Faculty Bibliography

BACKGROUND: Emerging experimental evidence suggests that air pollution may contribute to development of obesity and diabetes, but studies of children are limited. OBJECTIVES: We hypothesized that pollution effects would be magnified after bariatric surgery for treatment of obesity, reducing benefits of surgery. METHODS: In 75 obese adolescents, excess weight loss (EWL), high-density lipoprotein (HDL) cholesterol, triglycerides, alkaline phosphatase (ALP) and hemoglobin A1c (HbA1c ) were measured prospectively at baseline and following laparoscopic adjustable gastric banding (LAGB). Residential distances to major roads and the average two-year follow-up exposure to particulate matter <2.5 mum (PM2.5 ), nitrogen dioxide (NO2 ) and ozone were estimated. Associations of exposure with change in outcome and with attained outcome two years post-surgery were examined. RESULTS: Major-roadway proximity was associated with reduced EWL and less improvement in lipid profile and ALP after surgery. NO2 was associated with less improvement in HbA1c and lower attained HDL levels and change in triglycerides over two years post-surgery. PM2.5 was associated with reduced EWL and reduced beneficial change or attained levels for all outcomes except HbA1c . CONCLUSIONS: Near-roadway, PM2.5 and NO2 exposures at levels common in developed countries were associated with reduced EWL and metabolic benefits of LAGB. This novel approach provides a model for investigating metabolic effects of other exposures.

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: 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

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.

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

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

OBJECTIVE:The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation. RESEARCH DESIGN AND METHODS:Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences. RESULTS:< 0.001). CONCLUSIONS:A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.