Faculty Bibliography

Sexual and gender minorities (SGM) include persons identifying as lesbian, gay, bisexual, transgender/non-binary, and queer experience a greater cancer burden than their heterosexual or cisgender counterparts. Access to cancer care includes prevention and early detection, however despite known increased risk for various malignancies among SGM individuals, cancer screening rates remain low. This commentary outlines disparities in cancer screening for SGM individuals and provides the current evidence-based screening guidelines for these patients.

BACKGROUND:Little is known about the prevalence and prognostic impact of preexisting frailty on acute care and in-hospital outcomes in older adults in the setting of acute myocardial infarction (AMI). METHODS:Preexisting frailty was assessed at baseline in consecutive AMI patients ≥65 years of age treated at 778 hospitals participating in the NCDR ACTION Registry between January 1, 2015 to December 31, 2016. Three domains of preexisting frailty (cognition, ambulation, and functional independence) were abstracted from chart review and summed in 2 ways: an ACTION Frailty Scale based on responses to 6 groups adapted from the Canadian Study of Health and Aging Clinical Frailty Scale and an ACTION Frailty Score derived by summing a rank score of 0-2 assigned for each grade (total ranged between 0 to 6). Multivariable logistic regression examined the association between assigned frailty by score or scale and in-hospital mortality. RESULTS:Among 143,722 older AMI patients, 108,059 (75.2%) were fit and/or well and 6,484 (4.5%) were vulnerable to frailty, while 7,527 (5.2%) had mild, 3,913 (2.7%) had moderate, 2,715 had (1.9%) severe, and 632 (0.4%) had very severe frailty according to the ACTION Frailty Scale, while 14,392 (10.0%) could not be categorized due to incomplete ascertainment. Frail patients were older, more frequently female, of non-white race and/or ethnicity, and less likely to be treated with guideline-recommended therapies. Increasing severity of frailty by this scale was associated with a step-wise higher risk for in-hospital mortality (P-trend < .001). Patient categories of the ACTION Frailty Score provided similar results. After adjustment, each 1-unit increase in Frailty Score was associated with a 12% higher mortality risk (OR 1.12, 95% CI 1.10-1.15). CONCLUSIONS:Among older patients with acute myocardial infarction, frailty is common and independently associated with in-hospital mortality. These findings show the importance of pragmatic evaluation of frailty in hospital-level quality scores, guideline recommendations, and incorporation into other registry data collection efforts.

Secondhand smoke (SHS) exposure remains a major public health concern in the United States. Homes have become the primary source of SHS exposure, with elevated risks for residents of multiunit housing. Though this differential risk is well-documented, little is known about whether SHS exposure varies by floor height. The aim of this study was to examine whether SHS accumulates in higher floors of multiunit housing. Using validated passive nicotine sampling monitors, we sampled air nicotine concentrations on multiple floors of 21 high-rise (&gt;15 floors) buildings in New York City. Within the buildings, measurements were collected in three locations: non-smoking individual apartments, hallways and stairwells. Measurements were collected in two winter and two summer waves to account for potential seasonality effects. We analyzed the percent of filters with detectable nicotine and quantified nicotine concentration (µg/m³). Higher floor levels were positively associated with both airborne nicotine measures, with some variation by location and season observed. In winter, the trends were statistically significant in apartments (floors ≤7: 0.022 µg/m³; floors 8-14: 0.026 µg/m³; floors ≥15: 0.029 µg/m³; p = 0.011) and stairwells (floors ≤7: 0.18 µg/m³; floors 8-14: 0.19 µg/m³; floors ≥15: 0.59 µg/m³; p = 0.006). These findings can inform interventions to mitigate the SHS exposure of residents in multiunit housing.

BACKGROUND:Large-scale longitudinal studies evaluating influences of the built environment on risk for type 2 diabetes (T2D) are scarce, and findings have been inconsistent. OBJECTIVE:To evaluate whether land use environment (LUE), a proxy of neighborhood walkability, is associated with T2D risk across different US community types, and to assess whether the association is modified by food environment. METHODS:The Veteran's Administration Diabetes Risk (VADR) study is a retrospective cohort of diabetes-free US veteran patients enrolled in VA primary care facilities nationwide from January 1, 2008, to December 31, 2016, and followed longitudinally through December 31, 2018. A total of 4,096,629 patients had baseline addresses available in electronic health records that were geocoded and assigned a census tract-level LUE score. LUE scores were divided into quartiles, where a higher score indicated higher neighborhood walkability levels. New diagnoses for T2D were identified using a published computable phenotype. Adjusted time-to-event analyses using piecewise exponential models were fit within four strata of community types (higher-density urban, lower-density urban, suburban/small town, and rural). We also evaluated effect modification by tract-level food environment measures within each stratum. RESULTS:In adjusted analyses, higher LUE had a protective effect on T2D risk in rural and suburban/small town communities (linear quartile trend test p-value <0.001). However, in lower density urban communities, higher LUE increased T2D risk (linear quartile trend test p-value <0.001) and no association was found in higher density urban communities (linear quartile trend test p-value = 0.317). Particularly strong protective effects were observed for veterans living in suburban/small towns with more supermarkets and more walkable spaces (p-interaction = 0.001). CONCLUSION/CONCLUSIONS:Among veterans, LUE may influence T2D risk, particularly in rural and suburban communities. Food environment may modify the association between LUE and T2D.

Breakfast consumption among youth is associated with improved diet quality, weight, cognition, and behavior. However, not all youth in the United States consume breakfast. Participation in the School Breakfast Program (SBP) is also low relative to the lunch program. Universal free breakfast (UFB) policies have been implemented to increase breakfast participation by reducing cost and stigma associated with the SBP. This study examined whether a UFB policy implemented in a school district in the Southeast US was associated with changes in breakfast participation, school attendance, and student weight. A longitudinal study of secondary data was conducted, and a mixed modeling approach was used to assess patterns of change in SBP participation. General linear models were used to assess attendance and student weight change. On average, across schools in the district, there was an increase in breakfast participation of 4.1 percentage points following the implementation of the policy. The change in breakfast participation in schools differed by the percent of students in the school who received school meals for free or at a reduced price, the percent of students of color, and the grade level of the school. Increases in SBP participation were not associated with significant changes in attendance or weight. UFB policies may be effective in increasing participation in the SBP.

Exposure to endocrine-disrupting chemicals (EDCs) contributes to substantial disease burden worldwide. We aim to quantify the disease burden and costs of EDC exposure in Canada and to compare these results with previously published findings in the European Union (EU) and United States (US). EDC biomonitoring data from the Canadian Health Measures Survey (2007-2011) was applied to 15 exposure-response relationships, and population and cost estimates were based on the 2010 general Canadian population. EDC exposure in Canada (CAD 24.6 billion) resulted in substantially lower costs than the US (USD 340 billion) and EU (USD 217 billion). Nonetheless, our findings suggest that EDC exposure contributes to substantial and costly disease burden in Canada, amounting to 1.25% of the annual Canadian gross domestic product. As in the US, exposure to polybrominated diphenyl ethers was the greatest contributor of costs (8.8 billion for 374,395 lost IQ points and 2.6 billion for 1610 cases of intellectual disability). In the EU, organophosphate pesticides were the largest contributor to costs (USD 121 billion). While the burden of EDC exposure is greater in the US and EU, there remains a similar need for stronger EDC regulatory action in Canada beyond the current framework of the Canadian Environmental Protection Act of 1999.

To describe how social disruptions caused by the COVID-19 pandemic impacted child access to healthcare and child health behaviors in 2020. We used mixed-methods to conduct surveys and in-depth interviews with English- and Spanish-speaking parents of young children from five geographic regions in the USA. Participants completed the COVID-19 Exposure and Family Impact Survey (CEFIS). Semistructured telephone interviews were conducted between August and October 2020. Of the 72 parents interviewed, 45.8% of participants were Hispanic, 20.8% Black (non-Hispanic), and 19.4% White (non-Hispanic). On the CEFIS, the average (SD) number of social/family disruptions reported was 10.5 (3.8) out of 25. Qualitative analysis revealed multiple levels of themes that influenced accessing healthcare during the pandemic, including two broad contextual themes: (a) lack of trustworthiness of medical system/governmental organizations, and (b) uncertainty due to lack of consistency across multiple sources of information. This context influenced two themes that shaped the social and emotional environments in which participants accessed healthcare: (a) fear and anxiety and (b) social isolation. However, the pandemic also had some positive impacts on families: over 80% indicated that the pandemic made it "a lot" or "a little" better to care for their new infants. Social and family disruptions due to COVID-19 were common. These disruptions contributed to social isolation and fear, and adversely impacted multiple aspects of child and family health and access to healthcare. Some parents of infants reported improvements in specific health domains such as parenting, possibly due to spending more time together.

BACKGROUND:Urologists frequently treat patients for tobacco-related conditions but infrequently engage in evidence-based practices (EBPs) that screen for and treat tobacco use. Improving the use of EBPs will help to identify smokers, promote cessation, and improve patients' health outcomes. METHODS:A prospective type I hybrid effectiveness-implementation study was performed to test the feasibility and effectiveness of using a multilevel implementation strategy to improve the use of tobacco EBPs. All urology providers at outpatient urology clinics within the Veterans Health Administration Greater Los Angeles and all patients presenting for a new urology consultation were included. The primary outcome was whether a patient was screened for tobacco use at the time of consultation. Secondary outcomes included a patient's willingness to quit, chosen quit strategy, and subsequent engagement in quit attempts. RESULTS:In total, 5706 consecutive veterans were seen for a new consultation during the 30-month study period. Thirty-six percent of all visits were for a tobacco-related urologic diagnosis. The percentage of visits that included tobacco use screening increased from 18% (before implementation) to 57% in the implementation phase and to 60% during the maintenance phase. There was significant provider-level variation in adherence to screening. Of all screened patients, 38% were willing to quit, and most patients chose a "cold turkey" method; 22% of the patients elected referral to a formal smoking cessation clinic, and 24% chose telephone counseling. Among those willing to quit, 39% and 49% made a formal quit attempt by 3 and 6 months, respectively. CONCLUSIONS:A strategy that includes provider education and a customized clinical decision support tool can facilitate provider use of tobacco EBPs in a surgery subspecialty clinic.