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David E Vance,1 Pariya L Fazeli,1 Shameka L Cody,1 Tyler R Bell,2 Caitlin Northcutt Pope,3 1Department of Acute, Chronic and Continuing Care, School of Nursing, 2Lifespan Developmental Psychology Program, 3Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA Abstract: For centuries, since the advent of harnessing magnetic and electrical energies, humans have been applying such energies to various body parts, including the brain, with the goal of improving health. Advancements over the past 2 decades in the production and affordability of such devices that precisely deliver such energies have resulted in novel therapeutic uses. One technique in particular, transcranial direct current stimulation, uses electrodes placed on the scalp to deliver a low electrical current to various areas on the surface of the neocortex. Such electrical currents stimulate neurons, which depending on the area of the neocortex it is applied and certain stimulation parameters, can either excite or inhibit certain functions within the brain that may result in alterations in mood, cognition, and behavior. This article provides an overview of this approach, explains how it is used, describes the hypothesized neurobiomechanisms involved, and explores its therapeutic potential. From this overview, implications for nursing practice and innovative uses for nursing research are posited. Keywords: tDCS, mood, cognition, electrical stimulation, cognitive training, depression

Background: We aimed to better understand the impact of statewide legislation removing personal belief exemptions (PBEs) for the measles, mumps, and rubella (MMR) school immunization requirement and factors associated with resulting health-seeking behaviors., Methods: We used chi-squared tests and logistic regression models to determine individual- and school-level characteristics associated with holding a MMR PBE and with post-law MMR immunization status among students linked to the Washington State Immunization Information System., Results: Of students with a MMR PBE pre-law change, 43.0% completed the MMR vaccine series and 40.4% sought another exemption type. Religious exemptions made up most new MMR exemptions signed (71.8%), followed by medical exemptions (18.5%), and religious membership exemptions (9.7%). Students were more likely to complete the vaccine series post-law change if they attended a school with a low school-level MMR exemption rate, a public school, or held a lower number of school-required immunization exemptions., Conclusions: This study confirms previous concerns that parents might replace their PBE with another exemption type; however, nearly half the students in the cohort completed the MMR vaccine series. Our findings suggest that targeted immunization policies can increase MMR coverage 1-year post-law change but must account for a replacement effect when exemption categories are eliminated., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Chronic pain leads to tau accumulation and hippocampal atrophy, which may be moderated through inflammation. In older men, we examined associations of chronic pain with Alzheimer's disease (AD)-related plasma biomarkers and hippocampal volume as moderated by systemic inflammation., Methods: Participants were men without dementia. Chronic pain was defined as moderate-to-severe pain in 2+ study waves at average ages 56, 62, and 68. At age 68, we measured plasma amyloid-beta (Aβ42, n = 871), Aβ40 (n = 887), total tau (t-tau, n = 841), and neurofilament light chain (NfL, n = 915), and serum high-sensitivity C-reactive protein (hs-CRP, n = 968), a marker of systemic inflammation. A subgroup underwent structural MRI to measure hippocampal volume (n = 385). Analyses adjusted for medical morbidities, depressive symptoms, and opioid use., Results: Chronic pain was related to higher Aβ40 (β = 0.25, p = .009), but hs-CRP was unrelated to AD-related biomarkers (ps > .05). There was a significant interaction such that older men with both chronic pain and higher levels of hs-CRP had higher levels of Aβ42 (β = 0.36, p = .001) and Aβ40 (β = 0.29, p = .003). Chronic pain and hs-CRP did not interact to predict levels of Aβ42/Aβ40, t-tau, or NfL. Furthermore, there were significant interactions such that Aβ42 and Aβ40 were associated with lower hippocampal volume, particularly when levels of hs-CRP were elevated (hs-CRP × Aβ42: β = -0.19, p = .002; hs-CRP × Aβ40: β = -0.21, p = .001), regardless of chronic pain status., Conclusions: Chronic pain was associated with higher plasma Aβ, especially when hs-CRP was also elevated. Higher hs-CRP and Aβ levels were both related to smaller hippocampal volumes. Chronic pain, when accompanied by systemic inflammation, may elevate the risk of neurodegeneration in AD-vulnerable regions., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Multivariate network-based analytic methods such as weighted gene co-expression network analysis are frequently applied to human and animal gene-expression data to estimate the first principal component of a module, or module eigengene (ME). MEs are interpreted as multivariate summaries of correlated gene-expression patterns and network connectivity across genes within a module. As such, they have the potential to elucidate the mechanisms by which molecular genomic variation contributes to individual differences in complex traits. Although increasingly used to test for associations between modules and complex traits, the genetic and environmental etiology of MEs has not been empirically established. It is unclear if, and to what degree, individual differences in blood-derived MEs reflect random variation versus familial aggregation arising from heritable or shared environmental influences. We used biometrical genetic analyses to estimate the contribution of genetic and environmental influences on MEs derived from blood lymphocytes collected on a sample of N = 661 older male twins from the Vietnam Era Twin Study of Aging (VETSA) whose mean age at assessment was 67.7 years (SD = 2.6 years, range = 62-74 years). Of the 26 detected MEs, 14 (56%) had statistically significant additive genetic variation with an average heritability of 44% (SD = 0.08, range = 35%-64%). Despite the relatively small sample size, this demonstration of significant family aggregation including estimates of heritability in 14 of the 26 MEs suggests that blood-based MEs are reliable and merit further exploration in terms of their associations with complex traits and diseases., (© 2024 The Author(s). American Journal of Medical Genetics Part B: Neuropsychiatric Genetics published by Wiley Periodicals LLC.)

Background and Objectives: Ensuring equitable vaccination access for immigrant communities is critical for guiding efforts to redress health disparities, but vaccine coverage data are limited. We evaluated childhood vaccination coverage by parental birth country (PBC) through the linkage of Washington State Immunization Information System data and birth records., Methods: We conducted a retrospective cohort evaluation of children born in Washington from January 1, 2006 to November 12, 2019. We assessed up-to-date vaccination coverage status for measles, mumps, and rubella (MMR), diphtheria, tetanus, and pertussis (DTaP), and poliovirus vaccines at ages 36 months and 7 years. Children with ≥1 parent(s) born in selected non-US countries were compared with children with 2 US-born parents, using Poisson regression models to provide prevalence ratios., Results: We identified 902 909 eligible children, of which 24% had ≥1 non-US-born parent(s). Vaccination coverage at 36 months by PBC ranged from 41.0% to 93.2% for ≥1 MMR doses and ≥3 poliovirus doses and 32.6% to 86.4% for ≥4 DTaP doses. Compared with children of US-born parents, the proportion of children up to date for all 3 vaccines was 3% to 16% higher among children of Filipino-, Indian-, and Mexican-born parents and 33% to 56% lower among children of Moldovan-, Russian-, and Ukrainian-born parents. Within-PBC coverage patterns were similar for all vaccines with some exceptions. Similar PBC-level differences were observed at 7 years of age., Conclusions: The linkage of public health data improved the characterization of community-level childhood immunization outcomes. The findings provide actionable information to understand community-level vaccination determinants and support interventions to enhance vaccine coverage., (Copyright © 2024 by the American Academy of Pediatrics.)

Chronic pain leads to tau accumulation and hippocampal atrophy in mice. In this study, we provide one of the first assessments in humans, examining the associations of probable chronic pain with hippocampal volume, integrity of the locus coeruleus (LC)-an upstream site of tau deposition-and Alzheimer's Disease-related plasma biomarkers. Participants were mostly cognitively unimpaired men. Probable chronic pain was defined as moderate-to-severe pain in 2+ study waves at average ages 56, 62, and 68. At age 68, 424 participants underwent structural magnestic resonance imaging (MRI) of hippocampal volume and LC-sensitive MRI providing an index of LC integrity (LC contrast-to-noise ratio). Analyses adjusted for confounders including major health conditions, depressive symptoms, and opioid use. Models showed that men with probable chronic pain had smaller hippocampal volume and lower rostral-middle-but not caudal-LC contrast-to-noise ratio compared to men without probable chronic pain. Men with probable chronic pain also had higher levels of plasma total tau, beta-amyloid-42, and beta-amyloid-40 compared to men without probable chronic pain. These findings suggest that probable chronic pain is associated with tau accumulation and reduced structural brain integrity in regions affected early in the development of Alzheimer's Disease. PERSPECTIVE: Probable chronic pain was associated with plasma biomarkers and brain regions that are affected early in Alzheimer's disease (AD). Reducing pain in midlife and elucidating biological mechanisms may help to reduce the risk of AD in older adults., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Abnormal tau, a hallmark Alzheimer's disease (AD) pathology, may appear in the locus coeruleus (LC) decades before AD symptom onset. Reports of subjective cognitive decline are also often present prior to formal diagnosis. Yet, the relationship between LC structural integrity and subjective cognitive decline has remained unexplored. Here, we aimed to explore these potential associations., Methods: We examined 381 community-dwelling men (mean age = 67.58; SD = 2.62) in the Vietnam Era Twin Study of Aging who underwent LC-sensitive magnetic resonance imaging and completed the Everyday Cognition scale to measure subjective cognitive decline along with their selected informants. Mixed models examined the associations between rostral-middle and caudal LC integrity and subjective cognitive decline after adjusting for depressive symptoms, physical morbidities, and family. Models also adjusted for current objective cognitive performance and objective cognitive decline to explore attenuation., Results: For participant ratings, lower rostral-middle LC contrast to noise ratio (LC CNR ) was associated with significantly greater subjective decline in memory, executive function, and visuospatial abilities. For informant ratings, lower rostral-middle LC CNR was associated with significantly greater subjective decline in memory only. Associations remained after adjusting for current objective cognition and objective cognitive decline in respective domains., Conclusions: Lower rostral-middle LC integrity is associated with greater subjective cognitive decline. Although not explained by objective cognitive performance, such a relationship may explain increased AD risk in people with subjective cognitive decline as the LC is an important neural substrate important for higher order cognitive processing, attention, and arousal and one of the first sites of AD pathology.

Objectives: Processing speed is essential to functional independence in later life, such as driving a vehicle. Few studies have examined processing speed and driving mobility in the context of racial differences and social determinants of health (SDoH). This study characterized the longitudinal association between processing speed and driving mobility, and how it varied by race and SDoH. Methods: Using data from the control arm of the Advanced Cognitive Training in Vital Elderly study ( n = 581, 24.5% Black), multilevel models examined longitudinal associations between processing speed and driving mobility outcomes (driving space, exposure, and difficulty). Race and SDoH moderations were explored. Results: Decline in processing speed measures was associated with increased self-reported driving difficulty, but only for older adults with below-average to average scores for neighborhood and built environments and social community context SDoH domains. Discussion: Findings emphasize the influence of physical and social environmental characteristics on processing speed and driving mobility., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Karlene Ball owns stock in the Visual Awareness Research Group (formerly Visual Awareness, Inc.), and Posit Science, Inc., the companies that market the Useful Field of View Test and speed of processing training software. Posit Science acquired Visual Awareness, and Dr. Ball continues to collaborate on the design and testing of these assessments and training programs as a member of the Posit Science Scientific Advisory Board. The other authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Composite scores of magnetic resonance imaging-derived metrics in brain regions associated with Alzheimer's disease (AD), commonly termed AD signatures, have been developed to distinguish early AD-related atrophy from normal age-associated changes. Diffusion-based gray matter signatures may be more sensitive to early AD-related changes compared with thickness/volume-based signatures, demonstrating their potential clinical utility. The timing of early (i.e., midlife) changes in AD signatures from different modalities and whether diffusion- and thickness/volume-based signatures each capture unique AD-related phenotypic or genetic information remains unknown., Methods: Our validated thickness/volume signature, our novel mean diffusivity (MD) signature, and a magnetic resonance imaging-derived measure of brain age were used in biometrical analyses to examine genetic and environmental influences on the measures as well as phenotypic and genetic relationships between measures over 12 years. Participants were 736 men from 3 waves of the Vietnam Era Twin Study of Aging (VETSA) (baseline/wave 1: mean age [years] = 56.1, SD = 2.6, range = 51.1-60.2). Subsequent waves occurred at approximately 5.7-year intervals., Results: MD and thickness/volume signatures were highly heritable (56%-72%). Baseline MD signatures predicted thickness/volume signatures over a decade later, but baseline thickness/volume signatures showed a significantly weaker relationship with future MD signatures. AD signatures and brain age were correlated, but each measure captured unique phenotypic and genetic variance., Conclusions: Cortical MD and thickness/volume AD signatures are heritable, and each signature captures unique variance that is also not explained by brain age. Moreover, results are in line with changes in MD emerging before changes in cortical thickness, underscoring the utility of MD as a very early predictor of AD risk., (Copyright © 2022 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Some evidence suggests a biphasic pattern of changes in cortical thickness wherein higher, rather than lower, thickness is associated with very early Alzheimer's disease (AD) pathology. We examined whether integrating information from AD brain signatures based on mean diffusivity (MD) can aid in the interpretation of cortical thickness/volume as a risk factor for future AD-related changes. Participants were 572 men in the Vietnam Era Twin Study of Aging who were cognitively unimpaired at baseline (mean age = 56 years; range = 51-60). Individuals with both high thickness/volume signatures and high MD signatures at baseline had lower cortical thickness/volume in AD signature regions and lower episodic memory performance 12 years later compared to those with high thickness/volume and low MD signatures at baseline. Groups did not differ in level of young adult cognitive reserve. Our findings are in line with a biphasic model in which increased cortical thickness may precede future decline and establish the value of examining cortical MD alongside cortical thickness to identify subgroups with differential risk for poorer brain and cognitive outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives. To assess the impact of Washington State's 2019 Engrossed House Bill (EHB) 1638-which removed measles, mumps, and rubella (MMR) personal belief exemptions-on MMR vaccine series completion and exemption rates in K-12 students. Methods. We used interrupted time-series analyses to examine changes in MMR vaccine series completion rates before and after EHB 1638 was passed and the χ 2 test for differences in exemption rates. Results. EHB 1638 implementation was associated with a 5.4% relative increase in kindergarten MMR vaccine series completion rates (95% confidence interval = 3.8%, 7.1%; P  ≤ .001), and results were similar with Oregon as a control state (no change observed in Oregon; P  = .68). MMR exemptions overall decreased 41% (from 3.1% in 2018-2019 to 1.8% in 2019-2020; P  ≤ .001), and religious exemptions increased 367% (from 0.3% to 1.4%; P  ≤ .001). Conclusions. EHB 1638 was associated with an increase in MMR vaccine series completion rates and a decrease in any MMR exemption. However, effects were partially offset by an increase in religious exemption rates. Public Health Implications. Removal of personal belief exemptions for the MMR immunization requirement only may be an effective approach to increase MMR vaccine coverage rates statewide and among underimmunized communities. ( Am J Public Health . 2023;113(7):795-804. https://doi.org/10.2105/AJPH.2023.307285).

Importance: Subjective memory concern has long been considered a state-related indicator of impending cognitive decline or dementia. The possibility that subjective memory concern may itself be a heritable trait is largely ignored, yet such an association would substantially confound its use in clinical or research settings., Objective: To assess the heritability and traitlike dimensions of subjective memory concern and its clinical correlates., Design, Setting, and Participants: This longitudinal twin cohort study was conducted from 1967 to 2019 among male adults with a mean (SD) age of 37.75 (2.52) years to follow-up at mean ages of 56.15 (2.72), 61.50 (2.43), and 67.35 (2.57) years (hereafter, 38, 56, 62, and 67 years, respectively) in the Vietnam Era Twin Study of Aging. The study included a national community-dwelling sample with health, education, and lifestyle characteristics comparable to a general sample of US men in this age cohort. Participants were monozygotic and dizygotic twins randomly recruited from the Vietnam Era Twin Registry. Data were analyzed from May 2021 to December 2022., Main Outcomes and Measures: Measures included subjective memory concern at 4 time points; objective memory, depressive symptoms, and anxiety at the last 3 time points; negative emotionality (trait neuroticism) at age 56 years; polygenic risk scores (PRSs) for neuroticism, depression, and Alzheimer disease; APOE genotype; and parental history of dementia. Primary outcomes were heritability and correlations between subjective memory concern and other measures., Results: The sample included 1555 male adults examined at age 38 years, 520 at age 56 years (due to late introduction of subjective memory concern questions), 1199 at age 62 years, and 1192 at age 67 years. Phenotypically, subjective memory concerns were relatively stable over time. At age 56 years, subjective memory concern had larger correlations with depressive symptoms (r, 0.32; 95% CI, 0.21 to 0.42), anxiety (r, 0.36; 95% CI, 0.18 to 0.51), and neuroticism (r, 0.34; 95% CI, 0.26 to 0.41) than with objective memory (r, -0.24; 95% CI, -0.33 to -0.13). Phenotypic results were similar at ages 62 and 67 years. A best-fitting autoregressive twin model indicated that genetic influences on subjective memory concern accumulated and persisted over time (h2 = 0.26-0.34 from age 38-67 years). At age 56 years, genetic influences for subjective memory concern were moderately correlated with genetic influences for anxiety (r, 0.36; 95% CI, 0.18 to 0.51), negative emotionality (r, 0.51; 95% CI, 0.44-0.57), and depressive symptoms (r, 0.20; 95% CI, 0.10 to 0.29) as well as objective memory (r, -0.22; 95% CI, -0.30 to -0.14). Similar genetic correlations were seen at ages 62 and 67 years. The neuroticism PRS was associated with subjective memory concern at age 38 years (r, 0.10; 95% CI, 0.03. to 0.18) and age 67 years (r, 0.09; 95% CI, 0.01 to 0.16). Subjective memory concern was not associated with any Alzheimer disease risk measures., Conclusions and Relevance: This cohort study found stable genetic influences underlying subjective memory concern dating back to age 38 years. Subjective memory concern had larger correlations with affect-related measures than with memory-related measures. Improving the utility of subjective memory concern as an indicator of impending cognitive decline and dementia may depend on isolating its statelike component from its traitlike component.

Background: Pain is associated with cognitive decline among older adults, but few studies have investigated bidirectional associations between pain and cognitive decline, especially in older Hispanic populations. Our objective was to assess the bidirectional association between pain interference and cognitive performance in a sample of older Puerto Rican adults., Methods: Data came from baseline and 4-year follow-up of the Puerto Rican Elderly: Health Conditions Study, a longitudinal representative study of Puerto Rican older adults aged 60 and older. Pain and cognitive performance were assessed at each wave. A pain interference variable was created using the sum of pain status (yes/no) and pain interference (yes/no; range 0-2). Global cognitive performance was assessed with the Mini-Mental Cabán. We tested bidirectional associations using a path model with concurrent and cross-lagged paths between pain and cognitive performance, adjusting for sociodemographic and health factors (n = 2 349)., Results: Baseline pain interference was not associated with baseline cognitive performance (p = .636) or with cognitive performance at follow-up (p = .594). However, increased pain interference at follow-up was associated with greater cognitive decline at follow-up (β = -0.07, standard error [SE] = 0.02, p = .003). Greater baseline cognitive performance was associated with lower pain interference at follow-up (β = -0.07, SE = 0.02, p = .007)., Conclusions: These findings highlight the importance of worsening pain interference as a potentially modifiable risk factor for cognitive decline, as pain treatment options exist. Additionally, better baseline cognitive performance may be a protective factor for pain, providing further evidence of the dynamic relationship between pain and cognitive performance., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America.)

COVID-19 can lead to severe outcomes in children (1). Vaccination decreases risk for COVID-19 illness, severe disease, and death (2). On December 13, 2020, CDC recommended COVID-19 vaccination for persons aged ≥16 years, with expansion on May 12, 2021, to children and adolescents (children) aged 12-15 years, and on November 2, 2021, to children aged 5-11 years (3). As of March 8, 2023, COVID-19 vaccination coverage among school-aged children remained low nationwide, with 61.7% of children aged 12-17 years and approximately one third (32.7%) of those aged 5-11 years having completed the primary series (3). Intention to receive COVID-19 vaccine and vaccination coverage vary by demographic characteristics, including race and ethnicity and socioeconomic status (4-6). Seattle Public Schools (SPS) implemented a program to increase COVID-19 vaccination coverage during the 2021-22 school year, focusing on children aged 5-11 years during November 2021-June 2022, with an added focus on populations with low vaccine coverage during January 2022-June 2022. † The program included strategic messaging, school-located vaccination clinics, and school-led community engagement. Vaccination data from the Washington State Immunization Information System (WAIIS) were analyzed to examine disparities in COVID-19 vaccination by demographic and school characteristics and trends over time. In December 2021, 56.5% of all SPS students, 33.7% of children aged 5-11 years, and 81.3% of children aged 12-18 years had completed a COVID-19 primary vaccination series. By June 2022, overall series completion had increased to 80.3% and was 74.0% and 86.6% among children aged 5-11 years and 12-18 years, respectively. School-led vaccination programs can leverage community partnerships and relationships with families to improve COVID-19 vaccine access and coverage., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Janet A. Englund reports institutional support from Pfizer, GlaxoSmithKline, AstraZeneca, and Merck; consulting fees from Pfizer, Moderna, Abbvie, Merck, and AstraZeneca; and travel support to attend the 2022 European Society for Paediatric Infectious Diseases meeting from AstraZeneca. No other potential conflicts of interest were disclosed.

Background and Objectives: Vascular theories of cognitive aging have focused on macrovascular changes and cognitive decline. However, according to the artery-size hypothesis, microvascular changes, such as those that underlie changes in erectile function, may also play an important role in contributing to cognitive decline. Thus, we examined associations between erectile function, sexual satisfaction, and cognition starting in middle age because this represents a transition period where declines in these areas emerge., Research Design and Methods: We examined 818 men from the Vietnam Era Twin Study of Aging across three waves at mean ages 56, 61, and 68. Erectile function and sexual satisfaction were measured using the International Index of Erectile Function. Cognitive performance was measured using factor scores for episodic memory, executive function, and processing speed. We tested multilevel models hierarchically, adjusting for demographics, frequency of sexual activity, and physical and mental health confounders to examine how changes in erectile function and sexual satisfaction related to changes in cognitive performance., Results: Lower erectile function at baseline was related to poorer performance in all cognitive domains at baseline and faster declines in processing speed over time. However, baseline sexual satisfaction was unrelated to cognitive performance. Decreases in erectile function and sexual satisfaction were both associated with memory decline., Discussion and Implications: Decreasing sexual health may signal an increased risk for cognitive decline. We discuss potential mechanisms, including microvascular changes and psychological distress. Discussing and tracking sexual health in middle-aged men may help to identify those likely to face memory decline., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

This study examined whether pain is associated with subjective memory problems or cognition in Puerto Rican older adults. Participants came from the Puerto Rican Elderly Health Conditions (PREHCO) study, aged 60 and over ( n  = 2,144). Analyses examined concurrent and longitudinal associations of pain with subjective memory problems and cognition using a cognitive screener. Overall, participants with pain were more likely to report concurrent subjective memory problems than those without pain. Older adults with pain also exhibited slightly lower concurrent cognition. Novel pain was associated with cognitive decline and greater likelihood of incident subjective memory problems at follow-up. Persistent pain was only related to incident subjective memory problems at follow-up. Pain is associated with cognitive decline and subjective memory problems in older Puerto Ricans. Future studies should implement more in-depth neuropsychological assessments and examine the potential role of barriers to pain management in this population.

Pain is inversely associated with cognitive function in older adults, but the effects of pain on cognitive decline are not fully clear. This study examined the associations of baseline pain, pain persistence, and incident pain with changes in cognition across 10 years in a sample of healthy community-dwelling older adults ( n = 688; M age = 74, SD = 6.05) from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial. While ACTIVE was a four-arm single-blind cognitive training randomized controlled trial, the present study includes only participants from the no-contact control group. Pain was examined using the Medical Outcomes Survey SF-36-Item (MOS SF-36) and cognitive tests examined simple processing speed, complex processing speed, divided and selective attention, memory, reasoning, and cognitive status. Multilevel models tested the associations of baseline pain, incident pain, and pain persistence on cognitive function and cognitive decline, adjusted for baseline age, time (years after follow-up), race, gender, education, marital status, and depressive symptoms at baseline and over time. Thirty-one percent reported pain at baseline which was related to worse baseline memory and accelerated decline in processing speed. Forty-two percent of older adults reported incident pain had accelerated decline in complex processing speed, divided attention, memory, reasoning, and cognitive status. On average, older adults reported a mean of two waves of pain persistence related to accelerated decline in memory. In sum, pain is common in community-dwelling older adults and is related to accelerated cognitive decline, especially when the incident. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objectives: To examine relationships between subjective memory impairment (SMI) and parental dementia among in older adults while considering the interactive influence of depressive symptoms, ethnicity, and race., Method: The sample was drawn from the Health and Retirement Study, a nationally representative longitudinal study of aging ( n  = 3,809; M age = 66.09; SD  = 1.88; 84.20% White; 12.23% Black; 7.88% Hispanic). Biennial assessments included two measures of SMI (current memory problems and perceived memory decline), depressive symptoms, and parental dementia, over periods of up to sixteen years. Multilevel modeling analyses examined longitudinal relationships between parental dementia and SMI and whether depressive symptoms, ethnicity, and race interactively influenced this association., Results: Results showed that when older adults reported parental dementia, they were more likely to report a decline in memory in the past two years. They also reported poorer current memory problems, especially when they experienced increased depressive symptoms. Associations of parental dementia were consistent across ethnicity and race., Conclusions: Results demonstrate the importance of considering parental dementia as a factor that may contribute to SMI in older adults.

This study examines geographic variations of human papillomavirus (HPV) vaccine uptake, the most significant disparity in HPV vaccination, in Washington State. We evaluated Washington State Immunization Information System (WA-IIS) data on target age (11-12 year old adolescents) between 2008 and 2018. A Bayesian spatio-temporal analysis was conducted to examine uptake at the census tract level. Urban-rural disparities in vaccine rates were assessed using t-tests. Persistently high and low vaccine areas and their contributing sociodemographic factors were then identified using a multinomial logistic regression. HPV vaccine uptake gradually increased after 2010, but remained persistently low. Average vaccine uptake rates from 2010 through 2018 in urban areas were 11%-34% for initiation and 4-19% for completion. These rates were 9-22% initiation and 3-11% completion in rural areas. We observed statistically significant (p < 0.05) differences between the estimated vaccine rates for urban and rural census tracts. Race/ethnicity and socioeconomic status were associated with this urban-rural disparity. The odds of being in low vaccine rural areas increased with increase in Area Deprivation Index (ADI) (OR = 1.14, CI = (1.10, 1.19)), and decreased with percentage increase in Black (OR = 0.43, CI = (0.02, 0.85)) and Hispanic (OR = 0.97, CI = (0.94, 1.00)) population. Bayesian spatial analysis was effective in capturing spatio-temporal patterns in HPV vaccine rates and identifying areas with persistently low vaccination over time. This analytic approach can be used to guide public health policies and geographically target interventions to reduce HPV vaccine disparities and to prevent future HPV-related cancers., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Current understanding of the psychometric properties of items intended to assess the multidimensional construct of subjective memory (SM) is limited, as longitudinal studies of aging commonly use single items or brief sets of items to assess SM. Investigating how SM items cluster within individuals over time would increase the understanding of how combining these items impacts their utility as an early indicator of cognitive change in the aging trajectory. To address this need, the current study examined the factor structure of a brief set of SM items in an existing longitudinal study focused on cognitive aging at both the within-person and between-person levels., Methods: Data were drawn from the Einstein Aging Study, a longitudinal cohort study of aging (N = 1,239, Mage = 77.51, SD = 5.03; 69.50% white; 24.27% black; 6.23% other). Community-dwelling older adults from an urban area of New York City were interviewed annually. At each wave, participants responded to 6 items intended to assess SM. Items assessed participants' perceived memory decline as well as current memory ability. Multilevel exploratory factor analyses examined which factor solution best fit the data at between-person and within-person levels., Results: Factor structure of the SM items varied at the two levels. At the within-person level, two factors emerged, whereas at the between-person level, a single factor best represented the SM items. Items assessing perceived declines in memory functioning tended to have similar trajectories, while items assessing current memory ability were less related to change over time., Conclusion: Items appeared to assess two different dimensions of SM when examining within-person changes in SM across time; however, the item structure suggested no other items covaried systematically within persons over time. In contrast to the conceptualization of SM as a multidimensional construct, our findings suggest that when measuring SM between individuals, SM items tend to capture a single dimension underlying SM. This may be due to the long retrospection period of items assessing perceived memory ability. A single item assessing perceived memory decline in older adults without evidence of objective cognitive impairment may be sufficient to monitor memory change in clinical or research settings., (© 2021 S. Karger AG, Basel.)

Objective: To assess the longitudinal association between fall history reported at a driver's license screening visit and the likelihood of subsequent vehicle crashes. Method: A total of 1,127 older adults were recruited from Maryland State Motor Vehicle Administration sites and interviewed annually over 15 years. Results: Individuals who reported a previous fall were more likely to be female, perform worse on physical functioning and divided attention tasks, and report more situational driving avoidance compared with non-fallers at baseline. Females who reported a fall at baseline had a 2.6× greater likelihood of subsequently reporting a crash over the 15 years than males. Among those who reported a fall at baseline, greater weekly driving exposure over the 15 years was associated with a 23% higher likelihood of a subsequent crash. Discussion: These findings support the utility of investigating nontraditional driver screening methods to identify drivers who may be at increased risk of future driving difficulties.

Objectives: The current study examined whether self-reported memory problems among cognitively intact older adults changed concurrently with, preceded, or followed depressive symptoms over time., Design: Data were collected annually via in-person comprehensive medical and neuropsychological examinations as part of the Einstein Aging Study., Setting: Community-dwelling older adults in an urban, multi-ethnic area of New York City were interviewed., Participants: The current study included a total of 1,162 older adults (Mage = 77.65, SD = 5.03, 63.39% female; 74.12% White). Data were utilized from up to 11 annual waves per participant., Measurements: Multilevel modeling tested concurrent and lagged associations between three types of memory self-report (frequency of memory problems, perceived one-year decline, and perceived ten-year decline) and depressive symptoms., Results: Results showed that self-reported frequency of memory problems covaried with depressive symptoms only in participants who were older at baseline. Changes in perceived one-year and ten-year memory decline were related to changes in depressive symptoms across all ages. Depressive symptoms increased the likelihood of perceived ten-year memory decline the next year; however, perceived ten-year memory decline did not predict future depressive symptoms. Additionally, no significant temporal relationship was observed between depressive symptoms and self-reported frequency of memory problems or perceived one-year memory decline., Conclusion: Our findings highlight the importance of testing the unique associations of different types of self-reported memory problems with depressive symptoms.

Background: Memory complaints and depressive symptoms are frequently associated in older adults and both serve as potential indicators of future cognitive decline. However, the temporal ordering of the development of these two symptoms remains unclear. The goal of the current study was to examine concurrent and temporal relationships between memory complaints and depressive symptoms in older adults., Methods: Data were drawn from two longitudinal, nationally representative datasets and included cognitively intact older adults aged 65 and over. The datasets in the current study were from the National Health and Aging Trends Study (NHATS) and the Health and Retirement Study (HRS). Using an integrative analytic framework, we tested bidirectional temporal relationships between memory complaints (memory ratings and perceived memory decline) and depressive symptoms over 6 to 9 years of data in over 5000 older adults across these two samples., Results: Across both datasets, perceived memory decline predicted future depressive symptoms whereas memory ratings did not. Additionally, results showed that at times when depressive symptoms tended to be higher, memory complaints were also higher, but depressive symptoms did not predict future memory complaints. One finding that was inconsistent across datasets was memory ratings predicting depressive symptoms. After accounting for covariates, this relationship was only significant in one dataset., Conclusions: Cognitively intact older adults who report memory decline may be at risk for developing depressive symptoms in the future. Furthermore, our findings highlight the importance of using immediate replication of results across datasets to determine the generalizability of conclusions.

The current study applied the Conservation of Resources (COR) disaster theory to explain suicide proneness after the Deepwater Horizon oilrig explosion. We had 213 residents in affected areas with complete measures of resource stability, distress, and coping 18 months after the disaster. Overall, 10% expressed clinically elevated suicide proneness. The COR model had excellent fit that accounted for 41% of inter-individual differences in suicide proneness. Aligned with theory, residents lacking resources who experienced distress and coped by avoidance were more suicide-prone. Fostering resource stability and constructive coping after catastrophe may help reduce suicide proneness and prevent suicide in disaster-impacted citizens.

The current study investigated whether having a first-degree relative with dementia influenced older adults' self-reported memory, if personality traits moderated these associations, and whether these associations differed by the type of item asked (ie, frequency of memory problems vs perceived memory decline). Data drawn from the Einstein Aging study included 454 older adults ( M age = 76.64, standard deviation = 4.77, 66.96% white, and 63% female). Multilevel modeling analyses showed participants who had a first-degree relative with dementia reported more frequent memory problems and were more likely to report memory decline over the past year. Among participants with a first-degree relative with dementia, higher levels of neuroticism were related to reports of more frequent memory problems at baseline, whereas higher levels of conscientiousness and lower levels of extraversion were related to reports of more frequent memory problems over time. Future research should consider personality traits and family history of dementia as potential contributors to self-reported memory problems.

Objectives: Memory complaints are a common concern for older adults and may co-occur with anxiety symptoms. Although both memory complaints and anxiety are associated with heightened cognitive decline risk, little is known about how these symptoms develop over time. The purpose of this study was to examine the differential concurrent and longitudinal relationships among anxiety symptoms and two types of memory complaints in cognitively intact older adults., Methods/design: The current study sample was drawn from two longitudinal, nationally representative datasets, the National Health and Aging Trends Study (NHATS) and the Health and Retirement Study (HRS). Cognitively intact older adults aged 65 and over were included, representing six (n = 5069; NHATS) and two (n = 5284; HRS) waves of data, respectively. Using multilevel linear modeling, we tested bidirectional relationships between anxiety and two types of memory complaints: current rating of memory performance and perceived memory decline., Results: Concurrent associations between anxiety symptoms and memory complaints were found in both datasets: At times when current memory performance was rated more poorly or perceived memory decline was reported, anxiety symptoms tended to be higher, and vice versa. A longitudinal relationship was identified in NHATS such that perceived memory decline, and not current memory rating, predicted future anxiety symptoms., Conclusion: This study provides a better understanding of the relationships between memory complaints and anxiety symptoms over time. Cognitively intact older adults with perceived memory decline are at greater risk for current as well as future anxiety symptoms., (© 2019 John Wiley & Sons, Ltd.)

Importance: Caregiver-targeted interventions to improve the use of child restraint systems (CRS) in motor vehicles are common and heterogeneous in their implementation. The effectiveness of these interventions is unknown., Objectives: To quantify the effects of caregiver-targeted interventions using meta-analytic methods, assess the quality of published studies, and assess for publication bias., Data Sources: PubMed and PsychINFO (January 1, 2004, to April 1, 2019) were searched for English-language studies using a list of search terms. The search and screening process was completed between May 25, 2018, and April 1, 2019., Study Selection: Studies met inclusion criteria if they included a caregiver-targeted intervention that focused on increasing CRS use for children (age, ≤9 years) and report the use of CRS before and after the intervention., Data Extraction and Syntheses: Cochrane and PRISMA guidelines were used for the meta-analysis and risk-of-bias review. Information was extracted on intervention type, setting, implementation, and attributes of the study independently between 2 coders. Data were pooled from independent samples, with 1 outcome measure from each intervention implementation or study., Main Outcomes and Measures: This study was an exploratory random-effects meta-analysis. Unadjusted odds ratios were calculated using the sample size and the observed number of children in incorrect or correct restraints in motor vehicles before and after the intervention to determine the odds of incorrect CRS use after completing an intervention. Setting, measurement method, randomization, use of vouchers, and types of restraint were tested as moderators. A funnel plot was used to assess for publication bias., Results: Of 1240 potential articles, 51 were deemed eligible for screening and 10 (8238 participants total) were included in the meta-analysis. Caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS (odds ratio, 0.51; 95% CI, 0.36-0.71; P < .001). Variance in the averaged effect size was driven by self-report methods (when removed from analyses, I2 = 61.8%; R2 change = 26.3; P = .02) and hospital settings (when removed from analyses, I2 = 70.7%; R2 change = 17.4; P = .002). Risk of bias was high in most studies; however, there was low evidence for publication bias., Conclusions and Relevance: In this meta-analysis, caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS in motor vehicles; however, the methodological rigor of intervention studies should be enhanced.

Background: Sexually transmitted infection (STI) partner services (PS) allow provision of human immunodeficiency virus (HIV)/STI prevention interventions to high-risk individuals, including testing reminders via short message service (SMS)., Methods: In King County, Washington, PS attempt to reach all men who have sex with men (MSM) with early syphilis and those with gonorrhea or chlamydia as resources allow. Since 2013, PS offered quarterly SMS testing reminders. We evaluated correlates of reminder uptake and the association between reminder uptake and postinterview asymptomatic STI diagnosis using Poisson regression, and the association between preinterview SMS reminder use and intertest interval among HIV-negative MSM using median regression., Results: During July 1, 2013 to January 17, 2018, 8236 MSM were reported with 1 or more STI diagnoses and 5237 received PS interviews. Of these, 4087 (78%) were offered SMS reminders; 545 (13%) accepted, 265 (7%) were already receiving SMS, 3277 (80%) refused. Of 2602 patients who refused and were asked about other reminders, 37% used none, 16% received reminders from medical providers, 20% tested at routine physicals, and 26% used other reminders. SMS reminder use before and after PS interview was associated with negative HIV status, younger age, and diagnosis with gonorrhea or chlamydia (vs. syphilis) (P < 0.05 for all). Preinterview intertest interval was longer among MSM testing at physicals (9.6 months) than those using no reminder (5.6), SMS reminders (4.7, P < 0.05 vs. physicals), and non-SMS reminders (3.6, P < 0.001 vs. SMS). Reminder uptake was not associated with postinterview STI diagnosis., Conclusions: Offering SMS reminders through STI PS is feasible. Uptake was low, but higher among young MSM not on preexposure prophylaxis. The SMS reminders may increase testing frequency.

Background: Sexually transmitted disease (STD) partner services (PS) are a core component of STD programs. Data on costs are needed to support PS programming., Methods: In Washington State STD PS programs, disease intervention specialists (DIS) conduct telephone-based interviews and occasional field visits, offer expedited partner therapy to heterosexuals with gonorrhea or chlamydia, and promote human immunodeficiency virus (HIV) testing, preexposure prophylaxis, and HIV care. We conducted activity-based microcosting of PS, including: observational and self-reported time studies and interviews. We analyzed cost, surveillance, and service delivery data to determine costs per program outcomes., Results: In King, Pierce, and Spokane counties, respectively, DIS allocated 6.5, 6.4, and 28.8 hours per syphilis case and 1.5, 1.6, and 2.9 hours per gonorrhea/chlamydia case, on average. In 2016, each full-time DIS investigated 270, 268, and 61 syphilis and 1177, 1105, and 769 gonorrhea/chlamydia cases. Greater than 80% of syphilis cases in King and Pierce were among men who have sex with men versus 38% in Spokane. Disease intervention specialists spent 12% to 39% of their time actively interviewing cases and notifying partners (clients), and the remaining time locating clients, coordinating and verifying care, and managing case reports. Time spent on expedited partner therapy, HIV testing, and referrals to HIV treatment or preexposure prophylaxis, was minimal (<5 minutes per interview) at locations with resources outside PS staff. Program cost-per-interview ranged from US $527 to US $2210 for syphilis, US $219 to US $484 for gonorrhea, and US $164 to US $547 for chlamydia., Discussion: The STD PS resource needs depended on epidemic characteristics and program models. Integrating HIV prevention objectives minimally impacted PS-specific program costs. Results can inform program planning, future budget impact, and cost-effectiveness analyses.

Self-reported memory problems are often the first indicator of cognitive decline; however, they are inconsistently associated with objective memory performance and are known to be influenced by individual factors, such as personality. The current study examined the relationships between personality traits and self-reported memory problems in cognitively intact older adults, and whether these associations differ across Black and White older adults. Data were collected annually via in-person comprehensive medical and neuropsychological examinations as part of the Einstein Aging Study. Community-dwelling older adults in an urban, multi-ethnic area of New York City were interviewed. The current study included a total of 425 older adults (Mage = 76.68, SD = 4.72, 62.59% female; 72.00% White). Multilevel modeling tested the associations of neuroticism, conscientiousness, extraversion, openness, and agreeableness with self-reported memory problems. Results showed that neuroticism was positively related to frequency of memory problems and perceived ten-year memory decline only when other personality traits were not accounted for. Extraversion was negatively related to frequency of memory problems and perceived ten-year decline for both White and Black participants. However, conscientiousness was negatively related to perceived ten-year decline for Black participants only. Our findings highlight the importance of examining the association of all five personality traits with self-reported memory problems, as well as examining whether these associations differ for participants from different race/ethnicities., Competing Interests: The authors have declared that no competing interests exist.

Background: For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study was to describe the driving habits of patients after right-sided foot surgery and assess the safety of left-footed driving using a driving simulator., Methods: Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via a REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 volunteer subjects to compare characteristics of left- versus right-footed driving., Results: Thirty-six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left-footed driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more ( P < .001) and hit other vehicles more ( P < .026) when driving with the right foot than the left. The time to fully brake and fully release the throttle in response to vehicular hazards was significantly prolonged in left-footed driving compared with right ( P = .019 and P = .034, respectively)., Conclusion: A significant proportion of right foot ankle surgery patients engaged in left-footed driving during postoperative recovery. Driving with both the right and left foot presents a risk of compromised safety. This study provides novel objective data regarding the potential risks of unipedal left-footed driving using a standard right-footed console, which indicates that driving with the left foot may prolong brake and throttle release times. Further studies are warranted for physicians to be able to appropriately advise patients about driving after foot and ankle surgery., Level of Evidence: Level IV, case series.

Background: Men who have sex with men (MSM) with bacterial sexually transmitted diseases (STDs) are at elevated risk of HIV. We evaluated the integration of pre-exposure prophylaxis (PrEP) referrals into STD partner services (PS) for MSM., Setting: King County, Washington., Methods: Disease Intervention Specialists (DIS) in King County attempt to provide PS to all MSM with early syphilis and, as resources allow, MSM with gonorrhea or chlamydia. Our health department defines MSM with any of the following as at high HIV risk: early syphilis, rectal gonorrhea, methamphetamine/poppers use, sex work, or an HIV-unsuppressed partner. DIS offer high-risk MSM referral to our STD Clinic for PrEP and other MSM referral to community providers. In 2017, we interviewed a random sample of MSM offered referrals in 2016 to assess PrEP initiation after PS., Results: From August 2014 to August 2017, 7546 cases of bacterial STDs were reported among HIV-negative MSM. DIS provided PS to 3739 MSM, of whom 2055 (55%) were at high risk. DIS assessed PrEP use in 1840 (90%) of these men, 895 (49%) of whom reported already using PrEP. DIS offered referrals to 693 (73%) of 945 MSM not on PrEP; 372 (54%) accepted. Among 132 interviewed for the random sample, men who accepted referrals at initial interview were more likely to report using PrEP at follow-up (32/68 = 47%) than those who did not (12/64 = 19%) (P = 0.0006). An estimated 10.4% of all interviewed MSM initiated PrEP following PS-based referral., Conclusions: Integrating PrEP referrals into STD PS is an effective population-based strategy to link MSM at high HIV risk to PrEP.

Cognitive impairments seen in people living with HIV (PLWH) are associated with difficulties in everyday functioning, specifically driving. This study utilized speed of processing cognitive remediation therapy (SOP-CRT) with transcranial direct current stimulation (tDCS) to gauge the feasibility and impact on simulated driving. Thirty PLWH ( M age = 54.53, SD = 3.33) were randomly assigned to either: sham tDCS SOP-CRT or active tDCS SOP-CRT. Seven indicators of simulated driving performance and safety were obtained. Repeated measures ANOVAs controlling for driver's license status (valid and current license or expired/no license) revealed a large training effect on average driving speed. Participants who received active tDCS SOP-CRT showed a slower average driving speed ( p = 0.020, d = 0.972) than those who received sham tDCS SOP-CRT. Non-significant small-to-medium effects were seen for driving violations, collisions, variability in lane positioning, and lane deviations. Combination tDCS SOP-CRT was found to increase indices of cautionary simulated driving behavior. Findings reveal a potential avenue of intervention and rehabilitation for improving driving safety among vulnerable at-risk populations, such as those aging with chronic disease.

Background: United States guidelines recommend azithromycin or doxycycline for chlamydia (Chlamydia trachomatis [CT]) treatment. These therapies are similarly efficacious for urogenital infections when outcomes are measured 7 to 42 days after treatment, although doxycycline may be superior for rectal infections. Some investigators have suggested that persistent rectal infections may lead to autoinfection of the urogenital tract, potentially resulting in higher rates of recurrent infection in azithromycin-treated women., Methods: We used Washington State surveillance data to identify women 14 years or older with urogenital CT (1992-2015) treated with azithromycin or doxycycline. We defined persistent/recurrent CT as a repeat positive CT test result 14 to 180 days after treatment of the initial infection. We used log binomial regression to estimate the adjusted relative risk (aRR) of persistent/recurrent infection associated with treatment with azithromycin versus doxycycline., Results: From 1992 to 2015, there were 268,596 reported cases of urogenital CT, including 168,301 (63%) who received azithromycin and 66,432 (25%) who received doxycycline. The risk of persistent/recurrent urogenital CT was 6.7% and 4.7% in azithromycin- and doxycycline-treated cases, respectively (P < 0.001). Adjusting for age, race/ethnicity, year, pregnancy status, jurisdiction reporting, reason for examination, and gonorrhea coinfection, azithromycin-treated women were significantly more likely to have persistent/recurrent urogenital CT than doxycycline-treated women (aRR, 1.24; 95% confidence interval [CI], 1.19-1.30). Adjusting the retesting window to 21 to 180 days (aRR, 1.24; 95% CI, 1.19-1.30) and 28 to 180 days (aRR, 1.25; 95% CI, 1.19-1.30) did not alter our primary findings., Conclusions: Persistent/recurrent urogenital CT may be more common among women treated with azithromycin than with doxycycline. The reason for this difference is uncertain and is an important area of future investigation.

Performing secondary tasks, such as texting while driving, is associated with an increased risk of motor vehicle collisions (MVCs). While cognitive processes, such as executive function, are involved in driving, little is known about the relationship between executive control and willingness to engage in distracted driving. This study investigated the relationship between age, behavioral manifestations of executive function, and self-reported distracted driving behaviors. Executive difficulty (assessed with the BRIEF-A) as well as demographics (age and gender) was considered as possible predictors of engagement in distracted driving behaviors. Fifty-nine young, middle, and older adults self-reported executive difficulty and weekly engagement in distracted driving behaviors. Results revealed that while partially accounted for by age, global executive difficulty was uniquely related to engagement in distracted driving behaviors. Older age was associated with fewer weekly self-reported distracted driving behaviors while higher self-reported executive difficulty was associated with more frequent weekly engagement in distracted behavior. No significant differences were found between young and middle-aged adults on distracted driving behaviors. Findings conclude that distracted driving is a ubiquitous phenomenon evident in drivers of all ages. Possible mechanisms underlying distracted driving behavior could potentially be related to deficits in executive function., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Men who have sex with men (MSM) with bacterial sexually transmitted diseases (STDs) are at elevated risk for HIV infection, but often do not test for HIV at time of STD diagnosis. We instituted and evaluated a program promoting HIV testing through STD partner services (PS). In May 2012, health departments in Washington State modified STD PS programs with the objective of providing PS to all MSM with early syphilis, gonorrhea, or chlamydial infection and ensuring that those without a prior HIV diagnosis tested for HIV infection. We used chi-square tests and logistic and log-binomial regression to compare the percentage of MSM who received PS, HIV tested, and were newly HIV diagnosed before (January 1, 2010 to April 30, 2012) and during the revised program (May 1, 2012 to August 31, 2014). Among MSM without a prior HIV diagnosis, 2008 (62%) of 3253 preintervention and 3712 (76%) of 4880 during the intervention received PS (p < 0.001). HIV testing among PS recipients increased from 63% to 91% (p < 0.001). PS recipients were more likely to be newly HIV diagnosed than nonrecipients during the preintervention (2.5% vs. 0.93%, p = 0.002) and intervention periods (2.4% vs. 1.4%, p = 0.050). The percentage of MSM with newly diagnosed HIV infection who had a concurrent STD diagnosis increased from 6.6% to 13% statewide (p < 0.0001). Among all MSM with bacterial STDs, 61 (1.9%) preintervention and 104 (2.1%) during the intervention were newly diagnosed with HIV infection (adjusted relative risk = 1.34, p = 0.07). In conclusion, promoting HIV testing through STD PS is feasible and increases HIV testing among MSM. Our findings suggest that integrating HIV testing promotion into STD PS may increase HIV case finding.

Background: Men who have sex with men (MSM) are at high risk for acquiring HIV infection after diagnosis with other sexually transmitted infections (STIs). Identifying the STIs associated with the greatest risk of subsequent HIV infection could help target prevention interventions, particularly preexposure prophylaxis (PrEP)., Methods: Using matched HIV and STI surveillance data from Washington State from January 1, 2007, to June 30, 2013, we calculated the incidence of new HIV diagnoses after different STI diagnoses among MSM. Men entered observation at the time of their first STI diagnosis during the study period and exited at HIV diagnosis or June 30, 2013. Cox proportional hazards regression was used to conduct a global comparison of rates., Results: From January 1, 2007, to June 30, 2013, 6577 HIV-negative MSM were diagnosed as having 10,080 bacterial STIs at 8371 unique time points and followed for 17,419 person-years. Two hundred eighty (4.3%) men were subsequently diagnosed as having HIV infection for an overall incidence of 1.6 per 100 person-years (95% confidence interval, 1.4-1.8). The estimated incidence of HIV diagnoses among all MSM in the state was 0.4 per 100 person-years. Men who have sex with men were at the greatest risk for HIV diagnosis after being diagnosed as having rectal gonorrhea (HIV incidence, 4.1 per 100 person-years), followed by early syphilis (2.8), urethral gonorrhea (1.6), rectal chlamydial infection (1.6), pharyngeal gonorrhea (1.1), late syphilis (1.0), and urethral chlamydial infection (0.6; P < 0.0001 overall)., Conclusions: Men who have sex with men diagnosed as having rectal gonorrhea and early syphilis were at the greatest risk for being diagnosed as having HIV infection after STI diagnosis. These men should be prioritized for more intensive prevention interventions, including PrEP.

Rabies prevention and control efforts have been successful in reducing or eliminating virus circulation regionally through vaccination of specific reservoir populations. A notable example of this success is the elimination of canine rabies virus variant from the United States and many other countries. However, increased international travel and trade can pose risks for rapid, long-distance movements of ill or infected persons or animals. Such travel and trade can result in human exposures to rabies virus during travel or transit and could contribute to the re-introduction of canine rabies variant or transmission of other viral variants among animal host populations. We present a review of travel- and trade-associated rabies events that highlight international public health obligations and collaborative opportunities for rabies prevention and control in an age of global travel. Rabies is a fatal disease that warrants proactive coordination among international public health and travel industry partners (such as travel agents, tour companies and airlines) to protect human lives and to prevent the movement of viral variants among host populations., (Published 2013. This article is a U.S. Government work and is in the public domain in the USA.)

US-bound immigrants with suspected non-infectious TB are encouraged to be medically re-evaluated after arrival in the United States. We evaluated the Centers for Disease Control and Prevention's immigrant referral process, designed to facilitate timely post-arrival evaluations. Over 1,200 immigrants with suspected TB arriving during October 1, 2008-September 30, 2010 were identified. In 2011, differences in days to evaluation initiation were assessed by referral type using survival analysis and Cox proportional hazard models. Among those receiving any referral, median time to post-arrival evaluation was significantly lower compared with immigrants receiving no referral (16 vs. 69 days, respectively; p < 0.0001). After adjusting for the covariates, immigrants receiving any referral initiated follow-up at 4 times the rate (adjusted hazard ratio = 4.0; p < 0.0001) of those receiving no referral. Implementing a referral system at US ports of entry will improve timeliness and increase the proportion of immigrants initiating domestic evaluation.

Background: In 2010, malaria caused approximately 216 million infections in people and 655,000 deaths. In the United States, imported malaria cases occur every year, primarily in returning travelers and immigrants from endemic countries. In 2010, five Plasmodium falciparum malaria cases occurred among crew members of one US commercial airline company (Airline A). This investigation aimed to assess the malaria prevention knowledge, attitudes, and practices (KAP) of Airline A crew members to provide information for potential interventions., Methods: The web link to a self-administered on-line survey was distributed by internal company communications to Airline A pilots and flight attendants (FA) eligible for international travel. The survey collected demographic information as well as occupation, work history, and malaria prevention education., Results: Of approximately 7,000 nonrandomly selected crew members, 220 FA and 217 pilots completed the survey (6%). Respondents correctly identified antimalarial medication (91% FA, 95% pilots) and insect repellents (96% FA, 96% pilots) as effective preventive measures. While in malaria-intense destinations, few FA and less than half of pilots always took antimalarial medication (4% FA, 40% pilots) yet many often spent greater than 30 minutes outdoors after sundown (71% FA, 66% pilots). Less than half in both groups always used insect repellents (46% FA, 47% pilots). Many respondents were unaware of how to get antimalarial medications (52% FA, 30% pilots) and were concerned about their side effects (61% FA, 31% pilots)., Conclusion: Overall, FA and pilots demonstrated good knowledge of malaria prevention, but many performed risky activities while practicing only some recommended malaria preventive measures. Malaria prevention education should focus on advance notification if traveling to a malaria-endemic area, how to easily obtain antimalarial medications, and the importance of practicing all recommended preventive measures., (© 2012 International Society of Travel Medicine.)

Purpose: Enuresis and sleep disordered breathing are common among children with sickle cell anemia. We evaluated whether enuresis is associated with sleep disordered breathing in children with sickle cell anemia., Materials and Methods: Baseline data were used from a multicenter prospective cohort study of 221 unselected children with sickle cell anemia. A questionnaire was used to evaluate, by parental report during the previous month, the presence of enuresis and its severity. Overnight polysomnography was used to determine the presence of sleep disordered breathing by the number of obstructive apneas and/or hypopneas per hour of sleep. Logistic and ordinal regression models were used to evaluate the association of sleep disordered breathing and enuresis., Results: The mean age of participants was 10.1 years (median 10.0, range 4 to 19). Enuresis occurred in 38.9% of participants and was significantly associated with an obstructive apnea-hypopnea index of 2 or more per hour after adjusting for age and gender (OR 2.19; 95% CI 1.09, 4.40; p = 0.03). Enuresis severity was associated with obstructive apneas and hypopneas with 3% or more desaturation 2 or more times per hour with and without habitual snoring (OR 3.23; 95% CI 1.53, 6.81; p = 0.001 and OR 2.07; 95% CI 1.09, 3.92; p = 0.03, respectively)., Conclusions: In this unselected group of children with sickle cell anemia, sleep disordered breathing was associated with enuresis. Results of this study support that children with sickle cell anemia who present with enuresis should be evaluated by a pulmonologist for sleep disordered breathing., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

The U.S. Department of Energy (DOE) has recently implemented a series of strategic initiatives to address long-term radiological surveillance needs at former U.S. test sites in the Marshall Islands. The plan is to engage local atoll communities in developing shared responsibilities for implementing radiation protection programs for resettled and resettling populations. As part of this new initiative, DOE agreed to design and construct a radiological laboratory on Enewetak Island, and help develop the necessary local resources to maintain and operate the facility. This cooperative effort was formalized in August 2000 between the DOE, the Republic of the Marshall Islands (RMI), and the Enewetak/Ujelang Local Atoll Government (EULGOV). The laboratory facility was completed in May 2001. The laboratory incorporates both a permanent whole body counting system to assess internal exposures to 137Cs, and clean living space for people providing 24-h void urine samples. DOE continues to provide on-going technical assistance, training, and data quality review while EULGOV provides manpower and infrastructure development to sustain facility operations on a full-time basis. This paper will detail the special construction, transportation and installation issues in establishing a whole body counting facility in an isolated, harsh environmental setting.