Faculty Bibliography

Real-time functional magnetic resonance imaging (rt-fMRI) has revived the translational perspective of neurofeedback (NF)¹. Particularly for stress management, targeting deeply located limbic areas involved in stress processing² has paved new paths for brain-guided interventions. However, the high cost and immobility of fMRI constitute a challenging drawback for the scalability (accessibility and cost-effectiveness) of the approach, particularly for clinical purposes³. The current study aimed to overcome the limited applicability of rt-fMRI by using an electroencephalography (EEG) model endowed with improved spatial resolution, derived from simultaneous EEG-fMRI, to target amygdala activity (termed amygdala electrical fingerprint (Amyg-EFP))^4-6. Healthy individuals (n = 180) undergoing a stressful military training programme were randomly assigned to six Amyg-EFP-NF sessions or one of two controls (control-EEG-NF or NoNF), taking place at the military training base. The results demonstrated specificity of NF learning to the targeted Amyg-EFP signal, which led to reduced alexithymia and faster emotional Stroop, indicating better stress coping following Amyg-EFP-NF relative to controls. Neural target engagement was demonstrated in a follow-up fMRI-NF, showing greater amygdala blood-oxygen-level-dependent downregulation and amygdala-ventromedial prefrontal cortex functional connectivity following Amyg-EFP-NF relative to NoNF. Together, these results demonstrate limbic specificity and efficacy of Amyg-EFP-NF during a stressful period, pointing to a scalable non-pharmacological yet neuroscience-based training to prevent stress-induced psychopathology.

BACKGROUND AND AIMS/OBJECTIVE:Cost-effectiveness studies in randomized clinical trials have shown that tobacco cessation pharmacotherapy is among the most cost-effective of health care interventions. Clinical trial eligibility criteria and treatment protocols may not be followed in actual practice. This study aimed to determine whether tobacco cessation pharmacotherapy is cost-effective in real-world settings. DESIGN/METHODS:A retrospective analysis of costs and outcomes SETTING: Hospitals and clinics of the US Veterans Health Administration, USA. PARTICIPANTS/METHODS:A total of 589,862 US veterans who screened positive for tobacco use in 2011. INTERVENTION AND COMPARATOR/UNASSIGNED:Tobacco users who initiated smoking cessation pharmacotherapy in the 6 months after screening were compared with those who did not use pharmacotherapy in this period. Pharmacotherapy included nicotine replacement theapy, bupropion (if prescribed at 300 mg per day or specifically for tobacco cessation), or varenicline. MEASURES/METHODS:Effectiveness was determined from responses to a subsequent tobacco screening conducted between 7 and 18 months after the treatment observation period. Cost of medications and prescribing health care encounters was determined for the period between initial and follow-up tobacco use screening. Multivariate fixed -effects regression was used to assess the effect of initial treatment status on cost and outcome while controlling for differences in case-mix with propensity weighting to adjust for confounding by indication. FINDINGS/RESULTS:13.0% of participants received tobacco cessation pharmacotherapy within 6 months of initial screening. After an average of an additional 218 days follow-up, those who initially received pharmacotherapy incurred $144 in additional treatment cost and had a 3.1% absolute increase in tobacco quit rates compared with those who were not initially treated. This represents an incremental cost-effectiveness ratio of $4,705 per quit. The upper limit of the 99.9% confidence region was $5,600 per quit. Without propensity adjustment, the cost-effectiveness ratio was $7,144 per quit, with the upper limit of the 99.9% confidence region $9,500/quit. CONCLUSIONS:Tobacco cessation pharmacotherapy provided by the US Veterans Health Administration in 2011/12 was cost-effective in this real-world setting, with an incremental cost-effectiveness ratio of $4,705 per quit.

As a prevention strategy, HIV pre-exposure prophylaxis (PrEP) may benefit men who participate in group sex, but little is known about PrEP among this group internationally and virtually nothing is known of the European context. This study used an online survey of gay men living in Paris, France to assess associations between group sex and awareness of, use and interest in PrEP in its once-daily, episodic, injectable, and microbicidal forms. Men reporting recent (within 3 months) condomless group sex were much more likely to report once-daily PrEP use than men with no group sex experience (41.5% vs 7.7%, p < .001). Uptake was similarly low among men who had group sex with condoms (8.0%) and those with less-recent experience (6.43%). Overall, willingness to use PrEP-including its non-daily forms-was high among men reporting group sex, suggesting opportunities for outreach and implementation.

OBJECTIVE:/UNASSIGNED:Despite the potential benefits of mobile mental health apps, real-world results indicate engagement issues because of low uptake and sustained use. This review examined how studies have measured and reported on user engagement indicators (UEIs) for mental health apps. METHODS:/UNASSIGNED:A systematic review of multiple databases was performed in July 2018 for studies of mental health apps for depression, bipolar disorder, schizophrenia, and anxiety that reported on UEIs, namely usability, user satisfaction, acceptability, and feasibility. The subjective and objective criteria used to assess UEIs, among other data, were extracted from each study. RESULTS:/UNASSIGNED:Of 925 results, 40 studies were eligible. Every study reported positive results for the usability, satisfaction, acceptability, or feasibility of the app. Of the 40 studies, 36 (90%) employed 371 indistinct subjective criteria that were assessed with surveys, interviews, or both, and 23 studies used custom subjective scales, rather than preexisting standardized assessment tools. A total of 25 studies (63%) used objective criteria-with 71 indistinct measures. No two studies used the same combination of subjective or objective criteria to assess UEIs of the app. CONCLUSIONS:/UNASSIGNED:The high heterogeneity and use of custom criteria to assess mental health apps in terms of usability, user satisfaction, acceptability, or feasibility present a challenge for understanding real-world low uptake of these apps. Every study reviewed claimed that UEIs for the app were rated highly, which suggests a need for the field to focus on engagement by creating reporting standards and more carefully considering claims.

BACKGROUND:Research on the patterns of use of medical cannabis among cancer patients is lacking. OBJECTIVE:To describe patterns of medical cannabis use by patients with cancer, and how patterns differ from patients without cancer. DESIGN/MEASUREMENTS/METHODS:We performed secondary data analysis using data from a medical cannabis licensee in New York State, analyzing demographic information, qualifying conditions, and symptoms, and the medical cannabis product used, including tetrahydrocannabinol (THC) to cannabidiol (CBD) ratios. SETTING/SUBJECTS/METHODS:Adults age ≥18 who used New York State medical cannabis licensee products between January 2016 and December 2017. RESULTS:There were a total of 11,590 individuals with 1990 (17.2%) having cancer who used at least one cannabis product. Patients with cancer using cannabis were older and more likely to be female. The most common qualifying symptom for both cancer and noncancer patients was severe or chronic pain. Cancer patients were more likely to use the sublingual tincture form of cannabis (n = 1098, 55.2%), while noncancer patients were more likely to use the vaporization form (n = 4222, 44.0%). Over time, across all patients, there was an increase in the THC daily dose by a factor of 0.20 mg/week, yielding a corresponding increase in the THC:CBD daily ratio. Compared with noncancer patients, these trends were not different in the cancer group for THC daily dose, but there were less pronounced increases in the THC:CBD daily ratio over time among cancer patients. CONCLUSIONS:Our study found some key differences in demographics and medical cannabis product use between patients with cancer and without cancer.

BACKGROUND:Cocaine is commonly involved in unintentional drug poisoning (overdose) deaths, accounting for 46% of overdose deaths in New York City (NYC) in 2016. However, little research exists regarding cocaine use by middle-aged and older adults, who are more likely than younger individuals to have underlying cardiovascular disease (CVD) and therefore, may be at increased risk for the adverse health consequences of cocaine. METHODS:We conducted a retrospective analysis of unintentional drug overdose deaths of middle-aged and older NYC residents age 45-84 from 2000 to 2016 using two linked sources, NYC death certificates and toxicology results from the Office of the Chief Medical Examiner. RESULTS:From 2000 to 2016, there were 6061 unintentional drug overdose deaths among New Yorkers age 45-84. Of those, cocaine was involved in 53% (n = 3183). Co-occurring opioid involvement (fentanyl, heroin, methadone, or opioid analgesics) among deaths involving cocaine was common (58%). Compared to decedents of non-cocaine involved overdose, decedents of cocaine-involved overdose were more likely to be male and non-Latino Black. Multivariable analysis showed that adults age 45-54 (adjusted odds ratio [AOR] = 1.34, 95% 1.05, 1.70), males (AOR = 1.30, 95% CI 1.15, 1.46), Bronx residence (AOR = 1.29, 95% CI 1.08, 1.54), and non-Latino black race/ethnicity (AOR = 2.37, 95% CI 2.07, 2.72) were independently associated with cocaine-involved overdose. CONCLUSION/CONCLUSIONS:Characteristics of decedents of cocaine-involved overdose overlap with populations with high CVD burden in NYC. Studies are needed to better understand the risks of cocaine among adults with underlying CVD.

In New York City, over 90% of women newly diagnosed with human immunodeficiency virus (HIV) are Black and Latina; a quarter of these infections occur among 30-39 year-olds. A survey was administered to 343 Black and Puerto Rican women (2014-2016) to examine two HIV infection risk factors: relationship exclusivity and having experienced childhood sexual abuse (CSA). A majority of male partners (69.7%) had at least one risk for HIV transmission. Women in non-exclusive sexual relationships (nESRs) had higher-risk partners, but engaged in safer sex practices than those in ESRs. Two-thirds of women in ESRs (64.8%) reported unprotected vaginal intercourse, although 33.5% had partners with a history of concurrent relationships. Among women in nESRs, having experienced CSA was a strong risk factor for HIV infection. Black and Latina women's vulnerability to HIV infection is significant, even when in exclusive relationships. Safer sex counseling should be integrated in primary care.

BACKGROUND:Full-term pregnancy (FTP) at an early age confers long-term protection against breast cancer. Previously, we reported that a FTP imprints a specific gene expression profile in the breast of postmenopausal women. Herein, we evaluated gene expression changes induced by parity in the breast of premenopausal women. METHODS:Gene expression profiling of normal breast tissue from 30 nulliparous (NP) and 79 parous (P) premenopausal volunteers was performed using Affymetrix microarrays. In addition to a discovery/validation analysis, we conducted an analysis of gene expression differences in P vs. NP women as a function of time since last FTP. Finally, a laser capture microdissection substudy was performed to compare the gene expression profile in the whole breast biopsy with that in the epithelial and stromal tissues. RESULTS:Discovery/validation analysis identified 43 differentially expressed genes in P vs. NP breast. Analysis of expression as a function of time since FTP revealed 286 differentially expressed genes (238 up- and 48 downregulated) comparing all P vs. all NP, and/or P women whose last FTP was less than 5 years before biopsy vs. all NP women. The upregulated genes showed three expression patterns: (1) transient: genes upregulated after FTP but whose expression levels returned to NP levels. These genes were mainly related to immune response, specifically activation of T cells. (2) Long-term changing: genes upregulated following FTP, whose expression levels decreased with increasing time since FTP but did not return to NP levels. These were related to immune response and development. (3) Long-term constant: genes that remained upregulated in parous compared to nulliparous breast, independently of time since FTP. These were mainly involved in development/cell differentiation processes, and also chromatin remodeling. Lastly, we found that the gene expression in whole tissue was a weighted average of the expression in epithelial and stromal tissues. CONCLUSIONS:Genes transiently activated by FTP may have a role in protecting the mammary gland against neoplastically transformed cells through activation of T cells. Furthermore, chromatin remodeling and cell differentiation, represented by the genes that are maintained upregulated long after the FTP, may be responsible for the lasting preventive effect against breast cancer.