Researchers at the School of Medicine, Brown and the University of Washington analyzed a nationwide database with data from 4,888 hospitals between 2016 and 2020. They found that less than two percent of patients who were diagnosed with both stroke and cardiac interventions were treated with endovascular thrombectomy, or EVT — the only effective treatment for patients dealing with cardiac malfunctions. 

“I’ve always felt that we weren’t able to offer as many stroke treatments to those patients [in cardiac intensive care units],” Adam de Havenon ’01, a professor of neurology at the School of Medicine and the lead author of the study, told the News. “But in medicine, there’s a huge gap between something you anecdotally experience and demonstrating that in a data set, which is what we did in this study.” 

According to de Havenon, cardiac interventions, after neurosurgical procedures, are the second leading surgical procedure that causes stroke. During cardiac interventions, surgeons can accidentally knock debris off of the aortic arch, causing clots and plaque to travel upstream to the brain, increasing the likelihood of stroke, specifically ischemic stroke.

Fabio Ramponi, a professor of cardiac surgery at the School of Medicine, the risk of stroke varies for different cardiac interventions. For minor surgeries, like valve replacement, the risk of stroke is roughly two percent. For patients who need multiple cardiac interventions, the risk of stroke increases to 10 percent. 

The researchers first analyzed patients’ billing codes and identified those who received EVT, the most effective stroke treatment for patients with ischemic strokes. During EVT, a surgeon inserts a thin catheter through a limb into the patient’s brain and uses a stent retriever to remove the clot. EVT is only effective within 24 hours of stroke symptoms. The team also determined the exact dates patients were diagnosed with a stroke and when they were treated with EVT. 

The researchers then identified the presence and timing of cardiac intervention among the patients treated with EVT. Of the 630,000 stroke patients, more than 12,000 patients also had a cardiac procedure, which they defined as including both cardiac surgeries and other interventions, such as catheter-based stent placement and inserting cardiac pacemakers. 

“What we found was that individuals who had their stroke after cardiac procedures were less than half as likely to get [EVT] within three days after the cardiac surgery,” de Havenon said. “And that was consistent with our hypothesis and my personal experience.”

According to Kevin Sheth, a professor of neurology at the School of Medicine and a co-author of the study, patients who had both a cardiac intervention and ischemic stroke — and were then treated with EVT — were twice as likely to be discharged home. Many patients who weren’t treated with EVT had to endure long-term care, Sheth said.

Ramponi noted that some patients may not receive EVT because it is harder to detect stroke among cardiac patients. While it can help doctors guess if there is decreased blood flow on one side of the body, doctors can’t always be sure.

“When the patient gets to intensive care, it’s hard to make a full neurologic exam because the patient is still under some sort of sedation,” Ramponi told the News. “The anesthesia is still lingering, so it’s hard to assess in a very systematic way.”

Further, de Havenon argued that it’s difficult to determine if EVT will be useful for patients — especially if doctors observe stroke symptoms hours after the patient wakes up from sedation — because the treatment is only effective for a short amount of time. Some cardiac procedures force patients to be sedated for days, making stroke detection even more difficult, according to de Havenon. 

Still, many doctors differ on how to help identify strokes in patients following cardiac interventions. For de Havenon, medical workers ought to monitor these patients more closely. For example, nurses could wake patients out of sedation to identify potential signs of stroke. They could also use bedside tests, such as an electroencephalogram, or EEG, to help determine the onset of stroke, he said. 

Still, Ramponi argued that doctors should focus more on preventing strokes altogether. 

“In my opinion, the focus has to be more on prevention,” Ramponi said. “Even if you detect [the stroke] early, the prognosis for the patient won’t be as good as if they never had a stroke.” 
The National Institute of Health estimates that roughly 795,000 people experience strokes in the United States per year.

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Based out of the Yale School of Public Health, the Housing and Health Equity Lab has explored the effects of housing disparities and homelessness on people’s health since its founding in 2020. Her team aims to get a deeper understanding of how access to housing affects health outcomes and develops solutions to address the health issues arising from inadequate housing access.

Since then, the lab has used a combination of data analysis and interviews with community members to develop evidence-based solutions that increase housing access and equity. Keene, an associate professor for public health, noted that her lab also hopes to improve collaboration between researchers while creating a training ground for students interested in the social determinants of health.

“Our mission is to conduct research that is actionable towards the goal of advancing housing and health justice,” Keene wrote in an email to the News. 

Since the COVID-19 pandemic moved much of the lab’s meetings and research online, Keene has been able to expand her research team beyond Yale. Now, her trainees include students at Columbia University, Ohio State University, Emory University and other institutions. 

These collaborations, she said, have strengthened the lab’s ability to investigate a wide range of issues related to housing and health. Some of her team’s ongoing projects explore the effects of evictions on mental and physical health and how the wait time for rental subsidies affects diabetes management.

“If you have spent most of your money on rent, you probably do not have enough left to buy enough food, fill prescriptions or pay utilities,” wrote Penelope Schlesinger, the lab’s manager and program administrator, in an email to the News. “There is a critical need for more affordable housing, [so] it’s critical to continue to explore the ways housing shapes health.”

Systemic health inequities

Whitney Denary, a lab member and doctorate candidate in social and behavioral sciences, noted that one of the lab’s research goals is to contextualize how racially discriminatory housing policies, such as redlining, have produced disparities in housing access — and lead to harmful health consequences.

As a result of these systemic practices, she explained, communities of color have a lower likelihood of home ownership and experience housing insecurity at a higher rate.

“In the 1930s, the Homeowner’s Association provided land in areas that aren’t good to people of color and provided them with higher mortgage rates,” Denary told the News. “People who weren’t able to buy housing at that time may go down the line of renting, which reduces generational wealth and ability to use money.” 

Additionally, redlining reduced public investment in marginalized communities, Denary added, leading to a broad scarcity of social infrastructure and resources in low-income communities. Combined, those impacts of historical housing inequities have produced poor health outcomes for low-income communities.

“The communities that were redlined don’t necessarily have parks, or libraries, or all of these really important community assets that then can push families and neighborhoods to ultimately have successful health,” Denary said.

More recently, homelessness in Connecticut has risen over the past two years, following nearly a decade of declining rates. After 2021, Connecticut saw a 13-percent spike in statewide homelessness rates, according to a publicly available point-in-time count by the organization Advancing CT Together. 

According to their latest available data in January 2023, there were over 3,000 individuals experiencing homelessness in the state — a nearly three percent increase from the year prior. While the number of individuals experiencing chronic homelessness remained the same, the report found a seven percent increase in the number of youth experiencing homelessness in the state.

As the Executive Director of New Haven’s Housing Authority, Karen DuBois-Walton ‘89, has helped many of those individuals and families find affordable housing throughout her career. Her experience mirrors some of the Housing and Health Equity Lab’s key findings: regardless of the cause, housing instability exacerbates health issues.

“It’s harder to stay connected with a treatment, it’s harder to keep up with a good health regimen, it’s harder to get access to healthy food, it’s hard to keep up with your medication,” Dubois-Walton said. “In the absence of stable housing, all of those things become more challenging.”

Housing and health are also a two-way street, she added, since health challenges can often cause housing insecurities, as well. Some health issues create obstacles to keeping a job, earning a consistent income, and paying rent on time, Dubois-Walton said.

Chronic conditions, ‘pure stress’

For individuals with chronic diseases, the financial uncertainty and food instability individuals experience while homeless can make managing their illness a daunting endeavor.

Unhoused patients with diabetes, for example, are often unable to use the medication insulin, since the drug requires long-term refrigeration, Denary said. Without a home, patients also might not have access to safe spaces to check their blood sugar or effectively maintain dietary restrictions doctors recommend for diabetes management.

Even for patients without diabetes, tenuous housing conditions can make it difficult for individuals to access nutritious, regular food sources. In 2023, Denary led a study that found that tenants in rental assistance programs were less likely to experience food insecurity. Those tenants also consumed more daily cups of fruits and vegetables than those not covered by the programs.

However, Keene said, it is often not enough that unhoused individuals try to keep a healthy diet. The body’s response to the stress of experiencing homelessness itself can be damaging, leading to post-traumatic stress symptoms and an increased rate of emergency department visits among unhoused people, her research has found. 

Particularly for individuals with chronic diseases like diabetes that require careful dietary regulations, those chronic stress factors can have damaging biological effects, even if patients try to eat as recommended by their doctors.

“Even if individuals that deal with housing insecurities eat healthy food and try to stay healthy, the pure stress of their housing situation leads to a release of hormones that cause blood sugar levels to rise,” Keene told the News.

Mark Colville, a New Haven-based housing activist, highlighted some of those cascading stressors that unhoused people face. Individuals who are evicted and lose their jobs are left unable to pay for rent, forcing many into overburdened shelters, he said.

“However, most shelters will kick out individuals in the morning and leave them stranded on the streets,” added Colville.

Colville said he has also come across scenarios where homelessness has exposed individuals to health and sanitation risks. He described his experience working with a woman who experienced unhygienic and environmentally hazardous conditions while unhoused.

“When she was living under the bridge, there were rats everywhere,” Colville told the News. “She knows that she was consuming rat waste in her food and that she was using her inhaler [for asthma].”

Blending research and activism

For Keene, a major component of her lab’s work entails advocating for practical policy interventions that combat crises at the intersection of housing and healthcare.

In 2021, she published an editorial in the CT Mirror that urged the state legislature to pass laws that ensure universal access to legal counsel when faced with eviction, based on the lab’s findings that evictions are linked with increases in maternal depression, climbing rates of sexually transmitted infections and worse child health outcomes, Keene said. 

Members of the lab have also submitted testimony that describes how raising rent can lead to higher rates of homelessness among low-income families, Denary said. Denary’s testimony encouraged the legislature to implement a stable rent cap in the state and regulations against owners raising rent when new tenants arrive. 

DuBois-Walton said she believes that there is a critical need for research that highlights the connections between housing and health to inform policymakers about the far-reaching consequences of homelessness. 

Given how widespread the impacts of stable housing are, she said, it is economically favorable to keep people in stable housing, instead of disrupting their education, employment and health.

“My hope is that housing researchers and health researchers will continue to keep that kind of research in front of policymakers so that we don’t just do it in a moment of crisis, like [COVID-19],” DuBois-Walton said. “It’s a basic human rights measure that everybody deserves.”

Moving forward, Keene said she aims to increase awareness about housing and healthcare research by participating in conferences nationwide. She also said she hopes the lab can establish a support network for students interested in the research field, especially among students who have experienced housing insecurities. 

Meanwhile, Keene also said she is planning to increase the lab’s engagement with groups that advocate for improved housing access — like tenant organizations, housing activists and legislators—to bridge the gap between research and policy.

“I think if we continue to have good research that shows [housing] is what is good for human development and for human wellbeing, it will get policymakers…to invest in those areas,” DuBois-Walton said. 

But for Keene, public health recommendations are only the first step.

“We’re identifying the health impacts of an unmet housing need, and we’re not going to address through public health interventions; the only way to address that is through housing,” Keene said. 

As of Jan. 15, there were over 800 unhoused people in Connecticut, 177 of whom were in the New Haven area, according to the Connecticut Coalition to End Homelessness.

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According to Hailey Reister, a postgraduate researcher associated with the study, a significant proportion of people who suffer from long COVID endure neuropsychiatric symptoms, such as the loss of the senses, memory loss and brain fog. In their study, the researchers investigated two potential causes of these symptoms: neuroinflammation, the brain’s immune response, which leads to the inflammation of nervous tissue, and dysfunction of the blood-brain barrier, a layer of blood cells that keeps harmful substances from entering the brain.

By comparing patients who suffered from neuropsychiatric symptoms of long COVID and those who were never infected with COVID-19, the researchers found that neuroinflammation and blood-brain barrier dysfunction are not the causes of neuropsychiatric symptoms.

“I think [our research] really suggests that strategies aimed at reducing brain inflammation are really unlikely to work for people who are suffering from these types of symptoms,” said Sheli Farhadian, lead author of the study and a professor of infectious diseases at the School of Medicine.

Long COVID refers to the variety of new or returning symptoms that people experience after their initial COVID-19 infection. According to Reister, the research team knew that many patients struggled with neuropsychiatric symptoms, though their precise causes were unclear.

So, the team sought to examine why these symptoms occurred, starting with neuroinflammation.

“We knew that [people with] other infectious diseases, who have similar symptoms to what people experience with long COVID, do have neuroinflammation,” Reister told the News. “We were wondering if long COVID’s neuropsychiatric symptoms were similar to people who have these symptoms with other infectious diseases.”

For Farhadian, the cerebrospinal fluid, or CSF, is the best place in the body to determine the presence of dysfunction and inflammation because it can travel across the central nervous system. By tracking CSF, the team analyzed its immunoglobulin production and white blood cell ratio, which indicate the amount of brain-blood barrier dysfunction and neuroinflammation, respectively. 

The team obtained the CSF from two groups. The first group included samples of patients with long COVID. The second group was the control group, which had samples from patients who volunteered to participate in other studies before the initial outbreak of COVID-19. 

“Both of the groups consented to a lumbar puncture [near the bottom of the back] to draw blood for analysis … and their blood samples were stored in freezers [for further analysis],” said Lindsay McAlpine, a lead investigator of the study and an Instructor in the Division of Neurological Infections and Global Neurology.

Then, the researchers compared the levels of the different markers for infection. 

Both groups’ white blood cell ratio and immunoglobulin production did not significantly increase, indicating a small infection of the nervous system.

“If there was an infection in the nervous system, it can get in there by blood-barrier breakdown. And inflammation is another way to say that the body is fighting an infection.” Reister said. 

Nevertheless, Riester said that the study had its limitations. Many patients in the experiment group were young white women, while there was a higher proportion of older men of color in the control group. 

Still, with little difference between the two groups’ results, Farhadian, and his team concluded that inflammation and dysfunction aren’t causes of neuropsychiatric symptoms of long COVID.

“Negative results in science are underpublished. But this is still pretty important in the field of Long Covid because we won’t be going down a pathway where there are no answers,” McAlpine said. 

McAlpine said that she hopes that their study will help guide other researchers to study other causes that are actual contributors to these neuropsychiatric symptoms.

As of September 2023, 6.9 percent of Americans have long COVID, according to the CDC.

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A group of Yale and University of North Carolina at Charlotte researchers compared and modeled COVID-19 with its evolutionary precursors, analyzing the seasonality of COVID-19 surges across the globe. 

“This research showed the average probabilities of COVID-19 infections over a year given the virus is endemic,” Jeffrey Townsend, a biostatistics professor at the School of Public Health, told the News. “This is pretty useful to have.”

Townsend noted that there have been several COVID-19 surges over the past few years.  However, many researchers have struggled to project international COVID-19 cases due to the variability across global health systems.

Towsend added that COVID-19 is still relatively young compared to other respiratory viruses. 

“We’ve only started seeing [COVID-19] human infection a few years ago and it’s all been in the pandemic phase,” Townsend said. “If you just try and look at when people got infected, the season and the climate, it’s very hard to come up with an expectation.”

Inspired by previous research on the longevity of COVID-19 immunity, Townsend and his team observed four other coronaviruses that were evolutionarily related to COVID-19, have been present for decades and caused a common cold. According to Hayley Hassler, a research associate at the School of Public Health and the team’s lead data analyst, the team sifted through various research studies on different coronaviruses to help predict COVID-19 trends.

By comparing the genetic sequences of different coronaviruses to COVID-19, the researchers were able to draw an evolutionary tree of the virus.

According to Hassler, the researchers discovered the numerical proportion of infection for every month in the year, which highlighted how often infection frequency fluctuates throughout the year. Most of the coronaviruses had higher rates of transmission in the winter months, though they each had distinct ranges of months when infection was highest.

“From there, the model leverages the evolutionary relatedness of the coronaviruses to predict the proportion of monthly cases COVID-19,” Hassler wrote in an email to the News. “In this sense, we’d expect more closely related coronaviruses to possess similar trends in seasonality.”

Towsend said they localized the relative frequency of coronavirus transmission to major temperate cities. The researchers can then predict where the COVID-19 surge will be most prevalent based on proximity to major cities.

Towsend and his team incorporated an abundance of data from the Northern Hemisphere, but, due to limited data from the Southern Hemisphere, they were unable to include it in their model.

“Unfortunately, there hasn’t been much research in the past in the Southern Hemisphere, but every location is important,” Towsend said.

The team’s model also had other limitations. The datasets involving older coronaviruses didn’t have a standardized age range. Some datasets were restricted to children while others contained data from multiple age groups. The team is also unsure whether COVID-19 will settle into a consistent seasonal pattern.

Towsend and his team’s research predicts COVID-19 transmission rates once the virus becomes endemic, or when it begins to follow regular immunity patterns and the disease spreads at a low level. 

Still, the team believes their research will benefit public health professionals. Aia Nisho ’21, a co-author of the study who helped write the manuscript, said that knowing when and where the virus will be can help providers reduce and mitigate COVID-19 transmission.

“If we don’t accurately predict outbreaks, we’re at risk of much higher rates of infection,” Nisho wrote in an email to the News. “In ‘at-risk’ communities, such as hospitals and care homes, this translates to an increase in potential fatalities. I hope the findings of this project will be used to efficiently direct funding to public health education in communities we found to be most at risk at different times throughout the year.” 

In Connecticut, there have been 1,375 COVID-19 cases in the past week. 

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