24-Month Outcomes of Primary Care Web-Based Depression Prevention Intervention in Adolescents: Randomized Clinical Trial.

BACKGROUND: Adolescent depression carries a high burden of disease worldwide, but access to care for this population is limited. Prevention is one solution to curtail the negative consequences of adolescent depression. Internet interventions to prevent adolescent depression can overcome barriers to access, but few studies examine long-term outcomes. OBJECTIVE: This study compares CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training), an internet-based intervention, to a general health education active control for depression onset at 12 and 24 months in adolescents presenting to primary care settings. METHODS: A 2-site randomized trial, blinded to the principal investigators and assessors, was conducted comparing Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training to health education to prevent depressive episodes in 369 adolescents (193 youths were randomly assigned to Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training and 176 to health education) with subthreshold depressive symptoms or prior depressive episodes. Participants were recruited from primary care settings in the United States. The primary outcome was the occurrence of a depressive episode, determined by the Depression Symptom Rating. The secondary outcome was functioning, measured by the Global Assessment Scale. RESULTS: In intention-to-treat analyses, the adjusted hazard ratio favoring Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training for first depressive episode was not statistically significant at 12 months (hazard ratio 0.77, 95% CI 0.42-1.40, P=.39) and 24 months (hazard ratio 0.87, 95% CI 0.52-1.47, P=.61). Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training provided preventive benefit for first depressive episode for those with mild hopelessness or at least moderate paternal monitoring at baseline. Global Assessment Scale scores improved comparably in both groups (intention-to-treat). CONCLUSIONS: A technology-based intervention for adolescent depression prevention implemented in primary care did not have additional benefit at 12 or 24 months. Further research is necessary to determine whether internet interventions have long-term benefit. TRIAL REGISTRATION: ClinicalTrials.gov NCT01893749; http://clinicaltrials.gov/ct2/show/NCT01893749.

Propensity Score-Based Estimators With Multiple Error-Prone Covariates.

Propensity score methods are an important tool to help reduce confounding in nonexperimental studies. Most propensity score methods assume that covariates are measured without error. However, covariates are often measured with error, which leads to biased causal effect estimates if the true underlying covariates are the actual confounders. Although some groups have investigated the impact of a single mismeasured covariate on estimating a causal effect and proposed methods for handling the measurement error, fewer have investigated the case where multiple covariates are mismeasured, and we found none that discussed correlated measurement errors. In this study, we examined the consequences of multiple error-prone covariates when estimating causal effects using propensity score-based estimators via extensive simulation studies and real data analyses. We found that causal effect estimates are less biased when the propensity score model includes mismeasured covariates whose true underlying values are strongly correlated with each other. However, when the measurement errors are correlated with each other, additional bias is introduced. In addition, it is beneficial to include correctly measured auxiliary variables that are correlated with confounders whose true underlying values are mismeasured in the propensity score model.

Health Disparities in Drug- and Alcohol-Use Disorders: A 12-Year Longitudinal Study of Youths After Detention.

OBJECTIVES: To examine sex and racial/ethnic differences in the prevalence of 9 substance-use disorders (SUDs)--alcohol, marijuana, cocaine, hallucinogen or PCP, opiate, amphetamine, inhalant, sedative, and unspecified drug--in youths during the 12 years after detention. METHODS: We used data from the Northwestern Juvenile Project, a prospective longitudinal study of 1829 youths randomly sampled from detention in Chicago, Illinois, starting in 1995 and reinterviewed up to 9 times in the community or correctional facilities through 2011. Independent interviewers assessed SUDs with Diagnostic Interview Schedule for Children 2.3 (baseline) and Diagnostic Interview Schedule version IV (follow-ups). RESULTS: By median age 28 years, 91.3% of males and 78.5% of females had ever had an SUD. At most follow-ups, males had greater odds of alcohol- and marijuana-use disorders. Drug-use disorders were most prevalent among non-Hispanic Whites, followed by Hispanics, then African Americans (e.g., compared with African Americans, non-Hispanic Whites had 32.1 times the odds of cocaine-use disorder [95% confidence interval = 13.8, 74.7]). CONCLUSIONS: After detention, SUDs differed markedly by sex, race/ethnicity, and substance abused, and, contrary to stereotypes, did not disproportionately affect African Americans. Services to treat substance abuse--during incarceration and after release--would reach many people in need, and address health disparities in a highly vulnerable population.

Inequities in Mental Health Services: A 16-Year Longitudinal Study of Youth in the Justice System.

OBJECTIVE: To examine: (1) if youth who have mental health disorders receive needed services after they leave detention-and as they age; and (2) inequities in service use, focusing on demographic characteristics and type of disorder. METHOD: We used data from the Northwestern Juvenile Project, a longitudinal study of 1,829 youth randomly sampled from detention in Chicago, Illinois in 1995. Participants were re-interviewed up to 13 times through 2015. Interviewers assessed disorders using structured diagnostic interviews and assessed service use using the Child and Adolescent Service Assessment and the Services Assessment for Children and Adolescents. RESULTS: Less than 20% of youth who needed services received them, up to median age 32 years. Female participants with any disorder had nearly twice the odds of receiving services compared with male participants (OR: 1.82; 95% CI: 1.41, 2.35). Compared with Black participants with any disorder, non-Hispanic White and Hispanic participants had 2.14 (95% CI: 1.57, 2.90) and 1.50 (95% CI: 1.04, 2.15) times the odds of receiving services. People with a disorder were more likely to receive services during childhood (< age 18) than during adulthood (OR: 2.29; 95% CI: 1.32, 3.95). Disorder mattered: participants with an internalizing disorder had 2.26 times and 2.43 times the odds of receiving services compared with those with a substance use disorder (respectively, 95% CI: 1.26, 4.04; 95% CI: 1.49, 3.97). CONCLUSION: Few youth who need services receive them as they age; inequities persist over time. We must implement evidence-based strategies to reduce barriers to services.

Antimüllerian hormone level predicts ovulation in women with polycystic ovary syndrome treated with clomiphene and metformin.

OBJECTIVE: To describe the serum anti-Müllerian hormone (AMH) concentrations in a large, well-phenotyped cohort of women with polycystic ovary syndrome (PCOS) and evaluate whether AMH predicts successful ovulation induction in women treated with clomiphene and metformin. DESIGN: Secondary analysis of randomized controlled trial. SETTING: Not applicable. PATIENT(S): A total of 333 women with anovulatory infertility attributed to PCOS who participated in the double-blind randomized trial entitled the Pregnancy in Polycystic Ovary Syndrome I (PPCOS I) study (registration number, NCT00068861) who had serum samples from baseline laboratory testing available for further serum analysis were studied. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): The association between the baseline AMH levels in each of the 3 treatment groups and ovulation, pregnancy, and live birth rates were assessed. RESULT(S): A total of 322 individuals had a baseline AMH concentration available, of which the mean AMH was 11.7 ± 8.3 ng/mL (range 0.1-43.0 ng/mL). With each unit (1 ng/mL) increase in baseline AMH, the odds of ovulation decreased by 10% (odds ratio, 0.90; 95% confidence interval, 0.86-0.93); this effect did not differ by treatment group. Women with a high baseline AMH concentration (>8 ng/mL) were significantly less likely to ovulate compared with those with a normal baseline AMH concentration (<4 ng/mL) (odds ratio, 0.23; 95% confidence interval, 0.05-0.68). This remained statistically significant when controlling for confounders, including age, body mass index, time in study, and Homeostatic Model Assessment for Insulin Resistance score. Ovulation occurred even at very high AMH concentrations; there was no maximum level noted at which no ovulation events occurred. Baseline AMH concentration was not associated with pregnancy or live birth rates when controlling for confounders. CONCLUSION(S): These AMH values in well-phenotyped individuals with PCOS add to the literature and will aid in identifying AMH criteria for the diagnosis of PCOS. In women with infertility and PCOS, a higher AMH concentration was associated with reduced odds of ovulation with ovulation induction with clomiphene, clomiphene + metformin, and metformin. CLINICAL TRIAL REGISTRATION NUMBER: The original trial from which this analysis is derived was entitled "Pregnancy in Polycystic Ovary Syndrome: A 30 Week Double-Blind Randomized Trial of Clomiphene Citrate, Metformin XR, and Combined Clomiphene Citrate/Metformin XR For the Treatment of Infertility in Women With Polycystic Ovary Syndrome" and was registered on ClinicalTrials.gov as number NCT00068861. The URL for the trial is https://clinicaltrials.gov/study/NCT00068861. The first subject was enrolled in November 2002.

Do Substances Used in Adolescence Predict the Persistence of Substance Use Disorders in Adulthood? A 15-Year Study of Youth After Detention.

PURPOSE: Investigate if the type of substance use disorder (SUD) in adolescence predicts SUDs in adulthood and examine sex and racial/ethnic differences in the persistence of SUDs. METHODS: Data are from the Northwestern Juvenile Project, a 15-year longitudinal study of 1829 youth randomly sampled from detention in Chicago, IL (1995-1998). Interviewers assessed SUDs using structured diagnostic interviews. RESULTS: Compared with females without an SUD at detention, females with cannabis alone, comorbid alcohol and cannabis, or SUDs other than alcohol and cannabis at detention had higher odds of having an SUD 5 years later (25%, 32%, and 36% vs. 15%, adjusted odds ratio [AOR] = 1.94, 95% confidence interval [CI] 1.11-3.40; AOR = 2.76, 95% CI 1.58-4.83; AOR = 3.46, 95% CI 1.56-7.66, respectively). Males and females with SUDs other than alcohol and cannabis at detention had greater odds of having an SUD 15 years later, compared with those without an SUD at detention (males: 36% vs. 14%, AOR = 2.98, 95% CI 1.14-7.83; females: 29% vs. 8%, AOR = 4.77, 95% CI 1.85-12.30). Among youth with an SUD at detention, males were more likely than females to have an SUD 15 years later (AOR = 1.84, 95% CI 1.03-3.29); non-Hispanic White and Hispanic males were more likely to persist than Black males (AOR = 3.32, 95% CI 1.50-7.35; AOR = 2.32, 95% CI 1.04-5.18, respectively). DISCUSSION: The type of SUD during adolescence matters. Youth with SUDs such as cocaine and opioids fared the worst. Healthcare providers must collaborate with correctional officials to increase service provision.

Altered sleep architecture in diabetes and prediabetes: findings from the Baependi Heart Study.

STUDY OBJECTIVES: People with diabetes and prediabetes are more likely to have sleep-disordered breathing (SDB), but few studies examined sleep architecture in people with diabetes or prediabetes in the absence of moderate-severe SDB, which was the aim of our cross-sectional study. METHODS: This cross-sectional sample is from the Baependi Heart Study, a family-based cohort of adults in Brazil. About 1074 participants underwent at-home polysomnography (PSG). Diabetes was defined as fasting glucose >125 mg/dL or HbA1c > 6.4 mmol/mol or taking diabetic medication, and prediabetes was defined as HbA1c ≥ 5.7 & <6.5 mmol/mol or fasting glucose ≥ 100 & ≤125 mg/dl. We excluded participants with an apnea-hypopnea index (AHI) ≥ 30 in primary analyses and ≥ 15 in secondary analysis. We compared sleep stages among the 3 diabetes groups (prediabetes, diabetes, neither). RESULTS: Compared to those without diabetes, we found shorter REM duration for participants with diabetes (-6.7 min, 95%CI -13.2, -0.1) and prediabetes (-5.9 min, 95%CI -10.5, -1.3), even after adjusting for age, gender, BMI, and AHI. Diabetes was also associated with lower total sleep time (-13.7 min, 95%CI -26.8, -0.6), longer slow-wave sleep (N3) duration (+7.6 min, 95%CI 0.6, 14.6) and higher N3 percentage (+2.4%, 95%CI 0.6, 4.2), compared to those without diabetes. Results were similar when restricting to AHI < 15. CONCLUSIONS: People with diabetes and prediabetes had less REM sleep than people without either condition. People with diabetes also had more N3 sleep. These results suggest that diabetes and prediabetes are associated with differences in sleep architecture, even in the absence of moderate-severe sleep apnea.

Nonfatal Firearm Injury and Firearm Mortality in High-risk Youths and Young Adults 25 Years After Detention.

Importance: Youths, especially Black and Hispanic males, are disproportionately affected by firearm violence. Yet, no epidemiologic studies have examined the incidence rates of nonfatal firearm injury and firearm mortality in those who may be at greatest risk-youths who have been involved with the juvenile justice system. Objectives: To examine nonfatal firearm injury and firearm mortality in youths involved with the juvenile justice system and to compare incidence rates of firearm mortality with the general population. Design, Setting, and Participants: The Northwestern Juvenile Project is a 25-year prospective longitudinal cohort study of 1829 youths after juvenile detention in Chicago, Illinois. Youths were randomly sampled by strata (sex, race and ethnicity, age, and legal status [juvenile or adult court]) at intake from the Cook County Juvenile Temporary Detention Center. Participants were interviewed at baseline (November 1995 to June 1998) and reinterviewed as many as 13 times over 16 years, through February 2015. Official records on mortality were collected through December 2020. Data analysis was conducted from November 2018 to August 2022. Main Outcomes and Measures: Participants self-reported nonfatal firearm injuries. Firearm deaths were identified from county and state records and collateral reports. Data on firearm deaths in the general population were obtained from the Illinois Department of Public Health. Population counts were obtained from the US census. Results: The baseline sample of 1829 participants included 1172 (64.1%) males and 657 (35.9%) females; 1005 (54.9%) Black, 524 (28.6%) Hispanic, 296 (16.2%) non-Hispanic White, and 4 (0.2%) from other racial and ethnic groups (mean [SD] age, 14.9 [1.4] years). Sixteen years after detention, more than one-quarter of Black (156 of 575 [27.1%]) and Hispanic (103 of 387 [26.6%]) males had been injured or killed by firearms. Males had 13.6 (95% CI, 8.6-21.6) times the rate of firearm injury or mortality than females. Twenty-five years after the study began, 88 participants (4.8%) had been killed by a firearm. Compared with the Cook County general population, most demographic groups in the sample had significantly higher rates of firearm mortality (eg, rate ratio for males, 2.8; 95% CI, 2.0-3.9; for females: 6.5; 95% CI, 3.0-14.1; for Black males, 2.5; 95% CI, 1.7-3.7; for Hispanic males, 9.6; 95% CI, 6.2-15.0; for non-Hispanic White males, 23.0; 95% CI, 11.7-45.5). Conclusions and Relevance: This is the first study to examine the incidence of nonfatal firearm injury and firearm mortality in youths who have been involved with the juvenile justice system. Reducing firearm injury and mortality in high-risk youths and young adults requires a multidisciplinary approach involving legal professionals, health care professionals, educators, street outreach workers, and public health researchers.

Substance Use Disorders and HIV/AIDS Risk Behaviors in Youth After Juvenile Detention: A 16-Year Longitudinal Study.

PURPOSE: To examine the association between substance use disorders (SUDs) and HIV/AIDS risk behaviors in detained youth as they age. METHODS: Prospective longitudinal study of a stratified random sample of 1,829 youth aged 10 to 18 years at baseline, sampled between November 1995 and June 1998 from the Cook County Juvenile Temporary Detention Center, Chicago, Illinois, and reinterviewed up to 13 times (to median age 32); 17,766 interviews overall. RESULTS: Youth had greater odds of engaging in every risk behavior when they had an SUD compared with when they did not have an SUD. For example, SUD was associated with condomless vaginal sex with a high-risk partner (OR: 2.28, 95% CI: 1.84-2.82). SUD was also associated with multiple partners, although the strength varied by time and sex (e.g., 16 years after baseline, OR: 3.58, 95% CI: 2.46-5.23 females; OR: 2.07, 95% CI: 1.48-2.88 males). Types of SUD-alcohol, comorbid alcohol and marijuana, drugs other than marijuana-were also associated with HIV/AIDS risk behaviors. DISCUSSION: SUDs and HIV/AIDS risk behaviors are linked among youth in the juvenile justice system and as they age. There is a longstanding need for targeted and integrated HIV and SUD services, but this need remains unmet.

Altered sleep architecture in diabetes and prediabetes: findings from the Baependi Heart Study.

Objective: People with diabetes are more likely to have obstructive sleep apnea, but there are few studies examining sleep architecture in people with diabetes, especially in the absence of moderate-severe sleep apnea. Therefore, we compared sleep architecture among people with diabetes, prediabetes or neither condition, whilst excluding people with moderate-severe sleep apnea. Research design and methods: This sample is from the Baependi Heart Study, a prospective, family-based cohort of adults in Brazil. 1,074 participants underwent at-home polysomnography (PSG). Diabetes was defined as 1) FBG>125 OR 2) HbA1c>6.4 OR 3) taking diabetic medication, and prediabetes was defined as 1) [(5.7≤HbA1c≤6.4) OR (100≤FBG≤125)] AND 2) not taking diabetic medication. We excluded participants that had an apnea-hypopnea index (AHI)>30 from these analyses to reduce confounding due to severe sleep apnea. We compared sleep stages among the 3 groups. Results: Compared to those without diabetes, we found shorter REM duration for participants with diabetes (-6.7min, 95%CI -13.2, -0.1) or prediabetes (-5.9min, 95%CI -10.5, -1.3), even after adjusting for age, gender, BMI, and AHI. Diabetes was also associated with lower total sleep time (-13.7min, 95%CI -26.8, -0.6), longer slow-wave sleep (N3) duration (+7.6min, 95%CI 0.6, 14.6) and higher N3 percentage (+2.4%, 95%CI 0.6, 4.2), compared to those without diabetes. Conclusions: People with diabetes and prediabetes had less REM sleep after taking into account potential confounders, including AHI. People with diabetes also had more N3 sleep. These results suggest that diabetes is associated with different sleep architecture, even in the absence of moderate-severe sleep apnea.

Prevalence, Comorbidity, and Continuity of Psychiatric Disorders in a 15-Year Longitudinal Study of Youths Involved in the Juvenile Justice System.

Importance: Previous studies have found that one-half to three-quarters of youths detained in juvenile justice facilities have 1 or more psychiatric disorders. Little is known about the course of their disorders as they age. Objective: To examine the prevalence, comorbidity, and continuity of 13 psychiatric disorders among youths detained in a juvenile justice facility during the 15 years after detention up to a median age of 31 years, with a focus on sex and racial/ethnic differences. Design, Setting, and Participants: The Northwestern Juvenile Project is a longitudinal cohort study of health needs and outcomes of 1829 randomly selected youths in a temporary juvenile detention center in Cook County, Illinois. Youths aged 10 to 18 years were interviewed in detention from November 20, 1995, through June 14, 1998. Participants were reinterviewed up to 12 times during the 15-year study period through February 2015, for a total of 16 372 interviews. The sample was stratified by sex, race/ethnicity (Black, Hispanic, and non-Hispanic White), age (10-13 years or 14-18 years), and legal status (processed in juvenile or adult court). Data analysis was conducted from February 2014, when data preparation began, to March 2020. Exposures: Detention in a juvenile justice facility. Main Outcomes and Measures: Psychiatric disorders, assessed by the Diagnostic Interview Schedule for Children, version 2.3 at the baseline interviews. Follow-up interviews were conducted using the Diagnostic Interview Schedule for Children, version IV; the Diagnostic Interview Schedule, version IV; and the World Mental Health Composite International Diagnostic Interview (beginning at the 6-year follow-up interview). Results: The study included 1829 youths sampled at baseline (1172 males and 657 females; mean [SD] age, 14.9 [1.4] years). Although prevalence and comorbidity of psychiatric disorders decreased as the 1829 participants aged, 52.3% of males and 30.9% of females had at least 1 or more psychiatric disorders 15 years postdetention. Among participants with a disorder at baseline, 64.3% of males and 34.8% of females had a disorder 15 years later. Compared with females, males had 3.37 times the odds of persisting with a psychiatric disorder 15 years after baseline (95% CI, 1.79-6.35). Compared with Black participants and Hispanic participants, non-Hispanic White participants had 1.6 times the odds of behavioral disorders (odds ratio, 1.56; 95% CI, 1.27-1.91 and odds ratio, 1.59; 95% CI, 1.23-2.05, respectively) and greater than 1.3 times the odds of substance use disorders (odds ratio, 1.90; 95% CI, 1.55-2.33 and odds ratio, 1.39; 95% CI, 1.11-1.73, respectively) throughout the follow-up period. Behavioral disorders and substance use disorders were the most prevalent 15 years after detention. Conclusions and Relevance: This study's findings suggest that persistent psychiatric disorders may complicate the transition from adolescence to adulthood, which is already challenging for youths involved in the juvenile justice system, many of whom are from racial/ethnic minority groups and low-income backgrounds. The pediatric health community should advocate for early identification and treatment of disorders among youths in the justice system.

Association of Firearm Access, Use, and Victimization During Adolescence With Firearm Perpetration During Adulthood in a 16-Year Longitudinal Study of Youth Involved in the Juvenile Justice System.

Importance: Preventing firearm violence requires understanding its antecedents. Yet no comprehensive longitudinal study has examined how involvement with firearms during adolescence-use, access, and victimization (defined as threatened with a weapon or gunshot injury)-is associated with the perpetration of firearm violence in adulthood. Objective: To examine the association between firearm involvement during adolescence and subsequent firearm perpetration and ownership in adulthood among youth involved in the juvenile justice system. Design, Setting, and Participants: This cohort study analyzed interview responses of 1829 randomly selected participants as part of the Northwestern Juvenile Project, a longitudinal study of health needs and outcomes of youth sampled from a temporary juvenile detention center in a large US city. Youth aged 10 to 18 years were interviewed in detention from November 1995 through June 1998. Participants were reinterviewed up to 13 times over 16 years through February 2015, for a total of 17 776 interviews. The sample was stratified by sex, race/ethnicity, age, and legal status (juvenile or adult court). Data were analyzed from April 2017, when data preparation began, through November 2020. Exposures: Firearm involvement during adolescence: use (ie, threaten, shoot), access (ownership, ease of access, firearm in household, membership in gang that carries firearms), and victimization (gunshot injury, threatened with a weapon). Main Outcomes and Measures: Firearm involvement during adulthood: perpetration of firearm violence (ie, threatening with or using a firearm) and firearm ownership. Results: Among the 1829 participants, 1388 had a 16-year follow-up interview: 860 males, 528 females; 809 were African American, 203 were non-Hispanic White; 374 were Hispanic; and 2 were other race/ethnicity; median (interquartile range) age of 32 (30-32) years. Eighty-five percent of males and 63.2% of females were involved with firearms as adolescents. Compared with females, males had significantly higher odds of every type of involvement except having a firearm in the home. In adulthood, 41.3% of males and 10.5% of females perpetrated firearm violence. Adolescents who had been threatened with a weapon or injured by firearms had 3.1 (95% CI, 2.0-4.9) and 2.4 (95% CI, 1.2-4.9) times the odds of perpetrating violence during adulthood. Similar associations were found for firearm ownership. Conclusions and Relevance: Involvement with firearms during adolescence-including victimization-is a significant risk factor for firearm perpetration and ownership during adulthood.

County-level factors affecting Latino HIV disparities in the United States.

OBJECTIVE: To determine which county-level social, economic, demographic, epidemiologic and access to care factors are associated with Latino/non-Latino White disparities in prevalence of diagnosed HIV infection. METHODS AND FINDINGS: We used 2016 county-level prevalence rates of diagnosed HIV infection rates for Latinos and non-Latino Whites obtained from the National HIV Surveillance System and factors obtained from multiple publicly available datasets. We used mixed effects Poisson modeling of observed HIV prevalence at the county-level to identify county-level factors that explained homogeneous effects across race/ethnicity and differential effects for Latinos and NL-Whites. Overall, the median Latinos disparity in HIV prevalence is 2.4; 94% of the counties have higher rates for Latinos than non-Latinos, and one-quarter of the counties' disparities exceeded 10. Of the 41 county-level factors examined, 24 showed significant effect modification when examined individually. In multi-variable modeling, 11 county-level factors were found that significantly affected disparities. Factors that increased disparity with higher, compared to lower values included proportion of HIV diagnoses due to injection drug use, percent Latino living in poverty, percent not English proficient, and percent Puerto Rican. Latino disparities increased with decreasing percent severe housing, drug overdose mortality rate, percent rural, female prevalence rate, social association rate, percent change in Latino population, and Latino to NL-White proportion of the population. These factors while significant had minimal effects on diminishing disparity, but did substantially reduce the variance in disparity rates. CONCLUSIONS: Large differences in HIV prevalence rates persist across almost all counties even after controlling for county-level factors. Counties that are more rural, have fewer Latinos, or have lower NL-White prevalence rates tend to have higher disparities. There is also higher disparity when community risk is low.

Assessment of Variability in End-of-Life Care Delivery in Intensive Care Units in the United States.

Importance: Overall, 1 of 5 decedents in the United States is admitted to an intensive care unit (ICU) before death. Objective: To describe structures, processes, and variability of end-of-life care delivered in ICUs in the United States. Design, Setting, and Participants: This nationwide cohort study used data on 16 945 adults who were cared for in ICUs that participated in the 68-unit ICU Liberation Collaborative quality improvement project from January 2015 through April 2017. Data were analyzed between August 2018 and June 2019. Main Outcomes and Measures: Published quality measures and end-of-life events, organized by key domains of end-of-life care in the ICU. Results: Of 16 945 eligible patients in the collaborative, 1536 (9.1%) died during their initial ICU stay. Of decedents, 654 (42.6%) were women, 1037 (67.5%) were 60 years or older, and 1088 (70.8%) were identified as white individuals. Wide unit-level variation in end-of-life care delivery was found. For example, the median unit-stratified rate of cardiopulmonary resuscitation avoidance in the last hour of life was 89.5% (interquartile range, 83.3%-96.1%; range, 50.0%-100%). Median rates of patients who were pain free and delirium free in last 24 hours of life were 75.1% (interquartile range, 66.0%-85.7%; range, 0-100%) and 60.0% (interquartile range, 43.7%-85.2%; range, 9.1%-100%), respectively. Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life (odds ratio, 0.70; 95% CI, 0.49-0.99; P = .04), and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death (odds ratio, 1.95; 95% CI, 1.37-2.77; P < .001). Death in a unit with an open visitation policy was associated with higher odds of pain in the last 24 hours of life (odds ratio, 2.21; 95% CI, 1.15-4.27; P = .02). Unsupervised cluster analysis revealed 3 mutually exclusive unit-level patterns of end-of-life care delivery among 63 ICUs with complete data. Cluster 1 units (14 units [22.2%]) had the lowest rate of cardiopulmonary resuscitation avoidance but achieved the highest pain-free rate. Cluster 2 (25 units [39.7%]) had the lowest delirium-free rate but achieved high rates of all other end-of-life events. Cluster 3 (24 units [38.1%]) achieved high rates across all favorable end-of-life events. Conclusions and Relevance: In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing. To achieve optimal care for patients who die in an ICU, future research should target unit-level variation and disseminate the successes of higher-performing units.

Effect of Internet-based Cognitive Behavioral Humanistic and Interpersonal Training vs. Internet-based General Health Education on Adolescent Depression in Primary Care: A Randomized Clinical Trial.

IMPORTANCE: Although 13-20% of American adolescents experience a depressive episode annually, no scalable primary care model for adolescent depression prevention is currently available. OBJECTIVE: To study whether CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral Humanistic and Interpersonal Training) reduces the hazard for depression in at-risk adolescents identified in primary care, as compared to a general health education attention control (HE). DESIGN: The Promoting AdolescenT Health (PATH) study compares CATCH-IT and HE in a phase 3 single-blind multicenter randomized attention control trial. Participants were enrolled from 2012 to 2016 and assessed at 2, 6, 12, 18, and 24 months post-randomization. SETTING: Primary care. PARTICIPANTS: Eligible adolescents were 13-18 years with subsyndromal depression and/or history of depression and no current depression diagnosis or treatment. Of 2,250 adolescents screened for eligibility, 446 participants completed the baseline interview and 369 were randomized into CATCH-IT (n=193) and HE (n=176). INTERVENTIONS: CATCH-IT is a 20-module (15 adolescent modules, 5 parent modules) online psychoeducation course that includes a parent program, supported by three motivational interviews. MAIN OUTCOMES AND MEASURES: Time-to-event for depressive episode; depressive symptoms at 6 months. RESULTS: Mean age was 15.4 years, and 68% were female; 28% had both a past episode and subsyndromal depression; 12% had a past episode only, 59% had subsyndromal depression only, and 1% had borderline subsyndromal depression. The outcome of time-to-event favored CATCH-IT but was not significant with intention-to-treat analyses (N=369; unadjusted HR=0.59; 95% CI 0.27, 1.29; p=0.18; adjusted HR=0.53; 95% CI 0.23, 1.23, p=0.14). Adolescents with higher baseline CES-D10 scores showed a significantly stronger effect of CATCH-IT on time-to-event relative to those with lower baseline scores (p=0.04). For example, for a CES-D10 score of 15 (significant sub-syndromal depression), HR=0.20 (95% CI 0.05, 0.77), compared to CES-D10 of 5 (no sub-syndromal depression), HR=1.44 (95% CI, 0.41, 5.03). In both CATCH-IT and HE groups, depression symptoms declined and functional scores increased. CONCLUSIONS AND RELEVANCE: CATCH-IT may be better than HE for preventing depressive episodes for at-risk adolescents with sub-syndromal depression. CATCH-IT may be a scalable approach to prevent depressive episodes in adolescents in primary care.

Disparities in HIV/AIDS Risk Behaviors After Youth Leave Detention: A 14-Year Longitudinal Study.

OBJECTIVES: To examine changes in the prevalence of 15 HIV/AIDS sex and drug risk behaviors in delinquent youth during the 14 years after they leave detention, focusing on sex and racial/ethnic differences. METHODS: The Northwestern Juvenile Project, a prospective longitudinal study of 1829 youth randomly sampled from detention in Chicago, Illinois, recruited between 1995 and 1998 and reinterviewed up to 11 times. Independent interviewers assessed HIV/AIDS risk behaviors using the National Institutes on Drug Abuse Risk Behavior Assessment. RESULTS: Fourteen years after detention (median age, 30 years), one-quarter of males and one-tenth of females had >1 sexual partner in the past 3 months. One-tenth of participants reported recent unprotected vaginal sex with a high-risk partner. There were many sex and racial/ethnic differences. For example, African American males had 4.67 times the odds of having >1 partner than African American females (95% confidence interval [CI], 3.22-6.76). Over time, compared with non-Hispanic white males, African American males had 2.56 times the odds (95% CI, 1.97-3.33) and Hispanic males had 1.63 times the odds (95% CI, 1.24-2.12) of having multiple partners, even after adjusting for incarceration and age. Non-Hispanic white females were more likely to have multiple partners than racial/ethnic minority females. CONCLUSIONS: Although rates decrease over time, prevalence of sex risk behaviors are much higher than the general population. Among males, racial/ethnic minorities were at particular risk. The challenge for pediatric health is to address how disproportionate confinement of racial/ethnic minority youth contributes to disparities in the HIV/AIDS epidemic.

Sex and Racial/Ethnic Differences in Positive Outcomes in Delinquent Youth After Detention: A 12-Year Longitudinal Study.

Importance: Longitudinal studies of delinquent youth have focused on criminal recidivism, not on psychosocial outcomes in adulthood. This omission is critical because after detention most youth return to the community, where they become the responsibility of pediatric health care professionals. Objective: To investigate 8 positive outcomes among delinquent youth 5 and 12 years after detention, focusing on sex and racial/ethnic differences. Design, Setting, and Participants: In the Northwestern Juvenile Project, a longitudinal US study of long-term outcomes of delinquent youth after detention, participants were interviewed in detention between November 20, 1995, and June 14, 1998, and reinterviewed up to 9 times during the 12-year study period, through May 12, 2011. Data analysis was conducted between November 18, 2013, and July 25, 2016. Exposures: Juvenile detention. Main Outcomes and Measures: Achievement of positive outcomes in 8 domains: educational attainment, residential independence, gainful activity, desistance from criminal activity, mental health, abstaining from substance abuse, interpersonal functioning, and parenting responsibility. Outcomes were assessed with widely used measures supplemented by correctional records. Results: The study included 1829 youth at baseline (1172 males and 657 females; mean [SD] age, 14.9 [1.4] years). At the end of the study, 1520 (83.1%) of the original sample remained (944 males and 576 females; mean [SD] age, 27.6 [1.4] years). Twelve years after detention, females were more likely than males to have positive outcomes for gainful activity (odds ratio [OR], 2.53; 95% CI, 1.86-3.44), desistance from criminal activity (OR, 5.89; 95% CI, 4.38-7.92), residential independence (OR, 3.41; 95% CI, 2.57-4.52), parenting responsibility (OR, 18.65; 95% CI, 12.29-28.30), and mental health (OR, 1.48; 95% CI, 1.13-1.92). Twelve years after detention, only 21.9% of males and 54.7% of females had achieved more than half of the outcomes. As youth aged, the number of positive outcomes increased only modestly (mean increase for males, 0.37; 95% CI, 0.13-0.62; for females, 0.29; 95% CI, 0.13-0.45). Among males, non-Hispanic white individuals were significantly more likely to achieve most positive outcomes compared with minorities, but less likely to abstain from substance abuse. For example, 12 years after detention, non-Hispanic white males had nearly 3 times the odds of educational attainment compared with African American (OR, 2.82; 95% CI, 1.77-4.50) and Hispanic males (OR, 2.91; 95% CI, 1.75-4.82), and 2 to 5 times the odds of gainful activity compared with African American (OR, 5.17; 95% CI, 3.16-8.45) and Hispanic males (OR, 2.58; 95% CI, 1.56-4.26). Latent class analysis shows that African American males fared the worst, with lives characterized by incarceration, criminal activity, and few positive outcomes. Conclusions and Relevance: Our findings highlight racial/ethnic disparities among youth in achieving positive outcomes after detention. To improve outcomes, pediatric health care professionals should recognize the importance of psychosocial health, partner with on-site psychosocial services in their practices, and facilitate access to services in the community.