Faculty Bibliography

In the era of highly active antiretroviral therapy (HAART), disseminated Kaposi sarcoma (KS) has become much rarer in the USA. We report a case of a 34-year-old man with KS of the skin, oropharynx, lung and rectum. Within the same lung nodule, we discovered significant burden of colesional Cryptococcus neoformans, in the context of a positive asymptomatic cryptococcal antigenemia, which was a previously unreported occurrence. The gold standard of treatment for KS continues to be HAART. The role of chemotherapy is still controversial. In addition, a cryptococcal antigen screen-and-treat approach with fluconazole is still not routinely recommended in the USA to prevent serious meningeal disease despite recent studies showing efficacy and applicability. We discuss both issues here and the outcome of our patient. We also present the patient's own unique perspective in dealing with the ramifications of these diagnoses.

We report a laboratory-confirmed case of adult intestinal toxemia botulism in an allogeneic hematopoietic stem cell transplantation (allo-HCT) recipient. Onset of symptoms occurred within the hospitalized setting, making this case particularly unique. Botulism may have arisen because of significant intestinal disruption and compromise, and not directly from immune compromise.

Diffractive waveplates and equivalent metasurfaces provide a promising path for applications in thin film beam steering, tunable lenses, and polarization filters. However, fixed metasurfaces alone are unable to be tuned electronically. By combining metasurfaces with tunable liquid crystals, we experimentally demonstrate a single layer device capable of electrically switching a diffractive waveplate design at a measured peak diffraction efficiency of 35%, and a minimum switching voltage of 10V. Furthermore, the nano-scale metasurface aligned liquid crystals are largely independent of variations in wavelength and temperature. We also present a computational analysis of the efficiency limits of liquid crystal based diffractive waveplates, and compare this analysis to experimental measurements.

PURPOSE/OBJECTIVE:An adverse drug reaction associated with the use of prasugrel for dual antiplatelet therapy after percutaneous coronary intervention (PCI) with stent placement is reported. SUMMARY/CONCLUSIONS:About one week after starting prasugrel use following angioplasty and a stent revision procedure, a 61-year-old woman arrived in the emergency department with wheezing, shortness of breath, a feeling of throat closure, and a widespread erythematous, maculopapular, pruritic rash. She reported that the respiratory symptoms had started to develop the previous day, with the onset of rash occurring about 24 hours after initiation of prasugrel therapy. The patient's symptoms subsided after administration of 0.3 mg epinephrine subcutaneously, diphenhydramine 50 mg i.v., and methylprednisolone 125 mg i.v. Prasugrel was discontinued, and the patient was switched to another P2Y12 inhibitor (ticagrelor) for continued dual antiplatelet therapy. Analysis of the case using the adverse drug reaction probability scale of Naranjo et al. indicated that prasugrel was the probable cause of the hypersensitivity reaction. Hypersensitivity manifesting as a rash has been previously reported in patients receiving prasugrel, a thienopyridine P2Y12 inhibitor. Desensitization may be an option for thienopyridine-allergic patients undergoing PCI with stenting; alternatively, the nonthienopyridine P2Y12 inhibitor ticagrelor may be used in a dual antiplatelet therapy regimen. CONCLUSION/CONCLUSIONS:A patient who had undergone PCI with stenting developed shortness of breath and rash associated with prasugrel therapy. Symptoms abated after supportive therapy and discontinuation of prasugrel, the probable offending agent. Treatment was safely switched to ticagrelor.

Breast cancer is the most commonly diagnosed malignancy in women, but little is known about therapeutic outcomes in patients with both breast cancer and HIV. We performed a retrospective cohort study of women with or without HIV undergoing treatment for breast cancer from 1996 to 2011. Cases with HIV were 1:2 matched to non-HIV controls based on age, sex, race, and date of cancer diagnosis. Dose reduction and/or delay during chemotherapy, overall survival, and development of metastatic disease were studied outcomes. 156 (52 HIV, 104 non-HIV) subjects were analyzed. The majority of breast cancers in both groups were clinical stages 0, I, II, and III (73%). HIV infection preceded cancer diagnosis by a median of 13 years. Median CD4 count at time of cancer diagnosis was 417 cells/mcL. Approximately 87% (45/52) were on HAART, mostly protease inhibitor-based (57%) therapy. HIV-infected women needed more dose reductions and/or delays to chemotherapy due to toxicity (56% vs. 30%; p=0.03). Stage at diagnosis, triple negative receptor status, and dose reduction and/or delay were predictors of metastatic disease and death. HIV-infected women experienced more adverse events during breast cancer treatment, and a potential causative factor could be drug-drug interactions between HAART and chemotherapy.

African Americans have higher colorectal cancer (CRC) mortality than White Americans and yet have lower rates of CRC screening. Increased screening aids in early detection and higher survival rates. Coupled with low literacy rates, the burden of CRC morbidity and mortality is exacerbated in this population, making it important to develop culturally and literacy appropriate aids to help low-literacy African Americans make informed decisions about CRC screening. This article outlines the development of a low-literacy computer touch-screen colonoscopy decision aid using an innovative marketing method called perceptual mapping and message vector modeling. This method was used to mathematically model key messages for the decision aid, which were then used to modify an existing CRC screening tutorial with different messages. The final tutorial was delivered through computer touch-screen technology to increase access and ease of use for participants. Testing showed users were not only more comfortable with the touch-screen technology but were also significantly more willing to have a colonoscopy compared with a "usual care group." Results confirm the importance of including participants in planning and that the use of these innovative mapping and message design methods can lead to significant CRC screening attitude change.

BACKGROUND:African Americans experience disproportionately higher morbidity and mortality from colorectal cancer (CRC), yet they complete screening at lower rates than Caucasians. While studies have identified barriers and facilitators to CRC screening among African Americans, no study has examined physician perceptions of these barriers. OBJECTIVE:The purpose of this study was to determine how resident physicians view barriers and facilitators to CRC screening among their African American patients, and to compare residents' perceptions with barriers and facilitators that have been reported in studies with African Americans. DESIGN/METHODS:Both quantitative and qualitative data were obtained during in-depth interviews with 30 upper-year residents from an urban academic internal medicine program. RESULTS:Residents recognized the low levels of awareness of CRC that have been reported among African American patients. The most common barriers reported by residents were lack of knowledge, fears, personal/social circumstances, and colonoscopy-specific concerns. Residents reported a need for increased education, increased public awareness, and easier scheduling as facilitators for screening. Residents failed to appreciate some key perceptions held by African Americans that have been documented to either impede or facilitate CRC screening completion, particularly the positive beliefs that could be used to overcome some of the perceived barriers. CONCLUSIONS:Residents may be missing opportunities to more effectively communicate about CRC screening with their African American patients. Residents need more explicit education about African Americans' perceptions to successfully promote screening behaviors in this high-risk population.

Colorectal cancer (CRC) screening remains significantly underutilized by African Americans despite their increased risk compared to whites. The purpose of this article is to review recent research on patterns of screening, perceptions of CRC screening methods and outcomes of seven intervention trials specifically designed to increase screening among African Americans in light of the recommendation of the American College of Gastroenterologists to make colonoscopy the screening method of choice for this population. This review shows that progress has been made in understanding the complexity of perceived barriers to CRC screening among African Americans. Interventions that used community-based education targeting individuals and clinically based education targeting clinicians showed modest increases in screening rates. Targeting entire communities did not show significant results. However, because intervention studies use not only different types of interventions but different screening outcome measures, results are not easily comparable. While there is growing evidence that interventions can increase the use of fecal occult blood test (FOBT), it is not yet known if similar interventions can increase rates of screening colonoscopy. Clinicians, patients and policymakers also need to consider the array of social, cultural and financial issues associated with CRC screening in African-American communities.

Hepatitis B Virus (HBV) infection is a serious health problem among Asian Americans. Vietnamese Americans are disproportionately affected by liver cancer compared with other racial and ethnic groups. Vietnamese males have the highest incidence of liver cancer of any racial group; incidence of liver cancer among Vietnamese males is 11 times higher than among White males. Nearly 80% of liver cancer is attributed to HBV. This study measured knowledge, attitudes, and behaviors related to HBV screening and vaccination. The study was conducted among 256 Vietnamese Americans in the greater Philadelphia and New Jersey area, with a large number of underserved, recent immigrants with low socioeconomic status and limited English proficiency. Participants were recruited from Vietnamese community-based organizations. Overall, 46.3% of the sample had heard of HBV or knew about the availability of screening (32.6%) or vaccination (35.5%) while 7.5% were ever screened and 6.3% had been vaccinated. Community-based, culturally appropriate interventions for Vietnamese Americans and health care providers should increase screening and vaccination rates.