Faculty Bibliography

BACKGROUND:Permanent supportive housing (PSH) is the gold standard intervention for chronic homelessness, but PSH tenants face high risk for overdose due to a combination of individual and environmental risk factors. Little research has examined overdose prevention in PSH. METHODS:We conducted baseline surveys with staff from 20 New York PSH buildings participating in an overdose prevention technical assistance intervention study. PSH staff from participating buildings were invited via email to complete a brief online survey about their knowledge of overdose and perspectives on implementing overdose prevention practices in PSH. RESULTS:Surveys were completed by 178 staff of 286 invitations sent (response rate 62.2%). Average score on the Brief Opioid Overdose Knowledge (BOOK) questionnaire was 8.62 (SD 2.64) out of 12 points. Staff felt very positively (91.6-97.2% agreed or completely agreed) regarding the appropriateness and acceptability of implementing overdose prevention practices in PSH, but less certain about the feasibility of implementing these practices (62.4-65.5% agreed or completely agreed). Most (77.3%) felt it was mostly or definitely true that overdose prevention was a top priority in their building. Most PSH staff (median = 85.0%) but fewer tenants (median = 22.5%) had received a naloxone kit and training in overdose response. CONCLUSION/CONCLUSIONS:Staff feel positively about the acceptability and appropriateness of implementing overdose response practices in PSH, but somewhat more uncertain about the feasibility of implementing these practices. This study's results help hone targets for interventions to help PSH buildings take steps to reduce tenant overdose risk.

The concept of 'food justice' recognizes the systemic injustices embedded in the U.S. food system and the urgent need for transformative policies to ensure equitable access to affordable, nutritious, and culturally relevant food. Limited access to these foods drives food insecurity and increases the prevalence of diet-related diseases in low-income and minority communities. Dominant narratives that individualize hunger and food insecurity often blame the individual and overlook the underlying structural factors that sustain these issues. These narratives have considerable influence. They shape public opinion and can also guide policy decisions. This commentary explores the goals of the food justice movement in the U.S., describes how the food and racial justice movements intersect, and examines the role of commercial marketing and public policy in shaping the food justice discourse. We also reflect on the efforts that should be made to reframe these dominant narratives and facilitate meaningful change in the food environment.

BACKGROUND:To encourage high-quality, reduced-cost care for total joint arthroplasty (TJA), the Centers of Medicare & Medicaid Services mandated a pay-for-performance model, the Comprehensive Care for Joint Replacement (CJR), as part of the Patient Protection and Affordable Care Act (PPACA). The CJR incentivizes cost containment, and it was anticipated that its implementation would reduce access to TJA for high-cost populations. Patients with end-stage kidney disease (ESKD) undergoing kidney replacement therapy (dialysis and kidney transplant) are costly compared with healthier patients, but it was unknown whether this population lost access to hip and knee replacement because of CJR implementation. This population allows study of whether TJA is accessible for medically complex patients whose risk of surgical complications has been mitigated, as kidney transplantation improves outcomes compared with dialysis, allowing evaluation as to whether access improved when patients crossed over from dialysis to transplantation. Because all patients with ESKD are included in a mandated national registry, we can quantify whether access changed for patients who underwent dialysis and transplantation. QUESTIONS/PURPOSES/OBJECTIVE:(1) How did the rate of TJA change amid the shift to bundled payments for patients with ESKD receiving dialysis? (2) How did the rate of TJA change amid the shift to bundled payments for patients with ESKD after kidney transplant? METHODS:This was an observational cohort study from 2008 to 2018 using the United States Renal Data System, a mandatory national registry that allows for the opportunity to study all individuals with ESKD. During the study period, we identified 1,324,614 adults undergoing routine dialysis and 187,212 adult kidney transplant recipients; after exclusion for non-Medicare primary insurance (n = 785,224 for dialysis and 78,011 for transplant), patients who were 100 years or older (n = 79 and 0, respectively), those who resided outside of 50 US states and Puerto Rico (n = 781 and 87, respectively), missing dialysis status for the dialysis cohort (n = 8658), and multiorgan transplant recipients for the transplant cohort (n = 2442), our study population was 40% (529,872) of patients who underwent routine dialysis and 57% (106,672) of adult kidney transplant recipients, respectively. TJA was ascertained using Medicare Severity Diagnosis Related Groups and ICD-9 and ICD-10 codes. We divided the study period by PPACA (January 1, 2014, to March 31, 2016) and CJR (April 1, 2016, to December 31, 2018) implementation and compared the incidence of TJA by era using mixed-effects Poisson regression adjusting for calendar time and clinical and demographic variables. RESULTS:After adjustment for linear temporal trend and patient case mix, there was no evidence of association between policy implementation and the incidence of TJA. In the dialysis cohort, the adjusted incidence rate ratio (IRR) for TJA was 1.06 (95% confidence interval [CI] 0.98 to 1.14; p = 0.2) comparing PPACA with the previous period and 1.02 (95% CI 0.96 to 1.08; p = 0.6) comparing CJR with the previous periods. Similarly, in the transplant cohort, the adjusted IRR for TJA was 0.82 (95% CI 0.67 to 1.02; p = 0.07) comparing PPACA with the previous period and 1.10 (95% CI 0.94 to 1.28; p = 0.9) comparing CJR with the previous periods. CONCLUSION/CONCLUSIONS:There was no loss in access to TJA for medically complex patients receiving kidney replacement therapy. The increase in TJA incidence for patients after kidney transplant and decrease for patients receiving dialysis suggest that surgeons continued to provide care for higher risk patients whose risk of morbidity or mortality with total joint replacement has been maximally improved after transplantation. LEVEL OF EVIDENCE/METHODS:Level III, prognostic study.

IMPORTANCE/UNASSIGNED:Hearing loss treatment delays cognitive decline in high-risk older adults. The preventive potential of addressing hearing loss on incident dementia in a community-based population of older adults, and whether it varies by method of hearing loss measurement, is unknown. OBJECTIVE/UNASSIGNED:To calculate the population attributable fraction of incident dementia associated with hearing loss in older adults and to investigate differences by age, sex, self-reported race, and method of hearing loss measurement. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This prospective cohort study was part of the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS) and had up to 8 years of follow-up (2011-2019). The 4 ARIC field centers in the study included Jackson, Mississippi; Forsyth County, North Carolina; the Minneapolis suburbs, Minnesota; and Washington County, Maryland. Community-dwelling older adults aged 66 to 90 years without dementia at baseline who underwent a hearing assessment at ARIC-NCS visit 6 (2016-2017) were included in the analysis. Data analysis took place between June 2022 and July 2024. EXPOSURES/UNASSIGNED:Hearing loss measured objectively (audiometric) and subjectively (self-reported). MAIN OUTCOMES AND MEASURES/UNASSIGNED:The main outcome was incident dementia (standardized algorithmic diagnosis with expert panel review). The population attributable fractions of dementia from both audiometric and self-reported hearing loss were calculated in the same participants, which quantified the maximum proportion of dementia risk in the population that can be attributed to hearing loss. RESULTS/UNASSIGNED:Among 2946 participants (mean [SD] age, 74.9 [4.6] years; 1751 [59.4] female; 637 Black [21.6%] and 2309 White [78.4%] individuals), 1947 participants (66.1%) had audiometric hearing loss, and 1097 (37.2%) had self-reported hearing loss. The population attributable fraction of dementia from any audiometric hearing loss was 32.0% (95% CI, 11.0%-46.5%). Population attributable fractions were similar by hearing loss severity (mild HL: 16.2% [95% CI, 4.2%-24.2%]; moderate or greater HL: 16.6% [95% CI, 3.9%-24.3%]). Self-reported hearing loss was not associated with an increased risk for dementia, so the population attributable fraction was not quantifiable. Population attributable fractions from audiometric hearing loss were larger among those who were 75 years and older (30.5% [95% CI, -5.8% to 53.1%]), female (30.8% [95% CI, 5.9%-47.1%]), and White (27.8% [95% CI, -6.0% to 49.8%]), relative to those who were younger than 75 years, male, and Black. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This cohort study suggests that treating hearing loss might delay dementia for a large number of older adults. Public health interventions targeting clinically significant audiometric hearing loss might have broad benefits for dementia prevention. Future research quantifying population attributable fractions should carefully consider which measures are used to define hearing loss, as self-reporting may underestimate hearing-associated dementia risk.

PURPOSE/OBJECTIVE:The Veterans Affairs Health Administration (VA) has experience using telehealth (TH) to deliver care to 10 million enrolled Veterans for many clinical care needs. The VA National TeleOncology Service (NTO) was established in 2020 to provide specialized cancer services regardless of geography. We sought to compare quality in TH-delivered cancer services with traditional (TR) in-person VA care. METHODS:Using electronic health record data, we identified patients with an International Classification of Diseases-10 diagnostic code for an incident malignancy from December 2016 to March 2021 at early adopting sites providing both TR and TH care. We classified patients as TH users if they received TH services at least once for their cancer care. We gathered demographic, clinical, and treatment characteristics to calculate 25 Quality Oncology Practice Initiative (QOPI) measures in the symptoms and toxicity management (two), end of life and palliative care (10), and core measure domains (13). We report disease-specific measures, QOPI measures descriptively, and performed chi-square tests to compare TH and TR. RESULTS:= .002). TH and TR rates were similar for the other QOPI measures. CONCLUSION/CONCLUSIONS:VA is a leader in TH cancer care because of both its volume and quality. VA-provided TH cancer care quality is similar to or better than that of TR in-person care. NTO specifically, and VA teleoncology broadly, provides another option to Veterans for cancer care.

OBJECTIVE:Anogenital distance (AGD) is a postnatal marker of in utero exposure to androgens and anti-androgens, and a predictor of reproductive health. We examined the association between gestational exposure to phthalates and AGD in male and female infants. METHODS:In 506 mother-infant pairs (276 males, 230 females), we measured urinary concentrations of phthalate metabolites at < 18 and 18-25 weeks of gestation and AGD at child age 12.9 months (95 % range 11.4-21.1). Phthalate metabolite concentrations were adjusted for urinary dilution, averaged, and natural log-transformed. We measured anus-clitoris distance (AGDac) and anus-fourchette distance (AGDaf) in females, and anus-scrotum distance, anus-penis distance, and penile width in males. We used linear regression and partial-linear single-index (PLSI) models to examine associations between phthalates and AGD as single pollutants and in mixture. RESULTS:Fifty-eight percent of mothers were Hispanic, followed by 27 % non-Hispanic White. Higher exposures to ∑di-isononyl(phthalate) (∑DiNP) was associated with longer AGDaf [1.28 mm (95 % confidence interval [CI]: 0.52, 2.03) and 0.97 mm (95 %CI: 0.25, 1.69), respectively]. Higher exposures to ∑di(2-ethylhexyl)phthalate (∑DEHP) was associated with longer AGDac [2.80 mm (95 %CI: 1.17, 4.44), and 1.90 mm (95 %CI: 0.76, 3.04), respectively]. No association was observed between phthalate metabolites and AGD in males after multiple testing correction. In mixture analyses, ∑DiNP and ∑DEHP were the main contributors to longer AGD in females. We also detected an interaction between ∑DiNP and ∑DEHP in association with AGD in females. CONCLUSION/CONCLUSIONS:Early pregnancy phthalate exposure was associated with longer AGD in female infants. Biological mechanisms underlying these associations should be further investigated.

BACKGROUND:Plant-based diets are associated with a lower risk of cardiovascular disease (CVD). Proteomics may improve our understanding of the biological pathways underlying these associations. OBJECTIVES/OBJECTIVE:Using large-scale proteomics, we aimed to examine if plant-based diet-related proteins, which have been previously identified, are associated with incident CVD and subtypes of CVD in the Atherosclerosis Risk in Communities (ARIC) Study and Framingham Heart Study (FHS) Offspring cohort. METHODS:Discovery analyses were based on 9,078 participants free of CVD at ARIC visit 3 (1993-1995). Cox proportional hazards regression was used to evaluate the associations between plant-based diet-related proteins and incident CVD, coronary heart disease, heart failure, and stroke. Replication analyses were based on 1,279 participants without CVD in FHS Offspring cohort. RESULTS:In the ARIC Study, over a median follow-up of 21 years, there were 3,167 CVD events. At a false discovery rate (FDR) <0.05, 26 out of 73 plant-based diet-related proteins were significantly associated with incident CVD, after adjusting for important confounders. 18, 1, and 0 proteins were associated with heart failure, stroke, and coronary heart disease, respectively. Three, and 2 additional proteins were associated with CVD, and heart failure risk in FHS Offspring cohort at the nominal threshold (p value <0.05). Soluble advanced glycosylation end product-specific receptor (AGER) was inversely associated with incident CVD whereas thrombospondin-2 (THBS2) and N-terminal pro-BNP (NT-proBNP) was positively associated with incident CVD. THBS2 was positively associated with incident heart failure, whereas neuronal growth factor regulator 1 (NEGR1) and insulin-like growth factor-binding protein 1 (IGFBP1) was inversely associated. CONCLUSION/CONCLUSIONS:These proteins highlight several pathways that could explain plant-based diets-CVD associations.