Faculty Bibliography

BACKGROUND: There is a need for screening and brief assessment instruments to identify primary care patients with substance use problems. This study's aim was to examine the performance of a two-step screening and brief assessment instrument, the TAPS Tool, compared to the WHO ASSIST. METHODS: Two thousand adult primary care patients recruited from five primary care clinics in four Eastern US states completed the TAPS Tool followed by the ASSIST. The ability of the TAPS Tool to identify moderate- and high-risk use scores on the ASSIST was examined using sensitivity and specificity analyses. RESULTS: The interviewer and self-administered computer tablet versions of the TAPS Tool generated similar results. The interviewer-administered version (at cut-off of 2), had acceptable sensitivity and specificity for high-risk tobacco (0.90 and 0.77) and alcohol (0.87 and 0.80) use. For illicit drugs, sensitivities were >0.82 and specificities >0.92. The TAPS (at a cut-off of 1) had good sensitivity and specificity for moderate-risk tobacco use (0.83 and 0.97) and alcohol (0.83 and 0.74). Among illicit drugs, sensitivity was acceptable for moderate-risk of marijuana (0.71), while it was low for all other illicit drugs and non-medical use of prescription medications. Specificities were 0.97 or higher for all illicit drugs and prescription medications. CONCLUSIONS: The TAPS Tool identified adult primary care patients with high-risk ASSIST scores for all substances as well moderate-risk users of tobacco, alcohol, and marijuana, although it did not perform well in identifying patients with moderate-risk use of other drugs or non-medical use of prescription medications. The advantages of the TAPS Tool over the ASSIST are its more limited number of items and focus solely on substance use in the past 3months.

BACKGROUND: The statistical association between increased exposure to air pollution and increased risk of morbidity and mortality is well established. However, documentation of the health benefits of lowering air pollution levels, which would support the biological plausibility of those past statistical associations, are not as well developed. A better understanding of the aftereffects of interventions to reduce air pollution is needed in order to: 1) better document the benefits of lowered air pollution; and, 2) identify the types of reductions that most effectively provide health benefits. METHODS: This study analyzes daily health and pollution data from three major cities in Israel that have undergone pollution control interventions to reduce sulfur emissions from combustion sources. In this work, the hypothesis tested is that transitions to cleaner fuels are accompanied by a decreased risk of daily cardiovascular and respiratory mortalities. Interrupted time series regression models are applied in order to test whether the cleaner air interventions are associated with a statistically significant reduction in mortality. RESULTS: In the multi-city meta-analysis we found statistically significant reductions of 13.3% [CI -21.9%, -3.8%] in cardiovascular mortality, and a borderline significant (p=0.06) reduction of 19.0% [CI -35.1%, 1.1%] in total mortality. CONCLUSIONS: Overall, new experiential evidence is provided consistent with human health benefits being associated with interventions to reduce air pollution. The methods employed also provide an approach that may be applied elsewhere in the future to better document and optimize the health benefits of clean air interventions.

BACKGROUND:The 2020 American Heart Association Impact Goal aims to improve cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular disease and stroke by 20%. A large step toward this goal would be to better understand and take advantage of the significant intersection between behavior and biology across the entire life-span. In the proposed FAMILIA studies, we aim to directly address this major knowledge and clinical health gap by implementing an integrated family-centric health promotion intervention and focusing on the intersection of environment and behavior, while understanding the genetic and biologic basis of cardiovascular disease. METHODS:We plan to recruit 600 preschool children and their 600 parents or caregivers from 12-15 Head Start schools in Harlem, NY, and perform a 2:1 (2 intervention/1 control) cluster randomization of the schools. The preschool children will receive our intensive 37-hour educational program as the intervention for 4 months. For the adults, those in the "intervention" group will be randomly assigned to 1 of 2 intervention programs: an "individual-focused" or "peer-to-peer based." The primary outcome in children will be a composite score of knowledge (K), attitudes (A), habits (H), related to body mass index Z score (B), exercise (E), and alimentation (A) (KAH-BEA), using questionnaires and anthropometric measurements. For adults, the primary outcome will be a composite score for behaviors/outcomes related to blood pressure, exercise, weight, alimentation (diet) and tobacco (smoking; Fuster-BEWAT score). Saliva will be collected from the children for SNP genotyping, and blood will be collected from adults for RNA sequencing to identify network models and predictors of primary prevention outcomes. CONCLUSION/CONCLUSIONS:The FAMILIA studies seek to demonstrate that targeting a younger age group (3-5 years) and using a family-based approach may be a critical strategy in promoting cardiovascular health across the life-span.

Serodiscussion-the mutual discussion of HIV statuses between sexual partners-can be viewed as an essential prerequisite for risk-reduction behaviors among men who have sex with men (MSM). The current study aimed to assess the prevalence of serodiscussion with one's most recent sexual partner and its association with sexual behaviors with these partners. Broadcast advertisements were placed on a geosocial-networking smartphone application, encouraging users to complete an online survey. A total of 200 MSM completed the survey. Serodiscussion occurred in 43.5% of dyads, and it was most common in dyads where both partners were reported to be HIV positive, chi2(5) = 60.3, P < .001. Serodiscussion was associated with engagement in both condomless insertive, chi2(1) = 3.847, P = .046, and receptive anal intercourse, chi2(1) = 6.5, P = .011. However, there were no significant differences in how recently a respondent was tested for HIV, representing potentially high-risk scenarios.

Limbic encephalitis presents as altered mood, memory loss and confusion. Clinical features may include psychiatric symptoms and seizures. In contrast to paraneoplastic disorders, non-paraneoplastic autoimmune encephalitis often responds to immunotherapy and sometimes with marked recovery. However, relapse can occur. An 82-year-old male presented with subacute episodes of memory loss over a few days. The patient was unable to recognize his own home and family members. Physical exam was unremarkable. Neuropsychological assessment revealed deficits in cognitive performance that could be consistent with moderate dementia or a more rapidly progressive encephalopathy. Agitated behavior and anxiety were also noted. Laboratory evaluation included hyponatremia, which was corrected with no symptom improvement. B12, TSH, and HIV were normal. CSF analysis revealed 10 WBCs/muL, Glucose-52 mg/dl, Protein-62 mg/dl and was negative for infectious, neoplastic causes, varicella, VDRL, viral cultures, NMDA receptor antibody, GAD 65 antibody and Anti-Hu antibody. Occult malignancy work up with CT scan of chest and abdomen and colonoscopy was normal. Serum for voltage-gated potassium channel antibodies was positive at 849 pmol/l (>88). EEG showed occasional focal left fronto-temporal slowing without epileptiform activity. MRI revealed focal enhancement of the medial left temporal lobe consistent with limbic encephalitis. The patient started high dose steroids with improvement in memory and complete resolution of focal abnormality within the left hippocampal/parahippocampal region suggestive of resolving encephalitis. At seven months after tapering steroids the patient presented with myoclonus and recurrent memory loss. MRI demonstrated recurrent encephalitis with gyral swelling and FLAIR hyperintensity in the left temporal lobe. The patient was restarted on high dose steroids with addition of Rituximab. This case illustrates that limbic encephalitis can present as a rapidly progressive dementia. Differential diagnosis should include more unusual forms of rapidly progressive dementia such as Jakob-Creutzfeldt disease if myoclonus is present, Lewy body dementia if waxing and waning memory, and Alzheimer's dementia with acute delirium if presenting over a period of months. In this patient, MRI changes were crucial to recognizing a potentially reversible limbic encephalitis. Early recognition and treatment may decrease relapse and reduce functional impairment

In a longitudinal population-based study of 2,905 children, we investigated if infants' neuromotor development was associated with autistic traits in childhood. Overall motor development and muscle tone were examined by trained research assistants with an adapted version of Touwen's Neurodevelopmental Examination between ages 2 and 5 months. Tone was assessed in several positions and items were scored as normal, low, or high tone. Parents rated their children's autistic traits with the Social Responsiveness Scale (SRS) and the Pervasive Developmental Problems (PDP) subscale of the Child Behavior Checklist at 6 years. We defined clinical PDP if scores were >98th percentile of the norm population. Diagnosis of autism spectrum disorder (ASD) was clinically confirmed in 30 children. We observed a modest association between overall neuromotor development in infants and autistic traits. Low muscle tone in infancy predicted autistic traits measured by SRS (adjusted beta = 0.05, 95% CI for B: 0.00-0.02, P = 0.01), and PDP (adjusted beta = 0.08, 95% CI for B: 0.04-0.10, P < 0.001). Similar results emerged for the association of low muscle tone and clinical PDP (adjusted OR = 1.36, 95% CI: 1.08-1.72, P = 0.01) at age 6 years. Results remained unchanged if adjusted for child intelligence. There was no association between high muscle tone and SRS or PDP. Exclusion of children with ASD diagnosis did not change the association. This large study showed a prospective association of infant muscle tone with autistic traits in childhood. Our findings suggest that early detection of low muscle tone might be a gateway to improve early diagnosis of ASD. Autism Res 2017. (c) 2017 International Society for Autism Research, Wiley Periodicals, Inc.

Background: The National Committee for Quality Assurance (NCQA) developed the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures to evaluate health plan performance against benchmarks or other plans. The Center for Medicare and Medicaid Services (CMS) requires insurance plans to submit HEDIS data to qualify as a Medicare Advantage Plan (MAP) or a MAP that includes Medicare Part D (MAPD). Our MAPD selected and tested HEDIS and other 5-Star measures comparing the quality of care for MAPD members who did and did not use a Geriatric Assessment Center (GAC) serving MAPD members within a markedly impoverished region in the western US. Members visit the GAC typically once per year. Methods: We selected eight measures reflecting preventive care, chronic disease management, and continuity of care (See Table). Within one Medical Group, we compared the performance of these measures for Plan Members having attended the GAC in 2014 with Plan members who did not but had at least one primary care provider (PCP) visit. We used exact match procedures to identify a comparison group based on age, gender, Low-Income Subsidy Level, Risk Adjustment Factor and Special Needs Plan. Results: We identified 258 members who used the GAC in 2014 and 258 as the matched control group (See Table). Preventive care but not chronic disease management performance measures were significantly better for members who used the GAC. GAC users had better care continuity performance (measured by readmission rates) but this was not statistically significant. Conclusions: The GAC is well suited to achieving high quality preventive care due to the ease of completion in one visit. Chronic disease management care continuity is likely better suited to a repeated visit care structure. (Table Presented)

Background: A comprehensive geriatric assessment clinic (GAC) was established in collaboration with a health plan within a markedly impoverished region in the US. Evaluation objectives were to assess the quality of chronic illness care from the perspective of member-patients and providers. Methods: We abstracted medical records of patients attending the GAC during one quarter of 2014 and administered the 20-item Patient Assessment of Chronic Illness Care (PACIC) survey in English and Spanish in 2015. We anonymously surveyed patients before and directly after visits. Survey questions, modified for low health literacy, used a 1-to-5-likert scale (1=none of the time to 5=always) for 5 domains: patient activation, decision support, goal setting, problem solving, and care coordination. We administered a 7-item quality assessment survey to providers for: relevance, ease of use, ability to apply findings, and agreement with diagnostic findings and recommendations, using a 1-to-5-likert scale (1=strongly disagree to 5=strongly agree). Results: Abstracted data for 193 patients demonstrated 51% had not finished high school and their chronic condition burden was high (mean: 7.2 conditions; 31% with diabetes). For patient surveys (n=165; 19% Spanish), post-visit PACIC domain scores ranged from 4.0-4.5 and post-visit ratings were higher across all domains (1.4 to 1.7 higher; p<0.001 for each). For each of 20 questions, aggregate post scores improved, indicating higher quality. For provider surveys, respondents (n=14) felt the GAC provided useful (50%) and relevant (64%) information for their practices, taught them how to provide better care for other patients (64%), and made it easier to provide care (50%). Less than one third (29%) felt their experience discouraged them from using the service again. Discussion: The AC greatly improved member-perceived care quality and facilitated provider care among patients with high chronic condition burden, suggesting a useful strategy for patients with high need. Since some providers did not find this service useful, provider focus groups are underway to understand and improve unmet provider needs

Background: Cocaine is commonly involved in unintentional drug poisoning (overdose) deaths, accounting for 41% of overdose in New York City (NYC) in 2014. 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 and other chronic conditions and therefore may be at increased risk for adverse health consequences of cocaine use including death.
Objective(s): To describe demographic characteristics of middle-and-older-aged NYC adults who died of a cocaine-involved overdose death, and to identify potential associations by age, race, borough of residence, and concomitant drugs among deaths involving cocaine compared with overdose deaths not involving cocaine.
Method(s): We conducted a retrospective analysis of unintentional drug overdose deaths of adults aged 45 to 84 in New York City (NYC) from 2000 to 2014 using 2 linked sources, NYC death certificates and toxicology results from the Office of the Chief Medical Examiner. We described demographic characteristics and drugs involved in overdoses, by age ranges 45 to 54, 55 to 64, and 65 to 84. Data were stratified and compared by cocaine involvement using bivariable analysis. The multivariable analysis included age, race, gender, and borough of residence to determine associations between demographic characteristics and cocaine-involved overdoses.
Result(s): From 2000 to 2014, there were 5339 unintentional drug overdose deaths among adults aged 45 to 84 in NYC. Of those, cocaine was involved in 54% (n = 2856). Co-occurring opioid involvement (heroin, methadone, or opioid analgesics) and alcohol use among deaths involving cocaine was common. Compared with decedents of noncocaine-involved overdose, decedents of cocaine-involved overdose were more likely to be younger (52.5-53.0 years, P = 0.002), male (75% vs 72%, P = 0.005), and non-Hispanic black (47% vs 26%, P < 0.001). Multivariate analysis showed that male gender (AOR=1.34, 95% CI 1.17-1.52), Bronx residence (AOR= 1.278, 95% CI 1.04-1.57), and non-Hispanic black race/ethnicity (AOR = 2.31, 95% CI 1.98-2.69) were independently associated with cocaine-involved overdose compared with none cocaine-involved overdose.
Conclusion(s): Cocaine was involved in over half of unintentional drug overdose deaths in NYC for adults aged 45 to 84. It remains unclear what the role of cocaine was in the setting of adults with underlying cardiovascular disease. Studies that examine autopsy data may be able to elucidate the underlying impact of cocaine in drug-related overdose deaths

Significance: Limited data exist regarding tobacco and nicotine containing product (TNCP) use and their association with other drugs of abuse in high-risk settings. The purpose of this study was to examine the associations between TNCP use and other common illicit drug use among adults attending Electronic Dance Music (EDM) parties at nightclubs and festivals in New York City (NYC).
Method(s): Adults (age 18-40) were recruited outside of EDM events in NYC between May and August 2016 and completed a computer-assisted personal interview on a tablet. The survey took approximately 10 minutes and queried sociodemographic characteristics, and self-reported use of TNCPs (e-cigarettes, hookah, and "tobacco") and other drugs. Among recent (12-month) TNCP users, we compared illicit drug use according to the number of TNCPs reportedly used with the use of 1 TNCP representing mono-use, any 2 representing dual-use, and all 3 representing poly-use.
Result(s): More than half the overall sample (54%; N = 524 of 965) reported past year use of a TNCP. Participants' mean age was (25.1+4.5) years, and 55.2% were male. Almost half (46%) were mono users, 27% were dual TNCP users, and 27% were poly TNCP users. Sociodemographic characteristics were not associated with a number of TNCPs used; however, a number of products was significantly different regarding the past-year use of marijuana, powder cocaine, ecstasy (MDMA, "Molly"), LSD, and psilocybin ("magic mushrooms"). Poly users were more likely to report use of marijuana (94.4% vs 87.9% dual and 68.3% mono; P < 0.001), cocaine (69.2% vs 56.7% dual and 32.1% mono; P < 0.001), ecstasy (65.0% vs 61.0% dual and 49.6% mono; P = 0.007), LSD (46.9% vs 34.8% dual and 19.6% mono; P< 0.001), and psilocybin (44.8% vs 31.2% dual and 16.7% mono; P< 0.001).
Conclusion(s): Among this sample of EDM attendees in NYC, past-year use of TNCPs was strongly associated with the use of illicit drugs suggesting the use of more TNCPs is associated with risky behavior in high-risk settings. A limitation was that "tobacco" included all other TNCPs other than e-cigarettes and hookah. Adults' TNCP use patterns might be indicative of the extent of illicit drug use, especially among those frequenting high-risk settings. Future research needs to probe in the reasons behind the patterns of TNCP use among those in high-risk settings