Faculty Bibliography

OBJECTIVE: This study sought to identify rates and predictors of obesity counseling performed by outpatient psychiatrists in the United States. METHODS: The 2005-2010 National Ambulatory Medical Care Surveys provided data from 7,309 outpatient psychiatry visits. Logistic regression was used to examine associations between patient, visit, and practice characteristics and outcomes. RESULTS: Most (81%) visits occurred in a private practice setting. Nine percent (N=657) of visits included measurement of patient body mass index (BMI); 30% of these visits were with patients who met the obesity criterion (BMI >/=30.0 kg/m2). Among visits with obese patients, 16% included exercise counseling, 22% included weight reduction counseling, and 24% included diet or nutrition counseling. Patients with obesity were more likely than patients without obesity to receive diet or nutrition counseling (p<.05) and weight reduction counseling (p<.05), but not exercise counseling. Black patients were significantly less likely to receive any form of counseling (p<.05). CONCLUSIONS: There is a significant need to improve psychiatrists' obesity counseling.

Background: Interactions of resident intestinal microbes with the luminal contents and the mucosal surface play important roles in normal intestinal development, nutrition and immunity. Long-standing infections such as gastric H. pylori modify the gastric microbiota and might modify fecal microbiota composition. Objective: To evaluate the fecal microbiota of mother-child pairs and its relation to H. pylori status. Methods: Consecutive mothers and their newborns were recruited in the maternity unit, immediately after delivery. After signing informed consent, we took one stool sample of the mother before hospital discharge and one stool sample of the newborns at home (15 days old). Maternal H. pylori status was evaluated by H. pylori antigen detection (Platinum HpSA, Meridian Diagnostics, Ohio, USA). Collected samples were stored at-80degreeC until processing. The V4 region of the 16S rRNA gene was sequenced using Illumina MiSeq platform. Sequences were analyzed using the QIIME pipeline. Results: 22 mother-child pairs were recruited and 11 of them have positive maternal H. pylori status (50%). Thirteen babies were vaginally delivered and 9 were born by Caesarean section. All babies were fully breastfed. H. pylori was not detected in the feces of newborns. The analyses showed that there were differences in the structure of the microbiota by maternal H. pylori status only in infant feces born vaginally (PERMANOVA, p=0.01). Although with similar bacterial alpha diversity level, infants born vaginally to H. pylori-infected mothers had higher abundance of Enterobacteriaceae and Veilonella (LEfSe analysis, LDA > 3.0-fold). Conclusions: Maternal H. pylori status affects the fecal microbiota composition in babies born by vaginal delivery, but not in babies born by Caesarean section. The results suggest that the effect of the maternal H. pylori on the infant fecal microbiota is mediated by the acquired vaginal microbiota at birth

Background/Purpose: Chinese-Americans are one of the fastest growing immigrant groups in the US. They often use Traditional Chinese Medicine (TCM), but whether that affects medication adherence is unknown. This question is important because data suggest that ethnic Chinese have more severe SLE and RA than Caucasians, and thus nonadherence could be especially problematic. This study evaluates whether TCM use is associated with nonadherence to western medicines prescribed for chronic rheumatic diseases among Chinese- American patients. Secondary aims are to explore differences in self-reported health status between TCM users and non-users. Methods: Recruitment was from a rheumatology clinic that serves a predominantly Chinese-American immigrant population. A bilingual Mandarin/English speaker evaluated TCM use, medication adherence, patient-reported outcomes from the Patient-Reported Outcomes Measurement Information System (PROMIS), and other patient-level factors, all administered with validated instruments available in English and Mandarin. Inclusion criteria included speaking Mandarin or English, prescription of > 1 medication by the rheumatologist, and being actively followed for a systemic rheumatic disease or OA of hands, knees, or hips. Those with only fibromyalgia, neck/back pain, or other soft tissue diseases were excluded. Adherence was analyzed as low, medium or high based on the 8-item Morisky Medication Adherence Scale. Results: Seventy-three enrolled, mean age 56y (range 22-97), 59% female, 77% Medicaid, and only 21% spoke English. Diagnoses included RA (37%), spondyloarthropathies (22%), SLE (15%), SS (7%), gout/pseudogout (7%), OA (3%), and other (9%). Forty-nine percent reported TCM use in the past year, most commonly massage (53%), acupuncture (47%), and herbs (44%). There was a trend for TCM use to be more common in SLE vs. RA (65% vs. 37%, p=0.5) and TCM users had a shorter disease duration (5.3 vs. 11.2 years, p=0.03). Overall, 70% reported nonadherence to rheumatic medication. In multivariate analysis adjusting for patient characteristics, TCM use was not associated with lower adherence (OR 0.34, 95% CI 0.09-1.26), while herb use was associated (OR 5.3, 95% CI 1.09-25.87). TCM users also had worse PROMIS scores in anxiety (mean T-score 52 vs. 46, p=0.01) and depression (mean T-score 52 vs. 46, p=0.007), and a trend for worse pain (mean T-score 58 vs. 56, p=0.2), fatigue (mean T-score 55 vs. 51, p=0.1), function (mean T-score 43 vs.47, p=0.1), and worse ability to participate in social roles and activities (mean T-score 55 vs.59, p=0.06). Conclusion: In this group of poorly integrated Chinese-American rheumatology patients, most were non-adherent with western medicines, but only herb use was associated with non-adherence. This could reflect two divergent beliefs towards TCM. In general TCM is complementary, but herb may be seen as an alternative to western medicine. In addition, TCM users had worse scores in several important self-reported health domains. This may indicate unmet needs, particularly in mental health. These associations should be explored longitudinally, including the association of TCM use and adherence on disease activity

OBJECTIVE:To evaluate the association between Cushing syndrome and hypercoagulability in children. STUDY DESIGN:A prospective, observational study was performed of 54 patients with Cushing syndrome, 15.1 ± 3.9 years, treated at the National Institutes of Health Clinical Center. Coagulation profiles were taken before and 6-12 months after surgery and compared with18 normocortisolemic children, 13.7 ± 3.6 years. RESULTS:At baseline, patients with Cushing syndrome had greater levels of the procoagulant factor VIII (FVIII) vs controls (145 IU/dL ± 84 vs 99 ± 47, P = .04); 6-12 months after surgery, FVIII levels decreased to 111 ± 47, P = .05. Patients with Cushing syndrome had greater levels of the antifibrinolytic α2-antiplasmin, 96 ± 17% vs 82 ± 26%, P = .015. After surgery, antifibrinolytic α2-antiplasmin levels decreased to 82 ± 24%, P < .001. Anticoagulants were greater in patients with Cushing syndrome vs controls at baseline, including protein C (138 ± 41% vs 84 ± 25%, P < .001), protein S (94 ± 19% vs 74 ± 19%, P = .001), and antithrombin III (96 ± 18% vs 77 ± 13%, P < .0001). The 24-hour urinary free cortisol levels correlated positively with FVIII levels, r = 0.43, P = .004. CONCLUSION:Children with Cushing syndrome had elevated procoagulants, antifibrinolytics, and anticoagulants at baseline compared with controls; normalization of coagulation measures was seen after surgical cure. Despite the increase in anticoagulants, hypercortisolemia is associated with a hypercoagulable state in children, as is the case in adults. This finding has potential implications for prevention of venous thromboembolism in children with Cushing syndrome. TRIAL REGISTRATION:ClinicalTrials.gov:NCT00001595.

BACKGROUND:The cost of diabetes care accounts for a significant proportion of healthcare expenditures. Cost models based on updated incident complication rates and associated costs are needed to improve financial planning and quality assessment across the U.S. healthcare system. We developed a cost model using published data to estimate the direct medical costs of incident diabetes-related complications in a U.S. population of adults. MATERIALS AND METHODS:A systematic literature review of MEDLINE, EMBASE, and TRIP databases was conducted on studies reporting the incidence and/or cost of diabetes-related complications (cardiovascular disease, neuropathy, nephropathy, ophthalmological disease, and acute metabolic events). A total of 54 studies met eligibility criteria. A baseline model was constructed for a U.S. population with type 1 and 2 diabetes mellitus and used to determine the expected costs of managing such a population over 1-, 3-, and 5-year time horizons. RESULTS:The most costly incident complications in a population of 10,000 adults with diabetes were (1) congestive heart failure (CHF): annual expected cost of $7,320,287, 5-year expected cost of $50,697,865; (2) end-stage renal disease (ESRD): annual expected cost of $4,225,384, 5-year expected cost of $13,211,204; and (3) gangrene: annual expected cost of $2,844,381, 5-year expected cost of $17,200,417. CONCLUSIONS:This cost model estimates the direct healthcare costs of incident diabetes-related complications in a U.S. adult population with diabetes and provides a benchmark for evaluating the cost-effectiveness and potential leakage within a care delivery network.

Background/Purpose: The relationship between gout and cancer remains unclear. Whereas some studies have reported possible anti-cancer benefits of uric acid and monosodium urate crystals, others have found an increased risk of cancer in gout patients. Our study aimed to clarify the relationship between gout and colon metaplasia, including cancer and polyps. Methods: We conducted a retrospective study of patients in a VA hospital system using two distinct approaches. To obtain a historical, cross-sectional view of colon cancer prevalence, we assessed the presence of physiciancoded diagnoses of colon cancer and/or polyps in gout patients, versus patients with osteoarthritis (OA) but no gout, with active records in our computerized patient record system (CPRS) between 2007 and 2008. Lung and prostate cancer prevalence were recorded for comparison. In the second approach, we included only patients with documented colonoscopy reports in CPRS, and performed a retrospective cohort study of colon cancer and polyp incidences in gout versus OA patients over a ten-year period (2001-2010). In addition, colon cancer and polyp incidences were compared between patients who had undergone screening versus diagnostic colonoscopy, those who used aspirin or NSAIDs and those who did not, and between gout patients who used allopurinol and/or colchicine and those who did not. Results: 1287 gout patients and 1287 OA patients were included. Gout and OA patients were similar in age, ethnicity, BMI and smoking history. Gout patients had a lower physician-coded prevalence of all colonic lesions (cancer or polyp: 1.8 versus 9.6%, p<0.001), and a lower prevalence of colon cancer (1.0 versus 1.9%, p<0.001), than OA patients (Figure A). Lung and prostate cancer were similar between the two groups. Among 581 gout patients and 598 OA subjects with documented colonoscopies, the ten-year incidence of colon cancer was lower in gout patients than in patients with OA (0.8 versus 3.7%, p=0.0008) (Figure B). This difference in colon cancer incidence remained significant after accounting for NSAID and/or aspirin use. Among gout patients, the use of colchicine and/or allopurinol, as well as the presence or absence of concomitant of OA, did not appear to influence colon cancer prevalence. Differences in colon cancer incidence were significant between gout and OA patients undergoing diagnostic colonoscopy (0.5% in gout patients versus 4.6% in OA patients, p<0.001) but not those undergoing screening colonoscopy (0.9% in gout patients versus 1% in OA patients, p=1.0). No protective effect of gout was observed for prostate or lung cancer. Conclusion: Patients with gout had decreased physician-reported prevalence, and colonoscopy-documented incidence of colon cancer compared to patients with OA, suggesting a possible protective effect of gout or a goutassociated clinical, epidemiological or genetic factor. (Figure Presented)

The design of randomized controlled clinical studies can greatly benefit from iterative assessments of population representativeness of eligibility criteria. We propose a multi-trait metric - GIST 2.0 that can compute the a priori generalizability based on the population representativeness of a clinical study by explicitly modeling the dependencies among all eligibility criteria. We evaluate this metric on twenty clinical studies of two diseases and analyze how a study's eligibility criteria affect its generalizability (collectively and individually). We statistically analyze the effects of trial setting, trait selection and trait summarizing technique on GIST 2.0. Finally we provide theoretical as well as empirical validations for the expected properties of GIST 2.0.