Faculty Bibliography

We sought to qualitatively explore how those at highest risk for lung cancer, current smokers, experienced, understood, and made decisions about participation in lung cancer screening (LCS) after being offered in the target setting for implementation, routine primary care visits. Thirty-seven current smokers were identified within 4 weeks of being offered LCS at seven sites participating in the Veterans Health Administration Clinical Demonstration Project and interviewed via telephone using semi-structured qualitative interviews. Transcripts were coded by two raters and analyzed thematically using iterative inductive content analysis. Five challenges to smokers' decision-making lead to overestimated benefits and minimized risks of LCS: fear of lung cancer fixated focus on inflated screening benefits; shame, regret, and low self-esteem stemming from continued smoking situated screening as less averse and more beneficial; screening was mistakenly believed to provide general evaluation of lungs and reassurance was sought about potential damage caused by smoking; decision-making was deferred to providers; and indifference about numerical educational information that was poorly understood. Biased understanding of risks and benefits was complicated by emotion-driven, uninformed decision-making. Emotional and cognitive biases may interfere with educating and supporting smokers' decision-making and may require interventions tailored for their unique needs.

BACKGROUND:Optical coherence tomography (OCT) measurements of ganglion cell + inner plexiform layer (GCIPL) and peripapillary retinal nerve fiber layer (pRNFL) thicknesses are associated with visual function (VF) and disability in multiple sclerosis (MS). However, the value of measuring Bruch membrane opening-minimum rim width (BMO-MRW) thickness in MS remains unclear. METHODS:Sixty-eight patients with MS and 22 healthy controls (HCs) underwent spectral domain OCT, 100%-contrast visual acuity (VA), 2.5%- and 1.25%-contrast letter acuity (LA), and Expanded Disability Status Scale (EDSS) testing. Mixed-effects linear regression models, accounting for within-subject, intereye correlations, were used to assess relationships. RESULTS:The MS cohort exhibited significantly lower BMO-MRW (P = 0.01), pRNFL at 3.7-, 4.1-, and 4.7-mm diameters surrounding the optic disc (P < 0.001 for all), and GCIPL (P < 0.001) thicknesses than HCs. BMO-MRW thickness was associated with 100%-VA (P < 0.001, R = 0.08), 2.5%-LA (P < 0.001; R = 0.13), and 1.25%-LA (P = 0.002; R = 0.11). All measured pRNFL thicknesses were associated with high- and low-contrast VF (all: P < 0.001). GCIPL thickness was more strongly associated with 100%-VA (P < 0.001; R = 0.23), 2.5%-LA (P < 0.001; R = 0.27), and 1.25%-LA (P < 0.001; R = 0.21) than the other OCT measures assessed. All OCT measures were significantly, but weakly, associated with EDSS scores. CONCLUSIONS:BMO-MRW and pRNFL thicknesses are reduced and associated with VF and disability in MS, but GCIPL thickness is a stronger marker of visual impairment. Our findings corroborate the utility of OCT in providing valuable information regarding the MS disease process.

BACKGROUND:Among older adults (age≥75) hospitalized for acute myocardial infarction, acute kidney injury after coronary angiography is common. Aging-related conditions may independently predict acute kidney injury, but have not yet been analyzed in large acute myocardial infarction cohorts. METHODS:We analyzed data from 2212 participants age≥75 in the SILVER-AMI study who underwent coronary angiography. Acute kidney injury was defined using KDIGO criteria (serum Cr increase ≥0.3mg/dL from baseline or≥1.5 times baseline). We analyzed the associations of traditional acute kidney injury risk factors and aging-related conditions (ADL impairment, prior falls, cachexia, low physical activity) with acute kidney injury, and then performed logistic regression to identify independent predictors. RESULTS:Participants' mean age was 81.3years, 45.2% were female, and 9.5% were nonwhite; 421 (19.0%) experienced acute kidney injury. Comorbid diseases and aging-related conditions were both more common among individuals experiencing acute kidney injury. However, after multivariable adjustment, no aging-related conditions were retained. There were 11 risk factors in the final model; the strongest were heart failure on presentation (OR 1.91, 95% CI 1.41-2.59), BMI >30 (vs. BMI 18-25: OR 1.75, 95% CI 1.27-2.42), and nonwhite race (OR 1.65, 95% CI 1.16-2.33). The final model achieved an AUC of 0.72 and was well calibrated (Hosmer-Lemeshow P=0.50). Acute kidney injury was independently associated with 6month mortality (OR 1.98, 95% CI 1.36-2.88) but not readmission (OR 1.26, 95% CI 0.98-1.61). CONCLUSIONS:Acute kidney injury is common among older adults with acute myocardial infarction undergoing coronary angiography. Predictors largely mirrored those in previous studies of younger individuals, which suggests that geriatric conditions mediate their influence through other risk factors.

BACKGROUND:Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care. OBJECTIVE:To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs). DESIGN/METHODS:As part of a multi-phase study implementing electronic health record-integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted. PARTICIPANTS/METHODS:Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine. APPROACH/METHODS:Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework. KEY RESULTS/RESULTS:Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment. CONCLUSIONS:Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.

The Robert Wood Johnson Foundation (RWJF)'s Culture of Health Action Framework guides a movement to improve health and advance health equity across the nation. Action Area One of the Framework, Making Health a Shared Value, highlights the role of individual and community factors in achieving a societal commitment to health and health equity, centered around three drivers: Mindset and Expectations, Sense of Community, and Civic Engagement. To stimulate research about how Action Area One and its drivers may impact health, Evidence for Action (E4A), a signature research funding program of RWJF, developed and released a national Call for Proposals (CFP). The process of formulating the CFP and reviewing proposals surfaced important challenges for research on creating and sustaining shared values to foster and maintain a Culture of Health. In this essay, we describe these considerations and provide examples from funded projects regarding how challenges can be addressed.

BACKGROUND/OBJECTIVES/OBJECTIVE:The American College of Cardiology (ACC) Geriatric Cardiology Section Leadership Council recently outlined 4 key domains (which are composed of 14 subdomains) that are important to assess in older adults with heart failure (HF). We sought to determine which geriatric domains/subdomains are routinely assessed, how they are assessed, and how they impact clinical management in the care of ambulatory older adults with HF. DESIGN/METHODS:Survey. SETTING/METHODS:Ambulatory. PARTICIPANTS/METHODS:Fifteen active ACC member physicians from the geriatric cardiology community. MEASUREMENTS/METHODS:Electronic survey assessing which domains/subdomains are currently assessed in these selected real-world practices, how they are assessed, and how they are incorporated into clinical management. RESULTS:Of 15 clinicians, 14 responded to the survey. The majority routinely assess 3 to 4 domains (median, 3; interquartile range, 3-4) and a range of 4 to 12 subdomains (median, 8; interquartile range, 6-11). All respondents routinely assess the medical and physical function domains, 71% routinely assess the mind/emotion domain, and 50% routinely assess the social domain. The most common subdomains included comorbidity burden (100%), polypharmacy (100%), basic function (93%), mobility (86%), falls risk (71%), frailty (64%), and cognition (57%). Sensory impairment (50%), social isolation (50%), nutritional status (43%), loneliness (7%), and financial means (7%) were least frequently assessed. There was significant heterogeneity with regard to the tools used to assess subdomains. Common themes for how the subdomains influenced clinical care included informing prognosis, informing risk-benefit of pharmacologic therapy and invasive procedures, and consideration for palliative care. CONCLUSIONS:While respondents routinely assess multiple domains and subdomains and view these as important to clinical care, there is substantial heterogeneity regarding which subdomains are assessed and the tools used to assess them. These observations provide a foundation that inform a research agenda with regard to providing holistic and patient-centered care to older adults with HF.

In New York City, over 90% of women newly diagnosed with human immunodeficiency virus (HIV) are Black and Latina; a quarter of these infections occur among 30-39 year-olds. A survey was administered to 343 Black and Puerto Rican women (2014-2016) to examine two HIV infection risk factors: relationship exclusivity and having experienced childhood sexual abuse (CSA). A majority of male partners (69.7%) had at least one risk for HIV transmission. Women in non-exclusive sexual relationships (nESRs) had higher-risk partners, but engaged in safer sex practices than those in ESRs. Two-thirds of women in ESRs (64.8%) reported unprotected vaginal intercourse, although 33.5% had partners with a history of concurrent relationships. Among women in nESRs, having experienced CSA was a strong risk factor for HIV infection. Black and Latina women's vulnerability to HIV infection is significant, even when in exclusive relationships. Safer sex counseling should be integrated in primary care.