Faculty Bibliography

Background: Despite the health care sector's growing interest in systematic collection of social risk data, little is known about patient acceptability of health care-based social risk screening. Acceptability to patients and caregivers has implications for adoption, utility and sustainability. We aimed to explore acceptability of the Center for Medicare and Medicaid Innovation's (CMMI) social risk screening tool, which covers 5 actionable social domains: food, housing, utilities, and transportation security, and personal safety.
Method(s): Cross-sectional analysis of patients or caregivers of pedi-atric patients recruited from 6 primary care clinics (PCCs) and 4 emergency departments (EDs). Participants completed a tablet-based survey that included the CMMI social risk tool and questions related to both acceptability of social screening and predictors of acceptability. The primary acceptability measure was perceived appropriateness of screening in health care settings; a secondary outcome was comfort with including social risk data in electronic health records (EHRs). Multilevel mixed-effects logistic regressions were used to evaluate acceptability measures, clustering by site.
Result(s): 969 patients/caregivers completed the survey; 952 (98%) answered survey questions about acceptability. 72% of participants screened positive for at least 1 of 5 social risks. 80% of respondents reported screening was very or somewhat appropriate; 7% reported screening was very or somewhat inappropriate. 65% of participants reported being completely or somewhat comfortable with social risk data being included in EHRs; 18% reported being completely or somewhat uncomfortable. In the primary multivariable model, participants reporting higher acceptability of social risk screening had higher odds of previous social risk screening in a health care setting (aOR 1.80 [95% CI 1.31-2.47]); not endorsing prior discrimination in a health care setting (aOR 1.45 [95% CI 1.07-1.97]); being from a safety-net setting (aOR 1.85 [95% CI 1.11-3.10]); and being recruited in a PCC (aOR 2.10 [95% CI 1.01-4.32]). Participants who were more comfortable with including social risk data in EHRs had higher odds of previous social risk screening in a health care setting (aOR 1.56 [95% CI 1.17 to 2.09]). There were no associations between specific social risk domains or cumulative number of social risks with either measure of acceptability. No additional respondent-level characteristics were associated with acceptability.
Conclusion(s): Across PCC and ED settings, a majority of respondents found social risk screening acceptable. Acceptability levels did not differ across individual health care settings or level of social risks, though we identified some potentially modifiable factors associated with acceptability. High rates of acceptability support health care-based social screening implementation efforts, although future research should explore how to improve acceptability in specific patient populations and acceptability of EHR integration

Background: As research supporting potential benefits of social risk screening in health settings continues to emerge, there is little data on the patient perspective on social screening. The aim of this study is to describe the perspectives and preferences of patients and caregivers on being screened for social risks in diverse health care settings.
Method(s): As part of a larger mixed Methods multi-site study, we conducted semi-structured interviews lasting approximately 30 minutes with patients or caregivers who had completed the Center for Medicare and Medicaid Innovation (CMMI) social risk screening tool. After completion of the screening questions, 5 randomly selected respondents from each of 10 study sites were invited to participate in an interview. Interviews were conducted in English or Spanish. The interview guide asked about reactions to social risk screening and screening acceptability, preferences on screening administration, prior experiences that informed perspectives, and expectations for social assistance. Interviews were recorded, transcribed and translated. Two coders used basic thematic analysis and constant comparative Methods to identify codes, group codes into unified themes and map themes into domains of screening acceptability.
Result(s): Fifty adult patients or caregivers participated in semi-structured interviews across all study sites, which included 6 primary care clinics and 4 emergency departments. Respondents were 78% female, 36% Black, 32% Hispanic, 20% caregivers, and 71% reported having one or more social risk factor. There was broad consensus among interviewees across all clinical sites that social risk screening was acceptable. Several themes emerged: (1) respondents felt screening was the " right thing to do; " (2) respondents identified framing and compassionate approach as the most important aspects of administration; (3) respondents had insight into the connections between social risks and physical and mental health. Despite overall agreement that social risk screening is appropriate, respondents did not expect their health care team to address or resolve all of the identified issues. Interviewees felt referrals out to social services and resource sheets were adequate, and that there was benefit to the act of screening itself. Patients emphasized that screening should be done with empathy while protecting patient confidentiality.
Conclusion(s): Respondents agree that social risk screening is important, acceptable, and relevant to health. Respondents believed social risk screening would be most acceptable when implemented by a clinic staff member trained to ensure privacy and compassion. Despite published concerns about futility of social risk screening when social resources are inadequate, respondents expressed that they did not expect the health care system, and physicians in particular, to solve unmet social problems. Done appropriately, screening for social risk can build trust and strengthen relationships between patients and health care providers

Mobile technology has been designed to serve a number of functions relating to health, but we know little about individuals who use these tools to track sleep. This study utilized data from a cross-sectional, geographically diverse survey of adults in the USA (N = 934). Among the sample, 28.2% (n = 263) report current use of a mobile phone for sleep tracking. Income and gender were significant correlates of sleep tracking (p < 0.05). Compared to a poor diet, a reported "excellent" diet was associated with sleep tracking (p < 0.05). Interestingly, compared to individuals who never smoke, report of smoking "everyday" was associated with sleep tracking (p < 0.05). Finally, individuals who reported current use of their mobile device for other health functions (e.g., chat with their doctor or log symptoms) were more likely to report sleep tracking on their mobile device (p < 0.05). Results appear to suggest sleep tracking is common among individuals with good general health.

BACKGROUND/AIM/OBJECTIVE:National guidelines offer little guidance on the use of PSA progression (PSA increase as defined below) as a clinical endpoint in metastatic castration-resistant prostate cancer (mCRPC). The aim of the study was to examine treatment patterns/outcomes with abiraterone (abi)/enzalutamide (enza) throughout PSA progression and near the end of life (EOL). PATIENTS AND METHODS/METHODS:Cases of mCRPC treated with abi or enza from the New York Veterans Affairs (VA) from 6/2011-8/2017 were reviewed. Regression analyses were conducted to identify factors associated with continuation of abi/enza treatment up to the EOL, and survival. RESULTS:Of 184 patients, 72 received abi alone, 28 received enza alone, and 84 received both. Treatment was changed for PSA progression alone in 39.1% (abi) and 25.7% (enza) of patients. A total of 37 patients (20%) received abi/enza within 1 month before death, 30% of whom were receiving hospice services. Older patients and black patients were less likely to receive abi/enza up to the EOL. CONCLUSION/CONCLUSIONS:Abi/enza are frequently discontinued for PSA progression alone and continued at EOL. The clinical benefit of these practices warrants additional study.

OBJECTIVE:Young black men who have sex with men (YBMSM) in the USA represent a subgroup that has the highest HIV incidence among the overall population. In the USA, pre-exposure prophylaxis (PrEP) is an effective prevention intervention to prevent HIV acquisition when taken regularly. Neighbourhood and network factors may relate to PrEP awareness, but have not been studied in YBMSM. This study aimed to examine the relationship of neighbourhood and network characteristics with PrEP awareness among YBMSM. METHODS:We used data collected from a sample of 618 YBMSM in Chicago (2013-2014). Home addresses were collected for participants and enumerated network members. Administrative data (eg, 2014 American Community Survey, Chicago Department of Public Health) were used to describe residence characteristics. Network member characteristics were also collected (eg, sexual partners' sex-drug use, confidant network members who were also MSM). Multilevel analysis was performed to examine the relationships of neighbourhood and network characteristics to PrEP awareness. RESULTS:Higher neighbourhood-level educational attainment (adjusted odds ratio (aOR) 1.02, p=0.03) and greater primary care density (aOR 1.38, p=0.01) were associated with greater PrEP awareness; greater neighbourhood alcohol outlet density (aOR 0.52, p=0.004) was associated with less PrEP awareness. Sexual network members residing in the same neighbourhood as the participants (aOR 2.58, p=0.03) and discussions around avoiding HIV acquisition with confidants (aOR 2.26, p=0.04) were associated with greater PrEP awareness. CONCLUSIONS:The results suggest that neighbourhood and network characteristics can influence PrEP awareness in YBMSM. Additional studies are needed to understand the influences of neighbourhood (eg, MSM serving venues) and network (eg, peer to peer communication) characteristics on dissemination of PrEP information, uptake and adherence and the related mechanisms behind the associations.

BACKGROUND:Preschool-based interventions offer promise to instill healthy behaviors in children, which can be a strategy to reduce the burden of cardiovascular disease later. However, their efficacy in underserved communities is not well established. OBJECTIVES/OBJECTIVE:The purpose of this study was to assess the impact of a preschool-based health promotion educational intervention in an underserved community. METHODS:This cluster-randomized controlled study involved 15 Head Start preschools in Harlem, New York. Schools and their children were randomized 3:2 to receive either a 4-month (50 h) educational intervention to instill healthy behaviors in relation to diet, physical activity, body/heart awareness, and emotion management; or their standard curriculum (control). The primary outcome was the change from baseline in the overall knowledge, attitudes, and habits (KAH) score of the children at 5 months. As secondary outcomes, we evaluated the changes in KAH subcomponents and emotion comprehension. Linear mixed-effects models were used to test for intervention effects. RESULTS:The authors enrolled 562 preschool children age 3 to 5 years, 51% female, 54% Hispanic/Latino, and 37% African-American. Compared with the control group, the mean relative change from baseline in the overall KAH score was ∼2.2 fold higher in the intervention group (average absolute difference of 2.86 points; 95% confidence interval: 0.58 to 5.14; p = 0.014). The maximal effect was observed in children who received >75% of the curriculum. Physical activity and body/heart awareness components, and knowledge and attitudes domains, were the main drivers of the effect (p values <0.05). Changes in emotion comprehension trended toward favoring intervened children. CONCLUSIONS:This multidimensional school-based educational intervention may be an effective strategy for establishing healthy behaviors among preschoolers from a diverse and socioeconomically disadvantaged community. Early primordial prevention strategies may contribute to reducing the global burden of cardiovascular disease. (Family-Based Approach in a Minority Community Integrating Systems-Biology for Promotion of Health [FAMILIA]; NCT02343341).

OBJECTIVE:The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation. Measures of rapid automatic naming (RAN) have been used for over 50 years to capture aspects of vision and cognition. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. We examined MULES performance in youth, collegiate and professional athletes at pre-season baseline and at the sidelines following concussion. METHODS:Our study teams administered the MULES to youth, collegiate and professional athletes during pre-season baseline testing. Sideline post-concussion time scores were compared to pre-season baseline scores among athletes with concussion to determine degrees and directions of change. RESULTS:Among 681 athletes (age 17 ± 4 years, range 6-37, 38% female), average test times at baseline were 41.2 ± 11.2 s. The group included 280 youth, 357 collegiate and 44 professional athletes; the most common sports were ice hockey (23%), soccer (17%) and football (11%). Age was a predictor of MULES test times, with longer times noted for younger participants (P < .001, linear regression). Consistent with other timed performance measures, significant learning effects were noted for the MULES during baseline testing with trial 1 test times (mean 49.2 ± 13.1 s) exceeding those for trial 2 (mean 41.3 ± 11.2 s, P < .0001, paired t-test). Among 17 athletes with concussion during the sports seasons captured to date (age 18 ± 3 years), all showed increases (worsening) of MULES time scores from pre-season baseline (median increase 11.2 s, range 0.6-164.2, P = .0003, Wilcoxon signed-rank test). The Symptom Severity Score from the SCAT5 Symptom Evaluation likewise worsened from pre-season baseline following injury among participants with concussion (P = .002). CONCLUSIONS:Concussed athletes demonstrate worsening performance on the MULES test compared to their baseline time scores. This test samples a wide network of brain pathways and complements other vision-based measures for sideline concussion assessment. The MULES test demonstrates capacity to identify athletes with sports-related concussion.

There are many avenues by which early life poverty relates to the development of school readiness. Few studies, however, have examined the extent to which sustained attention, a central component of self-regulation in infancy, mediates relations between poverty-related risk and cognitive and emotional self-regulation at school entry. To investigate longitudinal relations among poverty-related risk, sustained attention in infancy, and self-regulation prior to school entry, we analyzed data from the Family Life Project, a large prospective longitudinal sample (N = 1292) of children and their primary caregivers in predominantly low-income and nonurban communities. We used structural equation modeling to assess the extent to which a latent variable of infant sustained attention, measured in a naturalistic setting, mediated the associations between cumulative poverty-related risk and three domains of self-regulation. We constructed a latent variable of infant sustained attention composed of a measure of global sustained attention and a task-based sustained attention measure at 7 and 15 months of age. Results indicated that infant sustained attention was negatively associated with poverty-related risk and positively associated with a direct assessment of executive function abilities and teacher-reported effortful control and emotion regulation in pre-kindergarten. Mediation analysis indicated that the association between poverty-related risk and each self-regulation outcome was partially mediated by infant attention. These results provide support for a developmental model of self-regulation whereby attentional abilities in infancy act as a mechanism linking the effects of early-life socioeconomic adversity with multiple aspects of self-regulation in early childhood.

Airway hyperreactivity (AHR) related to environmental exposure is a significant public health risk worldwide. Similarly, metabolic syndrome (MetSyn), a risk factor for obstructive airway disease (OAD) and systemic inflammation, is a significant contributor to global adverse health. This prospective cohort study followed N = 7486 World Trade Center (WTC)-exposed male firefighters from 11 September 2001 (9/11) until 1 August 2017 and investigated N = 539 with newly developed AHR for clinical biomarkers of MetSyn and compared them to the non-AHR group. Male firefighters with normal lung function and no AHR pre-9/11 who had blood drawn from 9 September 2001-24 July 2002 were assessed. World Trade Center-Airway Hyperreactivity (WTC-AHR) was defined as either a positive bronchodilator response (BDR) or methacholine challenge test (MCT). The electronic medical record (EMR) was queried for their MetSyn characteristics (lipid profile, body mass index (BMI), glucose), and routine clinical biomarkers (such as complete blood counts). We modeled the association of MetSyn characteristics at the first post-9/11 exam with AHR. Those with AHR were significantly more likely to be older, have higher BMIs, have high intensity exposure, and have MetSyn. Smoking history was not associated with WTC-AHR. Those present on the morning of 9/11 had 224% increased risk of developing AHR, and those who arrived in the afternoon of 9/11 had a 75.9% increased risk. Having ≥3 MetSyn parameters increased the risk of WTC-AHR by 65.4%. Co-existing MetSyn and high WTC exposure are predictive of future AHR and suggest that systemic inflammation may be a contributor.