Publications

Background

The US homeless population is aging. Older adults and those living in poverty are at a high risk of food insecurity.

Methods

We conducted a cross-sectional analysis of baseline data from a population-based study of 350 homeless adults aged ≥50. We assessed food security and receipt of food assistance. We used multivariable logistic regression to examine factors associated with very low food security.

Results

The majority of the cohort was male and African American. Over half (55.4%) met criteria for food insecurity, 24.3% reported very low food security. Half (51.7%) reported receiving monetary food assistance. In the multivariable model, those who were primarily sheltered in the prior 6 months, (multi-institution users [AOR = 0.44, 95% CI: 0.22-0.86]) had less than half the odds of very low food security compared with those who were unsheltered. Depressive symptoms (AOR = 3.01, 1.69-5.38), oral pain (AOR = 2.15, 1.24-3.74) and cognitive impairment (AOR = 2.21, 1.12-4.35) were associated with increased odds of very low food security.

Conclusions

Older homeless adults experience a high prevalence of food insecurity. To alleviate food insecurity in this population, targeted interventions must address specific risk groups.

Activation of TGF-β1 initiates a program of temporary collagen accumulation important to wound repair in many organs. However, the outcome of temporary extracellular matrix strengthening all too frequently morphs into progressive fibrosis, contributing to morbidity and mortality worldwide. To avoid this maladaptive outcome, TGF-β1 signaling is regulated at numerous levels and intimately connected to feedback signals that limit accumulation. Here, we examine the current understanding of the core functions of TGF-β1 in promoting collagen accumulation, parallel pathways that promote physiological repair, and pathological triggers that tip the balance toward progressive fibrosis. Implicit in better understanding of these processes is the identification of therapeutic opportunities that will need to be further advanced to limit or reverse organ fibrosis.

Cardiovascular involvement is measured by three items in the BILD index, so clearly it can play a role in overall levels of damage accumulation. However, efforts to unravel the impact of traditional versus SLE-specific risk factors remain challenging, and we are unable to examine these relationships with our current data. Moreover, we do not believe that the understanding of what drives cardiovascular disease in persons with SLE has progressed to the point to make this distinction more generally. This article is protected by copyright. All rights reserved.

PURPOSE

We compared the quality of care received by SLE patients in two settings within the same academic institution (Lupus Clinic, LC and General Rheumatology Clinic, GRC) using validated SLE quality measures (QM).

METHODS

150 consenting, consecutive SLE patients receiving longitudinal care at Rush University GRC (73) and subspecialty LC (77) were recruited. An updated QM survey and retrospective medical chart review was used for evaluation of each QM. The overall and individual (20) QM performance was calculated and compared between two groups. Data on number of SLE patients seen by each rheumatologist was collected to assess the relationship between SLE patient volume and QM.

RESULTS

Overall QM performance was significantly greater among LC SLE patients [85.8% vs. 70.2%, P= 0.001]. Differences noted among the two groups were in sunscreen counseling (98.7% vs. 83.6%, P=0.001), antiphospholipid antibody testing (71.4% vs. 37%, P< 0.001), pneumococcal vaccination (84.8% vs. 48.8%, P< 0.001), bone mineral density testing (94.2% vs. 54.5%, P<0.001), drug counseling (92.2% vs. 80.8%, P=0.04), steroid sparing agent and ACE inhibitor use (100% vs. 82%, P< 0.007 and 94.4% vs. 58.3%, P=0.03, respectively) and cardiovascular disease risk assessment (40.3% vs. 15.1%, P=0.01). There was a moderate correlation between the rheumatologists' number of SLE patients seen and QM performance (rho 0.48, P<0.001).

CONCLUSION

SLE patients seen in dedicated LC had better QM performance in this cross sectional single center study. In our health system, we also found indicators to suggest that rheumatologists with higher SLE patient-volume provide better quality of care. This article is protected by copyright. All rights reserved.

AIMS

Several published investigations demonstrated that a longer T-peak to T-end interval (Tpe) implies increased risk for ventricular tachyarrhythmia (VT/VF) and mortality. Tpe has been measured using diverse methods. We aimed to determine the optimal Tpe measurement method for screening purposes.

METHODS AND RESULTS

We evaluated 305 patients with LVEF ≤ 35% and an implantable cardioverter-defibrillator implanted for primary prevention. Tpe was measured using seven different methods described in the literature, including six manual methods and the automated algorithm '12SL', and was corrected for heart rate. Endpoints were VT/VF and death. To account for differences in the magnitude of Tpe measurements, results are expressed in standard deviation (SD) increments. We evaluated the clinical utility of each measurement method based on predictive ability, fraction of immeasurable tracings, and intra- and interobserver correlation. >Over 31 ± 23 months, 82 (27%) patients had VT/VF, and over 49 ± 21 months, 91 (30%) died. Several rate-corrected Tpe measurement methods predicted VT/VF (HR per SD 1.20-1.34; all P < 0.05), and nearly all methods (both corrected and uncorrected) predicted death (HR per SD 1.19-1.35; all P < 0.05). Optimal predictive ability, readability, and correlation were found in the automated 12SL method and the manual tangent method in lead V2.

CONCLUSION

For the prediction of VT/VF, the utility of Tpe depends upon the measurement method, but for the prediction of mortality, most published Tpe measurement methods are similarly predictive. Heart rate correction improves predictive ability. The automated 12SL method performs as well as any manual measurement, and among manual methods, lead V2 is most useful.

This paper advances research on racism and health by presenting a conceptual model that delineates pathways linking policing practices to HIV vulnerability among Black men who have sex with men in the urban USA. Pathways include perceived discrimination based on race, sexuality and gender performance, mental health, and condom-carrying behaviors. The model, intended to stimulate future empirical work, is based on a review of the literature and on ethnographic data collected in 2014 in New York City. This paper contributes to a growing body of work that examines policing practices as drivers of racial health disparities extending far beyond violence-related deaths.

IMPORTANCE

The Institute of Medicine described diagnostic error as the next frontier in patient safety and highlighted a critical need for better measurement tools.

OBJECTIVES

To estimate the proportions of emergency department (ED) visits attributable to symptoms of imminent ruptured abdominal aortic aneurysm (AAA), acute myocardial infarction (AMI), stroke, aortic dissection, and subarachnoid hemorrhage (SAH) that end in discharge without diagnosis; to evaluate longitudinal trends; and to identify patient characteristics independently associated with missed diagnostic opportunities.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cohort study of all Medicare claims for 2006 to 2014. The setting was hospital EDs in the United States. Participants included all fee-for-service Medicare patients admitted to the hospital during 2007 to 2014 for the conditions of interest. Hospice enrollees and patients with recent skilled nursing facility stays were excluded.

MAIN OUTCOMES AND MEASURES

The proportion of potential diagnostic opportunities missed in the ED was estimated using the difference between observed and expected ED discharges within 45 days of the index hospital admissions as the numerator, basing expected discharges on ED use by the same patients in earlier months. The denominator was estimated as the number of recognized emergencies (index hospital admissions) plus unrecognized emergencies (excess discharges).

RESULTS

There were 1 561 940 patients, including 17 963 hospitalized for ruptured AAA, 304 980 for AMI, 1 181 648 for stroke, 19 675 for aortic dissection, and 37 674 for SAH. The mean (SD) age was 77.9 (10.3) years; 8.9% were younger than 65 years, and 54.1% were female. The proportions of diagnostic opportunities missed in the ED were as follows: ruptured AAA (3.4%; 95% CI, 2.9%-4.0%), AMI (2.3%; 95% CI, 2.1%-2.4%), stroke (4.1%; 95% CI, 4.0%-4.2%), aortic dissection (4.5%; 95% CI, 3.9%-5.1%), and SAH (3.5%; 95% CI, 3.1%-3.9%). Longitudinal trends were either nonsignificant (AMI and aortic dissection) or increasing (ruptured AAA, stroke, and SAH). Patient characteristics associated with unrecognized emergencies included age younger than 65 years, dual eligibility for Medicare and Medicaid coverage, female sex, and each of the following chronic conditions: end-stage renal disease, dementia, depression, diabetes, cerebrovascular disease, hypertension, coronary artery disease, and chronic obstructive pulmonary disease.

CONCLUSIONS AND RELEVANCE

Among Medicare patients, opportunities to diagnose ruptured AAA, AMI, stroke, aortic dissection, and SAH are missed in less than 1 in 20 ED presentations. Further improvement may prove difficult.