Faculty Bibliography

OBJECTIVE:To define the rates of common Hospital Acquired Conditions (HACs) in patients undergoing major urological surgery over a period of time encompassing the implementation of the Hospital Acquired Condition Reduction program, and to evaluate whether implementation of the HAC reimbursement penalties in 2008 was associated with a change in the rate of HACs. METHODS:Using American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data, we determined rates of HACs in patients undergoing major inpatient urological surgery from 2005 to 2012. Rates were stratified by procedure type and approach (open vs. laparoscopic/robotic). Multivariable logistic regression was used to determine the association between year of surgery and HACs. RESULTS:We identified 39,257 patients undergoing major urological surgery, of whom 2300 (5.9%) had at least one hospital acquired condition. Urinary tract infection (UTI, 2.6%) was the most common, followed by surgical site infection (SSI, 2.5%) and venous thrombotic events (VTE, 0.7%). Multivariable logistic regression analysis demonstrated that open surgical approach, diabetes, congestive heart failure, chronic obstructive pulmonary disease, weight loss, and ASA class were among the variables associated with higher likelihood of HAC. We observed a non-significant secular trend of decreasing rates of HAC from 7.4% to 5.8% HACs during the study period, which encompassed the implementation of the Hospital Acquired Condition Reduction Program. CONCLUSIONS:HACs occurred at a rate of 5.9% after major urological surgery, and are significantly affected by procedure type and patient health status. The rate of HAC appeared unaffected by national reduction program in this cohort. Better understanding of the factors associated with HACs is critical in developing effective reduction programs.

PURPOSE: To better understand the decision making behind the ordering of CT pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE) in the emergency department. METHODS: We conducted semistructured interviews with our institution's emergency medicine (EM) providers and radiologists who read CTPAs performed in the emergency department. We employed the Theoretical Domains Framework-a formal, structured approach used to better understand the motivations and beliefs of physicians surrounding a complex medical decision making-to categorize the themes that arose from our interviews. RESULTS: EM providers were identified as the main drivers of CTPA ordering. Both EM and radiologist groups perceived the radiologist's role as more limited. Experience- and gestalt-based heuristics were the most important factors driving this decision and more important, in many cases, than established algorithms for CTPA ordering. There were contrasting views on the value of d-dimer in the suspected PE workup, with EM providers finding this test less useful than radiologists. EM provider and radiologist suggestions for improving the appropriateness of CTPA ordering consisted of making this process more arduous and incorporating d-dimer tests and prediction rules into a decision support tool. CONCLUSION: EM providers were the main drivers of CTPA ordering, and there was a marginalized role for the radiologist. Experience- and gestalt-based heuristics were the main influencers of CTPA ordering. Our findings suggest that a more nuanced intervention than simply including a d-dimer and a prediction score in each preimaging workup may be necessary to curb overordering of CTPA in patients suspected of PE.

Purpose To retrospectively assess whether there is an association between screening mammography and the use of a variety of preventive services in women who are enrolled in Medicare. Materials and Methods U.S. Medicare claims from 2010 to 2014 Research Identifiable Files were reviewed to retrospectively identify a group of women who underwent screening mammography and a control group without screening mammography in 2012. The screened group was divided into positive versus negative results at screening, and the positive subgroup was divided into false-positive and true-positive findings. Multivariate logistic regression models and inverse probability of treatment weighting were used to examine the relationship between screening status and the probabilities of undergoing Papanicolaou test, bone mass measurement, or influenza vaccination in the following 2 years. Results The cohort consisted of 555 705 patients, of whom 185 625 (33.4%) underwent mammography. After adjusting for patient demographics, comorbidities, geographic covariates, and baseline preventive care, women who underwent index screening mammography (with either positive or negative results) were more likely than unscreened women to later undergo Papanicolaou test (odds ratio [OR], 1.49; 95% confidence interval: 1.40, 1.58), bone mass measurement (OR, 1.70; 95% confidence interval: 1.63, 1.78), and influenza vaccine (OR, 1.45; 95% confidence interval: 1.37, 1.53). In women who had not undergone these preventive measures in the 2 years before screening mammography, use of these three services after false-positive findings at screening was no different than after true-negative findings at screening. Conclusion In beneficiaries of U.S. Medicare, use of screening mammography was associated with higher likelihood of adherence to other preventive guidelines, without a negative association between false-positive results and cervical cancer screening.

Considering the vast ongoing challenge of preventing obesity, the time has come to reconceptualize and change the way we study the development of obesity in childhood. The developmental cascade model, which refers to the cumulative consequences and spreading downstream effects of risk and protective factors, offers a longitudinal framework for understanding obesity. This perspective elucidates the way an accumulation of risk factors, across and within biopsychosocial spheres and phases of development, can propel individuals toward obesity. In this article, we use a theory-driven model-building approach and a review of published literature to propose a developmental cascade model of pediatric obesity focused on proximal biopsychosocial influences (e.g., genetic, intrapersonal, familial). A two-stage scoping review conducted in January 2015 and May 2016 identified 1315 unique studies; 310 were included in the final review. The proposed developmental cascade model provides a basis for testing hypothesized cascades with multiple intervening variables and complex longitudinal processes. Moreover, the model informs future research by resolving seemingly contradictory findings on pathways to obesity previously thought to be distinct (low self-esteem, consuming sugary foods, and poor sleep cause obesity) that are actually processes working together over time (low self-esteem causes consumption of sugary foods which disrupts sleep quality and contributes to obesity). The resultant empirical findings of such inquiries are highly informative for identifying the timing and specific targets of preventive interventions across and within developmental phases. The implications of such a cascade model of pediatric obesity for health psychology and developmental and prevention sciences are discussed.

BACKGROUND:Community violence may affect a broad range of health outcomes through physiologic stress responses and changes in health behaviors among residents. However, existing research on the health impacts of community violence suffers from problems with bias. METHODS:We examined the relations of acute changes in community violence with hospital visits and deaths due to stress-responsive diseases (mental, respiratory, and cardiac conditions) in statewide data from California 2005-2013. The community violence exposure was measured as both binary spikes and continuous acute changes. We applied a combined fixed-effects and time-series design that separates the effects of violence from those of community- and individual-level confounders more effectively than past research. Temporal patterning was removed from community violence rates and disease rates in each place using a Kalman smoother, resulting in residual rates. We used linear regression with place fixed-effects to examine within-place associations of acute changes in community violence with residual rates of each outcome, controlling for local time-varying covariates. RESULTS:We found acute increases in hospital visits and deaths due to anxiety disorders (0.31 per 100,000; 95% confidence interval [CI] = 0.02, 0.59), substance use (0.47 per 100,000; 95% CI = 0.14, 0.80), asthma (0.56 per 100,000; 95% CI = 0.16, 0.95), and fatal acute myocardial infarction (0.09 per 100,000; 95% CI = 0.00, 0.18) co-occurring with violence spikes. The pattern of findings was similar for the exposure of continuous acute violence changes. CONCLUSIONS:Although the associations were small, the identified increases in stress-responsive conditions suggest the possibility of health impacts of acute changes in community violence.

DPP (dipeptidyl peptidase)-4 inhibitors are antidiabetic drugs that may increase heart failure in high-risk patients. NPY (neuropeptide Y) is coreleased with norepinephrine, causes vasoconstriction via the Y1 receptor, and is degraded by DPP4 to NPY (3-36) in vitro. NPY (3-36) decreases release of norepinephrine via the Y2 receptor. We tested the hypothesis that DPP4 inhibition would potentiate the vasoconstrictor effect of NPY. Eighteen nonsmokers (12 healthy controls and 6 with type 2 diabetes mellitus) participated in 1 of 2 randomized, double-blind, placebo-controlled crossover studies. First, subjects were randomized to order of treatment with sitagliptin 100 mg/d versus placebo for 7 days separated by 4-week washout. On the last day of treatment, NPY was infused by brachial artery and forearm blood flow was measured using plethysmography. Blood samples were collected after each dose. NPY infusions were repeated after 90-minute washout and intra-arterial enalaprilat. Second, 5 healthy subjects were randomized to crossover treatment with sitagliptin 100 mg/d plus valsartan 160 mg/d versus placebo plus valsartan. NPY infusions were performed on the seventh day of treatment. NPY caused dose-dependent vasoconstriction. During enalaprilat, sitagliptin significantly potentiated NPY-induced vasoconstriction in controls and diabetics ( P≤0.02 for forearm blood flow in either group). Baseline norepinephrine release was increased during sitagliptin and enalaprilat, but not further by NPY. Sitagliptin increased the ratio of NPY to NPY (3-36). During valsartan, sitagliptin also significantly potentiated NPY-induced vasoconstriction ( P=0.009 for forearm blood flow). Potentiation of endogenous NPY could contribute to cardiovascular effects of DPP4 inhibitors in patients taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.

While research increasingly studies how neighborhood contexts influence HIV among gay, bisexual and other men who have sex with men (MSM) populations, to date, no research has used global positioning system (GPS) devices, an innovative method to study spatial mobility through neighborhood contexts, i.e., the environmental riskscape, among a sample of Black MSM. The purpose of this study was to examine the feasibility of collecting two-week GPS data (as measured by a pre- and post-surveys as well as objectively measured adherence to GPS protocol) among a geographically-diverse sample of Black MSM in the Deep South: Gulfport, MS, Jackson, MS, and New Orleans LA (n = 75). GPS feasibility was demonstrated including from survey items, e.g. Black MSM reported high ratings of pre-protocol acceptability, ease of use, and low levels of wear-related concerns. Findings from this study demonstrate that using GPS methods is acceptable and feasible among Black MSM in the Deep South.