Faculty Bibliography

Introduction: Blacks are less likely to adhere to sleep apnea treatment compared with whites. This study explored the unique perspectives of blacks with metabolic syndrome who were referred for treatment of obstructive sleep apnea (OSA) at local sleep clinics. Methods: A total of 340 adults from the Metabolic Syndrome Outcome Study (MetSO), an NIH-funded cohort study of blacks, were randomly assigned to receive either Tailored-Telephone Intervention or regular standard of care. Prior to randomization, participants provided a detailed sleep history assessing sleep habits and OSA risk. The qualitative study involved 4 focus groups (mean age = years; 4 Males, 22 Females). A focus group guide was used to elicit responses from participants. Interviews were audio-taped and transcribed verbatim. Initial a priori codes were developed to guide initial coding. Analysis was guided by grounded theory. We explored 3 important questions: Q1) What are the potential barriers and facilitators of OSA evaluation? Q2) What are the potential barriers and facilitators of CPAP adherence? Q3) What are the experiences of blacks who participated in the intervention? Results: Themes for each question were as follows: Q1 a) general sleep disturbances, b) presence of other health conditions, c) encouragement from loved ones and d) rapport with medical provider plays a key role in adhering to OSA evaluation. Q2 a) improvement in sleep apnea, b) CPAP side effects, c) mistrust of the medical system, d) socio-economic factors limiting ability to participate and e) perception that CPAP device is not necessary were barriers and facilitators of CPAP adherence. Q3 a) having received meaningful information about sleep disorders, sleep hygiene b) increase in health information and c) rapport with the health educator were the experiences of participants in the intervention. Conclusion: To our knowledge, this is the irst study to describe qualitative indings of blacks with metabolic syndrome that participated in an OSA-related interve!

BACKGROUND: The rising burden of chronic non-communicable diseases in low and middle income countries has major implications on the ability of these countries to achieve universal health coverage. In this paper we discuss the impact of cardiovascular diseases (CVD) on primary healthcare services in urban poor communities in Accra, Ghana. METHODS: We review the evidence on the evolution of universal health coverage in Ghana and the central role of the community-based health planning services (CHPS) programme and the National Health Insurance Scheme in primary health care. We present preliminary findings from a study on community CVD knowledge, experiences, responses and access to services. RESULTS: The rising burden of NCDs in Ghana will affect the achievement of universal health coverage, particularly in urban areas. There is a significant unmet need for CVD care in the study communities. The provision of primary healthcare services for CVD is not accessible, equitable or responsive to the needs of target communities. CONCLUSIONS: We consider these findings in the context of the primary healthcare system and discuss the challenges and opportunities for strengthening health systems in low and middle-income countries.

BACKGROUND: Observational studies of patients with rheumatoid arthritis have suggested that racial and ethnic disparities exist for minority populations. We compared disease activity and clinical outcomes across racial and ethnic groups using data from a large, contemporary US registry. METHODS: We analyzed data from 2 time periods (2005-2007 and 2010-2012). The Clinical Disease Activity Index was examined as both a continuous measure and a dichotomous measure of disease activity states. Outcomes were compared in a series of cross-sectional and longitudinal multivariable regression models. RESULTS: For 2005-2007, significant differences of mean disease activity level (P < .001) were observed across racial and ethnic groups. Over the 5-year period, modest improvements in disease activity were observed across all groups, including whites (3.7; 95% confidence interval [CI], 3.2-4.1) compared with African Americans (4.3; 95% CI, 2.7-5.8) and Hispanics (2.7; 95% CI, 1.2-4.3). For 2010-2012, significant differences of mean disease activity level persisted (P < .046) across racial and ethnic groups, ranging from 11.6 (95% CI, 10.4-12.8) in Hispanics to 10.7 (95% CI, 9.6-11.7) in whites. Remission rates remained significantly different across racial/ethnic groups across all models for 2010-2012, ranging from 22.7 (95% CI, 19.5-25.8) in African Americans to 27.4 (95% CI, 24.9-29.8) in whites. CONCLUSIONS: Despite improvements in disease activity across racial and ethnic groups over a 5-year period, disparities persist in disease activity and clinical outcomes for minority groups versus white patients.

OBJECTIVE: Obesity is a pressing public health problem without proven population-wide solutions. Researchers sought to determine whether a city-mandated policy requiring calorie labeling at fast food restaurants was associated with consumer awareness of labels, calories purchased and fast food restaurant visits. DESIGN AND METHODS: Difference-in-differences design, with data collected from consumers outside fast food restaurants and via a random digit dial telephone survey, before (December 2009) and after (June 2010) labeling in Philadelphia (which implemented mandatory labeling) and Baltimore (matched comparison city). Measures included: self-reported use of calorie information, calories purchased determined via fast food receipts, and self-reported weekly fast-food visits. RESULTS: The consumer sample was predominantly Black (71%), and high school educated (62%). Postlabeling, 38% of Philadelphia consumers noticed the calorie labels for a 33% point (P < 0.001) increase relative to Baltimore. Calories purchased and number of fast food visits did not change in either city over time. CONCLUSIONS: While some consumers report noticing and using calorie information, no population level changes were noted in calories purchased or fast food visits. Other controlled studies are needed to examine the longer term impact of labeling as it becomes national law.

Global health (GH) spans every scientific, clinical and social science discipline. Cultural competency/ cross-cultural sensitivity has been identified as a GH priority for U.S. medical schools (Peluso 2013). As part of Curriculum for the 21st Century (C21), the Global Health Selective is prerequisite to the new Global Health Concentration at NYU School of Medicine (SoM). With special emphasis on cultural competency/ crosscultural sensitivity, its primary aim is to teach future physicians fund of knowledge and clinical skills that strengthen GH care. As a 4-week clinical clerkship, the GH Selective was first completed by 9 medical students in 2012, and again by 12 medical students in 2013. Activities included 18 ninety-minute patient case discussions in tropical medicine; related clinical assignments at NYU; literature review and journal clubs; and 9 half-day clinical skills simulation workshops covering 1) diarrhea in Haiti and Egypt, 2) tuberculosis in Peru 3) malaria in sub-Saharan Africa 4) hypertension screening by community health workers in Ghana 5) survivors of torture from central Africa 6) humanitarian response to tsunami in Indonesia 7) obstetrical emergencies in rural Liberia 8) interpreter exercise in Tibetan, and 9) smoking cessation via interpreters. Leadership is from NYU SoM Departments of Medicine and Population Health, and Center for Healthful Behavior Change. Over two years of the GH Selective, student feedback was overwhelmingly positive. Each year, at least 37 faculty volunteered from 11 departments at SoM to log at least 225 hours of direct contact teaching hours each offering. In its first two years, the GH Selective exceeded expectations. Its interdisciplinary curriculum is a particular strength, and its special emphasis on working with standardized patients in cross-cultural settings, focused on communication skills, health literacy, and health navigation, provided students with knowledge and clinical skills applicable for any clinical care provided locally, nationally,!

BACKGROUND: Black men have the greatest burden of premature death and disability from hypertension (HTN) in the United States, and the highest incidence and mortality from colorectal cancer (CRC). While several clinical trials have reported beneficial effects of lifestyle changes on blood pressure (BP) reduction, and improved CRC screening with patient navigation (PN), the effectiveness of these approaches in community-based settings remains understudied, particularly among Black men. METHODS/DESIGN: MISTER B is a two-parallel-arm randomized controlled trial that will compare the effect of a motivational interviewing tailored lifestyle intervention (MINT) versus a culturally targeted PN intervention on improvement of BP and CRC screening among black men aged >/=50 with uncontrolled HTN who are eligible for CRC screening. Approximately 480 self-identified black men will be randomly assigned to one of the two study conditions. This innovative research design allows each intervention to serve as the control for the other. Specifically, the MINT arm is the control condition for the PN arm, and vice-versa. This novel, simultaneous testing of two community-based interventions in a randomized fashion is an economical and yet rigorous strategy that also enhances the acceptability of the project. Participants will be recruited during scheduled screening events at barbershops in New York City. Trained research assistants will conduct the lifestyle intervention, while trained community health workers will deliver the PN intervention. The primary outcomes will be 1) within-patient change in systolic and diastolic BP from baseline to six months and 2) CRC screening rates at six months. DISCUSSION: This innovative study will provide a unique opportunity to test two interventions for two health disparities simultaneously in community-based settings. Our study is one of the first to test culturally targeted patient navigation for CRC screening among black men in barbershops. Thus, our study has the potential to improve the reach of hypertension control and cancer prevention efforts within a high-risk population that is under-represented in primary care settings. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01092078.

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.

BACKGROUND: African Americans have higher rates of nocturnal hypertension and less nocturnal blood pressure (BP) dipping compared with whites. Although nocturnal hypertension is associated with increased cardiovascular morbidity and mortality, its clinical significance among those with normal daytime BP is unclear. This paper reports the prevalence and correlates of isolated nocturnal hypertension (INH) in a population-based cohort of African Americans enrolled in the Jackson Heart Study (JHS). METHODS: The study sample included 425 untreated, normotensive and hypertensive JHS participants who underwent 24-hour ambulatory BP monitoring (ABPM), echocardiography, and 24-hour urine collection. Multiple logistic regression and 1-way analysis of variance models were used to test the hypothesis that those with INH have worse target organ damage reflected by greater left ventricular (LV) mass and proteinuria compared with normotensive participants. RESULTS: Based on 24-hour ABP profiles, 19.1% of participants had INH. In age and sex-adjusted models, participants with INH had greater LV mass compared with those who were normotensive (P = 0.02), as well as about 3 times the odds of LV hypertrophy and proteinuria (Ps < 0.10). However, multivariable adjustment reduced the magnitude and statistical significance of each of these differences. CONCLUSIONS: INH was associated with increased LV mass compared with normo tension in a population-based cohort of African Americans enrolled in the JHS. There were trends toward a greater likelihood of LV hyper trophy and proteinuria among participants with INH vs. those who were normotensive. The clinical significance of the noted target organ damage should be explored in this population.