Faculty Bibliography

PURPOSE OF REVIEW:This article reviews the case for recognizing (1) the epidemics of opioid misuse, overdose, hepatitis C virus, and HIV as a syndemic and (2) the importance of examining and addressing structural factors in responses to this syndemic. We focus on the current syndemic in the US, but also consider data from other locations to highlight the issues existing and arising in various contexts. RECENT FINDINGS:Advances in multi-level theory and statistical methods allow sound ecologic and multi-level analyses of the impact of structural factors on the syndemic. Studies of opioid misuse, overdoses, hepatitis C virus, and HIV demonstrate that area-level access to healthcare, medication-assisted treatment of opioid use disorders, sterile injection equipment, and overdose prevention with naloxone, as well as factors such as opioid marketing, income inequality, intensity of policing activities, and health care policies, are related to the prevalence of substance misuse, overdoses, infection risk, and morbidity. Structural variables can predict area-level vulnerability to the syndemic. The implementation of combined prevention and treatment interventions can control and reverse components of the syndemic. Recognizing and monitoring potent structural factors can facilitate the identification of areas at risk of vulnerability to the syndemic. Further, many structural factors are modifiable through intervention and policy to reduce structural vulnerability and create health-enabling environments. Evidence supports the immediate implementation of broader HCV and HIV testing and substance use screening, medication-assisted treatment, needle/syringe exchange programs, naloxone programs, increased population-level implementation of HCV treatment, and further attention to structural-level factors predicting, and contributing to, area-level vulnerability, such as degrees of opioid marketing, distribution, and prescribing.

Background/UNASSIGNED:Severe Chronic Obstructive Pulmonary Disease patients are often unprepared to make decisions about accepting intubation for respiratory failure. We developed a Web-based decision aid, InformedTogether, to facilitate severe Chronic Obstructive Pulmonary Disease patients' preparation for decision making about whether to accept invasive mechanical ventilation for respiratory failure. Objective/UNASSIGNED:We describe feasibility testing of the InformedTogether decision aid. Methods/UNASSIGNED:Mixed methods, pre- and postintervention feasibility study in outpatient pulmonary and geriatric clinics. Clinicians used InformedTogether with severe Chronic Obstructive Pulmonary Disease patients. Patient-participants completed pre- and postassessments about InformedTogether use. The outcomes measured were the following: feasibility/acceptability, communication (Combined Outcome Measure for Risk Communication [COMRADE], Medical Communication Competency Scale [MCCS], Observing Patient Involvement [OPTION] scales), and effectiveness of InformedTogether on changing patients' knowledge, Decisional Conflict Scale, and motivation. Results/UNASSIGNED:=.006). Motivation increased after viewing the decision aid. Conclusions/UNASSIGNED:InformedTogether supports high-quality communication and shared decision making among Chronic Obstructive Pulmonary Disease patients, clinicians, and surrogates. The increased knowledge and opportunity to deliberate and discuss treatment choices after using InformedTogether should lead to improved decision making at the time of critical illness.

BACKGROUND:A dose of 30 mg/kg of azithromycin is recommended for treatment of yaws, a disease targeted for global eradication. Treatment with 20 mg/kg of azithromycin is recommended for the elimination of trachoma as a public health problem. In some settings, these diseases are co-endemic. We aimed to determine the efficacy of 20 mg/kg of azithromycin compared with 30 mg/kg azithromycin for the treatment of active and latent yaws. METHODS:We did a non-inferiority, open-label, randomised controlled trial in children aged 6-15 years who were recruited from schools in Ghana and schools and the community in Papua New Guinea. Participants were enrolled based on the presence of a clinical lesion that was consistent with infectious primary or secondary yaws and a positive rapid diagnostic test for treponemal and non-treponemal antibodies. Participants were randomly assigned (1:1) to receive either standard-dose (30 mg/kg) or low-dose (20 mg/kg) azithromycin by a computer-generated random number sequence. Health-care workers assessing clinical outcomes in the field were not blinded to the patient's treatment, but investigators involved in statistical or laboratory analyses and the participants were blinded to treatment group. We followed up participants at 4 weeks and 6 months. The primary outcome was cure at 6 months, defined as lesion healing at 4 weeks in patients with active yaws and at least a four-fold decrease in rapid plasma reagin titre from baseline to 6 months in patients with active and latent yaws. Active yaws was defined as a skin lesion that was positive for Treponema pallidum ssp pertenue in PCR testing. We used a non-inferiority margin of 10%. This trial was registered with ClinicalTrials.gov, number NCT02344628. FINDINGS:Between June 12, 2015, and July 2, 2016, 583 (65·1%) of 895 children screened were enrolled; 292 patients were assigned a low dose of azithromycin and 291 patients were assigned a standard dose of azithromycin. 191 participants had active yaws and 392 had presumed latent yaws. Complete follow-up to 6 months was available for 157 (82·2%) of 191 patients with active yaws. In cases of active yaws, cure was achieved in 61 (80·3%) of 76 patients in the low-dose group and in 68 (84·0%) of 81 patients in the standard-dose group (difference 3·7%; 95% CI -8·4 to 15·7%; this result did not meet the non-inferiority criterion). There were no serious adverse events reported in response to treatment in either group. The most commonly reported adverse event at 4 weeks was gastrointestinal upset, with eight (2·7%) participants in each group reporting this symptom. INTERPRETATION:In this study, low-dose azithromycin did not meet the prespecified non-inferiority margin compared with standard-dose azithromycin in achieving clinical and serological cure in PCR-confirmed active yaws. Only a single participant (with presumed latent yaws) had definitive serological failure. This work suggests that 20 mg/kg of azithromycin is probably effective against yaws, but further data are needed. FUNDING:Coalition for Operational Research on Neglected Tropical Diseases.

PURPOSE/OBJECTIVE:This guideline is structured to provide a clinical framework stratified by cancer severity to facilitate care decisions and guide the specifics of implementing the selected management options. The summary presented herein represents Part II of the two-part series dedicated to Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline discussing risk stratification and care options by cancer severity. Please refer to Part I for discussion of specific care options and outcome expectations and management. MATERIALS AND METHODS/METHODS:The systematic review utilized in the creation of this guideline was completed by the Agency for Healthcare Research and Quality and through additional supplementation by ECRI Institute. This review included articles published between January 2007 and March 2014 with an update search conducted through August 2016. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. Additional information is provided as Clinical Principles and Expert Opinions (table 2 in supplementary unabridged guideline, http://jurology.com/). RESULTS:The AUA (American Urological Association), ASTRO, and SUO (Society of Urologic Oncology) formulated an evidence-based guideline based on a risk stratified clinical framework for the management of localized prostate cancer. CONCLUSIONS:This guideline attempts to improve a clinician's ability to treat patients diagnosed with localized prostate cancer, but higher quality evidence in future trials will be essential to improve the level of care for these patients. In all cases, patient preferences should be considered when choosing a management strategy.

This study tests the factor structure, measurement invariance, and correlates of the Childhood Executive Functioning Inventory (CHEXI) with a large and diverse sample of 3- to 5-year-olds (n = 844). Consistent with previous studies, a two-factor model that distinguishes working memory from inhibition provides the best fit to the observed data. This two-factor model has been shown to demonstrate strong measurement invariance for different subgroups of children (boys vs. girls, high vs. low income). Whereas boys tend to have greater working memory and inhibition difficulties (Cohen's d = 0.15 and 0.20, respectively), children from low-income households tend to have more working memory problems than their peers from high-income households (Cohen's d = 0.25). Finally, correlations between CHEXI scores, examiner reports of child behavior, and child performance on a battery of executive function (EF) tasks were investigated. CHEXI scores were found to be more consistently related to examiner reports of child behavior than child performance on EF tasks. Tthe strengths and weaknesses of the CHEXI as a questionnaire measure of EF are discussed, and directions for future research are suggested.

PURPOSE/OBJECTIVE:This study sought to identify the policies and guidelines regarding culturally competent care of sexual and gender minority (SGM) cancer patients and survivors at National Cancer Institute (NCI)-Designated Comprehensive Cancer Centers. METHODS:This study used an in-depth interview qualitative approach. Semistructured interviews were conducted via telephone with representatives from 21 of the 45 NCI-Designated Comprehensive Cancer Centers in 2015. Verbatim transcripts were created from the audiotapes for content analysis. RESULTS:Two main themes were identified as follows: (1) patient-focused experiences and support and (2) organization-focused development activities. Most of the cancer centers in this study had an advisory committee to assist with SGM policies and guidelines. Despite the existence of these committees, the majority of centers did not have explicit policies, guidelines, or routine practices addressing the following issues: the collection and integration of sexual orientation and gender identity information in the medical record, gender-neutral language on patient forms, patient educational materials with SGM-specific health concerns, SGM-specific support for cancer survivors, or required SGM-specific cultural competency trainings for medical and nonmedical staff. CONCLUSION/CONCLUSIONS:In general, the cancer centers in this study lacked institutional policies, guidelines, and practices focused on patient-centered cancer care for SGM populations. Coordinated efforts are needed to systemically improve patient-centered cancer care for these populations.

Individuals must feel free to exert personal control over decisions regarding research participation. We present an examination of participants' perceived personal control over, as well as reported pressures and threats from others, influencing their decision to join a study assessing the effectiveness of extended-release naltrexone in preventing opioid dependence relapse. Most participants endorsed a strong sense of control over the decision; few reported pressures or threats. Although few in number, participants' brief narrative descriptions of the pressures and threats are illuminating and provide context for their perceptions of personal control. Based on this work, we propose a useful set of tools to help ascertain participants' sense of personal control in joining research.

Nonmedical opioid use has been linked to lifetime heroin use; however, research is needed to examine associations between nonmedical opioid use and current or recent heroin use, as current users appear to be at highest risk for harm. Data were from a nationally representative sample of non-institutionalized adults (age 18-64) in households participating in the National Survey of Drug Use and Health who reported lifetime heroin use (2005-2014, N = 7,111). We examined associations between frequency and recency of nonmedical opioid use and recency of heroin use. Most (86.7%) lifetime heroin users reported no heroin use in the last 12 months, while 6.1% reported current use (use in the last 30 days). The majority of the sample (69.3%) reported lifetime nonmedical opioid use; 14.3% reported nonmedical use in the last 30 days. Adjusted odds for current heroin use increased as frequency of past-year nonmedical opioid use increased, with a quarter (24.7%) of current heroin users reporting nonmedical opioid use on 157-365 days in the last year. Over half (54.7%) of current heroin users reported current nonmedical opioid use. Prevention efforts should consider that high-frequency and current nonmedical opioid use is a robust correlate of continued heroin use.

OBJECTIVE: To examine Supplemental Nutrition Assistance Program (SNAP) recipients' use of the first online supermarket accepting Electronic Benefit Transfer (EBT) payment. METHODS: In this mixed-methods study, the authors collected EBT purchase data from an online grocer and attempted a randomized controlled trial in the South Bronx, New York City, followed by focus groups with SNAP beneficiaries aged >/=18 years. Participants were randomized to shop at their usual grocery store or an online supermarket for 3 months. Focus groups explored barriers and motivators to online EBT redemption. RESULTS: Few participants made online purchases, even when incentivized in the randomized controlled trial. Qualitative findings highlighted a lack of perceived control over the online food selection process as a key barrier to purchasing food online. Motivators included fast, free shipping and discounts. CONCLUSIONS AND IMPLICATIONS: Electronic Benefit Transfer for online grocery purchases has the potential to increase food access among SNAP beneficiaries, but challenges exist to this new food buying option. Understanding online food shopping barriers and motivators is critical to the success of policies targeting the online expansion of SNAP benefits.