Faculty Bibliography

Racial and ethnic minorities in the U.S. experience higher incidence of and greater morbidity from chronic disease. Limited English proficiency (LEP) is a known contributor to these health disparities. The Culturally and Linguistically Appropriate Services (CLAS) standards of the U.S. Department of Health and Human Services promote health equity through the incorporation of professional interpreter services. While such services have been shown to improve quality of care, limited data exist on patient perspectives regarding these services. Better understanding patient experiences with telephone interpreter services (TIS), an increasingly used modality for professional interpretation, could elucidate ways of improving care for this population. This study explored Spanish-speaking patient experiences with TIS at an urban community clinic. Qualitative data collected via focus groups was analyzed using content analysis and grounded theory methods. Our findings suggest that TIS are generally well accepted by Spanish-speaking LEP patients. Limited relationship development with providers and physician attitudes toward TIS were among reported barriers to the use of these services.

BACKGROUND:Because of the strong link between childhood obesity and adulthood obesity comorbidities, and the difficulty in decreasing body mass index (BMI) later in life, effective strategies are needed to address this condition in early childhood. The ability to predict obesity before age five could be a useful tool, allowing prevention strategies to focus on high risk children. The few existing prediction models for obesity in childhood have primarily employed data from longitudinal cohort studies, relying on difficult to collect data that are not readily available to all practitioners. Instead, we utilized real-world unaugmented electronic health record (EHR) data from the first two years of life to predict obesity status at age five, an approach not yet taken in pediatric obesity research. METHODS AND FINDINGS/RESULTS:We trained a variety of machine learning algorithms to perform both binary classification and regression. Following previous studies demonstrating different obesity determinants for boys and girls, we similarly developed separate models for both groups. In each of the separate models for boys and girls we found that weight for length z-score, BMI between 19 and 24 months, and the last BMI measure recorded before age two were the most important features for prediction. The best performing models were able to predict obesity with an Area Under the Receiver Operator Characteristic Curve (AUC) of 81.7% for girls and 76.1% for boys. CONCLUSIONS:We were able to predict obesity at age five using EHR data with an AUC comparable to cohort-based studies, reducing the need for investment in additional data collection. Our results suggest that machine learning approaches for predicting future childhood obesity using EHR data could improve the ability of clinicians and researchers to drive future policy, intervention design, and the decision-making process in a clinical setting.

Amongst other indications, cyclosporine therapy has emerged as a novel agent for the management of severe refractory ulcerative colitis (UC). In the historic population of patients receiving cyclosporine therapy-namely solid organ transplant patients-renal toxicity has proven to be a significant mitigating side effect limiting the therapeutic window. However, dose-limiting sequelae amongst patients receiving cyclosporine for inflammatory bowel disease (IBD) have not been as significant. As a result, the fear of renal toxicity as an adverse effect is less of a concern in IBD patients. The goal of this manuscript is to emphasize the need for future research to explore optimal drug dosing and extended use of cyclosporine therapy in the treatment of IBD-given its pathophysiology, efficacy, and safety profile in patients with IBD.

Background: There is growing evidence for the role of TRPC1 in regulating glucose & lipid metabolism. Secretion of insulin, leptin & adiponectin is sensitive to cell free Ca. TRPC1 may mediate the effects of leptin in anorexigenic hypothalamic neurons. TRPC1 iwas found low in diabetes & we recently found hyperglycemia in null mice. We tested if TRPC1 deficiency produces MetS & if 45% HFD x 3 mon aggravates it.
Method(s): In age-matched TRPC1 +/+. +/-, & -/-mice, we measured glucose & lipids using standard methods & insulin, leptin, & adiponectin by mouse ELISA. We did glucose tolerance test (GTT) by IP glucose (2 mg/kg) after 13 h fast.
Result(s): From 4-30 week, null mice ate & weighed more than +/-& wt. At 4 mon, HOMA-insulin resistance (IR) was up 60% & HOMA beta down 40%. By 12 mon, HOMAIR was up 8 fold. At 7 mon, by GTT, both TRPC1 +/-& -/-mice were diabetic. In null, adiponectin was down 11% but leptin up 77%. At 2 mon, total cholesterol was 85% hgher in null, their liver 36% heavier, & triglyceride content (TGC) 47% higher. Liver echogenicity was up by 50-150% at 7, 11, & 22 mon, confirmed by 140% higher liver TGC. At 12 mon, only null mice had hyperlipidemia (cholesterol up 30%, LDL up 60%, & TG up 200%). In +/-& wt, lipids, liver density at 12 & 19 mon, & liver TGC at 19 mon were all normal. Fasting glucose was high only in null from 1 through 16 mon). Thus on a normal fat diet (NFD), 1 wt allele prevented hyperphagia, obesity, MetS & hepatic steatosis. As expected, HFD vs NFD stimulated leptin & insulin, similarly in all 3 genotypes without altering adiponectin. Unlike NFD, HFD increased liver density in +/-& wt, but not in null. HFD induced the highest HOMA-IR in wt (3.1 vs 1.3 x in +/-) & the largest liver TGC hike in wt (3.3 vs 1.6 x in null). During GTT, AUC for glucose vs time was the highest in wt vs null.
Conclusion(s): 1. Diploid TRPC1 deletion produces hyperphagia, obesity & Met S, all resolvable by caloric restriction, implying hypothalamic resistance to leptin in null mice. 2. HFD raises the risks of dyslipidemia & hepatic steatosis, only in the presence of 1-2 wt alleles, as if deficiency would block the pathogenic Ca-CM-NFAT signaling pathway. 3. TRPC1 -/-is a good model to study MetS

BACKGROUND/AIMS/OBJECTIVE:The current diagnostic workup of Cushing's syndrome (CS) requires various tests which only capture short-term cortisol exposure, whereas patients with endogenous CS generally have elevated long-term cortisol levels. Scalp hair assessment has emerged as a convenient test in capturing glucocorticoid concentrations over long periods of time. The aim of this multicenter, multinational, prospective, case-control study was to evaluate the diagnostic efficacy of scalp hair glucocorticoids in screening of endogenous CS. <br>Methods: We assessed the diagnostic performances of hair cortisol (HairF), hair cortisone (HairE), and sum of both (sumHairF+E), as measured by state-of-the-art LC-MS/MS technique, in untreated patients with confirmed endogenous CS (n=89), and community controls (n=295) from the population-based Lifelines cohort study. <br>Results: Both glucocorticoids were significantly elevated in CS patients when compared to controls. High diagnostic efficacy was found for HairF (area under the curve (AUC), 0.87 [95% CI, 0.83 to 0.92]), HairE (0.93 [0.89 to 0.96]) and sumHairF+E (0.92 [0.88 to 0.96]; all P<.001). Participants were accurately classified at optimal cut-off threshold in 86% of cases (81% sensitivity, 88% specificity, 94% negative predictive value (NPV)) for HairF, in 90% of cases (87% sensitivity, 90% specificity, 96% NPV) for HairE, and 87% of cases (86% sensitivity, 88% specificity, 95% NPV) for the sum. HairE was shown to be most accurate in differentiating CS patients from controls. <br>Conclusion: Scalp hair glucocorticoids, especially hair cortisone, can be seen as a promising biomarker in screening of CS. Its convenience in collection and workup additionally makes this feasible for first-line screening <br>.

Problem: Much of the medical education literature on clinical reasoning (CR) comes from primarily English-speaking countries. It is less clear how these educational interventions translate to environments with non-native English speakers, and in clinical systems where there is higher patient volumes.
Purpose(s): To implement a CR session for 6th year medical students at a university hospital in Istanbul, Turkey. Description of Program: In November, 2018 we conducted a 3-hour session on CR at Koc University in Istanbul developed from a curriculum at our home institution in the United States. In an interactive case-based didactic, students were introduced to the CR concepts of problem representation (PR), illness scripts, and diagnostic time outs. Students then applied these concepts to a case during facilitated small group breakouts. Outcomes Twenty-four 6th year medical students participated. Retrospective pre-post self-assessments of confidence in and likelihood of using CR concepts on an eight-point Likert scale were completed, and qualitative data on use in clinical practice were obtained. Results were analyzed using a paired t-test. After participating in this session, students were more confident in and more likely to use all domains of the CR framework taught with large effect sizes in eight of ten domains (Figure 1). A common theme in the qualitative data was that the use of PR would be helpful to communicate about patients efficiently in the busy clinical environment.
Discussion(s): Teaching CR skills translated well to an international setting. Critical to the session's success was demonstrating relevance to the local institution's clinical environment, in particular taking into account the higher patient volume experienced by providers, and changing the attitude that better decision-making does not necessarily take longer. The impact of culture and environment was evidenced by what the students found to be most effective-use of PR to communicate efficiently about patients in a busy clinical environment-which is different from our experiences teaching this in the US where learners often highlight the utility of the diagnostic time out. Significance of Findings Our findings speak to the need to contextualize CR concepts within the local learning culture to define relevance and meet the learners' needs. (Figure Presented)