HPV vaccine coverage in Texas counties: An application of multilevel, small area estimation

Health departments, research institutions, policy-makers, and healthcare providers are often interested in knowing the health status of their clients/constituents. Without the resources, financially or administratively, to go out into the community and conduct health assessments directly, these entities frequently rely on data from population-based surveys to supply the information they need. Unfortunately, these surveys are ill-equipped for the job due to sample size and privacy concerns. Small area estimation (SAE) techniques have excellent potential in such circumstances, but have been underutilized in public health due to lack of awareness and confidence in applying its methods. The goal of this research is to make model-based SAE accessible to a broad readership using clear, example-based learning. Specifically, we applied the principles of multilevel, unit-level SAE to describe the geographic distribution of HPV vaccine coverage among females aged 11-26 in Texas.^ Multilevel (3 level: individual, county, public health region) random-intercept logit models of HPV vaccination (receipt of ≥ 1 dose Gardasil® ) were fit to data from the 2008 Behavioral Risk Factor Surveillance System (outcome and level 1 covariates) and a number of secondary sources (group-level covariates). Sampling weights were scaled (level 1) or constructed (levels 2 & 3), and incorporated at every level. Using the regression coefficients (and standard errors) from the final models, I simulated 10,000 datasets for each regression coefficient from the normal distribution and applied them to the logit model to estimate HPV vaccine coverage in each county and respective demographic subgroup. For simplicity, I only provide coverage estimates (and 95% confidence intervals) for counties.^ County-level coverage among females aged 11-17 varied from 6.8-29.0%. For females aged 18-26, coverage varied from 1.9%-23.8%. Aggregated to the state level, these values translate to indirect state estimates of 15.5% and 11.4%, respectively; both of which fall within the confidence intervals for the direct estimates of HPV vaccine coverage in Texas (Females 11-17: 17.7%, 95% CI: 13.6, 21.9; Females 18-26: 12.0%, 95% CI: 6.2, 17.7).^ Small area estimation has great potential for informing policy, program development and evaluation, and the provision of health services. Harnessing the flexibility of multilevel, unit-level SAE to estimate HPV vaccine coverage among females aged 11-26 in Texas counties, I have provided (1) practical guidance on how to conceptualize and conduct modelbased SAE, (2) a robust framework that can be applied to other health outcomes or geographic levels of aggregation, and (3) HPV vaccine coverage data that may inform the development of health education programs, the provision of health services, the planning of additional research studies, and the creation of local health policies.^

Validity of using item response theory to analyze data from the Work Limitations Questionnaire

The Work Limitations Questionnaire (WLQ) is used to determine the amount of work loss and productivity which stem from certain health conditions, including rheumatoid arthritis and cancer. The questionnaire is currently scored using methodology from Classical Test Theory. Item Response Theory, on the other hand, is a theory based on analyzing item responses. This study wanted to determine the validity of using Item Response Theory (IRT), to analyze data from the WLQ. Item responses from 572 employed adults with dysthymia, major depressive disorder (MDD), double depressive disorder (both dysthymia and MDD), rheumatoid arthritis and healthy individuals were used to determine the validity of IRT (Adler et al., 2006).^ PARSCALE, which is IRT software from Scientific Software International, Inc., was used to calculate estimates of the work limitations based on item responses from the WLQ. These estimates, also known as ability estimates, were then correlated with the raw score estimates calculated from the sum of all the items responses. Concurrent validity, which claims a measurement is valid if the correlation between the new measurement and the valid measurement is greater or equal to .90, was used to determine the validity of IRT methodology for the WLQ. Ability estimates from IRT were found to be somewhat highly correlated with the raw scores from the WLQ (above .80). However, the only subscale which had a high enough correlation for IRT to be considered valid was the time management subscale (r = .90). All other subscales, mental/interpersonal, physical, and output, did not produce valid IRT ability estimates.^ An explanation for these lower than expected correlations can be explained by the outliers found in the sample. Also, acquiescent responding (AR) bias, which is caused by the tendency for people to respond the same way to every question on a questionnaire, and the multidimensionality of the questionnaire (the WLQ is composed of four dimensions and thus four different latent variables) probably had a major impact on the IRT estimates. Furthermore, it is possible that the mental/interpersonal dimension violated the monotonocity assumption of IRT causing PARSCALE to fail to run for these estimates. The monotonicity assumption needs to be checked for the mental/interpersonal dimension. Furthermore, the use of multidimensional IRT methods would most likely remove the AR bias and increase the validity of using IRT to analyze data from the WLQ.^

Dynamic population coding in primary visual cortex

More than a century ago Ramon y Cajal pioneered the description of neural circuits. Currently, new techniques are being developed to streamline the characterization of entire neural circuits. Even if this 'connectome' approach is successful, it will represent only a static description of neural circuits. Thus, a fundamental question in neuroscience is to understand how information is dynamically represented by neural populations. In this thesis, I studied two main aspects of dynamical population codes. ^ First, I studied how the exposure or adaptation, for a fraction of a second to oriented gratings dynamically changes the population response of primary visual cortex neurons. The effects of adaptation to oriented gratings have been extensively explored in psychophysical and electrophysiological experiments. However, whether rapid adaptation might induce a change in the primary visual cortex's functional connectivity to dynamically impact the population coding accuracy is currently unknown. To address this issue, we performed multi-electrode recordings in primary visual cortex, where adaptation has been previously shown to induce changes in the selectivity and response amplitude of individual neurons. We found that adaptation improves the population coding accuracy. The improvement was more prominent for iso- and orthogonal orientation adaptation, consistent with previously reported psychophysical experiments. We propose that selective decorrelation is a metabolically inexpensive mechanism that the visual system employs to dynamically adapt the neural responses to the statistics of the input stimuli to improve coding efficiency. ^ Second, I investigated how ongoing activity modulates orientation coding in single neurons, neural populations and behavior. Cortical networks are never silent even in the absence of external stimulation. The ongoing activity can account for up to 80% of the metabolic energy consumed by the brain. Thus, a fundamental question is to understand the functional role of ongoing activity and its impact on neural computations. I studied how the orientation coding by individual neurons and cell populations in primary visual cortex depend on the spontaneous activity before stimulus presentation. We hypothesized that since the ongoing activity of nearby neurons is strongly correlated, it would influence the ability of the entire population of orientation-selective cells to process orientation depending on the prestimulus spontaneous state. Our findings demonstrate that ongoing activity dynamically filters incoming stimuli to shape the accuracy of orientation coding by individual neurons and cell populations and this interaction affects behavioral performance. In summary, this thesis is a contribution to the study of how dynamic internal states such as rapid adaptation and ongoing activity modulate the population code accuracy. ^

Habitat use and foraging ecology of a batoid community in Shark Bay, Western Australia

Worldwide declines in populations of large elasmobranchs and the potential cascading effects on marine ecosystems have garnered considerable attention. Far less appreciated are the potential ecological impacts of changes in abundances of small to medium bodied elasmobranchs mesopredators. Crucial to elucidating the role of these elasmobranchs is an understanding of their habitat use and foraging ecology in pristine conditions. I investigated the trophic interactions and factors driving spatiotemporal variation in abundances of elasmobranch mesopredators in the relatively pristine ecosystem of Shark Bay, Australia. First, I describe the species composition and seasonal habitat use patterns of elasmobranch mesopredator on the sandflats of Shark Bay. Juvenile batoids dominated this diverse community and were extremely abundant in nearshore microhabitats during the warm season. Stomach content analysis and stable isotopic analysis revealed that there is a large degree of dietary overlap between common batoid species. Crustaceans, which tend to be found in seagrass habitats, dominated diets. Despite isotopic differences between many species, overlap in isotopic niche space was high and there was some degree of individual specialization. I then, investigated the importance of abiotic (temperature and water depth) and biotic (prey and predator abundance) factors in shaping batoid habitat use. Batoids were most abundant and tended to rest in shallow nearshore waters when temperatures were high. This pattern coincides with periods of large shark abundance suggesting batoids were seeking refuge from predators rather than selecting optimal temperatures. Finally, I used acoustic telemetry to examine batoid residency and diel use of the sandflats. Individual batoids were present on the sandflats during both the warm and cold seasons and throughout the diel cycle, suggesting lower sandflat densities during the cold season were a result of habitat shifts rather than migration out of Shark Bay. Combined, habitat use and dietary results suggest that batoids have the potential to seasonally impact sandflat dynamics through their presence, although foraging may be limited on the sandflats. Interestingly, my results suggest that elasmobranch mesopredators in pristine ecosystems probably are not regulated by food supply and their habitat use patterns and perhaps ecosystem impacts may be influenced by their predators.

Endocrine regulation of dynamic communication signals in gymnotiform fish

Communication signals are shaped by the opposing selection pressures imposed by predators and mates. A dynamic signal might serve as an adaptive compromise between an inconspicuous signal that evades predators and an extravagant signal preferred by females. Such a signal has been described in the gymnotiform electric fish, Brachyhypopomus gauderio, which produces a sexually dimorphic electric organ discharge (EOD). The EOD varies on a circadian rhythm and in response to social cues. This signal plasticity is mediated by the slow action of androgens and rapid action of melanocortins. My dissertation research tested the hypotheses that (1) signal plasticity is related to sociality levels in gymnotiform species, and (2) differences in signal plasticity are regulated by differential sensitivity to androgen and melanocortin hormones. To assess the breadth of dynamic signaling within the order Gymnotiformes, I sampled 13 species from the five gymnotiform families. I recorded EODs to observe spontaneous signal oscillations after which I injected melanocortin hormones, saline control, or presented the fish with a conspecific. I showed that through the co-option of the ancient melanocortin pathway, gymnotiforms dynamically regulate EOD amplitude, spectral frequency, both, or neither. To investigate whether observed EOD plasticities are related to species-specific sociality I tested four species; two territorial, highly aggressive species, Gymnotus carapo and Apteronotus leptorhynchus, a highly gregarious species, Eigenmannia cf. virescens , and an intermediate short-lived species with a fluid social system, Brachyhypopomus gauderio. I examined the relationship between the androgens testosterone and 11-ketotestosterone, the melanocortin α-MSH, and their roles in regulating EOD waveform. I implanted all fish with androgen and blank silicone implants, and injected with α-MSH before and at the peak of implant effect. I found that waveforms of the most territorial and aggressive species were insensitive to hormone treatments; maintaining a static, stereotyped signal that preserves encoding of individual identity. Species with a fluid social system were most responsive to hormone treatments, exhibiting signals that reflect immediate condition and reproductive state. In conclusion, variation in gymnotiform signal plasticity is hormonally regulated and seems to reflect species-specific sociality.

Social and environmental regulation of signal plasticity and signal reliability in the electric fish Brachyhypopomus gauderio

The balance between the costs and benefits of conspicuous signals ensures that the expression of those signals is related to the quality of the bearer. Plastic signals could enable males to maximize conspicuous traits to impress mates and competitors, but reduce the expression of those traits to minimize signaling costs, potentially compromising the information conveyed by the signals. ^ I investigated the effect of signal enhancement on the information coded by the biphasic electric signal pulse of the gymnotiform fish Brachyhypopomus gauderio. Increases in population density drive males to enhance the amplitude of their signals. I found that signal amplitude enhancement improves the information about the signaler's size. Furthermore, I found that the elongation of the signal's second phase conveys information about androgen levels in both sexes, gonad size in males and estrogen levels in females. Androgens link the duration of the signal's second phase to other androgen-mediated traits making the signal an honest indicator of reproductive state and aggressive motivation. ^ Signal amplitude enhancement facilitates the assessment of the signaler's resource holding potential, important for male-male interactions, while signal duration provides information about aggressive motivation to same-sex competitors and reproductive state to the opposite sex. Moreover, I found that female signals also change in accordance to the social environment. Females also increase the amplitude of their signal when population density increases and elongate the duration of their signal's second phase when the sex ratio becomes female-biased. Indicating that some degree of sexual selection operates in females. ^ I studied whether male B. gauderio use signal plasticity to reduce the cost of reproductive signaling when energy is limited. Surprisingly, I found that food limitation promotes the investment in reproduction manifested as signal enhancement and elevated androgen levels. The short lifespan and single breeding season of B. gauderio diminishes the advantage of energy savings and gives priority to sustaining reproduction. I conclude that the electric signal of B. gauderio provides reliable information about the signaler, the quality of this information is reinforced rather than degraded with signal enhancement.^

Factors influencing movements and foraging ecology of American alligators (Alligator mississippiensis) in a dynamic subtropical coastal ecosystem

Top predators can have large effects on community and population dynamics but we still know relatively little about their roles in ecosystems and which biotic and abiotic factors potentially affect their behavioral patterns. Understanding the roles played by top predators is a pressing issue because many top predator populations around the world are declining rapidly yet we do not fully understand what the consequences of their potential extirpation could be for ecosystem structure and function. In addition, individual behavioral specialization is commonplace across many taxa, but studies of its prevalence, causes, and consequences in top predator populations are lacking. In this dissertation I investigated the movement, feeding patterns, and drivers and implications of individual specialization in an American alligator (Alligator mississippiensis ) population inhabiting a dynamic subtropical estuary. I found that alligator movement and feeding behaviors in this population were largely regulated by a combination of biotic and abiotic factors that varied seasonally. I also found that the population consisted of individuals that displayed an extremely wide range of movement and feeding behaviors, indicating that individual specialization is potentially an important determinant of the varied roles of alligators in ecosystems. Ultimately, I found that assuming top predator populations consist of individuals that all behave in similar ways in terms of their feeding, movements, and potential roles in ecosystems is likely incorrect. As climate change and ecosystem restoration and conservation activities continue to affect top predator populations worldwide, individuals will likely respond in different and possibly unexpected ways.

Behavioral effects of plasma tryptophan depletion in aggressive and nonaggressive men

Serotonin (5-HT) neurotransmission deficits have been implicated in impulsive aggression. A Trp-free beverage of amino acids competitively inhibits Trp uptake into the brain for 5-HT synthesis and also lowers endogenous plasma Trp for several hours. This has worsened mood and/or increased aggressive behavior, especially in hostile persons or those with histories of depression. In 24 community-recruited men (12 each with and without significant aggression histories), aggressive and impulsive behavior in the laboratory was assessed before and after plasma Trp depletion and Trp loading. In the aggression model, subjects were provoked by periodic subtractions of participation earnings, and these subtractions were blamed on a ficitious other participant. Aggression was measured as the responses the subject made to subtract money from his antagonist. Impulsiveness was operationalized as: (1) the choice of smaller reward after a shorter delay over having to wait longer to receive a larger reward, and (2) “false alarm” commission errors in a modified Continuous Performance Task, which represent a failure to inhibit responding to stimuli similar (but not identical) to target stimuli. Finally, plasma cortisol and Trp were measured under each condition immediately following a aggression testing session when subjects were highly provoked. I hypothesized that 5-HT may tonically modulate (inhibit) the hypothalmnic-pituitary-adrenal stress response, such that Trp depletion may enhance the cortisol response to high provocation in aggressive men. ^ Trp depletion had no effect in the laboratory tasks purported to measure impulsive behavior, and failed to cause increases in aggressive behavior under low provocation conditions. Under higher provocation, however, aggressive responses we re elevated under Trp-depleted conditions relative to Trp-loaded conditions in aggressive men, whereas the reverse was true in nonaggressive men. Cortisol levels nonsignificantly paralled the group differences in aggression under Trp-depleted and Trp-loaded conditions. Aggressive men achieved lower plasma Trp levels after Trp loading than did nonaggressive men, possibly due to heavy alcohol use histories. The high post-loading plasma Trp levels in nonaggressive men tended also to correlate with their aggressive responding rates, due perhaps to increases in other psychoactive Trp metabolites. ^

Stressful life events and their contributions to symptoms of anxiety and depression in adolescents

There are several innovative aspects to this thesis that extend our current knowledge of the relations between stress and psychiatric symptoms in adolescents. First, distal and proximal stressors are differentiated. This approach allows one to specifically examine the role of early childhood stressors as well as stressors experienced more recently as they impact the expression of depression and anxiety during adolescence. Second, a state-of-the-art assessment instrument was used to examine proximal stressors, helping to distinguish several aspects of stress, including objective stress and subjective stress. Third, the parent study from which these data were derived was designed to examine the role of familial risk for depression and related risk factors for the initial development of depression and alcohol use disorders. This allowed for a very thorough collection of demographic characteristics of the study population. Accordingly, this thesis examines the initial prodromal expression of anxiety and depressive symptoms as they are originally expressed prior to the development, if any, of a full-blown psychiatric disorder.^

“What Happens When Pollinators Get Sick? Behavioral Impacts of Honeybee Viruses”

Like all organisms on the planet, honeybees (Apis mellifera) are susceptible to infection with a wide variety of viruses. These viruses may produce infections with no visible symptoms or may have devastating consequences on both the individual bee and the entire hive. Deformed Wing Virus, a member of the Iflavirus group of viruses, has an RNA genome and has had a particularly important impact on bee health. It can be spread between bees in a several ways – bees can infect each other during feeding or grooming activities, drones can pass the virus to the queen during mating and queens can lay infected eggs. The primary and most devastating way that these viruses are transmitted within and between hives involves a parasitic mite, an animal known ominously as Varroa destructor. The talk will discuss the effect that viruses have on the health and behavior of honeybees and will outline the collaborative research activities of Drs. Evans and Pizzorno over the last 7 years.

Proactive aggression: A two part study

Aggressive behavior can be divided into the subtypes: reactive and proactive. Reactive aggressive acts occur in response to a stimulus or provocation. Proactive aggressive acts occur without provocation and are goal-directed. A number of findings have suggested that individuals displaying proactive aggression may be discerned from individuals not displaying proactive aggression on measures of personality, psychopathology and psychopathy, as well as on aggressive histories and type and severity of aggressive behaviors committed. The current study was conducted in two phases; phase 1 and 2. This was because phase 1 compared proactive aggressive, reactive aggressive and non-aggressive subjects on questionnaire measures, while phase 2 observed the acute effects of the benzodiazepine alprazolam on only proactive aggressive subjects. The phase 1 hypotheses were that proactive aggressive subjects would show greater numbers of personality disorders and have greater psychopathy relative to reactive and non-aggressive subjects. To verify these hypotheses subjects were recruited from the community and classified as proactive (n = 20), reactive (n = 20) or non-aggressive (n = 10) via laboratory behavioral testing. Classified subjects were administered a battery of questionnaires pertaining to personality disorders (SCID-II, OMNI-IV), psychopathy (PCL-R) and aggression history. The results of these questionnaire measures were subjected to statistical analyses, which confirmed the hypotheses. In the second phase, the acute effects of three doses of the benzodiazepine alprazolam were evaluated in proactive aggressive subjects on proactive aggressive responding in the computer-based Point Subtraction Aggression Paradigm (PSAP). In phase 2 it was hypothesized that alprazolam would produce dose dependent decreases in aggressive responding. Subjects were never provoked in this phase, and aggressive responding was classified as proactive. Studies of drugs acting on the GABA system have frequently found decreases in aggression in animals and humans, although there have also been findings of increased (paradoxical) aggression. The hypothesis was tested by statistical analysis of proactive aggressive responding under placebo vs. under alprazolam. The hypothesis was supported by six of seven subjects. Aggressive responding was significantly, decreased under alprazolam relative to placebo in six subjects. One subject showed increases in aggressive responding.^

Gender differences in colorectal cancer screening and incidence in large nationwide, population-based cohorts

Background. A few studies have reported gender differences along the colorectal cancer (CRC) continuum but none has done so longitudinally to compare a cancer and a non-cancer populations.^ Objectives and Methods. To examine gender differences in colorectal cancer screening (CRCS); to examine trends in gender differences in CRC screening among two groups of patients (Medicare beneficiaries with and without cancer); to examine gender differences in CRC incidence; and to examine for any differences over time. In Paper 1, the study population consisted of men and women, ages 67–89 years, with CRC (73,666) or without any cancer (39,006), residing in 12 U.S. Surveillance Epidemiology and End-Results (SEER) regions. Crude and age-adjusted percentages and odds ratios of receiving fecal occult blood test (FOBT), sigmoidoscopy (SIG), or colonoscopy (COL) were calculated. Multivariable logistic regression was used to assess gender on the odds of receiving CRC screening over time.^ In Paper 2, age-adjusted incidence rates and proportions over time were reported across race, CRC subsite, CRC stage and SEER region for 373,956 patients, ages 40+ years, residing in 9 SEER regions and diagnosed with malignant CRC. ^ Results. Overall, women had higher CRC screening rates than men and screening rates in general were higher in the SEER sample of persons with CRC diagnosis. Significant temporal divergence in FOBT screening was observed between men and women in both cohorts. Although the largest temporal increases in screening rates were found for COL, especially among the cohort with CRC, little change in the gender gap was observed over time. Receipt of FOBT was significantly associated with female gender especially in the period of full Medicare coverage. Receipt of COL was also significantly associated with male gender, especially in the period of limited Medicare coverage.^ Overall, approximately equal numbers of men (187,973) and women (185,983) were diagnosed with malignant CRC. Men had significantly higher age-adjusted CRC incidence rates than women across all categories of age, race, subsite, stage and SEER region even though rates declined in all categories over time. Significant moderate increases in rate difference occurred among 40-59 year olds; significant reductions occurred among patients age 70+, within subsite rectum, unstaged and distant stage CRC, and eastern and western SEER regions. ^ Conclusions. Persistent gender differences in CRC incidence across time may have implications for gender-based interventions that take age into consideration. A shift toward proximal cancer was observed over time for both genders, but the high proportion of men who develop rectal cancer suggests that a greater proportion of men may need to be targeted with newer screening methods such as fecal DNA or COL. Although previous reports have documented higher CRC screening among men, higher incidence of CRC observed among men suggests that higher risk categories of men are probably not being reached. FOBT utilization rates among women have increased over time and the gender gap has widened between 1998 and 2005. COL utilization is associated with male gender but the differences over time are small.^