Department of Epidemiology and Biostatistics

Background: Survey data over the last several decades suggests that emergency department (ED) access to diagnostic ultrasound performed by the radiology department is unreliable, particularly outside of regular business hours.

Objective: To evaluate the association between the time of day of patient presentation and the use of diagnostic ultrasound services in United States (U.S.) EDs.

Methods: This was a cross-sectional study of ED patient visits using the National Hospital Ambulatory Medical Care Survey for the years 2003 to 2005. Our main outcome measure was the use of diagnostic ultrasound during the ED patient visit as abstracted from the medical record. We performed multivariate analyses to identify any association between ultrasound use and time of presentation for all patients, as well as for two subgroups who are more likely to need ultrasound as part of their routine workup: patients at risk of deep venous thrombosis, and patients at risk for ectopic pregnancy.

Results: During the three-year period, we analyzed 110,447 patient encounters, representing 39 million national visits. Of all ED visits, 2.6% received diagnostic ultrasound. Presenting to the ED “off hours” (defined as Monday through Friday 7pm to 7am and weekends) was associated with a lower rate of ultrasound use independent of potential confounders (odds ratio [OR] 0.73, 95% confidence interval [CI]: 0.65 - 0.82). Patients at increased risk of deep venous thrombosis who presented to the ED during “off hours” were also less likely to undergo diagnostic ultrasound (OR 0.34, 95% CI: 0.15 - 0.79). Similarly, patients at increased risk of ectopic pregnancy received fewer diagnostic ultrasounds during “off hours” (OR 0.56, 95% CI 0.35 - 0.91).

Conclusion: In U.S. EDs, ultrasound use was lower during “off hours,” even among patient populations where its use would be strongly indicated. [West J Emerg Med. 2011;12(1):90-95.]

Healthcare-associated infections (HAI), particularly those involving multi-drug resistant organisms (MDRO), pose a significant public health threat. Understanding the transmission of these pathogens in short-term acute care hospitals (STACH) is crucial for effective control. Mathematical and computational models play a key role in studying transmission but often overlook the influence of long-term care facilities (LTCFs) and the broader community on transmission. In a systematic scoping review of 4,733 unique studies from 2016 to 2022, we explored the modeling landscape of the hospital-community interface in HAI-causing pathogen transmission. Among the 29 eligible studies, 28 % (n = 8) exclusively modeled LTCFs, 45 % (n = 13) focused on non-healthcare-related community settings, and 31 % (n = 9) considered both settings. Studies emphasizing screening and contact precautions were more likely to include LTCFs but tended to neglect the wider community. This review emphasizes the crucial need for comprehensive modeling that incorporates the communitys impact on both clinical and public health outcomes.

BACKGROUND: Methamphetamine use is a pressing public health concern among people who inject drugs (PWID) worldwide. This study aimed to estimate the prevalence of methamphetamine use and its correlates in a nationwide survey among PWID in Iran in 2020. METHODS:  We recruited 2,684 PWID in 11 major cities from July 2019 to March 2020 using respondent-driven sampling (RDS). Participants were eligible if they were ≥ 18 years old, self-reported drug injection in the last 12 months, resided in the city of the study, and provided a valid RDS coupon. Behavioral data was collected using a standard questionnaire via face-to-face interviews. 2,259 PWID (84.2%) with valid responses to the primary outcome (i.e., methamphetamine use (either injecting or non-injection use) in the last three months) were included in the analysis. We used RDS-Giles SS weighted analysis for descriptive statistics and a survey package (svy) using linearized variance estimations and stratification by cities for bivariable and multivariable logistic regression analyses. RESULTS: The last 3-month prevalence of methamphetamine use among PWID was 47.0% (95% CI: 44.9, 49.1). The following factors were significantly associated with methamphetamine use in the last three months: history of homelessness in the last 12 months (aOR = 1.57; 1.77, 2.10), drug use onset before the age 18 (aOR = 1.40; 1.05, 1.87), injecting drug for more than ten years (aOR = 1.47; 1.11, 1.95), using non-injection (aOR = 7.18; 4.93, 10.47) and injecting illicit opioids (aOR = 2.98; 2.03, 4.36) in the last three months, as well as having multiple sex partners in the last 12 months (aOR = 1.60; 1.50, 2.73) and region (north: aOR = 5.42; 2.92 10.03; south: aOR = 2.95; 2.04, 4.27; east: aOR = 24.43; 15.62, 38.22). CONCLUSIONS: The frequency of methamphetamine use among PWID is considerable in Iran. Our findings underscore the importance of implementing tailored comprehensive harm reduction services for this sub-population of PWID. They also emphasize the urgent need for evidence-based interventions to address the harms associated with the increasing co-use of opioids and methamphetamine among PWID.

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Significant quality gaps exist in the management of chronic liver diseases and cirrhosis. Clinical decision support systems-information-driven tools based in and launched from the electronic health record-are attractive and potentially scalable prospective interventions that could help standardize clinical care in hepatology. Yet, clinical decision support systems have had a mixed record in clinical medicine due to issues with interoperability and compatibility with clinical workflows. In this review, we discuss the conceptual origins of clinical decision support systems, existing applications in liver diseases, issues and challenges with implementation, and emerging strategies to improve their integration in hepatology care.

BACKGROUND: Person-centered maternity care (PCMC) refers to respectful, responsive, and compassionate childbirth care. The PCMC scale enables quantitative measurement of PCMC. Despite the widespread use of the PCMC scale, no global synthesis exists. We, therefore, conducted a global systematic review of studies using the PCMC scale to quantitatively assess womens childbirth experiences, evaluate the scales psychometric properties, and identify predictors of PCMC. METHODS: We searched PubMed, Web of Science, and Embase from inception to September 3, 2024. Included studies used the PCMC scale by Afulani et al. to examine the facility-based childbirth experiences of women in any setting, with no time or language restrictions. Three reviewers independently assessed titles, abstracts, and full texts. We assessed study quality using Joanna Briggs Institute critical appraisal tools. We utilized a standardized extraction template to extract full PCMC and sub-scale scores (standardizing scores to a 0-100 range for easier comparison), predictors, and psychometric properties. The primary outcome is the mean PCMC score. FINDINGS: Our initial search yielded 415 articles, of which 41 publications from 32 independent samples were included. Most studies were conducted in Africa (63%). Mean PCMC scores were generally lower in studies from Africa (under 75), moderate in Asia (60 to over 90), and higher in North America (over 80). The lowest score reported was 38.2/100 (SD = 15.8) in an observational study conducted in Sierra Leone, while the highest was 97.1/100 (SD = 2.9) following an intervention in India. The lowest scoring domain across countries was communication and autonomy, with the lowest score at 18.1/100 in a study in Ethiopia. Positive predictors of PCMC included higher wealth, education, early antenatal care, and birth in lower-level and private health facilities. Inconsistent predictors included age, marital status, and obstetric complications. INTERPRETATION: PCMC is sub-optimal globally, particularly in the domain of communication and autonomy. There are also inequities in PCMC driven by various sociodemographic and health systems-related factors. Interventions to improve womens experiences and to address the inequities are therefore needed. FUNDING: None.

With advances in cancer screening and treatment, there is a growing population of cancer survivors who may develop subsequent primary cancers. While hereditary cancer syndromes account for only a portion of multiple cancer cases, we sought to explore the role of common genetic variation in susceptibility to multiple primary tumors. We conducted a cross-ancestry genome-wide association study (GWAS) and transcriptome-wide association study (TWAS) of 10,983 individuals with multiple primary cancers, 84,475 individuals with single cancer, and 420,944 cancer-free controls from two large-scale studies. Our GWAS identified six lead variants across five genomic regions that were significantly associated (p < 5 × 10^-8) with the risk of developing multiple primary tumors (overall and invasive) relative to cancer-free controls (at 3q26, 8q24, 10q24, 11q13.3, and 17p13). We also found one variant significantly associated with multiple cancers when compared with single cancer cases (at 22q13.1). Multi-tissue TWAS detected associations with genes involved in telomere maintenance in two of these regions (ACTRT3 in 3q26 and SLK and STN1 in 10q24) and the development of multiple cancers. Additionally, the TWAS also identified several novel genes associated with multiple cancers, including two immune-related genes, IRF4 and TNFRSF6B. Telomere maintenance and immune dysregulation emerge as central, common pathways influencing susceptibility to multiple cancers. These findings underscore the importance of exploring shared mechanisms in carcinogenesis, offering insights for targeted prevention and intervention strategies.

BACKGROUND: People who use non-injection drug use are at risk of transitioning to injecting drugs, which increases their vulnerability to HIV and other blood-borne infections. This study aimed to investigate the correlates of the duration between the first drug use and the first drug injection among people who inject drugs (PWID) in Iran, as well as the reasons for injection initiation. METHODS: We analyzed data from the fourth national bio-behavioral surveillance survey among PWID in Iran, conducted in 2020 across 11 cities using respondent-driven sampling (n = 2,684). A generalized linear mixed model with a gamma-distributed dependent variable and log link function was used to investigate the correlates of transition time from non-injection to injection drug use. RESULTS: Among 2,356 participants included in the analysis, the mean ± SD of the duration between the first drug use and the first drug injection was 9.37 ± 6.8 years. Factors associated with earlier injection initiation included: age under 30 years (p-value < 0.001), being single (p-value < 0.001) or divorced/widowed (p-value = 0.007), history of incarceration (p-value = 0.001), sexual debut before age 18 (p-value < 0.001), and history of depression (p-value < 0.001). Peer influence (665;29.1%) and pleasure-seeking behavior (534; 23.3%) were the most common motives for injection initiation. CONCLUSIONS: The transition to injection drug use among PWID in Iran often occurs within a decade of initial drug use and is influenced by demographic, social, and psychological factors. Prevention strategies should focus on early intervention for at-risk youth, address mental health needs, and leverage peer influence. Policymakers should prioritize evidence-based, multi-faceted approaches that target both individual and structural factors to delay or prevent the transition to injection drug use and reduce associated health risks.

The human Fallopian tube (FT) is an important organ in the female reproductive system and has been implicated as a site of origin for pelvic serous cancers, including high-grade serous tubo-ovarian carcinoma (HGSC). We have generated comprehensive whole-genome bisulfite sequencing, RNA-seq, and proteomic data of over 100 human FTs, with detailed clinical covariate annotations. Our results challenge existing paradigms that extensive epigenetic, transcriptomic and proteomic alterations exist in the FTs from women carrying heterozygous germline BRCA1/2 pathogenic variants. We find minimal differences between BRCA1/2 carriers and non-carriers prior to loss of heterozygosity. Covariates such as age and surgical indication can confound BRCA1/2-related differences reported in the literature, mainly through their impact on cell composition. We systematically document and highlight the degree of variations across normal human FT, defining five groups capturing major cellular and molecular changes across various reproductive stages, pregnancy, and aging. We are able to associate gene, protein, and epigenetic changes with these and other clinical covariates, but not heterozygous BRCA1/2 mutation status. This sheds new light into prevention and early detection of tumorigenesis in populations at high-risk for ovarian cancer.

INTRODUCTION: The COVID-19 pandemic negatively impacted the working conditions and mental health of healthcare workers (HCWs) across the globe. Little is understood of the factors influencing the mental health of HCWs in low-and middle-income countries like Ghana, which faced significant challenges from the COVID-19 pandemic due to their overburdened healthcare systems. Our study qualitatively examined the multilevel factors influencing HCWs mental health in response to the pandemic in Ghana, as well as coping strategies. METHODS: Utilizing an exploratory, descriptive qualitative research design, we purposively sampled and interviewed HCWs (n = 26) and administrators (n = 3) across 13 regions in Ghana from our parent study (N = 646) between November 2020 and February 2021. Semi-structured interviews explored pandemic preparedness, experiences responding to the pandemic, the impact of the pandemic on life, work, quality of care, and mental health; challenges and facilitators of the COVID-19 response; and coping strategies. Transcripts were coded through a group-based collaborative approach in the Dedoose software and analyzed thematically guided by the socio-ecological framework. RESULTS: HCWs reported experiencing fear, anxiety, stress, and depression due to the COVID-19 pandemic and cited several individual, interpersonal, institutional, and societal factors that adversely impacted their mental health. Individual-level factors included low knowledge of COVID-19 risk and sequelae and contraction of COVID-19. Interpersonal factors included being a parent/caregiver, risk posed to family/household as frontline workers, and social isolation. Institutional factors included inadequate health system capacity (i.e., low staffing capacity) and pandemic preparedness (i.e., inadequate COVID-19 training), and frontline working conditions (i.e., long work hours; higher COVID-19 infection risk). Societal factors were COVID-19-related stigma against HCWs, COVID-19 social conspiracies, and sociocultural beliefs about mental health in Ghana. Despite the negative impact of the pandemic on HCWs lives, most reported not receiving adequate support from their workplace or the government to mitigate mental health distress. However, HCWs identified several protective factors and coping strategies, including prayer/spirituality, spiritual and emotional support from family and colleagues, and, although limited, work-based or government incentives and appreciation. CONCLUSION: The COVID-19 pandemic has adversely impacted the mental health of HCWs in Ghana, who have inadequate resources to address these distresses. Investing in healthcare infrastructure, including expanding workforce and facility capacity and providing workplace mental health wellness services, can help mitigate the mental health impact of health crises like the COVID-19 pandemic on the healthcare workforce and subsequently maximize the capacity of the health system to respond to future pandemics.