Faculty Bibliography

PURPOSE: Correctional settings create unique challenges for patients with special needs, including transgender patients, who have an increased rate of overall discrimination, sexual abuse, healthcare disparities, and improper housing. As part of our correctional health quality improvement process, we sought to review and evaluate the adequacy of care for transgender patients in the New York City jail system. METHODS: Using correctional pharmacy records, transgender patients receiving hormonal treatment were identified. A brief in-person survey was conducted to evaluate their care in the community before incarceration, medical care in jail, and experience in the jail environment. RESULTS: Survey findings and analysis of transgender patient healthcare-related complaints revealed opportunities for improvements in the provision of care and staff understanding of this population. Utilizing these findings, we conducted lesbian, gay, bisexual, and transgender (LGBT) trainings in all 12 jail clinics for medical, nursing, and mental health staff. Three months after LGBT training, patient complaints dropped by over 50%. After the development and implementation of a newly revised transgender healthcare policy, complaints dropped to zero within 6 months. CONCLUSION: Our efforts to assess the quality of care provided to transgender patients revealed significant areas for improvement. Although we have made important gains in providing quality care through the implementation of policies and procedures rooted in community standards and the express wishes of our patients, we continue to engage this patient population to identify other issues that impact their health and well-being in the jail environment.

OBJECTIVE: To determine range of bottle sizes used and examine the relationship between bottle size and total daily consumption of infant formula. METHODS: Cross-sectional analysis of baseline data collected as part of Greenlight, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics. The Greenlight study included healthy, term infants. For our analysis, parents of exclusively formula-fed infants reported volume per feed, number of feeds per day, and bottle size, which was dichotomized into small (<6 oz) or large (>/=6 oz). We identified determinants of bottle size, and then examined relationships between bottle size and volume fed with log-transformed ordinary least squares regression, adjusting for infant age, sex, birth weight, current weight, race/ethnicity, and enrollment in Special Supplemental Nutrition Program for Women, Infants, and Children. RESULTS: Of 865 participants in the Greenlight study, 44% (n = 378; 21.8% white, 40.6% black, 35.3% Hispanic, 2.4% other) of infants were exclusively formula fed at 2 months. Median volume per day was 30 oz (interquartile range 12), and 46.0% of infants were fed with large bottles. Adjusted for covariates, parents using larger bottles reported feeding 4 oz more formula per day (34.2 oz, 95% confidence interval 33.5-34.9 vs 29.7 oz, 95% confidence interval 29.2-30.3, P = .03). CONCLUSIONS: Among exclusively formula-fed infants, use of a larger bottle is associated with parental report of more formula intake compared to infants fed with smaller bottles. If infants fed with larger bottles receive more formula, these infants may be overfed and consequently at risk for obesity.

A goal of aspirin therapy is to inhibit thromboxane production and platelet aggregation without inhibiting endothelial production of the vasodilator and anti-thrombotic prostacyclin. This study tested the hypothesis that extended-release aspirin (NHP-554C) would have increased selectivity for inhibition of basal and simulated thromboxane formation compared to immediate-release aspirin (ASA). Thirty-six healthy subjects were randomized to NHP-554C or ASA groups. Within each group, subjects were randomized to 5-day treatment with 81 mg/d, 162.5 mg/d and placebo in a crossover design in which treatment periods were separated by 2-week washout. On the fifth day of treatment, 81 mg/d and 162.5 mg/d ASA reduced basal urinary excretion of the stable thromboxane metabolite 11-dehydro-thromboxane B2 62.3% and 66.2% and basal excretion of the stable prostacyclin metabolite 2,3-dinor-6-keto-PGF1α 22.8% and 26.5%, respectively, compared to placebo. NHP-554C 81 mg/d and 162.5 mg/d reduced 11-dehydro-thromboxane B2 53% (P = 0.03 vs. ASA 81 mg/d) and 67.9% and 2,3-dinor-6-keto-PGF1α 13.4% and 18.5%, respectively. NHP-554C 81 mg/d did not significantly reduce basal excretion of the prostacyclin metabolite. Both doses of ASA and NHP significantly reduced excretion of both thromboxane and prostacyclin metabolites following intravenous bradykinin. During NHP-554C 162.5 mg/d, but not during ASA, bradykinin significantly increased urinary 2,3-dinor-6-keto-PGF1α. Nevertheless, 11-dehydro-thromboxane B2 and 2,3-dinor-6-keto-PGF1α responses to bradykinin were statistically similar during ASA and NHP-554C. In conclusion, at doses of 81 and 162.5 mg/d immediate- and extended-release aspirin selectively decrease basal thromboxane production. Both forms of aspirin decrease bradykinin-stimulated thromboxane and prostacyclin production, but some stimulated prostacyclin production remains during treatment with NHP-554C.

BACKGROUND: Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited. METHODS: In this five-site, open-label, randomized trial, we compared a 24-week course of extended-release naltrexone (Vivitrol) with usual treatment, consisting of brief counseling and referrals for community treatment programs, for the prevention of opioid relapse among adult criminal justice offenders (i.e., persons involved in the U.S. criminal justice system) who had a history of opioid dependence and a preference for opioid-free rather than opioid maintenance treatments and who were abstinent from opioids at the time of randomization. The primary outcome was the time to an opioid-relapse event, which was defined as 10 or more days of opioid use in a 28-day period as assessed by self-report or by testing of urine samples obtained every 2 weeks; a positive or missing sample was computed as 5 days of opioid use. Post-treatment follow-up occurred at weeks 27, 52, and 78. RESULTS: A total of 153 participants were assigned to extended-release naltrexone and 155 to usual treatment. During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to relapse than did those assigned to usual treatment (10.5 vs. 5.0 weeks, P<0.001; hazard ratio, 0.49; 95% confidence interval [CI], 0.36 to 0.68), a lower rate of relapse (43% vs. 64% of participants, P<0.001; odds ratio, 0.43; 95% CI, 0.28 to 0.65), and a higher rate of opioid-negative urine samples (74% vs. 56%, P<0.001; odds ratio, 2.30; 95% CI, 1.48 to 3.54). At week 78 (approximately 1 year after the end of the treatment phase), rates of opioid-negative urine samples were equal (46% in each group, P=0.91). The rates of other prespecified secondary outcome measures--self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration--were not significantly lower with extended-release naltrexone than with usual treatment. Over the total 78 weeks observed, there were no overdose events in the extended-release naltrexone group and seven in the usual-treatment group (P=0.02). CONCLUSIONS: In this trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00781898.).

Traumatic events are linked with an array of adverse consequences such as substance use. Only a few individuals exposed to traumatic events, however, suffer from post traumatic stress disorder (PTSD) or substance use. The present longitudinal study examined the inter-relationship among victimization, PTSD, and substance use. 674 participants (53% African Americans, 47% Puerto Ricans) were surveyed over five time waves at mean ages 14, 19, 24, 29, and 36. Of the 674, 60% were females. We used Mplus to perform structural equation modeling. Victimization at ages 19, 24, and 29 was directly associated with substance use at age 36 and was also related to PTSD at age 36. PTSD, in turn, was related to substance use at age 36. This study indicates the importance of intervention for those who have been victimized with a focus on PTSD treatment. From a public health perspective, health providers should consider treatment and prevention programs for helping individuals cope with some of the consequences of victimization. This might ultimately reduce substance use.

BACKGROUND: Sub-Saharan Africa (SSA) is facing a double burden of disease with a rising prevalence of non-communicable diseases (NCDs) while the burden of communicable diseases (CDs) remains high. Despite these challenges, there remains a significant need to understand how or under what conditions health interventions implemented in sub-Saharan Africa are sustained. The purpose of this study was to conduct a systematic review of empirical literature to explore how health interventions implemented in SSA are sustained. METHODS: We searched MEDLINE, Biological Abstracts, CINAHL, Embase, PsycInfo, SCIELO, Web of Science, and Google Scholar for available research investigating the sustainability of health interventions implemented in sub-Saharan Africa. We also used narrative synthesis to examine factors whether positive or negative that may influence the sustainability of health interventions in the region. RESULTS: The search identified 1819 citations, and following removal of duplicates and our inclusion/exclusion criteria, only 41 papers were eligible for inclusion in the review. Twenty-six countries were represented in this review, with Kenya and Nigeria having the most representation of available studies examining sustainability. Study dates ranged from 1996 to 2015. Of note, majority of these studies (30 %) were published in 2014. The most common framework utilized was the sustainability framework, which was discussed in four of the studies. Nineteen out of 41 studies (46 %) reported sustainability outcomes focused on communicable diseases, with HIV and AIDS represented in majority of the studies, followed by malaria. Only 21 out of 41 studies had clear definitions of sustainability. Community ownership and mobilization were recognized by many of the reviewed studies as crucial facilitators for intervention sustainability, both early on and after intervention implementation, while social and ecological conditions as well as societal upheavals were barriers that influenced the sustainment of interventions in sub-Saharan Africa. CONCLUSION: The sustainability of health interventions implemented in sub-Saharan Africa is inevitable given the double burden of diseases, health care worker shortage, weak health systems, and limited resources. We propose a conceptual framework that draws attention to sustainability as a core component of the overall life cycle of interventions implemented in the region.

Matching methods are common in studies across many disciplines. However, there is limited evidence on how to optimally combine matching with subsequent analysis approaches to minimize bias and maximize efficiency for the quantity of interest. We conducted simulations to compare the performance of a wide variety of matching methods and analysis approaches in terms of bias, variance, and mean squared error (MSE). We then compared these approaches in an applied example of an employment training program. The results indicate that combining full matching with double robust analysis performed best in both the simulations and the applied example, particularly when combined with machine learning estimation methods. To reduce bias, current guidelines advise researchers to select the technique with the best post-matching covariate balance, but this work finds that such an approach does not always minimize mean squared error (MSE). These findings have important implications for future research utilizing matching. To minimize MSE, investigators should consider additional diagnostics, and use of simulations tailored to the study of interest to identify the optimal matching and analysis combination.

OBJECTIVE: Concussion is a major public health problem and considerable efforts are focused on sideline-based diagnostic testing to guide return-to-play decision-making and clinical care. The King-Devick (K-D) test, a sensitive sideline performance measure for concussion detection, reveals slowed reading times in acutely concussed subjects, as compared to healthy controls; however, the normal behavior of eye movements during the task and deficits underlying the slowing have not been defined. METHODS: Twelve healthy control subjects underwent quantitative eye tracking during digitized K-D testing. RESULTS: The total K-D reading time was 51.24 (+/-9.7) seconds. A total of 145 saccades (+/-15) per subject were generated, with average peak velocity 299.5 degrees /s and average amplitude 8.2 degrees . The average inter-saccadic interval was 248.4ms. Task-specific horizontal and oblique saccades per subject numbered, respectively, 102 (+/-10) and 17 (+/-4). Subjects with the fewest saccades tended to blink more, resulting in a larger amount of missing data; whereas, subjects with the most saccades tended to make extra saccades during line transitions. CONCLUSIONS: Establishment of normal and objective ocular motor behavior during the K-D test is a critical first step towards defining the range of deficits underlying abnormal testing in concussion. Further, it sets the groundwork for exploration of K-D correlations with cognitive dysfunction and saccadic paradigms that may reflect specific neuroanatomic deficits in the concussed brain.