Faculty Bibliography

Little Fockers [Motion Picture] -- [...] beta blockers can sometimes precipitate impotence by preventing the penis from getting all the blood it needs to create and sustain an erection

PURPOSE: This study investigates the impact of a multilingual, multidisciplinary team targeting social and economic determinants of cancer treatment adherence among at-risk Hispanic immigrants. METHODS: Patients were recruited at 10 hospital-based cancer clinics in New York City between December 2008 and November 2009. This is a nested cohort study of Hispanic patients and their sociodemographic characteristics, areas of needed assistance, and reported impact of meeting service needs on keeping appointments. At the core of the intervention is the trained, bilingual Portal Access Facilitator, who assesses needs and synchronizes an individualized set of transdisciplinary services for each patient. RESULTS: A total of 328 Hispanic patients participated in the study. Of these, 89% preferred to speak Spanish in the health care setting, and 17% had no health insurance. The most common cancer diagnosis among participants was breast cancer (35%) followed by GI (17%) and gynecologic (16%) cancers. Patients most commonly requested financial support (59%), food support (37%), transportation assistance (21%), social work services (14%), psychosocial support (6%), help with health insurance issues (5%), and legal services (5%). In a follow-up assessment of high-need patients in urgent need of financial support, 86% reported that portal services helped them attend cancer care and treatment appointments, and 72% reported that portal services decreased worry about their care. CONCLUSION: Most patients reported that financial, social, and logistical support would help them attend their appointments for cancer care and treatment. Further multidisciplinary interventions should be implemented and evaluated to address social and economic determinants in cancer care for this population

Chinese immigrants have high rates of a variety of cancers and face numerous social and economic barriers to cancer treatment appointment keeping. This study is a nested cohort of 82 Chinese patients participating in the Immigrant Cancer Portal Project. Twenty-two percent reported having missed appointments for oncology follow-up, radiation therapy, and/or chemotherapy. Patients most commonly reported needing assistance with financial support to enable appointment keeping. Efforts to further address social and economic correlates in cancer care should be developed for this population

BACKGROUND: Suicide is a global public health problem. Recently in the U.S., much attention has been given to preventing suicide and other premature mortality in veterans returning from Iraq and Afghanistan. A strong predictor of suicide is a past suicide attempt, and suicide attempters have multiple physical and mental comorbidities that put them at risk for additional causes of death. We examined mortality among U.S. military veterans after hospitalization for attempted suicide. METHODS: A retrospective cohort study was conducted with all military veterans receiving inpatient treatment during 1993-1998 at United States Veterans Affairs (VA) medical facilities following a suicide attempt. Deaths occurring during 1993-2002, the most recent available year at the time, were identified through VA Beneficiary and Records Locator System data and National Death Index data. Mortality data for the general U.S. adult population were also obtained from the National Center for Health Statistics. Comparisons within the veteran cohort, between genders, and against the U.S. population were conducted with descriptive statistics and standardized mortality ratios. The actuarial method was used estimate the proportion of veterans in the cohort we expect would have survived through 2002 had they experienced the same rate of death that occurred over the study period in the U.S. population having the age and sex characteristics. RESULTS: During 1993-1998, 10,163 veterans were treated and discharged at a VA medical center after a suicide attempt (mean age = 44 years; 91% male). There was a high prevalence of diagnosed alcohol disorder or abuse (31.8%), drug dependence or abuse (21.8%), psychoses (21.2%), depression (18.5%), and hypertension (14.2%). A total of 1,836 (18.1%) veterans died during follow up (2,941.4/100,000 person years). The cumulative survival probability after 10 years was 78.0% (95% CI = 72.9, 83.1). Hence the 10-year cumulative mortality risk was 22.0%, which was 3.0 times greater than expected. The leading causes overall were heart disease (20.2%), suicide (13.1%), and unintentional injury (12.7%). Whereas suicide was the ninth leading cause of death in the U.S. population overall (1.8%) during the study period, suicide was the leading and second leading cause among women (25.0%) and men (12.7%) in the cohort, respectively. CONCLUSIONS: Veterans who have attempted suicide face elevated risks of all-cause mortality with suicide being prominent. This represents an important population for prevention activities

BACKGROUND: The United States faces a shortage of primary care physicians and declining number of medical students choosing primary care careers. METHODS: We conducted a secondary analysis of 2 similar national surveys of senior medical students from 1990 and 2007 that addressed student characteristics, specialties chosen, clerkship experiences, perceptions of internal medicine (IM) compared with other specialties, and influential aspects of IM. We compared responses from 1990 and 2007 by analyzing a merged data set of identical items from the 2 surveys (65% of the items). RESULTS: The total sample of 2421 students comprised 1244 at 16 schools in 1990 (response rate, 75%) and 1177 at 11 schools in 2007 (82%). In 2007, there were more women (52% vs 37%, P < .001) and more educational debt (mean, $101 000 vs $63 000, P < .001). Similar proportions of students planned IM careers (23% vs 24%), although plans to practice general IM dropped from 9% to 2% (P < .001). The appeal of primary care as an influence toward IM declined from 57% to 33% (P < .001). More 2007 students reported high satisfaction with the IM clerkship (78% vs 38%, P < .001). Both cohorts thought that workload and stress are greater in IM than in other fields. Students in 2007 felt that opportunities for meaningful work in IM were greater than did students in 1990 (58% vs 42%, P < .001). CONCLUSIONS: More students in 2007 than in 1990 viewed IM as a potentially meaningful career. However, the 2007 students had higher debt, more negative perceptions of workload and stress in IM, and less career interest in general IM. To rebuild the generalist physician workforce, improving students' experience of IM in medical school is no longer sufficient. Bolder reform will be required to improve the educational pipeline, practice, and payment of generalist IM physicians

While the long-term goal is to develop highly effective AIDS vaccines, first generation vaccines may be only partially effective. Other HIV prevention modalities such as preexposure prophylaxis with antiretrovirals (PrEP) may have limited efficacy as well. The combined administration of vaccine and PrEP (VAXPREP), however, may have a synergistic effect leading to an overall benefit that is greater than the sum of the individual effects. We propose two test-of-concept trial designs for an AIDS vaccine plus oral or topical ARV. In one design, evidence that PrEP reduces the risk of HIV acquisition is assumed to justify offering it to all participants. A two-arm study comparing PrEP alone to VAXPREP is proposed in which 30 to 60 incident infections are observed to assess the additional benefit of vaccination on risk of infection and setpoint viral load. The demonstrated superiority of VAXPREP does not imply vaccine alone is efficacious. Similarly, the lack of superiority does not imply vaccine alone is ineffective, as antagonism could exist between vaccine and PrEP. In the other design, PrEP is assumed not to be in general use. A 2 x 2 factorial design is proposed in which high-risk individuals are randomized to one of four arms: placebo vaccine given with placebo PrEP, placebo vaccine given with PrEP, vaccine given with placebo PrEP, or VAXPREP. Between 60 and 210 infections are required to detect a benefit of vaccination with or without PrEP on risk of HIV acquisition or setpoint viral load, with fewer infections needed when synergy is present

South Asian immigrants are a large, rapidly growing community in the United States. The rate of cardiovascular disease in immigrants from India, Pakistan, and Bangladesh is disproportionately high. We conducted focus groups with diverse South Asian community members in New York City to elucidate hypertension knowledge, and screening and treatment practices. Focus groups were conducted in partnership with community-based organizations. 47 participants across Bangladeshi, Pakistani and Indian immigrants participated in three focus groups. Participants hesitated accessing services because of immigration fears, financial concerns, scheduling constraints, and dissatisfaction with their interactions with doctors. Discussions detailed knowledge about, and barriers to following, advice on diet and exercise. The findings compel further development of culturally- and linguistically-tailored research and interventions to address the specific needs of this large at-risk community. Potential culturally appropriate approaches are discussed to bridge barriers faced by the community.