Faculty Bibliography

[...] Mr. Cheney has begun resuming his old activities. Besides the Cino fund-raiser, he attended a round of holiday parties in Washington -- leaving whispers in his trail about his weight loss.

The fundraiser for [Maria Cino], held at the Alexandria, Va., home of [Dick Cheney]'s former aide Mary Matalin, was his first major foray into partisan Washington political theater since receiving a mechanical heart pump in July that has, most doctors say, saved Cheney's life by taking on the task of helping to push blood through his arteries. With George W. Bush having decided to stay largely silent during [Barack Obama]'s tenure, Cheney embraced the role of public critic, accusing the new, young president of rolling back Bush-era policies and undermining the nation's security. In 2009, Cheney and Obama gave dueling speeches on the same day. At 69, Cheney's heart will never beat at full strength again, doctors say. His new mechanical pump, a partial artificial heart known as a ventricular assist device, leaves patients without a pulse because it pushes blood continuously instead of mimicking the heart's own beat. Most pulseless patients feel nothing unusual, but the devices do pose significant risks of infection. They are implanted as a last resort either for permanent use or as a bridge to transplant until a donor heart can be found. Cheney, who has participated in some of the nation's toughest decisions for decades, now faces a crucial one of his own: whether to seek a full heart transplant

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.

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

Case Presentation: A 39-year-old African American woman presented with nausea, postprandial emesis, early satiety, abdominal distension/pain for 1 week, and 2 days of hematemesis. Physical exam revealed a diffusely distended, tender abdomen and a firm, immobile 8 x 12 cm abdominal mass in the left upper quadrant. A complete blood count was significant for a hemoglobin and hematocrit of 6.5 and 21.5, respectively. She was transfused 2 units of packed red blood cells. CT revealed gastric trichobezoars. On further questioning, she revealed a 28-year history of trichotillomania and trichophagia and reported consuming a quart-sized bag of hair daily that she obtained from barber shops. Esophagogastroduodenoscopy demonstrated 3 large trichobezoars within the stomach and a 1-cm nonbleeding ulcer on the greater curvature, without evidence of complete gastric outlet obstruction or Rapunzel syndrome (tracking beyond the pylorus). The trichobezoars were deemed too large to be removed endoscopically. She was started on Prozac 20 mg by mouth daily to decrease the compulsion to consume hair, Coca-Cola 300 mL 3 times a day to decrease the size of the trichobezoars in anticipation of surgical removal, and metoclopramide 10 mg by mouth twice a day. Psychiatric management was initiated. Discussion: Trichobezoars are accumulations of hair typically located in the stomach that may track beyond the pylorus into the small bowel. This finding is associated with the psychiatric disorders trichotillomania and trichophagia, which usually occur in young females. When not recognized early, trichobezoars may continue growing because of persistent hair consumption and cause gastric erosion, ulceration, or gastric outlet obstruction (Gorter RR, Kneepkens CMF, Mattens ECJL, Aronson DC, Heij HA. Management of trichobezoar: case report and literature review. Ped Surg Int. 2010;26:457-463). In this case, the significant size of this patient's trichobezoars resulted in partial pyloric obstruction, leading to gastrointestinal (GI) symptoms. We propose that the trichobezoars eroded the gastric mucosa causing ulceration. During 1 week of vomiting, the marked increase in intra-abdominal pressure was transmitted to the esophagus, which likely caused Mallory-Weiss syndrome, manifesting as hematemesis. The patient's malnutrition resulted in severe iron -deficiency anemia, which was exacerbated by hematemesis and gastric ulceration. Conclusions: Although a rare occurrence, trichobezoars must be considered in a differential diagnosis of a patient, especially in young females presenting with either an abdominal mass or nonspecific GI symptoms in the context of an upper GI bleed. We also highlight the importance of managing trichobezoars medically and with psychiatric counseling prior to surgical removal in order to alleviate GI symptoms and prevent reoccurrence. 1

ackground: Screening, diagnosis and treatment have significantly reduced the cancer burden of several cancers in the US for certain populations. Incorrect knowledge of cancer diagnosis can hinder treatment. Immigrant minorities and the underserved face unique challenges in the receipt of appropriate cancer care. Barriers to understanding cancer diagnoses include language, culture, and health literacy. This study investigates knowledge of cancer diagnosis among immigrant minorities. Methods: Patients were recruited at ten hospital-based cancer clinics in New York City between September 2008 and December 2010. Bilingual staff administered a survey for a sample of 471 patients with a clinical cancer diagnosis. Demographic and self-reported diagnosis and treatment information were collected. Patient charts were reviewed to ascertain cancer diagnosis. Results: 92% of patients were foreign-born. 81% preferred to speak a language other than English in the health care setting. 64% of foreign-born patients had resided in the US for 15 years or less. 25% were uninsured. Among those who were insured, 50% had Medicaid only, and 39% had Medicaid for Emergency Services only. 60% did not have a primary care provider, and 84% did not have a social worker assisting them with their care. The most common cancer diagnoses were breast (28%), colorectal (9%), cervical (8%), and lung (7%). 14% had incorrect knowledge of their cancer diagnosis. An additional 6 participants reported the correct metastatic site, but wrong primary cancer, or correct site, but wrong type of cancer. Of the 68 patients with incorrect knowledge of their diagnosis, 91% preferred a non-English language in the health care setting. Conclusions: Among this cohort of predominantly immigrant cancer patients, a considerable proportion were unaware of their correct cancer diagnoses. This may have a significant impact on subsequent cancer treatment and care. Language discordance likely has an important role in this miscommunication between patients and the health care system. Limited English proficient patients may be at particular risk for suboptimal cancer care. More research is needed to better understand cancer care in the language discordant encounter

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