Faculty Bibliography

Chronic stress is a risk factor for incident cardiovascular (CV) disease. Emotion regulation is the ability to modulate one's state or behavior in response to a given situation or stressor, and may mitigate the effect of chronic stress on CV disease risk. Data from a cohort of 754 community-dwelling young to middle-aged adults who were assessed between 2007 and 2012 on stress, emotion regulation, and CV risk measures were used to test the hypothesis that emotion regulation mitigates the effect of chronic stress on CV risk. Emotion regulation was measured using the Difficulties in Emotion Regulation Scale (DERS). We created a composite stress score using data from the Cumulative Adversity Interview and the Perceived Stress Scale. Our outcomes included blood pressure, body mass index, and insulin resistance separately and combined into a composite CV risk score. Covariates included age, sex, race, years of education, and smoking status. We used multivariable logistic regression to evaluate associations between stress measures and CV risk among participants and the impact of emotion regulation (DERS scores) on this association. We found that composite stress interacted significantly with the DERS score to affect CV risk (p = .007). A median split of the DERS scores indicated that CV risk was associated with the composite stress score in the fully adjusted model (ß = 0.206; p = .005) among participants with low emotion regulation, but not among those with high emotion regulation (ß = 0.048; p = .59). Chronic stress was associated with CV risk only among participants with poor emotion regulation. Emotion regulation is a teachable skill, and may play a role in preventing CV disease.Lay summaryEmotion regulation is the ability to modify one's reaction to a negative or stressful event, and is a teachable skill. Effective emotion regulation dampens the negative effect of chronic stress on the body, which may reduce risk for cardiovascular disease.

Use of synthetic cathinones ("bath salts") has been associated with tens of thousands of emergency department visits. Few surveys, however, query use. Research on "bath salt" use is needed, especially in high-risk populations, to inform prevention and harm reduction efforts. A total of 933 adults (ages 18-40) were surveyed entering electronic dance music (EDM) parties in New York City in 2017. Lifetime use of 22 different synthetic cathinones was queried, and agreement with four statements about "bath salts" was also assessed. Prevalence and correlates of self-reported "bath salt" use was examined as well as correlates of beliefs about "bath salts." An estimated 3.5% of EDM attendees have knowingly used "bath salts." Almost half (46.7%) believe "bath salts" are more harmful than MDMA, 30.1% believe "bath salts" have turned users into cannibals, 30.0% believe "bath salts" are sometimes found in Molly, and 14.9% believe they might have unknowingly used "bath salts." Males, those earning <$500 per week, and those with a college degree were at higher risk for use. Believing "bath salts" have turned users into cannibals, however, was protective against use. Findings suggest the need for more accurate information (e.g., regarding drug effects) on this large and heterogeneous group of compounds.

Communication-and-resolution programs (CRPs) are intended to promote accountability, transparency, and learning after adverse events. In this article we address five key challenges to the programs' future success: implementation fidelity, the evidence base for CRPs and their link to patient safety, fair compensation of harmed patients, alignment of CRP design with participants' needs, and public policy on CRPs. While the field has arrived at an understanding of the core communication-and-resolution practices, limited adherence fuels skepticism that programs are meeting the needs of patients and families who have been injured by care or improving patient safety. Adherence to communication-and-resolution practices could be enhanced by adopting measures of CRP quality and implementing programs in a comprehensive, principled, and systematic manner. Of particular importance is offering fair compensation to patients in CRPs and supporting their right to attorney representation. There is evidence that the use of CRPs reduces liability costs, but research on other outcomes is limited. Additional research is especially needed on the links between CRPs and quality and on the programs' alignment with patients' and families' needs. By honoring principles of transparency, quality improvement, and patient and family empowerment, organizations can use their CRPs to help revitalize the medical profession.

Objective: To investigate the effects of decreasing insufflation pressure during robotic-assisted gynecologic surgery on intraoperative and postoperative parameters. The primary outcomes were patient-reported postoperative pain scores and length of stay in the post-anesthesia care unit (PACU). Secondary outcomes included intraoperative respiratory parameters, duration of surgery, total anesthesia time, and postoperative pain medication use. Design: Retrospective cohort study. Settings: Single academic urban hospital. Patients: Female patients undergoing robot-assisted surgery for benign gynecologic conditions performed by a single surgeon from 2014 to 2018. Interventions: Exposure to surgery performed at four different insufflation pressures: 15 mmHg (n = 99), 12 mmHg (n = 100), 10 mmHg (n = 99), and 8 mmHg (n = 300). Measurements/Results: 598 patients were identified. P values for continuous variables were determined using analysis of variance. Two-sided chi² test was used for categorical variables. When comparing the four groups, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs 3.8, p = < 0.0001), anesthesia time (p = .007), and length of stay in the PACU (449 vs 467 vs 351 vs 317 minutes, p = < 0.0001). There was no difference in duration of surgery (p = .31) or estimated blood loss (p = .09). Throughout the surgery, lower operating pressure was correlated with significantly lower peak inspiratory pressures (p < .0001) and tidal volumes (p < .0001), but a higher end tidal CO2 (p < .0001). Conclusions: Robot-assisted gynecologic surgery is associated with improved intraoperative and postoperative clinical outcomes with each decrease in insufflation pressure. Significant improvements include faster postoperative recovery times, decreased immediate postoperative pain, and improved intraoperative respiratory parameters without increasing duration of surgery or blood loss. [Figure presented] [Figure presented] [Figure presented]

Objective: To validate prior findings of retrospective studies that endometriosis presents with left-sided predominance. Design: Retrospective cohort study. Settings: A single university medical center. Patients: Patients undergoing robot-assisted gynecologic procedures from December 2013 to January 2018. Based on distribution of endometriotic specimens submitted to pathology, patients were divided into three groups: left-predominant, right-predominant, and bilateral/midline. [Figure presented] Interventions: Robot-assisted laparoscopic treatment of endometriosis. Measurements/Results: The three study groups did not differ in median in age, body mass index (BMI), gravidity, parity, and type of prior endometriosis treatment. Distribution of endometriosis was significantly more likely to exhibit left predominance than right-predominant or bilateral distribution (median number of total specimens: 6 vs. 3 vs. 3, p < .05). Endometriotic lesions were significantly located in the left periureteral and uterosacral regions compared to right-predominant and bilateral distribution (median number of total specimens: 1 vs. 0 vs. 0, p < .05 and 1 vs. 0 vs. 0, p = .05, respectively). There was no significant difference in distribution of endometriomas (median number of total endometriomas: 1 vs. 1 vs. 2, left vs. right vs. bilateral, respectively, p = .34). Operative times were not significantly different between groups (60 vs. 84 vs. 90 minutes, left-predominant vs. right-predominant vs. bilateral/midline distribution, respectively, p = .20). Overall complication rates were low with a total of 5 patients requiring intraoperative consults to other surgical teams including general surgery, gynecology oncology, and urology. Four total reoperations were performed in non-urgent fashion due to recurrence of endometriosis. Conclusions: This study reaffirms prior findings that endometriosis often demonstrates a left-predominant distribution. Surgical time, which may function as a surrogate for disease severity, was not significantly different between groups, though may be underpowered. Further investigation will focus on the clinical significance of endometriosis distribution, such as complication rates, intraoperative consults, and disease recurrence.

Data from a six-year study of married women's sexual health in a low-income community in Mumbai indicated that almost half the sample of 1125 women reported that they had a negative view of sex with their husbands. Qualitative interviews and quantitative survey data identified several factors that contributed to this diminished interest including: a lack of foreplay, forced sex, the difficulty of achieving privacy in crowded dwellings, poor marital relationships and communication, a lack of facilities for post-sex ablution and a strong desire to avoid conception. Women's coping strategies to avoid husband's demands for sex included refusal based on poor health, the presence of family members in the home and non-verbal communication. Factors that contributed to a satisfactory or pleasurable sexual relationship included greater relational equity, willingness on the part of the husband to not have sex if it is not wanted, a more 'loving' (pyaar karna) approach, women able to initiate sex and greater communication about sexual and non-sexual issues. This paper examines the ecological, cultural, couple and individual dynamics of intimacy and sexual satisfaction as a basis for the development of effective interventions for risk reduction among married women.

OBJECTIVES:Only 12 countries in the WHO's African region met Millennium Development Goal 4 (MDG 4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country mixed methods study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia was selected for an in-depth case study due to its success in reducing under-five mortality by 73% and thus successfully meeting MDG 4. Liberia's success was particularly notable given the civil war that ended in 2003. We examined some factors contributing to their reductions in under-five mortality. DESIGN:A case study mixed methods approach drawing on data from quantitative indicators, national documents and qualitative interviews was used to describe factors that enabled Liberia to rebuild their maternal, neonatal and child health (MNCH) programmes and reduce under-five mortality following the country's civil war. SETTING:The interviews were conducted in Monrovia (Montserrado County) and the areas in and around Gbarnga, Liberia (Bong County, North Central region). PARTICIPANTS:Key informant interviews were conducted with Ministry of Health officials, donor organisations, community-based organisations involved in MNCH and healthcare workers. Focus group discussions were conducted with women who have experience accessing MNCH services. RESULTS:Three prominent factors contributed to the reduction in under-five mortality: national prioritisation of MNCH after the civil war; implementation of integrated packages of services that expanded access to key interventions and promoted intersectoral collaborations; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals. CONCLUSIONS:Although Liberia experiences continued challenges related to limited resources, Liberia's effective strategies and rapid progress may provide insights for reducing under-five mortality in other post-conflict settings.