with post-release binge drinking (adjusted odds ratio (AOR) 4.2, 95% confidence interval (CI); 1.4-15.5). Those who experienced incarceration-related partnership dissolution were much more likely to engage in multiple/concurrent partnerships or sex trade defined as buying or selling sex (64%) than those who returned to the partner (12%; AOR 20.1, 95% CI 3.4-175.6). Policies that promote maintenance of relationships during incarceration may be important for protecting health.

Sedentary behavior and lack of physical activity are key modifiable behavioral risk factors for chronic health problems, such as obesity and diabetes. Little is known about how sedentary behavior and physical activity among adolescents spatially cluster. The objective was to detect spatial clustering of sedentary behavior and physical activity among Boston adolescents. Data were used from the 2008 Boston Youth Survey Geospatial Dataset, a sample of public high school students who responded to a sedentary behavior and physical activity questionnaire. Four binary variables were created: 1) TV watching (>2 hours/day), 2) video games (>2 hours/day), 3) total screen time (>2 hours/day); and 4) 20 minutes/day of physical activity (≥5 days/week). A spatial scan statistic was utilized to detect clustering of sedentary behavior and physical activity. One statistically significant cluster of TV watching emerged among Boston adolescents in the unadjusted model. Students inside the cluster were more than twice as likely to report > 2 hours/day of TV watching compared to respondents outside the cluster. No significant clusters of sedentary behavior and physical activity emerged. Findings suggest that TV watching is spatially clustered among Boston adolescents. Such findings may serve to inform public health policymakers by identifying specific locations in Boston that could provide opportunities for policy intervention. Future research should examine what is linked to the clusters, such as neighborhood environments and network effects.