Faculty Bibliography

PURPOSE/OBJECTIVE:Tobacco-use is a causative or exacerbating risk factor for benign and malignant urologic disease. However, it is not well known how often urologists screen for tobacco use and provide tobacco cessation treatment at the population level. Therefore, we sought to evaluate how often urologists see patients for tobacco-related diagnoses in the outpatient setting and how often these visits include tobacco-use screening and treatment. MATERIALS AND METHODS/METHODS:We used the National Ambulatory Medical Care Survey (NAMCS) public use files for the years 2014-2016 to identify all outpatient urology visits with adults 18 years and older. Clinic visit reasons were categorized according to diagnoses associated with the encounter: all urologic diagnoses, a tobacco-related urologic condition, or a urologic cancer. Our primary outcome was the percentage of visits during which tobacco screening was reported. Secondary outcomes included reported delivery of cessation counseling and provision of cessation pharmacotherapy. RESULTS:We identified 4,625 unique urologic outpatient encounters, representing a population-weighted estimate of 63.9 million visits over three years. Approximately a third of all urology visits were for a tobacco-related urologic diagnoses and 15% were for urologic cancers. An estimated 1.1 million visits over three years were with patients who identified as current tobacco users. Of all visits, 70% included tobacco screening. However, only 7% of visits with current smokers included counseling and only 3% were prescribed medications. No differences in screening and treatment were observed between visit types. CONCLUSIONS:Urologists regularly see patients for tobacco-related conditions and frequently, though not universally, screen patients for tobacco. However, urologists rarely offer counseling or cessation treatment. These findings may represent missed opportunities to decrease the morbidity associated with tobacco use.

BACKGROUND/OBJECTIVES/OBJECTIVE:Poor communication is a barrier to care for people with hearing loss. We assessed the feasibility and potential benefit of providing a simple hearing assistance device during an emergency department (ED) visit, for people who reported difficulty hearing. DESIGN/METHODS:Randomized controlled pilot study. SETTING/METHODS:The ED of New York Harbor Manhattan Veterans Administration Medical Center. PARTICIPANTS/METHODS:One hundred and thirty-three Veterans aged 60 and older, presenting to the ED, likely to be discharged to home, who either (1) said that they had difficulty hearing, or (2) scored 10 or greater (range 0-40) on the Hearing Handicap Inventory-Survey (HHI-S). INTERVENTION/METHODS:Subjects were randomized (1:1), and intervention subjects received a personal amplifier (PA; Williams Sound Pocketalker 2.0) for use during their ED visit. MEASUREMENTS/METHODS:Three survey instruments: (1) six-item Hearing and Understanding Questionnaire (HUQ); (2) three-item Care Transitions Measure; and (3) three-item Patient Understanding of Discharge Information. Post-ED visit phone calls to assess ED returns. RESULTS:Of the 133 subjects, 98.3% were male; mean age was 76.4 years (standard deviation (SD) = 9.2). Mean HHI-S score was 19.2 (SD = 8.3). Across all HUQ items, intervention subjects reported better in-ED experience than controls. Seventy-five percent of intervention subjects agreed or strongly agreed that ability to understand what was said was without effort versus 56% for controls. Seventy-five percent of intervention subjects versus 36% of controls said clinicians provided them with an explanation about presenting problems. Three percent of intervention subjects had an ED revisit within 3 days compared with 9.0% controls. CONCLUSION/CONCLUSIONS:Veterans with hearing difficulties reported improved in-ED experiences with use of PAs, and were less likely to return to the ED within 3 days. PAs may be an important adjunct to older patient ED care but require validation in a larger more definitive randomized controlled trial.

Background/UNASSIGNED:We explored characteristics and beliefs associated with e-cigarette use patterns among cigarette smokers requiring inpatient detoxification for opioid and/or alcohol use disorder(s). Methods/UNASSIGNED:-test statistics, and logistic regression models were used. Results/UNASSIGNED: Conclusions/UNASSIGNED:E-cigarette use seems to be appealing to a small proportion of cigarette smokers with SUD. Although, dual smokers seem to use e-cigarettes for its cessation premise, they don't appear to be actively seeking to quit. E-cigarettes may offer a more effective method for harm reduction, further evaluation of incorporating it within smoking cessation protocols among patients in addiction treatment is needed.

BACKGROUND:In 2012, the United States Preventative Services Task Force (USPSTF) formally recommended against all Prostate Specific Antigen (PSA) screening for prostate cancer. Our goal was to characterize PSA screening trends in the Veterans Health Administration (VA) before and after the USPSTF recommendation, and to determine if PSA screening was more likely to be ordered based on a Veteran's race or age. METHODS:Using the VA Corporate Data Warehouse, we created 10 annual groups of PSA-eligible men covering 2009-2018. We identified all PSA tests performed in the VA to determine yearly rates of PSA screening. All statistical tests were two-sided. RESULTS:The overall rate of PSA testing in the VA decreased from 63.3% in 2009 to 51.2% in 2018 (p<.001). PSA screening rates varied markedly by age group during our study period, with men aged 70-80 having the highest initial rate and greatest decline (70.6% in 2009 to 48.4% in 2018, p<.001). Men aged 55-69 saw a smaller decline (65.2% in 2009 to 58.9% in 2018, p<.001) while the youngest men, aged 40-54, had an increase in PSA screening (26.2% in 2009 to 37.8 in 2018, p<.001). CONCLUSIONS:In this analysis of PSA screening rates among veterans before and after the 2012 USPSTF recommendation against screening, we found that overall PSA screening decreased only modestly, continuing for more than half of the men in our study. Veterans of different races had similar screening rates, suggesting that VA care may minimize racial disparities. Veterans of varying age experienced significantly different trends in PSA screening.

OBJECTIVE:Individuals with posttraumatic stress disorder (PTSD) smoke at higher rates compared to the general population and experience significant barriers to initiating cessation treatment. Proactive outreach addresses these barriers by directly engaging with smokers and facilitating access to treatment. The objective of the present study was to evaluate a proactive outreach intervention for increasing rates of treatment utilization and abstinence among veteran smokers with and without PTSD. METHOD/METHODS:= 1,583) a diagnosis of PTSD. Logistic regressions modeled cessation treatment utilization (counseling, nicotine replacement therapy [NRT], and combination treatment) and abstinence (7-day point prevalence and 6-month prolonged at 6- and 12-month follow-ups) among participants randomized to proactive outreach versus usual care in the PTSD and non-PTSD subgroups, respectively. RESULTS:= 1.61, [1.11, 2.34]). CONCLUSIONS:Proactive outreach increased treatment utilization and abstinence among smokers with and without PTSD. Smokers with PTSD may need additional facilitation to initiate cessation treatment but are receptive when it is offered proactively. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

CONTEXT/BACKGROUND:Use of electronic cigarettes (e-cigarettes) has rapidly increased despite unclear longitudinal health effects. Once thought to be a safer alternative to tobacco smoke, it is possible that e-cigarettes expose the user to similar carcinogenic byproducts during the vaping process. These toxicants are metabolized and excreted in the urine, and may have oncogenic implications for bladder urothelium. OBJECTIVE:To characterize and summarize known urinary carcinogenic biomarkers in e-cigarette users as they relate to the risk of developing bladder cancer. EVIDENCE ACQUISITION/METHODS:A systematic literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and included PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Relevant articles published in peer-reviewed journals, through January 2019, that reported on urinary biomarkers in e-cigarettes users were included. Parent compounds and urinary biomarkers were classified according to the International Agency for Research on Cancer Monographs on the Evaluation of Carcinogenic Risks to Humans and cross referenced using the Collaborative on Health and the Environment, Toxicant and Disease Database to determine a link to bladder cancer, grouped by strength of evidence. EVIDENCE SYNTHESIS/RESULTS:Our initial search identified 1385 articles, 22 of which met final inclusion criteria and were included for analysis. In summation, these studies described 40 different parent compounds and four metals found in the urine of e-cigarette users. Since each parent compound can be metabolized several different ways, 63 unique toxicant or carcinogenic metabolite biomarkers were identified. Compared with nonuser controls, e-cigarette users had higher concentrations of urinary biomarkers of several carcinogenic compounds linked to bladder cancer. The majority of studies were limited by heterogeneous reporting and a dearth of control individuals who had never smoked. CONCLUSIONS:Biomarkers of carcinogens, several with a strong link to bladder cancer, are present in the urine of e-cigarette users. Long-term implications of urothelial exposure to these toxicants are unknown but concerning, given the similarities to tobacco smoke and its established relationship with bladder cancer. Further study on the urological safety of e-cigarettes is necessary. PATIENT SUMMARY/UNASSIGNED:Our review shows that several carcinogens that have a known link to bladder cancer are present in the urine of electronic cigarette (e-cigarette) users. Further study on the urological safety of e-cigarettes is necessary.

Meeting the mental health needs of our current veteran population is one of the primary challenges facing the Veteran's Health Administration (VHA). Particularly for veterans residing in rural areas, the lack of providers, high provider turnover, and the burden of traveling long distances to VHA facilities may contribute to difficulties accessing mental health care. Telemental Health (TMH) services help bridge the geographic gap between mental health providers and veterans who need mental health services. The VHA TMH Hub initiative has attempted to leverage changes in technology-facilitated care by developing a model in which a facility "hub" could expand mental health resources to remote "spoke" clinics and veterans' residences. This paper describes the implementation of the VA New York Harbor Health care System (VA NYH) TMH Hub, which was one of 6 programs funded by the VHA Office of Rural Health (ORH) in September 2016. We will describe the structure of the program, services provided, veterans served, and our efforts to integrate quality improvement, research, and clinical training into the operations of the program. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

BACKGROUND:People with a psychiatric diagnosis smoke at high rates, yet are rarely treated for tobacco use. Health care systems often use a 'no treatment' default for tobacco, such that providers must actively choose (opt-in) to treat their patients who express interest in quitting. Default bias theory suggests that opt-in systems may reinforce the status quo to not treat tobacco use in psychiatry. We aim to conduct a pilot study testing an opt-out system for implementing a 3A's (ask, advise, assist) tobacco treatment model in outpatient psychiatry. METHODS:We will use a mixed-methods, cluster-randomized study design. We will implement a tobacco use clinical reminder for outpatient psychiatrists at the VA New York Harbor Healthcare System. Psychiatrists (N = 20) will be randomized 1:1 to one of two groups: (1) Opt-In Treatment Approach: Psychiatrists will receive a reminder that encourages them to offer cessation medications and referral to cessation counseling; or (2) Opt-Out Treatment Approach: Psychiatrists will receive a clinical reminder that includes a standing cessation medication order and a referral to cessation counseling that will automatically generate unless the provider cancels. Prior to implementation of the reminders, we will hold a 1-hour training on tobacco treatment for psychiatrists in both arms. We will use VA administrative data to calculate the study's primary outcomes: 1) the percent of smokers prescribed a cessation medication and 2) the percent of smokers referred to counseling. During the intervention period, we will also conduct post-visit surveys with a cluster sample of 400 patients (20 per psychiatrist) to assess psychiatrist fidelity to the 3 A's approach and patient perceptions of the opt-out system. At six months, we will survey the clustered patient sample again to evaluate the study's secondary outcomes: 1) patient use of cessation treatment in the prior 6 months and 2) self-reported 7-day abstinence at 6 months. At the end of the intervention period, we will conduct semi-structured interviews with 12-14 psychiatrists asking about their perceptions of the opt-out approach. DISCUSSION/CONCLUSIONS:This study will produce important data on the potential of opt-out systems to overcome barriers in implementing tobacco use treatment in outpatient psychiatry. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov Identifier NCT04071795 (registered August 28, 2019). https://www.clinicaltrials.gov/ct2/show/NCT04071795.

INTRODUCTION AND OBJECTIVE/OBJECTIVE:Cigarette smoking is the leading modifiable risk factor for several genitourinary (GU) malignancies. Although smoking cessation after GU cancer diagnosis is a critical component of survivorship, factors related to continued smoking are understudied. METHODS:A cross-sectional analysis was conducted using data from the NHIS (2014-2018). Our primary study outcome was the prevalence and correlates of cigarette smoking among adults with history of smoking-related (kidney or bladder) urologic cancer compared with a nonsmoking-related control (prostate cancer). We used regression analyses to assess the association of having a smoking-related GU cancer history with continued cigarette smoking after diagnosis. Secondary outcomes were yearly smoking trends, quit attempts and reported receipt of smoking cessation counseling. RESULTS:A total of 2,664 respondents reported a history of a GU cancer, representing weighted estimates of 990,820 (smoking-related GU cancer) and 2,616,596 (prostate cancer) adults. Survivors of smoking-related GU cancers had a significantly higher overall prevalence of current cigarette use (14.8% vs 8.6%, p <0.001) and also reported more frequent receipt of counseling (79.8% vs 66.2%, p=0.02) but did not attempt to quit any more often than those with prostate cancer (52.4% vs 47.2%, p=0.44). Time trends demonstrated stable and persistent cigarette use among survivors of all GU cancers. After adjustment for sociodemographic confounders, cancer type was not associated with current cigarette smoking (OR 1.23, 95% CI 0.86-1.77). However, older age and more advanced educational attainment were associated with lower odds of current cigarette smoking while single marital status was associated with higher odds. CONCLUSIONS:In this population-based cross-sectional study of survivors of GU cancers, those with a reported smoking-related GU cancer had a higher prevalence of current cigarette smoking compared to prostate cancer, our nonsmoking related control. Those with smoking-related GU cancers reported more frequent receipt of smoking cessation counseling.