Education Mediates Racial Disparities in Cognitive Impairment Among Older Adults With Schizophrenia.

OBJECTIVES: In the general population, the construct of race is associated with disparities in cognitive aging. There are notable racial group disparities and inequities among people living with schizophrenia (PLWSz). Despite the salience of the construct of race in schizophrenia, there remains a knowledge gap about racial disparities in cognitive impairment among older adults in this vulnerable population. Our study uses mediation analysis to examine racial disparities in cognitive impairment among older adults with schizophrenia. METHODS: We assess global cognition in PLWSz over age 55 with the Measurement and Treatment Research to Improve Cognition in Schizophrenia cognitive test battery in our "all-comer" sample (N = 64). The primary exposure is self-reported racial group. We examine mediation of cognitive impairment through educational attainment, adjusting for psychiatric illness severity, history of substance use, and vascular risk factors. RESULTS: There was a Black/non-Black group racial disparity in global cognitive score (-2.8, 95% CI: -4.4, -1.3) after adjusting for confounding and interaction. This disparity was significantly mediated by years of education. CONCLUSIONS: There are notable racial disparities in cognitive impairment among older adults with schizophrenia; however, differences in cognitive scores between racial groups are mediated by level of education. CLINICAL IMPLICATIONS: Social determinants of health, particularly educational attainment, are important risk factors for cognitive impairment in PLWSz and should be considered by clinicians. Early screening and assessment of cognitive symptoms is essential to addressing health disparities/inequalities among older adults living with schizophrenia. ABBREVIATIONS CDE: Controlled Direct EffectsHIV: Human Immunodeficiency VirusMATRICS: Measurement and Treatment Research to Improve Cognition in SchizophreniaMCCB: MATRICS Consensus Cognitive BatteryMTE: Marginal Total EffectsNDE: Natural Direct EffectsPANSS: Positive and Negative Symptom ScalePLWSz: People with schizophrenia.

Engagement in HIV care and viral suppression following changes in long-term opioid therapy for treatment for chronic pain.

Chronic pain is common among persons living with HIV and changes in opioid prescribing practices may complicate HIV care management. Using medical record data from a retrospective cohort study conducted January 1, 2012 to June 30, 2019 for 300 publicly insured HIV-positive primary care patients prescribed opioids for chronic non-cancer pain in San Francisco, we examined associations between opioid dose changes and both time to disengagement from HIV care and experiencing virologic failure using logistic regression. Discontinuation of prescribed opioids was associated with increased odds of disengagement in care at 3, 6, and 9 months after discontinuation. There were no associations with virologic failure. Providers and policy makers must weigh impacts on HIV care when implementing necessary changes in opioid prescribing.

Antiracist symptom science: A call to action and path forward.

Nurse scientists recognize the experience of racism as a driving force behind health. However, symptom science, a pillar of nursing, has rarely considered contributions of racism. Our objective is to describe findings within symptom science research related to racial disparities and/or experiences of racism and to promote antiracist symptom science within nursing research. In this manuscript, we use an antiracist lens to review a predominant symptom science theory and literature in three areas of symptom science research-oncology, mental health, and perinatal health. Finally, we make recommendations for increasing antiracist research in symptom science by altering (a) research questions, (b) recruitment methods, (c) study design, (d) data analysis, and (e) dissemination of findings. Traditionally, symptom science focuses on individual level factors rather than broader contexts driving symptom experience and management. We urge symptom science researchers to embrace antiracism by designing research with the specific intent of dismantling racism at multiple levels.

"Looking Forward": a qualitative evaluation of a physical activity program for middle-aged and older adults with serious mental illness.

OBJECTIVES: Older adults with serious mental illness (SMI) often have poor physical health in addition to serious mental health issues. Sustained engagement in a group physical activity program may provide necessary physical and mental health benefits. The purpose of this report is to describe participants' feedback about a video game-based group physical activity program using the Kinect for Xbox 360 game system (Microsoft, Redmond, WA). In particular, we wanted to understand what worked about the program, what was not ideal, and how it impacted their lives. DESIGN: Semi-structured interviews were collected and analyzed with grounded theory methodology. SETTING: Mental health facility. PARTICIPANTS: Sixteen older adults with SMI. MEASUREMENTS: Participants played an active video game for 50-minute sessions, three times a week for 10 weeks. Qualitative interviews were conducted with 16 participants upon completion of the program. RESULTS: Participants expressed enthusiasm for the physical activity program, indicating it was an activity that they looked forward to doing. The results of the study provide insight into how the program may be implemented into practice at mental health facilities. Three implementation to practice categories were identified: (1) programmatic considerations, such as when to hold the groups and where; (2) the critical importance of staff involvement; and (3) harnessing patients' interest in the program. CONCLUSION: Our results suggest that engagement in an intense video game-based group physical activity program has a positive impact on participants' overall health. The group atmosphere, staff involvement, availability of the program at a mental health facility, and health benefits were critical.

Play provides social connection for older adults with serious mental illness: A grounded theory analysis of a 10-week exergame intervention.

Introduction: The number of older adults with serious mental illness (SMI) is predicted to reach 15 million by 2030. Social isolation is known to contribute to morbidity and mortality, and those with SMI experience more social isolation than older adults in the general population. Social isolation in these older adults is complex and involves factors including organic psychopathology, effects of medications and/or other substances, medical co-morbidity, disability, and social stigma. The burgeoning field of inquiry of exergames, which are video games with gestural interfaces, for older adults has found that they are safe, effective, enjoyable, and may decrease social isolation. This qualitative study was conducted to gain insight into the effects of group exergame play on the psychosocial wellbeing of older adults with SMI.Methods: We explored the psychosocial effects of a 10-week group exergame program for 16 older adults with SMI using grounded theory methodology within a symbolic interactionist framework.Results: Participants experienced positive social contact, engaged in social attunement, and expressed motivation to take risks and face problem-solving and physical challenges. Two interrelated concepts emerged from the integrated data: Social connectedness and competence. The theoretical construct that was abducted from these concepts was that play and playfulness were the vehicle for many interacting social processes to take place.Conclusion: Group play through exergames for older adults with SMI may promote recovery and healthy aging by increasing social integration, improving self-efficacy, and promoting physical health through exercise.

The Applicability of Resilience Training to the Mitigation of Trauma-Related Mental Illness in Military Personnel [Formula: see text].

BACKGROUND: Ongoing participation by the United States in military operations around the world places military personnel at an increased potential for exposure to trauma, which may directly result in an increased risk for mental health issues. It is important to develop and test new approaches to prevent and mitigate the effects of trauma in military personnel. One such area of research is focused on psychological resilience to prevent the sequelae of trauma. OBJECTIVES: This article examines empirical research of resilience training in military personnel and discusses the potential applicability of such training in this population. DESIGN: In this literature review, four randomized control trials and one retrospective, parallel group study were reviewed. RESULTS: Each intervention had the goal of mitigating behavioral health issues after trauma exposure. The results of the various interventions were wide-ranging from no measurable difference in treatment groups to significant differences in outcomes. CONCLUSIONS: Despite the inconclusive results of our review, we have determined that resilience training for active duty service members to help prevent the deleterious effects of trauma on mental health is a compelling and necessary avenue for further research.

Continued Homelessness and Depressive Symptoms in Older Adults.

Importance: Depression is common in adults experiencing homelessness. It is unclear whether continued homelessness is associated with more depressive symptoms. Objective: To examine the association between residential status and depressive symptoms in adults aged 50 years or older experiencing homelessness at study entry. Design, Setting, and Participants: This cohort study analyzed results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age (HOPE HOME) project, which in 2013 began enrolling adults aged 50 years or older experiencing homelessness in Oakland, California, and conducted structured interviews every 6 months for a mean duration of 5.5 years through 2023 (for this cohort study). Eligible participants included those aged 50 years or older, able to speak English, and experiencing homelessness at enrollment. We analyzed data collected from 2013 to 2023. Exposures: The exposure of interest was residential status. At follow-up visits, residential status was categorized as (1) homelessness (meeting the HEARTH [Homeless Emergency Assistance and Rapid Transition to Housing] Act definition) or (2) housed (living in a noninstitutional environment and not meeting the HEARTH Act definition). Main Outcomes and Measures: The primary outcome was moderate to severe depressive symptoms (with Center for Epidemiologic Studies-Depression [CES-D] scale score ≥22). The augmented inverse probability of treatment weighting (AIPTW) approach was used to examine the association between continued homelessness and depressive symptoms. The AIPTW adjusted for the following variables: number of chronic health conditions, age, sex, visiting a health care practitioner, receiving outpatient mental health treatment, receiving mental health medication, exposure to abuse, substance use disorder, and binge drinking. Results: The cohort was composed of 450 participants, of whom 343 (76.2%) were males, and the mean (SD) age was 58.5 (5.2) years. Participants completed a median (IQR) of 8.9 (8-11) follow-up visits. With 1640 person-years of observation time, participants continued homelessness for 880 person-years (57.1%) and experienced being housed for 715 person-years (44.3%). Many participants (304 [78.0%]) were housed during at least 1 follow-up visit. The odds of a CES-D scale score of 22 or higher was significantly higher among participants who continued experiencing homelessness than among housed participants (marginal causal odds ratio, 1.08; 95% CI, 1.04-1.11; P < .001). Conclusions and Relevance: This cohort study found that continued homelessness was associated independently with increased odds of depressive symptoms. Obtaining housing may have a favorable role in depression and overall well-being of older adults experiencing homelessness and may be considered as a mental health intervention.

The Howard Street Method: A Community Pharmacy-led Low Dose Overlap Buprenorphine Initiation Protocol for Individuals Using Fentanyl.

OBJECTIVES: Buprenorphine treatment significantly reduces morbidity and mortality for people with opioid use disorder. Fear of precipitated withdrawal remains a barrier to starting buprenorphine for patients who use synthetic opioids, particularly fentanyl. We aim to evaluate the development and implementation of a buprenorphine low dose overlap initiation (LDOI) protocol in an urban public health community pharmacy. METHODS: We performed a retrospective chart review of patients with nonprescribed fentanyl use (N = 27) to examine clinical outcomes of a buprenorphine LDOI schedule, named the Howard Street Method, dispensed from a community pharmacy in San Francisco from January to December 2020. RESULTS: Twenty-seven patients were prescribed the Howard Street Method. Twenty-six patients picked up the prescription and 14 completed the protocol. Of those who completed the protocol, 11 (79%) reported no symptoms of withdrawal and 3 (21%) reported mild symptoms. Four patients (29%) reported cessation of full opioid agonist use and 10 (71%) reported reduction in their use by the end of the protocol. At 30 days, 12 patients (86%) were retained in care and 10 (71%) continued buprenorphine. At 180 days, 6 patients (43%) were retained in care and 2 (14%) were still receiving buprenorphine treatment. CONCLUSIONS: We found that a LDOI blister-pack protocol based at a community pharmacy was a viable intervention for starting buprenorphine treatment and a promising alternative method for buprenorphine initiation in an underresourced, safety-net population of people using fentanyl.

Racial variation in timing of pyeloplasty: prenatal versus postnatal diagnosis.

PURPOSE: We have previously shown that nonwhite patients with ureteropelvic junction obstruction undergo pyeloplasty at a younger age than white patients. The mechanisms behind this finding are unclear, since there is no known racial variation in the natural history of ureteropelvic junction obstruction. We used a detailed clinical database to explain this phenomenon. MATERIALS AND METHODS: We retrospectively reviewed all patients undergoing primary pyeloplasty at our institution between 1992 and 2008. More than 360 data points were abstracted for each patient, including self-reported race, socioeconomic status, symptom duration and presentation. RESULTS: Of 847 patients undergoing pyeloplasty during the study period 741 met inclusion criteria. Nonwhite patients underwent surgery at a younger age (0.6 years) than whites (2.6 years, p <0.0001). When stratified by timing of clinical presentation (prenatal vs postnatal), there was no significant difference in race among patients presenting prenatally (0.37 vs 0.36 years, p = 0.22). Nonwhite patients presenting postnatally were significantly younger than white patients (6.3 vs 8.2 years, p = 0.03). This finding appeared to be due to differences in age at initial clinical presentation (5.4 vs 7.0 years, p = 0.03) and in time from initial clinical presentation to urological evaluation (0.6 vs 3.2 months, p = 0.03). These differences persisted after correcting for other factors, including markers of socioeconomic status. CONCLUSIONS: Consistent with previous studies, we found that nonwhite patients underwent primary pyeloplasty at a younger age than whites. This difference is limited to patients presenting after birth. Prenatally diagnosed patients underwent surgery at similar ages regardless of race.

Assessing Health Span in Caenorhabditis elegans: Lessons From Short-Lived Mutants.

Genetic changes resulting in increased life span are often positively associated with enhanced stress resistance and somatic maintenance. A recent study found that certain long-lived Caenorhabditis elegans mutants spent a decreased proportion of total life in a healthy state compared with controls, raising concerns about how the relationship between health and longevity is assessed. We evaluated seven markers of health and two health-span models for their suitability in assessing age-associated health in invertebrates using C elegans strains not expected to outperform wild-type animals. Additionally, we used an empirical method to determine the transition point into failing health based on the greatest rate of change with age for each marker. As expected, animals with mutations causing sickness or accelerated aging had reduced health span when compared chronologically to wild-type animals. Physiological health span, the proportion of total life spent healthy, was reduced for locomotion markers in chronically ill mutants, but, surprisingly, was extended for thermotolerance. In contrast, all short-lived mutants had reduced "quality-of-life" in another model recently employed for assessing invertebrate health. Results suggest that the interpretation of physiological health span is not straightforward, possibly because it factors out time and thus does not account for the added cost of extrinsic forces on longer-lived strains.

Nurses in Supportive Housing are Associated With Decreased Health Care Utilization and Improved HIV Biomarkers in Formerly Homeless Adults.

A San Francisco study conducted in 2008 showed that the permanent supportive housing program, Direct Access to Housing, dramatically decreased the risk of death in people living with HIV. In our study, we compared the health care utilization patterns and HIV-related biological markers of formerly homeless adults with HIV before and during two types of permanent supportive housing: (a) housing with on-site nursing care for residents, and (b) housing without on-site nursing care. Using nearest-neighbor matching with propensity scoring, the difference in outcomes was calculated. In the matched analysis, adjusted for adherence to combination antiretroviral therapy, people housed at sites with nurses had 4.8 fewer emergency department visits per person (SE: 1.53, p < .01), and they had an increased mean CD4+ T cell count (101.14 cells per person [SE: 55.10, p < .05]) compared to those who lived at sites without nurses.

Misclassification of acute respiratory distress syndrome after traumatic injury: The cost of less rigorous approaches.

BACKGROUND: Adherence to rigorous research protocols for identifying adult respiratory distress syndrome (ARDS) after trauma is variable. To examine how misclassification of ARDS may bias observational studies in trauma populations, we evaluated the agreement of two methods for adjudicating ARDS after trauma: the current gold standard, direct review of chest radiographs and review of dictated radiology reports, a commonly used alternative. METHODS: This nested cohort study included 123 mechanically ventilated patients between 2005 and 2008, with at least one PaO2/FIO2 less than 300 within the first 8 days of admission. Two blinded physician investigators adjudicated ARDS by two methods. The investigators directly reviewed all chest radiographs to evaluate for bilateral infiltrates. Several months later, blinded to their previous assessments, they adjudicated ARDS using a standardized rubric to classify radiology reports. A κ statistics was calculated. Regression analyses quantified the association between established risk factors as well as important clinical outcomes and ARDS determined by the aforementioned methods as well as hypoxemia as a surrogate marker. RESULTS: The κ was 0.47 for the observed agreement between ARDS adjudicated by direct review of chest radiographs and ARDS adjudicated by review of radiology reports. Both the magnitude and direction of bias on the estimates of association between ARDS and established risk factors as well as clinical outcomes varied by method of adjudication. CONCLUSION: Classification of ARDS by review of dictated radiology reports had only moderate agreement with the current gold standard, ARDS adjudicated by direct review of chest radiographs. While the misclassification of ARDS had varied effects on the estimates of associations with established risk factors, it tended to weaken the association of ARDS with important clinical outcomes. A standardized approach to ARDS adjudication after trauma by direct review of chest radiographs will minimize misclassification bias in future observational studies. LEVEL OF EVIDENCE: Diagnostic study, level II.

Hospital-based violence intervention: risk reduction resources that are essential for success.

INTRODUCTION: Hospital-based violence intervention programs (VIPs) aim to reduce violent injury and recidivism. The aim of this study was to determine the most significant risk reduction variables associated with success in our VIP. We hypothesized that our recidivism rate declined since VIP's inception and that we could identify risk reduction variables that were independent determinants of program success. METHODS: We analyzed our prospectively collected data for 2005-2011 from our VIP database. Success was defined as more than 50% needs met without recidivism or attrition. Impact and outcome evaluation was performed per a model promoted by the Centers for Disease Control. Rates of risk reduction and injury recidivism were calculated. Case management time spent per client (dose) was defined as low (0-1 hours per week), medium (1-3 hours per week), moderate (3-6 hours per week), and high (>6 hours per week). Correlation coefficients and logistic regression were used to examine associations between variables and success in the VIP. RESULTS: Two hundred fifty-four clients received services. Meeting needs in mental health (odds ratio, 5.97; 95% confidence interval, 2.72-13.07) and employment (odds ratio, 4.41:95% confidence interval, 1.56-12.46) proved significantly associated with success (p < 0.005). The 6-year program recidivism rate was 4% versus historical control of 16% (p < 0.05). Moderate and high exposure to intensive case management in the first 3 months was also significantly associated with success (p < 0.05). Success in our VIP was not associated with age, gender, education level, previous incarceration, probation status, or length of time in program. DISCUSSION: For 6 years, our recidivism rate has decreased fourfold compared with the rate before VIP inception. For startup and maintenance of a VIP, it is essential to know where to focus collaborative efforts in communities to target the most critical risk reduction resources. This study provides guidance-securing mental health care and employment for our clients appears to be predictive of success. The value of early "high-dose" intensive case management is also essential for reducing recidivism. LEVEL OF EVIDENCE: Care management study, level III.

Using trauma center data to identify missed bicycle injuries and their associated costs.

BACKGROUND: Recently, there has been a 58% increase in the number of observed cyclists in San Francisco. In 2009, 3.2% of commuters were traveling by bicycle in this city, which is well above the national average of less than 1%. Police reports are the industry standard for assessing transportation-related collisions and informing policies and interventions that address the issue. Previous studies have suggested that police reports miss a substantial portion of bicycle crashes not involving motor vehicles. No study to date has explored the health and economic impact of cyclist-only (CO) injuries for adults in the United States. Our objective was to use trauma registry data to investigate possible underrepresentation of certain cyclist injuries and characterize cost. METHODS: We reviewed hospital and police records for 2,504 patients treated for bicycle-related injuries at San Francisco General Hospital (SFGH). We compared incidence, injury severity, admission rate, and cost of injury for CO and auto-versus-bicycle (AVB) injuries treated at SFGH. We then calculated the cost of injury. RESULTS: Of all bicycle-related injuries at SFGH, 41.5% were CO injuries and 58.5% were AVB injuries. Those with CO injuries were more than four times as likely to be required of hospital admission compared with those with AVB injuries (odds ratio, 4.76; 95% confidence interval, 3.93-5.76; p < 0.0001). From 2000 to 2009, 54.5% of bicycle injuries treated at SFGH were not associated with a police report, revealing that bicycle crashes and injuries are underrecognized in San Francisco. Costs for care were significantly higher for AVB injuries and increased dramatically over time; total cost for CO and AVB injuries were $12.6 and $17.8 million. CONCLUSION: Based on this study, we conclude that trauma centers can play a key role in future collaborations to define issues and develop prevention strategies for CO crashes. LEVEL OF EVIDENCE: Epidemiologic study, level II.