Discordant and Concordant Substance Use and Daily Partner Violence in Adolescent and Young Adult Relationships With Baseline Dating Violence.

PURPOSE: Intimate partner violence (IPV) and substance use in adolescents and young adults (AYAs) are significant public health issues in the United States. Together, they can harm emotional regulation and romantic relationship functioning. This study examines the role of concordant and discordant substance use on IPV within AYA relationships. METHODS: A prospective cohort of community-recruited AYA women in a heterosexual dating relationship with past-month IPV completed four months of daily surveys via a cell phone. Each day, participants reported any IPV perpetration and/or victimization, their alcohol and drug use, and observed partner substance use. Concordant substance use was coded when the participant and partner used drugs or alcohol on the same day. Discordant use was coded when only the participant or partner used drugs or alcohol on a given day. Alcohol and drug use were modeled separately. Generalized estimating equations accounted for the correlation of repeated measures. RESULTS: Participants (N = 143) were 18.2 (1.1) years old, 93% African American race. Discordant alcohol and drug use was associated with same-day victimization, perpetration, and co-occurring violence compared to concordant nonuse. Similarly, concordant alcohol use, drug use, and alcohol/drug use were associated with increased odds of victimization, perpetration, and co-occurring violence compared to concordant nonuse. DISCUSSION: Daily data illustrated that dyadic patterns of substance use are associated with IPV. These findings may facilitate the development of effective and developmentally appropriate IPV intervention programs for AYA that also integrate strategies to reduce substance use.

Does Consumer Credit Precede or Follow Health Among Older Adults? An Investigation in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Trial.

Background and Objectives: Consumer credit has shown increasing relevance to the health of older adults; however, studies have not been able to assess the extent to which creditworthiness influences future health or health influences future creditworthiness. We assessed the relationships between 4-year pre and postmorbid consumer credit history and self-rated physical and mental health outcomes among older adults. Research Design and Methods: Generalized estimating equations models assessed pre and postmorbid credit history (credit scores, derogatory accounts, and unpaid accounts in collections) and the onset of poor self-rated health (SF-36 score <50) among 1,740 participants aged 65+ in the Advanced Cognitive Training for Independent and Vital Elderly study from 2001 to 2017, linked to TransUnion consumer credit data. Results: In any given year, up to 1/4 of participants had a major derogatory, unpaid, or collections account, and up to 13% of the sample had poor health. Each 50-point increase in credit score trended toward a 5% lower odds of poor health in the next 1 year, a 6% lower odds in the next 2 years, and a statistically significant finding of 13% lower odds by 3 years. A drop in credit score was associated with a 10% greater odds of poor health in the next year, and having a major derogatory account was associated with an 86% greater odds of poor health in the next 3 years. After poor health onset, credit scores continued to see significant losses up to the 3 years, with larger decrements over time. Discussion and Implications: Having a major derogatory account or a sudden loss in credit may be a time to monitor older adults for changes in health. After a downturn in health, supporting older adults to manage their debt may help stabilize their credit.

Does Consumer Credit Precede or Follow Changes in Cognitive Impairment Among Older Adults? An Investigation in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Trial.

OBJECTIVES: We assessed the relationships between pre- and post-morbid consumer credit history (credit scores, debts unpaid, or in collections) and classification of mild (or greater) cognitive impairment (MCI). METHODS: Generalized Estimating Equation models assessed pre-and post-morbid credit history and MCI risk among 1740 participants aged 65+ in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study, linked to TransUnion consumer credit data. RESULTS: Each 50-point increase in credit score was associated with up to 8% lower odds of MCI in the next 3 years. In contrast, new unpaid collections over doubled the odds of having MCI in the next 3 years. MCI was associated with subsequent credit score declines and a 47%-71% greater risk of having a new unpaid collection in the next 4 years. DISCUSSION: Credit declines may signal risk for future MCI. MCI may lead to financial challenges that warrant credit monitoring interventions for older adults.

Hierarchical Development of Physical Frailty and Cognitive Impairment and Their Association With Incident Cardiovascular Disease.

BACKGROUND: Frailty and cognitive impairment (CI) are geriatric conditions that lead to poor health outcomes among older adults with cardiovascular disease. The association between their temporal patterns of development and cardiovascular risk is unknown. OBJECTIVES: This study aims to examine the 5-year cardiovascular outcomes by the pattern of development of frailty and CI in older adults without a history of coronary artery disease. METHODS: We used the National Health and Aging Trends Study, linked to Medicare data. Frailty was measured using the physical frailty phenotype. CI was measured using the AD8 Dementia Screening Interview, measured cognitive performance, or self-report by patient or caregiver for a diagnosis given by a physician. The primary outcome was incident major adverse cardiovascular event at 5 years. RESULTS: Of a total 2,189 study participants aged 65 and older, 38.5% were male. In this study population, 154 (7%) participants developed frailty first, 829 (38%) developed CI first, and 195 (9%) participants developed both simultaneously (frail-CI group). Those who developed frailty and CI simultaneously were older, more likely to be female, and had multiple chronic conditions. The frail-CI group had the highest risk of major adverse cardiovascular event (hazard ratio [HR]: 1.81; 95% CI: 1.47-2.23) followed by frail first (HR: 1.46; 95% CI: 1.17-1.81) and CI first (HR: 1.31; 95% CI: 1.15-1.50). Frailty first was associated with the greater risk of stroke (HR: 1.49; 95% CI: 1.06-2.09) compared to the intact group. CONCLUSIONS: The simultaneous development of frailty and CI is associated with an increased risk of adverse cardiovascular outcomes including death compared with the development of each syndrome alone. Diagnostics to detect frailty and CI are critical in assessment of cardiovascular risk in the older population.

Social isolation and 9-year dementia risk in community-dwelling Medicare beneficiaries in the United States.

BACKGROUND: Social isolation can influence whether older adults develop dementia. We examine the association between social isolation and incident dementia among older adults in a nationally representative sample of community dwelling older adults in the United States (U.S.). We also investigate whether this association varies by race and ethnicity. METHODS: Data (N = 5022) come from the National Health and Aging Trends Study, a longitudinal and nationally representative cohort of older adults in the U.S. A composite measure of social isolation was used to classify older adults as socially isolated or not socially isolated at baseline. Demographic and health factors were measured at baseline via self-report. Dementia was measured at each round of data collection. Discrete-time proportional hazard time-to-event models were used to assess the association between social isolation and incident dementia over 9 years (2011-2020). RESULTS: Of 5022 older adults, 1172 (23.3%) were socially isolated, and 3850 (76.7%) were not socially isolated. Adjusting for demographic and health factors, being socially isolated (vs. not socially isolated) was associated with a 1.28 (95% CI: 1.10-1.49) higher hazard of incident dementia over 9 years. There was no statistically significant difference by race and ethnicity. CONCLUSION: Social isolation among older adults is associated with greater dementia risk. Elucidating the pathway by which social isolation impacts dementia may offer meaningful insights for the development of novel solutions to prevent or ameliorate dementia across diverse racial and ethnic groups.

The combined effects of physical frailty and cognitive impairment on emergency department- versus direct-admission hospitalizations.

BACKGROUND: We aimed to study whether physical frailty and cognitive impairment (CI) increase the risk of recurrent hospitalizations in older adults, independent of comorbidity, and disability. METHODS: Two thousand five hundred forty-nine community-dwelling participants from the National Health and Aging Trends Study (NHATS) with 3 + years of continuous Medicare coverage from linked claims data were included. We used the marginal means/rates recurrent events model to investigate the association of baseline CI (mild CI or dementia) and physical frailty, separately and synergistically, with the number of all-source vs. Emergency Department (ED)-admission vs. direct admission hospitalizations over 2 years. RESULTS: 17.8% of participants had at least one ED-admission hospitalization; 12.7% had at least one direct admission hospitalization. Frailty and CI, modeled separately, were both significantly associated with risk of recurrent all-source (Rate Ratio (RR) = 1.24 for frailty, 1.21 for CI; p < .05) and ED-admission (RR = 1.49 for frailty, 1.41 for CI; p < .05) hospitalizations but not direct admission, adjusting for socio-demographics, obesity, comorbidity and disability. When CI and frailty were examined together, 64.3% had neither (Unimpaired); 28.1% CI only; 3.5% Frailty only; 4.1% CI + Frailty. Compared to those Unimpaired, CI alone and CI + Frailty were predictive of all-source (RR = 1.20, 1.48, p < .05) and ED-admission (RR = 1.36, 2.14, p < .05) hospitalizations, but not direct admission, in our adjusted model. CONCLUSIONS: Older adults with both CI and frailty experienced the highest risk for recurrent ED-admission hospitalizations. Timely recognition of older adults with CI and frailty is needed, paying special attention to managing cognitive impairment to mitigate preventable causes of ED admissions and potentiate alternatives to hospitalization.

Getting under the skin: Social isolation and biological markers in the National Health and Aging Trends Study.

BACKGROUND: Social isolation is a risk factor for morbidity and mortality comparable to well-established risk factors including smoking, hypertension, and a sedentary lifestyle. The specific biological mechanisms that connect social isolation to morbidity and mortality remain unclear. Interleukin-6 (IL-6) and C-reactive protein (CRP) are biological markers that are upregulated during inflammation and can have long-term negative consequences for the health of individuals as they age. METHODS: Utilizing Round 7 (2017) data from the National Health and Aging Trends Study (NHATS), we examine the relationship between social isolation and two biological markers: IL-6 and high-sensitivity CRP. This study included a nationally representative sample of 4648 Medicare beneficiaries 65 years and older who provided samples using dried blood spot (DBS) techniques. We defined social isolation utilizing a multi-domained typology that considers living arrangement, core discussion network, religious attendance, and social participation. IL-6 and CRP were obtained via DBS that were collected in Round 7 of the NHATS. We performed linear regression to examine the association between social isolation and biological markers IL-6 and CRP. RESULTS: After adjusting for age, gender, race/ethnicity, income, tobacco use, body mass index, and chronic conditions, we found that severe social isolation and social isolation were significantly associated with higher levels of IL-6 and CRP values among older adults. CONCLUSIONS: Social isolation is associated with higher levels of biological markers (IL-6 and CRP). Our findings inform the pathway between social isolation and morbidity and mortality among older adults. IL-6 or CRP could be a proximal outcome measures for future clinical and social interventions that seek to alter the trajectory of social isolation and its associated health outcomes.

Frailty and cardiovascular outcomes in the National Health and Aging Trends Study.

AIMS: Physical frailty is a commonly encountered geriatric syndrome among older adults without coronary heart disease (CHD). The impact of frailty on the incidence of long-term cardiovascular outcomes is not known.We aimed to evaluate the long-term association of frailty, measured by the Fried frailty phenotype, with all-cause-mortality and MACE among older adults without a history of CHD at baseline in the National Health and Aging Trends Study. METHODS AND RESULTS: We used the National Health and Aging Trends Study, a prospective cohort study linked to a Medicare sample. Participants with a prior history of CHD were excluded. Frailty was measured during the baseline visit using the Fried physical frailty phenotype. Cardiovascular outcomes were assessed during a 6-year follow-up.Of the 4656 study participants, 3259 (70%) had no history of CHD 1 year prior to their baseline visit. Compared to those without frailty, subjects with frailty were older (mean age 82.1 vs. 75.1 years, P < 0.001), more likely to be female (68.3% vs. 54.9%, P < 0.001), and belong to an ethnic minority. The prevalence of hypertension, falls, disability, anxiety/depression, and multimorbidity was much higher in the frail and pre-frail than the non-frail participants. In a Cox time-to-event multivariable model and during 6-year follow-up, the incidences of death and of each individual cardiovascular outcomes were all significantly higher in the frail than in the non-frail patients including major adverse cardiovascular event (MACE) [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.53, 2.06], death (HR 2.70, 95% CI 2.16, 3.38), acute myocardial infarction (HR 1.95, 95% CI 1.31, 2.90), stroke (HR 1.71, 95% CI 1.34, 2.17), peripheral vascular disease (HR 1.80, 95% CI 1.44, 2.27), and coronary artery disease (HR 1.35, 95% CI 1.11, 1.65). CONCLUSION: In patients without CHD, frailty is a risk factor for the development of MACEs. Efforts to identify frailty in patients without CHD and interventions to limit or reverse frailty status are needed and, if successful, may limit subsequent adverse cardiovascular events.

Adolescent and Young Women's Daily Reports of Emotional Context and Episodes of Dating Violence.

PURPOSE: To investigate same day, previous day, and next day associations between trust, closeness, commitment, jealousy and provision of instrumental support with dating violence victimization and perpetration. METHOD: A convenience sample of young women, 16-19 years, in a heterosexual dating relationship with at least one act (past month) of physical or psychological victimization or perpetration, were recruited from urban public locations. Participants answered questions daily via text continuously for four months on dating violence and partner-specific emotions. Daily surveys asked about trust, closeness, commitment for their partner, jealousy, perceptions of partner's jealousy and provision of instrumental support to and from partner, and dating violence victimization and perpetration. Multilevel modeling examined within-relationship associations over time. RESULTS: Mean (sd) age for the full sample was 18.1 (1.1) years. Same-day emotional context (trust, closeness, commitment, jealousy and provision of instrumental support) was more strongly associated with victimization and perpetration compared to previous day emotions. Strongest same-day positive associations were with partner's perpetration, both partner's jealousy, and females' instrumental support. Partner's jealousy and increased trust were best predictors of next day victimization. Closeness, commitment and trust went down on the day of violence. Perpetration was positively associated with next day commitment. Victimization was positively associated with next day trust. CONCLUSIONS: This event-level analysis demonstrates the role and timing that emotional aspects of adolescent relationships - including positive feelings - have surrounding episodes of dating violence. This granular understanding of the emotional context of dating violence has the potential to facilitate development of effective, developmentally appropriate interventions.

Association Between Receipt of Cancer Screening and All-Cause Mortality in Older Adults.

Importance: Guidelines recommend against routine breast and prostate cancer screenings in older adults with less than 10 years' life expectancy. One study using a claims-based prognostic index showed that receipt of cancer screening itself was associated with lower mortality, suggesting that the index may misclassify individuals when used to inform cancer screening, but this finding was attributed to residual confounding because the index did not account for functional status. Objective: To examine whether cancer screening remains significantly associated with all-cause mortality in older adults after accounting for both comorbidities and functional status. Design, Setting, and Participants: This cohort study included individuals older than 65 years who were eligible for breast or prostate cancer screening and who participated in the 2004 Health and Retirement Study. Data were linked to Medicare claims from 2001 to 2015. Data analysis was conducted from January to November 2020. Main Outcomes and Measures: A Cox model was used to estimate the association between all-cause mortality over 10 years and receipt of screening mammogram or prostate-specific antigen (PSA) test, adjusting for variables in a prognostic index that included age, sex, comorbidities, and functional status. Potential confounders (ie, education, income, marital status, geographic region, cognition, self-reported health, self-care, and self-perceived mortality risk) of the association between cancer screening and mortality were also tested. Results: The breast cancer screening cohort included 3257 women (mean [SD] age, 77.8 [7.5] years); the prostate cancer screening cohort included 2085 men (mean [SD] age, 76.1 [6.8] years). Receipt of screening mammogram was associated with lower hazard of all-cause mortality after accounting for all index variables (adjusted hazard ratio [aHR], 0.67; 95% CI, 0.60-0.74). A weaker, but still statistically significant, association was found for screening PSA (aHR 0.88; 95% CI, 0.78-0.99). None of the potential confounders attenuated the association between screening and mortality except for cognition, which attenuated the aHR for mammogram from 0.67 (95% CI, 0.60-0.74) to 0.73 (95% CI, 0.64-0.82) and the aHR for PSA from 0.88 (95% CI, 0.78-0.99) to 0.92 (95% CI, 0.80-1.05), making PSA screening no longer statistically significant. Conclusions and Relevance: In this study, cognition attenuated the observed association between cancer screening and mortality among older adults. These findings suggest that existing mortality prediction algorithms may be missing important variables that are associated with receipt of cancer screening and long-term mortality. Relying solely on algorithms to determine cancer screening may misclassify individuals as having limited life expectancy and stop screening prematurely. Screening decisions need to be individualized and not solely dependent on life expectancy prediction.

Caring for Older Adults With Self-Reported Vision Impairment: Findings from the National Study of Caregiving.

PURPOSE: The purpose of this study was to examine caregiving relationships for older adults with vision impairment (VI). DESIGN: Cross-sectional study with a nationally representative sample. METHODS: Setting: the National Health and Aging Trends Study linked to the National Study of Caregiving, Year 2011. STUDY POPULATION: 1,776 family or unpaid caregivers to community-dwelling Medicare beneficiaries age ≥65 years old. OUTCOME MEASUREMENT: in the preceding month, 1) the number of hours of care provided; 2) the valued activities affected by caregiving; and 3) the odds of experiencing substantial emotional, financial, and physical difficulty related to providing care. EXPOSURE: VI was defined as a report of blindness or difficulty with distance or near vision. RESULTS: Among 1,776 caregivers, 428 caregivers spent an average ± standard error (SE) of 111 ± 9.1 hours per month assisting older adults with VI, whereas 1,348 spent an average of 72 ± 3.3 hours assisting older adults without VI. In fully adjusted negative binomial regression analyses, caregivers of older adults with VI spent 36% more hours (incident rate ratio [IRR]: 1.36; 95% confidence interval [CI]: 1.15-1.60) providing care and reported having 61% more valued activities affected (IRR: 1.61; 95% CI: 1.23-2.10) than caregivers of older adults without VI. In fully adjusted logistic regression analyses, caregivers of older adults with VI had greater odds of emotional (odds ratio [OR]: 1.46; 95% CI: 1.04-2.03) but not financial (OR: 1.33; 95% CI: 0.87-2.03) or physical (OR: 1.13; 95% CI: 0.74-1.74) difficulty related to providing care than caregivers of older adults without VI. CONCLUSIONS: These results suggest that caring for older adults with VI places different demands on time and emotional wellbeing than caring for older adults without VI, but no differences in financial or physical difficulties.

The Impact of Relationship Stressors on Trust and Prorelationship Behavior Within Adolescent Romantic Relationships: A Systems Approach.

PURPOSE: Trust is an essential component of romantic relationships. It is not understood how youth respond to a relationship stressor, which may impact trust, such as perceiving to be at risk for a sexually transmitted infection or their partner has other sex partners. We used a system science approach to examine feedback between trust and prorelationship behaviors within adolescent relationships. METHODS: A prospective cohort of clinic-recruited young women (N = 122), aged 16-19 years, completed daily questionnaires on partner-specific feelings and risk perceptions for 18 months. Relationship stressor defined as either perceiving the risk of sexually transmitted infection from a partner or partner had other sex partners. Prorelationship behaviors were more time spent with partner, sex with partner, and/or gift from partner. Time-lagged generalized estimating equation models were used to examine whether a relationship stressor is associated with a decrease in trust and whether prorelationship behaviors changed following the stressor. RESULTS: Experiencing a stressor was associated with threefold increased odds of having a decrease in trust in the same week (odds ratio [OR] = 3.30, 95% confidence interval [CI]: 2.30-4.72). Trust increased significantly the week following the stressor (OR = 2.09, 95% CI: 1.54-2.85). An increase in trust relative to the week of the stressor was associated with a 65% increase in prorelationship behavior in the week following the stressor (OR = 1.65, 95% CI: 1.20-2.26). CONCLUSIONS: Data uniquely show that trust is impacted following a relationship stressor and that youth increase prorelationship behaviors following a drop in trust. The findings suggest that adolescents prioritize maintaining trust, which may impact engagement in protective health behaviors.

Physical Frailty Phenotype and the Development of Geriatric Syndromes in Older Adults with Coronary Heart Disease.

BACKGROUND: Frailty, a clinical state of vulnerability, is associated with subsequent adverse geriatric syndromes in the general population. We examined the long-term impact of frailty on geriatric outcomes among older patients with coronary heart disease. METHODS: We used the National Health and Aging Trends Study, a prospective cohort study linked to a Medicare sample. Coronary heart disease was identified by self-report or International Classification of Diseases (ICD) codes 1-year prior to the baseline visit. Frailty was measured using the Fried physical frailty phenotype. Geriatric outcomes were assessed annually during a 6-year follow-up. RESULTS: Of the 4656 participants, 1213 (26%) had a history of coronary heart disease 1-year prior to their baseline visit. Compared to those without frailty, subjects with frailty were older (ages ≥75: 80.9% vs 68.9%, P < 0.001), more likely to be female, and belong to an ethnic minority. The prevalence of hypertension, stroke, falls, disability, anxiety/depression, and multimorbidity were much higher in the frail, than nonfrail, participants. In a discrete time survival model, the incidence of geriatric syndromes during 6-year follow-up including 1) dementia, 2) loss of independence, 3) activities of daily living disability, 4) instrumental activities of daily living disability, and 5) mobility disability were significantly higher in the frail than in the nonfrail older patients with coronary heart disease. CONCLUSION: In patients with coronary heart disease, frailty is a risk factor for the accelerated development of geriatric outcomes. Efforts to identify frailty in the context of coronary heart disease are needed, as well as interventions to limit or reverse frailty status for older patients with coronary heart disease.

Caring for Older Adults With Vision Impairment and Dementia.

BACKGROUND AND OBJECTIVES: Dementia and vision impairment (VI) are common among older adults but little is known about caregiving in this context. RESEARCH DESIGN AND METHODS: We used data from the 2011 National Health and Aging Trends Study, a nationally representative survey of Medicare beneficiaries, linked to their family/unpaid helpers from the National Study of Caregiving. Vision impairment was defined as self-reported blindness or difficulty with distance/near vision. Probable dementia was based on survey report, interviews, and cognitive tests. Our outcomes included hours of care provided, and number of valued activities (scored 0-4) affected by caregiving, per month. RESULTS: Among 1,776 caregivers, 898 (55.1%, weighted) assisted older adults without dementia or VI, 450 (21.9%) with dementia only, 224 (13.0%) with VI only, and 204 (10.0%) with dementia and VI. In fully adjusted negative binomial regression analyses, caregivers of individuals with dementia and VI spent 1.7 times as many hours (95% confidence interval [CI] = 1.4-2.2) providing care than caregivers of those without either impairment; however, caregivers of individuals with dementia only (95% CI = 1.1-1.6) and VI only (95% CI = 1.1-1.6) spent 1.3 times more hours. Additionally, caregivers of individuals with dementia and VI had 3.2 times as many valued activities affected (95% CI = 2.2-4.6), while caregivers of dementia only and VI only reported 1.9 times (95% CI = 1.4-2.6) and 1.3 times (95% CI = 0.9-1.8) more activities affected, respectively. DISCUSSION AND IMPLICATIONS: Our results suggest that caring for older adults with VI involves similar time demands as caring for older adults with dementia, but that participation impacts are greater when caring for older adults with both dementia and VI.

The AgingPLUS trial: Design of a randomized controlled trial to increase physical activity in middle-aged and older adults.

BACKGROUND: Negative views of aging (NVOA), low self-efficacy beliefs, and poor goal planning skills represent risk factors that undermine adults' motivation to engage in physical activity (PA). Targeting these three risk factors may motivate adults to become physically active. OBJECTIVE: To assess the efficacy of AgingPLUS, a 4-week educational program that explicitly targets NVOA, low self-efficacy beliefs, and poor goal planning skills compared to a 4-week health education program. The study also examines the role of NVOA, self-efficacy beliefs, and goal planning as the mechanisms underlying change in PA. DESIGN: This randomized controlled trial (RCT) utilizes the experimental medicine approach to assess change in PA as a function of modifying three risk factors. The RCT recruitment target includes 288 mostly sedentary adults ranging in age from 45 to 75 years. METHODS: Eligible middle-aged and older adults are recruited through community sources. Participants are randomized to either the AgingPLUS or the control group. Participants in both groups are enrolled in the trial for 8 months total, with four assessment points: Baseline (pre-test), Week 4 (immediate post-test), Week 8 (delayed post-test), and Month 6 (long-term follow-up). The intervention takes place over 4 consecutive weeks with 2-h sessions each week. PA engagement is the primary outcome variable. Positive changes in NVOA, self-efficacy beliefs, and goal planning are the intervention targets and hypothesized mediators of increases in PA. SUMMARY: By utilizing a multi-component approach and targeting a cluster of psychological mechanisms, the AgingPLUS program implements the experimental medicine approach to health behavior change.

Clearance of Mycoplasma genitalium and Trichomonas vaginalis Among Adolescents and Young Adults With Pelvic Inflammatory Disease: Results From the Tech-N Study.

Current pelvic inflammatory disease (PID) treatment effectively treats Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). However, coverage may be inadequate for Mycoplasma genitalium (MG)/Trichomonas vaginalis (TV) infections. We compared the longitudinal MG and TV outcomes with NG/CT outcomes for women enrolled in a longitudinal randomized controlled trial to optimize outcomes after PID. The prevalences of CT and NG were lower at 30- and 90-day follow-up compared with the prevalence at the time of diagnosis. No significant difference was observed for MG (odds ratio, 0.95; 0.86-1.04; P = 0.265) and TV (odds ratio, 0.89; 0.75-1.04; P = 0.146) over time for both treatment groups, showing that persistence and/or reinfection with MG and TV occurs more frequently than with CT or NG after treatment of PID using current national treatment guidelines.

Efficacy of a Technology-Enhanced Community Health Nursing Intervention vs Standard of Care for Female Adolescents and Young Adults With Pelvic Inflammatory Disease: A Randomized Clinical Trial.

Importance: Pelvic inflammatory disease (PID) is a common reproductive health disorder that disproportionately affects female adolescents and young adults. Despite data indicating poor adherence and adverse outcomes among those who experience subsequent Neisseria gonorrhoeae and Chlamydia trachomatis infection, few trials have been designed to address this public health need. Objective: To examine the efficacy of a technology-enhanced community health nursing (TECH-N) intervention vs standard of care for improving PID self-management behaviors and 90-day longitudinal prevalence of N gonorrhoeae and C trachomatis infection. Design, Setting, and Participants: This randomized clinical trial of the TECH-N intervention was conducted among female patients 13 to 25 years of age diagnosed with mild to moderate PID who were being discharged to outpatient treatment from September 6, 2012, to December 8, 2016, at a large academic medical center. The final analysis of data was completed in November 2018. This study compared the efficacy of the intervention with that of the standard of care using an intention-to-treat analysis. Interventions: Enrolled participants completed an audio computer-assisted self-interview, provided specimens for N gonorrhoeae and C trachomatis testing, and were randomized to standard treatment (n = 137) or the TECH-N intervention (n = 149). Intervention participants received text-messaging support and a community health nurse visit within 5 days of diagnosis. Change in the prevalence of N gonorrhoeae and C trachomatis infection was estimated with logistic regression. The N gonorrhoeae and C trachomatis positivity rate over time was evaluated using generalized estimating equations. Main Outcomes and Measures: The primary outcome was the prevalence of N gonorrhoeae and C trachomatis infection at 90-day follow-up. The secondary outcome was adherence to the Centers for Disease Control and Prevention recommendations for self-care. Results: A total of 286 patients (mean [SD] age, 18.8 [2.5] years; 268 [93.7%] African American) participated in the study. Although the study groups were demographically similar, the intervention group had a higher baseline rate of C trachomatis infection (45 of 139 [32.4%] vs 25 of 132 [18.9%], P = .01). Although N gonorrhoeae and C trachomatis positivity was not statistically different between groups at 90-day follow-up (6 of 135 [4.4%] vs 13 of 125 [10.4%], P = .07), the differential rate of decrease was significantly higher in the intervention group (48 of 140 [34.4%] to 6 of 135 [4.4%] compared with 34 of 133 [25.6%] to 13 of 112 [10.4%], P = .02). Intervention participants were more likely to receive the Centers for Disease Control and Prevention-recommended short-term follow-up visit compared with the control group (131 of 139 [94.2%] vs 20 of 123 [16.3%], P < .001). Conclusions and Relevance: Adolescent and young adults with PID in the TECH-N intervention were more likely to experience decreases in N gonorrhoeae and C trachomatis positivity compared with the control group and to receive short-term clinical assessment. These findings suggest that the TECH-N intervention should be considered as a potential enhancement of standard of care approaches for management of female adolescents and young adults with mild to moderate PID in urban communities facing significant sexually transmitted infection disparities. Trial Registration: ClinicalTrials.gov identifier: NCT01640379.

Clustered randomized controlled trial of a clinic-based problem-solving intervention to improve adherence in adolescents with cystic fibrosis.

BACKGROUND: In Cystic Fibrosis (CF), adherence to pulmonary medications is about 50% and decreases during adolescence. Effective interventions have not been integrated into CF care. This effectiveness study tested a brief, clinic-based behavioral intervention to improve adherence. METHODS: iCARE (I Change Adherence and Raise Expectations) was a pragmatic, clustered, 2-arm randomized controlled trial at 18 CF Centers. 607 adolescents with CF, ages 11-20 years, participated. Centers were randomized to IMPACT (n = 9; 300 adolescents), a brief problem-solving + education intervention, or standard care (SC; n = 9; 307 adolescents). IMPACT was delivered during a regularly scheduled clinic visit by a member of the clinical care team. The primary outcome was composite pulmonary medication possession ratio (cMPR); secondary endpoints were lung function, Body Mass Index percentile, courses of IV antibiotics, and health-related quality of life at 12 months. RESULTS: Effectiveness of the intervention was tested using mixed models, generalized estimating equations comparing IMPACT to SC. Fifty-eight percent of problem-solving sessions targeted barriers to airway clearance, exercise or nutrition, while 18% addressed pulmonary medications. Average intervention fidelity score was 67% (SD = 14%; Range = 25-100%). No significant intervention effects were found for cMPR or any of the secondary outcomes compared to SC. CONCLUSIONS: The IMPACT intervention did not improve medication adherence or health outcomes over 12 months. Challenges to implementing the intervention as intended during busy clinic visits were identified. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01232478; URL: www.clinicaltrials.gov.

Evaluating the implementation of a multicomponent asthma education program for Head Start staff.

OBJECTIVE: Asthma disproportionately affects minority groups, low income populations, and young children under 5. Head Start (HS) programs predominantly serve this high-risk population, yet staff are not trained on asthma management. The objective of this study was to assess a 5-year, multicomponent HS staff asthma education program in Baltimore City HS programs. METHODS: All HS programs were offered annual staff asthma education by a medical research team that included didactic lectures and hands-on training. Attendees received continuing education credits. HS staff were anonymously surveyed on asthma knowledge and skills and asthma medication management practices in Year 1 (preimplementation) and Year 5. RESULTS: There was an estimated response rate of 94% for Year 1 and 82% for Year 5. Compared to staff in Year 1, Year 5 staff were significantly more likely to report they had very good knowledge and skills related to asthma [odds ratio (OR) 1.63; p < 0.05] and were engaged in asthma care activities (OR 2.02; p < 0.05). Self-reported presence of asthma action plans for all children with asthma was 82% at Year 1 and increased to 89% in Year 5 (p = 0.064). CONCLUSIONS: Year 5 HS staff reported higher self-assessed knowledge and skills, self-reports of asthma medication management practices, and self-reports of asthma activities compared to Year 1 staff. HS serves high-risk children with asthma, and a multicomponent program can adequately prepare staff to manage asthma in the child care setting. Our results indicate the feasibility of providing efficacious health skill education into child care provider training to reduce asthma knowledge gaps.

Relationship Status and Sexual Behaviors in Post-Pelvic Inflammatory Disease (PID) Affected Urban Young Women: A Sub-Study of a Randomized Controlled Trial.

Adolescent and young adult women disproportionately experience Pelvic Inflammatory Disease (PID) as a complication of Sexually Transmitted Infections (STIs). This study seeks to understand the relationship context, changes in sexual behavior, and impact of partner sexual behavior on recurrent STI diagnoses at 3-months post-diagnosis. Adolescents and young adult women 13-25 were recruited from an outpatient disposition from an outpatient clinic, and pediatric and adult emergency rooms. Participants received treatment at baseline and follow-up at 2-weeks, 1-month and 3-month post-diagnosis, including interviews about personal and partner sexual behaviors and STI screening (n = 94). At the 2-week interview, 53% of participants (50/94) believed they could acquire an STI from their current partner if they did not use a condom. However, at 3-month follow-up only 35% reported condom usage at last sex. At 3-month follow-up, 55% (50/91) of participants were still in a sexual relationship with the previously reported partner and 38% of participants who reported they could get an STI from their partner were diagnosed with an STI; compared with 25% of participants who predicted that they could not get an STI (OR 1.85; 95% CI: 0.67-5.30). There was no association between maintaining the same partner and having an STI at 3-months (OR 0.5; 95% CI: 0.27-1.96). Most young women diagnosed with PID report exclusive relationships, but are simultaneously aware of their risk for recurrent STIs. Given the short-term stability of many relationships, couples interventions are an unexplored opportunity for prevention of recurrent STIs after PID.