Black Adolescent Females' Perceptions of PrEP for HIV Risk Reduction.

Preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention is approved for use in adolescents, though uptake remains low. Black adolescent females experience higher rates of HIV transmission compared to adolescent females of other racial/ethnic groups. Increasing PrEP awareness and education among this population may be an effective strategy to mitigate disparities in HIV transmission among Black adolescent females. Twenty-seven Black adolescent females participated in focus groups which were coded using the constant comparative method of qualitative analysis to identify major themes: (1) PrEP is not commonly framed as an HIV prevention strategy for heterosexual Black adolescent females, (2) PrEP use among peers is perceived as mostly positive, (3) Adoption of PrEP among Black adolescent females is impeded by perceived barriers such as stigma, negative side effects, and adherence concerns. These findings may inform the development of targeted culturally tailored marketing and educational campaigns centered on Black heterosexual adolescent females to increase PrEP awareness and uptake in this population disproportionately affected by HIV.

Pilot-testing a Multiplayer HIV and Sexually Transmitted Infection Prevention Video Game Intervention for Black Adolescent Girls: Protocol for a Randomized Controlled Trial.

BACKGROUND: Black adolescent girls aged between 14 and 19 years are more likely than White girls to be diagnosed with a sexually transmitted infection (STI). As STI diagnosis is associated with an increase in the risk for HIV acquisition, an early intervention specifically tailored to Black adolescent girls is warranted. A web-based video game intervention has the potential to reach this demographic. Because studies of social and behavioral determinants of disease demonstrate the protective role of peer group structures on individual outcomes, a multiplayer game can facilitate opportunities to exchange and evaluate information, learn social norms, develop behavioral skills, and allow peers to influence attitudes and behavior. No prior research has examined the feasibility of a web-based multiplayer game intervention for this population. OBJECTIVE: This study describes the protocol for a randomized controlled trial (RCT) pilot-testing the feasibility, acceptability, and limited efficacy of a multiplayer game-based intervention for increasing HIV and STI testing and condom use in Black adolescent girls. METHODS: We enrolled 79 Black adolescent girls aged 14 to 19 years residing in the United States into a 2-arm parallel RCT. The intervention is a theory-based, community-informed, multiplayer game that can be played with peers on the web using videoconferencing software. The goal of the game is to empower Black adolescent girls to make healthy decisions regarding dating, relationships, and sex, thus reducing HIV and STI infection. Control condition participants received a list of resources after playing a time and attention control game. All study procedures were conducted via the internet. We conveniently sampled Black adolescent girls using web-based advertisements. Study assessments occurred at enrollment, 1 week, 1 month, and 4 months after enrollment. The primary outcome of this study is increased HIV and STI testing by Black adolescent girls. Secondary outcomes include increased condom use, self-efficacy to use condoms, positive attitudes toward condom use, intentions, harm perceptions, HIV and STI and pre-exposure prophylaxis knowledge, positive sexual norms, sexual communication with partners, and reduced incidence of sexual risk behaviors associated with HIV and STI transmission. Secondary outcomes also included assessment of intervention feasibility and acceptability. RESULTS: From February to April 2022, a total of 79 Black adolescent girls were enrolled, with 40 (51%) having been randomized into the intervention condition and 39 (49%) into the control condition. At baseline, participant ages ranged from 14 to 19 (mean 16.4, SD 1.23) years. CONCLUSIONS: Web-accessible game interventions overcome common impediments of face-to-face interventions presenting a unique opportunity to reach Black adolescent girls and improve their sexual health and self-efficacy. Trial data will provide information about the limited efficacy of the intervention and inform future web-based studies and a larger RCT aimed at improving the sexual health of Black adolescent girls. TRIAL REGISTRATION: ClinicalTrials.gov NCT04108988; https://clinicaltrials.gov/ct2/show/NCT04108988. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43666.

A Mixed-Methods Analysis of a Special Supplemental Nutrition Program for Women, Infants, and Children and Primary Care Partnership to Promote Responsive Feeding for Infants in Group Well-Child Care.

OBJECTIVE: To evaluate the Healthy Eating through Group Well-Child Care (GWCC) intervention, a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and primary care partnership which seeks to promote responsive feeding practices among low-income caregivers, by examining its impact on infant growth and exploring the experiences of caregivers who participated in this intervention. METHODS: Using a difference-in-differences approach, we examined change in weight-for-length among infants in GWCC before versus after implementation of the intervention compared with infants in individual well-child care (IWCC) over the same time-period. In parallel, we conducted semi-structured interviews in English and Spanish with caregivers who participated in the intervention to explore their perspectives and analyzed transcripts via the constant comparative method to identify salient themes. RESULTS: Using electronic health record data from 279 GWCC and 6134 IWCC participants, we found no significant difference in first-year weight-for-length trajectory associated with participation in the intervention. We reached thematic saturation after 19 interviews with 22 caregivers and identified four major themes around feeding: 1) structural barriers limit access to healthy foods through WIC, 2) conflicting sources of nutrition advice challenge parental decision making, 3) exposure to novel foods facilitated further experimentation with healthier foods, and 4) discussion of responsive feeding facilitated awareness and adoption. CONCLUSIONS: A primary care and WIC partnership to promote responsive feeding in the context of GWCC was well received by caregivers but was not associated with improved weight-for-length among infants. Structural barriers to implementing responsive feeding and healthy eating practices may have impacted lack of measurable results from the intervention.

Rapid Deployment of a Mobile Medical Clinic During the COVID-19 Pandemic: Assessment of Dyadic Maternal-Child Care.

OBJECTIVES: To describe demographic characteristics and health-related social needs of families who accessed maternal-infant care through a mobile medical clinic (MMC) during the COVID-19 pandemic and to explore feasibility, acceptability, perceived benefits, and barriers to care. METHODS: In this mixed-methods observational study, chart reviews, telephone surveys, and qualitative interviews in English and Spanish were conducted with caregivers who accessed the MMC between April and November 2020. Qualitative interviews were analyzed with the constant comparative method alongside descriptive chart and survey data analyses. RESULTS: Of 139 caregiver-infant dyads contacted, 68 (48.9%) completed the survey; 27 also completed the qualitative interview. The survey participants did not differ from the larger sample; most (86.7%) were people of color (52.9% identified as Latino and 33.8% as Black). Health-related social needs were high, including food insecurity (52.9%), diaper insecurity (44.1%), and anxiety (32%). Four women (6.1%) were diagnosed with hypertension requiring urgent evaluation. Nearly all (98.5%) reported being very satisfied with the services. Major themes from qualitative interviews included (1) perceived patient- and family-centered care, (2) perceived safety, and (3) perceived benefits of dyadic mother-infant care. CONCLUSIONS FOR PRACTICE: In this assessment of caregivers who accessed the MMC-a rapidly-developed COVID-19 pandemic response-insights from caregivers, predominantly people of color, provided considerations for future postpartum/postnatal service delivery. Perceptions that the MMC addressed health-related social needs and barriers to traditional office-based visits and the identification of maternal hypertension requiring urgent intervention suggest that innovative models for postpartum mother-infant care may have long-lasting benefits.

Medical Student Patient Outreach to Ensure Continuity of Care During the COVID-19 Pandemic.

Background: In response to the COVID-19 pandemic, the Yale New Haven Health System began rescheduling nonurgent outpatient appointments as virtual visits in March 2020. While Yale New Haven Health expanded its telemedicine infrastructure to accommodate this shift, many appointments were delayed and patients faced considerable uncertainty. Objective: Medical students created the Medical Student Task Force (MSTF) to help ensure continuity of care by calling patients whose appointments were delayed during this transition to telemedicine. Methods: Eighty-five student volunteers called 3765 internal medicine patients with canceled appointments, completing screening for 2197 patients. Volunteers screened for health care needs, assessed preferences for future appointments, and offered emotional support and information about COVID-19. Urgent or emergent patient concerns were triaged and escalated to providers. In this analysis, we used a mixed-methods approach: call information and provider responses were analyzed quantitatively, and patient feedback was analyzed qualitatively via thematic analysis. Results: Ninety-one percent of patients screened found the MSTF calls helpful. Twenty-one percent of patients reported health concerns, with 1% reporting urgent concerns escalated to and addressed by providers. Themes of patient comments included gratitude for outreach and social contact, utility of calls, and well-wishes for health care workers. Conclusions: By calling patients whose appointments had been canceled during a rapid transition to telemedicine, the MSTF helped bridge a potential gap in care by offering patients communication with their care teams, information, and support. We propose that this model could be used in other care systems urgently transitioning to outpatient telemedicine, whether during ongoing outbreaks of COVID-19 or other public health emergencies.

White matter hyperintensities mediate the association of nocturnal blood pressure with cognition.

OBJECTIVE: To test the hypotheses that hypertension and nocturnal blood pressure are related to white matter hyperintensity (WMH) volume, an MRI marker of small vessel cerebrovascular disease, and that WMH burden statistically mediates the association of hypertension and dipping status with memory functioning, we examined the relationship of hypertension and dipping status on WMH volume and neuropsychological test scores in middle-aged and older adults. METHODS: Participants from the community-based Maracaibo Aging Study received ambulatory 24-hour blood pressure monitoring, structural MRI, and neuropsychological assessment. Four hundred thirty-five participants (mean ± SD age 59 ± 13 years, 71% women) with available ambulatory blood pressure, MRI, and neuropsychological data were included in the analyses. Ambulatory blood pressure was used to define hypertension and dipping status (i.e., dipper, nondipper, and reverse dipper based on night/day blood pressure ratio <0.9, 0.9-1, and >1, respectively). Outcome measures included regional WMH and memory functioning derived from a neuropsychological test battery. RESULTS: The majority of the participants (59%) were hypertensive. Ten percent were reverse dippers, and 40% were nondippers. Reverse dipping in the presence of hypertension was associated with particularly elevated periventricular WMH volume (F 2,423 = 3.78, p = 0.024) and with lowered memory scores (F 2,423 = 3.911, p = 0.021). Periventricular WMH volume mediated the effect of dipping status and hypertension on memory (ß = -4.1, 95% confidence interval -8.7 to -0.2, p < 0.05). CONCLUSION: Reverse dipping in the presence of hypertension is associated with small vessel cerebrovascular disease, which, in turn, mediates memory functioning. These results point toward reverse dipping as a marker of poor nocturnal blood pressure control, particularly among hypertensive individuals, with potentially pernicious effects on cerebrovascular health and associated cognitive function.

Tract-defined regional white matter hyperintensities and memory.

White matter hyperintensities (WMH) are common radiological findings among older adults and strong predictors of age-related cognitive decline. Recent work has implicated WMH in the pathogenesis and symptom presentation of Alzheimer's disease (AD), which is characterized clinically primarily by a deficit in memory. The severity of WMH volume is typically quantified globally or by lobe, whereas white matter itself is organized by tracts and fiber classes. We derived WMH volumes within white matter tract classes, including association, projection, and commissural tracts, in 519 older adults and tested whether WMH volume within specific fiber classes is related to memory performance. We found that increased association and projection tract defined WMH volumes were related to worse memory function but not to a global cognition summary score that excluded memory. We conclude that macrostructural damage to association and projection tracts, manifesting as WMH, may result in memory decline among older adults.

The ModRey: An Episodic Memory Test for Nonclinical and Preclinical Populations.

List learning tests are used in practice for diagnosis and in research to characterize episodic memory, but often suffer from ceiling effects in unimpaired individuals. We developed the Modified Rey Auditory Verbal Learning Test, or ModRey, an episodic memory test for use in normal and preclinical populations. We administered the ModRey to 230 healthy adults and to 86 of the same individuals 102 days later and examined psychometric properties and effects of demographic factors. Primary measures were normally distributed without evidence of ceiling effect. Differences between alternate forms were of very small magnitude and not significant. Test-retest reliability was good. Higher participant age and lower participant education was associated with poorer performance across most outcome measures. We conclude that the ModRey is appropriate for episodic memory characterization in normal populations and could be used as an outcome measure in studies involving preclinical populations.

Letter and Category Fluency Performance Correlates with Distinct Patterns of Cortical Thickness in Older Adults.

Verbal fluency tasks are generally thought to be mediated by frontal brain regions for letter fluency and temporal regions for category fluency. This idea, however, is primarily based on lesion studies and adapted versions of the fluency tasks in functional neuroimaging, without fundamental evidence from structural neuroimaging in healthy individuals. We investigated the cortical structural correlates of letter and category fluency, including overlapping and different regions, in 505 individuals who participated in a community-based study of healthy aging. The correlation between cortical thickness and verbal fluency in whole-brain analyses revealed distinct cortical signatures for letter fluency, primarily in frontal regions, and category fluency, in frontal and temporal-parietal regions. There was a dissociation in the left inferior frontal gyrus between letter and category fluency, with increased thickness in the posterior-dorsal versus anterior-ventral parts, respectively. These results distinguish the detailed anatomical correlates for verbal fluency within the coarse frontal-temporal distinction inferred from lesion studies and among the mixture of regions identified in functional neuroimaging. The evidence for the anatomical substrates of letter and category fluency, each recruiting slightly different language and cognitive processes, can serve both clinical applications as well as a deeper theoretical understanding of the organization of the cerebral cortex.

Cerebrovascular Disease and Neurodegeneration in Alzheimer's Disease with and without a Strong Family History: A Pilot Magnetic Resonance Imaging Study in Dominican Republic.

The incidence and prevalence of Alzheimer's disease (AD) dementia are higher among Caribbean Hispanics than among non-Hispanic Whites. The causes of this health disparity remain elusive, partially because of the relative limited capacity for biomedical research in the developing countries that comprise Caribbean Latin America. To begin to address this issue, we were awarded a Development Research Award from the US NIH and Fogarty International Center in order to establish the local capacity to integrate magnetic resonance imaging (MRI) into studies of cognitive aging and dementia in Dominican Republic, establish collaborations with Dominican investigators, and conduct a pilot study on the role of cerebrovascular markers in the clinical expression of AD. Ninety older adult participants with and without AD dementia and with and without a strong family history of AD dementia received MRI scans and clinical evaluation. We quantified markers of cerebrovascular disease (white matter hyperintensities [WMH], presence of infarct, and presence of microbleed) and neurodegeneration (entorhinal cortex volume) and compared them across groups. Patients with AD dementia had smaller entorhinal cortex and greater WMH volumes compared with controls, regardless of family history status. This study provides evidence for the capacity to conduct MRI studies of cognitive aging and dementia in Dominican Republic. The results are consistent with the hypothesis that small vessel cerebrovascular disease represents a core feature of AD dementia, as affected participants had elevated WMH volumes irrespective of family history status.

The effect of white matter hyperintensities on cognition is mediated by cortical atrophy.

White matter hyperintensities (WMH) have been linked to cognitive dysfunction and dementia, although the reasons are unclear. One possibility is that WMH promote neurodegeneration, which, in turn, affects cognition. We examined whether cortical thickness, a marker of neurodegeneration, mediates the relationship between WMH and cognition among 519 older adults. Using conditional process analysis modeling techniques, we examined the association between WMH volume and global cognition and tested whether cortical thickness mediates this relationship statistically. We also tested specific regional hypotheses to determine whether cortical thickness or volume in the medial temporal lobe mediates the relationship between WMH volume and memory. Increased total WMH volume was associated with poorer global cognition and memory. Global cortical thickness and medial temporal lobe thickness/volume mediated the relationship of WMH volume on global cognition and memory functioning. The mediating relationship was similar across racial and ethnic groups and across diagnostic groups (i.e., mild cognitive impairment/Alzheimer's disease). The findings suggest that WMH promote atrophy, which, in turn, drives cognitive decline and highlight a potential pathway in which small vessel cerebrovascular disease affects cognition by promoting neurodegenerative changes directly.