Faculty Bibliography

Introduction: Efficacy of colonoscopy is limited by inadequate preparation. A high social deprivation index has been identified as a risk factor for failure to repeat a colonoscopy when indicated. It is unknown whether or not split dose preparation increases adherence to recommendation for repeat colonoscopy. Few studies to date have evaluated the potential barriers to likelihood of repeating a bowel preparation in an underserved population. The purpose of this study was to identify factors associated with an increased likelihood of repeating a bowel preparation in a population with a high social deprivation index in a split-dose versus a single dose cohort Methods: Demographic, socioeconomic, medical, education and tolerability data were collected prospectively using a multi-language questionnaire. Descriptive statistics and multivariate analyses were performed on all variables assessed by our questionnaire to evaluate for differences in patients who were likely and unlikely to repeat the preparation. Results: Demographics are presented in table 1 (N=990). 336 (34%) completed single dose and 654 (66%) completed split dose colon preparation. Split dose patients were equally willing-to-repeat colonoscopy preparation compared to single dose patients (69.0% vs. 71.6%; P=0.45) (Table 2). Patients who were not willing to repeat split preparation complained of significantly more adverse gastrointestinal symptoms and difficulty completing dosing instructions due to social barriers and tolerability issues compared to single-dose cohort. Multivariable analysis revealed that concerns with time off work (OR: 0.48; 95% CI: 0.29-0.80), availability of appropriate food/drinks (OR: 0.59; CI: 0.36-0.97), tolerability (OR: 0.72; CI: 0.57-0.92), and colonoscopy scheduling (OR: 0.77; CI: 0.63- 0.94) were all factors independently associated with decreased willingness to repeat in the split dose cohort. Nurse's instruction in preferred language (OR: 2.69; CI: 1.22-5.91) and tolerability (OR: 0.71; CI: 0.55-0.92) were independently associated with patient willingness-to-repeat in the single-dose cohort. Conclusion: This study highlights that tolerability significantly effects repeatability in both single and split dose cohorts. It should be noted that patients with a high social deprivation index identify different barriers to single and split dose preparations. This observation could impact choice of preparation as it affects adherence to physician recommendations. (Figure Presented)

Cardiovascular disease (CVD) is the leading cause of mortality in the US and is largely preventable with lifestyle and medications. Statins are among the most prescribed medications in the United States. While several large trials have shown statins to be safe and effective, rare adverse events may be seen including the development or exacerbation of ulcerative colitis (UC). A 66-year-old woman with UC (diagnosed 5 years prior; well controlled on mesalamine with rare breakthrough symptoms), hypertension, hyperlipidemia, family history of premature CAD and 15+ pack year smoking history was evaluated for primary prevention of CVD and started on atorvastatin. Upon starting atorvastatin she noted myalgias and recurrence of proctitis. A colonoscopy at that time demonstrated active inflammation in the distal 5 cm of the rectum. All symptoms abated upon discontinuing the statin. Years later she was noted to be at increased risk for CVD, with an elevated coronary calcium score of 89 and an LDL of 149, and was re-challenged with low dose rosuvastatin. Soon after initiation, the patient again experienced a flare, this time requiring steroids to achieve remission despite stopping the statin. There is a paucity of data on statin-induced colitis. One reported case of pravastatin induced severe UC lead to colectomy and subsequent death, and several cases of statin-induced colitis have been reported to manufacturers. A RCT of 64 patients with UC and mild-moderate activity given atorvastatin vs. placebo for 8 weeks showed that patients on atorvastatin had worse outcomes (an increase of partial Mayo score by 1.5 points vs. decrease by 0.31 on placebo (p = 0.04)). However, a large retrospective, matched case-control study of 9,617 cases of IBD and 46,665 controls showed any statin exposure was associated with a significantly decreased risk of IBD (OR 0.68, 95% CI 0.64-0.72): CD (0.64, 95% CI 0.59-0.71), and UC (OR 0.70, 95% CI 0.65-0.76). This effect was similar for most statins and present regardless of the intensity of therapy. Given the known benefits of statin therapy in the prevention and treatment of CVD and conflicting data about its effects on IBD, patients with UC who are eligible for statin therapy should proceed with treatment but be counseled that they may be more susceptible to a flare. If UC symptoms are exacerbated, an alternative statin should not be employed. Instead, a different class of lipid-lowering therapy should be tried

This retrospective cohort study compared blood pressure (BP) control (BP <140/90 mm Hg) and all-cause mortality between US- and foreign-born blacks. We used data from a clinical data warehouse of 41 868 patients with hypertension who received care in a New York City public healthcare system between 2004 and 2009, defining BP control as the last recorded BP measurement and mean BP control. Poisson regression demonstrated that Caribbean-born blacks had lower BP control for the last BP measurement compared with US- and West African-born blacks, respectively (49% vs 54% and 57%; P<.001). This pattern was similar for mean BP control. Caribbean- and West African-born blacks showed reduced hazard ratios of mortality (0.46 [95% CI, 0.42-0.50] and 0.28 [95% CI, 0.18-0.41], respectively) compared with US-born blacks, even after adjustment for BP. BP control rates and mortality were heterogeneous in this sample. Caribbean-born blacks showed worse control than US-born blacks. However, US-born blacks experienced increased hazard of mortality. This suggests the need to account for the variations within blacks in hypertension management.

Background: There is growing evidence that the accumulation of protein-bound uremic retention solutes, such as indoxyl sulfate (IS), p-cresyl sulfate (PCS) and kynurenic acid (KA), play a role in the accelerated cardiovascular disease seen in patients undergoing chronic hemodialysis. Protein-binding, presumably to albumin, renders these solutes poor-dialyzable. We had previously observed that the concentration of free solute and its unbound fraction were markedly reduced at the end of hemodialysis. We hypothesized that solute binding might be pH-dependent and the changes attributable to the higher serum pH at the end of hemodialysis. In vitro, acidification of uremic plasma to pH 6 greatly increased the proportion of unbound indoxyl sulfate.
Method(s): We tested our hypothesis by reducing the dialysate bicarbonate buffer concentration to 25 mEq/L for the initial half of hemodialysis ('isohydric dialysis'). Eight stable hemodialysis patients underwent 'isohydric dialysis' and, midway, were switched to standard buffer (37 mEq/L). A second dialysis, 2 days later, employed standard buffer throughout.
Result(s): We found a clearcut separation of blood pH and bicarbonate concentrations 90 minutes following 'isohydric dialysis' (pH = 7.37, HCO3 =22.4 mEq/l) and standard dialysis (pH= 7.49, HCO3 = 29.5). Analysis of free and bound concentrations of uremic retention solutes confirmed our prediction that binding of solute is affected by pH. However, in mixed models analysis, we found that the reduction in total uremic solute concentration during dialysis accounted for a greater proportion of the variation in free concentration, presumably an effect of saturation binding to albumin, than did the relatively small change in pH produced by isohydric dialysis.
Conclusion(s): These findings suggest that modification of dialysis technique that would expose blood to a transient decrease in pH might increase the free fraction of solute and enhance the efficacy of hemodialysis in the removal of protein-bound uremic retention solutes

Poor school-functioning can be indicative of parent and adolescent mental health and adolescent behavior problems. This study examined 472 adolescents enrolled in the World Trade Center (WTC) Health Registry, with a two-step path analysis, using regression-based models, to unravel the relationships between parent and adolescent mental health, adolescent behavior problems, and adolescent unmet healthcare need (UHCN) on the outcome school-functioning. WTC exposure was associated with UHCN and parental mental health was a significant mediator. There was no evidence that family WTC exposure was associated with UHCN independent of its effect on parental mental health. For the second path, after accounting for the effects of adolescent mental health, behavioral problems, and UHCN, there remained a significant association between parental mental health and school-functioning. Interventions for poor school-functioning should have multiple components which address UHCN, mental health, and behavioral problems, as efforts to address any of these alone may not be sufficient.

Introduction: Effectiveness of colonoscopy is limited by inadequate bowel preparation. Failure of proper cleansing is multifactorial, but includes the inability of patients to tolerate the bowel preparation due to side effects. It is unknown whether or not the experience with split dose preparation increases adherence to recommendation for repeat colonoscopy. Few studies to date have evaluated potential barriers to bowel preparation in underserved populations. The purpose of this study was to identify whether adverse effects of bowel preparation affect the likelihood of repeating a colonoscopy in a split-dose versus a single dose cohort Methods: Demographic, socioeconomic, medical, education and tolerability data were collected prospectively using a multi-language questionnaire. Descriptive statistics and multivariate analyses were performed on all variables assessed by our questionnaire to evaluate for differences in patients who were likely or unlikely to repeat the preparation. Results: A total of 990 patients satisfied the study criteria (Figure 1). 54.6% of the patients were male, 39.7% Hispanic, 41.2% with less than a high school education, and 38.9% without medical insurance. 336 (34%) completed single dose and 654 (66%) completed split dose colon preparation. In the single dose cohort there were no statistically significant differences in the side effects experienced between patients who would and would not repeat the bowel preparation (Table 1). In contrast, in the split-dose cohorts, complaints of bad taste in mouth, nausea/vomiting and headache were statistically significant causes of a patient being unlikely to repeat the bowel preparation (p < .05) (Table 2). Despite the difference in the role of symptoms in willingness to repeat colon preparation between split dose versus single does preparation groups, there was no significant difference in overall willingness to repeat colon preparation between groups (69.0% versus 71.6%, p = 0.45). Conclusion: This study highlights differences in side effects experienced by patients taking a split dose compared to a single dose preparation. Despite these differences, patients in both groups were likely to repeat a colonoscopy. These results should give a provider confidence in prescribing a split dose preparation to a diverse patient population

RATIONALE:Physical environmental features of neighborhoods are associated with physical activity, but the influence of mental health factors, such as depression, on these associations is poorly understood. OBJECTIVE:We examined whether the perceived neighborhood environment mediated associations between the observed neighborhood environment and physical activity, and whether these associations were moderated by depressive symptoms. METHODS:Data consisted of systematic social observations of 343 neighborhoods and resident surveys. Participants' (N = 2969) mean age was 41.9 ± 16.2 years, 60.2% were female, and 67.9% were non-White. We conducted multiple linear regression and tests for mediation and moderated mediation. RESULTS:Observed recreation facilities, commercial destinations, physical disorder, and physical deterioration were indirectly associated with walking via perceived neighborhood environment variables. Observed recreation facilities was indirectly and positively associated with leisure-time physical activity via perceived park access, and indirectly and inversely associated with walking and leisure-time physical activity via perceived traffic danger, but only among participants with low depressive symptom scores. Observed recreation facilities was indirectly and inversely associated, and observed physical disorder and physical deterioration were indirectly and positively associated with walking via perceived disorder, but only among participants with high depressive symptom scores. CONCLUSION:Depressive symptoms affected the strength and direction of associations between the observed neighborhood environment and physical activity via residents' perceptions.

OBJECTIVES: Low provider adoption continues to be a significant barrier to realizing the potential of clinical decision support. "Think Aloud" and "Near Live" usability testing were conducted on two clinical decision support tools. Each was composed of an alert, a clinical prediction rule which estimated risk of either group A Streptococcus pharyngitis or pneumonia and an automatic order set based on risk. The objective of this study was to further understanding of the facilitators of usability and to evaluate the types of additional information gained from proceeding to "Near Live" testing after completing "Think Aloud". METHODS: This was a qualitative observational study conducted at a large academic health care system with 12 primary care providers. During "Think Aloud" testing, participants were provided with written clinical scenarios and asked to verbalize their thought process while interacting with the tool. During "Near Live" testing participants interacted with a mock patient. Morae usability software was used to record full screen capture and audio during every session. Participant comments were placed into coding categories and analyzed for generalizable themes. Themes were compared across usability methods. RESULTS: "Think Aloud" and "Near Live" usability testing generated similar themes under the coding categories visibility, workflow, content, understand-ability and navigation. However, they generated significantly different themes under the coding categories usability, practical usefulness and medical usefulness. During both types of testing participants found the tool easier to use when important text was distinct in its appearance, alerts were passive and appropriately timed, content was up to date, language was clear and simple, and each component of the tool included obvious indicators of next steps. Participant comments reflected higher expectations for usability and usefulness during "Near Live" testing. For example, visit aids, such as automatically generated order sets, were felt to be less useful during "Near-Live" testing because they would not be all inclusive for the visit. CONCLUSIONS: These complementary types of usability testing generated unique and generalizable insights. Feedback during "Think Aloud" testing primarily helped to improve the tools' ease of use. The additional feedback from "Near Live" testing, which mimics a real clinical encounter, was helpful for eliciting key barriers and facilitators to provider workflow and adoption.