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Continuum of care is a concept that has been widely applied in HIV prevention and treatment studies. However, measuring care continuum can be challenging because it involves multiple stages and multiple components or domains at each stage of care. In this study, we introduced an analytical framework to (1) estimate intervention effects overall and by domain using a multi-level modeling approach, and (2) learn possible patterns of domains over time utilizing a multi-layer heatmap visualization. Longitudinal data from an intervention study conducted among people who use drugs in Vietnam were used to construct Seek, Test, Treat, and Retain (STTR) domain and overall scores. Findings from the adjusted analysis showed that people who use drugs in the intervention exhibited a significantly greater improvement in the overall STTR score than those in the control (p-values < .0001). The multi-layer heatmap revealed different patterns of the individual domains over time and the inter-relationships among the individual domains. This study demonstrates the feasibility of constructing a general fulfillment score and domain specific scores to measure care continuum among people who use drugs. The analytical framework can be readily extended to evaluate service fulfillment outcomes in health services and treatment studies for other key populations.

Loss of lean muscle mass and accumulation of adipose tissue are changes associated with aging. Previous studies have documented various components of body composition as predictors for insulin resistance. The objective of this study was to investigate whether components of body composition-appendicular lean mass (ALM) and/or abdominal fat mass (AFM)-correlate with insulin resistance in older men and women. This was a cross-sectional study of 92 older men and women. Weight was classified according to body mass index (BMI)-normal (BMI 30). All body composition data was determined by dual energy x-ray absorptiometry (DEXA), and insulin resistance was assessed by the homeostatic model assessment of insulin resistance (HOMA-IR). Multivariable regression models with two-way interaction terms were employed to assess whether the associations between components of body composition and log HOMA varied by BMI categories. Adjusted regression showed that log HOMA was significantly associated with AFM (estimate ± standard error: 0.055 ± 0.026) and ALM (0.057 ± 0.029) for the overweight participants (p-values

BACKGROUND: Physician Orders for Life Sustaining Treatment (POLST) document instructions for intensity of care based upon patient care preferences. POLST forms generally reflect patients wishes and dictate subsequent medical care, but it is not known how POLST use and content among nursing home residents is associated with inpatient utilization across a large population. OBJECTIVE: Evaluate the relationship between POLST use and content with hospital utilization among nursing home residents in California. DESIGN: Retrospective cohort study using the Minimum Data Set linked to California Section S (POLST documentation), the Medicare Beneficiary Summary File, and Medicare line item claims. PATIENTS: California nursing home residents with Medicare fee-for-service insurance, 2011-2016. MAIN MEASURES: Hospitalization, days in the hospital, and days in the intensive care unit (ICU) after adjustment for resident and nursing home characteristics. KEY RESULTS: The 1,112,834 residents had a completed and signed (valid) POLST containing orders for CPR with Full treatment 29.6% of resident-time (in person-years) and a DNR order with Selective treatment or Comfort care 27.1% of resident-time. Unsigned POLSTs accounted for 11.3% of resident-time. Residents experienced 14 hospitalizations and a mean of 120 hospital days and 37 ICU days per 100 person-years. Residents with a POLST indicating CPR Full treatment had utilization nearly identical to residents without a POLST. A gradient of decreased utilization was related to lower intensity of care orders. Compared to residents without a POLST, residents with a POLST indicating DNR Comfort care spent 56 fewer days in the hospital and 22 fewer days in the ICU per 100 person-years. Unsigned POLST had a weaker and less consistent relationship with hospital utilization. CONCLUSIONS: Among California NH residents, there is a direct relationship between intensity of care preferences in POLST and hospital utilization. These findings emphasize the importance of a valid POLST capturing informed preferences for nursing home residents.

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) are commonly used for nursing home (NH) residents. Treatment orders differ across race and ethnicity, presumably related to cultural and socioeconomic variation and levels of access to care and trust. Because national efforts focus on addressing the underpinnings of racial and ethnic differences in treatment (i.e., access to care and trust), we describe POLST use and content by race and ethnicity. METHODS: California requires NHs to document POLST completion and content in the Minimum Data Set. We describe POLST completion and content for all California NH residents from 2011 to 2016 (N = 1,120,376). Adjusting for resident characteristics, we compared changes in completion rate and differences by race and ethnicity in POLST content-orders for cardiopulmonary resuscitation (CPR), do not resuscitate (DNR), CPR with full treatment, DNR with selective treatment or comfort orders, and if unsigned. RESULTS: POLST completion increased across all racial and ethnic groups from 2011 to 2016; by 2016, NH residents had a POLST two-thirds or more of the time. In 2011, Black residents had a POLST with a CPR order 30.4% of the time, Hispanic residents 25.6%, and White residents 19.7%. By 2016, this grew to 42.5%, 38.2%, and 28.1%, respectively, with Black and Hispanic residents demonstrating larger increases than White residents (p

BackgroundA chronic condition, drug addiction, requires long-term multipronged health care and treatment services. Community-based approaches can offer the advantages of managing integrated care along the care continuum and improving clinical outcomes. However, scant rigorous research focuses on sustainable, community-based care and service delivery.ObjectiveThis protocol describes a study aiming to develop and test an intervention that features the alliance of community health workers and family members to provide integrated support and individualized services and treatment for people who use drugs (PWUD) in community settings.MethodsBased on the National Institute on Drug Abuse's Seek-Test-Treat-Retain (STTR) framework, an intervention that provides training to community health workers will be developed and piloted before an intervention trial. Trained community health workers will conduct home visits and provide support for PWUD and their families. The intervention trial will be conducted in 3 regions in Vietnam, with 60 communities (named communes). These communes will be randomized to either an intervention or control condition. Intervention outcomes will be evaluated at baseline and at 3, 6, 9, and 12 months. The primary outcome measure is PWUD's STTR fulfillment, consisting of multiple individual fulfillment indicators across 5 domains: Seek, Test, Treat, Retain, and Health. The secondary outcomes of interest are the community health workers' service provision and family members' support. The primary analysis will follow an intention-to-treat approach. Generalized mixed-effects regression models will be used to compare changes in the outcome measures from baseline between intervention and control conditions.ResultsDuring the first year of the project, we conducted formative studies, including in-depth interviews and focus groups, to identify service barriers and intervention strategies. The intervention and assessment pilots are scheduled in 2023 before commencing the trial. Reports based on the baseline data will be distributed in early 2024. The intervention outcome results will be available within 6 months of the final data collection date, that is, the main study findings are expected to be available in early 2026.ConclusionsThis study will inform the establishment of community health workers and family members alliance, a locally available infrastructure, to support addiction services and care for PWUD. The methodology, findings, and lessons learned are expected to shed light on the addiction service continuum's implementation and demonstrate a community-based addiction service delivery model that can be transferable to other countries.Trial registrationClinicalTrials.gov NCT05315492; https://clinicaltrials.gov/ct2/show/NCT05315492.International registered report identifier (irrid)DERR1-10.2196/44219.

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) facilitates documentation and transition of patients life-sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016. METHODS: California requires NHs to document in the Minimum Data Set whether residents complete a POLST and orders within POLST. Using a serial cross-sectional design for each year, we describe POLST completion and orders for all California NH residents from 2011 to 2016 (N = 1,112,668). We used logistic mixed-effects regression models to estimate POLST completion and resuscitation orders to understand the relationship with resident and facility characteristics, including Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare overall five-star quality rating. RESULTS: POLST completion significantly increased from 2011 to 2016 with most residents having a POLST in 2016 (short-stay:68%; long-stay:81%). Among those with a POLST in 2016, 54% of long-stay and 41% of short-stay residents had a DNR order. Among residents with DNR, >90% had orders for limited medical interventions or comfort measures. Few residents (

Background and aimsFish consumption has been associated with better health outcomes. Dietary patterns may vary substantially by neighborhood of residence. However, it is unclear if the benefits of a healthy diet are equivalent in different communities. This study examines associations of fish consumption with stroke incidence and stroke risk factors, and whether these differ by neighborhood socioeconomic status (NSES).Methods and resultsWe studied 4007 participants in the Cardiovascular Health Study who were 65 years or older and recruited between 1989 and 1990 from 4 US communities. Outcomes included fish consumption type (bakes/broiled vs. fried) and frequency, stroke incidence, and stroke risk factors. Multilevel regressions models were used to estimate fish consumption associations with clinical outcomes. Lower NSES was associated with higher consumption of fried fish (aOR = 1.47, 95% CI: 1.10-1.98) and lower consumption of non-fried fish (0.64, 0.47-0.86). Frequent fried fish (11.9 vs. 9.2 person-years for at least once weekly vs. less than once a month, respectively) and less frequent non-fried fish (17.7 vs. 9.6 person-years for less than once a month vs. at least once weekly, respectively) were independently associated with an increased risk of stroke (p-values < 0.05). However, among those with similar levels of healthy fish consumption, residents with low NSES had less benefit on stroke risk reduction, compared with high NSES.ConclusionFish consumption type and frequency both impact stroke risk. Benefits of healthy fish consumption differ by neighborhood socioeconomic status.

BACKGROUND Serious mental illnesses (SMI) are common, disabling, and challenging to treat, requiring years of monitoring and treatment adjustments. Stress or reduced medication adherence can lead to rapid worsening of symptoms and behaviors. Illness exacerbations and relapses generally occur with little or no clinician awareness in real time, leaving limited opportunity to modify treatments. Previous research suggests that passive mobile sensing may be beneficial for individuals with SMI by helping them monitor mental health status, behaviors, and quickly detect worsening mental health for prompt assessment and intervention. However, there is too little research on its feasibility and acceptability in patients with SMI, and the extent to which passive data can predict changes in behaviors and symptoms. OBJECTIVE To study the feasibility, acceptability and safety of passive mobile sensing for tracking behaviors and symptoms of patients in treatment for SMI, as well as developing analytics that utilize passive data to predict changes in behaviors and symptoms. METHODS A mobile application (app) monitors and transmits passive mobile sensor and phone utilization data to track activity, sociability and sleep in patients with SMI. The study consists of a user-centered design phase and a mobile sensing phase. In the design phase, focus groups, interviews and in-lab usability testing inform further app development. In the mobile sensing phase, passive mobile sensing occurs with participants engaging in weekly assessments for up to nine months. Three and nine month interviews study the perceptions of passive mobile sensing and ease of app use. Clinician interviews before and after the mobile sensing phase study the usefulness and feasibility of app utilization in clinical care. Predictive analytic models are built, trained and selected, and make use of machine learning methods. Models use sensor and phone utilization data to predict behavioral changes and symptoms. RESULTS The study was funded in October 2020 and has received IRB approval. The user-centered design phase, consisting of focus groups, usability testing, and pre-intervention clinician interviews has been completed. Recruitment and enrollment for the mobile sensing phase are ongoing. CONCLUSIONS Findings may inform the development of passive sensing apps and self-tracking in patients with SMI, and integration into care to improve assessment, treatment, and patient outcomes. CLINICALTRIAL ClinicalTrials.gov NCT05023252; https://clinicaltrials.gov/ct2/show/NCT05023252

BackgroundPeople living with HIV who use drugs (PLHWUD) face enormous challenges to access antiretroviral therapy (ART), addiction treatment, and other healthcare services. This study evaluated the effect of a community capacity-building approach on PLHWUD's access to healthcare services.MethodsA cluster randomized controlled trial was conducted in four provinces of Vietnam. Trained commune health workers in the intervention condition were encouraged to provide services to PLHWUD in the community and engage them in HIV/addiction treatment and care using learned knowledge and skills. A total of 241 PLHWUD participated in surveys at the baseline and every three months for one year. The primary outcome was PLHWUD's reported barriers to seeking healthcare. A linear mixed-effects regression model with a difference in difference approach was used to estimate the intervention effect on the primary outcome.ResultsAdjusted analyses indicated that significant intervention effects were observed at the Sixth and ninth month follow-ups for those on ART at the baseline and increased motivation to engage in treatment at the 3-month follow-up (60.2% vs 34.4% for the intervention and control groups, respectively).ConclusionsThe community capacity-building intervention had shown promising yet limited outcomes among a subset of PLHWUD in the community, that is, PLHWUD who had already initiated ART.

Scientific findings and policy guidelines recommend integrating HIV and drug addiction prevention and care into community-based settings. Systematic capacity-building efforts are warranted to provide technical support for community health workers and improve their confidence in the integrated service provision. An intervention trial was conducted between 2018 and 2019 with 120 community health workers (CHW) from 60 communes in Vietnam's four provinces. The 60 intervention CHW received in-person training to enhance their HIV/addiction-related service knowledge and skills. Online support groups were established between trained CHW and local HIV and addiction specialists. The intervention outcomes were assessed using mixed-effects regression models with the data collected at baseline and every 3 months for 1 year. Adjusted analyses showed that intervention CHW reported a significant increase in the interaction with other treatment providers than the control group at 6 months and remained at the 12-month follow-up. The difference in the improvement of confidence in HIV/addiction-related service delivery between the intervention and control groups was significant at 6-month but became insignificant at the 12-month. Male CHW were more confident in providing services than female CHW at baseline, and gender differences in the changing patterns were observed over time. This capacity-building intervention demonstrated promising outcomes on CHW inter-agency collaborations and confidence in service delivery. Gender divides in healthcare professionals should be attended to in future studies.

BackgroundSerious mental illnesses (SMI) are common, disabling, and challenging to treat, requiring years of monitoring and treatment adjustments. Stress or reduced medication adherence can lead to rapid worsening of symptoms and behaviors. Illness exacerbations and relapses generally occur with little or no clinician awareness in real time, leaving limited opportunity to modify treatments. Previous research suggests that passive mobile sensing may be beneficial for individuals with SMI by helping them monitor mental health status and behaviors, and quickly detect worsening mental health for prompt assessment and intervention. However, there is too little research on its feasibility and acceptability and the extent to which passive data can predict changes in behaviors or symptoms.ObjectiveThe aim of this research is to study the feasibility, acceptability, and safety of passive mobile sensing for tracking behaviors and symptoms of patients in treatment for SMI, as well as developing analytics that use passive data to predict changes in behaviors and symptoms.MethodsA mobile app monitors and transmits passive mobile sensor and phone utilization data, which is used to track activity, sociability, and sleep in patients with SMI. The study consists of a user-centered design phase and a mobile sensing phase. In the design phase, focus groups, interviews, and usability testing inform further app development. In the mobile sensing phase, passive mobile sensing occurs with participants engaging in weekly assessments for 9 months. Three- and nine-month interviews study the perceptions of passive mobile sensing and ease of app use. Clinician interviews before and after the mobile sensing phase study the usefulness and feasibility of app utilization in clinical care. Predictive analytic models are built, trained, and selected, and make use of machine learning methods. Models use sensor and phone utilization data to predict behavioral changes and symptoms.ResultsThe study started in October 2020. It has received institutional review board approval. The user-centered design phase, consisting of focus groups, usability testing, and preintervention clinician interviews, was completed in June 2021. Recruitment and enrollment for the mobile sensing phase began in October 2021.ConclusionsFindings may inform the development of passive sensing apps and self-tracking in patients with SMI, and integration into care to improve assessment, treatment, and patient outcomes.Trial registrationClinicalTrials.gov NCT05023252; https://clinicaltrials.gov/ct2/show/NCT05023252.International registered report identifier (irrid)DERR1-10.2196/39010.

Study objectivesPerson-centered obstructive sleep apnea (OSA) care is a collaborative approach that is respectful of an individual's health priorities. Informed decision-making is essential to person-centered care, especially as patients age. In a feasibility study, we evaluated the effects of a new decision aid (Decide2Rest) on OSA treatment decision-making in older adults.MethodsPatients (aged ≥ 60 years) with newly diagnosed OSA were recruited from two health care systems and randomized either to Decide2Rest or to a control program. Postintervention outcomes included 1) Decisional Conflict Scale (0-100, where 0 = low and 100 = high conflict), which measures perceptions of uncertainty, whether decisions reflect what matters most to patients, and whether patients feel supported in decision-making; 2) Preparation for Decision-Making scale (0-100, where 0 = least and 100 most prepared); and 3) OSA knowledge (0-100, where 0 = poor and 100 = outstanding). Multivariable linear regression models examined relationships between Decide2Rest and outcomes (Decisional Conflict Scale, Preparation for Decision-Making, OSA knowledge).ResultsSeventy-three patients were randomized to Decide2Rest (n = 36; mean age, 69 years; 72% male) vs control (n = 37; mean age, 69 years; 70% male). Results from the regressions, controlling for study site, indicate that the Decide2Rest program resulted in less decisional conflict (20.5 vs 32.7 on the Decisional Conflict Scale; P = .014), more preparedness for decision-making (87.8 vs 66.2 on the Preparation for Decision-Making scale; P < .001), and greater OSA knowledge (75.1 vs 65.3 OSA knowledge score; P = .04) scores than in the control group.ConclusionsThe Decide2Rest program promotes person-centered OSA decision-making for older patients with newly diagnosed OSA. Future studies are needed to optimize implementation of the program.Clinical trial registrationRegistry: ClinicalTrials.gov, Name: Improving Older Adults' Decision-Making for OSAT (eDecide2Rest); URL: https://clinicaltrials.gov/ct2/show/NCT03138993; Identifier: NCT03138993.

BackgroundD. Frank Benson and colleagues first described the clinical and neuropathological features of posterior cortical atrophy (PCA) from patients in the UCLA Neurobehavior Program.ObjectiveWe reviewed the Program's subsequent clinical experience with PCA, and its potential for clarifying this relatively rare syndrome in comparison to the accumulated literature on PCA.MethodsUsing the original criteria derived from this clinic, 65 patients with neuroimaging-supported PCA were diagnosed between 1995 and 2020.ResultsOn presentation, most had visual localization complaints and related visuospatial symptoms, but nearly half had memory complaints followed by symptoms of depression. Neurobehavioral testing showed predominant difficulty with visuospatial constructions, Gerstmann's syndrome, and Balint's syndrome, but also impaired memory and naming. On retrospective application of the current Consensus Criteria for PCA, 59 (91%) met PCA criteria with a modification allowing for "significantly greater visuospatial over memory and naming deficits." There were 37 deaths (56.9%) with the median overall survival of 10.3 years (95% CI: 9.6-13.6 years), consistent with a slow neurodegenerative disorder in most patients.ConclusionTogether, these findings recommend modifying the PCA criteria for "relatively spared" memory, language, and behavior to include secondary memory and naming difficulty and depression, with increased emphasis on the presence of Gerstmann's and Balint's syndromes.

ObjectiveThis study examined bereavement-related risk markers (number of deaths, cause of death, and relationship to deceased) of mental and behavioral health problems (suicidal thoughts or behaviors, self-injury, depression, posttraumatic stress, and substance use) in a national sample of clinic-referred bereaved adolescents.MethodParticipants included 1281 bereaved youth aged 12-21 years (M=15, SD=1.8; 62.1% female), from the National Child Traumatic Stress Network Core Data Set.ResultsGeneralized linear mixed-effects regression models controlling for demographics and other traumas revealed that youth bereaved by multiple deaths had higher posttraumatic stress scores than youth bereaved by a single death (Estimated difference ±SE=3.36 ± 1.11, p=0.003). Youth bereaved by suicide were more likely to report experiencing suicidal thoughts or behaviors (AOR=1.68, p=0.049) and alcohol use (AOR=2.33, p

HCV co-infection is widespread among people living with HIV who use drugs (PLHWUD). However, HCV testing was inconsistently implemented among PLHWUD. The low infection awareness and mental health challenges together impede PLHWUD's treatment-seeking. The study used baseline data of a randomized controlled trial conducted in Vietnam. HCV infection status was collected through self-report and medical record review. A linear mixed-effects regression model was used to examine the relationships between PLHWUD's perceived barriers to seeking healthcare, their depressive symptoms, and the consistencies in HCV status reports. Among the 181 PLHWUD in the study, one-third (64; 35.4%) had inconsistent self-reports and medical records of HIV infection status. The agreement between the two records was fair (Kappa statistics = 0.43). PLHWUD with consistent HCV infection confirmed by both medical records and self-reports perceived lower levels of healthcare-seeking barriers than those with discrepant HCV reports (estimated difference = -1.59, SE = 0.71, P = 0.027). Depressive symptoms were significantly correlated with healthcare-seeking barriers among those with discrepant HCV results (estimate = 0.17, SE = 0.06, P = 0.007). There is an urgent need to extend HCV screening efforts and increase HCV awareness among PLHWUD. Explicit HCV result notification and integrated mental health support are recommended to facilitate patients' access to needed care.

This study compared community health workers' (CHW) stigma towards people living with HIV (PLH) and people who use drugs (PWUD) and explored the relationship between stigma and CHWs' confidence level in providing HIV/drug-related services. Using two sets of identically worded questions, levels of stigma towards PWUD and PLH were measured among 120 CHW from 60 communes in Vietnam. The associations between CHWs' confidence in service provision and stigma towards PWUD and PLH were examined using a linear mixed-effects regression model. The majority of the CHW reported higher levels of stigma towards PWUD than towards PLH. Compared to the CHW reporting higher stigma towards PWUD, those with higher stigma towards PLH were significantly less confident in service provision. Social opprobrium attached to drug-using behaviors can be a major driver behind the overall HIV stigma. CHWs' fear of HIV infection should be tackled to boost their confidence in HIV/drug-related care provision.

This study assessed the effects of a multilevel intervention on HIV-affected children's negative behaviors. A total of 536 children aged 6-18 years from 475 HIV-affected families in Anhui, China, participated in the randomized controlled trial. A significant overall intervention effect on reducing negative behaviors was observed at 18-month follow-up, and the effect remained at 24-month follow-up. The intervention showed greater effects for children aged 13-18 years than those aged 6-12 years. Study findings suggest that a multilevel intervention approach could be beneficial for reducing negative behavior in HIV-affected children. Age-specific programs should be considered to maximize the intervention effects.

Objective: To evaluate potential differences in therapeutic outcomes between youths who completed a full course of treatment as planned compared to youths who terminated treatment prematurely. Method: Using longitudinal data from the National Child Traumatic Stress Network (NCTSN) Core Data Set, the present study examined demographic characteristics, trauma history, scores on standardized measures, and ratings of functional impairment and behavior problems in a large clinical sample of children and adolescents exposed to trauma who received treatment at NCTSN centers across the United States. Baseline and follow-up data were used to compare treatment completers (n= 3,108) and noncompleters (n = 4,029). Results: Both treatment completers and noncompleters received benefits from treatment by NCTSN mental health providers in that both groups showed significant decreases in mean scores from baseline to follow-up on all standardized measures. However, compared to noncompleters, treatment completers showed three types of significantly greater benefit at follow-up. These included: (a) greater rates of decline (i.e., steeper slopes) on all outcome measures; (b) greater reductions in the odds of falling within the clinical range on standardized measures; and (c) greater reductions in the odds of exhibiting functional impairment and behavior problems at follow-up. In contrast, compared to treatment completers, noncompleters reported significantly higher rates of lifetime exposure to community violence, psychological maltreatment, physical abuse, neglect, sexual abuse, and sexual assault. Conclusion: These findings underscore the value of incorporating engagement and retention strategies in treatments for traumatized youths to maximize therapeutic benefit and raise the standard of care.

BackgroundThis study evaluated an intervention aiming to improve methadone maintenance therapy (MMT) service providers' interaction with their patients in China.MethodsSixty-eight MMT clinics were randomized to either an intervention or a control condition. Providers in the intervention group attended three group training sessions to enhance their communication skills. Trained providers were encouraged to practice the taught communication skills through provider-initiated individual sessions with their patients. A total of 418 service providers completed assessments from baseline to 24-month. Linear mixed-effects regression models were used to compare self-reported short-term and sustained improvement in provider-patient interaction between the intervention and the control conditions.ResultsThe intervention group service providers perceived significantly greater short-term and sustained improvement in provider-patient interaction compared to the control group service providers (estimated difference (±SE): 1.20 (0.24) and 1.35 (0.33), respectively; p-values

BackgroundService providers including doctors, nurses, and other healthcare professionals play an essential role in methadone maintenance treatment (MMT). This study evaluated the impact of an intervention targeting MMT providers on their clients' treatment retention.MethodsThis study was conducted in 68 MMT clinics in five provinces of China with 36 clients randomly selected from each clinic. The clinics were randomized to intervention or control condition. The MMT CARE intervention started with group sessions to enhance providers' communication skills. The trained providers were encouraged to conduct individual sessions with clients to promote treatment engagement. The outcomes, which include client retention (main outcome) and their reception of provider-delivered individual sessions (process outcome), were measured over a 24-month period.ResultsSignificantly fewer intervention clients dropped out from MMT than control clients during the study period (31% vs. 41%; p

BACKGROUND: Little data exist to describe serial population-level trends in cognitive impairment- especially among minority communities. Because memory problems are among the first warning signs of cognitive impairment, they provide a potential method for monitoring changes in cognitive health at the population level. This exploratory study aimed to: 1) estimate prevalence of memory problems among US residents by race/ethnicity, age category; and 2) examine whether racial/ethnic differences in subjective cognitive concerns (memory problems) varied across recent time periods. DESIGN AND SETTING: Serial cross-sectional analysis of self-reported data from the National Health and Examination Survey (NHANES), 1999-2014. PARTICIPANTS: 20,585 participants aged ≥45 years during 1999-2014, who reported race/ethnicity as non-Hispanic White (NHW), non-Hispanic Black (NHB), and Latino/Hispanic. MEASUREMENTS: The outcome of interest was subjective cognitive concerns, identified as self-reported memory problems. The frequencies of memory problems were examined for each 4-year period, across racial/ethnic groups. RESULTS: In adjusted analyses, compared with older (aged ≥ 65 years) NHWs, disparities in subjective cognitive concerns were observed for older Latinos for most periods (range of AOR: 1.43 - 2.01, P

BackgroundLittle data exist to describe serial population-level trends in cognitive impairment- especially among minority communities. Because memory problems are among the first warning signs of cognitive impairment, they provide a potential method for monitoring changes in cognitive health at the population level. This exploratory study aimed to: 1) estimate prevalence of memory problems among US residents by race/ethnicity, age category; and 2) examine whether racial/ethnic differences in subjective cognitive concerns (memory problems) varied across recent time periods.Design and settingSerial cross-sectional analysis of self-reported data from the National Health and Examination Survey (NHANES), 1999-2014.Participants20,585 participants aged ≥45 years during 1999-2014, who reported race/ethnicity as non-Hispanic White (NHW), non-Hispanic Black (NHB), and Latino/Hispanic.MeasurementsThe outcome of interest was subjective cognitive concerns, identified as self-reported memory problems. The frequencies of memory problems were examined for each 4-year period, across racial/ethnic groups.ResultsIn adjusted analyses, compared with older (aged ≥ 65 years) NHWs, disparities in subjective cognitive concerns were observed for older Latinos for most periods (range of AOR: 1.43 - 2.01, P

OBJECTIVE:Examine 30-day readmission rates for indicator conditions before and after adoption of the Hospital Readmissions Reduction Program (HRRP). DATA:California hospital discharge data, 2005 to 2014. STUDY DESIGN:Estimated difference between pre-HRRP trends and post-HRRP rates of hospital readmissions after hospitalization for indicator conditions targeted by the HRRP (heart attack, heart failure, and pneumonia) by payer among insured adults. PRINCIPAL FINDINGS:Post-HRRP, reductions occurred for the three conditions among Fee-for-Service (FFS) Medicare. Readmissions decreased for heart attack and heart failure in Medicare Managed Care (MC). No reductions were observed in the younger commercially insured. CONCLUSIONS:Post-HRRP, greater than expected reductions occurred in rehospitalizations for patients with Medicare FFS and Medicare MC. HRRP incentives may be influencing system-wide changes influencing care outside of traditional Medicare.

BackgroundThe authors investigated disparities in the survivorship experience among Latinas with breast cancer (BC) in comparison with non-Latinas.MethodsA cross-sectional bilingual telephone survey was conducted among 212 Latina and non-Latina women within 10 to 24 months after a diagnosis of BC (AJCC TNM staging system stage 0-III) at 2 Los Angeles County public hospitals. Data were collected using the Preparing for Life as a (New) Survivor (PLANS) scale, Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI), Breast Cancer Prevention Trial (BCPT) Symptom Checklist, Satisfaction with Care and Information Scale, Consumer Assessment of Healthcare Providers and Systems (CAHPS) tool, Charlson Comorbidity Index adapted for patient self-report, and the 12-item Short Form Health Survey. Controlling variables included age, stage as determined by the American Joint Committee on Cancer (AJCC) TNM staging system, educational level, and study site in multivariate analyses.ResultsThe mean ages of Latinas and non-Latinas were 51.5 years and 56.6 years, respectively. Compared with non-Latinas, Latinas reported less BC survivorship knowledge (27.3 vs 30.7; P

ObjectivesTo evaluate the efficacy of an intervention targeted to commune health workers (CHWs) who deliver services to people who inject drugs (PWID) in Vietnam.MethodsFrom 2014 to 2016, we conducted a cluster randomized controlled trial of 300 CHWs and 900 PWID in 60 communes in 2 provinces of Vietnam. Intervention CHWs participated in training sessions to enhance their communication skills. Trained CHWs were asked to deliver individual sessions to PWID. We assessed the outcomes at baseline and at 3-, 6-, 9-, and 12-month follow-ups.ResultsIntervention CHWs showed greater improvement in provider-client interactions than did control CHWs at all follow-ups (range of difference = 3.33-5.18; P

BackgroundTrends in cardiovascular disparities are poorly understood, even as diversity increases in the United States.ObjectiveTo examine U.S. trends in racial/ethnic and nativity disparities in cardiovascular health.DesignRepeated cross-sectional study.SettingNHANES (National Health and Nutrition Examination Survey), 1988 to 2014.ParticipantsAdults aged 25 years or older who did not report cardiovascular disease.MeasurementsRacial/ethnic, nativity, and period differences in Life's Simple 7 (LS7) health factors and behaviors (blood pressure, cholesterol, hemoglobin A1c, body mass index, physical activity, diet, and smoking) and optimal composite scores for cardiovascular health (LS7 score ≥10).ResultsRates of optimal cardiovascular health remain below 40% among whites, 25% among Mexican Americans, and 15% among African Americans. Disparities in optimal cardiovascular health between whites and African Americans persisted but decreased over time. In 1988 to 1994, the percentage of African Americans with optimal LS7 scores was 22.8 percentage points (95% CI, 19.3 to 26.4 percentage points) lower than that of whites in persons aged 25 to 44 years and 8.0 percentage points (CI, 6.4 to 9.7 percentage points) lower in those aged 65 years or older. By 2011 to 2014, differences decreased to 10.6 percentage points (CI, 7.4 to 13.9 percentage points) and 3.8 percentage points (CI, 2.5 to 5.0 percentage points), respectively. Disparities in optimal LS7 scores between whites and Mexican Americans were smaller but also decreased. These decreases were due to reductions in optimal cardiovascular health among whites over all age groups and periods: Between 1988 to 1994 and 2011 to 2014, the percentage of whites with optimal cardiovascular health decreased 15.3 percentage points (CI, 11.1 to 19.4 percentage points) for those aged 25 to 44 years and 4.6 percentage points (CI, 2.7 to 6.5 percentage points) for those aged 65 years or older.LimitationOnly whites, African Americans, and Mexican Americans were studied.ConclusionCardiovascular health has declined in the United States, racial/ethnic and nativity disparities persist, and decreased disparities seem to be due to worsening cardiovascular health among whites rather than gains among African Americans and Mexican Americans. Multifaceted interventions are needed to address declining population health and persistent health disparities.Primary funding sourceNational Institute of Neurological Disorders and Stroke and National Center for Advancing Translational Sciences of the National Institutes of Health.

BackgroundWith the recent increase use of observation care, it is important to understand the characteristics of patients that utilize this care and either have a prolonged observation care stay or require admission.MethodsWe a conducted a retrospective cohort study utilizing 5% sample data from Medicare patients age ≥65 years that was nationally representative in the year 2013. We performed a generalized estimating equation (GEE) logistic regression analysis to evaluate the relationship between an unsuccessful observation stay (defined as either requiring an inpatient admission from observation or having a prolonged observation stay) compared to having successful observation care. Observation cut offs of "successful" vs. "unsuccessful" were based on the CMS 2 midnight rule.ResultsOf 154,756 observation stays in 2013, 19 percent (n = 29,604) were admitted to the inpatient service and 34,275 (22.2%) had a prolonged observation stay. The two diagnoses most likely to have an unsuccessful observation stay were intestinal infections (OR 1.56, 95% CI 1.32⁻1.83) and pneumonia (OR 1.26, 95% CI 1.13⁻1.41).ConclusionWe found patients placed in observation care with intestinal infections and pneumonia to have the highest odds of either being admitted from observation or having a prolonged observation stay.

ObjectiveHIV has a profound impact on infected individuals and their families. This study evaluated the efficacy of an intervention aimed at improving the mental health of people living with HIV (PLH) and their family members.MethodA randomized controlled trial of 475 PLH and 522 family members was conducted in Anhui, China. The intervention comprised activities at individual, family, and community levels. The study outcomes, which included depressive symptoms and coping with illness for the PLH and depressive symptoms and caregiver burden for the family members, were assessed at baseline and at 6-, 12-, 18-, and 24-month follow-up. We used a mixed-effects regression model with village- and participant-level random effects to assess the intervention effect on the improvement of outcome measures.ResultsRelative to the control condition, the PLH and family members of the intervention group reported a significant reduction in depressive symptoms. The largest difference in depressive symptoms was observed at 6 months for the PLH and at 12 months for family members. Decreases in perceived caregiver burden over time were observed for family members in both conditions; however, the group difference did not reach statistical significance. Significant intervention effect on the coping with illness was reported by the PLH.ConclusionsThe study highlights the importance of empowering families affected by HIV to confront the challenges together rather than individually. It may be optimal for future programs to include both PLH and their family members to maximize intervention effects through strengthening interactions and support within a family. (PsycINFO Database Record

BackgroundThe validity and concordance of two main measures of drug use behavior, self-report and urinalysis, has long been discussed. More understanding is needed about the underlying factors associated with discordance between these two methods.ObjectivesDescribe the pattern and associated factors of discordance between self-reported heroin use and the urinalysis results of opiate use among methadone maintenance therapy (MMT) patients in China.MethodsA total of 2,448 MMT patients from 68 clinics in five provinces of China participated in a survey, which collected information on demographics, drug use and MMT-related factors, depressive symptoms, and drug avoidance self-efficacy. The most recent urine morphine test result was obtained from medical records and compared with self-reported heroin use. Participants who had urinalysis within 14 days of the survey were included in the analysis.ResultsAmong the 1,092 participants, 70 (6.4%) self-reported heroin use and 195 (17.9%) had positive urinalysis results. The over-reporters group had significantly higher education, and the under-reporters had significantly higher level of drug-avoidance self-efficacy and lower level of depressive symptoms. Among the participants who either self-reported heroin use or had positive urinalysis results, being young, having higher education, and having lower level of depressive symptoms were associated with discordance between self-reports and urinalysis results.ConclusionThe combination of both measures in assessing drug use behavior seems necessary. The validity of self-report should be considered differently based on demographic and psychosocial characteristics.

HIV seropositive individuals and their heterosexual partners/spouses, either seropositive or seronegative, are facing several mental health challenges. The objective of this study was to examine gender differences in depressive symptoms among HIV-positive concordant and HIV-discordant couples. We identified heterosexual couples from participants of a randomized controlled trial conducted in Anhui province, China. A total of 265 couples, comprising 129 HIV+ male/HIV- female couples, 98 HIV- male/HIV+ female couples, and 38 HIV-positive concordant couples, were included in the analyses. We collected data using the computer-assisted personal interview method. We used a linear mixed-effects regression model to assess whether gender differences in depressive symptoms varied across couple types. HIV-positive women reported a significantly higher level of depressive symptoms than their partners/spouses. HIV-positive women with HIV-positive partners had higher depressive symptoms than those with HIV-negative partners, whereas HIV-positive men reported similar levels of depressive symptoms regardless of their partners' serostatus. Among the concordant couples, those with the highest annual family income showed the greatest gender differences in depressive symptoms. We suggest that family interventions should be gender- and couple-type specific and that mental health counseling is warranted not only for HIV-positive women but also for HIV-negative women in an HIV-affected relationship.

This study examined the associations between parent and adolescent reports of bonding within families and the relationships among reported parental bonding, family conflict and adolescent stress. A total of 118 families from Anhui, China, were recruited for this study. Two family-level bonding scores were constructed: the average of and difference between parent and adolescent bonding scores. Study results indicated that the difference between parent and adolescent bonding reports was associated with higher levels of adolescent daily stress. A negative association was observed between average family-level bonding and the level of parent-reported conflict. Our findings highlight the importance of combining data from both parents and adolescents when studying issues related to family wellbeing.

China's HIV/AIDS treatment policies have been evolving over the preceding decade. This study describes patterns of antiretroviral therapy (ART) initiation for a sample of people living with HIV/AIDS (PLHIV) in rural Anhui, China, where most PLHIV were infected via paid plasma donation during the 1990s. A total of 481 PLHIV who were receiving ART were included in our analyses. Times between HIV diagnosis and the initiation of ART were examined relative to the time points when major ART-related policies changed in China. More than half (53%) of PLHIV who had been diagnosed by 2003 received ART within 6 months, whereas 93% of PLHIV who had been diagnosed in 2010 or later received ART within 6 months. The study results provide additional support that the "Four Frees and One Care" policy in 2003 and the relaxation of ART eligibility in 2010 have facilitated the initiation of treatment for PLHIV in China.

China's HIV/AIDS treatment policies have been evolving over the preceding decade. This study describes patterns of antiretroviral therapy (ART) initiation for a sample of people living with HIV/AIDS (PLHIV) in rural Anhui, China, where most PLHIV were infected via paid plasma donation during the 1990s. A total of 481 PLHIV who were receiving ART were included in our analyses. Times between HIV diagnosis and the initiation of ART were examined relative to the time points when major ART-related policies changed in China. More than half (53%) of PLHIV who had been diagnosed by 2003 received ART within 6 months, whereas 93% of PLHIV who had been diagnosed in 2010 or later received ART within 6 months. The study results provide additional support that the "Four Frees and One Care" policy in 2003 and the relaxation of ART eligibility in 2010 have facilitated the initiation of treatment for PLHIV in China.

We and others have shown that the cystatin E/M gene is inactivated in primary human tumors, pointing to its role as a tumor suppressor gene. However, the molecular mechanism of tumor suppression is not yet understood. Using plasmid-directed cystatin E/M gene overexpression, a lentivirus-mediated tetracycline-inducible vector system, and human papillomavirus 16 (HPV 16) E6 and E7 gene-immortalized normal human epidermal keratinocytes, we demonstrated intracellular and non-cell-autonomous apoptotic growth inhibition of tumor cell lines and that growth inhibition is associated with cytoplasmic retention of NF-κB. We further demonstrated decreased phosphorylation of IκB kinase (IKKβ) and IκBα in the presence of tumor necrosis factor alpha (TNF-α), confirming the role of cystatin E/M in the regulation of the NF-κB signaling pathway. Growth suppression of nude mouse xenograft tumors carrying a tetracycline-inducible vector system was observed with the addition of doxycycline in drinking water, confirming that the cystatin E/M gene is a tumor suppressor gene. Finally, immunohistochemical analyses of cervical carcinoma in situ and primary tumors have shown a statistically significant inverse relationship between the expression of cystatin E/M and cathepsin L and a direct relationship between the loss of cystatin E/M expression and nuclear expression of NF-κB. We therefore propose that the cystatin E/M suppressor gene plays an important role in the regulation of NF-κB.

Social support promotes positive coping strategies among people living with HIV (PLH); however, little is known about the various aspects of social support and their distinct effects on coping. The present study investigates the specific links between coping and perceived social support with respect to gender and education among PLH. A total of 522 PLH in Anhui, China, participated in an assessment that collected data on demographics, perceived tangible and emotional support, and cognitive and behavioral coping. The assessment was conducted using the computer-assisted personal interviewing method. The data were analyzed using linear mixed models. Emotional support was significantly associated with both cognitive and behavioral coping. Tangible support was significantly associated with behavioral coping but not with emotional coping. Women reported significantly lower levels of emotional support, cognitive coping, and behavioral coping than men did. Significant associations between tangible support and coping were found only among illiterate males. Women living with HIV are in greater need of social support and coping strategies. Future interventions should be gender specific, with targeted support for women with lower education levels to enhance their coping strategies.

ObjectiveTo describe the design and rationale of the Healthy Community Neighborhood Initiative (HCNI), a multi-component study to understand and document health risk and resources in a low-income and minority community.DesignA community-partnered participatory research project.SettingA low-income, biethnic African American and Latino neighborhood in South Los Angeles.ParticipantsAdult community residents aged >18 years.Main outcome measuresHousehold survey and clinical data collection; neighborhood characteristics; neighborhood observations; and community resources asset mapping.ResultsWe enrolled 206 participants (90% of those eligible), of whom 205 completed the household interview and examination, and 199 provided laboratory samples. Among enrollees, 82 (40%) were aged >50 years and participated in functional status measurement. We completed neighborhood observations on 93 street segments; an average of 2.2 (SD=1.6) study participants resided on each street segment observed. The community asset map identified 290 resources summarized in a Community Resource Guide given to all participants.ConclusionsThe HCNI community-academic partnership has built a framework to assess and document the individual, social, and community factors that may influence clinical and social outcomes in a community at high-risk for preventable chronic disease. Our project suggests that a community collaborative can use culturally and scientifically sound strategies to identify community-centered health and social needs. Additional work is needed to understand strategies for developing and implementing interventions to mitigate these disparities.

ObjectiveTo examine variation by race and gender in the association between neighborhood socioeconomic status and walking among community-dwelling older adults.DesignCross-sectional.SettingCardiovascular Health Study, a longitudinal population-based cohort.Participants4,849 adults, aged > 65 years.MeasurementsParticipants reported the number of city blocks walked in the prior week. Neighborhood socioeconomic status (NSES) was measured at the level of the census tract. Negative binominal regression models were constructed to test the association between NSES and blocks walked. In the fully adjusted models, we included two-way and three-way interaction terms among race, gender, and NSES.ResultsIn adjusted analyses, among White residents in the lowest NSES quartile (most disadvantaged), men walked 64% more than women (P

Previous studies suggest that the implementation of universal precaution (UP) plays a role in reducing HIV stigma. In this study we investigate the efficacy of a stigma reduction intervention on UP compliance and explore whether UP compliance could potentially influence HIV stigma reduction in medical settings. A randomized controlled intervention trial was conducted in two provinces of China with 1760 healthcare service providers recruited from 40 county-level hospitals. Longitudinal analyses included data collection at baseline, 6-, and 12-month follow-up assessments. Using a hierarchical modeling approach, we estimated the intervention effect for each provider's UP compliance and its potential mediating role on HIV stigma with the bootstrapping method. A significant intervention effect on UP compliance was observed at both the 6- and 12-month follow-up assessments. The intervention effect on provider avoidance intent was partially mediated by the provider's own UP compliance at the two follow-up points. This study provides evidence that UP compliance should be part of HIV stigma reduction programs, especially in resource-restrained countries. Findings suggest that a protected work environment may be necessary but not sufficient to address HIV stigma in medical settings.

Vasoactive intestinal peptide (VIP) is a 28-amino acid neuropeptide that belongs to the secretin-glucagon superfamily of peptides and has 68 % homology with PACAP. VIP is abundantly expressed in the central and peripheral nervous system and in the gastrointestinal tract, where it exercises several physiological functions. Previously, it has been reported that VIP regulates feeding behavior centrally in different species of vertebrates such as goldfishes, chicken and rodents. Additional studies are necessary to analyze the role of endogenous VIP on the regulation of appetite/satiety, feeding behavior, metabolic hormones, body mass composition and energy balance. The aim of the study was to elucidate the physiological pathways by which VIP regulates appetite/satiety, feeding behavior, metabolic hormones, and body mass composition. VIP deficient (VIP -/-) and age-matched wild-type (WT) littermates were weekly monitored from 5 to 22 weeks of age using a whole body composition EchoMRI analyzer. Food intake and feeding behavior were analyzed using the BioDAQ automated monitoring system. Plasma levels of metabolic hormones including active-ghrelin, GLP-1, leptin, PYY, pancreatic polypeptide (PP), adiponectin, and insulin were measured in fasting as well as in postprandial conditions. The genetic lack of VIP led to a significant reduction of body weight and fat mass and to an increase of lean mass as the mice aged. Additionally, VIP-/- mice had a disrupted pattern of circadian feeding behavior resulting in an abolished regular nocturnal/diurnal feeding. These changes were associated with an altered secretion of adiponectin, GLP-1, leptin, PYY and insulin in VIP-/- mice. Our data demonstrates that endogenous VIP is involved in the control of appetite/satiety, feeding behavior, body mass composition and in the secretion of six different key regulatory metabolic hormones. VIP plays a key role in the regulation of body phenotype by significantly enhancing body weight and fat mass accumulation. Therefore, VIP signaling is critical for the modulation of appetite/satiety and body mass phenotype and is a potential target for future treatment of obesity.

BackgroundThe current study was performed to identify risk factors for a lower quality of life (QOL) among low-income women with breast cancer (BC), with an emphasis on the impact of patient-physician communication. In addition, ethnic/racial group differences in QOL changes over time were examined.MethodsA longitudinal study was conducted among 921 low-income women with BC. Patients were interviewed at 6 months, 18 months, 36 months, and 60 months after their diagnosis of BC. Mixed-effect regression models were performed to investigate predictors for and time effects on QOL. The main outcomes included the Medical Outcomes Study Health Survey Short Form-36 Mental Component Summary scale (SF-36 MCS), Medical Outcomes Study Health Survey Short Form-36 Physical Component Summary scale (SF-36 PCS), and the Ladder of Life scale. Chief independent variables included physician information-giving and patient self-efficacy in interacting with physicians.ResultsThere were no significant changes noted over time in QOL except with regard to physical functioning, with survivors reporting a significant decrease over time (P

Study objectiveOlder adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes.MethodsThis randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction.ResultsStudy staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction.ConclusionAn ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.

PurposeA randomized controlled trial with a matched design was conducted during October 2008 and February 2010, aiming at reducing HIV-related stigma in healthcare settings.MethodsForty county hospitals in Fujian and Yunnan provinces of China were matched into pairs and randomized to either an intervention condition or a control condition. Forty-four service providers were randomly selected from each hospital, yielding a sample of 1,760. Intervention outcomes were assessed at baseline, 6 and 12 months based on venue-based pair comparisons. We identified and trained 30 popular opinion leaders in each intervention hospital among service providers to disseminate stigma-reduction messages to their peer providers.ResultsHospital and participant characteristics were comparable between the intervention and control conditions. Thirteen out of twenty pairs of hospitals showed significant reduction in the stigma outcome measure at the 6-month follow-up assessment. For most hospitals, the intervention effects were maintained at the 12-month follow-up assessment. Among the 13 pair of hospitals, which showed intervention effects at 6 months, eight were in Fujian and five were in Yunnan. The non-significant hospitals at 6 months had more beds than significant hospitals. However, the difference did not reach statistical significance.ConclusionsA matched design and venue-based analysis provide more insight in assessing intervention effects for facility-based intervention trials. The identification of venue-based or hospital characteristics that are associated with intervention efficacy provides additional implications for the adaptation and implementation of future interventions.

BackgroundThe interrelationship between the well-being of injecting drug users (IDUs) and their family environment has been widely documented. However, few intervention programs have addressed the needs of both IDUs and their family members.MethodsThis study describes a randomized intervention pilot targeting 83 IDUs and 83 of their family members from four communes in Phú Thọ province, Vietnam. The IDUs and family members in the intervention condition received multiple group sessions, with the intent to improve psychological well-being and family relationships. The intervention outcomes (depressive symptoms and family relations) were evaluated at baseline, 3-month and 6-month follow-up assessments.ResultsDepressive symptoms and family relations reported by IDUs were found to be correlated to those reported by their family members. Overall, significant intervention effects on depressive symptoms and family relations were observed for both IDUs and family members. A similar improvement pattern in family relations emerged for both the IDU and family member samples, although the intervention effect of reducing depressive symptoms was more sustainable for family members at the 6-month assessment when compared to the IDU sample.ConclusionThe intervention pilot addressed challenges faced by IDUs and their family members and revealed correlated outcomes for the two groups. Findings suggest a vital need to include family members in future drug prevention and harm reduction intervention efforts.

OBJECTIVE: Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patients likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these bounceback admissions. METHODS: We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission. RESULTS: We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00). CONCLUSIONS: Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.