Computer-generated recall letters for underimmunized children: how cost-effective?

OBJECTIVE

To evaluate the effectiveness and cost effectiveness of computer-generated recall letters to parents of children overdue for immunizations.

METHODS

This randomized controlled trial included children of two facilities in a regional health maintenance organization. Parents of 20-month-olds who had not yet received a measles-mumps-rubella (MMR) immunization were identified via a computerized immunization tracking system. One half were mailed personalized letters that included the recommended immunization schedule and a request to call for an appointment; the other half served as a control group. Receipt of the MMR between 20 and 24 months of age was evaluated with the computerized tracking system. A telephone survey was conducted with parents whose children had not received the MMR by 24 months. Decision analysis was used to project the theoretical outcomes and costs of a recall letter policy for other populations.

RESULTS

Among 20-month-old children 10% had not received the MMR; 289 families were included in the analysis. Of families who were mailed letters, 54% (82 of 153) received the MMR by 24 months of age, compared with 35% (47 of 136) of those in the control group (P = 0.001). The telephone survey was completed with 110 parents of children who still did not appear on the health plan computer as having received the MMR by 24 months. Fifteen percent said the child had received an immunization at an outside provider, and of the rest 62% said they had not been aware that an immunization was due. In the cost effectiveness analysis it was projected that recall letters would increase the immunization rate for the regional population of approximately 30000 children from 86% to 90% at a total cost of $5031 annually. The cost per additional child appropriately immunized was $4.04. In sensitivity analyses this cost effectiveness ratio varied depending on the baseline population coverage rate as well as the estimated effectiveness of recall letters.

CONCLUSIONS

Computer-generated letters to recall children overdue for immunizations resulted in a higher proportion of children appropriately immunized in this setting. However, the strategy was not as cost-effective as intuition might suggest. Further studies in health maintenance organization (HMO) settings should compare the cost effectiveness of letters with other low cost strategies including automated telephone reminders.

The cost of childhood chickenpox: parents' perspective

The development of a varicella vaccine has raised questions about the cost effectiveness of vaccination, but little information on the costs of chickenpox exists. The purpose of this study was to evaluate medical costs and the value of work loss among families whose children had chickenpox. Interviews were conducted with 179 families who made advice nurse calls or urgent care clinic visits to three clinics in the Northern California Kaiser Permanente Medical Care Plan. Two-thirds of working mothers and one-third of working fathers missed work to care for children with chickenpox. The mean value of the work lost because of chickenpox was $293/family or $183/chickenpox case. The estimated costs of nonprescription medications were $20/family or $12.50/chickenpox case. Children were sick enough to need to stay home for only one-third as many days as chicken actually stayed home because of school exclusion policies. These empiric results differ from previous estimates of the medical and work loss costs of varicella and should be included in analyses of the cost effectiveness of proposed vaccination programs.

Integrated cognitive behavioral therapy for comorbid cannabis use and anxiety disorders: A pilot randomized controlled trial

Cannabis use disorder (CUD) is the most common illicit substance use disorder and individuals with CUD have high rates of comorbid anxiety disorders. Comorbidity between CUD and anxiety disorders is of public health relevance given that although motivation enhancement therapy (MET) combined with cognitive-behavioral therapy (CBT) is an efficacious intervention for CUD, outcomes are worse for patients with elevated anxiety. The current study tested the acceptability and efficacy of the integration of a transdiagnostic anxiety CBT (i.e., treatment of patients with any anxiety disorder) with MET-CBT (integrated cannabis and anxiety reduction treatment, or ICART) for CUD compared to MET-CBT alone. Treatment-seeking cannabis users (56.4% male, M_age = 23.2, 63.3% non-Hispanic White) with CUD and at least one comorbid anxiety disorder were randomly assigned to ICART (n = 27) or MET-CBT (n = 28). Patients in the ICART condition attended significantly more treatment sessions than those in the MET-CBT condition. Patients in the ICART condition were more likely to be abstinent post-treatment than those in MET-CBT. Further, treatment produced decreases in cannabis use and related problems. Notably, therapy type did not moderate the impact of treatment on frequency of use and related problems. Together, these data suggest that ICART may be at least as efficacious as a gold-standard psychosocial CUD treatment, MET-CBT, for a difficult-to-treat subpopulation of cannabis users.

Safety of combined oligosaccharide conjugate Haemophilus influenzae type b (HbOC) and whole cell diphtheria-tetanus toxoids-pertussis vaccine in infancy. The Kaiser Permanente Pediatric Vaccine Study Group

The safety of the combined oligosaccharide conjugate Haemophilus influenzae (Hib) type b (HbOC) and whole cell diphtheria-tetanus toxoids-pertussis (DTP) vaccine (Tetramune, HbOC-DTP; Lederle) in infancy was evaluated in 6644 recipients of this vaccine and compared with 3914 recipients of separate injections of whole cell DTP and HbOC vaccines when given as a three dose regimen to infants at 2, 4 and 6 months of age in each group. Of the total number of infants in the study, a subset of 1435 were enrolled into the study and then randomly assigned to receive either the Hib-DPT combined vaccine or the separate components. This subset was used to assess local and systemic side effects which were evaluated utilizing telephone interviews 48 to 72 hours after vaccine. The remaining children in the study population were enrolled in a nonrandomized manner. For these children parents were offered the experimental Hib-DPT vaccine and refusers were given HbOC and DTP. Both of these groups of children as well as the randomized subset described above were used to assess rates of episodes of hospitalization, emergency room utilization and sudden infant death syndrome in HbOC-DTP recipients and children who received HbOC and DTP separately. Immunogenicity was evaluated in 123 children by collection of a single serum sample 30 days after the third dose of HbOC-DTP. The observed immunogenicity was comparable to that observed in other recent studies for HbOC and DTP component antigens. The profile of local and systemic side effects observed was virtually identical to that observed after DTP plus HbOC given separately.(ABSTRACT TRUNCATED AT 250 WORDS)

Context-specific drinking and social anxiety: The roles of anticipatory anxiety and post-event processing

Individuals with clinically elevated social anxiety are especially vulnerable to alcohol-related problems, despite not drinking more than those with less anxiety. It is therefore important to identify contexts in which socially anxious persons drink more to inform intervention efforts. This study tested whether social anxiety was related to greater drinking before, during, or after a social event and whether such drinking was related to the psychosocial factors anticipatory anxiety or post-event processing (PEP; review of the social event). Among past-month drinkers, those with clinically elevated or higher social anxiety (HSA; n = 212) reported more anticipatory anxiety, more pre-event drinking to manage anxiety, and PEP than those with normative or lower social anxiety (LSA; n = 365). There was a significant indirect effect of social anxiety on pre-drinking via anticipatory anxiety. Social anxiety was related to more drinking during the event indirectly via the serial effects of anticipatory anxiety and pre-drinking. Unexpectedly, PEP did not mediate or moderate the relation between social anxiety and post-event drinking. In sum, anticipatory anxiety was related to more drinking before, during, and after a social event and HSA drinkers were especially vulnerable to drinking more to manage this anxiety, which increased drinking before and during the event. This effect was specific to anticipatory anxiety and not evident for another social anxiety-specific risk factor, PEP. Thus, anticipatory anxiety may be an important therapeutic target for drinkers generally and may be especially important among HSA drinkers.

Assessing the acquisition of core clinical skills through the use of serial standardized patient assessments

PURPOSE

Students in many medical schools now undergo multiple standardized-patient-based assessments. In this study, the authors examine the ability of such serial assessments to detect interval learning.

METHOD

Twenty-one students from the University of California, Irvine, College of Medicine, class of 1999, underwent a clinical skills appraisal after three months of their third-year instruction. After nine months, all 89 members of that class completed an OSCE. Subsequently, all 87 students in the class of 2000 also completed clinical skills assessments after their third and ninth months of third-year instruction. All of these exercises included identical or similar stations measuring history, physical examination, and communication skills. Communication skills were measured somewhat differently during some of the exercises, using checklists that were either "content-" or "process-"oriented. The authors compared the performances for all groups.

RESULTS

Both classes demonstrated significant improvement in physical examination performance, while their history performances remained unchanged. According to the assessments, their communication skills deteriorated over the course of their third-year instruction. Repeated exposures to similar or identical cases on the serial assessments did not impact the students' performances. Both content- and process-oriented measures of communication skills yielded highly similar results.

CONCLUSIONS

Serial assessments using standardized patients can detect interval changes in performance that are independent of repeated exposures to similar or identical cases. Changes detected using this approach may have important curricular implications.

Cannabis use motives on weekends versus weekdays: Direct and indirect relations with cannabis use and related problems

College cannabis users report using more cannabis during the weekend than on weekdays, yet little attention has been paid to the role of weekend and weekday-specific motives for use. The present investigation evaluated the impact of weekend and weekday-specific cannabis motives on cannabis use and related problems among current (past-3 month) cannabis using undergraduates (N = 276). Participants reported more cannabis use motives during the weekend than weekday. Enhancement and social motives were greater than coping, conformity, and expansion motives during weekends. Enhancement and conformity motives were indirectly related to problems via cannabis use frequency for both weekdays and weekends. Yet social, coping, and expansion motives were indirectly related to problems via cannabis use frequency for only weekdays. Findings support the differential impact of weekend and weekday-specific motives on cannabis use and related problems.

Biopsychosocial Model Social Anxiety and Substance Use Revised

PURPOSE OF REVIEW

To review data published in the past 5 years to evaluate the utility of our biopsychosocial model of social anxiety's relation to substance misuse to evaluate the model's utility and update it.

RECENT FINDINGS

Data support the utility of our revised model-e.g., socially anxious persons report using substances to manage subjective anxiety, despite evidence that some substances may not have a direct effect on physiological responding. Other factors with promise include social influence, cognitive processes (e.g., post-event processing), and avoidance. Data highlight the importance of context as socially anxious persons use some substances more in some high-risk situations, despite lack of relation between social anxiety and use generally. Sociocultural factors remain understudied. This updated model is a theory- and data-driven model of the relations between social anxiety and substance misuse that can inform future work to improve substance-related outcomes among this especially vulnerable group.

Cannabis-Related Impairment and Social Anxiety: The Role of Use to Manage Negative and Positive Affect in Social Situations

Background and Objectives: Individuals with elevated social anxiety are thought to be at high risk for developing cannabis-related problems because they use cannabis to cope with anxiety-provoking social situations. Social anxiety is unique among the anxiety conditions in that it is characterized by both elevated negative affect (NA) and lower positive affect (PA). Yet it is unclear whether persons with elevated social anxiety use cannabis to decrease their NA or to increase their PA. Methods: This study examined the role of PA and NA (including cannabis use to increase PA and to decrease NA in social situations) on cannabis use frequency and related problems among current (past three-month) cannabis users (N = 278). Results: Social anxiety was significantly correlated with NA, PA, cannabis use to decrease NA, and use to increase PA. Serial mediation analyses tested the paths between social anxiety, affect, use to manage affect, typical cannabis use frequency, and cannabis use-related problems. Contrary to prediction, social anxiety was not indirectly related to use frequency or related problems via NA or PA generally. Rather, social anxiety was indirectly related to cannabis problems via the serial effect of use to cope with NA and typical use frequency and via the serial effect of use to increase PA and typical use frequency. Conclusions/Importance: Social anxiety may be associated with using cannabis to decrease NA and increase PA specifically in social situations, which increases cannabis use frequency and thus, problem risk.

Mental Health Problems and Suicide Risk: The Impact of Acute Suicidal Affective Disturbance

Acute Suicidal Affective Disturbance (ASAD) is a suicide-specific, episodic clinical entity that is theorized to characterize acute suicide risk. Little work has examined the role of ASAD in mental health conditions linked to suicide risk. Thus, the current study examined whether depression, social anxiety, panic, and alcohol-related problems were related to suicide risk via ASAD history. A total of 527 undergraduates completed an online survey. Depression, social anxiety, and alcohol problem risk (but not panic) were robustly, significantly related to suicide risk, but only social anxiety and depression were robustly related to ASAD history. Depression and social anxiety symptoms were indirectly related to suicide risk via ASAD. ASAD may serve as a potential explanatory pathway through which some mental health conditions may lead to greater suicide risk.

Safety and immunogenicity of Chiron/Biocine recombinant acellular pertussis-diphtheria-tetanus vaccine in infants and toddlers

OBJECTIVE

To evaluate the safety and immunogenicity of the recombinant acellular pertussis-diphtheria-tetanus (aPDT) vaccine (C-aPDT, Chiron/Biocine).

STUDY DESIGN

This is a randomized blinded trial evaluating the safety and immunogenicity of the recombinant aPDT vaccine (C-aPDT, Chiron/Biocine) in 2000 infant recipients compared with 498 controls who received whole cell diphtheria-pertussis-tetanus (wDPT; Connaught) vaccine at 2, 4 and 6 months of age. In addition the safety and immunogenicity of the same C-aPDT vaccine were evaluated as a booster dose in a subset of the same population when given at 15 to 18 months of age and compared with licensed Lederle aPDT vaccine.

RESULTS

The C-aPDT vaccine was associated with very few local or systemic reactions when compared with wDPT. In toddlers the local and systemic side effects observed were similar after either acellular vaccine. When the immunogenicity of the C-aPDT vaccine was compared with the wDPT (Connaught) in infancy, the vaccines were equivalent for anti-diphtheria response, the wDPT developed higher anti-tetanus response and the C-aPDT vaccine was significantly more immunogenic for all other antigens tested. In toddlers the C-aPDT acellular vaccine exhibited equal or improved immunogenicity for antigens tested as compared with Lederle aPDT except for a higher anti-filamentous hemagglutinin response with the Lederle aPDT vaccine.

CONCLUSION

The Chiron/Biocine aPDT vaccine offers an improved safety profile as well as improved immunogenicity when compared with a licensed wDPT product.

Dose Timing of D-Cycloserine to Augment Exposure Therapy for Social Anxiety Disorder: A Randomized Clinical Trial

IMPORTANCE

Findings suggest that the efficacy of D-cycloserine (DCS) for enhancing exposure therapy may be strongest when administered after sessions marked by low fear at the conclusion of exposure practice. These findings have prompted investigation of DCS dosing tailored to results of exposure sessions.

OBJECTIVE

To compare tailored postsession DCS administration with presession DCS administration, postsession DCS administration, and placebo augmentation of exposure therapy for social anxiety disorder.

DESIGN, SETTING, AND PARTICIPANTS

This double-blind randomized clinical trial involved adults with social anxiety disorder enrolled at 3 US university centers. Symptom severity was assessed at baseline, weekly during treatment, and at 1-week and 3-month follow-up. Data analysis was performed from September 2019 to March 2020.

INTERVENTIONS

Participants completed a 5-session treatment and received pills commensurate with their condition assignment at sessions 2 through 5, which emphasized exposure practice.

MAIN OUTCOMES AND MEASURES

Symptom severity was evaluated by the Liebowitz Social Anxiety Scale and Social Phobic Disorders-Severity Form as administered by independent evaluators.

RESULTS

A total of 152 participants were enrolled (mean [SD] age, 29.24 [10.16] years; 84 men [55.26%]). Compared with placebo, presession and postsession conditions showed greater symptom improvement (b = -0.25; 95% CI, -0.37 to -0.13; P < .001; d = 1.07; and b = -0.20; 95% CI, -0.32 to -0.07; P = .002; d = 0.85) and lower symptom severity (b = -0.51; 95% CI, -0.81 to -0.21; P < .001; d = 0.76; and b = -0.49; 95% CI, -0.80 to -0.18; P = .002; d = 0.72) at 3-month follow-up. No differences were found between presession and postsession conditions. The tailored condition showed no advantage over placebo. Compared with the tailored condition, presession and postsession conditions evidenced greater decreases (b = -0.22; 95% CI, -0.34 to -0.10; P < .001; d = 0.94; and b = -0.17, 95% CI, -0.29 to -0.04; P = .008; d = 0.72) and lower symptom severity (b = -0.44, 95% CI, -0.73 to -0.14; P = .004; d = 0.64; and b = -0.41, 95% CI, -0.72 to -0.11; P = .008; d = 0.61) at 3-month follow-up.

CONCLUSIONS AND RELEVANCE

Administration of DCS enhanced exposure therapy for social anxiety disorder when given before or after the exposure session. However, the study failed to achieve the aim to develop a tailored clinical application.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02066792.

Smoking and social anxiety: the role of false safety behaviors

Despite the negative health consequences associated with smoking, most smokers find it difficult to quit. This is especially true for smokers with elevated social anxiety. One factor that may play a role in maintaining smoking with elevated anxiety is false safety behavior (FSB), behaviors geared toward decreasing anxiety short-term but that maintain or increase anxiety long-term. The present study tested whether FSB explained the relation of social anxiety severity with smoking among 71 current smokers. Avoidance-related FSB was the only type of FSB related to cigarettes smoked per day (CPD) and it was robustly related to more CPD. Further, social anxiety was related to CPD indirectly via FSB-Avoidance. Findings suggest that more frequent use of avoidance behaviors to manage anxiety may maintain smoking and may partially explain the high rates of smoking among those with elevated social anxiety. Thus, FSB may be a promising target in smoking cessation interventions, especially among those with elevated social anxiety.

Difficulties with emotion regulation and drinking during the COVID-19 pandemic among undergraduates: the serial mediation of COVID-related distress and drinking to cope with the pandemic

The coronavirus disease 2019 (COVID-19) pandemic has contributed to thousands of hospitalizations and deaths worldwide. Although alcohol use has increased in response to the pandemic, no known studies have identified transdiagnostic risk factors for greater drinking in response to COVID-related distress. Individuals with more difficulty with emotion regulation may drink more during the pandemic to manage pandemic-related distress. The current study tested whether difficulty with emotion regulation was related to greater estimated blood alcohol content (eBAC) during a typical week in the past month and if this was due to COVID-related distress and drinking to cope with the pandemic. The sample consisted of 347 past-month drinking undergraduates in Louisiana, a state with some of the U.S. highest rates of COVID-19 infections and related deaths. Difficulty with engaging in goal-directed behaviors was related to greater past-month eBAC and this relation was mediated by the sequential effects of COVID-related worry and drinking to cope with the pandemic. Results indicate that individuals with difficulty engaging in goal-directed behaviors are especially vulnerable to greater eBAC during the COVID-19 pandemic which may be due in part to their vulnerability to more COVID-related worry which may lead to more drinking to cope with the pandemic.

On-line personalized feedback intervention for negative affect and cannabis: A pilot randomized controlled trial

Cannabis is the most commonly used illicit substance and many users report difficulty quitting. Situations involving stress and negative affect are the most difficult in which to abstain during quit/reduction attempts. Further, cannabis users with elevated social anxiety experience greater cannabis-related impairment than individuals with more normative levels of social anxiety. Yet, although most persons with cannabis-related problems are interested in quitting and endorse negative emotional symptoms, the vast majority do not seek in-person treatment. Thus, the current study tested the utility of an online personalized feedback intervention (PFI) that integrates feedback regarding cannabis with strategies to manage negative affect (PFI-NAC). Current (past month) cannabis using undergraduates (who used cannabis weekly, on average) were randomly assigned to the 1-session PFI-NAC (n = 37) or an assessment-only control (n = 26) and completed a 2-week follow-up assessment. After controlling for baseline negative affect and cannabis use frequency, social anxiety interacted with condition to predict follow-up cannabis use frequency. Specifically, among those with moderate or high levels of social anxiety, those in PFI-NAC reported less use at follow up than controls; this was not the case among those with lower social anxiety. Results of this pilot study indicate a 1-session intervention that teaches simultaneously teaching skills to manage negative affect and cannabis may benefit some cannabis users with moderate to high social anxiety. Future work with larger samples and a wider range of cannabis users, with longer follow-up assessments, are important next steps. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Drinking Problems and Social Anxiety among Young Adults: The Roles of Drinking to Manage Negative and Positive Affect in Social Situations

Background: Socially anxious individuals seem to be at a high risk for alcohol-related problems because they drink to cope. Yet social anxiety is unique among the anxiety conditions in that it is characterized by lower positive affect (PA). It is unclear whether drinking to cope is related to drinking to decrease negative affect (NA) or increase PA. Objectives: We tested whether social anxiety was related to more drinking problems via the sequential relations between affect (NA or PA), drinking to change affect (decrease NA or increase PA), and drinking quantity. We also tested whether the indirect effect of drinking to increase PA was significantly less than that of drinking to decrease NA. Methods: Past-month drinkers with clinically elevated social anxiety (n = 174) and those with more normative or lower social anxiety (n = 362) completed an online survey. Results: Social anxiety was indirectly related to drinking problems via the sequential effect of NA, drinking to decrease NA, and drinking quantity. Social anxiety was indirectly related to drinking problems via the sequential relations of PA and drinking quantity and of drinking to increase PA and drinking quantity. The indirect effect of drinking to increase PA did not significantly differ from drinking to decrease NA. Conclusions/Importance: Socially anxious drinkers may drink not only to decrease NA but also to increase PA in social situations. Both of these drinking motives appear to play important roles in socially anxious drinkers' experience of drinking-related problems.

A comparison of succinyladenylate lyase activity and serum sialic acid as markers of malignancy

A comparison was made of succinyladenylate lyase (SAMP lyase), total serum sialic (TSA), and lipid soluble serum sialic acid (LSA) as early markers of malignancy in three experimentally induced rat tumor models. Elevation of SAMP lyase in 3'-methyl-dimethylaminoazobenzene-induced hepatic tumors at 2 weeks corresponded with microscopic detection of preneoplastic lesions with elevation of LSA occurring 2 weeks later. Elevation of breast SAMP lyase concurred with macroscopic presence of dimethylbenzanthracene involved breast tumors with elevation of LSA occurring 12 weeks later. Neither colon SAMP lyase nor LSA increased in rats bearing colon tumors induced by dimethylhydrazine. The determination of TSA was not a reliable indicator of tumor presence for the three types of tumors investigated. Both SAMP lyase and LSA are very good early indicators of hepatic tumor with SAMP lyase an earlier indicator of breast tumor than LSA.

Online personalized feedback intervention reduces cannabis-related problems among college students with high problem distress

Despite experiencing problems related to using cannabis, very few undergraduate cannabis users are interested in treatment for cannabis-related problems or benefit from cannabis-focused online personalized feedback interventions (PFIs). Thus, it may be important to determine whether individuals perceive their problems as distressing, as only those who are distressed by their problems may be motivated to change their cannabis use or benefit from cannabis-related interventions. The current study examined cannabis-related problem distress, its relation to motivation to change cannabis use, and whether problem distress impacted outcomes of a problem-focused online PFI. Past-month cannabis-using undergraduates who endorsed experiencing at least one cannabis-related problem in the past 3 months were randomized to a PFI (n = 102) or a personalized normative feedback (PNF)-only condition (n = 102). Problem distress was robustly related to readiness, importance, and confidence to change cannabis use at baseline. Among those with high levels of problem distress at baseline, those in the PFI condition reported a greater decrease in problems than those in the PNF-only condition. This was not the case among those with lower levels of problem distress. Further, the number of cannabis-related problems did not moderate intervention outcomes. Cannabis users who perceive their problems as more distressing may be more motivated to change their cannabis use and more likely to benefit from a problem-focused PFI relative to a PNF-only intervention. Results have implications for the personalization of cannabis-focused interventions to maximize the impacts of interventions and decrease cannabis-related problems. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Impact of Brief Mindfulness Training on Postevent Processing Among Individuals With Clinically Elevated Social Anxiety

Postevent processing (PEP), the engagement in detailed and repetitive self-focused review of one's performance in social situations, is theorized to maintain pathological social anxiety. However, little is known about interventions that may impact this maintenance factor. The current study examined the impact of brief mindfulness training (BMT) on PEP among socially anxious individuals. There were 77 participants (75.32% female, 63.64% non-Hispanic/Latinx White) with clinically elevated social anxiety who attended one appointment in the laboratory during which they were randomized to receive a brief mindfulness-based training (n = 37) or no training (i.e., thinking as usual control group; n = 40). After the training period, participants underwent a 3-minute social anxiety induction task, after which they were instructed to apply their thinking strategy. Participants were then asked to complete 2 weeks of daily online surveys that included a PEP induction task, instructions to use their thinking strategy following PEP induction, and a measure of state PEP. Individuals in the BMT condition reported a significant reduction in state anxiety posttraining compared to individuals in the control condition. Conditions did not differ on state PEP after the social anxiety induction task. However, compared to those in the control condition, participants in the BMT condition reported significantly greater decreases in state PEP over the 14-day follow-up period. Thus, this brief mindfulness-based strategy may be useful for individuals with clinically elevated social anxiety who engage in PEP, a cognitive vulnerability factor implicated in the maintenance of social anxiety.