Faculty Bibliography

The number of new HIV infections continues to be on the rise in many high-income countries, most notably among men who have sex with men (MSM). Despite recent attention to the use of antiretroviral medications as pre-exposure prophylaxis (PrEP) among MSM, considerably less research has been devoted to examining the awareness and use of post-exposure prophylaxis (PEP). Based on a convenience sample of 179 self-reported HIV-uninfected MSM using a geosocial-networking smartphone application, this study is among the first to examine the awareness and use of PEP and their demographic and behavioral correlates among MSM in London. Most respondents (88.3%) had heard of PEP, where 27.4% reported having used it. In multivariable models, the disclosure of one's sexual orientation to their general practitioner (Prevalence ratio [PR]: 3.49; 95% confidence interval (CI): 1.14, 10.70; p = .029) and reporting one's HIV status as negative (rather than unknown) (PR: 11.49; 95% CI: 1.68, 76.92; p = .013) were associated with having heard of PEP; while the recent use of club drugs (PR: 3.02; 95% CI: 1.42, 6.43; p = .004) was associated with having ever used PEP. High awareness and use in this sample suggest that PEP is a valuable risk-reduction strategy that should be capitalized on, be it in addition to or in the absence of PrEP.

Background: Asian Americans are one of the fastest growing minority populations in the United States. With increases in the older adult population too, there needs to be research dedicated to their health. Past studies have shown that social isolation and loneliness predict greater physical, mental, and cognitive decline. This literature review was conducted to address this emerging need to understand the scope of research focused on social isolation and Asian American older adults. Methods: The PRISMA guidelines were used to guide this review. Four interdisciplinary databases searched were: PubMed, CINAHL, PsychINFO, and AgeLine. Search terms included variations on the words social isolation, loneliness, Asian Americans, and older adults. The date of the last search was July 6th, 2016. Articles were reviewed based on 5 eligibility criteria: (1) topic relevance, (2) study participants > 60 years of age, (3) Asian immigrants as main participants, (4) conducted in a Western country, and (5) published in the English language. The remaining studies were assessed on eight categories: ethnic group, health topic, geographic location, subject population, recruitment site, study design, outcomes accessed, and outcomes measures. Results: The search yielded 203 articles from the four databases. 49 articles were removed as duplicates. The 154 remaining studies were reviewed based on their abstract and 34 met the eligibility criteria and underwent full text review. Existing research has focused primarily on immigrant Chinese and Korean older adult populations located in major gateway cities (ex: Los Angeles, New York City). Studies were largely observational studies that were conducted using small community-based samples which makes generalizability difficult. There were zero interventional studies. Conclusions: There are critical gaps in the literature on social isolation in Asian immigrant populations. Future studies should prioritize health promotion intervention research and focus on diverse understudied Asian subgroups (e.g. South Asians, Cambodians, Filipinos). Potential pitfalls of this literature review include: accessing only four major databases, limiting searches to after 1995, and studies were conducted throughout countries with different healthcare systems

BACKGROUND: There is a need for screening and brief assessment instruments to identify primary care patients with substance use problems. This study's aim was to examine the performance of a two-step screening and brief assessment instrument, the TAPS Tool, compared to the WHO ASSIST. METHODS: Two thousand adult primary care patients recruited from five primary care clinics in four Eastern US states completed the TAPS Tool followed by the ASSIST. The ability of the TAPS Tool to identify moderate- and high-risk use scores on the ASSIST was examined using sensitivity and specificity analyses. RESULTS: The interviewer and self-administered computer tablet versions of the TAPS Tool generated similar results. The interviewer-administered version (at cut-off of 2), had acceptable sensitivity and specificity for high-risk tobacco (0.90 and 0.77) and alcohol (0.87 and 0.80) use. For illicit drugs, sensitivities were >0.82 and specificities >0.92. The TAPS (at a cut-off of 1) had good sensitivity and specificity for moderate-risk tobacco use (0.83 and 0.97) and alcohol (0.83 and 0.74). Among illicit drugs, sensitivity was acceptable for moderate-risk of marijuana (0.71), while it was low for all other illicit drugs and non-medical use of prescription medications. Specificities were 0.97 or higher for all illicit drugs and prescription medications. CONCLUSIONS: The TAPS Tool identified adult primary care patients with high-risk ASSIST scores for all substances as well moderate-risk users of tobacco, alcohol, and marijuana, although it did not perform well in identifying patients with moderate-risk use of other drugs or non-medical use of prescription medications. The advantages of the TAPS Tool over the ASSIST are its more limited number of items and focus solely on substance use in the past 3months.

Background: A comprehensive geriatric assessment clinic (GAC) was established in collaboration with a health plan within a markedly impoverished region in the US. Evaluation objectives were to assess the quality of chronic illness care from the perspective of member-patients and providers. Methods: We abstracted medical records of patients attending the GAC during one quarter of 2014 and administered the 20-item Patient Assessment of Chronic Illness Care (PACIC) survey in English and Spanish in 2015. We anonymously surveyed patients before and directly after visits. Survey questions, modified for low health literacy, used a 1-to-5-likert scale (1=none of the time to 5=always) for 5 domains: patient activation, decision support, goal setting, problem solving, and care coordination. We administered a 7-item quality assessment survey to providers for: relevance, ease of use, ability to apply findings, and agreement with diagnostic findings and recommendations, using a 1-to-5-likert scale (1=strongly disagree to 5=strongly agree). Results: Abstracted data for 193 patients demonstrated 51% had not finished high school and their chronic condition burden was high (mean: 7.2 conditions; 31% with diabetes). For patient surveys (n=165; 19% Spanish), post-visit PACIC domain scores ranged from 4.0-4.5 and post-visit ratings were higher across all domains (1.4 to 1.7 higher; p<0.001 for each). For each of 20 questions, aggregate post scores improved, indicating higher quality. For provider surveys, respondents (n=14) felt the GAC provided useful (50%) and relevant (64%) information for their practices, taught them how to provide better care for other patients (64%), and made it easier to provide care (50%). Less than one third (29%) felt their experience discouraged them from using the service again. Discussion: The AC greatly improved member-perceived care quality and facilitated provider care among patients with high chronic condition burden, suggesting a useful strategy for patients with high need. Since some providers did not find this service useful, provider focus groups are underway to understand and improve unmet provider needs

The King-Devick (K-D) test of rapid number naming is a visual performance measure that captures saccadic eye movements. Patients with multiple sclerosis (MS) have slowed K-D test times associated with neurologic disability and reduced quality of life. We assessed eye movements during the K-D test to identify characteristics associated with slowed times. Participants performed a computerized K-D test with video-oculography. The 25-Item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) and its 10-Item Neuro-Ophthalmic Supplement measured vision-specific quality of life (VSQOL). Among 25 participants with MS (age 37 +/- 10 years, range 20-59) and 42 controls (age 33 +/- 9 years, range 19-54), MS was associated with significantly longer (worse) K-D times (58.2 +/- 19.8 vs. 43.8 +/- 8.6 s, P = 0.001, linear regression models, accounting for age). In MS, test times were slower among patients with higher (worse) Expanded Disability Status Scale scores (P = 0.01). Average inter-saccadic intervals (ISI) were significantly longer in MS participants compared to controls (362 +/- 103 vs. 286 +/- 50 ms, P = 0.001), and were highly associated with prolonged K-D times in MS (P = 0.006). MS participants generated greater numbers of saccades (P = 0.007). VSQOL scores were reduced in MS patients with longer (worse) K-D times (P = 0.04-0.001) and longer ISI (P = 0.002-0.001). Patients with MS have slowed K-D times that may be attributable to prolonged ISI and greater numbers of saccades. The K-D test and its requisite eye movements capture VSQOL and make rapid number naming a strong candidate efferent visual performance measure in MS.

OBJECTIVES:This study sought to evaluate the association of physical activity with chronic myocardial damage, assessed by elevated high-sensitivity cardiac troponin T (hs-cTnT), in individuals with and without obesity. BACKGROUND:Physical activity is associated with reduced risk of heart failure (HF), particularly among obese people. The role of chronic myocardial damage in this association is uncertain. METHODS:. Physical activity was categorized per American Heart Association guidelines as recommended, intermediate, or poor. We evaluated cross-sectional associations of physical activity and obesity with elevated hs-cTnT (≥14 ng/l). In prospective analyses, we quantified the association of elevated hs-cTnT with HF risk within cross-categories of baseline physical activity and obesity. RESULTS:People with poor physical activity were more likely to have elevated hs-cTnT than those with recommended levels (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.15 to 1.68). In cross-categories of physical activity and obesity, using the non-obese/recommended activity group as the reference, individuals with obesity and poor activity were most likely to have elevated hs-cTnT (OR: 2.46; 95% CI: 1.91 to 3.19), whereas the obese/recommended activity group had a weaker association (OR: 1.68; 95% CI: 1.28 to 2.21; p < 0.001 for interaction between physical activity and obesity). In prospective analyses, elevated hs-cTnT was strongly associated (p < 0.001) with incident HF in all obesity/physical activity cross-categories (p > 0.20 for interaction). CONCLUSIONS:Physical activity is inversely associated with chronic subclinical myocardial damage. Physical activity might lessen the association between obesity and subclinical myocardial damage, which could represent a mechanism by which physical activity reduces HF risk.

OBJECTIVE: To determine whether patient-specific 3D printed renal tumor models change pre-operative planning decisions made by urological surgeons in preparation for complex renal mass surgical procedures. MATERIALS AND METHODS: From our ongoing IRB approved study on renal neoplasms, ten renal mass cases were retrospectively selected based on Nephrometry Score greater than 5 (range 6-10). A 3D post-contrast fat-suppressed gradient-echo T1-weighted sequence was used to generate 3D printed models. The cases were evaluated by three experienced urologic oncology surgeons in a randomized fashion using (1) imaging data on PACS alone and (2) 3D printed model in addition to the imaging data. A questionnaire regarding surgical approach and planning was administered. The presumed pre-operative approaches with and without the model were compared. Any change between the presumed approaches and the actual surgical intervention was recorded. RESULTS: There was a change in planned approach with the 3D printed model for all ten cases with the largest impact seen regarding decisions on transperitoneal or retroperitoneal approach and clamping, with changes seen in 30%-50% of cases. Mean parenchymal volume loss for the operated kidney was 21.4%. Volume losses >20% were associated with increased ischemia times and surgeons tended to report a different approach with the use of the 3D model compared to that with imaging alone in these cases. The 3D printed models helped increase confidence regarding the chosen operative procedure in all cases. CONCLUSIONS: Pre-operative physical 3D models created from MRI data may influence surgical planning for complex kidney cancer.

Limbic encephalitis presents as altered mood, memory loss and confusion. Clinical features may include psychiatric symptoms and seizures. In contrast to paraneoplastic disorders, non-paraneoplastic autoimmune encephalitis often responds to immunotherapy and sometimes with marked recovery. However, relapse can occur. An 82-year-old male presented with subacute episodes of memory loss over a few days. The patient was unable to recognize his own home and family members. Physical exam was unremarkable. Neuropsychological assessment revealed deficits in cognitive performance that could be consistent with moderate dementia or a more rapidly progressive encephalopathy. Agitated behavior and anxiety were also noted. Laboratory evaluation included hyponatremia, which was corrected with no symptom improvement. B12, TSH, and HIV were normal. CSF analysis revealed 10 WBCs/muL, Glucose-52 mg/dl, Protein-62 mg/dl and was negative for infectious, neoplastic causes, varicella, VDRL, viral cultures, NMDA receptor antibody, GAD 65 antibody and Anti-Hu antibody. Occult malignancy work up with CT scan of chest and abdomen and colonoscopy was normal. Serum for voltage-gated potassium channel antibodies was positive at 849 pmol/l (>88). EEG showed occasional focal left fronto-temporal slowing without epileptiform activity. MRI revealed focal enhancement of the medial left temporal lobe consistent with limbic encephalitis. The patient started high dose steroids with improvement in memory and complete resolution of focal abnormality within the left hippocampal/parahippocampal region suggestive of resolving encephalitis. At seven months after tapering steroids the patient presented with myoclonus and recurrent memory loss. MRI demonstrated recurrent encephalitis with gyral swelling and FLAIR hyperintensity in the left temporal lobe. The patient was restarted on high dose steroids with addition of Rituximab. This case illustrates that limbic encephalitis can present as a rapidly progressive dementia. Differential diagnosis should include more unusual forms of rapidly progressive dementia such as Jakob-Creutzfeldt disease if myoclonus is present, Lewy body dementia if waxing and waning memory, and Alzheimer's dementia with acute delirium if presenting over a period of months. In this patient, MRI changes were crucial to recognizing a potentially reversible limbic encephalitis. Early recognition and treatment may decrease relapse and reduce functional impairment

Background: There is little data on presentation of and care for oncology patients in the ED. Our goal was to describe the characteristics and dispositions of patients with active cancer who present to EDs of the Comprehensive ONCologic Emergencies Research Network. Methods: Prospective, observational study of patients >=18 years of age with active cancer in 19 US tertiary-care EDs. A patient survey was administered in the ED, and a 30-day chart review identified ED course, comorbidities, revisits, and outcomes. Descriptive statistics were calculated. Results: We enrolled 616 patients, with 364 having complete 30 day chart reviews. The population was 50% female, 13% African-American, 3% Asian, and 7% Hispanic. Mean age was 63 years with 291 >=65. The most common cancer types were gastrointestinal (22%), breast (12%), and lung (10%). Almost half (47%) had no living will or advanced directive. In the week prior to ED visit, symptoms reported as present "quite a bit" or "very much" included pain (47%), shortness of breath (24%), and nausea (20%). ED symptom-related complaints were common including pain (69%), shortness of breath (38%), and nausea (34%). Ten percent reported fever >=100.4degree F prior to ED arrival. In the 364 subjects with completed chart reviews, 52% received pain medication and 31% nausea medication in the ED. Antibiotics were administered to 28% (n=99). ED disposition included admission in 64% (12% to step-down or ICU), observation in 7%, and discharge in 28%. 30-day mortality was 5.7% (95% CI 3.4-8.7%). 30-day ED revisit and hospital readmission rates were 27% and 23%.< Conclusion: ED patients with active cancer present with high acuity and substantial symptom burden including pain, nausea, and shortness of breath. Infection is a frequent concern in the ED with high rates of antibiotic administration. These patients have high admission, mortality, and revisit rates. Additional studies to identify optimal ED care and disposition practices for this population are warranted

Background: Cocaine is commonly involved in unintentional drug poisoning (overdose) deaths, accounting for 41% of overdose in New York City (NYC) in 2014. However, little research exists regarding cocaine use by middle-aged and older adults, who are more likely than younger individuals to have underlying cardiovascular disease and other chronic conditions and therefore may be at increased risk for adverse health consequences of cocaine use including death.
Objective(s): To describe demographic characteristics of middle-and-older-aged NYC adults who died of a cocaine-involved overdose death, and to identify potential associations by age, race, borough of residence, and concomitant drugs among deaths involving cocaine compared with overdose deaths not involving cocaine.
Method(s): We conducted a retrospective analysis of unintentional drug overdose deaths of adults aged 45 to 84 in New York City (NYC) from 2000 to 2014 using 2 linked sources, NYC death certificates and toxicology results from the Office of the Chief Medical Examiner. We described demographic characteristics and drugs involved in overdoses, by age ranges 45 to 54, 55 to 64, and 65 to 84. Data were stratified and compared by cocaine involvement using bivariable analysis. The multivariable analysis included age, race, gender, and borough of residence to determine associations between demographic characteristics and cocaine-involved overdoses.
Result(s): From 2000 to 2014, there were 5339 unintentional drug overdose deaths among adults aged 45 to 84 in NYC. Of those, cocaine was involved in 54% (n = 2856). Co-occurring opioid involvement (heroin, methadone, or opioid analgesics) and alcohol use among deaths involving cocaine was common. Compared with decedents of noncocaine-involved overdose, decedents of cocaine-involved overdose were more likely to be younger (52.5-53.0 years, P = 0.002), male (75% vs 72%, P = 0.005), and non-Hispanic black (47% vs 26%, P < 0.001). Multivariate analysis showed that male gender (AOR=1.34, 95% CI 1.17-1.52), Bronx residence (AOR= 1.278, 95% CI 1.04-1.57), and non-Hispanic black race/ethnicity (AOR = 2.31, 95% CI 1.98-2.69) were independently associated with cocaine-involved overdose compared with none cocaine-involved overdose.
Conclusion(s): Cocaine was involved in over half of unintentional drug overdose deaths in NYC for adults aged 45 to 84. It remains unclear what the role of cocaine was in the setting of adults with underlying cardiovascular disease. Studies that examine autopsy data may be able to elucidate the underlying impact of cocaine in drug-related overdose deaths