Faculty Bibliography

OBJECTIVES/OBJECTIVE:To assess the acceptability of an infection-control prevention strategy during the COVID-19 pandemic for skilled nursing facilities (SNFs) staff and residents, to describe implementation challenges and potential solutions, and to explore intervention impact perceptions. DESIGN/METHODS:Qualitative investigation of a multimethod pragmatic clinical trial designed to develop and test a novel cohorting intervention to mitigate infection transmission in SNFs during the COVID-19 pandemic. SETTING AND PARTICIPANTS/METHODS:We used a purposive sample of staff and residents in 2 New York City nonprofit SNFs participating in the intervention trial. METHODS:We developed a novel cohorting strategy to minimize infection transmission by using infection risk (vaccination or prior infection history) to assign staff to specific residents. We employed a qualitative descriptive approach using content thematic analysis of semistructured interviews with staff and residents to identify themes of acceptability, challenges, and potential impact. RESULTS:Seventy-one staff and 16 residents completed semistructured interviews. Staff and residents supported the intervention. However, both identified challenges, including concerns that switching assignments could lead to staffing issues and care discontinuity. Staff identified communication about the intervention as both a challenge and potential solution, citing a desire for clear and consistent communication across all employees. Staff felt the intervention had potential impact in reducing infection risk fear, promoting effective protective equipment usage, and encouraging more interaction and less isolation than standard prevention practices. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:We developed a novel and acceptable preventive strategy that may increase residents' flexibility and reduce their isolation as well as staff stress. Clear, consistent, and proactive communication may improve intervention acceptability and perceptions about impact. Similar infection-control protocols might be adapted for different long-term care infection risks. Communication at all staffing levels and with residents is essential to ensure the intervention is acceptable to both. Future trials could include social isolation and staff burnout as potential outcomes.

OBJECTIVE:Primary care-based literacy promotion enhances caregiver-child shared reading and child language outcomes, yet variation in implementation may dilute its impact. This study examines expert perspectives on intended outcomes of literacy promotion, as well as its core components, those necessary to achieve intended outcomes, and components that are recommended but adaptable to context. METHODS:We purposively sampled healthcare and policy experts in primary care-based literacy promotion from the U.S. and Canada for online, in-depth interviews. Interviews were recorded, transcribed verbatim, and analyzed iteratively engaging emergent and a priori codes based on the COmponents and Rationales for Effectiveness Fidelity Method and the team's prior work to identify themes. RESULTS:We achieved saturation after 22 interviews with 24 participants (16 U.S. participants, 8 Canadian). We identified four themes: 1) Traditionally, literacy promotion focused on enhancing preliteracy skills and school readiness. Over time, this outcome has evolved to include fostering early relational health as a foundational goal; 2) Core components include a trusted clinician delivering a strength-based, family-centered message, while modeling developmentally-informed shared reading; 3) Components that are adaptable to setting and context include literacy-rich clinical environments and community resource referrals; 4) Experts diverged on whether providing a children's book during literacy promotion is essential, but there was congruence that book provision alone is insufficient. CONCLUSION/CONCLUSIONS:Experts identified strength-based, family-centered guidance from a trusted clinician with developmentally-focused modeling as core to support intended outcomes of early relational health and school readiness. This understanding can inform training and healthcare improvement activities aimed at optimizing primary care-based literacy promotion.

BACKGROUND/UNASSIGNED:We investigated whether the associations of state medical and recreational cannabis legalization (MCL, RCL enactment) with increasing prevalence of Cannabis Use Disorder (CUD) differed among patients in the United States (US) Veterans Health Administration (VHA) who did or did not have common psychiatric disorders. METHODS/UNASSIGNED:Electronic medical record data (2005-2022) were analyzed on patients aged 18-75 with ≥1 VHA primary care, emergency department, or mental health visit and no hospice/palliative care within a given year (sample sizes ranging from 3,234,382 in 2005 to 4,436,883 in 2022). Patients were predominantly male (>80%) and non-Hispanic White (>60%). Utilizing all 18 years of data, CUD prevalence increases attributable to MCL or RCL enactment were estimated among patients with affective, anxiety, psychotic-spectrum disorders, and Any Psychiatric Disorder (APD) using staggered difference-in-difference (DiD) models and 99% Confidence Intervals (CIs), testing differences between patient groups with and without psychiatric disorders via non-overlap in the 99% CIs of their DiD estimates. FINDINGS/UNASSIGNED:Among APD-negative patients, CUD prevalence was <1.0% in all years, while among APD-positive patients, CUD prevalence increased from 3.26% in 2005 to 5.68% in 2022 in no-CL states, from 3.51% to 6.35% in MCL-only states, and from 3.41% to 6.35% in MCL/RCL states. Among the APD group, DiD estimates of MCL-only and MCL/RCL effects were modest-sized, but the lower bound of the 99% CI for the DiD estimate for MCL-only and MCL/RCL effects was larger than the upper bound of the 99% CI among the no-APD group, indicating significantly stronger MCL-only and MCL/RCL effects among patients with APD. Results were similar for MCL-only and MCL/RCL effects among disorder-specific groups (depression, post-traumatic stress disorder [PTSD], anxiety or bipolar disorders) and for MCL/RCL effects among patients with psychotic-spectrum disorders. INTERPRETATION/UNASSIGNED:Cannabis legalization contributed to greater CUD prevalence increases among patients with psychiatric disorders. However, modest-sized DiD estimates suggested operation of other factors, e.g., commercialization, changing attitudes, expectancies. As cannabis legalization widens, recognizing and treating CUD in patients with psychiatric disorders becomes increasingly important. FUNDING/UNASSIGNED:This study was supported by National Institute on Drug Abuse grant R01DA048860, the New York State Psychiatric Institute, and the VA Centers of Excellence in Substance Addiction Treatment and Education.

IMPORTANCE:Recent studies have identified characteristic symptom patterns of long COVID (LC) in adults and children older than 5 years. However, LC remains poorly characterized in early childhood. This knowledge gap limits efforts to identify, care for, and prevent LC in this vulnerable population. OBJECTIVES:To identify symptoms that had the greatest difference in frequency comparing children with a history of SARS-CoV-2 infection to those without, to identify differences in the types of symptoms by age group (infants/toddlers [0-2 years] vs preschool-aged children [3-5 years]), and to derive an index that can be used in research studies to identify young children with LC. DESIGN, SETTING, AND PARTICIPANTS:This was a multisite longitudinal cohort study with enrollment from over 30 US health care and community settings, including infants, toddlers, and preschool-aged children with and without SARS-CoV-2 infection history. Study data were analyzed from May to December 2024. EXPOSURE:SARS-CoV-2 infection. MAIN OUTCOMES AND MEASURES:LC and 41 symptoms among infants/toddlers and 75 symptoms among preschool-aged children. RESULTS:The study included 472 infants/toddlers (mean [SD] age, 12 [9] months; 278 infected with SARS-CoV-2; 194 uninfected; 234 male [50%]; 73 Black or African American [16%]; 198 Hispanic, Latino, or Spanish [43%]; 242 White [52%]) and 539 preschool-aged children (mean [SD] age, 48 [10] months; 399 infected with SARS-CoV-2; 140 uninfected; 277 female [51%]; 70 Black or African American [13%]; 210 Hispanic, Latino, or Spanish [39%]; 287 White [54%]). The median (IQR) time between first infections and completion of symptom surveys was 318 (198-494) days for infants/toddlers and 520 (330-844) days for preschool-aged children. A research index was derived for each age group based on symptoms most associated with infection history. The index is calculated by summing scores assigned to each prolonged symptom that was present, where higher scores indicate greater magnitude of association with history of SARS-CoV-2 infection: poor appetite (5 points), trouble sleeping (3.5 points), wet cough (3.5 points), dry cough (3 points), and stuffy nose (0.5 points) for infants/toddlers, and daytime tiredness/sleepiness/low energy (6.5 points) and dry cough (3 points) for preschool-aged children. Among infants/toddlers with infection, 40 of 278 (14%) were classified as having probable LC by having an index of at least 4 points. Among preschool-aged children, 61 of 399 (15%) were classified as having probable LC by having an index of at least 3 points. Participants with higher indices often had poorer overall health, lower quality of life, and perceived delays in developmental milestones. CONCLUSIONS AND RELEVANCE:This cohort study identified symptom patterns and derived research indices that were distinct between the 2 age groups and differed from those previously identified in older ages, demonstrating the need to characterize LC separately across age ranges.

Cardiovascular disease (CVD) and cancer remain the leading causes of mortality in the United States, where poor diet has surpassed smoking as the leading risk factor for death, and life expectancy has hit a plateau as CVD mortality has stagnated over the past decade. Although the pathophysiology of CVD and cancer is complex and multifactorial, lifestyle factors including diet often contribute significantly to their pathogenesis. There is a wealth of observational data as well as emerging trial data supporting the benefits of a predominantly whole-food plant-based diet in the prevention of CVD and cancer. However, there is a need for implementation science to effectuate existing knowledge. Given the shortcomings of the standard American diet, characterized by excessive intake of red meat and ultraprocessed foods, while deficient in fiber and phytonutrients, it will be necessary to shift default patterns of eating to make healthy choices the path of least resistance.

INTRODUCTION/BACKGROUND:Identifying strategies to mitigate the effects of secondhand smoke exposure is crucial for public health. Thus, we estimated the effect of a 2018 federal smoke-free housing (SFH) policy on adverse birth outcomes among New York City (NYC) public-housing residents. METHODS:We obtained data on all live births to NYC residents in NYC from 2013 to 2022, using the borough-block-lot of the birthing person's address to identify births to public-housing residents. We then estimated the effect of the SFH policy on risk of preterm birth or low birth weight among births to NYC public-housing residents using a linear-probability difference-in-differences estimator, weighted by inverse probability weights to increase the plausibility of the parallel-trends assumption. RESULTS:Our sample included 44 455 births to public-housing residents and 803 648 births to non-public-housing residents. Difference-in-difference analyses suggested the SFH policy did not affect risk of preterm birth (risk difference (RD) per 100: 0.1; 95% CI -0.6 to 0.9) or low birth weight (RD per 100: 0.3, 95% CI -0.4 to 1.0). Event-study analyses supported these findings and lent credibility to the parallel-trends assumption. CONCLUSIONS:We estimated no initial effects of a federal SFH policy on risk of preterm birth or low birth weight among births to NYC public-housing residents.

AIMS/OBJECTIVE:Carotid-femoral pulse wave velocity (cfPWV) is a representative measure of central arterial stiffness and an independent predictor of cardiovascular disease (CVD). Femoral-ankle PWV (faPWV) represents peripheral arterial stiffness, but its association with CVD has not been specifically investigated. METHODS:We analyzed 3,402 ARIC participants without prior coronary heart disease (CHD), heart failure (HF), or stroke at Visit 5 (2011-13) (mean age 74.8 [4.9] years, 36.1% male, 22.0% Black). faPWV and cfPWV were measured by Omron VP-1000 Plus. The primary outcome was CVD (CHD, HF, and stroke). We used multivariable Cox proportional hazards models. RESULTS:During a median 9.0-year follow-up, 607 CVD events occurred. Overall, faPWV showed an inverse association with CVD, with hazard ratio (HR) for top vs. bottom quartile 0.80 (95%CI 0.64-1.01) and p-for-trend 0.017 in Model 1 (demographically adjusted) and HR 0.86 (0.68-1.09) and p-for-trend 0.096 in Model 2 (further adjusted for CVD risk factors). In contrast, cfPWV was positively associated with CVD in both Models (HR for top vs. bottom quartile 1.22 [0.95-1.56], p-for-trend=0.043 in Model 2). The ratio of cfPWV to faPWV ("cf-fa ratio") showed a stronger association with CVD (HR 1.37 [1.07-1.74], p-for-trend=0.005) than cfPWV. Examining CVD subtypes, the significant contrast in Model 2 was cf-fa ratio and HF. CONCLUSIONS:faPWV showed a borderline significant inverse association with CVD, and cf-fa ratio appeared more strongly associated with CVD than cfPWV. Our findings indicate distinct prognostic implications of central vs. peripheral arterial stiffness and support cf-fa ratio as an alternative measure for CVD risk assessment.

BACKGROUND/UNASSIGNED:Electronic cigarettes (EC) may serve as a potential smoking harm reduction tool by addressing both nicotine and behavioral dependence. This qualitative study reports the feasibility and acceptability of using EC and telehealth counseling among individuals in treatment programs for opioid use disorders (OUD) who smoke combustible cigarette, and was conducted as part of a randomized controlled trial. We report findings among participants in the EC arm. METHODS/UNASSIGNED:Qualitative interviews were conducted from March to May 2021. The interviews were audio recorded, transcribed, and de-identified. An inductive approach guided by the Theoretical Framework of Acceptability was used. We developed and refined a codebook through a collaborative iterative process and team discussions. Five analysts coded the transcripts using Quirkos, with independent double coding for each transcript to achieve consensus and ensure inter-coder reliability. In-depth thematic analysis was conducted via synthesizing relevant codes that were described and exemplified using representative quotes. Saturation was achieved when no additional codes emerged. RESULTS/UNASSIGNED:Eleven participants randomized to EC were interviewed: average age = 55 years (range = 39-69), 88% were male, 41% non-Hispanic black, and 35% non-Hispanic white. Four main themes identified included inciting sense of accountability toward cigarette smoking reduction; acknowledging the value of telehealth counseling; noting positive attributes such as addressing craving, as well as challenges in utilizing EC such as the need to remember charging the EC; and finally, participants' expression of the satisfaction with their perceived improvements in their health and other behavioral aspects. CONCLUSION/UNASSIGNED:The intervention combining telehealth counseling with EC was perceived as acceptable and helpful for reducing cigarette smoking, as well as resulting in other positive health benefits. ECs were easy to use and seemed to address craving; albeit with some challenges that can be addressed in future trials. EC combined with telehealth counseling carries great promise in smoking reduction among individuals with OUD.

Lingering effects of the COVID-19 pandemic are still of grave concern to families within the U.S. Latine community, as pre-pandemic disparities in healthcare and economic stability were significantly exacerbated by the global crisis (Martínez et al., 2021). In this mixed-methods study, we interviewed 42 pregnant and postpartum Latine mothers from low-income households living in the New York Metropolitan area to better understand pandemic related challenges and potential sources of support unique to this group of women. First, we identified broad themes related to specific psychosocial stressors impacting Latine mothers and their families. Second, in an effort to investigate coping strategies that may buffer feelings of persistent stress, mothers were divided into sustained-stress and tapered-stress groups based on reported levels of perceived stress during the height of the pandemic (March-April 2020) compared to the time of interview (August-December 2020). These two groups of mothers were significantly different on levels of PTSD symptoms, social support, and perceived discrimination. Notably, mothers in the tapered-stress group who reported lower-levels of stress at the time of interview described experiences of being distracted by daily activities or by family members as a coping mechanism. Together, these findings highlight the need to address structural barriers and improve access to mental health support in order to mitigate continuing sources of pandemic related stressors for Latine families.

INTRODUCTION/BACKGROUND:Many health life exposure factors (LEFs) influence cognitive decline and dementia incidence, but their relative importance to episodic memory (an early indicator of cognitive decline) among diverse older adults is unclear. We used machine learning to rank LEFs for memory performance in a large and diverse US cohort. METHODS:Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) and Study of Healthy Aging in African Americans (STAR), participants underwent neuropsychological testing and answered questionnaires about multiple LEFs. XGBoost and Shapley Additive exPlanation values ranked the importance of factors influencing cross-sectional episodic memory in the full sample and by sex and ethnic group. RESULTS:Among 2245 adults (mean age: 74 years; range 54-90), age, sex, education, volunteering, income, vision, hearing, sleep, and exercise contributed to memory performance regardless of group stratification. DISCUSSION/CONCLUSIONS:This innovative methodology can help identify risk factors important for memory performance and guide future dementia risk reduction interventions among older adults. HIGHLIGHTS/CONCLUSIONS:This work uses a regression tree machine learning model (XGBoost) with highly interpretable Shapley Additive exPlanation values to analyze impacts of 12 life exposure factors plus age, sex and ethnoracial identity on episodic memory outcome. This approach has valuable properties, including the ability to implicitly account for variable interactions, non-linear relations with outcome, and missing values. Age, sex, education, income, volunteering, exercise, hearing and vision, and sleep (quality and duration) have important impacts on memory outcome in a combined model and in stratified models regardless of ethnoracial identity. We also demonstrate individualized models for subgroups of participants, showing how life exposure factors vary in importance between divergent populations and suggesting an approach to personalized interventions. This approach can be valuable for both policy decisions and individualized interventions to support healthy cognitive aging.