Faculty Bibliography

To compare the prevalence of mammography and prostate-specific antigen (PSA) testing in 9/11-exposed persons with the prevalence among the US population, and examine the association between 9/11 exposures and these screening tests using data from the World Trade Center Health Registry (WTCHR) cohort. We studied 8190 female and 13,440 male enrollees aged ≥40 years at survey completion (2015-2016), who had a medical visit during the preceding year, had no self-reported breast or prostate cancer, and did not have screening for non-routine purposes. We computed age-specific prevalence of mammography (among women) and PSA testing (among men), and compared to the general population using 2015 National Health Interview Survey data (NHIS). We also computed the adjusted prevalence ratio (PR) and 95% confidence interval (95% CI) to examine the relationship between 9/11 exposures and screening uptakes using modified Poisson regression. Our enrollees had higher prevalences of mammogram and PSA testing than the US general population. 9/11 exposure was not associated with mammography uptake. Proximity to the WTC at the time of the attacks was associated with PSA testing in the age 60-74 group (PR = 1.06; 95% CI = 1.00-1.12). Among rescue/recovery workers and volunteers (RRW), being a firefighter was associated with higher PSA testing than other RRW across all age groups (40-49: PR = 1.45, 95% CI 1.16-1.81; 50-59: PR = 1.33, 95% CI 1.22-1.44; 60-74: PR = 1.14, 95% CI 1.06-1.23). Screening activities should be considered when studying cancer incidence and mortality in 9/11 exposed populations.

OBJECTIVE:Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients' perceptions of bias, and suggestions for restoring relationships if bias is perceived. METHODS:The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory. RESULTS:Ten focus groups (in English (6) and Spanish (4)) with N = 74 participants occurred. Data analysis revealed multiple influences patients' perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions. CONCLUSIONS:Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias. PRACTICE IMPLICATIONS:Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.

BACKGROUND:Common mechanisms against small intestinal bacterial overgrowth (SIBO), including an intact ileocecal valve, gastric acid secretion, intestinal motility, and an intact immune system, are compromised in inflammatory bowel disease (IBD), and therefore, a relatively high incidence of SIBO has been reported in this population. AIMS/OBJECTIVE:We aimed to determine whether an improvement in IBD clinical activity scores is seen after testing and treating SIBO. METHODS:A retrospective cohort study of 147 patients with inflammatory bowel disease who were referred for SIBO breath testing from 1/2012 to 5/2016 was performed. Characteristics of SIBO positive and treated patients were compared to SIBO negative patients, including the changes in Partial Mayo Score or Harvey Bradshaw Index (HBI), using Student's t test for continuous variables and Chi-squared or Fisher's exact test for categorical variables. RESULTS:61.9% were SIBO positive and treated, and 38.1% were SIBO negative. In Crohn's disease, the median HBI decreased from 5 to 3 and 5 to 4, in the SIBO positive and negative groups, respectively (p = 0.005). In ulcerative colitis, the Partial Mayo Score decreased from 2 to 1.5 and 2 to 1, respectively (p = 0.607). CONCLUSIONS:This study examines the clinical effect of testing and treating for SIBO in an IBD population. We see a significant reduction in HBI after testing for and treating SIBO. Future prospective studies are necessary to further investigate the role of SIBO in the evaluation and management of IBD.

BACKGROUND & AIMS/OBJECTIVE:Treatment options for recurrent ascites resulting from decompensated cirrhosis include serial large volume paracentesis and albumin infusion (LVP+A) or insertion of a transjugular intrahepatic portosystemic shunt (TIPS). Insertion of TIPSs with covered stents during early stages of ascites (early TIPS, defined as 2 LVPs within the past 3 weeks and less than 6 LVPs in the prior 3 months) significantly improves chances of survival and reduces complications of cirrhosis compared to LVP+A. However, it is not clear if TIPS insertion is cost-effective in these patients. METHODS:We developed a Markov model using the payer perspective for a hypothetical cohort of patients with cirrhosis with recurrent ascites receiving early TIPSs or LVP+A using data from publications and national databases collected from 2012-2018. Projected outcomes included quality-adjusted life-year (QALY), costs (2017 US dollars), and incremental cost-effectiveness ratios (ICERs; $/QALY). Sensitivity analyses (1-way, 2-way, and probabilistic) were conducted. ICERs less than $100,000 per QALY were considered cost effective. RESULTS:In base case analysis, early insertion of TIPS had a higher cost, ($22,770) than LVP+A, ($19,180) but also increased QALY (0.73 for early TIPSs and 0.65 for LVP+A), resulting in an ICER of $46,310/QALY. Results were sensitive to cost of uncomplicated TIPS insertion and transplant, need for LVP+A, probability of transplant, and decompensated QALY. In probabilistic sensitivity analysis, TIPS insertion was the optimal strategy in 59.1% of simulations. CONCLUSIONS:Based on Markov model analysis, early placement of TIPSs appears to be a cost-effective strategy for management of specific patients with cirrhosis and recurrent ascites. TIPS placement should be considered early and as a first-line treatment option for select patients.

Shortening emergency department (ED) boarding time and managing hospital bed capacity by expediting the inpatient discharge process have been challenging for hospitals nationwide. The objective of this study is was to explore the effect of an innovative prospective intervention on hospital workflow, specifically on early inpatient discharges and the ED boarding time. The intervention consisted of a structured nursing "admission discharge transfer" (ADT) protocol receiving new admissions from the ED and helping out floor nursing with early discharges. ADT intervention was implemented in a 38-bed hospitalist run inpatient unit at an academic hospital. The study population consisted of 4486 patients (including inpatient and observation admissions) who were hospitalized to the medicine unit from March 2013-March 2014. Of these hospitalizations, 2259 patients received the ADT intervention. Patients' demographics, discharge and ED boarding data were collected for from March 4, 2013 to March 31, 2014 for both intervention and control groups (28 weeks each). Chi-square and unpaired t tests were utilized to compare population characteristics. Poisson regression analysis was conducted to estimate the association between intervention and hospital length of stay adjusted for differences in patient demographics. Mean age of the study population was 58.6 years, 23% were African Americans and 55% were women. A significant reduction in ED boarding time (p < 0.001) and improvement in early (before 2 PM) hospital discharges (p = 0.01) were noticed among patients in the intervention groups. There was a slight but significant reduction in hospital length of stay for observation patients in the intervention group; however, no such difference was noted for inpatient admissions. Our study showed that dedicating nursing resources towards ED-boarded patients and early inpatient discharges can significantly improve hospital workflow and reduce hospital length of stay.

Background/Purpose: Previous studies suggest that patients with gout are at increased risk for developing diabetes.1 One possible explanation for this increased risk is the activation of pathologic pathways common to both diabetes and gout, including IL-1b.2 Among its many mechanisms, colchicine has been found to suppress activation of the NLRP3 inflammasome, inhibiting activation of IL-1b. Colchicine may also activate AMPK, a down regulator of inflammation and gluconeogenesis.3 In the present study, we investigated whether chronic colchicine use reduces diabetes incidence among patients with gout.
Method(s): We reviewed the Computerized Patient Record System (CPRS) of the New York Harbor Veterans' Affairs Healthcare System to assess the incidence of diabetes between 2000 and 2015 among 140 randomly selected patients with gout who had taken colchicine daily for some or all of the study period. We compared the diabetes incidence among these patients with 115 randomly selected patients with gout who did not take colchicine during the same time period. At study entry, all subjects met a modified version of 1977 ARA gout classification criteria and had no diabetes diagnosis. Patients were excluded if their duration of colchicine use was <60 contiguous days. Incident diabetes was defined as a new hemoglobin A1c value of >=6.5% during the study period.
Result(s): Among gout patients who had taken colchicine, we observed no difference in diabetes incidence compared to patients not taking colchicine (17.1% versus 17.4%, OR = 0.983, p = 1.0). When patients were analyzed by duration of colchicine use, there was no significant difference in diabetes incidence between patients in the longest (36.5 to 114 months) compared to the shortest tertile (2.3 to 14 months)(27.3% versus 9.1%, p=0.24) of colchicine exposure. Among patients in the colchicine group who experienced incident diabetes during the study period (n=24), 50% (n=12) were actively taking colchicine at the time of their diagnosis and 50% (n=12) had discontinued colchicine use prior to their diabetes diagnosis.
Conclusion(s): We found no significant difference in the 15-year diabetes incidence between patients taking colchicine and those not taking colchicine, suggesting that colchicine is not beneficial to prevent incident diabetes. Larger and prospective studies will be needed to confirm this observation

BACKGROUND:The landmark National Lung Screening Trial demonstrated significant reduction in lung cancer-related mortality. However, European lung cancer screening (LCS) trials have not confirmed such benefit. We examined LCS patterns and determined the impact of LCS-led diagnosis on the mortality of newly diagnosed patients with lung cancer in an underserved community. PATIENTS AND METHODS/METHODS:Medical records of patients diagnosed with primary lung cancer in 2013 through 2016 (n = 855) were reviewed for primary care provider (PCP) status and LCS eligibility and completion, determined using United States Preventative Services Task Force guidelines. Univariate analyses of patient characteristics were conducted between LCS-eligible patients based on screening completion. Survival analyses were conducted using Kaplan-Meier and multivariate Cox regression. RESULTS:In 2013 through 2016, 175 patients with primary lung cancer had an established PCP and were eligible for LCS. Among them, 19% (33/175) completed screening prior to diagnosis. LCS completion was associated with younger age (P = .02), active smoking status (P < .01), earlier stage at time of diagnosis (P < .01), follow-up in-network cancer treatment (P = .03), and surgical management (P < .01). LCS-eligible patients who underwent screening had improved all-cause mortality compared with those not screened (P < .01). Multivariate regression showed surgery (hazard ratio, 0.31; P = .04) significantly affected mortality. CONCLUSION/CONCLUSIONS:To our knowledge, this is the first study to assess LCS patterns and mortality differences on patients with screen-detected lung cancer in an urban underserved setting since the inception of United States Preventative Services Task Force guidelines. Patients with a LCS-led diagnosis had improved mortality, likely owing to cancer detection at earlier stages with curative treatment, which echoes the finding of prospective trials.

BACKGROUND:Although exercise is an effective treatment for fibromyalgia, the relationships between lifestyle physical activity and multiple symptomology domains of fibromyalgia are not clear. Thus, the purpose of this study was to comprehensively examine the relationships between lifestyle physical activity with multiple outcome domains in women with fibromyalgia, including pain, fatigue, function, pain-related psychological constructs, and quality of life. METHODS:Women (N = 171), aged 20 to 70 years, diagnosed with fibromyalgia, recruited from an ongoing two-site clinical trial were included in this prespecified subgroup analysis of baseline data. Physical activity was assessed using self-report and accelerometry. Symptomology was assessed using questionnaires of perceived physical function, quality of life, fatigue, pain intensity and interference, disease impact, pain catastrophizing, and fear of movement. In addition, quantitative sensory testing of pain sensitivity and performance-based physical function were assessed. Correlation coefficients, regression analyses and between-group differences in symptomology by activity level were assessed, controlling for age and body mass index (BMI). RESULTS:Lifestyle physical activity was most closely associated with select measures of physical function and fatigue, regardless of age and BMI. Those who performed the lowest levels of lifestyle physical activity had poorer functional outcomes and greater fatigue than those with higher physical activity participation. No relationships between lifestyle physical activity and pain, pain sensitivity, or pain-related psychological constructs were observed. CONCLUSIONS:Lifestyle physical activity is not equally related to all aspects of fibromyalgia symptomology. Lifestyle physical activity levels have the strongest correlations with function, physical quality of life, and movement fatigue in women with fibromyalgia. No relationships between lifestyle physical activity and pain, pain sensitivity, or psychological constructs were observed. These data suggest that physical activity levels are more likely to affect function and fatigue, but have negligible relationships with pain and pain-related psychological constructs, in women with fibromyalgia. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov, NCT01888640 . Registered on 28 June 2013.

Diverticula and calcification of tissue are both common processes; however, when occurring synergistically, they present a rare phenomenon. Our case of a 62-year-old female with frank blood per rectum revealed calcified diverticula on a non-contrast computed tomography (CT) scan. This is a diagnosis of exclusion having ruled out differentials such as calcified fecaliths, ingestion of radiopaque liquids, pills or objects, calcified infectious cysts, and neoplastic masses. After resuscitation and stabilization of the patient, the subsequent priority shifted to the assessment of the rebleeding risk. With calcification being a rare occurrence with diverticula, it is unclear how this constant irritating nidus will affect the chances of rebleeding. Thus, for this particular phenomenon, patients with calcified diverticula should be monitored with dedicated surveillance to ascertain rebleeding rates.