Faculty Bibliography

This study examined predictors of TV use at bedtime and associations with toddlers' sleep and behavior using data from the Smart Beginnings study with 403 Medicaid-eligible, racial/ethnic minority participants from two cities in the United States. We first estimated predictors of TV use at bedtime at 18 months. We then examined whether TV at bedtime was associated with concurrent parent-report of nighttime sleep duration and quality, and later problem behavior at 24 months. Results showed that around half of the sample reported using TV at bedtime with their toddlers, and particularly first-time mothers and those receiving public assistance. We also found that use of TV at bedtime was related to concurrent sleep issues and increases in later problem behavior. Mediational path analyses revealed that TV at bedtime affected behavior via sleep quality. Despite the heterogeneity within this Medicaid-eligible sample, the results underscore the universally harmful effects of TV use at bedtime and lend support for structuring nighttime routines for toddlers to promote better sleep and behavioral outcomes.

BACKGROUND:Health system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk. METHODS:We used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0). RESULTS:We surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10-36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1-600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949. CONCLUSIONS:This analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension. TRIAL REGISTRATION/BACKGROUND:Trial Registered on ClinicalTrials.gov NCT03543787 , June 1, 2018.

BACKGROUND:Glycated albumin is of growing interest as an alternative biomarker of glycemia. However, the association of glycated albumin with long-term outcomes in the general population is uncharacterized. We evaluated the associations of glycated albumin and hemoglobin A1c (HbA1c) with mortality in US adults. METHODS:We conducted a prospective analysis of 12 915 participants in the National Health and Nutrition Examination Survey 1999-2004. We used Cox regression to characterize associations of glycated albumin and HbA1c with all-cause and cardiovascular mortality through 2014. We categorized glycated albumin based on percentiles corresponding to clinical cut-points for HbA1c. No diagnosed diabetes: <5.0% (<12th percentile), 5.0% to 5.6% (12th-82nd percentile, reference), 5.7% to 6.4% (83rd-97th percentile), and ≥6.5% (≥98th percentile). Diagnosed diabetes: <7.0% (<50th percentile), 7.0% to 8.9% (50th-83rd percentile), and ≥9.0% (≥84th percentile). RESULTS:Among US adults (mean age 46 years), the prevalence of diagnosed diabetes was 6.8%. Glycated albumin and HbA1c were highly correlated (r = 0.76). Over the median 16.8 years follow-up, there were 2818 deaths (652 cardiovascular). Adults with diagnosed diabetes and glycated albumin ≥84th percentile had the highest risk for all-cause mortality [hazard ratio (HR) 3.96, 95% CI 3.06-5.13] and cardiovascular mortality (HR 6.80, 95% CI 4.20-11.03). HbA1c had associations with all-cause and cardiovascular mortality that were similar to those for glycated albumin. CONCLUSIONS:Among US adults, increased values of glycated albumin and HbA1c were associated with all-cause and cardiovascular mortality, particularly in persons with diagnosed diabetes. Glycated albumin may be a useful alternative test of glycemia.

BACKGROUND:Plant-based diets are associated with multiple health benefits and a favorable environmental impact. For prostate cancer, previous studies suggest a beneficial role of specific plant-based foods (e.g., tomatoes) and a potentially harmful role of specific animal-based foods (e.g., meat, dairy). However, less is known about plant-based dietary patterns. OBJECTIVES:We sought to examine the relation between plant-based diet indices and prostate cancer risk, including clinically relevant disease. METHODS:This was a prospective cohort study including 47,239 men in the Health Professionals Follow-Up Study (1986-2014). Overall and healthful plant-based diet indices were calculated from FFQs. Cox proportional hazards models were used to estimate HRs and 95% CIs to examine the risk of incident prostate cancer (total and by clinical category), among men ages <65 and ≥65 y. RESULTS:Of the 47,239 men, 6655 men were diagnosed with prostate cancer over follow-up, including 515 with advanced-stage disease at diagnosis, 956 with lethal disease (metastasis or death), and 806 prostate cancer deaths. Greater overall plant-based consumption was associated with a significantly lower risk of fatal prostate cancer (HR: 0.81; 95% CI: 0.64, 1.01; P-trend = 0.04). In men aged <65, a higher plant-based diet index was associated with a lower risk of advanced, lethal, and fatal prostate cancer. Moreover, greater consumption of a healthful plant-based diet was associated with lower risks of total (HR: 0.84; 95% CI: 0.73, 0.98; P-trend = 0.046) and lethal prostate cancer (HR: 0.56; 95% CI: 0.34, 0.94; P-trend = 0.03) at age <65. There were no associations between overall or healthful plant-based diet indices with prostate cancer among men ≥65 y. Fewer than 1% of participants followed a strict vegetarian or vegan diet. CONCLUSIONS:This prospective study provides supportive evidence that greater consumption of healthful plant-based foods is associated with a lower risk of aggressive forms of prostate cancer, with stronger benefit among men aged <65 y.

BACKGROUND:There is growing interest in using glycated albumin for the diagnosis of diabetes, especially when standard tests (glucose and hemoglobin A1c [Hb A1c]) are unavailable. However, it is unknown how well glycated albumin identifies diabetes in the general population. METHODS:We measured glycated albumin in stored serum samples from the 1999-2004 National Health and Nutrition Examination Survey. We evaluated the ability of glycated albumin to identify undiagnosed diabetes in US adults aged ≥20 (n = 4785), overall and at thresholds corresponding to clinical cut points for Hb A1c and fasting plasma glucose (FPG). We assessed 4 reference definitions for undiagnosed diabetes: increased FPG (≥126 mg/dL) [≥6.99 mmol/L), increased Hb A1c (≥6.5%), either FPG or Hb A1c increased, or both FPG and Hb A1c increased. RESULTS:Among US adults, glycated albumin had excellent diagnostic accuracy across all 4 definitions of undiagnosed diabetes, with the area under the receiver operating characteristic curve (AUC) ranging from 0.824 to 0.951. Performance was generally consistent across patient demographic and clinical characteristics. Glycated albumin cut points of 16.5% and 17.8% were equivalent to an FPG of 126 mg/dL (6.99 mmol/L; 97th percentile) and Hb A1c of 6.5% (98th percentile) and had low to moderate sensitivity (0.273 to 0.707) but high specificity (0.980 to 0.992) for detecting undiagnosed diabetes. CONCLUSION:The excellent diagnostic performance of glycated albumin to identify diabetes defined by either FPG or Hb A1c suggests that glycated albumin may be useful for identifying adults with undiagnosed diabetes when standard tests are unavailable.

BACKGROUND:Participation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults' uptake, and efficacy data are currently lacking. OBJECTIVE:This study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial. METHODS:RESILIENT is a multicenter randomized clinical trial that is enrolling patients aged ≥65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement). RESULTS:As of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024. CONCLUSIONS:The RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:DERR1-10.2196/32163.

BACKGROUND:Understanding how substance use is associated with severe crash injuries may inform emergency care preparedness. OBJECTIVES/OBJECTIVE:This study aims to assess the association of substance use and crash injury severity at all times of the day and during rush (6-9 AM; 3-7 PM) and non-rush-hours. Further, this study assesses the probabilities of occurrence of low acuity, emergent, and critical injuries associated with substance use. METHODS:Crash data were extracted from the 2019 National Emergency Medical Services Information System. The outcome variable was non-fatal crash injury, assessed on an ordinal scale: critical, emergent, low acuity. The predictor variable was the presence of substance use (alcohol or illicit drugs). Age, gender, injured part, revised trauma score, the location of the crash, the road user type, and the geographical region were included as potential confounders. Partially proportional ordinal logistic regression was used to assess the unadjusted and adjusted odds of critical and emergent injuries compared to low acuity injury. RESULTS:Substance use was associated with approximately two-fold adjusted odds of critical and emergent injuries compared to low acuity injury at all times of the day and during the rush and non-rush hours. Although the proportion of substance use was higher during the non-rush hour period, the interaction effect of rush hour and substance use resulted in higher odds of critical and emergent injuries compared to low acuity injury. CONCLUSION/CONCLUSIONS:Substance use is associated with increased odds of critical and emergent injury severity. Reducing substance use-related crash injuries may reduce adverse crash injuries.

PURPOSE:The aim of the study was to describe factors that may impact pediatric trainees' willingness to disclose medical errors using clinical vignettes. METHODS:A single-center cross-sectional anonymous survey of pediatric residents and fellows at a large urban medical center in 2019 was conducted. Trainees were provided with clinical vignettes depicting an error resulting in a serious safety event (SSE), minor safety event (MSE), and near miss safety event (NMSE) and were asked to classify the type of safety event and rate and explain their agreement or disagreement with disclosure. Survey items also evaluated trainees' personal experiences with errors and disclosure. Descriptive and correlational analyses were used to characterize responses. Qualitative content from open-ended survey questions was analyzed using the constant comparative method. RESULTS:Of 126 trainees, 42 (33%) completed the survey. All agreed with disclosing the hypothetical error presented in the vignette resulting in an SSE (100%), with rates falling for the MSE (95%) and NMSE (7%). There were no significant associations between disclosure agreement for the vignettes and trainee demographic features, knowledge of safety events, prior personal experiences with errors, and disclosure. Four themes that emerged from qualitative analysis of trainees' rationales for disclosure or nondisclosure of the vignette errors are harm, parental preferences, ethical principles, and anticipatory guidance. CONCLUSIONS:Trainees had high rates of disclosure for the vignette errors cases that depicted SSEs and MSEs but lower rates for NMSEs. Trainees considered the type and level of harm caused, parental preferences, upholding ethical principles, and the need for anticipatory guidance in their rationales for disclosure or nondisclosure of the vignette errors.

PURPOSE/OBJECTIVE:Cardiac rehabilitation (CR) is a key aspect of secondary prevention following acute myocardial infarction (AMI). While there is growing evidence of unique benefits of CR in older adults, it remains underutilized. We aimed to examine specific demographic, clinical, and functional factors associated with utilization of CR among older adults hospitalized with AMI. METHODS:Our project used data from the SILVER-AMI study, a nationwide prospective cohort study of patients age ≥75 yr hospitalized with AMI and followed them up for 6 mo after discharge. Extensive baseline data were collected on demographics, clinical and psychosocial factors, and functional and sensory impairments. The utilization of CR was collected by a survey at 6 mo. Backward selection was employed in a multivariable-adjusted logistic regression model to identify independent predictors of CR use. RESULTS:Of the 2003 participants included in this analysis, 779 (39%) reported participating in CR within 6 mo of discharge. Older age, longer length of hospitalization, having ≤12 yr of education, visual impairment, cognitive impairment, and living alone were associated with decreased likelihood of CR participation; receipt of diagnostic and interventional procedures (ie, cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft) was associated with increased likelihood of CR participation. CONCLUSIONS:Demographic and clinical factors, as well as select functional and sensory impairments common in aging, were associated with CR participation at 6 mo post-discharge in older AMI patients. These results highlight opportunities to increase CR usage among older adults and identify those at risk for not participating.