Faculty Bibliography

AIMS/OBJECTIVE:To assess pharmacy claims and self-report data as measures of medication adherence and to describe baseline characteristics of subjects in the Improving Diabetes Outcomes Study. METHODS:Multi-ethnic, lower-income, insured adults (n = 526) in New York City with Type 2 diabetes were enrolled in a randomized, controlled, behavioural intervention study delivered by telephone. Baseline data were examined, including glycated haemoglobin (HbA(1c)), objective measures of diabetes medication adherence [claims data medication possession ratio (MPR)], and two self-report measures [Morisky Medication-taking Scale and the medication-taking item of the Summary of Diabetes Self-Care Activities (SDSCA)]. Associations of highest tertile HbA(1c) (>or= 9.3%) with lowest tertile MPR (< 42%) were assessed with logistic regression models adjusting for potential confounders. Subset analyses were performed based on assessment of potential interaction. RESULTS:Participants (mean +/- sd age 56 +/- 7 years) had median (interquartile range) HbA(1c) 8.6% (8.0-10.0). Correlations of baseline MPR with Morisky score and SDSCA medication-taking item were strongly significant (both rho = 0.21, P < 0.001). Lowest MPR was significantly (P = 0.008) associated with highest HbA(1c) in the group as a whole and among the subset taking two or more oral glucose-lowering agents (OGLA) (P = 0.002), but not among the subset taking only one (P = 0.83). Self-report adherence measures were not significantly associated with HbA(1c) in either the whole group or either subset. CONCLUSIONS:These results support the validity of MPR as an adherence measure for OGLA among insured diabetes patients with poorly controlled HbA(1c), especially those taking two or more OGLA.

Most healthy women have normal pregnancies; however, even healthy women may experience serious morbidity during pregnancy. Women with chronic medical problems face increased pregnancy-related risks compared with their healthy peers. Planning pregnancy improves maternal and fetal outcomes; medical conditions can be stabilized, teratogens can be avoided, and early antenatal intervention and surveillance can be instituted. The safest and most effective forms of contraception should be offered to women with medical conditions. Overestimatation of risk associated with the use of contraception among clinicians and women limits access to effective contraception. Contraception decision making should include consideration of the risks and benefits of a given method vs. the consequences of an unintended pregnancy. Published guidelines can inform contraceptive management of women with chronic medical conditions. Patient counseling should focus on helping women understand the need for contraception while optimizing their health for pregnancy.

BACKGROUND:Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners' opinions are vital to the development of future curricula. DESIGN/METHODS:Qualitative research using focus group methodology. OBJECTIVES/OBJECTIVE:Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught. PARTICIPANTS/METHODS:Study participants were first year medical students with an interest in health disparities (n = 17). APPROACH/METHODS:Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process. MAIN RESULTS/RESULTS:The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities. CONCLUSIONS:While many of the students' opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.

The presence of mural calcification has, for decades, been recognized as a marker for atheromatous plaque in the coronary arteries and the aorta, but only in the past decade has the application of noncontrast computed tomography (CT) been shown to be a reproducible, safe, and convenient test, which now is available worldwide. However, awareness of coronary artery calcium scanning is insufficient and the practitioner must be aware of the available literature as well as understanding clinical recommendations for applications and interpretation. It is best applied in the medium/intermediate risk, asymptomatic adult regardless of ethnicity across broad age ranges for both men and women; additional prognostic information is also afforded from the calcium distribution in the coronary artery system. Additionally, information can also be derived from the same CT scan regarding heart and aorta size and assessment of the epicardial fat pad (an anatomic marker for the metabolic syndrome). Details of how this test can aid in cardiovascular risk assessment and management in adults are provided.

BACKGROUND:Elevated low-density lipoprotein cholesterol (LDL-C) levels are a major cardiovascular disease risk factor. Genetic factors are an important determinant of LDL-C levels. METHODS:To identify single nucleotide polymorphisms associated with LDL-C and subclinical coronary atherosclerosis, we performed a genome-wide association study of LDL-C in 841 asymptomatic Amish individuals aged 20 to 80 years, with replication in a second sample of 663 Amish individuals. We also performed scanning for coronary artery calcification (CAC) in 1018 of these individuals. RESULTS:From the initial genome-wide association study, a cluster of single nucleotide polymorphisms in the region of the apolipoprotein B-100 gene (APOB) was strongly associated with LDL-C levels (P < 10(-68)). Additional genotyping revealed the presence of R3500Q, the mutation responsible for familial defective apolipoprotein B-100, which was also strongly associated with LDL-C in the replication sample (P < 10(-36)). The R3500Q carrier frequency, previously reported to be 0.1% to 0.4% in white European individuals, was 12% in the combined sample of 1504 Amish participants, consistent with a founder effect. The mutation was also strongly associated with CAC in both samples (P < 10(-6) in both) and accounted for 26% and 7% of the variation in LDL-C levels and CAC, respectively. Compared with noncarriers, R3500Q carriers on average had LDL-C levels 58 mg/dL higher, a 4.41-fold higher odds (95% confidence interval, 2.69-7.21) of having detectable CAC, and a 9.28-fold higher odds (2.93-29.35) of having extensive CAC (CAC score ≥400). CONCLUSION/CONCLUSIONS:The R3500Q mutation in APOB is a major determinant of LDL-C levels and CAC in the Amish.

Aortic valve calcium (AVC) can be quantified on the same computed tomographic scan as coronary artery calcium (CAC). Although CAC is an established predictor of cardiovascular events, limited evidence is available for an independent predictive value for AVC. We studied a cohort of 8,401 asymptomatic subjects (mean age 53 ± 10 years, 69% men), who were free of known coronary heart disease and were undergoing electron beam computed tomography for assessment of subclinical atherosclerosis. The patients were followed for a median of 5 years (range 1 to 7) for the occurrence of mortality from any cause. Multivariate Cox regression models were developed to predict all-cause mortality according to the presence of AVC. A total of 517 patients (6%) had AVC on electron beam computed tomography. During follow-up, 124 patients died (1.5%), for an overall survival rate of 96.1% and 98.7% for those with and without AVC, respectively (hazard ratio 3.39, 95% confidence interval 2.09 to 5.49). After adjustment for age, gender, hypertension, dyslipidemia, diabetes mellitus, smoking, and a family history of premature coronary heart disease, AVC remained a significant predictor of mortality (hazard ratio 1.82, 95% confidence interval 1.11 to 2.98). Likelihood ratio chi-square statistics demonstrated that the addition of AVC contributed significantly to the prediction of mortality in a model adjusted for traditional risk factors (chi-square = 5.03, p = 0.03) as well as traditional risk factors plus the presence of CAC (chi-square = 3.58, p = 0.05). In conclusion, AVC was associated with increased all-cause mortality, independent of the traditional risk factors and the presence of CAC.

BACKGROUND:The presence of coronary artery calcium (CAC) is an independent marker of increased risk of cardiovascular disease (CVD) events and mortality. However, the predictive value of thoracic aorta calcification (TAC), which can be additionally identified without further scanning during assessment of CAC, is unknown. METHODS:We followed a cohort of 8401 asymptomatic individuals (mean age: 53+/-10 years, 69% men) undergoing cardiac risk factor evaluation and TAC and CAC testing with electron beam computed tomography. Multivariable Cox proportional hazards models were developed to predict all-cause mortality based on the presence of TAC. RESULTS:During a median follow-up period of 5 years, 124 (1.5%) deaths were observed. Overall survival was 96.9% and 98.9% for those with and without detectable TAC, respectively (p<0.0001). Compared to those with no TAC, the hazard ratio for mortality in the presence of TAC was 3.25 (95% CI: 2.28-4.65, p<0.0001) in unadjusted analysis. After adjusting for age, gender, hypertension, dyslipidemia, diabetes mellitus, smoking and family history of premature coronary artery disease, and presence of CAC the relationship remained robust (HR 1.61, 95% CI: 1.10-2.27, p=0.015). Likelihood ratio chi(2) statistics demonstrated that the addition of TAC contributed significantly in predicting mortality to traditional risk factors alone (chi(2)=13.62, p=0.002) as well as risk factors+CAC (chi(2)=5.84, p=0.02) models. CONCLUSION/CONCLUSIONS:In conclusion, the presence of TAC was associated with all-cause mortality in our study; this relationship was independent of conventional CVD risk factors as well as the presence of CAC.