Faculty Bibliography

OBJECTIVE: Omega-3 polyunsaturated fatty acid (omega-3 PUFA) supplementation during pregnancy remains controversial. We sought to examine the effects of omega-3 PUFA on inflammation and oxidative stress in vitro and in vivo using a model of preterm labor. METHODS: In vivo. Female Swiss Webster mice were fed a normal diet or a 5% fish oil (FO) diet for 3 weeks then mated with normal-fed males. On gestational day 15, dams were injected with either saline (n=10 per group) or lipopolysaccharide (LPS, intrauterine) (n=10 per group). Maternal plasma, amniotic fluid, placentas, and uteri were collected 4 h later and assessed for cytokines; maternal plasma and amniotic fluids were analyzed for oxidative stress. In vitro. RAW264.7 mouse macrophage-like cells were treated with either: vehicle, H2O2, docosahexaenoic acid (DHA), or eicosapentaenoic acid (EPA) (0, 0.1-100 muM) and analyzed for oxidative stress. RESULTS: In vivo. Administration of the 5% FO diet enhanced LPS-induced cytokines in the placenta (P<0.05-0.01) and increased tumor necrosis factor-alpha in the uterus (P<0.05) and amniotic fluid (P<0.01) when compared to LPS-treated normal-fed animals. Maternal plasma obtained from FO-fed dams showed higher LPS-induced oxidative stress than control-fed animals (P<0.035). However, no differences in oxidative stress were observed in the amniotic fluid. In vitro. Treatment of macrophage-like cells with omega-3 PUFA significantly and dose-dependently increased oxidative stress (P<0.001-0.0001). CONCLUSIONS: Supplementation with FO for prior to and during pregnancy significantly increased LPS-induced inflammation in the amniotic fluid, uterus, and placenta and significantly increased maternal systemic oxidative stress in vivo. Likewise, DHA and EPA induced oxidative stress in macrophage-like cells in vitro.

In this single-blind, crossover study, the difference between a brushless tooth cleaner and a soft toothbrush was studied to compare plaque removal efficiency. The sample was composed of 15 human subjects who were categorized into two groups. Group 1 was composed of subjects randomly assigned to the brushless tooth cleaner for the first two weeks. Group 2 was composed of those randomly assigned to begin the study using the soft toothbrush. After two weeks of brushing with their assigned device, subjects returned to their normal modality to brush their teeth for one week. For the last two weeks of the study, subjects were told to brush with the opposite device they were originally assigned to at the beginning of the trial. Investigators recorded the subjects' gingival indices (based on probe depths) and Quigley scores (based on plaque indices using disclosing solution) at the beginning of week one, the end of week two, the end of week three and the end of week five. The main outcomes in this study were the Silness Loe Index (SLI) and the Quigley Hein Index (QHI). The SLI was assessed on the buccal, lingual, mesial and distal surfaces of six teeth, for a total of 24 surfaces. The QHI was assessed on the buccal and lingual surfaces of six teeth, for a total of 12 surfaces. Each index was measured at each visit by the sum total score divided by the total number of surfaces. The data were analyzed separately using a mixed-effects repeated measures analysis of variance (RMANOVA) for crossover designs. Results indicate that, according to the SLI, there is no significant difference between the two treatments after the first or second weeks. However, based on the QHI, statistically significant differences existed between the two treatments after week one and two. After week one, the soft toothbrush use had a higher QHI than the brushless tooth cleaner. After week two, the brushless tooth cleaner had a higher QHI than the soft toothbrush.

BACKGROUND: We designed and tested an innovative transitional care program, involving cardiac surgery nurse practitioners, to improve care continuity after patient discharge home from coronary artery bypass graft (CABG) operations and decrease the composite end point of 30-day readmission and death. METHODS: A total of 401 consecutive CABG patients were eligible between May 1, 2010, and August 31, 2011, for analysis. Patient data were entered prospectively into The Society of Thoracic Surgeons database and the New York State Cardiac Surgery Reporting System and retrospectively analyzed with Institutional Review Board approval. The "Follow Your Heart" program enrolled 169 patients, and 232 controls received usual care. Univariate and multivariate analyses were used to identify readmission predictors, and propensity score matching was performed with 13 covariates. RESULTS: Binary logistic regression analysis identified "Follow Your Heart" as the only independently significant variable in preventing the composite outcome (p = 0.015). Odds ratios for readmission were 3.11 for dialysis patients, 2.17 for Medicaid recipients, 1.87 for women, 1.86 for non-Caucasians, 1.78 for chronic obstructive pulmonary disease, 1.26 for diabetes, and 1.09 for congestive heart failure. Propensity score matching yielded matches for 156 intervention patients (92%). The intervention showed a significantly lower 30-day readmission/death rate of 3.85% (6 of 156) compared with 11.54% (18 of 156) for the usual care matched group (p = 0.023). CONCLUSIONS: A home transition program providing continuity of care, communication hub, and medication management by treating hospital nurse practitioners significantly reduced the 30-day composite end point of readmission/death after CABG. More targeted resource allocation based on odds ratios of readmission may further improve results and be applicable to other patient groups.

BACKGROUND: To evaluate resident knowledge of colorectal cancer (CRC) screening guidelines and to define areas requiring attention. METHODS: A survey was created using three published guidelines for CRC screening. Program directors for internal medicine residency programs were contacted within the metro New York City area to have their residents participate. RESULTS: Five programs participated, and 115 responses were recorded. For the appropriate testing and interval to screen for CRC, 61/115 residents identified flexible sigmoidoscopy every 5 years, 108/115 identified colonoscopy every 10 years, 16/115 identified double contrast barium enema (DCBE) every 5 years and only 12/115 thought CT-colography every 5 years was appropriate. Only 40/115 respondents appropriately identified fecal occult blood testing (FOBT) administered in the patient's home annually, while fecal immunohistochemical testing (FIT) annually at home was identified by 8/115 residents. CONCLUSION: While most residents seem knowledgeable regarding CRC screening with colonoscopy, many deficiencies remain. FOBT for screening purposes remains undervalued, and confusion about administering the test persists. The distinction between screening and prevention needs further reinforcement.

Low albumin and the albumin-globulin ratio (AGR) were associated with vascular adverse events. Our study explores the AGR as a predictor of mortality after non-ST-segment elevation myocardial infarction (NSTEMI). In an observational study of 570 NSTEMI patients admitted to a tertiary center between 2004 and 2006, patients were stratified into equal tertiles according to AGR. The primary outcome was 4-year all-cause mortality. The 4-year mortality rates in the first, second, and third AGR tertiles were 88 (47%) of 189, 48 (25%)of 190 , and 19 (10%) of 191, respectively (P < .0001). After adjusting for 20 confounding variables, AGR first tertile (AGR <1.12) had a higher mortality versus second tertile (hazard ratio [HR] 2.6, P < .001). Likewise, the AGR second tertile had higher mortality versus the third tertile (AGR ≥1.34; HR 2.3, P = .004). The albumin-globulin ratio is a significant independent predictor of long-term mortality after NSTEMI in patients with normal serum albumin levels. Further studies are needed to explain the underlying mechanisms.

Seroprevalence of antibodies to influenza A(H1N1)pdm09 virus among 193 emergency department health care personnel was similar among 147 non-health care personnel (odds ratio 1.4, 95% CI 0.8-2.4). Working in an acute care setting did not substantially increase risk for virus infection above risk conferred by community-based exposures.

OBJECTIVE:To study medication discrepancies in clinical transitions across a large health care system. DESIGN/METHODS:Randomized chart review of electronic medical records and paper chart medication reconciliation lists across 3 transitions of care. SETTINGS AND PARTICIPANTS/METHODS:Subacute patient medication records were reviewed through 3 transition care points at a large health care system, including hospital admission to discharge (time I), hospital discharge to skilled nursing facility (SNF; time II) and SNF admission to discharge home or long term care (LTC; time III). MEASUREMENTS/METHODS:Medication discrepancies were identified and categorized by the principal investigator and a pharmacist. Discrepancies were defined as any unexplained documented change in the patients' medication lists between sites and unintentional discrepancies were defined as any omission, duplication, or failure to change back to original regimen when indicated. RESULTS:We reviewed 1696 medications in the 132 transition records of 44 patients, identifying 1002 discrepancies. Average age was 71.4 years and 68% were female. Median hospital stay was 5.5 days and 14.5 SNF days. Total medications at hospital admission, hospital discharge, SNF admission, and SNF discharge were 284, 472, 555, and 392, respectively. Total medication discrepancies were 357 (time I), 315 (time II), and 330 (time III). All patients experienced discrepancies and 86% had at least 1 unintentional discrepancy. The average number of medications per patient increased at time I from 6.5 to 10.7 (P < .001), increased at time II from 10.7 to 12.6 (P <.0174), and decreased at time III from 12.6 to 8.9 (P < .001). Patients, on average, had 8.1, 7.2, and 7.6 medication discrepancies at times I, II, and III, respectively. Surgical patients had more discrepancies than medical at times I and III (8.94 vs 5.3, P < .019; 8.0 vs 5.8, P < .028). In the unintentional group, cardiovascular drugs represented the highest number of discrepancies (26%). CONCLUSION/CONCLUSIONS:This study is the first to follow medication changes throughout 3 transition care points in a large health care system and to demonstrate the widespread prevalence of medication discrepancies at all points. Our findings are consistent with previously published results, which all focused on single site transitions. Outcomes of the current reconciliation process need to be revisited to insure safe delivery of care to the complex geriatric patient as they transition through health care systems.

OBJECTIVE:To report incidence and relevance of positive intraoperative total hip replacement (THR) bacterial cultures taken at the time of surgical closure in dogs having unilateral THR. STUDY DESIGN/METHODS:Retrospective case series. ANIMALS/METHODS:Dogs (n = 100) with cemented (CFX), cementless (BFX), or hybrid THR. METHODS:Medical records (January 2007-March 2010) of dogs that had THR were reviewed. Signalment, type and side of THR, concurrent surgery, operative and anesthetic times, intraoperative coxofemoral closing (CC) bacterial culture results, organism cultured, duration of postoperative antibiotic administration, physical examination findings at 3 weeks, 3 months, and at 6 months to 1 year after surgery, radiographic findings at 3 months and between 6 months and 1 year after surgery, and incidence of complications were retrieved. RESULTS:There was a significant difference in duration of surgery between CC culture negative and CC culture positive groups (103.27 minutes versus 122.50 minutes, respectively, P < .038) and in total anesthetic time between CC culture negative and culture positive groups (165.20 minutes versus 189.50 minutes, respectively, P < .038). There was no significant difference between CC culture negative and culture positive groups for median age (30 months versus 39 months, respectively, P < .75), median weight (36.91 kg versus 35.68 kg, respectively, P < .61), median clinical signs (4 months versus 3.5 months, respectively, P < .65), sex (males 44.32% versus females 25.00%, respectively, P < .20), laterality (left 55.68% versus right 50.00%, respectively, P < .71), concurrent surgery (extracapsular lateral imbrication/medial patella luxation/lateral patella luxation [ECLI/MPL/LPL] 22.73% versus none 25.00%, respectively, P < 1.00), and THR type (hybrid 17.05% versus 25.00% respectively; CFX 60.23% versus 75.0%; BFX 22.73% versus 0.0%; Fisher's exact test P < .17). CONCLUSIONS:Surgical and anesthetic duration were significantly associated with positive CC culture results. Positive CC culture results were not associated with adverse results at 3 months and at 6-month to 1-year follow-up evaluation.

Prior studies demonstrated the association between the major adverse cardiovascular outcomes and both higher platelet and lower lymphocyte counts. Our study explores the value of the platelet/lymphocyte ratio (PLR) as a marker of long-term mortality in patients presented with non-ST segment elevation myocardial infarction (NSTEMI). This is an observational study with a total 619 NSTEMI patients admitted to a tertiary center between 2004 and 2006. Patients were stratified into equal tertiles according to their admission PLR. The primary outcome, 4 year all-cause mortality, was compared among the PLR tertiles. The first, second and third PLR tertiles were PLR < 118.4, 118.4 ≤ PLR ≤ 176, and PLR > 176, respectively) included 206, 206 and 207 patients, respectively. There was a significant higher 4 year all-cause mortality in the higher PLR tertiles (the mortalities were 17, 23 and 42 % for the first, second and third PLR tertiles respectively, p < 0.0001). After exclusion of patients expired in the first 30 days, patients in the first PLR tertile had a significant lower 4 year mortality (33/205, 16 %) versus those in the third PLR tertile (72/192, 38 %), p < 0.0001. After controlling for Global Registry of Acute Coronary Events risk scores and other confounders, the hazard ratio of mortality increased 2 % per each 10 U increase of PLR (95 % CI 1.01-1.03, p < 0.0001). In patients with PLR ≥ 176, the mortality rate was statistically higher in those received mono-antiplatelet (30/60 = 50 %) compared to those received dual antiplatelet therapy (48/149 = 32 %), p = 0.0018. However in PLR < 176, the mortality was not significantly different between mono-antiplatelet group (20/94 = 21 %) versus dual antiplatelets group (53/213 = 25 %), p = 0.56. The PLR is a significant independent predictor of long-term mortality after NSTEMI. Among patients with PLR > 176, patients with dual antiplatelet therapy had lower mortality versus those with mono-platelet therapy. Further studies are needed to clarify these findings.

Male NZW/BXSB.Yaa (W/B) mice express two copies of TLR7 and develop pathogenic autoantibodies, whereas females with only one copy of TLR7 have attenuated disease. Our goal was to analyze the regulation of the autoantibody response in male and female W/B mice bearing the autoreactive site-directed H chain transgene 3H9. Serum anti-dsDNA Abs appeared in males at 12 wk, and most had high-titer IgG anti-dsDNA and anti-cardiolipin Abs and developed >300 mg/dl proteinuria by 8 mo. Females had only low-titer IgG anti-cardiolipin Abs, and none developed proteinuria by 1 y. Males had a smaller marginal zone than females with a repertoire that was distinct from the follicular repertoire, indicating that the loss of marginal zone B cells was not due to diversion to the follicular compartment. Vk5-43 and Vk5-48, which were rare in the naive repertoire, were markedly overrepresented in the germinal center repertoire of both males and females, but the VJ junctions differed between males and females with higher-affinity autoreactive B cells being selected into the germinal centers of males. Administration of IFN-α to females induced anti-cardiolipin and anti-DNA autoantibodies and proteinuria and was associated with a male pattern of junctional diversity in Vk5-43 and Vk5-48. Our studies are consistent with the hypothesis that presence of the Yaa locus, which includes an extra copy of Tlr7, or administration of exogenous IFN-α relaxes the stringency for selection in the germinal centers resulting in increased autoreactivity of the Ag-driven B cell repertoire.