Intervention to increase colorectal cancer screening among emergency department patients: results from a randomised pilot study

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths worldwide. Emergency departments (ED) represent a promising setting to address preventive health measures like CRC screening.

OBJECTIVES

The current study adapted an existing cervical cancer screening intervention for use in catalysing CRC screening. We evaluated feasibility of identification, provided preliminary effect size estimates and documented participant acceptability.

METHODS

This study was funded by the University of Rochester (ClinicalTrials.gov # NCT05004376). We enrolled ED patients, 45-75 years old, in the Greater Rochester, NY region into a randomised controlled pilot from January to May 2022. Patients were excluded if non-English speaking, lacking a cell phone or had a history of CRC, colorectal resection, inflammatory bowel disease or abdominal radiation. Participants were surveyed to determine adherence with recommended CRC screening guidelines. Patients found non-adherent were randomised to receive (1) recommendation for CRC screening only or (2) recommendation and a text-based intervention aimed at generating intention and motivation to get screened. Patients were blind to allocation at enrolment. The primary outcome was patient CRC screening or scheduling.

RESULTS

1438 patients were approached, with 609 found ineligible, 576 declining participation and 253 enrolled. A randomised sample of 114 non-adherent patients were split evenly between the control and intervention arms. Among participants with follow-up data (n control=38, n intervention=36), intervention participants had a 2%-3% higher rate of scheduling or receiving screening (7%-27% relative improvement). When using the complete sample (n=114) and conservatively assuming no screening for those lost to follow-up, differences in screening across arms were mildly decreased (0%-2% absolute difference). Acceptability of CRC intervention was high, and participants offered formative feedback.

CONCLUSION

The piloted text message intervention through the ED shows potential promise for catalysing CRC screening. Subsequent replication in a fully powered trial is needed.

A Pilot Study Investigating the Use of serum GFAP to Monitor Changes in Brain White Matter Integrity after Repetitive Head Hits During a Single Collegiate football game

Repetitive head hits (RHHs) in sports and military settings are increasingly recognized as a risk factor for adverse neurologic outcomes, but they are not currently tracked. Blood-based biomarkers of concussion have recently been shown to increase after non-concussive RHHs during a single sporting contest, raising the possibility that they could be used in real-time to monitor the brain's early response to repeated asymptomatic head hits. In order to test this hypothesis, we measured GFAP in serum immediately before (T0), immediately after (T1) and 45 minutes (T2) after a single collegiate football game in 30 athletes. GFAP changes were correlated to 3 measures of head impact exposure (number of hits, total linear acceleration, and total rotational acceleration captured by helmet impact sensors) and to changes in brain white matter (WM) integrity, estimated by regional changes in fractional anisotropy (FA) and mean diffusivity (MD) on diffusion tensor imaging from 24 hours before (T-1) to 48 hours after (T3) the game). To account for the potentially confounding effects of physical exertion on GFAP, correlations were adjusted for kilocalories of energy expended during the game measured by wearable body sensors. All 30 participants were male with a mean age of 19.5+1.2 years. No participant had a concussion during the index game. We observed a significant increase in GFAP from T0 to T1 (mean 79.69 vs 91.95 pg/mL, p=0.008) and from T0 to T2 (mean 79.69 vs 99.21 pg/mL, p<0.001). White matter integrity decreased in multiple WM regions but was statistically significant in the right fornix (mean % FA change -1.43, 95% CI:-2.20, -0.66). T0 to T2 increases in GFAP correlated with reduced FA in the left fornix, right fornix, and right medical meniscus, and with increased MD in the right fornix (|r-values| ranged from 0.59-0.61). Adjustment for exertion had minimal effect on these correlations. GFAP changes did not correlate to head hit exposure, but after adjustment for exertion, T0 to T2 increases correlated with all three hit metrics (r-values ranged from 0.69-0.74). Thus, acute elevations in GFAP after a single collegiate football game of RHHs correlated with in-game head hit exposure and with reduced WM integrity 2 days later. These results suggest that GFAP may be a biologically relevant indicator of the brain's early response to RHHs during a single sporting event. Developing tools to measure the neurologic response to RHHs on an individual level has the potential to provide insight into the heterogeneity in adverse outcomes after RHH exposure and for developing effective and personalized countermeasures. Due to small sample size, these findings should be considered preliminary; validation in a larger, independent cohort is necessary.

Brief, cognitive-behavioral intervention to promote treatment seeking in adults with severe alcohol use disorder: A randomized controlled trial

BACKGROUND AND AIMS

There is little RCT evidence that brief interventions improve treatment seeking in individuals with severe alcohol use disorder (AUD) or treatment seeking reduces alcohol use. The aim was to test the efficacy of a brief intervention to increase treatment seeking in treatment naïve adults with severe AUD and measure its effects on alcohol use.

DESIGN

Parallel group, non-pharmacologic RCT with intervention (n = 197) and active control (n = 203) conditions, with blinded assessors conducting follow-ups at 1, 3 and 6 months.

SETTING

Online recruitment in a 17-county region of upstate New York, USA.

PARTICIPANTS

Inclusion criteria consisted of ages ≥18 years, Alcohol Use Disorders Identification Test score ≥16, exceeds recommended limits for alcohol use and no history of AUD treatment. n = 400; 50% female; 79% white; mean age, 40.7; mean education, 14.6 years.

INTERVENTION AND COMPARATOR

One-session telephone-delivered interventions: Cognitive-Behavioral Therapy for Treatment Seeking (CBT-TS; intervention), review of a National Institute on Alcohol Abuse and Alcoholism pamphlet on AUD treatment (control).

MEASUREMENTS

Self-report of any AUD treatment use over 3 months (primary outcome) and two standard measures of alcohol use over 6 months (secondary outcomes).

FINDINGS

Intent-to-treat analyses were used. Assessment follow-up rates were ≥93%. Any alcohol-related treatment use over 3-month follow-up was obtained by 38 (19%) intervention participants and 36 (18%) control participants, a non-significant difference, χ2 [1] = 0.16, P = 0.689. Secondary analysis showed a significant interaction term between sex and intervention assignment (β = -1.197, P = 0.027). The interaction suggested CBT-TS was effective in men (22% vs 13%), although the evidence was somewhat weak (P = 0.071), and it was not effective in women (17% vs 24%).

CONCLUSIONS

A one-session cognitive-behavioral therapy intervention to increase treatment seeking in treatment naïve adults with severe alcohol use disorder did not increase treatment seeking.

A scalable approach to determine cervical cancer screening needs among emergency department patients in the United States

The emergency department patient population is disproportionately under-screened for cancer, making it an optimal environment to promote cancer screening among hard-to-reach populations and those without routine access to primary care. The first step in a cancer screening process is identifying screening eligibility (e.g. age, sex) and need (i.e. due or past due). In an effort to support the scalability of an emergency department (ED)-based cervical cancer screening intervention, we examined the performance of a low-resource approach of determining cervical cancer screening needs among ED patients. A convenience sample of ED patients (N = 2807) was randomized to (a) an in-person interview with human subjects research staff or, (b) a self-administered, tablet computer-based survey for determining cervical cancer eligibility and need. Patients were recruited from a high-volume urban ED in Rochester, NY and a low-volume rural ED in Dansville, NY between December 2020 and December 2022. Results of these approaches were compared for equivalence of method for determining adherence status with screening guidelines and under/over-reporting of screening activity. Nearly identical reported rates of non-adherence with screening were identified across conditions (1.7% absolute difference; Χ21 = 0.96, p = 0.33). Our results demonstrate that a low-resource approach of using a tablet-based self-administered survey to determine cervical cancer screening needs is equivalent to a labor intensive in-person interview approach conducted by trained research staff among ED patients.

Effects of Physical Exertion on Early Changes in Blood-Based Brain Biomarkers: Implications for the Acute Point of Care Diagnosis of Concussion

Blood-based brain biomarkers (BBM) such as glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) have potential to aid in the diagnosis of concussion. Recently developed point-of-care test devices would enable BBMs to be measured in field settings such military and sport environments within minutes of a suspicious head hit. However, head hits in these environments typically occur in the setting of vigorous physical exertion, which can itself increase BBMs levels. Thus, efforts to develop BBMs as acute concussion aids in field settings need to account for the effects of physical exertion. To determine the acute effects of physical exertion on the BBMs, we measured GFAP, UCH-L1, tau, and neurofilament light chain (NF-L) immediately before, immediately after, and 45 min after a single workout session consisting of aerobic and resistance exercises in 30 collegiate football players. Subjects wore body sensors measuring several aspects of exertion and underwent diffusion tensor imaging 24 h before and 48 h after exertion. All subjects were male with a mean age of 19.5 ± 1.2 years. The mean duration of activity during the workout session was 94 ± 31 min. There was a significant decrease in serum GFAP immediately after (median decrease of 27.76%, p < 0.0001) and a significant increase in serum UCH-L1 45 min after (median increase of 37.11%, p = 0.016) exertion, compared with pre-exertion baseline. No significant changes in tau or NF-L were identified. The duration of exertion had a significant independent linear correlation to the increase in serum UCHL1 from pre-exertion to 45 min after exertion (r = 0.68, p = 0.004). There were no significant pre- to post-exertional changes in any of the 39 examined brain white matter regions, and biomarker changes did not correlate to variation in white matter integrity in any of these regions. Thus, exertion appeared to be associated with immediate decreases in serum GFAP and very acute (45 min) increases in UCH-L1. These changes were related to the duration of exertion, but not to changes in brain white matter integrity. Our results have important implications for how these BBMs might be used to aid in the on-scene diagnosis of concussion occurring in the setting of physical exertion.

Characterization of older adults with cancer seeking acute emergency department care: A prospective observational study

INTRODUCTION

Disparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED with active cancer.

MATERIALS AND METHODS

Planned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017.

RESULTS

Compared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics.

DISCUSSION

We identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.

Alcohol-related consequences and the intention to seek care in treatment naïve women and men with severe alcohol use disorder

INTRODUCTION

Research on treatment utilization for alcohol use disorder (AUD) is based primarily on clinical samples and community samples of low AUD severity that may not need formal care. Using a community sample of adults with untreated but severe AUD symptoms, we tested the hypothesis that alcohol-related consequences, but not alcohol consumption levels, are associated with the intention to seek AUD treatment, examined associations of specific types of alcohol-related consequences with intention, and explored sex differences in these associations.

METHODS

The sample was recruited using social media ads for a randomized controlled trial to test a brief intervention to promote AUD treatment seeking. This report is based on analysis of baseline data collected prior to treatment intervention. Multiple linear regressions examined associations of measures of alcohol consumption, alcohol-related consequences broadly, and specific alcohol-related consequences with the intention to seek treatment. Moderating effects of sex on associations were explored.

RESULTS

Subjects (n = 349) averaged 41 years of age, 48% were female, 6% were Latinx, 80% were white, 15% were Black, and 92% met criteria for severe AUD. Alcohol consumption measures were not associated with intention to seek treatment whereas interpersonal- and intrapersonal- consequences were associated with intention. Sex served as a moderator, with intrapersonal consequences (e.g., sad mood) showing a stronger association with intention in women and social responsibility consequences (particularly financial) associated with intention in men.

CONCLUSION

Select alcohol-related consequences may be keys to understanding increased intention to seek AUD treatment including intrapersonal consequences in women and financial consequences in men.

Heterogeneity in Alcohol-Related Severity and Interests in Going to Treatment in Community Adults with Alcohol Use Disorder (AUD)

RATIONALE

Alcohol use disorder (AUD) is highly prevalent among adults in the US and is associated with substantial personal and societal costs. Yet only a small percentage of adults with AUD initiate treatment, including those with severe AUD symptoms who are most in need of treatment. In this paper we use latent profile analysis (LPA) to describe differences in symptoms of AUD severity and alcohol-related consequences among untreated adults with severe AUD symptoms who were recruited from the community. Identification of such differences will result in better understanding of this population and will improve methods of treatment outreach.

METHOD

The LPAs were conducted on the baseline data of 403 (50% male, 77% White, M age = 40.74 with severe AUD recruited from the community and enrolled in a trial of an intervention designed to encourage treatment initiation. Participants reported no prior AUD treatment history. The LPAs were based on indicators of AUD severity, alcohol-related negative consequences, and self-reported intention to initiate AUD treatment.

RESULTS

The LPAs revealed 4 profiles. Profile membership was predicted by baseline participant sex and whether they were living with a partner and was associated with baseline past 30-days alcohol consumption.

CONCLUSIONS

The findings characterize and describe the variability among adults in the community with untreated severe AUD on variables that tend to motivate such individuals to seek treatment, which could significantly advance treatment outreach efforts.

Palliative Care Needs and Clinical Outcomes of Patients with Advanced Cancer in the Emergency Department

Background: Older adults with cancer use the emergency department (ED) for acute concerns. Objectives: Characterize the palliative care needs and clinical outcomes of advanced cancer patients in the ED. Design: A planned secondary data analysis of the Comprehensive Oncologic Emergencies Research Network (CONCERN) data. Settings/Subjects: Cancer patients who presented to the 18 CONCERN affiliated EDs in the United States. Measurements: Survey included demographics, cancer type, functional status, symptom burden, palliative and hospice care enrollment, and advance directive code status. Results: Of the total (674/1075, 62.3%) patients had advanced cancer and most were White (78.6%) and female (50.3%); median age was 64 (interquartile range 54-71) years. A small proportion of them were receiving palliative (6.5% [95% confidence interval; CI 3.0-7.6]; p = 0.005) and hospice (1.3% [95% CI 1.0-3.2]; p = 0.52) care and had a higher 30-day mortality rate (8.3%, [95% CI 6.2-10.4]). Conclusions: Patients with advanced cancer continue to present to the ED despite recommendations for early delivery of palliative care.

Alcohol Use During COVID-19 in Adults with Severe Untreated AUD

Evidence demonstrating increased alcohol use during COVID-19 comes from low- to moderate-alcohol use samples and has yet to use adults with severe but untreated AUD. Using a community sample of adults with severe AUD, this exploratory, cross-sectional study examined associations of COVID-19 alcohol use. Participants were recruited for a phase-II RCT. Only baseline measures, completed prior to randomization, were analyzed in the present study. Key variables were alcohol consumption, COVID-19-related worries and experiences, and qualitative responses of 1) alcohol use and 2) positive changes during COVID-19. 176 pariticpants recruited since COVID-19 were on average 41.4 years old, 49.1% female, and 79% White. Participants drank alcohol nearly 23 of the past 30 days, consumed 7 standard drinks per drinking day, and nearly 90% reported increased alcohol use. More heavy episodic drinking was reported in the first six-months of COVID-19 and more COVID-related concerns in the most recent six-months. Participants reported drinking increased due to "more time on their hands", but the pandemic also "strengthened relationships". Results affirm an increase in alcohol use during COVID-19 in adults with severe, untreated AUD. Findings underscore the need to understand how alcohol use and pandemic-related circumstances may influence one another for adults with severe AUD.

Intervention during wait time: identification and referral of individuals non-adherent for colorectal cancer screening

Background

Despite unanimous recommendations from numerous specialty societies on regular colorectal cancer screening, a substantial proportion of eligible adults are non-adherent with screening. The current study investigated whether research associates (RAs) in the emergency department (ED) can adequately assess patients’ adherence with colorectal cancer screening recommendations, outlined by the US Preventive Services Task Force (USPSTF), and provide referrals to individuals who are found to be non-adherent.

Methods

RAs at seven heterogeneous hospitals in the USA queried non-emergent adult patients and visitors between the ages of 50 and 75. After obtaining verbal consent, the participant’s adherence with USPSTF guidelines for colorectal cancer screening was assessed. Participants found due for screening were provided with referrals to obtain these recommended screenings.

Results

A total of 8258 participants were surveyed on their colorectal cancer screening status, with RAs identifying 2063 participants who were not adherent with USPSTF guidelines for colorectal cancer screening and 67 for whom adherence could not be determined (total 27%).

Conclusions

Our study demonstrates that RAs can identify a large volume of eligible adults who would benefit from colorectal cancer screening across a variety of emergency department settings.

Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN

PURPOSE

Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED.

METHODS

We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay.

RESULTS

Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index.

CONCLUSION

In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.

Academic and Professional Outcomes of Participants in an Emergency Department Research Associate Program

OBJECTIVES

Studies have found that participation in emergency department research associate (EDRA) programs is associated with medical school acceptance. However, little is known about the association between EDRA program participation and other academic and professional outcomes. We sought to characterize the academic and professional outcomes of EDRA program participants and their perception of program influence on academic and professional outcomes.

METHODS

We conducted a cross-sectional study of University of Rochester EDRA program participants who graduated from the program May 2010 to May 2017. EDRAs were sent a secure, deidentified, survey. Standard descriptive statistics were used to characterize participant demographics and outcomes. National acceptance rates were referenced from sources.

RESULTS

A total of 56 graduates completed the survey (64% response rate). Forty (71%) identified as female, 12 (21%) identified as Asian, one (2%) identified as Black or African American, and three (5%) identified as Hispanic or Latino. Acceptance rates to MD programs, DO programs, PhD programs, and master's programs were 88% (22/25), 92% (12/13), 100% (2/2), and 100% (9/9), respectively. Rates were significantly higher compared to national rates (all p < 0.001). Eighty-three percent (30/36 responses) and 74% (37/50) spoke about the EDRA program during postgraduate program and job interviews, respectively, and 78% (35/45 responses) included the EDRA program in their personal statements. Twenty-five percent (14/55) changed their career goals after participating in the EDRA program, of which 36% (5/14) left medicine and 21% (3/14) were undecided and chose to become a physician.

CONCLUSIONS

An EDRA program can help develop and support a career in medicine and science. EDRA graduates used their experiences directly in their postgraduate program applications and job interviews. Acceptance rates of EDRA program graduates to postgraduate programs were higher than national averages. An EDRA program can help clarify career goals after program participation.

Classification of Comprehensive Neuro-Ophthalmologic Measures of Postacute Concussion

IMPORTANCE

Symptom-based methods of concussion diagnosis in contact sports result in underdiagnosis and repeated head injury exposure, increasing the risk of long-term disability. Measures of neuro-ophthalmologic (NO) function have the potential to serve as objective aids, but their diagnostic utility is unknown.

OBJECTIVE

To identify NO measures that accurately differentiate athletes with and without concussion.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among athletes with and without concussion who were aged 17 to 22 years between 2016 and 2017. Eye movements and cognitive function were measured a median of 19 days after injury among patients who had an injury meeting the study definition of concussion while playing a sport (retrospectively selected from a concussion clinic), then compared with a control group of participants without concussion (enrolled from 104 noncontact collegiate athlete volunteers without prior head injury). Data analysis was conducted from November 2019 through May 2020.

EXPOSURE

Concussion.

MAIN OUTCOMES AND MEASURES

Classification accuracy of clinically important discriminator eye-tracking (ET) metrics. Participants' eye movements were evaluated with a 12-minute ET procedure, yielding 42 metrics related to smooth pursuit eye movement (SPEM), saccades, dynamic visual acuity, and reaction time. Clinically important discriminator metrics were defined as those with significantly different group differences and area under the receiver operator characteristic curves (AUROCs) of at least 0.70.

RESULTS

A total of 34 participants with concussions (mean [SD] age, 19.7 [2.4] years; 20 [63%] men) and 54 participants without concussions (mean [SD] age, 20.8 [2.2] years; 31 [57%] men) completed the study. Six ET metrics (ie, simple reaction time, discriminate reaction time, discriminate visual reaction speed, choice visual reaction speed, and reaction time on 2 measures of dynamic visual acuity 2) were found to be clinically important; all were measures of reaction time, and none were related to SPEM. Combined, these 6 metrics had an AUROC of 0.90 (95% CI, 0.80-0.99), a sensitivity of 77.8%, and a specificity of 92.6%. The 6 metrics remained significant on sensitivity testing.

CONCLUSIONS AND RELEVANCE

In this study, ET measures of slowed visual reaction time had high classification accuracy for concussion. Accurate, objective measures of NO function have the potential to improve concussion recognition and reduce the disability associated with underdiagnosis.

Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN)

PURPOSE

Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes.

METHODS

We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition.

RESULTS

The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status).

CONCLUSIONS

Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Identifying Cancer Screening Adherence in the Emergency Department Utilizing Research Associates

BACKGROUND

Despite the demonstrated benefits of regular screening, a large proportion of the adult female population are out of compliance with recommendations from specialty societies regarding breast and cervical cancer.

OBJECTIVE

The current study investigated whether research associates (RAs) in the emergency department (ED) can usefully assess patients' recent compliance with breast and cervical cancer screening (BCCS) recommendations and provide information regarding how patients may access any recommended screening when it is overdue.

METHODS

RAs at 5 heterogeneous hospitals in the United States approached willing nonemergent female patients and visitors between the ages of 21 and 74 years. After obtaining verbal consent, the participant's compliance with U.S. Preventive Service Task Force recommendations for BCCS was assessed. Participants found overdue for screening were provided information on how to obtain these recommended screenings.

RESULTS

A total of 5419 participants were between 50 and 74 years old and would be recommended to have breast cancer screening, and 11,667 participants were between 21 and 65 years old and would be recommended to have cervical cancer screening. Among women of age for either of these screenings, 3169 reported that they did not have a women's primary health care provider (i.e., doctor, nurse practitioner, or physician assistant who manages women's primary health care issues). A total of 786 women (15% of women 50-74 years old) were found to be out of compliance with breast cancer screening guidelines and 1208 women (12% of women 21 to 65 years with intact uteruses) were found to be out of compliance with cervical cancer screening guidelines.

CONCLUSIONS

Our results indicate that RAs can identify large numbers of women who should undergo BCCS screening across a variety of emergency department settings.

Spatial regression analysis of MR diffusion reveals subject-specific white matter changes associated with repetitive head impacts in contact sports

Repetitive head impacts (RHI) are a growing concern due to their possible neurocognitive effects, with research showing a season of RHI produce white matter (WM) changes seen on neuroimaging. We conducted a secondary analysis of diffusion tensor imaging (DTI) data for 28 contact athletes to compare WM changes. We collected pre-season and post-season DTI scans for each subject, approximately 3 months apart. We collected helmet data for the athletes, which we correlated with DTI data. We adapted the SPatial REgression Analysis of DTI (SPREAD) algorithm to conduct subject-specific longitudinal DTI analysis, and developed global inferential tools using functional norms and a novel robust p value combination test. At the individual level, most detected injured regions (93.3%) were associated with decreased FA values. Using meta-analysis techniques to combine injured regions across subjects, we found the combined injured region at the group level occupied the entire WM skeleton, suggesting the WM damage location is subject-specific. Several subject-specific functional summaries of SPREAD-detected WM change, e.g., the [Formula: see text] norm, significantly correlated with helmet impact measures, e.g. cumulative unweighted rotational acceleration (adjusted p = 0.0049), time between hits rotational acceleration (adjusted p value 0.0101), and time until DTI rotational acceleration (adjusted p = 0.0084), suggesting RHIs lead to WM changes.

Retrospective analysis of the hemodynamic consequences of prehospital supplemental oxygen in acute stroke

OBJECTIVE

Hyperoxia, the delivery of high levels of supplemental oxygen (sO₂) despite normoxia, may increase cerebral oxygenation to penumbral tissue and improve stroke outcomes. However, it may also alter peripheral hemodynamic profiles with potential negative effects on cerebral blood flow (CBF). This study examines the hemodynamic consequences of prehospital sO₂ in stroke.

METHODS

A retrospective analysis of adult acute stroke patients (aged ≥18 years) presenting via EMS to an academic Comprehensive Stroke Center between January 1, 2013 and December 31, 2017 was conducted using demographic and clinical characteristics obtained from Get with the Guidelines-Stroke registry and subjects' medical records. Outcomes were compared across three groups based on prehospital oxygen saturation and sO₂ administration. Chi-square, ANOVA, and multivariable linear regression were used to determine if sO₂ was associated with differences in peripheral hemodynamic profiles.

RESULTS

All subjects had similar initial EMS vitals except for oxygen saturation. However, both univariate and multivariable analysis revealed that hyperoxia subjects had slightly lower average ED mean arterial pressures (MAP) compared to normoxia (Cohen's d = 0.313).

CONCLUSIONS

Prehospital-initiated hyperoxia for acute stroke is associated with a small, but significant decrease in average ED MAP, without changes in heart rate, compared to normoxia. While limited by the inability to link changes in peripheral hemodynamical profiles directly to changes in CBF, this study suggests that hyperoxia may result in a relative hypotension. Further studies are needed to determine if this small change in peripheral vascular resistance translates into a clinically significant reduced CBF.

Prehospital supplemental oxygen for acute stroke - A retrospective analysis

OBJECTIVE

Brief early administration of supplemental oxygen (sO₂) to create hyperoxia may increase oxygenation to penumbral tissue and improve stroke outcomes. Hyperoxia may also result in respiratory compromise and vasoconstriction leading to worse outcomes. This study examines the effects of prehospital sO₂ in stroke.

METHODS

This is a retrospective analysis of adult acute stroke patients (aged ≥18 years) presenting via EMS to an academic Comprehensive Stroke Center between January 1, 2013 and December 31, 2017. Demographic and clinical characteristics obtained from Get with the Guidelines-Stroke registry and subjects' medical records were compared across three groups based on prehospital oxygen saturation and sO₂ administration. Chi-square, ANOVA, and multivariate logistic regression were used to determine if sO₂ status was associated with neurological outcomes or respiratory complications.

RESULTS

1352 eligible patients were identified. 62.7% (n = 848) did not receive sO₂ ("controls"), 10.7% (n = 144) received sO₂ due to hypoxia ("hypoxia"), and 26.6% (n = 360) received sO₂ despite normoxia ("hyperoxia"). The groups represented a continuum from more severe deficits (hypoxia) to less severe deficits (controls): mean prehospital GCS (hypoxia -12, hyperoxia - 2, controls - 14 p ≤ 0.001), mean initial NIHSS (hypoxia - 15, hyperoxia - 13, controls - 8 p < 0.001). After controlling for potential confounders, all groups had similar rates of respiratory complications and favorable neurological outcomes.

CONCLUSIONS

Hyperoxic subjects had no significant increase in respiratory complications, nor did they differ in neurologic outcomes at discharge when controlling for confounders. While limited by the retrospective nature, this suggests brief, early sO₂ for stroke may be safe to evaluate prospectively.

Effectiveness and Cost of Recruiting Participants to a Research Registry Using an Emergency Department Research Associate Program

We identified a novel way to recruit participants into a research registry by using an Emergency Department Research Associate (EDRA) Program. Research associates working in the Emergency Department at Strong Memorial Hospital approached patients and family members to enroll into the University of Rochester Research Participant Registry and for http://ResearchMatch.org. We found that 73% of individuals (574/781) approached agreed to register for either one or both registries. Those who registered were more diverse than individuals who registered through other methods. Overall, using EDRAs to enroll adult patients and their family members is an effective method for growing research participant registries.

An Intervention to Increase Uptake of Cervical Cancer Screening Among Emergency Department Patients: Results of a Randomized Pilot Study

BACKGROUND

Emergency departments (EDs) have the potential to promote critical public and preventive health interventions. Cervical cancer (CC) screening has been a cornerstone of preventive health efforts for decades. Approximately 20% of U.S. women are not adherent with CC screening guidelines-considerably below the U.S. Federal Government's target. ED patients are disproportionately nonadherent with CC screening guidelines. The ED, therefore, is an optimal setting to target women with an intervention that promotes CC screening.

OBJECTIVES

To assess the feasibility and potential efficacy of an intervention, grounded in behavioral change theory, to promote uptake of CC screening among ED patients.

METHODS

Design: Randomized clinical trial pilot study; Patients: Women aged 21-65 years that were identified in the ED to be nonadherent with CC screening recommendations; Setting: Single center urban academic ED.

RESULTS

Among enrolled participants, 355 (79%) were determined to be adherent with screening recommendations and 95 (21%) were determined to be either nonadherent or have uncertain adherence. Among the nonadherent/uncertain group, 47 were randomized to the control condition (referral only) and 48 were randomized to the intervention condition. Thirty-six percent of participants in the control condition received or scheduled screening during the follow-up period. In the intervention condition, 43% received or scheduled screening during the follow-up period-a 19% relative improvement over the control condition.

CONCLUSION

This pilot study demonstrates feasibility and preliminary efficacy of a behavioral intervention to increase uptake of CC screening among ED patients.

Validation of the Emergency Severity Index (Version 4) for the Triage of Adult Emergency Department Patients With Active Cancer

BACKGROUND

Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for this population is fundamental to facilitating their emergency care.

OBJECTIVES

We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer.

METHODS

We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute-supported Comprehensive Oncologic Emergencies Research Network's multicenter (18 sites) study of ED visits by patients with active cancer (N = 1075). We used a series of χ² tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality.

RESULTS

Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values < 0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality.

CONCLUSION

ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.

Latent Class Analysis of Barriers to Care Among Emergency Department Patients

Introduction

Emergency department (ED) patients experience a variety of barriers to care that can lead to unnecessary or repeated visits. By identifying the patterns of barriers experienced by subsets of the ED patient population, future researchers might effectively design interventions to circumvent these barriers and improve care. This study sought to identify classes of individuals with regard to perceived barriers to care.

Methods

Over a 10-week period, two medical students distributed surveys to eligible patients ≥18 years who presented to the ED. After consent, patients provided demographics data and rated their perceived access to care on nine specific items (scored 1–5). We used latent class analysis (LCA), a parametric clustering method, to determine patient groups. Demographic characteristics were then compared across classes.

Results

We enrolled a total of 637 patients. Results of the LCA indicated that a six-class solution fit best: 1) low barriers (60%); 2) “work responsibility” barriers (13%); 3) economic-related barriers (10%); 4) “appointment difficulty” barriers (8%); 5) “illness and care responsibilities” barriers (6%); and 6) diverse barriers (2%). Patients in the low-barriers class were the oldest across classes (p<.001). Individuals in the low-barriers class were also more likely to be White (p=.015) and have private insurance (p<.001) than those in the “appointment difficulty,” “illness and care responsibilities,” and diverse barriers classes.

Conclusion

LCA suggests there are six distinct classes of patients with regard to perceived access to care. These classes may be used as a potential starting point in designing targeted interventions for ED patients to improve continuity of care.

Depression symptomology groups among middle and older adult emergency department patients

INTRODUCTION

Middle and late life adults may present depression symptomology differently than the expected symptoms of depression. Clusters of common symptoms may be overlooked when determining the most appropriate treatment options, leading to a less than effective treatment. Investigation of these clusters is needed to better understand patterns of depressive symptomology among middle and late life adults.

METHODS

Consent, demographics, self-report items and PHQ-9 items were administered to subjects. Latent class analysis (LCA), was used to determine groupings of patients based on PHQ-9 items. Demographics were compared across classes for additional information.

RESULTS

A total of 252 subjects aged 45-85 years old were enrolled. An LCA indicated that a 3 class solution explained the clusters endorsed: Low Concerns (35%), Many Concerns (34%), and Sleep and Fatigue Concerns (31%). Patients in the Low Concerns class were more likely to have private insurance compared to those in the Many Concerns class (57% vs 34%, p = 0.003). They also reported better general health (M = 2.39 vs M = 1.58, p < 0.001), and visited their PCP less frequently (M = 1.64 visits vs M = 3.31 visits, p = 0.004).

LIMITATIONS

Recall bias may have been present due to self-report of symptoms which was a report based on a low threshold for endorsement of items. Future larger studies should utilize more response options.

CONCLUSION

LCA suggests there are three unique groupings of symptoms as reported by the PHQ-9. These clusters may be valuable in determining treatment options and designing interventions.

Perceived access to care among adult patients who attempted suicide

This study examined perceptions of barriers to care among patients presenting through the emergency department with a suicide attempt. Eighteen patients were surveyed on their perceived access to providers and how they felt 6 distinct barriers limited their access to treatment. Although most (73%) reported having a health care provider they could have contacted before their suicide attempt, the majority (78%) reported at least 1 moderate barrier to care, with the most common barrier being difficulty finding transportation. Of those reporting any experienced barriers, 80% reported more than 1. Knowledge of the most prevalent and serious barriers perceived can subsequently be used to craft tailored follow-up instructions to prevent repeated attempts. (PsycINFO Database Record

Sick and unsheltered: Homelessness as a major risk factor for emergency care utilization

OBJECTIVE

Homelessness is a critical public health issue and socioeconomic epidemic associated with a disproportionate burden of disease and significant decrease in life expectancy. We compared emergency care utilization between individuals with documented homelessness to those enrolled in Medicaid without documented homelessness.

METHODS

We conducted a retrospective cohort study consisting of electronic medical record review of demographics, chief complaints, and health care utilization metrics of adults with homelessness compared to a group enrolled in Medicaid without identified homelessness. The chart review spanned two years of emergency visits at a single urban, academic, tertiary care medical center. Descriptive statistics, bivariate and multivariate analyses were utilized.

RESULTS

Over the study period, 986 patients experiencing homelessness accounted for 7532 ED visits, with a mean of 7.6 (SD 19.9) and max of 316 visits. The control group of 3482 Medicaid patients had 5477 ED visits, with a mean of 1.6 visits (SD 2.1) and max of 49 visits. When controlling for age, sex, race, ethnicity, and ESI, those living with homelessness were 7.65 times more likely to return to the ED within 30 days of their previous visit, 9.97 times more likely to return within 6 months, 10.63 times more likely to return within one year, and 11 times more likely to return within 2 years.

CONCLUSIONS

Compared to non-homeless Medicaid patients, patients with documented homelessness were over seven times more likely to return to the ED within 30 days and over eleven times more likely to return to the ED in two years.

Implementation of an Emergency Medicine Research Associates Program: Sharing 20 Years of Experience

Introduction

The use of research associates (RA) programs to facilitate study enrollment in the emergency department was initiated during the mid-1990s. The University of Rochester Medical Center (URMC) was an early adopting site for this model, which has experienced considerable growth and development over the past 20 years.

Methods

Our goal was to detail the Emergency Department Research Associates (EDRA) program processes developed at the URMC that has led to our program’s sustainability and productivity. These processes, and the lessons learned during their development, can assist institutions seeking to establish an RA program or refine an existing program.

Results

Defined procedures for selecting, training, and monitoring EDRAs have been created and refined with the goal of maximizing study enrollment and minimizing protocol deviations. Our EDRA program functions as a paid service center for investigators, and our EDRAs engage in a variety of study-related activities including screening and enrolling patients, administering surveys, collecting bio-specimens, and making follow-up calls. Over the past two years, our program has averaged 222 enrollments/month (standard deviation = 79.93), gathering roughly 25 participants per study per month.

Conclusion

Our EDRA model has consistently resulted in some of the highest number of enrollments across a variety of recently funded, multi-center studies. Maintaining a high-quality EDRA program requires continual investment on the part of the leadership team, though the benefits to investigators within and outside the department outweigh these costs.

Differences in the ability to predict and prepare for sexual activity between HIV-infected and HIV-uninfected young South African Women

The Human Research Council's National HIV Prevalence, Incidence and Behavior Survey ranks South Africa first in HIV incidence in the world with 400,000 new infections in 2012 and found the HIV incidence rate among female youth aged 15 to 24 years to be 2.5% that year. The objective of this study was to compare the pattern and predictability of sexual activity between HIV-infected and HIV-uninfected young South African women. Sexually active young women between the ages of 16 and 21 years old completed a study survey between October 2012 and 2014 at two Desmond Tutu HIV Foundation centers. 100 young women with a mean age of 19.04 years responded to the survey. 51 women (51%) were HIV-infected and 49 were HIV-uninfected (49%). HIV-infected young women were found to be statistically less likely to have a temporal pattern to their sexual activity as compared to HIV-uninfected young women (56.9 vs. 95.9%, p<0.0001). While controlling for frequency of sex and lifetime sexual partners, HIV status remains a significant predictor of having a pattern of sexual activity (OR=16.13, p=0.0004) and a predictor of having sex on the weekend only (OR=4.41, p=0.0022). The ability to predict when sexual activity will occur enables a woman to prepare for its associated risks. HIV-uninfected young women are more likely to have a predictable pattern to their sexual activity as compared to HIV-infected young women. Knowledge of the sexual behavior patterns of this high-risk population will aid in the development of effective HIV prevention campaigns.

Ecological momentary assessment and first smoking cessation lapse after an acute cardiac event: A pilot study

This 28-day pilot study assessed the feasibility of cell phone ecological momentary assessment in 40 smokers who received emergency department evaluations for acute coronary syndrome. Ecological momentary assessments used familiar touch tone response technology during a cell phone call to capture ratings of illness perceptions, emotion, behavioral intentions, and smoking. Ecological momentary assessments were conducted 1-8 times/day and took 1-2 minutes to complete. The mean ecological momentary assessment call compliance for all 40 subjects was 56.3 percent (standard deviation = 29.4), and during an ecological momentary assessment, 72.5 percent of participants reported a first lapse. We found that first-week call compliance was significantly correlated with subsequent compliance (r = 0.55, p < 0.001).

Human papillomavirus clustering patterns among HIV-infected and HIV-uninfected adolescent females in South Africa

The global burden of disease caused by both human immunodeficiency virus (HIV) and human papillomavirus (HPV) is the greatest in the developing world, with the highest rates in sub-Saharan Africa. South African women not only have high rates of infection with HPV, but also have high rates of multiple concurrent infections with two or more HPV genotypes, and are among the world's most vulnerable to developing invasive cervical cancer. HIV co-infection increases these risks. Understanding clustering patterns of concurrent HPV infections in this population has important implications for HPV screening and will help define vaccination strategies in the future as vaccines continue to be developed to target more HPV genotypes. Latent class analysis was used to identify four distinct patterns of HPV co-infection: individuals with at least one low risk HPV genotype, but no high-risk HPV (HR-HPV) infections; individuals with a disperse pattern of HR-HPV infections; individuals infected with members of the alpha-7 group, but not HPV-18; and individuals infected with HPV-16, but not HPV-18. In this analysis, although alpha-7 HPV infections were more prevalent among HIV-infected adolescents than their HIV-uninfected counterparts, overall clustering patterns were not different based on HIV status.

Depression and Anxiety Among Emergency Department Patients: Utilization and Barriers to Care

BACKGROUND

Anxiety and depression rates among emergency department (ED) patients are substantially higher than those in the general population. Additionally, those with mental health issues often have difficulty accessing care. Unfortunately, issues of anxiety and depression are frequently not addressed in the ED due to competing care priorities. This may lead to increased burden and overcrowding in EDs.

OBJECTIVE

This study related anxiety and depression with ED utilization and perceived barriers to care.

METHODS

To limit the impact of insurance coverage on ED utilization and access to care, a convenience sample of adults 45 to 85 years of age in the ED were surveyed. The Generalized Anxiety Disorder 7 and Patient Health Questionnaire 9 were used to measure anxiety and depression.

RESULTS

A total of 251 subjects were enrolled. Severe anxiety was observed in 10% of patients, while moderately severe or severe depression was observed in 12%. Patients who were both severely anxious and depressed visited the ED nearly twice as often as nonanxious and nondepressed patients. The majority of patients cited at least one moderate barrier to care, and greater anxiety and depression scores were related to greater perceived barriers to care. Perceived barriers to care were more than three times higher among patients who were both anxious and depressed compared to those in patients who were neither depressed nor anxious and twice as high as in those who were either depressed or anxious (p < 0.001).

CONCLUSION

Patients identified with internalizing mental health concerns utilize the ED at elevated rates while also reporting the greatest difficulties accessing care. These findings highlight the need for ED interventions aimed at identifying patient mental health concerns, as well as perceived barriers to care, to design interventions to effectively improve continuity of care.

Childbearing intentions among sexually active HIV-infected and HIV-uninfected female adolescents in South Africa

Women of reproductive age account for nearly half of all HIV-infected people worldwide. Childbearing intention among HIV-infected women is complicated by social and reproductive concerns related to their HIV status. We conducted a cross-sectional study of HIV-infected and HIV-uninfected sexually active South African women aged 17 to 21 in order to compare their childbearing intentions and to identify predictors of the desire to have children among women with HIV. We found the rate of childbearing intention to be similarly high among both HIV-infected and HIV-uninfected study participants (80 and 79% respectively, p=0.81). History of previous parity was found to be associated with decreased intention to have children. No difference in childbearing intention was found between HIV-infected women on anti-retroviral therapy (ART) and women not on ART. High rates of childbearing intention among HIV-infected women require integration of reproductive health services with comprehensive HIV/AIDS care in order to mitigate the risks of sexual and vertical transmission of HIV.

Health Evaluation and Referral Assistant: A Randomized Controlled Trial of a Web-Based Screening, Brief Intervention, and Referral to Treatment System to Reduce Risky Alcohol Use Among Emergency Department Patients

Background

Computer technologies hold promise for implementing alcohol screening, brief intervention, and referral to treatment (SBIRT). Questions concerning the most effective and appropriate SBIRT model remain.

Objective

The aim of this study was to evaluate the impact of a computerized SBIRT system called the Health Evaluation and Referral Assistant (HERA) on risky alcohol use treatment initiation.

Methods

Alcohol users (N=319) presenting to an emergency department (ED) were considered for enrollment. Those enrolled (n=212) were randomly assigned to the HERA, to complete a patient-administered assessment using a tablet computer, or a minimal-treatment control, and were followed for 3 months. Analyses compared alcohol treatment provider contact, treatment initiation, treatment completion, and alcohol use across condition using univariate comparisons, generalized estimating equations (GEEs), and post hoc chi-square analyses.

Results

HERA participants (n=212; control=115; intervention=97) did not differ between conditions on initial contact with an alcohol treatment provider, treatment initiation, treatment completion, or change in risky alcohol use behavior. Subanalyses indicated that HERA participants, who accepted a faxed referral, were more likely to initiate contact with a treatment provider and initiate treatment for risky alcohol use, but were not more likely to continue engaging in treatment, or to complete treatment and change risky alcohol use behavior over the 3-month period following the ED visit.

Conclusions

The HERA promoted initial contact with an alcohol treatment provider and initiation of treatment for those who accepted the faxed referral, but it did not lead to reduced risky alcohol use behavior. Factors which may have limited the HERA’s impact include lack of support for the intervention by clinical staff, the low intensity of the brief and stand-alone design of the intervention, and barriers related to patient follow-through, (eg, a lack of transportation or childcare, fees for services, or schedule conflicts).

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): NCT01153373; https://clinicaltrials.gov/ct2/show/NCT01153373 (Archived by WebCite at http://www.webcitation.org/6pHQEpuIF)

Early caregiving stress exposure moderates the relation between respiratory sinus arrhythmia reactivity at 1 month and biobehavioral outcomes at age 3

There is a growing scientific interest in the psychophysiological functioning of children living in low-socioeconomic status (SES) contexts, though this research is complicated by knowledge that physiology-behavior relations often operate differently in these environments among adults. Importantly, such research is made more difficult because SES may be a proxy for a wide range of risk factors including poor caregiving and exposure to parental substance use. We used factor analysis to organize risk-exposure data collected from 827 children-many of whom were raised in low-SES contexts and exposed to substances prenatally-into dissociable components including economic stress, caregiving stress (e.g., stress the caregiver may experience, including parental psychopathology), and postnatal substance exposure. These factors, along with respiratory sinus arrhythmia (RSA) reactivity at age 1 month, were used to predict behavior dysregulation and resting RSA at age 3 years. A significant RSA Reactivity × Caregiving Stress interaction indicated that infants who exhibited high RSA reactivity at 1 month experienced the greatest behavior dysregulation at 3 years, but only when they were exposed to high levels of caregiving stress. Among African Americans, the highest resting RSA at 3 years was found in infants with less RSA reactivity, but only if they also experienced less caregiving stress. Our work is consistent with biological sensitivity to context, adaptive calibration, and allostatic load models, and highlights the importance of studying Physiology × Environment interactions in low-SES contexts for predicting behavior and resting RSA.

Novel Method of Weighting Cumulative Helmet Impacts Improves Correlation with Brain White Matter Changes After One Football Season of Sub-concussive Head Blows

One football season of sub-concussive head blows has been shown to be associated with subclinical white matter (WM) changes on diffusion tensor imaging (DTI). Prior research analyses of helmet-based impact metrics using mean and peak linear and rotational acceleration showed relatively weak correlations to these WM changes; however, these analyses failed to account for the emerging concept that neuronal vulnerability to successive hits is inversely related to the time between hits (TBH). To develop a novel method for quantifying the cumulative effects of sub-concussive head blows during a single season of collegiate football by weighting helmet-based impact measures for time between helmet impacts. We further aim to compare correlations to changes in DTI after one season of collegiate football using weighted cumulative helmet-based impact measures to correlations using non-weighted cumulative helmet-based impact measures and non-cumulative measures. We performed a secondary analysis of DTI and helmet impact data collected on ten Division III collegiate football players during the 2011 season. All subjects underwent diffusion MR imaging before the start of the football season and within 1 week of the end of the football season. Helmet impacts were recorded at each practice and game using helmet-mounted accelerometers, which computed five helmet-based impact measures for each hit: linear acceleration (LA), rotational acceleration (RA), Gadd Severity Index (GSI), Head Injury Criterion (HIC₁₅), and Head Impact Technology severity profile (HITsp). All helmet-based impact measures were analyzed using five methods of summary: peak and mean (non-cumulative measures), season sum-totals (cumulative unweighted measures), and season sum-totals weighted for time between hits (TBH), the interval of time from hit to post-season DTI assessment (TUA), and both TBH and TUA combined. Summarized helmet-based impact measures were correlated to statistically significant changes in fractional anisotropy (FA) using bivariate and multivariable correlation analyses. The resulting R ² values were averaged in each of the five summary method groups and compared using one-way ANOVA followed by Tukey post hoc tests for multiple comparisons. Total head hits for the season ranged from 431 to 1850. None of the athletes suffered a clinically evident concussion during the study period. The mean R ² value for the correlations using cumulative helmet-based impact measures weighted for both TUA and TBH combined (0.51 ± 0.03) was significantly greater than the mean R ² value for correlations using non-cumulative HIMs (vs. 0.19 ± 0.04, p < 0.0001), unweighted cumulative helmet-based impact measures (vs. 0.27 + 0.03, p < 0.0001), and cumulative helmet-based impact measures weighted for TBH alone (vs. 0.34 ± 0.02, p < 0.001). R ² values for weighted cumulative helmet-based impact measures ranged from 0.32 to 0.77, with 60% of correlations being statistically significant. Cumulative GSI weighted for TBH and TUA explained 77% of the variance in the percent of white matter voxels with statistically significant (PWMVSS) increase in FA from pre-season to post-season, while both cumulative GSI and cumulative HIC₁₅ weighted for TUA accounted for 75% of the variance in PWMVSS decrease in FA. A novel method for weighting cumulative helmet-based impact measures summed over the course of a football season resulted in a marked improvement in the correlation to brain WM changes observed after a single football season of sub-concussive head blows. Our results lend support to the emerging concept that sub-concussive head blows can result in sub-clinical brain injury, and this may be influenced by the time between hits. If confirmed in an independent data set, our novel method for quantifying the cumulative effects of sub-concussive head blows could be used to develop threshold-based countermeasures to prevent the accumulation of WM changes with multiple seasons of play.

First- and second-hand consequences of alcohol in college: Differential associations with later alcohol use

INTRODUCTION

College students are at increased risk of experiencing a variety of consequences as result of their own as well as others' alcohol consumption. The current study examined the differential associations between both first-hand consequences (resulting from one's own drinking) and second-hand consequences (resulting in victimization as a result of others' drinking) and subsequent alcohol consumption across the first year of college.

METHOD

First year students (n = 253) from a large northeastern U.S. university were randomly selected to participate and surveyed at the end of the first semester of college (time 1) and during the first semester of the second year of college (time 2).

RESULTS

Results showed a significant, positive relationship between first-hand consequences and subsequent weekend drinking (β = .16, p < .05) and heavy episodic drinking (β = .49, p < .01), after controlling for individual and friend drinking. A negative association between second-hand consequences and later heavy episodic drinking was also observed (β = -.16, p < .05).

DISCUSSION AND CONCLUSIONS

The findings provided partial support for both a positive association hypothesis and a negative association hypothesis. The importance of personal alcohol consumption and peers' drinking in relation to first- and second-hand consequences are discussed.

Health evaluation and referral assistant: a randomized controlled trial to improve smoking cessation among emergency department patients

BACKGROUND

Computer technologies hold promise for implementing tobacco screening, brief intervention, and referral to treatment (SBIRT). This study aims to evaluate a computerized tobacco SBIRT system called the Health Evaluation and Referral Assistant (HERA).

METHODS

Smokers (n = 421) presenting to an emergency department were randomly assigned to the HERA or a minimal-treatment Control and were followed for 3 months. Analyses compared smoking cessation treatment provider contact, treatment initiation, treatment completion, and smoking behavior across condition using univariable comparisons, generalized estimating equations (GEE), and post hoc Chi square analyses.

RESULTS

HERA participants were more likely to initiate contact with a treatment provider but did not differ on treatment initiation, quit attempts, or sustained abstinence. Subanalyses revealed HERA participants who accepted a faxed referral were more likely to initiate treatment but were not more likely to stop smoking.

CONCLUSIONS

The HERA promoted initial contact with a smoking cessation provider and the faxed referral further promoted treatment initiation, but it did not lead to improved abstinence.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT01153373.

Cross-national comparison of prenatal methamphetamine exposure on infant and early child physical growth: a natural experiment

The current study seeks to compare the effects of prenatal methamphetamine exposure (PME) on infant and child physical growth between the USA and New Zealand (NZ). This cross-national comparison provides a unique opportunity to examine the potential impact of services provided to drug using mothers on child health. The longitudinal Infant Development, Environment and Lifestyle study of PME from birth to 36 months was conducted in the USA and NZ. The US cohort included 204 children with PME and 212 non-PME matched comparisons (NPME); the NZ cohort included 108 children with PME and 115 NPME matched comparisons. Latent growth curve models were used to examine effects of PME, country of origin, and the country × PME interaction on growth in length/height and weight. In regard to length/height, PME and country of origin were associated with initial length and growth over time. There was also a significant interaction effect, such that children with PME in the USA were shorter at birth than children with PME in NZ after controlling for other prenatal exposures, infant set, socioeconomic status, and maternal height. In regard to weight, there was only an effect of country of origin. Effects of PME on infant and child growth were shown to differ across countries, with exposed children in NZ faring better than exposed children in the USA. Implications for prevention programs and public policy are discussed.

Knowledge of HPV among HIV-Infected and HIV-Uninfected Adolescent Women in South Africa

OBJECTIVE

The aim of this study is to examine the knowledge of human papillomavirus (HPV) and cervical cancer among HIV-infected and HIV-uninfected female adolescents in South Africa.

METHODS

Subjects were recruited from a parent study of HPV infection comprised of females ages 16-21 in Masiphumelele, Cape Town, South Africa. A total of 30 subjects, 15 HIV-infected and 15 HIV-uninfected, were selected via randomization and completed a measure of HPV knowledge, based on a previously validated instrument. The study took place in May 2013.

RESULTS

The overall mean score on the measure for all subjects was 43.3% (S.D. 10.9). There was no significant difference in HPV knowledge between the HIV-infected and HIV-uninfected groups. Based on results from a previous large-scale study using the same validated measure, this sample scored significantly worse on general HPV knowledge than samples from the US, UK, and Australia.

CONCLUSION

Given the limited knowledge of HPV in this sample, there is greater need for education about the prevention of cervical cancer, specifically among high-risk adolescent women.

Concussions are associated with decreased batting performance among Major League Baseball players

BACKGROUND

Concussions impair balance, visual acuity, and reaction time--all of which are required for high-level batting performance--but the effects of concussion on batting performance have not been reported. The authors examined this relationship between concussion and batting performance among Major League Baseball (MLB) players.

HYPOTHESIS

Batting performance among concussed MLB players will be worse upon return to play than batting performance among players missing time for noninjury reasons.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors identified MLB players who sustained a concussion between 2007 and 2013 through league disabled-list records and a Baseball Prospectus database. For a comparison group, they identified players who went on paternity or bereavement leave during the same period. Using repeated-measures generalized linear models, the authors compared 7 batting metrics between the 2 groups for the 2 weeks upon return, as well as 4 to 6 weeks after return, controlling for pre-leave batting metrics, number of days missed, and position.

RESULTS

The authors identified 66 concussions and 68 episodes of bereavement/paternity leave to include in the analysis. In the 2 weeks after return, batting average (.235 vs .266), on-base percentage (.294 vs .326), slugging percentage (.361 vs .423), and on-base plus slugging (.650 vs .749) were significantly lower among concussed players relative to the bereavement/paternity leave players (time×group interaction, P<.05). In weeks 4 to 6 after leave, these metrics were slightly lower in concussed players but not statistically significantly so.

CONCLUSION

Although concussed players may be asymptomatic upon return to play, the residual effects of concussion on the skills required for batting may still be present. Further work is needed to clarify the mechanism through which batting performance after concussion is adversely affected and to identify better measures to use for return-to-play decisions.

High risk human papillomavirus persistence among HIV-infected young women in South Africa

OBJECTIVES

Persistence of infection with high-risk Human papillomaviruses (HR-HPV) increases the risk of incident and progressive precancerous lesions of the cervix. Rates of HR-HPV persistence have been shown to be increased among HIV-infected adult women, however there is a paucity of literature addressing HPV persistence in the young HIV-infected population. We compared rates of HR-HPV persistence between HIV-infected and HIV-uninfected young women.

METHODS

We obtained self-collected vaginal swabs at six-month intervals from 50 HIV-uninfected and 33 HIV-infected young women recruited through a community youth center (age 17-21 years) and compared rates of HR-HPV persistence. HR-HPV testing was conducted using the Roche's Linear Array® HPV Test.

RESULTS

Eighty-three prevalent (upon baseline testing) and incident (upon subsequent testing) individual HR-HPV infections were identified among 43 members of the cohort (23 HIV-uninfected and 20 HIV-infected). At twelve months, 19% of baseline HR-HPV infections continued to be present with a statistically significant difference between HIV-uninfected and HIV-infected participants (4% versus 31%; p=0.01).

CONCLUSIONS

HIV-infected young women in our cohort had a seven-fold increased rate of persistence of HR-HPV overall at 12 months, indicating an increased risk for incident and progressive precancerous lesions. Identification of persistent infection with HR-HPV may complement cytological findings in determining the need for colposcopy.

Understanding smoking after acute illness: An application of the sentinel event method

The sentinel event theory provides a stepwise approach for building models to understand how negative events can spark health behaviour change. This study tested a preliminary model using the sentinel events method in a sample (N = 300) of smokers who sought care for acute cardiac symptoms. Patients completed measures on: smoking-related causal attribution, perceived severity of the acute illness event, illness-related fear and intentions to quit smoking. Patients were followed up one week after the health event and a seven-day timeline follow back was completed to determine abstinence from tobacco. Structural equation models were performed using average predictor scale scores at baseline, as well as three different time anchors for ratings of illness severity and illness-related fear. Quit intentions, actual illness severity and age were the consistent, positive and independent predictors of seven-day point prevalence abstinence. Additional research on the influences of perceptions and emotional reactions is warranted.