Faculty Bibliography

Emerging techniques and instrumentation have allowed orthopaedic surgeons to achieve rotator cuff repair through an all-arthroscopic technique. The most critical steps in rotator cuff repair consist of proper identification of the cuff tear pattern and anatomic restoration of the torn tendon footprint. With anatomic reduction of the rotator cuff tendons, a sound fixation construct can help restore rotator cuff contact pressure and kinematics, allowing for decreased repair tension and optimal healing potential. We provide surgical methods to recognize tear patterns and present a repair construct that will restore the anatomic footprint of the torn rotator cuff tendon. The key, initial maneuver to restore the anatomic footprint of the cuff includes placement of a suture anchor at the anterolateral corner for L-shaped tears and at the posterolateral corner for reverse L-shaped and U-shaped tears. After insertion of the medial-row anchors, the tendon stitches should be planned by use of a grasper to hold the tendon in a reduced position and guide location of the stitch. The lateral row with suture bridge can be visualized, and the final repair construct should produce an anatomic restoration of the rotator cuff footprint.

OBJECTIVE: To develop and evaluate a pictorial, web-based version of the NCI diet history questionnaire (Web-PDHQ). DESIGN: The Web-PDHQ and paper version of the DHQ (Paper-DHQ) were administered 4 weeks apart with 218 participants randomised to order. Dietary data from the Web-PDHQ and Paper-DHQ were validated using a randomly selected 4 d food record recording period (including a weekend day) and two randomly selected 24 h dietary recalls during the 4 weeks intervening between these two diet history administrations. SETTING: Research office in Reston, VA, USA. PARTICIPANTS: Computer-literate men and women recruited through newspaper advertisements. RESULTS: Mean correlation of energy and the twenty-five examined nutrients between the Web-PDHQ and Paper-DHQ was 0.71 and 0.51, unadjusted and energy-adjusted by the residual method, respectively. Moderate mean correlations (unadjusted 0.41 and 0.38; energy-adjusted 0.41 and 0.34) were obtained between both the Web-PDHQ and Paper-DHQ with the 4 d food record on energy and nutrients, but the correlations between the Web-PDHQ and Paper-DHQ with the 24 h recalls were modest (unadjusted 0.31 and 0.29; energy-adjusted 0.37 and 0.26). A subset of participants (n 48) completing the Web-PDHQ at the initial visit performed a retest on the same questionnaire 1 week later to determine repeatability, and the unadjusted mean correlation was 0.82. CONCLUSIONS: These data indicate that the Web-PDHQ has comparable repeatability and validity to the Paper-DHQ but did not improve the relationship of the DHQ to other food intake measures (e.g. food records, 24 h recall).

BACKGROUND AIMS: Objective structured clinical encounters (OSCEs) are used widely to educate and assess the competence of medical students and residents; they generally are absent from fellowship training. The Accreditation Council for Graduate Education has cited OSCEs as a best practice for assessing the 6 core competencies. This article reports on the use of an OSCE to assess the competence of second-year gastroenterology fellows in the difficult-to-assess core competencies: interpersonal and communication skills and professionalism. METHODS: We developed a 4-station, faculty-observed OSCE with 4 standardized patients. Information gathering, relationship development, patient education, and counseling skills were assessed. Professionalism skills assessed included obtaining informed consent, delivering bad news, managing difficult situations, and showing interdisciplinary respect. In each station, faculty and standardized patients completed an 18- to 24-item checklist evaluating fellows' performance and provided feedback to the fellows. Nine fellows and 5 faculty from 4 gastroenterology training programs in NYC participated. RESULTS: Fellows and faculty generally highly rated the realism of the OSCE and favorably rated the OSCE for its difficulty and their overall experience. Across all cases, fellows were rated as receiving "well dones" for 56.4% of the communication items (SD, 18.3%) and for 79.1% of the professionalism items (SD, 16.4%). CONCLUSIONS: Integrating OSCEs into gastroenterology fellowship training may help enhance communication skills and prepare fellows for dealing with difficult clinical situations and provides mechanisms for constructive feedback. OSCEs developed collaboratively can assist in program self-evaluation and reduce costs by sharing resources, in addition to fulfilling Accreditation Council for Graduate Education mandates.

African Americans with high blood pressure (BP) can benefit greatly from therapeutic lifestyle changes (TLC) such as diet modification, physical activity, and weight management. However, they and their health care providers face many barriers in modifying health behaviors. A multidisciplinary panel synthesized the scientific data on TLC in African Americans for efficacy in improving BP control, barriers to behavioral change, and strategies to overcome those barriers. Therapeutic lifestyle change interventions should emphasize patient self-management, supported by providers, family, and the community. Interventions should be tailored to an individual's cultural heritage, beliefs, and behavioral norms. Simultaneously targeting multiple factors that impede BP control will maximize the likelihood of success. The panel cited limited progress with integrating the Dietary Approaches to Stop Hypertension (DASH) eating plan into the African American diet as an example of the need for more strategically developed interventions. Culturally sensitive instruments to assess impact will help guide improved provision of TLC in special populations. The challenge of improving BP control in African Americans and delivery of hypertension care requires changes at the health system and public policy levels. At the patient level, culturally sensitive interventions that apply the strategies described and optimize community involvement will advance TLC in African Americans with high BP

CONTEXT: Little is known about the influence of the primary care workplace on patient care. Assessing physician opinion through focus groups can elucidate factors related to safety and error in this setting. METHOD: During phase 1 of the Minimizing Error, Maximizing Outcome (MEMO) Study, 9 focus groups were conducted with 32 family physicians and general internists from 5 areas in the upper Midwest and New York City. RESULTS: The physicians described challenging settings with rapidly changing conditions. Patients are medically and psychosocially complex and often underinsured. Communication is complicated by multiple languages, time pressure, and inadequate information systems. Complex processes of care have missing elements including medication lists and test results. Physicians are pressed to be more productive, and key administrative decisions are made without their input. Targeted areas to improve safety and reduce error included teamwork, aligned leadership values, diversity, collegiality, and respect. CONCLUSIONS: Primary care physicians clearly described positive and negative workplace factors related to safety and error. The themes suggest that systems of care and their dynamic nature warrant attention. Enhancing positive and ameliorating negative cultures and processes of care could bring real benefits to patients, physicians, and ambulatory office settings.

Weighted survey data with missing data for some covariates presents a substantial challenge for analysis. We addressed this problem by using a reweighting technique in a logistic regression model to estimate parameters. Each survey weight was adjusted by the inverse of the probability that the possibly missing covariate was observed. The reweighted estimating equations procedure was compared with a complete case analysis (after discarding any subjects with missing data) in a simulation study to assess bias reduction. The method was also applied to data obtained from a national health survey (National Health and Nutritional Examination Survey or NHANES). Adjusting the sampling weights by the inverse probability of being completely observed appears to be effective in accounting for missing data and reducing the bias of the complete case estimate of the regression coefficients

Virtually all new tuberculosis vaccine candidates are tested in animals using the laboratory strains H37Rv or Erdman. However, naturally occurring M. tuberculosis infections are caused by strains that are widely different in phenotype and genotype. Very little is known about the characteristics of these clinical isolates in terms of basic biology, virulence and in vivo pathogenicity. In this study, we have used a standardized aerosol infection of guinea pigs to compare in vivo differences between clinical strains of M. tuberculosis. Strains consisted of both drug sensitive and multi-drug resistant (MDR) strains of Beijing and non-Beijing varieties. Collectively, these clinical isolates tested in the guinea pig model exhibited a wide range of virulence. Infection with certain isolates caused severe and rapidly progressive pulmonary and extra-pulmonary lesion necrosis, some of which progressed to atypical cavitary lesions in draining mediastinal and tracheobronchial lymph nodes. The two MDR-TB strains used in this study exhibited low level virulence as determined by bacterial growth, lesion scores and survival. Since infections with clinical M. tuberculosis isolates produce such varied disease, it is unknown whether new tuberculosis vaccines being developed will provide the same level of protection as seen when tested using laboratory challenge strains. The use of appropriate animal models allows for this important question to be addressed

The emergence of Mycobacterium tuberculosis resistant to first-line antibiotics has renewed interest in second-line antitubercular agents. Here, we aimed to extend our understanding of the mechanisms underlying para-aminosalicylic acid (PAS) resistance by analysis of six genes of the folate metabolic pathway and biosynthesis of thymine nucleotides (thyA, dfrA, folC, folP1, folP2, and thyX) and three N-acetyltransferase genes [nhoA, aac(1), and aac(2)] among PAS-resistant clinical isolates and spontaneous mutants. Mutations in thyA were identified in only 37% of the clinical isolates and spontaneous mutants. Overall, 24 distinct mutations were identified in the thyA gene and 3 in the dfrA coding region. Based on structural bioinformatics techniques, the altered ThyA proteins were predicted to generate an unfolded or dysfunctional polypeptide. The MIC was determined by Bactec/Alert and dilution assay. Sixty-three percent of the PAS-resistant isolates had no mutations in the nine genes considered in this study, revealing that PAS resistance in M. tuberculosis involves mechanisms or targets other than those pertaining to the biosynthesis of thymine nucleotides. The alternative mechanism(s) or pathway(s) associated with PAS resistance appears to be PAS concentration dependent, in marked contrast to thyA-mutated PAS-resistant isolates

OBJECTIVE: To evaluate the effect of patients' perceptions of providers' communication on medication adherence in hypertensive African Americans. METHODS: Cross-sectional study of 439 patients with poorly controlled hypertension followed in community-based healthcare practices in the New York metropolitan area. Patients' rating of their providers' communication was assessed with a perceived communication style questionnaire,while medication adherence was assessed with the Morisky self-report measure. RESULTS: Majority of participants were female, low-income, and had high school level educations, with mean age of 58 years. Fifty-five percent reported being nonadherent with their medications; and 51% rated their provider's communication to be non-collaborative. In multivariate analysis adjusted for patient demographics and covariates (depressive symptoms, provider degree), communication rated as collaborative was associated with better medication adherence (beta=-.11, p=.03). Other significant correlates of medication adherence independent of perceived communication were age (beta=.13, p=.02) and depressive symptoms (beta=-.18, p=.001). CONCLUSION: Provider communication rated as more collaborative was associated with better adherence to antihypertensive medications in a sample of low-income hypertensive African-American patients. PRACTICE IMPLICATIONS: The quality of patient-provider communication is a potentially modifiable element of the medical relationship that may affect health outcomes in this high-risk patient population