Faculty Bibliography
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department:Medicine. General Internal Medicine
recentyears:2
school:SOM
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14611
Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center
BACKGROUND:Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. RESULTS:Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. CONCLUSIONS:Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
PMCID:7183732
PMID: 31658831
ISSN: 1941-3297
CID: 4591282
The Covenant
Burnout among doctors appears to be at epidemic proportions these days, with concomitant gushing prescriptions for wellness and resilience. But in reality, most doctors are not burned out, in the traditional sense of the word: most love taking care of patients and want nothing more than to be able to do just that. The source of the agony is the profession-or rather the corporatization of the profession-that has so impinged upon the doctors' ability to practice medicine. Doctors placed their trust in the medical profession, but that trust has been roundly trounced. So, rather than prescribe Pilates classes for overstressed doctors, it is time for the medical profession-and the health care industry that has subsumed it-to get a check-up.
PMID: 31425190
ISSN: 1938-808x
CID: 4046572
Age- and gender-adjusted percentiles for number of calcified plaques in coronary artery calcium scanning
BACKGROUND:Age- and gender-adjusted percentiles of coronary artery calcium (CAC) score are commonly reported to compare a patient's coronary atherosclerosis burden to that of others of the same age and gender. The number of calcified plaques (numCP) detected on CAC scanning, a measure of plaque diffusivity, is associated with increased cardiovascular risk and, in the intermediate CAC range, adds to the CAC score in predicting mortality. This study aims to develop adjusted percentiles for numCP to provide a better context for understanding CAC scan findings. METHODS AND RESULTS/RESULTS:Using nonparametric modeling techniques, the distribution of numCP was analyzed in 70,320 consecutive, asymptomatic patients without prior clinically-diagnosed cardiovascular disease who were part of the Coronary Artery Calcium Consortium and supplemented by additional patients referred for clinical CAC scanning in a single center between 1998 and 2016. Nomograms for age-adjusted numCP percentiles for each gender were generated using quantile regression. The prevalence and average number of calcified coronary plaque were found to be higher in men than women. Distribution of numCP in women was found to closely mirror that of men approximately a decade younger. NumCP increased consistently across age groups in both men and women for each quantile category. CONCLUSIONS:A nomogram for age and gender-adjusted percentiles for the numCP on CAC scans has been developed in a large population of asymptomatic patients studied across multiple centers. This numCP nomogram may provide an additional tool for refining physician recommendations regarding treatment and expressing to patients how their CAC findings relate to others of similar age and gender. The numCP percentiles may also provide a meaningful way to evaluate and report the rate of progression of CAC on serial studies.
PMID: 30598344
ISSN: 1876-861x
CID: 4961552
Perceived Barriers to Adherence to Hemodialysis Dietary Recommendations
Barriers to following dietary recommendations have been described; however, they remain poorly understood. The purpose of this qualitative study was to explore perceived barriers to adherence to dietary recommendations in a diverse hemodialysis patient population. Participants were eligible to participate in a semi-structured qualitative telephone interview prior to randomization for an ongoing clinical trial to evaluate the efficacy of an intervention designed to reduce dietary sodium intake. Interviews were digitally recorded, transcribed verbatim and coded using an iterative qualitative process. In total, 30 (37% females, 53% Caucasians) participants, 63.2 ± 13.3 years, were interviewed. Time, convenience, and financial constraints hindered dietary adherence. Dietary counseling efforts were rated positively but require individualization. Ability to follow recommended guidelines was challenging. Suggestions for addressing barriers include technology-based interventions that allow patients to improve food choices and real-time decision-making, and permit tailoring to individual barriers and preferences.
PMID: 29732932
ISSN: 1552-3799
CID: 3163862
A Systematic Review of Advocacy Curricula in Graduate Medical Education
BACKGROUND:Professionalism standards encourage physicians to participate in public advocacy on behalf of societal health and well-being. While the number of publications of advocacy curricula for GME-level trainees has increased, there has been no formal effort to catalog them. OBJECTIVE:To systematically review the existing literature on curricula for teaching advocacy to GME-level trainees and synthesize the results to provide a resource for programs interested in developing advocacy curricula. METHODS:A systematic literature review was conducted to identify articles published in English that describe advocacy curricula for graduate medical education trainees in the USA and Canada current to September 2017. Two reviewers independently screened titles, abstracts, and full texts to identify articles meeting our inclusion and exclusion criteria, with disagreements resolved by a third reviewer. We abstracted information and themes on curriculum development, implementation, and sustainability. Learning objectives, educational content, teaching methods, and evaluations for each curriculum were also extracted. RESULTS:After reviewing 884 articles, we identified 38 articles meeting our inclusion and exclusion criteria. Curricula were offered across a variety of specialties, with 84% offered in primary care specialties. There was considerable heterogeneity in the educational content of included advocacy curriculum, ranging from community partnership to legislative advocacy. Common facilitators of curriculum implementation included the American Council for Graduate Medical Education requirements, institutional support, and preexisting faculty experience. Common barriers were competing curricular demands, time constraints, and turnover in volunteer faculty and community partners. Formal evaluation revealed that advocacy curricula were acceptable to trainees and improved knowledge, attitudes, and reported self-efficacy around advocacy. DISCUSSION:Our systematic review of the medical education literature identified several advocacy curricula for graduate medical education trainees. These curricula provide templates for integrating advocacy education into GME-level training programs across specialties, but more work needs to be done to define standards and expectations around GME training for this professional activity.
PMID: 31385216
ISSN: 1525-1497
CID: 4662222
Parents' Awareness and Perceptions of JUUL and Other E-Cigarettes
INTRODUCTION/BACKGROUND:The purpose of this study is to examine awareness, attitudes, and related knowledge of e-cigarettes, and JUUL specifically, among parents of middle and high school students. METHODS:Data were collected in October-November 2018 from a nationally representative sample of U.S. parents of middle and high school students aged 11-18 years (n=2,885) to examine e-cigarette and JUUL awareness, concern about e-cigarette use, and school communication regarding e-cigarettes. Weighted frequencies and percentages are reported; Rao-Scott chi-square tests examined differences by school level. Data were analyzed in 2019. RESULTS:Although most parents (96.2%) had seen or heard of e-cigarettes, only 55.9% had seen or heard of JUUL, and only 44.2% accurately identified an image of JUUL as a vaping device. Many parents reported concern about adolescent e-cigarette use (60.6%), but fewer reported concern about their own child's use (32.9%). Most parents (73.5%) reported receiving no communication from their child's school about e-cigarettes or JUUL. CONCLUSIONS:There are notable gaps in parents' awareness of JUUL. School-to-parent communication efforts are necessary to build parents' knowledge of e-cigarettes like JUUL to prevent the growing youth uptake of these novel and addictive products.
PMID: 31420121
ISSN: 1873-2607
CID: 4179692
Incidence of CKD with TDF and non-TDF containing antiretroviral regimens by baseline D:A:D CKD risk in people living with HIV (PLWH) [Meeting Abstract]
Purpose: Given recent evidence that the risk of renal toxicities with TDF may increase with coadministration of a pharmacoenhancer (Hill 2018), we assessed the risk of chronic kidney disease (CKD) associated with TDF and non- TDF containing regimens by D:A:D CKD risk and boosting.
Method(s): ART-naive adults initiating treatment with eGFR>=60 mL/min/ 1.73 m2 (last eGFR within 12 months pre-initiation) were identified in the OPERA cohort. CKD was defined as>=2 consecutive eGFR<60 mL/min/1.73 m2, >90 days apart. The associations between TDF use, baseline D:A:D CKD risk, and incident CKD were assessed with unadjusted incidence rates (IR, Poisson regression) and adjusted survival analyses (pooled logistic regression). Secondary analysis evaluated the contribution of pharmacoenhancers.
Result(s): Of 9,802 PLWH included, 6,222 initiated TDF (76% low-risk D:A:D CKD score, 16% medium-risk, 8% high-risk) and 3,580 did not (79% low-risk, 13% medium-risk, 8% high-risk; Table 1); 40-47% initiated a boosted regimen (Table 2). Overall, 125 incident CKD events occurred over 24,382 person-years of follow-up. Within strata of D:A:D risk score, IRs were similar by TDF exposure, with high baseline CKD risk associated with highest incidence regardless of TDF use (Figure 1). Compared to the low-risk group without TDF, there was no statistical difference in odds of incident CKD in the medium-risk group without TDF (aOR: 2.32, 95% CI: 0.72, 7.52) or the low-risk group with TDF (aOR: 0.55, 95% CI: 0.19, 1.54; Figure 2). Odds of incident CKD did not differ by pharmacoenhancer exposure, with or without TDF.
Conclusion(s): In this large cohort of ART-naive PLWH, incident CKD following ART initiation was relatively infrequent and was strongly associated with baseline CKD risk. TDF-containing regimens did not appear to increase the risk of CKD in those with a low baseline D:A:D CKD risk, the largest group of naive PLWH, and may remain a viable treatment option. (Figure Presented)
Method(s): ART-naive adults initiating treatment with eGFR>=60 mL/min/ 1.73 m2 (last eGFR within 12 months pre-initiation) were identified in the OPERA cohort. CKD was defined as>=2 consecutive eGFR<60 mL/min/1.73 m2, >90 days apart. The associations between TDF use, baseline D:A:D CKD risk, and incident CKD were assessed with unadjusted incidence rates (IR, Poisson regression) and adjusted survival analyses (pooled logistic regression). Secondary analysis evaluated the contribution of pharmacoenhancers.
Result(s): Of 9,802 PLWH included, 6,222 initiated TDF (76% low-risk D:A:D CKD score, 16% medium-risk, 8% high-risk) and 3,580 did not (79% low-risk, 13% medium-risk, 8% high-risk; Table 1); 40-47% initiated a boosted regimen (Table 2). Overall, 125 incident CKD events occurred over 24,382 person-years of follow-up. Within strata of D:A:D risk score, IRs were similar by TDF exposure, with high baseline CKD risk associated with highest incidence regardless of TDF use (Figure 1). Compared to the low-risk group without TDF, there was no statistical difference in odds of incident CKD in the medium-risk group without TDF (aOR: 2.32, 95% CI: 0.72, 7.52) or the low-risk group with TDF (aOR: 0.55, 95% CI: 0.19, 1.54; Figure 2). Odds of incident CKD did not differ by pharmacoenhancer exposure, with or without TDF.
Conclusion(s): In this large cohort of ART-naive PLWH, incident CKD following ART initiation was relatively infrequent and was strongly associated with baseline CKD risk. TDF-containing regimens did not appear to increase the risk of CKD in those with a low baseline D:A:D CKD risk, the largest group of naive PLWH, and may remain a viable treatment option. (Figure Presented)
EMBASE:631782917
ISSN: 1468-1293
CID: 4457352
Physician Judgment and Circulating Biomarkers Predict 28-Day Mortality in Emergency Department Patients
OBJECTIVES/OBJECTIVE:To determine whether biomarkers of endothelial activation and inflammation provide added value for prediction of in-hospital mortality within 28 days when combined with physician judgment in critically ill emergency department patients. DESIGN/METHODS:Prospective, observational study. SETTING/METHODS:Two urban, academic emergency departments, with ≈80,000 combined annual visits, between June 2016 and December 2017. PATIENTS/METHODS:Admitted patients, greater than 17 years old, with two systemic inflammatory response syndrome criteria and organ dysfunction, systolic blood pressure less than 90 mm Hg, or lactate greater than 4.0 mmol/L. Patients with trauma, intracranial hemorrhage known prior to arrival, or without available blood samples were excluded. INTERVENTIONS/METHODS:Emergency department physicians reported likelihood of in-hospital mortality (0-100%) by survey at hospital admission. Remnant EDTA blood samples, drawn during the emergency department stay, were used to measure angiopoietin-1, angiopoietin-2, tumor necrosis factor receptor-1, interleukin-6, and interleukin-8. MEASUREMENTS AND MAIN RESULTS/RESULTS:We screened 421 patients and enrolled 314. The primary outcome of in-hospital mortality within 28 days occurred in 31 (9.9%). When predicting the primary outcome, the best biomarker model included angiopoietin-2 and interleukin-6 and performed moderately well (area under the curve, 0.72; 95% CI, 0.69-0.75), as did physician judgment (area under the curve, 0.78; 95% CI, 0.74-0.82). Combining physician judgment and biomarker models improved performance (area under the curve, 0.85; 95% CI, 0.82-0.87), with area under the curve change of 0.06 (95% CI, 0.04-0.09; p < 0.01) compared with physician judgment alone. CONCLUSIONS:Predicting in-hospital mortality within 28 days among critically ill emergency department patients may be improved by including biomarkers of endothelial activation and inflammation in combination with emergency department physician judgment.
PMID: 31369425
ISSN: 1530-0293
CID: 4011322
Early results of the emulate therapeutics HaeloTM system in pediatric brain tumors [Meeting Abstract]
BACKGROUND: The EMulate Therapeutics Halo system is an investigational non-sterile, non-invasive, non-thermal, non-ionizing, portable, home-use medical device that uses a specific, localized ultra-low radio frequency energy (ulRFER) cognate for the treatment of pediatric brain tumors.
METHOD(S): Sixteen patients with brain tumors consisting of diffuse midline glioma/diffuse intrinsic pontine glioma (DMG/DIPG, n=14), recurrent medulloblastoma (n=1), or anaplastic astrocytoma (n=1) - were treated with the Halo under FDA's single-patient compassionate use pathway, as protocol deviations in a glioblastoma trial, or under TGA's Special Access Scheme. Baseline information and on-treatment safety and exposure data were collected.
RESULT(S): Patients ranged in age from 4 to 28 years (median = 8 years) and were diagnosed 91 - 1399 days (median = 397 days) prior to treatment with the Halo system. Patients were treated for 2 - 52 weeks (median = 15 weeks), with 4 patients still alive (all with a diagnosis of DMG/DIPG), and 3 still on treatment (ranging 18 - 52 weeks). Two out of the 16 patients reported mild-moderate adverse events - one patient reported nausea, fatigue, and excessive sleepiness, and one patient reported vomiting. No device-related serious adverse events were reported. Other adverse events reported were generally associated with progressive disease. Unsolicited, anecdotal reports from some parents/caregivers noted improvements in mobility, speech, and visual acuity while on treatment.
CONCLUSION(S): The Halo system appears to be safe and feasible for the treatment of pediatric brain tumors. Given that therapy is delivered non-invasively and no device-related serious adverse events were reported, further prospective study of the investigational device is warranted
METHOD(S): Sixteen patients with brain tumors consisting of diffuse midline glioma/diffuse intrinsic pontine glioma (DMG/DIPG, n=14), recurrent medulloblastoma (n=1), or anaplastic astrocytoma (n=1) - were treated with the Halo under FDA's single-patient compassionate use pathway, as protocol deviations in a glioblastoma trial, or under TGA's Special Access Scheme. Baseline information and on-treatment safety and exposure data were collected.
RESULT(S): Patients ranged in age from 4 to 28 years (median = 8 years) and were diagnosed 91 - 1399 days (median = 397 days) prior to treatment with the Halo system. Patients were treated for 2 - 52 weeks (median = 15 weeks), with 4 patients still alive (all with a diagnosis of DMG/DIPG), and 3 still on treatment (ranging 18 - 52 weeks). Two out of the 16 patients reported mild-moderate adverse events - one patient reported nausea, fatigue, and excessive sleepiness, and one patient reported vomiting. No device-related serious adverse events were reported. Other adverse events reported were generally associated with progressive disease. Unsolicited, anecdotal reports from some parents/caregivers noted improvements in mobility, speech, and visual acuity while on treatment.
CONCLUSION(S): The Halo system appears to be safe and feasible for the treatment of pediatric brain tumors. Given that therapy is delivered non-invasively and no device-related serious adverse events were reported, further prospective study of the investigational device is warranted
EMBASE:631168436
ISSN: 1523-5866
CID: 4388162
Emotional Well-Being Is Impaired in Hidradenitis Suppurativa Patients
BACKGROUND:Hidradenitis suppurativa (HS) is a chronic inflammatory condition. OBJECTIVE:To measure emotional well-being in HS patients and compare to other populations, assess if there is an effect of disease severity on emotional well-being, and determine if emotional well-being is correlated with quality of life and depression. METHODS:A total of 153 HS subjects were recruited, and 66 Positive and Negative Affect Schedule (PANAS) surveys assessing emotional well-being were completed. Norms for comparison populations (disease-free undergraduates and adults) were used. A validated self-assessment tool was used to determine disease severity. Subjects completed the Patient Health Questionnaire-9 (PHQ-9) and Dermatology Life Quality Index (DLQI) to examine depression and quality of life, respectively. RESULTS:< 0.00001). CONCLUSION/CONCLUSIONS:HS patients have poor emotional well-being. PANAS scores correlated with worse quality of life and depression. Providing appropriate resources and treatments may be beneficial for HS patients.
PMCID:6883437
PMID: 31799265
ISSN: 2296-9195
CID: 5505622
