Faculty Bibliography

IMPORTANCE/UNASSIGNED:US territory nativity and/or residence may be associated with health because it affects environmental exposures, insurance coverage, prenatal care, and other factors. Investigations of preterm birth in the US territories are limited. OBJECTIVE/UNASSIGNED:To assess the association between maternal territory status and preterm birth, as well as whether insurance type modified associations. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Cross-sectional study of restricted-use birth certificates of in-hospital, singleton births in the US and territories from 2014 to 2023. EXPOSURES/UNASSIGNED:Maternal territory status was defined for births in territories where data were available (Guam, Northern Mariana Islands, Puerto Rico, and Virgin Islands) for the following groups: (1) those with territory nativity and residence; (2) those with territory nativity and mainland residence; (3) those with mainland nativity and territory residence; and (4) those with mainland nativity and residence (reference group). Insurance type (private, Medicaid, or other) was evaluated as well. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Preterm birth (live birth before 37 weeks' gestation). RESULTS/UNASSIGNED:Among 28 627 700 births, 465 291 (1.6%) had any maternal territory status (nativity or residence). This group had a mean (SD) age of 27.1 (6.0) years, and 297 593 (64.0%) had Medicaid insurance. The highest preterm birth rate was among those with territory nativity and residence (10.5%; 95% CI, 10.4%-10.7%); the lowest was among those with mainland nativity and residence (8.4%; 95% CI, 8.4%-8.5%). Individuals with territory nativity and residence had an adjusted relative risk (aRR) of 1.30 (95% CI, 1.29-1.32) for preterm birth compared with the reference group. There was significant interaction between territory residence and insurance. Compared with individuals with mainland residence and private insurance, those with territory residence and Medicaid had the highest preterm birth risk (aRR, 1.57; 95% CI, 1.55-1.59), followed by territory residence and private insurance (aRR, 1.42; 95% CI, 1.39-1.45). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study, maternal territory nativity and residence were associated with preterm birth. Territory residence was associated with a higher risk of preterm birth, regardless of insurance type. Privately insured-individuals in US territories had a higher risk of preterm birth than Medicaid-insured individuals in the mainland. Given differential access to health care, health insurance, and other social exposures between territory and mainland populations, future work should explore causal effects and related policies that may improve birth outcomes in US territories.

BACKGROUND:The role of modifiable environmental factors in Alzheimer's disease (AD) risk remains poorly understood. Built environment features such as neighbourhood walkability (NW) may influence long-term cognitive health among women. METHODS:The New York University Women's Health Study recruited 14 273 cognitively healthy women aged 35-65 years between 1985 and 1991, with follow-up for over 30 years. We geocoded residential addresses for each participant to derive a validated four-item baseline NW measure and a two-item average annual NW index over the follow-up period. We conducted a nested case-control study of 1865 AD cases identified via linkage to Medicare claims during follow-up matched to 3730 controls on age, race/ethnicity and Medicare coverage using risk-set sampling. We used conditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals for AD in relation to tertiles of NW measures, adjusting for potential confounders. Subgroup analyses examined potential effect modification. RESULTS:Compared with women living in areas with the lowest baseline NW, those in the middle and highest tertiles had lower odds of having a diagnosis of AD during follow-up, with an OR of 0.95 (0.82-1.11) and 0.83 (0.71-0.98), respectively (P-trend = .03). Results were similar when using average annual NW. The association did not differ appreciably by age, smoking status, education or body mass index. CONCLUSIONS:Higher midlife NW was associated with reduced odds of AD later in life. These findings highlight the potential for built environment interventions to promote cognitive health and support healthy ageing in women.

BACKGROUND:Tools for predicting heart failure (HF) in CKD patients remain limited. We aimed to study whether standard ECG features or heart rate variability parameters predict de novo HF hospitalization in individuals with CKD. METHODS:Utilizing a large NYU ECG database linked with electronic health records (2012-2021), we analyzed a cohort of patients with pre-existing CKD. Besides standard ECG features, we extracted heart rate variability (measures the time between consecutive heart beats in milliseconds) features from the ECGs as predictors. The index ECG was the first ECG performed after the index eGFR date (baseline) and was required to be done prior to initiation of dialysis, end-stage kidney disease (ESKD), or transplant. The primary outcome was time to index HF hospitalization (≥30 days after the index ECG) based on discharge ICD-10 codes. LASSO-penalized Cox regression was used to identify predictors. Sensitivity analyses used Fine-Gray competing risk models for death and ESKD. RESULTS:Among 11,409 individuals (median age: 72; ∼50% male) with a median of 976 days, 880 individuals (8%) experienced an index HF hospitalization. Models incorporating ECG and clinical parameters had excellent discrimination (C-statistic 0.76 in the training set and 0.73 in the validation set). Among ECG features, the PR interval, corrected QT, and T axis were independently associated with higher risks of index HF hospitalization ≥30 days after the index ECG in both primary models (p<0.001 for all) and in models accounting for competing risks (p<0.01 for all). History of arrhythmia (hazard ratio (HR, 1.60, 95% CI: 1.36-1.88), valvular disease (HR1.51, 95% CI: 1.27-1.81), and diabetes (HR 1.41, 95% CI: 1.22-1.65) were the strongest clinical predictors. HRV parameters were not independently associated with HF. CONCLUSIONS:Although ECG-derived HRV indices were not independently associated with risk of HF, several standard ECG features are associated with HF hospitalization in CKD.

OBJECTIVE:To identify optimal strategies to integrate early relational health (ERH) programs in pediatric primary care (PPC) and to describe the development of a best practices toolkit to provide guidance and useful tools that clinicians can use to navigate this process. METHODS:A two-phased approach to develop, assess, and refine a best practices toolkit for the integration of multiple ERH programs in PPC through a modified Delphi process. Phase One included identification and assessment around barriers to ERH program integration and strategies to address them through surveys and focus groups of PPC clinics nationwide. Phase Two then utilized the identified barriers and strategies from Phase One to create a toolkit of best practices on integrating ERH programs in PPC that included two rounds of revision for a final version. RESULTS:126 PPC personnel from 44 clinics nationwide completed the Phase One survey, with respondents reporting many notable strengths and challenges to ERH program integration. 18 survey participants also participated in follow-up focus groups, which reiterated the strengths and challenges found in the surveys. An initial toolkit was then drafted, and experts provided qualitative, free-response feedback around clarity and presentation. Further improvement was made to create the final toolkit, which was rated highly useful and important, though slightly less feasible, by practitioners using formal feedback questions. CONCLUSION/CONCLUSIONS:This study employed a modified Delphi process to create a consensus-based best practices toolkit for integrating multiple ERH programs in PPC to help meet the heterogeneous needs of families to promote optimal child development.

INTRODUCTION/BACKGROUND:Safety net hospitals (SNHs), defined as the members of America's essential hospitals, are lifelines for over 28 million uninsured and Medicaid-dependent Americans, yet systemic inequities trap both patients and institutions in a vicious cycle. METHODS:A narrative review was performed to examine the impact of late-stage cancer presentations on patient outcomes and cost implications. RESULTS:Late-stage cancer diagnoses (stages III and IV) are more common at SNHs than other hospitals, likely due to limited access to preventative services. The higher rate of late-stage diagnoses leads to a higher cost of treatment. In fact, patients with stage IV cancer incur 60%-80% higher treatment costs than those with early-stage diagnoses. CONCLUSIONS:SNHs are a vital source of health care for vulnerable populations across the country, with 75% of the SNH patient population being uninsured or underinsured. SNHs more frequently see patients with advanced stage cancers and disproportionately bear the expense of caring for these patients. American College of Surgeons accreditation, which emphasizes screening, quality improvement and strict standards, provides a roadmap to earlier detection and standardized high-quality care. However, only half of SNHs have American College of Surgeons quality accreditations in place, and only 12% of SNHs nationwide have American College of Surgeons cancer-related accreditations in place. Barriers to accreditation include staffing shortages and budget constraints, exacerbated by reductions in disproportionate share hospital funding and anticipated cuts to Medicare and Medicaid funding. Despite these challenges, the long-term benefits of accreditation outweigh the investment. Addressing these barriers is crucial to ensuring that SNHs can provide high-quality care to vulnerable populations.

OBJECTIVE:Exposure to per- and polyfluoroalkyl substances (PFAS) may increase the risk of gestational diabetes mellitus (GDM), with adverse consequences for pregnant women and their offspring. However, epidemiologic studies have shown inconsistent results. We addressed this question in a large, pooled sample of U.S. women. RESEARCH DESIGN AND METHODS/METHODS:Participants (n = 5,229) from 16 cohorts had singleton pregnancies. PFAS were quantified in a single plasma or serum sample during pregnancy (1999-2021); six PFAS detected in ≥60% of participants were analyzed. The primary outcome was GDM diagnosis based on self-report or medical record documentation. The secondary outcome, among 1,213 participants, was fasting glucose. We estimated associations between each PFAS and GDM using generalized estimating equations models with Poisson distribution and robust variance, and estimated associations between each PFAS and fasting glucose using generalized estimating equations models for linear regression. Effect modification by prepregnancy BMI or race and ethnicity was evaluated via interaction terms and stratification. We quantified the combined effect of the PFAS mixture using quantile-based g-computation. RESULTS:Associations between individual PFAS and GDM were null or weakly inverse; the association with the six-PFAS mixture was negative (prevalence ratio [95% CI] per quartile increase: 0.75 [0.58, 0.96]). Certain PFAS were more strongly negatively associated with GDM among participants with BMI <25 kg/m2. Associations between PFAS and fasting glucose were largely null, although both positive and negative associations were observed in specific race and ethnicity strata. CONCLUSIONS:In a large, pooled sample of U.S. pregnant women, greater concentrations of PFAS were not associated with higher prevalence of GDM.

Evidence for an association between insulin-like growth factors (IGF) and multiple myeloma (MM) is inconsistent. We examined total IGF-I concentrations and risk of MM by combining baseline serological data among UK Biobank participants (n = 444 187; 732 incident MM) with a two-sample Mendelian randomisation (MR) analysis using identified genetic variants associated with circulating total IGF-I and IGF-binding protein 3 (IGFBP-3) in the InterLymph consortium (2434 MM and their 2567 controls). Finally, additional lymphoid neoplasm (LN) subtypes were included for comparison with the main hypothesis. Circulating IGF-I level was positively associated with MM risk Hazard ratio-HR-per one standard deviation-SD-increase (HR_1-SD = 1.11, 95% confidence interval [CI]: 1.01-1.22; p-value = 0.03), especially closer to diagnosis. Genetically inferred IGF-I levels were associated with increased MM risk (odds ratio [OR] = 1.27, 95% CI: 1.05-1.54) but not with any other LNs. Genetically inferred IGFBP-3 levels showed no associations with any LN evaluated. Corroborating previous findings, in a secondary analysis, IGF-I levels were associated with the risk of chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL) in males with higher body mass index (HR_{1-SD in obese male} = 1.36, 95% CI: 1.14-1.61). Our serological and MR analyses suggest a contributing role of IGF-I in the susceptibility of MM; the CLL/SLL findings warrant further investigation considering sex-specific adiposity.

Several reports have described increases in children's behavior problems since the onset of the COVID-19 pandemic, but few were based on prospective data or represented groups who disproportionately experienced pandemic-related hardships. This study followed low-income and racially diverse young children from 3 U.S. cities-New York, NY, Pittsburgh, PA, and Tulsa, OK-with repeated measures of child behavior between 2016 and 2023. A total of 1,124 children were included (50% female; 48% Hispanic/Latine; 30% Black; 22% White/Other race/ethnicity; aged 3-7 at pandemic onset). Results reveal different patterns of behavior change by city. In New York, children's behavior stayed the same or slightly improved following the pandemic onset, whereas it stayed the same or got slightly worse in Tulsa, and got worse in Pittsburgh. Future studies of pandemic impacts should consider regional variation.

Chinese Americans who smoke have low use of nicotine replacement therapy (NRT). This study explored perceptions of NRT and decision-making around product choice among Chinese American smokers who received NRT. From September 2023 to January 2024, we conducted in-depth phone interviews with 20 participants recruited in New York City from a WeChat-based cessation pilot trial and a community-based cessation program, both providing free nicotine patches, gum, or lozenges. Participants (aged 26-72; 85% male; 60% current smoking) included 12 consistent NRT users (≥2 weeks), four trial users (<2 weeks), and four non-users. Five participants (25%) had never heard of NRT before program enrollment, and 14 (70%) had never used it previously. Consistent users generally viewed NRT as helpful in reducing cravings. Others reported barriers, including culturally rooted skepticism toward pharmacotherapy, preference for unassisted quitting, lack of readiness to quit, prior negative experiences, and unpleasant taste or side effects. Product choice was influenced by lay knowledge, ease of integrating NRT into daily routines, perceived effectiveness, and taste and side effects. Cessation programs addressing cultural beliefs, reframing willpower, engaging individuals not ready, and providing diverse NRT options with guidance on side effect management and routine integration may increase NRT use among this population.