Caregiver Experience of Tele-dementia Care for Older Veterans

BACKGROUND

For the 5 million persons living with dementia (PLWD) in the USA, telemedicine may improve access to specialty care from their homes.

OBJECTIVE

To elicit informal caregiver perceptions of tele-dementia care provided during COVID-19.

DESIGN

Qualitative, observational study using grounded theory.

PARTICIPANTS

Informal caregivers aged 18 + who cared for an older adult who received tele-dementia services at two major VA healthcare systems participated in 30-60-min semi-structured telephone interviews.

INTERVENTIONS

Interviews were designed using Fortney's Access to Care model.

MAIN MEASURES

Thirty caregivers (mean age = 67, SD = 12, 87% women) were interviewed.

KEY RESULTS

Five major themes were (1) Tele-dementia care avoids routine disruption and pre-visit stress; (2) Transportation barriers to in-person visits include not only travel logistics but navigating the sequelae of dementia and comorbid medical conditions. These include cognitive, behavioral, physical, and emotional challenges such as balance issues, incontinence, and agitation in traffic; (3) Tele-dementia care saves time and money and improves access to specialists; (4) Tele-dementia facilitated communication between caregiver and provider without hindering communication between PLWD and provider; and (5) Caregivers described ideal future dementia care as a combination of virtual and in-person modalities with in-home help, financial and medical support, and dementia-sensitive caregiver access. Caregivers interviewed saved 2.6 h ± 1.5 h (range: 0.5 to 6 h) of travel time. Multiple caregivers described disruption of routines as difficult in PLWD and appreciated the limited preparation and immediate return to routine post telemedicine visit as positives.

CONCLUSIONS

Caregivers found tele-dementia care convenient, comfortable, stress reducing, timesaving, and highly satisfactory. Caregivers would prefer a combination of in-person and telemedicine visits, with an opportunity to communicate with providers privately. This intervention prioritizes care for older Veterans with dementia who have high care needs and are at higher risk for hospitalization than their same age counterparts without dementia.

Stressors and Maladaptive Coping Mechanisms Associated with Elevated Perinatal Depressive Symptoms and Suicidality Among Women Living with HIV in Uganda

BACKGROUND

Perinatal depression is highly prevalent among women living with HIV and contributes to nonadherence to the PMTCT (prevention of mother-to-child transmission) care continuum. We examined correlates of elevated depressive symptoms and suicidality in this population.

METHOD

Baseline data from 391 Ugandan women enrolled in a cluster randomized controlled trial of a depression care intervention were analyzed. Adult women with confirmed sero-positive HIV status were eligible if their gestation period was ≤ 32 weeks, and they had a Patient Health Questionnaire (PHQ-9) score ≥ 5. Correlates of elevated depressive symptoms (PHQ-9 > 9) and moderate-to-severe suicidal ideation (more than half of the days in the prior 2 weeks) were assessed using bivariate and multivariate logistic regression models, controlling for clustering within study sites by using a random effects specification (with study site as the random effect), as well as age and education.

RESULTS

The mean PHQ-9 score was 12.7 (SD = 5.1); 267 (68.3%) participants had elevated depressive symptoms, and 51 (13.0%) reported moderate-to-severe suicidality. In multiple logistic regression analysis, perceived provider stigma of childbearing [OR (95% CI) = 1.81 (1.16, 2.84)], greater use of negative problem-solving [OR (95% CI) = 1.09 (1.04, 1.15)], and lower general social support [OR (95% CI) = 0.50 (0.30, 0.82)] were correlated with elevated depression symptoms, while moderate-to-severe suicidal ideation was correlated with greater experience of physical interpersonal violence (IPV) and greater use of negative problem-solving.

CONCLUSIONS

Programs aimed at improving provider support for the childbearing needs of persons living with HIV, supporting women who are experiencing IPV, and helping women to develop effective problem-solving skills and social supports may reduce symptoms of perinatal depression and help optimize PMTCT care outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03892915 (registered March 21, 2019).

Effects of M-DEPTH Model of Depression Care on Maternal HIV Viral Suppression and Adherence to the PMTCT Care Continuum Among HIV-Infected Pregnant Women in Uganda: Results from a Cluster Randomized Controlled Trial at Pregnancy Completion

Perinatal depression has been shown to impede adherence to antiretroviral therapy (ART) and the prevention of mother-to-child transmission (PMTCT) care continuum; therefore, treating perinatal depression may result in increased viral suppression and PMTCT adherence. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on depression, maternal viral suppression and adherence to PMTCT care processes in an ongoing cluster-randomized controlled trial of 391 HIV-infected pregnant women (200 usual care; 191 intervention) with at least mild depressive symptoms enrolled across 8 antenatal care clinics in Uganda. At baseline, 68.3% had clinical depression and 41.7% had detectable HIV viral load. Adjusted repeated-measures multivariable regression models found that the intervention group was nearly 80% less likely to be clinically depressed [Adjusted OR (95% CI) 0.22 (0.05, 0.89)] at the 2-month post-pregnancy assessment, compared to the control group. However, the intervention and control groups did not differ meaningfully on maternal viral suppression, ART adherence, and other PMTCT care processes and outcomes. In this sample of women who were mostly virally suppressed and ART adherent at baseline, the depression care model had a strong effect on depression alleviation, but no downstream effects on viral suppression or other PMTCT care processes.Trial Registration NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Severe Acute Respiratory Syndrome Associated Infections

Viral infections are some of the most common sources of respiratory illness in pediatric and adult populations worldwide. Influenza and coronaviruses are viral pathogens that could lead to severe respiratory illness and death. More recently, respiratory illness from coronaviruses, accounts for more than 1 million deaths in the United States alone. This article will explore the epidemiology, pathogenesis, diagnosis, treatment, and prevention of severe acute respiratory syndrome caused by coronavirus-2, and Middle Eastern respiratory syndrome.

Functional gene delivery to and across brain vasculature of systemic AAVs with endothelial-specific tropism in rodents and broad tropism in primates

Delivering genes to and across the brain vasculature efficiently and specifically across species remains a critical challenge for addressing neurological diseases. We have evolved adeno-associated virus (AAV9) capsids into vectors that transduce brain endothelial cells specifically and efficiently following systemic administration in wild-type mice with diverse genetic backgrounds, and in rats. These AAVs also exhibit superior transduction of the CNS across non-human primates (marmosets and rhesus macaques), and in ex vivo human brain slices, although the endothelial tropism is not conserved across species. The capsid modifications translate from AAV9 to other serotypes such as AAV1 and AAV-DJ, enabling serotype switching for sequential AAV administration in mice. We demonstrate that the endothelial-specific mouse capsids can be used to genetically engineer the blood-brain barrier by transforming the mouse brain vasculature into a functional biofactory. We apply this approach to Hevin knockout mice, where AAV-X1-mediated ectopic expression of the synaptogenic protein Sparcl1/Hevin in brain endothelial cells rescued synaptic deficits.

COVID-19's Still-Urgent Lessons of Structural Inequality and Child Health in the United States

COVID-19's lessons on structural inequality should have been painful and embarrassing to all of us. These daily experiences of an unacceptable status quo among US children are still with us in a post-COVID America. Addressing the multi-sectoral factors that undermine the nation...s health should remain urgent priorities for all health professionals.

Functional gene delivery to and across brain vasculature of systemic AAVs with endothelial-specific tropism in rodents and broad tropism in primates

Delivering genes to and across the brain vasculature efficiently and specifically across species remains a critical challenge for addressing neurological diseases. We have evolved adeno-associated virus (AAV9) capsids into vectors that transduce brain endothelial cells specifically and efficiently following systemic administration in wild-type mice with diverse genetic backgrounds and rats. These AAVs also exhibit superior transduction of the CNS across non-human primates (marmosets and rhesus macaques), and ex vivo human brain slices although the endothelial tropism is not conserved across species. The capsid modifications translate from AAV9 to other serotypes such as AAV1 and AAV-DJ, enabling serotype switching for sequential AAV administration in mice. We demonstrate that the endothelial specific mouse capsids can be used to genetically engineer the blood-brain barrier by transforming the mouse brain vasculature into a functional biofactory. Vasculature-secreted Hevin (a synaptogenic protein) rescued synaptic deficits in a mouse model.

UNMET NEEDS AND PERCEIVED BARRIERS TO ACCESSING HCBS AMONG CAREGIVERS OF VETERANS OF ALL ERAS

VA has several HCBS to offset caregiver burden, facilitate caregiving, and enhance Veterans’ home-based care, but they remain underutilized. We aimed to describe: the unmet psychosocial and HCBS needs of caregivers, barriers to accessing services, and gaps in available programs. Twenty-three caregivers participated in a 1-hr semi-structured interview (62.9□13.5y; 74.0% women; 47.8% White; 17.4% Hispanic; 65.2% spouses). Caregivers provided 7.3 hrs of daily care (SD=5.5 hrs, Range=1-24); most had provided care for 1+ year. Barriers to accessing HCBS included: a) disagreement with Veterans regarding service preferences and needs; b) lack of awareness of VA and non-VA programs; c) delays in obtaining services; and d) emotional toll of caregiving on personal health and relationship with the Veteran. The VA may need to invest in advertising existing services, develop strategies to match caregivers with available services when needed, and enhancing mental health and relationship quality for Veterans and caregivers.

DEMENTIA CAREGIVER PERCEPTIONS OF TELE-DEMENTIA CARE FOR VETERANS DURING THE COVID-19 PANDEMIC

The estimated 5 million persons living with dementia in the United States have been greatly impacted by the medical and psychosocial impacts of the COVID-19 pandemic, respite program closures, social isolation, and Veterans seen within the Veterans Health Administration system are particularly vulnerable. Telemedicine provides needed specialty dementia care to these patients with complex needs in their homes, and its uptake has increased during the pandemic. This qualitative, observational study explored informal caregivers’ perceptions of tele-dementia care for Veterans seen at 2 sites, Palo Alto and Cleveland, via semi-structured interviews. Twenty-five caregivers (Mean age = 67y, SD=12y, 88% women) were interviewed over telephone following a tele-dementia visit. Themes that emerged from the interviews were that tele-dementia visits: (1) saved caregivers 2.6h±1.5h (Range: 0.5 to 6h) of travel time, (2) required limited preparation compared to in-person visits, (3) mitigated COVID-19 risk and avoided needs for masking and social distancing, (4) avoided behavioral challenges during appointments, and (5) allowed participation from home with minimal disruption of routine. Caregivers described significant physical challenges that made leaving the home for appointments difficult including balance issues, incontinence, and difficulties getting into vehicle. Caregivers plan to continue using tele-dementia services beyond the pandemic due to the convenience. Taken together, these findings indicate that caregivers find tele-dementia care convenient, comfortable, helpful, and timesaving and highly satisfactory. A combination of both in-person and virtual visits would be an ideal future state. This study illustrates how caregivers experience virtual visits for dementia care and will shape future intervention design.

Active vision during prey capture in wild marmoset monkeys

A foundational pressure in the evolution of all animals is the ability to travel through the world, inherently coupling the sensory and motor systems. While this relationship has been explored in several species,1-4 it has been largely overlooked in primates, which have typically relied on paradigms in which head-restrained subjects view stimuli on screens.5 Natural visual behaviors, by contrast, are typified by locomotion through the environment guided by active sensing as animals explore and interact with the world,4,6 a relationship well illustrated by prey capture.7-12 Here, we characterized prey capture in wild marmoset monkeys as they negotiated their dynamic, arboreal habitat to illustrate the inherent role of vision as an active process in natural nonhuman primate behavior. Not only do marmosets share the core properties of vision that typify the primate Order,13-18 but they are prolific hunters that prey on a diverse set of prey animals.19-22 Marmosets pursued prey using vision in several different contexts, but executed precise visually guided motor control that predominantly involved grasping with hands for successful capture of prey. Applying markerless tracking for the first time in wild primates yielded novel findings that precisely quantified how marmosets track insects prior to initiating an attack and the rapid visually guided corrections of the hands during capture. These findings offer the first detailed insight into the active nature of vision to guide multiple facets of a natural goal-directed behavior in wild primates and can inform future laboratory studies of natural primate visual behaviors and the supporting neural processes.

BETA: a comprehensive benchmark for computational drug-target prediction

Internal validation is the most popular evaluation strategy used for drug-target predictive models. The simple random shuffling in the cross-validation, however, is not always ideal to handle large, diverse and copious datasets as it could potentially introduce bias. Hence, these predictive models cannot be comprehensively evaluated to provide insight into their general performance on a variety of use-cases (e.g. permutations of different levels of connectiveness and categories in drug and target space, as well as validations based on different data sources). In this work, we introduce a benchmark, BETA, that aims to address this gap by (i) providing an extensive multipartite network consisting of 0.97 million biomedical concepts and 8.5 million associations, in addition to 62 million drug-drug and protein-protein similarities and (ii) presenting evaluation strategies that reflect seven cases (i.e. general, screening with different connectivity, target and drug screening based on categories, searching for specific drugs and targets and drug repurposing for specific diseases), a total of seven Tests (consisting of 344 Tasks in total) across multiple sampling and validation strategies. Six state-of-the-art methods covering two broad input data types (chemical structure- and gene sequence-based and network-based) were tested across all the developed Tasks. The best-worst performing cases have been analyzed to demonstrate the ability of the proposed benchmark to identify limitations of the tested methods for running over the benchmark tasks. The results highlight BETA as a benchmark in the selection of computational strategies for drug repurposing and target discovery.

Deep Denoising of Raw Biomedical Knowledge Graph from COVID-19 Literature, LitCovid and Pubtator

Background

Multiple types of biomedical associations of knowledge graphs, including COVID-19–related ones, are constructed based on co-occurring biomedical entities retrieved from recent literature. However, the applications derived from these raw graphs (eg, association predictions among genes, drugs, and diseases) have a high probability of false-positive predictions as co-occurrences in the literature do not always mean there is a true biomedical association between two entities.

Objective

Data quality plays an important role in training deep neural network models; however, most of the current work in this area has been focused on improving a model’s performance with the assumption that the preprocessed data are clean. Here, we studied how to remove noise from raw knowledge graphs with limited labeled information.

Methods

The proposed framework used generative-based deep neural networks to generate a graph that can distinguish the unknown associations in the raw training graph. Two generative adversarial network models, NetGAN and Cross-Entropy Low-rank Logits (CELL), were adopted for the edge classification (ie, link prediction), leveraging unlabeled link information based on a real knowledge graph built from LitCovid and Pubtator.

Results

The performance of link prediction, especially in the extreme case of training data versus test data at a ratio of 1:9, demonstrated that the proposed method still achieved favorable results (area under the receiver operating characteristic curve >0.8 for the synthetic data set and 0.7 for the real data set), despite the limited amount of testing data available.

Conclusions

Our preliminary findings showed the proposed framework achieved promising results for removing noise during data preprocessing of the biomedical knowledge graph, potentially improving the performance of downstream applications by providing cleaner data.

470 Financial and Efficacy Analysis of a Centralised Neck of Femur Fracture Service

Aim

Osteoporotic fractures are rising in incidence, costing the National Health Service up to £1.1 billion for hospital care. The implementation of the Best Practice Tariff (BPT) of fragility fractures in 2010 created a financial incentive to achieve standards of best practice. In June 2015, a dedicated hip fracture unit (HFU) was set up at Princess Royal Hospital (PRH). The aim of this study is (A) to assess changes in performance to the BPT after the introduction of a dedicated HFU, and (B) whether the performance of a HFU is affected by direct/indirect presentation to the HFU.

Method

The performance of Brighton and Sussex University Hospitals (BSUH) to BPT pre and post HFU was assessed by a retrospective review of BPT performance data between 2015 and 2016. 870 patients who were treated for NOFF at BSUH were reviewed to assess whether the performance of the HFU was impacted by patients presenting either directly (PRH) to the HFU or indirectly (presentation to Royal Sussex County Hospital). Appropriate statistical tests were used to analyse the significant differences between these outcome measures.

Results

The comparison between pre and post HFU showed there was a significant increase in the time between A&E admission to ward, theatre or orthogeriatric (OG) assessment (P < 0.001) in patients presenting indirectly to HFU compared to direct presentations.

Conclusions

Having a HFU is cost neutral, and advantages of HFU include focusing NOFF care which improves in patient care. BPT achievements could be improved by increasing the direct admission of NOFF to the HFU.

The Relationship Between the Functional Gait Assessment and Quality-of-Life Data in Patients Undergoing Vestibular Schwannoma Resection

OBJECTIVE

To examine the relationship between the Functional Gait Assessment (FGA) and quality of life (QOL) measurements relating to balance before and after vestibular schwannoma (VS) resection and to assess the role of preoperative FGA in predicting postoperative QOL.

STUDY DESIGN

A prospective clinical study of adult patients undergoing VS resection between September 2018 and December 2019. FGA was administered 1 week before and after surgery. Dizziness Handicap Inventory (DHI) and Penn Acoustic Neuroma Quality of Life (PANQOL) were administered preoperatively and at 3 months postoperatively.

SETTING

Single tertiary center.

PATIENTS

Patients (age ≥ 18 years old) with VS undergoing microsurgical resection. Excluded were patient with previous surgery or radiation.

INTERVENTION

VS resection.

MAIN OUTCOMES AND MEASURES

Primary outcome: correlation between FGA and QOL surveys. Secondary outcome: correlation between preoperative measurements of balance and postoperative PANQOL.

RESULTS

One hundred thirty-eight patients were analyzed (mean age: 48 years old, 65.9% female). The translabyrinthine approach was most commonly performed. Under multivariate analysis, preoperative FGA significantly correlated with preoperative PANQOL balance score (p < 0.0001), preoperative PANQOL total score (p = 0.0002), and preoperative DHI (p < 0.0001). However, postoperative FGA did not significantly correlate with postoperative PANQOL balance or total scores (p = 0.446 and p = 0.4, respectively), or postoperative DHI (p = 0.3). Univariate analysis demonstrated that preoperative DHI and preoperative FGA were predictive of changes in postoperative PANQOL balance and total scores. However under multivariate analysis, preoperative FGA did not predict changes in postoperative PANQOL balance or total score (p = 0.24; p = 0.28, respectively). Preoperative DHI remained predictive of changes in postoperative PANQOL balance (p = 0.03) score but not of postoperative PANQOL total score (p = 0.37).

CONCLUSIONS

Although FGA and QOL data significantly correlated in the preoperative setting, our results did not suggest that preoperative FGA can be used to determine postoperative QOL. Additionally, the lack of correlation between FGA and QOL measurements in the acute postoperative setting suggests that further research is needed to determine contributors to postoperative QOL.

Leveraging Genetic Reports and Electronic Health Records for the Prediction of Primary Cancers: Algorithm Development and Validation Study

BACKGROUND

Precision oncology has the potential to leverage clinical and genomic data in advancing disease prevention, diagnosis, and treatment. A key research area focuses on the early detection of primary cancers and potential prediction of cancers of unknown primary in order to facilitate optimal treatment decisions.

OBJECTIVE

This study presents a methodology to harmonize phenotypic and genetic data features to classify primary cancer types and predict cancers of unknown primaries.

METHODS

We extracted genetic data elements from oncology genetic reports of 1011 patients with cancer and their corresponding phenotypical data from Mayo Clinic's electronic health records. We modeled both genetic and electronic health record data with HL7 Fast Healthcare Interoperability Resources. The semantic web Resource Description Framework was employed to generate the network-based data representation (ie, patient-phenotypic-genetic network). Based on the Resource Description Framework data graph, Node2vec graph-embedding algorithm was applied to generate features. Multiple machine learning and deep learning backbone models were compared for cancer prediction performance.

RESULTS

With 6 machine learning tasks designed in the experiment, we demonstrated the proposed method achieved favorable results in classifying primary cancer types (area under the receiver operating characteristic curve [AUROC] 96.56% for all 9 cancer predictions on average based on the cross-validation) and predicting unknown primaries (AUROC 80.77% for all 8 cancer predictions on average for real-patient validation). To demonstrate the interpretability, 17 phenotypic and genetic features that contributed the most to the prediction of each cancer were identified and validated based on a literature review.

CONCLUSIONS

Accurate prediction of cancer types can be achieved with existing electronic health record data with satisfactory precision. The integration of genetic reports improves prediction, illustrating the translational values of incorporating genetic tests early at the diagnosis stage for patients with cancer.

The Impact of the COVID-19 Pandemic on College Students' Health and Financial Stability in New York City: Findings from a Population-Based Sample of City University of New York (CUNY) Students

Understanding the effect of the coronavirus disease 2019 (COVID-19) pandemic on students' health and financial stability is important to establish effective interventions to mitigate these effects, which may have long-term consequences on their health and well-being. Public universities in urban centers represent a substantial proportion of college students in the USA. We implemented a cross-sectional population-based online survey of 2282 students in a large, public university in New York City in April 2020. We created weights to account for non-response and used Poisson regression with robust standard errors to estimate adjusted prevalence ratios (aPR) for factors associated with mental health outcomes. Students experienced high rates of anxiety/depression and financial instability due to the pandemic. Half of the students reported anxiety/depression (54.5%) and an increased need for mental health services (49.0%) as a result of the COVID-19 pandemic. The majority (81.1%) reported loss of household income, and half (49.8%) reported worries about losing housing. High levels of food (aPR  = 1.4, 95% CI 1.2, 1.6) and housing (aPR = 1.3, 95% CI 1.2, 1.4) insecurity were the strongest predictors of anxiety/depression. Household and personal experiences with possible COVID-19 symptoms were also associated with anxiety/depression or the need for increased mental health services. Addressing student needs at public urban universities requires an integrated holistic approach that targets urgent mental health and economic needs related to the impact of COVID-19. Students who become infected need mental health services as well as health monitoring.

Assessing the Quality of Electronic Data for 'Fit-for-Purpose' by Utilizing Data Profiling Techniques Prior to Conducting a Survival Analysis for Adults with Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia affects both children and adults. Rising costs of cancer care and patient burden contribute to the need to study factors influencing outcomes. This study explored the quality of datasets generated from a clinical research institution. The 'fit-for-use' of data prior to examining survival/complications was determined through a systematic approach guided by the Weiskopf et al. 3x3 Data Quality Assessment Framework. Constructs of completeness, correctness, and currency were explored for the data dimensions of patient, variables, and time. There were 11 types of data retrieved. Sufficient data points were found for patient and variable data in each dataset (≥70% of its cells filled with patient level data). Although there was concordance between variables, we found the distribution of lab values and death data to be incorrect. There were missing values for labs ordered and death dates. Our study showed that datasets retrieved can vary, even from the same institution.

Navigating telemedicine for facial trauma during the COVID-19 pandemic

Importance

The COVID-19 pandemic is changing how health care providers practice. As some telemedicine and telecommunication support tools have been incorporated into the otolaryngology practice in response to safety and access demands, it is essential to review how these tools and services can help facilitate facial trauma evaluation during a time when clinical resources are limited.

Objective

To review applications of telemedicine for the evaluation of facial trauma to better direct utilization of these methods and technologies during times of limited access to clinical resources such as the COVID-19 pandemic.

Methods

A systematic review was conducted using PubMed, Embase, and Web of Science.

Results

After screening 158 titles and abstracts, we identified 16 eligible studies involving facial trauma evaluation using telemedicine. Telemedicine opportunities for facial trauma evaluation have the potential to be developed in the areas of multidisciplinary remote consultations, facial trauma triage, patient engagement, and postoperative follow-up.

Conclusion

The COVID-19 pandemic is posing obstacles for both providers and patients in the delivery of health care at a time of limited clinical resources. Telemedicine may provide a potential useful tool in the evaluation and triage of facial injuries and patient engagement.

The Personal Health Network Mobile App for Chemotherapy Care Coordination: Qualitative Evaluation of a Randomized Clinical Trial

BACKGROUND

Cancer care coordination addresses the fragmented and inefficient care of individuals with complex care needs. The complexity of care coordination can be aided by innovative technology. Few examples of information technology-enabled care coordination exist beyond the conventional telephone follow-up. For this study, we implemented a custom-designed app, the Personal Health Network (PHN)-a Health Insurance Portability and Accountability Act-compliant social network built around a patient to enable patient-centered health and health care activities in collaboration with clinicians, care team members, caregivers, and others designated by the patient. The app facilitates a care coordination intervention for patients undergoing chemotherapy.

OBJECTIVE

This study aimed to understand patient experiences with PHN technology and assess their perspectives on the usability and usefulness of PHNs with care coordination during chemotherapy.

METHODS

A two-arm randomized clinical trial was conducted to compare the PHN and care coordination with care coordination alone over a 6-month period beginning with the initiation of chemotherapy. A semistructured interview guide was constructed based on a theoretical framework of technology acceptance addressing usefulness, usability, and the context of use of the technology within the participant's life and health care setting. All participants in the intervention arm were interviewed on completion of the study. Interviews were recorded and transcribed verbatim. A summative thematic analysis was completed for the transcribed interviews. Features of the app were also evaluated.

RESULTS

A total of 27 interviews were completed. The resulting themes included the care coordinator as a partner in care, learning while sick, comparison of other technology to make sense of the PHN, communication, learning, usability, and usefulness. Users expressed that the nurse care coordinators were beneficial to them because they helped them stay connected to the care team and answered their questions. They shared that the mobile app gave them access to the health information they were seeking. Users expressed that the mobile app would be more useful if it was fully integrated with the electronic health record.

CONCLUSIONS

The findings highlight the value of care coordination from the perspectives of cancer patients undergoing chemotherapy and the important role of technology, such as the PHN, in enhancing this process by facilitating better communication and access to information regarding their illness.

Tobacco Smoking and Antisocial Deviance among Vietnamese, Vietnamese-American, and European-American Adolescents

Tobacco smoking is one of the most significant modifiable behavioral health risk factors worldwide. Although smoking rates in some high-income countries (HIC) have declined, rates in many low-and-middle-income countries (LMIC) remain high. Adolescence is a key developmental risk period for smoking initiation. Research indicates that a major adolescent risk factor for tobacco smoking is antisocial deviance, which includes such behaviors as aggression, risk-taking, and rule-breaking. The linkages between antisocial deviance and smoking suggest that these behaviors and their underlying attitudes can be important targets for smoking prevention programs, but for public health efficiency it is important to target the components of antisocial deviance most closely linked smoking. However, although 80% of smokers live in LMIC, most relevant research has been conducted in HIC and its applicability to LMIC is unclear, given cultural differences between many HIC and LMIC. The purpose of the present study was to assess cross-cultural variations in relations among components of antisocial deviance and self-reported tobacco smoking among 2,724 10th and 11th grade Vietnamese, Vietnamese-American, and European-American students. Within the combined sample the relation between self-reported smoking and overall antisocial deviance was β = 0.33. However, the component of antisocial deviance most strongly related to smoking varied across groups, with Risk-taking most strongly related to smoking for Vietnamese-American (β = 0.37) and Vietnamese (β = 0.36) adolescents, and Rule-breaking Behavior most strongly related to smoking for European-American (β = 0.51) adolescents. These and other findings suggest the possible importance of culturally-tailored foci for smoking prevention programs emphasizing different aspects of antisocial deviance.

Maternal depression treatment in HIV (M-DEPTH): Study protocol for a cluster randomized controlled trial

INTRODUCTION

Over one-third of human immunodeficiency virus (HIV)-infected pregnant women are clinically depressed, increasing the risk of mother-to-child transmission (MTCT) of HIV, as well as negative birth and child development outcomes. This study will evaluate the efficacy and cost-effectiveness of an evidence-based stepped care treatment model for perinatal depression (maternal depression treatment in HIV [M-DEPTH]) to improve adherence to prevention of MTCT care among HIV+ women in Uganda.

METHODS

Eight antenatal care (ANC) clinics in Uganda will be randomized to implement either M-DEPTH (n=4) or usual care (n=4) for perinatal depression among 400 pregnant women (n=50 per clinic) between June 2019 and August 2022. At each site, women who screen positive for potential depression will be enrolled and followed for 18 months post-delivery, assessed in 6-month intervals: baseline, within 1 month of child delivery or pregnancy termination, and months 6, 12, and 18 following delivery. Primary outcomes include adherence to the prevention of mother-to-child transmission (PMTCT) care continuum-including maternal antiretroviral therapy and infant antiretrovial prophylaxis, and maternal virologic suppression; while secondary outcomes will include infant HIV status, post-natal maternal and child health outcomes, and depression treatment uptake and response. Repeated-measures multivariable regression analyses will be conducted to compare outcomes between M-DEPTH and usual care, using 2-tailed tests and an alpha cut-off of P <.05. Using a micro-costing approach, the research team will relate costs to outcomes, examining the incremental cost-effectiveness ration (ICER) of M-DEPTH relative to care as usual.

DISCUSSION

This cluster randomized controlled trial will be one of the first to compare the effects of an evidence-based depression care model versus usual care on adherence to each step of the PMTCT care continuum. If determined to be efficacious and cost-effective, this study will provide a model for integrating depression care into ANC clinics and promoting adherence to PMTCT.

TRIAL REGISTRATION

NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Native American Youth Citizen Scientists Uncovering Community Health and Food Security Priorities

Citizen science based on principles of community-based participatory research involves the co-creation of research among citizens and professional researchers in substantive aspects of scientific inquiry including equitable contributions to governance, research questions, data collection, analysis, application of findings, and dissemination. This article reports on a citizen science project conducted by 12 youth in the Karuk Tribe collaborating with university scientists. The youth participated in a research leadership development program conducted in their community located in rural/remote northern California. The youth led a community health and food security assessment survey using a mobile application tool (n = 212). They uncovered community concerns about the health of residents and healthfulness of food choices in schools, as well as a significant difference related to confidence in making healthy food choices between those who are and are not physically active. The Tribe applied the study findings with youth in alignment with cultural values and practices investing in developing community gardens, improving school food quality, and promoting native food practices that incorporate physical activities such as hiking, gathering, and preserving food. This study offers lessons for research collaborations among citizen scientists from communities underrepresented in health research and university scientists.

Prospective relations between parent-adolescent acculturation conflict and mental health symptoms among Vietnamese American adolescents

OBJECTIVES

Intergenerational acculturation conflict in immigrant families has been implicated as a risk factor for adolescent maladjustment. However, the directionality and specific family related mediators of this association have not been identified. The present study prospectively examined relations between adolescent reports of perceived acculturation conflict and internalizing and externalizing mental health symptoms. Perceived parent-adolescent relationship strain and perceived parental psychological control were examined as potential mediators.

METHOD

Survey measures were administered to 375 Vietnamese American adolescents (48.8% males; M = 15.55 years, SD = .59) at 3 time points over 6 months.

RESULTS

Using cross-lagged path analysis, perceived acculturation conflict predicted externalizing symptoms, whereas internalizing symptoms predicted perceived acculturation conflict. Perceived maternal psychological control mediated the association between perceived acculturation conflict and later externalizing symptoms, whereas maternal psychological control, parental unresponsiveness, and unmet parent expectations mediated the association between internalizing symptoms and later acculturation conflict.

CONCLUSION

Culturally competent enhancement of parental sensitivity and responsiveness might be targeted as a modifiable protective factor in family-based preventive interventions for at-risk immigrant families. (PsycINFO Database Record

Deep mining heterogeneous networks of biomedical linked data to predict novel drug-target associations

Motivation

A heterogeneous network topology possessing abundant interactions between biomedical entities has yet to be utilized in similarity-based methods for predicting drug-target associations based on the array of varying features of drugs and their targets. Deep learning reveals features of vertices of a large network that can be adapted in accommodating the similarity-based solutions to provide a flexible method of drug-target prediction.

Results

We propose a similarity-based drug-target prediction method that enhances existing association discovery methods by using a topology-based similarity measure. DeepWalk, a deep learning method, is adopted in this study to calculate the similarities within Linked Tripartite Network (LTN), a heterogeneous network generated from biomedical linked datasets. This proposed method shows promising results for drug-target association prediction: 98.96% AUC ROC score with a 10-fold cross-validation and 99.25% AUC ROC score with a Monte Carlo cross-validation with LTN. By utilizing DeepWalk, we demonstrate that: (i) this method outperforms other existing topology-based similarity computation methods, (ii) the performance is better for tripartite than with bipartite networks and (iii) the measure of similarity using network topology outperforms the ones derived from chemical structure (drugs) or genomic sequence (targets). Our proposed methodology proves to be capable of providing a promising solution for drug-target prediction based on topological similarity with a heterogeneous network, and may be readily re-purposed and adapted in the existing of similarity-based methodologies.

Availability and Implementation

The proposed method has been developed in JAVA and it is available, along with the data at the following URL: https://github.com/zongnansu1982/drug-target-prediction .

Contact

nazong@ucsd.edu.

Supplementary information

Supplementary data are available at Bioinformatics online.

Atypical Presentation of Escherichia coli Monomicrobial Necrotizing Fasciitis in a Renal Transplant Patient: A Case Report

Skin and soft tissue infections (SSTIs) are one of most frequent infectious causes for referral to the emergency department and one of the most frequent infectious causes of hospital admissions. Escherichia coli, the most commonly occurring gram-negative pathogen involved in these infections, contributes to about 7% of all SSTIs cases where gram-positive organisms reign dominant. Patients are more susceptible to these gram-negative SSTIs if they are neutropenic, have hematologic malignancies, have undergone solid organ or hematopoietic transplantation, or have cirrhotic liver disease. Due to their immunocompromised state, the prognosis is very poor and not well understood. We report a case of an atypical presentation of an E coli monomicrobial necrotizing fasciitis in a renal transplant patient. Our findings support improved mortality with rapid aggressive interventions, such as amputation, in immunocompromised patients.

Cultural Differences in the Reciprocal Relations between Emotion Suppression Coping, Depressive Symptoms and Interpersonal Functioning among Adolescents

The current study examined the prospective relations between emotion suppression and maladjustment (i.e., depressive symptoms, family stress events, peer stress events, and family and peer support) among Vietnamese American (n = 372) and European American adolescents (n = 304). We found that at baseline Vietnamese Americans adolescents reported greater use of emotion suppression coping than European American adolescents. Multi-group structural equation modeling indicated that for European American teens emotion suppression was significantly related to increased depression symptoms and decreased quality of peer relationships. In contrast, for the Vietnamese Americans teens emotion suppression relations to later maladjustment was either nonsignificant or attenuated relative to the European American. These findings suggest ethnic group differences in both the utilization, and consequences and function of emotion suppression among Vietnamese American and European American adolescents.

Adolescents' stigma attitudes toward internalizing and externalizing disorders: Cultural influences and implications for distress manifestations

OBJECTIVE

This study examined predictors of stigma attitudes toward common youth emotional behavioral problems to test the hypothesis that interdependent cultural values would be associated with differential stigma towards externalizing versus internalizing disorders. Furthermore, we examined whether problem-specific stigma attitudes would predict adolescent's own self-reported manifestations of distress.

METHOD

1224 Vietnamese American and European American adolescents completed measures of social distance stigma attitudes in response to vignettes depicting youth with internalizing (depression, social anxiety, somatization) and externalizing (alcohol use, aggressive behaviors, delinquency) disorders. A subset of 676 youth also provided self-reports on their own adjustment prospectively over six months.

RESULTS

Measurement models revealed clear separation of negatively correlated factors assessing stigma toward externalizing versus internalizing problems. Values related to family interdependence were significantly associated with greater tolerance of internalizing disorders and lower tolerance of externalizing disorders. Stigma towards internalizing disorders was associated with lower concurrent self-reported internalizing symptoms, whereas stigma towards externalizing symptoms was associated with lower concurrent externalizing symptoms and greater decreases in externalizing symptoms over time.

CONCLUSIONS

The results of the study suggest that stigma attitudes are differentiated by problem type and may represent one cultural factor shaping distress manifestations.

Structuralizing biomedical abstracts with discriminative linguistic features

OBJECTIVE

Nearly 75% of the abstracts in MEDLINE papers present in an unstructured format. This study aims to automate the reformatting of unstructured abstracts into the Introduction, Methods, Results, and Discussion (IMRAD) format. The quality of this reformatting relies on the features used in sentence classification. Therefore, we explored the most effective linguistic features in MEDLINE papers.

METHODS

We constructed a feature set consisting of bag of words, linguistic features, grammatical features, and structural features. In order to evaluate the effectiveness, which is the capability of the sentence classification with the features, three datasets from PubMed Central Open Access Subset were selected and constructed: (1) structured abstract (SA) for training, (2) unstructured RCT abstract (UA-1) and (3) unstructured general abstract (UA-2). F-score and accuracy were used to measure the effectiveness on IMRAD section level and the overall classification.

RESULTS

Adding linguistic features improves the classification of the abstract sentence from 1.2% to 35.8% in terms of accuracy in three abstract datasets. The highest accuracies achieved were 91.7% in SA, 86.3% in UA-1, and 77.9% in UA-2. Linguistic features (dimensions=15) had fewer dimensions than bag-of-words (dimensions= 1541). All representative linguistic features (n-gram and verb phrase, and noun phrase) for each section are identified in our system (available at http://abstract.bike.re.kr).

CONCLUSION

Linguistic features can be used to effectively classify sentence with low computation burden in MEDLINE abstract.

Usability and acceptance of novel personal health technology to support early palliative care for patients with cancer and caregivers

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Background: Little research has assessed whether and how technology can support early palliative care. Our team developed a HIPAA-compliant, cloud-based Personal Health Network (PHN) with a secure, online network of family, caregivers, clinicians and service providers designated by the patient; symptom reporting/management resources; and support for communication among network members via audio/video conferencing, messaging, and document sharing. This study examines PHN usability and acceptance, and identifies additional functions for early palliative care. Methods: Patients undergoing chemotherapy in a Comprehensive Cancer Center (n = 19) and their caregivers (n = 17) watched video demonstrations of the technology, participated in semi-structured interviews, and completed surveys measuring computer self-efficacy, PHN usability and acceptance. Results: Most participants were male with college education; mean age was 58 years. Most had a tablet or desktop computer (75%), a mobile phone (94%) and believed that technology improves the security of medication information (66%). At the same time, only 44% used email to contact healthcare providers and 30% used the internet to connect with others for support and information. Most reported the PHN was easy to learn and use and was an efficient and useful tool for patient-driven social networking, team communication, care coordination and symptom management. Participants suggested adapting the PHN to support spiritual and emotional needs and advance care planning. Common concerns included skepticism about receipt of timely responses from providers to symptom reports and the need for ongoing support for older adults with limited technology experience. Conclusions: These preliminary findings support adaption of the PHN to support palliative care components identified as important to patients and caregivers and further PHN usability and acceptance testing in larger, more diverse samples. The results also underscore the need for systems to support technology users, to clarify expectations of response time with patients and caregivers, and to assure these expectations can be met by healthcare providers.

A Structured Protocol Model of Depression Care versus Clinical Acumen: A Cluster Randomized Trial of the Effects on Depression Screening, Diagnostic Evaluation, and Treatment Uptake in Ugandan HIV Clinics

Depression is common among people living with HIV, and it has consequences for both HIV prevention and treatment response, yet depression treatment is rarely integrated into HIV care in sub-Saharan Africa, partly due to the paucity of mental health professionals. We conducted a cluster randomized controlled trial of two task-shifting models to facilitating depression care delivered by medical providers: one that utilized a structured protocol, and one that relied on clinical acumen, in 10 HIV clinics in Uganda. Both models started with routine depression screening of all clients at triage using the 2-item Patient Health Questionnaire (PHQ-2), from which we enrolled 1252 clients (640 at structured protocol clinics, 612 at clinical acumen clinics) who had screened positive over 12 months. We compared the two models on (1) proportion of all client participants, and those clinically depressed (based on survey-administered 9-item PHQ-9>9), who received post-screening evaluation for depression using the PHQ-9; and (2) proportion of clinically depressed who were prescribed antidepressant therapy. Linear probability regression analyses were conducted using a wild cluster bootstrap to control for clustering; patient characteristics, clinic size and time fixed effects were included as covariates. Among all client participants, those in the structured protocol arm were far more likely to have received further evaluation by a medical provider using the PHQ-9 (84% vs. 49%; beta = .33; p = .01). Among the clinically depressed clients (n = 369), the advantage of the structured protocol model over clinical acumen was not statistically significant with regard to PHQ-9 depression evaluation (93% vs. 68%; beta = .21; p = .14) or prescription of antidepressants (69% vs. 58%; beta = .10; p = .50), in part because only 30% of clients who screened positive were clinically depressed. These findings reveal that in both models depression care practices were widely adopted by providers, and depression care reached most depressed clients. The structured protocol model is advantageous for ensuring that positively screened clients receive a depression evaluation, but the two models performed equally well in ensuring the treatment of depressed clients in the context of strong supervision support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02056106.

A Personal Health Network for Chemotherapy Care Coordination: Evaluation of Usability Among Patients

Cancer is a top concern globally. Cancer care suffers from lack of coordination, silos of information, and high cost. Interest is emerging in person-centered technology to assist with coordination to address these challenges. This study evaluates the usability of the "personal health network" (PHN), a novel solution leveraging social networking and mobile technologies, among individuals undergoing chemotherapy and receiving care coordination. Early results from interviews of 12 participants in a randomized pragmatic trial suggest that they feel more connected to the healthcare team using the PHN, find value in access to the patient education library, and are better equipped to organize the many activities that occur during chemotherapy. Improvements are needed in navigation, connectivity, and integration with electronic health records. Findings contribute to improvements in the PHN and informs a roadmap for potentially greater impact in technology-enabled cancer care coordination.

A cluster randomized controlled trial of two task-shifting depression care models on depression alleviation and antidepressant response among HIV clients in Uganda

BACKGROUND

depression is common among people living with HIV, but rarely diagnosed and treated in sub-Saharan Africa, in part due to the paucity of mental health professionals. Task-shifting approaches have been used to address this barrier. We compared the effects of two task-shifting models of depression care on depression alleviation and antidepressant response.

METHODS

we conducted a cluster randomized controlled trial of two task-shifting models to facilitating depression care delivered by trained medical providers, one that utilized a structured protocol (protocolized) and one that relied on the judgment of trained providers (clinical acumen), in 10 HIV clinics in Uganda. A sample of 1252 clients (640 at protocolized clinics, 612 at clinical acumen clinics) who had screened positive for potential depression on the 2-item Patient Health Questionnaire (PHQ-2) were enrolled and followed for 12 months. Interviewer-administered 9-item PHQ (PHQ-9) data from the research surveys, and provider administrations to clients treated with antidepressant therapy, were examined. Linear probability regression analyses were conducted using a wild cluster bootstrap to control for clustering.

RESULTS

among the whole sample (regardless of treatment status), rates of depression alleviation (PHQ-9<5) at month 12 were equivalent in the protocolized (75%) and clinical acumen (77%) arms, in an intention-to-treat analysis. Similarly, among the 415 participants who received antidepressant care, rates of treatment response (PHQ-9<5) at the last provider administered PHQ-9 (average of 8 months into treatment) were equivalent between the protocolized (65%) and clinical acumen (69%) arms; rate of improvement over the course of treatment was also equivalent.

CONCLUSIONS

nurses can provide quality depression care to HIV clients, regardless of whether treatment is guided by a structured protocol or clinical acumen, in the context of appropriate training and ongoing supervision support.

12-month outcomes of community engagement versus technical assistance to implement depression collaborative care: a partnered, cluster, randomized, comparative effectiveness trial

BACKGROUND

Depression collaborative care implementation using community engagement and planning (CEP) across programs improves 6-month client outcomes in minority communities, compared with technical assistance to individual programs (resources for services [RS]). However, 12-month outcomes are unknown.

OBJECTIVE

To compare effects of CEP and RS on mental health-related quality of life (MHRQL) and use of services among depressed clients at 12 months.

DESIGN

Matched health and community programs (n = 93) in 2 communities randomly assigned to receive CEP or RS. (ClinicalTrials.gov: NCT01699789).

MEASUREMENTS

Self-reported MHRQL and services use at baseline, 6 months, and 12 months.

SETTING

Los Angeles, California.

PATIENTS

1018 adults with depressive symptoms (8-item Patient Health Questionnaire score ≥10), 88% of whom were an ethnic minority.

INTERVENTION

CEP and RS to implement depression collaborative care.

MEASUREMENTS

The primary outcome was poor MHRQL (12-item mental health composite score ≤40) at baseline, 6 months, and 12 months; the secondary outcome was use of services at 12 months.

RESULTS

At 6 months, the finding that CEP outperformed RS to reduce poor MHRQL was significant but sensitive to underlying statistical assumptions. At 12 months, some analyses suggested that CEP was advantageous to MHRQL, whereas others did not confirm a significant difference favoring CEP. The finding that CEP reduced behavioral health hospitalizations at 6 months was less evident at 12 months and was sensitive to underlying statistical assumptions. Other services use did not significantly differ between interventions at 12 months.

LIMITATION

Data are self-reported, and findings are sensitive to modeling assumptions.

CONCLUSION

In contrast to 6-month results, no consistent effects of CEP on reducing the likelihood of poor MHRQL and behavioral health hospitalizations were found at 12 months. Still, given the needs of underresourced communities, the favorable profile of CEP, and the lack of evidence-based alternatives, CEP remains a viable strategy for policymakers and communities to consider.

PRIMARY FUNDING SOURCE

National Institute of Mental Health, Robert Wood Johnson Foundation, California Community Foundation, National Library of Medicine, and National Institutes of Health/National Center for Advancing Translational Science for the UCLA Clinical and Translational Science Institute.

Giving "Sadness" a Name: The Need for Integrating Depression Treatment into HIV Care in Uganda

Depression is common among people living with HIV/AIDS (PLWHA) in sub-Saharan Africa (SSA), and can have significant consequences for HIV disease progression, treatment response and prevention. Yet mental health services are limited in most HIV care programs in this region, in part due to severe shortages of mental health professionals. To address the need for establishing an effective, sustainable model for integrating depression treatment into HIV care in SSA, we have embarked upon a 3-year research project, INDEPTH Uganda (INtegrating DEPression Treatment and in HIV care in Uganda), to evaluate a task-sharing, protocolized approach to providing antidepressant care in ten HIV clinics in Uganda. In this paper we share our experiences with two treated cases identified during the initial days of implementation, which we believe highlight the potential value and policy implications for task shifting depression care models in under-resourced settings.

The hydrodynamics of swimming at intermediate Reynolds numbers in the water boatman (Corixidae)

The fluid forces that govern propulsion determine the speed and energetic cost of swimming. These hydrodynamics are scale dependent and it is unclear what forces matter to the tremendous diversity of aquatic animals that are between a millimeter and a centimeter in length. Animals at this scale generally operate within the regime of intermediate Reynolds numbers, where both viscous and inertial fluid forces have the potential to play a role in propulsion. The present study aimed to resolve which forces create thrust and drag in the paddling of the water boatman (Corixidae), an animal that spans much of the intermediate regime (10<Re<200). By measuring the force generated by tethered water boatmen, we found that thrust is generated primarily by drag on the paddling appendages, with a negligible contribution from the acceleration reaction force. Based on these findings, we developed a forward-dynamic model of propulsion in free swimming that accurately predicted changes in the body's center of mass over time. For both tethered and free swimming, we used non-linear optimization algorithms to determine the force coefficients that best matched our measurements. With this approach, the drag coefficients on the body and paddle were found to be up to three times greater than on static structures in fully developed flow at the same Reynolds numbers. This is likely a partial consequence of unsteady interactions between the paddles or between the paddles and the body. In addition, the maximum values for these coefficients were inversely related to the Reynolds number, which suggests that viscous forces additionally play an important role in the hydrodynamics of small water boatmen. This understanding for the major forces that operate at intermediate Reynolds numbers offers a basis for interpreting the mechanics, energetics and functional morphology of swimming in many small aquatic animals.

INtegration of DEPression Treatment into HIV Care in Uganda (INDEPTH-Uganda): study protocol for a randomized controlled trial

BACKGROUND

Despite 10 to% of persons living with HIV in sub-Saharan Africa having clinical depression, and the consequences of depression for key public health outcomes (HIV treatment adherence and condom use), depression treatment is rarely integrated into HIV care programs. Task-shifting, protocolized approaches to depression care have been used to overcome severe shortages of mental health specialists in developing countries, but not in sub-Saharan Africa and not with HIV clients. The aims of this trial are to evaluate the implementation outcomes and cost-effectiveness of a task-shifting, protocolized model of antidepressant care for HIV clinics in Uganda.

METHODS/DESIGN

INDEPTH-Uganda is a cluster randomized controlled trial that compares two task-shifting models of depression care--a protocolized model versus a model that relies on the clinical acumen of trained providers to provide depression care in ten public health HIV clinics in Uganda. In addition to data abstracted from routine data collection mechanisms and supervision logs, survey data will be collected from patient and provider longitudinal cohorts; at each site, a random sample of 150 medically stable patients who are depressed according to the PHQ-2 screening will be followed for 12 months, and providers involved in depression care implementation will be followed over 24 months. These data will be used to assess whether the two models differ on implementation outcomes (proportion screened, diagnosed, treated; provider fidelity to model of care), provider adoption of treatment care knowledge and practices, and depression alleviation. A cost-effectiveness analysis will be conducted to compare the relative use of resources by each model.

DISCUSSION

If effective and resource-efficient, the task-shifting, protocolized model will provide an approach to building the capacity for sustainable integration of depression treatment in HIV care settings across sub-Saharan Africa and improving key public health outcomes.

TRIAL REGISTRATION

INDEPTH-Uganda has been registered with the National Institutes of Health sponsored clinical trials registry (3 February 2013) and has been assigned the identifier NCT02056106.

Health coaching to improve hypertension treatment in a low-income, minority population

PURPOSE

Poor blood pressure control is common in the United States. We conducted a study to determine whether health coaching with home titration of antihypertensive medications can improve blood pressure control compared with health coaching alone in a low-income, predominantly minority population.

METHODS

We randomized 237 patients with poorly controlled hypertension at a primary care clinic to receive either home blood pressure monitoring, weekly health coaching, and home titration of blood pressure medications if blood pressures were elevated (n = 129) vs home blood pressure monitoring and health coaching but no home titration (n = 108). The primary outcome was change in systolic blood pressure from baseline to 6 months.

RESULTS

Both the home-titration arm and the no-home-titration arm had a reduction in systolic blood pressure, with no significant difference between them. When both arms were combined and analyzed as a before-after study, there was a mean decrease in systolic blood pressure of 21.8 mm Hg (P <.001) as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 during the 6-month study period (P <.001) and 2.4 in the 6 months after the study (P <.001). The more coaching encounters patients had, the greater their reduction in blood pressure.

CONCLUSIONS

Blood pressure control in a low-income, minority population can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients, in particular, by counseling them on medication adherence. The improved blood pressure control can be achieved while reducing the time spent by physicians.

Sox9-haploinsufficiency causes glucose intolerance in mice

The HMG box transcription factor Sox9 plays a critical role in progenitor cell expansion during pancreas organogenesis and is required for proper endocrine cell development in the embryo. Based on in vitro studies it has been suggested that Sox9 controls expression of a network of important developmental regulators, including Tcf2/MODY5, Hnf6, and Foxa2, in pancreatic progenitor cells. Here, we sought to: 1) determine whether Sox9 regulates this transcriptional network in vivo and 2) investigate whether reduced Sox9 gene dosage leads to impaired glucose homeostasis in adult mice. Employing two genetic models of temporally-controlled Sox9 inactivation in pancreatic progenitor cells, we demonstrate that contrary to in vitro findings, Sox9 is not required for Tcf2, Hnf6, or Foxa2 expression in vivo. Moreover, our analysis revealed a novel role for Sox9 in maintaining the expression of Pdx1/MODY4, which is an important transcriptional regulator of beta-cell development. We further show that reduced beta-cell mass in Sox9-haploinsufficient mice leads to glucose intolerance during adulthood. Sox9-haploinsufficient mice displayed 50% reduced beta-cell mass at birth, which recovered partially via a compensatory increase in beta-cell proliferation early postnatally. Endocrine islets from mice with reduced Sox9 gene dosage exhibited normal glucose stimulated insulin secretion. Our findings show Sox9 plays an important role in endocrine development by maintaining Ngn3 and Pdx1 expression. Glucose intolerance in Sox9-haploinsufficient mice suggests that mutations in Sox9 could play a role in diabetes in humans.

The effectiveness of peer health coaching in improving glycemic control among low-income patients with diabetes: protocol for a randomized controlled trial

Background

Although self-management support improves diabetes outcomes, it is not consistently provided in health care settings strained for time and resources. One proposed solution to personnel and funding shortages is to utilize peer coaches, patients trained to provide diabetes education and support to other patients. Coaches share similar experiences about living with diabetes and are able to reach patients within and beyond the health care setting. Given the limited body of evidence that demonstrates peer coaching significantly improves chronic disease care, this present study examines the impact of peer coaching delivered in a primary care setting on diabetes outcomes.

Methods/Design

The aim of this multicenter, randomized control trial is to evaluate the effectiveness of utilizing peer coaches to improve clinical outcomes and self-management skills in low-income patients with poorly controlled diabetes. A total of 400 patients from six primary health centers based in San Francisco that serve primarily low-income populations will be randomized to receive peer coaching (n = 200) or usual care (n = 200) over 6 months. Patients in the peer coach group receive coaching from patients with diabetes who are trained and mentored as peer coaches. The primary outcome is change in HbA1c. Secondary outcomes include change in: systolic blood pressure, body mass index (BMI), LDL cholesterol, diabetes self-care activities, medication adherence, diabetes-related quality of life, diabetes self-efficacy, and depression. Clinical values (HbA1c, LDL cholesterol and blood pressure) and self-reported diabetes self-efficacy and self-care activities are measured at baseline and after 6 months for patients and coaches. Peer coaches are also assessed at 12 months.

Discussion

Patients with diabetes, who are trained as peer health coaches, are uniquely poised to provide diabetes self management support and education to patients. This study is designed to investigate the impact of peer health coaching in patients with poorly controlled diabetes. Additionally, we will assess disease outcomes in patients with well controlled diabetes who are trained and work as peer health coaches.

Trial Registration

ClinicalTrials.gov identifier: NCT01040806

Development of Clinical Psychology and Mental Health Resources in Vietnam

In this paper, we discuss development of the Vietnam National University graduate Clinical Psychology Program, which has the goal of training both Vietnamese researchers who will develop and evaluate culturally appropriate mental health treatments, as well as Vietnamese clinicians who will implement and help disseminate these evidence-based treatments. We first review the background situation in Vietnam regarding mental health, and its infrastructure and training needs, and discuss the process through which the decision was made to develop a graduate program in clinical psychology as the best approach to address these needs. We then review the development process for the program and its current status, and our focus on the schools as a site for service provision and mental health task shifting. Finally, we outline future goals and plans for the program, and discuss the various challenges that the program has faced and our attempts to resolve them.