Faculty Bibliography

AIMS:To assess associations between body mass index (BMI), waist circumference (WC), and computed tomography-determined volumes of pericardial, visceral, and subcutaneous adipose tissue with magnetic resonance imaging-(MRI) based cerebral structure and cognitive performance in individuals with type 2 diabetes (T2D). METHODS:This study was performed in 348 African Americans (AAs) and 256 European Americans (EAs) with T2D. Associations between adiposity measures with cerebral volumes of white matter (WMV), gray matter (GMV), white matter lesions, hippocampal GMV, and hippocampal WMV, cognitive performance and depression were examined using marginal models incorporating generalized estimating equations. All models were adjusted for age, sex, education, smoking, HbA1c, hypertension, statins, cardiovascular disease, MRI scanner (MRI outcomes only), and time between scans; some neuroimaging measures were additionally adjusted for intracranial volume. RESULTS:Participants were 59.9% female with mean (SD) age 57.7(9.3)years, diabetes duration 9.6(6.8)years, and HbA1c 7.8(1.9)%. In AAs, inverse associations were detected between hippocampal GMV and both BMI (β [95% CI]-0.18 [-0.30, -0.07], P=0.0018) and WC (-0.23 [-0.35, -0.12], P=0.0001). In the full bi-ethnic sample, inverse associations were detected between hippocampal WMV and WC (P≤0.0001). Positive relationships were observed between BMI (P=0.0007) and WC (P<0.0001) with depression in EAs. CONCLUSIONS:In patients with T2D, adiposity is inversely associated with hippocampal gray and white matter volumes.

CONTEXT:Relative to European Americans, calcified atherosclerotic plaque (CP) is less prevalent and severe in African-Americans (AAs). OBJECTIVE:Predictors of progression of CP in the aorta, carotid, and coronary arteries were examined in AAs over a mean 5.3 ± 1.4-year interval. DESIGN:This is the African American-Diabetes Heart Study. SETTING:A type 2 diabetes (T2D)-affected cohort was included. PARTICIPANTS:A total of 300 unrelated AAs with T2D; 50% female, mean age 55 ± 9 years, baseline hemoglobin A1c 8.1 ± 1.8% was included. MAIN OUTCOME MEASURES:Glycemic control, renal parameters, vitamin D, and computed tomography-derived measures of adiposity, vascular CP, and volumetric bone mineral density (vBMD) in lumbar and thoracic vertebrae were obtained at baseline and follow-up. RESULTS:CP increased in incidence and quantity/mass in all three vascular beds over the 5-year study (P < .0001). Lower baseline lumbar and thoracic vBMD were associated with progression of abdominal aorta CP (P < .008), but not progression of carotid or coronary artery CP. Lower baseline estimated glomerular filtration rate was associated with progression of carotid artery CP (P = .0004), and higher baseline pericardial adipose volume was associated with progression of coronary artery (P = .001) and aorta (P = .0006) CP independent of body mass index. There was a trend for an inverse relationship between change in thoracic vBMD and change in aortic CP (P = .05). CONCLUSIONS:In this longitudinal study, lower baseline thoracic and lumbar vBMD and estimated glomerular filtration rate and higher pericardial adipose volumes were associated with increases in CP in AAs with T2D. Changes in these variables and baseline levels and/or changes in glycemic control, albuminuria, and vitamin D were not significantly associated with progression of CP.

Background: Geosocial-networking smartphone applications (apps) have been used increasingly by men who have sex with men (MSM) to meet new sexual partners. The purpose of this study was to examine associations between contexts of app use (e.g. using apps when drinking) and condomless anal intercourse among a sample of MSM who use these apps. Methods: MSM (n=174) in New York City were recruited through Grindr, a geosocial-networking app popular among MSM, using broadcast advertisements asking MSM to complete an Internet-based survey about their app use and sexual behaviours. Log-binomial regression models were fit to assess the association between each of the six app-use contexts (e.g. using apps when lonely, when drinking) and engagement in condomless insertive and receptive anal intercourse with one or more partners in the past 3 months. Results: Engagement in condomless receptive and insertive anal intercourse with one or more partners in the preceding 3 months was common (39.7% and 43.1% respectively) and was associated with several app-use contexts. For example, significant associations (P<0.05) were observed between alcohol and other drug use when using these apps and engagement in condomless receptive and insertive anal intercourse. Conclusion: Given that 57.5% of respondents had engaged in condomless anal intercourse in the preceding 3 months and the associations of app-use contexts with condomless sexual behaviours, these findings suggest that reductions in substance use may lead to safer sexual practices among MSM who use apps to meet sexual partners.

OBJECTIVE: To examine how food store environments can promote healthful eating, including (1) preferences for a variety of behavioral economics strategies to promote healthful food purchases, and (2) the cross-sectional association between the primary food store where participants reported shopping, dietary behaviors, and body mass index. METHODS: Intercept survey participants (n = 342) from 2 midsized eastern North Carolina communities completed questionnaires regarding preferred behavioral economics strategies, the primary food store at which they shopped, and consumption of fruits, vegetables, and sugary beverages. RESULTS: Frequently selected behavioral economic strategies included: (1) a token and reward system for fruit and vegetable purchases; and (2) price discounts on healthful foods and beverages. There was a significant association between the primary food store and consumption of fruits and vegetables (P = .005) and sugary beverages (P = .02). CONCLUSIONS AND IMPLICATIONS: Future studies should examine associations between elements of the in-store food environment, purchases, and consumption.

OBJECTIVES: To determine consumer and fast-food purchase characteristics associated with the purchase of a sugar-sweetened beverage, as well as calories and grams of sugar, for children at a fast-food restaurant. METHODS: We completed cross-sectional analyses of fast-food restaurant receipts and point-of-purchase surveys (n = 483) collected during 2013 and 2014 in New York City and Newark and Jersey City, New Jersey. RESULTS: Caregivers purchased beverages for half of all children in our sample. Approximately 60% of these beverages were sugar-sweetened beverages. Fast-food meals with sugar-sweetened beverages had, on average, 179 more calories than meals with non-sugar-sweetened beverages. Being an adolescent or male, having a caregiver with a high school degree or less, having a caregiver who saw the posted calorie information, ordering a combination meal, and eating the meal in the restaurant were associated with ordering a sugar-sweetened beverage. Purchases that included a combination meal or were consumed in the restaurant included more beverage grams of sugar and calories. CONCLUSIONS: Characteristics of fast-food purchases appear to have the largest and most important association to beverage calories for children at fast-food restaurants. Targeting fast-food restaurants, particularly combination meals, may improve childhood obesity rates.

INTRODUCTION: Studies have shown that a large number of ambulance transports to emergency departments (ED) could have been safely treated in an alternative environment, prompting interest in the development of more patient-centered models for prehospital care. We examined patient attitudes, perspectives, and agreement/comfort with alternate destinations and other proposed innovations in Emergency Medical Services (EMS) care delivery and determined whether demographic, socioeconomic, acuity, and EMS utilization history factors impact levels of agreement. METHODS: We conducted a cross-sectional study on a convenience sample of patients and caregivers presenting to an urban academic ED between July 2012 and May 2013. Respondents were surveyed on levels of agreement with 13 statements corresponding to various aspects of a proposed patient-centered emergency response system including increased EMS access to healthcare records, shared decision making with the patient and/or primary care physician, transport to alternative destinations, and relative importance of EMS assessment versus transportation. Information on demographic and socioeconomic factors, level of acuity, and EMS utilization history were also determined via survey and chart review. Responses were analyzed descriptively and compared across patient characteristics using chi-square and regression analyses. RESULTS: A total of 621 patients were enrolled. The percentage of patients who agreed or strongly agreed with each of the 13 statements ranged from 48.2 to 93.8%. About 86% agreed with increased EMS access to healthcare records; approximately 72% agreed with coordinating disposition decisions with a primary physician; and about 58% supported transport to alternative destinations for low acuity conditions. No association was found between levels of agreement and the patient's level of acuity or EMS utilization history. Only Black or Hispanic race showed isolated associations with lower rates of agreement with some aspects of an innovative EMS care delivery model. CONCLUSION: A substantial proportion of patients surveyed in this cross sectional study agreed with a more patient-centered approach to prehospital care where a 9-1-1 call could be met with a variety of treatment and transportation options. Agreement was relatively consistent among a diverse group of patients with varying demographics, levels of acuity and EMS utilization history. MeSH Key words: emergency medical services; triage; telemedicine; surveys and questionnaires; transportation of patients.

Understanding the nexus of aging, HIV, and substance use is key to providing appropriate services and support for their aging, HIV seropositive patients. The proportion of PLWHA aged 50 and older is growing due to a variety of factors like decreases in mortality due to highly active retroviral therapy and non-negligible HIV incidence. We describe prevalence of alcohol, tobacco, and other drug use and participation in substance use treatment and 12-step programs among 95 HIV-positive patients aged 50 and older engaged in care. Most (73.7%) smoked cigarettes in their lifetime and 46.3% were current smokers. Most were at medium (81.1%) or high risk (13.7%) for an alcohol use disorder. With respect to illicit drug use, 48.4% had used marijuana, cocaine, crack, methamphetamines, heroin, and/or prescription opiates without a prescription in the last 12 months; 23.2% met criteria for drug dependence. Marijuana was the most commonly reported illicit drug (32.6%) followed by cocaine and crack (10.5% each), heroin and prescription opiates (7.4% each), and methamphetamines (6.3%). Among those who had not used drugs in the past 12 months, 36.7% had been in a substance use treatment program and 26.5% had participated in a 12-step program in their lifetime; 8.2% were currently in treatment and 16.3% were currently participating in a 12-step program. Among those who had used an illicit drug in the past 12 months, 37.0% had never been in treatment, 34.8% had been in treatment in their lifetime, and 28.3% were currently in treatment. With respect to 12-step programs, 27.3% of those meeting dependence criteria had never participated, 45.5% had participated in their lifetimes, and 27.3% were currently participating. Our findings suggest that older adults in HIV care settings could benefit from Screening, Brief Intervention, and Referral to Treatment interventions and/or integrated services for substance abuse and medical treatment.

We examine ethical challenges encountered in the design of an effectiveness trial (CTN-0051; X:BOT), comparing sublingual buprenorphine-naloxone (BUP-NX), an established treatment for opioid dependence, to the newer extended-release injectable naltrexone (XR-NTX). Ethical issues surrounded: 1) known poor effectiveness of one possible, commonly used treatment as usual control condition-detoxification followed by counseling without medication; 2) the role of patients' preferences for treatments, given that treatments were clinically approved and available to the population; 3) differences between the optimal "usual treatment" clinical settings for different treatments making it challenging to design a fair comparison; 4) vested interest groups favoring different treatments exerting potential influence on the design process; 5) potentially vulnerable populations of substance users and prisoners; 6) potential therapeutic misconception in the implementation of safety procedures; and 7) high cost of a large trial limiting questions that could be addressed. We examine how the design features underlying these ethical issues are characteristic of effectiveness trials, which are often large trials that compare treatments with varying degrees of existing effectiveness data and familiarity to patients and clinicians, in community-based treatment settings, with minimal exclusion criteria that could involve vulnerable populations. Hence, investigators designing effectiveness trials may wish to remain alert to the possibility of similar ethical issues.

OBJECTIVE: To assess the impact of the 2005 modification of the Gleason classification on risk of biochemical recurrence (BCR) after radical prostatectomy (RP). PATIENTS AND METHODS: In the Prostate Cancer data Base Sweden (PCBaSe), 2,574 men assessed with the original Gleason classification and 1,890 men assessed with the modified Gleason classification, diagnosed between 2003 and 2007, underwent primary RP. Histopathology was reported according to the Gleason Grading Groups (GGG): GGG1 = Gleason score (GS) 6, GGG2 = GS 7(3 + 4), GGG3 = GS 7(4 + 3), GGG4 = GS 8 and GGG5 = GS 9-10. Cumulative incidence and multivariable Cox proportional hazards regression models were used to assess difference in BCR. RESULTS: The cumulative incidence of BCR was lower using the modified compared to the original classification: GGG2 (16% vs. 23%), GGG3 (21% vs. 35%) and GGG4 (18% vs. 34%), respectively. Risk of BCR was lower for modified versus original classification, GGG2 Hazard ratio (HR) 0.66, (95%CI 0.49-0.88), GGG3 HR 0.57 (95%CI 0.38-0.88) and GGG4 HR 0.53 (95%CI 0.29-0.94). CONCLUSION: Due to grade migration following the 2005 Gleason modification, outcome after RP are more favourable. Consequently, outcomes from historical studies cannot directly be applied to a contemporary setting. J. Surg. Oncol. 2016;114:664-670. (c) 2016 Wiley Periodicals, Inc.