Faculty Bibliography

The association between cigarette smoking and mortality from hepatocellular carcinoma (HCC) is ambiguous. We analyzed the association between smoking and mortality in HCC patients seen at our center. We collected data retrospectively on patients diagnosed with HCC between 2002 and 2009. We estimated the association of smoking history with demographic, clinical and treatment factors. We then modeled these factors as predictors of mortality. Among smokers, we analyzed the effects of pack-year history and cessation times on survival. Two hundred and twenty-three out of 444 patients with HCC had a history of smoking. Smokers were more likely to be younger at diagnosis, to have alpha fetoprotein (AFP) values less than the median, and to have had surgery (p=0.04) compared to non-smokers. In a Cox model, younger age, lower AFP and Child's Class were all independently predictive of survival, but smoking was not. Smokers with over 20 pack-years did not have worse survival than lighter smokers, and cessation times also did not affect survival after controlling for age. We found a significant interaction between smoking and drinking. In our data, smoking was not independently associated with HCC survival in a multivariable model. Smoking was associated with favorable prognostic features which likely outweighed any independent effect of smoking.

Benjamin Chu, M.D., sees system change from the patient's perspective.

Evidence on the relationship between political contributions and legislators' voting behavior is marred by concerns about endogeneity in the estimation process. Using a legislator's offspring sex mix as a truly exogenous variable, we employ an instrumental variable estimation procedure to predict the effect of voting behavior on political contributions. Following previous research, we find that a legislator's proportion daughters has a significant effect on voting behavior for women's issues, as measured by score in the "Congressional Record on Choice" issued by NARAL Pro-Choice America. In the second stage, we make a unique contribution by demonstrating a significant impact of exogenous voting behavior on PAC contributions, lending further credibility to the hypothesis that Political Action Committees respond to legislators' voting patterns by "rewarding" political candidates that vote in line with the positions of the PAC, rather than affecting those same votes - at least in this high-profile policy domain.

OBJECTIVE:Active Cushing's syndrome (CS) is associated with cardiomyopathy, characterized by myocardial structural, and ultrastructural abnormalities. The extent of myocardial fibrosis in patients with CS has not been previously evaluated. Therefore, the objective of this study was to assess myocardial fibrosis in CS patients, its relationship with left ventricular (LV) hypertrophy and function, and its reversibility after surgical treatment. DESIGN AND METHODS/METHODS:Fifteen consecutive CS patients (41±12 years) were studied together with 30 hypertensive (HT) patients (matched for LV hypertrophy) and 30 healthy subjects. Echocardiography was performed in all patients including i) LV systolic function assessment by conventional measures and by speckle tracking-derived global longitudinal strain, ii) LV diastolic function assessment using E/E', and iii) myocardial fibrosis assessment using calibrated integrated backscatter (IBS). Echocardiography was repeated after normalization of cortisol secretion (14±3 months). RESULTS:CS patients showed the highest value of calibrated IBS (-15.1±2.5  dB) compared with HT patients (-20.0±2.6  dB, P<0.01) and controls (-23.8±2.4  dB, P<0.01), indicating increased myocardial fibrosis independent of LV hypertrophy. Moreover, calibrated IBS in CS patients was significantly related to both diastolic function (E/E', r=0.79, P<0.01) and systolic function (global longitudinal strain, r=0.60, P=0.02). After successful surgical treatment, calibrated IBS normalized (-21.0±3.8 vs -15.1±2.5  dB, P<0.01), suggestive of regression of myocardial fibrosis. CONCLUSIONS:Patients with CS have increased myocardial fibrosis, which is related to LV systolic and diastolic dysfunction. Successful treatment of CS normalizes the extent of myocardial fibrosis. Therefore, myocardial fibrosis appears to be an important factor in the development and potential regression of CS cardiomyopathy.

Barriers to blood pressure control exist at the patient, physician, and system levels. We review the current evidence for interventions that target patient- and physician-related barriers, such as patient education, home blood pressure monitoring, and computerized decision-support systems for physicians, and we emphasize the need for more studies that address the effectiveness of these interventions in African American patients

OBJECTIVES: The objective of this study was to compare the Pelvic Organ Prolapse Quantification (POPQ) system teaching practices among obstetrics/gynecology (ob/gyn) and urology residents in the United States. METHODS: Anonymous Web-based survey was e-mailed to the residency program directors/coordinators of all urology and ob/gyn programs in the United States with a request to forward it to all their residents. Fisher exact and z tests for proportions and multivariate regression analysis examining factors associated with POPQ system use were used in the statistical analysis. RESULTS: Sixty percent (45/75) of urology and 78.9% (105/133) of responding ob/gyn residents (P = 0.006) reported having used the POPQ system, whereas 42.7% and 59.4% of them, respectively, reported current use (P = 0.03). The latter also reported more protected educational time (P < 0.001), more urogynecologists in their programs (P = 0.032), and learning more frequently from drawings (P = 0.025). Opinions about the routine clinical and scientific usefulness of POPQ system and the perceived difficulty in learning it did not vary between groups. After performing multivariate logistic regression analysis, the presence of a fellowship, the number of subspecialists in the program, and the number of POPQ system teaching sessions were the studied variables found to contribute independently to the residents' use of that system. CONCLUSIONS: Obstetrics/gynecology residents use POPQ system more frequently than do urology residents. This could be related to differences in teaching practices between urology and ob/gyn programs.

BACKGROUND: To determine whether a 'lay' rater could assess clinical reasoning, interrater reliability was measured between physician and lay raters of patient notes written by medical students as part of an 8-station objective structured clinical examination. METHODS: Seventy-five notes were rated on core elements of clinical reasoning by physician and lay raters independently, using a scoring guide developed by physician consensus. Twenty-five notes were rerated by a 2nd physician rater as an expert control. Kappa statistics and simple percentage agreement were calculated in 3 areas: evidence for and against each diagnosis and diagnostic workup. RESULTS: Agreement between physician and lay raters for the top diagnosis was as follows: supporting evidence, 89% (kappa = .72); evidence against, 89% (kappa = .81); and diagnostic workup, 79% (kappa = .58). Physician rater agreement was 83% (kappa = .59), 92% (kappa = .87), and 96% (kappa = .87), respectively. CONCLUSIONS: Using a comprehensive scoring guide, interrater reliability for physician and lay raters was comparable with reliability between 2 expert physician raters

BACKGROUND: Teaching professionalism effectively to fully engaged residents is a significant challenge. A key question is whether the integration of professionalism into residency education leads to a change in resident culture. METHODS: The goal of this study was to assess whether professionalism has taken root in the surgical resident culture 3 years after implementing our professionalism curriculum. Evidence was derived from 3 studies: (1) annual self-assessments of the residents' perceived professionalism abilities to perform 20 defined tasks representing core Accrediting Council on Graduate Medical Education professionalism domains, (2) objective metrics of their demonstrated professionalism skills as rated by standardized patients annually using the objective structure clinical examination tool, and (3) a national survey of the Surgical Professionalism and Interpersonal Communications Education Study Group. RESULTS: Study 1: aggregate perceived professionalism among surgical residents shows a statistically significant positive trend over time (P = .016). Improvements were seen in all 6 domains: accountability, ethics, altruism, excellence, patient sensitivity, and respect. Study 2: the cohort of residents followed up over 3 years showed a marked improvement in their professionalism skills as rated by standardized patients using the objective structure clinical examination tool. Study 3: 41 members of the national Surgical Professionalism and Interpersonal Communications Education Study Group rated their residents' skills in admitting mistakes, delivering bad news, communication, interdisciplinary respect, cultural competence, and handling stress. Twenty-nine of the 41 responses rated their residents as 'slightly better' or 'much better' compared with 5 years ago (P = .001). Thirty-four of the 41 programs characterized their department's leadership view toward professionalism as 'much better' compared with 5 years ago. CONCLUSIONS: All 3 assessment methods suggest that residents feel increasingly prepared to effectively deal with the professionalism challenges they face. Although professionalism seminars may have seemed like an oddity several years ago, residents today recognize their importance and value their professionalism skills. As importantly, department chairpersons report that formal professionalism education for residents is viewed more favorably compared with 5 years ago