Faculty Bibliography

Children and adolescents are affected in different ways by HIV/AIDS. Neurocognitive deficits are one of the most significant long term effects on HIV infected children and adolescents. Several factors are thought to influence cognitive outcomes and this include immune status, Highly Active Antiretroviral Therapy (HAART), education and social support. The aim of the study was to assess the neurocognitive function of HIV infected children and adolescents and correlate it with psychosocial factors. A cross sectional study was carried out involving a sample of 90 children living with HIV between 8 and 15 years (M = 11.38, SD = 2.06) attending Comprehensive Care Clinic (CCC) at Kenyatta National Hospital (KNH). Samples were selected by using purposive sample technique. Kaufman Assessment Battery for Children-Second Edition was used to assess cognitive function and psychosocial issues were assessed using HEADS-ED. Data was analyzed using SPSS v23 and independent T-tests, Pearson's correlation and linear regression were used. The prevalence of neurocognitive deficits among HIV positive children attending CCC at KNH was 60% with neurocognitive performance of 54 children being at least 2SD below the mean based on the KABC-II scores. There was no significant correlation between mental processing index and CD4 count (Pearson's rho =  -0.01, p = 0.39). There was no significant association between Mental Processing Index and viral load (p = 0.056) and early ARV initiation (0.27). Using the HEADS-ED, risks factors related to education (β =  -5.67, p = 0.02) and activities and peer support (β =  -9.1, p = 0.002) were significantly associated with poor neurocognitive performance. Neurocognitive deficits are prevalent among HIV positive children attending CCC-KNH. This extent of the deficits was not associated with low CD4 count, high viral load or early initiation in HIV care. However, poor school performance and problem with peers was associated with poor neurocognitive performance.

In many emergency departments (EDs) around the country, providers care for patients experiencing homelessness on every single shift. Despite its proven impact on health, housing status is not a routine part of the history taken by most emergency providers, and in many cases providers are unaware that they are caring for someone who has no stable home. Patients experiencing homelessness have unique needs spanning acute and chronic illness, injury, behavioral health diagnoses, and material deprivation.

Background: Previous studies have shown that ED patients have significantly higher rates of food insecurity than the general population. However, little research has examined the impact of food insecurity on health or the health service use of ED patients. In this study, we examine the relationship between food insecurity and frequent ED use. We hypothesized that food insecurity would be independently associated with frequent ED use. Methods: We surveyed a random sample of ED patients at an urban, public hospital from Nov 2016-Sept 2017. To minimize sampling bias, research assistants (RAs) followed strict protocols for randomly approaching patients. Surveying occurred across all days and hours. Eligible patients were: >=18 years old, clinically stable, not arrested or incarcerated, spoke English or Spanish, and had not already participated. RAs administered a survey covering a wide range of health-related topics. Frequent ED use was defined as self-report of >=4 visits to any ED in the past year including the current visit. Food insecurity was defined as responding positively to any of 4 food insecurity questions from the USDA Food Security Module. We performed chi-squared and Kruskal-Wallis tests for bivariate relationships and multivariable logistic regression to examine the independent association of food insecurity with frequent ED use while controlling for potential confounders. Results: 52% of approached were ineligible, mainly because they were medically unfit, intoxicated, or in prison/police custody. 2,396 of 2,924 eligible patients participated (81.9%). 31.0% reported frequent ED use and 50.9% reported food insecurity. Food insecurity rates were higher among frequent vs. non-frequent ED users (62.9% vs. 45.5%, p<001). Food insecurity remained a significant predictor of frequent ED use in multivariable analyses (OR 1.47, 95%CI 1.19-1.82). This relationship was partially mediated by self-reported overall health, cost-related medication nonadherence, anxiety, and depression. Conclusion: Food insecurity was common and was independently associated with frequent ED use in this study. We plan future longitudinal analyses to confirm and further explore this relationship. In the meantime, interventions and studies of frequent ED users should consider the potential role of food insecurity

Socioeconomic disadvantage (SED) experienced in early life is linked to a range of risk behaviors and diseases. Neuroimaging research indicates that this association is mediated by functional changes in corticostriatal reward systems that modulate goal-directed behavior, reward evaluation, and affective processing. Existing research has focused largely on adults and within-household measures as an index of SED, despite evidence that broader community-level SED (e.g., neighborhood poverty levels) has significant and sometimes distinct effects on development and health outcomes. Here, we test effects of both household- and community-level SED on resting-state functional connectivity (rsFC) of the ventral striatum (VS) in 100 racially and economically diverse children and adolescents (ages 6-17). We observed unique effects of household income and community SED on VS circuitry such that higher community SED was associated with reduced rsFC between the VS and an anterior region of the medial prefrontal cortex (mPFC), whereas lower household income was associated with increased rsFC between the VS and the cerebellum, inferior temporal lobe, and lateral prefrontal cortex. Lower VS-mPFC rsFC was also associated with higher self-reported anxiety symptomology, and rsFC mediated the link between community SED and anxiety. These results indicate unique effects of community-level SED on corticostriatal reward circuitry that can be detected in early life, which carries implications for future interventions and targeted therapies. In addition, our findings raise intriguing questions about the distinct pathways through which specific sources of SED can affect brain and emotional development.

Background/Introduction: The 2016 ESC Guideline on the Diagnosis and Treatment of Acute and Chronic Heart Failure endorsed sacubitril/valsartan (S/V) as class I-B treatment for heart failure with reduced ejection fraction(HFrEF) based on the PARADIGM-HF trial. Data on characteristics of S/V initiators and S/V adherence among renin-angiotensin aldosterone system inhibitor (RAASi)-nai ve patients treated in the community are limited. Purpose: Determine associated baseline patient and healthcare facility characteristics and medication adherence of S/V vs angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in RAASi-naive HFrEF patients. Methods: Retrospective cohort study of U.S. Veterans Affairs (VA) data including HFrEF ( = 1 record of left ventricular ejection fraction (LVEF) = 40%) patients with = 1 in/outpatient visit for HF within 1-year pre-index (baseline period) treated with S/V, ACEI, or ARB from July 2015-June 2017. The index date was first S/V pharmacy fill and if none, first ACEI or ARB fill. RAASi-naive defined as no S/V, ACEI, or ARB fills during the baseline period. Poisson regression models with robust errors were used to compare baseline characteristics and 4-month medication adherence (i.e. follow-up fills, proportion of days covered [PDC], and discontinuation) for S/V vs ACEI or ARB. Medication adherence comparisons were adjusted for baseline characteristics using matching weights. Results: Among RAASi-naive HFrEF Veterans (N = 10,743),most (97.5%)weremale and 371 (3.5%) had an S/V pharmacy fill and 10,372 (96.5%) had an ACEI or ARB fill on the index date. Mean (standard deviation) baseline age, estimated glomerular filtration rate, and LVEF in S/V vs ACEI or ARB initiators were 73.6 (10.7) vs 70.3 (11.4) years, 61.3 (19.1) vs 66.4 (25.2) mL/min/1.73 m2, and 27.9% (8.3%) vs 34.4% (12.0%), respectively. History of ischemic cardiomyopathy was associated with S/V vs ACEI or ARB initiation. Veterans with lower systolic blood pressure, history of stroke, hypertension, myocardial infarction, or a visit with a Cardiologist on the index date were less likely to initiate S/V. In Veterans with a 30 day-supply index fill (N = 251 S/V and N = 3,101 ACEI or ARB) the adjusted risk ratio for 4-month PDC >80% was 0.78, 95% (confidence interval: 0.66-0.93) for S/V vs ACEI or ARB. Follow-up fills and discontinuation were similar for S/V vs ACEI or ARB. Adherence was similar for S/V vs ACEI or ARB among Veterans with a 90 day-supply. Conclusions: In a large, integrated healthcare system, 3.5% RAASi-naive HFrEF patients initiated S/V during the first 2-years post U.S. FDA approval. Overall, our findings suggest that S/V adherence is similar to ACEI or ARB in community-treated RAASi-naive HFrEF patients. The low numbers of S/V initiation may reflect a lag in formulary availability; S/V was added to the VA Formulary in October 2016. The reasons for lack of guideline-directed S/V initiation needs further elucidation

Background: Older adults are increasingly presenting to US emergency departments but frequently have different patterns of presentation, ED care, and disposition than younger adults. Older adults have been understudied in the cancer population. Our objective was to identify differences in presentation and ED care in older adults with cancer. Methods: Prospective observational study in 18 EDs of the Comprehensive ONCologic Emergencies Research Network. We enrolled a convenience sample of ED patients with active cancer. Descriptive statistics including confidence intervals (CIs) and chi-square tests were calculated comparing older adults >=65 years of age with younger adults aged 18-64. Results: Of 1,075 enrolled patients, 503 (47%) were older adults including 313 (29%) aged 65-74 years, 152 (14%) 75-84 years, and 38 (3.5%) >=85 years. Older adults had similar ESI score distribution to younger adults (p=0.519). Older adults were more likely to be admitted with a 62% (95% CI 57-66) rate versus 54% younger adults (95% CI 50-58%)(p=0.010). There were similar ED observation unit placement rates, 6.8% in older and 6.4% in younger adults. Older adults were less likely to report moderate-to-severe pain, 42% (95% CI 38-47%) versus 55% (95% CI 51-59%)(p<0.001). They were less likely to receive narcotics in the ED (29%, 95% CI 25-33) versus 42% (95% CI 38-46%)(p<0.001). However, older adults with moderate to severe pain received narcotics at similar rates as young adults, 52% (95% CI 45-59%) versus 60% (95% CI 54-66%). Older adults were less likely to complain of nausea, but were treated at equal rates. Twentyeight percent of older adults complained of nausea and 57% of those were treated, whereas 34% of younger patients had nausea of whom 64% were treated. Rates of fever were equal between older and younger adults, 14% and 16%. Conclusion: Older adults with cancer have similar triage severity scores but are admitted at greater rates from the Ed than younger adults. They are less likely to complain of pain and nausea, but unlike in other ED populations, when these symptoms are present they receive treatment at similar rates as younger adults. Further work should explore distinct patterns of presentation and risk stratification for this subpopulation

Objectives: Patients with active cancer have a high admission rate following emergency department (ED) evaluation. Observation medicine has evolved in recent years to offer an alternative to short inpatient hospital care. As visits for cancer patients increase and hospital crowding increases, observation care may be an important strategy for delivering safe and efficient care in this vulnerable population. In this investigation we studied the use of observation in a population of cancer patients presenting to the ED. Methods: We performed a multicenter prospective cohort study patients with active cancer presenting to the ED at 18 member hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between December 1st, 2016 and June 1st, 2017. We recorded key patient demographic and health history items (e.g., age, sex, cancer type), ED and hospital length of stay and diagnosis, and initial ED disposition. Results: We enrolled 1,075 patients. The initial inpatient admission rate was 57% (95% CI 54-60%) and 8.4% (95% CI 6.8-10%) initially received observation care with 6.5% (95% CI 5.1-8.2%) in a dedicated ED observation unit. The conversion rate from ED observation to inpatient was 30% (21 of 70) (95% CI 20- 42%). Of those initially admitted, 24% (141 of 596) (95% CI 20-27%) had inpatient admissions a&48 hours. The most common observation diagnoses were anemia (n=7), fever or infection (n=6), cardiac diseases (e.g., chest pain, syncope) (n=9), various pain complaints (n=8), and venous thromboembolism (n=4). In unadjusted logistic regression analysis, age over 65 (p=0.254), chest pain (p=0.980), nausea (p=0.206), fever (p=0.115), and moderate-severe pain (p=0.599) were not associated with admission from ED observation units. Conclusion: The admission rate is high and observation care appears to be used less often in cancer patients than among others given this high admission rate. Unique barriers may exist to discourage observation use in this population, but a significant number of short-stay inpatient admissions suggest an opportunity to increase observation care, especially in dedicated observation units. ED observation care for cancer patients resulted in an acceptable rate of inpatient conversion but predictors of conversion could not be identified. Further research specific to observation protocols for cancer patients is needed