Faculty Bibliography

OBJECTIVE:It is anticipated that an intake of vitamin D found acceptable by Endocrine Society Guidelines (10,000 IU/day) with co-administered calcium supplements may result in frequent hypercalciuria and hypercalcemia. This combination may be associated with kidney stones. The objective of this study was to compare the episodes of hypercalciuria and hypercalcemia from calcium supplements co-administered with 10,000 IU or 600 IU vitamin D daily. This design allows a comparison of the Institute of Medicine recommendation for the RDA of vitamin D along with the Upper Limit of calcium intake with the high intake of vitamin D suggested by the Endocrine Society. CONTEXT/BACKGROUND:Harms of currently recommended high intake of vitamin D have not been studied. DESIGN/METHODS:. PATIENTS/METHODS:This study was conducted in an ambulatory research center in healthy, white postmenopausal women. MEASUREMENTS/METHODS:Serum and 24-hour urine calcium were measured. RESULTS:Hypercalcemia and hypercalciuria occurred in both groups. At the final visit, 19/48 in the high dose D group had hypercalciuria. The odds of developing hypercalciuria was 3.6 [OR=3.6(1.39, 9.3)] times higher in the high dose D group. The odds of developing hypercalcemia did not differ between groups. CONCLUSIONS:The safe upper level of vitamin D recommended by the Endocrine Society when accompanied by calcium supplements results in frequent hypercalciuria. The risk of kidney stones at these levels should be investigated.

Cold stimulation reduces airway compromise in adults with dysphagia. However, there is no sufficient evidence to support its use in the pediatric population. The primary goal of this pilot study is to assess the effect of cold liquid on the pharyngeal swallow mechanism in preterm infants with dysphagia. We hypothesized that thermal stimulation from cold liquid will decrease the risk of airway compromise in dysphagic preterm infants. Nine preterm infants with clinical symptoms of dysphagia were included. Video fluoroscopic swallow studies were used to assess the swallowing mechanism of each participant. The occurrence of swallow dysfunctions under room temperature liquid swallows (RTS) vs. short period cold liquid swallows (CS) was compared. Paired t test was used to test significance. The occurrence of deep penetration (p = 0.007) and aspiration (p = 0.002) decreased significantly in the CS condition compared with the RTS condition. There was a trend of less nasopharyngeal reflux with CS but did not reach statistical significance (p = 0.084). No differences were noted for mild penetration (p = 0.824). CS reduced airway compromise in dysphagic preterm infants compared to RTS. These data provide important information regarding the immediate effects of CS on pharyngeal swallowing in preterm infants with dysphagia. However, further investigation regarding its sustained effects is required before introducing to clinical practice.

RATIONALE/BACKGROUND:Vitamin D deficiency is associated with bone loss, poor muscle strength, falls and fracture. This information in older African Americans (AAs) is sparse. OBJECTIVE:The study of the relationship of Physical performance, Osteoporosis prevention with vitamin D in older African Americans (PODA) is a randomized, double-blind, placebo-controlled 3-year trial examining the effect of vitamin D on bone loss and physical performance in older AA women. METHODS:dose was determined by the baseline serum 25OHD level, and adjusted further to maintain serum 25OHD between 30 and 69ng/ml. Subjects with baseline 25OHD levels ≤8ng/ml or ≥26ng/ml were excluded. Objective measures of neuromuscular strength [Short Physical Performance Battery (SPPB), grip strength and 6-minute walking distance (6MWD)] and bone mineral density (BMD) were obtained. RESULTS:SPPB gait speed, grip strength and 6MWD showed a significant positive correlation with free 25OHD. 1pg/ml increase in free 25OHD predicted a 32% increase in the odds of having higher gait speed and a 1.42lb. increase in grip strength. No significant differences in BMI, BMD, muscle mass, grip strength, serum total 25OHD and free 25OHD were observed between groups. None of the measures of physical performance showed an association with baseline serum 25OHD. CONCLUSIONS:This is the first study to show an association between free 25OHD and physical performance. These findings indicate a positive relationship of free 25OHD with gait speed and grip strength in older AA women. Further studies are needed to understand the role of free 25OHD.

This project aimed to improve pain management through clinician education, updated assessment tools, computer resources, and improved ordering and delivery systems. Clinicians were surveyed and results analyzed using Wilcoxon-Mann-Whitney testing and χ² testing. Prescribing patterns were evaluated by comparing proportions of prescription orders and dose intervals. Cochran-Armitage Trend Test was used for linear trends in proportion of prescription orders over time. Knowledge scores improved significantly for nurses ( P = .004) and nurse practitioners/physician assistants ( P < .0001). Patient surveys showed a reduction in the percentage of patients dissatisfied with pain control. There was a decrease of 3.6% in intramuscular orders of opioids ( P < .0001). A significant reduction was found in the percentage of orders of potentially high initial doses of opioids of hydromorphone and morphine after implementing an electronic alert. This project demonstrates that a comprehensive educational strategy with improved assessment tools, clinical resources, and educational programming can have a significant impact on pain management.

PURPOSE/OBJECTIVE:To compare the effectiveness of continuous infusion of hydrocortisone versus intermittent boluses in the resolution of septic shock. METHODS:A retrospective chart review was performed to investigate the effects of low-dose hydrocortisone continuous infusion (200 mg per day) versus intermittent boluses (50 mg every six hours) in septic shock patients who did not respond to fluid resuscitation and vasopressors. The primary outcome was time to resolution of shock, defined by time from the initiation of hydrocortisone to time of vasopressor withdrawal when mean arterial pressure was greater than 65 mm Hg. Hospital length of stay, intensive care unit (ICU) length of stay, 28-day all-cause in-hospital mortality, and hyperglycemia were secondary outcomes. RESULTS:= 0.04). CONCLUSION/CONCLUSIONS:There was no significant difference in time to resolution of septic shock between continuous infusion (200 mg per day) and intermittent boluses (50 mg every six hours) of hydrocortisone. There were also no statistically significant differences in overall hospital length of stay, ICU length of stay, and 28-day all-cause in-hospital mortality. However, there was a significant difference in the incidence of hyperglycemia between the two groups, with patients in the bolus group experiencing more hyperglycemia than those in the continuous infusion group.

BACKGROUND:The Phoenix definition (PD) and Stuttgart definition (SD) designed to determine biochemical recurrence (BCR) in patients with postradiotherapy and high-intensity focused ultrasound organ-confined prostate cancer are being applied to follow patients after cryosurgery. We sought to identify predictors of BCR using the PD and SD criteria in patients who underwent primary focal cryosurgery (PFC). MATERIALS AND METHODS:We performed a retrospective review of patients who underwent PFC (hemiablation) at 2 referral centers from 2000 to 2014. Patients were followed up with serial prostate-specific antigen (PSA). PSA levels, pre- and post-PFC biopsy, Gleason scores, number of positive cores, and BCR (PD = [PSA nadir+2ng/ml]; SD = [PSA nadir+1.2ng/ml]) were recorded. Patients who experienced BCR were biopsied, monitored carefully or treated at the discretion of the treating urologist. Cox regression and survival analyses were performed to assess time to BCR using PD and SD. RESULTS:A total of 163 patients were included with a median follow-up of 36.6 (interquartile range: 18.9-56.4) months. In all, 64 (39.5%) and 98 (60.5%) experienced BCR based on PD and SD, respectively. On multivariable Cox regression, the number of positive pre-PFC biopsy cores was an independent predictor of both PD (hazard ratio [HR] = 1.4, P = 0.001) and SD (HR = 1.3, P = 0.006) BCRs. Post-PFC PSA nadir was an independent predictor of BCR using the PD (HR = 2.2, P = 0.024) but not SD (HR = 1.4, P = 0.181). Survival analysis demonstrated a 3-year BCR-free survival rate of 56% and 36% for PD and SD, respectively. Of those biopsied after BCR, 14/26 (53.8%) using the PD and 18/35 (51.4%) using the SD were found to have residual/recurrent cancer. Of those with prostate cancer on post-PFC biopsy, 57.1% of those with BCR by the PD and 66.7% of those with BCR by the SD were found to have a Gleason score ≥7. CONCLUSION:Both the PD and the SD may be used to determine BCR in post-PFC patients. However, the ideal definition of BCR after PFC remains to be elucidated.

OBJECTIVES/OBJECTIVE:The purpose of this study was to investigate the relationship between operator volume and implantable defibrillator lead failure and patient mortality at a single large implanting center. METHODS:This study analyzed the differences between high-volume and low-volume defibrillator implanters in the Pacemaker and Implantable Defibrillator Lead Survival Study ("PAIDLESS") between February 1, 1996 and December 31, 2011 at NYU Winthrop Hospital. "High-volume" was defined as performing ≥500 implants over the study period, while "low-volume" was defined as performing <500 implants. Comparisons between the procedure volume groups were performed using Fisher's Exact test, Wilcoxon rank-sum test, and Kaplan-Meier analysis as appropriate. RESULTS:Eight operators participated in the study, four of whom were high-volume operators. Of 3801 patients, a total of 3149 (83%) were operated upon by high-volume operators. Low-volume operators implanted fewer recalled leads (12% vs 42%; P<.001) and more often obtained venous access through the cephalic vein cutdown approach (63% vs 38%; P<.001) than high-volume operators. Kaplan-Meier analysis revealed shorter time to lead failure in the low-volume group (P=.02). Time to mortality was not significantly different between the high-volume and low-volume groups (P=.18). When adjusted for lead recall status, patients of high-volume operators were 43% less likely to experience lead failure compared to patients of low-volume operators. CONCLUSIONS:High-volume defibrillator implanters selected a higher percentage of recalled leads, but their patients were less likely to encounter lead failure when adjusted for lead recall status compared to low-volume operators.