Faculty Bibliography

CONTEXT: Active surveillance (AS) is an important strategy to reduce prostate cancer overtreatment. However, the optimal criteria for eligibility and predictors of progression while on AS are debated. OBJECTIVE: To review primary data on markers, genetic factors, and risk stratification for patient selection and predictors of progression during AS. EVIDENCE ACQUISITION: Electronic searches were conducted in PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to April 2014 for original articles on biomarkers and risk stratification for AS. EVIDENCE SYNTHESIS: Patient factors associated with AS outcomes in some studies include age, race, and family history. Multiple studies provide consistent evidence that a lower percentage of free prostate-specific antigen (PSA), a higher Prostate Health Index (PHI), a higher PSA density (PSAD), and greater biopsy core involvement at baseline predict a greater risk of progression. During follow-up, serial measurements of PHI and PSAD, as well as repeat biopsy results, predict later biopsy progression. While some studies have suggested a univariate relationship between urinary prostate cancer antigen 3 (PCA3) and transmembrane protease, serine 2-v-ets avian erythroblastosis virus E26 oncogene homolog gene fusion (TMPRSS2:ERG) with adverse biopsy features, these markers have not been consistently shown to independently predict AS outcomes. No conclusive data support the use of genetic tests in AS. Limitations of these studies include heterogeneous definitions of progression and limited follow-up. CONCLUSIONS: There is a growing body of literature on patient characteristics, biopsy features, and biomarkers with potential utility in AS. More data are needed on practical applications such as combining these tests into multivariable clinical algorithms and long-term outcomes to further improve AS in the future. PATIENT SUMMARY: Several PSA-based tests (free PSA, PHI, PSAD) and the extent of cancer on biopsy can help to stratify the risk of progression during active surveillance. Investigation of several other markers is under way.

BACKGROUND: The US Preventive Services Task Force recommends screening for and treating obesity. However, there are many barriers to successfully treating obesity in primary care (PC). Technology-assisted weight loss interventions offer novel ways of improving treatment, but trials are overwhelmingly conducted outside of PC and may not translate well into this setting. We conducted a systematic review of technology-assisted weight loss interventions specifically tested in PC settings. METHODS: We searched the literature from January 2000 to March 2014. INCLUSION CRITERIA: (1) Randomized controlled trial; (2) trials that utilized the Internet, personal computer, and/or mobile device; and (3) occurred in an ambulatory PC setting. We applied the Cochrane Effective Practice and Organization of Care (EPOC) and Delphi criteria to assess bias and the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) criteria to assess pragmatism (whether trials occurred in the real world versus under ideal circumstances). Given heterogeneity, results were not pooled quantitatively. RESULTS: Sixteen trials met inclusion criteria. Twelve (75 %) interventions achieved weight loss (range: 0.08 kg - 5.4 kg) compared to controls, while 5-45 % of patients lost at least 5 % of baseline weight. Trial duration and attrition ranged from 3-36 months and 6-80 %, respectively. Ten (63 %) studies reported results after at least 1 year of follow-up. Interventions used various forms of personnel, technology modalities, and behavior change elements; trials most frequently utilized medical doctors (MDs) (44 %), web-based applications (63 %), and self-monitoring (81 %), respectively. Interventions that included clinician-guiding software or feedback from personnel appeared to promote more weight loss than fully automated interventions. Only two (13 %) studies used publically available technologies. Many studies had fair pragmatism scores (mean: 2.8/4), despite occurring in primary care. DISCUSSION: Compared to usual care, technology-assisted interventions in the PC setting help patients achieve weight loss, offering evidence-based options to PC providers. However, best practices remain undetermined. Despite occurring in PC, studies often fall short in utilizing pragmatic methodology and rarely provide publically available technology. Longitudinal, pragmatic, interdisciplinary, and open-source interventions are needed.

Adult hospitalized patients are at risk for malnutrition. The sensitivity and specificity of screening tools were compared with Subjective Global Assessment. Methods included a systematic review using PubMed, CINAHL Plus, and EMBASE through April 2014. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies method. The results showed that the Malnutrition Universal Screening Tool, Nutrition Risk Screening-2002, and Malnutrition Screening Tool were most frequently tested. The specificity was generally good (>80%), but sensitivity was variable. Malnutrition Universal Screening Tool, Nutrition Risk Screening-2002, and Malnutrition Screening Tool are screening tools that consider population characteristics and risk cut points and are easy to administer.

A need was identified by the Department of Population Health (DPH) for an academic medical center to facilitate research using large, externally funded datasets. Barriers identified included difficulty in accessing and working with the datasets, and a lack of knowledge about institutional licenses. A need to facilitate sharing and reuse of datasets generated by researchers at the institution (internal datasets) was also recognized. The library partnered with a researcher in the DPH to create a catalog of external datasets, which provided detailed metadata and access instructions. The catalog listed researchers at the medical center and the main campus with expertise in using these external datasets in order to facilitate research and cross-campus collaboration. Data description standards were reviewed to create a set of metadata to facilitate access to both externally generated datasets, as well as the internally generated datasets that would constitute the next phase of development of the catalog. Interviews with a range of investigators at the institution identified DPH researchers as most interested in data sharing, therefore targeted outreach to this group was undertaken. Initial outreach resulted in additional external datasets being described, new local experts volunteering, proposals for additional functionality, and interest from researchers in inclusion of their internal datasets in the catalog. Despite limited outreach, the catalog has had ~250 unique page views in the three months since it went live. The establishment of the catalog also led to partnerships with the medical center’s data management core and the main university library. The Data Catalog in its present state serves a direct user need from the Department of Population Health to describe large, externally funded datasets. The library will use this initial strong community of users to expand the catalog and include internally generated research datasets. Future expansion plans will include working with DataCore and the main university library

OBJECTIVES: In response to the lack of evidence-based guidance for how to continue scaling up antiretroviral therapy (ART) in ways that make optimal use of limited resources, to assess comparative studies of ART service delivery models implemented in sub-Saharan Africa. METHODS: A systematic literature search and analysis of studies that compared two or more methods of ART service delivery using either CD4 count or viral load as a primary outcome. RESULTS: Most studies identified in this review were small and non-randomised, with low statistical power. Four of the 30 articles identified by this review conclude that nurse management of ART compares favourably to physician management. Seven provide evidence of the viability of managing ART at lower levels within the health system, and one indicates that vertical and integrated ART programmes can achieve similar outcomes. Five articles show that community/home-based ART management can be as effective as facility-based ART management. Five of seven articles investigating community support link it to better clinical outcomes. The results of four studies suggest that directly observed therapy may not be an important component of ART programmes. CONCLUSIONS: Given that the scale-up of antiretroviral therapy represents the most sweeping change in healthcare delivery in sub-Saharan Africa in recent years, it is surprising to not find more evidence from comparative studies to inform implementation strategies. The studies reported on a wide range of service delivery models, making it difficult to draw conclusions about some models. The strongest evidence was related to the feasibility of decentralisation and task-shifting, both of which appear to be effective strategies.

OBJECTIVE: To conduct a systematic literature review appraising the effects of interventions to improve patient-practitioner communication on cardiovascular-related clinical outcomes. METHODS: Databases were searched up to March 27, 2013 to identify eligible studies that included interventions to improve patient and/or practitioner communication skills and assessment of a cardiovascular-related clinical outcome in adults >/=18 years of age. RESULTS: Fifteen papers were reviewed: the primary focus in seven studies was the patient; seven included a practitioner-focused intervention and one targeted both. Two patient-focused and two practitioner-focused studies demonstrated a beneficial effect of the intervention compared to a control group. Patient-focused studies were designed to improve patients' information-seeking and question-asking skills with their practitioner. Practitioner-focused studies were designed to either improve practitioner's general patient-centered communication or risk communication skills. CONCLUSION: Few interventions targeting patient-practitioner communication have assessed the impact on cardiovascular-related clinical outcomes, limiting the ability to determine effectiveness. Additional rigorous research supported by theoretical frameworks and validated measurement is needed to understand the potential of patient-practitioner communication to improve cardiovascular-related clinical outcomes. PRACTICE IMPLICATIONS: Investments in communication skills trainings in medical education and practice are needed in order to attain the full potential of patient-centered care on cardiovascular-related clinical outcomes.

CONTEXT: Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment. OBJECTIVE: To review primary data on PCa overdiagnosis and overtreatment. EVIDENCE ACQUISITION: Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches. EVIDENCE SYNTHESIS: The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management. CONCLUSIONS: Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy. PATIENT SUMMARY: Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.

BACKGROUND: Obesity disproportionately affects Latinas living in the United States, and cultural food patterns contribute to this health concern. OBJECTIVE: The aim of this study was to synthesize the qualitative results of research regarding Latina food patterns in order to (a) identify common patterns across Latino culture and within Latino subcultures and (b) inform future research by determining gaps in the literature. METHODS: A systematic search of three databases produced 13 studies (15 manuscripts) that met the inclusion criteria for review. The Critical Appraisal Skills Program tool and the recommendations of Squires for evaluating translation methods in qualitative research were applied to appraise study quality. Authors coded through directed content analysis and an adaptation of the Joanna Briggs Institute Qualitative Assessment and Review Instrument coding template to extract themes. Coding focused on food patterns, obesity, population breakdown, immigration, acculturation, and barriers and facilitators to healthy eating. Other themes and categories emerged from this process to complement this approach. RESULTS: Major findings included the following: (a) Immigration driven changes in scheduling, food choice, socioeconomic status, and family dynamics shape the complex psychology behind healthy food choices for Latina women; (b) in Latina populations, barriers and facilitators to healthy lifestyle choices around food are complex; and (c) there is a clear need to differentiate Latino populations by country of origin in future qualitative studies on eating behavior. DISCUSSION: Healthcare providers need to recognize the complex influences behind eating behaviors among immigrant Latinas in order to design effective behavior change and goal-setting programs to support healthy lifestyles.