Faculty Bibliography

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

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

Latinos are the largest immigrant group in the United States, representing 17.6% of the total U.S. population, and are therefore critical to include in research. However, Latino immigrants-and particularly those who are undocumented residents-may be increasingly wary of participating in research amidst hostile anti-immigrant rhetoric and high profile cases of deportation. In this commentary we discuss challenges of conducting research with undocumented Latino immigrants in the current sociopolitical climate. We provide suggestions for data collection, data protection, and research recruitment techniques that may mitigate some of these challenges.

Early brain activity is crucial for neurogenesis and the development of brain networks. However, it has been challenging to localize regions in the developing human brain that contribute to spontaneous waves of neuronal activity. Recently, Arichi and colleagues reported that the temporal and heteromodal insular cortices have a central role in propagating these neural instructional signals.

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.

Advances in neuroimaging and network analyses have lead to discovery of highly connected regions, or hubs, in the connectional architecture of the human brain. Whether these hubs emerge in utero, has yet to be examined. The current study addresses this question and aims to determine the location of neural hubs in human fetuses. Fetal resting-state fMRI data (N = 105) was used to construct connectivity matrices for 197 discrete brain regions. We discovered that within the connectional functional organization of the human fetal brain key hubs are emerging. Consistent with prior reports in infants, visual and motor regions were identified as emerging hub areas, specifically in cerebellar areas. We also found evidence for network hubs in association cortex, including areas remarkably close to the adult fusiform facial and Wernicke areas. Functional significance of hub structure was confirmed by computationally deleting hub versus random nodes and observing that global efficiency decreased significantly more when hubs were removed (p < .001). Taken together, we conclude that both primary and association brain regions demonstrate centrality in network organization before birth. While fetal hubs may be important for facilitating network communication, they may also form potential points of vulnerability in fetal brain development.

Healthy parenting may be protective against the development of emotional psychopathology, particularly for children reared in stressful environments. Little is known, however, about the brain and behavioral mechanisms underlying this association, particularly during childhood and adolescence, when emotional disorders frequently emerge. Here, we demonstrate that psychological control, a parenting strategy known to limit socioemotional development in children, is associated with altered brain and behavioral responses to emotional conflict in 27 at-risk (urban, lower income) youth, ages 9-16. In particular, youth reporting higher parental psychological control demonstrated lower activity in the left anterior insula, a brain area involved in emotion conflict processing, and submitted faster but less accurate behavioral responses-possibly reflecting an avoidant pattern. Effects were not replicated for parental care, and did not generalize to an analogous nonemotional conflict task. We also find evidence that behavioral responses to emotional conflict bridge the previously reported link between parental overcontrol and anxiety in children. Effects of psychological control may reflect a parenting style that limits opportunities to practice self-regulation when faced with emotionally charged situations. Results support the notion that parenting strategies that facilitate appropriate amounts of socioemotional competence and autonomy in children may be protective against social and emotional difficulties.

Non-heme iron is a vital metabolic cofactor for many core processes of brain development including myelination, dendritogenesis, and neurotransmitter synthesis, and accumulates in the brain with age. However, little is known about development-related differences in brain iron and its association with emerging cognitive abilities during formative years. In this study, we estimated brain iron via R2* relaxometry in children ages 7-16 (N = 57; 38 females) and examined its relation to age-related differences in cognitive ability. As we hypothesized, age correlated positively with iron content in the hippocampus and across subregions of the basal ganglia. The magnitude of age differences in iron content differed between regions such that the largest effects were observed in basal ganglia subregions: globus pallidus, substantia nigra, caudate nucleus, and putamen, as compared to values obtained for the hippocampus and red nucleus. We did not observe sex or hemispheric differences in iron content. Notably, greater brain iron content was associated with both faster processing speed and higher general intelligence, and shared 21.4% of the age-related improvement in processing speed and 12.5% of the improvement in general intelligence. These results suggest that non-heme iron plays a central neurobiological role in the development of critical cognitive abilities during childhood.