Faculty Bibliography

Environmental justice efforts in the United States seek to provide equal protection from environmental hazards, such as air pollution, to all groups, particularly among traditionally disadvantaged populations. To accomplish this objective, the U.S. EPA has previously required states to use an environmental justice screening tool as part of air quality planning decision-making. The generally utilized approach to assess potential areas of environmental justice concern relies on static comparisons of environmental and demographic information to identify areas where minority and low income populations experience elevated environmental exposures, but does not include any additional information that may inform the trade-offs that sub-populations of varying socio-demographic groups make when choosing where to reside in cities. In order to address this limitation, job accessibility (measured by a mobility index defining the number of jobs available within a set commuting time) was developed as a novel environmental justice indicator of environmental justice priority areas at the local level. This approach is modeled using real-world data in Allegheny County, PA (USA), and identifies areas with relatively high levels of outdoor air pollution and low access to jobs. While traditional tools tend to flag the poorest neighborhoods for environmental justice concerns, this new method offers a more refined analysis, targeting populations suffering from the highest environmental burden without the associated benefits of urban living.

The burden of alcohol and drug use disorders (substance use disorders [SUDs]) has intensified efforts to expand access to cost-effective psychosocial interventions and pharmacotherapies. This article provides an overview of technology-based interventions (eg, computer-based and Web-based interventions, text messaging, interactive voice recognition, smartphone apps, and emerging technologies) that are extending the reach of effective addiction treatments both in substance use treatment and primary care settings. It discusses the efficacy of existing technology-based interventions for SUDs, prospects for emerging technologies, and special considerations when integrating technologies in primary care (eg, privacy and regulatory protocols) to enhance the management of SUDs.

PURPOSE/OBJECTIVE:To evaluate the ability of OCT optic nerve head (ONH) and macular parameters to detect disease progression in eyes with advanced structural glaucomatous damage of the circumpapillary retinal nerve fiber layer (cRNFL). DESIGN/METHODS:Longitudinal study. PARTICIPANTS/METHODS:Forty-four eyes from 37 patients with advanced average cRNFL damage (≤60 μm) followed up for an average of 4.0 years. METHODS:All patients were examined with spectral-domain OCT and visual field (VF) assessment during at least 4 visits. MAIN OUTCOME MEASUREMENTS/METHODS:Visual field mean deviation (MD) and VF index. OCT cRNFL (average, superior, and inferior quadrants), ganglion cell-inner plexiform layer (GCIPL) (average, superior, and inferior), rim area, cup volume, average cup-to-disc (C:D) ratio, and vertical C:D ratio. RESULTS:/year). CONCLUSIONS:Macula GCIPL and ONH parameters may be useful in tracking progression in patients with advanced glaucoma.

BACKGROUND:Understanding where and how young black men who have sex with men (YBMSM) in the southern United States meet their sexual partners is germane to understanding the underlying factors contributing to the ongoing HIV transmission in this community. Men who have sex with men (MSM) commonly use geosocial networking apps to meet sexual partners. However, there is a lack of literature exploring geosocial networking app use in this particular population. OBJECTIVE:Our aim was to examine the characteristics, preferences, and behaviors of a geographically diverse sample of geosocial networking app-using YBMSM in the southern United States. METHODS:Data were collected from a sample of 75 YBMSM across three cities (Gulfport, Mississippi; Jackson, Mississippi; and New Orleans, Louisiana). Multiple aspects of geosocial networking app use were assessed, including overall app use, age of participant at first app use, specific apps used, reasons for app use, photos presented on apps, logon times and duration, number of messages sent and received, and characteristics of and behaviors with partners met on apps. Survey measures of app-met partner and sexual behavior characteristics assessed at midpoint (Day 7) and completion visits (Day 14) were compared using McNemar's test or Wilcoxon signed-rank test. In addition, we assessed activity spaces derived from GPS devices that participants wore for 2 weeks. RESULTS:, P=.011). CONCLUSIONS:Use of geosocial networking apps to meet sexual partners among our sample of YBMSM in the southern United States was common, with a diverse range of app use behaviors being reported. Further research should characterize the association between geosocial networking app use and engagement in sexual behaviors that increase risk for HIV acquisition and transmission. In addition, geosocial networking apps present a promising platform for HIV prevention interventions targeting YBMSM who use these apps.

Background/UNASSIGNED:Self-reported smoking is the principal measure used to assess lung cancer risk in epidemiological studies. We evaluated if circulating cotinine-a nicotine metabolite and biomarker of recent tobacco exposure-provides additional information on lung cancer risk. Methods/UNASSIGNED:The study was conducted in the Lung Cancer Cohort Consortium (LC3) involving 20 prospective cohort studies. Pre-diagnostic serum cotinine concentrations were measured in one laboratory on 5364 lung cancer cases and 5364 individually matched controls. We used conditional logistic regression to evaluate the association between circulating cotinine and lung cancer, and assessed if cotinine provided additional risk-discriminative information compared with self-reported smoking (smoking status, smoking intensity, smoking duration), using receiver-operating characteristic (ROC) curve analysis. Results/UNASSIGNED:We observed a strong positive association between cotinine and lung cancer risk for current smokers [odds ratio (OR ) per 500 nmol/L increase in cotinine (OR500): 1.39, 95% confidence interval (CI): 1.32-1.47]. Cotinine concentrations consistent with active smoking (≥115 nmol/L) were common in former smokers (cases: 14.6%; controls: 9.2%) and rare in never smokers (cases: 2.7%; controls: 0.8%). Former and never smokers with cotinine concentrations indicative of active smoking (≥115 nmol/L) also showed increased lung cancer risk. For current smokers, the risk-discriminative performance of cotinine combined with self-reported smoking (AUCintegrated: 0.69, 95% CI: 0.68-0.71) yielded a small improvement over self-reported smoking alone (AUCsmoke: 0.66, 95% CI: 0.64-0.68) (P = 1.5x10-9). Conclusions/UNASSIGNED:Circulating cotinine concentrations are consistently associated with lung cancer risk for current smokers and provide additional risk-discriminative information compared with self-report smoking alone.

OBJECTIVE:To define the rates of common Hospital Acquired Conditions (HACs) in patients undergoing major urological surgery over a period of time encompassing the implementation of the Hospital Acquired Condition Reduction program, and to evaluate whether implementation of the HAC reimbursement penalties in 2008 was associated with a change in the rate of HACs. METHODS:Using American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data, we determined rates of HACs in patients undergoing major inpatient urological surgery from 2005 to 2012. Rates were stratified by procedure type and approach (open vs. laparoscopic/robotic). Multivariable logistic regression was used to determine the association between year of surgery and HACs. RESULTS:We identified 39,257 patients undergoing major urological surgery, of whom 2300 (5.9%) had at least one hospital acquired condition. Urinary tract infection (UTI, 2.6%) was the most common, followed by surgical site infection (SSI, 2.5%) and venous thrombotic events (VTE, 0.7%). Multivariable logistic regression analysis demonstrated that open surgical approach, diabetes, congestive heart failure, chronic obstructive pulmonary disease, weight loss, and ASA class were among the variables associated with higher likelihood of HAC. We observed a non-significant secular trend of decreasing rates of HAC from 7.4% to 5.8% HACs during the study period, which encompassed the implementation of the Hospital Acquired Condition Reduction Program. CONCLUSIONS:HACs occurred at a rate of 5.9% after major urological surgery, and are significantly affected by procedure type and patient health status. The rate of HAC appeared unaffected by national reduction program in this cohort. Better understanding of the factors associated with HACs is critical in developing effective reduction programs.

BACKGROUND:While the Affordable Care Act's (ACA) Medicaid expansion has increased insurance coverage, its effects on health outcomes have been mixed. This may be because previous research did not disaggregate mental and physical health or target populations most likely to benefit. OBJECTIVE:To examine the association between Medicaid expansion and changes in mental health, physical health, and access to care among low-income childless adults with and without chronic conditions. DESIGN/METHODS:We used a difference-in-differences analytical framework to assess differential changes in self-reported health outcomes and access to care. We stratified our analyses by chronic condition status. PARTICIPANTS/METHODS:Childless adults, aged 18-64, with incomes below 138% of the federal poverty level in expansion (n = 69,620) and non-expansion states (n = 57,628). INTERVENTION/METHODS:Active Medicaid expansion in state of residence. MAIN MEASURES/METHODS:Self-reported general health; total days in past month with poor health, poor mental health, poor physical health, or health-related activity restrictions; disability; depression; insurance coverage; cost-related barriers; annual check-up; and personal doctor. KEY RESULTS/RESULTS:Medicaid expansion was associated with reductions in poor health days (-1.2 days [95% CI, -1.6,-0.7]) and days limited by poor health (-0.94 days [95% CI, -1.4,-0.43]), but only among adults with chronic conditions. Trends in general health measures appear to be driven by fewer poor mental health days (-1.1 days [95% CI, -1.6,-0.6]). Expansion was also associated with a reduction in depression diagnoses (-3.4 percentage points [95% CI, -6.1,-0.01]) among adults with chronic conditions. Expansion was associated with improvements in access to care for all adults. CONCLUSIONS:Medicaid expansion was associated with substantial improvements in mental health and access to care among low-income adults with chronic conditions. These positive trends are likely to be reversed if Medicaid expansion is repealed.

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