Faculty Bibliography

Most medical organizations recommend informed decision making before undergoing prostate cancer screening. The authors conducted a detailed evaluation of men's use of an interactive, Web-based prostate cancer screening decision aid. Participants (N = 531) were 57 years old (SD = 6.8), 37% were African American, and 92% had Internet access. Men completed 2 telephone interviews, pre- and 1-month post-Web site availability. Half of the sample (n = 256) accessed the Web site. Multivariate analysis revealed that users were more likely than nonusers to be White (OR = 2.37, CI 1.6-3.6), previously screened (OR = 2.13, CI 1.07-4.26), have Internet access (OR = 3.66, CI 1.15-11.58), and to report daily Internet use (OR = 2.58, CI 1.47-4.55). Agreement between self-reported and actual Web site use was moderate (kappa = .67). Tracking software revealed a mean of 1.3 (SD = 0.5) log-ons and a median of 38 min per log-on. Of participants, 84% used the values clarification tool, and more than 50% viewed each video testimonial. Baseline screening preference was associated with values clarification tool responses and Web site feedback. This study revealed that, beyond the digital divide, Web site use depended on more than Internet access. Further, electronic tracking of Web site use demonstrated overestimation of self-reported use, high use of interactive features, and effect of baseline screening preference on men's response to the Web site.

BACKGROUND: Congestive heart failure (CHF) is one of the leading causes of hospital readmissions within 30 days of discharge. Due to the substantial costs associated with these readmissions, several interventions to reduce CHF readmissions have been developed and implemented. METHODS: To reduce CHF readmissions at our community teaching hospital, the Smooth Transitions Equal Less Readmission (STELR) program was developed. Utilizing the Plan-Do-Check-Act cycle for quality improvement, resident physicians tracked patients enrolled in the STELR program. The resident contribution to the program was substantial in that they were able to quantify the improvement in both physician practices and patient readmissions. This provided insight into program areas requiring further modification, which the hospital would not have obtained without resident participation. RESULTS: The readmission rate for patients diagnosed with heart failure decreased from 32% prior to program implementation, to 24% hospital wide (including patients who were not tracked in the STELR program), and 21% among patients tracked by the residents. CONCLUSION: This effective CHF readmission reduction program requires less financial resources compared to government funded programs. The resident involvement in the STELR program helped to assess and improve the program and also allowed the residents to gain an awareness of the resources available to their patients to facilitate their transition home. The program exposed the residents to systems-based practice, a fundamental element of their residency training and, more generally, community care.

OBJECTIVE:To test the association between statin use and low-density-lipoprotein (LDL)-cholesterol control in outpatient community practices undergoing quality improvement efforts in diabetes care. DESIGN/METHODS:A retrospective observational study of primary care practices that underwent efforts at improving the quality of diabetes care. Each practice provided an electronic registry-based monthly report of the percentage of patients with LDL <130 mg/dl (3.4 mmol/l), LDL <100 mg/dl (2.6 mmol/l) and statin use. SETTING/METHODS:Primary care practices in Pennsylvania focused on improving diabetes care by implementing the Chronic Care Model in urban, suburban and rural regions. PARTICIPANTS/METHODS:Consisted of 109 primary care practices, academic practices and federal health centres. Practices typically saw patients from a mix of government-funded and commercial health plan carriers. RESULTS:There was a positive linear association between documented statin use and the percentage of patients with LDL <130 mg/dl (3.4 mmol/l) and LDL <100 mg/dl (2.6 mmol/l = goal for patients with diabetes). The correlation between statin use and LDL <130 was 0.50 (95% CI 0.41-0.64), and between statin use and the percentage of patients with LDL <100 was 0.47 (95% CI 0.29-0.58). Practices with 5% larger statin use had an expected 1.9% larger percentage of patients with LDL <130 (95% CI 1.4 -2.9%) and an expected 1.7% larger percentage of patients with LDL <100 (95% CI 0.9- 2.3%). CONCLUSION/CONCLUSIONS:An association exists between statin use and LDL control in the real world of primary care practices undergoing quality improvement. Additional studies are necessary to ultimately test the validity of statin use as a process measure and/or surrogate for LDL-cholesterol control.

BACKGROUND: Obesity is a serious disease that is associated with an increased risk of diabetes, hypertension, heart disease, stroke, and cancer, among other diseases. The United States Centers for Disease Control and Prevention (CDC) estimates a 20% obesity rate in the 50 states, with 12 states having rates of over 30%. Currently, the body mass index (BMI) is most commonly used to determine adiposity. However, BMI presents as an inaccurate obesity classification method that underestimates the epidemic and contributes to failed treatment. In this study, we examine the effectiveness of precise biomarkers and duel-energy x-ray absorptiometry (DXA) to help diagnose and treat obesity. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional study of adults with BMI, DXA, fasting leptin and insulin results were measured from 1998-2009. Of the participants, 63% were females, 37% were males, 75% white, with a mean age = 51.4 (SD = 14.2). Mean BMI was 27.3 (SD = 5.9) and mean percent body fat was 31.3% (SD = 9.3). BMI characterized 26% of the subjects as obese, while DXA indicated that 64% of them were obese. 39% of the subjects were classified as non-obese by BMI, but were found to be obese by DXA. BMI misclassified 25% men and 48% women. Meanwhile, a strong relationship was demonstrated between increased leptin and increased body fat. CONCLUSIONS/SIGNIFICANCE: Our results demonstrate the prevalence of false-negative BMIs, increased misclassifications in women of advancing age, and the reliability of gender-specific revised BMI cutoffs. BMI underestimates obesity prevalence, especially in women with high leptin levels (>30 ng/mL). Clinicians can use leptin-revised levels to enhance the accuracy of BMI estimates of percentage body fat when DXA is unavailable.

BACKGROUND: We performed this study 1) to determine the prevalence of community-associated extended spectrum beta-lactamase producing Enterobacteriaceae (ESBLPE) colonization and infection in New York City (NYC); 2) to determine the prevalence of newly-acquired ESBLPE during travel; 3) to look for similarities in contemporaneous hospital-associated bloodstream ESBLPE and travel-associated ESBLPE. METHODS: Subjects were recruited from a travel medicine practice and consented to submit pre- and post-travel stools, which were assessed for the presence of ESBLPE. Pre-travel stools and stools submitted for culture were used to estimate the prevalence of community-associated ESBLPE. The prevalence of ESBLPE-associated urinary tract infections was calculated from available retrospective data. Hospital-associated ESBLPE were acquired from saved bloodstream isolates. All ESBLPE underwent multilocus sequence typing (MLST) and ESBL characterization. RESULTS: One of 60 (1.7%) pre- or non-travel associated stool was colonized with ESBLPE. Among community-associated urine specimens, 1.3% of Escherichia coli and 1.4% of Klebsiella pneumoniae were identified as ESBLPE. Seven of 28 travelers (25.0%) acquired a new ESBLPE during travel. No similarities were found between travel-associated ESBLPE and hospital-associated ESBLPE. A range of imported ESBL genes were found, including CTX-M-14 and CTX-15. CONCLUSION: ESBL colonization and infection were relatively low during the study period in NYC. A significant minority of travelers acquired new ESBLPE during travel.

BACKGROUND: Recent reports highlight the incursion of community-associated MRSA within healthcare settings. However, knowledge of this phenomenon remains limited in Latin America. The aim of this study was to evaluate the molecular epidemiology of MRSA in three tertiary-care hospitals in Medellin, Colombia. METHODS: An observational cross-sectional study was conducted from 2008-2010. MRSA infections were classified as either community-associated (CA-MRSA) or healthcare-associated (HA-MRSA), with HA-MRSA further classified as hospital-onset (HAHO-MRSA) or community-onset (HACO-MRSA) according to standard epidemiological definitions established by the U.S. Centers for Disease Control and Prevention (CDC). Genotypic analysis included SCCmec typing, spa typing, PFGE and MLST. RESULTS: Out of 538 total MRSA isolates, 68 (12.6%) were defined as CA-MRSA, 243 (45.2%) as HACO-MRSA and 227 (42.2%) as HAHO-MRSA. The majority harbored SCCmec type IVc (306, 58.7%), followed by SCCmec type I (174, 33.4%). The prevalence of type IVc among CA-, HACO- and HAHO-MRSA isolates was 92.4%, 65.1% and 43.6%, respectively. From 2008 to 2010, the prevalence of type IVc-bearing strains increased significantly, from 50.0% to 68.2% (p = 0.004). Strains harboring SCCmec IVc were mainly associated with spa types t1610, t008 and t024 (MLST clonal complex 8), while PFGE confirmed that the t008 and t1610 strains were closely related to the USA300-0114 CA-MRSA clone. Notably, strains belonging to these three spa types exhibited high levels of tetracycline resistance (45.9%). CONCLUSION: CC8 MRSA strains harboring SCCmec type IVc are becoming predominant in Medellin hospitals, displacing previously reported CC5 HA-MRSA clones. Based on shared characteristics including SCCmec IVc, absence of the ACME element and tetracycline resistance, the USA300-related isolates in this study are most likely related to USA300-LV, the recently-described 'Latin American variant' of USA300.

The popularity of smokeless tobacco (ST), or noncombusted tobacco, usually placed within the mouth to be chewed, sucked, or swallowed, is growing rapidly and its prevalence of use is rising globally, due (in part) to greater convenience, as allowable cigarette smoking areas are rapidly decreasing, and increased social acceptability. Though data are limited, ST usage has been directly linked to a number of adverse health outcomes. The potential role that immune dysfunction, including dysregulation of immune cells and their components, may play in the progression of these adverse health outcomes is only just beginning to emerge. Evidence suggesting reproductive outcomes, such as perinatal mortality, preterm birth, and reduced sperm viability, also exists in conjunction with ST use. Cardiovascular health may also be impacted by ST use, resulting in increased blood pressure and endothelial dysfunction, both of which may potentially lead to cardiovascular diseases. This review describes the toxicological implications associated with ST use, with emphasis on immune, reproductive, and cardiovascular outcomes. Epidemiological studies are discussed with respect to experimental studies to help develop the relationship between ST and disease pathology. This review also summarizes the gaps in ST knowledge and potential future directions that are needed to more fully delineate the complex systems driving the adverse health outcomes associated with its use.