Faculty Bibliography

OBJECTIVE: To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system. DATA SOURCES/STUDY SETTING: Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008). STUDY DESIGN: We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it. PRINCIPAL FINDINGS: We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging. CONCLUSIONS: Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.

OBJECTIVE: To provide evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medication in an emergency department (ED). We addressed two clinically relevant questions: (1) Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED? METHODS: The American Headache Society convened an expert panel of authors who defined a search strategy and then performed a search of Medline, Embase, the Cochrane database and clinical trial registries from inception through 2015. Identified articles were rated using the American Academy of Neurology's risk of bias tool. For each medication, the expert panel determined likelihood of efficacy. Recommendations were created accounting for efficacy, adverse events, availability of alternate therapies, and principles of medication action. RESULTS/CONCLUSIONS: The search identified 68 unique randomized controlled trials utilizing 28 injectable medications. Of these, 19 were rated class 1 (low risk of bias), 21 were rated class 2 (higher risk of bias), and 28 were rated class 3 (highest risk of bias). Metoclopramide, prochlorperazine, and sumatriptan each had multiple class 1 studies supporting acute efficacy, as did dexamethasone for prevention of headache recurrence. All other medications had lower levels of evidence. RECOMMENDATIONS: Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer-Level B). Dexamethasone should be offered to these patients to prevent recurrence of headache (Should offer-Level B). Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid-Level C).

Introduction: Task-shifting to non-physician health workers (NPHWs) has been an effective model for managing infectious diseases and improving maternal and child health. There is inadequate evidence to show the effectiveness of NPHWs to manage cardiovascular diseases (CVD). Objectives: The Global Alliance for Chronic Diseases funded twelve studies in 2012 of which six focussed on task-shifting to NPHWs for the management of hypertension. We report the lessons learnt from the field. Methods: All six studies were cluster randomised control trials aimed at using NPHWs, within the local health care system, to improve the management of hypertension. The studies were conducted in Colombia, Ghana, India, Kenya, Malaysia and South Africa. From each of the studies we obtained information on the types of tasks shifted, the professional level from which the task was shifted, the training provided and the challenges faced. These details were collated and mapped for analysis. Results: The tasks shifted to NPHWs included screening of individuals, referral to physicians for diagnosis and management, patient education for lifestyle improvement, followup and patient reminders for medication adherence and appointments. In four studies, tasks were shifted from physicians to NPHWs and in two studies tasks were shared between two different levels of NPHWs. Training programs ranged between 3 and 7 days with refresher training at regular intervals. Two studies involved the use of clinical decision support tools. Challenges faced by the studies included system level barriers such as inability to prescribe evidence based medications, varying capacity and skill sets of NPHWs, high workload and staff turnover. Conclusion: With the acute shortage and mal-distribution of the health workforce in low and middle income countries (LMIC), achieving better health outcomes for the prevention and control of CVD is a major challenge. Task-shifting provides a potentially cost-effective and viable model for the management of CVD in LMICs

PURPOSE/OBJECTIVE:Findings on the influences of the media on the sexual health of adolescents in vulnerable communities in Ibadan are presented. METHODS:Phase I of the WAVE study in Ibadan was conducted among participants purposively selected from disadvantaged communities in Ibadan North Local Government Area (LGA). Qualitative research methods (key informant interviews, in-depth interviews, community mapping and focus group discussions as well as photovoice sessions) were utilized. RESULTS:A total of 132 key informants and adolescents (aged 15-19 years) participated. The key informants were teachers, youth workers, and religious leaders working with adolescents within the LGA. Respondents mentioned a number of media technologies (such as television, cellphones, computers, the Internet as well as online and hard copy novels) that adolescents are exposed to in contemporary times. They said these had positive and negative influences on them. Adolescents often looked up information on the Internet although it was mostly used as a means of meeting and communicating with friends. Respondents stated that the media had a strong influence on adolescents' sexual and reproductive health especially regarding dating, relationships, and sexual practices. It also exposed them to pornography and Internet fraud. CONCLUSIONS:The study highlighted the important role the media plays in the sexual health of adolescents in Ibadan. Intervention programmes need to make use of this medium to reach out to more adolescents and measures should be instituted to prevent adolescents from misusing the media.

Participation in biobanking among individuals with familial risk for hereditary cancer (IFRs) and underserved/minority populations is vital for biobanking research. To address gaps in researcher knowledge regarding ethical concerns of these populations, we developed a web-based curriculum. Based on formative research and expert panel assessments, a curriculum and website was developed in an integrative, systematic manner. Researchers were recruited to evaluate the curriculum. Public health graduate students were recruited to pilot test the curriculum. All 14 researchers agreed the curriculum was easy to understand, adequately addressed the domains, and contained appropriate post-test questions. The majority evaluated the dialgoue animations as interesting and valuable. Twenty-two graduate students completed the curriculum, and 77 % improved their overall test score. A web-based curriculum is an acceptable and effective way to provide information to researchers about vulnerable populations' biobanking concerns. Future goals are to incorporate the curriculum with larger organizations.

BACKGROUND: Arsenic has been linked to disrupted immune function and greater infection susceptibility in highly exposed populations. Well arsenic levels above the EPA limit occur in our U.S. study area and are of particular concern for pregnant women and infants. OBJECTIVES: We investigated whether in utero arsenic exposure affects the risk of infections and respiratory symptoms over the first year of life. METHODS: We prospectively obtained information on infant infections and symptoms, including their duration and treatment (n = 412) at 4, 8 and 12 months using a parental telephone survey. Using generalized estimating equation models adjusted for potential confounders, we evaluated the association between maternal pregnancy urinary arsenic and infant infections and symptoms over the first year. RESULTS: Each doubling of maternal urinary arsenic was related to increases in the total number of infections requiring prescription medication in the first year (RR = 1.1; 95% CI: 1.0, 1.2). Urinary arsenic was related specifically to respiratory symptoms (difficulty breathing, wheezing and cough) lasting >/= 2 days or requiring prescription medication (RR = 1.1; 95% CI: 1.0, 1.2; RR = 1.2; 95% CI: 1.0, 1.5, respectively), and wheezing lasting >/=2 days, resulting in a doctor visit or prescription medication treatment (RR = 1.3; 95% CI: 1.0, 1.7; RR = 1.3; 95% CI: 1.0, 1.8, and RR = 1.5; 95% CI: 1.0, 2.2). Associations also were observed with diarrhea (RR = 1.4; 95% CI: 1.1, 1.9) and fever resulting in a doctor visit (RR = 1.2; 95% CI: 1.0, 1.5). CONCLUSIONS: In utero arsenic exposure was associated with a higher risk of infection during the first year of life in our study population, particularly infections requiring medical treatment, and with diarrhea and respiratory symptoms.

Squamous cell carcinoma (SCC) of the skin is a malignancy arising from epithelial keratinocytes. Experimental and epidemiologic evidence raise the possibility that human polyomaviruses (PyV) may be associated with the occurrence of SCC. To investigate whether the risk for SCC was associated with PyV infection, seropositivity to 10 PyV types was assessed following diagnosis in a population-based case-control study conducted in the United States. A total of 253 SCC cases and 460 age group and gender-matched controls were included. Antibody response against each PyV was measured using a multiplex serology-based glutathione S-transferase capture assay of recombinantly expressed VP1 capsid proteins. Odds ratios (OR) for SCC associated with seropositivity to each PyV type were estimated using logistic regression, with adjustment for potentially confounding factors. SCC cases were seropositive for a greater number of PyVs than controls (P = 0.049). Those who were JC seropositive had increased odds of SCC when compared to those who were JC seronegative (OR = 1.37, 95% CI: 0.98-1.90), with an increasing trend in SCC risk with increasing quartiles of seroreactivity (P for trend = 0.04). There were no clear associations between SCC risk and serostatus for other PyV types. This study provides limited evidence that infection with certain PyVs may be related to the occurrence of SCC in the general population of the United States.