Faculty Bibliography

BACKGROUND:Cancer incidence in exposed rescue/recovery workers (RRWs) and civilians (non-RRWs) was previously reported through 2008. METHODS:We studied occurrence of first primary cancer among World Trade Center Health Registry enrollees through 2011 using adjusted standardized incidence ratios (SIRs), and the WTC-exposure-cancer association, using Cox proportional hazards models. RESULTS:All-cancer SIR was 1.11 (95% confidence interval (CI) 1.03-1.20) in RRWs, and 1.08 (95% CI 1.02-1.15) in non-RRWs. Prostate cancer and skin melanoma were significantly elevated in both populations. Thyroid cancer was significantly elevated only in RRWs while breast cancer and non-Hodgkin's lymphoma were significantly elevated only in non-RRWs. There was a significant exposure dose-response for bladder cancer among RRWs, and for skin melanoma among non-RRWs. CONCLUSIONS:We observed excesses of total and specific cancers in both populations, although the strength of the evidence for causal relationships to WTC exposures is somewhat limited. Continued monitoring of this population is indicated. Am. J. Ind. Med. 59:709-721, 2016. © 2016 Wiley Periodicals, Inc.

BACKGROUND:Although airborne respiratory irritants at the World Trade Center (WTC) site have been associated with asthma among WTC Ground Zero workers, little is known about asthma associated with work at the Staten Island landfill or barges. METHODS:To evaluate the risk of asthma first diagnosed among Staten Island landfill and barge workers, we conducted a survey and multivariable logistic regression analysis regarding the association between Staten Island landfill and barge-related work exposures and the onset of post-9/11 asthma. RESULTS:Asthma newly diagnosed between September 11, 2001 and December 31, 2004 was reported by 100/1,836 (5.4%) enrollees. Jobs involving sifting, digging, welding, and steel cutting, enrollees with high landfill/barge exposure index scores or who were police and sanitation workers, and enrollees with probable posttraumatic stress disorder all had increased odds ratios for new-onset asthma. CONCLUSIONS:Post-9/11 asthma cumulative incidence among Staten Island landfill/barge workers was similar to that of other WTC disaster rescue and recovery workers. Am. J. Ind. Med. 59:795-804, 2016. © 2016 Wiley Periodicals, Inc.

BACKGROUND:Little is known about the direction of causality among asthma, posttraumatic stress disorder (PTSD), and onset of gastroesophageal reflux symptoms (GERS) after exposure to the 9/11/2001 World Trade Center (WTC) disaster. METHODS:Using data from the WTC Health Registry, we investigated the effects of early diagnosed post-9/11 asthma and PTSD on the late onset and persistence of GERS using log-binomial regression, and examined whether PTSD mediated the asthma-GERS association using structural equation modeling. RESULTS:Of 29,406 enrollees, 23% reported GERS at follow-up in 2011-2012. Early post-9/11 asthma and PTSD were each independently associated with both the persistence of GERS that was present at baseline and the development of GERS in persons without a prior history. PTSD mediated the association between early post-9/11 asthma and late-onset GERS. CONCLUSIONS:Clinicians should assess patients with post-9/11 GERS for comorbid asthma and PTSD, and plan medical care for these conditions in an integrated fashion. Am. J. Ind. Med. 59:805-814, 2016. © 2016 Wiley Periodicals, Inc.

OBJECTIVE: Friedreich ataxia (FRDA) is a progressive neurodegenerative disorder of adults and children. This study analyzed neurological outcomes and changes to identify predictors of progression and generate power calculations for clinical trials. METHODS: Eight hundred and twelve subjects in a natural history study were evaluated annually across 12 sites using the Friedreich Ataxia Rating Scale (FARS), 9-Hole Peg Test, Timed 25-Foot Walk, visual acuity tests, self-reported surveys and disability scales. Cross-sectional outcomes were assessed from recent visits, and longitudinal changes were gaged over 5 years from baseline. RESULTS: Cross-sectional outcomes correlated with measures of disease severity. Age, genetic severity (guanine-adenine-adenine [GAA] repeat length), and testing site predicted performance. Serial progression was relatively linear using FARS and composite measures of performance, while individual performance outcomes were nonlinear over time. Age strongly predicted change from baseline until removing the effects of baseline FARS scores, when GAA becomes a more important factor. Progression is fastest in younger subjects and subjects with longer GAA repeats. Improved coefficients of variation show that progression results are more reproducible over longer assessment durations. INTERPRETATION: While age predicted progression speed in simple analyses and may provide an effective way to stratify cohorts, separating the effects of age and genetic severity is difficult. Controlling for baseline severity, GAA is the major determinant of progression rate in FRDA. Clinical trials will benefit from enrollment of younger subjects, and sample size requirements will shrink with longer assessment periods. These findings should prove useful in devising gene therapy trials in the near future.

The Accreditation Council of Graduate Medical Education requires that residency programs teach and assess trainees in six core competencies. Assessments are imperative to determine trainee competence and to ensure that excellent care is provided to all patients. A structured, direct observation program is feasible for assessing nontechnical core competencies and providing trainees with immediate constructive feedback. Direct observation of residents in the outpatient setting by trained faculty allows assessment of each core competency. Checklists are used to document residents' basic communication skills, clinical reasoning, physical examination methods, and medical record keeping. Faculty concerns regarding residents' professionalism, medical knowledge, fatigue, or ability to self-assess are tracked. Serial observations allow for the reinforcement and/or monitoring of skills and attitudes identified as needing improvement. Residents who require additional coaching are identified early in training. Progress in educational milestones is recorded, allowing an individualized educational program that ensures that future orthopaedic surgeons excel across all domains of medical and surgical competence.

OBJECTIVES: Professionalism education is a vital component of surgical training. This research attempts to determine whether an annual, year-long professionalism curriculum in a large surgical residency can effectively change professionalism attitudes. SUMMARY OF BACKGROUND DATA: The ACGME mandated 6 competencies in 2003. The competencies of Professionalism and Interpersonal/Professional Communication Skills had never been formally addressed in surgical resident education in the past. METHODS: A professionalism curriculum was developed focusing on specific resident professionalism challenges: admitting mistakes, effective communication with colleagues at all levels, delivering the news of an unexpected death, interdisciplinary challenges of working as a team, the cultural challenge of obtaining informed consent through an interpreter, and the stress of surgical practice on you and your family. These professionalism skills were then evaluated with a 6-station Objective Structured Clinical Examination (OSCE). Identical OSCE scenarios were administered to 2 cohorts of surgical residents: in 2007 (before instituting the professionalism curriculum in 2008) and again in 2014. Surgical residents were rated by trained Standardized Patients according to a behaviorally anchored professionalism criteria checklist. RESULTS: An analysis of variance was conducted of overall OSCE professionalism scores (% well done) as the dependent variable for the 2 resident cohorts (2007 vs 2014). The 2007 residents received a mean score of 38% of professionalism items "well done" (SD 9%) and the 2014 residents received a mean 59% "well done" (SD 8%). This difference is significant (F = 49.01, P < .001). CONCLUSIONS: Professionalism education has improved surgical resident understanding, awareness, and practice of professionalism in a statistically significant manner from 2007 to 2014. This documented improvement in OSCE performance reflects the value of a professionalism curriculum in the care of the patients we seek to serve.

AIM: We sought to investigate the number of US medical schools utilizing portfolios, the format of portfolios, information technology (IT) innovations, purpose of portfolios and their ability to engage faculty and students. METHODS: A 21-question survey regarding portfolios was sent to the 141 LCME-accredited, US medical schools. The response rate was 50% (71/141); 47% of respondents (33/71) reported that their medical school used portfolios in some form. Of those, 7% reported the use of paper-based portfolios and 76% use electronic portfolios. Forty-five percent reported portfolio use for formative evaluation only; 48% for both formative and summative evaluation, and 3% for summative evaluation alone. RESULTS: Seventy-two percent developed a longitudinal, competency-based portfolio. The most common feature of portfolios was reflective writing (79%). Seventy-three percent allow access to the portfolio off-campus, 58% allow usage of tablets and mobile devices, and 9% involve social media within the portfolio. Eighty percent and 69% agreed that the portfolio engaged students and faculty, respectively. Ninety-seven percent reported that the portfolios used at their institution have room for improvement. CONCLUSION: While there is significant variation in the purpose and structure of portfolios in the medical schools surveyed, most schools using portfolios reported a high level of engagement with students and faculty.

AIM/OBJECTIVE:Using a population-based, cross-sectional design, we aimed to assess whether the presence of calcifications in the carotid siphon (as seen on computed tomography) is associated with silent markers of cerebral small vessel disease (on magnetic resonance imaging) in apparently healthy older adults living in Atahualpa, a rural Ecuadorian village. METHODS:Stroke-free Atahualpa residents aged ≥60 years identified during a door-to-door survey underwent head computed tomography for assessment of carotid siphon calcifications, and brain magnetic resonance imaging for identification of white matter hyperintensities and silent lacunar infarcts. We evaluated the association between calcifications and markers of small vessel disease using logistic regression models adjusted for demographics and cardiovascular risk factors. RESULTS:The mean age of the 236 participants was 71 ± 8 years, and 139 (59%) were women. Computed tomography readings showed high calcium content in the carotid siphon in 64 individuals (27%), and magnetic resonance imaging showed moderate-to-severe white matter hyperintensities in 51 (30%) and lacunar infarcts in 28 (12%). In the univariate analysis, individuals with high calcium content were older and were more likely to have high fasting glucose levels than those with low calcium content. After adjusting for confounding variables, we found an independent association between high calcium content in the carotid siphon and moderate-to-severe white matter hyperintensities (OR 2.3, 95% CI 1.1-4.9, P = 0.035) as well as lacunar infarcts (OR 3.1, 95% CI 1.3-7.6, P = 0.013). CONCLUSIONS:The present study shows a direct relationship between calcium content in the carotid siphon and silent small vessel disease in an indigenous Latin American population. Geriatr Gerontol Int 2016; 16: 1063-1067.

BACKGROUND: Studies report variability in the rates and causes of isolation errors among in-patients with active tuberculosis (TB). We reviewed our experience with delays or premature discontinuation of airborne infection isolation (AII). METHODS: Medical records of patients admitted to the Bellevue Hospital Center, New York City Health & Hospitals, New York, NY, USA, between January 2006 and July 2012 with a positive respiratory culture for Mycobacterium tuberculosis were reviewed. Patients who were out of AII despite being infectious were identified, as the episodes had prompted a contact investigation. RESULTS: Of 246 admissions with positive respiratory cultures, 35 AII errors were identified among 27 patients. Most patients had signs or symptoms of TB on admission. Only four patients had positive sputum smears. In 16 (46%) episodes, the patients had never been isolated, 11 (31%) had delayed isolation, and 8 (23%) were prematurely taken off AII. The most common reasons for patients being off AII while infectious were an incorrect alternative diagnosis (15/35, 43%) or a dual diagnosis (9/35, 26%). CONCLUSIONS: Particularly in smear-negative cases, AII errors due to TB may occur when providers conclude that another diagnosis explains their findings. In many cases, that diagnosis is correct, but TB is also present. This error rate might be a useful quality indicator.