Faculty Bibliography

Introduction: The assessment of dysphagia in preterm infants has been limited to clinical bedside evaluation followed by videofluoroscopic swallow study (VFSS) in selected patients. Recently, fiberoptic endoscopic evaluation of swallowing (FEES) is being described more in literature for preterm infants. However, it is unclear if one test has a better diagnostic utility than the other in this population. Furthermore, it is also unclear if performing FEES and VFSS simultaneously will increase the sensitivity and specificity of detecting dysphagia compared to either test performed independently. Objectives: The primary objective of this study is to evaluate the feasibility of performing VFSS and FEES simultaneously in preterm infants. Our secondary objective is to determine whether simultaneously performed VFSS-FEES improves the diagnostic ability in detecting dysphagia in preterm infants compared to either test done separately. Methods: In this pilot study, we describe the process involved in performing simultaneous VFSS-FEES in five preterm infants (postmenstrual age ≥36 weeks) with dysphagia. A total of 26 linked VFSS-FEES swallows were analyzed, where the same bolus during the same swallow was compared using simultaneous fluoroscopy and endoscopy. The sensitivity and specificity of detecting penetration and aspiration were evaluated in simultaneous VFSS-FEES compared with each test done independently. Results: Our results demonstrated that performing simultaneous VFSS-FEES is feasible in preterm infants with dysphagia. All patients tolerated the procedures well without any complications. Our pilot study in these five symptomatic preterm infants demonstrated a low incidence of aspiration but a high incidence of penetration. Simultaneous VFSS-FEES (26 linked swallows) improved the ability to detect penetration compared to each test done separately. Conclusion: To our knowledge, this study is the first to demonstrate the feasibility of performing VFSS and FEES simultaneously in symptomatic preterm infants with dysphagia resulting in potentially higher diagnostic yield than either procedure done separately.

BACKGROUND:Traumatic kidney injury is an infrequent event with a wide range of injury patterns. The aim of this paper is to review the incidence, mechanisms of injury, diagnostic methods, and therapeutic indications of renal injury according to the most recent evidence and to perform an analysis of mortality rates on these patients. OBJECTIVES/OBJECTIVE:To perform a systematic review of the literature and a meta-analysis on traumatic kidney injuries. DATA SOURCES/METHODS:A literature search was performed using PubMed, Embase, and Scopus databases. Articles published in English, French and Spanish were selected from 1963 to 2018. MeSH terms utilized were renal trauma, kidney trauma, blunt renal trauma, and penetrating renal trauma. STUDY PARTICIPANTS/METHODS:The eligilibility criteria included only original and human subject articles. Articles not involving human patients, cancer related, review articles, surveys, iatrogenic injuries, pediatric patients, and case reports were excluded from this search. RESULTS:Forty-six articles met the inclusion criteria of which 48,660 patients were identified and included in this review. Gender was reported in 32,918 cases, of which 75.3% of patients were male with a mean age of 33 years. Of the 44,865 patients where the mechanism of injury was described, we identified 36,086 (80.5%) patients that sustained blunt trauma, while 8,779 (19.5%) were due to penetrating mechanisms. Twenty one series with a total of 31,689 patients included the mortality rate. Overall mortality rate with exact binomial 95% confidence interval estimated via random effects model was 6.4% (4.8%-8.4%). CONCLUSIONS:Non-operative management has become the standard in renal trauma management with good results in morbidity and mortality. This has resulted in a decrease in the number of unnecessary iatrogenic nephrectomies and potential improvement in a patient's quality of life. When an invasive treatment is necessary, angioembolization for active bleeding or nephrorrhaphy is usually sufficient.

Introduction/UNASSIGNED:Patients often transition between health care settings, such as office to hospital, hospital to nursing facility, or hospital to home. When a patient is admitted, it is imperative that clinicians review prior medication lists along with new orders to reconcile any discrepancies. This process should occur in a standardized manner to reduce medication errors leading to adverse events and patient harm. Methods/UNASSIGNED:We developed this program as an instructional method via PowerPoint to teach the importance of accurate medication reconciliation. We implemented the program in multiple grand rounds settings with students, trainees, and attending physicians in internal medicine and surgery. Approximately 150 learners attended the sessions. We assessed learners with pre/post self-efficacy assessment (74 completed precourse surveys, 39 completed posttest surveys, and 49 participated in the audience response during the course) and multiple-choice knowledge questions. Results/UNASSIGNED:The results of the postcourse knowledge assessment demonstrated improvement in every question we tested, with two of the improvements reaching statistical significance. We found that 30% of attendees were not at all confident or only somewhat confident in conducting an appropriate medication reconciliation on admission to the hospital. Additionally, 82% of respondents reported that the presentation was likely or extremely likely to improve their medication reconciliation efforts. Discussion/UNASSIGNED:Our educational program was successful in improving learners' knowledge in every question we tested; however, only two of the improvements were statistically significant. Our program is an organized and effective tool for teaching effective and reliable medication reconciliation.

Background/UNASSIGNED:There is considerable heterogeneity in clinical trials examining the role of vitamin D in the prevention of acute respiratory infections (ARIs). Methods/UNASSIGNED:The primary aim of the Physical Performance, Osteoporosis, and Vitamin D in Older African-American Women (PODA) trial was the prevention of bone loss and decline in physical performance. A questionnaire about ARIs was administered every 3 months for 3 years to 260 black American women in a double-blind randomized clinical trial that had a placebo group and a vitamin D supplementation group. The serum 25(OH)D level was maintained >30 ng/mL in the vitamin D group. Results/UNASSIGNED:Serum 25(OH)D was maintained >30 ng/mL in 90% of the active group, whereas levels approximated those associated with the recommended dietary allowance (20 ng/mL) in the placebo group. There was no difference in occurrence of ARIs in the treatment group vs the placebo group. ARIs were not related to total or free 25(OH)D, which were measured at baseline and annually for 36 months. Conclusions/UNASSIGNED:Vitamin D supplementation sufficient to maintain serum 25(OH)D >30 ng/mL does not prevent ARIs in older African American women. ClinicalTrialsgov Registration Number/UNASSIGNED:NCT01153568.

Objective: Most acute-care hospitals have transitioned from sliding-scale to basal-bolus insulin therapy to manage hyperglycemia during hospitalization, but there is limited scientific evidence demonstrating better short-term clinical outcomes using the latter approach. The present study sought to determine if using basal-bolus insulin therapy favorably affects these outcomes in noncritical care settings and, if so, whether the magnitude of benefit differs in patients with known vs. newly diagnosed type 2 diabetes. Methods: This natural experiment compared outcomes in 10,120 non-critically ill adults with type 2 diabetes admitted to an academic teaching hospital before and after hospital-wide implementation of a basal-bolus insulin therapy protocol. A group of 30,271 inpatients without diabetes (type 1 or 2) served as controls. Binomial models were used to compare percentages of patients with type 2 diabetes who were transferred to intensive care, experienced complications, or died in the hospital before and after implementation of the protocol, controlling for changes in the control group. The analysis also evaluated before-after changes in length of stay and glucometric indicators. Results: Implementation of basal-bolus therapy did not reduce intensive care use (the primary outcome), complications, mortality, or median length of stay, except in patients with newly diagnosed diabetes (n=234), who experienced a statistically significant decline in the incidence of complications (p<0.01). The absence of effect in previously diagnosed patients was observed in spite of a 32% decline (from 3.7% to 2.5%) in the proportion of inpatient days with hypoglycemia <70 mg/dL (p<0.01) and a 16% decline (from 13.5% to 11.3%) in the proportion of days with hyperglycemia >300 mg/dL (p<0.01). Conclusions: Despite achieving significant reductions in both hyperglycemia and hypoglycemia, use of basal-bolus insulin therapy to manage hyperglycemia in non-critically ill hospitalized patients did not improve short-term clinical outcomes, except in the small minority of patients with newly diagnosed diabetes. The optimal management of hyperglycemia for improving these outcomes has yet to be determined.

Context/UNASSIGNED:There is limited information on the influence of vitamin D on physical performance in black Americans. Objective/UNASSIGNED:To determine if maintenance of serum 25(OH)D above 75 nmol/L prevents the decline in physical performance. Design/UNASSIGNED:The PODA trial had a prospective, randomized, placebo controlled, double-dummy design with two arms: one with placebo vitamin D3 adjusted to maintain serum 25(OH)D above 75 nmol/L. Patients/UNASSIGNED:The target population was healthy elderly black women with serum 25(OH)D between 20 and 65 nmol/L. The trial was 3 years in duration with measurement of physical performance every 6-months: Grip strength, Short Physical Performance Battery (SPPB), 10 chair rises and 6-minute walk distance. 260 women entered the study and 184 completed 3 years. Mean age was 68.2 years. Baseline 25(OH)D was 53 nmol/L and total SPPB was 11 (10-12). Setting/UNASSIGNED:Research Center in an Academic Health Center. Main Outcomes Measure/UNASSIGNED:Prevention of decline in physical performance measures. Intervention/UNASSIGNED:Participants were randomly assigned to placebo or active vitamin D. Vitamin D3 dose was adjusted to maintain serum 25(OH)D above 75 nmol/l. Results/UNASSIGNED:There was a decline with time in grip strength and the 6-minute walk. The SPBB increased with time. There were no significant differences between the placebo and active vitamin D3 groups with respect to the temporal patterns observed for any of the performance measures. Conclusions/UNASSIGNED:There is no benefit of maintaining serum 25(OH)D above 75 nmol/L in preventing the decline in physical performance in healthy black American women.

BACKGROUND:Limited information is available on the influence of vitamin D on falls in older high-functioning black American women. Endocrine Society guidelines propose serum 25(OH)D levels over 30 ng/mL. OBJECTIVE:To determine if maintenance of serum 25(OH)D above 30 ng/mL protects against falls. DESIGN/METHODS:adjusted to maintain serum 25(OH)D above 30 ng/mL. The primary outcomes were the prevention of bone loss and the decline in physical performance. PATIENTS/METHODS:The target population was healthy black women older than 60 years with serum 25(OH)D between 8 and 26 ng/mL. The trial was 3 years in duration with a falls questionnaire administered every 3 months. A total of 260 women entered the study, and 184 completed the 3 years. Mean age was 68.2 years. SETTING/METHODS:Research center in an academic health center. MAIN OUTCOMES MEASURE/METHODS:Prevention of falls. INTERVENTION/METHODS:dose was adjusted to maintain serum 25(OH)D above 30 ng/mL in the active group using a double-dummy design. RESULTS:Baseline 25(OH)D was 22 ng/mL. Mean serum 25(OH)D reached 47 ng/mL in the active group compared with 21 ng/mL in the placebo group. There were 14.2% falls in the previous year recalled at baseline. During the study, 46% reported falling in the treatment group compared with 47% in the placebo group. There was no association of serum 25(OH)D or vitamin D dose with the risk of falling. CONCLUSIONS:There is no benefit of maintaining serum 25(OH)D above 30 ng/mL compared with the Institute of Medicine recommendation (20 ng/mL) in preventing falls in healthy older black American women.

Asthma and obesity are both prevalent conditions that appear related, but the etiology for this association remains unclear. This study examines whether asthma is associated with obesity and physical activity limits 10 years later among a subsample from the National Longitudinal Survey of Youth 1979 who were age 40 at baseline. We addressed selection bias using inverse-propensity score weighting (N?=?5077), and confirmed the results with full matching (N?=?5041), and with both methods we estimated new sampling weights so that the sample would remain nationally representative. Both matched sampling methods balanced adults with asthma versus those without asthma on all 7 covariates: baseline obesity, sex, race/ethnicity, family income, poverty status, general health status and physical activity limits. Before matching, baseline asthma was significantly associated with developing obesity 10 years later in an unadjusted model [OR?=?1.44 (1.10-1.90)], but not in the multivariable model [OR?=?1.15 (0.80-1.67)]. Baseline asthma was not associated with obesity 10 years later after inverse propensity weighting [OR (95% CI?=?1.03 (0.69-1.53)] and full matching [1.16 (0.75-1.80)]. Results remained similar after excluding subjects with baseline obesity. In a cumulative logistic model using complex survey and full matching weights, those with baseline asthma had 83% greater odds of reporting physical activity limits compared to those without asthma, OR?=?1.83 (1.21-2.76). Baseline asthma was not associated with obesity among either a nationally representative sample of middle-aged adults or a non-obese subset. However, asthma was associated with physical activity limits in the full matched sample. Asthma disease management programs should communicate that asthma does not imply obesity and also encourage exercise within the physical limitations of their populations. Selection bias on factors such as low socioeconomic status may explain previous asthma-obesity associations

OBJECTIVES/OBJECTIVE:To examine the effect of 25-hydroxyvitamin D (25(OH)D) levels recommended by Endocrine Society guidelines (>30 ng/mL) on cognition in healthy older African-American women over 3 years. DESIGN/METHODS:Randomized, double-blind, placebo-controlled clinical trial. SETTING/METHODS:Bone Mineral Research Center at New York University Winthrop Hospital. PARTICIPANTS/METHODS:Healthy postmenopausal African American women aged 65 and older (N=260; mean age 68.2 ± 4.9; 46% college education or higher). INTERVENTION/METHODS:Half of the women were randomized to receive vitamin D (adjusted to achieve a serum level > 30 ng/mL) with calcium (diet and supplement total of 1,200 mg), and half were randomized to receive placebo with calcium (1,200 mg). MEASUREMENTS/METHODS:Cognitive assessments every 6 months using the Mini-Mental State Examination (MMSE) to detect cognitive decline. Mean MMSE scores were calculated over time for both groups. Those with MMSE scores less than 21 at baseline were excluded. RESULTS:was 3,490 ± 1,465 IU per day, and average serum 25(OH)D at 3 years was 46.8 ± 1.2 ng/mL in the active group and 20.7 ± 1.1 ng/mL in the placebo group. Serum 25(OH)D concentration was maintained at greater than 30 ng/mL in 90% of the active group. Over the 3-year period, MMSE scores increased in both groups (p < .001), although change over time was not significantly different between the groups. No adverse events associated with vitamin D were observed. CONCLUSION/CONCLUSIONS:There was no difference in cognition over time between older African-American women with serum concentrations of 25(OH)D of 30 ng/mL and greater than those taking placebo. There is no evidence to support vitamin D intake greater than the recommended daily allowance in this population for preventing cognitive decline.