Faculty Bibliography

INTRODUCTION/BACKGROUND:The aim of this review article is to compare the outcomes of newer non-thermal endovenous ablation techniques to thermal ablation techniques for the treatment of symptomatic venous insufficiency. EVIDENCE ACQUISITION/METHODS:Three independent reviewers screened PubMed® and EMBASE® databases to identify relevant studies. A total of 1173 articles were identified from database search that met our inclusion criteria. Two articles were identified through reference search. Removal of duplicates from our original search yielded 695 articles. We then screened these articles and assessed 173 full-text articles for eligibility. Subsequent to exclusion, 11 full-text articles were selected for final inclusion. EVIDENCE SYNTHESIS/RESULTS:The non-thermal techniques are similar to thermal techniques in terms of a high technical success rate, closure rate at 12 months, change in Venous Clinical Severity Score and change in quality of life after procedure. However, the length of procedure is shorter for non-thermal modalities and patient comfort is improved with lower pain scores. Return to work may also be earlier after non-thermal ablation. The rates of bruising, phlebitis and paresthesia are higher after thermal ablation. CONCLUSIONS:The non-thermal modalities are safe and effective in treating venous reflux and have shown improved patient comfort and shorter length of procedure which may make them favorable for use compared to the thermal modalities.

Migraine affects over 40 million Americans and is the world's second most disabling condition. As the majority of medical care for migraine occurs in primary care settings, not in neurology nor headache subspecialty practices, healthcare system interventions should focus on primary care. Though there is grade A evidence for behavioral treatment (e.g., biofeedback, cognitive behavioral therapy (CBT), and relaxation techniques) for migraine, these treatments are underutilized. Behavioral treatments may be a valuable alternative to opioids, which remain widely used for migraine, despite the US opioid epidemic and guidelines that recommend against them. Identifying and removing barriers to the use of headache behavioral therapy could help reduce the disability as well as the personal and social costs of migraine. These techniques will have their greatest impact if offered in primary care settings to the lower socioeconomic status groups at greatest risk for migraine. We review the societal and cultural challenges that impose barriers to optimal use of non-pharmacological treatment services. These barriers include insufficient knowledge of migraine/headache behavioral treatments and insufficient availability of clinicians trained in non-pharmacological treatment delivery; limited access in underserved communities; financial burden; and stigma associated with both headache and mental health diagnoses and treatment. For each barrier, we discuss potential approaches to minimizing its effect and thus enhancing non-pharmacological treatment utilization.Case ExampleA 25-year-old graduate student with a prior history of headaches in college is attending school in the evenings while working a full-time job. Now, his headaches have significant nausea and photophobia. They are twice weekly and are disabling enough that he is unable to complete homework assignments. He does not understand why the headaches occur on Saturdays when he pushes through all week to get through his examinations that take place on Friday evenings. He tried two different migraine preventive medications, but neither led to the 50% reduction in headache days his doctor had hoped for. His doctor had suggested cognitive behavioral therapy (CBT) before initiating the medications, but he had been too busy to attend the appointments, and the challenges in finding an in-network provider proved difficult. Now with the worsening headaches, he opted for the CBT and by the fifth week had already noted improvements in his headache frequency and intensity.

OBJECTIVE:To characterize the general health status of infertile men in the United States using a nationally representative sample of men. METHODS:Using the National Survey for Family Growth from 2011 to 2017, infertile subgroups were created using a range of inclusion criteria. Univariate and multivariate analyses were conducted comparing these men to fertile men. RESULTS:Using population estimates, 6.5 million men with reduced fertility potential were compared to 26 million fertile men. After controlling for demographic and healthcare utilization factors, these groups did not have significantly different rates of key medical co-morbidities, including cancer, obesity, and overall disability. Looking at the subset of men who had received a specific infertility diagnosis, estimated as a population of nearly 600,000 men, this pattern held, in that there were no significant differences in the rates of medical co-morbidities. Notably, the rate of male infertility evaluation among potentially infertile men was only 50%. These findings also persisted after a propensity-matched analysis. CONCLUSIONS:In this cohort, there was no significant relationship between infertility and specific medical co-morbidities. We must consider the influence of sample selection as we continue to investigate the relationship between medical co-morbidities and reduced fertility potential. Given the persistent low rates of infertility evaluation, even among men who seek medical advice to conceive, we must continue to search for ways to characterize the infertile male population while simultaneously working to improve access.

BACKGROUND:Older adults undergoing noncardiac surgery have a high risk of major adverse cardiovascular events (MACE). This study aims to estimate the magnitude of increased perioperative risk, and examine national trends in perioperative MACE following in-hospital noncardiac surgery in older adults compared to middle-aged adults. DESIGN/METHODS:Time-series analysis of retrospective longitudinal data. SETTING/METHODS:The United States Agency for Healthcare Research and Quality National Inpatient Sample (NIS). PARTICIPANTS/METHODS:Hospitalizations for major noncardiac surgery among adults age ≥45 years between January 2004 and December 2014. MEASUREMENTS/METHODS:Inpatient perioperative MACE was defined as a composite of in-hospital death, myocardial infarction (MI), and ischemic stroke. In hospital death was determined from the NIS discharge disposition. MI and ischemic stroke were defined by International Classification of Diseases, Ninth Revision codes. RESULTS:Of an estimated 55,349,978 surgical hospitalizations, 26,423,039 (47.7%) were for adults age 45-64, 14,231,386 (25.7%) age 65-74, 10,621,029 (19.2%) age 75-84 years, and 4,074,523 (7.4%) age ≥85 years. MACE occurred in 1,601,022 surgical hospitalizations (2.9%). Adults 65-74 (2.8%; aOR 1.16, 95% CI 1.14-1.17), 75-84 years (4.5%; aOR 1.30, 95% CI 1.28-1.32), and ≥85 years (6.9%; aOR 1.55, 95% CI 1.52-1.57) had greater risk of MACE than those 45-64 years (1.7%). From 2004 to 2014, MACE declined among adults 65-74 (3.1-2.5%, p < 0.001), 75-85 years (4.9-3.9%, p < 0.001), and ≥85 years (7.7-6.1%, p < 0.001), but was unchanged for adults age 45-64. Declines in MACE were driven by decreased MI and mortality despite increased stroke. CONCLUSION/CONCLUSIONS:Older adults accounted for half of hospitalizations, but experienced the majority of MACE. Older adults had greater adjusted odds of MACE than younger individuals. The proportion of perioperative MACE declined over time, despite increases in ischemic stroke. These data highlight risks of noncardiac surgery in older adults that warrant increased attention to improve perioperative outcomes.

INTRODUCTION:In ED patients with acute drug overdose involving prescription medication and/or substances of abuse, severe QTc prolongation (> 500 ms) is predictive of adverse cardiovascular events (ACVE), defined as myocardial injury, ventricular dysrhythmia, shock, or cardiac arrest. However, it is unclear whether delayed severe QTc prolongation (dsQTp) is a risk factor for ACVE and if specific clinical factors are associated with occurrence of dsQTp. METHODS:A secondary analysis of a prospective cohort of consecutive adult ED patients with acute drug overdose was performed on patients with initial QTc < 500 ms. The predictor variable, dsQTp, was defined as initial QTc < 500 ms followed by repeat QTc ≥ 500 ms. The primary outcome was occurrence of ACVE. Multivariable logistic regression was performed to test whether dsQTp was an independent predictor of ACVE and to derive clinical factors associated with dsQTp. RESULTS:Of 2311 patients screened, 1648 patients were included. The dsQTp group (N = 27) was older than the control group (N = 1621) (51.6 vs 40.2, p < 0.001) and had a higher number of drug exposures (2.92 vs 2.16, p = 0.003). Following adjustment for age, sex, race/ethnicity, number of exposures, serum potassium, and opioid exposure, dsQTp remained an independent predictor of ACVE (aOR: 12.44, p < 0.0001). Clinical factors associated with dsQTp were age > 45 years and polydrug (≥ 3) overdoses. CONCLUSION:In this large secondary analysis of ED patients with acute drug overdose, dsQTp was an independent risk factor for in-hospital occurrence of ACVE.

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OBJECTIVES:To determine whether lower serum albumin in community-dwelling, older adults is associated with increased risk of hospitalization and death independent of pre-existing disease. DESIGN:Prospective cohort study of participants in the fifth visit of the Atherosclerosis Risk in Communities (ARIC) study. Baseline data were collected from 2011 to 2013. Follow-up was available to December 31, 2017. Replication was performed in Geisinger, a health system in rural Pennsylvania. SETTING:For ARIC, four US communities: Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and suburbs of Minneapolis, Minnesota. PARTICIPANTS:A total of 4947 community-dwelling men and women aged 66 to 90 years. EXPOSURE:Serum albumin. MAIN OUTCOMES:Incident all-cause hospitalization and death. RESULTS:Among the 4947 participants, mean age was 75.5 years (SD: 5.12) and mean baseline serum albumin concentration was 4.05 g/dL (SD: 0.30). Over a median follow-up period of 4.42 years (interquartile interval: 4.16-5.05), 553 participants (11.2%) died and 2457 participants (49.7%) were hospitalized at least once. The total number of hospitalizations was 5725. In analyses adjusted for demographics and numerous clinical characteristics, including tobacco use, obesity, frailty, cardiovascular disease, kidney disease, diabetes C-reactive protein (CRP), cognitive status, alcohol use, medication use, respiratory disease, and systolic blood pressure, 1 g/dL lower baseline serum albumin concentration was associated with higher risk of both hospitalization (incidence rate ratio [IRR]: 1.58; 95% confidence interval [CI]: 1.36-1.82; p < 0.001) and death (hazard ratio [HR]: 1.67; 95% CI: 1.24-2.24; p < 0.001). Associations were weaker with older age but not different by frailty status or level of high-sensitivity CRP. Associations between serum albumin, hospitalizations, and death were also similar in a real-world cohort of primary care patients. CONCLUSIONS:Lower baseline serum albumin was significantly associated with increased risk of both all-cause hospitalization and death, independent of pre-existing disease. Older adults with low serum albumin should be considered a high-risk population and targeted for interventions to reduce the risk of adverse outcomes.

Evidence-based and culturally relevant parenting programs strengthen adults' capacity to support children's health and development. Optimizing parent participation in programs implemented at scale is a prevailing challenge. Our collaborative team of program developers, implementers, and researchers applied insights from the field of behavioral economics (BE) to support parent participation in ParentCorps-a family-centered program delivered as an enhancement to pre-kindergarten-as it scaled in a large urban school district. We designed a bundle of BE-infused parent outreach materials and successfully showed their feasibility in site-level randomized pilot implementation. The site-level study did not show a statistically significant impact on family attendance. A sub-study with a family-level randomization design showed that varying the delivery time of BE-infused digital outreach significantly increased the likelihood of families attending the parenting program. Lessons on the potential value of a BE-infused approach to support outreach and engagement in parenting programs are discussed in the context of scaling up efforts.

STUDY OBJECTIVE/OBJECTIVE:Input from adolescents and healthcare providers is needed to develop electronic tools that can support patient-centered sexual and reproductive (SRH) care. This study explores facilitators and barriers to patient-centered communication in the context of developing an electronic appointment planning tool to promote SRH communication in clinic settings. DESIGN/METHODS:In-depth interviews were conducted to explore what constitutes adolescent-friendly SRH care and communication, as well as on the design of the appointment planning tool. Interviews were coded iteratively, and analyzed using the software Atlas.TI v8. SETTING/METHODS:An adolescent primary care clinic, and a pediatric and adolescent gynecology clinic. PARTICIPANTS/METHODS:Adolescent girls (N=32; ages 14-18) and providers who care for adolescent girls (N=10). MAIN OUTCOME MEASURES/METHODS:Thematic analyses explored facilitators/barriers to SRH communication and care and preferences for the tool. RESULTS:Facilitators identified by adolescents and providers included: direct patient/provider communication; adolescent-driven decision-making regarding care and contraceptive choice; supplementing clinic visits with electronic resources; and holistic care addressing physical, mental, and social needs. Barriers identified by participants included: limited time for appointments; limited adolescent autonomy in appointments; and poor continuity of care when adolescents cannot see the same provider. Given the complexity of issues raised, adolescents and providers were interested in developing an appointment planning tool to guide communication during appointments, and contributed input on its design. The resulting Appointment Planning Tool app pilot is in progress. CONCLUSIONS:Qualitative interviews with adolescents and providers offer critical insights for the development and implementation of mobile health (mHealth) tools that can foster patient-centered care.

OBJECTIVES/OBJECTIVE:Understanding barriers to care for transgender people with cancer is necessary to increase oncologic care access. Little has been published regarding the experiences of transgender people with cancer. We sought to explore these experiences, assess barriers to oncologic care, and elucidate potential solutions. METHODS:Using an interpretive descriptive approach, we conducted two group interviews with transgender people who had been diagnosed with cancer and one with physicians who treat patients with cancer. Two investigators independently analyzed verbatim transcripts and, together, refined themes, resolving disagreements with consensus. Member checking and peer debriefing were used to confirm and elaborate on findings. RESULTS:Seven people who had been diagnosed with cancer and five physicians who treat people with cancer participated in group interviews. Themes included: (a) experiences with cancer may uniquely impact transgender people; (b) enforcement of clinician and systemic gender expectations creates barriers to cancer care; and (c) resistance to gender expectations may facilitate care. CONCLUSIONS:Gender expectations create barriers to oncologic care, which can be resisted by patients, clinicians, and institutions. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:Clinicians and institutions should create gender-inclusive oncologic spaces, demonstrate allyship, and support patient autonomy to decrease barriers to care for transgender people with cancer.