Faculty Bibliography

BACKGROUND:A substantial proportion of all pheochromocytomas is currently detected during the evaluation of an adrenal incidentaloma. Recently, it has been suggested that biochemical testing to rule out pheochromocytoma is unnecessary in case of an adrenal incidentaloma with an unenhanced attenuation value ≤10 Hounsfield Units (HU) at computed tomography (CT). OBJECTIVES/OBJECTIVE:We aimed to determine the sensitivity of the 10 HU threshold value to exclude a pheochromocytoma. METHODS:Retrospective multicenter study with systematic reassessment of preoperative unenhanced CT scans performed in patients in whom a histopathologically proven pheochromocytoma had been diagnosed. Unenhanced attenuation values were determined independently by two experienced radiologists. Sensitivity of the 10 HU threshold was calculated, and interobserver consistency was assessed using the intraclass correlation coefficient (ICC). RESULTS:214 patients were identified harboring a total number of 222 pheochromocytomas. Maximum tumor diameter was 51 (39-74) mm. The mean attenuation value within the region of interest was 36 ± 10 HU. Only one pheochromocytoma demonstrated an attenuation value ≤10 HU, resulting in a sensitivity of 99.6% (95% CI: 97.5-99.9). ICC was 0.81 (95% CI: 0.75-0.86) with a standard error of measurement of 7.3 HU between observers. CONCLUSION/CONCLUSIONS:The likelihood of a pheochromocytoma with an unenhanced attenuation value ≤10 HU on CT is very low. The interobserver consistency in attenuation measurement is excellent. Our study supports the recommendation that in patients with an adrenal incidentaloma biochemical testing for ruling out pheochromocytoma is only indicated in adrenal tumors with an unenhanced attenuation value >10 HU.

Like many states, North Carolina faces an opioid crisis that has rapidly intensified in recent years. Addressing this epidemic requires interventions such as judicious prescribing of opioids, community based prevention efforts, broader naloxone distribution, law enforcement efforts to curb drug trafficking, and harm reduction efforts like safe syringe programs. Expanding access to treatment and recovery services, as well as affordable health insurance for individuals with substance use disorder or at risk for developing a disorder, is also critical. North Carolina has made significant progress, but we have much more work to do.

Background: Catheter ablation has become an increasingly common elective therapy for symptomatic atrial fbrillation (AF). Few data are available regarding outcomes of urgent AF ablation performed during AF related hospital admission, and the impact of these procedures on healthcare utilization. Objective: To evaluate patient characteristics, procedural outcomes, and impact on healthcare utilization in patients undergoing urgent AF ablation. Methods: Procedural outcomes of patients undergoing urgent frst-time AF ablation during an AF related hospital admission between 1/2014 and 8/2017 at a single tertiary care medical center were compared to those of 2:1 matched control patients undergoing frst-time elective AF ablation. An inverse probability weighted marginal structural model was constructed and the weighted means of the average hospital days and number of hospital visits in the six-months post ablation were compared. Results: 25 patients (1% of frst-time AF ablations) underwent an urgent procedure. There were no major procedural complications in either group. Incidence of arrhythmia recurrence within one year was similar in urgent and elective patients (20% vs. 18%, respectively, p=0.85). Urgent ablation patients had a greater number of hospital utilization days in the 6-months pre-ablation (mean 8.9+/-4.5 vs 2.6+/-1.1, p<.001) and a similar number of hospital utilization days in the 6-months post-ablation (1.8+/-4.5 vs 0.59+/- 1.07, p=.05) The marginal structural model of the change in number of hospital visits due to being in the urgent ablation group was-0.924 (-1.43 to-0.41; P <0.001). Conclusion: Urgent ablation for treatment resistant, symptomatic AF is feasible and safe with procedural outcomes were similar to those of elective AF ablation. There is and increased rate of healthcare utilization in prior to ablation in the urgent group, and a statistically signifcant reduction in healthcare utilization following urgent AF ablation. Defning the cost-effectiveness of and optimal patient selection for urgent ablation requires further investigation

We would like to respond to some concerns raised by Dr. McClellan in his editorial comment¹ on our article that reported the results of a placebo-controlled study of lurasidone for the treatment of children and adolescents with bipolar I depression.².

BACKGROUND:Type 2 diabetes mellitus (DM) affects 9.4% of US adults and children, while another 33.9% of Americans are at risk of DM. Health care institutions face many barriers to systematically delivering the preventive care needed to decrease DM incidence. Community health workers (CHWs) may, as frontline public health workers bridging clinic and community, help overcome these challenges. This paper presents the protocol for a pragmatic, cluster-randomized trial integrating CHWs into two primary care clinics to support DM prevention for at-risk patients. METHODS:The trial will randomize 15 care teams, stratified by practice site (Bellevue Hospital and Manhattan VA), totaling 56 primary care physicians. The study cohort will consist of ~ 2000 patients who are 18-75 years of age, actively enrolled in a primary care team, able to speak English or Spanish, and have at least one glycosylated hemoglobin (HbA1c) result in the prediabetic range (5.7-6.4%) since 2012. Those with a current DM diagnosis or DM medication prescription (other than metformin) are ineligible. The intervention consists of four core activities - setting health goals, health education, activation for doctor's appointments, and referrals to DM prevention programs - adjustable according to the patient's needs and readiness. The primary outcome is DM incidence. Secondary outcomes include weight loss, HbA1C, and self-reported health behaviors. Clinical variables and health behaviors will be obtained through electronic medical records and surveys, respectively. Implementation outcomes, namely implementation fidelity and physicians' perspectives about CHW integration into the clinic, will be assessed using interviews and CHW activity logs and analyzed for the influence of moderating organizational factors. DISCUSSION/CONCLUSIONS:This is the first rigorous, pragmatic trial to test the effectiveness of integrating CHWs into primary care for DM prevention reaching a population-based sample. Our study's limitations include language-based eligibility and the use of HbA1c as a measure of DM risk. It will measure both clinical and implementation outcomes and potentially broaden the evidence base for CHWs and patient-centered medical home implementation. Further, the intervention's unique features, notably patient-level personalization and referral to existing programs, may offer a scalable model to benefit patients at-risk of DM. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov NCT03006666 (Received 12/27/2016).