Search

BackgroundThe US homeless population is aging. Older adults and those living in poverty are at a high risk of food insecurity.MethodsWe conducted a cross-sectional analysis of baseline data from a population-based study of 350 homeless adults aged ≥50. We assessed food security and receipt of food assistance. We used multivariable logistic regression to examine factors associated with very low food security.ResultsThe majority of the cohort was male and African American. Over half (55.4%) met criteria for food insecurity, 24.3% reported very low food security. Half (51.7%) reported receiving monetary food assistance. In the multivariable model, those who were primarily sheltered in the prior 6 months, (multi-institution users [AOR = 0.44, 95% CI: 0.22-0.86]) had less than half the odds of very low food security compared with those who were unsheltered. Depressive symptoms (AOR = 3.01, 1.69-5.38), oral pain (AOR = 2.15, 1.24-3.74) and cognitive impairment (AOR = 2.21, 1.12-4.35) were associated with increased odds of very low food security.ConclusionsOlder homeless adults experience a high prevalence of food insecurity. To alleviate food insecurity in this population, targeted interventions must address specific risk groups.

BackgroundThe homeless population in the United States is aging. Aging-associated comorbidities are associated with increased symptoms.ObjectiveTo describe the prevalence of symptoms among older homeless-experienced adults, analyze factors associated with moderate-high physical symptom burden, and identify symptom clusters.DesignCross-sectional analysis within longitudinal cohort study.ParticipantsUsing population-based sampling from shelters, meal programs, encampments, and a recycling center in Oakland, CA, we recruited homeless adults aged ≥ 50 for a longitudinal cohort. This study includes participants who participated in the 18-month follow-up visit.Main measuresWe assessed physical symptoms using the Patient Health Questionnaire-15 (PHQ-15); psychological symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D), Primary Care PTSD Screen (PC-PTSD), and psychiatric section of the Addiction Severity Index (ASI); loneliness using the Three-Item Loneliness Scale; and regret using a six-item regret scale.Key resultsTwo hundred eighty-three participants (75.6% men and 82.3% African-Americans) completed symptoms interviews. Over a third (34.0%) had moderate-high physical symptom burden. The most prevalent physical symptoms were joint pain, fatigue, back pain, and sleep trouble. Over half (57.6%) had psychological symptoms; 39.6% exhibited loneliness and 26.5% had high regret. In a multivariate model, being a woman (AOR 2.54, 95% CI 1.28-5.03), childhood abuse (AOR 1.88, 95% CI 1.00-3.50), cannabis use (AOR 2.59, 95% CI 1.38-4.89), multimorbidity (AOR 2.50, 95% CI 1.36-4.58), anxiety (AOR 4.30, 95% CI 2.24-8.26), hallucinations (AOR 3.77, 95% CI 1.36-10.43), and loneliness (AOR 2.32, 95% CI 1.26-4.28) were associated with moderate-high physical symptom burden. We identified four symptom clusters: minimal overall (n = 129), moderate overall (n = 68), high physical and high psychological (n = 67), and high physical and low psychological (n = 17).ConclusionsOlder homeless-experienced adults exhibit a high prevalence of symptoms across multiple dimensions. To reduce suffering, clinicians should recognize the interaction between symptoms and address multiple symptom dimensions.

Background: The homeless population in the United States is aging. Aging-associated comorbidities are associated with increased symptoms.Objective: To describe the prevalence of symptoms among older homeless-experienced adults, analyze factors associated with moderate-high physical symptom burden, and identify symptom clusters.Design: Cross-sectional analysis within longitudinal cohort study.Participants: Using population-based sampling from shelters, meal programs, encampments, and a recycling center in Oakland, CA, we recruited homeless adults aged ≥ 50 for a longitudinal cohort. This study includes participants who participated in the 18-month follow-up visit.Main Measures: We assessed physical symptoms using the Patient Health Questionnaire-15 (PHQ-15); psychological symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D), Primary Care PTSD Screen (PC-PTSD), and psychiatric section of the Addiction Severity Index (ASI); loneliness using the Three-Item Loneliness Scale; and regret using a six-item regret scale.Key Results: Two hundred eighty-three participants (75.6% men and 82.3% African-Americans) completed symptoms interviews. Over a third (34.0%) had moderate-high physical symptom burden. The most prevalent physical symptoms were joint pain, fatigue, back pain, and sleep trouble. Over half (57.6%) had psychological symptoms; 39.6% exhibited loneliness and 26.5% had high regret. In a multivariate model, being a woman (AOR 2.54, 95% CI 1.28-5.03), childhood abuse (AOR 1.88, 95% CI 1.00-3.50), cannabis use (AOR 2.59, 95% CI 1.38-4.89), multimorbidity (AOR 2.50, 95% CI 1.36-4.58), anxiety (AOR 4.30, 95% CI 2.24-8.26), hallucinations (AOR 3.77, 95% CI 1.36-10.43), and loneliness (AOR 2.32, 95% CI 1.26-4.28) were associated with moderate-high physical symptom burden. We identified four symptom clusters: minimal overall (n = 129), moderate overall (n = 68), high physical and high psychological (n = 67), and high physical and low psychological (n = 17).Conclusions: Older homeless-experienced adults exhibit a high prevalence of symptoms across multiple dimensions. To reduce suffering, clinicians should recognize the interaction between symptoms and address multiple symptom dimensions. [ABSTRACT FROM AUTHOR]

When interpreting disjunctive sentences of the form'A or B', young children have been reported to differ fromadults in twoways. First, children have been reported to interpret disjunction inclusively rather than exclusively, accepting 'A or B' in contexts in which both A and B are true (Chierchia et al. 2001; Gualmini et al. 2001). Second, some children have been reported to interpret disjunction conjunctively, rejecting 'A or B' in contexts in which only one of the disjuncts is true (Paris 1973; Braine & Rumain 1981; Chierchia et al. 2004; Singh et al. 2015). In this article, weextend the investigation of children's interpretation of disjunction to include both simple and complex forms of disjunction, in two typologically unrelated languages: French and Japanese. First, given that complex disjunctions have been argued to give rise to obligatory exclusivity inferences (Spector 2014), we investigated whether the obligatoriness of the inference would play a role in the acquisition of the exclusive interpretation. Second, using a paradigm that makes the use of disjunction felicitous, we aimed to establish whether the finding of conjunctive interpretations would be replicated for both simple and complex forms of disjunction, and in languages other than English. Themain findings from our experiment are that both French- and Japanese-speaking children interpreted the simple and complex disjunctions either inclusively or conjunctively; in contrast, adults generally accessed exclusive readings of both disjunctions. We argue that our results lend further support to the proposal put forth in Singh et al. (2015), according to which the reason some children compute conjunctivemeanings while adults compute exclusivemeanings is that the two groups differ in their respective sets of alternatives for disjunction. Crucially, adults access conjunction as an alternative to disjunction, and compute exclusive interpretations; in contrast, children access only the individual disjuncts as alternatives, and therefore either interpret the disjunction literally or compute conjunctive inferences. More generally, our findings can be explained quite naturally within recent proposals according to which children differ from adults in the computation of scalar inferences because they are more restricted than adults in the set of scalar alternatives they can access (Barner et al. 2011; Tieu et al. 2015b, among others). [ABSTRACT FROM AUTHOR]

Cancer is becoming the leading cause of death all around the world. To develop better therapeutic options against cancer, we need a thorough understanding of tumor development and dissemination. As our knowledge increases, it becomes apparent that cancer is a very complex disease and this complexity is partially due to the great level of heterogeneity even within the same tumor mass. Therefore, there is a pressing need to decipher complex regulations and interactions of the tumor cells that lead to different hierarchies. Concepts of tumor-initiating and self-renewing stem cell have long been proposed to explain the emergence of a vast number of progenies within monoclonal neoplastic growth. It is now known that cancer stem cells which are found in many cancers have many roles in tumor development and dissemination. Many fascinating properties of cancer stem cells draw further attention to clarify their involvement in tumor cell plasticity, epithelial to mesenchymal transition, chemotherapy resistance and to develop therapeutic strategies for their targeting. Here we summarized recent efforts to illustrate the progress in our understanding of the biology of cancer stem cells.

Addiction is commonly characterized by escalation of drug intake, compulsive drug seeking, and continued use despite harmful consequences. However, the factors contributing to the transition from moderate drug use to these problematic patterns remain unclear, particularly regarding the role of sex. Many preclinical studies have been limited by small sample sizes, low genetic diversity, and restricted drug access, making it challenging to model significant levels of intoxication or dependence and translate findings to humans. To address these limitations, we characterized addiction-like behaviors in a large sample of >500 outbred heterogeneous stock (HS) rats using an extended cocaine self-administration paradigm (6 hr/daily). We analyzed individual differences in escalation of intake, progressive ratio (PR) responding, continued use despite adverse consequences (contingent foot shocks), and irritability-like behavior during withdrawal. Principal component analysis showed that escalation of intake, progressive ratio responding, and continued use despite adverse consequences loaded onto a single factor that was distinct from irritability-like behaviors. Categorizing rats into resilient, mild, moderate, and severe addiction-like phenotypes showed that females exhibited higher addiction-like behaviors, with a lower proportion of resilient individuals compared to males. These findings suggest that, in genetically diverse rats with extended drug access, escalation of intake, continued use despite adverse consequences, and PR responding are highly correlated measures of a shared underlying construct. Furthermore, our results highlight sex differences in resilience to addiction-like behaviors., Competing Interests: Gd, LC, MK, MB, BB, LM, DC, SS, LT, MF, AM, NV, DO, BS, JR, JL, JK, AK, SS, LS, KS, SB, ES, AA, SP, JM, CC, LC, AV, KM, PS, BL, BP, AC, OP, LS, AP, OG No competing interests declared, (© 2023, de Guglielmo, Carrette et al.)

Objective: We assessed the performance of ICD codes to identify patients with hepatocellular carcinoma (HCC) in a large academic health system and determined whether employing an algorithm using a combination of ICD codes could deliver higher accuracy and precision than single ICD codes in identifying HCC cases using electronic health record (EHR) data., Results: The use of a single ICD code entry for HCC (ICD-9-CM 155.0 or ICD-10-CM C22.0) in our cohort of 1,007 established ambulatory care patients with potential HCC yielded 58% false positives (not true HCC cases) based on chart reviews. We developed an ICD code-based algorithm that prioritized positive predictive value (PPV), F-score, and accuracy to minimize false positives and negatives. The highest performing algorithm required at least 10 ICD code entries for HCC and the sum of ICD code entries for HCC to exceed the sum of ICD code entries for non-HCC malignancies. The algorithm demonstrated high performance (PPV 97.4%, F-score 0.92, accuracy 94%), which was internally validated (PPV 92.3%, F-score 0.90, accuracy 91%) using a separate sample of potential HCC cases. Our findings support the need to assess the accuracy and precision of ICD codes before using EHR data to study HCC more broadly., Competing Interests: Additional Declarations: No competing interests reported.

Emoji symbols are widely used in online communication, particularly in instant messaging and on social media platforms. Existing research draws comparisons between the functions of emoji and those of gestures, with recent work extending a proposed typology of gestures to emoji, arguing that different emoji types can be distinguished by their placement within the modified text and by their semantic contribution (the linguistic inferences that they give rise to). In this paper, we present four experiments designed to test the predictions of this extended typology, the results of which suggest that emoji symbols indeed trigger the hypothesised linguistic inferences. The findings provide support for a semantic typology of emoji and contribute further evidence of the parallels between gesture and emoji., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Social media are widely used by young people (YP), but how YP with language disorders use social media for social interaction remains insufficiently studied. This article provides an overview of the research on social media use by YP with language disorders., Materials and Methods: A scoping review was conducted, guided by a five-stage framework. Ten databases were searched (CENTRAL, CINAHL, ERIC, LLBA, Medline, PsychINFO, Scopus, speechBITE, Web of Science, ProQuest Dissertations & Theses Global). Chaining searches of papers identified for inclusion were conducted., Results: After screening 199 unique papers, 44 were included. Findings revealed that YP with language disorders use social media less compared to typically developing peers; their profile of communication difficulties may impact the types of social media with which they engage. Although intervention studies are limited, the results offer encouraging findings regarding the positive impact of support for use of social media. Barriers and facilitators for social media use are identified., Conclusions: YP with language disorders use social media for social purposes. However, co-designed research into what YP with language disorders perceive their social media needs to be is urgently needed. How to support YP with language disorders to use social media is subject to future investigation.

Background: Social media is increasingly used by young people, including those with communication disability. To date, though, little is known about how speech-language therapists (SLTs) support the social media use of young people with communication disability., Aims: To explore what services SLTs provide to facilitate the social media use of young people with communication disability, including what these services look like, and the factors that impact SLTs' professional practices., Methods & Procedures: A sequential mixed methods approach was employed including an online survey and in-depth semi-structured interviews. Participants were qualified practising SLTs in Australia with a caseload that included clients aged 12-16 years. Quantitative data were analysed with SPSS. A thematic analysis of qualitative data was conducted with NVivo., Outcomes & Results: Survey responses from 61 SLTs were analysed. Interviews were conducted with 16 participants. Survey data indicated that SLTs do not systematically assess or treat young people's use of social media as part of their professional practice. Interview data revealed that where SLTs do support young people's use of social media, they transfer knowledge and practices typically used in offline contexts to underpin their work supporting clients' use of social media. In terms of factors that affect SLTs' practices, three major themes were identified: client/family factors, SLT factors, and societal factors., Conclusions & Implications: While young people with communication disability may desire digital participation in social media spaces, SLTs' current professional practices do not routinely address this need. Professional practice guidelines would support SLTs' practices in this area. Future research should seek the opinions of young people with communication disability regarding their use of social media, and the role of SLTs in facilitating this., What This Paper Adds: What is already known on the subject Young people with communication disability use social media, but digital inequality means that they may not do so to the same extent as their typically developing peers. Services targeting a young person's social media use is within the SLT scope of practice. Whether or not SLTs routinely address the social media use of young people with communication disability as part of their professional practice is unknown. What this study adds to existing knowledge This study found that SLTs in Australia do not systematically provide professional services targeting young people's use of social media. When services do address a young person's use of social media, knowledge and practices typically used by SLTs in offline contexts are adapted to support their work targeting online social media contexts. What are the potential or actual clinical implications of this work? This study indicates that SLTs should consider a range of factors when deciding whether to address a young person's social media use. Adapting existing offline professional practices to online environments could support SLTs' work in providing services targeting social media use. Professional practice guidelines would support SLTs' work facilitating the social media use of young people with communication disability., (© 2022 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language Therapists.)

Behavioral health integration (BHI) within primary care settings is shown to improve outcomes. However, achieving BHI requires identifying best practices and a reliable tool that can be used to measure existing levels and progress toward BHI. The objective of this study was to develop and apply a conceptual framework to measure BHI, test the approach, and examine challenges to achieving BHI. Surveys and interviews were conducted with key informants within 17 designated public hospitals in California at the midpoint of participating in a 5-year project to establish BHI. A framework and coding methodology were developed to assess BHI best practices at each hospital. BHI status was assessed in the domains of infrastructure and process. Each domain included 5 themes such as electronic health record integration and functionality (infrastructure) and interprovider communication (process). Themes were assessed using a 6-point scale for various activities under a theme and associated weights. Theme-specific values were standardized from 0% to 100% to compare BHI scores between hospitals. Overall progress toward BHI ranged from scores of 52% to 83% (mean 63%) and indicated greater contribution of infrastructure versus process implementation. Within the infrastructure domain, scores were higher for having institutional and provider support, but lagged in establishing provider proximity. Within the process domain, scores were highest for implementation of behavioral health screening, but were frequently lower for other themes such as use of care coordination and referral processes. Further research is needed to test the robustness of this approach in other settings.

Purpose: Many patients seek medications without animal-derived ingredients for a multitude of reasons. The purpose of this comprehensive qualitative review is to assess current literature on the topic of animal-free medications and identify the roles that key stakeholders can play in addressing the needs of these patients. Methods: A comprehensive literature search was conducted on PubMed and Google Scholar from inception to June 2022 to identify key articles surrounding the topic of animal-free ingredients and medications. Results: The need for animal-free medications impacts not just vegans and vegetarians, but also those with dietary restrictions due to other beliefs. Three key stakeholder initiatives can address the needs of these patients: 1) Healthcare professionals (HCPs) should strive to select appropriate medications considering their patients' religious and/or cultural background; 2) patients must be involved and notify their providers about their dietary requirements; 3) pharmaceutical industry and manufacturers need to consider animal-free product formulations and provide clear labeling. Conclusion: There is a rising interest in animal-free medications and several organizations and advocacy groups have raised concerns for easier access to these medications. However, more regulatory guidance or oversight is needed. For the nearly 25% animal-free medications available in the market, independent certification marks would facilitate informed consumer decision-making., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Authors JU and YN are employees of VeganMed. All other authors have no conflict of interest., (Copyright © 2022 The Author(s).)

Among other uses, co-speech gestures can contribute additional semantic content to the spoken utterances with which they coincide. A growing body of research is dedicated to understanding how inferences from gestures interact with logical operators in speech, including negation ("not"/"n't"), modals (e.g., "might"), and quantifiers (e.g., "each," "none," "exactly one"). A related but less addressed question is what kinds of meaningful content other than gestures can evince this same behaviour; this is in turn connected to the much broader question of what properties of gestures are responsible for how they interact with logical operators. We present two experiments investigating sentences with co-speech sound effects and co-text emoji in lieu of gestures, revealing a remarkably similar inference pattern to that of co-speech gestures. The results suggest that gestural inferences do not behave the way they do because of any traits specific to gestures, and that the inference pattern extends to a much broader range of content.

Abstract: The long-term course of depression is not well-understood among minority women. We assessed depression trajectory, barriers to depression care, and life difficulties among minority women accessing health and social service programs as part of the Community Partners in Care study. Data include surveys ( N = 339) and interviews ( n = 58) administered at 3-year follow-up with African American and Latina women with improved versus persistent depression. The majority of the sample reported persistent depression (224/339, 66.1%), ≥1 barrier to mental health care (226/339, 72.4%), and multiple life difficulties (mean, 2.7; SD, 2.3). Many barriers to care ( i.e. , related to stigma and care experience, finances, and logistics) and life difficulties ( i.e. , related to finances, trauma, and relationships) were more common among individuals reporting persistent depression. Results suggest the importance of past experiences with depression treatment, ongoing barriers to care, and negative life events as contributors to inequities in depression outcomes experienced by minority women., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The current landscape of speech-language pathology (SLP) services for 12- to 16-year olds in Australia remains largely unchartered. Implementing the Speech Pathology 2030 vision necessitates mapping current services, and gaps in services, provided by speech-language pathologists (SLPs). However, the last survey of Australian SLPs' practices with young people was conducted in 2005. The aim of this study was to bridge the service delivery information gap. Method: Ninety-six SLPs working with 12- to 16-year olds in Australia completed an anonymous online survey consisting of binary choice, multiple choice, and Likert scale questions. A theoretical approach to service delivery based on response to intervention models underpinned question design. Result: SLP clinical practices remain traditional, following an impairment/diagnostic model. Additionally, there is an inequitable provision of SLP services across states/territories of Australia, according to whether or not there is government provision for SLP services in public schools. Conclusion: The results suggest a need for standard government provision of SLP services across Australia to ensure equity of access. These findings inform our understanding of contemporary assessment and intervention practices of SLPs working with 12- to 16-year olds in Australia.

Rationale: Cannabidiol (CBD) reduces craving in animal models of alcohol and cocaine use and is known to modulate nicotinic receptor function, suggesting that it may alleviate symptoms of nicotine withdrawal. However, preclinical evaluation of its efficacy is still lacking., Objectives: The goal of this study was to test the preclinical efficacy of a chronic CBD treatment in reducing nicotine dependence using measures of withdrawal symptoms including somatic signs, hyperalgesia, and weight gain during acute and protracted abstinence., Methods: Male and female Wistar rats were made dependent on nicotine using osmotic minipumps (3.15 mg/kg/day) for 2 weeks, after which minipumps were removed to induce spontaneous withdrawal. Three groups received CBD injections at doses of 7.5, 15, and 30 mg/kg/day for 2 weeks, starting 1 week into chronic nicotine infusion. The control groups included rats with nicotine minipumps that received vehicle injections of sesame oil instead of CBD; rats implanted with saline minipumps received sesame oil injections (double vehicle) or the highest dose of CBD 30 mg/kg/day. Throughout the experiment, serum was collected for determination of CBD and nicotine concentrations, mechanical sensitivity threshold and withdrawal scores were measured, and body weight was recorded., Results: CBD prevented rats from exhibiting somatic signs of withdrawal and hyperalgesia during acute and protracted abstinence. There was no dose-response observed for CBD, suggesting a ceiling effect at the doses used and the potential for lower effective doses of CBD. The saline minipump group did not show either somatic signs of withdrawal or hyperalgesia during acute and protracted abstinence, and the highest dose of CBD used (30 mg/kg/day) did not alter these results., Conclusions: This preclinical study suggests that using CBD as a strategy to alleviate the withdrawal symptoms upon nicotine cessation may be beneficial., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The rat oxycodone and cocaine biobanks contain samples that vary by genotypes (by using genetically diverse genotyped HS rats), phenotypes (by measuring addiction-like behaviors in an advanced SA model), timepoints (samples are collected longitudinally before, during, and after SA, and terminally at three different timepoints in the addiction cycle: intoxication, withdrawal, and abstinence or without exposure to drugs through age-matched naive rats), samples collected (organs, cells, biofluids, feces), preservation (paraformaldehyde-fixed, snap-frozen, or cryopreserved) and application (proteomics, transcriptomics, microbiomics, metabolomics, epigenetics, anatomy, circuitry analysis, biomarker discovery, etc.Substance use disorders (SUDs) are pervasive in our society and have substantial personal and socioeconomical costs. A critical hurdle in identifying biomarkers and novel targets for medication development is the lack of resources for obtaining biological samples with a detailed behavioral characterization of SUD. Moreover, it is nearly impossible to find longitudinal samples. As part of two ongoing large-scale behavioral genetic studies in heterogeneous stock (HS) rats, we have created two preclinical biobanks using well-validated long access (LgA) models of intravenous cocaine and oxycodone self-administration (SA) and comprehensive characterization of addiction-related behaviors. The genetic diversity in HS rats mimics diversity in the human population and includes individuals that are vulnerable or resilient to compulsive-like responding for cocaine or oxycodone. Longitudinal samples are collected throughout the experiment, before exposure to the drug, during intoxication, acute withdrawal, and protracted abstinence, and include naive, age-matched controls. Samples include, but are not limited to, blood plasma, feces and urine, whole brains, brain slices and punches, kidney, liver, spleen, ovary, testis, and adrenal glands. Three preservation methods (fixed in formaldehyde, snap-frozen, or cryopreserved) are used to facilitate diverse downstream applications such as proteomics, metabolomics, transcriptomics, epigenomics, microbiomics, neuroanatomy, biomarker discovery, and other cellular and molecular approaches. To date, >20,000 samples have been collected from over 1000 unique animals and made available free of charge to non-profit institutions through https://www.cocainebiobank.org/ and https://www.oxycodonebiobank.org/., (Copyright © 2021 Carrette et al.)

Purpose: Young adulthood is characterized by changes in health care decision-making, insurance coverage, and sexual risk. Although the human papillomavirus (HPV) vaccine is now approved for adults up to age 45, and catch-up vaccination is currently recommended up through age 26, vaccination rates remain low in young adults. This study explored perspectives on HPV vaccination among young adults receiving care at the student health center of a large public university., Methods: We conducted semi-structured interviews (n = 27) and four focus groups with female and male undergraduate and graduate students (n = 18) and semi-structured interviews with health care providers (n = 6). Interviews and focus groups explored perceived risk of HPV infection, benefits of the HPV vaccine, and motivations for and barriers to HPV vaccination., Results: Many young adults cited their parents' views and recommendations from medical providers as influential on their decision-making process. Students perceived that cervical cancer prevention was a main benefit of the HPV vaccine and sexual activity was a risk factor for HPV infection. Students often lacked knowledge about the vaccine's benefits for males and expressed some concerns about the safety and side effects of a vaccine perceived as new. Logistical barriers to vaccination included uncertainty over vaccination status and insurance coverage for the vaccine, and concerns about balancing the vaccine schedule with school obligations. Providers' vaccine recommendations were impacted by health system factors, including clinical infrastructure, processes for recommending and documenting vaccination, and office visit priorities. Suggested vaccination promotion strategies included improving the timing and messaging of outreach efforts on campus and bolstering clinical infrastructure., Conclusions: Although college may be an opportune time to reach young adults for HPV vaccination, obstacles including navigating parental influence and independent decision-making, lack of awareness of vaccination status, and numerous logistical and system-level barriers may impede vaccination during this time., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose: Cancer survivors diagnosed at an early age remain at risk for cancer recurrence and other chronic diseases. This study assessed engagement in surveillance for recurrence, cancer screening, and other recommended preventive health services among breast and colorectal cancer survivors with early-onset disease (≤ 50 years) who were diagnosed in California., Methods: Breast and colorectal cancer survivors diagnosed with early-onset cancer between 1999 and 2009 were identified through the California Cancer Registry, the state-based cancer registry, and surveyed. Multivariable regression analyses were used to assess correlates of receipt of cancer surveillance, cancer screening, and other preventive health services., Results: Of the 497 survivors that were invited to participate in the study, 156 completed the survey for a response rate of 31%. The sample was 50 years of age on average (range 32-69 years) with a mean time since diagnosis of 9 years. The majority of the sample (71%) was a racial/ethnic minority (24% Latino, 15% African American, 29% Asian). Overall, 80% received appropriate surveillance for recurrence, and 72% received recommended screening for early detection of other cancers (breast, cervical, colorectal). Increasing age was associated with lower likelihood of early detection screening (adjusted odds ratio (aOR) 0.28, 95% confidence interval (CI) 0.11-0.69), and higher income was associated with a greater likelihood (aOR 4.89, 95% CI 1.62-14.81). Screening rates were highest for blood pressure (96%), cholesterol (86%), and diabetes (81%), followed by dental visits (64%) and flu vaccination (35%). Greater use of recommended preventive health services was associated with increasing age, female sex, higher education level, and having health insurance., Conclusions: Although the majority of survivors received appropriate surveillance for recurrence, engagement in other preventive health services varied substantially., Implications for Cancer Survivors: Efforts are needed to address gaps in the use of recommended cancer screening and preventive health services among cancer survivors, particularly survivors with early-onset disease who may be at increased risk for additional cancers and common chronic conditions over their lifetime.

Plural morphology in English is associated with a multiplicity inference. For example, "Emily fed giraffes" is typically interpreted to mean that Emily fed multiple giraffes. It has long been observed that this inference disappears in downward-entailing linguistic environments, such as in the scope of negation. For example, "Emily didn't feed giraffes" does not merely suggest that she didn't feed multiple giraffes, but rather that she didn't feed any. There are three main approaches to explaining this puzzle: the first proposes that the plural is ambiguous, and invokes a preference for stronger meanings; the second derives multiplicity inferences as implicatures; and the third provides a homogeneity-based account. These different approaches can all account for the interpretation of the plural across upward- and downward-entailing environments. They differ, however, in what they predict for three further aspects of the plural: the status of positive and negative plural sentences in singular contexts, children's acquisition of plural meanings, and the relationship between plural meanings and scalar implicatures. In this paper, we report on three experiments investigating adults' and preschool-aged children's interpretation of plural morphology in English. The experiments reveal that participants distinguish positive and negative plural sentences presented in singular contexts, and that adults assign a different status to these positive and negative sentences. It is also observed that children, unlike adults, tend to accept underinformative positive plural sentences in singular contexts - in parallel with their behavior on standard scalar implicatures - while they are relatively more adult-like when it comes to negative plural sentences in the same contexts, showing a tendency to reject the negative sentences. We discuss how the findings of the three experiments are expected on a scalar implicature approach to multiplicity inferences, and the open challenges they pose for the ambiguity and homogeneity approaches., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The debate about electronic cigarettes is dividing healthcare professionals, policymakers, manufacturers, and communities. A key limitation in our understanding of the cause and consequences of vaping is the lack of animal models of nicotine vapor self-administration. Here, we developed a novel model of voluntary electronic cigarette use in rats using operant behavior. We found that rats voluntarily exposed themselves to nicotine vapor to the point of reaching blood nicotine levels that are similar to humans. The level of responding on the active (nicotine) lever was similar to the inactive (air) lever and lower than the active lever that was associated with vehicle (polypropylene glycol/glycerol) vapor, suggesting low positive reinforcing effects and low nicotine vapor discrimination. Lever pressing behavior with nicotine vapor was pharmacologically prevented by the α4β2 nicotinic acetylcholine receptor partial agonist and α7 receptor full agonist varenicline in rats that self-administered nicotine but not vehicle vapor. Moreover, 3 weeks of daily (1 h) nicotine vapor self-administration produced addiction-like behaviors, including somatic signs of withdrawal, allodynia, anxiety-like behavior, and relapse-like behavior after 3 weeks of abstinence. Finally, 3 weeks of daily (1 h) nicotine vapor self-administration produced cardiopulmonary abnormalities and changes in α4, α3, and β2 nicotinic acetylcholine receptor subunit mRNA levels in the nucleus accumbens and medial prefrontal cortex. These findings validate a novel animal model of nicotine vapor self-administration in rodents with relevance to electronic cigarette use in humans and highlight the potential addictive properties and harmful effects of chronic nicotine vapor self-administration.

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., (© 2018 American Association of Public Health Dentistry.)

Plural definite descriptions give rise to homogeneity effects: the positive The trucks are blue and the negative The trucks aren't blue are both neither true nor false when some of the trucks are blue and some are not, that is, when the group of trucks is not homogeneous with respect to the property of being blue (Löbner, 1987, 2000; Schwarzschild, 1994; Križ, 2015b). The only existing acquisition studies related to the phenomenon have examined children's comprehension only of the affirmative versions of such sentences, and moreover have yielded conflicting data; while one study reports that preschoolers interpret definite plurals maximally (Munn et al., 2006, see also Royle et al., 2018), two other studies report that preschoolers allow non-maximal interpretations of definite plurals where adults do not (Karmiloff-Smith, 1979; Caponigro et al., 2012). Moreover, there is no agreed upon developmental trajectory to adult homogeneity. In this paper, we turn to acquisition data to investigate the predictions of a recent analysis of homogeneity that treats homogeneous meanings as the result of a scalar implicature (Magri, 2014). We conducted two experiments targeting 4- and 5-year-old French-speaking children's interpretations of plural definite descriptions in positive and negative sentences, and tested the same children on standard cases of scalar implicature. The experiments revealed three distinct subgroups of children: those who interpreted the plural definite descriptions existentially and failed to compute implicatures; those who both accessed homogeneous interpretations and computed implicatures; and finally, a smaller subgroup of children who appeared to access homogeneous interpretations without computing implicatures. We discuss the implications of our findings, which appear to speak against the implicature theory as the adult-like means of generating homogeneous meanings., (Copyright © 2019 Tieu, Križ and Chemla.)

Aims: To examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults., Methods: Among 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need., Results: Among those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment., Conclusion: Older homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population., (© 2019 Wiley Periodicals, Inc.)

Background: Patient experience surveys are widely used to capture the patient-reported quality of care and are increasingly being used for formal reporting purposes. There is evidence that certain patient subgroups are less likely to respond to traditional CAHPS surveys. As patient-facing technologies become more common, it is important to examine whether tablet-based patient experience surveys have the potential to promote responses from more diverse populations., Objectives: To develop, gain perspectives about, and pilot an English and Spanish low-literacy adaptation of the Consumer Assessment of Healthcare Providers & Systems Clinician & Group Survey (CG-CAHPS) administered on a tablet device at the point of care., Research Design: Cognitive testing and evaluation of a quality improvement pilot comparing a tablet-based adaptation and traditional paper-based versions of the CG-CAHPS survey., Subjects: English-speaking and Spanish-speaking patients receiving primary care in an urban community clinic., Measures: To compare the acceptability of low-literacy tablet-based and traditional paper-based patient experience surveys, we examined the concordance of responses between survey modes and preferences for modality, as well as perspectives on usability and reporting care experiences. We examined demographic differences in responses to tablet-based versus mailed surveys from a quality improvement pilot., Results: The majority of cognitive interview participants preferred a low-literacy, tablet-based survey over a paper-based survey with traditional wording. In a quality improvement pilot comparing tablet-based administration at the point of care versus mailed surveys, respondents to the tablet-based survey were more likely to be younger and Latino., Conclusions: If designed with patient input, tablet-based surveys have the potential to improve the collection of patient experience data among diverse populations.

Contemporary semantics has uncovered a sophisticated typology of linguistic inferences, characterized by their conversational status and their behavior in complex sentences. This typology is usually thought to be specific to language and in part lexically encoded in the meanings of words. We argue that it is neither. Using a method involving "composite" utterances that include normal words alongside novel nonlinguistic iconic representations (gestures and animations), we observe successful "one-shot learning" of linguistic meanings, with four of the main inference types (implicatures, presuppositions, supplements, homogeneity) replicated with gestures and animations. The results suggest a deeper cognitive source for the inferential typology than usually thought: Domain-general cognitive algorithms productively divide both linguistic and nonlinguistic information along familiar parts of the linguistic typology., Competing Interests: The authors declare no conflict of interest.

Background: After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care., Methods: First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care., Results: The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care., Conclusions: There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Patient portals are becoming ubiquitous. Previous research has documented substantial barriers, especially among vulnerable patient subgroups such as those with lower socioeconomic status or limited health literacy (LHL). We tested the effectiveness of delivering online, video-based portal training to patients in a safety net setting., Methods: We created an online video curriculum about accessing the San Francisco Health Network portal, and then randomized 93 English-speaking patients with 1+ chronic diseases to receive 1) an in-person tutorial with a research assistant, or 2) a link to view the videos on their own. We also examined a third, nonrandomized usual care comparison group. The primary outcome was portal log-in (yes/no) 3 to 6 months post-training, assessed via the electronic health record. Secondary outcomes were self-reported attitudes and skills collected via baseline and follow-up surveys., Results: Mean age was 54 years, 51% had LHL, 60% were nonwhite, 52% were female, 45% reported fair/poor health, and 76% reported daily Internet use. At followup, 21% logged into the portal, with no differences by arm ( P = .41), but this was higher than the overall clinic rate of 9% ( P < .01) during the same time period. We found significant prepost improvements in self-rated portal skills ( P = .03) and eHealth literacy ( P < .01). Those with LHL were less likely to log in post-training ( P < .01)., Conclusions: Both modalities of online training were comparable, and neither mode enabled a majority of vulnerable patients to use portals, especially those with LHL. This suggests that portal training will need to be more intensive or portals need improved usability to meaningfully increase use among diverse patients., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)

Background: The median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults., Objective: This study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years., Methods: We recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies., Results: Of the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72)., Conclusions: Older homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes., (©Maria C Raven, Lauren M Kaplan, Marina Rosenberg, Lina Tieu, David Guzman, Margot Kushel. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 10.12.2018.)

Previous developmental studies have revealed variation in children's ability to compute scalar inferences. While children have been shown to struggle with standard scalar inferences (e.g., with scalar quantifiers like "some") (Chierchia, Crain, Guasti, Gualmini, & Meroni, 2001; Guasti et al., 2005; Noveck, 2001; Papafragou & Musolino, 2003), there is also a growing handful of inferences that children have been reported to derive quite readily (Barner & Bachrach, 2010; Hochstein, Bale, Fox, & Barner, 2016; Papafragou & Musolino, 2003; Singh, Wexler, Astle-Rahim, Kamawar, & Fox, 2016; Stiller, Goodman, & Frank, 2015; Tieu, Romoli, Zhou, & Crain, 2016; Tieu et al., 2017). One recent approach, which we refer to as the Alternatives-based approach, attributes the variability in children's performance to limitations in how children engage with the alternative sentences that are required to compute the relevant inferences. Specifically, if the alternative sentences can be generated by simplifying the assertion, rather than by lexically replacing one scalar term with another, children should be better able to compute the inference. In this paper, we investigated this prediction by assessing how children and adults interpret sentences that embed disjunction under a universal quantifier, such as "Every elephant caught a big butterfly or a small butterfly". For adults, such sentences typically give rise to the distributive inference that some elephant caught a big butterfly and some elephant caught a small butterfly (Crnič, Chemla, & Fox, 2015; Fox, 2007; Gazdar, 1979). Another possible interpretation, though not one typically accessed by adults, is the conjunctive inference that every elephant caught a big butterfly and a small butterfly (Singh, Wexler, Astle-Rahim, Kamawar, & Fox, 2016). Crucially, for our purposes, it has been argued that both of these inferences can be derived using alternatives that are generated by deleting parts of the asserted sentence, rather than through lexical replacement, making these sentences an ideal test case for evaluating the predictions of the Alternatives-based approach. The findings of our experimental study reveal that children are indeed able to successfully compute this class of inferences, providing support for the Alternatives-based approach as a viable explanation of children's variable success in computing scalar inferences., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Previous developmental studies of conjunction have focused on the syntax of phrasal and sentential coordination (Lust, 1977; de Villiers, Tager-Flusberg & Hakuta, 1977; Bloom, Lahey, Hood, Lifter & Fiess, 1980, among others). The present study examined the flexibility of children's interpretation of conjunction. Specifically, when two predicates that can apply simultaneously to a single individual are conjoined in the scope of a plural definite (The bears are big and white), conjunction receives a Boolean, intersective interpretation. However, when the conjoined predicates cannot apply simultaneously to an individual (The bears are big and small), conjunction receives a weaker 'split' interpretation (Krifka, 1990; Lasersohn, 1995; Winter, 1996). Our experiments reveal that preschool-aged children are sensitive to both intersective and split interpretations, and can use their lexical and world knowledge of the relevant predicates in order to select an appropriate reading.

Objective: US health care institutions are implementing secure websites (patient portals) to achieve federal Meaningful Use (MU) certification. We sought to understand efforts to implement portals in "safety net" health care systems that provide services for low-income populations., Materials and Methods: Our rapid ethnography involved visits at 4 California safety net health systems and in-depth interviews at a fifth. Visits included interviews with clinicians and executives ( n  = 12), informal focus groups with front-line staff ( n  = 35), observations of patient portal sign-up procedures and clinic work, review of marketing materials and portal use data, and a brief survey ( n  = 45)., Results: Our findings demonstrate that the health systems devoted considerable effort to enlisting staff support for portal adoption and integrating portal-related work into clinic routines. Although all health systems had achieved, or were close to achieving, MU benchmarks, patients faced numerous barriers to portal use and our participants were uncertain how to achieve and sustain "meaningful use" as defined by and for their patients., Discussion: Health systems' efforts to achieve MU certification united clinic staff under a shared ethos of improved quality of care. However, MU's assumptions about patients' demand for electronic access to health information and ability to make use of it directed clinics' attention to enrollment and message routing rather than to the relevance and usability of a tool that is minimally adaptable to the safety net context., Conclusion: We found a mismatch between MU-based metrics of patient engagement and the priorities and needs of safety net patient populations., (© The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0-10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4-3.7), arthritis (AOR: 4.8, 95% CI, 3.0-7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3-4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness., Perspective: This article describes the prevalence and factors associated with chronic pain in older homeless adults. Almost half report chronic pain, which was associated with PTSD, arthritis, and personal history of abuse. Clinicians should address chronic pain, trauma, and the associated mental health conditions in this high-risk population., (Copyright © 2017 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Background: We evaluated cognitive function and factors associated with cognitive impairment in a cohort of older homeless adults. We hypothesized that substance use and a history of traumatic brain injury would be associated with cognitive impairment., Methods: We recruited 350 homeless individuals aged ≥50 years using population-based sampling and conducted structured interviews and neuropsychological testing. We evaluated alcohol use with the Alcohol Use Disorder Identification Test, defining high-severity alcohol use as a total score ≥16 or ≥4 on the alcohol dependency sub-scale. We assessed global cognition with the Modified Mini-Mental State Test (3MS) and processing speed and executive function with the Trail Making Test (TMTB), defining impairment as performing 1.5 standard deviations below the standardized mean. We used multivariable logistic regression to examine the association between alcohol use and cognition., Results: Participants had a median age of 58 years [IQR 54-61], 76.7% were men, and 79.9% were African American. A quarter (25.1%) of participants met criteria for impairment on the 3MS; 32.9% met criteria for impairment on TMTB. In models adjusted for sociodemographic variables and health conditions, high-severity alcohol use was associated with global cognitive impairment (AOR 2.39, CI 1.19-4.79) and executive dysfunction (AOR 3.09, CI 1.61-5.92)., Conclusions: Older homeless adults displayed a prevalence of cognitive impairment 3-4 times higher than has been observed in general population adults aged 70 and older. Impaired cognition in older homeless adults could impact access to housing programs and the treatment of health conditions, including the treatment of alcohol use disorders., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose of the Study: Older homeless adults living in shelters have high rates of geriatric conditions, which may increase their risk for acute care use and nursing home placement. However, a minority of homeless adults stay in shelters and the prevalence of geriatric conditions among homeless adults living in other environments is unknown. We determined the prevalence of common geriatric conditions in a cohort of older homeless adults, and whether the prevalence of these conditions differs across living environments., Design and Methods: We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, CA. We evaluated participants for common geriatric conditions. We assessed living environment using a 6-month follow-back residential calendar, and used cluster analysis to identify participants' primary living environment over the prior 6 months., Results: Participants stayed in 4 primary environments: unsheltered locations (n = 162), multiple locations including shelters and hotels (n = 88), intermittently with family/friends (n = 57), and, in a recently homeless group, rental housing (n = 43). Overall, 38.9% of participants reported difficulty performing 1 or more activities of daily living, 33.7% reported any falls in the past 6 months, 25.8% had cognitive impairment, 45.1% had vision impairment, and 48.0% screened positive for urinary incontinence. The prevalence of geriatric conditions did not differ significantly across living environments., Implications: Geriatric conditions were common among older homeless adults living in diverse environments, and the prevalence of these conditions was higher than that seen in housed adults 20 years older. Services that address geriatric conditions are needed for older homeless adults living across varied environments., (Published by Oxford University Press on behalf of the Gerontological Society of America 2016.)

Objective: With the rapid rise in the adoption of patient portals, many patients are gaining access to their personal health information online for the first time. The objective of this study was to examine specific usability barriers to patient portal engagement among a diverse group of patients and caregivers., Materials and Methods: We conducted interviews using performance testing and think-aloud methods with 23 patients and 2 caregivers as they first attempted to use features of a newly launched patient portal., Results: In navigating the portal, participants experienced basic computer barriers (eg, difficulty using a mouse), routine computer barriers (eg, mistyping, navigation issues), reading/writing barriers, and medical content barriers. Compared to participants with adequate health literacy, participants with limited health literacy required 2 additional minutes to complete each task and were more likely to experience each type of navigational barrier. They also experienced more inaccuracies in interpreting a test result and finding a treatment plan within an after-visit summary., Discussion: When using a patient portal for the first time, participants with limited health literacy completed fewer tasks unassisted, had a higher prevalence of encountering barriers, took longer to complete tasks, and had more problems accurately interpreting medical information., Conclusion: Our findings suggest a strong need for tailored and accessible training and support to assist all vulnerable patients and/or caregivers with portal registration and use. Measuring the health literacy of a patient population might serve as a strong proxy for identifying patients who need the most support in using health technologies., (© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Objective: To examine whether childhood adversity is associated with depressive symptoms, suicide attempts, or psychiatric hospitalization., Methods: History of seven childhood adversities (physical neglect, verbal abuse, physical abuse, sexual abuse, parental death, parental incarceration, and child welfare system placement) was gathered through in-person interviews. Multivariate models examined associations between history of childhood adversities and moderate to severe depressive symptoms, lifetime history of suicide attempt, or lifetime history of psychiatric hospitalization. The study enrolled 350 homeless adults, aged 50 and older, in Oakland, California, using population-based sampling methods. Moderate to severe depressive symptoms were measured on a Center for Epidemiologic Studies-Depression Scale (≥22), self-reported lifetime history of suicide attempt, and self-reported lifetime history of psychiatric hospitalization., Results: Participants with exposure to one childhood adversity had elevated odds of reporting moderate to severe depressive symptoms (adjusted odds ratio [AOR]: 2.0; 95% confidence interval [CI]: 1.1-3.7) and lifetime history of suicide attempt (AOR: 4.6; 95% CI: 1.0-21.6) when compared with those who had none; the odds of these two outcomes increased with exposure to additional childhood adversities. Participants with four or more childhood adversities had higher odds of having a lifetime history of psychiatric hospitalization (AOR: 7.1; 95% CI: 2.8-18.0); no increase with fewer adversities was found., Conclusion: Childhood adversities are associated with poor mental health outcomes among older homeless adults. Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations., Competing Interests: M.B. Kushel is a member of the leadership board of Everyone Home, which seeks to end homelessness in Alameda County, CA. No other conflicts of interest were reported., (Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: The median age of the single adult homeless population is 50 and rising. Although the prevalence of substance use decreases as individuals age, older adults now have a higher prevalence of substance use than older adults did 10 years ago. Homeless individuals have a higher prevalence of substance use disorders than the general population. However, little is known about substance use in older homeless adults., Methods: The objective of the study was to examine prevalence of and factors associated with substance use in a population-based sample (N = 350) of homeless individuals aged 50 and older in Oakland, California. Dependent variables included moderate or greater severity illicit drug symptoms (Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) score >3) and moderate or greater alcohol symptoms (Alcohol Use Disorders Identification Test (AUDIT) score >7). Independent variables included demographics, mental health problems, and negative life course events such as physical and sexual abuse, school expulsion, and onset of homelessness., Results: Almost two thirds of participants, 64.6%, had moderate or greater severity symptoms for at least 1 illicit drug; 25.8% had moderate or greater severity alcohol symptoms. History of psychiatric hospitalization was associated with moderate or greater illicit drug symptoms (adjusted odds ratio [AOR] = 1.9, 1.0-3.6). The presence of major depressive symptoms was associated with moderate or greater severity alcohol symptoms (AOR = 1.8, 1.1-3.0)., Conclusions: In this sample of older homeless adults, substance use is common. There is a need for substance use treatment programs, integrated with mental health services, which are targeted towards the needs of older homeless adults.

Objective: The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older., Methods: We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use., Results: In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates., Conclusions: A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness., (© 2016 by the Society for Academic Emergency Medicine.)