Degree: MPH-45 Field of Study: Quantitative Methods Practicum … · 2019. 8. 30. · Degree: MPH-45 Field of Study: Quantitative Methods Practicum Project Abstracts 2019 surgery

Degree: MPH-45

Field of Study: Quantitative Methods Practicum Project Abstracts 2019

Practice Organization Project Title and Abstract

Harvard T.H. Chan School of Public Health

Association of childhood adversity and psychosis-like experience among Peruvian pregnant women ABSTRACT Objectives: Adverse childhood experiences (ACEs) are associated with increased risk of psychological and physical health problems as adult. Previous studies have shown relationship between ACEs and psychosis in adults. To the best of our knowledge, no study has evaluated association of types and the number of ACEs and psychosis-like experience among pregnant women. These ACEs included childhood abuse (physical, psychological, or sexual), household dysfunction (growing up with substance abuse, mentally ill, or criminal family members or witnessing of a mother treated violently) and emotional neglect. Methods: This cross-sectional study included 2,068 pregnant women in Peru, Lima. Interviews were conducted in person in early pregnancy to collect data regarding socio-geographic characteristics, history of ACEs, and psychosis-like experience. We calculated the Adverse Childhood Experience Score (ACE Score) to examine the amount of ACEs that individuals exposed to in their childhood. We used the Prodromal Questionnaire (PQ-16) in Spanish to assess risk of psychosis. Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CIs). Results: Each type of ACEs is related to the high-risk of psychosis in early pregnancy. Women who experienced sexual abuse in their childhood had a 2.15-fold increased odds of being at high risk of psychosis during early pregnancy (aOR=2.15; 95% CI: 1.68, 2.74) as compared with women who reported no sexual abuse. Women who reported that they were not emotionally supported in their childhood had an increased odds of high-risk of psychosis (aOR=1.80; 95% CI: 1.42, 2.28) in comparison to those who did not report. Compared with women with the ACE Score of 0, women with a score of equal to or higher than 4 were more than twice as likely to have high-risk of psychosis during early pregnancy (aOR=2.53; 95% CI: 1.90-3.36). Conclusions: The ACE Score is associated with increased odds of the high risk of psychosis during pregnancy. These findings, if replicated, indicate the necessity of screening and treatment for pregnant women with ACEs.

Brigham and Women's Hospital

Risk Prediction Models For Atrial Fibrillation After Cardiac Surgery: A Systematic Review And Retrospective External Validation Objective: To perform a thorough systematic review, critical appraisal and external validation of models used to predict atrial fibrillation after cardiac surgery. Background: Postoperative atrial fibrillation (POAF) is the most common adverse event after cardiac surgery and is associated with increased morbidity, mortality and longer hospital and intensive care unit length of stay. Despite progressive improvements in overall cardiac surgical operative mortality and morbidity, the incidence of POAF has remained unchanged at 30%-50%. While many POAF risk prediction models have been published in the medical literature, there has been little systematic appraisal of their development, predictive performance and clinical usefulness on external datasets. Methods: The protocol for this systematic review was registered and published on PROSPERO (#: CRD42019127329). A validation cohort of 13314 adult patients who underwent CABG and/or valve

Degree: MPH-45


surgery at the Brigham and Women’s Hospital between Jan 2002 and Dec 2016 were identified. Predictive ability of each model identified will be assessed using the area under the ROC curves, Calibration and Decision Curve Analyses. Results: A total of 3237 studies were identified for title and abstract screening. A thorough full text review of 14 prediction models is currently underway on Covidence. Out of 13314 patients in the validation cohort, 31.4% (4179) developed post-operative atrial fibrillation.. The area under the ROC curves were as follows, 0.645 (95% CI, 0.635 - 0.654) for Tran et al., 0.655(95% CI, 0.634 - 0.663) for the Atrial Fibrillation Risk Index and 0.654 (0.645 - 0.664) for Thoren et al. Model calibration and Decision Curve Analyses are currently ongoing. Conclusions: POAF models found have a very limited ability to predict POAF in cardiac surgical patients. Future research should continue to focus on developing better predictive models.

Laboratories of Cognitive Neuroscience, Boston Children's Hospital

Inflammation, Electroencephalography, and Cognitive Outcomes in the Bangladesh Early Adversity Neuroimaging Study Objective: In the Bangladesh Early Adversity Neuroimaging (BEAN) project we seek to evaluate the association between exposure to early adversities and neurodevelopment of infants and young children growing up in an urban slum in Dhaka, Bangladesh. We specifically seek to examine the association between inflammation, electroencephalography (EEG), and cognitive outcomes to determine whether inflammation is a mediator of the impact of early adversities on the developing brain. Public Health Impact: Tens of millions of children worldwide are exposed to early biological and psychosocial hazards that negatively impact their long-term health and hinder them from reaching their full developmental potential. In the BEAN project we are assessing inflammation, a potential consequence of various adversities, with the goal of informing targets for interventions to support healthy development among children facing adversity. Background: There are multiple possible mechanisms by which early exposure to systemic, chronic inflammation may impact brain development, and more research is needed to understand the impact of early childhood inflammation in at-risk populations on neurodevelopmental outcomes. Neuroimaging may improve early detection of adverse developmental trajectories and thus inform targets for interventions. Methods: The BEAN study is a longitudinal observational cohort study. Our cohort consisted of 118 participants who had C-reactive protein (CRP) levels collected at 6, 18, 40, 53, and 104 weeks of age, height measured at 21, 30, and 36 months, EEG data collected at 36 months, and cognitive outcomes measured at 4 and 5 years using the Wechsler Preschool and Primary Scale of Intelligence (WPPSI). CRP elevation was defined as > 5 ug/mL, and multiple imputation was conducted to impute 1-2 missing values for 10 of the participants. Participants’ height-for-age (HAZ) scores were calculated and averaged across time points. Family care indicators (FCIs), a survey measure of stimulation in the home environment, were collected for all participants during home visits. Multiple linear regression is used to assess the associations between inflammation and cognitive outcomes, inflammation and EEG measures, and EEG measures and cognitive outcomes. A path analysis is then performed to determine if EEG measures mediate the effect of inflammation on cognitive outcomes. These analyses are ongoing.

Degree: MPH-45


Results: Preliminary results indicate that there is a significant negative association between the frequency of CRP elevation and verbal IQ at 4 years (p=0.03) and 5 years (p=0.022), and a borderline significant negative association with full-scale IQ at 5 years (p=0.048), after controlling for HAZ and FCIs. Evaluations of the associations between inflammation and EEG measures (global and regional power and functional connectivity), and EEG measures and cognitive outcomes are underway. Conclusions: Our preliminary results suggest that early life inflammation is negatively associated with cognitive outcomes at 4 and 5 years, after controlling for stunting and home care environment. We anticipate that inflammation will be negatively associated with EEG measures, that EEG measures will be associated with cognitive outcomes, and that a path analysis may demonstrate that EEG measures mediate the effect of inflammation on cognitive outcomes.

Massachusetts General Hospital

Predictors of face-to-face visit recommendation following teledermatology evaluation of suspected skin cancer OBJECTIVE: Teledermatology is increasingly being used to evaluate cases of suspected skin cancer, but its effectiveness has not been definitively established. This study aimed to identify predictors of "successful" teledermatology use where face-to-face visits could be avoided. METHODS: Data were collected at Massachusetts General Hospital on dermatology e-consults submitted as "suspicious lesions" between 2014 and 2017. Our primary outcome was face-to-face visit recommendation by the e-consulting dermatologist. Data were analyzed using independent T-test, Fisher's exact test, and logistic regression. RESULTS: History of prior skin cancer (OR 2.71, p=0.012), skin phototype of 3 (OR 0.30, p=0.017) or 4 (OR 0.18, p=0.018) compared to 1, and malignant lesion named by the referring provider (OR 3.33, p < 0.0001) were significantly associated with face-to-face visit recommendation after e-consult. All three predictors remained significant after multivariable adjustment. CONCLUSION: Teledermatology patients who have a paler skin phototype, have a history of skin cancer, or are suspected of a named malignancy by their primary provider are more likely to require a subsequent face-to-face visit and may benefit from initial ambulatory referral rather than teledermatology. SIGNIFICANCE: This information has implications for optimizing appropriate utilization of teledermatology resources so that patients will be properly triaged for direct ambulatory referral versus teledermatology referral.

Harvard T H Chan School of Public Health

Practice applications of analytical, evaluation and analysis methods for public health and emergency preparedness. This MPH-QM practicum involves a practice component and an integrated learning experience (ILE) component that was formerly referred to as the MPH "culminating experience". The practice component will provide the real-world experience and exposure to various projects within the public health and emergency preparedness fields. The ILE will involve working on one or more specific projects involving the use of various quantitative methods involving database computing, evaluation methods and/or statistical analyses applicable to real-world public health preparedness evaluation problems and questions. The specific ILE application that I will use will depend upon the topic and the status of the current EPREP projects that fit within the timeframe of the practicum period. Fitting within the practicum time-frame is the project currently being sponsored by the National Academy of Science, Engineering and Medicine (NASEM) Committee on Evidence-Based Practices for Public Health Emergency Preparedness and Response. The NASEM has been tasked with conducting a comprehensive review and grading of evidence for public health emergency preparedness and response (PHEP) practices, based on literature generated since September 11,

Degree: MPH-45


2001. This project will seek to aid in this task to inform the NASEM's deliberations regarding the evidence base for the 15 capabilities listed in CDC's Public Health Preparedness Capabilities: National Standards for State and Local Planning. Working as a four-person student team, participants will conduct a review and evidence mapping of academic and gray literature that examines and describes the extent and nature of the research conducted on practices that fall within the 15 PHEP capabilities since September 11, 2001. Specifically, the analysis will entail 1) identifying studies relevant to the 15 PHEP capabilities through a systematic search of the following databases and gray literature sources, 2) Selecting studies for inclusion based on selected NASEM criteria 3) mapping the information components to a meta-analytic data base and 4) synthesizing information in the form of a report that maps the evidence, describes themes and gaps in the existing evidence base, and includes author conclusions.

Harvard Chan School of Public Health

Life-course changes in adiposity from age 5 to 60 years old and the association of sex hormone concentration Background One of the mechanisms that obesity increases the risk of cancer and cardiovascular diseases is through the change in the level of sex hormones. However, little is known about the association between life-course change of adiposity and sex hormone concentration. Design Association between sex hormones (estrone, estradiol, sex hormone-binding globulins, testosterones) and trajectory adiposity is investigated with 5705 women of Nurse Health study and 1517 men of Health Professional Follow-Up Study. We use group-based trajectory models to create trajectories groups based on recalled somatotype data at age 5, 10, 18/21, 40 and body mass index at age 45, 50, 55, 60. Multivariate linear regression models were used.

HSPH The effects of omega-3 fatty acids on proteinuria among diabetic patients Omega-3 fatty acids help slow the progression of proteinuria among non-insulin dependent diabetes mellitus particularly after supplementing with omega-3 fatty acids for more than 24 weeks

Brigham and Women's Hospital, Department of Pharmacoepidemiology and Pharmacoeconomics

Prevalence, Predictors, and Outcomes of Treatment Resistant Hypertension in the Action to Control Cardiovascular Risk in Diabetes Trial (ACCORD) Background: The prevalence, predictors, and outcomes of resistant hypertensives are not well-elucidated, particularly in diabetic patients. Methods: We evaluated 2371 patients from the standard blood pressure arm of the Action to Control Cardiovascular Risk in Diabetes Trial. Resistant hypertension was defined as BP above goal ( ≥ 140 mmHg systolic) despite perfect adherence to ≥ 3 antihypertensive medications or BP control ( 20 mL/min decrease in eGFR (HR=1.49; 95% CI: 1.11-2.01; p=0.008). Conclusion: Resistant hypertension is more common among patients who are black, have macroalbuminuria, higher BMI, higher baseline SBP, and are taking more anti-hypertensive baseline medications. These patients are at increased risk for cardiovascular and mortality events, as well as renal events.

Degree: MPH-45


Boston Medical Center, BI, Boston Childrens, BWH

The Theory of Planned Behavior: How Cultural Attitudes, Social Norms, and Perceived Control Affect Infant Care Practices Despite its’ well-documented emotional and health benefits to both mother and infant, the practice of breastfeeding remains relatively low amongst a subset of mothers.1 Previous studies have shown that many factors, including psychosocial and socioeconomic status, contribute to mothers’ intentions to initiate and adhere to breastfeeding practices.2 Studies have also shown that there is racial/ethnic disparity in breastfeeding practice.2 What has not been studied however, is whether the domains of the theory of planned behavior(TPB) which include, attitude, perceived control and social norm, mediate the effect of maternal race/ethnicity on breastfeeding practices. In understanding this relationship, we can better elucidate the mechanism by which maternal intentions vary according to race/ethnicity. This will allow us to implement interventions that mitigate the effects of negative attitude, social norm and low perception of behavior control, on breastfeeding practices, thereby increasing the rates amongst mothers, closing the disparity gap and improving the overall health of mothers and their infants. The purpose of this study is to utilize data from the Study of Attitudes and Factors Effecting (SAFE) Infant Care Practices to determine whether racial/ethnic disparities in breastfeeding practices can be explained by maternal attitudes, perceived control and behavioral norms, using the Barron and Kenny approach to mediation analysis. In order to do this, we must 1.) examine how the TPB vary according to one’s race/ethnicity 2.) examine the association of TPB and breastfeeding practices and 3.) assess the association between maternal race/ethnicity and breastfeeding practices after controlling for the domains of the TPB.

Boston Children's Hospital

Is glutamine synthetase associated with PDAC patient outcomes? The purpose of this study is to investigate whether glutamine synthetase (GS) levels are associated with clinical outcomes for patients with pancreatic ductal adenocarcinoma (PDAC). We analyzed a tissue microarray from 142 patients who underwent surgical tumor resection at Massachusetts General Hospital. We found no association between GS levels and patient survival at the 5% significance level; however, patients with the lowest levels of GS experienced the worst survival. We found no association between GS levels and tumor extent, lymph node involvement, or grade of differentiation. Under low-glutamine conditions, GS activity may be an important component of metabolic adaptation of PDAC cells; however the biological mechanisms relating GS level and patient outcomes requires further exploration.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health

Evaluation of the Larval Index Rapid Assay for Aedes aegypti (LIRAa) as a predictor of dengue epidemics Examining whether the LIRAa larval survey served as a useful tool in predicting the occurrence of future dengue epidemics within Brazilian municipalities from 2009-2015. The findings of which are intended to help advise the Brazilian Ministry of Health, PAHO and the WHO update guidelines for dengue prediction and vector control efforts within Latin American countries.

MGH Using 311 Needle Database to Understand the Opioid Epidemic Background: Drug overdoses are a major cause of mortality in the United States, now outnumbering automobile accidents and gun violence. San Francisco (SF) has experienced one of the highest rates of overdose-related mortality in California, and public injection drug use and associated litter are major public health concerns.

Degree: MPH-45


Objectives: To use a publicly available, crowdsourced database of reports of discarded needles to understand the evolving drug overdose epidemic in SF. Methods: We conducted a longitudinal analysis of 311 needle reports in SF over a 10 - year period. Results: Between January 1, 2009 and December 31, 2018, 27,637 discarded needles were reported. The number of needles reported per year rose on average 3250% over the 10-year study period. Needle reports were primarily made via the Mobile/Open 311 app (59%) and direct calls to 311 (36%). More needle reports were made on weekdays (16% of needle reports per day, on average), whereas 10% of needle reports were logged per weekend day, on average (p < 0.001). By neighborhood, the most needle reports originated from South of Market (30%), Mission (16%), Civic Center (8%), and the Tenderloin (6%). Reported number of needles increased in all four of these neighborhoods during the study period, by 4710%, 2870%, 5260%, and 6580% respectively. Conclusion: Reports of discarded needles in SF have increased dramatically over the past 10 years and are primarily concentrated in 4 neighborhoods. Reports of discarded needled could be used to guide the development of harm reduction programs or target the installation of future needle disposal sites, as well as to provide an opportunity to engage the community.

Emergency Preparedness, Research, Evaluation and Practice (EPREP)

Practice applications of analytical, evaluation and analysis methods for public health and emergency preparedness This MPH-QM practicum involves a practice component and an integrated learning experience (ILE) component that was formerly referred to as the MPH "culminating experience". The practice component will provide the real-world experience and exposure to various projects within the public health and emergency preparedness fields. The ILE will involve working on one or more specific projects involving the use of various quantitative methods involving database computing, evaluation methods and/or statistical analyses applicable to real-world public health preparedness evaluation problems and questions. The specific ILE application that I will use will depend upon the topic and the status of the current EPREP projects that fit within the timeframe of the practicum period. Fitting within the practicum time-frame is the project currently being sponsored by the National Academy of Science, Engineering and Medicine (NASEM) Committee on Evidence-Based Practices for Public Health Emergency Preparedness and Response. The NASEM has been tasked with conducting a comprehensive review and grading of evidence for public health emergency preparedness and response (PHEP) practices, based on literature generated since September 11, 2001. This project will seek to aid in this task to inform the NASEM's deliberations regarding the evidence base for the 15 capabilities listed in CDC's Public Health Preparedness Capabilities: National Standards for State and Local Planning. Working as a four-person student team, participants will conduct a review and evidence mapping of academic and gray literature that examines and describes the extent and nature of the research conducted on practices that fall within the 15 PHEP capabilities since September 11, 2001. Specifically, the analysis will entail 1) identifying studies relevant to the 15 PHEP capabilities through a systematic search of the following databases and gray literature sources, 2) Selecting studies for inclusion based on selected NASEM criteria 3) mapping the information components to a meta-analytic data base and 4) synthesizing information in the form of a report that maps the evidence, describes themes and gaps in the existing evidence base, and includes author conclusions.

Degree: MPH-45



Angiogenic Biomarkers and Spontaneous Preterm Birth Preterm birth is a significant cause of perinatal morbidity worldwide. Approximately two thirds of these births are classified as “spontaneous.” The causes of preterm birth are not well understood. Studied have associated imbalances in angiogenic biomarkers with poor pregnancy outcomes, including preeclampsia. The purpose of this analysis is to evaluate whether there exists an association between imbalanced angiogenic biomarkers and spontaneous preterm birth. This project involved conducting a literature review and analyzing data from a cohort of women at Brigham and Women’s Hospital. Analysis drew upon coursework including logistic regression, propensity scores and inverse probability weighting, with exploration of two-stage models and survival analysis.

I did not work at an organization. I collaborated with a preceptor from MGH

Quantifying the impact of the opioid crisis on organ donation and transplantation in the United States he US is experiencing an epidemic of opioid abuse, which caused ~50,000 deaths in 2017. Separately, the US has a chronic shortage of organ donors available for life-saving transplant operations. Opioid-overdose victims are eligible for organ donation, and preliminary evidence suggests the opioid crisis has altered donation patterns in some regions. The goal of this project was to conduct a quantitative analysis of the burden of opioid overdose deaths and their impact on organ transplants, for year 2017. Mortality was tracked using the National Vital Statistics System. The age-distribution of opioid-overdose deaths showed two peaks, near 30 and 50, causing ~25% of deaths in these age groups. Deaths were concentrated in New England, Ohio, Appalachia, and the Capital Region. An estimated 2 million years of life lost were attributed to opioid overdoses, with 2/3 occurring in males. White non-Hispanic males were estimated to have lost 0.75 years of life expectancy. Data describing organ donors and transplant candidates/recipients were obtained from the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. Drug overdose was the 4th leading cause of death among donors nationwide and 1st in high opioid-burden states. The estimated years of life gained from transplant were heart:39000, kidney:180000, liver:87000, and lung:7700. Of the total 313000 life years gained across all organs, 45000 of these could be attributed to donors who died of drug overdoses. Overall, the opioid epidemic has dramatically changed the patterns of mortality and significantly impacted the pool of organ donors in the US.

University of Pennsylvania

Association of Medicaid expansion with cardiovascular mortality Background: Medicaid expansion under the Patient Protection and Affordable Care Act led to one of the largest gains in health insurance coverage for non-elderly adults in the US. However, its impact on cardiovascular mortality is unclear. Aim/Methods: We aimed to investigate the association of Medicaid expansion with cardiovascular mortality rates for middle-aged adults. Using the Centers for Disease Control WONDER database we obtained county-level age-adjusted cardiovascular mortality rates for 45-64 year old residents from 2010 to 2016. We used a difference-in-differences design to compare counties in Medicaid expansion states with those that did not expand coverage. Results:

Degree: MPH-45


As of 2016, 29 states and DC had expanded Medicaid eligibility, while 19 states had not (excluding Massachusetts and Wisconsin). Counties in expansion states had a smaller change in cardiovascular mortality rates, from the pre-expansion to post-expansion period, [146.5 (95% CI 132.4, 160.7) to 146.4 (95% CI 131.9, 161.0) deaths per 100,000 residents per year] compared with counties in non-expansion states [176.3 (95% CI 154.2, 198.5) to 180.9 (95% CI 158.0, 203.8) deaths per 100,000 residents per year]. After accounting for demographic, clinical and economic differences, counties in expansion states had 4.3 (95% CI 1.8, 6.9) fewer deaths per 100,000 residents per year from cardiovascular causes after Medicaid expansion, compared to if they had followed the same trends as counties in non-expansion states. Conclusions: Our findings suggest that recent Medicaid expansion was associated with lower cardiovascular mortality in middle-aged adults and may be of consideration as further expansion of Medicaid is debated.


combined use of Lewis antigen phenotype and carbohydrate antigen 19-9 concentration for prediction of survival in patients with pancreatic cancer Importance: It remains unclear that a combined status of serum Lewis antigen phenotype and serum CA 19-9 concentration has clinical utility to predict mortality of patients with pancreatic cancer. Objective: To access an association of a combined status of serum Lewis antigen phenotype and serum CA 19-9 concentration and mortality in pancreatic cancer patients. Design, setting, and participants: A total of 1187 patients diagnosed to pancreatic ductal adenocarcinoma (PDAC) from January 2010 to August 2017 were evaluated in a prospective cohort, Severance Hospital Cancer Registry Follow-up Cohort by a single tertiary hospital. Patients were classified into three different groups by Lewis antigen phenotype: (1) Lewis A antigen positive (La(a+b-)), (2) Lewis B antigen positive (La(a-b+)), and (3) Lewis antigen negative (La(a-b-)). Overall mortality was analyzed after adjusting for other potential predictors for PDAC survival. The study was conducted from January 31, 2017 to February 1, 2019. Main outcomes and measures: Hazard ratios (HRs) and 95% CIs of death after adjusting for other potential predictors for PDAC survival. Results: Of the 1187 patients, 375 (31.0%) were La(a-b-), 592 (50.1%) were La(a-b+), and 220 (18.5%) were La(a+b-). Median CA 19-9 concentrations increased in the order of La(a-b-), La(a-b+), and La(a+b-) (median [interquartile range]; 23.2 [2.7-312.6] U/mL; 180.3 [31.1-965.0] U/mL; 482.8 [108.2-2370.0] U/mL, respectively). Of the 375 La(a-b-) patients, 172 (46%) demonstrated CA 19-9 concentration greater than 37 U/mL. The risk of mortality increases in the order of La(a+b-), La(a-b+), and La(a-b-) (reference; HR=1.21, 95% CI=[1.00-1.42], p=.08; HR=1.47, 95% CI=[1.23-1.71], p=0.002) after adjusting for CA 19-9 (HR=1.24, 95% CI=[1.16-1.32], p < .001), AJCC stage with liver metastasis (I, reference; II, HR=3.71, 95% CI=[3.17-4.26], p < .001; III, HR=5.35, 95% CI=[4.77-5.93], p < .001; IV without liver metastasis, HR=7.95, 95% CI=[7.39-8.51], p < .001; IV with liver metastasis, HR=11.48, 95% CI=[10.91-12.06], p < .001), no chemotherapy history (HR=1.72, 95% CI=[1.54-1.91], p < .001) and so on.

Degree: MPH-45


Conclusions and relevance: The risk of mortality increases in the order of La(a+b-), La(a-b+), and La(a-b-) in PDAC patients, as serum CA 19-9 concentration increases. Our findings provide support for clinical recommendations to account for both of Lewis antigen phenotype and CA19-9 to predict a survival of pancreatic cancer

Massachusetts Institute of Technology, Harvard T.H. Chan School of Public Health

Identifying documented medical non-adherence from clinical notes using natural language processing Patient non-adherence (NA), which is estimated to cost around $100 billion annually to the United States healthcare system is an example of clinical information that is only recorded in unstructured clinical notes1. NA is a behavior when patients do not follow important medical advice. It is thought that NA increases the risk of undiagnosed and poorly-treated illnesses, with consequences ranging from worse patient-centered outcomes to biasing results of clinical drug trials if the effect was not properly controlled. Our contribution is twofold. Firstly, we present an experts-in-the-loop distantly-supervised NLP pipeline to extract NA. Note that this is documented non-adherence, which results from clinicians choosing to make a note. Such decisions may be shaded by clinician bias but this analysis of this is out of scope. The NLP pipeline was developed without spending significant clinical resources on annotation (< 30 hours). We show a comparison of the estimated clinical resource if we had tried to develop a fully supervised NLP algorithm to extract the NA feature. Our second contribution is a quantitative characterisation of patients exhibiting “documented non-adherence”. To the best of our knowledge, this has not been done before in the clinical literature. The patient population in our case came from a tertiary academic hospital in the United States. However, the approach presented should be replicable to extract the NA feature and understand characteristics of other patient populations.


Returning Actionable Pathogenic Genetic Results to Biobank Participants Partners Healthcare Biobank belongs to one of the research centers of eMERGE (Electronic Medical Records and Genomics) network. Different work groups have their own protocols of recruiting the participants for collect DNA samples for analysis, and returning the incidental actionable pathogenic genetic variants to them. Some biobanks have commercialized the recruiting process as an opportunity to understand each individual’s genomic data, but it appears to be promoting free preventive healthcare screening rather than inviting the participants to join the study for biomedical research. Therefore, with different types of language used in the recruiting process, there should be difference in the success rate in returning the results, and we are interested in studying the gaps.


Obesity over the life course and the risk of conventional adenoma and serrated polyp Obesity has been established as a public health epidemic. It leads to a number of comobidities, including cardiovascular diseases, diabetes, and cancer...etc. Obesity has been linked to colorectal cancer and its precursor lesions conventional adenoma and serrated polyp. However, little is known about the effect of obesity over the life course on the risk of conventional adenoma and serrated polyp. We analyzed participants who underwent at least one endoscopy in the Nurses' Health Study and Health Professional Follow-up Study. Multivariate logistic regression was used to model the risk

Degree: MPH-45


of conventional adenoma and serrated polyp. In men, the association of obesity with both types of polyp is more evident later in life, while the association is strong over the entire life course for women.

Harvard School of Public Health

The association between history of small for gestational age, preterm birth and metabolic syndrome among women, the National Health and Nutrition Examination Survey (1999-2006) Background Emerging evidence suggest that pregnancy complications may signal later-life cardiovascular disease risk, like metabolic syndrome (MetS). We sought to determine the association between a history of LBW infant and preterm birth with risk of MetS and its components. Methods We analyzed data from 4433 participants in the National Health and Nutrition Examination Survey (NHANES) 1999-2006. Participants were classified as “LBW only,” “LBW+Preterm,” or “Neither LBW nor Preterm.” MetS was defined by National Cholesterol Education Program’s Adult Treatment Panel III report criteria. Prevalence odds ratios and 95% confidence intervals were calculated using multivariable logistic regression, adjusting for potential confounders. Results The odds of MetS was 25% higher (95% CI -10%, +74%) in the LBW only group compared to the reference group. When fully adjusted, women with a history of LBW only (adj. OR: 0.91; 95% CI: 0.65, 1.28) and LBW+Preterm birth (adj. OR: 0.83; 95% CI: 0.64, 1.09) had slight inverse associations with MetS that was not statistically significant. There was a 47% increased odds of hypertension in the LBW+Preterm group (95% CI: +15%, +88%). Women with a history LBW only (OR: 0.73; 95%CI 0.53, 1.0) and LBW+Preterm birth (OR: 0.68; 95% CI .54, .84) had reduced odds of central obesity. Conclusions Women with a history of LBW and/or preterm birth may have altered metabolic risk which may have implications for later-life health in mothers. Future work is needed to determine the exact mechanisms involved and whether this information could be used in clinical settings for prevention of chronic disease.

HSPH Simulation of time limited trial in the ICU for cirrhotic patients in critical care Objective: To determine the optimal length of time-limited trial (TLT) care for cirrhotic patients in the intensive care unit (ICU) as opposed to time unrestricted invasive care.

Degree: MPH-45


Public Health Impact: Mortality due to cirrhosis in the ICU is high, it is reported that 40-90% of cirrhotic patients die during their stay in the ICU. Time unrestricted invasive procedures can reduce this mortality by up to 46%, however patient response is often unpredictable. In 2005, Vincent et al developed the TLT to overcome this unpredictability. A TLT is an agreement between the physician and patient/family to use specific, normally invasive, procedures over a defined period of time. At the end of this period, if the patient improves, care is continued, but if the patient deteriorates care is normally stopped and the patient is transferred to palliation. Unfortunately, there is very limited evidence on the period of time a TLT should last. This places tremendous uncertainty and burden on the physician, patient and family. Simulation models may overcome these challenges and provide certainty and reduce burden. Background: Under survival uncertainty, ICU patients may benefit from TLTs. However, due to the ethics of designating time limited care in clinical trials, there is very limited empirical evidence on the optimal duration of a TLT. Simulation models can overcome these ethical challenges to help determine the optimal duration of TLTs. Methods: We obtained data from the Medical Information Mart for Intensive Care III (MIMIC-III v1.4). Eligible patients were adults admitted to the ICU for the first time with a diagnosis of cirrhosis. We extracted demographic data and state transition probabilities from MIMIC-III, while utilities were derived from the literature in Tufts cost-effective analysis registry, and costs from Beth Israel Deaconess Medical Center Financial Services and Harvard Medical Faculty Physician Finance Services. Using first order Monte Carlo simulation models and various sensitivity analysis we simulated the flow of these patients throughout the ICU until they were discharged or died. As such we determined the minimal amount of time in days for a TLT that led to greater quality-adjusted life days than standard time unrestricted invasive care, the associated costs of care, and 30-day survival rates. Results: There were 419 unique cirrhotic patients in the MIMIC-III which had received invasive care and were then discharged to non-aggressive care, palliation, home or died. Their median age was 59, they had a median length of stay duration of 3 days, and a mortality ratio of 14%. Under the base case scenario, time unrestricted invasive care was more effective and costly than TLT. Once mortality after treatment was greater than or equal to 25% TLT was more cost-effective than time unrestricted invasive care and consistently had higher 30-day survival rates. Conclusions: For the first time in medical literature, we compute and report the optimal trial duration of TLTs for cirrhotic patients in the ICU. We also show that TLTs are cost-effective alternatives to standard time unrestricted invasive care, and have better 30-day survival rates. The method we use also provides easily interpretable results, is very generalizable to other pathologies and not computationally intense. We show that when evidence generation is limited due to ethical challenges, simulation models are a necessary alternative to clinical trials, expert opinion, and

Degree: MPH-45


descriptive studies, and can lead to better resource utilization and contribute to the reduction of patient, family, and caregiver burden.


Longitudinal analysis of long-term intervention effects on physical performance among older adults Objective: To examine the long-term effect of 24-week multicomponent frailty intervention on the socioeconomically vulnerable geriatric population in Pyeongchang, South Korea Methods: This is a prospective cohort study with intervention arm from the delayed-start intervention study within the cohort, and comparison arm from the group who denied receiving intervention but followed as a part of the cohort study. Descriptive statistics were used to describe covariate and outcome characteristics at the baseline for both intervention and comparison group. Means, standard deviations, counts and proportions, standardized mean difference (SMD) were described for both before and after propensity score matching. Propensity score matching was used to construct comparable groups having similar baseline characteristics. Multiple imputation by chained reaction was performed for missing values of both repeated outcome measures and baseline covariates. The longitudinal analysis will be conducted for outcome measures to perform a hypothesis test. Results: After propensity score matching, the magnitude of SMD was less than 0.1 for all characteristics. All three component of SPPB score, chair stand, gait speed, and balance at baseline had minimal SMD less than 0.09 between two groups. All three parts showed significant improvements in month 12, right after finishing the 24-week intervention program, which started at month 6. The scores of all components showed a decline at month 24 and month 36 but showed a positive standardized difference compared with the comparison group up to 36 months. Frailty phenotype decreased at month 12, and the effect of the intervention was sustained up to month 36.

Department of Epidemiology at Harvard T.H. Chan School of Public Health

A Comparative Study of Machine Learning Methods for Predicting Progression from Mild Cognitive Impairment to Alzheimer’s Disease Using the NACC Dataset Objective: To compare several machine learning techniques in order to build a model for identifying MCI subjects at high risk of conversion to Alzheimer’s disease (AD) within 5 years using a restricted set of non-invasive and easily collected baseline clinical, neuropsychological and sociodemographic predictors. Background: Alzheimer’s disease is a major public health issue across the globe. Given that current treatments can only decelerate the progression of AD, commencing treatment during the earlier stages might have the most impact since cognitive function would be preserved at the highest level possible. The earliest clinically detectable stage of this disease is mild cognitive impairment (MCI), therefore identification of MCI subjects at high risk of conversion to full AD is crucial to lessening morbidity.

Degree: MPH-45


Methods: This study used the NACC’s Uniform Dataset which contains longitudinal data collected annually on subjects from 2005 until present. Only individuals with MCI at baseline and 5 or more years of follow-up were included in this study. Three statistical learning techniques were used to create predictive models: K-Nearest Neighbour, logistic LASSO regression and Random Forest. Cross-validation was used to improve and then compare the performance of each technique. Results: Random Forest performed the best, with an optimal specificity of 81.0%, and corresponding sensitivity and AUC of 54.7% and 0.68, respectively. Conclusions: Although the exclusion of more invasive or expensive predictors enables easier adoption into clinical practice, this has likely disadvantaged the model’s predictive performance. Once further optimized, next steps will require further evaluation in independent clinical samples.


Maternal and infant predictors of culture-positive sepsis and death among young infants in Ethiopia Ethiopia has an under-five mortality rate of 58.5 per 1000 live births and a neonatal mortality rate of 28.9 per 1000 live births, well above the SDG target. Major causes for neonatal mortality in Ethiopia include prematurity, birth asphyxia, and neonatal sepsis. The diagnosis of neonatal sepsis is challenging, and in a limited resource setting, it is often made by clinical decision over laboratory assay. Decision rules have been developed and implemented to aid in clinical decision making around possible serious bacterial infection (PSBI) in infants. The aim of this study is to identify infant and maternal characteristics associated with blood culture-confirmed neonatal sepsis and mortality. Data collected from a prospective cohort study of 5000 pregnant women and their newborns in Addis Ababa were used for analysis. Mother-infant dyads were enrolled at presentation for labor and followed up to 60 days of infant life. Over the study period, 380 (6.14%) infants were found to have culture-confirmed sepsis and 303 (4.9%) had passed. Of those who had a positive blood culture, 24.5% passed by the end of follow up. Bivariate and multivariate analyses are underway to assess infant and maternal predictors of neonatal sepsis and mortality. Next steps after these analyses are completed include the development a clinical decision algorithm incorporating maternal risk factors to aid in future diagnoses of neonatal infection.

Emergency Preparedness, Research, Evaluation and Practice (EPREP) Program, Division of Policy Translation and Leadership Development, Harvard Chan

Practice applications of analytical, evaluation and analysis methods for public health and emergency preparedness Summary Report of Project I conducted scoping review/evidence map of evidence-based preparedness research which reviewed public health and emergency preparedness practices and capabilities. The project was sponsored by the National Academy of Science, Engineering and Medicine (NASEM) Committee on Evidence-Based Practices for Public Health Emergency Preparedness and Response. Working with other team members, we performed a comprehensive review, grading, and analysis of evidence for public health emergency preparedness and response (PHEP) practices, based on literature generated since September 11, 2001. We also wrote a paper detailing our results, conclusions and

Degree: MPH-45


recommendations which will inform NASEM’s deliberations regarding the evidence base for the 15 capabilities listed in CDC’s Public Health Preparedness Capabilities: National Standards for State and Local Planning.


Healthy lifestyle factors and cardiovascular disease risk in a large prospective cohort of women with a history of gestational diabetes Background Women with a history of gestational diabetes mellitus (GDM) are at an elevated risk of developing cardiovascular disease (CVD) later in life. However, it is unclear whether healthy lifestyle practices can mitigate this risk. Methods We included 4,372 women from the Nurses’ Health Study II with a self-reported diagnosis of GDM either before the start of the study or during follow-up, who were free of cancer or CVD at the time of GDM diagnosis. Lifestyle factors which included nonsmoking, normal body mass index (BMI 0-15 g/day). All lifestyle factors were repeatedly assessed after the development of GDM every 2 to 4 years. We defined a composite outcome of incident CVD as the combination of nonfatal myocardial infarction (MI), nonfatal stroke, cardiovascular deaths, angiographically confirmed angina pectoris, and coronary artery bypass surgery or angioplasty/stenting. We used Cox proportional hazards models to calculate the hazard ratio (HR) and 95% confidence interval (CI). Results During follow-up, 179 incident CVD events were ascertained. After multivariate adjustment, we found that each individual healthy lifestyle factor was associated with a lower risk of CVD. Compared to individuals with 0-1 healthy lifestyle factors, those who had 2, 3, and ≥4 factors had a multivariate adjusted HR (95% CI) of 1.13 (0.75, 1.71), 0.51 (0.31, 0.84), and 0.38 (0.20, 0.71), respectively (Ptrend < 0.001). Similar results were observed for clinical CVD outcomes (nonfatal MI, nonfatal stroke, and cardiovascular deaths) and MI, separately. Additionally, each incremental healthy lifestyle factor was associated with a lower risk of the composite outcome, HR (95% CI): 0.71 (0.59, 0.84); clinical CVD, HR (95% CI): 0.78 (0.61, 1.00); and MI, HR (95% CI): 0.68 (0.47, 0.97), all Ptrend < 0.001. Conclusions Higher adherence to healthy lifestyle factors were associated with a significant reduction in incident CVD events in women with a history of GDM. Our study provides additional evidence that maintaining a healthy lifestyle may be an effective strategy for the prevention of long-term complications in this high-risk group.

HSPH/CHDS Decision and Cost-Effectiveness Analysis of Empiric Treatment Strategies for Uncomplicated Urinary Tract Infections in the Emergency Department Setting Urinary tract infections (UTIs) are one of the most common infectious disease diagnoses presenting to the Emergency Department (ED), with an estimated incidence rate of 8 per 1000 US civilian noninstitutionalized persons, of whom, over 80% receive an antibiotic prescription. . Emergency physicians have an array of oral antibiotics to treat UTIs, each of which vary in efficacy, side-effect profiles and cost. Additionally, clinicians must consider local rates of antibiotic resistance which vary by both location and antibiotic. The empiric treatment of UTIs is a problem of competing choice under uncertainty and has been investigated in several decision and cost-effectiveness analyses, some of which have impacted guidelines of when to discontinue routine use of an antibiotic due to local resistance rates. However, none of these models have examined the ED population, which can differ in resistance patterns compared to inpatient and ambulatory populations. Additionally, these models do not

Degree: MPH-45


consider that ED patients may be lost to follow-up when up to 30% of patients discharged with an antibiotic prescription receive inappropriate empiric therapy. In collaboration with researchers at the Center for Health Decision Sciences and clinicians at Mass General Hospital, I conducted a decision and cost-effectiveness analysis to determine the optimal empiric treatment for uncomplicated UTIs presenting to the ED, accounting for resistance and lost to follow-up in this population. Secondary aims of the study include quantifying the value of information that would be gained from additional future studies on resistance and loss to follow-up in this population.

National Malaria Elimination Center, Ministry of Health of Zambia

Strengthening malaria outbreak identification and response in Zambia Malaria in Zambia remains a major public health concern, with an annual burden of more than 5 million cases and over 1,800 deaths. The Zambian Ministry of Health (MOH), through its National Malaria Elimination Centre (NMEC), has embarked on an ambitious agenda to eliminate and prevent reintroduction of malaria in Zambia by 2021 throughout its 10 provinces. The team from Harvard Chan undertook five main activities to answer this question: 1) literature review, 2), stakeholder interviews, 3) field visits to a District Health Office and a Rural Health Centre, 4) review of malaria data in Zambia’s Malaria Rapid Reporting (MRR) System, and 5) interviews with experts in Zambia, and at Harvard Chan. Stakeholder interviews and field visits were conducted during a 2.5-week trip to Zambia in January 2019, with literature review, data review, and additional expert interviews conducted before and after this trip. After conducting an extensive literature review and consulting with multiple faculty members at Harvard who specialize in modeling and statistics, the team believes that statistical modeling in Excel is likely not an appropriate platform to build an algorithm to detect outbreaks in low-incidence settings. The team recommends that dynamical outbreak modeling approaches using open-source platforms such as R in coordination with Excel be investigated further and considered for the outbreak algorithm instead of statistical modeling using methods like percentile thresholds or the Cullen method.

Center for Surgery and Public Health

The Effect of Energy-based Devices Compared to Conventional Hemostasis on Post-operative Neck Hematoma after Thyroid Operations Importance: Energy-based devices such as the harmonic scalpel have been popularized for use in thyroid operations, however the effect on postoperative neck hematoma, a rare but potentially fatal complication, has not been well studied. Design, Setting, and Participants: Retrospective cohort study of 10,903 patients in the NSQIP Database between 2016-2017. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in baseline covariates including demographics, comorbidities, indications for thyroid procedure, and several other thyroid-specific characteristics. Main Outcomes and Measures: Primary outcome was postoperative hematoma. Secondary outcomes include recurrent laryngeal nerve injury, operative duration, and hospital length of stay. Results: One-to-one propensity-score matching yielded 6,522 patients with 3,261 in each exposure group. Within the matched cohort, CH was associated with 2.33 (CI: 1.55-3.49, p=0.001) higher odds of neck hematoma compared to the EBD group, with 34 (1.04%) hematomas in the EBD group and 78 (2.39%) in the CH group. Secondary outcomes demonstrated longer length of hospital stay (IRR 1.29 [CI: 1.23-1.36, p < 0.001]) in the CH group, but no difference in odds of recurrent laryngeal nerve injury (OR 0.90 [CI: 0.73, 1.11, p < 0.32]) or operative duration (IRR: 0.99, [CI:0.96, 1.01,

Degree: MPH-45


p=0.24]). Conclusions and Relevance: Use of energy-based devices during thyroid operations was associated with reduced odds of neck hematoma compared to conventional hemostasis techniques. This study suggests postoperative neck hematoma rates after thyroid surgery may differ based on the hemostasis technique. These differences should be considered when developing strategies for quality improvement of postoperative outcomes.

Boston Children's Hospital

Adolescent Males Experience of Sexual Violence Victimization and Sexual Health Behaviors Secondary data analysis using Youth Risk Behavior Surveillance Survey data to assess association between adolescent males report of sexual violence victimization and sexual health behaviors.

Dana Farber Cancer Institute

Cancer Treatment Predictors of Excess Heart Age in Young Breast Cancer Survivors With increasing survival rates due to advances in treatment, young breast cancer survivors (less than 40 years at diagnosis) are likely to have long periods of survivorship and thus may develop premature cardiovascular disease. Young women are often diagnosed with more advances diseases and may need aggressive cancer treatment. Cancer treatment such as anthracyclines, trastuzumab, and radiation therapy are associated with cardiovascular disease. In older breast cancer survivors, heart disease is the leading cause of death. Risk of heart disease is greater than risk of breast cancer recurrence. Little data is available about the cardiovascular risk of young breast cancer survivors. The purpose of the study is to identify cancer treatment predictors of excess heart age at 2-year and 5-year post diagnosis among young breast cancer survivors. The data was obtained from the Helping Ourselves, Helping Others: The Young Women’s Breast Cancer Study (PI: Ann Partridge, MD, MPH). The purpose of this 10-year prospective, cohort study was to follow women newly diagnosed with breast cancer in Eastern Massachusetts and characterize the population regarding disease and psychosocial outcomes. Participants complete a survey every 6 months for the first 3 years, and then annually for a total of 10-years of follow-up. The current study selected a subset of women within this cohort who were 30-40 years of age at diagnosis, diagnosed with stage 0-III breast cancer, and completed the baseline survey, in addition to the two-year and/or five-year survey. Exclusion criteria are stage IV or recurrent breast cancer, history of cardiovascular disease, and/or missing heart age variables (i.e., systolic blood pressure, antihypertensive medication use, body mass index, history of smoking, history of diabetes). There were two primary outcomes: excess heart age at two-years post diagnosis and excess heart age at five-years post diagnosis. Heart age was calculated using chronological age, systolic blood pressure, antihypertensive medication use, body mass index, diabetes status, and smoking status. Then, excess heart age was calculated by subtracting chronological age from heart age to estimate cardiovascular disease risk. The primary predictor includes cardiotoxic chemotherapy defined as dichotomous variable for anthracyclines and/or trastuzumab use. Additional predictors included other cancer treatment such as radiation, endocrine therapy, and/or surgery. Statistical analyses included descriptive statistics (mean, SD for quantitative variables; frequency and percent for continuous variables, t-tests, chi-squared-tests, ANOVA, correlations). Future analyses will include linear regression modeling will be used to examine predictors of excess heart age at 2-year and 5-years post diagnosis, controlling for stage and baseline excess heart age. A stepwise, backward elimination technique for model selection will be used. Alpha will be set at p < 0.05. Data will be analyzed using R v.3.5.2. Of the 1,301 participants in the Helping Ourselves, Helping Others dataset, there were 299 women who met the inclusion/exclusion criteria. Of the women, 273 (91.3%) were followed at all time points, 292 (97.7%) had available two-year follow-up data, 280 (93.6%) had available five-year follow-up

Degree: MPH-45


data. The average of women at the time diagnosis was 36.6 years (SD 3.03 years), and majority of women were diagnosed at Stage II or III. Most commonly type of breast cancer was ER positive and PR positive, but also 30% were diagnosed with HER2 positive breast cancer. The women were well educated with over 80% having a college degree or higher, most were married, and nearly half were employed full-time. Treatment varied: All women received a form of surgery; 72.6% used chemotherapy including 59.5% with anthracyclines and 27.4% with trastuzumab (HER2 targeted therapy). Some women received both anthracyclines and trastuzumab, and as a result, 67.6% of women who used either both or one of the drugs. Mean excess heart age at baseline was .61 (SD 6.85). At 2-year follow-up the mean excess heart age was -.67 (SD 6.32) with a mean increase in excess heart age of 1.27 (p equal to 0.25). At 2-year follow-up the mean excess heart age was .09 (SD 7.01) with a mean increase in excess heart age of .52 (p equal to 0.383). Mean difference from 2-year to 5-year follow-up was -1.02 (p less than .001). Additional results will be from linear regression.

HSPH Department of Epidemiology

Transcriptomic analysis of prostate cancer by age of diagnosis Age of diagnosis appears to be an independent prognostic factor for prostate cancer outcomes. It is unclear whether this observed differences in clinical outcomes is due to fundamental differences in tumor biology or due to other factors (such as less aggressive clinical intervention). By performing a transcriptomic analysis of prostate cancer tissue samples by age of diagnosis, we hope to identify if there is differing gene expression by age of diagnosis in prostate cancer. If there is differential transcriptome expression, this could suggest fundamental difference in tumor biology depending on age at diagnosis.

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Degree: MPH-45 Field of Study: Quantitative Methods Practicum … · 2019. 8. 30. · Degree: MPH-45 Field of Study: Quantitative Methods Practicum Project Abstracts 2019 surgery