Faculty Bibliography

Background/UNASSIGNED:Conventionally, endoscopic ultrasound-guided fine-needle aspiration and biopsy (EUS-FNA)/EUS-FNB) has been used for tissue diagnosis of upper gastrointestinal (GI) subepithelial tumors (SETs). However, deep biopsy (DB) via endoscopic submucosal dissection (ESD) is emerging as an alternative technique, given the inadequate tissue sampling with EUS-FNA/EUS-FNB. Our aim was to conduct a systematic review and meta-analysis to report the overall diagnostic yield of DB via ESD for upper GI SETs. Methods/UNASSIGNED:PubMed, Cochrane Library and Web of Science databases were searched to identify studies (from commencement to Oct 2017) that reported the DB via ESD technique for diagnosis of upper GI SETs. The primary outcome of interest was the method's overall diagnostic yield and the secondary outcome was to the occurrence of complications. The meta-analysis was performed using the DerSimonian and Laird random-effects model. Results/UNASSIGNED:=0%) respectively. Data regarding major bleeding and perforation rates were not reported in 2 studies. Substantial heterogeneity was observed in our meta-analysis. Conclusion/UNASSIGNED:DB via ESD is an effective and safe procedure for diagnosing upper GI SETs. Further multicenter randomized controlled trials are needed to validate these findings.

BACKGROUND:The development of guidelines for opioid prescribing, including those from the Society of Hospital Medicine and the Centers for Disease Control and Prevention, has been associated with changes in prescription patterns. However, many providers remain unaware of best practices surrounding appropriate opioid prescribing. METHODS:The research team implemented a multimodal quality improvement intervention, led by first-year medical students, designed to increase clinician adherence to current prescribing guidelines for patients discharged on opioids. This intervention included an awareness campaign, educational sessions for providers, and weekly performance feedback. RESULTS:A total of 4,993 discharges were identified in the baseline period and 4,811 discharges in the intervention period. During the baseline period, 12.3% of all patients discharged were discharged with opioid prescriptions vs. 11.4% during the intervention period (p = 0.165). Of these, approximately 60% were new opioid prescriptions during both periods (p = 0.991). The study's efforts were associated with a decrease in the percentage of patients discharged with opioid prescriptions longer than seven days (45.2% preintervention to 39.5% postintervention, p < 0.042); an increase in the percentage of patients with follow-up appointments within seven days of discharge (38.6% to 65.9%, p = 0.001); and an increase in documentation of prescription history obtained from the state Prescription Monitoring Program registry (32.5% to 39.7%, p = 0.042). CONCLUSION/CONCLUSIONS:This intervention provided a successful framework to engage learners in improving opioid prescribing practices. The results are promising, but the experiences highlight the significant effort and resources needed to change prescriber practices, potentially limiting sustainability.

This paper aims to analyze the regulatory structure of nursing in Mexico through its legislation and perspectives of participant stakeholders. A case study was undertaken using qualitative and quantitative data sources, as well as from the review of official documents. The analysis included data from the sources according to the four realms proposed by the Moran & Wood (1993) model. The more advanced realm was the market entry since the state regulates entry through a license of practice. The regulation of competition is weak, showing very reduced areas of autonomous practice. The labor market is offering a wide variety of entry options with clear signs of deterioration. The dominant payment mechanism is salary, showing a structure that incorporates a component that does not impact on pensions at the end of the labor cycle. The regulation of nursing is a component of its professionalization, and as such, it is understood as a multidimensional consolidating process, particularly realms related to the regulation of competition, market structure, and payment mechanisms, in which nursing representatives should play a more active role in the future.

INTRODUCTION/BACKGROUND:Parents are essential stakeholders for policy implementation. However, data on parents' support for e-cigarette- and tobacco-related policies is limited. This study examines parents' support for five e-cigarette- and tobacco-related policies targeted to prevent youth initiation and exposure to industry marketing practices. METHODS:Data were from a 2018 nationally representative sample of US parents of 11-18-year-old middle and high school students. Weighted adjusted logistic regression models examined correlates of support for policy outcomes, controlling for demographics. Analyses were performed among the full sample (n=2,743) and among current tobacco users (n=355). RESULTS:The majority of parents, including current tobacco users, supported tobacco control efforts to protect adolescents. Over 90% of all parents supported restrictions on e-cigarette marketing to youth and 75% supported a ban on flavored e-cigarette sales. Additionally, over 80% of all parents supported increasing the age of tobacco product sale to 21, limiting tobacco retailer density near schools, and keeping tobacco products out of view where youth shop. Presence of strict home tobacco rules or reporting a high priority to prevent child's e-cigarette use were significantly associated with higher odds of policy support. Results were similar among current tobacco users. CONCLUSIONS:Parents are an important group of tobacco control stakeholders and should be utilized to garner support for tobacco control policies in the context of the recent growth in youth tobacco and e-cigarette use. Parents' public support for tobacco control policies, particularly regulations on e-cigarette sales and marketing, can motivate advocates and policymakers to advance tobacco control policy agendas.

OBJECTIVES/OBJECTIVE:This study sought to describe the patterns of heart failure (HF)-exacerbating medications used among older adults hospitalized for HF and to examine determinants of HF-exacerbating medication use. BACKGROUND:HF-exacerbating medications can potentially contribute to adverse outcomes and could represent an important target for future strategies to improve post-hospitalization outcomes. METHODS:Medicare beneficiaries ≥65 years of age with an adjudicated HF hospitalization between 2003 and 2014 were derived from the geographically diverse REGARDS (Reasons for Geographic and Racial Difference in Stroke) cohort study. Major HF-exacerbating medications, defined as those listed on the 2016 American Heart Association Scientific Statement listing medications that can precipitate or induce HF, were examined. Patterns of prescribing medications at hospital admission and at discharge were examined, as well as changes that occurred between admission and discharge; and a multivariable logistic regression analysis was conducted to identify determinants of harmful prescribing practices following HF hospitalization (defined as either the continuation of an HF-exacerbating medications or an increase in the number of HF-exacerbating medications between hospital admission and discharge). RESULTS:Among 558 unique individuals, 18% experienced a decrease in the number of HF-exacerbating medications between admission and discharge, 19% remained at the same number, and 12% experienced an increase. Multivariable logistic regression analysis revealed that diabetes (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.18 to 2.75]) and small hospital size (OR: 1.93; 95% CI: 1.18 to 3.16) were the strongest, independently associated determinants of harmful prescribing practices. CONCLUSIONS:HF-exacerbating medication regimens are often continued or started following an HF hospitalization. These findings highlight an ongoing need to develop strategies to improve safe prescribing practices in this vulnerable population.

Vaccines for two viruses which cause cancer, human papillomavirus (HPV) and hepatitis B virus (HBV), are recommended for all children in the United States. Numerous parallels exist between the two vaccines in addition to their roles in cancer prevention, including transmission through sexual contact, multiple doses needed for series completion, and vaccine administration in adolescence for HPV and in the initial phase of the HBV vaccination program. All of these factors were viewed as potential barriers to achieving high rates of coverage, yet the ultimate success of the HBV vaccination program led to predictions that similarly high rates of coverage could be achieved for the HPV vaccine. However, currently, only the recommendation for HBV vaccination is supported by mandates for school entry in most states. Uptake of the HPV vaccine has lagged far behind U.S. goals for public health promotion. The aim of this paper is to examine factors which may account for the divergent pathways of the two vaccines. Four main factors are identified: logistical challenges of vaccine administration, attitudes of parents and healthcare providers, safety concerns, and cost. For each factor examined, recommendations are offered to confront similar barriers likely to arise for future vaccines. The authors conclude that gender-neutral state mandates coupled with school-located vaccination programs, stronger gender-neutral messaging from pharmaceutical companies and healthcare providers, and younger age of vaccine administration, if approved, present the most promising approaches to improving uptake of the HPV vaccine, and similar vaccines down the road.

OBJECTIVE:Cardiovascular responses to hypovolemia and hypotension are depressed during general anesthesia. A considerable number of anesthetized and critically ill animals may not benefit hemodynamically from a fluid bolus; therefore, it is important to have measures for accurate prediction of fluid responsiveness. Static measures of preload, such as central venous pressure, do not provide accurate prediction of fluid responsiveness, whereas dynamic measures of cardiovascular function, obtained during positive pressure ventilation, are highly predictive. This review describes key physiological concepts behind heart-lung interactions during positive pressure ventilation, factors that can modify this relationship and provides the basis for a rational interpretation of the information obtained from dynamic measurements, with a focus on pulse pressure variation (PPV). DATABASE USED/UNASSIGNED:PubMed. Search items used were: heart-lung interaction, positive pressure ventilation, pulse pressure variation, dynamic index of fluid therapy, goal-directed hemodynamic therapy, dogs, cats, pigs, horses and rabbits. CONCLUSIONS:The veterinary literature suggests that targeting specific PPV thresholds should guide fluid therapy in lieu of conventional assessments. Understanding the physiology of heart-lung interactions during intermittent positive pressure ventilation provides a rational basis for interpreting the literature on dynamic indices of fluid responsiveness, including PPV. Clinical trials are needed to evaluate whether goal-directed fluid therapy based on PPV results in improved outcomes in veterinary patient populations.

OBJECTIVE:Autoimmune disease is an emerging condition among persons exposed to the September 11, 2001, attack on the World Trade Center (WTC). Components of the dust cloud resulting from the collapse of the WTC have been associated with systemic autoimmune diseases (SAID), as has posttraumatic stress disorder (PTSD). We sought to determine whether dust exposure and PTSD were associated with an increased risk of SAID in a 9/11-exposed cohort. METHODS:Among 43,133 WTC Health Registry enrollees, 2,786 self-reported a post-9/11 SAID. We obtained consent to review medical records to validate SAID diagnoses for 1,041. SAIDs were confirmed by classification criteria, rheumatologist diagnosis, or having been prescribed SAID medication. Controls were enrollees who denied an autoimmune disease diagnosis (n=37,017). We used multivariable log-binomial regression to examine the association between multiple 9/11 exposures and risk of post-9/11 SAID, stratifying by responders and community members. RESULTS:We identified 118 persons with SAID. Rheumatoid arthritis was most frequent (n=71), followed by SjÓ§gren's syndrome (n=22), systemic lupus erythematosus (n=20), myositis (n=9), mixed connective tissue disease (n=7), and scleroderma (n=4). Among 9/11 responders, those with intense dust cloud exposure had almost twice the risk of SAID (adjusted risk ratio =1.86, 95% CI=1.02-3.40). Community members with PTSD had a nearly three-fold increased risk of SAID. CONCLUSION/CONCLUSIONS:Intense dust cloud exposure among responders and PTSD among community members were associated with a statistically significant increased risk of new-onset SAID. Clinicians treating 9/11 survivors should be aware of the potential increased risk of SAID in this population.