Faculty Bibliography

OBJECTIVE:To assess the contemporary incidence of cancers using American Samoa as a learning set for insights into similar populations. METHODS:A retrospective observational analysis of de-identified data held in public-access databases (2004-2014) and data on uterine cancer from a hospital, both in American Samoa (2015-2016). RESULTS:There were 341 new cases of cancer in 2004-2014 (111 per 100 000 women/year), including breast (20.2%), uterine (19.4%), and cervical (5.0%); and 287 in 2011-2015 (103 per 100 000 women/year), including uterine (24.0%), breast (18.5%), and cervical (5.2%). Uterine cancer increased from 21.4 to 60.3 per 100 000 women/year, becoming the most common cancer in American Samoa. In 2011-2015, the incidence-rate ratio of uterine cancer to other cancers in American Samoa was 1.3-, 3.8-, 4.6-, 7.7-, and 23-fold higher than breast, colon, cervical, ovarian, and lung cancer, respectively. Among the most recent cases (n=33), median age was 55 years (10 [30.3%] <50 years), median BMI was 38.2; and 11 (33.3%) cases had grade 3 histology. CONCLUSION/CONCLUSIONS:The pattern of cancers in American Samoa differs from that in the US mainland. The findings reflect significant changes in cancer incidence. Cancer control programs should evaluate the potential of uterine screening in accordance with their community's needs and characteristics.

BACKGROUND:For people with advanced stage cystic fibrosis (CF), tailored survival estimates could facilitate preparation for decision-making in the event of acutely deteriorating respiratory function. METHODS:We used the US CF Foundation national database (2008-2013) to identify adult people with incident advanced stage CF (forced expiratory volume in 1 s (FEV1) ≤45% predicted). Using the lasso method for variable selection, we divided the dataset into training and validation samples (2:1), and developed two multivariable Cox proportional hazards models to calculate probabilities of survival from baseline (T0 model), and from 1 year after (T12 model). We also performed Kaplan-Meier survival analyses. RESULTS:colonisation; cirrhosis; depression; dialysis; current smoking; unclassifiable mutation class and cumulative CF exacerbations predicted increased mortality. Baseline transplant evaluation status of 'accepted, on waiting list' predicted decreased mortality. For the T12 model, interim decrease in FEV1 >10%, and pulmonary exacerbations additionally increased predicted mortality. Lung transplantation was associated with lower mortality. Of the 4752, 93.5%, 86.4%, 79.7% and 73.9% survived to 1, 2, 3 and 4 years, respectively, without considering any confounding variables. The models had moderate predictive ability indicated by the area under the time-dependent receiver operating characteristic curve (0.787, 95% CI 0.769 to 0.794 for T0 model; and 0.779, 95% CI 0.767 to 0.797 for T12 model). CONCLUSION/CONCLUSIONS:We have developed models predicting survival in people with incident advanced stage CF, which can be reapplied over time to support shared decision-making about end-of-life treatment choices and lung transplantation. These estimates must be updated as data become available regarding long-term outcomes for people treated with CF transmembrane conductance regulator modulators.

BACKGROUND AND AIMS:Previous community-based studies have demonstrated sex and race-based disparities in the risk of cardiovascular disease. We sought to examine the association of sex and race with incident peripheral artery disease (PAD-) and critical limb ischemia (CLI-) related hospitalizations. METHODS:In 13,451 Black and White ARIC participants without prevalent PAD at baseline (1987-89), we estimated the cumulative incidence of PAD- and CLI-related hospitalization over a median follow-up of 26 years. We quantified hazard ratios (HRs) using Cox models across four sex- and race-groups. PAD and CLI were defined by hospitalization discharge codes. RESULTS:The cumulative incidence of PAD-related hospitalization was higher in males than females in Whites (5.1% vs. 2.7%; p<0.001) but not in Blacks (5.7% vs. 5.0%; p=0.39). The cumulative incidence of CLI-related hospitalization differed significantly by race more than sex, occurring in 3.1% Black males, 3.1% Black females, 1.4% White males, and 0.8% White females (p<0.001). After risk factor adjustment, the risk of incident PAD-related hospitalization was similar for White males vs. White females [HR 1.14, 95%CI 0.90-1.45], and slightly higher for Black males [HR 1.26, 95%CI 0.92-1.72] and Black females [HR 1.39, 95%CI 1.03-1.87] compared to White females. The adjusted risk of incident CLI-related hospitalization was similar for White males vs. White females [HR 1.15, 95%CI 0.75-1.76], and significantly higher for Black males [HR 1.96, 95%CI 1.22-3.16] and Black females [HR 2.06, 95%CI 1.31-3.24] compared to White females. CONCLUSIONS:These data suggest that there are both sex- and race-specific patterns of PAD-related hospitalization that lead to differences in clinical disease risk and presentation.

BACKGROUND AND AIMS/OBJECTIVE:Three to ten minutes of smoking cessation advice by physicians is effective to increase quit rates but not routinely practised. We examined the effectiveness of physicians' very brief (about 30 seconds) smoking cessation intervention on quit rates among Chinese outpatient smokers. DESIGN/METHODS:A pragmatic, open-label, individually randomized controlled trial. SETTING/METHODS:Seventy-two medical outpatient departments of hospitals and/or community health centers in Guangdong, China. PARTICIPANTS/METHODS:Chinese adults who were daily cigarette smokers (N = 13,671, 99% males) were invited by their physician to participate during outpatient consultation. Smokers who were receiving smoking cessation treatment or were judged to needed specialist treatment for cessation were excluded. INTERVENTIONS/METHODS:The intervention group (n = 7,015) received a 30-second intervention including physician's very brief advice, a leaflet with graphic warnings, and a card with contact information of available cessation services. The control group (n = 6,656) received a very brief intervention on consuming vegetables and fruits. A total of 3,466 participants in the intervention group were further randomized to receive a brief booster advice from trained study personnel through telephone one month following their doctor visit. MEASUREMENTS/METHODS:The primary outcome was self-reported 7-day point prevalence abstinence in the intervention and control group at the 12-month follow-up. Secondary outcomes included self-reported 30-day abstinence and biochemically validated abstinence at 12-month follow-up. FINDINGS/RESULTS:By intention-to-treat, the intervention (vs. control) group had greater self-reported 7-day abstinence (9.1% vs. 7.8%; odds ratio (OR) 1.14; 95% Confidence Interval (CI) 1.03-1.26; P = .008) and 30-day abstinence (8.0% vs. 6.9%; OR 1.14 95% CI 1.03-1.27; P=0.01) at 12-month follow-up. The effect size increased when only participants who received the intervention from compliant physicians were included (7-day PPA OR = 1.42; 1.11-1.74). The group difference in biochemically validated abstinence was small (0.8% vs. 0.8%; OR 1.00 95% CI 0.71-1.42; P=0.99). CONCLUSION/CONCLUSIONS:A 30-second smoking cessation intervention increased self-reported abstinence among mainly male smokers in China at 12-month follow-up (risk difference = 1.3%) and should be feasible to provide in most settings and delivered by all healthcare professionals.

BACKGROUND:Adults age ≥ 50 are among the fastest growing populations in correctional supervision and are medically underserved while experiencing unique health disparities. Community-living older adults, referred to as "justice-involved," are people who have been recently arrested, or are on probation or parole. Although medical complexity is common among incarcerated older adults, the occurrence of medical morbidity, substance use disorder (SUD), and mental illness among justice-involved older adults living in US communities is poorly understood. OBJECTIVE:To estimate the prevalence of medical multimorbidity (≥ 2 chronic medical diseases), SUDs, and mental illness among justice-involved adults age ≥ 50, and the co-occurrence of these conditions. DESIGN/METHODS:Cross-sectional analysis. PARTICIPANTS/METHODS:A total of 34,898 adults age ≥ 50 from the 2015 to 2018 administrations of the US National Survey on Drug Use and Health. MAIN MEASURES/METHODS:Demographic characteristics of justice-involved adults age ≥ 50 were compared with those not justice-involved. We estimated prevalence of mental illness, chronic medical diseases, and SUD among adults age ≥ 50 reporting past-year criminal justice system involvement. Logistic regression was used to estimate the odds of these conditions and co-occurrence of conditions, comparing justice-involved to non-justice-involved adults. KEY RESULTS/RESULTS:An estimated 1.2% (95% confidence interval [CI] = 1.1-1.3) of adults age > 50 experienced criminal justice involvement in the past year. Compared with non-justice-involved adults, justice-involved adults were at increased odds for mental illness (adjusted odds ratio [aOR] = 3.04, 95% CI = 2.09-4.41) and SUD (aOR = 8.10, 95% CI = 6.12-10.73), but not medical multimorbidity (aOR = 1.15, 95% CI = 0.85-1.56). Justice-involved adults were also at increased odds for all combinations of the three outcomes, including having all three simultaneously (aOR = 8.56, 95% CI = 4.10-17.86). CONCLUSIONS:Community-based middle-aged and older adults involved in the criminal justice system are at high risk for experiencing co-occurring medical multimorbidity, mental illness, and SUD. Interventions that address all three social and medical risk factors are needed for this population.

PURPOSE/OBJECTIVE:To characterize the demographic differences between infertile/sub-fertile women who utilized infertility services vs. those that do not. METHODS:A retrospective analysis of cross-sectional data obtained during the 2011-2013, 2013-2015, and 2015-2017 cycles of National Survey for Family Growth from interviews administered in home for randomly selected participants by a National Center of Health Statistics (NCHS) surveyor was used to analyze married, divorced, or women with long-term partners who reported difficulty having biological children (sub-fertile/infertile women). Demographic differences such as formal marital status, education, race, and religion were compared between women who presented for infertility care vs. those that did not. The primary outcome measure was presenting for infertility evaluation and subsequently utilizing infertility services. Healthcare utilization trends such as having a usual place of care and insurance status were also included as exposures of interest in the analysis. RESULTS:Of the 12,456 women included in the analysis 1770 (15.3%) had used infertility services and 1011 (8.3%) said it would be difficult for them to have a child but had not accessed infertility services. On univariate analysis, compared to women who used infertility services, untreated women had lower average household incomes (295.3 vs. 229.8% of the federal poverty line respectively). Untreated women also had lower levels of education and were more likely to be divorced or never have married. In terms of health status, unevaluated women were less likely to have a usual place for healthcare (87.3%) as compared to women presenting for fertility care (91.9%) (p = 0.004). When examining insurance status, 23.3% of unevaluated women were uninsured as compared to 8.3% of evaluated women. On multivariate analysis, infertile women without insurance were at 0.37 odds of utilizing infertility care compared to women with insurance. CONCLUSIONS:Demographic factors are associated with the utilization of infertility care. Insurance status is a significant predictor of whether or not infertile women will access treatment. Data from the three most recent NSFG surveys along with prior analyses demonstrate the need for expanded insurance coverage in order to address the socioeconomic disparities between infertile women who are accessing services vs. those that are not.

Rationale: Only nine studies in the current literature focus on the effects of air pollution exposures among patients with Interstitial Lung Diseases (ILD), most of which focus on idiopathic pulmonary fibrosis (IPF). Even less is known about the effects of air pollution exposure on non-IPF ILDs and particularly in populations that are not in major metropolitan regions in the US, where there is a sparse distribution of air pollution monitoring sites.
Method(s): A study cohort of 1,365 patients with ILD (including non-IPF ILDs) living across the Intermountain West region of the US were followed at the University of Utah, with hospitalization data collected from 2009 to 2018. Daily concentrations of major pollutants (PM2.5, NO2, and O3) were calculated using two methods of exposure assessment: 1) weighted mean concentrations from all EPA monitors within a 20km radius of the patient with missing data filled in using imputed values, and 2) using a validated spatiotemporal model, the Optimal Interpolation (OI) model, that integrates satellite remote sensing data and EPA monitoring data with modeled concentrations. A time-stratified, case-crossover study was performed using a 14-day interval to estimate the association between short-term exposure to air pollution and hospitalizations. Conditional logistic regression models were used to estimate adjusted odds ratios (aORs) per interquartile range (IQR) of the pollutant and reported for a 4-day average lag structure from lag days 0 through 3, controlling for daily apparent temperature and holidays. Results were stratified by season, where season was determined by high (March to October) and low (November to February) ozone months.
Result(s): We evaluated 1,277 hospitalizations, and neither exposure assessment model found those to be significantly associated with increased concentrations of PM2.5 or O3. However, the OI model found that in the colder season, an IQR increase in daily average NO2 exposure is associated with 1.5 times the odds of being hospitalized (aOR: 1.53, 95% CI: 1.03, 2.35). These odds are significantly more pronounced in males (aOR: 2.50, 95% CI: 1.14, 5.50).
Conclusion(s): This analysis provides important insight on the impacts of short-term air pollution exposure on hospitalizations in patients with ILD. Improved exposure assessment using an integrated pollution model was critical to identifying these associations due to the sparse distribution of monitors, particularly for pollutants like NO2. Further research using ILD patient populations will help transition clinical guidance regarding air pollution exposures from common sense recommendations to evidence-based guidance

BACKGROUND:Children residing in communities near metalworking industries are vulnerable to multiple toxic metal exposures. Understanding biomarkers of exposure to multiple toxic metals is important to characterize cumulative burden and to distinguish potential exposure sources in such environmental justice neighborhoods impacted by industrial operations. Exposure to metal mixtures has not been well-characterized among children residing in the United States, and is understudied in communities of color. METHODS:In this study we used toenail clippings, a noninvasive biomarker, to assess exposure to arsenic (As), cadmium (Cd), mercury (Hg), manganese (Mn), lead (Pb), antimony (Sb), selenium (Se), and vanadium (V). We used nonnegative matrix factorization (NMF) to identify "source" signatures and patterns of exposure among predominantly working class Latinx children residing near an industrial corridor in Southeast Los Angeles County. Additionally, we investigated the association between participant demographic, spatial, and dietary characteristics with identified metal signatures. RESULTS:Through NMF, we identified three groupings (source factors) for the metal concentrations in children's toenails. A grouping composed of Sb, Pb, As, and Cd, was identified as a potential industrial source factor, reflective of known airborne elemental emissions in the industrial corridor. We further identified a manganese source factor primarily composed of Mn, and a potential dietary source factor driven by Se and Hg. We observed differences in the industrial source factor by age of participants, while the dietary source factor varied by neighborhood. CONCLUSION/CONCLUSIONS:Utilizing an unsupervised dimension reduction technique (NMF), we identified a "source signature" of contamination in toenail samples from children living near metalworking industry. Investigating patterns and sources of exposures in cumulatively burdened communities is necessary to identify appropriate public health interventions.

Objectives: Sexual health is an important component of overall health and well-being for older adults. Despite this, little is known about the importance of sex to quality of life, as part of romantic relationships for older adults, and potential drivers of interactions between healthcare providers and older adults about sexual health. In this study using a nationally representative population, we describe perceptions and experiences of sex among older adults.Methods: A nationally representative, cross-sectional sample of community-dwelling U.S. adults aged 65-80 was surveyed about their sexual health and interaction with their health care providers about sexual health.Results: The survey completion rate was 75% (N = 1,002). Overall, 50.9% of men and 30.8% of women reported being sexually active. In all, 17.3% of adults aged 65-80 reported speaking to their health care provider about sexual health in the past two years and of those, 60.5% of patients initiated the conversation. Multivariable logistic regression demonstrated that sexual activity (yes/no), interest in sex, and satisfaction with sex life are major drivers of sexual health conversations between patients and healthcare providers.Conclusions: Many adults aged 65-80 are interested in and engage in sexual activity. While the majority of older adults reported a willingness to discuss their sexual health with their health care providers, few had done so, and most conversations were initiated by patients. Iterest in sex and satisfaction with sex life may be targets for intervention and offer a segue for providers as they begin the conversation to engage with older adults about their sexual health.Clinical Implications: Providers may have conversations with older adults about sexual health and may need sexual health training to have effective discussions; age nor chronic conditions should preclude this essential conversation. Clinical gerontologists may be helpful in this training and in encouraging patients to bring up sexual health concerns during their medical appointments.