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Patients experiencing homelessness and mental illness face conditions and circumstances that deserve focused ethical and clinical attention. The first commentary on the case applies insights from qualitative research about social determinants of health to these patients' care and dignity. The second commentary describes 3 kinds of power wielded by physicians--charismatic, social, and Aesculapian--each of which is considered in terms of whether and to what extent physicians' power should be owned, aimed, or shared. [ABSTRACT FROM AUTHOR]

The contemporary scientific community places a growing emphasis on the reproducibility of research. The projects R package is a free, open-source package created in the interest of facilitating reproducible research workflows. It adds to existing software tools for reproducible research and introduces several practical features that are helpful for scientists and their collaborative research teams. For each individual project, it supplies a framework for storing raw and cleaned study data sets, and it provides script templates for protocol creation, data cleaning, data analysis and manuscript development. Internal databases of project and author information are generated and displayed, and manuscript title pages containing author lists and their affiliations are automatically generated from the internal database. File management tools allow teams to organize multiple projects. When used on a shared file system, multiple researchers can harmoniously contribute to the same project in a less punctuated manner, reducing the frequency of misunderstandings and the need for status updates. [ABSTRACT FROM AUTHOR]

In epidemiology, gerontology, human development and the social sciences, age-period-cohort (APC) models are used to study the variability in trajectories of change over time. A well-known issue exists in simultaneously identifying age, period and birth cohort effects, namely that the three characteristics comprise a perfectly collinear system. That is, since age = period−cohort, only two of these effects are estimable at a time. In this paper, we introduce an alternative framework for considering effects relating to age, period and birth cohort. In particular, instead of directly modeling age in the presence of period and cohort effects, we propose a risk modeling approach to characterize age-related risk (i.e., a hybrid of multiple biological and sociological influences to evaluate phenomena associated with growing older). The properties of this approach, termed risk-period-cohort (RPC), are described in this paper and studied by simulations. We show that, except for pathological circumstances where risk is uniquely determined by age, using such risk indices obviates the problem of collinearity. We also show that the size of the chronological age effect in the risk prediction model associates with the correlation between a risk index and chronological age and that the RPC approach can satisfactorily recover cohort and period effects in most cases. We illustrate the advantages of RPC compared to traditional APC analysis on 27496 individuals from NHANES survey data (2005–2016) to study the longitudinal variability in depression screening over time. Our RPC method has broad implications for examining processes of change over time in longitudinal studies. [ABSTRACT FROM AUTHOR]

Background: Inequality in health outcomes in relation to Americans' socioeconomic position is rising.Objective: First, to evaluate the spatial relationship between neighborhood disadvantage and major atherosclerotic cardiovascular disease (ASCVD)-related events; second, to evaluate the relative extent to which neighborhood disadvantage and physiologic risk account for neighborhood-level variation in ASCVD event rates.Design: Observational cohort analysis of geocoded longitudinal electronic health records.Setting: A single academic health center and surrounding neighborhoods in northeastern Ohio.Patients: 109 793 patients from the Cleveland Clinic Health System (CCHS) who had an outpatient lipid panel drawn between 2007 and 2010. The date of the first qualifying lipid panel served as the study baseline.Measurements: Time from baseline to the first occurrence of a major ASCVD event (myocardial infarction, stroke, or cardiovascular death) within 5 years, modeled as a function of a locally derived neighborhood disadvantage index (NDI) and the predicted 5-year ASCVD event rate from the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association. Outcome data were censored if no CCHS encounters occurred for 2 consecutive years or when state death data were no longer available (that is, from 2014 onward).Results: The PCERM systematically underpredicted ASCVD event risk among patients from disadvantaged communities. Model discrimination was poorer among these patients (concordance index [C], 0.70 [95% CI, 0.67 to 0.74]) than those from the most affluent communities (C, 0.80 [CI, 0.78 to 0.81]). The NDI alone accounted for 32.0% of census tract-level variation in ASCVD event rates, compared with 10.0% accounted for by the PCERM.Limitations: Patients from affluent communities were overrepresented. Outcomes of patients who received treatment for cardiovascular disease at Cleveland Clinic were assumed to be independent of whether the patients came from a disadvantaged or an affluent neighborhood.Conclusion: Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes.Primary Funding Source: The Clinical and Translational Science Collaborative of Cleveland and National Institutes of Health. [ABSTRACT FROM AUTHOR]

Background: Self-management of bipolar disorder (BD) is challenging for many individuals. Material: Interviews were used to assess perceived barriers to disease self-management among 21 high-risk patients with BD. Content analysis, with an emphasis on dominant themes, was used to analyze the data. Results: Three major domains of barriers emerged: individual barriers (psychological, knowledge, behavioral and physical health); family/community-level barriers (lack of support and resources); and provider/healthcare system (inadequate communication and access to care). Conclusion: Care approaches providing social and peer support, optimizing communication with providers and integrating medical and psychiatric care may improve self-management of BD in this vulnerable population. [ABSTRACT FROM AUTHOR]

Objective: Patients with hepatitis C virus (HCV) are advised to refrain from alcohol consumption. A questionnaire was developed to measure concepts associated with alcohol use for individuals with HCV Method: Subjects with HCV (N = 527) completed a telephone survey. Eligible respondents had screened negative for current abuse/dependence disorders (Alcohol Use Disorders Identification Test [AUDIT] < 10). Measures of personality, self-efficacy, knowledge, readiness, coping styles, stigma, and symptoms were examined for associations with alcohol use. Results: Factor analysis supported a measurement structure of 105 items in 35 subdomains. A total of 26 subdomains had significant bivariate associations with alcohol use. Higher self-efficacy for resisting drinking in social situations was associated with lower alcohol use (r = -.68, p < .001), as was knowledge of alcohol and HCV (r = -.27, p < .001). Although agreeableness and marital status are typically associated with lower current drinking in samples of those with alcohol use problems, in our study agreeableness (P = .13, p < .01) and marital status (P = .08, p < .05) were modestly associated with higher current drinking. The final multivariate R2 was .55. Conclusions: The pattern of associations suggests the importance of the social aspects of drinking for drinking decisions. Existing brief interventions will need to be tailored to a contextualized psychosocial model for medical patients with HCV and AUDIT scores < 10 to optimize effectiveness. Such future interventions should emphasize the potential medical hazards of drinking for persons with HCV, the maintenance of social relationships in the absence of alcohol use, and strategies for building confidence for resisting drinking in specific situations. [ABSTRACT FROM AUTHOR]

Objectives. We examine anticipated preferences for nursing home placement as a strategy for meeting possible future long-term care needs among a sample of community-dwelling elderly European Americans who migrated to Florida after retirement. We synthesize prior research on ethnicity in late life, retirement migration patterns, and informal networks of retired migrants. Methods. We gathered data through structured personal interviews with 578 retired migrants identified through screening from telephone listings, supplemented with snowball sampling techniques. Results. Lifetime migration patterns and current ethnic involvement are significant predictors of mentioning nursing home placement as a strategy for possible long-term care needs. Discussion. We interpret these results within the framework of Rowles's emphasis on the permeability of communitynursing home boundaries. [ABSTRACT FROM AUTHOR]

Presents a study which examined the decision process that led to retirement migration. Review of literature on retirement migration; Method; Results and discussion.

Patients with autoimmune disease (AD) are at increased risk for complications from COVID-19 infection, so, optimizing vaccine utilization in this population is of particular importance. We compared COVID-19 vaccination perspectives among persons with and without AD. 471 patients in the MetroHealth System and Cleveland Veteran Affairs Medical Center completed a 38-item questionnaire between August 2021 and February 2022. This survey containing questions regarding COVID-19 vaccine perceptions and demographics was administered both to unvaccinated individuals and individuals who delayed vaccination for at least 2 months. Multivariable ordinary least squares regression models were created to assess factors associated with vaccination likelihood. The number of reasons given for (p < 0.001) and against receiving COVID-19 vaccination (p < 0.001) were highly associated with increased and decreased vaccination likelihood respectively. Factors most closely associated with obtaining vaccine were: protecting family (p = 0.045) personal safety (p < 0.001) and preventing serious infection (p < 0.001). Reasons associated with decreased vaccination likelihood were: lack of concern of COVID-19 infection (p < 0.001), vaccine safety (p < 0.001) and beliefs that the vaccine was made too quickly (p = 0.024). AD patients were more likely to cite having a chronic condition (29.1 % vs 17.1 %, p = 0.003) and physician recommendation(s) (18.4 % vs 9.1 %, p = 0.005) as reasons for vaccination and were more concerned about potential medication interaction than non-AD respondents (22.4 % vs 3.3 %, p < 0.001). The number of benefits of vaccination identified strongly related to vaccination likelihood. Affirmative provider recommendations correlated with increased vaccination likelihood in AD patients. Clinical conversations centered on the benefits of COVID-19 vaccination may help increase vaccine acceptance. [ABSTRACT FROM AUTHOR]

We used a collective impact model to form a statewide diabetes quality improvement collaborative to improve diabetes outcomes and advance diabetes health equity. Between 2020 and 2022, in collaboration with the Ohio Department of Medicaid, Medicaid Managed Care Plans, and Ohio's seven medical schools, we recruited 20 primary care practices across the state. The percentage of patients with hemoglobin A1c greater than 9% improved from 25% to 20% over two years. Applying our model more broadly could accelerate improvement in diabetes outcomes. (Am J Public Health. 2023;113(12):1254–1257. https://doi.org/10.2105/AJPH.2023.307410) [ABSTRACT FROM AUTHOR]

Background: Evidence on the effects of neighborhood socioeconomic disadvantage on dementia risk in racially and ethically diverse populations is limited. Our objective was to evaluate the relative extent to which neighborhood disadvantage accounts for racial/ethnic variation in dementia incidence rates. Secondarily, we evaluated the spatial relationship between neighborhood disadvantage and dementia risk. Methods: In this retrospective study using electronic health records (EHR) at two regional health systems in Northeast Ohio, participants included 253,421 patients aged >60 years who had an outpatient primary care visit between January 1, 2005 and December 31, 2015. The date of the first qualifying visit served as the study baseline. Cumulative incidence of composite dementia outcome, defined as EHR‐documented dementia diagnosis or dementia‐related death, stratified by neighborhood socioeconomic deprivation (as measured by Area Deprivation Index) was determined by competing‐risk regression analysis, with non‐dementia‐related death as the competing risk. Fine‐Gray sub‐distribution hazard ratios were determined for neighborhood socioeconomic deprivation, race/ethnicity, and clinical risk factors. The degree to which neighborhood socioeconomic position accounted for racial/ethnic disparities in the incidence of composite dementia outcome was evaluated via mediation analysis with Poisson rate models. Results: Increasing neighborhood disadvantage was associated with increased risk of EHR‐documented dementia diagnosis or dementia‐related death (most vs. least disadvantaged ADI quintile HR = 1.76, 95% confidence interval = 1.69–1.84) after adjusting for age and sex. The effect of neighborhood disadvantage on this composite dementia outcome remained after accounting for known medical risk factors of dementia. Mediation analysis indicated that neighborhood disadvantage accounted for 34% and 29% of the elevated risk for composite dementia outcome in Hispanic and Black patients compared to White patients, respectively. Conclusion: Neighborhood disadvantage is related to the risk of EHR‐documented dementia diagnosis or dementia‐related death and accounts for a portion of racial/ethnic differences in dementia burden, even after adjustment for clinically important confounders. [ABSTRACT FROM AUTHOR]

Retrospective self-reported data have limitations, making it important to evaluate alternative forms of measurement for nutrition behaviors. Ecological momentary assessment (EMA) attempts to overcome the challenges of recalled data with real-time data collection in a subject's natural environment, often leveraging technology. This perspective piece 1) introduces the concepts and terminology of EMA, 2) provides an overview of the methodological and analytical considerations, 3) gives examples of past research using EMA, and 4) suggests new opportunities (including combining assessment and intervention) and limitations (including the need for technology) for the application of EMA to research and practice regarding nutrition behaviors. [ABSTRACT FROM AUTHOR]

Background: Proton pump inhibitors (PPIs) are potent inhibitors of acid secretion and are the mainstay of therapy for gastroesophageal reflux disease (GERD). Initially designed to be taken 30 min before the first daily meal, these agents are commonly used suboptimally, which adversely affects symptom relief. No study to date has assessed whether correcting dosing regimens would improve symptom control. The objective of this study was to determine whether patients with persistent GERD symptoms on suboptimal omeprazole dosing experience symptomatic improvement when randomized to commonly recommended dosing regimen and to evaluate the economic impact of suboptimal PPI dosing in GERD patients.Methods: Patients with persistent heartburn symptoms ≥ 3 times per week treated with omeprazole 20 mg daily were enrolled and randomized to commonly recommended dosing or continued suboptimal dosing of omeprazole. The primary outcomes were changes in symptom, frequency, and severity, as determined using the Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) 4 weeks after the intervention was administered. In secondary analysis, an alternative measure of symptom load was used to infer potential costs.Results: Sixty-four patients were enrolled. GSAS symptom, frequency, and severity scores were significantly better when dosing was optimized for overall and heartburn-specific symptoms (P < 0.01 for all parameters). Cost savings resulting from reduced medical care and workplace absenteeism were estimated to be $159.60 per treated patient, with cost savings potentially exceeding $4 billion annually in the USA.Discussion: Low-cost efforts to promote commonly recommended PPI dosing can dramatically reduce GERD symptoms and related economic costs. ClinicalTrials.gov, number: NCT02623816. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "A New Research and Development Policy Framework for the Biomedical Research Enterprise," by Howard J. Federoff and Elaine R. Rubin in a 2010 issue, as well as a reply by the authors of the article.

Healthcare systems are increasingly investing in approaches to address social determinants of health and health disparities. Such initiatives dovetail with certain approaches to neighborhood development, such as the EcoDistrict standard for community development, that prioritize both ecologically and socially sustainable neighborhoods. However, healthcare system and community development initiatives can be untethered from the preferences and lived realities of residents in the very neighborhoods upon which they focus. Utilizing the go‐along approach to collecting qualitative data in situ, we interviewed 19 adults to delineate residents' community health perspectives and priorities. Findings reveal health priorities distinct from clinical outcomes, with residents emphasizing social connectedness, competing intra‐ and interneighborhood perceptions that potentially thwart social connectedness, and a neighborhood emplacement of agency, dignity, and self‐worth. Priorities of healthcare systems and community members alike must be accounted for to optimize efforts that promote health and social well‐being by being valid and meaningful to the community of focus. Highlights: Health system investments in social determinants are often untethered from neighborhood preferences.Go‐along interviews efficiently ascertain community priorities for neighborhood transformation.Neighborhood residents articulate social connectedness as a key meaning of health.Participants described neighborhood emplacement of self‐worth from internalizing outsiders' views.Community development interventions should include resident voices in planning and evaluation. [ABSTRACT FROM AUTHOR]

Despite having a higher prevalence and severity of obstructive sleep apnea (OSA), African Americans have lower adherence to continuous positive airway pressure (CPAP) compared to other groups. Information regarding challenges faced by African Americans prescribed CPAP are lacking. To determine the barriers and facilitators to optimal management of OSA with CPAP among African Americans and to understand the role bed partners may play. We conducted semi-structured in-depth interviews via video conferencing with African American patients of an urban safety-net health care system with OSA prescribed CPAP and their bed partners. Recruitment continued until theoretical saturation was achieved. Verbatim transcripts were analyzed using the principles of thematic analysis. 15 patients (12 women) diagnosed with OSA and prescribed CPAP a mean 2.6 years prior along with 15 bed partners (3 women) were individually interviewed. Four themes emerged regarding impediments to CPAP use: 1) inadequate education and support, 2) CPAP maintenance and hygiene, 3) inconvenient design of CPAP interfaces, and 4) impediment to intimacy. Four themes emerged as facilitators to CPAP use: 1) provider and technical support, 2) properly fitted CPAP masks, 3) active support from partner and family, and 4) experiencing positive results from CPAP. African American patients with OSA and their bed partners identified several unique barriers and facilitators to CPAP use. Active involvement by bed partners was considered by both patients and partners as helpful in improving CPAP adherence. Interventions to improve OSA outcomes in this population should focus on patients and their bed partners. [ABSTRACT FROM AUTHOR]

Background: Community members may provide useful perspectives on manuscripts submitted to medical journals. Objective: To determine the impact of community members reviewing medical journal manuscripts. Design: Randomized controlled trial involving 578 original research manuscripts submitted to two medical journals from June 2018 to November 2021. Participants: Twenty-eight community members who were trained, supervised, and compensated. Interventions: A total of 289 randomly selected control manuscripts were reviewed by scientific reviewers only. And 289 randomly selected intervention manuscripts were reviewed by scientific reviewers and one community member. Journal editorial teams used all reviews to make decisions about acceptance, revision, or rejection of manuscripts. Main Measures: Usefulness of reviews to editors, content of community reviews, and changes made to published articles in response to community reviewer comments. Key Results: Editor ratings of community and scientific reviews averaged 3.1 and 3.3, respectively (difference 0.2, 95% confidence interval [CI] 0.1 to 0.3), on a 5-point scale where a higher score indicates a more useful review. Qualitative analysis of the content of community reviews identified two taxonomies of themes: study attributes and viewpoints. Study attributes are the sections, topics, and components of manuscripts commented on by reviewers. Viewpoints are reviewer perceptions and perspectives on the research described in manuscripts and consisted of four major themes: (1) diversity of study participants, (2) relevance to patients and communities, (3) cultural considerations and social context, and (4) implementation of research by patients and communities. A total of 186 community reviewer comments were integrated into 64 published intervention group articles. Viewpoint themes were present more often in 66 published intervention articles compared to 54 published control articles (2.8 vs. 1.7 themes/article, difference 1.1, 95% CI 0.4 to 1.8). Conclusions: With training, supervision, and compensation, community members are able to review manuscripts submitted to medical journals. Their comments are useful to editors, address topics relevant to patients and communities, and are reflected in published articles. Trial Registration: ClinicalTrials.gov NCT03432143 [ABSTRACT FROM AUTHOR]

The article presents a study on the obstacles to self-management of serious mental illness (SMI) and diabetes mellitus (DM). It discusses findings on the domains of barriers to such self-management including personal level barriers such as stress, isolation and stigma, family and community level barriers such as lack of support from family and friends and provider and health care system level barriers such as poor relationships and communication with providers as well as fragmentation of care.

AimTo better understand the type and range of health issues initiated by patients and providers in ‘high-quality’ primary-care for adults with diabetes and low socio-economic status (SES).BackgroundAlthough quality of care guidelines are straightforward, diabetes visits in primary care are often more complex than adhering to guidelines, especially in adults with low SES who experience many financial and environmental barriers to good care.MethodsWe conducted a qualitative study using direct observation of primary-care diabetes visits at an exemplar safety net practice in 2009–2010.FindingsIn a mainly African American (93%) low-income population with fair cardiovascular control (mean A1c 7.5%, BP 134/81 mmHg, and low-density lipoprotein cholesterol 100 mg/dL), visits addressed a variety of bio-psychosocial health issues [median: 25 problems/visit (range 13–32)]. Physicians most frequently initiated discussions about chronic diseases, prevention, and health behavior. Patients most frequently initiated discussions about social environment and acute symptoms followed by prevention and health behavior.ConclusionsPrimary-care visits by diabetes patients with low SES address a surprising number and diversity of problems. Emerging new models of primary-care delivery and quality measurement should allow adequate time and resources to address the range of tasks necessary for integrating biomedical and psychosocial concerns to improve the health of socio-economically disadvantaged patients. [ABSTRACT FROM PUBLISHER]

Healthcare systems and providers have increasingly acknowledged the role and impact of social determinants in overall health. However, gender-diverse individuals face persistent health disparities due to their identities. There is limited research on the impact of clinical and sociodemographic characteristics on mood and quality of life (QoL) for transgender (TG) individuals. Our study aims to understand and better elucidate social and clinical characteristics of transmasculine (TM) and transfeminine (TF) individuals and their impact on quality of life and depressive symptoms. In this cross-sectional study, 298 TF and TM individuals on gender-affirming hormone therapy (GAHT) were surveyed about their demographic characteristics (age, gender identity, body mass index (BMI), and education), social needs, mood, and quality of life. Multivariable regression modelling was performed to assess the effect of each variable listed above on three domains of QoL (psychological, environmental, and physical) as well as depressive symptoms. We find that QoL scores are similar between TM and TF individuals, with scores in the psychological domain particularly low in both cohorts. TM individuals report higher rates of stress and restroom avoidance than TF individuals. In particular, psychological well-being (measured by the psychological domain of QoL and depressive symptoms) is significantly associated with increased BMI, financial instability, and stress in TM individuals while for TF individuals, psychological well-being is associated with stress and social integration. These data suggest that social circumstances are key drivers of QoL and psychological well-being among gender-diverse individuals receiving GAHT with specific differences between TF and TM individuals. This information may be utilized by healthcare providers and policymakers to address and improve clinical care and social policies to improve health equity for gender-diverse individuals. • Transmasculine individuals reported higher levels of stress than transfeminine individuals. • Higher levels of stress correlated with lower quality of life (QoL) scores in both groups. • Strong social support in transfeminine individuals correlated with higher QoL scores. • Financial stability in transmasculine individuals correlated with higher QoL scores. • Delayed urination due to inadequate facilities was more frequent in transmasculine individuals. [ABSTRACT FROM AUTHOR]

Since its development, Singh's 2003 Area Deprivation Index (ADI) has been routinely used by researchers to measure a global construct of neighborhood socioeconomic deprivation and to investigate how living in neighborhoods of different levels of socioeconomic deprivation affects individuals' health. We empirically tested the ADI's dimensionality, using 2013–2017 American Community Survey tract-level estimates (N = 73,056), and the stability of its performance across time and place. Factor analysis findings illuminated three distinct dimensions, the ADI-3, consisting of neighborhood financial strength, economic hardship and inequality, and educational attainment. The prior-assumed unidimensional ADI measure fails standard tests of construct validity. Findings from multigroup structural equation modeling across 2009 and 2017 and between New York and Minnesota suggest that the ADI performs with only partial stability across time and place. In order to most precisely understand the complex role of neighborhood socioeconomic position in health, public health researchers must integrate construct-valid and regionally and temporally relevant measures. [ABSTRACT FROM AUTHOR]

The article reports a study which was conducted to determine, using factor analysis, the reliability of a 19-item 360 degree peer evaluation in physical medicine and rehabilitation residency program. The results of the factor analysis indicate that one overall opinion of the evaluated resident was informing the responses of the evaluating resident. Shortening the instrument may improve evaluations and should be studied in the future.

Background: Social and ecological differences in early SARS-CoV-2 pandemic screening and outcomes have been documented, but the means by which these differences have arisen are not well understood. Objective: To characterize socioeconomic and chronic disease-related mechanisms underlying these differences. Design: Observational cohort study. Setting: Outpatient and emergency care. Patients: 12900 Cleveland Clinic Health System patients referred for SARS-CoV-2 testing between March 17 and April 15, 2020. Interventions: Nasopharyngeal PCR test for SARS-CoV-2 infection. Measurements: Test location (emergency department, ED, vs. outpatient care), COVID-19 symptoms, test positivity and hospitalization among positive cases. Results: We identified six classes of symptoms, ranging in test positivity from 3.4% to 23%. Non-Hispanic Black race/ethnicity was disproportionately represented in the group with highest positivity rates. Non-Hispanic Black patients ranged from 1.81 [95% confidence interval: 0.91–3.59] times (at age 20) to 2.37 [1.54–3.65] times (at age 80) more likely to test positive for the SARS-CoV-2 virus than non-Hispanic White patients, while test positivity was not significantly different across the neighborhood income spectrum. Testing in the emergency department (OR: 5.4 [3.9, 7.5]) and cardiovascular disease (OR: 2.5 [1.7, 3.8]) were related to increased risk of hospitalization among the 1247 patients who tested positive. Limitations: Constraints on availability of test kits forced providers to selectively test for SARS-Cov-2. Conclusion: Non-Hispanic Black patients and patients from low-income neighborhoods tended toward more severe and prolonged symptom profiles and increased comorbidity burden. These factors were associated with higher rates of testing in the ED. Non-Hispanic Black patients also had higher test positivity rates. [ABSTRACT FROM AUTHOR]

• Alzheimer's Disease (AD) is a major cause of dementia in the United States. • Non-traditional risk factors can help identify areas of higher AD Burden. • Machine learning techniques can help unravel this complex relationship. Geographical disparities in mortality among Alzheimer's disease (AD) patients have been reported and complex sociodemographic and environmental determinants of health (SEDH) may be contributing to this variation. Therefore, we aimed to explore high-risk SEDH factors possibly associated with all-cause mortality in AD across US counties using machine learning (ML) methods. We performed a cross-sectional analysis of individuals ≥65 years with any underlying cause of death but with AD in the multiple causes of death certificate (ICD-10,G30) between 2016 and 2020. Outcomes were defined as age-adjusted all-cause mortality rates (per 100,000 people). We analyzed 50 county-level SEDH and Classification and Regression Trees (CART) was used to identify specific county-level clusters. Random Forest, another ML technique, evaluated variable importance. CART's performance was validated using a "hold-out" set of counties. Overall, 714,568 individuals with AD died due to any cause across 2,409 counties during 2016–2020. CART identified 9 county clusters associated with an 80.1% relative increase of mortality across the spectrum. Furthermore, 7 SEDH variables were identified by CART to drive the categorization of clusters, including High School Completion (%), annual Particulate Matter 2.5 Level in Air, live births with Low Birthweight (%), Population under 18 years (%), annual Median Household Income in US dollars ($), population with Food Insecurity (%), and houses with Severe Housing Cost Burden (%). ML can aid in the assimilation of intricate SEDH exposures associated with mortality among older population with AD, providing opportunities for optimized interventions and resource allocation to reduce mortality among this population. [ABSTRACT FROM AUTHOR]

BACKGROUND: Accurate assessment of atherosclerotic cardiovascular disease (ASCVD) risk across heterogeneous populations is needed for effective primary prevention. Little is known about the performance of standard cardiovascular risk factors in older adults. OBJECTIVE: To evaluate the performance of the American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE) risk model, as well as the underlying cardiovascular risk factors, among adults older than 65 years. DESIGN AND SETTING: Retrospective cohort derived from a regional referral system's electronic medical records. PARTICIPANTS: A total of 25 349 patients who were 65 years or older at study baseline (date of the first outpatient lipid panel taken between 2007 and 2010). MEASUREMENTS: Exposures of interest were traditional cardiovascular risk factors, as defined by inclusion in the PCE model. The primary outcome was major ASCVD events, defined as a composite of myocardial infarctions, stroke, and cardiovascular death. RESULTS: The PCE and internally estimated models produced similar risk distributions for white men aged 65 to 74 years. For all other groups, PCE predictions were generally lower than those of the internal models, particularly for African Americans. Discrimination of the PCE was poor for all age groups, with concordance index (95% confidence interval) estimates of 0.62 (0.60‐0.64), 0.56 (0.54‐0.57), and 0.52 (0.49‐0.54) among patients aged 65 to 74, 75 to 84, and 85 years and older, respectively. Reestimating relationships within these age groups resulted in better calibration but negligible improvements in discrimination. Blood pressure, total cholesterol, and diabetes either were not associated at all or had inverse associations in the older age groups. CONCLUSION: Traditional clinical risk factors for cardiovascular disease failed to accurately characterize risk in a contemporary population of Medicare‐aged patients. Among those aged 85 years and older, some traditional risk factors were not associated with ASCVD events. Better risk models are needed to appropriately inform treatment decision making for the growing population of older adults. J Am Geriatr Soc 68:754–761, 2020 [ABSTRACT FROM AUTHOR]

Purpose: This study compared a novel self-management (TargetEd MAnageMent Intervention [TEAM]) versus treatment as usual (TAU) to reduce stroke risk in African American (AA) men.Design: Six-month prospective randomized controlled trial with outcomes evaluated at baseline, 3 months, and 6 months.Setting: Academic health center.Participants: Thirty-eight (age < 65) AA men who had a stroke or transient ischemic attack and a Barthel index score of >60 were randomly assigned to TEAM (n = 19) or TAU (n = 19).Intervention: Self-management training, delivered in 1 individual and 4 group sessions (over 3 months).Measures: Blood pressure, glycosylated hemoglobin (HbA1c), lipids, medication adherence, weight, and standardized measures of health behaviors (diet, exercise, smoking, substances), depression, and quality of life. Qualitative assessments evaluated the perspectives of TEAM participants.Analysis: T tests for paired differences and nonparametric tests. Thematic content qualitative analysis.Results: Mean age was 52.1 (standard deviation [SD] = 7.4) and mean body mass index was 31.4 (SD = 7.4). Compared to TAU, TEAM participants had significantly lower mean systolic blood pressure by 24 weeks, and there was also improvement in HbA1c and high-density lipoprotein cholesterol ( P = .03). Other biomarker and health behaviors were similar between groups. Qualitative results suggested improved awareness of risk factors as well as positive effects of group support. [ABSTRACT FROM AUTHOR]

This study examined (a) the extent of heterogeneity in the patterns of developmental trajectories of language development and academic functioning in children who have experienced maltreatment, (b) how maltreatment type (i.e., neglect or physical abuse) and timing of abuse explained variation in developmental trajectories, and (c) the extent to which individual protective factors (i.e., preschool attendance, prosocial skills), relationship protective factors (i.e., parental warmth, absence of past-year depressive episode, cognitive/verbal responsiveness) and community protective factors (i.e., neighborhood safety) promoted the development of resilient language/academic functioning trajectories. Longitudinal data analyses were conducted using cohort sequential Growth Mixture Model (CS-GMM) with a United States national representative sample of children reported to Child Protective Services (n = 1,776). Five distinct developmental trajectories from birth to age 10 were identified including two resilient groups. Children who were neglected during infancy/toddlerhood or physically abused during preschool age were more likely to be in the poorer language/academic functioning groups (decreasing/recovery/decreasing and high decreasing) than the resilient high stable group. Child prosocial skills, caregiver warmth, and caregiver cognitive stimulation significantly predicted membership in the two resilient academic functioning groups (low increasing and high stable), after controlling for demographics and child physical abuse and neglect. Results suggest that it is possible for a maltreated child to successfully achieve competent academic functioning, despite the early adversity, and identifies three possible avenues of intervention points. This study also makes a significant contribution to the field of child development research through the novel use of CS-GMM, which has implications for future longitudinal data collection methodology. [ABSTRACT FROM AUTHOR]

Objective Epilepsy is a common neurological condition that is often associated with stigmatizing attitudes and negative stereotypes among the general public. This randomized controlled trial ( RCT) tested two new communication approaches targeting epilepsy stigma versus an education-alone approach. Methods Two brief stigma-reduction videos were developed, informed by community stakeholder input; one highlighted role competency in people with epilepsy; the other highlighted social inclusion of people with epilepsy. A control video was also developed. A Web-based survey using a prospective RCT design compared effects of experimental videos and control on acceptability, perceived impact, epilepsy knowledge, and epilepsy stigma. Epilepsy knowledge and stigma were measured with the Epilepsy Knowledge Questionnaire ( EKQ) and Attitudes and Beliefs about Living with Epilepsy ( ABLE), respectively. Results A total of 295 participants completed the study. Mean age was 23.1 ( standard deviation = 3.27) years; 59.0% were male, and 71.4% were white. Overall, respondents felt videos impacted their epilepsy attitudes. EKQ scores were similar across videos, with a trend for higher knowledge in experimental videos versus control (p = 0.06). The role competency and control videos were associated with slightly better perceived impact on attitudes. There were no differences between videos on ABLE scores (p = 0.568). There were subgroup differences suggesting that men, younger individuals, whites, and those with personal epilepsy experience had more stigmatizing attitudes. Significance This RCT tested communication strategies to improve knowledge and attitudes about epilepsy. Although this initial effort will require follow-up, we have demonstrated the acceptability, feasibility, and potential of novel communication strategies to target epilepsy stigma, and a Web-based approach for assessing them. [ABSTRACT FROM AUTHOR]

The longitudinal pathways connecting physical abuse and substance use in child welfare-involved adolescents, a population with multiple risk factors for substance use problems, remain unclear. This study examined the relation between self-reported physical abuse among adolescents investigated by Child Protective Services (CPS) and later substance use, with a particular focus on exposure to physical abuse after CPS investigation as a potential contributing factor to this relation. Using data from the first National Survey of Child and Adolescent Well-being (NSCAW-I), a path analysis was conducted on a sample of 1079 adolescents aged 11–15 years who had recently been investigated by CPS. At baseline and 18-month follow-up, youths self-reported past-year physical abuse using the Parent-Child Conflicts Tactic Scale and past 30-day substance use frequency. At baseline, youths self-reported current internalizing and externalizing problems to the Youth Self Report. Path analysis revealed no significant relation between physical abuse at baseline and substance use at 18 months. Physical abuse at baseline was associated with higher levels of concurrent substance use and externalizing problems, which in turn predicted higher substance use at 18 months. Furthermore, physical abuse and externalizing problems at baseline predicted physical abuse at 18 months, which in turn was related to higher substance use at 18 months. The findings suggest that physical abuse after CPS investigation contributes to the development of adolescent substance use behaviors. Results indicate a need for innovative efforts to prevent physical abuse after CPS investigation, as well as assessment and treatment of substance use and externalizing problems at the point of investigation, to reduce future substance use in child welfare-involved adolescents. [ABSTRACT FROM AUTHOR]

Objectives Serious mental illness is disproportionately common in people with epilepsy and contributes to complications and mortality. Few care approaches specifically target individuals who have epilepsy and severe mental illness. We used an iterative process to refine an existing intervention and tested the novel intervention, T argeted Self-Management for Ep i lepsy and Me ntal Illness (TIME) in individuals with epilepsy and comorbid mental illness (E-MI). Methods The TIME intervention was developed with input from a community advisory board and then tested for feasibility, acceptability, and preliminary efficacy in people with E-MI, using a 16-week prospective, randomized controlled design comparing TIME (N = 22) vs. treatment as usual (TAU, N = 22). Primary outcome was change in depressive symptoms, assessed by the Montgomery Asberg Depression Rating Scale (MADRS). Secondary assessments included global psychiatric symptom severity, seizure frequency, sleep patterns, quality of life, stigma, social support, and self-efficacy. Results There were 44 individuals enrolled, mean age 48.25 (SD = 11.82) with 25 (56.8%) African-Americans. The majority (N = 31, 70.5%) were unemployed, and most (N = 41, 95.5%) had annual income < U.S. $25,000. With respect to study retention, there were 36 individuals (18 in TIME, 18 in TAU) assessed at 12 weeks and 35 individuals (19 in TIME, 16 in TAU) assessed at 16 weeks. There was a significant effect for MADRS (p = 0.036; effect size of 0.70), with lower MADRS at 16 weeks in TIME, while TAU MADRS did not change. Differences between most secondary measures were not statistically significant. Significance The TIME intervention engages individuals to actively participate in self-management and can reduce depression in E-MI. Given the high morbidity and mortality associated with epilepsy complicated by serious mental illness, additional research is needed to better identify how TIME might be implemented in routine care settings. [ABSTRACT FROM AUTHOR]

Objective This systematized literature review identified reports describing epilepsy misconceptions in the developed Western countries and research interventions focused on reducing these misconceptions. Materials and methods English language publications from January 2004 to January 2015 that described original research conducted in Europe, North/Central/South America, or Australia on misconceptions about epilepsy among the general public were used for this review. Results Eighty-one publications were selected. Most studies were conducted in the Americas (N = 30) and Europe (N = 31). Misconceptions and attitudes about epilepsy were assessed among clinical providers (N = 9), family members of people with epilepsy (PWE) (N = 5), teachers (N = 11), students (N = 22), and the general public (N = 25). Most studies used structured questionnaires, sometimes adding open-ended questions. Misconceptions reflected socially exclusionary attitudes directed at PWE, ignorance about treatment, and overgeneralizations that are stigmatizing when applied to all PWE. Misconceptions were more prevalent in those with less education, lower socioeconomic status, and no exposure to PWE. There were only 12 intervention studies. While intervention studies were generally effective in improving attitudes, many were targeted to healthcare and education settings, were time-intensive, and impractical for broad general population implementation. None incorporated newer technology-based strategies regarding effective health communication approaches. Conclusions Types of epilepsy misconceptions were similar in reports published over the last decade, although most referred to misconceptions that have already been previously described. Existing questionnaires may fail to identify more subtle forms of current misconceptions and negative attitudes. Few interventional studies specifically target epilepsy stigma. Practical and broad scalable approaches to destigmatize epilepsy may help reduce misconceptions. [ABSTRACT FROM AUTHOR]

In this study we investigated whether witnessing violence and violence victimization were associated with children's internalizing and externalizing behavior problems and examined the mediating role of posttraumatic stress (PTS) symptoms in these relationships. Secondary data analysis was conducted using 3 waves of data from the National Survey of Child and Adolescent Well-Being. Path analyses were conducted to test direct and indirect effects of violence exposure on behavior problems, using 2,064 children (ages 8-15 years) reported to Child Protective Services for maltreatment. Being a victim of violence in the home was directly associated with more internalizing (β = .06, p = .007) and externalizing behavior problems (β = .07, p = .002), whereas witnessing violence was not directly related to either internalizing (β = .04, p = .056) or externalizing behavior problems (β = .03, p = .130). PTS symptoms mediated the effects of witnessing violence and violence victimization on internalizing behavior problems (β = .02, p = .002). Our findings suggest that PTS symptoms may be a mechanism underlying the association between violence exposure and internalizing behavior problems (R(2) = .23), underscoring the potential importance of assessing PTS symptoms and providing targeted trauma-focused interventions for children exposed to violence at home. [ABSTRACT FROM AUTHOR]

Objective Epilepsy is a chronic neurological condition that significantly increases risk of injury and premature death. Rates of mental illness are also disproportionately high in those with epilepsy, which can be attributed in part to the stress and stigma associated with epilepsy. Psychiatric conditions generally complicate the management of epilepsy, and understanding how psychiatric comorbidity affects use of crisis-based health resources could inform care approaches that help improve epilepsy care. To better understand effects of psychiatric comorbidity on epilepsy burden, we conducted a 5-year retrospective analysis of data from a large safety-net healthcare network and compared the occurrence of negative health events (NHEs), defined as emergency department (ED) visits and hospitalizations, among individuals with epilepsy and mental illness (E–MI) vs. those with epilepsy alone (E). Methods Electronic health record (EHR) data from a large Midwestern U.S. safety-net healthcare system were queried to identify a study population of adults ≥ 18 years with a diagnosis of epilepsy, with or without mental illness. We assessed demographic and clinical characteristics for each of the 5 years and compared NHEs between subgroups with E–MI vs. E. An additional analysis focused on those individuals who remained in the healthcare system over the entire 5-year study time frame (January, 2010 to December, 2014). Annual and cumulative NHE counts and hospital length of stay for individuals with E–MI and E were assessed, as were hospital discharge diagnoses. Results The number (approximately 2000) and demographic characteristics of individuals with epilepsy who received care each year of the study period was relatively consistent. In 2014, mean age of individuals with epilepsy was 48 (range: 18–95), 48.2% were women, 51.5% were White, 37.9% were African-American, and 8.6% were Hispanic. In 2014, there were 1616 (78.6%) individuals in the subgroup with E and 439 (21.4%) in the subgroup with E–MI. Most clinical and demographic variables between the subgroups with E–MI and E were similar, except that individuals with E–MI were less likely to be employed or commercially insured. Overall, NHEs were common, with over 1/4 (27.5%) of all individuals with epilepsy having an ED visit during the year, 13.7% having hospitalization, and 34.2% having either an ED visit or hospitalization. Individuals with E–MI had significantly more NHEs compared to individuals with epilepsy only, as evidenced by higher rates of any NHE (p < .001), ED visits (p < .001), and hospitalizations (p < .001). The cumulative differential in ED and hospital use between subgroups with E–MI and E was substantial over a 5-year time period. While most NHEs were directly related to seizures for the overall group, substance-use complications appeared as a top reason for hospitalization only in the group with E–MI. Conclusions Individuals with E–MI made up just over 20% of all people with epilepsy in a safety-net system and had higher rates of NHEs than those without mental illness. Better and earlier identification of individuals with E–MI, assistance with self-management including helping individuals to optimize ambulatory care settings as opposed to the ED, and treatment for substance use disorders could eventually reduce NHEs in this vulnerable subgroup of individuals with epilepsy. [ABSTRACT FROM AUTHOR]

Objectives: To examine management strategies and goals reported by people diagnosed with chronic hepatitis C. Methods: We analyzed data from semistructured interviews (N=42) and from electronic sources [illness narratives (N=79) and Internet threaded discussions (N=264)]. Line-by-line coding, comparisons, and team discussions generated catalogs of lay management strategies and goals. We analyzed code-based files to identify informants' selection of specific strategies for each goal. Results: We classified lay management strategies into 3 categories: medical self-care, behavior change, and coping. These strategies were used selectively In addressing multiple goals, categorized as fighting the virus, strengthening the body, and managing consequences. Conclusions: Results underscore the diversity of strategies for living with a disease characterized by uncertain prognosis and variable expression of symptoms. [ABSTRACT FROM AUTHOR]

Background: Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C(HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not bea problem in the absence of their HCV diagnosis.Objective: This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.Design: We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N=50) and healthcare providers (N=14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.Results: We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients.Patient respondents who reported hearing “stop completely”were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in“medical language” than were GI providers.Conclusions: To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV. [ABSTRACT FROM AUTHOR]

Background: Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis.Objective: This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.Design: We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.Results: We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing "stop completely" were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in "medical language" than were GI providers.Conclusions: To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV. [ABSTRACT FROM AUTHOR]