Faculty Bibliography

The effect of dietary isoflavone intake on systolic blood pressure (SBP) has not been studied in a large community-based cohort inclusive of African Americans. The authors analyzed data from the year 20 examination of the Coronary Artery Risk Development in Young Adults (CARDIA) study, including medical history, physical examination, and dietary intake surveys for 3142 participants. Multivariable linear regression models controlled for age, sex, body mass index, smoking, physical activity, and intakes of alcohol and total energy. Effect modification by race was tested. Overall, patients with hypertension had a lower daily intake of total dietary isoflavones (2.2±5.2 mg/d vs 4.1±11.7 mg/d; P<.001). In fully adjusted models, the highest quartile of dietary isoflavone intake was associated with a 4.4 mm Hg lower SBP on average compared with SBP for the lowest quartile. The relationship between dietary isoflavone intake and SBP was more pronounced among African Americans compared with Caucasians (P for interaction <.001). Greater dietary intake of isoflavones was independently associated with a lower SBP.

BACKGROUND:Promoting use of community trails is a recommended strategy for increasing population levels of physical activity. Correlates of walking and cycling for recreation or transportation differ, though few studies have compared correlates of trail-based physical activity for recreation and transportation purposes. This study examined associations of demographic, social, and perceived built environmental factors with trail use for recreation and transportation and whether associations were moderated by age, gender, and prior trail use. METHODS:Adults (N = 1195) using 1 of 5 trails in Massachusetts responded to an intercept survey. We used multiple linear and logistic regression models to examine associations with trail use. RESULTS:Respondents' mean age was 44.9 years (standard deviation = 12.5), 55.3% were female, and 82.0% were white. Age (longer-term users only), trail use with others, travel time to the trail, and trail design were significantly associated with use for recreation (P < .05). Age, gender, trail safety (longer-term users only), travel time to the trail, trail design (younger users only), and trail beauty were associated with use for transportation (P < .05). CONCLUSIONS:Some common correlates were found for recreational and transportation trail use, whereas some variables were uniquely associated with use for 1 purpose. Tailored strategies are suggested to promote trail use for recreation and transportation.

BACKGROUND:Oily fish is a major dietary source of omega-3 polyunsaturated fatty acids (ω-3 PUFAs). These nutrients improve endothelial dysfunction, reduce β-amyloid induced damage of neurovascular units, and might prevent the occurrence of cerebral microbleeds. However, this relationship has not been investigated so far. AIM/OBJECTIVE:To evaluate the association between oily fish intake and cerebral microbleeds in a population of frequent fish consumers living in coastal Ecuador. METHODS:Cerebral microbleeds were identified by gradient-echo MRI and oily fish consumption was calculated in community-dwellers aged ≥60 years enrolled in the Atahualpa Project. The association between cerebral microbleeds and fish servings was examined in regression models adjusted for relevant confounders. A predictive model was constructed using quintiles of fish servings to take into account the non-linearity in the relationship. RESULTS:Out of 311 eligible individuals, 293 (94 %) were enrolled. Cerebral microbleeds were recognized in 37 (13 %) individuals. Mean fish consumption was 8.8 ± 5.4 servings per week (ω-3 PUFAs estimates: 10.2 ± 7.1 g). Multivariate analysis showed an inverse relationship between cerebral microbleeds and fish consumption (p < 0.001). Predictive margins of CMB were higher for individuals in the lowest (≤4.3) than for those in the highest (≥13.1) quintile of fish servings (17.4 vs 2.3 %, p < 0.001). CONCLUSIONS:This study shows a lower cerebral microbleed presence among older adults eating large amounts of oily fish (13 servings per week, equivalent to about 15 g of ω-3 PUFAs). These high requirements can be more readily accomplished in other populations by taking fish oil preparations. Longitudinal studies are warranted to assess whether these interventions reduce incident cerebral microbleeds in high-risk individuals.

Patients with non-valvular atrial fibrillation (AF) have an elevated stroke risk that is 2-7 times greater than in those without AF. Intravenous unfractionated heparin (UFH) is commonly used for hospitalized patients with atrial fibrillation and atrial flutter (AFL) to prevent stroke. Dosing strategies exist for intravenous anticoagulation in patients with acute coronary syndromes and venous thromboembolic diseases, but there are no data to guide providers on a dosing strategy for intravenous anticoagulation in patients with AF/AFL. 996 hospitalized patients with AF/AFL on UFH were evaluated. Bolus dosing and initial infusion rates of UFH were recorded along with rates of stroke, thromboemobolic events, and bleeding events as defined by the International Society on Thrombosis and Haemostasis criteria. Among 226 patients included in the analysis, 76 bleeding events occurred. Using linear regression analysis, initial rates of heparin infusion ranging from 9.7 to 11.8 units/kilogram/hour (U/kg/h) resulted in activated partial thromboplastin times that were within therapeutic range. The median initial infusion rate in patients with bleeding was 13.3 U/kg/h, while in those without bleeding it was 11.4 U/kg/h; p = 0.012. An initial infusion rate >11.0 U/kg/h yielded an OR 1.95 (1.06-3.59); p = 0.03 for any bleeding event. Using IV heparin boluses neither increased the probability of attaining a therapeutic aPTT (56.1 vs 56.3 %; p = 0.99) nor did it significantly increase bleeding events in the study (35.7 vs 31.3 %; p = 0.48). The results suggest that higher initial rates of heparin are associated with increased bleeding risk. From this dataset, initial heparin infusion rates of 9.7-11.0 U/kg/h without a bolus can result in therapeutic levels of anticoagulation in hospitalized patients with AF/AFL without increasing the risk of bleeding.

Remediation in medical education, the process of facilitating corrections for physician trainees who are not on course to competence, predictably consumes significant institutional resources. Although remediation is a logical consequence of mandating, measuring, and reporting clinical competence, many program leaders continue to take an unstructured approach toward organizing effective, efficient plans for struggling trainees, almost all of who will become practicing physicians. The following 12 tips derive from a decade of remediation experience at each of the authors' three institutions. It is informed by the input of a group of 34 interdisciplinary North American experts assembled to contribute two books on the subject. We intend this summary to guide program leaders to build better remediation systems and emphasize that developing such systems is an important step toward enabling the transition from time-based to competency-based medical education.

The deployment of health information technologies promises to optimize clinical outcomes for populations with substance use disorders. Electronic health records, web-based counseling interventions, and mobile phone applications enhance the delivery of evidence-based behavioral and pharmacological treatments, with minimal burden to clinical personnel, infrastructure, and work flows. This clinical case shares a recent experience utilizing mobile phone text messaging between an office-based buprenorphine provider in a safety net ambulatory clinic and a patient seeking buprenorphine treatment for opioid use disorder. The case highlights the use of text message-based physician-patient communication to facilitate unobserved "home" induction onto buprenorphine.

"What's your specialty?" That's the question people always ask, as soon as they learn that you are a doctor