Faculty Bibliography

The percentage of adults in the United States reporting current marijuana use has more than doubled, from 4 to 9% between 2002 and 2018, suggesting that exposure to secondhand marijuana smoke (SHMS) has probably increased. Few studies have characterized the extent to which residents experience SHMS, particularly those living in multi-unit housing. It remains unknown how recently-implemented smoke-free housing policies (SFH) targeting cigarette smoke in public housing authorities (PHAs) will affect SHMS exposure. We sought to characterize prevalence of self-reported SHMS exposure among residents living in two different subsidized housing settings prior to SFH policy implementation in PHAs: New York City Housing Authority (NYCHA) buildings and private sector buildings where most residents receive Section 8 subsidy vouchers (herein 'Section 8' buildings). Residents were recruited from 21 purposefully-selected buildings: 10 NYCHA and 11 Section 8 buildings (> 15 floors). Survey responses were collected during April-July 2018 for NYCHA residents (n = 559) and August-November 2018 for Section 8 residents (n = 471). Of 4628 eligible residents, 1030 participated (response rates, 35% NYCHA, 32% Section 8). Overall, two-thirds of residents reported smelling marijuana smoke (67%) in their home over the past year, higher than reports of smelling cigarette smoke (60%). Smoking status and smelling SHS were both strong predictors of smelling SHMS (p < 0.05). Nearly two thirds of residents perceived smoking marijuana and smelling SHMS as harmful to health. Our findings suggest that, immediately prior to SFH rule implementation in PHAs, SHMS was pervasive in low-income multi-unit housing, suggesting SFH policies should expand to cover marijuana use.

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

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.

Controlled heart donation after circulatory determination of death (cDCD) is well-established internationally with good outcomes and could be adopted in the United States to increase heart supply if ethical and logistical challenges are comprehensively addressed. The most effective and resource-efficient method for mitigating warm ischemia after circulatory arrest is normothermic regional perfusion (NRP) in situ. This strategy requires restarting circulation after declaration of death according to circulatory criteria, which appears to challenge the legal circulatory death definition requiring irreversible cessation. Permanent cessation for life-saving efforts must be achieved to assuage this concern and ligating principal vessels maintains no blood flow to the brain, which ensures natural progression to cessation of brain function. This practice - standard in some countries - raises unique concerns about prioritizing life-saving efforts, informed authorization from decision-makers, and the clinician's role in the patient's death. To preserve public trust, medical integrity, and respect for the donor, the donation conversation must not take place until after an un-coerced decision to withdraw life-sustaining treatment made in accordance with the patient's treatment goals. The decision maker(s) must understand cDCD procedure well enough to provide genuine authorization and the preservation/procurement teams must be kept separate from the clinical care team.

Purpose: Almost uniformly, patients with frequent Emergency Department (ED) use and severe alcohol use disorders (AUDs) do not receive alcohol pharmacotherapy and are excluded from research as they are difficult to engage and retain and suffer from myriad bio-psychosocial comorbidities. We assessed the feasibility and acceptability of initiating and continuing treatment with extended-release naltrexone (XR-NTX) as well as studying its effects in this challenging population and clinical setting.
Method(s): In this randomized, open-label study, ED patient-participants with > 4 ED visits and moderate- severe AUD were randomized (1:1) to XR-NTX and research assistant-delivered care management or treatment as usual enhanced by a one-time warm referral and motivation enhancement. XR-NTX was first administered during the index ED visit. Thereafter, participants could receive up to 11 additional doses at clinic visits with arrangements to allow unscheduled visits. Non-clinical research visits (both arms) were scheduled at 3, 6, and 12 months with a considerable date variation permitted and expected. Drinking was assessed via 30-day timeline followback with heavy drinking day (HDD) thresholds of 5 for males and 4 for females. Resuts: The 48 participants were aged 55.0 +/- 8.2, 88% male, 51% white, 79% homeless, and reported an average of 23.4 HDDs in the priormonth and 24.4 standard drinks/drinking day. Approximately 70%lacked reliable contact information. Research visit attendance was 70.8%, 77.1%, and 70.8%with a median time to first visit of 126 days [Interquartile Range: 89-242]. In the XR-NTX arm (N = 24), a total of 173 injections were administered with amean of 7.2 per participant; 20 (83%) participants received 2 or more injections, 14 (56%) received 6 or more injections, and 6 (24%) received 12 injections. There was a significantly greater decrease in HDDs per month among those receiving XR-NTX compared to those who did not: 15.3 (95%CI 9.7-21.0) and 9.6 (95%CI 1.5-17.6), respectively. Baseline rates were imputed for two missing participants in each arm.
Conclusion(s): Among this population whose complicated AUDs pose considerable challenges from clinical and research perspectives, initiating and continuing treatment with XR-NTX was feasible, acceptable, and demonstrated promising preliminary drinking outcomes. Additional sensitivity analyses and evaluation of other outcomes of interest are underway. Further study on a larger scale is warranted

Background/UNASSIGNED:Emergency departments are seeing an increase in acute exacerbations of chronic disease in the older-adult population. The delivery of palliative care in the emergency department can increase goal-concordant care at the end-of-life for this population. New interventions in palliative care for emergency medicine require large, pragmatic, complex health interventions due to the heterogeneous and dynamic environment of emergency departments. These complex interventions must balance fidelity with adaptability, while being rooted in theory, to produce an intervention that can be applied in a variety of contexts. Methods/UNASSIGNED:Primary Palliative Care for Emergency Medicine (PRIM-ER) is a large, pragmatic, complex health intervention. This paper outlines the conceptual theory-based design as well as the study form and functions of PRIM-ER to exemplify how this complex intervention has balanced fidelity with adaptability. Results/UNASSIGNED:A form and function matrix was created to highlight the key objectives and tailored intervention components of PRIM-ER. Each intervention component was also linked to one or more elements of the Theory of Planned Behavior to support provider behavior change and the delivery of palliative care services and referrals. Conclusion/UNASSIGNED:The application of theory and delineation of forms and functions, as well prospective adaptation monitoring of large complex interventions can support the balance of fidelity with adaptability to encourage successful interventions among a variety of clinical environments.

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.