Faculty Bibliography

BACKGROUND:Several distinct plant-based diet indices (PDIs) have been developed to characterize adherence to plant-based diets. OBJECTIVE:We contrasted 5 PDIs in a community-based cohort by assessing characteristics of the diet and evaluating whether these PDIs are associated with risk of incident hypertension. METHODS:Using FFQ data from adults (45-64 y, n = 8041) without hypertension at baseline in the Atherosclerosis Risk in Communities (ARIC) Study, we scored participants' diets using the overall PDI (oPDI), healthy PDI (hPDI), less healthy (unhealthy) PDI (uPDI), provegetarian diet index, and PDI from the Rotterdam Study (PDI-Rotterdam). For the oPDI, provegetarian diet, and PDI-Rotterdam, higher intakes of all or selected plant foods received higher scores. For the hPDI, higher intakes of plant foods identified as healthful received higher scores. For the uPDI, higher intakes of less healthy plant foods received higher scores. All indices scored higher intakes of animal foods lower. We examined agreement between indices, and whether scores on these indices were associated with risk of hypertension using Cox proportional hazard models. RESULTS:The PDIs were moderately-to-strongly correlated and largely ranked subjects consistently, except for the uPDI. Over a median follow-up of 13 y, 6044 incident hypertension cases occurred. When adjusted for sociodemographic characteristics, other dietary factors, and health behaviors, the highest compared with the lowest quintile for adherence to the oPDI, hPDI, and provegetarian diet was associated with a 12-16% lower risk of hypertension (all P-trend <0.05). Highest adherence to the uPDI was associated with a 13% higher risk of hypertension, when clinical factors were further adjusted for (P-trend = 0.03). No significant association was observed with the PDI-Rotterdam. The oPDI, hPDI, and provegetarian diet moderately improved the prediction of hypertension. CONCLUSIONS:In middle-aged US adults, despite moderate agreement in ranking subjects across PDIs, operational differences can affect the ability to detect diet-disease associations, such as hypertension.

INTRODUCTION/BACKGROUND:In the USA, transgender women are among the most vulnerable to HIV. In particular, transgender women of colour face high rates of infection and low uptake of important HIV prevention tools, including pre-exposure prophylaxis (PrEP). This paper describes the design, sampling methods, data collection and analyses of the TURNNT ('Trying to Understand Relationships, Networks and Neighbourhoods among Transgender women of colour') study. In collaboration with communities of transgender women of colour, TURNNT aims to explore the complex social and environmental (ie, neighbourhood) structures that affect HIV prevention and other aspects of health in order to identify avenues for intervention. METHODS AND ANALYSES/UNASSIGNED:TURNNT is a prospective cohort study, which will recruit 300 transgender women of colour (150 Black/African American, 100 Latina and 50 Asian/Pacific Islander participants) in New York City. There will be three waves of data collection separated by 6 months. At each wave, participants will provide information on their relationships, social and sexual networks, and neighbourhoods. Global position system technology will be used to generate individual daily path areas in order to estimate neighbourhood-level exposures. Multivariate analyses will be conducted to assess cross-sectional and longitudinal, independent and synergistic associations of personal relationships (notably individual social capital), social and sexual networks, and neighbourhood factors (notably neighbourhood-level social cohesion) with PrEP uptake and discontinuation. ETHICS AND DISSEMINATION/UNASSIGNED:The TURNNT protocol was approved by the Columbia University Institutional Review Board (reference no. AAAS8164). This study will provide novel insights into the relationship, network and neighbourhood factors that influence HIV prevention behaviours among transgender women of colour and facilitate exploration of this population's health and well-being more broadly. Through community-based dissemination events and consultation with policy makers, this foundational work will be used to guide the development and implementation of future interventions with and for transgender women of colour.

This study evaluated the safety of early anti-factor Xa assay-guided enoxaparin dosing for chemoprophylaxis in patients with TBI. We hypothesized that assay-guided chemoprophylaxis would be comparable in the risk of intracranial hemorrhage (ICH) progression to fixed dosing. An observational analysis of adult patients with blunt traumatic brain injury (TBI) was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group were treated with an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured four hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with a dose adjustment of ± 10 mg based on the assay result. The assay-guided group was compared with historical fixed-dose controls and to a TBI cohort from the most recent Trauma Quality Improvement Project dataset. Of 179 patients included in the study, 85 were in the assay-guided group and 94 were in the fixed-dose group. Compared with the fixed-dose group, the assay-guided group had a lower Glasgow Coma Score and higher Injury Severity Score. The proportion of severe (Abbreviated Injury Score, head ≥3) TBI, ICH progression, and venous thromboembolism rates were similar between all groups. The assay-guided and fixed-dose groups had chemoprophylaxis initiated earlier than the Trauma Quality Improvement Project group. The assay-guided group had the highest percentage of low molecular weight heparin use. Early initiation of enoxaparin anti-factor Xa assay-guided venous thromboembolism chemoprophylaxis has a comparable risk of ICH progression to fixed dosing in patients with TBI. These findings should be validated prospectively in a multicenter study.

An increasing number of young children nationally participate in preschool education, yet very little is known about the influence of peers' behavioral regulation, such as maintaining focus on a task in the face of distractions and inhibiting a dominant response (attentionimpulse control), and remembering instructions (engagement) on children's motor-cognitive readiness skills (i.e., peer effects). This study determined whether peer effects are present in this earliest sector of schooling. Research has shown that a child's own behavioral regulation is associated with his or her academic outcomes. However, not much is known about how children are affected by classmates with poor behavioural regulation. This study begins to fill the gaps in our understanding of preschool peer effects in the form of peers' behavioral regulation relative to children's motor-cognitive readiness skills. It addresses two research questions: (1) Is the average level and amount of variation of peers' behavioral regulation skills (i.e., engagement and attentionimpulse control) in a classroom associated with growth in children's motor-cognitive readiness outcomes in preschool (motor, content knowledge, and language)? (2) Do these associations differ for children with high and low initial levels of behavioral regulation? The analytic sample is drawn from a cluster (school) randomized controlled trial testing a family-centered, school-based intervention (N=1050 children in 99 classrooms drawn from 10 high-poverty schools). Results indicated that classroom-level peer engagement skills made a unique contribution to children's growth of motor skills during the preschool academic year. Furthermore, children with higher engagement skills at the beginning of the preschool year had higher motor-cognitive readiness skills (motor, content knowledge, and language) at the end of the year when they were in classrooms with peers with high engagement skills. This study extends previous work with older children and indicates that after adjusting for an assortment of demographic, preschool program-related factors, and motor-cognitive readiness at entry into preschool, peers' engagement skills may make a unique contribution to children's motor-cognitive readiness skills during the preschool academic year.

OBJECTIVE:To examine the associations between breastfeeding intensity and underexplored features of maternal-child interaction quality over and above the influence of breastfeeding initiation. METHODS:The current study leveraged an on-going, multisite randomized controlled trial of a tiered parenting program for 462 Medicaid-eligible mothers and their infants in the United States. We examined whether breastfeeding intensity and exclusivity was associated with observed maternal sensitivity, intrusiveness, and detachment, as well as self-reported maternal verbal responsiveness, 6 months infant age. Analyses controlled for breastfeeding initiation, demographics, and early parenting experiences. RESULTS:Higher intensity breastfeeding at 6 months was significantly related to higher maternal sensitivity (β = 0.12, p = 0.004) and lower maternal intrusiveness (β = -0.10, p = 0.045). There was no significant association between breastfeeding intensity at 6 months and detachment (β = -0.02, no significant [ns]) or self-reported verbal responsiveness (β = 0.11, ns). Results were the same when intensity was measured as a dichotomous indicator for exclusive breastfeeding. Effect sizes were small-to-moderate, ranging from Cohen's d = 0.26 to 0.31. Associations did not vary by site, race/ethnicity, infant difficultness, or household poverty. CONCLUSION/CONCLUSIONS:The finding that breastfeeding intensity was significantly and independently associated with maternal sensitivity and intrusiveness is novel in the literature on low-income families from the United States. These findings have implications for breastfeeding promotion strategies and indicate that future research should explore synergistic or spillover effects of interventions aimed at maternal-child interaction quality into the infant feeding domain, particularly in the primary care setting.

Background: Caregivers (CGs) of older-adults with Alzheimer's disease and related dementias (ADRD) and CGs of older-adults with diabetes (DM) report substantial CG burden. CG burden is known to be linked to patients' behavioral problems, poor cognition, and increased dependency. There is no literature addressing CG burden in CGs of individuals with co-occurring diabetes and dementia (DM-ADRD). The aim of this study was to identify CG and care-recipient (CR) factors associated with high levels of CG burden in CGs of DM-ADRD patients.
Method(s): This study used bivariate and descriptive statistics to analyze surveys collected as part of a quality improvement intervention being conducted at NYU Langone Health primary care and endocrine Faculty Group Practices and Family Health Centers. Inclusion criteria for patients were age >= 65, cognitive impairment, and DM with recent HbA1c > 6.4 or ever prescribed hyperglyemic medication. Telephonic surveys were conducted with CGs of eligible patients. The Treatment Burden Questionnaire (TBQ) was used to measure CG burden. TBQ results were analyzed for association with CG factors including age, sex, race, relationship to patient, education level, residence status, and level of social support, as well as CR factors including age, sex, race, dementia severity, Charlson comorbidity score, and recent HbA1c values.
Result(s): CGs that completed surveys (n=58) had a mean age of 54.3 years, 74% (n=43) female, 46% (n=27) white, 84% (n=49) were children of CRs, 70% (n=41) had education beyond 12th grade, and 55% (n=32) lived separately from CR. CRs of CGs that completed surveys (n=58) had a mean age of 80.5 years, 67% (n=39) female, 67% (n=37) white. We found CGs who were male, Asian, co-resident, with low level of social support, of CRs with more-advanced dementia, and of CRs with recent out-of-range HbA1c had significantly higher levels of CG burden (p<0.1).
Conclusion(s): Our study demonstrates there are several CG and CR factors that are associated with increased levels of CG burden in this population. Findings may assist in identification of CGs at risk for increased burden. If these results are found to be replicable, future studies should focus on the development of prevention and treatment plans consistent with these findings

Background: Delirium affects 14-56% of hospitalized older adults, and leads to higher morbidity and increased healthcare costs. At NYULH we implemented the EmpoweRing elder Novel Interventions (ERNI) program in 2017, modeled after Hospital Elder Life Program (HELP), but we utilize trained pre-med and pre-nursing volunteers to prevent delirium. We have shown reduced length of stay and a decreased incidence of delirium with ERNI. Here we report on ERNI as a novel method to grow the geriatrics workforce.
Method(s): Patients 65 years or older admitted to ICU, ED observation, neurology, cardiology, and general medicine units determined to be at high risk for delirium were visited by trained pre-med/ nursing volunteers who engaged them in conversations, listened to music, reoriented them, worked on puzzles, and advocated for patients' needs. We assessed nursing and volunteer satisfaction, and patient/family satisfaction using Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data from April 2017- July 2019.
Result(s): 26/31 (84%) nurses rated volunteers 7 or higher on a scale of 1-10, and 84% of nurses felt volunteers helped prevent delirium. The volunteers expressed satisfaction with the program, 17/18 (94%), and felt appreciated by patients and families[BC1]. 16/18 (89%) volunteers plan to pursue a career in healthcare, and 17/18 volunteers (94%) plan to work with older adults. 12/18 (67%) volunteers were the first in their families to work in healthcare. Although not directly related to ERNI, patient HCAHPS scores in the Observation Unit (measured by the hospital), improved after ERNI implementation, with nursing communication increasing from 70.5% to 77% and pain communication from 34.1% to 45.6%.
Conclusion(s): Our ERNI program demonstrated high rates of nursing and volunteer satisfaction, and patients in ED Observation had increased satisfaction. Exposing pre-med/nursing volunteers to older patients in a modified HELP program may be an important step toward increasing recruitment to the geriatrics workforce. For those already considering this career, the ERNI experience might solidify those intentions. Future plans are to expand this program by recruiting more college students as volunteers

Background: Social isolation is common among community dwelling older adults and is associated with adverse health outcomes. Its inverse, social engagement, depends on verbal communication, which can be disrupted by age-related hearing loss (AHRL). AHRL is mitigated with hearing aids, but hearing aid costs can be prohibitive for low income, under-resourced communities. As such, personal amplifiers or hearing assistance devices (HADs), are a feasible alternative that can be delivered at point-of-care to older adults with AHRL. Despite the link between social engagement and hearing, there is little research on mitigating hearing loss to improve patient-reported outcomes such as depressed mood and loneliness, particularly in low-income communities.
Method(s): This ongoing pilot study has enrolled older adults living in federally subsidized Los Angeles housing to assess the feasibility of community-based hearing assessment and provision of hearing assistance devices (HAD). We seek to understand the potential impact of HAD use on patient-reported symptoms. We measure self-reported hearing loss using the Hearing Handicap Inventory (HHI), and at baseline, one, and two months: social isolation using a 4-item instrument, depressed mood using the Patient Health Questionnaire (PHQ)-9, a 6-item loneliness score, and HAD utility using the International Outcome Inventory for Alternative Interventions (IOI-AI).
Result(s): Among 36 recruited participants in three buildings thus far, 30 (83%) reported having hearing difficulties (HHI >=10) and were given Pocket-Talkers. For those with self-reported hearing-related psychosocial difficulties, 8 (27%) endorsed social isolation (>1 of 4); 18 (60%) endorsed at least mild depression (PHQ-9 > 4); and 19 (63%) endorsed loneliness (>1 of 6). Among 16 who have completed 1-month follow-up, no changes have been noted, but 1-month scores on the IOI-AI (mean: 4; range 0-5) suggest very favorable utility.
Conclusion(s): Early results from this pilot study support this as a feasible intervention with positive impact associated with Pocket- Talker use. Further follow-up and subject enrollment is needed to determine whether this intervention improves patient-reported outcomes

OBJECTIVE:Self-management education and support are essential for improved diabetes control. A 1-year randomized telephonic diabetes self-management intervention (Bronx A1C) among a predominantly Latino and African American population in New York City was found effective in improving blood glucose control. To further those findings, this current study assessed the intervention's impact in reducing health care utilization and costs over 4 years. RESEARCH DESIGN AND METHODS:= 816) health care utilization for Bronx A1C participants using an administrative data set containing all hospital discharges for New York State from 2006 to 2014. Multilevel mixed modeling was used to assess changes in health care utilization and costs between the telephonic diabetes intervention (Tele/Pr) arm and print-only (PrO) control arm. RESULTS:during individuals' participation in the 1-year intervention. CONCLUSIONS:These results indicate that the impact of the Bronx A1C intervention was not just on short-term improvements in glycemic control but also on long-term health care utilization. This finding is important because it suggests the benefits of the intervention were long-lasting with the potential to not only reduce hospitalizations but also to lower hospital-associated costs.