Faculty Bibliography

RATIONALE & OBJECTIVE:Influenza vaccination is recommended for all adults but particularly for older adults and those with high-risk conditions. Reduced kidney function is an important high-risk condition, but the effectiveness of influenza vaccination across kidney function is uncharacterized. We assessed the effectiveness of influenza vaccination among older adults with and without reduced kidney function. STUDY DESIGN:Observational cohort study. SETTING & PARTICIPANTS:454,634 person-seasons among 110,968 individuals 65 years or older in the Geisinger Health System between the 2005 and 2015 influenza seasons, with baseline characteristics matched between those with and without vaccination using inverse probability weighting. EXPOSURES:Status of influenza vaccination. OUTCOMES:). ANALYTICAL APPROACH:Pooled logistic regression analysis to estimate adjusted ORs. RESULTS:(ORs of 1.04 [95% CI, 0.79-1.36] for pneumonia/influenza, 1.03 [95% CI, 0.87-1.23] for coronary heart disease, and 1.10 [95% CI, 0.92-1.33] for heart failure). LIMITATIONS:Possible unmeasured confounding. CONCLUSIONS:.

BACKGROUND:Beverages are a source of calories and other bioactive constituents but are an understudied aspect of the diet. Different beverages have varying effects on health outcomes. OBJECTIVES/OBJECTIVE:We created the Healthy Beverage Score (HBS) to characterize participants' beverage patterns and examined its association with chronic kidney disease (CKD) progression, incident cardiovascular disease (CVD), and all-cause mortality among individuals with CKD. METHODS:from the Chronic Renal Insufficiency Cohort. Diet was assessed using a 124-item FFQ at visit 1 (2003-2008). The HBS, ranging from 7 to 28 possible points, consisted of 7 components, each scored from 1 to 4 based on rank distribution by quartile, except alcohol, which was based on sex-specific cutoffs. Participants were given more points for higher consumption of low-fat milk and of coffee/tea, for moderate alcohol, and for lower consumption of 100% fruit juice, whole-fat milk, artificially sweetened beverages, and sugar-sweetened beverages. CKD progression, incident CVD, and mortality were ascertained through January 2018. We conducted multivariable Cox proportional hazards models. RESULTS:-trend = 0.04) after adjusting for sociodemographic, clinical, and dietary factors. There was no significant trend for incident CVD. CONCLUSIONS:Among individuals with CKD, a healthier beverage pattern was inversely associated with CKD progression and all-cause mortality. Beverage intake may be an important modifiable target in preventing adverse outcomes for individuals with CKD.

BACKGROUND:As more older adults undergo surgery, it is critical to understand the long-term effects of surgery on brain health, particularly in relation to the development of Alzheimer's disease. This study examined the association of surgical hospitalization with subsequent brain β-amyloid deposition in nondemented older adults. METHODS:The Atherosclerosis Risk in Communities-Positron Emission Tomography (ARIC-PET) study is a prospective cohort study of 346 participants without dementia who underwent florbetapir PET imaging. Active surveillance of local hospitals and annual participant contact were used to gather hospitalization and surgical information (International Classification of Disease, Ninth Revision, Clinical Modification codes) over the preceding 24-yr period. Brain amyloid measured using florbetapir PET imaging was the primary outcome. Elevated amyloid was defined as a standardized uptake value ratio of more than 1.2. RESULTS:Of the 313 participants included in this analysis (age at PET: 76.0 [SD 5.4]; 56% female), 72% had a prior hospitalization, and 50% had a prior surgical hospitalization. Elevated amyloid occurred in 87 of 156 (56%) participants with previous surgical hospitalization, compared with 45 of 87 (52%) participants who had no previous hospitalization. Participants with previous surgical hospitalizations did not show an increased odds of elevated brain amyloid (odds ratio, 1.32; 95% CI, 0.72 to 2.40; P = 0.370) after adjusting for confounders (primary analysis). Results were similar using the reference group of all participants without previous surgery (hospitalized and nonhospitalized; odds ratio, 1.58; 95% CI, 0.96 to 2.58; P = 0.070). In a prespecified secondary analysis, participants with previous surgical hospitalization did demonstrate increased odds of elevated amyloid when compared with participants hospitalized without surgery (odds ratio, 2.10; 95% CI, 1.09 to 4.05; P = 0.026). However, these results were attenuated and nonsignificant when alternative thresholds for amyloid-positive status were used. CONCLUSIONS:The results do not support an association between surgical hospitalization and elevated brain amyloid.

OBJECTIVE:Incorporation of comorbidity burden to inform diabetes management in older adults remains challenging. High-sensitivity cardiac troponins are objective, quantifiable biomarkers that may improve risk monitoring in older adults. We assessed the associations of elevations in high-sensitivity cardiac troponin I (hs-cTnI) and T (hs-cTnT) with comorbidities and improvements in mortality risk stratification. RESEARCH DESIGN AND METHODS:We used logistic regression to examine associations of comorbidities with elevations in either troponin (≥85th percentile) among 1,835 participants in the Atherosclerosis Risk in Communities (ARIC) Study with diabetes (ages 67-89 years, 43% male, 31% black) at visit 5 (2011-2013). We used Cox models to compare associations of high cardiac troponins with mortality across comorbidity levels. RESULTS:Elevations in either troponin (≥9.4 ng/L for hs-cTnI, ≥25 ng/L for hs-cTnT) were associated with prevalent coronary heart disease, heart failure, chronic kidney disease, pulmonary disease, hypoglycemia, hypertension, dementia, and frailty. Over a median follow-up of 6.2 years (418 deaths), both high hs-cTnI and high hs-cTnT further stratified mortality risk beyond comorbidity levels; those with a high hs-cTnI or hs-cTnT and high comorbidity were at highest mortality risk. Even among those with low comorbidity, a high hs-cTnI (hazard ratio 3.0 [95% CI 1.7, 5.4]) or hs-cTnT (hazard ratio 3.3 [95% CI 1.8, 6.2]) was associated with elevated mortality. CONCLUSIONS:Many comorbidities were reflected by both hs-cTnI and hs-cTnT; elevations in either of the troponins were associated with higher mortality risk beyond comorbidity burden. High-sensitivity cardiac troponins may identify older adults at high mortality risk and be useful in guiding clinical care of older adults with diabetes.

Background: The Veterans Administration (VA) cares for over 8 million U.S. veterans annually, approximately 20% of whom have prevalent diabetes. To foster research and intervention opportunities, we developed the VA Diabetes Risk (VADR) Cohort using the VA electronic health record, a national cohort of diabetes-free U.S. veterans receiving primary care at the VA since January 1, 2008. This cohort provides important opportunities to study community-level risk factors for diabetes, such as attributes of the food environment, via geospatial linkage to residence information. We describe here the cohort profile and diabetes incidence by sub-group.
Method(s): To be eligible, diabetes-free patients had to have at least 2 primary care visits at least 30 days apart prior to enrollment. Diabetes incidence was defined as having >=2 inpatient or outpatient encounters with diabetes ICD-9/10 codes, any prescription of diabetes medicine, or one encounter with diabetes ICD-9/10 codes and >=2 hemoglobin A1C >=6.5%. The incidence of diabetes was calculated as the number of new cases diagnosed per 1000 person-years (PY) through December 31, 2018. Demographic and comorbidities data were abstracted using diagnostic codes, labs, prescriptions, and vital signs.
Result(s): The VADR cohort consisted of 6.17 million veterans, the majority of whom were male (91.7%) and non- Hispanic (NH) white (75.7%). Nearly half were above 60 years of age at enrollment (48.8%). The diabetes incidence rate was 27.0 per 1000 PY, increasing with age from 13.3 per 1000 PY among adults <45 years old to 41.8 per 1000 PY among those 65 years and older. Incidence was higher among men than women (34.6 vs. 18.6 per 1000 PY) and higher among NH black patients compared to NH white patients (38 vs. 31.7 per 1000 PY).
Conclusion(s): The VADR cohort provides a novel infrastructure for examination of community-level risk factors for diabetes among veterans, and facilitates assessment of the impact of national or regional strategies to prevent or manage diabetes in veterans

Current guidelines recommend conservative management as the preferred option for most low-risk prostate cancer cases, with certain possible exceptions (age <55yr, African Americans, and high-volume grade group 1). Although previous studies have documented substantial heterogeneity in the uptake of conservative management, less is known about the underlying reason for this variation and whether it is due to guideline-concordant factors (age, race, and biopsy cancer volume). We explored variation in the use of conservative management for low-risk prostate cancer among 20 597 men diagnosed in the US Veterans Affairs health care system from 2010 to 2016. Conservative management increased substantially over this time from 51% to 76% (p< 0.001). However, there was substantial variation by facility (35-100%). Multivariable analysis revealed that patient factors included in the guidelines (e.g., age and biopsy cores), other patient factors (eg, marital status and PSA) and non-patient factors (eg, geographic region, case volume, year) were associated with conservative management use. In conclusion, even within an integrated health care system, there remains significant heterogeneity in the uptake of conservative management for low-risk prostate cancer. Both guideline-concordant factors and other factors not discussed in the guidelines were associated with conservative management use. PATIENT SUMMARY: In the US Veterans Affairs health care system the vast majority of men with low-risk prostate cancer were managed conservatively by 2016, although there was significant variation by facility. Patient factors specifically mentioned in guidelines had the greatest impact on prediction of conservative management.

A crisis of mass immigration detention exists in the United States, which is home to the world's largest immigration detention system. The immigration detention system is legally classified as civil, rather than criminal, and therefore non-punitive. Yet it mimics the criminal incarceration system and holds detained individuals in punitive, prison-like conditions. Within immigration detention centers, there are increasing reports and recognition of civil and human rights abuses, including preventable in-custody deaths. In this paper, we propose understanding the health impacts of detention as an accumulation of mental and physical trauma that take place during the entirety of a detained immigrant's experience, from migration to potential deportation and removal. Further, we explore the social-structural determinants of health as they relate to immigration detention, contextualize these determinants within a human rights framework, and draw parallels to the larger context of US mass incarceration. Realizing the right to health requires addressing these social-structural determinants of health. For the care of immigrant patients to be effective, clinicians and public health professionals must incorporate an awareness of the health risks of the immigration detention system into trauma- and human rights-informed models of care during and after detention.

Background-Financial incentives for smoking cessation and use of evidence-based therapy may increase quit rates and reduce health and economic disparities. Methods-We randomized a low-income population of 182 hospitalized patients (mean age 58 years, 45% with high school education or less) to enhanced usual care, which included hospital-directed cessation care and Quitline referral, or enhanced usual care plus financial incentives. All patients received enhanced usual care, while participants randomized to the financial incentives group were also eligible to receive up to $550 for participation in Quitline counseling ($50), participation in a community-based cessation program ($50), use of pharmacotherapy ($50), and biochemically-confirmed smoking cessation at 2 months ($150) and 6 months ($250). Primary outcome was biochemically-confirmed smoking cessation at 6 months after hospital discharge. Results-Total mean payment was $84 (SD=$133) in the incentive group. The 6-month rate of biochemically-confirmed smoking cessation was 19.6% in the incentive group and 8.9% in the enhanced usual care group (odds ratio, 2.56; 95% CI, 0.84 to 7.83, P=0.10). Participants in the incentive group had higher rates of nicotine replacement therapy use (57.3% versus 31.3%, P=0.002). Financial incentives did not improve subjective social status but did increase financial stress. Conclusions-Rates of bioconfirmed smoking cessation were higher among hospitalized patients randomized to financial incentives compared to usual care alone, but the difference was not significant. Considering the frequency of low payouts and the importance of assistance for successful quitting, future studies should explore the effectiveness of financial incentives sufficiently large to overcome barriers to evidence-based therapy.

OBJECTIVE:Tests of rapid automatized naming (RAN) have been used for decades to evaluate neurological conditions. RAN tests require extensive brain pathways involving visual perception, memory, eye movements and language. To the extent that different naming tasks capture varied visual pathways and related networks, we developed the Staggered Uneven Number (SUN) test of rapid number naming to complement existing RAN tests, such as the Mobile Universal Lexicon Evaluation System (MULES). The purpose of this investigation was to determine values for time scores for SUN, and to compare test characteristics between SUN and MULES. METHODS:We administered the SUN and MULES tests to healthy adult volunteers in a research office setting. MULES consists of 54 color photographs; the SUN includes 145 single- and multi-digit numbers. Participants are asked to name each number or picture aloud. RESULTS: = 0.43, P = .001). Learning effects between first and second trials were greater for the MULES; participants improved (reduced) their time scores between trials by 5% on SUN and 16% for MULES (P < .0001, Wilcoxon signed-rank test). CONCLUSION/CONCLUSIONS:The SUN is a new vision-based test that complements presently available picture- and number-based RAN tests. These assessments may require different brain pathways and networks for visual processing, visual memory, language and eye movements.

BACKGROUND:Community volunteerism is essential in the implementation of the Community-based Health Planning and Services (CHPS) in Ghana. We explored the responsibilities, motivations and challenges of community health management committees (CHMCs) in two CHPS+ Project districts in Ghana. METHODS:We used a qualitative approach to collect data through 4 focus group discussions among a purposive sample of community health volunteers in December 2018 and analysed them thematically. RESULTS:Community health management committees (CHMCs) were found to provide support in running the CHPS programme through resource mobilisation, monitoring of logistics, assisting the Community Health Officers (CHO) in the planning of CHPS activities, and the resolution of conflicts between CHOs and community members. The value, understanding and protective functions were the key motivations for serving on CHMCs. Financial, logistical and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation and lack of regular skill development training programmes for CHMC members who serve as traditional birth attendants (TBAs) were major challenges in CHMC volunteerism. CONCLUSION/CONCLUSIONS:Community health volunteerism needs to be prioritised by the Ghana Health Service and other health sector stakeholders to make it attractive for members to give off their best in the discharge of their responsibilities.