Faculty Bibliography

BACKGROUND:The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes. OBJECTIVES/OBJECTIVE:The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature. METHODS:An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents. FINDINGS/RESULTS:Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks. CONCLUSIONS:Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.

Aims:Pathologic evidence supports unique sex-specific mechanisms as precursors for acute cardiovascular (CV) events. Current evidence on long-term CV risk among women when compared with men based on measures of coronary artery calcium (CAC) remains incomplete. Methods and results:A total of 63 215 asymptomatic women and men were enrolled in the multicentre, CAC Consortium with median follow-up of 12.6 years. Pooled cohort equation (PCE) risk scores and risk factor data were collected with the Agatston score and other CAC measures (number of lesions and vessels, lesion size, volume, and plaque density). Cox proportional hazard models were employed to estimate CV mortality (n = 919). Sex interactions were calculated. Women and men had average PCE risk scores of 5.8% and 9.1% (P < 0.001). Within CAC subgroups, women had fewer calcified lesions (P < 0.0001) and vessels (P = 0.017), greater lesion size (P < 0.0001), and higher plaque density (P = 0.013) when compared with men. For women and men without CAC, long-term CV mortality was similar (P = 0.67), whereas detectable CAC was associated with 1.3-higher hazard for CV death among women when compared with men (P < 0001). Cardiovascular mortality was higher among women with more extensive, numerous, or larger CAC lesions. The relative hazard for cardiovascular disease (CVD) mortality for women and men was 8.2 vs. 5.1 for multivessel CAC, 8.6 vs. 5.9 for ≥5 CAC lesions, and 8.5 vs. 4.4 for a lesion size ≥15 mm3, respectively. Additional explorations revealed that women with larger sized and more numerous CAC lesions had 2.2-fold higher CVD mortality (P < 0.0001) as compared to men. Moreover, CAC density was not predictive of CV mortality in women (P = 0.51) but was for men (P < 0.001), when controlling for CAC volume and cardiac risk factors. Conclusion:Our overall findings support that measures beyond the Agatston score provide important clues to sex differences in atherosclerotic plaque and may further refine risk detection and focus preventive strategies of care.

Features that enhance neighborhood walkability (higher population density, street connectivity and access to destinations) are associated with higher levels of physical activity among older adults. The perceived neighborhood environment appears to mediate associations between the objective built environment and physical activity. The role of depressed mood in these associations is poorly understood. We examined the degree to which depressive symptoms moderated indirect associations between the objective neighborhood environment and physical activity via the perceived neighborhood environment in older women. We analyzed data on 60,133 women (mean age = 73.1 ± 6.7 years) in the U.S. Nurses' Health Study cohort who completed the 2008 questionnaire. Self-reported measures included the Geriatric Depression Scale, perceived presence of recreational facilities, retail destinations, sidewalks, and crime, and participation in recreational physical activity and neighborhood walking. We created an objective walkability index by summing z-scores of intersection and facility counts within 1200-meter residential network buffers and census tract-level population density. We used multiple regression with bootstrap-generated 95% bias-corrected confidence intervals (BC CIs) to test for mediation and moderated mediation. Objective walkability was associated with 1.99 times greater odds of neighborhood walking (95% BC CI = 1.92, 2.06) and 1.38 times greater odds of meeting physical activity recommendations (95% BC CI = 1.34, 1.43) via the perceived neighborhood environment. These indirect associations were weaker among women with higher depressive symptom scores. Positive associations between objective neighborhood walkability and physical activities such as walking among older women may be strengthened with a reduction in their depressive symptoms.

OBJECTIVES/OBJECTIVE:To measure disparities in hepatitis B virus (HBV) infection and immunity among a high-risk patient population at a community health center in New York City. METHODS:and logistic regression analysis. RESULTS:Of 25 565 adults, 13.4% were currently infected, 52.1% were ever infected, 33.4% were immune from vaccination, and 14.5% were susceptible. Significant factors associated with ever infection were age, male sex, being China-born, limited English proficiency, having Medicaid or no insurance, and family history of HBV (P < .01). CONCLUSIONS:Our study demonstrated a high burden of HBV infection among foreign-born Asian Americans seeking care at a community health center. Public Health Implications. It is important to test patients at high risk for HBV infection with all 3 tests to identify those with current infection, risk for reactivation, or need for vaccination, and to assess the effectiveness of public health interventions.

Background. Despite the high efficacy of PrEP, it continues to be underutilized. We examined the extent to which patients with a documented positive test for STIs were provided PrEP at an urban municipal medical center. Methods. We reviewed data of all patients seen between January 1, 2014 and July 30, 2017 who were > 18 years old and had an initial HIV negative test and >=1 positive test for Chlamydia, Gonorrhea, or Syphilis. We examined PrEP prescription data by gender, race/ethnicity, and clinic location. Differences between groups were compared using Chi-squared analysis and logistic regression. Results. Of 1,142 initially HIV- patients who were identified as having a positive STI result, 52% were female, 89% either Black or Hispanic, with a median age of 40 years (quartiles 30, 47). 58% had Medicare/Medicaid and 34% were self-pay or uninsured (Table 1). Only 25 (2.1%) of 1,142 patients who had >=1 STI test positive were prescribed PrEP. No women received PrEP. Whites (aOR: 21.7 [95% CI:4.4, 107, P < 0.001] and Hispanics (aOR:6.64 [95% CI:1.35, 32.8, P = 0.02] were both more likely to receive PrEP than Blacks, after adjusting for age, sex, marital status, and insurance. All PrEP prescriptions originated from the Medicine, Emergency, or HIV specialty clinics although most STI testing was obtained in Emergency and Obstetrical/Gynecological clinics (Table 2). Conclusion. There were significant missed opportunities for HIV prevention among patients with STIs within the medical center, particularly among Hispanic and Black patients. Enrichment programs to educate providers and increase PrEP prescriptions may have a major impact on expanding HIV prevention, especially for women. (Figure Presented)

In the version of this Letter originally published, in Fig. 2d, in the third graph, the label for the y axis was incorrect as 'TNF-α (pg ml^-1)'; it should have read 'IL-1β (pg ml^-1)'. This has now been corrected.

BACKGROUND:Circulating free DNA sequencing (cfDNA-Seq) can portray cancer genome landscapes, but highly sensitive and specific technologies are necessary to accurately detect mutations with often low variant frequencies. METHODS:We developed a customizable hybrid-capture cfDNA-Seq technology using off-the-shelf molecular barcodes and a novel duplex DNA molecule identification tool for enhanced error correction. RESULTS:mutations originating from clonal hematopoiesis. Furthermore, cfDNA-Seq off-target read analysis allowed simultaneous genome-wide copy number profile reconstruction in 20 of 28 cases. Copy number profiles were validated by low-coverage whole-genome sequencing. CONCLUSIONS:This error-corrected, ultradeep cfDNA-Seq technology with a customizable target region and publicly available bioinformatics tools enables broad insights into cancer genomes and evolution. CLINICALTRIALSGOV IDENTIFIER/UNASSIGNED:NCT02112357.

Psoriasis is a chronic inflammatory disease with both a physical and psychosocial burden. To offer strategies for dermatology residents to assess and manage psychosocial aspects of psoriasis, a PubMed search of articles indexed for MEDLINE was performed using the following terms: psoriasis, depression, anxiety, work productivity, sexual functioning, and interpersonal relationships. Selected articles covered the prevalence, assessment, and management of each of the psychosocial domains of psoriasis. Depression is a common comorbidity in psoriasis patients, and the psychosocial burden of psoriasis is immense. Dermatology providers play a vital role in assessing and managing the psychosocial aspects of the disease along with medical management.

Introduction: Cardiovascular risk factors associated with the development of systemic atherosclerosis relate in part to socioeconomic environment, but the relationship between the socioeconomic environment and vascular disease is uncertain. Hypothesis: A poorer socioeconomic environment is associated with increased prevalence of lower extremity peripheral artery disease (PAD) and carotid artery stenosis (CAS) even after adjusting for traditional cardiovascular risk factors.
Method(s): Retrospective analysis of ~3 million participants in the cross-sectional pay-for-screening Life Line Screening survey in 2003-2008 at 20,000 sites across all 50 states. Socioeconomic environment scores (SES) were constructed from US Census data. Prevalence of PAD (ABI <0.9) and CAS (stenosis >=50% on carotid ultrasound) were compared by SES quartile within sex and race subgroups using the Cochran Armitage trend test. Logistic regression models were used to assess strength of association and adjusted for demographics, cardiovascular risk factors, and state of residence.
Result(s): Of 3,696,778 participants, 2,851,470 white and black participants were included for PAD and 2,981,111 for CAS; mean age was 63.7+/-10.4 years and 63.8% were female. The prevalence of PAD and CAS was greater with lower SES quartiles in all race and sex subgroups (Figure 1; p<0.0001 for trend for each comparison). The associations between SES and both PAD and CAS remained significant after multivariable adjustment including traditional cardiovascular risk factors and state of residence (Figure 2).
Conclusion(s): A poorer socioeconomic environment is associated with a higher prevalence of PAD and CAS and may be an independent risk factor beyond traditional cardiovascular risk factors. Figures: (Figure Presented)