Faculty Bibliography

Older (aged ≥55 years) kidney transplant (KT) recipients diagnosed with a sleep disorder after transplantation may be at increased risk for developing dementia. Using the United States Renal Data System/Medicare claims (2010-2020), we identified 16 573 older KT recipients with a functioning graft 1-year post-KT. First-time sleep disorders and newly prescribed sleep medications were ascertained within the first year post-KT. We used cause-specific hazard models to estimate the adjusted hazard ratio of diagnosed dementia with inverse probability of treatment weights. Overall, 3615 (21.8%) KT recipients were newly diagnosed with sleep disorders. Recipients diagnosed with a sleep disorder had a 1.32-fold increased risk for dementia (95% CI:1.15-1.51); those with insomnia had a 1.56-fold increased risk (95% CI:1.20-2.03). Of those diagnosed with insomnia, only 7.5% underwent cognitive behavioral therapy for insomnia. Of the recipients, 12.9% with a sleep disorder were prescribed sleep medications. Recipients prescribed sleep medication had a 1.44-fold increased risk for dementia (95% CI:1.16-1.77). Those prescribed zolpidem, the most commonly prescribed medication (80.1%), had a 1.41-fold increased risk (95% CI:1.12-1.78) for dementia; those prescribed other sleep medications had 3.13-fold (95% CI:1.41-6.98) increased risk for dementia. Post-KT sleep disorders are modifiable dementia risk factors; medication-associated dementia risk should be weighed against other therapies such as cognitive behavioral therapy for insomnia during management.

BACKGROUND/UNASSIGNED:While there is wide evidence on concentrations of cytokines in patients attending health care facilities, evidence is scant on physiological, basal concentrations of cytokines in the general population and across sociodemographic groups, as well as on their potential stability over time. Furthermore, from a public health perspective it is remarkable that no studies have analyzed intraindividual changes in such concentrations from before the COVID-19 pandemic until its outbreak. OBJECTIVES/UNASSIGNED:To investigate: (a) prepandemic concentrations of cytokines and immunoglobulins to viral exposures in a general, non-institutionalized population, and their associated sociodemographic variables; (b) the intraindividual change in such concentrations between a prepandemic period (2016-17) and the initial pandemic period (2020-21); and (c) whether such change was similar in participants who in 2020-21 were SARS-CoV-2 seronegative and seropositive, and between participants who did and did not develop COVID-19. METHODS/UNASSIGNED:We conducted a prospective cohort study in 240 individuals from the general population of Barcelona, Spain. Thirty cytokines and 31 immunoglobulins were measured in paired serum samples collected in 2016-17 and 2020-21 in the same individuals. RESULTS/UNASSIGNED:The median value of the relative intraindividual change in cytokine concentrations between 2016 and 2020 was <15% for 29 of the 30 cytokines. A substantial number of participants had an intraindividual increase or decrease ≥15% in some cytokines. No major differences in intraindividual changes of cytokine and immunoglobulin levels between 2016 and 2020 were observed between participants who did and did not develop COVID-19. CONCLUSION/UNASSIGNED:We provide novel information on physiological, basal ex-vivo concentrations of cytokines and immunoglobulins in a general population, which should be relevant for clinical practice and public health. Intraindividual changes in cytokines and immunoglobulins during the 4 years from 2016-17 to 2020-21 were moderate, and they did not differ between participants who in 2020-21 were SARS-CoV-2 seropositive and seronegative, nor between participants who did and did not develop COVID-19 disease. These findings are also novel and relevant for medicine and public health. In particular, the stability in the biomarkers is relevant to assess the role of the immunological and inflammatory state (measured through baseline levels of cytokines and immunoglobulins) in the development of SARS-CoV-2 seropositivity and COVID-19 disease, as well as in the susceptibility to other infections and pathologies.

BACKGROUND:Advances in antiretroviral therapy have enabled people living with HIV (PLHIV) to live longer and healthier lives. However, aging with HIV infection is accompanied by an increased risk of non-communicable diseases (NCDs), highlighting the need to integrate care services. The Academic Model Providing Access to Healthcare (AMPATH) in Eldoret, Kenyahas, which has been providing care for PLHIV for over 30 years, is seeing an increase in NCDs, particularly hypertension and diabetes, especially among older patients. It is unclear how healthcare providers manage the complex healthcare needs of older adults living with HIV (OALWH) and comorbid NCDs, or how they perceive the integration of hypertension and diabetes care within the HIV care platform. METHODS:We conducted in-depth interviews at an AMPATH facility in Eldoret, Kenya. Ten healthcare providers (three nurses and seven clinical officers) were interviewed to explore the facilitators and barriers to integrating HIV and NCD care services for OALWH. Audio records were transcribed verbatim, content analysis was performed, and the capabilities (C), opportunities (O), and motivation (M) models for behavior change (COM-B model) were used to comprehensively map the drivers and barriers that shape healthcare providers' acceptance, adoption, and implementation of integrated HIV and NCD care services. RESULTS:The majority of participants had worked for more than five years, offering care for people living with HIV. All participants had experience managing older adults living with HIV and expressed challenges with the lack of coordinated care delivery for HIV and NCDs. The participants highlighted the potential challenges of optimal adherence to antiretroviral therapy (ART) among OALWH in the presence of multiple chronic conditions. Based on these challenges, participants perceived the integration of hypertension and diabetes care into the HIV care platform as beneficial to clients and the overall healthcare system. Factors such as the availability of physical resources and infrastructure (C), availability of training opportunities for NCD care (O), leadership support (M), and motivation to provide person-centered care (M) were perceived as facilitators of HIV/NCD integrated care delivery. Impeding factors such as lack of guidelines for integration (O), siloed healthcare service delivery (O), inadequate resource allocation for NCDs (O), and perceived increased workload (M) were also highlighted by healthcare providers. CONCLUSION/CONCLUSIONS:The findings of this study highlight healthcare providers' perceived facilitators and barriers to the integration of NCD care into HIV care platforms. The insights gained from this study hold the potential to inform tailored interventions, policy decisions, and capacity-building initiatives aimed at fostering successful integration and improving overall health care delivery to meet the needs of OALWH in resource-constrained settings.

IMPORTANCE/UNASSIGNED:With acute care utilization and mortality rates increasing among people with opioid use disorder, hospital addiction consult services can provide an important touchpoint for care, potentially leading to improved outcomes. OBJECTIVE/UNASSIGNED:To study the effectiveness of interprofessional hospital addiction consultation services on postdischarge acute care utilization and mortality. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:In this pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) clinical trial, 6 New York City public hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Participants included adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Eligible patients had an admission or discharge diagnosis of opioid use disorder or opioid poisoning or adverse effects, were hospitalized at least 1 night in a medical or surgical inpatient unit, and were not receiving medication for opioid use disorder before hospitalization. INTERVENTION/UNASSIGNED:Hospitals implemented the Consult for Addiction Treatment and Care in Hospitals (CATCH) program, an interprofessional inpatient addiction consult service providing specialty care for substance use disorders, with teams consisting of a medical clinician, social worker or addiction counselor, and peer counselor. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Acute care utilization (hospitalizations and emergency department [ED] visits) and mortality rates (all-cause deaths, overdose deaths, and opioid-involved overdose deaths) 1 year after hospital discharge. Data for the eligible patients were analyzed July 2023 to September 2024. RESULTS/UNASSIGNED:In total, 1355 eligible admissions were identified (968 [71.4%] men; mean [SD] age, 46.6 [12.4] years). A majority of patients (835 [61.5%]) had at least 1 subsequent hospitalization or ED visit. There were 113 deaths, including 34 overdose deaths (30.1%), of which 28 (82.4%) involved opioids. ED admissions were lower in the intervention period compared with TAU (incidence rate ratio, 0.79 [95% CI, 0.72-0.88]; P < .001). There were no statistically significant differences between CATCH and TAU periods in numbers of hospitalizations (incidence rate ratio, 0.99 [95% CI, 0.87-1.13]) or mortality (eg, hazard ratio for all-cause death, 1.14 [95% CI, 0.98-1.92]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this prespecified secondary analysis of a cluster randomized clinical trial, postdischarge ED visits decreased with the CATCH program, highlighting the potential of hospital-based addiction consult services to address needs of patients with opioid use. Nonetheless, high rates of acute care utilization and mortality persisted, underscoring the need for comprehensive care strategies that extend beyond the hospital walls, and addressing the complex health and social needs of individuals with opioid use. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03611335.

IMPORTANCE/UNASSIGNED:Inequities in rapid access to emergency medical services (EMS) represent a critical gap in prehospital care and the first system-level milestone for critically injured patients. As delays in EMS response are associated with increased mortality and known disparities within historically redlined areas are prevalent, this study sought to examine disparities in rapid access to EMS across the United States. OBJECTIVE/UNASSIGNED:To assess the association between historically redlined areas and rapid EMS access (defined as ≤5-minute response time) across the United States. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective, cross-sectional study analyzed the geographic distribution of EMS centers in relation to 2020 US Census block groups and Home Owners' Loan Corporation (HOLC) residential security maps, classified by grades (A-D). Populations of 236 US cities with publicly available redlining data were included. Travel distance radius (5-minute drive times) was centered on population-weighted block group centroids. Redlining grades include A ("most desirable," green), B ("still desirable," blue), C ("declining," yellow), and D ("hazardous," red). EXPOSURE/UNASSIGNED:HOLC grade classification (A-D). MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the proportion of the population with rapid EMS access. Secondary outcomes included the socioeconomic and demographic profiles of populations without rapid access. RESULTS/UNASSIGNED:Of the total US population (N = 333 036 755), 41 367 025 (12.42%) lived in cities with redlining data. Among these, 2 208 269 (5.34%) lacked rapid access to 42 472 EMS stations. Grade D areas had a higher proportion of residents without rapid EMS access compared with grade A areas (7.06% vs 4.36%; P < .001). The odds of having no rapid access to EMS in grade D areas were 1.67 (95% CI, 1.66-1.68) times higher than in grade A areas. Compared with grade A, grade D areas had a lower percentage of non-Hispanic White residents (65.21% [95% CI, 59.43%-70.99%] vs 39.36% [95% CI, 36.99%-41.73%]; P < .001), a higher percentage of non-Hispanic Black residents (10.38% [95% CI, 7.14%-13.62%] vs 27.85% [95% CI, 25.4%-30.3%]; P < .001), and greater population density (7500.72 [95% CI, 4341.26-10 660.18] persons/km2 vs 15 277.87 [95% CI, 13 281.7-17 274.04] persons/km2; P < .001). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study, structural disparities in rapid EMS access were associated with historically redlined areas. Strategic resource allocation and system redesign are warranted to address these inequities in prehospital emergency care.

INTRODUCTION/BACKGROUND:The impact of remote patient monitoring (RPM) for hypertension (HTN) on cardiovascular health (CVH) remains ill-defined. This study characterized the association between a RPM, team-based HTN intervention and CVH markers. METHODS:This retrospective, single-arm cohort study included patients with uncontrolled HTN enrolled February 2022-July 2024 in the ALTA trial (clinicaltrials.gov NCT03713515) at five safety-net practices. The ALTA intervention involves RPM supported by a virtual clinic including a nurse practitioner (NP), registered nurse, and community health worker. Demographics, ALTA utilization, and CVH markers (blood pressure [BP], lipids, glycemic indicators, body mass index [BMI], and smoking) at baseline and 12 months were collected. Five markers were scored (0=poor, 1=intermediate, 2=ideal) and summed into a CVH score. The primary endpoint was the 12-month CVH score change in patients with baseline score ≤7. Secondary endpoints included individual non-BP marker changes in patients with baseline derangements. RESULTS:Among 568 patients (mean age: 56 years), most were female, non-Hispanic Black, and English-speaking. NP visits were more common among females (p=0.04); no other demographics predicted ALTA utilization. The CVH score improved from 4.5 to 5.2 (n=196, p<0.001), independent of ALTA utilization. Total cholesterol (n=86, p<0.001), LDL (n=128, p<0.001), and triglycerides (n=51, p=0.004) improved. Hemoglobin A1c (n=195) dropped among patients with ≥1 NP visit (p=0.02). Fasting glucose (n=135) and BMI (n=289) decreased in the highest tertile of NP visits (p=0.03) and RPM (p=0.02), respectively. 4 of 27 patients quit smoking. CONCLUSIONS:RPM with team-based support was associated with CVH improvements. Benefits may depend on intervention utilization.

While approximately one in five Americans with substance use disorder (SUD) receives treatment in addiction treatment programs, a majority have seen a primary care medical provider in the past year. Recognizing the critical role of primary care in addressing prevention and treatment of unhealthy substance use, for over a decade the National Drug Abuse Treatment Clinical Trials Network (CTN) has supported research to build the tools and evidence needed to support the integration of SUD care, while remaining realistic about the barriers to doing so. Authored by primary care and addiction medicine physician researchers, this commentary provides an overview of CTN primary care-focused research, from developing and implementing substance use screening tools to advancing evidence-based SUD treatment delivery in primary care settings. We identify three priority areas for research and practice innovations: 1) identifying effective treatment interventions to address polysubstance use; 2) improved screening and treatment for cannabis use; and 3) building the evidence base for substance use interventions among non-treatment seeking patients who have unhealthy drug use identified through screening. Addressing these areas can help primary care fulfill its potential as a key component of the substance use services continuum of care.

BACKGROUND:Investigation of circulating plasma proteins may reveal insights into molecular pathways that contribute to the development of heart failure (HF) among people with chronic kidney disease. OBJECTIVES/OBJECTIVE:The authors aimed to identify circulating kidney function-related plasma proteins that are associated with the risk of incident HF. METHODS:The authors studied participants of the ongoing longitudinal ARIC (Atherosclerosis Risk In Communities) study. Relative plasma concentrations of 4,697 unique proteins were measured with the use of an aptamer assay (Somalogic). Each protein was tested for associations with estimated glomerular filtration rate (eGFR), log-transformed urine albumin-to-creatinine ratio (UACR), and incident HF by means of multivariable linear and Cox regression models. Protein-HF associations were validated externally in the CRIC (Chronic Renal Insufficiency Cohort) study. Two-sample mendelian randomization was used to test for potential causal associations. RESULTS:In fully adjusted models, 44 plasma proteins were associated with either eGFR or UACR and incident HF at 2 separate ARIC study visits, of which 29 were validated externally in CRIC. Most plasma proteins were associated with HF with preserved ejection fraction, but not reduced ejection fraction. A cluster within these 44 plasma proteins were associated with larger left ventricular end-diastolic volume index and left ventricular diastolic dysfunction. Mendelian randomization suggests that Golgi membrane protein 1 is causally associated with HF and eGFR. CONCLUSIONS:This study identified 44 eGFR- and UACR-related plasma proteins that are associated with incident HF independently from demographics, risk factors, and kidney function. These results may inform future therapeutic and biomarker development for the prevention and treatment of incident HF.