Neuroticism/negative emotionality is associated with increased reactivity to uncertain threat in the bed nucleus of the stria terminalis, not the amygdala.

Neuroticism/Negative Emotionality (N/NE)-the tendency to experience anxiety, fear, and other negative emotions-is a fundamental dimension of temperament with profound consequences for health, wealth, and wellbeing. Elevated N/NE is associated with a panoply of adverse outcomes, from reduced socioeconomic attainment and divorce to mental illness and premature death. Work in animals suggests that N/NE reflects heightened reactivity to uncertain threat in the bed nucleus of the stria terminalis (BST) and central nucleus of the amygdala (Ce), but the relevance of these discoveries to the human brain and temperament have remained unclear. Here we used a combination of psychometric, psychophysiological, and neuroimaging approaches to rigorously test this hypothesis in an ethnoracially diverse sample of 220 emerging adults selectively recruited to encompass a broad spectrum of N/NE. Cross-validated robust-regression analyses demonstrated that N/NE is selectively associated with heightened BST activation during the uncertain anticipation of a genuinely distressing threat. In contrast, N/NE was unrelated to BST activation during certain-threat anticipation, Ce activation during either type of threat anticipation, or BST/Ce reactivity to 'threat-related' faces. Implicit in much of the neuroimaging literature is the assumption that different threat paradigms are statistically interchangeable probes of individual differences in neural function, yet our results revealed negligible evidence of convergence between popular threat-anticipation and emotional-face tasks. These observations provide a framework for conceptualizing emotional traits and disorders; for guiding the design and interpretation of biobank and other neuroimaging studies of psychiatric risk, disease, and treatment; and for informing the next generation of mechanistic research. SIGNIFICANCE STATEMENT: Neuroticism/Negative Emotionality (N/NE) is a core dimension of mammalian temperament. Elevated levels of N/NE confer risk for a panoply of adversities-from reduced wealth and divorce to depression and death-yet the underlying neurobiology remains unclear. Here we show that N/NE is associated with heightened activation in the bed nucleus of the stria terminalis (BST) during the uncertain anticipation of a genuinely distressing threat. In contrast, N/NE was unrelated to BST reactivity during the certain anticipation of threat or the acute presentation of 'threat-related' face photographs, two popular probes of the emotional brain. These findings refine our understanding of what has been termed the single most important psychological risk factor in public health, with implications for on-going biobank research.

Real-World Outcomes of Trilaciclib Among Patients with Extensive-Stage Small Cell Lung Cancer Receiving Chemotherapy.

INTRODUCTION: Trilaciclib was recently approved in the USA for reducing chemotherapy-induced myelosuppression (CIM) among adults with extensive-stage small cell lung cancer (ES-SCLC) when administered prior to chemotherapy. There is limited understanding of real-world outcomes of trilaciclib. METHODS: A comprehensive literature review was conducted using a keyword search in the MEDLINE, Embase, and conference abstracts. Additional studies were identified through communications with the authors of relevant studies. Published and unpublished real-world studies of trilaciclib- and comparable non-trilaciclib-treated patients with ES-SCLC were included. Evidence on myelosuppressive hematologic adverse events (HAEs), cytopenia-related healthcare utilization, and other reported outcomes (e.g., hospitalizations, dose reduction, and treatment delay) were synthesized. If feasible, outcomes were compared qualitatively between the trilaciclib and historical reference groups, and between first-line trilaciclib initiators and the overall trilaciclib population. Weighted averages were estimated for selected outcomes using sample size as the weight. RESULTS: The literature search identified five unique studies based on eight records-two included trilaciclib only, two non-trilaciclib only, and one both. In trilaciclib cohorts, the weighted average prevalence of grade ≥ 3 myelosuppressive HAEs in ≥ 1 lineage, ≥ 2 lineages, and all three lineages was 40.5%, 14.5%, and 7.5%, respectively. All rates were numerically lower compared to the historical non-trilaciclib cohorts (58.8%, 28.0%, 13.0% respectively). Cytopenia-related healthcare utilization was also lower in the trilaciclib cohorts. In general, first-line trilaciclib initiators had numerically lower myelosuppressive HAEs and cytopenia-related healthcare utilization than the overall trilaciclib patients. CONCLUSIONS: The existing evidence suggests that trilaciclib may reduce single and multilineage grade ≥ 3 myelosuppressive HAEs and cytopenia-related healthcare utilization among patients with ES-SCLC in the real world. It is a promising new treatment for CIM prevention in ES-SCLC and may bring greater benefits to first-line trilaciclib initiators. Future studies are recommended to further evaluate the real-world effectiveness of trilaciclib.

Acute nicotine abstinence amplifies subjective withdrawal symptoms and threat-evoked fear and anxiety, but not extended amygdala reactivity.

Tobacco smoking imposes a staggering burden on public health, underscoring the urgency of developing a deeper understanding of the processes that maintain addiction. Clinical and experience-sampling data highlight the importance of anxious withdrawal symptoms, but the underlying neurobiology has remained elusive. Mechanistic work in animals implicates the central extended amygdala (EAc)-including the central nucleus of the amygdala and the neighboring bed nucleus of the stria terminalis-but the translational relevance of these discoveries remains unexplored. Here we leveraged a randomized trial design, well-established threat-anticipation paradigm, and multidimensional battery of assessments to understand the consequences of 24-hour nicotine abstinence. The threat-anticipation paradigm had the expected consequences, amplifying subjective distress and arousal, and recruiting the canonical threat-anticipation network. Abstinence increased smoking urges and withdrawal symptoms, and potentiated threat-evoked distress, but had negligible consequences for EAc threat reactivity, raising questions about the translational relevance of prominent animal and human models of addiction. These observations provide a framework for conceptualizing nicotine abstinence and withdrawal, with implications for basic, translational, and clinical science.

Real-World Biomarker Testing Patterns in Patients With Metastatic Non-Squamous Non-Small Cell Lung Cancer (NSCLC) in a US Community-Based Oncology Practice Setting.

INTRODUCTION/BACKGROUND: This study was designed to describe real-world changes in biomarker testing among patients with non-squamous, metastatic non-small cell lung cancer (mNSCLC) in a community oncology setting from 2015 to 2020. PATIENTS AND METHODS: This retrospective study randomly selected 500 adult patients diagnosed with nonsquamous mNSCLC to undergo chart review and data extraction. Data were extracted and validated by 2 independent abstractors. Biomarker testing rates were described before and after national guideline updates and FDA approval of targeted agents. RESULTS: At least 1 biomarker test was received by 89.4% of patients with mNSCLC. Of all patients, 46.6%, 34.6%, and 8.2% received both single-gene and next generation sequencing (NGS)-based testing, single-gene testing only, and NGS-based testing only, respectively. However, there were changes in testing rates at the time of drug approvals for targeted agents. Biomarker testing increased for ALK (45.0% before to 78.3% after ALK-targeted drug approval), BRAF (from 20.0% to 67.8%), EGFR (from 20.0% to 78.2%), NTRK (from 34.6% to 55.7%), and ROS1 (increased from 29.6% before approval to 74.2% after). Biomarker testing increased after changes were made to national guidelines for BRAF (from 18.8% before to 68.1% after inclusion in guidelines), NTRK (from 37.2% to 56.5%), and ROS1 (increased from 40.8% to 74.5% after guideline updates). Targeted therapy was received by 62.4% of patients with a positive biomarker. CONCLUSION: Increases in biomarker testing rates were observed relative to targeted agent approvals and national guideline updates. However, many patients with non-squamous mNSCLC did not receive full genotyping in accordance with national guidelines and represent an opportunity to identify reasons and solutions for barriers to care.

Burden of chemotherapy-induced myelosuppression among patients with extensive-stage small cell lung cancer: A retrospective study from community oncology practices.

BACKGROUND: Myelosuppression is a major dose-limiting complication of chemotherapy for patients with extensive-stage small cell lung cancer (ES-SCLC). The objective was to describe the burden of myelosuppression, treatment patterns, and supportive care use among patients with ES-SCLC treated with chemotherapy in a US community oncology setting. METHODS: This retrospective cohort study used structured electronic medical record (EMR) data from the Florida Cancer Specialists & Research Institute between January 2013 and December 2020. Adult patients with ES-SCLC who were treated with chemotherapy between September 2013 and November 2020 were identified. The index date was the date of the first chemotherapy-containing line of therapy (LOT). Patients were followed for a minimum of 30 days after index (unless patient died) until December 31, 2020, or end of activity in the EMR data, whichever occurred first. Incidence and frequency of myelosuppressive episodes/events, treatment patterns, eligibility for red blood cell (RBC) or platelet transfusions, and supportive care use (granulocyte colony-stimulating factor [G-CSF], erythropoiesis-stimulating agents [ESAs], intravenous [IV] hydration) during the follow-up period were reported. RESULTS: The study population included 1239 patients. Most (94.0%) patients started first-line chemotherapy at index. During follow-up and across all chemotherapy-containing LOTs, 1222 (98.6%) patients had at least 1 myelosuppressive episode; 62.1% of patients had grade ≥ 3 myelosuppressive episodes in at least one lineage, 33.9% had grade ≥ 3 myelosuppressive episodes in at least two lineages, and 15.5% had grade ≥ 3 myelosuppressive episodes in all three lineages. Supportive care use included 89.7% of patients who received G-CSF, 24.4% who received ESAs, and 52.1% who received IV volume expansion. Almost one-third (32.6%) of patients were eligible to receive RBC transfusions based on lab values (hemoglobin < 8 g/dL). CONCLUSION: There is a high burden related to multilineage myelosuppression among chemotherapy-treated patients with ES-SCLC in the community oncology setting. Reducing myelosuppression could make chemotherapy treatment safer, reduce the need for supportive care, and potentially prevent the treatment of complications.

Structural Brain Correlates of Childhood Inhibited Temperament: An ENIGMA-Anxiety Mega-analysis.

Temperament involves stable behavioral and emotional tendencies that differ between individuals, which can be first observed in infancy or early childhood and relate to behavior in many contexts and over many years.1 One of the most rigorously characterized temperament classifications relates to the tendency of individuals to avoid the unfamiliar and to withdraw from unfamiliar people, objects, and unexpected events. This temperament is referred to as behavioral inhibition or inhibited temperament (IT).2 IT is a moderately heritable trait1 that can be measured in multiple species.3 In humans, levels of IT can be quantified from the first year of life through direct behavioral observations or reports by caregivers or teachers. Similar approaches as well as self-report questionnaires on current and/or retrospective levels of IT1 can be used later in life.

Anxiety-Related Frontocortical Activity Is Associated With Dampened Stressor Reactivity in the Real World.

Negative affect is a fundamental dimension of human emotion. When extreme, it contributes to a variety of adverse outcomes, from physical and mental illness to divorce and premature death. Mechanistic work in animals and neuroimaging research in humans and monkeys have begun to reveal the broad contours of the neural circuits governing negative affect, but the relevance of these discoveries to everyday distress remains incompletely understood. Here, we used a combination of approaches-including neuroimaging assays of threat anticipation and emotional-face perception and more than 10,000 momentary assessments of emotional experience-to demonstrate that individuals who showed greater activation in a cingulo-opercular circuit during an anxiety-eliciting laboratory paradigm experienced lower levels of stressor-dependent distress in their daily lives (ns = 202-208 university students). Extended amygdala activation was not significantly related to momentary negative affect. These observations provide a framework for understanding the neurobiology of negative affect in the laboratory and in the real world.

Training the Next Generation of Clinical Psychological Scientists: A Data-Driven Call to Action.

The central goal of clinical psychology is to reduce the suffering caused by mental health conditions. Anxiety, mood, psychosis, substance use, personality, and other mental disorders impose an immense burden on global public health and the economy. Tackling this burden will require the development and dissemination of intervention strategies that are more effective, sustainable, and equitable. Clinical psychology is uniquely poised to serve as a transdisciplinary hub for this work. But rising to this challengerequires an honest reckoning with the strengths and weaknesses of current training practices. Building on new data, we identify the most important challenges to training the next generation of clinical scientists. We provide specific recommendations for the full spectrum of stakeholders-from funders, accreditors, and universities to program directors, faculty, and students-with an emphasis on sustainable solutions that promote scientific rigor and discovery and enhance the mental health of clinical scientists and the public alike.

Adherence to fecal immunochemical test screening among adults at average risk for colorectal cancer.

PURPOSE: This study examined adherence to screening for fecal immunochemical test (FIT). METHODS: Adults (≥ 50-75) with a FIT between 1/1/2014 and 6/30/2019 in MarketScan administrative claims were selected (index = earliest FIT). Patients were followed for 10 years pre- and 3 years post-index. Patients at increased risk for CRC or with prior screening were excluded. Year over year adherence was measured post-index. RESULTS: Of 10,253 patients, the proportion adherent to repeat testing at year 2 was 23.4% and 10.6% at year 3. Of 76.6% not adherent in year 2, 5.4% were adherent in year 3. CONCLUSION: Results suggest adherence to FIT tests is poor, minimizing potential benefits. Future studies are needed to consider alternative test options and whether more choice will improve long-term adherence.

Anxiety and the Neurobiology of Temporally Uncertain Threat Anticipation.

When extreme, anxiety-a state of distress and arousal prototypically evoked by uncertain danger-can be debilitating. Uncertain anticipation is a shared feature of situations that elicit signs and symptoms of anxiety across psychiatric disorders, species, and assays. Despite the profound significance of anxiety for human health and wellbeing, the neurobiology of uncertain-threat anticipation remains unsettled. Leveraging a paradigm adapted from animal research and optimized for fMRI signal decomposition, we examined the neural circuits engaged during the anticipation of temporally uncertain and certain threat in 99 men and women. Results revealed that the neural systems recruited by uncertain and certain threat anticipation are anatomically colocalized in frontocortical regions, extended amygdala, and periaqueductal gray. Comparison of the threat conditions demonstrated that this circuitry can be fractionated, with frontocortical regions showing relatively stronger engagement during the anticipation of uncertain threat, and the extended amygdala showing the reverse pattern. Although there is widespread agreement that the bed nucleus of the stria terminalis and dorsal amygdala-the two major subdivisions of the extended amygdala-play a critical role in orchestrating adaptive responses to potential danger, their precise contributions to human anxiety have remained contentious. Follow-up analyses demonstrated that these regions show statistically indistinguishable responses to temporally uncertain and certain threat anticipation. These observations provide a framework for conceptualizing anxiety and fear, for understanding the functional neuroanatomy of threat anticipation in humans, and for accelerating the development of more effective intervention strategies for pathological anxiety.SIGNIFICANCE STATEMENT Anxiety-an emotion prototypically associated with the anticipation of uncertain harm-has profound significance for public health, yet the underlying neurobiology remains unclear. Leveraging a novel neuroimaging paradigm in a relatively large sample, we identify a core circuit responsive to both uncertain and certain threat anticipation, and show that this circuitry can be fractionated into subdivisions with a bias for one kind of threat or the other. The extended amygdala occupies center stage in neuropsychiatric models of anxiety, but its functional architecture has remained contentious. Here we demonstrate that its major subdivisions show statistically indistinguishable responses to temporally uncertain and certain threat. Collectively, these observations indicate the need to revise how we think about the neurobiology of anxiety and fear.

Treatment patterns, healthcare resource utilization, and costs among patients with idiopathic pulmonary fibrosis treated with antifibrotic medications in US-based commercial and Medicare Supplemental claims databases: a retrospective cohort study.

BACKGROUND: Pirfenidone and nintedanib are antifibrotic therapies which slow disease progression in idiopathic pulmonary fibrosis (IPF), an irreversible, progressive lung disease with poor prognosis. We compared adherence, persistence, and healthcare costs between patients initiating one of the two therapies. METHODS: We used the IBM Watson Health Commercial and Medicare Supplemental claims databases to select patients with IPF with ≥1 pharmacy claim for pirfenidone or nintedanib between 10/1/2014 and 6/30/2018. Adherence (proportion of days covered ≥0.80) and persistence (time to a gap of ≥60 days without medication or switch to the other antifibrotic medication) based on the days' supply and service date fields on claims were measured over a variable-length follow-up period. Healthcare costs, all-cause and respiratory-related, were measured over the persistent period and a fixed 12-month follow-up period. Inverse probability of treatment weights were applied to models comparing adherence, persistence, and costs between the two cohorts. RESULTS: Overall, 799 pirfenidone patients and 656 nintedanib patients were identified. Similar proportions of patients were adherent in both cohorts (pirfenidone = 49% vs. nintedanib = 51%) and there was no significant difference in the odds of being adherent after weighting (odds ratio = 1.1, p = 0.513). The proportions of patients who discontinued/switched were also similar (pirfenidone = 41% vs. nintedanib 43%); however, in a weighted model, the hazards of discontinuation/switching was lower for the pirfenidone cohort (hazard ratio = 0.8, p = 0.032). While patients were persistent on therapy, weighted all-cause healthcare costs were comparable (pirfenidone = $11,272 vs. nintedanib = $11,987 per-patient per-month; p = 0.115), but weighted respiratory-related costs were significantly lower for the pirfenidone cohort ($9015 vs. $10,167 per-patient per-month, p < 0.001). Weighted annual total all-cause and respiratory-related healthcare costs were comparable between cohorts over the fixed 12-month follow-up period, but the pirfenidone cohort had significantly lower weighted annual mean antifibrotic drug costs than the nintedanib cohort ($68,850 vs. $77,033, p = 0.007). CONCLUSIONS: Pirfenidone use was associated with longer time to discontinuation/switch, lower antifibrotic drug costs, and lower respiratory-related total costs compared to nintedanib use.

Treatment Patterns and Costs in Biologic DMARD-Naive Patients with Rheumatoid Arthritis Initiating Etanercept or Adalimumab with or Without Methotrexate.

BACKGROUND: Etanercept (ETN) and adalimumab (ADA) are tumor necrosis factor inhibitors indicated for treatment of moderate to severe rheumatoid arthritis (RA) and are used as monotherapy or in combination with conventional disease-modifying antirheumatic drugs (DMARDs) such as methotrexate (MTX). Data on treatment patterns and costs of ETN and ADA as monotherapies or in combination therapy with MTX are lacking in biologic DMARD (bDMARD)-naive patients with RA. OBJECTIVE: To evaluate treatment patterns and costs of ETN and ADA monotherapy and combination therapy in bDMARD-naive patients with RA. METHODS: Data from adult bDMARD-naive patients with RA were evaluated according to index therapy (ADA or ETN as monotherapy or combination therapy with MTX) in a retrospective cohort study using the IBM MarketScan Commercial Claims and Encounters and Medicare Supplemental Databases from January 1, 2010, to June 30, 2017. Participants were bDMARD-naive for ≥ 12 months before initial ETN or ADA pharmacy claim (index date) and had continuous enrollment for ≥ 12 months pre-index and 24 months post-index. Combination therapy cohorts had an MTX claim within 30 days of the index date. Outcomes included persistence (no treatment changes or gap [≥ 60 days]); modifications to index therapy (discontinuation or switching without prior gap, restarting as switch or restart after gap, or MTX initiation/discontinuation); and mean total bDMARD costs for 2 years post-index. RESULTS: Patients on ETN monotherapy (n = 2,064) had higher persistence (26.8% vs. 21.1%, respectively; P < 0.001) on index treatment and received treatment for a longer duration (mean 375.9 days vs. 339.7 days, respectively; P < 0.001) than those on ADA monotherapy (n = 1,528). Regimen changes were more common in patients on ADA monotherapy than patients on ETN monotherapy (38.0% vs. 33.4%, respectively; P = 0.004). More patients on ADA monotherapy added MTX than those on ETN (17.5% vs. 12.6%, respectively; P < 0.001). Overall, 790 patients receiving index monotherapy had a regimen change following a gap (≥ 60 days), with a similar proportion between cohorts. Among these patients, 13.8% restarted index therapy, and 7.9% switched from index therapy. Significantly more patients receiving ETN monotherapy restarted their index regimen after a gap than those receiving ADA monotherapy (14.9% vs. 12.2%, respectively; P = 0.023). The proportion of patients persistent on combination therapy was similar between the ETN and ADA combination therapy cohorts (21.9% vs. 22.2%, respectively; P = 0.818). Treatment pattern rates were similar regardless of index combination therapy. Overall, costs for ADA were consistently higher within the index regimen throughout the follow-up period irrespective of MTX. CONCLUSIONS: ETN monotherapy as first-line treatment was associated with higher persistence, lower rate of MTX supplementation, and lower bDMARD costs than ADA monotherapy. ETN monotherapy may represent a less costly option for achieving treatment targets in bDMARD-naive patients with RA. DISCLOSURES: This study was sponsored by Amgen. Tkacz, Henderson DeYoung, and Wilson are employees of IBM Watson Health, which received funding from Amgen for this study. Collier and Oko-osi are employees and shareholders of Amgen. Gharaibeh was an employee of Amgen at the time of study execution and manuscript drafting. Data pertaining to this study were presented in a poster at AMCP Nexus 2018; October 25-28, 2018; Orlando, FL.

Social context and the real-world consequences of social anxiety.

BACKGROUND: Social anxiety lies on a continuum, and young adults with elevated symptoms are at risk for developing a range of psychiatric disorders. Yet relatively little is known about the factors that govern the hour-by-hour experience and expression of social anxiety in the real world. METHODS: Here we used smartphone-based ecological momentary assessment (EMA) to intensively sample emotional experience across different social contexts in the daily lives of 228 young adults selectively recruited to represent a broad spectrum of social anxiety symptoms. RESULTS: Leveraging data from over 11 000 real-world assessments, our results highlight the central role of close friends, family members, and romantic partners. The presence of such close companions was associated with enhanced mood, yet socially anxious individuals had fewer confidants and spent less time with the close companions that they do have. Although higher levels of social anxiety were associated with a general worsening of mood, socially anxious individuals appear to derive larger benefits - lower levels of negative affect, anxiety, and depression - from their close companions. In contrast, variation in social anxiety was unrelated to the amount of time spent with strangers, co-workers, and acquaintances; and we uncovered no evidence of emotional hypersensitivity to these less-familiar individuals. CONCLUSIONS: These findings provide a framework for understanding the deleterious consequences of social anxiety in emerging adulthood and set the stage for developing improved intervention strategies.

Validation of a Syndromic Case Definition for Detecting Emergency Department Visits Potentially Related to Marijuana.

OBJECTIVES: Reliable methods are needed to monitor the public health impact of changing laws and perceptions about marijuana. Structured and free-text emergency department (ED) visit data offer an opportunity to monitor the impact of these changes in near-real time. Our objectives were to (1) generate and validate a syndromic case definition for ED visits potentially related to marijuana and (2) describe a method for doing so that was less resource intensive than traditional methods. METHODS: We developed a syndromic case definition for ED visits potentially related to marijuana, applied it to BioSense 2.0 data from 15 hospitals in the Denver, Colorado, metropolitan area for the period September through October 2015, and manually reviewed each case to determine true positives and false positives. We used the number of visits identified by and the positive predictive value (PPV) for each search term and field to refine the definition for the second round of validation on data from February through March 2016. RESULTS: Of 126 646 ED visits during the first period, terms in 524 ED visit records matched ≥1 search term in the initial case definition (PPV, 92.7%). Of 140 932 ED visits during the second period, terms in 698 ED visit records matched ≥1 search term in the revised case definition (PPV, 95.7%). After another revision, the final case definition contained 6 keywords for marijuana or derivatives and 5 diagnosis codes for cannabis use, abuse, dependence, poisoning, and lung disease. CONCLUSIONS: Our syndromic case definition and validation method for ED visits potentially related to marijuana could be used by other public health jurisdictions to monitor local trends and for other emerging concerns.

Using Spatial Analysis to Inform Community Immunization Strategies.

INTRODUCTION: Recent pertussis outbreaks in the United States suggest our response to local disease outbreaks (eg, vaccine-preventable Bordetella pertussis) may benefit from understanding and applying spatial analytical methods that use data from immunization information systems at a subcounty level. METHODS: A 2012 study on Denver, CO, residents less than 19 years of age confirmed pertussis cases and immunization information system records were geocoded and aggregated to the census tract (CT) level. An algorithm assessed whether individuals were up-to-date (UTD) for pertussis vaccines. Pearson, Spearman, and Kendall correlations assessed relations between disease incidence and pertussis vaccine coverage. Using spatial analysis software, disease incidence and UTD rates were spatially weighted, and smoothed. Global and local autocorrelations based on univariate Moran's I spatial autocorrelation statistics evaluated whether a CT's rate belong to a cluster based on incidence or UTD measures. RESULTS: Overall disease incidence rate was 116.8/100 000. Assessment of pertussis vaccination coverage was available for 90% of the population. Among 134 672 Denver residents less than 19 years old, 103 496 (77%) were UTD for pertussis vaccines. Raw correlation coefficients showed weak relationships between incidence and immunization rates due to the presence of outliers. With geospatial and clustering analysis, estimates and correlation coefficients were improved with statistically significant Moran's I values for global and local autocorrelations rejecting the null hypothesis that incidence or UTD rates were randomly distributed. With evidence indicating the presence of clusters, smoothed and weighted disease incidence and UTD rates in 144 CTs identified 21 CTs (15%) for potential public health intervention. CONCLUSIONS: Correlation of raw disease incidence and vaccine UTD rates in subcounty regions showed limited association, providing limited information for decision making. By assessing for clusters using spatial analysis methods, we identified CTs with higher incidence and lower immunization coverage for targeted public health interventions.

Perspectives of Suicide Bereaved Individuals on Military Suicide Decedents' Life Stressors and Male Gender Role Stress.

The objective of this study was to pilot the newly developed Male Gender Role Stressor Inventory (MGRSI) in military suicide bereaved (i.e., decedents' family members and significant others) and to determine the association between Male Gender Role Stress (MGRS) and other life stressors observed by survivors. Sixty-five survivors attending a national survivor seminar completed original surveys, reporting demographic information about themselves and the decedent and observations of the decedent's life stressors during the 1-month and 1-year periods prior to death. The MGRSI obtained acceptable internal reliability (α = .76) and indicated that factors including honor, strength, and achievement were the most commonly reported sources of MGRS. Correlational and regression analyses revealed that legal- and trauma-related stressors 1 month prior to suicide were significantly associated with MGRSI score. MGRS may contribute to a better understanding of military male suicide. The Department of Defense and the Veterans Administration may benefit from suicide prevention programs targeting rigid male gender role beliefs and male-specific stressors.

Principal Component Analysis of the Suicide Opinion Questionnaire in a U.S. Military Sample of Marine Corps Non-Commissioned Officers.

Attitudes about suicide are important to examine among individuals within a specific setting, profession, and/or culture; if found to be condemnatory, such attitudes can be effectively modified with training. The Suicide Opinion Questionnaire (SOQ) is one of the most commonly used instruments for the measurement of attitudes toward suicide. The SOQ has not been tested in military populations and the measure has demonstrated multiple different factor structures across various studies performed on civilian samples. The purpose of this study was twofold: (1) to gain an understanding of the applicability and utility of the SOQ for the military; and (2) to examine the relationship among sex, education, prior exposure to suicide within one's military unit, and suicide opinions. A total of 1,758 Marine Non-Commissioned Officers (NCOs) completed the SOQ as part of a suicide program evaluation study. Results demonstrated a 4-component structure for the SOQ, accounting for approximately 30% of the total variance. Sex, education, and prior exposure to suicide within one's military unit were significantly related to suicide opinions. Recommendations are made for the development and empirical evaluation of a new and/or adapted, culturally sensitive suicide attitude measure for the military.

Perceived barriers to seeking mental health care among United States Marine Corps noncommissioned officers serving as gatekeepers for suicide prevention.

Reducing mental health stigma and perceived barriers to care is a necessary strategy for addressing the public health problem of suicide among the United States Armed Forces. The purpose of this study was threefold: (a) to empirically evaluate the principal component structure of the Perceived Barriers to Care (PBTC) measure; (b) to gain an understanding of the perceived barriers to seeking mental health services among Marine Corps noncommissioned officers (NCOs) selected to participate in a primary suicide prevention training program, Never Leave a Marine Behind (NLMB); and (c) to explore the relationship among sex, education, prior exposure to suicide within one's military unit, and perceived barriers to seeking mental health services. The data for the PBTC (N = 1,758) were drawn from a previously performed pretest/posttest program evaluation study of the Marine Corp's NLMB program, which took place over 6 months in 2009 (April-October). The three highest perceptions of barriers to care reported by NCOs for their Marines were related to being embarrassed, having members of one's unit have less confidence in the Marine, and concerns about being treated differently by military unit leadership. Three principal components for PBTC were identified, accounting for approximately 59% of the total variance. Higher education and prior exposure to suicide within one's military unit significantly correlated with greater perceived barriers to care; sex was not significantly correlated with greater perceived barriers to care. Implications of these findings, in relation to future research, are further discussed. (PsycINFO Database Record

Evaluation of the National HIV Behavioral Surveillance System among men who have sex with men in Denver, Colorado.

Denver Public Health implements the National HIV Behavioral Surveillance System (NHBS), a cyclical survey of populations at increased risk for HIV. We evaluated the implementation of NHBS among Denver men who have sex with men (MSM), considering the system's simplicity, data quality, representativeness, and sensitivity to trends. We found that the time required for implementation and the complexity of data management and analysis are barriers to disseminating local findings. Data quality has improved in each cycle of the study but must be protected by continually checking for errors and training field staff to be attentive to detail. Compared with the US census and other convenience samples of Denver MSM, the overall demographic representativeness of NHBS has improved over time. However, there is concern that the underlying population included in the study may be changing. NHBS survey data show evidence of two suspected trends in the local MSM population at risk for HIV: increasing sexual risk-taking and the transition away from bars as a dominant partner-finding location. It is unclear whether the increasing reports of sexual risk-taking reflect a real trend or simply a change in the population sampled, since most NHBS participants are recruited at gay bars and other venues. To ensure that the sample continues to represent the underlying population at risk and accurately identify trends, it is necessary to closely monitor MSM sample characteristics during implementation and incorporate weighted data provided by the Centers for Disease Control and Prevention into analyses.

Diagnostic and psychosocial differences in psychiatrically hospitalized military service members with single versus multiple suicide attempts.

INTRODUCTION: Individuals with multiple versus single suicide attempts present a more severe clinical picture and may be at greater risk for suicide. Yet group differences within military samples have been vastly understudied. PURPOSE: The objective is to determine demographic, diagnostic, and psychosocial differences, based on suicide attempt status, among military inpatients admitted for suicide-related events. METHOD: A retrospective chart review design was used with a total of 423 randomly selected medical records of psychiatric admissions to a military hospital from 2001 to 2006. RESULTS: Chi-square analyses indicated that individuals with multiple versus single suicide attempts were significantly more likely to have documented childhood sexual abuse (p =.025); problem substance use (p=.001); mood disorder diagnosis (p=.005); substance disorder diagnosis (p =.050); personality disorder not otherwise specified diagnosis (p =.018); and Axis II traits or diagnosis (p=.038) when compared to those with a single attempt history. Logistic regression analyses showed that males with multiple suicide attempts were more likely to have problem substance use (p=.005) and a mood disorder diagnosis (p =.002), while females with a multiple attempt history were more likely to have a history of childhood sexual (p =.027). DISCUSSION: Clinically meaningful differences among military inpatients with single versus multiple suicide attempts exist. Targeted Department of Defense suicide prevention and intervention efforts that address the unique needs of these two specific at-risk subgroups are additionally needed.