Faculty Bibliography

IMPORTANCE:Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. OBJECTIVE:To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. DESIGN, SETTING, AND PARTICIPANTS:This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. EXPOSURE:ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. MAIN OUTCOMES AND MEASURES:The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. RESULTS:There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. CONCLUSIONS AND RELEVANCE:These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.

INTRODUCTION/BACKGROUND:In July 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. We measured secondhand smoke (SHS) exposure immediately before, and repeatedly up to 36 months post-SFH policy implementation in a purposeful sample of 21 New York City (NYC) high-rise buildings (>15 floors): 10 NYC Housing Authority (NYCHA) buildings subject to the policy and 11 privately managed buildings in which most residents received housing vouchers (herein 'Section 8'). METHODS:We invited participants from non-smoking households (NYCHA n=157, Section 8 n=118) to enroll into a longitudinal air monitoring study, measuring (1) nicotine concentration with passive, bi-sulfate-coated filters, and (2) particulate matter (PM2.5) with low-cost particle sensors. We also measured nicotine concentrations and counted cigarette butts in common areas (n=91 stairwells and hallways). We repeated air monitoring sessions in households and common areas every 6 months, totaling six post-policy sessions. RESULTS:After three years, we observed larger declines in nicotine concentration in NYCHA hallways than in Section 8, [difference-in-difference (DID) = -1.92 µg/m 3 (95% CI -2.98, -0.87), p=0.001]. In stairwells, nicotine concentration declines were larger in NYCHA buildings, but the differences were not statistically significant [DID= -1.10 µg/m 3 (95% CI -2.40, 0.18), p=0.089]. In households, there was no differential change in nicotine concentration (p=0.093) or in PM2.5 levels (p=0.385). CONCLUSIONS:Nicotine concentration reductions in NYCHA common areas over three years may be attributable to the SFH policy, reflecting its gradual implementation over this time. IMPLICATIONS/CONCLUSIONS:Continued air monitoring over multiple years has demonstrated that SHS exposure may be declining more rapidly in NYCHA common areas as a result of SFH policy adherence. This may have positive implications for improved health outcomes among those living in public housing, but additional tracking of air quality and studies of health outcomes are needed. Ongoing efforts by NYCHA to integrate the SFH policy into wider healthier-homes initiatives may increase policy compliance.

Environmental health research aims to assess the impact of environmental exposures, making it crucial to understand their effects due to their broad impacts on the general population. However, a common issue with measuring exposures using bio-samples in laboratory is that values below the limit of detection (LOD) are either left unreported or inaccurately read by machines, which subsequently influences the analysis and assessment of exposure effects on health outcomes. We address the challenge of handling exposure variables subject to LOD when they are treated as either covariates or an outcome. We evaluate the performance of commonly-used methods including complete-case analysis and fill-in method, and advanced techniques such as multiple imputation, missing-indicator model, two-part model, Tobit model, and several others. We compare these methods through simulations and a dataset from NHANES 2013"“2014. Our numerical studies show that the missing-indicator model generally yields reasonable estimates when considering exposure variables as covariates under various settings, while other methods tend to be sensitive to the LOD-missing proportions and/or distributional skewness of exposures. When modeling an exposure variable as the outcome, Tobit model performs well under Gaussian distribution and quantile regression generally provides robust estimates across various shapes of the outcome"™s distribution. In the presence of missing data due to LOD, different statistical models should be considered for being aligned with scientific questions, model assumptions, requirements of data distributions, as well as their interpretations. Sensitivity analysis to handle LOD-missing exposures can improve the robustness of model conclusions.

BACKGROUND:The association of renin with adverse kidney outcomes is largely unknown, and renin measurement strategies vary. We aimed to measure the clinical correlates of different renin measurements and the association between renin and incident chronic kidney disease (CKD), end-stage kidney disease (ESKD), and mortality. METHODS:We performed a prospective cohort analysis 9420 participants in the Atherosclerosis Risk in Communities (ARIC) study followed from 1996-1998 through 2019. We estimated longitudinal associations of renin measured using SomaScan modified nucleotide aptamer assay with incident CKD, ESKD, and death using Cox proportional hazards models. Using samples from a subsequent study visit, we compared SomaScan renin with plasma renin activity (PRA) and renin level from Olink, and estimated associations with covariates using univariate and multivariable regression. RESULTS:Higher SomaScan renin levels were associated with higher risk of incident CKD (hazard ratio per two-fold higher [HR], 1.14; 95% confidence interval [CI], 1.09 to 1.20), ESKD (HR, 1.20; 95% CI, 1.03 to 1.41), and mortality (HR, 1.08; 95% CI, 1.04 to 1.13) in analyses adjusted for demographic, clinical, and socioeconomic covariates. SomaScan renin was moderately correlated with PRA (r=0.61) and highly correlated with Olink renin (r=0.94). SomaScan renin and PRA had similar clinical correlates except for divergent associations with age and beta blocker use, both of which correlated positively with SomaScan renin but negatively with PRA. CONCLUSIONS:SomaScan aptamer-based renin level was associated with higher risk of CKD, ESKD, and mortality. It was moderately correlated with PRA, sharing generally similar clinical covariate associations.

Introduction: In STRIVE, natalizumab treatment demonstrated effectiveness in clinical, magnetic resonance imaging (MRI), and patient-reported outcomes (PROs) in patients with early relapsing"“remitting multiple sclerosis (RRMS). This post hoc analysis examined the effectiveness and safety of natalizumab in patients who self-identified as either Black/African American (AA) or Hispanic/Latino. Methods: Clinical, MRI, and PROs were assessed for the Black/AA subgroup (n = 40) and compared with the non-Hispanic White subgroup (n = 158). As a result of the very small sample size, outcomes for the Hispanic/Latino subgroup (n = 18) were assessed separately, including a sensitivity analysis with Hispanic/Latino patients who completed the 4-year study on natalizumab. Results: Clinical, MRI, and PROs were comparable between the Black/AA and non-Hispanic White subgroups except for MRI outcomes at year 1. A higher proportion of non-Hispanic White than Black/AA patients achieved MRI no evidence of disease activity (NEDA; 75.4% vs. 50.0%, p = 0.0121) and no new or newly enlarging T2 lesions (77.6% vs. 50.0%, p = 0.0031) at year 1; these differences were not observed in years 2"“4 of the study. For the Hispanic/Latino subgroup in the intent-to-treat population, 46.2% and 55.6% achieved NEDA at years 1 and 2; 66.7% and 90.0% achieved clinical NEDA at years 3 and 4. Annualized relapse rate was reduced by 93.0% at year 1 versus the year before natalizumab initiation; this reduction was maintained throughout the study. Over 4 years, 37.5"“50.0% of patients had a clinically meaningful improvement in their Symbol Digit Modalities Test score, and 81.8"“100.0% and 90.9"“100.0% had stable/improved Multiple Sclerosis Impact Scale-29 physical and psychological scores, respectively. Similar results were observed in the sensitivity analysis with Hispanic/Latino subgroup of the 4-year natalizumab completers. Conclusion: These results highlight the effectiveness and safety of natalizumab in patients with early RRMS who self-identified as Black/AA or Hispanic/Latino. ClinicalTrials.gov: NCT01485003.

Evidence-based interventions (EBIs) are considered the gold standard but it is unclear if they are effective across settings. Reach Out and Stay Strong, Essentials for new Mothers (ROSE) has been shown to prevent postpartum depression in clinical settings, but has not been implemented or tested in homeless populations. We used the Exploration, Preparation, Implementation and Sustainment (EPIS) model overlaid with the Dynamic Adaptation Process (DAP) to adapt ROSE for implementation in a homeless shelter system in a large U.S. city, using feedback from both the organization and community. The adapted intervention was called Strong in Shelter (SIS). In this paper, we present 4 DAPS (April, 2018- December, 2020); the EPIS stages within each DAP are described. The Exploration Stage is centered around early and ongoing engagement with shelter providers and residents. The Preparation Stage includes adaptations based on learnings from the Exploration and the Implementation Stages from previous DAPs. The Implementation Stage highlights what we learned from implementation and both quantitative and qualitative feedback from shelter staff and residents. Following the DAP cycles, we created scalable plans in the Sustainment Stage. Thematic analysis was used to identify, analyze and report patterns within qualitative data, and descriptive analyses were conducted with quantitative data. Participant engagement and satisfaction were high and facilitators reported implementing SIS with fidelity to ROSE"™s core components. By engaging staff and the participants early and continually, and utilizing an iterative and flexible adaptation process, EBIs such as ROSE can be adapted and implemented with fidelity in new settings.