AbstractObjectivesWe are often confronted in public health by associations that vary by population or subpopulation. Much effort has focused on the statistical and biological interpretation of such ...effect measure modification (EMM) because of the importance to public health. However, EMM remains difficult to conceptualize because it apparently violates everyday understanding of causes as usually acting consistently, making it difficult to predict when EMM may occur and raises questions about how to determine the external validity of interventions without extensive retesting by population or subpopulation. Study Design and SettingMethods exposition. ResultsWe propose that EMM can be thought of as mediation of an intervention (or exposure) on outcome by mechanism(s) whose relevance differs between population groups, which can be illustrated in causal diagrams, that is, directed acyclic graphs and selection diagrams, meaning external validity can be formally considered as mediation according to “selection variables.” EMM can then be represented graphically and its consequences predicted. ConclusionThis new conceptualization of EMM transforms EMM from a concept that violates everyday understanding of causes into an insight generating means of thinking about interventions (or exposures) in terms of their mediating mechanism(s) and corresponding population- or subpopulation-specific attributes to help target interventions effectively.
Introduction This study examined feasibility of a place-based community health worker (CHW) and health advocate (HA) initiative in five public housing developments selected for high chronic disease ...burden and described early outcomes. Methods This intervention was informed by a mixed-method needs assessment performed December 2014–January 2015 (representative telephone survey, n =1,663; six focus groups, n =55). Evaluation design was a non-randomized, controlled quasi-experiment. Intake and 3-month follow-up data were collected February–December 2015 (follow-up response rate, 93%) on 224 intervention and 176 comparison participants, and analyzed in 2016. All participants self-reported diagnoses of hypertension, diabetes, or asthma. The intervention consisted of chronic disease self-management and goal setting through six individual CHW-led health coaching sessions, instrumental support, and facilitated access to insurance/clinical care navigation from community-based HAs. Feasibility measures included CHW service satisfaction and successful goal setting. Preliminary outcomes included clinical measures (blood pressure, BMI); disease management behaviors and self-efficacy; and preventive behaviors (physical activity). Results At the 3-month follow-up, nearly all intervention participants reported high satisfaction with their CHW (90%) and HA (76%). Intervention participants showed significant improvements in self-reported physical activity ( p =0.005) and, among hypertensive participants, self-reported routine blood pressure self-monitoring ( p =0.013) compared with comparison participants. No improvements were observed in self-efficacy or clinical measures at the 3-month follow-up. Conclusions Housing-based initiatives involving CHW and HA teams are acceptable to public housing residents and can be effectively implemented to achieve rapid improvements in physical activity and chronic disease self-management. At 3-month assessment, additional time and efforts are required to improve clinical outcomes.
While health care-associated financial burdens among uninsured individuals are well described, few studies have systematically characterized the array of financial and logistical complications faced ...by insured individuals with low household incomes. In this mixed methods paper, we conducted 6 focus groups with a total of 55 residents and analyzed programmatic administrative records to characterize the specific financial and logistic barriers faced by residents living in public housing in East and Central Harlem, New York City (NYC). Participants included individuals who enrolled in a municipal community health worker (CHW) program designed to close equity gaps in health and social outcomes. Dedicated health advocates (HAs) were explicitly paired with CHWs to provide health insurance and health care navigational assistance. We describe the needs of 150 residents with reported financial barriers to care, as well as the navigational and advocacy strategies taken by HAs to address them. Finally, we outline state-level policy recommendations to help ameliorate the problems experienced by participants. The model of paired CHW–HAs may be helpful in addressing financial barriers for insured populations with low household income and reducing health disparities in other communities.
Abstract Electrosurgical generator units (ESUs) are instrumental in modern therapeutic gastrointestinal (GI) endoscopy, converting household alternating current into high-frequency current to ...generate thermal energy within tissues. This review elucidates the essentials of electrosurgery, exploring the thermal effects on tissue, current resistance, voltage, current density, duty cycle, crest factor, and the distinctions between monopolar and bipolar circuitry. The concept of duty cycle, the proportion of time electrical current is delivered, and crest factor, the ratio of peak to root mean square voltage, are essential while comparing differently named modes across various commercially available ESUs. This article discusses the practical applications of electrosurgery in therapeutic GI endoscopy procedures, including endoscopic sphincterotomy, polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, and peroral endoscopic myotomy. It outlines recommended modes and settings for ESUs across various procedures, emphasizing the balance between cutting and coagulation to achieve optimal outcomes while minimizing adverse effects. The review further addresses special considerations for the use of grounding pads and the management of patients with implanted cardiac devices during electrosurgical procedures. This article concludes with a call for a deeper understanding of electrosurgical principles and their application in GI endoscopy to ensure patient safety and procedural success, backed by references to relevant literature and detailed tables summarizing electrosurgical modes and settings for various therapeutic interventions.
Physical activity is protective against type 2 diabetes (T2D) incidence and supports T2D management. Access to local facilities such as gyms and parks enables leisure-time physical activity (LTPA) . ...We examined associations between T2D patients’ access to LTPA facilities and parks and whether repeated A1C follow-up tests were within a desired range. We analyzed data on 271,5 patients from the Veterans Administration Diabetes Risk Cohort who developed T2D from 2008-2018. We measured an A1C test as in-range if 5.0-7.0 (<80 years of age) or 5.0-8.5 (≥80 years of age) , density of facilities within street network buffers, and population-weighted distance to the closest 7 parks. We used generalized estimating equations with a logit link function to predict the log odds of an in-range vs. out-of-range A1C test. We tested environment-by-time interactions, controlling for individual and neighborhood demographics and baseline A1C. On average, patients were 60 years of age, male (95%) , white (71%) , and had A1C tests during follow-up. Higher facility density, but not park distance, was narrowly associated with lower odds ofan in-range A1C test (ORdensity=.99, 95% CI=.98, 1.0) . As years since T2D diagnosis increased, the odds of an in-range A1C test decreased (ORtime=.88, 95% CI=.88, .88) . For those living in higher facility density, the odds of an in-range A1C decreased over time by only a slightly lower factor than for those living in lower facility density (P<.0 for interaction term) . For those living farther from parks, the odds of an in-range A1C decreased over time by only a slightly higher factor than for those living closer to parks (P=.001) . As odds of in-range A1C tests decline over time, broader access to facilities and parks may not soften the decline since the modified effects were clinically negligible. Viable interventions for maintaining healthy A1C after diagnosis may include efforts to both increase access to and promote the use of the LTPA environment.
Disclosure
S.L.Orstad: None. P.M.Lopez: None. S.Adhikari: Research Support; Johnson & Johnson. D.C.Lee: None. R.Kanchi: None. M.D.Schwartz: None. F.Alemi: None. B.Elbel: None. L.Thorpe: None.
Funding
This study was funded by the Centers for Disease Control and Prevention (5 U01DP006299-02-00; PI: Lorna Thorpe)
Introduction: This study applies a novel epidemiologic approach to perform temporal, multilevel analysis of nationally representative, repeated cross-sectional data to assess the relationship between ...diabetes and various county-level environmental measures, including socioeconomic context, walkability, and the food environment.
Methods: We obtained data from the 2003-2012 Behavioral Risk Factor Surveillance System, an ongoing, nationally representative, cross-sectional telephone survey of the U.S. noninstitutionalized population ages ≥ 18 years. County-level variables included economic (unemployment), food (convenience store and fast food density), and built environment (active commuting) measures. Using random-effects within-between (REWB), we fit a logistic mixed-effects model to estimate associations between community exposures and odds of prevalent diabetes, adjusted for individual-level demographic and other characteristics. REWB models incorporate temporality into analyses of repeated cross-sectional surveys by using group-mean-centering.
Results: Age-adjusted diabetes prevalence across the study period was 7.9%. County unemployment, fast food density, and convenience store density were positively associated with diabetes prevalence, and active commuting had an inverse association. Odds ratios ranged from 0.95 for an increment in active commuting to 1.05 for convenience store density. Within-county associations were attenuated for convenience stores and fast food restaurants, but within-county change in active commuting was higher (aOR: 0.92; 95% CI: 0.82, 1.02).
Discussion: These analyses demonstrate the utility of REWB models in evaluating effects of group-level exposures on diabetes risk using repeated cross-sectional survey data and provide preliminary evidence towards our hypotheses of community-level drivers of diabetes risk.
Disclosure
P.M. Lopez: None. J. Feldman: None. P.E. Rummo: None. B. Elbel: None. L. Thorpe: None.
PurposeThe veterans administration diabetes risk (VADR) cohort facilitates studies on temporal and geographic patterns of pre-diabetes and diabetes, as well as targeted studies of their predictors. ...The cohort provides an infrastructure for examination of novel individual and community-level risk factors for diabetes and their consequences among veterans. This cohort also establishes a baseline against which to assess the impact of national or regional strategies to prevent diabetes in veterans.ParticipantsThe VADR cohort includes all 6 082 018 veterans in the USA enrolled in the veteran administration (VA) for primary care who were diabetes-free as of 1 January 2008 and who had at least two diabetes-free visits to a VA primary care service at least 30 days apart within any 5-year period since 1 January 2003, or veterans subsequently enrolled and were diabetes-free at cohort entry through 31 December 2016. Cohort subjects were followed from the date of cohort entry until censure defined as date of incident diabetes, loss to follow-up of 2 years, death or until 31 December 2018.Findings to dateThe incidence rate of type 2 diabetes in this cohort of over 6 million veterans followed for a median of 5.5 years (over 35 million person-years (PY)) was 26 per 1000 PY. During the study period, 8.5% of the cohort were lost to follow-up and 17.7% died. Many demographic, comorbidity and other clinical variables were more prevalent among patients with incident diabetes.Future plansThis cohort will be used to study community-level risk factors for diabetes, such as attributes of the food environment and neighbourhood socioeconomic status via geospatial linkage to residence address information.
To examine how the choice of neighborhood food environment definition impacts the association with diet.
Using food frequency questionnaire data from the Reasons for Geographic and Racial Differences ...in Stroke study at baseline (2003–2007), we calculated participants’ dietary inflammation score (DIS) (n = 20,331); higher scores indicate greater pro-inflammatory exposure. We characterized availability of supermarkets and fast food restaurants using several geospatial measures, including density (i.e., counts/km2) and relative measures (i.e., percentage of all food stores or restaurants); and various buffer distances, including administrative units (census tract) and empirically derived buffers (“classic” network, “sausage” network) tailored to community type (higher density urban, lower density urban, suburban/small town, rural). Using generalized estimating equations, we estimated the association between each geospatial measure and DIS, controlling for individual- and neighborhood-level sociodemographics.
The choice of buffer-based measure did not change the direction or magnitude of associations with DIS. Effect estimates derived from administrative units were smaller than those derived from tailored empirically derived buffer measures. Substantively, a 10% increase in the percentage of fast food restaurants using a “classic” network buffer was associated with a 6.3 (SE = 1.17) point higher DIS (P< .001). The relationship between the percentage of supermarkets and DIS, however, was null. We observed high correlation coefficients between buffer-based density measures of supermarkets and fast food restaurants (r = 0.73–0.83), which made it difficult to estimate independent associations by food outlet type.
Researchers should tailor buffer-based measures to community type in future studies, and carefully consider the theoretical and statistical implications for choosing relative (vs. absolute) measures.
South Asians experience a disproportionate burden of high blood pressure (BP) in the United States, arguably the most preventable risk factor for cardiovascular disease.
We report 12-month results of ...an electronic health record (EHR)-based intervention, as a component of a larger project, "Implementing Million Hearts for Provider and Community Transformation." The EHR intervention included launching hypertension patient registries and implementing culturally tailored alerts and order sets to improve hypertension control among patients treated in 14 New York City practices located in predominantly South Asian immigrant neighborhoods.
Using a modified stepped-wedge quasi-experimental study design, practice-level EHR data were extracted, and individual-level data were obtained on a subset of patients insured by a Medicaid insurer via their data warehouse. The primary aggregate outcome was change in proportion of hypertensive patients with controlled BP; individual-level outcomes included average systolic BP (SBP) and diastolic BP (DBP) at last clinic visit. Qualitative interviews were conducted to assess intervention feasibility.
Hypertension was defined as having at least 1 hypertension ICD-9/10 code. Well-controlled hypertension was defined as SBP<140 and DBP<90 mm Hg.
Postintervention, we observed a significant improvement in hypertension control at the practice level, adjusting for age and sex patient composition (adjusted relative risk, 1.09; 95% confidence interval, 1.04-1.14). Among the subset of Medicaid patients, we observed a significant reduction in average SBP and DBP adjusting for time, age, and sex, by 1.71 and 1.13 mm Hg, respectively (P<0.05). Providers reported feeling supported and satisfied with EHR components.
EHR initiatives in practices serving immigrants and minorities may enhance practice capabilities to improve hypertension control.
Evidence for the existence of condensed-phase isomers of silver-lipoate clusters, Ag29(LA)12, where LA = (R)-α lipoic acid, was obtained by reversed-phase ion-pair liquid chromatography with in-line ...UV–vis and electrospray ionization (ESI)-MS detection. All components of a raw mixture were separated according to surface chemistry and increasing size via reversed-phase gradient HPLC methods and identified by their corresponding m/z ratio by ESI in the negative ionization mode. Aqueous and methanol mobile-phase mixtures, each containing 400 mM hexafluoroisopropanol (HFIP)–15 mM triethylamine (TEA), were employed to facilitate the interaction between the clusters and stationary phase via formation of ion-pairs. TEA-HFIP (triethylammonium-hexafluoroisopropoxide) had been shown to provide superior chromatographic peak shape and mass spectral signal compared with alternative modifiers such as TEAA (triethylammonium-acetate) for analysis of oligonucleotide samples. Liquid chromatographic separation prior to mass spectrometry detection facilitated sample analysis by production of simplified mass spectra for each eluting cluster species and provided insight into the existence of at least two major solution-phase isomers of Ag29(LA)12. UV–vis detection in-line with ESI analysis provided independent confirmation of the existence of the isomers and their similar electronic structure as judged from their identical optical spectra in the 300–500 nm range. Diastereomerism provides a possible interpretation for the near-equal abundance of the two forms, based on a structurally defined nonaqueous homologue.
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