Person: Fitzmaurice, Garrett
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Fitzmaurice
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Fitzmaurice, Garrett
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Publication Explaining geographic patterns of suicide in the US: the role of firearms and antidepressants(Springer International Publishing, 2014) Opoliner, April; Azrael, Deborah; Barber, Catherine; Fitzmaurice, Garrett; Miller, MattBackground: Suicide rates vary more than 3-fold across the fifty states. Previous ecological studies have pointed, separately, to covariation of suicide mortality with rates of a) household firearm ownership, and b) antidepressant prescriptions. Methods: An ecologic study using panel data from 2001-2005 was used to evaluate the joint and separate association of household firearm ownership and antidepressant prescription rates with the distribution of suicide rates across the United States. Key exposures were household firearm ownership prevalence (using data from the 2004 Behavioral Risk Factor Surveillance System) and antidepressant prescription rates (using data supplied by IMS health). Negative binomial mixed-effect models were used to estimate the association between household firearm ownership prevalence and antidepressant prescriptions rates and state level suicide rates (using data from the National Vital Statistics System), overall and by method of suicide (firearm vs. non-firearm). Sensitivity analyses examined analogous county-level data for those counties for which firearm ownership measures were available. All analyses were adjusted for median income, unemployment rate, and percent of population in urban areas. Results: In adjusted analyses, household firearm prevalence is significantly associated with overall suicide rates (adjusted incidence rate ratio (IRRa) = 1.28, 95% confidence interval (CI): 1.18, 1.38) and firearm suicides rates (IRRa = 1.61, CI: 1.45, 1.80), but not with non-firearm suicide rates (IRRa = 1.05, 95% CI: 0.95, 1.16). By contrast, adjusted analyses find no relationship between suicide rates and antidepressant prescription rates. Findings from county-level analyses were consistent with state-level results. Conclusion: The prevalence of household firearm ownership is strongly and significantly associated with overall suicide rates, due to its association with firearm suicide rates. This association is robust to consideration of the role of antidepressant prescription rates. A relationship between antidepressant prescription rates and suicide rates was not observed before or after adjusting for firearm ownership.Publication Treatment guidelines and early loss from care for people living with HIV in Cape Town, South Africa: A retrospective cohort study(Public Library of Science, 2017) Katz, Ingrid; Kaplan, Richard; Fitzmaurice, Garrett; Leone, Dominick; Bangsberg, David R.; Bekker, Linda-Gail; Orrell, CatherineBackground: South Africa has undergone multiple expansions in antiretroviral therapy (ART) eligibility from an initial CD4+ threshold of ≤200 cells/μl to providing ART for all people living with HIV (PLWH) as of September 2016. We evaluated the association of programmatic changes in ART eligibility with loss from care, both prior to ART initiation and within the first 16 weeks of starting treatment, during a period of programmatic expansion to ART treatment at CD4+ ≤ 350 cells/μl. Methods and findings We performed a retrospective cohort study of 4,025 treatment-eligible, non-pregnant PLWH accessing care in a community health center in Gugulethu Township affiliated with the Desmond Tutu HIV Centre in Cape Town. The median age of participants was 34 years (IQR 28–41 years), almost 62% were female, and the median CD4+ count was 173 cells/μl (IQR 92–254 cells/μl). Participants were stratified into 2 cohorts: an early cohort, enrolled into care at the health center from 1 January 2009 to 31 August 2011, when guidelines mandated that ART initiation required CD4+ ≤ 200 cells/μl, pregnancy, advanced clinical symptoms (World Health Organization [WHO] stage 4), or comorbidity (active tuberculosis); and a later cohort, enrolled into care from 1 September 2011 to 31 December 2013, when the treatment threshold had been expanded to CD4+ ≤ 350 cells/μl. Demographic and clinical factors were compared before and after the policy change using chi-squared tests to identify potentially confounding covariates, and logistic regression models were used to estimate the risk of pre-treatment (pre-ART) loss from care and early loss within the first 16 weeks on treatment, adjusting for age, baseline CD4+, and WHO stage. Compared with participants in the later cohort, participants in the earlier cohort had significantly more advanced disease: median CD4+ 146 cells/μl versus 214 cells/μl (p < 0.001), 61.1% WHO stage 3/4 disease versus 42.8% (p < 0.001), and pre-ART mortality of 34.2% versus 16.7% (p < 0.001). In total, 385 ART-eligible PLWH (9.6%) failed to initiate ART, of whom 25.7% died before ever starting treatment. Of the 3,640 people who started treatment, 58 (1.6%) died within the first 16 weeks in care, and an additional 644 (17.7%) were lost from care within 16 weeks of starting ART. PLWH who did start treatment in the later cohort were significantly more likely to discontinue care in <16 weeks (19.8% versus 15.8%, p = 0.002). After controlling for baseline CD4+, WHO stage, and age, this effect remained significant (adjusted odds ratio [aOR] = 1.30, 95% CI 1.09–1.55). As such, it remains unclear if early attrition from care was due to a “healthy cohort” effect or to overcrowding as programs expanded to accommodate the broader guidelines for treatment. Our findings were limited by a lack of generalizability (given that these data were from a single high-volume site where testing and treatment were available) and an inability to formally investigate the effect of crowding on the main outcome. Conclusions: Over one-quarter of this ART-eligible cohort did not achieve the long-term benefits of treatment due to early mortality, ART non-initiation, or early ART discontinuation. Those who started treatment in the later cohort appeared to be more likely to discontinue care early, and this outcome appeared to be independent of CD4+ count or WHO stage. Future interventions should focus on those most at risk for early loss from care as programs continue to expand in South Africa.Publication Effects of Inhaled Glucocorticoids on Bone Density in Premenopausal Women(Massachusetts Medical Society, 2001-09-27) Israel, Elliot; Banerjee, Taruna; Fitzmaurice, Garrett; Kotlov, Tania; Lahive, Karen; Leboff, MerylInhaled glucocorticoids are the most commonly used medications for the long-term treatment of patients with asthma. Whether long-term therapy with inhaled glucocorticoids reduces bone mass, as oral glucocorticoid therapy does, is controversial. In a three-year prospective study, we examined the relation between the dose of inhaled glucocorticoids and the rate of bone loss in premenopausal women with asthma. METHODS: We studied 109 premenopausal women, 18 to 45 years of age, who had asthma and no known conditions that cause bone loss and who were treated with inhaled triamcinolone acetonide (100 μg per puff). We measured bone density by dual-photon absorptiometry at base line, at six months, and at one, two, and three years. Serum osteocalcin and parathyroid hormone and urinary N-telopeptide, cortisol, and calcium excretion were measured serially. We measured inhaled glucocorticoid use by means of monthly diaries, supported by the use of an automated actuator-monitoring device. RESULTS: Inhaled glucocorticoid therapy was associated with a dose-related decline in bone density at both the total hip and the trochanter of 0.00044 g per square centimeter per puff per year of treatment (P=0.01 and P=0.005, respectively). No dose-related effect was noted at the femoral neck or the spine. Even after the exclusion of all women who received oral or parenteral glucocorticoids at any time during the study, there was still an association between the decline in bone density and the number of puffs per year of use. Serum and urinary markers of bone turnover or adrenal function did not predict the degree of bone loss.Publication Acute low back pain is marked by variability: An internet-based pilot study(Springer Science and Business Media LLC, 2011-10-05) Suri, Pradeep; Rainville, James; Fitzmaurice, Garrett; Katz, Jeffrey; Jamison, Robert; Martha, Julia; Hartigan, Carol; Limke, Janet; Jouve, Cristin; Hunter, DavidBackground: Pain variability in acute LBP has received limited study. The objectives of this pilot study were to characterize fluctuations in pain during acute LBP, to determine whether self-reported 'flares' of pain represent discrete periods of increased pain intensity, and to examine whether the frequency of flares was associated with back-related disability outcomes. Methods: We conducted a cohort study of acute LBP patients utilizing frequent serial assessments and Internet-based data collection. Adults with acute LBP (lasting ≤3 months) completed questionnaires at the time of seeking care, and at both 3-day and 1-week intervals, for 6 weeks. Back pain was measured using a numerical pain rating scale (NPRS), and disability was measured using the Oswestry Disability Index (ODI). A pain flare was defined as 'a period of increased pain lasting at least 2 hours, when your pain intensity is distinctly worse than it has been recently'. We used mixed-effects linear regression to model longitudinal changes in pain intensity, and multivariate linear regression to model associations between flare frequency and disability outcomes. Results: 42 of 47 participants (89%) reported pain flares, and the average number of discrete flare periods per patient was 3.5 over 6 weeks of follow-up. More than half of flares were less than 4 hours in duration, and about 75% of flares were less than one day in duration. A model with a quadratic trend for time best characterized improvements in pain. Pain decreased rapidly during the first 14 days after seeking care, and leveled off after about 28 days. Patients who reported a pain flare experienced an almost 3-point greater current NPRS than those not reporting a flare (mean difference [SD] 2.70 [0.11]; p < 0.0001). Higher flare frequency was independently associated with a higher final ODI score (ß [SE} 0.28 (0.08); p = 0.002). Conclusions: Acute LBP is characterized by variability. Patients with acute LBP report multiple distinct flares of pain, which correspond to discrete increases in pain intensity. A higher flare frequency is associated with worse disability outcomes.Publication Association of local capacity for endoscopy with individual use of colorectal cancer screening and stage at diagnosis(Wiley-Blackwell, 2010) Haas, Jennifer; Brawarsky, Phyllis; Iyer, Aarthi; Fitzmaurice, Garrett; Neville, Bridget; Earle, Craig; Kaplan, Celia PatriciaBACKGROUND: Limited capacity for endoscopy in areas in which African Americans and Hispanics live may be a reason for persistent disparities in colorectal cancer (CRC) screening and stage at diagnosis. METHODS: The authors linked data from the National Health Interview Survey on the use of CRC screening and data from Surveillance, Epidemiology, and End Results-Medicare on CRC stage with measures of county capacity for colonoscopy and sigmoidoscopy (endoscopy) derived from Medicare claims. RESULTS: Hispanics lived in counties with less capacity for endoscopy than African Americans or whites (for National Health Interview Survey, an average of 1224, 1569, and 1628 procedures per 100,000 individuals aged > or = 50 years, respectively). Individual use of CRC screening increased modestly as county capacity increased. For example, as the number of endoscopies per 100,000 residents increased by 750, the odds of being screened increased by 4%. Disparities in screening were mitigated or diminished by adjustment for area endoscopy capacity, racial/ethnic composition, and socioeconomic status. Similarly, among individuals with CRC, those who lived in counties with less endoscopy capacity were marginally less likely to be diagnosed at an early stage. Adjustment for area characteristics diminished disparities in stage for Hispanics compared with whites but not African Americans. CONCLUSIONS: Increasing the use of CRC screening may require interventions to improve capacity for endoscopy in some areas. The characteristics of the area where an individual resides may in part mediate disparities in CRC screening use for both African Americans and Hispanics, and disparities in cancer stage for Hispanics.Publication Sierra Leone's Former Child Soldiers: A Longitudinal Study of Risk, Protective Factors, and Mental Health(Elsevier BV, 2010) Betancourt, Theresa; Brennan, Robert; Rubin-Smith, Julia; Fitzmaurice, Garrett; Gilman, Stephen EdwardObjective To investigate the longitudinal course of internalizing and externalizing problems and adaptive/prosocial behaviors among Sierra Leonean former child soldiers and whether post-conflict factors contribute to adverse or resilient mental health outcomes. Method Male and female former child soldiers (N=260, ages 10–17 at baseline) were recruited from the roster of an NGO-run Interim Care Center in Kono District and interviewed in 2002, 2004 and 2008. The retention rate was 69%. Linear growth models were used to investigate trends related to war and post-conflict experiences. Results The long-term mental health of former child soldiers was associated with war experiences and post-conflict risk factors, which were partly mitigated by post-conflict protective factors. Increases in externalizing behavior were associated with killing/injuring others during the war and post-conflict stigma while increased community acceptance was associated with decreases in externalizing problems (B=−1.09). High baseline levels of internalizing problems were associated with surviving rape while increases were associated with younger involvement in armed groups and social and economic hardships. Improvements in internalizing problems were associated with higher levels of community acceptance and increases in community acceptance (B=−0.86). Decreases in adaptive/prosocial behaviors were associated with killing/injuring others during the war and post-conflict stigma, but partially mitigated by social support, being in school and increased community acceptance (B=1.93). Conclusions Psychosocial interventions for former child soldiers may be more effective if they account for post-conflict factors in addition to war exposures. Youth with accumulated risk factors, lack of protective factors, and persistent distress should be identified; sustainable services to promote community acceptance, reduce stigma, and expand social supports and educational access are recommended.Publication Association of Regional Variation in Primary Care Physicians’ Colorectal Cancer Screening Recommendations with Individual Use of Colorectal Cancer Screening(Centers for Disease Control and Prevention, 2007) Haas, Jennifer; Fitzmaurice, Garrett; Brawarsky, Phyllis; Liang, Su-Ying; Hiatt, Robert A; Phillips, Kathryn A; Klabunde, Carrie N; Brown, Martin LIntroduction: Studies show that the recommendations of a primary care physician for colorectal cancer screening may be one important influence on an individual's use of screening. However, another possible influence, the effect of regional differences in physicians' beliefs and recommendations on screening use, has not been assessed. Methods: We linked data from the National Health Interview Survey on the use of colorectal cancer screening by respondents aged 50 years or older, by hospital-referral region, with data from the Survey of Colorectal Cancer Screening Practices on the colorectal cancer screening recommendations of primary care physicians, by region. Our principal independent variables were the proportion of physicians in a region who recommended screening at age 50 and continuing screening at the recommended frequency. Results: On average, 53.3% of physicians in a region correctly recommended initiating colorectal cancer screening, and 64.8% advised screening at the recommended frequency. Of adults who lived in regions where less than 30% of physicians correctly recommended initiating screening, 47.3% had been screened, in contrast to 54.8% in areas where 70% or more of physicians made correct recommendations. Seventy-one percent of respondents living in regions where less than 30% of physicians advised screening at the recommended frequency were current on screening, in contrast to 79.9% of respondents living in regions where 70% or more of physicians made this recommendation. These differences were statistically significant after adjustment for individual characteristics. Conclusion: Strategies to improve colorectal cancer screening recommendations of primary care physicians may improve the use of screening for millions of Americans.Publication Correlates of Opioid Abstinence in a 42-Month Posttreatment Naturalistic Follow-Up Study of Prescription Opioid Dependence(Physicians Postgraduate Press, Inc, 2019-03-26) Weiss, Roger; Griffin, Margaret; Marcovitz, David; Hilton, Blake; Fitzmaurice, Garrett; McHugh, R. Kathryn; Carroll, Kathleen M.Objective: The natural course of prescription opioid use disorder has not been examined in longitudinal studies. The current study examined correlates of opioid abstinence over time after completing a treatment trial for prescription opioid dependence. Methods: The multi-site Prescription Opioid Addiction Treatment Study (POATS) examined different durations of buprenorphine-naloxone and different intensities of counseling to treat prescription opioid dependence; a longitudinal study was conducted following the clinical trial, from March 2009-January 2013. At 18, 30, and 42 months after treatment entry, telephone interviews were conducted (N=375). In this exploratory, naturalistic study, logistic regression analyses examined the association between treatment modality (including formal treatment and mutual help) and opioid abstinence rates at the follow-up assessments. Results: At the three follow-up assessments, approximately half of the participants reported engaging in current substance use disorder treatment (47-50%). The most common treatments were buprenorphine maintenance (27-35%) and mutual-help group attendance (27-30%), followed by outpatient counseling (18-23%) and methadone maintenance (4%). In adjusted analyses, current opioid agonist treatment showed the strongest association with current opioid abstinence (ORs=5.4, 4.6, and 2.8 at the three assessments), followed by current mutual-help attendance (ORs=2.2, 2.7, and 1.9); current outpatient counseling was not significantly associated with abstinence in the adjusted models. Conclusion: While opioid agonist treatment was most strongly associated with opioid abstinence among patients with prescription opioid dependence over time, mutual-help group attendance was independently associated with opioid abstinence. Clinicians should consider recommending both of these interventions to patients with opioid use disorder.