Publications

Internalized HIV-related stigma undermines mental health, quality of life, and engagement in care among people living with HIV (PLHIV), yet data from Vietnam remain limited. We analyzed data from the 2020 PLHIV Stigma Index, a cross-sectional study conducted in seven provinces. Participants were recruited primarily from public outpatient HIV treatment clinics and through limited chain referral. Internalized stigma was assessed using the 6-item Internalized AIDS-Related Stigma Scale (IARSS); scores of 5-6 were classified as high internalized stigma. Among 1,623 participants (mean age 34.6 years, 74.6% male), the IARSS showed acceptable internal consistency (Cronbach's alpha = 0.74), and 29.4% had high internalized stigma. In the multivariable logistic regression, secondary/high school education (adjusted odds ratio [aOR]: 0.47, 95% confidence interval [CI]: 0.35-0.65), university/tertiary education (aOR: 0.34, 95% CI: 0.22-0.52), and more than 5 years since HIV diagnosis (aOR: 0.66, 95% CI: 0.49-0.89) were associated with lower odds of high internalized stigma. Higher odds were observed among participants with depression/anxiety symptoms (aOR: 2.02, 95% CI 1.56-2.62), those unaware of their partner's HIV status (aOR: 1.79, 95% CI 1.21-2.65), and those reporting community stigma or discrimination in the prior 12 months (aOR: 1.49, 95% CI 1.06-2.09); internalized stigma also varied by province. Internalized stigma remains common among PLHIV in Vietnam and appears shaped by psychological, relational, community, and geographic factors. Integrated mental health, stigma-reduction, and context-responsive interventions may help reduce internalized stigma.

Background: Anaphylaxis is a life-threatening allergic reaction that requires prompt epinephrine and post-treatment management. Guidelines recommend prescribing epinephrine at discharge from the emergency department (ED), yet results of studies show lower-than-recommended prescribing rates and variable ED lengths of stay (LOS). Large-scale analyses of adult anaphylaxis care in U.S. EDs remain limited. Objective: The objective was to estimate the proportion of adults discharged from U.S. EDs with an epinephrine prescription, characterize ED LOS, and identify predictors of these outcomes. Methods: We analyzed 2013-2015 and 2018-2022 National Hospital Ambulatory Medical Care Survey-ED visits for adults ages ≥ 18 years diagnosed with anaphylaxis who were discharged home. Outcomes were (1) epinephrine prescription at discharge and (2) ED LOS < 4 hours. Patients who arrived by emergency medical services (EMS) were excluded for LOS analysis. Multivariable log-binomial regression estimated risk ratios (RR) between outcomes and clinical predictors. Results: Among 609 ED visits, 14% resulted in an epinephrine prescription at discharge (95% confidence interval [CI], 10%-18%). The median (interquartile range) LOS was 138 minutes (80-199 minutes), with 83% discharged within 4 hours (95% CI, 78%-87%). Older adults (≥42 years) and Hispanic patients were less likely to receive an epinephrine prescription (RR 0.47 [95% CI, 0.25-0.90]; RR 0.34 [95% CI, 0.12-0.95], respectively). Rural visits were more likely to have LOS < 4 hours (RR 1.12 [95% CI, 1.02-1.23]). Conclusion: Epinephrine prescribing at discharge was infrequent across the full cohort, whereas ED LOS was typically brief among the patients who did not arrive by EMS. Older adults and Hispanic patients were less likely to receive epinephrine, and rural visits had shorter LOS. These findings highlight potential disparities in discharge prescribing and ED management of adult anaphylaxis in U.S. EDs.

Per- and polyfluoroalkyl substances (PFAS) and metals are ubiquitous environmental contaminants that have been individually linked to childhood adiposity, but their combined effects remain understudied. In the Project Viva cohort (n = 845), we evaluated joint associations of six first-trimester PFAS in plasma and five essential and six nonessential metals in erythrocytes with child and adolescent body mass index (BMI) z-scores and dual-energy X-ray absorptiometry (DXA) total and truncal fat mass indices. We used Bayesian kernel machine regression to evaluate joint associations of PFAS and metals with adiposity. Higher prenatal PFAS and nonessential metal mixture levels were significantly associated with higher mid-childhood and early adolescent BMI z-scores (75th vs 50th percentile: 0.17 [95% Credible Interval (CrI): 0.06, 0.28]; 0.14 [95% CrI: 0.02, 0.25]) and DXA total fat mass (0.17 kg/m2 [0.05, 0.30]; 0.20 kg/m2 [0.07, 0.32]), but not adiposity in late adolescence. Children with lower levels of the prenatal essential metal mixture had higher early and late adolescent DXA total fat mass (25th vs 50th percentile: 0.13 [0.04, 0.22]; 0.08 [0.01, 0.16]). Our findings underscore the importance of considering concurrent prenatal exposures across multiple chemical classes when evaluating environmental influences on child adiposity.

BACKGROUND: Unplanned readmission within 30 days following colorectal surgery occurs in up to 20% of older patients (≥65 years), representing a significant clinical and economic burden. Designing effective interventions to reduce readmission depends on whether risk factors are modifiable or actionable. This study identified and categorized the drivers of readmission, with a specific focus on actionable factors.

METHODS: We analyzed data from 49,021 elective colectomy and proctectomy cases aged ≥65 years and discharged home in the National Surgical Quality Improvement Program from 2016 to 2020 using univariate and multivariable logistic regression. We categorized factors associated with readmission in 4 groups: (1) comorbidities, (2) preoperative clinical characteristics and geriatric vulnerabilities, (3) surgical stressors, and (4) postoperative complications before discharge. We restricted our analytic cohort to patients aged ≥65 years who were initially discharged to their home. The primary outcome was a composite of unplanned readmission or 30-day mortality.

RESULTS: Unplanned readmission occurred in 4,569 (9.3%) of this sample; an additional 76 patients (0.2%) died within 30 days without a prior readmission, yielding a composite adverse outcome of 4,645 (9.5%). Among comorbidities, chronic heart failure (strongest predictor) (odds ratio, 1.96; 95% confidence interval, 1.49-2.53), insulin-dependent diabetes (odds ratio, 1.52; 95% confidence interval, 1.35-1.7), and chronic obstructive pulmonary disease (odds ratio, 1.38; 95% confidence interval, 1.23-1.55) were most strongly associated with readmission. Geriatric vulnerabilities included total functional dependence (strongest predictor) (odds ratio, 2.81; 95% confidence interval, 1.24-6.35) and preoperative hypoalbuminemia (<3.0 g/dL; odds ratio, 1.75; 95% confidence interval, 1.47-2.08). Surgical stressors-ostomy creation (odds ratio, 1.83; 95% confidence interval, 1.69-1.99), prolonged operations (>240 minutes; odds ratio, 1.87; 95% confidence interval, 1.71-2.05)-and complications (ileus: odds ratio, 5.56; 95% confidence interval, 5.16-5.98; and acute renal failure: odds ratio, 6.09; 95% confidence interval, 2.82-13.16) also increased risk.

DISCUSSION: Readmissions in older adults reflect the interplay of medical, geriatric, and surgical risks, some of which are modifiable or actionable. A holistic approach that integrates perioperative optimization (eg, malnutrition), proactive comorbidity control (eg, diuretic and insulin management), and tailored postdischarge monitoring and support may mitigate readmission rates.

STUDY OBJECTIVES: To compare end-of-life predictions as measured by the physician-answered surprise question (SQ), "Would you be surprised if this patient died in the next 6 months?"), the Geriatric End-of-Life Screening Tool (GEST) artificial intelligence (AI) model, and a new collaborative GEST+SQ model for predicting 6-month mortality in older emergency department (ED) patients.

METHODS: This was a single-site prospective cohort study (Nov 2022 to June 2023) at a tertiary academic ED of patients aged 65 years and older. Answers to the SQ were collected within the electronic health record at ED disposition and GEST scores were calculated from available records using laboratory, vital signs, demographic and historical data. Six-month mortality was adjudicated via electronic health record and state records. SQ and GEST were compared using sensitivity and specificity. A new logistic regression model was developed combining SQ and GEST (GEST+SQ) and compared with GEST alone, using area under receiver-operating characteristic curves (ROC-AUC) for discrimination and expected calibration error for calibration. We modeled a sequential screening pathway where low- and high-risk patients received only GEST screening, whereas intermediate-risk patients received both GEST and SQ, reporting the proportion of patients for whom adding the SQ to GEST would change a theoretical referral to intervention.

RESULTS: From 9,256 eligible patients, 3,479 had SQ responses (37.6%), with 13.3% 6-month mortality. When matching GEST sensitivity to SQ (83.8%), GEST had greater specificity than the SQ (61.5% [56.7 to 67.1] vs. 50.8% [49.1 to 52.6]). At matching specificity (50.8%), GEST sensitivity (90.0% [87.0 to 92.7]) exceeded the SQ (83.8% [80.3 to 87.0]). GEST had an receiver-operating characteristic - area under the curve (ROC-AUC) of 0.79 (0.77 to 0.81), whereas the GEST+SQ model had ROC-AUC of 0.80 (0.78 to 0.82). The GEST+SQ model had significantly improved expected calibration error of 0.01 (0.01 to 0.02) for GEST+SQ vs. 0.042 (0.03 to 0.05) for GEST alone. In a sequential screening pathway, as few as 5% of patients required SQ screening following GEST risk scoring.

CONCLUSION: GEST modestly outperformed the SQ for predicting 6-month mortality. A GEST+SQ collaborative model did not improve discrimination (ROC-AUC) over GEST alone, but improved calibration. Sequential screening using GEST and then the SQ for intermediate-risk patients could decrease physician screening burden by 95% relative to manual, SQ-only screening. Collaborative approaches integrating automated tools with targeted physician input may enhance ED mortality risk assessment while reducing clinician effort.

BACKGROUND: Female reproductive factors including menopausal age and number of live births have been associated with cardiovascular disease risk, but their role in atrial fibrillation (AF) is underexplored, especially in older adults.

METHODS: We analyzed data from the CHS (Cardiovascular Health Study), a US population-based longitudinal study of adults aged ≥65 years including 3065 women reporting their menopausal age and 3236 reporting number of live births at participation. We followed participants for incident AF until June 2015. NT-proBNP (N-terminal pro-B-type natriuretic peptide) was measured at baseline. Maximal P-wave duration, P-wave terminal force in V1, and P-wave dispersion were calculated from baseline ECGs. We assessed the associations of menopausal age, number of live births, and NT-proBNP and electrocardiographic findings with incident AF using linear regression and a Cox model.

RESULTS: After a median follow-up of 7.5 years, 1266 women (41.3%) developed AF. Each 5-year increase in menopausal age was associated with lower AF risk (hazard ratio [HR], 0.96 [95% CI, 0.92-1.00]). Menopausal age <40 years was associated with higher AF risk (HR, 1.21 [95% CI, 1.02-1.44]). No association was found between the number of live births and AF risk (HR, 0.98 [95% CI, 0.95-1.02]). Cross-sectional analyses showed younger menopausal age was associated with higher NT-proBNP levels, longer maximal P-wave duration, and longer P-wave dispersion.

CONCLUSIONS: Among women aged ≥65 years, earlier menopausal age was associated with higher NT-proBNP, longer P-wave duration, longer P-wave dispersion, and higher AF risk. Number of live births was not associated with these end points.

BACKGROUND: Whether to continue breast cancer screening beyond age 74 is uncertain. Decision aids may improve understanding of health information and support informed screening decisions. The goal of this study was to develop a video-based decision aid for breast cancer screening among older women using patient-centered design.

METHODS: Following the Framework for Innovation, the research team first used formative focus groups to understand older women's perspectives on mammography. We developed a prototype video based on decision aid best practices and formative focus group findings. We then evaluated the content, clarity, and style of the decision aid in cognitive testing focus groups. We made iterative changes to the video in response to focus group feedback. Focus groups included women age ≥ 70 without a personal history of breast cancer from Connecticut-area community and clinical settings. We coded and analyzed transcripts using both abductive and deductive approaches.

RESULTS: We convened 6 formative focus groups and 7 cognitive testing groups with 31 participants (mean age 78 [range 70-93]); 39% Black, 58% White, and 3% Latina. In focus groups, participants perceived screening as largely beneficial and saw overdiagnosis as unfamiliar. Some participants valued quantitative information about risks and benefits of screening, while others relied on experience, perceptions of risk, and beliefs about the efficacy of mammography to make screening decisions. We incorporated these perspectives into the framing, language, and narrative arc of the decision aid. In cognitive testing focus groups, participants found the decision aid informative and engaging.

DISCUSSION: Using a patient-centered approach, we developed a video-based decision aid for breast cancer screening for older women. Our design, which drew on the perspectives of older women, was perceived as easy to understand and informative. We will assess the impact of the decision aid on decision quality, decisional conflict, and intention to screen in future work.

BACKGROUND: Serum neurofilament light chain (NfL) is a biomarker of brain injury. We examined the associations of serum NfL concentration with able life and healthy life among older adults.

METHODS: We analyzed Cardiovascular Health Study participants with measured NfL and no history of stroke or transient ischemic attack (TIA). Over 13 years' follow-up, outcomes were years of life (YOL), years of able life (YAL), years of healthy life (YHL), and proportion of follow-up spent able (YAL/YOL%) or healthy (YHL/YOL%). "Able" was defined by independence in all activities of daily living, and "healthy" was defined by self-reported health status. Linear regression and linear spline regression models were used to estimate the difference in each outcome associated with a 50% increment in serum NfL, an increment within the range of the observed data.

RESULTS: Among 1957 participants (mean age 77.8; 61% female), in the adjusted linear model, each 50% increment in NfL was associated with 0.6 fewer YOL (95% CI: -0.7, -0.4), 0.7 fewer YAL (-0.8, -0.5), 0.5 fewer YHL (-0.7, -0.4), 2.9% lower YAL/YOL% (-4.0%, -1.7%) and 1.8% lower YHL/YOL% (-3.1%, -0.6%). Spline analysis showed the strongest associations at NfL of 19.7-33.9 pg/mL, where each 50% increment in NfL was associated with 6.5% lower YAL/YOL% (-9.4%, -3.6%) and 5.6% lower YHL/YOL% (-8.8%, -2.4%).

CONCLUSIONS: Higher serum NfL concentration was associated with less able and healthy life among older adults free of stroke or TIA. Further investigation of NfL, including longitudinal evaluation, is needed to understand its relationship with functional status.