Faculty Bibliography

We conducted a systematic review and meta-analysis analysing the existing data on transcutaneous electrical nerve stimulation (TENS) or interferential current (IFC) for chronic low back pain (CLBP) and/or neck pain (CNP) taking into account intensity and timing of stimulation, examining pain, function and disability. Seven electronic databases were searched for TENS or IFC treatment in non-specific CLBP or CNP. Four reviewers independently selected randomized controlled trials (RCTs) of TENS or IFC intervention in adult individuals with non-specific CLBP or CNP. Primary outcomes were for self-reported pain intensity and back-specific disability. Two reviewers performed quality assessment, and two reviewers extracted data using a standardized form. Nine RCTs were selected (eight CLBP; one CNP), and seven studies with complete data sets were included for meta-analysis (655 participants). For CLBP, meta-analysis shows TENS/IFC intervention, independent of time of assessment, was significantly different from placebo/control (p < 0.02). TENS/IFC intervention was better than placebo/control, during therapy (p = 0.02), but not immediately after therapy (p = 0.08), or 1-3 months after therapy (p = 0.99). Analysis for adequate stimulation parameters was not significantly different, and there was no effect on disability. This systematic review provides inconclusive evidence of TENS benefits in low back pain patients because the quality of the studies was low, and adequate parameters and timing of assessment were not uniformly used or reported. Without additional high-quality clinical trials using sufficient sample sizes and adequate parameters and outcome assessments, the outcomes of this review are likely to remain unchanged.

Background /UNASSIGNED:Evaluation of resident physicians' communications skills is a challenging task and is increasingly accomplished with standardized examinations. There exists a need to identify the effective, efficient methods for assessment of communications skills. Objective /UNASSIGNED:We compared objective structured clinical examination (OSCE) and direct observation as approaches for assessing resident communications skills. Methods /UNASSIGNED:We conducted a retrospective cohort analysis of orthopaedic surgery resident physicians at a single tertiary care academic institution, using the Institute for Healthcare Communication "4 Es" model for effective communication. Data were collected between 2011 and 2015. A total of 28 residents, each with OSCE and complete direct observation assessment checklists, were included in the analysis. Residents were included if they had 1 OSCE assessment and 2 or more complete direct observation assessments. Results /UNASSIGNED: = .16), after adjusting for chance agreement. Conclusions /UNASSIGNED:Our results suggest that OSCE and direct observation tools provide different insights into resident communications skills (simulation of rare and challenging situations versus real-life daily encounters), and may provide useful perspectives on resident communications skills in different contexts.

BACKGROUND:Cocaine use has a high prevalence in the United States and can be associated with significant cardiovascular disease, even in asymptomatic users. β-Adrenergic receptor hyperactivation is the underlying pathophysiologic pathway of cocaine cardiotoxicity. β-Blocker therapy is controversial in patients with active cocaine use. HYPOTHESIS/OBJECTIVE:β-Blocker therapy is associated with clinical improvement in patients with heart failure despite active cocaine use. METHODS:In a single-center, retrospective chart analysis, patients with newly diagnosed heart failure and active cocaine use who had been started on β-blocker therapy were reviewed. The New York Heart Association (NYHA) functional class and the left ventricular ejection fraction (LVEF) were recorded at baseline and after 12 monthsnthsnths of β-blocker use. Patients were excluded if they had been on prior β-blocker therapy, had other reasons for volume overload, had chronic kidney disease stages G4 or G5, or had a life expectancy <12 months. RESULTS:Thirty-eight patients were identified; most were African American males. A statistically significant improvement was found in both NYHA functional class (P < 0.0001) and LVEF (P < 0.0001) after 12 months of β-blocker therapy. No major adverse cardiovascular events occurred in this population. CONCLUSIONS:β-Blocker use in cocaine users with heart failure with a reduced ejection fraction is associated with a lower NYHA functional class and a higher LVEF at 12-month follow-up. No major adverse cardiovascular events were observed.

OBJECTIVE:There is limited research on metabolic abnormalities in psychotropic-naïve patients with serious mental illness (SMI). Our study examined metabolic conditions in a large, ethnically diverse sample of psychotropic-naïve and non-naïve adults with SMI at an urban public hospital. METHODS:In this cross-sectional study of 923 subjects, the prevalences of hyperglycemia meeting criteria for type 2 diabetes mellitus (T2DM) based on fasting plasma glucose and obesity defined by BMI and abdominal girth were compared across duration of psychotropic medication exposure. Multiple logistic regression models used hyperglycemia and obesity as dependent variables and age, sex, race/ethnicity, and years on psychotropics as independent variables. RESULTS:Psychotropic-naïve patients, including both schizophrenia and non-psychotic subgroups, showed an elevated prevalence of hyperglycemia meeting criteria for T2DM and a decreased prevalence of obesity compared to the general population. Obesity rates significantly increased for those on psychotropic medications more than 5 years, particularly for patients without psychosis (BMI: aOR = 5.23 CI = 1.44-19.07; abdominal girth: aOR = 6.40 CI = 1.98-20.69). Women had a significantly higher obesity rate than men (BMI: aOR = 1.63 CI = 1.17-2.28; abdominal girth: aOR = 3.86 CI = 2.75-5.44). Asians had twice the prevalence of hyperglycemia as whites (aOR = 2.29 CI = 1.43-3.67), despite having significantly less obesity (BMI: aOR = .39 CI = .20-.76; abdominal girth: aOR = .34 CI = .20-.60). Hispanics had a higher rate of obesity by BMI than whites (aOR = 1.91 CI = 1.22-2.99). CONCLUSIONS:This study showed disparities between obesity and T2DM in psychotropic-naïve patients with SMI, suggesting separate risk pathways for these two metabolic conditions.

We report the emergence of colistin resistance in Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae after 8 days of colistin-based therapy, resulting in relapse of bloodstream infection and death. Disruption of the mgrB gene by insertion of a mobile genetic element was found to be the mechanism, which was replicated in vitro after exposure to subinhibitory concentrations of colistin and meropenem.

Hormone therapy containing synthetic progestins has been associated with an increased incidence of abnormal mammograms [1,2]. The REPLENISH (NCT01942668) study, a 12-month, phase 3 randomized, double-blind, placebo-controlled, multicenter trial, evaluated mammograms from women who took TX-001HR (TherapeuticsMD, Boca Raton, FL). TX-001HR, an investigational drug, consists of 17beta-estradiol and progesterone (E2/P4, sometimes referred to as bioidentical hormones) combined in a single, oral softgel capsule, which is currently being evaluated for the treatment of menopausal, moderate-to-severe vasomotor symptoms (VMS) in women with an intact uterus. The breast cancer incidence rate observed with TX-001HR (0.36%; 6/1684) is consistent with SEER data (0.29%) for women 40 to 64 years of age [3]. The objective of this analysis was to determine the proportion of women with abnormal mammograms after 1 year of TX-001HR vs placebo. Women (n=1835) were randomized to daily E2/P4 of 1.0 mg/100 mg (n=415) 0.5 mg/100 mg (n=424) 0.5 mg/50 mg (n=421) 0.25 mg/50 at screening or within 6 months prior to first dose and study end, and were read locally. Abnormal mammograms were considered those as BI-RADS 3 (short interval follow-up suggested) or 4 (suspicious abnormality). A total of 3171 mammograms were performed 1831 at screening and 1340 at study end (month 12 or early termination). At screening 99.5% of participants had a normal mammogram (BI-RADS 1 or 2); 8 (0.4%) had BI-RADS 3 or 4. With up to 1 year of TX-001HR use, most women (96.4%) had normal mammograms and 39 (2.9%) had abnormal mammograms. Similar rates of abnormal mammograms were observed between all TX-001HR doses and placebo: 3.7% (n=11) with 1 mg E2/100 mg P4 3.5% (n=11) with 0.5 mg/100 mg P4 2.8% (n=9) with 0.5 mg E2/50 mg P4 1.7% (n=5) with 0.25 mg E2/50 mg P4 and 3.1% (n=3) with placebo. In the REPLENISH trial, a low incidence of abnormal mammograms in postmenopausal women was found with all doses of TX-001HR versus placebo consistent with the background rate of abnormal mammograms in a population of women who get yearly screens. In this analysis, TX-001HR, a novel 17beta-estradiol and natural progesterone oral combination, was not associated with an increased risk of abnormal (BI-RADS 3 or 4) mammograms, which is in contrast to studies reporting an increased incidence of abnormal mammograms with hormone therapies containing synthetic progestins

Microcystic adnexal carcinoma (MAC) is a low-grade malignant tumor of the skin. Histologically, this tumor shows a biphasic pattern, with cords and nests of basaloid cells, as well as keratin horn cysts. This biphasic histological appearance has been interpreted by some authors as a sign of double eccrine and folliculosebaceous-apocrine differentiation, whereas some other authors defend a solely eccrine differentiation. In this context, sebaceous differentiation in MAC would support the first option. However, there are only 3 cases of MAC with sebaceous differentiation in the literature, and all of them were reported before adipophilin was available, which in the appropriate context (eg, testing clear cells for sebaceous vs eccrine differentiation) is very useful. In this study, we present 3 cases of MAC with focal sebaceous differentiation confirmed by immunoexpression of adipophilin in the sebaceous foci.

BACKGROUND:Physician well-being impacts both doctors and patients. In light of high rates of physician burnout, enhancing resilience is a priority. To inform effective interventions, educators need to understand how resilience develops during residency. METHODS:A qualitative study using grounded theory examined the lived experience of resilience in residents. A cohort of obstetrics and gynecology residents were selected as a purposive, intensity sample.. Eighteen residents in all years of training participated in semi-structured interviews. A three-phase process of open coding, analytic coding and thematic analysis generated a conceptual model for resilience among residents. RESULTS:Resilience among residents emerged as rooted in the resident's calling to the work of medicine. Drive to overcome obstacles arose from personal identity and aspiration to professional ideals. Adversity caused residents to examine and cultivate coping mechanisms. Personal connections to peers and mentors as well as to patients and the work helped buffer the stress and conflicts that present. Resilience in this context is a developmental phenomenon that grows through engagement with uncertainty and adversity. CONCLUSION/CONCLUSIONS:Resilience in residents is rooted in personal and professional identity, and requires engagement with adversity to develop. Connections within the medical community, finding personal fulfillment in the work, and developing self-care practices enhance resilience.

OBJECTIVES/OBJECTIVE:The present study examined the intersectionality of stigma across varying groups of older persons living with HIV (PWH). METHODS:Four focus groups of older PWH (gay/bisexual men, heterosexual men, heterosexual and bisexualwomen, and Spanish-speaking) were audio-recorded and transcribed. Inductive thematic text analysis was used to identify qualitative themes. RESULTS:Five major themes emerged from the data: 1) disclosure of HIV status; 2) types of stigma experienced; 3) discrimination experienced; 4) other outcomes associated with experiencing stigma; and 5) influence of aging on social isolation experienced due to stigma. Findings indicate women did not suffer from the intersection of stigmas. Other groups suffered from the intersection of stigma due to HIV status and age (gay/bisexual males); HIV status and perceived stigma of sexual orientation or drug use (heterosexual males); and HIV status and culture/ethnicity (Spanish-speaking). CONCLUSIONS:Results indicate that many at-risk groups, including heterosexual men, homosexual men, and Spanish-speaking individuals, experience an intersection of stigma between aging and their sexuality, HIV status, or real or perceived drug use. CLINICAL IMPLICATIONS/CONCLUSIONS:Results highlight the need for HIV support, especially social support, to address intersection of stigmas for unique groups of individuals disproportionately affected by HIV.