Faculty Bibliography

BACKGROUND:Despite an aging population, little is known about racial disparities in aging-specific functional impairments and mortality among older adults hospitalized for acute myocardial infarction (AMI). METHODS:We analyzed data from patients aged 75 years or older who were hospitalized for AMI at 94 US hospitals from 2013 to 2016. Functional impairments and geriatric conditions were assessed in-person during the AMI hospitalization. The association between race and risk of mortality (primary outcome) was evaluated with logistic regression adjusted sequentially for age, clinical characteristics, and measures of functional impairment and other conditions associated with aging. RESULTS:Among 2918 participants, 2668 (91.4%) self-identified as White and 250 (8.6%) as Black. Black participants were younger (80.8 vs 81.7 years; p = 0.010) and more likely to be female (64.8% vs 42.5%; p < 0.001). Black participants were more likely to present with impairments in cognition (37.6% vs 14.5%; p < 0.001), mobility (66.0% vs 54.6%; p < 0.001) and vision (50.1% vs 35.7%; p < 0.001). Black participants were also more likely to report a disability in one or more activities of daily living (22.4% vs 13.0%; p < 0.001) and an unintentional loss of more than 10 lbs in the year prior to hospitalization (37.2% vs 13.0%; p < 0.001). The unadjusted odds of 6-month mortality among Black participants (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.4-2.8) attenuated to non-significance after adjustment for age, clinical characteristics (OR 1.70, 95% CI 1.7, 1.2-2.5), and functional/geriatric conditions (OR 1.5, 95% CI 1.0-2.2). CONCLUSIONS:Black participants had a more geriatric phenotype despite a younger average age, with more functional impairments. Controlling for functional impairments and geriatric conditions attenuated disparities in 6-month mortality somewhat. These findings highlight the importance of systematically assessing functional impairment during hospitalization and also ensuring equitable access to community programs to support post-AMI recovery among Black older adults.

People with substance use disorder (SUD) smoke cigarettes at a rate more than twice that of the general population. Policies and programs have focused on promoting smoking cessation among people with SUD, yet it is unclear whether interventions have adequately reached the subgroup involved in the criminal legal system, who have among the highest smoking rates. Drawing on repeated cross-sections of the National Survey on Drug Use and Health, we found that smoking rates declined by 9.4 percentage points overall among people with SUD from 2010 to 2019, but rates remained virtually unchanged among the subgroup with criminal legal involvement. In regression analyses focused on people with SUD, three-quarters of the excess smoking burden for those with criminal legal involvement at baseline (2010-13) was accounted for by controlling for sociodemographics, substance use type, health insurance, and recent SUD treatment. However, even after we controlled for these same factors, the disparity in smoking prevalence among people with SUD between those with and without criminal legal involvement remained constant over time. These findings underscore the need for smoking cessation interventions focused on the criminal legal system, including correctional facilities and SUD treatment programs that serve people in this population.

AIM/OBJECTIVE:To test the hypothesis that glucagon-like peptide-1 receptor (GLP-1R) agonists have beneficial effects on vascular endothelial function, fibrinolysis and inflammation through weight loss-independent mechanisms. MATERIALS AND METHODS/METHODS:Individuals with obesity and prediabetes were randomized to 14 weeks of the GLP-1R agonist liraglutide, hypocaloric diet or the dipeptidyl peptidase-4 inhibitor sitagliptin in a 2:1:1 ratio. Treatment with drug was double blind and placebo-controlled. Measurements were made at baseline, after 2 weeks prior to significant weight loss and after 14 weeks. The primary outcomes were measures of endothelial function: flow-mediated vasodilation (FMD), plasminogen activator inhibitor-1 (PAI-1) and urine albumin-to-creatinine ratio (UACR). RESULTS:Eighty-eight individuals were studied (liraglutide N = 44, diet N = 22, sitagliptin N = 22). Liraglutide and diet reduced weight, insulin resistance and PAI-1, while sitagliptin did not. There was no significant effect of any treatment on endothelial vasodilator function measured by FMD. Post hoc subgroup analyses in individuals with baseline FMD below the median, indicative of greater endothelial dysfunction, showed an improvement in FMD by all three treatments. GLP-1R antagonism with exendin (9-39) increased fasting blood glucose but did not change FMD or PAI-1. There was no effect of treatment on UACR. Finally, liraglutide, but not sitagliptin or diet, reduced the chemokine monocyte chemoattractant protein-1 (MCP-1). CONCLUSION/CONCLUSIONS:Liraglutide and diet reduce weight, insulin resistance and PAI-1. Liraglutide, sitagliptin and diet do not change FMD in obese individuals with prediabetes with normal endothelial function. Liraglutide alone lowers the pro-inflammatory and pro-atherosclerotic chemokine MCP-1, indicating that this beneficial effect is independent of weight loss.

High quality and culturally responsive early childhood education and care (ECEC) for young children before kindergarten is seen as a way to ensure that all children enter school ready to learn. ECEC is even more crucial in the context of recovery from the COVID-19 pandemic and the disproportionate burden of trauma and stress borne by families of color in disinvested neighborhoods. Remote learning and repeated disruptions to in-person instruction as protocols shifted during waves of the pandemic placed an extra strain on families, and may have increased educational disparities in the U.S. Taken together, these challenges have implications for children's school readiness due to their impact on opportunities for learning at home and in the classroom. This paper explores how ECEC programs can be strengthened to better meet children's needs, and ways in which future research can shed light on these important issues.

Children suffer disproportionately from disease and disability due to environmental hazards, for reasons rooted in their biology. The contribution is substantial and increasingly recognized, particularly due to ever-increasing awareness of endocrine disruption. Regulatory actions can be traced directly to reductions in toxic exposures, with tangible benefits to society. Deep flaws remain in the policy framework in industrialized countries, failing to offer sufficient protection, but are even more limited in industrializing nations where the majority of chemical production and use will occur by 2030. Evidence-based steps for reducing chemical exposures associated with adverse health outcomes exist and should be incorporated into anticipatory guidance.

RATIONALE & OBJECTIVE/OBJECTIVE:Anemia is common in chronic kidney disease (CKD); although anemia is associated with adverse outcomes, the available treatments are not ideal. We characterized the burden, risk factors for, and risks associated with anemia by estimated glomerular filtration rate (eGFR) and hemoglobin level. STUDY DESIGN/METHODS:Cross-sectional and prospective cohort study. SETTING & PARTICIPANTS/METHODS:Outpatient data from 5,004,957 individuals across 57 health care centers in the United States from 2016 to 2019, extracted from the Optum Labs Data Warehouse. EXPOSURE/METHODS:Severity of anemia, presence of low iron test results, eGFR. OUTCOME/RESULTS:Incident kidney failure with replacement therapy, cardiovascular disease, coronary heart disease, stroke, heart failure, death. ANALYTICAL APPROACH/METHODS:deficiency, and erythropoiesis-stimulating agent (ESA) use, stratified by sex and eGFR, were characterized. Polychotomous logistic regression was used to estimate the adjusted odds ratios of different hemoglobin levels across eGFR. Cox proportional hazards regression was used to calculate adjusted hazard ratios for adverse outcomes across hemoglobin level. RESULTS:The mean age was 54 years, and 42% were male. Lower eGFR was very strongly associated with increased prevalence of anemia, even after adjustment. Although iron studies were checked infrequently in patients with anemia, low iron test results were highly prevalent in those tested: 60.4% and 81.3% of men and women, respectively. ESA use was uncommon, with a prevalence of use of<4%. Lower hemoglobin was independently associated with increased risk of incident kidney failure with replacement therapy, cardiovascular disease, coronary heart disease, stroke, heart failure, and death. LIMITATIONS/CONCLUSIONS:Reliance on ICD codes for medical diagnoses, death information obtained from claims data, observational study. CONCLUSIONS:Severe anemia was common and strongly associated with lower eGFR and multiple adverse outcomes. Low-iron test results were highly prevalent in those tested despite iron studies being checked infrequently. ESA use in nondialysis CKD patients was uncommon.

Neurologists have long-recognized the importance of the visual system in the diagnosis and monitoring of neurological disorders. This is particularly true since approximately 50% of the brain's pathways subserve afferent and efferent aspects of vision. During the past 30 years, researchers and clinicians have further refined this concept to include investigation of the visual system for patients with specific neurologic diagnoses, including multiple sclerosis (MS), concussion, Parkinson's disease (PD) and conditions along the spectrum of Alzheimer's disease (AD, mild cognitive impairment [MCI] and subjective cognitive decline [SCD]). This review, highlights the visual "toolbox" that has been developed over the past three decades and beyond to capture both structural and functional aspects of vision in neurologic disease. While the efforts to accelerate the emphasis on structure-function relationships in neurological disorders began with MS during the early 2000's, such investigations have broadened to recognize the need for outcomes of visual pathway structure, function and quality of life for clinical trials of therapies across the spectrum of neurological disorders. This review begins with a patient case study highlighting the importance utilizing the most modern technologies for visual pathway assessment, including optical coherence tomography (OCT). We emphasize that both structural and functional tools for vision testing can be used in parallel to detect what might otherwise be sub-clinical events or markers of visual and, perhaps, more global neurological, decline. Such measures will be critical as clinical trials and therapies become more available across the neurological disease spectrum.

During the start of the COVID-19 pandemic, shortages of personal protective equipment (PPE) necessitated unprecedented and non-validated approaches to conserve PPE at healthcare facilities, especially in high income countries where single-use disposable PPE was ubiquitous. Our team conducted a systematic literature review to evaluate historic approaches for conserving single-use PPE, expecting that lower-income countries or developing contexts may already be uniquely conserving PPE. However, of the 50 included studies, only 3 originated from middle-income countries and none originated from low-income countries. Data from the included studies suggest PPE remained effective with extended use and with multiple or repeated use in clinical settings, as long as donning and doffing were performed in a standard manner. Multiple decontamination techniques were effective in disinfecting single use PPE for repeated use. These findings can inform healthcare facilities and providers in establishing protocols for safe conservation of PPE supplies and updating existing protocols to improve sustainability and overall resilience. Future studies should evaluate conservation practices in low-resource settings during non-pandemic times to develop strategies for more sustainable and resilient healthcare worldwide.