Smokeless Tobacco-associated Lesions: A Mobile Health Approach.

AIM: Globally, India accounts for the highest number of oral cancer cases. The survival rates are about 30% lower than those in developing countries. The main reason for these dismal figures is the late presentation of patients. In order to downstage oral cancer in such a scenario, screening and diagnosis at an early stage is warranted. A pragmatic approach is needed for an oral cancer screening program, hence a mobile health (mHealth) approach was used. In this approach, health workers were empowered with mobile phones with decision-based algorithm. Risk stratification of tobacco habit enables us to identify lesions associated with particular habits. MATERIALS AND METHODS: A specific cohort of factory employees who predominantly had pure tobacco chewing habit was chosen to examine the effect of pure tobacco on oral mucosa. One thousand three hundred and fifty-seven subjects were screened in two phases. In the first phase, habits and oral lesions were identified and photographed. The photographs were remotely diagnosed by an oral medicine specialist and those subjects requiring biopsy were recalled for phase II. Cytology and biopsy were performed in phase II. RESULTS: The predominant habit was smokeless tobacco (SLT), in 582 subjects. The most commonly encountered lesion was tobacco pouch keratosis seen in 397 subjects. Biopsy was performed for 71 subjects, most cases showed hyperkeratosis and mild dysplasia. One subject had moderate dysplasia. CONCLUSION: There was minimal alteration of tissues in our study subjects, which can be considered as low-risk. Use of mHealth empowered frontline healthcare workers to identify subjects with lesions and enabled remote diagnosis by specialist in resource-constrained settings. CLINICAL SIGNIFICANCE: Use of mHealth enabled us have an electronic record of subject details. This data shall be used for a planned follow-up of the same cohort after 3 years.

Mobile health application for remote oral cancer surveillance.

BACKGROUND: To determine the effectiveness of a mobile phone-based remote oral cancer surveillance program (Oncogrid) connecting primary care dental practitioners and frontline health care workers (FHW) with oral cancer specialists. METHODS: The study population (N = 3,440) included a targeted cohort (n = 2,000) and an opportunistic cohort (n = 1,440) screened by FHW and dental professionals, respectively. The authors compared the screening efficacy in both groups, with specialist diagnosis considered the reference standard. The outcomes measured were lesion detection and capture of interpretable images of the oral cavity. RESULTS: In the targeted cohort, among 51 of 81 (61%) interpretable images, 23 of 51 (45%) of the lesions were confirmed by specialists, while the opportunistic cohort showed 100% concordance with the specialists (106 of 106). Sixty-two of 129 (48%) of the recommended patients underwent biopsy; 1 of 23 (4%) were in the targeted cohort, and 61 of 106 (57%) were in the opportunistic cohort. Ninety percent of the lesions were confirmed to be malignant or potentially malignant. CONCLUSIONS: The mobile health-based approach adopted in this study aided remote early detection of oral cancer by primary care dental practitioners in a resource-constrained setting. Further optimization of this program is required to adopt the system for FHW. Evaluation of its efficacy in a larger population is also warranted. PRACTICAL IMPLICATIONS: The increased efficiency of early detection by dentists, when assisted by a remote mobile health-based approach, is a step toward a more effective oral cancer screening program.

Associations between mental health and surgical outcomes among women undergoing mastectomy for cancer.

Following diagnosis of breast cancer, many women experience serious psychological distress, which can adversely affect their cancer care and outcomes. We conducted this study to examine the association between mental health conditions and hospital outcomes and costs among women undergoing mastectomy for invasive breast cancer. Using nationally representative data from the 2005 to 2008 Nationwide Inpatient Sample, we identified women aged ≥18 years with invasive breast cancer who underwent inpatient mastectomy (N = 40,202). Individuals with a psychiatric diagnosis (major depressive, posttraumatic stress, panic, adjustment, or generalized anxiety disorder) or substance abuse were compared with those without a mental health condition. Outcomes included risk of complications, prolonged hospitalization (>3 days), and direct costs of care. Multivariable logistic and linear regression analyses were performed to control for sociodemographic and clinical characteristics. Overall, 4.5% of patients had a mental health condition. Patients with substance abuse were more likely than those without to experience both complications (8.5% versus 4.8%; adjusted odds ratio [AOR] = 1.61 [1.30-2.00]) and prolonged hospitalization (26.4% versus 13.6%; AOR = 2.25 [1.95-2.59]), and to have higher average costs ($9,855 versus $9,128, p = 0.009). Presence of psychiatric diagnoses was also significantly associated with increased complications (5.9% versus 4.8%; AOR = 1.21 [1.10-1.34]), prolonged hospitalization (8.5% versus 4.8%; AOR = 1.40 [1.32-1.49]), and higher average costs ($9,723 versus $9,108, p < 0.001). Mental health conditions are associated with poorer outcomes and higher costs in breast cancer patients undergoing inpatient mastectomy. Greater efforts are needed to identify and manage these patients with psychiatric and substance use disorders during the perioperative period.

A pilot study examining food insecurity and HIV risk behaviors among individuals recently released from prison.

Annually 700,000 individuals are released from U.S. prison, many at risk for food insecurity and HIV. The association between food insecurity and HIV risk behaviors has been established but not in this population. To investigate this association, we recruited 110 recently released prisoners to participate in a survey. Ninety-one percent of our sample was food insecure; 37% did not eat for an entire day in the past month. Those who did not eat for an entire day were more likely to report using alcohol, heroin, or cocaine before sex or exchanging sex for money compared to those who had at least a meal each day. From this pilot study, released prisoners appear to be at risk for food insecurity, and not eating for an entire day is associated with certain HIV risk behaviors. HIV prevention efforts should include longitudinal studies on the relationship between food insecurity and HIV risk behaviors among recently released prisoners.

Pubertal status, sensation-seeking, impulsivity, and substance use in high school-aged boys and girls.

OBJECTIVE: To examine how factors such as pubertal status, sensation-seeking, and impulsivity are related to substance use (cigarettes, alcohol, and marijuana) in high school students and examine these associations by gender. METHODS: Ten public high schools in Connecticut participated in a survey of high-risk behaviors. Adolescents from grades 9 to 12 (N = 3068) completed measures of physical development (Pubertal Development Scale), perceived pubertal timing, impulsivity and sensation-seeking (Zuckerman-Kuhlman Personality Questionnaire-Form III), and cigarette, marijuana, and alcohol use in the past 30 days. RESULTS: Logistic regression analyses modeling each substance use (cigarettes, marijuana, and alcohol) and gender separately showed that (1) early perceived pubertal timing was associated with cigarette use but Pubertal Development Scale was not associated with any substance use, (2) sensation-seeking was associated with use of all 3 substances, and (3) gender differences were detected: impulsivity was associated with use of all 3 substances among girls, but this was not found among boys. CONCLUSION: Future studies should examine the relationship among pubertal status, sensation-seeking, and impulsivity from preadolescence through late adolescence to better understand how these relationships to substance use may change with time and growth.

Gambling-related attitudes and behaviors in adolescents having received instant (scratch) lottery tickets as gifts.

OBJECTIVE: Instant (scratch) lottery ticket gambling is popular among adolescents. Prior research has not determined whether adolescents' gambling behavior and attitudes toward gambling are influenced by the receipt of scratch lottery tickets as gifts. METHOD: Cross-sectional survey data from 2,002 Connecticut high school students with past-year gambling were analyzed using bivariate approaches and logistic regression analyses. Interactions between gambling-problem severity and lottery-gift status were examined in relation to multiple outcomes. RESULTS: Adolescents who received a scratch lottery ticket as a gift compared with those who did not were more likely to report features of problem gambling, buy scratch lottery tickets for themselves, and buy and receive other types of lottery tickets; they were also less likely to report parental disapproval of gambling and to see gambling prevention efforts as important. Later (≥15 years) age-at-gambling-onset was inversely linked to gambling-problem severity in the lottery gift group (odds ratio [OR] = .38) but not in the nongift group (OR = .91), yielding a significant severity by gift status interaction. Other academic, health, and gambling-related correlates of gambling-problem severity were similar in the gift and nongift groups. CONCLUSIONS: For adolescents, the receipt of scratch lottery tickets as gifts during childhood or adolescence was associated with risky/problematic gambling and with gambling-related attitudes, behaviors, and views suggesting greater gambling acceptability. The extent to which the receipt of scratch lottery tickets may promote gambling behaviors and the development of gambling problems warrants consideration. Education, prevention, and treatment strategies should incorporate findings relating to receipt of gambling products by underage individuals.

The association between substance use disorders and mortality among a cohort of Veterans with posttraumatic stress disorder: variation by age cohort and mortality type.

BACKGROUND: Prior studies of Veterans have linked posttraumatic stress disorder (PTSD) with an increased risk of mortality. Other studies of Veterans have found that substance use disorders (SUDs) are associated with an excess risk of mortality among those with psychiatric disorders. It is not known whether having an SUD increases the risk of mortality among Veterans with PTSD, and whether the association differs by mortality type or varies by age cohort. METHODS: A cohort of patients who received Veterans Health Administration services during fiscal year (FY) 2004 and diagnosed with PTSD (n=272,509) were followed from FY 2005 through FY 2007 for the main outcomes of mortality and cause of death. RESULTS: SUD was positively associated with mortality during follow-up (adjusted hazards ratio: 1.70; 95% confidence interval: 1.64, 1.77). SUD was a stronger predictor of non-injury-related mortality for the <45 years group compared with the 45-64 or ≥65 group. SUD predicted injury-related mortality for all age groups. CONCLUSIONS: Among Veterans with PTSD, the association between SUD and mortality was most pronounced for the youngest age group, which included Iraq/Afghanistan Veterans. For older age groups, which included Vietnam-era Veterans, SUD was a greater predictor of injury-related mortality. The findings could be useful for identifying PTSD patients at excess risk of mortality.

Smoke-free policies in drinking venues predict transitions in alcohol use disorders in a longitudinal U.S. sample.

BACKGROUND: Smoke-free legislation prohibiting smoking in indoor public venues, including bars and restaurants, is an effective means of reducing tobacco use and tobacco-related disease. Given the high comorbidity between heavy drinking and smoking, it is possible that the public health benefits of smoke-free policies extend to drinking behaviors. However, no prior study has examined whether tobacco legislation impacts the likelihood of alcohol use disorders (AUDs) over time. The current study addresses this gap in the literature using a large, prospective U.S. sample. METHOD: Using data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), we utilized logistic regression to examine whether the implementation of state-wide smoke-free legislation in bars and restaurants between Waves I (2001-2002) and II (2004-2005) predicted changes in DSM-IV AUD status (remission, onset, recurrence) in current drinkers at Wave I (n=19,763) and participants who drank in public ≥once per month (n=5913). RESULTS: Individuals in states that implemented smoke-free legislation in drinking venues had a higher likelihood of AUD remission compared to participants in states without such legislation. Among public drinkers, smoke-free legislation was associated with a greater likelihood of AUD remission and a lower likelihood of AUD onset. These findings were especially pronounced among smokers, men, and younger age groups. DISCUSSION: These results demonstrated the protective effects of smoke-free bar and restaurant policies on the likelihood of AUDs; furthermore, these findings call attention to an innovative legislative approach to decrease the morbidity and mortality associated with AUDs.

Measuring use of evidence based psychotherapy for posttraumatic stress disorder.

To improve methods of estimating use of evidence-based psychotherapy for posttraumatic stress disorder in the Veteran's health administration, we evaluated administrative data and note text for patients newly enrolling in six VHA outpatient PTSD clinics in New England during the 2010 fiscal year (n = 1,924). Using natural language processing, we developed machine learning algorithms that mimic human raters in classifying note text. We met our targets for algorithm performance as measured by precision, recall, and F-measure. We found that 6.3 % of our study population received at least one session of evidence-based psychotherapy during the initial 6 months of treatment. Evidence-based psychotherapies appear to be infrequently utilized in VHA outpatient PTSD clinics in New England. Our method could support efforts to improve use of these treatments.

The relationship of dysthymia, minor depression, and gender to changes in smoking for current and former smokers: longitudinal evaluation in the U.S. population.

BACKGROUND: Although data clearly link major depression and smoking, little is known about the association between dysthymia and minor depression and smoking behavior. The current study examined changes in smoking over 3 years for current and former smokers with and without dysthymia and minor depression. METHODS: Participants who were current or former daily cigarette smokers at Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions and completed the Wave 2 assessment were included in these analyses (n=11,973; 46% female). Analyses examined the main and gender-specific effects of current dysthymia, lifetime dysthymia, and minor depression (a single diagnostic category that denoted current and/or lifetime prevalence) on continued smoking for Wave 1 current daily smokers and continued abstinence for Wave 1 former daily smokers. RESULTS: Wave 1 current daily smokers with current dysthymia (OR=2.13, 95% CI=1.23, 3.70) or minor depression (OR=1.53, 95% CI=1.07, 2.18) were more likely than smokers without the respective diagnosis to report continued smoking at Wave 2. Wave 1 former daily smokers with current dysthymia (OR=0.44, 95% CI=0.20, 0.96) and lifetime dysthymia (OR=0.37, 95% CI=0.15, 0.91) were less likely than those without the diagnosis to remain abstinent from smoking at Wave 2. The gender-by-diagnosis interactions were not significant, suggesting that the impact of dysthymia and minor depression on smoking behavior is similar among men and women. CONCLUSIONS: Current dysthymia and minor depression are associated with a greater likelihood of continued smoking; current and lifetime dysthymia are associated with a decreased likelihood of continued smoking abstinence.

Trauma experience among homeless female veterans: correlates and impact on housing, clinical, and psychosocial outcomes.

This study examined lifetime exposure to traumatic events as reported by 581 homeless female veterans enrolled in a Homeless Women Veterans Program across 11 sites to characterize the types of trauma they experienced; their correlation with baseline characteristics; and their association with housing, clinical outcomes, and psychosocial functioning over a 1-year treatment period. Almost all participants endorsed multiple types and episodes of traumatic events. Among the most common were having someone close experience a serious or life-threatening illness (82%) and rape (67%). Exploratory factor analysis revealed 6 potential trauma categories: being robbed, experiencing accident or disasters, illness or death of others, combat, sexual assault, and physical assault. At baseline, trauma from sexual assault was associated with more days homeless (ß = .18, p < .001), trauma from accidents or disasters was associated with poorer physical health (ß = -.23, p < .001), and trauma from being robbed was related to greater use of drugs (ß = .22, p < .001). Trauma reported at baseline, however, was not predictive of 1-year outcomes, suggesting type and frequency of trauma does not negatively affect the housing gains homeless women veterans can achieve through homeless services.

Veterans health administration information systems as a resource for rare disorders research: Creutzfeldt-Jakob disease as a paradigm.

OBJECTIVE: To illustrate the application of Veterans Health Administration (VHA) information systems in both clinical and epidemiologic investigations of a rare disease, our specific aims were: (1) to determine the number and incidence of Creutzfeldt-Jakob disease (CJD) diagnoses in the VHA from fiscal year (FY) 1997 through FY 2010 and (2) to describe the relevant clinical features associated with those diagnoses. METHODS: The VHA Medical SAS Datasets were queried for all unique, incident CJD diagnoses between FY 1997 and 2010. Electronic health records were then reviewed to validate diagnoses using modified criteria. RESULTS: During the study period, 115 CJD diagnoses (43 definite, 27 probable, 19 possible, and 26 suspected) were identified. Annual incidence ranged between 0.8 per million (95% CI, 0.3-1.7) in FY 2009 and 3.7 per million (95% CI, 2.1-6.4) in FY 1997. Dementia was documented in 111 cases (96.5%) and myoclonus in 73 (63.5%). Discharges consistent with CJD were noted in 31 of 78 patients (39.7%) with documented electroencephalography. CONCLUSIONS: For certain rare diseases, VHA information systems can be used to assemble a substantive case series for clinical study. However, the VHA's distinctive demographic characteristics and population dynamics may limit the external validity of epidemiologic investigations.

Complementary and alternative medicine in VA specialized PTSD treatment programs.

OBJECTIVE: This survey documented the provision of complementary and alternative medicine (CAM) treatments in U.S. Department of Veterans Affairs (VA) specialized posttraumatic stress disorder (PTSD) treatment programs. METHODS: Program coordinators or designated staff from 125 of 170 VA specialized PTSD treatment programs completed and returned surveys between September 2010 and March 2011, indicating which of 32 CAM treatments were offered in that program. RESULTS: Ninety-six percent of programs reported use of at least one CAM treatment. Eighty-eight percent offered CAMs other than those that are commonly part of conventional PTSD treatments (guided imagery, progressive muscle relaxation, and stress management-relaxation therapies). CONCLUSIONS: The widespread use of CAM treatments in VA PTSD programs presents an opportunity for researchers to assess the effect of CAM on mental health service use and PTSD symptoms among veterans. Future research should assess the effectiveness of CAM treatments and develop methods to tailor these treatments to veterans with PTSD.

The use of yoga in specialized VA PTSD treatment programs.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a chronic, debilitating anxiety disorder that is highly prevalent among U.S. military veterans. Yoga, defined to include physical postures (asana) and mindfulness and meditation, is being increasingly used as an adjunctive treatment for PTSD and other psychological disorders. No research or administrative data have detailed the use of these services in Department of Veterans Affairs' (VA) 170 PTSD treatment programs. METHODS: One hundred twenty-five program coordinators or designated staff completed an 81-item survey of their program's use of complementary and alternative medicine modalities in the past year. This report describes data from a subset of 30 questions used to assess the prevalence, nature, and context of the use of yoga, mindfulness, and meditation other than mindfulness practices. RESULTS: Results revealed that these practices are widely offered in VA specialized PTSD treatment programs and that there is great variability in the context and nature of how they are delivered. CONCLUSIONS: Understanding how yoga is used by these programs may inform ongoing efforts to define and distinguish yoga therapy as a respected therapeutic discipline and to create patient-centered care models that mindfully fulfill the unmet needs of individuals with mental health issues, including veterans with PTSD.

Access to VA services for returning veterans with PTSD.

OBJECTIVE: In order to understand access to treatment services for post-traumatic stress disorder (PTSD) in the Veterans Health Administration (VHA), we reviewed existing literature to estimate the proportion of Iraq and Afghanistan veterans who have used VHA services. METHODS: We reviewed studies regarding the prevalence of PTSD among Iraq and Afghanistan War veterans to estimate the need for treatment. We then compared need to Veterans Affairs utilization in order to estimate the proportion accessing care. RESULTS: Access to VHA services is high, with 58% of the estimated population of Iraq and Afghanistan veterans accessing some PTSD-related service. However, there is insufficient information about the quality of these services. CONCLUSIONS: The Veterans Affairs has been successful in providing access to treatment services for Iraq and Afghanistan Veterans with PTSD. Additional studies are needed to further characterize the quality of services provided.

Comparison of treatment outcomes for veterans with posttraumatic stress disorder with and without comorbid substance use/dependence.

Most of the attention to the treatment of patients who have comorbid Substance Use/Dependence Disorder (SUD) and Posttraumatic Stress Disorder (PTSD) has focused on SUD outcomes. This study focuses on the PTSD outcomes of comorbid patients as compared to those with PTSD only. Altogether 8599 Veterans admitted to VA specialized inpatient/residential PTSD programs were assessed for PTSD and SUD symptoms at admission and four months following discharge. Two samples were drawn sequentially in separate phases due to unexpected results in the first sample: 4966 in the first sample and 3633 in the second sample. In the first sample, dually diagnosed Veterans had significantly better PTSD outcomes than Veterans diagnosed with PTSD only. The differences could be attributed primarily to improvement in comorbid SUD symptoms. These results were replicated in the second sample. The results suggest that there may be a synergistic effect operating in the treatment of the two comorbid disorders.

Pathological gambling severity and co-occurring psychiatric disorders in individuals with and without anxiety disorders in a nationally representative sample.

While anxiety disorders (ADs) and pathological gambling (PG) frequently co-occur with each other and other Axis I and Axis II disorders, previous studies have not examined the relative influence of ADs on the co-occurrences between PG severity and non-anxiety psychopathologies. The current study used data from the National Epidemiologic Survey on Alcohol and Related Conditions (N=43,093) to examine the influence of past-year ADs on the associations between past-year PG severity measures based on DSM-IV criteria for PG and non-anxiety psychiatric disorders. The findings revealed that increased PG severity was associated with Axes I and II psychopathology in both the groups with and without ADs. Significant anxiety-by-gambling-group interactions were also observed, particularly with respect to mood and personality disorders. The interactions indicate a stronger relationship between PG severity and psychopathology in participants without ADs than in those with ADs. Future research should investigate specific factors contributing to the co-occurrence of anxiety, gambling, and other psychiatric disorders and how the co-occurrences might influence clinically relevant phenomena such as treatment selection or course.

Appropriate and inappropriate imaging rates for prostate cancer go hand in hand by region, as if set by thermostat.

Policy makers interested in containing health care costs are targeting regional variation in utilization, including the use of advanced imaging. However, bluntly decreasing utilization among the highest-utilization regions may have negative consequences. In a cross-sectional study of prostate cancer patients from 2004 to 2005, we found that regions with lower rates of inappropriate imaging also had lower rates of appropriate imaging. Similarly, regions with higher overall imaging rates tended to have not only higher rates of inappropriate imaging, but also higher rates of appropriate imaging. In fact, men with high-risk prostate cancer were more likely to receive appropriate imaging if they resided in areas with higher rates of inappropriate imaging. This "thermostat model" of regional health care utilization suggests that poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients. Health care organizations need clearly defined quality metrics and supportive systems to encourage appropriate treatment for patients and to ensure that cost containment does not occur at the expense of quality.

Racial comparison of therapeutic support, service use, and satisfaction among male outpatients with severe mental illness.

This study examined racial differences among male outpatients with severe mental illness on therapeutic support, mental health service utilization, and service satisfaction. A total of 530 participants (289 white, 179 black, and 62 of another race) across three large mental health centers (two state funded and one federally funded) in Connecticut were examined cross-sectionally. No racial differences were found in therapeutic support, and there were essentially no racial differences in service satisfaction. Black clients reported greater use of substance abuse inpatient services than White clients and clients of other racial minorities reported greater use of mental health inpatient services than White clients, but differences were small. These findings suggest there are few racial differences in the reported quality of mental health care and service utilization among male outpatients with severe mental illness. More research is needed on where and under what circumstances health disparities exist.

Recent trends in the treatment of posttraumatic stress disorder and other mental disorders in the VHA.

OBJECTIVE: This study proposed to evaluate Veterans Health Administration (VHA) specialty mental health care workload for treating posttraumatic stress disorder (PTSD) and other mental disorders between 2005 and 2010 in comparison with results from 1997 to 2005. The 2005-2010 time frame represents a period of increased utilization of services by recently returning veterans and of program expansion within VHA. METHODS: VHA administrative databases were queried for all veterans receiving specialty mental health treatment annually between 2005 and 2010. Veterans were categorized by military service era (WWII or Korea, Vietnam, post-Vietnam, Persian Gulf War [including operations in Iraq and Afghanistan], and peacetime or other), diagnosis (PTSD or a non-PTSD mental disorder), and deployment to Iraq or Afghanistan. RESULTS: The total number of veterans served per year increased by 623,326 (117.6%) between 1997 and 2010. Veterans with PTSD increased at a greater rate since 2005 compared with veterans with other mental disorders. Vietnam veterans constituted a majority of all veterans treated for PTSD or for other mental disorders, and the number of Vietnam veterans treated for PTSD continues to grow. The number of visits per veteran with PTSD increased between 2006 and 2010, reversing previous trends. The rate of increase has been highest for Iraq and Afghanistan veterans. CONCLUSIONS: Both the number treated and treatment intensity have increased for veterans with PTSD who served in current conflicts, which might be expected, and in the Vietnam era, now 30 years past. A reversal of past declines in treatment intensity coincides with an increase in PTSD treatment funding and program expansion since 2005.