Faculty Bibliography

BACKGROUND:Arranging hospice services from the Emergency Department (ED) can be difficult due to physician discomfort, time constraints, and the intensity of care coordination needed. We report patient and visit characteristics associated with successful transition from the ED directly to hospice. METHODS:Setting: Academic ED with 82,000 annual visits. POPULATION/METHODS:ED patients with a referral to hospice order placed during the ED visit from January 2014-December 2018. Charts were abstracted by trained, non-blinded personnel. Primary goal was to evaluate patient and visit factors associated with requiring admission for hospice transition. RESULTS:Electronic Health Record inquiry yielded 113 patients, 93 of which met inclusion criteria. Patients were aged 65.8 years (range 32-92), 54% were female, and 78% were white, non-hispanic. The majority had cancer (78%, n = d72) and were on public insurance (60%, n = 56). Half (55%, n = 51) were full code upon arrival. Average ED length of stay was 4.6 ± 2.6 hours. Discharge from the ED to hospice was successful for 38% (n = 35), a few (n = 5) were dispositioned to an ED observation unit, and 57% (n = 53) were admitted. Only 10 (11%) required an inpatient length of stay longer than an observation visit (2 days). Case management and social work team arranged for transportation (54.8%, n = 51), hospital beds (16.1%, n = 16), respiratory equipment (18.3%, n = 17), facility placement (33.3%, n = 31), and home health aides (29.0%, n = 27). CONCLUSION/CONCLUSIONS:Transitioning patients to hospice care from the ED is possible within a typical ED length of stay with assistance from a case manager/social work team.

COVID-19 mortality has disproportionately affected specific occupations and industries. The Occupational Safety and Health Administration (OSHA) protects the health and safety of workers by setting and enforcing standards for working conditions. Workers may file OSHA complaints about unsafe conditions. Complaints may indicate poor workplace safety during the pandemic. We evaluated COVID-19-related complaints filed with California (Cal)/OSHA between January 1, 2020 and December 14, 2020 across seven industries. To assess whether workers in occupations with high COVID-19-related mortality were also most likely to file Cal/OSHA complaints, we compared industry-specific per-capita COVID-19 confirmed deaths from the California Department of Public Health with COVID-19-related complaints. Although 7820 COVID-19-related complaints were deemed valid by Cal/OSHA, only 627 onsite inspections occurred, and 32 citations were issued. Agricultural workers had the highest per-capita COVID-19 death rates (402 per 100,000 workers) but were least represented among workplace complaints (44 per 100,000 workers). Health Care workers had the highest complaint rates (81 per 100,000 workers) but the second lowest COVID-19 death rate (81 per 100,000 workers). Industries with the highest inspection rates also had high COVID-19 mortality. Our findings suggest complaints are not proportional to COVID-19 risk. Instead, higher complaint rates may reflect worker groups with greater empowerment, resources, or capacity to advocate for better protections. This capacity to advocate for safe workplaces may account for relatively low mortality rates in potentially high-risk occupations. Future research should examine factors determining worker complaints and complaint systems to promote participation of those with the greatest need of protection.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Novel aptamer-based technologies can identify >7000 analytes per sample, offering a high-throughput alternative to traditional immunoassays in biomarker discovery. However, the specificity for distinct proteins has not been thoroughly studied in the context of CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS/METHODS:We assessed the use of SOMAscan, an aptamer-based technology, for the quantification of eight immune activation biomarkers and cystatin C among 498 African American Study of Kidney Disease and Hypertension (AASK) participants using immunoassays as the gold standard. We evaluated correlations of serum proteins as measured by SOMAscan versus immunoassays with each other and with iothalamate-measured GFR. We then compared associations between proteins measurement with risks of incident kidney failure and all-cause mortality. RESULTS:both methods. On average, immunoassay measurements were more strongly associated with adverse outcomes than their SOMAscan counterparts. CONCLUSIONS:SOMAscan is an efficient and relatively reliable technique for quantifying IL-8, TNFRSF1B, cystatin C, and TNFRSF1A in CKD and detecting their potential associations with clinical outcomes.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_23_CJN11700921.mp3.

Low-income adults are significantly more likely to smoke, and face more difficulty in quitting, than people with high income. High rates of delay discounting (DD) may be an important factor contributing to the high rates of tobacco use among low-income adults. Future-oriented financial coaching may offer a novel approach in the treatment of smoking cessation among low-income adults. This secondary analysis (N = 251) of data from a randomized controlled trial examined the integration of future-oriented financial coaching into smoking cessation treatment for low-income smokers. Linear regression and finite mixture models (FMM) estimated the overall and the latent heterogeneity of the impact of the intervention versus usual care control on DD rates 6 months after randomization. Though standard linear regression found no overall difference in DD between intervention and control (β = -0.23, p = 0.338), the FMM identified two latent subgroups with different responses to the intervention. Subgroup 1 (79% of the sample) showed no difference in DD between intervention and control (β = 0.25, p = 0.08). Subgroup 2 (21% of the sample) showed significantly lower DD (β = -2.06, p = 0.003) among intervention group participants versus control at 6 months. Participants were more likely to be a member of subgroup 2 if they had lower baseline DD rates, were living at or below 100% of federal poverty, or were married/living with a partner. This study identified a group of low-income adults seeking to quit smoking who responded to financial coaching with decreased DD rates. These results can be used to inform future targeting of the intervention to individuals who may benefit most, as well as inform future treatment adaptations to support the subgroup of low-income smokers, who did not benefit.

BACKGROUND:The coronavirus pandemic (COVID-19) has placed strains on communities. In the midst of this public health crisis, health systems have created remote methods of monitoring symptom progression and delivering care virtually. OBJECTIVE:Using a text message-based system, we sought to build and test a remote model to explore community needs, connect individuals to curated resources, and facilitate community health worker intervention when needed during COVID-19. The primary aims of this pilot study were to establish the feasibility (i.e., engagement with the text line) and acceptability (i.e., participant ratings of resources and service) of delivering automated wellbeing resources via smartphone technology. METHODS:Eligible patients (18 years or older, cell phone with SMS capability, and recent ED visit) were identified using the EHR. Patients were consented to enroll and begin receiving COVID-19 related information and links to community resources. We collected open- and close-ended resource and mood ratings. We calculated the frequencies and conducted thematic review of open-ended responses. RESULTS:In seven weeks, 356 participants were enrolled; 13,917 messages were exchanged including 333 resource ratings (mean 4) and 673 well-being scores (mean 6.8). We received and coded 386 open-ended responses, most elaborated upon their self-reported mood score (29%). Overall, 77% of our participants rated the platform as a service they would highly recommend to a family member or friend. CONCLUSIONS:This approach is designed to broaden the reach of health systems, tailor to community needs in real-time, and connect at-risk individuals with robust community health support. CLINICALTRIAL/UNASSIGNED/:

Despite increased neuroscience interest at the undergraduate level, a significant shortage of neurologists in the United States (US) exists. To better understand how to generate more interest in neurology specifically at the undergraduate level, we conducted an anonymous cross-sectional online survey of 1085 undergraduates either in neuroscience courses or majoring/minoring in neuroscience from across the US to better understand their clinical neurology experiences and perspectives. The survey quantitatively and qualitatively assessed students' clinical neurology exposure inside and outside of the classroom, research experiences and career goals. Students were from a broad spectrum of undergraduate institutions (public research university (40.8%), liberal arts College (29.7%) and private research university (29.0%). Most students (89.9%) were looking to pursue graduate studies; 56.9% reported wanting to be a physician and 17.8% expressed interest in obtaining an MD/PhD. Importantly, students reported first exposure to neuroscience at age 16 but felt that they could be exposed to neuroscience as early as 13. Half (50.5%) decided to major in neuroscience before college and a quarter (25.6%) decided to major in their first year of college. Despite high interest in clinical neurology exposure, less than one-third of students had spoken with or shadowed a neurologist, and only 13.6% had interacted with clinical neurology populations. Only 20.8% of students felt volunteer and internship opportunities were sufficiently available. Qualitative results include student perspectives from those who did and did not work with a neurologist, describing how they were or were not able to obtain such opportunities. We discuss translating the survey findings into actionable results with opportunities to target the undergraduate neuroscience interest to improve the neurology pipeline. We describe existing programs that could be integrated into everyday neurology practices and new approaches to learning and training to help leverage the significant undergraduate neuroscience interest. We also raise questions for further research, including exploring (1) how students learn of neurologic conditions/expand their knowledge about additional neurologic conditions, (2) whether qualitative investigation of the experiences of neuroscience undergraduates at specific institutions might provide additional insight, and (3) systems to maintain interest in neuroscience/neurology as students enter medical school.

Electronic cigarettes (e-cigs) have become prevalent as an alternative to conventional cigarette smoking, particularly in youth. E-cig aerosols contain unique chemicals which alter the oral microbiome and promote dysbiosis in ways we are just beginning to investigate. We conducted a 6-month longitudinal study involving 84 subjects who were either e-cig users, conventional smokers, or nonsmokers. Periodontal condition, cytokine levels, and subgingival microbial community composition were assessed, with periodontal, clinical, and cytokine measures reflecting cohort habit and positively correlating with pathogenic taxa (e.g., Treponema, Saccharibacteria, and Porphyromonas). α-Diversity increased similarly across cohorts longitudinally, yet each cohort maintained a unique microbiome. The e-cig microbiome shared many characteristics with the microbiome of conventional smokers and some with nonsmokers, yet it maintained a unique subgingival microbial community enriched in Fusobacterium and Bacteroidales (G-2). Our data suggest that e-cig use promotes a unique periodontal microbiome, existing as a stable heterogeneous state between those of conventional smokers and nonsmokers and presenting unique oral health challenges. IMPORTANCE Electronic cigarette (e-cig) use is gaining in popularity and is often perceived as a healthier alternative to conventional smoking. Yet there is little evidence of the effects of long-term use of e-cigs on oral health. Conventional cigarette smoking is a prominent risk factor for the development of periodontitis, an oral disease affecting nearly half of adults over 30 years of age in the United States. Periodontitis is initiated through a disturbance in the microbial biofilm communities inhabiting the unique space between teeth and gingival tissues. This disturbance instigates host inflammatory and immune responses and, if left untreated, leads to tooth and bone loss and systemic diseases. We found that the e-cig user's periodontal microbiome is unique, eliciting unique host responses. Yet some similarities to the microbiomes of both conventional smokers and nonsmokers exist, with strikingly more in common with that of cigarette smokers, suggesting that there is a unique periodontal risk associated with e-cig use.

In the U.S., black men are at highest risk for requiring kidney transplants but are among those least likely to register for organ donation. Prior outreach used videos culturally targeted for Black communities, yet registration rates remain insufficient to meet demand. Therefore, we assessed whether generic versus videos culturally targeted or personally tailored based on prior organ donation beliefs differentially increase organ donor registration. In a randomized controlled trial, 1,353 participants in Black-owned barbershops viewed generic, targeted, or tailored videos about organ donation. Logistic regression models assessed the relative impact of videos on: 1) immediate organ donor registration, 2) taking brochures, and 3) change in organ donation willingness stage of change from baseline. Randomization yielded approximately equal groups related to demographics and baseline willingness and beliefs. Neither targeted nor tailored videos differentially affected registration compared with the generic video, but participants in targeted and tailored groups were more likely to take brochures. Targeted (OR = 1.74) and tailored (OR = 1.57) videos were associated with incremental increases in organ donation willingness stage of change compared to the generic video. Distributing culturally targeted and individually tailored videos increased organ donor willingness stage of change among Black men in Black-owned barbershops but was insufficient for encouraging registration.Abbreviations: CI - confidence interval; DMV - Department of Motor Vehicles; BOBs - Black-owned barbershops; ODBI - organ donation belief index; ODWS - organ donation willingness stage of change; OR - odds ratio.

INTRODUCTION/BACKGROUND:'Multimorbidity' describes the presence of two or more long-term conditions, which can include communicable, non-communicable diseases, and mental disorders. The rising global burden from multimorbidity is well documented, but trial evidence for effective interventions in low-/middle-income countries (LMICs) is limited. Selection of appropriate outcomes is fundamental to trial design to ensure cross-study comparability, but there is currently no agreement on a core outcome set (COS) to include in trials investigating multimorbidity specifically in LMICs. Our aim is to develop international consensus on two COSs for trials of interventions to prevent and treat multimorbidity in LMIC settings. METHODS AND ANALYSIS/UNASSIGNED:Following methods recommended by the Core Outcome Measures in Effectiveness Trials initiative, the development of these two COSs will occur in parallel in three stages: (1) generation of a long list of potential outcomes for inclusion; (2) two-round online Delphi surveys and (3) consensus meetings. First, to generate an initial list of outcomes, we will conduct a systematic review of multimorbidity intervention and prevention trials and interviews with people living with multimorbidity and their caregivers in LMICs. Outcomes will be classified using an outcome taxonomy. Two-round Delphi surveys will be used to elicit importance scores for these outcomes from people living with multimorbidity, caregivers, healthcare professionals, policy makers and researchers in LMICs. Finally, consensus meetings including all of these stakeholders will be held to agree outcomes for inclusion in the two COSs. ETHICS AND DISSEMINATION/UNASSIGNED:The study has been approved by the Research Governance Committee of the Department of Health Sciences, University of York, UK (HSRGC/2020/409/D:COSMOS). Each participating country/research group will obtain local ethics board approval. Informed consent will be obtained from all participants. We will disseminate findings through peer-reviewed open access publications, and presentations at global conferences selected to reach a wide range of LMIC stakeholders. PROSPERO REGISTATION NUMBER/UNASSIGNED:CRD42020197293.