Faculty Bibliography

OBJECTIVE:To estimate the prevalence of and risk factors for cardiovascular autonomic neuropathy (CAN) in adolescents and young adults with type 1 and type 2 diabetes enrolled in the SEARCH for Diabetes in Youth Study. METHODS:The study included 1646 subjects with type 1 diabetes (age 18 ± 4 years, diabetes duration 8 ± 2 years, HbA1c 9.1 ± 1.9%, 76% non-Hispanic Whites) and 252 with type 2 diabetes (age 22 ± 4 years, diabetes duration 8 ± 2 years, HbA1c 9.2 ± 3.0%, 45% non-Hispanic Blacks). Cross-sectional and longitudinal risk factors were assessed at baseline and follow-up visits. Area under the curve (AUC) was used to assess the longitudinal glycemic exposure and cardiovascular risk factors. CAN was assessed by time and frequency domain indices of heart rate variability (HRV). CAN was defined as the presence of ≥3 of 5 abnormal HRV indices. RESULTS:The prevalence of CAN was 12% in adolescents and young adults with type 1 diabetes and 17% in those with type 2 diabetes. Poor long-term glycemic control (AUC HbA1c), high blood pressure, and elevated triglyceride levels were correlates of CAN in subjects with type 1 diabetes. In those with type 2 diabetes, CAN was associated with elevated triglycerides and increased urinary albumin excretion. CONCLUSIONS:The prevalence of CAN in this multiethnic cohort of adolescents and young adults with type 1 and type 2 diabetes are comparable to those reported in adults with diabetes. Suboptimal glycemic control and elevated triglycerides were the modifiable risk factors associated with CAN.

Despite the availability of the human papillomavirus (HPV) vaccine for males, uptake of the vaccine has been low, particularly among young adult males. This study aimed to investigate the levels of HPV vaccination and predictors of HPV vaccine completion in college men ages 18-26. We analyzed data from the 2015 College Student Health Survey, which was administered at 17 post-secondary institutions in Midwest areas. We included only responses from male participants who were ages 18-26 years old, resulting in a sample size of 2516. We used Andersen's Behavioral Model of Health Services Utilization to guide our study design. Multivariate logistic regression was used to examine predictors of HPV vaccine receipt. College-aged males in our sample had a HPV vaccine completion rate of 50.0%. Male students who were younger, had at least one parent who held a graduate degree, had initiated sex, and were enrolled at a private 4-year institution were more likely to have been vaccinated. These findings suggest that HPV vaccination in college-aged men are low. Efforts are needed to increase HPV vaccination in male students who are older, from lower socioeconomic statuses, have not initiated sex, and enrolled at public institutions. Findings also indicate important gender disparities in vaccine uptake that must be addressed in order to achieve optimal vaccine uptake in college-aged males.

OBJECTIVE:Our objective was to determine specialist physicians' attitudes and practices regarding disclosure of pre-referral errors. SUMMARY BACKGROUND DATA/BACKGROUND:Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral. METHODS:We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure. RESULTS:Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the profession's reputation, and to patient-physician relationships. CONCLUSIONS:Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development.

BACKGROUND:Local and national policies to encourage supermarket opening or expansion are popular strategies for improving access to healthy food for residents in neighborhoods lacking these types of stores, yet few evaluations of such initiatives exist. OBJECTIVE:Our aim was to test whether a newly opened supermarket in the Bronx, NY, changed household availability of healthy and unhealthy food items and reported daily consumption of these items among respondents residing in close proximity (≤0.5 mile) to the new supermarket. DESIGN/METHODS:This quasi-experimental study evaluated changes in purchasing and consumption habits of residents within 0.5 mile of the new supermarket as compared to residents living more than 0.5 mile from the supermarket. Data were collected through street intercept surveys at three different times: once before the store opened (March to August 2011) and in two follow-up periods (1 to 5 months and 13 to 17 months after the store opened). This study analyzed a subset of successfully geocoded resident intersections from the larger study. PARTICIPANTS/SETTING/METHODS:We surveyed 3,998 residents older than the age of 18 years in two Bronx neighborhoods about their food-purchasing behaviors before the store opened and in two follow-up periods. Responses from residents whose intersections were successfully geocoded (N=3,378) were analyzed to examine the consumption and purchasing behaviors of those in close proximity to the new store. INTERVENTION/METHODS:A new supermarket opened in a low-access neighborhood in the Bronx with the help of financial incentives through New York City's Food Retail Expansion to Support Health (FRESH) program. MAIN OUTCOME MEASURES/METHODS:The primary outcome evaluated was the change in percent of respondents reporting that the following food items were "always available" in the home: milk, fruit juice, soda, pastries, packaged snacks, fruits, and vegetables. As a secondary outcome, we explored changes in self-reported daily servings of these items. STATISTICAL ANALYSIS PERFORMED/METHODS:A difference-in-difference analysis was performed, controlling for age, education, marital status, income, sex, race, and ethnicity. RESULTS:Residents within 0.5 mile of the store had increased household availability of both healthy and unhealthy foods. After the introduction of the supermarket, the percent of residents in close proximity to the store who reported always having produce available in the home increased by 8.8% compared to those living >0.5 mile from the store in the first post-period and by 10.6% compared to those living >0.5 mile from the store in the second post-period. A similar positive increase in household availability of salty snacks and pastries was observed. Residents living in close proximity also reported greater consumption of healthy foods like produce and water, and lower intake of soft drinks and pastries. CONCLUSIONS:Given the financial support at the national and local levels to encourage supermarket development and expansion in high-need communities, it is imperative to evaluate the impact of such initiatives. Although the findings have so far been equivocal, our findings give weight to the argument that, at a micro-level, the siting of a new supermarket can indeed impact local purchasing and consumption behavior. Although purchasing for both healthy and unhealthy food items increased, reported consumption showed an increase in servings of healthy items (water, vegetables, and fruit) and a decrease in servings of unhealthy foods (soft drinks, salty snacks, and pastries).

BACKGROUND:To reduce colorectal cancer (CRC) screening disparities, it is important to understand correlates of different types of cancer worry among ethnically diverse individuals. OBJECTIVES/OBJECTIVE:The current study examined the prevalence of three types of cancer worry (i.e., general cancer worry, CRC-specific worry, and worry about CRC test results) as well as sociodemographic and health-related predictors for each type of cancer worry. METHODS:Participants were aged 50-75, at average CRC risk, nonadherent to CRC screening guidelines, and enrolled in a randomized controlled trial to increase CRC screening. Participants completed a baseline questionnaire assessing sociodemographics, health beliefs, healthcare experiences, and three cancer worry measures. Associations between study variables were examined with separate univariate and multivariable logistic regression models. RESULTS:Responses from a total of 416 participants were used. Of these, 47% reported experiencing moderate-to-high levels of general cancer worry. Predictors of general cancer worry were salience and coherence (aOR = 1.1, 95% CI [1.0, 1.3]), perceived susceptibility (aOR = 1.2, 95% CI [1.1, 1.3), and social influence (aOR = 1.1, 95% CI [1.0, 0.1]). Fewer (23%) reported moderate-to-high levels of CRC-specific worry or CRC test worry (35%). Predictors of CRC worry were perceived susceptibility (aOR = 1.4, 95% CI [1.3, 1.6]) and social influence (aOR = 1.1, 95% CI [1.0, 1.2]); predictors of CRC test result worry were perceived susceptibility (aOR = 1.2, 95% CI [1.1, 1.3) and marital status (aOR = 2.0, 95% CI [1.1, 3.7] for married/partnered vs. single and aOR = 2.3, 95% CI [1.3, 4.1] for divorced/widowed vs. single). DISCUSSION/CONCLUSIONS:Perceived susceptibility consistently predicted the three types of cancer worry, whereas other predictors varied between cancer worry types and in magnitude of association. The three types of cancer worry were generally predicted by health beliefs, suggesting potential malleability. Future research should include multiple measures of cancer worry and clear definitions of how cancer worry is measured.

Aim: Naltrexone is first-line pharmacotherapy for alcohol use disorders (AUD). Oral naltrexone (ONTX) is under-prescribed in primary care and possibly limited by poor adherence. Monthly injectable extended-release naltrexone (XR-NTX) may improve rates of medication adherence, retention, good clinical outcomes (Aim 1), and cost savings (Aim 2). Methods: This is an on-going randomized, open-label, comparative effectiveness trial of 24 weeks of XR-NTX vs. O-NTX as AUD treatment in primary care at a public hospital in New York City. Adults (>18 yo) with a DSM-V diagnosis of AUD randomized to XR-NTX (380 mg/month) vs. O-NTX (50-100 mg/day).Medical Management visits occur biweekly (weeks 1-8), then monthly.Major research assessments occur at baseline, weeks 13, 25, 48. The primary outcome is a Good Clinical Outcome (GCO) across weeks 5-24: abstinence or moderate drinking and 0-2 days of heavy drinking per month. This preliminary, descriptive analysis presentsWeek 0-5 results among all participants. Results: N = 237 participants were randomized from 6/14-9/17: mean age 48.5 (SD = 10.6); 71% male; 54% AA, 21%Hispanic; 41% employed, 81%reported other lifetime substance use. Mean AUDIT scores (instrument range 0-40) at baseline: 24.2 (SD = 8.0); mean OCDS (range 0-40) scores 17.1 (SD = 8.1); mean drinks/day 9.6 (SD = 11.6) with 29%abstinent vs. 61% heavy drinking days. Medication induction was robust, 115 of 117 (98.2%) initiating XR-NTX and 120 (100%) filled or received an initial O-NTX prescription. The GCO was reported by 41%XR-NTX and 47%ONTX atWeek 5. DuringWeek 1-5, mean drinks/day were 3.1 (SD = 6.1), 63% abstinent/22%heavy drinking days for XR-NTX; 2.4 (SD = 4.03), 61%abstinent/22%heavy drinking days for O-NTX. 62%received XR-NTX injection #2 and 67%received O-NTXmonthly refill #2. Adherence self-report for O-NTX at Week 5 indicated moderate average daily adherence,MMAS-8 mean (range <6 low, 6 to <8 moderate, =8 high) score 6.13 (SD = 3.02). Conclusion: This on-going XR vs. oral naltrexone alcohol primary care treatment trial recruited a primarily male, unemployed, ethnic minority adult population. Initial acceptance of both XR and ONTX was high. Primary outcomes will focus on drinking reductions and cost and value comparisons during weeks 5-24

BACKGROUND:Despite the large volume of e-waste recycled informally, the prevalence of work-related injuries among e-waste workers is unknown. Therefore, this study assessed the prevalence, patterns and factors associated with occupational injuries among e-waste workers in the informal sector in Nigeria. METHODS:This cross-sectional study adopted a multistage sampling method to select 279 respondents from three cities (Ibadan, Lagos and Aba) in Nigeria. A questionnaire was used to obtain information on sociodemographics, work practices and injury occurrences from the respondents in 2015. The data were analysed using descriptive statistics and standard logistic regression. RESULTS:We found high injury prevalence of 38% and 68% in 1-2 weeks and 6 months preceding the study, respectively. The most common injuries were cuts (59%). Injuries were mainly caused by sharp objects (77%). The majority (82%) of the injuries occurred on the hands/fingers. Despite the high occurrence of injury, only 18% of the workers use personal protective equipment (PPE) and 51% of those that use PPE got at least an injury in 1-2 weeks and 88% got at least an injury in 6 months preceding the study. The factors associated with injury in 1-2 weeks were job designation and the geographical location, while the factors associated with injury in 6 months were job designation, geographical location and age. CONCLUSIONS:There is a high prevalence of injury and low use of PPE among the e-waste workers in Nigeria. Occupational injury can be reduced through health education and safety promotion programmes for e-waste workers.

Background: There are limited data on the adherence of migraine patients to recommendations for evidence-based behavioral treatments. Among patients seen by a headache specialist, we sought to determine rates of adherence to recommended behavioral treatments and barriers to adherence. We also sought to determine whether psychosocial factors such as migraine related disability, locus of control and self-efficacy were associated with adherence to migraine behavioral treatment recommendations. Methods: We conducted a prospective study of consecutive patients presenting to four headache specialists who were diagnosed with migraine at our Headache Center from 2016-2017 to examine whether they adhered to the recommendation to receive behavioral treatment. The primary outcome was whether patients had scheduled at least one visit for behavioral treatment. Descriptive statistics were reported. Patients who made an appointment for behavioral treatment were compared to those who did not across multiple categories including demographics, migraine characteristics, and personal beliefs with ANOVA and chi-square tests. Qualitative analyses were also done for open ended survey questions. Results: Of the 234 eligible patients, 69 (29.5%) were referred for behavioral treatment. Fifty-three (76.8%) patients referred for behavioral treatment were successfully reached by phone. Mean duration from time of referral to follow-up was 76 days (median 76, SD5 45). Just over half of patients (56.6%, N530) adhered to the recommendation for behavioral treatment. Patients who had previously seen a psychologist for their migraines were more likely to adhere to the behavioral treatment recommendation than patients who had not. Time constraints were the most common barrier cited for not scheduling a behavioral treatment appointment. Conclusion: Less than one third of eligible patients were referred for behavioral treatment and only about half adhered to the recommendation to schedule an appointment for behavioral treatment. More research should assess factors which might play a role in adherence to migraine behavioral treatment recommendations

Brazil has a sizable alcohol and substance use disorder (ASUD) population, yet there are considerable gaps in treatment access and retention. ASUD, a chronic medical condition, is highly comorbid with medical and behavioral health disorders. This indicates a need for more targeted interventions in order to achieve health care integration (a major goal of Brazil's health care system). Care management - that is, the organization of patient care by an institution - is a viable strategy to engage individuals with ASUD who might benefit from treatment but are not aware of or do not use the available resources, as well as to help maintain patients in treatment. Care management is considered an essential supplement to the treatment of chronic disease. The objective of this article is to discuss the applicability of care management for the treatment of ASUD within the public health care system in Brazil. We describe models of care management that have been adopted internationally and identify the feasibility and advantages for its adoption in Brazil.