Faculty Bibliography

Background: Transradial cardiac catheterization reduces bleeding compared with femoral access, but the initial arterial cannulation can be difficult due to weak pulses, hypotension, calcification, obesity or peripheral vascular disease. Multiple attempts at access may increase the time required, patient discomfort, risk of arterial spasm, and the need for cross-over to other access sites. Ultrasound (US) guidance has been demonstrated to facilitate vascular access and reduce vascular complications in multiple sites and locations, but has not been tested in a multicenter fashion in transradial access. Methods: We conducted a multicenter randomized controlled trial of 473 patients undergoing transradial cardiac catheterization. Four centers (6 hospitals) and 16 operators trained in US guidance participated in the study. Patients were randomized to needle insertion with either palpation (P) or real-time US guidance (237 P, 236 US). Primary endpoints were the number of forward attempts required for access, first pass success rate, and time to sheath insertion. Results: The mean number of attempts was reduced with US guidance (1.65 +/- 1.2 vs. 3.05 +/- 3.4, p< 0.0001) and the first pass success rate improved (64.8% vs. 43.9%, p< 0.0001). The mean time to sheath insertion was reduced (83 +/- 78 vs. 113 +/- 124 seconds, p=0.0016) as was the median time to insertion (60 [IQR 42-91] vs. 75 [50-119], p<0.005). Ten patients in the control group required cross-over to US guidance after 5 minutes of failed palpation attempts with 9/10 (90%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (6 vs. 44 for > 5 attempts, p <0.001; 6 vs. 15 for > 5min, p=0.07). There was no significant difference in the rate of operatorreported spasm (4.2% P vs. 5.5% US, p=0.53), crossover to other access sites (2.5% P vs. 1.3% US, p=0.34), mean patient pain scores (range 0-10) following the procedure (0.82 P vs. 0.89 US, p=0.29), or bleeding complications (1.7% !

BACKGROUND: A cohort study found that 9/11-related environmental exposures and posttraumatic stress disorder increased self-reported cardiovascular disease risk. We attempted to replicate these findings using objectively defined cardiovascular disease hospitalizations in the same cohort. METHODS AND RESULTS: Data for adult World Trade Center Health Registry enrollees residing in New York State on enrollment and no cardiovascular disease history (n = 46,346) were linked to a New York State hospital discharge-reporting system. Follow-up began at Registry enrollment (2003-2004) and ended at the first cerebrovascular or heart disease (HD) hospitalization, death, or December 31, 2010, whichever was earliest. We used proportional hazards models to estimate adjusted hazard ratios (AHRs) for HD (n = 1151) and cerebrovascular disease (n = 284) hospitalization during 302,742 person-years of observation (mean follow-up, 6.5 years per person), accounting for other factors including age, race/ethnicity, smoking, and diabetes. An elevated risk of HD hospitalization was observed among women (AHR 1.32, 95% CI 1.01 to 1.71) but not men (AHR 1.16, 95% CI 0.97 to 1.40) with posttraumatic stress disorder at enrollment. A high overall level of World Trade Center rescue and recovery-related exposure was associated with an elevated HD hospitalization risk in men (AHR 1.82, 95% CI 1.06 to 3.13; P for trend = 0.05), but findings in women were inconclusive (AHR 3.29, 95% CI 0.85 to 12.69; P for trend = 0.09). Similar associations were observed specifically with coronary artery disease hospitalization. Posttraumatic stress disorder increased the cerebrovascular disease hospitalization risk in men but not in women. CONCLUSIONS: 9/11-related exposures and posttraumatic stress disorder appeared to increase the risk of subsequent hospitalization for HD and cerebrovascular disease. This is consistent with findings based on self-reported outcomes.

IMPORTANCE/OBJECTIVE:The conflicting recommendations for prostate cancer (PCa) screening and the mixed messages communicated to the public about screening effectiveness make it critical to assist men in making informed decisions. OBJECTIVE:To assess the effectiveness of 2 decision aids in helping men make informed PCa screening decisions. DESIGN, SETTING, AND PARTICIPANTS/METHODS:A racially diverse group of male outpatients aged 45 to 70 years from 3 sites were interviewed by telephone at baseline, 1 month, and 13 months, from 2007 through 2011. We conducted intention-to-treat univariate analyses and multivariable linear and logistic regression analyses, adjusting for baseline outcome measures. INTERVENTION/METHODS:Random assignment to print-based decision aid (n = 628), web-based interactive decision aid (n = 625), or usual care (UC) (n = 626). MAIN OUTCOMES AND MEASURES/METHODS:Prostate cancer knowledge, decisional conflict, decisional satisfaction, and whether participants underwent PCa screening. RESULTS:Of 4794 eligible men approached, 1893 were randomized. At each follow-up assessment, univariate and multivariable analyses indicated that both decision aids resulted in significantly improved PCa knowledge and reduced decisional conflict compared with UC (all P <.001). At 1 month, the standardized mean difference (Cohen’s d) in knowledge for the web group vs UC was 0.74, and in the print group vs UC, 0.73. Decisional conflict was significantly lower for web vs UC (d = 0.33) and print vs UC (d = 0.36). At 13 months, these differences were smaller but remained significant. At 1 month, high satisfaction was reported by significantly more print (60.4%) than web participants (52.2%; P = .009) and significantly more web (P = .001) and print (P = .03) than UC participants (45.5%). At 13 months, differences in the proportion reporting high satisfaction among print (55.7%) compared with UC (49.8%; P = .06) and web participants (50.4%; P = .10) were not significant. Screening rates at 13 months did not differ significantly among groups. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Both decision aids improved participants’ informed decision making about PCa screening up to 13 months later but did not affect actual screening rates. Dissemination of these decision aids may be a valuable public health tool. TRIAL REGISTRATION/BACKGROUND:clinicaltrials.gov Identifier: NCT00196807.

Nonalcoholic fatty liver disease (NAFLD) is an emerging global health concern. It is the most common form of chronic liver disease in Western countries, affecting both adults and children. NAFLD encompasses a broad spectrum of fatty liver disease, ranging from simple steatosis (NAFL) to nonalcoholic steatohepatitis (NASH), and is strongly associated with obesity, insulin resistance, and dyslipidemia. First-line therapy for NAFLD includes weight loss achieved through diet and physical activity. However, there is a lack of evidenced-based dietary recommendations. The American Diabetes Association's (ADA) recommendations that aim to reduce the risk of diabetes and cardiovascular disease may also be applicable to the NAFLD population. The objectives of this review are to: (1) provide an overview of NAFLD in the context of insulin resistance, and (2) provide a rationale for applying relevant aspects of the ADA recommendations to the nutritional management of NAFLD.