Development of a sustainable diet index in US adults.

BACKGROUND: A transformation towards healthy diets through a sustainable food system is essential to enhance both human and planet health. Development of a valid, multidimensional, quantitative index of a sustainable diet would allow monitoring progress in the US population. We evaluated the content and construct validity of a sustainable diet index for US adults (SDI-US) based on data collected at the individual level. METHODS: The SDI-US, adapted from the SDI validated in the French population, was developed using data on US adults aged 20 years and older from the National Health and Nutrition Examination Survey, 2007-2018 (n = 25,543). The index consisted of 4 sub-indices, made up of 12 indicators, corresponding to 4 dimensions of sustainable diets (nutritional quality, environmental impacts, affordability (economic), and ready-made product use behaviors (sociocultural)). A higher SDI-US score indicates greater alignment with sustainable diets (range: 4-20). Validation analyses were performed, including the assessment of the relevance of each indicator, correlations between individual indicators, sub-indices, and total SDI-US, differences in scores between sociodemographic subgroups, and associations with selected food groups in dietary guidelines, the alternative Mediterranean diet (aMed) score, and the EAT-Lancet diet score. RESULTS: Total SDI-US mean was 13.1 (standard error 0.04). The correlation between SDI-US and sub-indices ranged from 0.39 for the environmental sub-index to 0.61 for the economic sub-index (Pearson Correlation coefficient). The correlation between a modified SDI-US after removing each sub-index and the SDI-US ranged from 0.83 to 0.93. aMed scores and EAT-Lancet diet scores were significantly higher among adults in the highest SDI-US quintile compared to the lowest quintile (aMed: 4.6 vs. 3.2; EAT-Lancet diet score: 9.9 vs. 8.7 p < .0001 for both). CONCLUSIONS: Overall, content and construct validity of the SDI-US were acceptable. The SDI-US reflected the key features of sustainable diets by integrating four sub-indices, comparable to the SDI-France. The SDI-US can be used to assess alignment with sustainable diets in the US. Continued monitoring of US adults' diets using the SDI-US could help improve dietary sustainability.

Sustainable dietary patterns and all-cause mortality among US adults.

BACKGROUND: Sustainable dietary patterns that incorporate multiple dimensions may have benefits for both human health and the environment. We examined the association between sustainable dietary patterns assessed by using the Sustainable Diet Index-US (SDI-US) and mortality in US adults. METHODS: This study used data from the National Health and Nutrition Examination Survey 2007-18 (N = 22 414 aged ≥20 years). The SDI-US (range: 4-20) was composed of four sub-indices representing nutritional, environmental, economic and sociocultural dimensions, and was computed using 24-h dietary recalls, food expenditures and food preparation habits. A higher score indicates a more sustainable dietary pattern. All-cause mortality from baseline until 31 December 2019 was obtained through linkage to the National Death Index. Hazard ratios (HRs) with 95% CIs were estimated using Cox proportional-hazards models, adjusting for covariates. RESULTS: During 150 386 person-years of follow-up, 2100 total deaths occurred and the median SDI-US was 9.8 in Quintile 1 (Q1) and 16.3 in Quintile 5 (Q5). In a multivariable-adjusted model, the highest SDI-US quintile was associated with a 36% reduction in mortality risk (Q5 vs Q1, HR 0.64, 95% CI 0.49-0.84, P = 0.002) compared with the lowest quintile. When stratified by age (P interaction = 0.002), an inverse association between SDI-US and mortality was observed in younger adults (<65 years, HR 0.41, 95% CI 0.25-0.68, P = 0.001) but not in older adults (≥65 years, HR 0.91, 95% CI 0.71-1.16, P = 0.15). CONCLUSIONS: A higher SDI-US score was associated with lower mortality risk among US adults, particularly in younger adults.

The cross-sectional association between a sustainable diet index and obesity among US adults.

OBJECTIVE: Adopting multidimensional sustainable dietary patterns may be beneficial to human and planetary health. The cross-sectional association between a multidimensional sustainable diet index-US (SDI-US) and obesity in US adults was examined. METHODS: This study used National Health and Nutrition Examination Survey (NHANES) data from 2007 to 2018 (n = 25,262). The SDI-US consisted of four subindices and was calculated using a 24-hour dietary recall, food expenditures, environmental impacts of foods, and food practices. A higher score indicates a more sustainable dietary pattern. Obesity was defined as BMI ≥ 30 kg/m2 . Logistic regression models were used to estimate odds ratios (OR) with 95% CI. RESULTS: Between 2007 and 2018, obesity prevalence in US adults was 38.2% (95% CI 37.0%-39.3%), and mean SDI-US score was 13.2 (range: 4.3-20.0). In a multivariable-adjusted model, a higher SDI-US score was associated with lower odds of obesity (Q5 vs. Q1, OR 0.68, 95% CI 0.58-0.79, p < 0.001). When stratified by sex (p interaction = 0.04), a stronger inverse association was observed in women (OR 0.64, 95% CI 0.53-0.77, p < 0.0001) than in men (OR 0.74, 95% CI 0.60-0.91, p = 0.01). CONCLUSIONS: More sustainable dietary patterns were inversely associated with obesity among US adults, supporting the potential of sustainable diets in preventing obesity.

Advance Care Planning Coaching in CKD Clinics: A Pragmatic Randomized Clinical Trial.

RATIONALE & OBJECTIVE: Although guidelines recommend more and earlier advance care planning (ACP) for patients with chronic kidney disease (CKD), scant evidence exists to guide incorporation of ACP into clinical practice for patients with stages of CKD prior to kidney failure. Involving nephrology team members in addition to primary care providers in this important patient-centered process may increase its accessibility. Our study examined the effect of coaching implemented in CKD clinics on patient engagement with ACP. STUDY DESIGN: Multicenter, pragmatic randomized controlled trial. SETTING & PARTICIPANTS: Three CKD clinics in different states participated: 273 patients consented to participate, 254 were included in analysis. Eligible patients were 55 years or older, had stage 3-5 CKD, and were English speaking. INTERVENTION: Nurses or social workers with experience in nephrology or palliative care delivered individualized in-person ACP sessions. The enhanced control group was given Make Your Wishes About You (MY WAY) education materials and was verbally encouraged to bring their completed advance directives to the clinic. OUTCOME: Primary outcome measures were scores on a 45-point ACP engagement scale at 14 weeks and a documented advance directive or portable medical order at 16 weeks after enrollment. RESULTS: Among 254 participants analyzed, 46.5% were 65-74 years of age, and 54% had CKD stage 3. The coached patients scored 1.9 points higher at 14 weeks on the ACP engagement scale (ß = 1.87 [95% CI, 0.13-3.64]) adjusted for baseline score and site. Overall, 32.8% of intervention patients (41 of 125) had an advance directive compared with 17.8% (23 of 129) of patients in the control group. In a site-adjusted multivariable model, coached patients were 79% more likely to have a documented advance directive or portable medical order (adjusted risk ratio, 1.79 [95% CI, 1.18-2.72]), with the impact principally evident at only 1 study site. LIMITATIONS: Small number of study sites and possible unrepresentativeness of the broader CKD population by study participants. CONCLUSIONS: Individualized coaching may be effective in enhancing ACP, but its impact may be influenced by the health care environment where it is delivered. FUNDING: The Patrick and Catherine Weldon Donaghue Medical Research Foundation, via the Greater Value Portfolio. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT03506087.

Longitudinal effects of cigarette pictorial warning labels among young adults.

Young adults are influenced by cigarette package marketing. Pictorial warning labels are a recommended intervention. Evidence demonstrates pictorial warnings impact negative emotion, risk perceptions, and motivation to quit smoking, but there is limited research on their effects over time. This study analyzes data from a randomized trial of young adult smokers (N = 229) exposed to a pictorial or text-only cigarette warning. We assessed changes in fear, anger, risk perceptions, and motivation to quit smoking after 4 weeks using latent change score modeling and over 3 months using latent growth modeling. Latent change results showed exposure was associated with increases in fear, anger, and motivation to quit after 4 weeks. Latent growth showed exposure was associated with increases in motivation to quit smoking over 3 months, but not other outcomes. Findings suggest pictorial warning labels produce an emotional response and increase motivation to quit among young adult smokers.

Mediational Effects on Motivation to Quit Smoking After Exposure to a Cigarette Pictorial Warning Label Among Young Adults.

BACKGROUND: Young adults are vulnerable to cigarette package marketing. Pictorial warning labels are recommended for tobacco control. Research should address questions raised in legal challenges including causal mechanisms. Evidence is mixed and understudied among young adults (e.g., discrete emotions and risk perceptions). PURPOSE: This study investigated mediators of pictorial warning label effects on motivation to quit smoking among young adult smokers. METHODS: This study analyzed data from a randomized trial with a 4 week exposure to a cigarette pictorial warning among young adult smokers (N = 229) aged 18-30 with assessments at baseline, immediately post-intervention, and 3 months. Mediation analyses used latent change scores to test the effects post-intervention on fear, anger, and risk perceptions. We also examined whether post-intervention measures predicted change in motivation to quit smoking at 3 months. The first model assessed aggregate risk perceptions and the second model assessed discrete risk perceptions (deliberative, affective). RESULTS: Pictorial warning label exposure led to increases in fear which led to increased motivation to quit smoking for the first (B = 0.12, 95% CI = 0.04, 0.26) and second (B = 0.12, 95% CI = 0.03, 0.25) model. Exposure modestly increased motivation to quit by way of fear and affective risk perceptions (B = 0.01, 95% CI = 0.00, 0.04). Exposure had a direct relationship on increased motivation to quit as well. CONCLUSIONS: Findings demonstrate factors contributing to change in motivation to quit smoking among young adult smokers after pictorial warning label exposure. Affective processes are mediators of pictorial warning label effects.

Recent sexual violence exposure is associated with immune biomarkers of HIV susceptibility in women.

PROBLEM: HIV/AIDS and sexual violence act synergistically and compromise women's health. Yet, immuno-biological mechanisms linking sexual violence and increased HIV susceptibility are poorly understood. METHODS: We conducted a cross-sectional pilot study of HIV-uninfected women, comparing 13 women exposed to forced vaginal penetration within the past 12 weeks (Exposed) with 25 Non-Exposed women. ELISA assays were conducted for 49 biomarkers associated with HIV pathogenesis in plasma and cervicovaginal lavage (CVL). Differences between Exposed and Non-Exposed were analyzed by linear and logistic regression, using propensity score weighting to control for age, race, socioeconomic status, menstrual cycle, and contraceptive use. RESULTS: In CVL, Exposed women had significantly reduced chemokines MIP-3α (p < .01), MCP-1 (p < .01), and anti-HIV/wound-healing thrombospondin-1 (p = .03). They also had significantly increased inflammatory cytokine IL-1α (p < 0.01) and were more likely to have detectable wound-healing PDGF (p = .02). In plasma, Exposed women had reduced chemokines MIP-3α (p < .01) and IL-8 (p < .01), anti-inflammatory cytokine TGF-ß (p = .02), anti-HIV/antimicrobial HBD-2 (p = .02), and wound-healing MMP-1 (p = 0.02). They also had increased thrombospondin-1 (p < .01) and Cathepsin B (p = .01). After applying the stringent method of false discovery rate adjustment, differences for IL-1α (p = .05) and MCP-1 (p = .03) in CVL and MIP-3α (p = .03) in plasma remained significant. CONCLUSIONS: We report systemic and mucosal immune dysregulation in women exposed to sexual violence. As these biomarkers have been associated with HIV pathogenesis, dysregulation may increase HIV susceptibility.

Highly variable trends in rates of newly diagnosed HIV cases in U.S. hotspots, 2008-2017.

The U.S. Ending the HIV Epidemic (EHE) initiative was announced in early 2019 and rapidly became a focal point for domestic HIV prevention and treatment programs. Using publicly available data from CDC, we examined historical trends in the average annual percent change (AAPC) in HIV diagnosis rates for the 57 EHE high incidence "hotspots" using Joinpoint analysis. We then assessed the ecologic association of various hotspot characteristics with changes in these rates over time using a multivariable regression model. From 2008-2017, the overall rate of newly diagnosed HIV cases in the U.S. declined from 19 to 14 per 100,000 persons, with the AAPC declining significantly in the U.S. overall (-3.1%; 95% CI: -3.7, -2.4) and in the 57 hotspots (-3.3%; 95% CI: -4.6, -2.8). There were large (AAPC <-5.0), moderate (-5.0 to -2.5) and small (-2.5 to 0.0) rates of decline in 14, 19 and 17 hotspots respectively, with increasing trends (AAPC >0.0) noted in seven hotspots. In the multivariable regression analysis, higher initial HIV diagnosis rate and location in the Northeast region were significantly associated with declining AAPC rates whereas no significant differences were found by hotspot gender, age, or race/ethnicity distribution. This analysis demonstrates that the rate of decline in HIV diagnosis rates in hotspots across the U.S. has been highly variable. Further exploration is warranted to assess the correlation between programmatic factors such as HIV testing and antiretroviral therapy and pre-exposure prophylaxis coverage with HIV trends across the hotspots.

Dietary Polyphenol Intake in US Adults and 10-Year Trends: 2007-2016.

BACKGROUND: Polyphenols are a class of phytochemicals that have antioxidant, anti-inflammatory, anticancer, and antiviral properties. Previous research suggests that dietary polyphenol intake is protective against major chronic diseases. To our knowledge, no data on polyphenol intake for the US adult population are available. OBJECTIVE: This study explored usual dietary polyphenol intake among US adults in 2013-2016 and examined trends in intake during 2007-2016 by demographic characteristics, and identified major dietary sources of polyphenols. DESIGN: The National Health and Nutrition Examination Survey is a series of cross-sectional surveys representative of the civilian noninstitutionalized US population. PARTICIPANTS/SETTING: This study included 9,773 adults aged 20 years and older. MAIN OUTCOME MEASURES: Dietary and supplement data were obtained from two 24-hour dietary recalls. Polyphenol intake was estimated using the Phenol Explorer Database and adjusted for total energy intake. STATISTICAL ANALYSIS PERFORMED: Usual intake was estimated both overall and by demographic characteristics using the National Cancer Institute method. Trends in intake on a given day over 10 years were evaluated using regression analysis. The complex survey design was incorporated in all analyses. RESULTS: In 2013-2016, the usual intake of dietary polyphenols was a mean (standard error) of 884.1 (20.4) mg per 1,000 kcal/d. Polyphenol intake was higher in adults 40 years and older, women, non-Hispanic White adults, and college graduates. During 2007-2016, the mean daily polyphenol intake did not change significantly over time for overall and demographic groups. Main polyphenol classes consumed were phenolic acids (mean [standard error] of 1,005.6 [34.3] mg/d) and flavonoids (mean [standard error] of 379.1 [10.7] mg/d). Foods and beverages contributed 99.8% of polyphenol intake, with coffee (39.6%), beans (9.8%), and tea (7.6%) as major dietary contributors. CONCLUSION: Findings from this study suggest that polyphenol intake is consistent with the low intake of fruits, vegetables, and whole grains in the US population, and provide more evidence of the need for increased consumption of these food groups.

Determinants of Childhood Zoonotic Enteric Infections in a Semirural Community of Quito, Ecuador.

Domestic animals in the household environment have the potential to affect a child's carriage of zoonotic enteric pathogens and risk of diarrhea. This study examines the risk factors associated with pediatric diarrhea and carriage of zoonotic enteric pathogens among children living in communities where smallholder livestock production is prevalent. We conducted an observational study of children younger than 5 years that included the analysis of child (n = 306) and animal (n = 480) fecal samples for Campylobacter spp., atypical enteropathogenic Escherichia coli, Shiga toxin-producing E. coli, Salmonella spp., Yersinia spp., Cryptosporidium parvum, and Giardia lamblia. Among these seven pathogens, Giardia was the most commonly identified pathogen among children and animals in the same household, most of which was found in child-dog pairs. Campylobacter spp. was also relatively common within households, particularly among child-chicken and child-guinea pig pairs. We used multivariable Poisson regression models to assess risk factors associated with a child being positive for at least one zoonotic enteric pathogen or having diarrhea during the last week. Children who interacted with domestic animals-a behavior reported by nearly three-quarters of households owning animals-were at an increased risk of colonization with at least one zoonotic enteric pathogen (prevalence ratio [PR] = 1.56, 95% CI: 1.00-2.42). The risk of diarrhea in the last seven days was elevated but not statistically significant (PR = 2.27, CI: 0.91, 5.67). Interventions that aim to reduce pediatric exposures to enteric pathogens will likely need to be incorporated with approaches that remove animal fecal contamination from the domestic environment and encourage behavior change aimed at reducing children's contact with animal feces through diverse exposure pathways.

Long-term outcomes in Juvenile Myositis patients.

OBJECTIVE: Juvenile idiopathic inflammatory myopathies (JIIM) are rare, chronic autoimmune muscle diseases of childhood, with the potential for significant morbidity. Data on long-term outcomes is limited. In this study we investigate correlations between clinical and demographic features with long-term outcomes in a referral population of adult patients with JIIM. METHODS: Forty-nine adults with JIIM were assessed at two referral centers between 1994 and 2016. Features of active disease and damage at a cross-sectional assessment were obtained. Regression modeling was used to examine factors associated with long-term outcomes, defined by the presence of calcinosis or a higher adjusted Myositis Damage Index (MDI) score. A multivariable model of MDI was constructed using factors that were statistically significant in bivariate models. RESULTS: At a median of 11.5 [IQR 4.5-18.9] years following diagnosis, median American College of Rheumatology (ACR) functional class was 2 [1.5-3.0], Health Assessment Questionnaire (HAQ) score was 0.4 out of 3.0 [0.0-1.0], and manual muscle testing (MMT) score was 229 out of 260 [212.6-256.8]. Median MDI score was 6.0 [3.5-8.9], with the most commonly damaged organ systems being cutaneous and musculoskeletal. Factors associated with an elevated MDI score were the presence of erythroderma and other cutaneous manifestations, disease duration, and ACR functional class. Calcinosis was present in 55% of patients. The strongest predictors of calcinosis were disease duration, periungual capillary changes, and younger age at diagnosis. CONCLUSION: In a tertiary referral population, long-term functional outcomes of JIIM are generally favorable, with HAQ scores indicative of mild disability. Although most patients had mild disease activity and virtually all had significant disease damage, severe or systemic damage was rare. Certain clinical features are associated with long-term damage and calcinosis.

Physical Activity and Cardiometabolic Risk Factor Clustering in Young Adults with Obesity.

INTRODUCTION: There is a paucity of information on the clustering of cardiometabolic risk factors in young adults and how this clustering may vary based on whether or not they perform sufficient levels of physical activity. METHODS: We analyzed baseline data from 346 young adults (23.3 ± 4.4 yr) participating in the Healthy Body Healthy U clinical trial from 2015 to 2018. Cardiometabolic risk factors were measured according to standard procedures and moderate- to vigorous-intensity physical activity (MVPA) was determined by accelerometry. A cardiometabolic clustering score (ranging from 0 to 5) was created from five biomarkers according to whether or not a standard clinical risk cut point was exceeded (0, no; 1, yes): abdominal circumference (>102 cm (men) or >88 cm (women)), hemoglobin A1c (≥5.7%), HDL cholesterol (<40 mg·dL (men) or <50 mg·dL (women)), systolic blood pressure (≥130 mm Hg), and diastolic blood pressure (≥85 mm Hg). Cardiometabolic dysregulation (CD) was defined as a cardiometabolic clustering score ≥3. Multiple logistic regression determined the independent association between level of MVPA and CD, while adjusting for sex, race/ethnicity, sedentary time, and smoking. RESULTS: The prevalence of CD was 18% (22% in men, 17% in women). We observed a nonlinear graded association between MVPA and CD. Participants performing 150-300 min·wk of MVPA significantly lowered their odds of CD by 66% (odds ratio, 0.34; 95% confidence interval, 0.16-0.75), whereas those exceeding 300 min·wk lowered their odds by 61% (odds ratio, 0.39; 95% confidence interval, 0.18-0.86) compared with those performing <150 min·wk, independent of obesity and the other covariables. CONCLUSION: Recommended levels of moderate-intensity physical activity is significantly associated with lower odds of CD and thus may prevent or diminish the need for expensive pharmaceutical treatment over the remainder of the life-span.

Perceived social support and the risk of cardiovascular disease and all-cause mortality in the Women's Health Initiative Observational Study.

OBJECTIVE: Previous studies have shown social support to be inversely associated with cardiovascular disease (CVD) in men, whereas fewer studies have assessed the relationship in women. The purpose of this study was to evaluate the relationship between perceived social support and cardiovascular outcomes among postmenopausal women enrolled in the Women's Health Initiative Observational Study. METHODS: We examined the relationships between perceived social support and (1) incident coronary heart disease (CHD), (2) total CVD, and (3) all-cause mortality. Participants were Women's Health Initiative Observational Study women, ages 50 to 79 years, enrolled between 1993 and 1998 and followed for up to 10.8 years. Social support was ascertained at baseline via nine questions measuring the following functional support components: emotional/informational, tangible, positive social interaction, and affectionate support. RESULTS: Among women with prior CVD (n = 17,351) and no prior CVD (n = 73,421), unadjusted hazard ratios ranged from 0.83 to 0.93 per standard deviation increment of social support. Adjustment for potential confounders, such as smoking and physical activity levels, eliminated the statistical significance of the associations with CHD and CVD. However, for all-cause mortality and among women free of baseline CVD, the association was modest but remained statistically significant after this adjustment (hazard ratio = 0.95 [95% confidence interval, 0.91-0.98]). No statistically significant association was observed among women with a history of CVD. CONCLUSIONS: After controlling for potential confounding variables, higher perceived social support is not associated with incident CHD or CVD. However, among women free of CVD at baseline, perceived social support is associated with a slightly lower risk of all-cause mortality.

Local Decision Making for Implementing Social Distancing in Response to Outbreaks.

OBJECTIVES: Social distancing is the practice of restricting contact among persons to prevent the spread of infection. This study sought to (1) identify key features of preparedness and the primary concerns of local public health officials in deciding to implement social distancing measures and (2) determine whether any particular factor could explain the widespread variation among health departments in responses to past outbreaks. METHODS: We conducted an online survey of health departments in the United States in 2015 to understand factors influencing health departments' decision making when choosing whether to implement social distancing measures. We paired survey results with data on area population demographic characteristics and analyzed them with a focus on broad trends. RESULTS: Of 600 health departments contacted, 150 (25%) responded. Of these 150 health departments, 63 (42%) indicated that they had implemented social distancing in the past 10 years. Only 10 (7%) health departments had a line-item budget for isolation or quarantine. The most common concern about social distancing was public health impact (n = 62, 41%). Concerns about law, politics, finances, vulnerable populations, and sociocultural issues were each identified by 7% to 10% of health departments. We were unable to clearly predict which factors would influence these decisions. CONCLUSIONS: Variations in the decision to implement social distancing are likely the result of differences in organizational authority and resources and in the primary concerns about implementing social distancing. Research and current social distancing guidelines for health departments should address these factors.

Preparing Interprofessional Faculty to Be Humanistic Mentors for Medical Students: The GW-Gold Mentor Development Program.

INTRODUCTION: The GW-Gold Humanistic Mentor Development Program addresses the challenge faced by medical schools to educate faculty to prepare students for humanistic practice. Grounded in Branch's Teaching Professional and Humanistic Values model, the program prepares interprofessional faculty mentoring teams in humanistic communities of practice. The teams consist of physician-psychosocial professional pairs, each mentoring a small student group in their professional development course. Through GW-Gold workshops, faculty mentors develop interprofessional humanistic communities of practice, preparing them to lead second such communities with their students. This article describes the program and its evaluation. METHODS: To assess outcomes and better understand the mentor experience, we used a mixed-method validating triangulation design consisting of simultaneous collection of quantitative (mentor and student surveys) and qualitative (open-ended survey questions and focus group) data. Data were analyzed in parallel and merged at the point of interpretation, allowing for triangulation and validation of outcomes. RESULTS: Mentors rated the program highly, gained confidence in their humanistic skills, and received high scores from students. Three themes emerged that validated program design, confirmed outcomes, and expanded on the mentor experience: (1) Interprofessional faculty communities developed through observation, collaboration, reflection, and dialogue; (2) Humanistic mentors created safe environments for student engagement; and (3) Engaging in interprofessional humanistic communities of practice expanded mentors' personal and professional identities. DISCUSSION: Outcomes support the value of the GW-Gold program's distinctive features in preparing faculty to sustain humanism in medical education: an interprofessional approach and small communities of practice built on humanistic values.

Collecting outcome data of a text messaging smoking cessation intervention with in-program text assessments: How reliable are the results?

BACKGROUND: Text messaging interventions have shown promise in helping people quit smoking. Texting programs periodically survey participants about their smoking status. This study examined the consistency of participant self-reported smoking between external surveys and internal program text message assessments. METHODS: Participants in Text2Quit program were surveyed about their past 7-day smoking at one, three, and six months post-enrollment using different survey modes (external surveys and internal program text message assessments) and responses were compared for consistency. The first set of analyses was conducted for participants responding on both modes (n = 45 at one month; n = 50 at three months; n = 42 at six months). Additional analyses, assuming missing = smoking, were conducted with the full sample of 262 smokers (68.7% female, mean age = 35.8 years) and compared to saliva-confirmed abstinence rates. RESULTS: Participants responding to both modes consistently reported smoking status at one (88.9%), three (88.0%) and six (88.1%) months post-enrollment, with fair to substantial levels of agreement (one month: κ = 0.24; three months: κ = 0.63; six months: κ = 0.66). Participants responding to both modes reported high rates of abstinence. In missing = smoking analyses, significant differences in abstinence rates reported across modes were detected at each timepoint (one month: external = 30.5%, internal = 16.4%; three months: external = 33.2%, internal = 16.0%; six months: external = 31.7%, internal = 12.2%; all p < .001). Moderate levels of agreement were found between the two modes. At 6 months, abstinence rates obtained via internal data were closer to those biochemically verified (15.7%) compared to external surveys. CONCLUSIONS: Results provide initial support for the use of internal program assessments in text messaging programs with missing = smoking assumptions in order to gather outcome data on smoking behavior.

The Role of Health in Climate Litigation.

OBJECTIVES: To examine how the courts, which play a critical role in shaping public policy, consider public health in climate change and coal-fired power plant lawsuits. METHODS: We coded US local, state, and federal court decisions relating to climate change and coal-fired power plants from 1990 to 2016 (n = 873) and qualitatively investigated 139 cases in which litigants raised issues concerning the health impacts of climate change. We also conducted 78 interviews with key litigants, advocates, industry representatives, advising scientists, and legal experts. RESULTS: Health has been a critical consideration in key climate lawsuits, but in a minority of cases. Litigants have presented health arguments most frequently and effectively in terms of airborne exposures. Health impacts have typically been used to gain standing and argue that the evidence for government actions is insufficient. CONCLUSIONS: The courts represent a pivotal branch of government in shaping climate policy. Increasing inclusion of health concerns in emergent areas of litigation could help drive more effective climate policymaking.

Characterization of Differences Between Prostate Cancer Patients Presenting With De Novo Versus Primary Progressive Metastatic Disease.

BACKGROUND: Men who present with metastatic disease can have de novo or primary progressive disease. We characterized and compared the outcomes between these 2 groups. PATIENTS AND METHODS: A retrospective cross-sectional analysis from a single institution of de novo versus primary progressive metastatic patients during a 2-year consecutive period was undertaken. Patient characteristics such as demographics, Gleason score, duration of hormone sensitivity, and treatment were obtained. The t test, Mann-Whitney U test, and Fisher exact test were used to test differences in patient and disease characteristics between the de novo and primary progressive metastatic groups. Differences in the Kaplan-Meier survival curves were compared using the log-rank test. RESULTS: A total of 90 patients (n = 38 with de novo and 52 with primary progressive disease) were included. Statistically significant median differences were found for the prostate-specific antigen level at the development of metastases: de novo 63.1 ng/ml vs primary progressive 12.5 ng/ml, p= <.001; albumin and hemoglobin, P = .03 and P = .045, respectively). The median duration of hormone sensitivity was 372 days (range, 54-3753 days) in the de novo group versus 1613 days (range, 7-4314 days) in the primary progressive group (P = .00006). Overall survival was worse in the de novo arm, with a median survival of 6.2 years compared with a median survival in the primary progressive group of 11.6 years (P = .027). CONCLUSION: Although the reported samples were small, our data revealed a potential difference in disease aggressiveness in those presenting with de novo metastatic cancer with higher risk disease and shorter time to castration resistance and worse survival. These data could have implications for earlier and more aggressive treatment for men presenting with de novo metastatic prostate cancer.

Does the Regulatory Environment Affect Nurse Practitioners' Patterns of Practice or Quality of Care in Health Centers?

OBJECTIVE: To examine the impact of state-granted nurse practitioner (NP) independence on patient-level quality, service utilization, and referrals. DATA SOURCES/STUDY SETTING: The National Ambulatory Medical Care Survey's community health center (HC) subsample (2006-2011). Primary analyses included approximately 6,500 patient visits to 350 NPs in 220 HCs. STUDY DESIGN: Propensity score matching and multivariate regression analysis were used to estimate the impact of state-granted NP independence on each outcome, separately. Estimates were adjusted for sampling weights and NAMCS's complex design. DATA COLLECTION/EXTRACTION METHODS: Every "NP-patient visit unit" was isolated using practitioner and patient visit codes and, using geographic identifiers, assigned to its state-year and that state-year's level of NP independence based on scope of practice policies. Nine outcomes were specified using ICD-9 codes, standardized drug classification codes, and NAMCS survey items. PRINCIPAL FINDINGS: After matching, no statistically significant differences in quality were detected by states' independence status, although NP visits in states with prescriptive independence received more educational services (aIRR 1.66; 95 percent CI 1.09-2.53; p = .02) and medications (aIRR 1.26; 95 percent CI 1.04-1.53; p = .02), and NP visits in states with practice independence had a higher odds of receiving physician referrals (AOR 1.88; 95 percent CI 1.10-3.22; p = .02) than those in restricted states. CONCLUSIONS: Findings do not support a quality-scope of practice relationship.