Faculty Bibliography

Background: Forty percent of Americans are expected to develop type 2 diabetes mellitus (DM) within their lifetime, and up to one third of older adults with DM face co-occurring cognitive impair-ment and/or Alzheimer's disease and Related Dementia (ADRD). These co-morbidities create significant challenges in management for both patient and care partner, which is further compounded by a lack of consensus regarding optimal care. We conducted a systematic liter-ature review to better characterize the evidence guiding care for older patients with DM-ADRD.
Method(s): We used the PRISMA method to guide this system-atic review. A specialized librarian searched PubMed (Medline) using relevant search terms related to the management of DM and ADRD. This process yielded 2,158 DM studies and 1,401 ADRD studies. We included studies that were applicable to adults over 60 years old, published within the past 5 years, conducted within a primary care setting and written in English. Our review returned 267 DM and 104 ADRD focused results, of which 50 DM and 40 ADRD studies were included after abstract and full text review requiring two expert votes. Additionally, through expert opinion, we identified an additional 40 DM and 60 ADRD studies for inclusion.
Result(s): Based on this evidence, we identified methods for screening, diagnosis and management of patients with DM and ADRD as well as general principles related to care partner support, geriat-ric care, geriatric syndromes and goals for blood pressure and lipid management.
Conclusion(s): A review of the literature suggested the importance of individualizing care while monitoring and managing care partner stress, geriatric conditions, cognitive changes, complication risks, and glycemic, blood pressure, and cholesterol targets in order to achieve high quality care. The next steps are to use this information to generate decisional guidance for providers of older adults with DM-ADRD

Introduction: We determined whether Obstructive Sleep Apnea (OSA) and beta-Amyloid Burden (Abeta) act additively or synergistically to promote conversion from cognitive normal (CN) to mild cognitive impairment (MCI) and from MCI to AD.
Method(s): In this longitudinal observational study, we examined CN (n=298) and MCI (n=418) older adults from the ADNI database (adni.loni.usc.edu). OSA was self-reported during a clinical interview. Brain Abeta was assessed using Florbetapir-PET imaging. The primary outcome of the analysis was conversion from CN to MCI (CN participants) and from MCI to AD (MCI participants). Participants were required to have a baseline and at least one follow-up clinical visit that identified their cognitive status. Logistic mixed-effects models with random intercept and slope were used to assess associations between OSA, Abeta, and risk of conversion from CN to MCI, and MCI to AD. All models included age at baseline, sex, APOE4 status, years of education, and their interactions with time.
Result(s): Of the 716 participants, 329 (46%) were women. The overall mean (SD) age was 74.7 (5.0) years, and the overall mean (SD) follow-up time was 5.5 (1.7) years (Range: 2.7 - 10.9 years). In CN participants at baseline, conversion to MCI was associated with both OSA (beta = 0.418; 95% CI, 0.133 to 0.703; P < .001) and higher Abeta-burden (beta = 0.554; 95% CI, 0.215 to 0.892; P < .001). The interaction of OSA and Abeta burden with time was significant (beta = 1.169, 95% CI, 0.776 to 1.562; P < .001), suggesting a synergistic effect. In MCI participants at baseline, conversion to AD was associated with both OSA (beta = 0.637; 95% CI, 0.291 to 0.982; P < .001) and higher Abeta-burden (beta = 1.061; 95% CI, 0.625 to 1.497; P < .001). The interaction of OSA and Abeta burden with time was significant (beta = 1.312, 95% CI, 0.952 to 1.671; P < .001), suggesting a synergistic effect.
Conclusion(s): In both CN and MCI elderly, Abeta modified the risk of progression to AD in OSA participants. OSA patients maybe more physiologically susceptible as Abeta load becomes increasingly abnormal

OBJECTIVES/OBJECTIVE:The present study investigates the association between skin color and academic achievement in young Latino students. METHOD/METHODS:= 750) were 4 and 5 years old when they were enrolled (baseline) and were followed through the end of first grade. Structural equation models and bootstrapping mediation tests were conducted to examine the effects of skin color on academic achievement at the end of first grade, partially mediated by academic and social emotional domains of school readiness in prekindergarten or kindergarten. This study considered the intersectionality of ethnicity and gender in the models. RESULTS:The findings showed that for Dominican-origin boys, being "collectively black" was indirectly associated with lower academic achievement in first grade, mediated by lower teacher-rated adaptive behavior in prekindergarten or kindergarten. CONCLUSIONS:Discussion focuses on the need for educational policies and practices to be conscious of phenotypicality bias. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

OBJECTIVES/OBJECTIVE:Residential time in the United States appears to be a risk factor for mental health problems among Latinos, according to studies of the immigrant paradox, or a pattern of findings documenting better health for immigrants relative to U.S.-born Latinos. The present study used an acculturative stress model to examine the immigrant paradox with a sample of Mexican-origin mothers. METHOD/METHODS:Mothers [N = 175; age = 33.52 (10.75)], who were foreign- or U.S.-born, were categorized as more acculturated or less acculturated based on cluster analyses using demographic and language proficiency variables. The association between acculturative status and depressive symptoms approximately 9 months later was tested with two models: with both cultural stressors (i.e., perceived discrimination, acculturative stress) and cultural assets (i.e., familismo, ethnic identity) as mediators, and with the effects of cultural stressors moderated by cultural assets. RESULTS:Data provide some support for the validity of the mediation model. Less acculturated mothers reported (a) a stronger ethnic identity, which appears to have protected them from later depression, and (b) stronger familismo, which increased risk for later depression. In addition, discrimination was negatively related to later depression. CONCLUSIONS:We found support for the mediating role of cultural assets in the link between acculturation and depression, but some associations were in unexpected directions. These findings highlight the complexities of preserving core cultural characteristics among Mexican-origin mothers living in the United States, and the need to consider the context in which cultural processes unfold. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

OBJECTIVE:Medicare's Bundle Payment for Care Improvement(BPCI) Model 2 groups reimbursement for valve surgery into 90-day episodes of care(EOC) which include operative costs, inpatient stay, physician fees, post-acute care, and readmissions up to 90 days post-procedure. We analyzed our BPCI patients' 90-day outcomes to understand the late financial risks and implications of the bundle payment system for valve patients. METHODS:All BPCI valve patients from 10/2013 (start of risk-sharing phase) through 12/2015 were included. Readmissions were categorized as early (≤30 days) or late (31-90 days). Data were collected from institutional databases as well as Medicare claims. RESULTS:Analysis included 376 BPCI valve patients: 202 open and 174 transcatheter aortic valves (TAVR). TAVR patients were older (83.6 vs 73.8 years; p=0.001) and had higher STS predicted risk (7.1% vs 2.8%; p=0.001). Overall, 18.6% of patients (70/376) had one-or-more 90-day readmission, and total claims was on average 51% greater for these patients. Overall readmissions were more common among TAVR patients (22.4%(39/174) vs 15.3%(31/202),p=0.052) as was late readmission. TAVR patients had significantly higher late readmission claims, and early readmission was predictive of late readmission for TAVR patients only (p=0.04). CONCLUSION/CONCLUSIONS:Bundled claims for a 90-day episode of care are significantly increased in patients with readmissions. TAVR patients represent a high-risk group for late readmission, possibly a reflection of their chronic disease processes. Being able to identify patients at highest risk for 90-day readmission and the associated claims will be valuable as we enter into risk-bearing EOC agreements with Medicare.

We examined the prevalence of infection with human papillomavirus (HPV) and HIV in a cohort of young gay, bisexual, and other men who have sex with men [sexual minority men (SMM)]. HPV vaccination uptake was assessed; HIV antibody testing was performed and genetic testing for oral and anal HPV infection was undertaken. We examined both HPV vaccination and infection in relation to key demographic and structural variables. Participants (n = 486) were on average 23 years old; 70% identified as a member of a racial/ethnic minority group, and 7% identified as transgender females. Only 18.1% of the participants indicated having received the full dosage of HPV vaccination and 45.1% were unvaccinated. Slightly over half the participants (58.6%) were infected with HPV, with 58.1% testing positive for anal infection and 8.8% for oral infection. HIV seropositivity was associated with infection to oral HPV [adjusted odds ratio (AOR) = 4.03] and vaccine-preventable HPV, whereas both neighborhood-level poverty (AOR = 1.68) and HIV infection (AOR = 31.13) were associated with anal infection to HPV (AOR = 1.68). Prevalence of HPV infection is high among unvaccinated young SMM, despite the availability and eligibility for vaccination. HPV infection adds further health burden to these populations and is particularly concerning for those who are HIV positive as HIV infection increases the risk of developing HPV-related cancers. These findings underscore a missed prevention opportunity for an at-risk and underserved population and suggest the need for active strategies to increase HPV vaccination uptake in young SMM before the onset of sexual behavior.

OBJECTIVE:Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less. DESIGN/METHODS:Retrospective cohort study. SETTING AND PARTICIPANTS/METHODS:All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. MEASURES/METHODS:Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge. RESULTS:Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78). CONCLUSIONS/IMPLICATIONS/CONCLUSIONS:The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.

Background and aims.- Prevalence of psychiatric disorders differs in males and females, and neurological studies suggest that sex-linked variation in the brain may underlie this dissociation. However, the origin of this difference, and how early in human life sexual dimorphism in brain function emerges is a topic that requires further investigation. Here, we address this gap by assessing brain resting-state functional connectivity (RSFC) between and within brain networks as it relates to fetal sex and gestational age (GA). Methods.- We examined 118 typical human fetuses (70 male; 48 female) between 25.9 and 39.6 weeks GA. Infomap was used to derive 16 separable fetal neural networks distributed across cortical, subcortical, and cerebellar regions. Using enrichment analysis, we identified network pairs revealing distinct patterns of GArelated change in males and females. Results.- Sex-dependent variation of between- and within- network RSFC-GA associations was observed: while females exhibited GA-related variation in connectivity between posterior cingulate and temporal pole regions, and between pre-frontal and cerebellar regions, males demonstrated increased intracerebellar RSFC with advancing age. Conclusions.- Such observations confirm that sex-related differences in functional brain development are present before birth. An important next step in this line of research will be to follow children across early development and discover how sex-related variation in network development relates to future health outcomes

Objective:This study explored the relationships between participation in group sex and risk for HIV and other sexually transmissible infections (STIs). Methods: An anonymous online survey collected data from 580 gay and bisexual men using a mobile sex and dating application in Paris, France. Logistic regression analyses were conducted, which controlled for HIV status, HIV pre-exposure prophylaxis (PrEP) use and participants' sociodemographic characteristics. Results: Compared with men with no recent group sex experience, those reporting group sex in the 3 months before the survey (30.7% of the sample) were more likely to have had condomless receptive anal sex at least once in the same period [adjusted odds ratio (aOR)=1.6, 95% confidence interval (CI)=1.1-2.4, P = 0.02], condomless insertive anal sex (aOR=2.0, 95%CI: 2.4-8.7, P < 0.001) and substance use before or during sex (aOR=1.6, 95%CI: 1.1-2.3, P = 0.02). Even when controlling for condom use, men involved with group sex were more likely to be have been diagnosed with a bacterial STI in the previous year (aOR=2.1, 95%CI: 1.3-3.3, P = 0.002). Conclusions: Group sex remains a useful marker of risk among gay and bisexual men, but research is needed that moves beyond individual practice in order to assess the epidemiological networks comprising group sex and the risks they pose relevant to HIV and other STIs.