ARRIVE Together: A Qualitative Process Evaluation of the New Jersey State Police Co-responding Pilot Program.

Law enforcement personnel are often first to respond to calls involving behavioral health emergencies. However, encounters with law enforcement are more dangerous and lethal for people with behavioral health conditions. Co-responding models, wherein law enforcement and behavioral health professionals respond to calls together, are among the top programs developed to improve responding to behavioral health crises. The current study describes a qualitative process evaluation of a co-responding pilot program in New Jersey: "Alternative Responses to Reduce Instances of Violence & Escalation" (ARRIVE Together). The evaluation centered on the experience of the co-responding team as to their perceptions of specific deployments and of the program implementation overall. Semi-structured interviews were conducted following 10 consecutive encounters (three interviews per encounter; February-March 2022). Transcripts were transcribed and thematically analyzed by two trained researchers independently. Once thematically analyzed, researchers determined a consensus and developed a SWOT analysis report. Thematic analysis produced six major themes: communication, staffing, training, resources, community outreach, and deployments with minors. Overall, participants were enthusiastic about the program, but they shared numerous observations about ways in which the program could be improved. Sample size, the brief follow-up window, and lack of generalizability to other contexts were among the most limiting factors. Further research should include an effectiveness evaluation and extend to urban and suburban communities and communities of color. Future research should also explore after-response affects including accessibility to follow-up care. The current study gives insight into piloting a co-responding model for approaching behavioral health crisis calls.

Retrospective Assessment of Risk Factors for Head and Neck Cancer Among World Trade Center General Responders.

Objective: To assess the reliability of a questionnaire designed to reconstruct risk factors for head and neck cancer relative to the 9/11 World Trade Center (WTC) response and over the lifetime. Methods: As part of a nested case-control study, 200 WTC Health Program (WTCHP) General Responder Cohort (GRC) members completed a newly-developed study questionnaire via telephone (with a trained interviewer) or online (self-administered). We assessed agreement between measures of tobacco and alcohol use in our questionnaire results and data collected previously during WTCHP-GRC monitoring visits using Cohens Kappa (κ) and intraclass correlation coefficient (ICC) for categorical and continuous measures, respectively. We compared agreement by disease status, survey mode, and year of WTCHP enrollment. Results: We observed high agreement between measures of lifetime, pre-WTC, and post-WTC smoking prevalence (all κ > 0.85) and smoking duration (all ICC > 0.84). There was moderate agreement between measures of smoking frequency (ICC: 0.61-0.73). Agreement between measures of smoking frequency, but not duration, differed by disease status, and agreement between smoking measures was higher for participants who completed our survey by phone than by web. Among cases, there were no differences based on enrollment in the WTCHP before or after diagnosis. Conclusion: Agreement between measures was generally high, although potential reporting bias and a mode effect that should be considered when interpreting analyses of self-reported data in this population; however differential misclassification appears to be minimal. Our questionnaire may be useful for future studies examining similar behavioral risk factors among disaster-exposed populations.

Risk factors for head and neck cancer in the World Trade Center Health Program General Responder Cohort: results from a nested case-control study.

OBJECTIVES: Head and neck cancers (HNCs) may be among the health consequences of involvement in the World Trade Center (WTC) response on and after 11 September 2001. We conducted a nested case-control study of WTC Health Program (WTCHP) general responders to examine the effects of WTC exposures and behavioural risk factors on HNC. METHODS: We enrolled 64 cases and 136 controls, matched on age, sex and race/ethnicity within risk sets. We assessed tobacco and alcohol use, sexual activity, and occupational exposures prior to, during and after WTC exposure until case diagnosis via questionnaire. We obtained WTC exposure information (duration (first to last day), total days and location of work) from the WTCHP General Responder Data Center. We assessed associations with HNC, and interaction among exposures, using conditional logistic regression. RESULTS: Responders in protective services versus other occupations had increased odds (OR: 2.51, 95% CI 1.09 to 5.82) of HNC. Among those in non-protective services occupations, arriving to the WTC effort on versus after 11 September 2001 was significantly associated with HNC (OR: 3.77, 95% CI 1.00 to 14.11). Duration of work was not significantly associated with HNC. Lifetime and post-WTC years of cigarette smoking and post-WTC number of sex partners were positively and significantly associated with HNC, while alcohol consumption was not. CONCLUSIONS: These findings suggest opportunities for HNC risk factor mitigation (eg, smoking cessation, human papillomavirus vaccination) and contribute to a risk factor profile which may assist WTCHP clinicians with identifying high-risk responders and improve detection and treatment outcomes in this population.

The Negative Clinical Impact of Diabetes on Tuberculosis: A Cross-Sectional Study in New Jersey.

CONTEXT: Numerous studies have investigated a link between tuberculosis (TB) and type 2 diabetes mellitus (DM) in high-incidence countries. There is a need to characterize the relationship of TB and DM in the United States. OBJECTIVE: To characterize the clinical and demographic differences in patients with TB with and without DM. DESIGN: Cross-sectional. SETTING: This study was performed at an institutional center providing TB care for New Jersey. PATIENTS OR OTHER PARTICIPANTS: A total of 353 cases of TB were seen at the Lattimore Clinic between 2009 and 2014. After excluding those with HIV infection and those under 19 years of age, 73 cases of TB were reviewed. INTERVENTIONS: No interventions performed. MAIN OUTCOME MEASURES: Sputum culture positivity, time to culture conversion, extent of disease on chest x-ray, and degree of cavitation on chest x-ray. Outcome measures were determined prior to data collection. RESULTS: Extent of disease on chest x-ray was higher for DM+ cases compared with DM- cases (P = 0.007). A total of 24% of DM+ cases had evidence of cavitation on chest x-ray compared with 5% of DM- cases (P = 0.03). DM+ cases were slightly more likely to have positive sputum cultures than were DM- cases (P = 0.07). The median time to sputum culture conversion was 27.5 days in the DM+ group vs 18.0 days in the DM- group (P = 0.26). CONCLUSIONS: Extent of disease on chest x-ray was significantly more severe in the DM+ group than in the DM- group.

Targeted Secure Messages to Facilitate Access to Tobacco Treatment Counseling for Veterans: Feasibility Study.

BACKGROUND: Studies show that combining nicotine replacement therapy (NRT) with tobacco treatment counseling is most effective for smoking cessation. However, tobacco treatment counseling has been underutilized across the nation. A secure email message sent to patients already taking NRT was hypothesized to increase the utilization of tobacco treatment counseling among Veterans in New Jersey. Secure messaging for communication between patients and providers was implemented through a web-based password-protected, secure messaging account, where veterans get notified through their personal email when they have a message awaiting them. OBJECTIVE: The main objective of this project was to determine if there was a significant increase in adoption of tobacco treatment counseling among Veterans who received a secure message describing the options for tobacco treatment counseling available to them. Secondary objectives were to demographically characterize Veterans who were and were not enrolled in secure messaging, as well as those who opened or did not open a message. Finally, because the language and content of the messages were changed across project phases, this project also sought to determine (by analysis of response rates) the type of language that was most effective at eliciting a response. METHODS: Over two phases, messages were sent to two samples of Veterans prescribed NRT within the prior 90 days of each phase. In phase 1, one message was sent in December 2015 (message 1). In phase 2, one message was sent in July 2016 (message 2) and the same message (message 3) was resent in August 2016 to persons who did not open message 2. Messages 2 and 3 were more directive than message 1. Response rates to message 1 versus message 2 were compared. A logistic regression analysis determined effect of age and gender on enrollment in secure messaging across both phases. The effectiveness of each phase at increasing tobacco treatment counseling was analyzed using a McNemar test. RESULTS: Message 2, sent to 423 Veterans, had a significantly higher response rate than message 1, sent to 348 Veterans (18%, 17/93 vs 8%, 6/78, P=.04). Phase 2 (ie, messages 2 and 3) significantly increased utilization of tobacco treatment counseling (net increase of six tobacco treatment counseling adopters, P=.04), whereas phase 1 (ie, message 1) did not (net increase of two tobacco treatment counseling adopters, P=.48). Women (odds ratio [OR] 1.6, 95% CI 1.1-2.3) and those aged 30 to 49 years (compared to other age groups) were more likely to be enrolled in secure messaging. Gender and age were not significant predictors of opening or replying to either message. CONCLUSIONS: Although the effect was small, secure messaging was a useful modality to increase tobacco treatment counseling. Directive content with a follow-up message appeared useful. Female Veterans and/or Veterans aged between 30 and 49 years are more likely to use secure messaging.

Young people who use drugs engaged in harm reduction programs in New York City: Overdose and other risks.

BACKGROUND: Little is known about the engagement of young people who use drugs (PWUD) in harm reduction programs (HRPs), and few studies have included non-opioid users and non-injectors. While HRPs have effectively engaged PWUD, young people are under-represented in their services. METHODS: The Injection Drug Users Health Alliance Citywide Study (IDUCS) is the largest community-based study of PWUD in HRPs in the US. From 2014-2015, 2421 HRP participants across New York City (NYC) completed a cross-sectional survey. We investigated differences in socio-demographics, service utilization, and risk behaviors between young (aged 18-30) and older participants and examined factors associated with overdose among young participants. RESULTS: The study included 257 young participants. They were significantly more likely than older participants to be white, educated, uninsured, unstably housed or homeless, and have a history of incarceration and residential drug treatment. They were more likely to report recent overdose but less likely to report knowledge of naloxone. Young participants also had higher rates of alcohol, marijuana, benzodiazepine, and injection drug use, and related risk behaviors such as public injection. Factors associated with past year overdose among young participants included experiencing symptoms of psychological distress (AOR=9.71), being unstably housed or homeless (AOR=4.39), and utilizing detox (AOR=4.20). CONCLUSIONS: Young PWUD who access services at HRPs in NYC differ significantly from their older counterparts. New York City and other urban centers that attract young PWUD should consider implementing harm reduction oriented services tailored to the unique needs of young people.

The joint contribution of neighborhood poverty and social integration to mortality risk in the United States.

PURPOSE: A well-established literature has shown that social integration strongly patterns health, including mortality risk. However, the extent to which living in high-poverty neighborhoods and having few social ties jointly pattern survival in the United States has not been examined. METHODS: We analyzed data from the Third National Health and Nutrition Examination Survey (1988-1994) linked to mortality follow-up through 2006 and census-based neighborhood poverty. We fit Cox proportional hazards models to estimate associations between social integration and neighborhood poverty on all-cause mortality as independent predictors and in joint-effects models using the relative excess risk due to interaction to test for interaction on an additive scale. RESULTS: In the joint-effects model adjusting for age, gender, race/ ethnicity, and individual-level socioeconomic status, exposure to low social integration alone was associated with increased mortality risk (hazard ratio [HR]: 1.42, 95% confidence interval [CI]: 1.28-1.59) while living in an area of high poverty alone did not have a significant effect (HR: 1.10; 95% CI: 0.95-1.28) when compared with being jointly unexposed. Individuals simultaneously living in neighborhoods characterized by high poverty and having low levels of social integration had an increased risk of mortality (HR: 1.63; 95% CI: 1.35-1.96). However, relative excess risk due to interaction results were not statistically significant. CONCLUSIONS: Social integration remains an important determinant of mortality risk in the United States independent of neighborhood poverty.

Interprofessional Integrative Medicine Training for Preventive Medicine Residents.

Integrative medicine training was incorporated into the Rutgers New Jersey Medical School Preventive Medicine residency at the Rutgers Biomedical and Health Sciences Newark Campus as a collaboration between the Rutgers New Jersey Medical School and the School of Health Related Professions. Beginning in 2012, an interdisciplinary faculty team organized an Integrative Medicine program in a Preventive Medicine residency that leveraged existing resources across Rutgers Biomedical and Health Sciences. The overarching aim of the programs was to introduce residents and faculty to the scope and practice of integrative medicine in the surrounding Newark community and explore evidence-based research on integrative medicine. The faculty team tapped into an interprofessional network of healthcare providers to organize rotations for the preventive medicine residents that reflected the unique nature of integrative medicine in the greater Newark area. Residents provided direct care as part of interdisciplinary teams at clinical affiliates and shadowed health professionals from diverse disciplines as they filled different roles in providing patient care. The residents also participated in research projects. A combination of formal and informal programs on integrative medicine topics was offered to residents and faculty. The Integrative Medicine program, which ran from 2013 through 2014, was successful in exposing residents and faculty to the unique nature of integrative medicine across professions in the community served by Rutgers Biomedical and Health Sciences.

How Neighborhood Poverty Structures Types and Levels of Social Integration.

Social integration is fundamental to health and well-being. However, few studies have explored how neighborhood contexts pattern types and levels of social integration that individuals experience. We examined how neighborhood poverty structures two dimensions of social integration: integration with neighbors and social integration more generally. Using data from the United States Third National Health and Nutrition Examination Survey, we linked study participants to percent poverty in their neighborhood of residence (N = 16,040). Social integration was assessed using a modified Social Network Index and neighborhood integration based on yearly visits with neighbors. We fit multivariate logistic regression models that accounted for the complex survey design. Living in high poverty neighborhoods was associated with lower social integration but higher visits with neighbors. Neighborhood poverty distinctly patterns social integration, demonstrating that contexts shape the extent and quality of social relationships.

What clinical activities do advanced-practice registered dietitian nutritionists perform? Results of a Delphi study.

Activities performed by advanced-practice registered dietitian nutritionists (RDNs) have yet to be clearly elucidated. The study aimed to gain consensus on the practice activities of advanced-practice RDNs who provide direct clinical nutrition care. A three-round Delphi study was conducted. Purposive sampling identified 117 RDN experts working as clinicians and/or managers in direct care settings that met inclusion criteria for advanced-level practice. In Round 1, 85 experts provided open-ended advanced-level practice activities linked to the Nutrition Care Process sections. Using content analysis, the responses were coded into activity statements. In Round 2, experts rated the essentiality of these activities. In Round 3, experts re-rated statements not reaching consensus while viewing their previous rating, the group median, and comments. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 were neither essential nor nonessential, and 5.0 to 7.0 were nonessential. Consensus was reached when the interquartile range of responses to each question was <2.0. Seventy-six (89.4%) experts completed all rounds. From 770 comments, 129 activity statements were generated. All statements reached consensus: 97.7% as essential; 0.8% as nonessential; and 1.5% as neither. Of essential activities, 67.5% were highly essential with limited variability (median=1.0; interquartile range≤2.0). Advanced-practice RDNs' tasks are patient-centered and reflect complex care; involve a comprehensive and discriminating approach; are grounded in advanced knowledge and expertise in clinical nutrition; include use of advanced interviewing, education, and counseling strategies; and require communication with patient, families, and the health care team. The high-level of consensus from experts suggest advanced-level clinical nutrition practice exists and can be defined.

Public Knowledge and Use of Sexual Offender Internet Registries: Results From a Random Digit Dialing Telephone Survey.

The present study examines public knowledge and use of a sexual offender Internet registry in New Jersey. A 20-item random digit dial telephone survey of 1,016 New Jersey residents was completed to determine public awareness and use of the New Jersey Sex Offender Internet Registry (NJSOIR). Approximately 51% of respondents reported knowledge of the NJSOIR, while 17% had accessed the site. Of those who accessed the site, 68% took some preventive measure based on the information they obtained. Logistic regression analyses demonstrate that ethnicity, education, and Internet access were associated with residents' knowledge of the NJSOIR, while sex, race, education, being the parent/caregiver of a child below 18 years of age, and access to the Internet were associated with respondents' likelihood to visit the registry website. These results suggest that an intervention that will increase public awareness of sex offender registries and provide specific preventive measures the public can take is needed.

Unrelenting violence: an analysis of 6,322 gunshot wound patients at a Level I trauma center.

BACKGROUND: Perceptions of violence are too often driven by individual sensational events, yet "routine" gunshot wound (GSW) injuries are largely underreported. Previous studies have mostly focused on fatal GSW. To illuminate this public health problem, we studied the health care burden of interpersonal GSW at a Level I trauma center. METHODS: Retrospective analysis of GSW injuries (excluding self and law enforcement) treated from January 2000 to December 2011. Data collected included body regions injured, number of wounds per patient, and mortality. Costs were calculated using Medicare cost-charge modifiers. Geographic information system mapping of the incident location and home addresses were determined to identify hot spot locations and the characterization of those neighborhoods. RESULTS: A total of 6,322 patients were treated. There were significant increases in patients with three or more wounds (13-22%, p < 0.0001) and three or more body regions injured (6-16%, p < 0.0001). Mortality increased from 9% to 14% (p < 0.0001). Nineteen percent of the patients were never seen by the trauma service. Geographic information system mapping revealed significant clustering of GSWs. Five cities accounted for 85% of the GSWs, with rates per 100,000 ranging from 19 to 108 compared with a national rate of 20. Only 19% of the census tracts had no GSWs during the period, and 39% of the census tracts had at least one GSW per year for 12 years. Fifteen percent of the census tracts accounted for 50% of the GSWs. Seventy percent of the patients were shot in their home city, 25% within 168 m, and 55% within 1,600 m of their home. Total inpatient cost was $115 million, with cost per patient increasing more than three times over the course of the study; 75% were unreimbursed. CONCLUSION: GSW violence remains a significant public health problem, with escalating mortality and health costs. Relying on trauma registry data seriously underestimates GSW numbers. In contrast to episodic mass casualties, routine GSW violence is geographically restricted and not random. To combat this problem, policy makers must understand that the determinants of firearm violence reside at the community level. LEVEL OF EVIDENCE: Epidemiologic study, level II.

Venous thromboembolism in children: preliminary results of a survey of POSNA members.

BACKGROUND: The term venous thromboembolism (VTE) includes deep venous thrombosis of the extremity and pulmonary embolism, a potentially fatal clinical entity. Although the prevalence of VTE may be lower in children compared with adults, recent reports suggest a possible rise in this diagnosis among pediatric patients, especially in association with certain risk factors. We assessed the clinical experience and practice of members of the Pediatric Orthopaedic Society of North America (POSNA) related to VTE among their pediatric patients. METHODS: A 36-question online survey was sent to all 636 active POSNA members. The proportion of surgeons who had encountered at least 1 child with VTE and the respondents' practice of using thromboprophylaxis in children (<18 y old) was assessed. The relationship of responders' experience with VTE among pediatric patients with various practice characteristics was evaluated. RESULTS: The response rate was 56% (354/636). More than half (55%) [95% confidence interval (CI), 50%-60%] of the respondents could recall at least 1 (median, 2 cases/member) pediatric patient with deep venous thrombosis and 29% (95% CI, 24%-34%) could recall ≥1 child with pulmonary embolism. Approximately one quarter (23%) (95% CI, 18%-27%) of all respondents reported never using mechanical prophylaxis and almost one half (45%) (95% CI, 40%-50%) of respondents reported never using pharmacologic prophylaxis against VTE in children. Only 16% (95% CI, 12%-20%) of the respondents had a thromboprophylaxis protocol for pediatric patients. Respondent characteristics such as being in clinical practice <5 years (P=0.01) and having a surgical volume of <100 cases/y (P=0.03) were associated with a lower likelihood of encountering a pediatric patient with VTE. CONCLUSIONS: More than half of responding active POSNA members reported having come across at least 1 case of VTE among pediatric patients during their practice. The routine use of VTE prophylaxis for children is uncommon among pediatric orthopaedists. Further studies aimed at determining the prevalence of VTE and developing specific guidelines for prophylaxis among pediatric patients seeking orthopaedic care are warranted. LEVEL OF EVIDENCE: IV.

Identifying components of advanced-level clinical nutrition practice: a Delphi study.

The dietetics profession lacks a comprehensive definition of advanced-level practice. Using a three-round Delphi study with mailed surveys, expert consensus on four dimensions of advanced-level practice that define advanced practice registered dietitians (RDs) in clinical nutrition was explored. Purposive sampling identified 117 RDs who met advanced-level practice criteria. In round 1, experts rated the essentiality of statements on a 7-point ordinal scale and generated open-ended practice activity statements regarding the following four dimensions of advanced-level practice: professional knowledge, abilities and skills, approaches to practice, roles and relationships, and practice behaviors. Median ratings of 1.0 to 3.0 were defined as essential, 4.0 was neutral, and 5.0 to 7.0 were nonessential. In rounds 2 and 3, experts re-rated statements not reaching consensus by evaluating their previous responses, group median rating, and comments. Consensus was reached when the interquartile range of responses to a statement was ≤2.0. Eighty-five experts enrolled (72.6%); 76 (89.4%) completed all rounds. In total, 233 statements were rated, with 100% achieving consensus; 211 (90.6%) were essential to advanced practice RD clinical practice. Having a master's degree; completing an advanced practice residency; research coursework; and advanced continuing education were essential, as were having 8 years of experience; clinical nutrition knowledge/expertise; specialization; participation in research activities; and skills in technology and communication. Highly essential approaches to practice were systematic yet adaptable and used critical thinking and intuition and highly essential values encompassed professional growth and service to patients. Roles emphasized patient care and leadership. Essential practice activities within the nutrition care process included provision of complex patient-centered nutrition care using application of advanced knowledge/expertise and interviewing and counseling strategies approached in a comprehensive yet discriminating manner. Communication with patients and the health care team is a priority. An advanced-level practice model in clinical nutrition was proposed depicting the requisite attributes and activities within four dimensions of professional practice.

Annual pediatric pedestrian education does not improve pedestrian behavior.

BACKGROUND: Pediatric pedestrian injuries are a major health care concern, specifically in urban centers. An educational program (WalkSafe), given one time during the school year, has been shown to improve childhood pedestrian safety. We examined whether this program could create similar long-term cognitive and behavioral changes in our school-aged children. METHODS: An established pediatric pedestrian curriculum was modified slightly for use in our area. Students K-fourth grade were exposed to the program once annually for 2 years. The program was carried out weekly for 3 consecutive weeks. The first and third sessions consisted of an educational module given by the classroom teacher. The second week consisted of an interactive assembly that allowed the children to demonstrate good pedestrian safety using a simulated street. Short- and intermediate-term cognitive knowledge was evaluated using standardized pre-, post- and 3-month follow-up tests. Long-term knowledge was assessed by comparing scores as students advanced in grade from year 1 to 2 of the program (K to first, first to second, etc.). At six schools during year 2, pedestrian behavior was measured through direct observation of children on city streets before and after administering the program. The project was approved by university and school board institutional review boards. RESULTS: During the 2 years, 1,564 students from nine schools were educated. In both years of the program, students in all grades had a significant gain in test scores immediately after and at 3 months compared with baseline knowledge. In contrast, only students moving from grade 3 to 4 demonstrated long-term retention (K→1: 7.7 vs. 6.7; grade 1→2: 7.8 vs. 6.7; grade 2→3: 7.3 vs. 6.8; grade 3→4: 7.1 vs. 8.0; all p < 0.05 year 2 pretest vs. year 1 3-month posttest; analysis of variance and generalized linear model). Only 30% of children walk with an adult. Direct observation showed 64% of children stopped at the curb but only 8% looked left-right-left. Children walking alone were more likely to cross mid-block compared with those walking with an adult (12% vs. 3%; p < 0.001) and also tend to look left-right-left significantly more than those walking with an adult (67% vs. 20%; p < 0.0001). CONCLUSIONS: A one-time annual educational program resulted in long-term knowledge retention between grades 3 and 4 only. In contrast, scores in younger grades reverted to baseline pretest values seen in year 1. Short- and intermediate-term knowledge gains were seen in all grades for both years. Because older children more often walk alone, we postulate that the improved retention may be the result of repeated exposure and practice as a pedestrian. Cognitive knowledge did not appear to translate into improved pedestrian behavior. Walking with an adult also had a negative impact on observed pedestrian safety behavior. The efficacy and impact of a one-time educational program may be insufficient to change long-term behavior and must be reevaluated.