Faculty Bibliography

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/Purpose: Parent anxiety can affect infant experiences of procedural pain. However, little is known about other parent psychological factors associated with parent anxiety related to infant/toddler cleft and craniofacial surgery, and to what degree preoperative parent anxiety affects infant/toddler experiences of postoperative pain. Objectives 1. To identify psychological factors associated with preoperative anxiety for parents with young infants/toddlers undergoing craniofacial surgery 2. To determine whether preoperative parent anxiety is associated with infant/toddler postoperative pain Methods/Description: This was a prospective cohort study of all patients undergoing primary cleft and craniofacial surgery at a tertiary care medical center. Seventy-one consecutive parents of infants/toddlers 2-18 months were recruited for this study. Preoperative parent assessment included: anxiety (Hospital Anxiety and Depression Scale [HADS]), coping (Brief COPE), Parent Health Locus of Control scale, de novo self-efficacy around child pain, and pain knowledge. Sociodemographic data included child's age, gender; previous surgery, NICU or feeding tube; and parent age, gender, socioeconomic status, and race. Subsequent nurse-assessed child pain scores were collected for patients admitted postoperatively. Analyses included hierarchical multivariable logistic and linear regression models. Results: Parents (n=71, 90% female) of young children (mean age 6.6 mo) undergoing cleft lip/palate (n=59) or cranial vault repair (n=13) were enrolled. Only maladaptive coping (OR 1.3, p<0.01, 95% CI 1.1, 1.6), low pain management parent self-efficacy (OR 2.4, p<0.01, 95% CI 1.3, 4.5), and external locus of control (1.74, p 0.024, 95% CI 11, 2.9) were associated with high anxiety on bivariable analysis. In the final model, odds of parent preoperative anxiety was associated with differences in maladaptive coping score (aOR). Moderate/severe preoperative parental anxiety (HADS>10) was correlated with significantly higher child mean hospital pain scores in families of children undergoing cleft lip repair (1.87 point on 0-10 scale, 95% CI.42, 3.70, p =0.045). Conclusions: Infants/toddlers undergoing cleft and craniofacial surgery with highly anxious parents prior to surgery are at greater risk for higher hospital pain. Coping and self-efficacy are modifiable factors that contribute to parent anxiety before and during hospitalization and may be targets for intervention. Health locus of control could be incorporated into preoperative screening for vulnerable families

Parathyroid hormone (PTH) is a primary calcium regulatory hormone. Elevated serum PTH concentrations in primary and secondary hyperparathyroidism have been associated with bone disease, hypertension, and in some studies, cardiovascular mortality. Genetic causes of variation in circulating PTH concentrations are incompletely understood. We performed a genome-wide association study of serum PTH concentrations among 29,155 participants of European ancestry from 13 cohort studies (n=22,653 and n=6502 in discovery and replication analyses, respectively). We evaluated the association of single nucleotide polymorphisms (SNPs) with natural log-transformed PTH concentration adjusted for age, sex, season, study site, and principal components of ancestry. We discovered associations of SNPs from five independent regions with serum PTH concentration, including the strongest association with rs6127099 upstream of CYP24A1 (P=4.2 × 10^-53), a gene that encodes the primary catabolic enzyme for 1,25-dihydroxyvitamin D and 25-dihydroxyvitamin D. Each additional copy of the minor allele at this SNP associated with 7% higher serum PTH concentration. The other SNPs associated with serum PTH concentration included rs4074995 within RGS14 (P=6.6 × 10^-17), rs219779 adjacent to CLDN14 (P=3.5 × 10^-16), rs4443100 near RTDR1 (P=8.7 × 10^-9), and rs73186030 near CASR (P=4.8 × 10^-8). Of these five SNPs, rs6127099, rs4074995, and rs219779 replicated. Thus, common genetic variants located near genes involved in vitamin D metabolism and calcium and renal phosphate transport associated with differences in circulating PTH concentrations. Future studies could identify the causal variants at these loci, and the clinical and functional relevance of these variants should be pursued.

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 AND OBJECTIVE: Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents. METHODS: Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as "excellent" on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English. RESULTS: Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing "excellent" vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter. CONCLUSIONS: Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.

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: Hispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents. METHODS: Cross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged 20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0-3; adequate = 4-6) and LEP (speaks English less than "very well"). RESULTS: A total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7-2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1-1.9]). CONCLUSIONS: Dosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.

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.

Older patients with ESRD who receive a kidney transplant (KT) may develop post-KT dementia and Alzheimer's disease (AD) associated with their long-standing kidney disease and/or neurotoxic immunosuppressant agents. To investigate this possibility, we studied 40,918 older (aged ≥55 years) KT recipients (January 1, 1999 to December 31, 2011) linked to Medicare claims through the US Renal Data System. We estimated dementia and AD risk (cumulative incidence) and studied factors associated with these sequelae using competing risks models. We estimated the risk of death-censored graft loss and mortality after developing dementia or the AD subtype of dementia, separately, using adjusted Cox proportional hazards models. Older recipients had a 10-year dementia risk ranging from 5.1% for recipients aged 55-60 years to 17.0% for recipients aged ≥75 years; 10-year AD risk ranged from 1.0% to 6.7%, respectively. The strongest predictors for dementia and AD were older recipient age and pretransplant diabetes. The 10-year graft loss risk was 28.8% for those who did not develop dementia and 43.1% for those who did, and the corresponding mortality risks were 55.7% and 89.9%, respectively. Older recipients with dementia had a 1.52-fold (95% confidence interval, 1.39 to 1.68) increased risk of graft loss and a 2.38-fold (95% confidence interval, 2.26 to 2.49) increased risk of mortality. We observed similar results for AD. We conclude that older KT recipients have a high risk of post-KT dementia and AD, and these sequelae associate with a profound effect on patient and graft survival.

PURPOSE OF REVIEW/OBJECTIVE:This article intends to review biomarkers derived from blood, urine, and tissue that can aid in the diagnosis of prostate cancer (PCa). RECENT FINDINGS/RESULTS:PCa screening requires tools that complement prostate-specific antigen (PSA) with a higher specificity for clinically significant disease. Novel blood biomarkers, such as the Prostate Health Index (phi) and 4Kscore, utilize isoforms of PSA to more accurately predict high-grade PCa than traditional tools such as PSA and the percentage free-to-total PSA. Several gene products associated with PCa can be detected in the urine through commercially available assays. PCa antigen 3 (PCA3), though approved for repeat biopsy decisions, appears inferior to other biomarkers such as phi for identifying aggressive disease. However, combinations of PCA3 with other urine assays have shown promising results. One tissue-based hypermethylation test, named ConfirmMDx, can also be used to determine the need for repeat biopsy in men with a prior negative biopsy. SUMMARY/CONCLUSIONS:Several biomarkers have been developed to aid in the screening and diagnosis of PCa. Such tests are often indicated in men with moderately elevated PSA or history of a prior negative biopsy. Their use facilitates reduction of unnecessary biopsies without sacrificing the early diagnosis of clinically significant PCa.