Does pain self-efficacy predict, moderate or mediate outcomes in people with chronic headache; an exploratory analysis of the CHESS trial.

BACKGROUND: Chronic headache disorders are disabling. The CHESS trial studied the effects of a short non-pharmacological intervention of education with self-management support for people affected by migraine and/or tension type headache for at least 15 days per month for at least three months. There were no statistically significant effects on the Headache Impact Test-6 (HIT-6) at 12-months. However, we observed improvement in pain self-efficacy questionnaire (PSEQ) and short-term HIT-6. We explored the impact of the CHESS intervention on PSEQ, and subsequently, on the HIT-6 and chronic headache quality of life questionnaire (CH-QLQ) at four, eighth and 12 months. METHODS: We included all 736 participants from the CHESS trial. We used simple linear regression models to explore the change of HIT-6 and CH-QLQ with treatment and PSEQ at baseline (predictor analysis), and the interaction between treatment and baseline PSEQ (moderator analysis). We considered the change of PSEQ from baseline to four months as a mediator in the mediation analysis. RESULTS: Baseline PSEQ neither predicted nor moderated outcomes. The prediction effect on change of HIT-6 from baseline to 12 months was 0.01 (95% CI, -0.03 to 0.04) and the interaction (moderation) effect was -0.07 (95% CI, -0.15 to 0.002). However, the change of PSEQ from baseline to 4-month mediated the HIT-6 (baseline to 8-, and 12-month) and all components of CH-QLQ (baseline to 8-, and 12-month). The CHESS intervention improved the mediated variable, PSEQ, by 2.34 (95% CI, 0.484 to 4.187) units and this corresponds to an increase of 0.21 (95% CI, 0.03 to 0.45) units in HIT-6 at 12-months. The largest mediated effect was observed on the CH-QLQ Emotional Function, an increase of 1.12 (95% CI, 0.22 to 2.20). CONCLUSIONS: PSEQ was not an effective predictor of outcome. However, change of short-term PSEQ mediated all outcomes, albeit minimally. Future behavioural therapy for chronic headache may need to consider how to achieve larger, and more sustained increases level of self-efficacy than that achieved within the CHESS trial. TRIAL REGISTRATION: ISRCTN79708100.

Rhinoviruses A and C elicit long-lasting antibody responses with limited cross-neutralization.

Rhinoviruses (RVs) can cause severe wheezing illnesses in young children and patients with asthma. Vaccine development has been hampered by the multitude of RV types with little information about cross-neutralization. We previously showed that neutralizing antibody (nAb) responses to RV-C are detected twofold to threefold more often than those to RV-A throughout childhood. Based on those findings, we hypothesized that RV-C infections are more likely to induce either cross-neutralizing or longer-lasting antibody responses compared with RV-A infections. We pooled RV diagnostic data from multiple studies of children with respiratory illnesses and compared the expected versus observed frequencies of sequential infections with RV-A or RV-C types using log-linear regression models. We tested longitudinally collected plasma samples from children to compare the duration of RV-A versus RV-C nAb responses. Our models identified limited reciprocal cross-neutralizing relationships for RV-A (A12-A75, A12-A78, A20-A78, and A75-A78) and only one for RV-C (C2-C40). Serologic analysis using reference mouse sera and banked human plasma samples confirmed that C40 infections induced nAb responses with modest heterotypic activity against RV-C2. Mixed-effects regression modeling of longitudinal human plasma samples collected from ages 2 to 18 years demonstrated that RV-A and RV-C illnesses induced nAb responses of similar duration. These results indicate that both RV-A and RV-C nAb responses have only modest cross-reactivity that is limited to genetically similar types. Contrary to our initial hypothesis, RV-C species may include even fewer cross-neutralizing types than RV-A, whereas the duration of nAb responses during childhood is similar between the two species. The modest heterotypic responses suggest that RV vaccines must have a broad representation of prevalent types.

HIV Testing Preferences and Characteristics of Those Who Have Never Tested for HIV in the United States.

BACKGROUND: The initial phase of the federal Ending the HIV Epidemic in the U.S. (EHE) initiative prioritized efforts in 57 geographic areas. The US Centers for Disease Control and Prevention recommends persons aged 13 to 64 years be tested for HIV at least once as part of routine health care; however, it is unclear how effectively these testing recommendations have been implemented in EHE priority areas. METHODS: In 2021 to 2022, we analyzed data from a Web-based, nationally representative survey of adults fielded in 2021. HIV testing preferences were compared by testing history, demographic characteristics, behaviors, and geography. RESULTS: An estimated 72.5% of US adults had never tested for HIV. Never testing was most prevalent among those aged 18 to 29 or those 50 years or older, non-Hispanic White persons, and those living in the Midwest. Among persons living in EHE priority areas and persons reporting at least one behavior that increases risk of HIV transmission, 69.1% and 48.0%, respectively, had never tested for HIV. The top 3 HIV testing preferences among never testers were as follows: testing for HIV during a routine health care visit (41.2%), testing at an urgent care or walk-in clinic (9.6%), and self-testing (8.1%). CONCLUSIONS: Most adults had not been tested for HIV, confirming that US Centers for Disease Control and Prevention recommendations are not being fully implemented, even in EHE priority areas. Moreover, most adults who never tested preferred testing in clinical settings, highlighting missed opportunities. As the EHE initiative continues to advance, it is critical to leverage preferred HIV testing modalities, such as routine testing in clinical settings or HIV self-testing.

Distribution of HIV Self-tests by Men Who have Sex with Men (MSM) to Social Network Associates.

Internet-recruited gay, bisexual, and other men who have sex with men (MSM) were offered HIV self-tests (HIVSTs) after completing baseline, 3-, 6-, and 9-month follow-up surveys. The surveys asked about the use and distribution of these HIVSTs. Among 995 who reported on their distribution of HIVSTs, 667 (67.0%) distributed HIVSTs to their social network associates (SNAs), which resulted in 34 newly identified HIV infections among 2301 SNAs (1.5%). The main reasons participants reported not distributing HIVSTs included: wanting to use the HIVSTs themselves (74.9%); thinking that their SNAs would get angry or upset if offered HIVSTs (12.5%); or not knowing that they could give the HIVSTs away (11.3%). Self-testing programs can provide multiple HIVSTs and encourage the distribution of HIVST by MSM to their SNAs to increase awareness of HIV status among persons disproportionately affected by HIV.

RESUMEN: Hombres gais, bisexuales y otros hombres que indicaron tener contacto sexual con hombres (MSM, por sus siglas en inglés) fueron reclutados por el Internet y se les ofreció autopruebas del VIH (HIVST, por sus siglas en inglés) después de completar una encuestas inicial y encuestas de seguimiento a los 3, 6 y 9 meses. Las encuestas recogieron datos sobre el uso y distribución de estas autopruebas del VIH. De los 995 MSM que indicaron distribuir las autopruebas, 667 (67.0%) distribuyeron las autopruebas a personas en sus redes sociales (SNA, por sus siglas en inglés), resultando en 34 nuevas infecciones por el VIH identificadas entre 2,301 SNA (1.5%). Las razones principales por las que algunos participantes no distribuyeron las autopruebas del VIH incluyen: el deseo de utilizar las autopruebas del VIH para sí mismos (74.9%); pensar que las SNA se enfadarían o molestarían si se les ofreciesen autopruebas del VIH (12.5%); o no saber que podían distribuir las autopruebas del VIH (11.3%). Los programas que proporcionen múltiples autopruebas del VIH podrían alentar la distribución de las autopruebas por parte de los MSM a las SNA para aumentar el conocimento sobre el estado del VIH entre personas afectadas de manera desproporcionada por el VIH.

Implementation of caregiver depression screening in an urban, community-based asthma clinic: a quality improvement project.

OBJECTIVE: Caregiver depressive symptoms are prevalent among children with asthma and associated with greater asthma morbidity. Identifying caregivers with depression and connecting them to appropriate treatment may reduce child asthma morbidity. The goal of this project was to implement a workflow for caregiver depression screening and treatment referral in an urban, community-based, asthma clinic serving under-resourced children. METHODS: The Model for Improvement with weekly Plan-Do-Study-Act cycles was utilized. A two-item depression screening tool (Patient Health Questionnaire-2; PHQ-2) and an acceptability question using a 5-point Likert scale were added to an existing social needs screening checklist administered to all caregivers during the child's clinic visit. Caregivers with a positive PHQ-2 score (≥3) received the PHQ-9. Positive screens on the PHQ-9 (≥5) received information and referrals by level of risk. PHQ-9 positive caregivers received a follow-up phone call two weeks post-visit to assess connection to support, improvement in depressive symptoms, and satisfaction with resources provided. RESULTS: The PHQ-2 was completed by 84.4% of caregivers (233/276). Caregivers had a mean age of 33.8 years (SD = 8.3; Range: 18-68) and were predominately female (86.4%), Black (80.4%), and non-Hispanic (78.4%). The majority (72.3%) found the screening acceptable (agree/strongly agree). Nearly one in six caregivers (37/233, 15.9%) reported depressive symptoms (PHQ-2 ≥ 3); 11.6% (27/233) had clinically significant symptoms (PHQ-9 score ≥ 10); and 2.1% (5/233) reported suicidal thoughts. Of those with depressive symptoms, 70.3% (26/37) participated in the follow-up phone call. While 50% (13/26) reported the resources given in clinic were "extremely helpful," no caregivers contacted or used them. CONCLUSIONS: Caregiver depression screening was successfully integrated into a pediatric asthma clinic serving under-resourced children. While caregivers found screening to be acceptable, it did not facilitate short-term connection to treatment among those with depressive symptoms.

StethAid: A Digital Auscultation Platform for Pediatrics.

(1) Background: Mastery of auscultation can be challenging for many healthcare providers. Artificial intelligence (AI)-powered digital support is emerging as an aid to assist with the interpretation of auscultated sounds. A few AI-augmented digital stethoscopes exist but none are dedicated to pediatrics. Our goal was to develop a digital auscultation platform for pediatric medicine. (2) Methods: We developed StethAid-a digital platform for artificial intelligence-assisted auscultation and telehealth in pediatrics-that consists of a wireless digital stethoscope, mobile applications, customized patient-provider portals, and deep learning algorithms. To validate the StethAid platform, we characterized our stethoscope and used the platform in two clinical applications: (1) Still's murmur identification and (2) wheeze detection. The platform has been deployed in four children's medical centers to build the first and largest pediatric cardiopulmonary datasets, to our knowledge. We have trained and tested deep-learning models using these datasets. (3) Results: The frequency response of the StethAid stethoscope was comparable to those of the commercially available Eko Core, Thinklabs One, and Littman 3200 stethoscopes. The labels provided by our expert physician offline were in concordance with the labels of providers at the bedside using their acoustic stethoscopes for 79.3% of lungs cases and 98.3% of heart cases. Our deep learning algorithms achieved high sensitivity and specificity for both Still's murmur identification (sensitivity of 91.9% and specificity of 92.6%) and wheeze detection (sensitivity of 83.7% and specificity of 84.4%). (4) Conclusions: Our team has created a technically and clinically validated pediatric digital AI-enabled auscultation platform. Use of our platform could improve efficacy and efficiency of clinical care for pediatric patients, reduce parental anxiety, and result in cost savings.

Association of mold levels in urban children's homes with difficult-to-control asthma.

BACKGROUND: Mold sensitization and exposure are associated with asthma severity, but the specific species that contribute to difficult-to-control (DTC) asthma are unknown. OBJECTIVE: We sought to determine the association between overall and specific mold levels in the homes of urban children and DTC asthma. METHODS: The Asthma Phenotypes in the Inner-City study recruited participants, aged 6 to 17 years, from 8 US cities and classified each participant as having either DTC asthma or easy-to-control (ETC) asthma on the basis of treatment step level. Dust samples had been collected in each participant's home (n = 485), and any dust remaining (n = 265 samples), after other analyses, was frozen at -20oC. The dust samples (n = 265) were analyzed using quantitative PCR to determine the concentrations of the 36 molds in the Environmental Relative Moldiness Index. Logistic regression was performed to discriminate specific mold content of dust from homes of children with DTC versus ETC asthma. RESULTS: Frozen-dust samples were available from 54% of homes of children with DTC (139 of 253) and ETC asthma (126 of 232). Only the average concentration of the mold Mucor was significantly (P < .001) greater in homes of children with DTC asthma. In homes with window air-conditioning units, the Mucor concentration contributed about a 22% increase (1.6 odds ratio; 95% CI, 1.2-2.2) in the ability to discriminate between cases of DTC and ETC asthma. CONCLUSIONS: Mucor levels in the homes of urban youth were a predictor of DTC asthma, and these higher Mucor levels were more likely in homes with a window air-conditioner.

A Culturally Adapted Breast and Cervical Cancer Screening Intervention Among Muslim Women in New York City: Results from the MARHABA Trial.

We examine the efficacy of MARHABA, a social marketing-informed, lay health worker (LHW) intervention with patient navigation (PN), to increase breast and cervical cancer screening among Muslim women in New York City. Muslim women were eligible if they were overdue for a mammogram and/or a Pap test. All participants attended a 1-h educational seminar with distribution of small media health education materials, after which randomization occurred. Women in the Education + Media + PN arm received planned follow-ups from a LHW. Women in the Education + Media arm received no further contact. A total of 428 women were randomized into the intervention (214 into each arm). Between baseline and 4-month follow-up, mammogram screening increased from 16.0 to 49.0% in the Education + Media + PN arm (p < 0.001), and from 14.7 to 44.6% in the Education + Media arm (p < 0.001). Pap test screening increased from 16.9 to 42.3% in the Education + Media + PN arm (p < 0.001) and from 17.3 to 37.1% in the Education + Media arm (p < 0.001). Cancer screening knowledge increased in both groups. Between group differences were not statistically significant for screening and knowledge outcomes. A longer follow-up period may have resulted in a greater proportion of up-to-date screenings, given that many women had not yet received their scheduled screenings. Findings suggest that the educational session and small media materials were perhaps sufficient to increase breast and cervical cancer screening among Muslim American women. ClinicalTrials.gov NCT03081507.

Enhanced Neutralizing Antibody Responses to Rhinovirus C and Age-Dependent Patterns of Infection.

Rationale: Rhinovirus (RV) C can cause asymptomatic infection and respiratory illnesses ranging from the common cold to severe wheezing.Objectives: To identify how age and other individual-level factors are associated with susceptibility to RV-C illnesses.Methods: Longitudinal data from the COAST (Childhood Origins of Asthma) birth cohort study were analyzed to determine relationships between age and RV-C infections. Neutralizing antibodies specific for RV-A and RV-C (three types each) were determined using a novel PCR-based assay. Data were pooled from 14 study cohorts in the United States, Finland, and Australia, and mixed-effects logistic regression was used to identify factors related to the proportion of RV-C versus RV-A detection.Measurements and Main Results: In COAST, RV-A and RV-C infections were similarly common in infancy, whereas RV-C was detected much less often than RV-A during both respiratory illnesses and scheduled surveillance visits (P < 0.001, χ2) in older children. The prevalence of neutralizing antibodies to RV-A or RV-C types was low (5-27%) at the age of 2 years, but by the age of 16 years, RV-C seropositivity was more prevalent (78% vs. 18% for RV-A; P < 0.0001). In the pooled analysis, the RV-C to RV-A detection ratio during illnesses was significantly related to age (P < 0.0001), CDHR3 genotype (P < 0.05), and wheezing illnesses (P < 0.05). Furthermore, certain RV types (e.g., C2, C11, A78, and A12) were consistently more virulent and prevalent over time.Conclusions: Knowledge of prevalent RV types, antibody responses, and populations at risk based on age and genetics may guide the development of vaccines or other novel therapies against this important respiratory pathogen.

Predictors of Elevated Social Risk in Pediatric Emergency Department Patients and Families.

OBJECTIVE: This study aimed to identify predictors of high unmet social needs among pediatric emergency department (ED) patients. We hypothesized that obesity, frequent nonurgent visits, reported food insecurity, or an at-risk chief complaint (CC) would predict elevated social risk. METHODS: We administered a tablet-based survey assessing unmet social needs in 13 domains to caregivers of patients aged 0 to 17 years presenting to an urban pediatric ED. Responses were used to tabulate a social risk score (SRS). We performed multivariable logistic regression to measure associations between a high SRS (≥3) and obesity, frequent nonurgent visits, food insecurity, or an at-risk CC (physical abuse, sexual abuse, assault, mammalian bites, reproductive/sexual health complaints, intoxication, ingestion/poisoning, psychiatric/behavioral complaints, or any complaint triaged as "least urgent"). RESULTS: Five hundred seventy caregivers completed the survey. Eighty-one percent reported at least one unmet social need, and 33% identified ≥3 social needs. Caregivers of patients with an at-risk CC had twice the odds of a high SRS (adjusted odds ratio [aOR], 1.8; 95% confidence interval [CI], 1.0-3.3). Caregivers of patients reporting food insecurity had 4 times the odds of a high SRS (aOR, 4.3; 95% CI, 2.5-7.3). Neither obesity (aOR, 1.5; 95% CI, 0.9-2.6) nor frequent nonurgent visits (aOR, 0.9; 95% CI, 0.4-1.9) were predictive of a high SRS. CONCLUSIONS: Unmet social needs are prevalent among caregivers of pediatric ED patients, supporting universal screening in this population. Patients with an at-risk CC or reported food insecurity might benefit from proactive intervention. Future studies should examine optimal methods for ED-based interventions that address social determinants of health.

Disparities in colorectal cancer screening among South Asians in New York City: a cross-sectional study.

Despite improvements in colorectal cancer (CRC) screening in New York City (NYC) since the early 2000s, the degree to which disparities persist for specific Asian American subgroups has yet to be fully elucidated. The purpose of this study is to examine disparities in rates of timely colonoscopy screening among five racial/ethnic groups in NYC. We performed a retrospective cross-sectional analysis of combined 2014-2018 NYC Community Health Survey data. Prevalence estimates of timely colonoscopy screening (within the past 10 years) among individuals ≥ 50 years of age were calculated and presented overall (n = 24,288) and by socio-demographic variables. Racial/ethnic categories included White, Black, Hispanic, East Asian, and South Asian. Multivariable models examined socio-demographic and racial/ethnic predictors of timely colonoscopy screening. A trend analysis examined colonoscopy screening by race/ethnicity and year from 2012 to 2018 (n = 33,130). Age-adjusted prevalence of timely colonoscopy screening was lowest among Asian Americans (South Asian 61.1% and East Asian 65.9%) compared to Hispanics (71.3%), Blacks (70.2%), and Whites (68.6%). Adjustment by socio-demographics, including insurance status, further explained disparities for South Asians (adjusted risk ratio [RR] = 0.84, 95% CI = 0.73-0.97) compared to Hispanics; additionally, Whites (adjusted RR=0.88, 95% CI = 0.84-0.92) were less likely to have received a timely colonoscopy compared to Hispanics. Age, health insurance, poverty group, and education were significant predictors in adjusted regression. Results indicate that South Asians have not equally benefited from campaigns to increase colonoscopy screening in NYC. Our findings support the development of targeted, and linguistically and culturally adapted campaigns that facilitate access to health systems and leverage existing community assets and social support systems among South Asian populations.

Measuring health-related quality of life in chronic headache: A comparative evaluation of the Chronic Headache Quality of Life Questionnaire and Headache Impact Test (HIT-6).

OBJECTIVE: To compare the quality and acceptability of a new headache-specific patient-reported measure, the Chronic Headache Quality of Life Questionnaire (CHQLQ) with the six-item Headache Impact Test (HIT-6), in people meeting an epidemiological definition of chronic headaches. METHODS: Participants in the feasibility stage of the Chronic Headache Education and Self-management Study (CHESS) (n = 130) completed measures three times during a 12-week prospective cohort study. Data quality, measurement acceptability, reliability, validity, responsiveness to change, and score interpretation were determined. Semi-structured cognitive interviews explored measurement relevance, acceptability, clarity, and comprehensiveness. RESULTS: Both measures were well completed with few missing items. The CHQLQ's inclusion of emotional wellbeing items increased its relevance to participant's experience of chronic headache. End effects were present at item level only for both measures. Structural assessment supported the three and one-factor solutions of the CHQLQ and HIT-6, respectively. Both the CHQLQ (range 0.87 to 0.94) and HIT-6 (0.90) were internally consistent, with acceptable temporal stability over 2 weeks (CHQLQ range 0.74 to 0.80; HIT-6 0.86). Both measures responded to change in headache-specific health at 12 weeks (CHQLQ smallest detectable change (improvement) range 3 to 5; HIT-6 2.1). CONCLUSIONS: While both measures are structurally valid, internally consistent, temporally stable, and responsive to change, the CHQLQ has greater relevance to the patient experience of chronic headache.Trial registration number: ISRCTN79708100. Registered 16th December 2015, http://www.isrctn.com/ISRCTN79708100.

Quality of life in at-risk school-aged children with asthma.

INTRODUCTION: Asthma is the most common chronic condition of childhood. Urban, minority children from families of lower socioeconomic status have disproportionately higher rates of asthma and worse outcomes. We investigated the association between the presence of asthma and asthma severity among American, urban, minority children and reported quality of life (QOL) of children and their families. METHODS: We performed a prospective, cross-sectional study comparing QOL of urban, minority elementary school-age children with and without asthma. A convenience sample of children was enrolled from the pediatric emergency department (ED) and a specialized asthma clinic, at a large urban children's hospital. We measured child and parent QOL using the Pediatric Quality of Life Inventory Version 4 (PEDSQL4), and evaluated associations with asthma, parental educational attainment, and frequency of ED visits. RESULTS: We enrolled 66 children, 76% were African American, and 61% were female. Overall child QOL was higher for those without asthma (p = 0.017, d = 0.59). Children with asthma also visited the ED almost twice as frequently (t [64] = -3.505, p < 0.001, d = 0.8), and parents of children with asthma reported a lower overall QOL (p = 0.04, d = 0.53) than those without asthma. Among children with asthma, a higher overall child QOL was associated with decreased asthma severity, more ED visits, and higher parental educational attainment. CONCLUSIONS: Urban, minority elementary school-age children with asthma report a lower QOL than those children without asthma, and decreased asthma severity was associated with higher QOL.

Identification of subgroup effect with an individual participant data meta-analysis of randomised controlled trials of three different types of therapist-delivered care in low back pain.

BACKGROUND: Proven treatments for low back pain, at best, only provide modest overall benefits. Matching people to treatments that are likely to be most effective for them may improve clinical outcomes and makes better use of health care resources. METHODS: We conducted an individual participant data meta-analysis of randomised controlled trials of three types of therapist delivered interventions for low back pain (active physical, passive physical and psychological treatments). We applied two statistical methods (recursive partitioning and adaptive risk group refinement) to identify potential subgroups who might gain greater benefits from different treatments from our individual participant data meta-analysis. RESULTS: We pooled data from 19 randomised controlled trials, totalling 9328 participants. There were 5349 (57%) females with similar ratios of females in control and intervention arms. The average age was 49 years (standard deviation, SD, 14). Participants with greater psychological distress and physical disability gained most benefit in improving on the mental component scale (MCS) of SF-12/36 from passive physical treatment than non-active usual care (treatment effects, 4.3; 95% confidence interval, CI, 3.39 to 5.15). Recursive partitioning method found that participants with worse disability at baseline gained most benefit in improving the disability (Roland Morris Disability Questionnaire) outcome from psychological treatment than non-active usual care (treatment effects, 1.7; 95% CI, 1.1 to 2.31). Adaptive risk group refinement did not find any subgroup that would gain much treatment effect between psychological and non-active usual care. Neither statistical method identified any subgroups who would gain an additional benefit from active physical treatment compared to non-active usual care. CONCLUSIONS: Our methodological approaches worked well and may have applicability in other clinical areas. Passive physical treatments were most likely to help people who were younger with higher levels of disability and low levels of psychological distress. Psychological treatments were more likely to help those with severe disability. Despite this, the clinical importance of identifying these subgroups is limited. The sizes of sub-groups more likely to benefit and the additional effect sizes observed are small. Our analyses provide no evidence to support the use of sub-grouping for people with low back pain.

Regional Differences in Pediatric Firearm-Related Emergency Department Visits and the Association With Firearm Legislation.

OBJECTIVE: The objective of this study was to describe regional and temporal trends in pediatric firearm-related emergency department (ED) visits and investigate association with regional firearm legislation. METHODS: We conducted a cross-sectional analysis using the Nationwide Emergency Department Sample from 2009 to 2013 for children aged 21 years or younger. We calculated national estimates of firearm-related visits using annual census data and measured trends. We used state-level gun law scores to derive regional scores to measure strictness of firearm legislation. We used multivariable logistic and linear regression to measure regional differences in visits and their association with regional gun law scores, respectively. RESULTS: There were 111,839 (95% confidence interval, 101,248-122,431) ED visits for pediatric firearm-related injuries. Rates of visits varied by region, with the lowest rate in the Northeast and highest rate in the South (40.0 [34-45]; 70.8 [63.7-76.9] per 100,000 ED visits, respectively). Compared with the Northeast, odds of firearm-related ED visits were higher in the Midwest (adjusted odds ratio [aOR], 1.8; 1.4-2.3), West (aOR, 2.5; 2.0-3.2), and South (aOR, 1.9; 1.5-2.4). Firearm-related visits remained consistent over time. A higher (stricter) regional median Brady gun law score was associated with a lower rate of firearm-related visits (ß = -0.8; R2 = 0.9; P = 0.03). CONCLUSIONS: Rates of pediatric firearm-related ED visits vary by region. Stricter regional gun laws were associated with lower rates of ED visits for pediatric firearm-related injuries. Further study of the social and cultural regional differences in gun ownership and the role of legislation in the prevention of pediatric firearm-related morbidity and mortality is warranted.

A Population Health Equity Approach Reveals Persisting Disparities in Colorectal Cancer Screening in New York City South Asian Communities.

To assess colorectal cancer (CRC) screening among South Asians (SAs) and explore the challenges and facilitators to CRC screening among SA subgroups in New York City (NYC). Fifty-one semi-structured in-depth interviews and surveys were conducted among SA immigrants in NYC. Qualitative results suggested challenges to CRC screening were related to socio-cultural factors, such as a lack of knowledge on CRC and CRC screening, and structural factors, such as cost and language. A physician referral was the most cited facilitator to CRC screening. Participants reported culturally and linguistically adapted education and information on CRC and CRC screening would help to overcome noted challenges. Our findings support the development of targeted, linguistically and culturally adapted campaigns for this population that facilitate access to health systems and leverage natural community assets and social support systems.

The Impact of an Online Training Program About Cancer Clinical Trials on Primary Care Physicians' Knowledge, Attitudes and Beliefs, and Behavior.

Participation in cancer clinical trials (CCTs) is critical to improving cancer treatments and quality of care. However, rates of patient participation remain low. Research has shown that a trusted physician recommendation is an important influence on patients' decisions to enroll in a CCT. Improving primary care providers' (PCPs') knowledge, attitudes, and beliefs about CCTs is a promising potential path for improving CCT participation. The aim of this pilot study was to test the effect of an online educational course for PCPs about clinical trials on primary care providers' knowledge, attitudes and beliefs, and behavior. Forty-one PCPs in the New York City area participated in a 1-h online training session on cancer clinical trials. These PCPs had self-selected to complete the training in a previous survey. The objectives of the training module were to (1) educate the PCPs about clinical trials, with a focus on overcoming misconceptions; and (2) discuss roles of PCPs in partnering with oncologists to help patients gain access to clinical trials. The training module included didactics, audio excerpts, and case descriptions. Participants completed a pre-test immediately before taking the course, a post-test immediately after taking the course, and a 3-month post-course survey. All three assessments included a general T/F knowledge test, a 7-item attitude/belief scale, and a knowledge test focused specifically on local resources and access for clinical trials. Forty-one PCPs completed the module and the pre-post course surveys. Eighty percent (33/41) also completed the 3-month post-course survey. General knowledge and local knowledge increased significantly (p < .05) from pre- to post-course. At 3 months post-training, both general and local knowledge scores remained significantly increased from baseline. For those who completed the 3-month post-course survey, attitudes and beliefs increased significantly from pre- to post-course, but this change was not sustained at 3 months post-training. At 3 months post-training, 52% of the PCPs who had an interaction with a recently diagnosed cancer patient reported speaking with patients about CCTs as a result of the training. A brief online course showed significant and sustained improvement in PCPs' general and local knowledge about cancer clinical trials, which translated into self-reported behavior change. Future dissemination of the course and further research into its impact are important next steps.

Facilitating the identification of patients hospitalized for acute myocardial infarction and heart failure and the assessment of their readmission risk through the Patient Navigator Program.

BACKGROUND: Optimal transition care mitigates early hospital readmission risk. Given limited resources, hospitals need to identify patients with high readmission risk. This article examines whether a coordinated quality improvement campaign can help achieve this objective. METHODS: The American College of Cardiology Patient Navigator Program, a 2-year quality improvement campaign, sought to assess the impact of transition care interventions on 30-day readmission rates for patients with acute myocardial infarction (AMI) or heart failure (HF) at 35 hospitals. This article examines the change in 2 of the 36 performance metrics the campaign tracked: the number of AMI and HF patients identified predischarge and those whose readmission risk was assessed. RESULTS: The number of facilities identifying AMI and HF patients predischarge increased from 24 (68.6%) and 28 (80.0%), respectively, at baseline, to 34 (97.1%) (P = .0016) and 34 (97.1%) (P = .014), respectively, at 2 years. The number of facilities assessing the readmission risk of AMI and HF patients risk increased from 9 (25.7%) and 11 (31.4%), respectively, at baseline, to 32 (91.4%) (P < .0001) and 33 (94.5%) (P < .0001), respectively, at 2 years. Importantly, baseline reporting of performance for both metrics was poor, with >25% of the hospitals missing data. CONCLUSIONS: Implementation of a coordinated quality improvement campaign may increase the number of facilities identifying AMI and HF patients predischarge and assessing their readmission risk. Further research is needed to determine if increased identification reduces 30-day readmission or facilitates improvement in other important clinical outcomes.

Self-Reported Prevalence of HIV Testing Among Those Reporting Having Been Diagnosed With Selected STIs or HCV, United States, 2005-2016.

BACKGROUND: Persons with STIs or HCV infection often have indicators of HIV risk. We used weighted data from 6 cycles of the National Health and Nutrition Examination Survey (NHANES) to assess the proportion of persons who reported ever being diagnosed as having a selected STI or HCV infection and who reported that they were ever tested for HIV. METHODS: Persons aged 20 to 59 years with prior knowledge of HCV infection before receiving NHANES HCV RNA-positive results (2005-2012) or reporting ever being told by a doctor that they had HCV infection (2013-2016), or ever had genital herpes, or had chlamydia or gonorrhea in the past 12 months were categorized as having had a selected STI or HCV infection. Weighted proportions and 95% confidence intervals were estimated for reporting ever being tested for HIV for those who did and did not report a selected STI or HCV infection. RESULTS: A total of 19,102 respondents had nonmissing data for STI and HCV diagnoses and HIV testing history; 44.4% reported ever having been tested for HIV, and 5.2% reported being diagnosed as having a selected STI or HCV infection. The proportion reporting an HIV test was higher for the group that reported an STI or HCV infection than for the group that did not. CONCLUSION: Self-reported HIV testing remains low in the United States, even among those who reported a previous selected STI or HCV infection. Ensuring HIV tests are conducted routinely for those with overlapping risk factors can help facilitate the diagnosis of HIV infections.

Performance of an Alternative Laboratory-Based HIV Diagnostic Testing Algorithm Using HIV-1 RNA Viral Load.

BACKGROUND: Since 2014, the recommended algorithm for laboratory diagnosis of HIV infection in the United States has consisted of an HIV-1/2 antigen/antibody (Ag/Ab) test followed by an HIV-1/2 antibody (Ab) differentiation test and, if necessary, a diagnostic HIV-1 nucleic acid test to resolve discordant or indeterminate results. METHODS: Using stored specimens from persons seeking HIV testing who had not received a previous diagnosis or treatment, we compared the performance of a 3-step alternative algorithm consisting of an Ag/Ab test followed by a quantitative HIV-1 RNA viral load assay and, if viral load is not detected, an Ab differentiation test, to that of the recommended algorithm. We calculated the sensitivity and specificity of 5 Ag/Ab tests and the proportion of specimens correctly classified by the alternative algorithm compared with the recommended algorithm. Results were examined separately for specimens classified as early infection, established infection, and false-reactive screening. RESULTS: Sensitivity and specificity were similar among all Ag/Ab tests. Viral load quantification correctly classified all specimens from early infection, all false-reactive screening specimens, and the majority of specimens from established infection. CONCLUSIONS: Although cost, regulatory barriers, test availability, and the ability to differentiate early from established infection must be considered, this alternative algorithm can potentially decrease the total number of tests performed and reduce turnaround time, thereby streamlining HIV diagnosis and initiation of treatment.