Faculty Bibliography

BACKGROUND:Hepatitis C affects racial minorities disproportionately and is greatest among the black population. The incidence of hepatocellular carcinoma has increased with the largest increase observed in black and Hispanic populations, but limited data remain on whether hepatitis C hepatocellular carcinoma in racial-ethnic minorities have the same utilization of services compared with the white population. METHODS:We used the database of the National Inpatient Sample to identify hepatitis C-hepatocellular carcinoma patients (N = 200,163) who underwent liver transplantation (n = 11,491), liver resection (n = 4,896), or ablation of liver lesions (n = 6,933) from 2005 to 2015. We estimated utilization over time and assessed differences in utilization and inpatient mortality across patient characteristics. RESULTS:In multivariate analysis, factors associated with utilization of services included treatment year, sex, race, insurance status, hospital type, and comorbidity burden, with black and Hispanic patients having statistically significantly decreased utilization. Factors associated with inpatient mortality included treatment year, sex, race, insurance status, hospital type, hospital region, and comorbidity burden, with black patients having a statistically significantly greater risk of inpatient mortality. CONCLUSION/CONCLUSIONS:We identified racial and socioeconomic factors which were associated with utilization of services and inpatient mortality for patients with hepatitis C hepatocellular carcinoma. Blacks were especially disadvantaged in the receipt of care. Further work to abrogate these findings is imperative to ensure equitable provision of surgical therapies.

OBJECTIVE:This analysis examined whether specific social, physical, and financial factors were associated with diet quality among older, community-dwelling women. METHODS:This cross-sectional analysis was conducted in a subset of 6,094 community-dwelling Women's Health Initiative participants who completed a food frequency questionnaire, administered from 2012 to 2013, and a self-administered supplemental questionnaire, administered approximately 1 year later. The supplemental questionnaire included five questions assessing social, physical, and financial factors related to eating. Diet quality was assessed with the Healthy Eating Index-2010 (HEI-2010; range of 0-100; higher score indicates a higher quality diet). The total HEI-2010 score was calculated by summing individual scores representing the intake of nine adequacy components (beneficial food groups) and three moderation components (food groups to limit). Associations of responses to the five questions on the supplemental questionnaire with HEI-2010 scores were examined with multiple linear regression, adjusting for relevant covariates. RESULTS:Mean ± standard deviation age of participants was 78.8 ± 6.7 years. Reporting eating fewer than two meals per day, having dental or other mouth problems causing problems with eating, and not always being able to shop, cook, or feed oneself were associated with statistically significantly lower HEI-2010 scores, compared with those not reporting these issues, after multivariable adjustment: 5.37, 2.98, and 2.39 lower scores, respectively (all P values <0.0001). Reporting eating alone most of the time and not always having enough money to buy food were not associated with HEI-2010 scores. CONCLUSIONS:Among older, community-dwelling women, eating fewer than two meals per day, dental and other mouth problems, and diminished ability to shop for food, prepare meals, and feed oneself were associated with lower diet quality. These are potential targets for interventions to improve diet quality in older women. : Video Summary:http://links.lww.com/MENO/A561.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the establishment of a Diabetes Prevention Clinic for veterans with prediabetes.

BACKGROUND: Social determinants of health (SDoH) play a significant role in health outcomes, but little is known about care teams' attitudes about addressing SDoH. Our safety-net clinic has begun to implement SDoH screening and referral systems, but efforts to increase clinical responses to SDoH necessitates an understanding of how providers and clinical teams see their roles in responding to particular SDoH concerns.
METHOD(S): An annual survey was administered (anonymously) to clinical care teams in an urban safety-net clinic from 2017-2019, asking about ten SDoH conditions (mental health, health insurance, food, housing, transportation, finances, employment, child care, education and legal Aid). For each, respondents rated with a 4-point Likert-scale whether they agreed that health systems should address it (not at all, a little, somewhat, a great deal). They also indicated their agreement (using strongly disagree, somewhat disagree, somewhat agree, strongly agree) with two statements 1) resources are available for SDoH and 2) I can make appropriate referrals.
RESULT(S): 232 surveys were collected (103 residents, 125 faculty and staff (F/S), 5 unknown) over three years. Of note, mental health (84%) and health insurance (79%) were seen as very important for health systems to address, with other SDoH items seen as very important by fewer respondents. They reported little confidence that the health system had adequate resources (51%) and were unsure how to connect patients with services (39%). When these results were broken out by year, we found the following: In 2017 (n=77), approximately 35% of respondents thought the issues of employment, childcare, legal aid, and adult education should be addressed "a little," but in 2018 (n=81) and 2019 (n=74) respondents found the health system should be more responsible, with over 35% of respondents stating that these four issues should be addressed "somewhat" by health systems. In addition, half of respondents in 2019 felt that financial problems should be addressed "a great deal," up from 31% in 2017. Across all years, food, housing, mental health, and health insurance were seen as SDoH that should be addressed "a great deal". It is of note that respondents across all years reported limited understanding of referral methods and options available to their patients.
CONCLUSION(S): Many of the SDoH conditions were seen by respondents as outside the purview of health systems. However, over the three years, more members increased the number of SDoH conditions that should be addressed a "great deal." Responses also indicated that many of the team members do not feel prepared to deal with "unmet social needs". Additional examination of clinic SDoH coding, referral rates, resources, and team member perspectives will deepen our understanding of how we can cultivate a culture that enables team members to respond to SDoH in a way that is sensitive to their needs and patient needs

LEARNING OBJECTIVE #1: Recognize the presentation of pure red cell aplasia caused from Azathioprine LEARNING OBJECTIVE #2: Distinguish key parts of history and lab findings that help diagnose pure red cell aplasia CASE: A 42-year-old female with a medical history of Crohn's disease, mixed connective tissue disease (MCTD), hypertension, and stage 3 chronic kidney disease, presented to the hospital with a complaint of fatigue and weakness for the previous two weeks. She was taking azathioprine, vedolizumab, and prednisone 5 mg for her Crohn's disease and MCTD. In addition, allopurinol was added 1.5 months prior. Initial lab workup revealed a macrocytic anemia with a hemoglobin of 7.5 mg/dl and a mean corpuscular volume of 100.9 fl. Previous CBCs showed a hemoglobin around 14 mg/dl with normal mean corpuscular volume. She reported no history concerning for bleed. She had normal ESR and CRP levels and an unremarkable CT abdomen. Folate and B12 levels were normal. She had a haptoglobin of 152 mg/dl, an LDH of 218 units/liter, and total bilirubin of .3 mg/dL, inconsistent with hemolysis. A peripheral smear did not reveal hypersegmented neutrophils. Her reticulocyte count was 0.58%, and absolute count of 0.013, which suggested bone marrow suppression. Her white blood cell count and platelets were both normal. A 6- thioguanine nucleotides RBC level was elevated at 559 pmol/8x10(8)RBC (normal 235-400). Her azathioprine was subsequently discontinued, and her symptoms improved. A CBC on follow up visit approximately 3.5 months after discharge showed a hemoglobin of 13 mg/dl. IMPACT/DISCUSSION: Azathioprine is a purine analogue that interferes with DNA synthesis and inhibits proliferation of rapidly growing cells. 6-mercaptopurine (6-MP) is a drug metabolite of azathioprine that is used in the treatment of autoimmune diseases such as Crohn's disease. This occurs in part by the active metabolite, 6-Thioguanine nucleotide (6- TGN). Bone marrow suppression has been documented as a possible adverse effect of azathioprine, which is thought to occur via 6-TGN. Rarely, the suppression can be specific for erythrocyte generation and lead to a pure red cell aplasia (PRCA). Of note, our patient recently began allopurinol treatment to attempt to increase efficacy of the azathioprine. This occurs in part due to the inhibition of one of the metabolic pathways of 6-MP via Xanthine oxidase which will lead to increased therapeutically active 6-TGN. This simultaneous use likely contributed to the elevated 6-TGN metabolites and myelosuppression. This occurs more commonly in patients with low levels of Thiopurine methyl transferase (TPMT), however, aplastic anemia secondary to azathioprine can occur in patients with normal TPMT activity.
CONCLUSION(S): Allopurinol is often added in combination with azathioprine in the treatment for Crohn's disease. If these patients present with fatigue and macrocytic anemia, drug induced pure red cell anemia must be considered

LEARNING OBJECTIVE #1: Recognize need for early diagnostic fluid study for patients presenting with new ascites or effusion and constitutional symptoms, despite history of CHF LEARNING OBJECTIVE #2: Diagnose and manage HIV-unrelated, HHV-8-associated PEL in patients presenting with unusual clinical presentation CASE: 70-year-old HIV-negative male with advanced heart failure presented with altered mental status and mild hypotension. Physical exam was remarkable for increased abdominal girth concerning for new ascites and lab work was remarkable for mild leukocytosis, hypercalcemia and supratherapeutic INR. With no history of liver cirrhosis, ascites was thought to be secondary to heart failure and congestive hepatopathy and paracentesis was delayed due to elevated INR. Patient remained lethargic despite negative stroke work up, and was treated for aspiration pneumonia. Patient was eventually transferred to ICU for worsening delirium, hypotension, atrial fibrillation with RVR, and new fever of 103 F. Paracentesis with cytology confirmed a new diagnosis of primary effusion lymphoma. Patient tested negative for HIV and Epstein-Barr Encoding region (EBER), but was positive for Human Herpesvirus Type 8 (HHV8). Clinical course was complicated by aspiration pneumonia, C. difficile infection, and persistent hypotension, making him a poor candidate for chemotherapy treatment. IMPACT/DISCUSSION: Primary effusion lymphoma (PEL) is a rare, high-grade non-Hodgkin's lymphoma (NHL) that typically develops in immunocompromised patients, with HIV or following organ transplant, and often associated with HHV8 or Ebstein-Barr virus. Patients often present with constitutional symptoms and effusions in body cavities with no defining mass or overt sign of malignancy. Our patient presented with new ascites but diagnosis was delayed due to elevated INR and attribution to acute decompensated heart failure with congestive hepatopathy. Recognition of unexplained hypercalcemia and constitutional symptoms followed by early diagnostic paracentesis may have expedited the diagnosis and affected patient's clinical course.
CONCLUSION(S): Primary effusion lymphoma is a very rare disease that almost exclusively occurs in HIV positive or immunocompromised patients, representing only 4% of NHL cases associated with HIV and only 0.1% to 1% of all lymphomas in patients with other types of immunodeficiency. This case highlights HIV- negative/EBV-negative/HHV-8-positive PEL in a patient presenting unusually as acute decompensated heart failure and altered mental status treated for aspiration pneumonia. It is imperative that patients presenting with new ascites or pleural effusion get an early diagnostic fluid study with a high suspicion of malignancy especially with other constitutional symptoms and metabolic encephalopathy with unexplained hypercalcemia and negative infectious workup. Early recognition in patients particularly with underlying CHF may lead to timely treatment initiation and further reduce complications

BACKGROUND: Race, ethnicity, and language have been identified as factors impacting uptake of HIV testing. This project sought to compare testing rates between predominant and non-predominant ethnic, racial, or language populations within neighborhood FQHCs.
METHOD(S): We identified Family Health Center network locations at which more than 50% of patients served identified as the same race, and/ or had the same preferred language, and focused our analysis on these sites. We used Excel and SPSS to compare HIV testing rates between predominant and non-predominant population groups at each clinic.
RESULT(S): At 2 of 5 sites with a predominant non-English preferred language, speakers of the predominant language were more likely to receive an HIV test than speakers of other languages (p<0.001 for both sites). The other sites showed no difference by language. Of 2 clinics with a predominant racial population, there was no difference between predominant and non-predominant populations in terms of HIV testing. At all included sites, with one exception, Hispanic ethnicity was associated with a significantly higher rate of HIV testing.
CONCLUSION(S): Predominant/non-predominant race did not affect HIV testing rates, but language and ethnicity did. One mechanism for this may be increased trust associated with patient-provider language concordance, resulting in greater uptake of tests. There is a need for future research to further explore the factors associated with these findings

BACKGROUND:This review examines the effectiveness of diet and physical activity interventions to reduce cardiometabolic risk among Chinese immigrants and their descendants living in high income countries. The objective of this review is to provide information to help build future interventions aimed at improving diet and increasing physical activity levels among Chinese immigrants. METHODS:Outcomes included BMI, weight, waist circumference (WC), waist-hip ratio (WHR), cholesterol (LDL, HDL), systolic and diastolic blood pressure (SBP, DBP), hemoglobin A1c (HgbA1c), fasting blood glucose (FBG), and HOMA-IR. Six databases were systematically searched from database inception to date of search (February 2020). Meta-analyses used random effect models to estimate pooled effects of outcomes with 95% confidence intervals. The outcomes assessed were changes in mean outcomes (post-intervention versus baseline) among the intervention group versus control groups. RESULTS: = 0%, respectively. Among adults there were no other significant effects among the meta-analyses conducted (weight, WC, LDL, HgbA1c, and FBG). CONCLUSIONS:This review is the first to summarize the effectiveness of diet and physical activity interventions specifically designed for Chinese immigrants living in high income countries. There were clinically meaningful changes in BMI and blood pressure among adults, but evidence was weak for other cardiometabolic outcomes (weight, WC, LDL, HgbA1c, and FBG), and among children, there was no evidence of effect for any cardiometabolic outcomes. Given our mixed findings, more work is needed to support the design of successful interventions, particularly those targeting children and their families. TRIAL REGISTRATION/BACKGROUND:The systematic review protocol was registered in PROSPERO on December 17, 2018, the international prospective register of systematic reviews (registration number: CRD42018117842 ).