Faculty Bibliography

BACKGROUND:Preliminary clinical studies on the safety and efficacy of the pipeline embolization device (PED) for the treatment of small/medium aneurysms have demonstrated high occlusion rates with low complications. OBJECTIVE:To evaluate the safety and effectiveness of the PED for treatment of wide necked small and medium intracranial aneurysms. METHODS:PREMIER is a prospective, multicenter, single arm trial. Patients were treated with the PED for unruptured wide necked aneurysms, measuring ≤12 mm along the internal carotid artery or vertebral artery, between July 2014 and November 2015. At 1 year post-procedure, the primary effectiveness endpoint was complete occlusion (Raymond grade 1) without major parent vessel stenosis (≤50%) or retreatment, and the primary safety endpoint was major stroke in the territory supplied by the treated artery or neurologic death. RESULTS:A total of 141 patients were treated with PEDs (mean age 54.6±11.3 years, 87.9% (124/141) women). Mean aneurysm size was 5.0±1.92 mm, and 84.4% (119/141) measured <7 mm. PED placement was successful in 99.3% (140/141) of patients. Mean number of PEDs implanted per patient was 1.1±0.26; a single PED was used in 92.9% (131/141) of patients. At 1 year, 97.9% (138/141) of patients underwent follow-up angiography with 76.8% (106/138) of patients having met the study's primary effectiveness endpoint. The combined major morbidity and mortality rate was 2.1% (3/140). CONCLUSIONS:Treatment of wide necked small/medium aneurysms with the PED results in high rates of complete occlusion without significant parent vessel stenosis and low rates of permanent neurologic complications. TRIAL REGISTRATION/BACKGROUND:NCT02186561.

BACKGROUND:Chinese-Americans are a fast-growing immigrant group with worse rheumatic disease outcomes compared to Caucasians and frequent use of Traditional Chinese Medicine (TCM). Whether TCM use is associated with lower adherence to western rheumatic medications is unknown. METHODS:Chinese-Americans actively treated for a systemic rheumatic disease were recruited from two Chinatown clinics. Socio-demographic, TCM use, and clinical data were gathered. Self-reported health status was assessed using Patient-Reported Outcome Measurement Information System (PROMIS®) short forms. Adherence was stratified using the 8-item Morisky Medication Adherence Scale. Factors independently associated with high adherence were identified using multivariable logistic regression. RESULTS:Among 230 subjects, median age was 55 (range 20-97), 65% were female, 71% had ≤ high school education, 70% were on Medicaid, and 22% reported English fluency. The most common rheumatic diagnoses were rheumatoid arthritis (41%), systemic lupus erythematosus (17%), and seronegative spondyloarthropathies (15%). Half reported TCM use in the past year, and 28% reported high adherence to western rheumatic medications. In multivariable analysis, high adherence was associated with TCM use (OR 3.96, p<0.001), being married (OR 3.69, p=0.004), medication regimen complexity (OR 1.13, p=0.004), older age (OR 1.06, p<0.001), and was negatively associated with anxiety (OR 0.94, p=0.001). CONCLUSIONS:While adherence to western rheumatic medications was low in this cohort, interestingly, it was higher among TCM users compared to non-users. TCM use appears to represent a complementary rather than an alternate approach to disease management for these patients. Future studies should evaluate whether TCM use is associated with better disease outcomes. This article is protected by copyright. All rights reserved.

AIM/OBJECTIVE:This paper seeks to describe best practices for conducting cross-language research with individuals who have a language barrier. DESIGN/METHODS:Discussion paper. DATA SOURCES/METHODS:Research methods papers addressing cross-language research issues published between 2000-2017. IMPLICATIONS FOR NURSING/CONCLUSIONS:Rigorous cross-language research involves the appropriate use of interpreters during the research process, systematic planning for how to address the language barrier between participant and researcher and the use of reliably and validly translated survey instruments (when applicable). Biases rooted in those who enter data into "big data" systems may influence data quality and analytic approaches in large observational studies focused on linking patient language preference to health outcomes. CONCLUSION/CONCLUSIONS:Cross-language research methods can help ensure that those individuals with language barriers have their voices contributing to the evidence informing healthcare practice and policies that shape health services implementation and financing. Understanding the inherent conscious and unconscious biases of those conducting research with this population and how this may emerge in research studies is also an important part of producing rigorous, reliable, and valid cross-language research. IMPACT/CONCLUSIONS:This study synthesized methodological recommendations for cross-language research studies with the goal to improve the quality of future research and expand the evidence-base for clinical practice. Clear methodological recommendations were generated that can improve research rigor and quality of cross-language qualitative and quantitative studies. The recommendations generated here have the potential to have an impact on the health and well-being of migrants around the world.

OBJECTIVE:The use of financial incentives to promote physical activity (PA) has grown in popularity due in part to technological advances that make it easier to track and reward PA. The purpose of this study was to update the evidence on the effects of incentives on PA in adults. DATA SOURCES/METHODS:Medline, PubMed, Embase, PsychINFO, CCTR, CINAHL and COCH. ELIGIBILITY CRITERIA/UNASSIGNED:Randomised controlled trials (RCT) published between 2012 and May 2018 examining the impact of incentives on PA. DESIGN/METHODS:A simple count of studies with positive and null effects ('vote counting') was conducted. Random-effects meta-analyses were also undertaken for studies reporting steps per day for intervention and post-intervention periods. RESULTS:23 studies involving 6074 participants were included (64.42% female, mean age = 41.20 years). 20 out of 22 studies reported positive intervention effects and four out of 18 reported post-intervention (after incentives withdrawn) benefits. Among the 12 of 23 studies included in the meta-analysis, incentives were associated with increased mean daily step counts during the intervention period (pooled mean difference (MD), 607.1; 95% CI: 422.1 to 792.1). Among the nine of 12 studies with post-intervention daily step count data incentives were associated with increased mean daily step counts (pooled MD, 513.8; 95% CI:312.7 to 714.9). CONCLUSION/CONCLUSIONS:after incentives were removed, though post-intervention 'vote counting' and pooled results did not align. Nonetheless, and contrary to what has been previously reported, these findings suggest a short-term incentive 'dose' may promote sustained PA.

Despite the efficacy of nicotine replacement therapy (NRT) in promoting smoking cessation, no studies have been done to evaluate NRT prescribing rates among immigrants, a vulnerable minority population in the United States. The aim of this study is to explore for differences in NRT prescribing behavior by immigrant status. Participants were enrolled in a smoking cessation trial for hospitalized patients between July 2011 and April 2014 at two NYC hospitals. For this analysis, we used baseline data from patient surveys and electronic medical-record reviews to examine associations between immigrant status and prescription of NRT in-hospital and on discharge, as well as acceptance of NRT in-hospital. We included age, gender, education, health literacy, race, ethnicity, English language ability, inpatient service, and site insurance in the models as potential confounders. Our study population included 1,608 participants, of whom 21% were not born in the United States. Bivariate analysis found that nonimmigrants were more likely than immigrants to be prescribed NRT in the hospital (46.1% vs. 35.7%, p = .0006) and similarly on discharge (19.4% vs. 15.3%, p = .09). Both groups were equally likely to accept NRT in-hospital when prescribed. On multivariable analysis, being an immigrant (OR 0.65), Black race (OR 0.52), and Hispanic ethnicity (OR 0.63) were associated with lower likelihood of being prescribed NRT in-hospital. Multivariable analysis for provision of NRT prescription at discharge showed no significant difference between immigrants and nonimmigrants. These findings show differences in in-hospital smoking cessation treatment between immigrants and nonimmigrants.

OBJECTIVE:The objective of the study is to examine the validity of body mass index z score (zBMI) as a measure of percent body fat in prepubertal children. METHODS:One hundred eleven multiethnic, healthy, Tanner 1 children aged 6-12 years had fat percent and fat mass measured by the four-compartment method as part of the Paediatric Rosetta Body Composition Cohort. Multiple regression models were developed with fat percent as the dependent variable and zBMI, age, sex and ethnicity as independent variables. RESULTS:0.81). The average percent error was 7.2% in girls and 8.7% in boys. Age was associated with percentage body fat (P < 0.01), while ethnicity was not (P > 0.05). CONCLUSIONS:scores are associated with significantly lower absolute percent errors in girls and boys.

IMPORTANCE:Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs). OBJECTIVES:To determine which EHR design and use factors are associated with clinician stress and burnout and to identify other sources that contribute to this problem. DESIGN, SETTING, AND PARTICIPANTS:This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019. MAIN OUTCOMES AND MEASURES:Clinician stress and burnout as measured with validated questions, the EHR design and use factors identified by clinicians as most associated with stress and burnout, and measures of clinician working conditions. RESULTS:Of 640 clinicians, 282 (44.1%) responded. Of these, 241 (85.5%) were physicians, 160 (56.7%) were women, and 193 (68.4%) worked in primary care. The most prevalent concerns about EHR design and use were excessive data entry requirements (245 [86.9%]), long cut-and-pasted notes (212 [75.2%]), inaccessibility of information from multiple institutions (206 [73.1%]), notes geared toward billing (206 [73.1%]), interference with work-life balance (178 [63.1%]), and problems with posture (144 [51.1%]) and pain (134 [47.5%]) attributed to the use of EHRs. Overall, EHR design and use factors accounted for 12.5% of variance in measures of stress and 6.8% of variance in measures of burnout. Work conditions, including EHR use and design factors, accounted for 58.1% of variance in stress; key work conditions were office atmospheres (β̂ = 1.26; P < .001), control of workload (for optimal control: β̂ = -7.86; P < .001), and physical symptoms attributed to EHR use (β̂ = 1.29; P < .001). Work conditions accounted for 36.2% of variance in burnout, where challenges included chaos (adjusted odds ratio, 1.39; 95% CI, 1.10-1.75; P = .006) and physical symptoms perceived to be from EHR use (adjusted odds ratio, 2.01; 95% CI, 1.48-2.74; P < .001). Coping strategies were associated with only 2.4% of the variability in stress and 1.7% of the variability in burnout. CONCLUSIONS AND RELEVANCE:Although EHR design and use factors are associated with clinician stress and burnout, other challenges, such as chaotic clinic atmospheres and workload control, explain considerably more of the variance in these adverse clinician outcomes.