Faculty Bibliography

OBJECTIVE: There is a shortage of trained health care personnel for cervical cancer screening in low-/middle-income countries. We evaluated the feasibility and limited efficacy of a smartphone-based training of community health nurses in visual inspection of the cervix under acetic acid (VIA). MATERIALS AND METHODS: During April to July 2015 in urban Ghana, we designed and developed a study to determine the feasibility and efficacy of an mHealth-supported training of community health nurses (CHNs, n = 15) to perform VIA and to use smartphone images to obtain expert feedback on their diagnoses within 24 hours and to improve VIA skills retention. The CHNs completed a 2-week on-site introductory training in VIA performance and interpretation, followed by an ongoing 3-month text messaging-supported VIA training by an expert VIA reviewer. RESULTS: Community health nurses screened 169 women at their respective community health centers while receiving real-time feedback from the reviewer. The total agreement rate between all VIA diagnoses made by all CHNs and the expert reviewer was 95%. The mean (SD) rate of agreement between each CHN and the expert reviewer was 89.6% (12.8%). The agreement rates for positive and negative cases were 61.5% and 98.0%, respectively. Cohen kappa statistic was 0.67 (95% CI = 0.45-0.88). Around 7.7% of women tested VIA positive and received cryotherapy or further services. CONCLUSIONS: Our findings demonstrate the feasibility and efficacy of mHealth-supported VIA training of CHNs and have the potential to improve cervical cancer screening coverage in Ghana.

Migraine is a highly prevalent and disabling neurological disorder associated with a wide range of psychiatric comorbidities. In this manuscript, we provide an overview of the link between migraine and several comorbid psychiatric disorders, including depression, anxiety and post-traumatic stress disorder. We present data on psychiatric risk factors for migraine chronification. We discuss the evidence, theories and methods, such as brain functional imaging, to explain the pathophysiological links between migraine and psychiatric disorders. Finally, we provide an overview of the treatment considerations for treating migraine with psychiatric comorbidities. In conclusion, a review of the literature demonstrates the wide variety of psychiatric comorbidities with migraine. However, more research is needed to elucidate the neurocircuitry underlying the association between migraine and the comorbid psychiatric conditions and to determine the most effective treatment for migraine with psychiatric comorbidity.

Dissection of the ascending aorta, type A aortic dissection (TAAD), represents a surgical emergency with high morbidity and mortality. Current open surgical techniques, although state-of-the-art procedures and having improved outcomes for patients with TAAD over the last decades, confer significant risk of complications and death. Recently, endovascular techniques for repair of both the abdominal and thoracic aorta have gained acceptance within the vascular and cardiovascular surgical communities as a useful tool in select pathologies and patient populations. As development of endovascular technology proceeds ever closer to the aortic valve, thoracic endovascular repair for TAAD deserves special investigation. A comprehensive literature search for studies reporting outcomes of endovascular repair in the ascending aorta was performed. In this review, we compile the worldwide experience of thoracic endovascular repair for TAAD as well as imaging studies for patient selection and the use of hybrid (open plus endovascular) techniques. The authors discuss the remaining challenges that preclude its broader adoption in this role, namely patient selection and device specificity.

Oral mucositis (OM) is among the most common, painful, and debilitating toxicities of cancer regimen-related treatment, resulting in the formation of ulcers, which are susceptible to increased colonization of microorganisms. Novel discoveries in OM have focused on understanding the host-microbial interactions, because current pathways have shown that major virulence factors from microorganisms have the potential to contribute to the development of OM and may even prolong the existence of already established ulcerations, affecting tissue healing. Additional comprehensive and disciplined clinical investigation is needed to carefully characterize the relationship between the clinical trajectory of OM, the local levels of inflammatory changes (both clinical and molecular), and the ebb and flow of the oral microbiota. Answering such questions will increase our knowledge of the mechanisms engaged by the oral immune system in response to mucositis, facilitating their translation into novel therapeutic approaches. In doing so, directed clinical strategies can be developed that specifically target those times and tissues that are most susceptible to intervention.

Thousands of lives are lost every year in developing countries for failing to detect epidemics early because of the lack of real-time disease surveillance data. We present results from a large-scale deployment of a telephone triage service as a basis for dengue forecasting in Pakistan. Our system uses statistical analysis of dengue-related phone calls to accurately forecast suspected dengue cases 2 to 3 weeks ahead of time at a subcity level (correlation of up to 0.93). Our system has been operational at scale in Pakistan for the past 3 years and has received more than 300,000 phone calls. The predictions from our system are widely disseminated to public health officials and form a critical part of active government strategies for dengue containment. Our work is the first to demonstrate, with significant empirical evidence, that an accurate, location-specific disease forecasting system can be built using analysis of call volume data from a public health hotline.

A previous report documented that endocrine disrupting chemicals contribute substantially to certain forms of disease and disability. In the present analysis, our main objective was to update a range of health and economic costs that can be reasonably attributed to endocrine disrupting chemical exposures in the European Union, leveraging new burden and disease cost estimates of female reproductive conditions from accompanying report. Expert panels evaluated the epidemiologic evidence, using adapted criteria from the WHO Grading of Recommendations Assessment, Development and Evaluation Working Group, and evaluated laboratory and animal evidence of endocrine disruption using definitions recently promulgated by the Danish Environmental Protection Agency. The Delphi method was used to make decisions on the strength of the data. Expert panels consensus was achieved for probable (>20%) endocrine disrupting chemical causation for IQ loss and associated intellectual disability; autism; attention deficit hyperactivity disorder; endometriosis; fibroids; childhood obesity; adult obesity; adult diabetes; cryptorchidism; male infertility, and mortality associated with reduced testosterone. Accounting for probability of causation, and using the midpoint of each range for probability of causation, Monte Carlo simulations produced a median annual cost of euro163 billion (1.28% of EU Gross Domestic Product) across 1000 simulations. We conclude that endocrine disrupting chemical exposures in the EU are likely to contribute substantially to disease and dysfunction across the life course with costs in the hundreds of billions of Euros per year. These estimates represent only those endocrine disrupting chemicals with the highest probability of causation; a broader analysis would have produced greater estimates of burden of disease and costs.

OBJECTIVE: Asthma is a leading cause of pediatric admissions. While several factors including race have been linked to increased overall asthma morbidity and mortality, few studies have explored factors associated with inpatient asthma outcomes. We examined factors associated with mortality and morbidity in children admitted for asthma. DESIGN/METHODS: Data were obtained from the US Nationwide Inpatient Sample for 2007-2011. Patients 2-18 years old with a primary diagnosis of asthma were included. Predictor variables were sociodemographic and hospital factors and acute/chronic secondary diagnoses. Outcomes were mortality, intubation, length of stay (LOS), and costs. Weighted national estimates were calculated. Multivariable analyses were performed. RESULTS: There were 97,379 (478,546 weighted) asthma admissions. Most patients were male (60.6%); 30% were white, 28% black, and 18% Hispanic. Mortality rate was 0.03%. 0.3% were intubated. Median (IQR) LOS was 2 (1-3) days. Median (IQR) costs were $2760 ($1860-4320). Native American race, older age (13-18 years), and West region were significant independent predictors of mortality. Intubation rate was lower in Hispanic compared to white children (p=0.028). LOS was shorter in Asian compared to white children (p=0.022) but longer in children with public insurance and from low income areas (p <0.001). Average costs were higher in black, Hispanic, and Asian compared to white children (p<0.05). CONCLUSIONS: With the exception of Native Americans, race/ethnicity is not associated with inpatient asthma mortality and has varied effects on morbidity. Recognition of factors associated with increased asthma mortality and morbidity may allow for earlier, more effective treatment and avoidance of complications.

BACKGROUND: Formula-fed infants may be at greater risk for overfeeding and rapid weight gain. Different size bottles are used for feeding infants, although little is known about whether bottle size is related to weight gain in bottle-fed infants. METHODS: Data from the Greenlight Intervention Study, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics, were used to analyze the exposure to regular (<6 oz) or large (>/=6 oz) bottle size at the 2-month visit on changes in weight, weight-for-age z score (WAZ), and weight-for-length z score (WLZ) at the 6-month visit. Using multivariable regression, we adjusted for potential confounders (birth weight, gender, age, weight measures at 2 months, parent race/ethnicity, education, household income and size, time between 2- and 6-month visits, and first child status). RESULTS: Forty-five percent (n = 386; 41% black, 35% Hispanic, 23% white, 2% other) of infants at the 2-month visit were exclusively formula-fed, and 44% used large (>/=6 oz) bottles. Infants whose parents fed with large bottles had 0.21 kg (95% confidence interval [CI]: 0.05 to 0.37) more weight change, 0.24 U (95% CI: 0.07 to 0.41) more change in WAZ, and 0.31 U (95% CI: 0.08 to 0.54) more change in WLZ during this period than infants fed with regular bottles. CONCLUSIONS: Using a large bottle in early infancy independently contributed to greater weight gain and change in WLZ at the 6-month visit. Although growth in infancy is complex, bottle size may be a modifiable risk factor for rapid infant weight gain and later obesity among exclusively formula-fed infants.