Oral health and access to dental care among older homeless adults: results from the HOPE HOME study.

OBJECTIVES: To describe the prevalence of and factors associated with oral health measures in a sample of older homeless adults in Oakland, CA. METHODS: We conducted a cross-sectional analysis of data from a population-based study of 350 homeless adults aged ≥50 in which trained researchers conducted structured interviews using validated questions regarding sociodemographics, health-related behaviors, healthcare utilization, and health status. We assessed self-reported tooth loss, oral pain, and unmet need for dental care. We used multivariable logistic regression to examine factors associated with missing half or more teeth. RESULTS: Over half 201/350 (57.4 percent) of participants were missing at least half of their teeth. Half 191/350 (54.6 percent) reported oral pain in the past 6 months; 101/350 (28.9 percent) reported that oral pain prevented them from eating and 73/350 (20.9 percent) reported that pain prevented sleeping. Almost half, 141/350 (40.3 percent), had not seen a dentist in over 5 years, and over half 190/350 (54.3 percent) reported being unable to obtain needed dental care. In multivariate models, increased age (AOR = 1.09, 95 percent CI 1.04-1.14), moderate-to-high risk alcohol use (AOR = 2.17, CI = 1.23-3.84), moderate-to-high risk cocaine use (AOR = 1.72, CI = 1.03-2.88), and ever smoking (AOR = 2.87, CI = 1.59-5.18) were associated with an increased odds of having lost half or more teeth. CONCLUSIONS: Tooth loss and oral pain are highly prevalent in older homeless adults. Increasing age, alcohol, drug, and tobacco use are associated with tooth loss.

A mixed-methods investigation of incident Hemodialysis access in a safety-net population.

BACKGROUND: Despite improved health outcomes associated with arteriovenous fistulas, 80% of Americans initiate hemodialysis using a catheter, influenced by low socioeconomic status among other factors. Risk factors for incident catheter use in safety-net populations are unknown. Our objective was to identify factors associated with incident catheter use among hemodialysis patients at one safety-net hospital, with a goal of informing fistula placement initiatives targeted at safety-net populations more generally. METHODS: We performed a retrospective review of all incident hemodialysis patients at a single urban safety-net hospital from January 1, 2010 - December 31, 2015 (n = 241), as well as semi-structured interviews with a multi-lingual convenience sample of patients (n = 10) from this cohort. The primary outcome was incident vascular access modality. Multivariable logistic regression was used to identify factors associated with incident catheter use. Interview transcripts were coded using a directed content analysis framework based on a model describing barriers to healthcare access. RESULTS: Subjects were 61.8% male, racially/ethnically diverse (19.5% white, 29.5% black, 28.6% Hispanic, 17.4% Asian), with a mean age of 52.4 years. Eighty-eight percent initiated hemodialysis using a catheter. In multivariable analysis, longer duration of nephrology care was associated with decreased catheter use (>12 months vs. 0-6 months: adjusted Odds Ratio [aOR] 0.07, 95% CI 0.02-0.23, p < 0.001), whereas uninsured status increased odds of catheter use (aOR 3.96, 1.23-12.76, p = 0.02). There was a decrease in catheter use after vascular surgery services became available in-hospital (OR 0.40, 95% CI 0.16-0.98, p = 0.04), however this association was not significant in multivariable analysis (aOR 0.48, 0.17-1.36, p = 0.17). During interviews, patients cited emotional responses to disease, lack of social and financial resources, and limited health knowledge as barriers to obtaining fistula surgery. CONCLUSIONS: The rate of catheter use in this urban safety-net population is above the national average. Access to health insurance, early referrals to nephrology, and provision of in-hospital vascular surgery should be prioritized in the safety-net. Additionally, services that support patients' emotional and learning needs may decrease delays in fistula placement.

Intermediate-term results of the Ex-PRESS miniature glaucoma implant under a scleral flap in previously operated eyes.

BACKGROUND: To report the safety and efficacy of Ex-PRESS(TM) miniature glaucoma implant under a scleral flap in patients with previous ocular surgeries. DESIGN: Retrospective, non-comparative case series from a tertiary care hospital. PARTICIPANTS: Patients with previous cataract or failed glaucoma surgeries who had undergone implantation of the Ex-PRESS(TM) miniature glaucoma implant (R-50 and T-50), under a scleral flap, with a minimum of 1-year postoperative follow up. METHODS: For postoperative outcome, success was defined as complete if intraocular pressure (IOP) was 5-21 mmHg without medication or surgical intervention, and qualified if intraocular pressure was within the same range with glaucoma medication. To compare the outcome between patients who had previous trabeculectomy or cataract surgery the definition of success was intraocular pressure of 5-15 mmHg. MAIN OUTCOME MEASURES: Intraocular pressure, number of antiglaucoma drugs, visual acuity and complications. RESULTS: One hundred eyes (100 patients; mean age: 77.4 years) with a mean follow-up period of 27 ± 13.2 months (range: 12-66) were considered. Success was complete in 60 (60%) and qualified in 24 (24%) eyes. The mean preoperative IOP of 27.7 ± 9.2 mmHg (range: 14-52 mmHg) with 2.73 ± 1.1 drugs declined to 14.02 ± 5.1 mmHg with 0.72 ± 1.06 drugs at the last follow up (P < 0.0001). Causes of failure were uncontrolled intraocular pressure (11%), bleb needling (4%) and persistent hypotony (1%). The probability of success in the patients with previous cataract surgery and trabeculectomy at 3 years was 60.6% and 50.9%, respectively. CONCLUSIONS: The Ex-PRESS(TM) implant under scleral flap was a safe and effective glaucoma surgery in the eyes with prior ocular surgery.