Faculty Bibliography
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department:Medicine. General Internal Medicine
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International journal of environmental research & public health. 2020:17(13).DOI: 10.3390/ijerph17134885
Park Proximity and Use for Physical Activity among Urban Residents: Associations with Mental Health
Increasing global urbanization limits interaction between people and natural environments, which may negatively impact population health and wellbeing. Urban residents who live near parks report better mental health. Physical activity (PA) reduces depression and improves quality of life. Despite PA's protective effects on mental health, the added benefit of urban park use for PA is unclear. Thus, we examined whether park-based PA mediated associations between park proximity and mental distress among 3652 New York City residents (61.4% 45 + years, 58.9% female, 56.3% non-white) who completed the 2010-2011 Physical Activity and Transit (PAT) random-digit-dial survey. Measures included number of poor mental health days in the previous month (outcome), self-reported time to walk to the nearest park from home (exposure), and frequency of park use for sports, exercise or PA (mediator). We used multiple regression with bootstrap-generated 95% bias-corrected confidence intervals (BC CIs) to test for mediation by park-based PA and moderation by gender, dog ownership, PA with others, and perceived park crime. Park proximity was indirectly associated with fewer days of poor mental health via park-based PA, but only among those not concerned about park crime (index of moderated mediation = 0.04; SE = 0.02; 95% BC CI = 0.01, 0.10). Investment in park safety and park-based PA promotion in urban neighborhoods may help to maximize the mental health benefits of nearby parks.
PMID: 32645844
ISSN: 1660-4601
CID: 4518012
Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study
BACKGROUND:The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. METHODS:This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. FINDINGS:This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047). INTERPRETATION:Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. FUNDING:National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
PMID: 32479829
ISSN: 1474-547x
CID: 4851402
Right ventricular stroke distance predicts death and clinical deterioration in patients with pulmonary embolism
PURPOSE/OBJECTIVE:The right ventricular outflow tract (RVOT) velocity time integral (VTI), an echocardiographic measure of stroke distance, correlates with cardiac index. We sought to determine the prognostic significance of low RVOT VTI on clinical outcomes among patients with acute pulmonary embolism (PE). MATERIALS AND METHODS/METHODS:We conducted a retrospective review of echocardiograms on Pulmonary Embolism Response Team (PERT) activations at our institution. The main outcome was a composite of death, cardiac arrest, or hemodynamic deterioration. RESULTS:Of 188 patients, 30 met the combined outcome (16%) and had significantly lower RVOT VTI measurements (9.0 cm v 13.4 cm, p < 0.0001). The AUC for RVOT VTI at a cutoff of 10 cm was 0.78 (95% CI 0.67-0.90) with a sensitivity, specificity, negative predictive value, and positive predictive value of 0.72, 0.81, 0.94, and 0.42, respectively. Fifty-two patients of the cohort were classified as intermediate-high-risk PE and 21% of those met the combined outcome. RVOT VTI was lower among outcome positive patients (7.3 cm v 10.7 cm, p = 0.02). CONCLUSIONS:Low RVOT VTI is associated with poor clinical outcomes among patients with acute PE.
PMID: 32652350
ISSN: 1879-2472
CID: 4527582
Emergence of Azole Resistant Candida Glabrata as an Important Cause of Hospital Acquired Infection: Its Risk Factors and Impact
ORIGINAL:0016071
ISSN: 2582-0370
CID: 5340822
[S.l.] : Health Affairs blog, 2020
Moving From The Five Whys To Five Hows: Addressing Racial Inequities In COVID-19 Infection And Death
(Website)CID: 4519322
Patient-reported outcomes in RA care improve patient communication, decision-making, satisfaction and confidence: qualitative results
OBJECTIVE:To evaluate the impact of integrating patient-reported outcomes (PROs) into routine clinics, from the perspective of patients with RA, clinicians and other staff. METHODS:We conducted a prospective cohort study using a mixed methods sequential explanatory design at an academic arthritis clinic. RA patients completed selected Patient-Reported Outcomes Measurement Information System measures on tablets in the waiting room. Results were immediately available to discuss during the visit. Post-visit surveys with patients and physicians evaluated topics discussed and their impact on decision making; patients rated confidence in treatment. Focus groups or interviews with patients, treating rheumatologists and clinic staff were conducted to understand perspectives and experiences. RESULTS:Some 196 patients and 20 rheumatologists completed post-visit surveys at 816 and 806 visits, respectively. Focus groups were conducted with 24 patients, 10 rheumatologists and 4 research/clinic staff. PROs influenced medical decision-making and RA treatment changes (38 and 18% of visits, respectively). Patients reported very high satisfaction and treatment confidence. Impact on clinical workflow was minimal after a period of initial adjustment. PROs were valued by patients and physicians, and provided new insight into how patients felt and functioned over time. Reviewing results together improved communication, and facilitated patient-centred care, shared decision making, and the identification of new symptoms and contributing psychosocial/behavioural factors. CONCLUSION:PRO use at RA visits was feasible, increased understanding of how disease affects how patients feel and function, facilitated shared decision-making, and was associated with high patient satisfaction and treatment confidence.
PMCID:7310086
PMID: 31665477
ISSN: 1462-0332
CID: 5204092
Association of Body Mass Index With Coronary Artery Calcium and Subsequent Cardiovascular Mortality: The Coronary Artery Calcium Consortium
BACKGROUND:Obesity is associated with higher risk for coronary artery calcium (CAC), but the relationship between body mass index (BMI) and mortality is complex and frequently paradoxical. METHODS:We analyzed BMI, CAC, and subsequent mortality using data from the CAC Consortium, a multi-centered cohort of individuals free of established cardiovascular disease (CVD) who underwent CAC testing. Mortality was assessed through linkage to the Social Security Death Index and cause of death from the National Death Index. Multivariable logistic regression was used to determine odds ratios for the association of clinically relevant BMI categories and prevalent CAC. Cox proportional hazards regression modeling was used to determine hazard ratios for coronary heart disease, CVD, and all-cause mortality according to categories of BMI and CAC. RESULTS:Our sample included 36 509 individuals, mean age 54.1 (10.3) years, 34.4% female, median BMI 26.6 (interquartile range, 24.1-30.1), 46.6% had zero CAC, and 10.5% had CAC ≥400. Compared with individuals with normal BMI, the multivariable adjusted odds of CAC >0 were increased in those overweight (odds ratio, 1.13 [95% CI, 1.1-1.2]) and obese (odds ratio, 1.5 [95% CI, 1.4-1.6]). Over a median follow-up of 11.4 years, there were 1550 deaths (4.3%). Compared with normal BMI, obese individuals had a higher risk of coronary heart disease, CVD, and all-cause mortality while overweight individuals, despite a higher odds of CAC, showed no significant increase in mortality. In a sex-stratified analysis, the increase in coronary heart disease, CVD, and all-cause mortality in obese individuals appeared largely limited to men, and there was a lower risk of all-cause mortality in overweight women (hazard ratio, 0.79 [95% CI, 0.63-0.98]). CONCLUSIONS:In a large sample undergoing CAC scoring, obesity was associated with a higher risk of CAC and subsequent coronary heart disease, CVD, and all-cause mortality. However, overweight individuals did not have a higher risk of mortality despite a higher risk for CAC.
PMCID:7398452
PMID: 32660258
ISSN: 1942-0080
CID: 4961702
Do providers document social determinants? our emrs say.! [Meeting Abstract]
BACKGROUND: There's been a recent shift toward addressing social determinants of health (SDoH) during the clinical encounter through discussion and documentation. SDoH documentation in the problem list and through billing-related z-code use is necessary for accurate, individual patient and population level tracking andmay improve quality of care.We sought to better understand if/how providers document their patient's SDoH when elicited during a clinical visit.
METHOD(S): Unannounced Standardized Patients (USPs) were sent to two safety-net clinics to assess how medicine residents care for a new patient presenting with one of six unique chief complaints, and accompanying underlying financial, housing, and social concerns. USPs assessed resident practices after the encounter through a behaviorally anchored checklist and systematic chart review. USPs volunteered financial concerns while housing insecurity and social isolation needed to be elicited by the provider. Checklist items assessed if the USP was able to fully disclose their SDoH to the provider. Provider documentation in the electronic medical record (EMR) in one of three spaces: the history of present illness (HPI), the problem list, or through use of a social determinant-specific Zcode was examined when a USP was able to share their concerns.
RESULT(S): 384 USP visits were sent to medical residents from 2017 to 2019. USPs were able to share their financial concerns during 84% of the encounters, but were less likely to be able to share their housing or social concerns with providers (35% and 28%, respectively). Documentation in the HPI and treatment list remained low across cases (<15%) and only one Z-code was used across all visits. On an individual case level, providers addressed housing insecurity most frequently in the asthma case (discussion 65%; documentation: HPI 39%, Plan 16%) and social isolation in the fatigue case (discussion 57%; documentation: HPI 49%, Plan 2%). Providers were least likely to discuss and document SDoH for patients presenting with acute pain.
CONCLUSION(S): In clinical scenarios where SDoH concerns were elicited, residents documented SDoH in less than half of visits. Omission of SDoH not only effects clinical care but also panel management and SDoH population-level estimations. New education strategies are needed to address resident's ability to elicit and accurately document SDoH
METHOD(S): Unannounced Standardized Patients (USPs) were sent to two safety-net clinics to assess how medicine residents care for a new patient presenting with one of six unique chief complaints, and accompanying underlying financial, housing, and social concerns. USPs assessed resident practices after the encounter through a behaviorally anchored checklist and systematic chart review. USPs volunteered financial concerns while housing insecurity and social isolation needed to be elicited by the provider. Checklist items assessed if the USP was able to fully disclose their SDoH to the provider. Provider documentation in the electronic medical record (EMR) in one of three spaces: the history of present illness (HPI), the problem list, or through use of a social determinant-specific Zcode was examined when a USP was able to share their concerns.
RESULT(S): 384 USP visits were sent to medical residents from 2017 to 2019. USPs were able to share their financial concerns during 84% of the encounters, but were less likely to be able to share their housing or social concerns with providers (35% and 28%, respectively). Documentation in the HPI and treatment list remained low across cases (<15%) and only one Z-code was used across all visits. On an individual case level, providers addressed housing insecurity most frequently in the asthma case (discussion 65%; documentation: HPI 39%, Plan 16%) and social isolation in the fatigue case (discussion 57%; documentation: HPI 49%, Plan 2%). Providers were least likely to discuss and document SDoH for patients presenting with acute pain.
CONCLUSION(S): In clinical scenarios where SDoH concerns were elicited, residents documented SDoH in less than half of visits. Omission of SDoH not only effects clinical care but also panel management and SDoH population-level estimations. New education strategies are needed to address resident's ability to elicit and accurately document SDoH
EMBASE:633955731
ISSN: 1525-1497
CID: 4803462
US nativity and dietary acculturation impact the gut microbiome in a diverse US population
Little is known regarding the impact of immigrant acculturation on the gut microbiome. We characterized differences in the gut microbiome between racially/ethnically diverse US immigrant and US-born groups, and determined the impact of dietary acculturation on the microbiome. Stool samples were collected from 863 US residents, including US-born (315 White, 93 Black, 40 Hispanic) and foreign-born (105 Hispanic, 264 Korean) groups. We determined dietary acculturation from dissimilarities based on food frequency questionnaires, and used 16S rRNA gene sequencing to characterize the microbiome. Gut microbiome composition differed across study groups, with the largest difference between foreign-born Koreans and US-born Whites, and significant differences also observed between foreign-born and US-born Hispanics. Differences in sub-operational taxonomic unit (s-OTU) abundance between foreign-born and US-born groups tended to be distinct from differences between US-born groups. Bacteroides plebeius, a seaweed-degrading bacterium, was strongly enriched in foreign-born Koreans, while Prevotella copri and Bifidobacterium adolescentis were strongly enriched in foreign-born Koreans and Hispanics, compared with US-born Whites. Dietary acculturation in foreign-born participants was associated with specific s-OTUs, resembling abundance in US-born Whites; e.g., a Bacteroides plebeius s-OTU was depleted in highly diet-acculturated Koreans. In summary, we observed that US nativity is a determinant of the gut microbiome in a US resident population. Dietary acculturation may result in loss of native species in immigrants, though further research is necessary to explore whether acculturation-related microbiome alterations have consequences for immigrant health.
PMID: 32210364
ISSN: 1751-7370
CID: 4358512
Heart failure disease management versus usual care in patients with a primary diagnosis of heart failure in skilled nursing facilities [Meeting Abstract]
BACKGROUND: Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). However, readmissions from SNFs and immediately after SNF discharge are common. In this study, we examined whether patients with a primary hospital discharge diagnosis of HF may benefit from a HF disease management program (HF-DMP) while undergoing post-acute rehabilitation in SNFs.
METHOD(S): This is a sub-group analysis of a cluster-randomized controlled trial of HF-DMP vs usual care (UC) for patients in SNF (n=671) with a HF diagnosis, regardless of ejection fraction (EF), conducted in 47 SNFs in the Denver-metropolitan area. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by a HF nurse advocate (HFNA). The HFNA directed a 7- component intervention focused on optimizing HF disease management through the following: documentation of EF, symptom and activity assessment, weights 3 times a week with dietary surveillance, recommendations for medication titration, patient/caregiver education, discharge instructions, and 7-day post- SNF discharge follow-up. This sub-group analysis examined patients discharged from hospital to SNF with a primary hospital discharge diagnosis of HF (n=125). The primary outcome was a composite of all-cause hospitalization, emergency department visits, and mortality at 60 days post-SNF admission. The etiology (HF related, non-HF cardiovascular (CV) related, or "other") of the first event was adjudicated by a Clinical Endpoints committee that was blinded to treatment group. Secondary outcomes were the composite outcome at 30 days, and change in health status and self-management from baseline to 60 days measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Self-care of HF Index (SCHFI).
RESULT(S): Of the 125 patients with a primary hospital discharge diagnosis of HF, 50were in the HF-DMP and 75 in UC. Overallmean age was 79+/-10, 53% were women, mean EF was 46+/-15%. At 60 days, the rate of the composite outcome was lower in the HF-DMP group (30%) compared to UC (52%) (p=0.02). Adjudicated events in the HF-DMP group revealed one HF related event, one CV related event, and 12 events classified as "other" within 60 days. In contrast, the UC group had 12 HF related events, 5 CV related events, and 19 events classified as "other" within 60 days. The rate of the composite outcome at 30 days for the HFDMP group was 18% versus 31% in the UC group (p=0.11). Change in KCCQ and SCHFI measures were not significantly different between groups at 60 days.
CONCLUSION(S): Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while receiving rehabilitation in a SNF had lower rates of the composite outcome at 60 days and less HF related events. Standardized HF management during SNF stays may be particularly important for patients with a primary discharge diagnosis of HF
METHOD(S): This is a sub-group analysis of a cluster-randomized controlled trial of HF-DMP vs usual care (UC) for patients in SNF (n=671) with a HF diagnosis, regardless of ejection fraction (EF), conducted in 47 SNFs in the Denver-metropolitan area. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by a HF nurse advocate (HFNA). The HFNA directed a 7- component intervention focused on optimizing HF disease management through the following: documentation of EF, symptom and activity assessment, weights 3 times a week with dietary surveillance, recommendations for medication titration, patient/caregiver education, discharge instructions, and 7-day post- SNF discharge follow-up. This sub-group analysis examined patients discharged from hospital to SNF with a primary hospital discharge diagnosis of HF (n=125). The primary outcome was a composite of all-cause hospitalization, emergency department visits, and mortality at 60 days post-SNF admission. The etiology (HF related, non-HF cardiovascular (CV) related, or "other") of the first event was adjudicated by a Clinical Endpoints committee that was blinded to treatment group. Secondary outcomes were the composite outcome at 30 days, and change in health status and self-management from baseline to 60 days measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Self-care of HF Index (SCHFI).
RESULT(S): Of the 125 patients with a primary hospital discharge diagnosis of HF, 50were in the HF-DMP and 75 in UC. Overallmean age was 79+/-10, 53% were women, mean EF was 46+/-15%. At 60 days, the rate of the composite outcome was lower in the HF-DMP group (30%) compared to UC (52%) (p=0.02). Adjudicated events in the HF-DMP group revealed one HF related event, one CV related event, and 12 events classified as "other" within 60 days. In contrast, the UC group had 12 HF related events, 5 CV related events, and 19 events classified as "other" within 60 days. The rate of the composite outcome at 30 days for the HFDMP group was 18% versus 31% in the UC group (p=0.11). Change in KCCQ and SCHFI measures were not significantly different between groups at 60 days.
CONCLUSION(S): Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while receiving rehabilitation in a SNF had lower rates of the composite outcome at 60 days and less HF related events. Standardized HF management during SNF stays may be particularly important for patients with a primary discharge diagnosis of HF
EMBASE:633955831
ISSN: 1525-1497
CID: 4818652
