Titilola Falasinnu

All Publications

• The problem of pain in systemic lupus erythematosus: A comprehensive analysis of pain distribution using the CHOIR body map and PROMIS measures. Lupus Jiang, T. E., Mackey, S., Darnall, B. D., Simard, J. F., Falasinnu, T. 2024: 9612033241301176

  Abstract

  Our study investigates the associations between pain distribution, biopsychosocial factors, and Patient-Reported Outcomes Measurement Information System (PROMIS) measures in patients with systemic lupus erythematosus (SLE). Employing self-reported pain body maps, we aim to characterize the distribution of pain and its impact on biopsychosocial measures.We retrospectively analyzed the electronic health records (EHR) of 332 adult patients with SLE attending pain clinics at an academic medical center. The study included demographics, pain distribution assessed via self-reported body maps, and PROMIS assessments of biopsychosocial experiences. We used linear regression models adjusted for age and sex to investigate associations between pain distribution and PROMIS outcomes.Men, on average, indicated pain in 3.2 regions, whereas women reported pain in 5.6 regions. Women predominantly highlighted the hip, buttock, and leg region, whereas men primarily emphasized the shoulder and arm region. We found a positive correlation between pain widespreadness and worse PROMIS measures, including pain interference, behavior, fatigue, depression, anxiety, sleep disturbance, and social isolation. Additionally, widespread pain was associated with lower physical function, emotional support, and satisfaction in roles and activities. Female patients reported higher levels of pain and PROMIS measures compared to males.Our findings highlight the multidimensional impact of pain on SLE patients' lives underscoring the need for holistic pain management approaches. The intricate associations between pain distribution and biopsychosocial factors emphasize the importance of considering spatial dimensions of pain in clinical interventions. Further research is warranted to explore effective interventions addressing psychosocial aspects of pain in SLE, aiming to enhance patient symptom management and quality of life.

  View details for DOI 10.1177/09612033241301176

  View details for PubMedID 39584468

• Addressing the research gap: access to care hinders genetic discovery in systemic lupus erythematosus patients throughout the African diaspora FRONTIERS IN GENETICS Hwang, J., Dzifa Dey, I., Ayanlowo, O., Flower, C., King, A., Johnson, N., Ima-Edomwonyi, U., Olasebikan, H., Falasinnu, T., Durairaj Pandian, V., Blazer, A. 2024; 15: 1414490

  Abstract

  Systemic lupus erythematosus (SLE) is a complex autoimmune condition that disproportionately impacts non-White ethnic and racial groups, particularly individuals in the African diaspora who experience heightened incidence, prevalence, and adverse outcomes. Genetic and epigenetic factors play significant roles in SLE risk, however these factors neither explain the whole of SLE risk nor the stark racial disparities we observe. Moreover, our understanding of genetic risk factors within African ancestry populations is limited due to social and environmental influences on research participation, disease presentation, and healthcare access. Globally, the African diaspora faces barriers in accessing essential SLE diagnostic tools, therapeutics, healthcare practitioners, and high-quality clinical and translational research studies. Here, we provide insights into the current state of genetic studies within African ancestry populations and highlight the unique challenges encountered in SLE care and research across countries of varying income levels. We also identify opportunities to address these disparities and promote scientific equity for individuals affected by SLE within the global African diaspora.

  View details for DOI 10.3389/fgene.2024.1414490

  View details for Web of Science ID 001302668800001

  View details for PubMedID 39211738

  View details for PubMedCentralID PMC11358083

• Misdiagnosis, missed diagnosis and delayed diagnosis of lupus: A qualitative study of rheumatologists. Arthritis care & research Bane, S., Falasinnu, T., Rodriguez Espinosa, P., Simard, J. F. 2024

  Abstract

  Diagnostic errors in outpatient settings lead to significant consequences, especially in rare diseases such as systemic lupus erythematosus (SLE). A recent vignette-based experimental study revealed that demographic factors influenced rheumatologists' diagnoses of SLE, raising concerns about potential diagnostic biases. We conducted a qualitative study to contextualize these results to generate insights about diagnostic challenges and biases, and root causes.We conducted 41 semi-structured interviews among U.S. rheumatologists. Transcripts were independently coded by at least two coders using a hybrid deductive-inductive approach and thematic analysis. A team of four researchers reviewed and defined themes collectively, and also resolved any discrepancies.Participants were 66% women and 49% had >10 years of post-fellowship experience. Five major themes were generated, including receiving training through the lens of race or gender, the role of the documented epidemiology of SLE, pattern recognition and test-taking strategies, case vignettes as an imperfect proxy for patient interactions, and varied consequences to patients from diagnostic bias. Participants noted that the consequences of diagnostic bias could include progressed disease from delayed diagnosis, unnecessary and inappropriate treatment due to missed diagnosis or misdiagnosis, and increased cost and harm.This study underscores the unique challenges of diagnosing SLE, with complex factors contributing to diagnosis bias and delays. Interventions during medical education could prevent downstream diagnostic biases. Future research should explore interventions to mitigate diagnostic bias and refine vignettes to better mirror real-world clinical scenarios. Understanding diagnostic bias in SLE is crucial for improving patient outcomes and refining medical training practices.

  View details for DOI 10.1002/acr.25405

  View details for PubMedID 39037219

• Annual trends in pain management modalities in patients with newly diagnosed autoimmune rheumatic diseases in the USA from 2007 to 2021: an administrative claims-based study. The Lancet. Rheumatology Falasinnu, T., Lu, D., Baker, M. C. 2024

  Abstract

  Autoimmune rheumatic diseases have distinct pathogenic mechanisms and are causes of disability and increased mortality worldwide. In this study, we aimed to examine annual trends in pain management modalities among patients with autoimmune rheumatic diseases.We identified newly diagnosed patients with ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, Sjögren's syndrome, systemic sclerosis, or systemic lupus erythematosus (SLE) in the Merative Marketscan Research Databases from 2007 to 2021. The database includes deidentified inpatient and outpatient health encounters with employment-sponsored health insurance claims in the USA. We found minimal occurrences of multiple overlapping conditions and included only the initial recorded diagnosis for each patient. We determined the annual incidence of patients treated with opioids, anticonvulsants, antidepressants, skeletal muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, and physical therapy in the year following diagnosis. Logistic regression was used to estimate the association between calendar year and outcomes, adjusted for age, sex, and region.We included 141 962 patients: 10 927 with ankylosing spondylitis, 21 438 with psoriatic arthritis, 71 393 with rheumatoid arthritis, 16 718 with Sjögren's syndrome, 18 018 with SLE, and 3468 with systemic sclerosis. 107 475 (75·7%) were women and 34 487 (24·3%) were men. Overall, the incidence of opioid use increased annually until 2014 by 4% (adjusted odds ratio [aOR] 1·04 [95% CI 1·03-1·04]) and decreased annually by 15% after 2014 (0·85 [0·84-0·86]). The incidence of physical therapy use increased annually by 5% until 2014 (aOR 1·05 [95% CI 1·04-1·06]), with a slight decrease annually by 1% after 2014 (0·99 [0·98-1·00]). The incidence of anticonvulsant use increased annually by 7% until 2014 (aOR 1·07 [95% CI 1·07-1·08]) and did not significantly change after 2014 (1·00 [0·99-1·00]). Before 2014, the incidence of NSAIDs use increased by 2% annually (aOR 1·02 [95% CI 1·02-1·03]); however, after 2014, the incidence decreased annually by 5% (0·95 [0·95-0·96]). These trends did not differ by sex except for NSAID use before 2014 (pinteraction=0·02) and topical analgesic use after 2014 (pinteraction=0·0100).Since 2014, the use of non-opioid pain management modalities has increased or stabilised, whereas opioid and NSAID use has declined. Future studies are needed to evaluate the effectiveness of these changes, and the effects they have had on outcomes such as quality of life, disability, and function.National Institute of Arthritis and Musculoskeletal and Skin Diseases.

  View details for DOI 10.1016/S2665-9913(24)00120-6

  View details for PubMedID 38945137

• Impact of Incentives on Physician Participation in Research Surveys: Randomized Experiment. JMIR formative research Hawa, S., Bane, S., Kinsler, K., Rector, A., Chaichian, Y., Falasinnu, T., Simard, J. F. 2024; 8: e54343

  Abstract

  Web-based surveys can be effective data collection instruments; however, participation is notoriously low, particularly among professionals such as physicians. Few studies have explored the impact of varying amounts of monetary incentives on survey completion.This study aims to conduct a randomized study to assess how different incentive amounts influenced survey participation among neurologists in the United States.We distributed a web-based survey using standardized email text to 21,753 individuals randomly divided into 5 equal groups (≈4351 per group). In phase 1, each group was assigned to receive either nothing or a gift card for US $10, $20, $50, or $75, which was noted in the email subject and text. After 4 reminders, phase 2 began and each remaining individual was offered a US $75 gift card to complete the survey. We calculated and compared the proportions who completed the survey by phase 1 arm, both before and after the incentive change, using a chi-square test. As a secondary outcome, we also looked at survey participation as opposed to completion.For the 20,820 emails delivered, 879 (4.2%) recipients completed the survey; of the 879 recipients, 622 (70.8%) were neurologists. Among the neurologists, most were male (412/622, 66.2%), White (430/622, 69.1%), non-Hispanic (592/622, 95.2%), graduates of American medical schools (465/622, 74.8%), and board certified (598/622, 96.1%). A total of 39.7% (247/622) completed their neurology residency more than 20 years ago, and 62.4% (388/622) practiced in an urban setting. For phase 1, the proportions of respondents completing the survey increased as the incentive amount increased (46/4185, 1.1%; 76/4165, 1.8%; 86/4160, 2.1%; 104/4162, 2.5%; and 119/4148, 2.9%, for US $0, $10, $20, $50, and $75, respectively; P<.001). In phase 2, the survey completion rate for the former US $0 arm increased to 3% (116/3928). Those originally offered US $10, $20, $50, and $75 who had not yet participated were less likely to participate compared with the former US $0 arm (116/3928, 3%; 90/3936, 2.3%; 80/3902, 2.1%; 88/3845, 2.3%; and 74/3878, 1.9%, for US $0, $10, $20, $50, and $75, respectively; P=.03). For our secondary outcome of survey participation, a trend similar to that of survey completion was observed in phase 1 (55/4185, 1.3%; 85/4165, 2%; 96/4160, 2.3%; 118/4162, 2.8%; and 135/4148, 3.3%, for US $0, $10, $20, $50, and $75, respectively; P<.001) and phase 2 (116/3928, 3%; 90/3936, 2.3%; 80/3902, 2.1%; 88/3845, 2.3%; and 86/3845, 2.2%, for US $0, $10, $20, $50, and $75, respectively; P=.10).As expected, monetary incentives can boost physician survey participation and completion, with a positive correlation between the amount offered and participation.

  View details for DOI 10.2196/54343

  View details for PubMedID 38743466

• The Problem of Pain in Lupus: Epidemiological Profiles of Patients Attending Multidisciplinary Pain Clinics. Pain management nursing : official journal of the American Society of Pain Management Nurses Jiang, T. E., Pascual, A. P., Le, N., Nguyen, T. B., Mackey, S., Darnall, B. D., Simard, J. F., Falasinnu, T. 2024

  Abstract

  Patients with systemic lupus erythematosus (SLE) bear a significant burden of pain. We aimed to identify factors that distinguish patients with SLE referred to comprehensive pain clinics and those who are not. Characterizing this patient population will identify unmet needs in SLE management and inform efforts to improve pain care in rheumatology.Among patients with SLE with ≥2 rheumatology clinic visits in a large hospital system from 1998 to 2023 (n = 1319), we examined factors that distinguished those who had at least one visit to multidisciplinary pain clinics (n = 77, 5.8%) from those who did not have any visits (n = 1242, 94.2%) with a focus on biopsychosocial and socioeconomic characteristics. We extracted demographic data and ICD-9/ICD-10 codes from the EHR.Patients with SLE attending the pain clinics exhibited characteristics including average older age (mean age ± SD: 54.1 ± 17.9 vs. 48.4 ± 19.9), a higher likelihood of relying on public health insurance (50.7% vs. 34.2%), and a greater representation of Black patients (9.1% vs. 4.4%) compared to SLE patients not seen in pain clinics. Nearly all patients seen at the pain clinics presented with at least one chronic overlapping pain condition (96.1% vs. 58.6%), demonstrated a higher likelihood of having a mental health diagnosis (76.7% vs. 42.4%), and exhibited a greater number of comorbidities (mean ± SD: 6.0 ± 3.0 vs. 2.9 ± 2.6) compared to those not attending the pain clinic.We found notable sociodemographic and clinical differences between these patient populations. Patients presenting with multiple comorbidities might benefit from further pain screening and referral to pain clinics to provide comprehensive care, and earlier referral could mitigate the development and progression of multimorbidities.

  View details for DOI 10.1016/j.pmn.2024.02.012

  View details for PubMedID 38494346

• Trends in patient representation in low back pain pharmacological randomized clinical trials, 2011-2020: A systematic review. The journal of pain Jiang, T. E., Edwards, K. A., Dildine, T. C., You, D. S., Nguyen, T., Pascual, A. P., Falasinnu, T. 2024

  Abstract

  Low back pain (LBP) significantly affects global health, with associated detrimental outcomes such as physical impairment, emotional distress, and exacerbated mental health symptoms. This study evaluated the representation of marginalized groups, including racialized, gender minority, pregnant/lactating, and elderly individuals in randomized controlled trials (RCTs) for pharmacological interventions treating LBP from 2011 to 2020. We searched Embase, MEDLINE, and CINAHL in December 2021, and 139 studies were eligible. Most trials (n = 113, 81%) reported participant sex; however, no study collected data on sexual and gender minorities, and the majority (n = 99, 71%) excluded pregnant/lactating individuals. Most trials (n = 105, 76%) reported no data on participant race or ethnicity. We limited within-country analyses of race and ethnicity to US-based trials because US-based trials were more likely to report race and/or ethnicity (48%) compared to non-US-based trials (8%). Black participants were the only racialized group whose composition were comparable to US Census estimates. About half (n = 73, 53%) of all trials had an upper age limit for eligibility (range: 40-85 years old) and 24% (n = 33) excluded adults aged > 65 years. Our findings confirm that trials for pharmacological LBP interventions underreport demographic data, and the trials that include this data have unrepresentative samples. There is an urgent need for more inclusive and representative patient samples to ensure generalizability and equitable benefits. Standardizing demographic data reporting and integrating community-based participatory research methods can help foster inclusive research practices. This review was registered with PROSPERO, ID 296017. PERSPECTIVE: This systematic review investigates patient representation in pharmacological-based clinical trials for low back pain, the most prevalent pain condition worldwide. Improvements in reporting demographic data and recruiting diverse participant populations-across different racialized, gender and sexual minority, and age groups- will help clinical research generalizability and provide equitable benefits. DATA AVAILABILITY: Please contact Tiffany Jiang (tjiang8@stanford.edu) for requests for extraction tool and extracted data.

  View details for DOI 10.1016/j.jpain.2023.12.013

  View details for PubMedID 38185211

• Impact of climate change on rheumatic diseases: A scoping review The Journal of Climate Change and Health Katsumoto, T. R., Stolyar, L., Dandeniya, C. L., Wong, H. N., Lanata, C. M., Falasinnu, T., Bush, T. 2024

  View details for DOI 10.1016/j.joclim.2024.100338

• The Problem of Pain in Rheumatology: Variations in Case Definitions Derived From Chronic Pain Phenotyping Algorithms Using Electronic Health Records. The Journal of rheumatology Falasinnu, T., Nguyen, T., En Jiang, T., Tamang, S., Chaichian, Y., Darnall, B. D., Mackey, S., Simard, J. F., Chen, J. H. 2023

  Abstract

  The aim of this study was to investigate and compare different case definitions for chronic pain to provide estimates of possible misclassification when researchers are limited by available electronic health record and administrative claims data, allowing for greater precision in case definitions.We compared the prevalence of different case definitions for chronic pain (N = 3042) in patients with autoimmune rheumatic diseases. We estimated the prevalence of chronic pain based on 15 unique combinations of pain scores, diagnostic codes, analgesic medications, and pain interventions.Chronic pain prevalence was lowest in unimodal pain phenotyping algorithms: 15% using analgesic medications, 18% using pain scores, 21% using pain diagnostic codes, and 22% using pain interventions. In comparison, the prevalence using a well-validated phenotyping algorithm was 37%. The prevalence of chronic pain also increased with the increasing number (bimodal to quadrimodal) of phenotyping algorithms that comprised the multimodal phenotyping algorithms. The highest estimated chronic pain prevalence (47%) was the multimodal phenotyping algorithm that combined pain scores, diagnostic codes, analgesic medications, and pain interventions. However, this quadrimodal phenotyping algorithm yielded a 10% overestimation of chronic pain compared to the well-validated algorithm.This is the first empirical study to our knowledge that shows that established common modes of phenotyping chronic pain can lead to substantially varying estimates of the number of patients with chronic pain. These findings can be a reference for biases in case definitions for chronic pain and could be used to estimate the extent of possible misclassifications or corrections in using datasets that cannot include specific data elements.

  View details for DOI 10.3899/jrheum.2023-0416

  View details for PubMedID 38101917

• Biologics Initiation in Rheumatoid Arthritis by Race and Ethnicity: Results From a Randomized Survey Study. ACR open rheumatology Simard, J. F., Lu, R., Falasinnu, T. O., Baker, M. C., Hawa, S., Deluna, M. D., Horomanski, A., Fairchild, R. M. 2023

  Abstract

  To investigate whether the race and ethnicity of a patient with rheumatoid arthritis (RA) influences rheumatologists' likelihood of choosing to initiate biologic disease-modifying antirheumatic drug (bDMARD) treatment.We conducted a randomized survey experiment in which identical brief case vignettes of hypothetical patients with RA were sent to US rheumatologists (respondents). Three of the four cases included some level of treatment decision ambiguity whereas the fourth case strongly favored bDMARD initiation. Each respondent was shown the four case vignettes, with the race and ethnicity (Black, Hispanic, White) randomly assigned for each case. Each vignette offered multiple choices for next therapeutic step, which we summarized using frequencies and proportions by race and ethnicity version.Among 159 US rheumatologists, we found that for the three cases with some level of treatment decision ambiguity, there was little to no variability in the proportions of respondents who chose to start a biologic for the Black and Hispanic variants (cases 1, 2, and 3). For case 4, respondents generally agreed to start a biologic with some minimal variability across the variants (92.6% for the Black version, 98.1% for the Hispanic version, and 96.2% for the White version).There are conflicting data regarding bDMARD use and initiation in patients with RA based on the sex and race of the patient. This work adds to this conversation by examining how the next therapeutic step chosen by rheumatologists varied by the race and ethnicity of the hypothetical patient.

  View details for DOI 10.1002/acr2.11573

  View details for PubMedID 37312437

• The Problem of Pain in the United States: A Population-Based Characterization of Biopsychosocial Correlates of High Impact Chronic Pain using the National Health Interview Survey. The journal of pain Falasinnu, T., Hossain, M. B., Weber, K. A., Helmick, C. G., Karim, M. E., Mackey, S. 2023

  Abstract

  Over 20 million adults in the United States live with High Impact Chronic Pain (HICP), or chronic pain that limits life or work activities for ≥3 months. It is critically important to differentiate people with HICP from those who sustain normal activities although experiencing chronic pain. Therefore, we aim to help clinicians and researchers identify those with HICP by: (1) developing models that identify factors associated with HICP using the 2016 National Health Interview Survey (NHIS) and (2) evaluating the performances of those models overall and by sociodemographic subgroups (sex, age, and race/ethnicity). Our analysis included 32,980 respondents. We fitted logistic regression models with LASSO (a parametric model) and random forest (a nonparametric model) for predicting HICP using the whole sample. Both models performed well. The most important factors associated with HICP were those related to underlying ill-health (arthritis and rheumatism, hospitalizations, and emergency department visits) and poor psychological well-being. These factors can be used for identifying higher-risk sub-groups for screening for HICP. We will externally validate these findings in future work. We need future studies that longitudinally predict the initiation and maintenance of HICP, then use this information to prevent HICP and direct patients to optimal treatments. PERSPECTIVE: Our study developed models to identify factors associated with high-impact chronic pain (HICP) using the 2016 National Health Interview Survey. There was homogeneity in the factors associated with HICP by gender, age and race/ethnicity. Understanding these risk factors is crucial to support the identification of populations and individuals at highest risk for developing HICP and improve access to interventions that target these high-risk subgroups.

  View details for DOI 10.1016/j.jpain.2023.03.008

  View details for PubMedID 36965649

• Risk of End-stage Renal Disease in Patients with Systemic Lupus Erythematosus and Diabetes Mellitus: Danish Nationwide Cohort Study. Arthritis care & research Hansen, R. B., Falasinnu, T., Faurschou, M., Jacobsen, S., Simard, J. F. 2023

  Abstract

  OBJECTIVES: The risk of end-stage renal disease (ESRD) is increased in patients with systemic lupus erythematosus (SLE). We estimated whether diabetes mellitus (DM) increases ESRD risk in a large inception cohort of patients with SLE.METHODS: By means of the Danish National Patient Register (DNPR), we identified 3178 adult patients diagnosed with SLE between January 1, 1996, and July 31, 2018. DM was defined as the date of first hospital contact for DM or date of a first prescription of an antidiabetic drug. ESRD was defined as first registration in DNPR of dialysis, renal transplant, or terminal renal insufficiency. ESRD incidence was compared between SLE patients with DM (SLE-DM) and those without DM (SLE-non-DM). Hazard ratios (HRs), adjusted for sex, age, educational level and occupational status at baseline, were calculated for sex, age, educational level and hypertension (at baseline or during follow up) strata. Overall HR was also adjusted for hypertension.RESULTS: The SLE-DM group included 290 patients of whom 77% were female, compared with 85% of the 2859 in the SLE-non-DM group. SLE-DM patients had three times higher risk of ESRD compared with SLE-non-DM patients (multivariable-adjusted HR=3.3 [95% CI: 1.8-6.1]). In stratified multivariable-adjusted analyses, DM increased the rate of ESRD in women and men, patients aged ≥50years at baseline, those with low educational level at baseline and concomitant hypertension.CONCLUSION: Our findings indicate that SLE patients with DM have a markedly higher risk of developing ESRD than SLE patients without DM.

  View details for DOI 10.1002/acr.25091

  View details for PubMedID 36705445

• The Problem of Pain in Rheumatology: Clinical Profiles Associated With Concomitant Diagnoses With Chronic Overlapping Pain Conditions. ACR open rheumatology Falasinnu, T., Nguyen, T., Jiang, T. E., Chaichian, Y., Rector, A., Darnall, B. D., Mackey, S., Simard, J. F. 2022

  Abstract

  OBJECTIVE: The chronification of pain is heterogeneous in rheumatology. Chronic overlapping pain conditions (COPCs) such as fibromyalgia, endometriosis, migraine, and back pain may co-occur with one another and in rheumatic diseases. We describe the sociodemographic and clinical profiles associated with concomitant COPCs among patients with rheumatic diseases.METHODS: We retrospectively identified patients visiting rheumatology clinics at a single institution from 2010 to 2020 for five common rheumatic conditions: psoriatic arthritis (PsA), rheumatoid arthritis (RA), Sjogren syndrome (SjS), systemic lupus erythematosus (SLE), and systemic sclerosis (SSc). We compared sociodemographic, clinical, and lifestyle factors by rheumatic condition and by COPC status. We also report sex-stratified diagnosis of COPCs. The primary outcome was diagnostic validation of one or more COPCs.RESULTS: We identified 5992 rheumatology patients: 846 with PsA, 2605 with RA, 956 with SjS, 975 with SLE, and 610 with SSc. Approximately 36-62% of patients had a concomitant COPC diagnosis. Patients with SjS had the highest prevalence (62%). Diagnosis of one or more COPCs was highest among Black patients and lowest among Asian patients. Patients using public insurance had a higher prevalence of one or more COPCs compared with those with private insurance. Patients with one or more COPCs had more depression and anxiety and more frequent emergency department visits, surgeries, and hospitalizations.CONCLUSION: Our findings suggest that COPCs are strikingly common among patients with rheumatic disease and are associated with lower quality of life and greater health care needs. Future research may elucidate drivers of chronic pain and how to best address the unique analgesic needs of this multimorbid population.

  View details for DOI 10.1002/acr2.11488

  View details for PubMedID 35872631

• A review of potential national chronic pain surveillance systems in the United States. The journal of pain Duca, L. M., Helmick, C. G., Barbour, K. E., Nahin, R. L., Von Korff, M., Murphy, L. B., Theis, K., Guglielmo, D., Dahlhamer, J., Porter, L., Falasinnu, T., Mackey, S. 2022

  Abstract

  Pain has been established as a major public health problem in the United States (U.S.) with 50 million adults experiencing chronic pain and 20 million afflicted with high-impact chronic pain (i.e., chronic pain that interferes with life or work activities). High financial and social costs are associated with chronic pain. Over the past two decades, pain management has been complicated by the marked increase in opioids prescribed to treat chronic non-cancer pain and by the concurrent opioid crisis. Monitoring the prevalence of chronic pain and pain management is especially important because pain management is changing in uncertain ways. We review potential U.S. chronic pain surveillance systems, present potential difficulties of chronic pain surveillance, and explore how to address chronic pain surveillance in the current opioid era. We consider case definitions, severity, anatomic site, and varieties of chronic pain management strategies in reviewing and evaluating national surveys for chronic pain surveillance. Based on the criteria evaluated, the National Health Interview Survey offers the best single source for pain surveillance as the pain-related questions administered are brief, valid, and cover a broad scope of pain-related phenomenon. Perspective: This review article describes data sources that can be leveraged to conduct national chronic pain surveillance in the United States, explores case defining or pain-related questions administered, and evaluates them against eight surveillance attributes.

  View details for DOI 10.1016/j.jpain.2022.02.013

  View details for PubMedID 35421595

• Factors Associated with the Initiation and Retention of Patients with Lupus in the Chronic Disease Self-Management Program. Arthritis care & research Falasinnu, T., Bao, G., Brady, T. J., Lim, S. S., Drenkard, C. 2021

  Abstract

  OBJECTIVE: The Chronic Disease Self-Management Program (CDSMP) is designed to enhance patients self-efficacy and skills to manage their chronic illness. There is compelling evidence for the benefits of the CDSMP among patients with systemic lupus erythematosus (SLE); however, little is known about predictors of participation among Black women with SLE. We examined factors associated with CDSMP initiation and completion in this population.METHODS: We studied 228 Black women with SLE who consented to attend a CDSMP workshop. We used logistic regression to calculate unadjusted and adjusted ORs for being a CDSMP initiator (a participant registered into the CDSMP who attended at least one of the first two weekly classes) and a CDSMP completer (a participant who completed >4 of 6 weekly classes).RESULTS: Majority of partipants were CDSMP initiators (74%, n=168). Of them, 126 (75%) were CDSMP completers. Older age [aOR: 1.03, 95% CI:1.00-1.06] and unemployment/disability [aOR: 2.05, 95% CI: 1.05-4.14] increased the odds of being a CDSMP initiator. The odds of initiating CDSMP decreased by 22% for each additional child in the household [OR: 0.78, 95% CI:0.62-0.98] but this association became non-significant in the adjusted model [aOR: 0.89, 95% CI:0.68-1.18]. The only factor that differed significantly between CDSMP completers and non-completers was age, with 4% higher odds of being a completer for each additional year of age (aOR: 1.04, 95% CI: 1.00-1.07).CONCLUSION: Our findings suggest that young Black women with SLE face barriers to attend and complete in-person CDSMP workshops, possibly in relation to work and childcare demands.

  View details for DOI 10.1002/acr.24811

  View details for PubMedID 34738339

• The Burden of Systemic Lupus in Five Distinct Racial and Ethnic Groups in Israel: A Population-based Study Falasinnu, T., Rizk, N., Feldman, B., Zisman, D., Leshchinsky, M., Lawrence, G., Chaichian, Y., Simard, J. WILEY. 2021: 1203-1207

  View details for Web of Science ID 000744545202106

• Global epidemiology of systemic lupus erythematosus. Nature reviews. Rheumatology Barber, M. R., Drenkard, C., Falasinnu, T., Hoi, A., Mak, A., Kow, N. Y., Svenungsson, E., Peterson, J., Clarke, A. E., Ramsey-Goldman, R. 2021

  Abstract

  Systemic lupus erythematosus (SLE) is an autoimmune disease with protean manifestations that predominantly affects young women. Certain ethnic groups are more vulnerable than others to developing SLE and experience increased morbidity and mortality. Reports of the global incidence and prevalence of SLE vary widely, owing to inherent variation in population demographics, environmental exposures and socioeconomic factors. Differences in study design and case definitions also contribute to inconsistent reporting. Very little is known about the incidence of SLE in Africa and Australasia. Identifying and remediating such gaps in epidemiology is critical to understanding the global burden of SLE and improving patient outcomes. Mortality from SLE is still two to three times higher than that of the general population. Internationally, the frequent causes of death for patients with SLE include infection and cardiovascular disease. Even without new therapies, mortality can potentially be mitigated with enhanced quality of care. This Review focuses primarily on the past 5 years of global epidemiological studies and discusses the regional incidence and prevalence of SLE and top causes of mortality.

  View details for DOI 10.1038/s41584-021-00668-1

  View details for PubMedID 34345022

• Are we missing lupus in males? Evidence of cognitive bias from a randomized experiment in the US. American journal of epidemiology Simard, J. F., Chaichian, Y., Rizk, N., Rector, A., Feldman, C. H., Falasinnu, T. O. 2021

  View details for DOI 10.1093/aje/kwab199

  View details for PubMedID 34308469

• Evidence of under-reporting of early-onset preeclampsia using register data. Paediatric and perinatal epidemiology Simard, J. F., Rossides, M., Wikstrom, A., Falasinnu, T., Palmsten, K., Arkema, E. V. 2021

  Abstract

  BACKGROUND: Early-onset preeclampsia, traditionally defined as presenting before 34 gestational weeks, is associated with even higher risks of perinatal death, placental abruption, and stroke, than late-onset preeclampsia.OBJECTIVE: We estimated the degree of misclassification in a high-risk population of lupus pregnancies and a general population comparator when gestational age at delivery defined preeclampsia phenotype compared to first preeclampsia diagnosis.METHODS: Patients with lupus and general population comparators from Sweden with ≥1 singleton pregnancy in the Medical Birth Register with a documented ICD code for preeclampsia were included (2002-2016). We used gestational age at delivery (<34 versus ≥34weeks) to phenotype preeclampsia early- versus late-onset and then reclassified based on first preeclampsia diagnosis date in the Patient Register. We cross-tabulated the two definitions and calculated sensitivity using the visit-based definition as the reference standard for general population and lupus pregnancies, overall and among nulliparous women.RESULTS: 331 pregnancies were diagnosed with preeclampsia, of which 322 were in both registers. Of those, 58 were early-onset based on gestational age at delivery (n=29 in lupus pregnancies). Overall, 9% of early-onset preeclampsia in lupus (sensitivity 91%, 95% confidence interval [CI] 75, 98) was misclassified as late-onset compared to 19% in the general population (sensitivity 81%, 95% CI 64, 92). We noted similar misclassification (4% vs 22%) among nulliparous women.CONCLUSIONS: In the general population, early-onset preeclampsia was more likely misclassified as late-onset than in the high-risk lupus population. Relying on gestational age at delivery to phenotype preeclampsia, this way underestimates the occurrence of early-onset preeclampsia. This also suggests that the burden of early-onset preeclampsia as a public health concern may be under-reported, although this may be more applicable to milder preeclampsia where expectant management is employed. Research of biological and maternal predictors of early-onset preeclampsia may be dealing with differentially misclassified outcomes or samples.

  View details for DOI 10.1111/ppe.12759

  View details for PubMedID 33956365

• Validation of a clinical prediction rule to predict asymptomatic chlamydia and gonorrhoea infections among internet-based testers. Sexually transmitted diseases Ablona, A., Falasinnu, T., Irvine, M., Estcourt, C., Flowers, P., Murti, M., Gomez-Ramirez, O., Fairley, C. K., Mishra, S., Burchell, A., Grennan, T., Gilbert, M. 2020

  Abstract

  BACKGROUND: Clinical prediction rules (CPRs) can be used in STI testing environments to prioritize individuals at highest risk of infection and optimize resource allocation. We previously derived a CPR to predict asymptomatic chlamydia and/or gonorrhea (CT/NG) infection among women and heterosexual men at in-person STI clinics based on five predictors. Population differences between clinic-based and internet-based testers may limit the tool's application across settings. The primary objective of this study was to assess the validity, sensitivity, and overall performance of this CPR within an internet-based testing environment (GetCheckedOnline.com).METHODS: We analyzed GetCheckedOnline online risk assessment and laboratory data from 10/2015-06/2019. We compared the STI clinic population used for CPR derivation (data previously published) and the GetCheckedOnline validation population using chi-square tests. Calibration and discrimination were assessed using the Hosmer-Lemeshow (H-L) goodness-of-fit test and the Area Under the Receiver Operating Curve (AUC), respectively. Sensitivity and the fraction of total screening tests offered were quantified for CPR-predicted risk scores.RESULTS: Asymptomatic CT/NG infection prevalence in the GetCheckedOnline population (n=5,478) was higher than in the STI clinic population (n=10,437; 2.4% vs. 1.8%, p=0.007). When applied to GetCheckedOnline, the CPR had reasonable calibration (H-L p=0.90) and discrimination (AUC=0.64). By screening only individuals with total risk scores ≥4, we would detect 97% of infections and reduce screening by 14%.CONCLUSIONS: The application of an existing CPR to detect asymptomatic CT/NG infection is valid within an internet-based STI testing environment. CPRs applied online can reduce unnecessary STI testing and optimize resource allocation within publicly-funded health systems.

  View details for DOI 10.1097/OLQ.0000000000001340

  View details for PubMedID 33315748

• The problem of pain in lupus: an explication of the role of biopsychosocial mechanisms. The Journal of rheumatology Falasinnu, T., Drenkard, C., Bao, G., Mackey, S., Lim, S. S. 2020

  Abstract

  OBJECTIVE: To define biopsychosocial mechanisms of pain that go above and beyond disease activity and organ damage in systemic lupus erythematosus (SLE).METHODS: We conducted a cross-sectional analysis of patient-reported data in a population-based registry of 766 people with SLE. Predictors of pain intensity and interference were examined using hierarchical linear regression. We built two main hierarchical regression models: pain intensity regressed on disease activity and organ damage; and pain interference regressed on disease activity and organ damage. For each model, we sought to establish the relationship between pain outcomes and the primary exposures using sequential steps comprising the inclusion of each construct in six stages: demographic, socioeconomic, physical, psychological, behavioral and social factors. We also conducted sensivity analyses eliminating all overt aspects of pain in the disease activity measure and reestimated the models.RESULTS: Disease activity and organ damage explained 32-33% of the variance in pain intensity and interference. Sociodemographic factors accounted for an additional 4-9% of variance in pain outcomes, while psychosocial/behavioral factors accounted for the final 4% of variance. In the sensitivity analyses, we found that disease activity and organ damage explained 25% of the variance in pain outcomes.CONCLUSION: Disease activity only explained 33% of the variance of pain outcomes. However, there was an attenuation in these associations after accounting for psychosocial/behavioral factors, highlighting their roles in modifying the relationship between disease activity and pain. These findings suggest that multilevel interventions may be needed to tackle the negative impact of pain in SLE.

  View details for DOI 10.3899/jrheum.200595

  View details for PubMedID 33262298

• "MINI DIAL-A-NURSES" AND "GOOD BRANDS": WHAT ARE THE DESIRABLE FEATURES OF ONLINE HIV/STI RISK CALCULATORS? AIDS EDUCATION AND PREVENTION Gomez-Ramirez, O., Thomson, K., Salway, T., Haag, D., Falasinnu, T., Grennan, T., Grace, D., Gilbert, M. 2020; 32 (6): 528–42

  View details for DOI 10.1521/aeap.2020.32.6.528

  View details for Web of Science ID 000618983800006

• Emerging Characteristics of Isotonitazene-Involved Overdose Deaths: A Case-Control Study. Journal of addiction medicine Shover, C. L., Falasinnu, T. O., Freedman, R. B., Humphreys, K. 2020

  Abstract

  OBJECTIVES: Case reports of fatal overdoses involving the novel synthetic opioid isotonitazene have prompted the U.S. Drug Enforcement Administration to consider an emergency scheduling of the drug in June 2020. We aimed to epidemiologically characterize deaths involving isotonitazene.METHODS: We conducted a case control study using publicly available mortality records from January 1, 2020 to July 31, 2020 in Cook County, IL and Milwaukee County, WI. Cases (all deaths involving isotonitazene) and controls (all deaths involving other synthetic opioids) were compared on demographic characteristics, number of substances involved in fatal overdose, and co-involvement of other substances.RESULTS: We identified 40 fatal overdoses involving isotonitazene and 981 fatal overdoses involving other synthetic opioids. Isotonitazene deaths involved a significantly greater number of substances, and were significantly more likely to involve the designer benzodiazepine flualprazolam.DISCUSSION: Isotonitazene was involved in a substantial minority of synthetic opioid overdose deaths in the first 7 months of 2020. Future studies characterizing its prevalence in other markets are warranted. Emergence of highly potent novel synthetic opioids underscore the need for comprehensive health services for people with opioid use disorder.

  View details for DOI 10.1097/ADM.0000000000000775

  View details for PubMedID 33234804

• Increasing Ancestral Diversity in Lupus Trials: Ways Forward. Rheumatic diseases clinics of North America Falasinnu, T., Chaichian, Y., Simard, J. F. 2020; 46 (4): 713–22

  Abstract

  Significant disparities exist in systemic lupus erythematosus (SLE) regarding prevalence, disease severity, and mortality, with race/ethnic minorities being disproportionately affected in the United States. This review highlights that despite these disparities, race/ethnic minority underrepresentation remains an issue within SLE research. Decreased race/ethnic minority involvement in SLE research has real-world implications, including less understanding of the disease and less applicability of approved therapies among diverse groups of patients. Members of the SLE research community have an obligation to narrow this gap to ensure that future advances within the field are derived from and benefit a more representative group of patients.

  View details for DOI 10.1016/j.rdc.2020.07.011

  View details for PubMedID 32981648

• Steep increases in fentanyl-related mortality west of the Mississippi River: Recent evidence from county and state surveillance. Drug and alcohol dependence Shover, C. L., Falasinnu, T. O., Dwyer, C. L., Santos, N. B., Cunningham, N. J., Freedman, R. B., Vest, N. A., Humphreys, K. 2020; 216: 108314

  Abstract

  BACKGROUND: Overdose deaths from synthetic opioids (e.g., fentanyl) increased 10-fold in the United States from 2013 to 2018, despite such opioids being rare in illicit drug markets west of the Mississippi River. Public health professionals have feared a "fentanyl breakthrough" in western U.S. drug markets could further accelerate overdose mortality. We evaluated the number and nature of western U.S. fentanyl deaths using the most recent data available.METHODS: We systematically searched jurisdictions west of the Mississippi River for publicly available data on fentanyl-related deaths since 2018, the most recent Centers for Disease Control and Prevention (CDC) statistics. Using mortality data from 2019 and 2020, we identified changes in fentanyl-related mortality rate and proportion of fatal heroin-, stimulant, and prescription pill overdoses involving fentanyl.RESULTS: Seven jurisdictions had publicly available fentanyl death data through December 2019 or later: Arizona; California; Denver County, CO; Harris County, TX; King County, WA; Los Angeles County, CA; and Dallas-Fort Worth, TX (Denton, Johnson, Parker, and Tarrant counties). All reported increased fentanyl deaths over the study period. Their collective contribution to national synthetic narcotics mortality increased 371 % from 2017 to 2019. Available 2020 data shows a 63 % growth in fentanyl-mortality over 2019. Fentanyl-involvement in heroin, stimulant, and prescription pill deaths has substantially grown.DISCUSSION: Fentanyl has spread westward, increasing deaths in the short-term and threatening to dramatically worsen the nation's already severe opioid epidemic in the long-term. Increasing the standard dose of naloxone, expanding Medicaid, improving coverage of addiction treatment, and public health educational campaigns should be prioritized.

  View details for DOI 10.1016/j.drugalcdep.2020.108314

  View details for PubMedID 33038637

• Association of State Policies Allowing Medical Cannabis for Opioid Use Disorder With Dispensary Marketing for This Indication. JAMA network open Shover, C. L., Vest, N. A., Chen, D., Stueber, A., Falasinnu, T. O., Hah, J. M., Kim, J., Mackey, I., Weber, K. A., Ziadni, M., Humphreys, K. 2020; 3 (7): e2010001

  Abstract

  Importance: Misinformation about cannabis and opioid use disorder (OUD) may increase morbidity and mortality if it leads individuals with OUD to forego evidence-based treatment. It has not been systematically evaluated whether officially designating OUD as a qualifying condition for medical cannabis is associated with cannabis dispensaries suggesting cannabis as a treatment for OUD.Objective: To examine whether state-level policies designating OUD a qualifying condition for medical cannabis are associated with more dispensaries claiming cannabis can treat OUD.Design, Setting, and Participants: This cross-sectional, mixed-methods study of 208 medical dispensary brands was conducted in 2019 using the brands' online content. The study included dispensaries operating in New Jersey, New York, and Pennsylvania, where OUD is a qualifying condition for medical cannabis, and in Connecticut, Delaware, Maryland, Ohio, and West Virginia, where this policy does not exist.Exposures: Presence of OUD on the list of qualifying conditions for a state's medical cannabis program.Main Outcomes and Measures: Binary indicators of whether online content from the brand said cannabis can treat OUD, can replace US Food and Drug Administration-approved medications for OUD, can be an adjunctive therapy to Food and Drug Administration-approved medications for OUD, or can be used as a substitute for opioids to treat other conditions (eg, chronic pain).Results: After excluding duplicates, listings for nonexistent dispensaries, and those without online content, 167 brands across 7 states were included in the analysis (44 [26.3%] in states where OUD was a qualifying condition and 123 [73.7%] in adjacent states). A dispensary listed in a directory for West Virginia was not operational; therefore, comparison states were Connecticut, Delaware, Maryland, and Ohio. In policy-exposed states, 39% (95% CI, 23%-55%) more dispensaries claimed cannabis could treat OUD compared with unexposed states (P<.001). For replacing medications for OUD and being an adjunctive therapy, the differences were 14% (95% CI, 2%-26%; P=.002) and 28% (95% CI, 14%-42%; P<.001), respectively. The suggestion that cannabis could substitute for opioids (eg, to treat chronic pain) was made by 25% (95% CI, 9%-41%) more brands in policy-exposed states than adjacent states (P=.002).Conclusions and Relevance: In this study, state-level policies designating OUD as a qualifying condition for medical cannabis were associated with more dispensaries claiming cannabis can treat OUD. In the current policy environment, in which medical claims by cannabis dispensaries are largely unregulated, these advertisements could harm patients. Future research linking these policies to patient outcomes is warranted.

  View details for DOI 10.1001/jamanetworkopen.2020.10001

  View details for PubMedID 32662844

• Toward the Estimation of Unbiased Disease Prevalence Estimates Using Administrative Health Records. The Journal of rheumatology Falasinnu, T., Simard, J. F. 2019; 46 (12): 1549–51

  View details for DOI 10.3899/jrheum.190484

  View details for PubMedID 31787592

• A review of non-immune mediated kidney disease in systemic lupus erythematosus: A hypothetical model of putative risk factors. Seminars in arthritis and rheumatism Falasinnu, T., O'Shaughnessy, M. M., Troxell, M. L., Charu, V., Weisman, M. H., Simard, J. F. 2019

  Abstract

  About half of patients with systemic lupus erythematosus (SLE) are diagnosed with lupus nephritis (LN). Patients with SLE are also at increased risk for diabetes, hypertension and obesity, which together account for >70% of end-stage renal disease in the general population. The frequencies of non-LN related causes of kidney disease, and their contribution to kidney disease development and progression among patients with SLE have been inadequately studied. We hypothesize that a substantial, and increasing proportion of kidney pathology in patients with SLE might not directly relate to LN but instead might be explained by non-immune mediated factors such as diabetes, hypertension, and obesity. The goal of the manuscript is to draw attention to hypertension, diabetes and obesity as potential alternative causes of kidney damage in patients with SLE. Further, we suggest that misclassification of kidney disease etiology in patients with SLE might have important ramifications for clinical trial recruitment, epidemiologic investigation, and clinical care. Future studies aiming to elucidate and distinguish discrete causes of kidney disease - both clinically and histologically - among patients with SLE are desperately needed as improved understanding of disease mechanisms is paramount to advancing therapeutic discovery. Collaboration among rheumatologists, pathologists, nephrologists, and endocrinologists, and the availability of dedicated research funding, will be critical to the success of such efforts.

  View details for DOI 10.1016/j.semarthrit.2019.10.006

  View details for PubMedID 31866044

• Demographic Characteristics of Participants in Rheumatoid Arthritis Randomized Clinical Trials: A Systematic Review. JAMA network open Strait, A., Castillo, F., Choden, S., Li, J., Whitaker, E., Falasinnu, T., Schmajuk, G., Yazdany, J. 2019; 2 (11): e1914745

  Abstract

  Importance: Racial/ethnic minority groups, women, and elderly people experience a disproportionate burden of disease in rheumatoid arthritis (RA), making it particularly important to examine drug therapies in these populations. Despite a national health agenda to improve representation of diverse populations in randomized clinical trials (RCTs), there have been few large-scale analyses examining RCT demographic characteristics within rheumatology and none focusing on RA.Objective: To characterize the representation of racial/ethnic minority groups, women, and elderly people through a comprehensive systematic review of RA RCTs.Data Sources: A literature search of PubMed's MEDLINE database was conducted to identify RA RCTs in adults 19 years and older published in English between January 1, 2008, and January 1, 2018.Study Selection: Randomized double-blind RCTs examining any systemic, disease-modifying therapy were included. Secondary analyses of previously published RCTs were excluded. Of 1195 identified records, 240 articles (20.1%) met final selection criteria. The analysis focused on RCTs with at least 1 US-based site.Data Extraction and Synthesis: Data were extracted and synthesized according to the PRISMA guidelines for systematic reviews. Studies were screened for eligibility criteria. Demographic data on the age, sex, and race/ethnicity of RCT participants were extracted. Data analysis was conducted from October 25, 2018, to March 15, 2019.Main Outcomes and Measures: Representation of race/ethnicity and sex, defined as the proportion of total participants that belonged to each racial/ethnic group or sex. Trends in proportions over time were examined and compared with US demographic data.Results: A total of 240 RCTs with 77 071 participants were included. Of 126 RCTs with at least 1 US-based site (52.5%), the enrollment of minority racial/ethnic groups was significantly lower than their representation within the US Census population (16% vs 40%; P<.001), and the enrollment of men was significantly lower than the incidence of RA in men nationally (20.4% vs 28.6%; P<.001). There was no trend toward improved representation of racial/ethnic minority groups or men over time.Conclusions and Relevance: Given the disproportionate burden of RA among racial/ethnic minority groups, it is imperative that policy makers better incentivize the inclusion of racial/ethnic minority groups in RA RCTs.

  View details for DOI 10.1001/jamanetworkopen.2019.14745

  View details for PubMedID 31722023

• Does SLE widen or narrow race/ethnic disparities in the risk of five co-morbid conditions? Evidence from a community-based outpatient care system. Lupus Falasinnu, T., Chaichian, Y., Li, J., Chung, S., Waitzfelder, B. E., Fortmann, S. P., Palaniappan, L., Simard, J. F. 2019: 961203319884646

  Abstract

  OBJECTIVE: The heterogeneous spectrum of systemic lupus erythematosus (SLE) often presents with secondary complications such as cardiovascular disease (CVD), infections and neoplasms. Our study assessed whether the presence of SLE independently increases or reduces the disparities, accounting for the already higher risk of these outcomes among racial/ethnic minority groups without SLE.METHODS: We defined a cohort using electronic health records data (2005-2016) from a mixed-payer community-based outpatient setting in California serving patients of diverse racial/ethnic backgrounds. The eligible population included adult patients with SLE and matched non-SLE patients (≥18 years old). SLE was the primary exposure. The following outcomes were identified: pneumonia, other infections, CVD and neoplasms. For each racial/ethnic group, we calculated the proportion of incident co-morbidities by SLE exposure, followed by logistic regression for each outcome with SLE as the exposure. We evaluated interaction on the additive and multiplicative scales by calculating the relative excess risk due to interaction and estimating the cross-product term in each model.RESULTS: We identified 1036 SLE cases and 8875 controls. The incidence for all outcomes was higher among the SLE exposed. We found little difference in the odds of the outcomes associated with SLE across racial/ethnic groups, even after multivariable adjustment. This finding was consistent on the multiplicative and additive scales.CONCLUSION: We demonstrated that SLE status does not independently confer substantial interaction or heterogeneity by race/ethnicity toward the risk of pneumonia, other infections, CVD or neoplasms. Further studies in larger datasets are necessary to validate this novel finding.

  View details for DOI 10.1177/0961203319884646

  View details for PubMedID 31660790

• Impact of Diabetes on Risk of End Stage Renal Disease in Danish Nationwide Cohort of Newly Diagnosed Patients with Systemic Lupus Erythematosus Hansen, R., Simard, J., Faurschou, M., Jacobsen, S., Falasinnu, T. WILEY. 2019

  View details for Web of Science ID 000507466902437

• Development of Comorbidity in Danish Nationwide Cohort of Newly Diagnosed Patients with Systemic Lupus Erythematosus Hansen, R., Falasinnu, T., Simard, J., Faurschou, M., Jacobsen, S. WILEY. 2019

  View details for Web of Science ID 000507466902436

• VALIDATING A CLINICAL PREDICTION RULE FOR CHLAMYDIA AND GONORRHEA INFECTION AMONG ONLINE TESTERS IN BRITISH COLUMBIA, CANADA Ablona, A., Falasinnu, T., Irvine, M., Haag, D., Chang, H., Mishra, S., Burchell, A., Fairley, C., Lachowsky, N., Flowers, P., Estcourt, C., Murti, M., Gomez-Ramirez, O., Krajden, M., Grennan, T., Gilbert, M. BMJ PUBLISHING GROUP. 2019: A87

  View details for DOI 10.1136/sextrans-2019-sti.223

  View details for Web of Science ID 000506050100220

• Years of Potential Life Lost Because of Cardiovascular Disease in Asian-American Subgroups, 2003-2012. Journal of the American Heart Association Iyer, D. G., Shah, N. S., Hastings, K. G., Hu, J., Rodriguez, F., Boothroyd, D. B., Krishnan, A. V., Falasinnu, T., Palaniappan, L. 2019; 8 (7): e010744

  Abstract

  Background Asian-American subgroups (Asian-Indian, Chinese, Filipino, Korean, Japanese, and Vietnamese) display varied cardiovascular disease mortality patterns, especially at younger ages. This study aims to examine the years of potential life lost because of ischemic heart disease and cerebrovascular disease among the 6 largest Asian-American subgroups compared with non-Hispanic whites. Methods and Results We used National Center for Health Statistics Multiple Causes of Death mortality files from 2003 to 2012 to calculate race-specific life expectancy, mean years of potential life lost, and years of potential life lost per 100000 population for each Asian subgroup and non-Hispanic whites. Asian-American subgroups display heterogeneity in cardiovascular disease burden. Asian-Indians had a high burden of ischemic heart disease; Asian-Indian men lost 724years per 100000 population in 2012 and a mean of 17years to ischemic heart disease. Respectively, Vietnamese and Filipino men and women lost a mean of 17 and 16years of life to cerebrovascular disease; Filipino men lost 352years per 100000 population in 2012. All Asian subgroups for both sexes had higher years of life lost to cerebrovascular disease compared with non-Hispanic whites. Conclusions Cardiovascular disease burden varies among Asian subgroups, and contributes to greater premature mortality in certain subgroups. Asian-Indian and Filipino populations have the highest years of life lost because of ischemic heart disease and Filipino and Vietnamese have the highest years of life lost because of cerebrovascular disease. Analysis of risk factors and development of subgroup-specific interventions are required to address these health disparities.

  View details for PubMedID 30890022

• Diabetes-Attributable Mortality in the United States from 2003-2016 Using a Multiple-Cause-of-Death Approach. Diabetes research and clinical practice Rodriguez, F., Blum, M. R., Falasinnu, T., Hastings, K. G., Hu, J., Cullen, M. R., Palaniappan, L. P. 2019

  Abstract

  AIMS: Deaths attributable to diabetes may be underestimated using an underlying cause of death (COD) approach in U.S. death records. This study sought to characterize the burden of diabetes deaths using a multiple-cause of death approach and to identify temporal changes in co-reported causes of death among those with diabetes listed anywhere on their death records.METHODS: COD were identified using data from the National Center for Health Statistics from 2003-2016. We calculated age-adjusted mortality rates for diabetes as the underlying or contributing COD by race/ethnicity. We used ICD-10 codes to identify leading causes of death among those with and without diabetes on their death records. We compared temporal changes in deaths due to cardiovascular disease, cerebrovascular disease, cancer, and other causes.RESULTS: The study population included 34,313,964 decedents aged ≥25 from 2003-2016. Diabetes was listed as an underlying COD in approximately 3.0% (n=1,031,000) and 6.7% (n=2,295,510) of the death records, respectively. Decedents with diabetes listed as an underlying COD experienced a 16% decline in mortality, and the race/ethnicity-specific average annual percentage changes (AAPC) showed significant declining trends for most groups (AAPC ranged from 0.18 to -2.83%). Cardiovascular disease remained the leading underlying COD among diabetes-attributable deaths, although its proportion of deaths fell from 31 to 27% over time. Co-reported COD diversified, and were more likely to include hypertension and hypertensive renal disease among those with diabetes on their death records.CONCLUSIONS: Our findings underscore the importance of using a multiple-cause-of-death approach for more completely characterizing diabetes' contribution to mortality.

  View details for PubMedID 30641162

• The Representation of Gender and Race/Ethnic Groups in Randomized Clinical Trials of Individuals with Systemic Lupus Erythematosus. Current rheumatology reports Falasinnu, T. n., Chaichian, Y. n., Bass, M. B., Simard, J. F. 2018; 20 (4): 20

  Abstract

  This review evaluated gender and race/ethnic representation in randomized controlled trials (RCTs) of patients with systemic lupus erythematosus (SLE).Whites comprise 33% of prevalent SLE cases and comprised 51% of RCT enrollees. Blacks encompass 43% of prevalent SLE cases, but only represented 14% of RCT enrollees. Hispanics comprise 16% of prevalent SLE cases and 21% of RCT enrollees, while Asians comprise 13% of prevalent SLE cases and 10% of RCT enrollees. Males encompass 9% of SLE cases and 7% of RCT enrollees. The reporting and representation of males have remained stable over time, although their representation in RCTs is slighter lower than the prevalence of SLE in males. The representation of Hispanics, Asians, and Native Americans increased over time. However, the representation of blacks among RCT participants has decreased since 2006-2011. RCTs among SLE patients need larger sample sizes in order to evaluate heterogeneity in outcomes among racial subgroups. It is imperative that novel strategies be developed to recruit racial minorities with SLE by identifying and improving barriers to RCT enrollment in order to better understand the disease's diverse population.

  View details for PubMedID 29550947

• Do Death Certificates Underestimate the Burden of Rare Diseases? The Example of Systemic Lupus Erythematosus Mortality, Sweden, 2001-2013. Public health reports (Washington, D.C. : 1974) Falasinnu, T., Rossides, M., Chaichian, Y., Simard, J. F. 2018: 33354918777253

  Abstract

  OBJECTIVES: Mortality due to rare diseases, which are substantial sources of premature mortality, is underreported in mortality studies. The objective of this study was to determine the completeness of reporting systemic lupus erythematosus (SLE) as a cause of death.METHODS: In 2017, we linked data on a Swedish population-based cohort (the Swedish Lupus Linkage, 2001-2013) comprising people with SLE (n = 8560) and their matched general population comparators (n = 37717) to data from the Cause of Death Register. We reviewed death records of deceased people from the cohort (n = 5110) and extracted data on patient demographic characteristics and causes of death. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for not reporting SLE as a cause of death by using multivariable-adjusted logistic regression models.RESULTS: Of 1802 deaths among SLE patients in the study, 1071 (59%) did not have SLE reported on their death records. Most SLE decedents were aged 75-84 at death (n = 584, 32%), female (n = 1462, 81%), and born in Nordic countries (n = 1730, 96%). Decedents aged ≥85 at death were more likely to have SLE not reported on their death records than were decedents aged <50 (OR = 2.34; 95% CI, 1.48-3.68). Having renal failure listed as a cause of death decreased the likelihood of SLE not being reported on the death record (OR = 0.54; 95% CI, 0.40-0.73), whereas having cancer listed as a cause of death increased this likelihood (OR = 2.39; 95% CI, 1.85-3.07).CONCLUSIONS: SLE was greatly underreported as a cause of mortality on death records of SLE patients, particularly in older decedents and those with cancer, thereby underestimating the true burden of this disease. Public health resources need to focus on improving the recording of rare diseases in order to enhance the epidemiological utility of mortality data.

  View details for DOI 10.1177/0033354918777253

  View details for PubMedID 29928843

• Unraveling Race and Social Context in Understanding Disparities in Lupus Mortality in the United States Falasinnu, T., Chaichian, Y., Palaniappan, L., Simard, J. F. WILEY. 2017

  View details for Web of Science ID 000411824101112

• Impact of Sex on Systemic Lupus Erythematosus-Related Causes of Premature Mortality in the United States. Journal of women's health (2002) Falasinnu, T. n., Chaichian, Y. n., Simard, J. F. 2017

  Abstract

  Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that is a source of significantly decreased life expectancy in the United States. This study investigated causes of deaths among males and females with SLE.This cross-sectional study used the national death certificate database of ∼2.7 million death records in the United States, 2014. SLE was defined using Tenth Revision of the International Classification of Diseases codes: M32.1, M32.9, and M32.8. We compared sex-stratified demographic characteristics and the most commonly listed comorbidities in decedents with and without SLE. Relative risks (RRs) quantified the risk of dying with the most commonly listed comorbidities among decedents with SLE aged ≤50 years compared with non-SLE decedents.There were 2,036 decedents with SLE in the United States (86.2% female). Female SLE decedents were 22 years younger than non-SLE females (median: 59 years vs. 81 years). This difference was 12 years among male decedents (median: 61 years vs. 73 years). The most frequently listed causes of death among female SLE decedents were septicemia (4.32%) and hypertension (3.04%). In contrast, heart disease (3.70%) and diabetes mellitus with complications (3.61%) were the most common among male SLE decedents. Among younger male decedents, SLE had higher co-occurrence of coagulation/hemorrhagic disorders and chronic renal failure compared with non-SLE (RR = 16.69 [95% confidence interval {CI} = 10.50-27.44] and RR = 5.76 [95% CI = 2.76-12.00], respectively). These also contributed to premature mortality among women (RR = 4.98 [95% CI = 3.69-6.70] and 8.55 [95% CI = 6.89-10.61], respectively).Our findings identify clinically relevant comorbidities that may warrant careful consideration in patients' clinical management and the natural history of SLE.

  View details for DOI 10.1089/jwh.2017.6334

  View details for PubMedID 28891746

• An assessment of population-based screening guidelines versus clinical prediction rules for chlamydia and gonorrhea case finding. Preventive medicine Falasinnu, T., Gilbert, M., Gustafson, P., Shoveller, J. 2016; 89: 51-56

  Abstract

  Much remains to be learned regarding the epistemology and utility of guidelines and clinical prediction rules (CPR), as well as the extent to which knowledge about risk at a population level might be pertinent to any given patient in terms of case finding accuracy. In the current paper, we offer an empirical examination that juxtaposes population-based guidelines and CPR for sexual health decision-making.We analyzed electronic medical records from asymptomatic patient visits involving tests for chlamydia or gonorrhea between 2000 and 2012 at nine publicly funded STI clinics in British Columbia to compare the case-finding accuracy for infection risk under two scenarios: (1) if the population had been screened using the Public Health Agency of Canada (PHAC) screening guidelines for chlamydia and gonorrhea; or (2) if the population has been screened using a CPR. Performance metrics evaluated included the area under the ROC curve (AUC).In total, 35,818 individuals met the study inclusion criteria. The overall infection rate was 3.0%. Using the PHAC guidelines, the discriminatory performance of using any versus no risk factors and counts of risk factors were: AUC=0.55, 95% CI: 0.54-0.56 and AUC=0.64, 95% CI: 0.63-0.66, respectively. The model used to derive the CPR demonstrated good discrimination (AUC=0.73, 95% CI: 0.71-0.74).The current paper provides empirical evidence that demonstrates that population-based guidelines may not necessarily be a perfect fit for application at the individual level. Thus, we recommend risk estimation algorithms for use in sexual health services and programs.

  View details for DOI 10.1016/j.ypmed.2016.04.001

  View details for PubMedID 27143496

• Integrating gender and sex to unpack trends in sexually transmitted infection surveillance data in British Columbia, Canada: an ethno-epidemiological study. BMJ open Knight, R., Falasinnu, T., Oliffe, J. L., Gilbert, M., Small, W., Goldenberg, S., Shoveller, J. 2016; 6 (8)

  Abstract

  Surveillance data frequently indicate that young men and women experience high-yet considerably different-reported rates of sexually transmitted infections (STIs), including bacterial infections such as chlamydia. We examined how several sex-based (eg, biological) and gender-based (eg, sociocultural) factors may interact to influence STI surveillance data trends.Employing ethno-epidemiological techniques, we analysed cross-sectional qualitative data collected between 2006 and 2013 about young people's experiences accessing STI testing services in five communities in British Columbia, Canada. These data included 250 semistructured interviews with young men and women aged 15-24 years, as well as 39 clinicians who provided STI testing services.The findings highlight how young women are socially and medically encouraged to regularly test, while young men are rarely offered similar opportunities. Instead, young men tend to seek out testing services: (1) at the beginning or end of a sexual relationship; (2) after a high-risk sexual encounter; (3) after experiencing symptoms; or (4) based on concerns about 'abnormal' sexual anatomy. Our results illustrate how institutions and individuals align with stereotypical gender norms regarding sexual health responsibilities, STI testing and STI treatments. While these patterns reflect social phenomena, they also appear to intersect with sex-based, biological experiences of symptomatology in ways that might help to further explain systematic differences between young men's and women's patterns of testing for STIs.The results point to the importance of taking a social and biological view to understanding the factors that contribute to the gap between young men's and women's routine engagement in STI care.

  View details for DOI 10.1136/bmjopen-2016-011209

  View details for PubMedID 27566628

• Predictors identifying those at increased risk for STDs: a theory-guided review of empirical literature and clinical guidelines. International journal of STD & AIDS Falasinnu, T., Gilbert, M., Hottes, T. S., Gustafson, P., Ogilvie, G., Shoveller, J. 2015; 26 (12): 839-51

  Abstract

  SummarySexually transmitted diseases (STDs) are leading causes of substantial morbidity worldwide. Identification of risk factors for estimating STD risk provides opportunities for optimising service delivery in clinical settings, including improving case finding accuracy and increasing cost-efficiency by limiting the testing of low-risk individuals. The current study was undertaken to synthesise the evidence supporting commonly cited chlamydia and gonorrhoea risk factors. The level of empirical support for the following predictors was strong/moderate: age, race/ethnicity, multiple lifetime sexual partners, sex with symptomatic partners and concurrent STD diagnosis. The following predictors had weak evidence: socio-economic status, transactional sex, drug/alcohol use, condom use and history of STD diagnosis. The most frequently listed predictors among nine clinical guidelines were younger age and multiple sexual partners; the least consistently listed predictor was inconsistent condom use. We found reasonably good concordance between risk factors consistently listed in the recommendations and predictors found to have strong empirical support in the literature. There is a need to continue building the evidence base to explicate the mechanisms and pathways of STD acquisition. We recommend periodic reviews of the level of support of predictors included in clinical guidelines to ensure that they are in accordance with empirical evidence.

  View details for DOI 10.1177/0956462414555930

  View details for PubMedID 25324350

• A validation study of a clinical prediction rule for screening asymptomatic chlamydia and gonorrhoea infections among heterosexuals in British Columbia. Sexually transmitted infections Falasinnu, T., Gilbert, M., Gustafson, P., Shoveller, J. 2015

  Abstract

  One component of effective sexually transmitted infections (STIs) control is ensuring those at highest risk of STIs have access to clinical services because terminating transmission in this group will prevent most future cases. Here, we describe the results of a validation study of a clinical prediction rule for identifying individuals at increased risk for chlamydia and gonorrhoea infection derived in Vancouver, British Columbia (BC), against a population of asymptomatic patients attending sexual health clinics in other geographical settings in BC.We examined electronic records (2000-2012) from clinic visits at seven sexual health clinics in geographical locations outside Vancouver. The model's calibration and discrimination were examined by the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (H-L) statistic, respectively. We also examined the sensitivity and proportion of patients that would need to be screened at different cut-offs of the risk score.The prevalence of infection was 5.3% (n=10 425) in the geographical validation population. The prediction rule showed good performance in this population (AUC, 0.69; H-L p=0.26). Possible risk scores ranged from -2 to 27. We identified a risk score cut-off point of ≥8 that detected cases with a sensitivity of 86% by screening 63% of the geographical validation population.The prediction rule showed good generalisability in STI clinics outside of Vancouver with improved discriminative performance compared with temporal validation. The prediction rule has the potential for augmenting triaging services in STI clinics and enhancing targeted testing in population-based screening programmes.

  View details for DOI 10.1136/sextrans-2014-051992

  View details for PubMedID 25933609

• Deriving and validating a risk estimation tool for screening asymptomatic chlamydia and gonorrhea. Sexually transmitted diseases Falasinnu, T., Gilbert, M., Gustafson, P., Shoveller, J. 2014; 41 (12): 706-712

  Abstract

  There has been considerable interest in the development of innovative service delivery modules for prioritizing resources in sexual health delivery in response to dwindling fiscal resources and rising infection rates.This study aims to derive and validate a risk scoring algorithm to accurately identify asymptomatic patients at increased risk for chlamydia and/or gonorrhea infection. We examined the electronic records of patient visits at sexual health clinics in Vancouver, Canada. We derived risk scores from regression coefficients of multivariable logistic regression model using visits between 2000 and 2006. We evaluated the model's discrimination, calibration, and screening performance. Temporal validation was assessed in visits from 2007 to 2012.The prevalence of infection was 1.8% (n = 10,437) and 2.1% (n = 14,956) in the derivation and validation data sets, respectively. The final model included younger age, nonwhite ethnicity, multiple sexual partners, and previous infection and showed reasonable performance in the derivation (area under the receiver operating characteristic curve = 0.74; Hosmer-Lemeshow P = 0.91) and validation (area under the receiver operating characteristic curve = 0.64; Hosmer-Lemeshow P = 0.36) data sets. A risk score cutoff point of at least 6 detected 91% and 83% of cases by screening 68% and 68% of the derivation and validation populations, respectively.These findings support the use of the algorithm for individualized risk assessment and have important implications for reducing unnecessary screening and saving costs. Specifically, we anticipate that the algorithm has potential uses in alternative settings such as Internet-based testing contexts by facilitating personalized test recommendations, stimulating health care-seeking behavior, and aiding risk communication by increasing sexually transmitted infection risk perception through the creation of tailored risk messages to different groups.

  View details for DOI 10.1097/OLQ.0000000000000205

  View details for PubMedID 25581805

• A Critical Appraisal of Risk Models for Predicting Sexually Transmitted Infections SEXUALLY TRANSMITTED DISEASES Falasinnu, T., Gustafson, P., Hottes, T. S., Gilbert, M., Ogilvie, G., Shoveller, J. 2014; 41 (5): 321-330

  Abstract

  Prediction rules have been proposed as alternatives to screening recommendations and have potential applications in sexual health decision making. To our knowledge, there has been no review undertaken providing a critical appraisal of existing prediction rules in sexual health contexts. This review aims to identify and characterize prediction rules developed and validated for sexually transmitted infection (STI) screening, describe the methodological issues essential to the suitability of derived models for clinical or public health application, and synthesize the literature on the performance of these models.We searched MEDLINE (2003-2012) to identify studies that reported on models predicting STIs. We explored the methodological quality of the studies based on a 16-item quality assessment checklist. We also evaluated the studies based on data extracted on model discrimination, calibration, sensitivity, and testing efficiency.We identified 16 publications reporting on STI prediction rules. The most poorly addressed quality items were missing values, calibration measures, and variable definition. Overall, the performance of risk models as measured by discrimination (area under the receiver operating characteristic curve range, 0.64-0.88) and calibration was found to be generally good or satisfactory. Eight studies attained or were close to attaining the performance benchmark of testing less than 60% of the target population to achieve 90% sensitivity. The 2 risk models that were externally validated displayed adequate discrimination in new settings.Although we identified several well-performing STI risk prediction rules, few have been validated. Future developments in the use of prediction rules should address their clinical consequence, comparative usefulness, external validity, and implementation impact.

  View details for DOI 10.1097/OLQ.0000000000000120

  View details for Web of Science ID 000334797300010

  View details for PubMedID 24722388

• Risk prediction in sexual health contexts: protocol. JMIR research protocols Falasinnu, T., Gustafson, P., Gilbert, M., Shoveller, J. 2013; 2 (2)

  Abstract

  In British Columbia (BC), we are developing Get Checked Online (GCO), an Internet-based testing program that provides Web-based access to sexually transmitted infections (STI) testing. Much is still unknown about how to implement risk assessment and recommend tests in Web-based settings. Prediction tools have been shown to successfully increase efficiency and cost-effectiveness of STI case finding in the following settings.This project was designed with three main objectives: (1) to derive a risk prediction rule for screening chlamydia and gonorrhea among clients attending two public sexual health clinics between 2000 and 2006 in Vancouver, BC, (2) to assess the temporal generalizability of the prediction rule among more recent visits in the Vancouver clinics (2007-2012), and (3) to assess the geographical generalizability of the rule in seven additional clinics in BC.This study is a population-based, cross-sectional analysis of electronic records of visits collected at nine publicly funded STI clinics in BC between 2000 and 2012. We will derive a risk score from the multivariate logistic regression of clinic visit data between 2000 and 2006 at two clinics in Vancouver using newly diagnosed chlamydia and gonorrhea infections as the outcome. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow statistic will examine the model's discrimination and calibration, respectively. We will also examine the sensitivity and proportion of patients that would need to be screened at different cutoffs of the risk score. Temporal and geographical validation will be assessed using patient visit data from more recent visits (2007-2012) at the Vancouver clinics and at clinics in the rest of BC, respectively. Statistical analyses will be performed using SAS, version 9.3.This is an ongoing research project with initial results expected in 2014.The results from this research will have important implications for scaling up of Internet-based testing in BC. If a prediction rule with good calibration, discrimination, and high sensitivity to detect infection is found during this project, the prediction rule could be programmed into GCO so that the program offers individualized testing recommendations to clients. Further, the prediction rule could be adapted into educational materials to inform other Web-based content by creating awareness about STI risk factors, which may stimulate health care seeking behavior among individuals accessing the website.

  View details for DOI 10.2196/resprot.2971

  View details for PubMedID 24300284

• Implementing a Novel Citywide Rapid HIV Testing Campaign in Washington, DC: Findings and Lessons Learned PUBLIC HEALTH REPORTS Castel, A. D., Magnus, M., Peterson, J., Anand, K., Wu, C., Martin, M., Sansone, M., Rocha, N., Jolaosho, T., West, T., Hader, S., Greenberg, A. E. 2012; 127 (4): 422-431

  Abstract

  In June 2006, the District of Columbia (DC) Department of Health launched a citywide rapid HIV screening campaign. Goals included raising HIV awareness, routinizing rapid HIV screening, identifying previously unrecognized infections, and linking positives to care. We describe findings from this seminal campaign and identify lessons learned.We applied a mixed-methods approach using quantitative analysis of client data forms (CDFs) and qualitative evaluation of focus groups with DC residents. We measured characteristics and factors associated with client demographics, test results, and community perceptions regarding the campaign.Data were available on 38,586 participants tested from July 2006 to September 2007. Of those, 68% had previously tested for HIV (44% within the last 12 months) and 23% would not have sought testing had it not been offered. Overall, 662 (1.7%) participants screened positive on the OraQuick® Advance™ rapid HIV test, with non-Hispanic black people, transgenders, and first-time testers being significantly more likely to screen positive for HIV than white people, males, and those tested within the last year, respectively. Of those screening positive for HIV, 47% had documented referrals for HIV care and treatment services. Focus groups reported continued stigma regarding HIV and minimal community saturation of the campaign.This widespread campaign tested thousands of people and identified hundreds of HIV-infected individuals; however, referrals to care were lower than anticipated, and awareness of the campaign was limited. Lessons learned through this scale-up of population-based HIV screening resulted in establishing citywide HIV testing processes that laid the foundation for the implementation of test-and-treat activities in DC.

  View details for Web of Science ID 000306622600010

  View details for PubMedID 22753985

• Use of AIDS Drug Assistance Program data to increase the completeness of HIV/AIDS reporting Journal of HIV/AIDS Surveillance & Epidemiology Castel, A., Jolaosho, T., Vangani, R., Griffin, A., Ehrmann, T., Gurung, D., West-Ojo, T., Hader, S. 2011; 3 (1)
• A Population-Based Evaluation of the Intention to Quit Smoking, Cervical Cancer Screening Behaviour, and Multiple Health Behaviours Among Female Canadian Smokers Journal of Smoking Cessation Falasinnu, T. 2011; 6 (2): 119-125
• Electronic Record Linkage to Identify Deaths Among Persons with AIDS --- District of Columbia, 2000--2005 MMWR Jolaosho, T., Gauntt, J., West-Ojo, T., Castel, A., Selik, R., Durant, T., Peters, P., Tai, E. 2008