Faculty Bibliography

Background: Increasing numbers of patients with cancer present to emergency departments (EDs), but there is little information on their ED care. Our objective was to describe the epidemiology of patients with active cancer presenting to US EDs. Methods: Prospective observational study using a convenience sample of ED patients >=18 years of age with active cancer presenting to 18 sites of the Comprehensive ONcologic Emergencies Research Network (CONCERN). ED patient surveys and 30-day chart reviews were completed. Descriptive statistics are reported. Results: We enrolled 1,075 patients (n per ED range 18-71). Mean age was 62 years with 52% female, 12% African American, 3.1% Asian, and 7.2% Hispanic. Common cancer types were gastrointestinal (20%); leukemia, myeloma and lymphoma (18%); lung (13%); and breast (11%). Seventy-two percent (n=773) had received cancer therapy within the prior 30 days including 495 (46%) chemotherapy,108 (10%) radiation, and 85 (7.9%) surgery. Emergency severity index scores included 0.9% Level 1, 40% Level 2, and 51% Level 3. Symptoms at presentation included nausea (32%), shortness of breath (35%), chest pain (16%), and abdominal pain (32%). ED nausea medicine was administered to 260 (25%), including half of those complaining of (160/326, 49%). Fifteen percent (n=152) had fever a%o38.0AdegreeC in the ED or within the prior 24 hours and 27% received ED antibiotics (n=285). Pain was present in 56% (n=604) and was moderate in 17% (n=186) and severe in 31% (n=338). Forty-eight percent (n=519) had pain medications in the ED including 35% with opioids (n=381). Only 35% (n=66) of those with moderate and 69% (n=232) of those with severe pain received opioids in the ED. Twenty five percent of all patients (n=274) had a final ED pain score in the moderate or severe range. Fifty-seven percent (n=615) were admitted (including 10% to stepdown or intensive care units), 6.6% (n=70) were placed in an ED observation unit, 1.9% (n=20) died in the ED, and 32% (n=342) were discharged. Thirty-day mortality was 5.8% (n=62) and 30- day ED revisit rate was 27% (n=286). Conclusion: ED patients with active cancer present with a substantial symptom burden and are frequently undertreated in the ED. This is a high acuity population with high rates of admission, revisit, and mortality. Further study to improve processes of care for this population is warranted

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

Objectives: 1-2% of all hospital discharges are designated as a discharge against medical advice (DAMA), and patients with DAMA have poorer outcomes. To our knowledge, there is no prior study that decomposes variation at the level of hospital discharges into patient and non-patient-level factors contributing to DAMA, and we seek to do so in our study. Methods: We used the National Inpatient Sample (NIS) 2014, an all-payer healthcare database that provides a stratified sample of 20% of all discharges from US hospitals. We included patients > 18 years, in the general medical group, with known discharge status, and who were not transferred out or did not die in hospital. With our final sample of 2,687,430 discharges, we grouped variables from our data, and ran incremental mixed-effects logit models, with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICC), and evaluated the percentage change in ICC. Results: Our preliminary analysis showed associations with DAMA in line with previous studies: younger age, male gender, African-American race, residence in a large metropolis. Of interest, however, is our finding that of the overall variation in DAMA outcomes, 12.8% is associated with the hospital the discharge occurred from, and 1.2% of the variation with the census division the hospital is located in. This decreased with the addition of variables to the models, and the final, fully-adjusted model has 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions occurring due to the addition of patient demographics. Conclusions: Our study is the first to explore the percentage in variation in DAMA due to patient, hospital and census-division characteristics. We find that even after adjusting for patient-level characteristics, there is a contribution of non-patient-level factors to DAMA outcomes

OBJECTIVES/OBJECTIVE:To explore the effect of the presence and timing of a do-not-resuscitate (DNR) order on short-term clinical outcomes, including mortality. DESIGN/METHODS:Retrospective cohort study with propensity score matching to enable direct comparison of DNR and no-DNR groups. SETTING/METHODS:Large, academic tertiary-care center. PARTICIPANTS/METHODS:Hospitalized medical patients aged 65 and older. MEASUREMENTS/METHODS:Primary outcome was in-hospital mortality. Secondary outcomes included discharge disposition, length of stay, 30-day readmission, restraints, bladder catheters, and bedrest order. RESULTS:Before propensity score matching, the DNR group (n=1,347) was significantly older (85.8 vs 79.6, p<.001) and had more comorbidities (3.0 vs 2.5, p<.001) than the no-DNR group (n=9,182). After propensity score matching, the DNR group had significantly longer stays (9.7 vs 6.0 days, p<.001), were more likely to be discharged to hospice (6.5% vs 0.7%, p<.001), and to die (12.2% vs 0.8%, p<.001). There was a significant difference in length of stay between those who had a DNR order written within 24 hours of admission (early DNR) and those who had a DNR order written more than 24 hours after admission (late DNR) (median 6 vs 10 days, p<.001). Individuals with early DNR were less likely to spend time in intensive care (10.6% vs 17.3%, p=.004), receive a palliative care consultation (8.2% vs 12.0%, p=.02), be restrained (5.8% vs 11.6%, p<.001), have an order for nothing by mouth (50.1% vs 56.0%, p=.03), have a bladder catheter (31.7% vs 40.9%, p<.001), or die in the hospital (10.2% vs 15.47%, p=.004) and more likely to be discharged home (65.5% vs 58.2%, p=.01). CONCLUSION/CONCLUSIONS:Our study underscores the strong association between presence of a DNR order and mortality. Further studies are necessary to better understand the presence and timing of DNR orders in hospitalized older adults.

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: Substance use (SU) is common among ED patients, with 1 in 10 ED users having an alcohol or drug use disorder. ED patients also have high levels of social needs such as homelessness and food insecurity. Yet, little research has examined how such social determinants of health (SDOH) intersect with SU among ED patients. In this study, we compared the prevalence of several SDOH among ED patients who did and did not screen positive for unhealthy alcohol and drug use. Methods: We surveyed a random sample of ED patients at a NYC public hospital from Nov 2016-Sept 2017. Eligible patients were >=18 years old, medically/psychiatrically stable, not in prison/police custody, and spoke English or Spanish. RA shifts occurred during all days of the week and hours of the day. RAs administered a 20-40 minute survey with validated single-item screeners for unhealthy alcohol and drug use and questions on self-reported past year social needs from national surveys or prior studies. We compared prevalence of SDOH by SU screening status in bivariate analyses with chisquare tests. Results: About half of patients (52.0%) approached were ineligible, primarily because they were medically unfit, intoxicated, or in prison/police custody. 2,396 of 2,925 eligible patients participated (81.9%); 76 duplicate patient records were removed, leaving a final sample size of 2,321 patients. Nearly one-third (32.3%) screened positive for unhealthy alcohol use and 21.8% for any drug use. Regarding SDOH, rates among patients overall vs. those with unhealthy alcohol use vs. those with drug use were: 1) homelessness 13.8%, 18.7% (X2 p<0.01 for difference between those who did vs. did not screen positive), 25.8% (p<0.01); 2) housing instability 25.2%, 29.5% (p<0.01), 35.9% (p<0.01); 3) food insecurity 50.9%, 56.3% (p<0.01), 63.4% (p<0.01); 4) inability to meet essential expenses 40.8%, 45.9% (p<0.01), 52.7% (p<0.01); and 5) unemployment 43.3%, 45.1% (p=0.23), 55.1% (p<0.01). Conclusion: Rates of homelessness and other social needs were high among ED patients in this study, suggesting the importance of considering SDOH in emergency medicine practice. We add to prior literature by showing that these needs were even higher among patients who screened positive for SU. These findings are important, as patients' significant comorbid social needs may affect the success of ED-based efforts to address substance use

INTRODUCTION/BACKGROUND:Veterans with a mental health diagnosis have high rates of tobacco use but encounter low rates of treatment from providers. This study tested whether a proactive tobacco treatment approach increases treatment engagement and abstinence rates in Department of Veterans Affairs mental health patients. STUDY DESIGN/METHODS:RCT. SETTING/PARTICIPANTS/METHODS:The study was performed from 2013 to 2017 and analyses were conducted in 2017. Investigators used the electronic medical record at four Veterans Administration facilities to identify patients documented as current smokers and who had a mental health clinic visit in the past 12 months. INTERVENTION/METHODS:Patients were mailed an introductory letter and baseline survey. Survey respondents were enrolled and randomized to intervention (n=969) or control (n=969). Control participants received a list of usual Veterans Administration smoking services. Intervention participants received a motivational outreach call, multisession telephone counseling, and assistance with obtaining nicotine replacement therapy. MAIN OUTCOME MEASURES/METHODS:Participants completed surveys at baseline, 6 months, and 12 months after randomization. The primary outcome was self-reported 7-day abstinence from cigarettes at 12-month follow-up. Secondary outcomes included use of cessation treatment, self-reported 7-day abstinence at 6-month follow-up, and 6-month prolonged abstinence at 12-month follow-up. RESULTS:At 12 months, intervention participants were more likely to report using telephone counseling (19% vs 3%, OR=7.34, 95% CI=4.59, 11.74), nicotine replacement therapy (47% vs 35%, OR=1.63, 95% CI=1.31, 2.03), or both counseling and nicotine replacement therapy (16% vs 2%, OR=11.93, 95% CI=6.34, 22.47). Intervention participants were more likely to report 7-day abstinence (19% vs 14%, OR=1.50, 95% CI=1.12, 2.01) and prolonged 6-month abstinence (16% vs 9%, OR=1.87, 95% CI=1.34, 2.61). After adjusting for non-ignorable missingness at follow-up, the intervention effects on 7-day and prolonged abstinence remained significant (p<0.05). CONCLUSIONS:Proactive outreach was more effective than usual Veterans Administration care at increasing treatment engagement and long-term abstinence in mental health patients. TRIAL REGISTRATION/BACKGROUND:This study is registered at www.clinicaltrials.gov NCT01737281.

BACKGROUND:Substance use and condomless sexual behaviours are both well studied in sexual minority men, but few researchers have used event-level data collection to examine sexualised drug use in sexual and gender minority young adults. The aim of this study is to describe the co-occurrence of sex under the influence of substances and condomless sexual behaviours, using nuanced event-level data, in a racially/ethnically and socioeconomically diverse sample in New York City. METHODS:Data from one wave of a cohort of sexual and gender minority young adults who were assigned male at birth (n = 500) were used to characterise co-occurrence of sex under the influence of drugs and condomless sexual behaviours (oral receptive, anal insertive, and anal receptive sex), in the last 30 days. Logistic regression models were constructed to assess associations between sex while high and condomless sexual behaviours, controlling for sociodemographic factors. RESULTS:Preliminary analyses indicated significant associations between engaging in sex while high and condomless sexual behaviours. In unadjusted regression models, sexualised and non-sexualised drug use were both significantly associated with increased odds of condomless sexual behaviours. In adjusted models, sexualised drug use remained significantly associated with condomless anal insertive sex (AOR = 3.57) and condomless anal receptive sex (AOR = 4.98). Having multiple sexual partners was also significantly associated with greater odds of condomless sexual activity in all three adjusted models. CONCLUSION/CONCLUSIONS:Multivariable analyses indicated that engaging in sex while high on any drug was associated with increased condomless sexual behaviour, but that sexualised drug use was associated with particularly elevated condomless anal sex. These findings provide insight for understanding the co-occurrence of substance use and condomless sex, and suggest a need for HIV/STI risk reduction strategies that address the role of sexualised drug use.