Faculty Bibliography

BACKGROUND AND AIMS: Relapse to addiction following incarceration is common. We estimated the feasibility and effectiveness of extended-release naltrexone (XR-NTX) as relapse prevention among opioid-dependent male adults leaving a large urban jail. DESIGN: Eight-week, proof-of-concept, open-label, non-blinded randomized effectiveness trial. SETTING: New York City jails and Bellevue Hospital Center Adult Primary Care clinics, USA. PARTICIPANTS: From January 2010 to July 2013, 34 opioid-dependent adult males with no stated interest in agonist treatments (methadone, buprenorphine) received a counseling and referral intervention and were randomized to XR-NTX (n = 17) versus no medication (n = 17) within one week prior to jail release. INTERVENTION: XR-NTX (Vivitrol((R)) ; Alkermes Inc.), a long-acting injectable mu opioid receptor antagonist. MEASURES: The primary intent-to-treat outcome was post-release opioid relapse at week 4, defined as >/=10 days of opioid misuse by self-report and urine toxicologies. Secondary outcomes were proportion of urine samples negative for opioids and rates of opioid abstinence, intravenous drug use (IVDU), cocaine use, community treatment participation, re-incarceration and overdose. FINDINGS: Acceptance of XR-NTX was high; 15 of 17 initiated treatment. Rates of the primary outcome of week 4 opioid relapse were lower among XR-NTX participants: 38 versus 88% [P<0.004; odds ratio (OR) = 0.08, 95% confidence interval (CI) = 0.01-0.48]; more XR-NTX urine samples were negative for opioids, 59 versus 29% (P<0.009; OR = 3.5, 95% CI = 1.4-8.5). There were no significant differences in the remaining secondary outcomes, including rates of IVDU, cocaine use, re-incarceration and overdose. CONCLUSION: Extended-release naltrexone is associated with significantly lower rates of opioid relapse among men in the United States following release from jail when compared with a no medication treatment-as-usual condition.

Electronic health records (EHRs) are transforming the practice of clinical medicine, but the extent to which they are being harnessed to advance public health goals remains uncertain. Data extracted from integrated EHR networks offer the potential for almost real-time determination of the health status of populations in care, for targeting interventions to vulnerable populations, and for monitoring the impact of such initiatives over time. This is especially true in ambulatory care settings, which are uniquely suited for monitoring population health indicators including risk factors and disease management indicators associated with chronic diseases. As efforts gather steam to integrate health data across delivery systems, large networks of electronic patient information are increasingly emerging. Few of the national population health surveillance systems that rely on EHR data have progressed beyond laying groundwork to launch and maintain EHR-based surveillance, but a limited number of more focused or local efforts have demonstrated innovation in population health surveillance. Common challenges include incompleteness of population coverage, lack of interoperability across data systems, and variable data quality. This review defines progress, opportunities, and challenges in using EHR data for population health surveillance. (Population Health Management 2015;18:209-216).

BACKGROUND: Energy medicine (EM) derives from the theory that a subtle biologic energy can be influenced for therapeutic effect. EM practitioners may be trained within a specific tradition or work solo. Few studies have investigated the feasibility of solo-practitioner EM in hospitals. OBJECTIVE: This study investigated the feasibility of EM as provided by a solo practitioner in inpatient and emergent settings. DESIGN: Feasibility study, including a prospective case series. SETTINGS: Inpatient units and emergency department. OUTCOME MEASURES: To investigate the feasibility of EM, acceptability, demand, implementation, and practicality were assessed. Short-term clinical changes were documented by treating physicians. PARTICIPANTS: Patients, employees, and family members were enrolled in the study only if study physicians expected no or slow improvement in specific symptoms. Those with secondary gains or who could not communicate perception of symptom change were excluded. RESULTS: EM was found to have acceptability and demand, and implementation was smooth because study procedures dovetailed with conventional clinical practice. Practicality was acceptable within the study but was low upon further application of EM because of cost of program administration. Twenty-four of 32 patients requested relief from pain. Of 50 reports of pain, 5 (10%) showed no improvement; 4 (8%), slight improvement; 3 (6%), moderate improvement; and 38 (76%), marked improvement. Twenty-one patients had issues other than pain. Of 29 non-pain-related problems, 3 (10%) showed no, 2 (7%) showed slight, 1 (4%) showed moderate, and 23 (79%) showed marked improvement. Changes during EM sessions were usually immediate. CONCLUSIONS: This study successfully implemented EM provided by a solo practitioner in inpatient and emergent hospital settings and found that acceptability and demand justified its presence. Most patients experienced marked, immediate improvement of symptoms associated with their chief complaint. Substantial practicality issues must be addressed to implement EM clinically in a hospital, however.

The persistence of disparities in STI/HIV risk among a new generation of emerging adult gay, bisexual, and other men who have sex with men (YMSM) warrant holistic frameworks and new methodologies for investigating the behaviors related to STI/HIV in this group. In order to better understand the continued existence of these disparities in STI/HIV risk among YMSM, the present study evaluated the presence and persistence of syndemic conditions among YMSM by examining the co-occurrence of alcohol and drug use, unprotected sexual behavior, and mental health burden over time. Four waves of data, collected over the first 18 months of a 7 wave, 36-month prospective cohort study of YMSM (n = 600) were used to examine the extent to which measurement models of drug use, unprotected sexual behavior, and mental health burden remained consistent across time using latent class modeling. Health challenges persisted across time as these YMSM emerged into young adulthood and the measurement models for the latent constructs of drug use and unprotected sexual behavior were essentially consistent across time whereas models for mental health burden varied over time. In addition to confirming the the robustness of our measurement models which capture a more holistic understandings of the health conditions of drug use, unprotected sex, and mental health burden, these findings underscore the ongoing health challenges YMSM face as they mature into young adulthood. These ongoing health challenges, which have been understood as forming a syndemic, persist over time, and add further evidence to support ongoing and vigilant comprehensive health programming for sexual minority men that move beyond a sole focus on HIV.

Research indicates that experiences of intimate partner violence (IPV) are common among young gay, bisexual, and other young men who have sex with men (YMSM). Yet, there is little understanding of the individual, mental health, and psychosocial variables associated with IPV in this population. The aim of this study is to assess the prevalence and correlates of IPV among a new generation of racially/ethnically diverse YMSM. Baseline data from a longitudinal cohort study of YMSM (N = 598) from New York City informed lifetime experiences of IPV victimization, perpetration, and mutual IPV (those reporting both victimization and perpetration). Multivariate logistic regression models were constructed to examine associations between IPV and individual, mental health, and psychosocial factors. Among YMSM, 39% reported IPV victimization, 31% reported perpetration, and 25% reported mutual IPV. Victimization and perpetration were highly correlated. Childhood mistreatment was related to all three IPV outcomes. With regard to psychosocial states, impulsivity was the only variable strongly related to all three IPV outcomes. PTSD was significantly related to IPV victimization but not IPV perpetration. In addition, personal gay-related stigma was associated with IPV victimization, whereas public gay-related stigma was associated with IPV perpetration. Findings extend previous research by identifying psychosocial and mental health variables associated with IPV, while controlling for childhood mistreatment. We recommend more systematic screening for IPV in healthcare settings that serve YMSM (e.g., HIV testing sites). Moreover, we suggest that IPV may be part of a larger syndemic disproportionately burdening YMSM.

OBJECTIVE: Some mothers of preterm infants continue to view them as vulnerable after their health has improved. These exaggerated perceptions of vulnerability lead to poor parent-child interactions and, subsequently, to adverse child outcomes. However, there is no theoretical model to explain why these exaggerated perceptions develop in only some mother-child dyads. METHOD: Data for this study come from a randomized trial of an intervention to reduce distress in mothers of preterm infants. A total of 105 mothers older than 18 years of infants aged 25-34 weeks, weighing >600 g and with clinically significant anxiety, depression, or trauma symptoms, were recruited and randomized. Women were assessed at baseline, after intervention, and at 6 months after birth. The outcome for these analyses was perceptions of infant vulnerability as measured by the Vulnerable Baby Scale (VBS) at 6 months after birth. A theoretical model developed from the extant literature was tested using the MacArthur Mediator-Moderator Approach. RESULTS: A dysfunctional coping style, high depression, anxiety, or trauma symptoms in response to the preterm birth, and low social support were related to 6-month VBS scores. Maternal response to trauma was directly related to VBS, and an important precursor of maternal response to trauma was a dysfunctional coping style. CONCLUSIONS: This model suggests that maternal responses to trauma are critical in the formation of exaggerated perceptions of vulnerability as are dysfunctional coping styles and low social support. Women with these characteristics should be targeted for intervention to prevent poor parenting practices that result from exaggerated perceptions of vulnerability.

Women with BRCA1/2 mutations have an elevated risk of breast and ovarian cancer. These patients and their clinicians are often concerned about their risk for other cancers, including skin cancer. Research evaluating the association between BRCA1/2 mutations and skin cancer is limited and has produced inconsistent results. Herein, we review the current literature on the risk of melanoma and nonmelanoma skin cancers in BRCA1/2 mutation carriers. No studies have shown a statistically significant risk of melanoma in BRCA1 families. BRCA2 mutations have been linked to melanoma in large breast and ovarian cancer families, though a statistically significant elevated risk was reported in only one study. Five additional studies have shown some association between BRCA2 mutations and melanoma, while four studies did not find any association. With respect to nonmelanoma skin cancers, studies have produced conflicting results. Given the current state of medical knowledge, there is insufficient evidence to warrant increased skin cancer surveillance of patients with a confirmed BRCA1/2 mutation or a family history of a BRCA1/2 mutation, in the absence of standard risk factors. Nonetheless, suspected BRCA1/2 mutation carriers should be counselled about skin cancer risks and may benefit from yearly full skin examinations.

Sudden hospital closures displace patients from usual sources of care and force them to access facilities that lack their prior medical records. For patients with complex needs and for nearby hospitals already strained by high volume, disaster-related hospital closures induce a public health emergency. Our objective was to analyze responses of patients from public versus private emergency departments after closure of their usual hospital after Hurricane Sandy. Using a statewide database of emergency visits, we followed patients with an established pattern of accessing 1 of 2 hospitals that closed after Hurricane Sandy: Bellevue Hospital Center and NYU Langone Medical Center. We determined how these patients redistributed for emergency care after the storm. We found that proximity strongly predicted patient redistribution to nearby open hospitals. However, for patients from the closed public hospital, this redistribution was also influenced by hospital ownership, because patients redistributed to other public hospitals at rates higher than expected by proximity alone. This differential response to hospital closures demonstrates significant differences in how public and private patients respond to changes in health care access during disasters. Public health response must consider these differences to meet the needs of all patients affected by disasters and other public health emergencies. (Disaster Med Public Health Preparedness. 2015;00:1-9).

BACKGROUND:: Observational studies and clinical trials have shown associations of diet and high blood pressure (BP). However, prospective studies on the association between dietary patterns and longitudinal BP change are lacking, especially in low-income populations. METHOD:: We evaluated the association of dietary patterns and food groups with longitudinal change of BP in 10 389 participants in the Health Effects of Arsenic Longitudinal Study, with a median of 6.7 years of follow-up. Dietary information was obtained through a previously validated food-frequency questionnaire. BP was measured at baseline and at each biennial follow-up using the same method. RESULT:: Each standard deviation (SD) increase for the 'gourd vegetable' dietary pattern score was related to a slower annual change of 0.08, 0.04, and 0.05 mmHg in SBP, DBP, or pulse pressure, respectively. Each SD increase in the 'balanced' dietary pattern score was related to a decreasing annual change of 0.06 mmHg (P = 0.012) and 0.08 mmHg in SBP and pulse pressure (P < 0.001). On the contrary, one SD increase in 'western' dietary pattern score was related to a greater annual increase of 0.07 (P = 0.005) and 0.05 mmHg in SBP and pulse pressure (P = 0.013). Higher intake of fruits and vegetables was associated with a slower rate of change in annual SBP and pulse pressure, whereas higher meat intake was related to a more rapid increase in annual pulse pressure. CONCLUSION:: The findings suggest that dietary patterns play a significant role in the rate of BP change over time in a low-income population.