Faculty Bibliography

BACKGROUND: Inpatient dysglycemia is associated with increased morbidity, mortality and cost. Medical education must not only address knowledge gaps, but also improve clinical care. METHODS: All 129 medicine residents at a large academic medical center were offered a case-based online curriculum on the management of inpatient dysglycemia in the fall of 2009. First-year residents took a 3-h course with 10 modules. Second and third-year residents, who had been educated the prior year, underwent abbreviated training. All residents were offered a 20-min refresher course in the spring of 2009. We assessed resident knowledge, resident confidence, and patient glycemia on two teaching wards before and after the initial intervention, as well as after the refresher course. RESULTS: A total of 117 residents (91%) completed the initial training; 299 analyzed admissions generated 11, 089 blood glucose values and 4799 event blood glucose values. Admissions with target glycemia increased from 19.4% to 33.0% (P = 0.035) by the end of the curriculum. There was a strong downward trend in hyperglycemia from 22.4% to 11.3% (P = 0.055) without increased hypoglycemia. Confidence and knowledge increased significantly among first-time and repeat participants. Residents rated the intervention as highly relevant to their practice and technologically well implemented. CONCLUSION: Optimization of an online curriculum covering the management of inpatient glycemia over the course of 2 years led to significantly more admissions in the target glycemia range. Given its scalability, modularity and applicability, this web-based educational intervention may become the standard curriculum for the management of inpatient glycemia.

Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder with skeletal involvement. It is caused by mutations in fibrillin1 (FBN1) gene resulting in activation of TGF-beta, which developmentally regulates bone mass and matrix properties. There is no consensus regarding bone mineralization in children with MFS. Using dual-energy X-ray absorptiometry (DXA), we evaluated bone mineralization in 20 children with MFS unselected for bone problems. z-Scores were calculated based on age, gender, height, and ethnicity matched controls. Mean whole body bone mineral content (BMC) z-score was 0.26+/-1.42 (P=0.41). Mean bone mineral density (BMD) z-score for whole body was -0.34+/-1.4 (P=0.29) and lumbar spine was reduced at -0.55+/-1.34 (P=0.017). On further adjusting for stature, which is usually higher in MFS, mean BMC z-score was reduced at -0.677+/-1.37 (P=0.04), mean BMD z-score for whole body was -0.82+/-1.55 (P=0.002) and for lumbar spine was -0.83+/-1.32 (P=0.001). An increased risk of osteoporosis in MFS is controversial. DXA has limitations in large skeletons because it tends to overestimate BMD and BMC. By adjusting results for height, age, gender, and ethnicity, we found that MFS patients have significantly lower BMC and BMD in whole body and lumbar spine. Evaluation of diet, exercise, vitamin D status, and bone turnover markers will help gain insight into pathogenesis of the reduced bone mass. Further, larger longitudinal studies are required to evaluate the natural history, incidence of fractures, and effects of pharmacological therapy.

IGF-I shares structural homology and in vitro metabolic activity with insulin. Laboratory models suggest that IGF-I and its binding proteins IGFBP-1 and IGFBP-2 have potentially beneficial effects on diabetes risk, whereas IGFBP-3 may have adverse effects. We therefore conducted a prospective nested case-control investigation of incident diabetes (n = 742 case subjects matched 1:1 to control subjects) and its associations with IGF-axis protein levels in the Nurses' Health Study, a cohort of middle-aged women. The median time to diabetes was 9 years. Statistical analyses were adjusted for multiple risk factors, including insulin and C-reactive protein. Diabetes risk was fivefold lower among women with baseline IGFBP-2 levels in the top versus bottom quintile (odds ratio [OR](q5-q1) = 0.17 [95% CI 0.08-0.35]; P trend < 0.0001) and was also negatively associated with IGFBP-1 levels (OR(q5-q1) = 0.37 [0.18-0.73]; P trend = 0.0009). IGFBP-3 was positively associated with diabetes (OR(q5-q1) = 2.05 [1.20-3.51]; P trend = 0.002). Diabetes was not associated with total IGF-I levels, but free IGF-I and diabetes had a significant association that varied (P interaction = 0.003) by insulin levels above the median (OR(q5-q1) = 0.48 [0.26-0.90]; P trend = 0.0001) versus below the median (OR(q5-q1) = 2.52 [1.05-6.06]; P trend < 0.05). Thus, this prospective study found strong associations of incident diabetes with baseline levels of three IGFBPs and free IGF-I, consistent with hypotheses that the IGF axis might influence diabetes risk.

Abstract Background and Purpose: Noncontrast abdominal/pelvic CT is the current imaging standard for patients who present with acute urinary colic. Conventional CT, however, exposes the patient to significant amounts of ionizing radiation, which is cumulative when additional CTs are used to monitor stone migration, outcomes, etc. We sought to maintain diagnostic adequacy while decreasing our patients' radiation exposure from CT by using a reduced tube current, an abbreviated scanning area, and the use of coronal reformatted images. Patients and Methods: Between March 3, 2011 and October 31, 2011, 101 consecutive adult patients with suspected urinary colic were evaluated with a "low" dose CT. If the suspected calculus(i) was not seen, the patient underwent immediate conventional CT imaging customized to their body habitus. Radiation exposure for each patient was calculated using an established formula of dose length product and scan length. The effective total radiation dose was measured in millisieverts (mSv). Results: Overall, 84 patients had an upper tract calculus(i) consistent with the clinical suspicion. Of these, 76 (90%) were adequately imaged with low dose and 8 (10%) with conventional noncontrast CTs. The mean effective radiation dose in the 76 low dose stone-positive CTs was 2.14 mSV (median 2.10 mSv). This was almost seven-fold lower than the mean conventional stone-positive CT dose of 14.5 mSv (median 13.1 mSv). Conclusions: Low dose noncontrast CT provided adequate imaging to guide optimal urologic management in the majority of our patients. This modality offered a significantly lower ionizing radiation dose and should be considered in patients who present with acute urinary colic.

Since 2009, a multidisciplinary team at Weill Cornell Medical College (WCMC) has collaborated to create a comprehensive, elective global health curriculum (GHC) for medical students. Increasing student interest sparked the development of this program, which has grown from ad hoc lectures and dispersed international electives into a comprehensive four-year elective pathway with over 100 hours of training, including three courses, two international experiences, a preceptorship with a clinician working with underserved populations in New York City, and regular lectures and seminars by visiting global health leaders. Student and administrative enthusiasm has been strong: In academic years 2009, 2010, and 2011, over half of the first-year students (173 of 311)participated in some aspect of the GHC, and 18% (55 of 311) completed all first-year program requirements.The authors cite the student-driven nature of GHC as a major factor in its success and rapid growth. Also important was the foundation previously established by WCMC global health faculty, the serendipitous timing of the GHC's development in the midst of curricular reform and review, as well as the presence of a full-time, nonclinical Global Health Fellow who served as a program coordinator. Given the enormous expansion of medical student interest in global health training throughout the United States and Canada over the past decade, the authors hope that medical schools developing similar programs will find the experience at Weill Cornell informative and helpful.

The general purpose of Antidote is to compensate when the media vilifies a good drug. This time the author wants to take on a test -- the Prostate Specific Antigen (PSA). The test is best diagnostic tool for prostate cancer, and a large part of the reason that death from prostate cancer has declined. Since prostate cancer is almost always asymptomatic, with over 200,000 new cases and 30,000 deaths in the US every year, the next test after the PSA to diagnose it is the autopsy

BACKGROUND: Assessing left ventricular function is a common indication for echocardiography. It generally requires expert echocardiographer estimation and is somewhat subjective and prone to reader discordance. Mitral annular plane systolic excursion (MAPSE) has been suggested as a surrogate measurement for left ventricular function. The aim of this study was to examine the accuracy of MAPSE for predicting left ventricular ejection fraction (EF) on the basis of a large cohort of consecutive echocardiograms. METHODS: The study design was a retrospective analysis of 600 two-dimensional echocardiographic studies performed in a single laboratory. MAPSE measurement was performed by an untrained observer and compared with the EF as determined by an expert echocardiographer. The first 300 studies served as a calibration cohort to establish an algorithm for predicting EF on the basis of MAPSE measurement. The following 300 studies served as a verification cohort to test the accuracy of the established algorithm. RESULTS: Using the first 300 studies, an algorithm was developed to predict EF. Cutoff values for normal EF (>/=11 mm for women and >/=13 mm for men) and severely reduced EF (<6 mm for men and women) were identified. For the intermediate-range MAPSE values, a gender-specific regression equation was calculated to generate a predicted EF. Using this algorithm, predicted EFs were determined for the 300 patients in the verification cohort. By comparing the predicted EF and the expert-reported EF, positive and negative predictive values, sensitivity (73%-92%), specificity (81%-100%), and accuracy (82%-86%) of MAPSE for predicting EF were calculated. CONCLUSIONS: MAPSE measurement by an untrained observer was found to be a highly accurate predictor of EF.

Abstract Although recent studies report a high prevalence of vitamin D deficiency in HIV-infected adults similar to that in the general population, metabolic complications of vitamin D deficiency may be worsened with HIV infection and remain insufficiently characterized. We conducted a retrospective cross-sectional cohort study to determine prevalence and correlates of vitamin D deficiency and hyperparathyroidism among HIV-infected patients attending an urban clinic. Vitamin D deficiency was defined as 25(OH)-vitamin D <20 ng/ml and insufficiency as 20 to <30 ng/ml, and hyperparathyroidism as parathyroid-hormone >65 pg/ml. We used the X(2) test to compare proportions and logistic regression to assess for associations. Among 463 HIV-infected patients, the prevalence of vitamin D deficiency was 59%. The prevalence of hyperparathyroidism was 30% among patients with vitamin D deficiency, 23% among those with insufficiency, and 12% among those with sufficient vitamin D levels. Vitamin D deficiency was associated with increased odds of hyperparathyroidism. Severe vitamin D deficiency was associated with elevated alkaline phosphatase, a marker for increased bone turnover. Although efavirenz use was associated with vitamin D deficiency, and protease inhibitor use with decreased odds of vitamin D deficiency, there was no statistical difference in rates of hyperparathyroidism stratified by combination antiretroviral therapy (cART) use. Given the increased risk of osteopenia with HIV infection and cART use, vitamin D supplementation for all HIV-infected patients on cART should be prescribed in accordance with the 2011 Endocrine Society guidelines. In HIV-infected patients with severe vitamin D deficiency or hyperparathyroidism, screening for osteomalacia and osteopenia may be warranted.

OBJECTIVE:To assess veterans' health communication preferences (in-person, telephone, or electronic) for primary care needs and the impact of computer use on preferences. METHODS:Structured patient interviews (n=448). Bivariate analyses examined preferences for primary care by 'infrequent' vs. 'regular' computer users. RESULTS:Only 54% were regular computer users, nearly all of whom had ever used the internet. 'Telephone' was preferred for 6 of 10 reasons (general medical questions, medication questions and refills, preventive care reminders, scheduling, and test results); although telephone was preferred by markedly fewer regular computer users. 'In-person' was preferred for new/ongoing conditions/symptoms, treatment instructions, and next care steps; these preferences were unaffected by computer use frequency. Among regular computer users, 1/3 preferred 'electronic' for preventive reminders (37%), test results (34%), and refills (32%). CONCLUSION/CONCLUSIONS:For most primary care needs, telephone communication was preferred, although by a greater proportion of infrequent vs. regular computer users. In-person communication was preferred for reasons that may require an exam or visual instructions. About 1/3 of regular computer users prefer electronic communication for routine needs, e.g., preventive reminders, test results, and refills. PRACTICE IMPLICATIONS/CONCLUSIONS:These findings can be used to plan patient-centered care that is aligned with veterans' preferred health communication methods.