Faculty Bibliography

OBJECTIVE: Determine maternal and infant characteristics associated with adding cereal into the bottle. DESIGN: Secondary data analysis. PARTICIPANTS: Study participants were immigrant, low-income, urban mother-infant dyads (n = 216; 91% Hispanic, 19% US-born) enrolled in a randomized controlled trial entitled the Bellevue Project for Early Language, Literacy and Education Success. MAIN OUTCOME MEASURES: Maternal characteristics (age, marital status, ethnicity, primary language, country of origin, education, work status, income, depressive symptoms, and concern about infant's future weight) and infant characteristics (gender, first born, and difficult temperament). ANALYSIS: Fisher exact test, chi-square test, and simultaneous multiple logistic regression of significant (P < .05) variables identified in unadjusted analyses. RESULTS: Twenty-seven percent of mothers added cereal into the bottle. After adjusting for confounding variables identified in bivariate analyses, mothers who were single (P = .02), had moderate to severe depressive symptoms (P = .01) and perceived their infant had a difficult temperament (P = .03) were more likely to add cereal into the bottle. Conversely, mothers who expressed concern about their infants becoming overweight were less likely to add cereal (P = .02). CONCLUSIONS AND IMPLICATIONS: Health care providers should screen for adding cereal in infant bottles. Further research is needed to investigate the impact of adding cereal into the bottle on weight trajectories over time. Causal associations also need to be identified to effectively prevent this practice.

Current guidelines for chronic kidney disease (CKD) recommend using albuminuria as well as estimated glomerular filtration rate (eGFR) to stage CKD. However, CKD progression is solely defined by change in eGFR with little regard to the risk implications of change in albuminuria. This is an observational study from the Stockholm CREAtinine Measurements (SCREAM) project, a health care utilization cohort from Stockholm, Sweden, with laboratory measures from 2006-2011 and follow-up through December 2012. Included were 31,732 individuals with two or more ambulatory urine albumin to creatinine ratio (ACR) tests. We assessed the association between change in ACR during a baseline period of 1, 2, or 3 years and end-stage renal disease (ESRD) or death. Using a 2-year baseline period, there were 378 ESRD events and 1712 deaths during a median of 3 years of follow-up. Compared to stable ACR, a 4-fold increase in ACR was associated with a 3.08-times (95% confidence interval 2.59 to 3.67) higher risk of ESRD while a 4-fold decrease in ACR was associated with a 0.34-times (0.26 to 0.45) lower risk of ESRD. Similar associations were found in people with and without diabetes mellitus, with and without hypertension, and also when adjusted for the change in eGFR during the same period. The association between change in ACR and mortality was weaker: ACR increase was associated with mortality, but the relationship was largely flat for ACR decline. Results were consistent for 1-, 2-, and 3-year ACR changes. Thus, changes in albuminuria are strongly and consistently associated with the risk of ESRD and death.

Program/Project Purpose: Teaching medicine in English in non-English-speaking countries is increasingly common. IMGs receive less communication skills training and tend to perform less well on communication skills assessments. This project's purpose was to create the first Objective Structured Clinical Examination (OSCE) program in English with standardized patients at one medical school in Turkey. Structure/Method/Design: All 48 medical students in the fourth year M.D. class (of six years) at Koc University School of Medicine, Istanbul, Turkey, were separated into two internal medicine blocks in 2015-16, and were given a single station, pass/fail, end-of-block OSCE in English. Palpitations and abdominal pain OSCE cases were adapted with permission from New York University. Six American teachers from the KU English Learning Center and five faculty from KUSOM were recruited and trained as SPs and faculty assessors, respectively, in 3 training sessions per OSCE. NYU's competency-based assessment checklists were used. To prepare students, specific bedside teaching sessions were delivered during the clinical block. Data was analyzed in REDCap and ethical approval was obtained at KUSOM. Outcome & Evaluation: For each block, 58-100% students passed the OSCE. SPs gave well done marks to 50-88% for eliciting the story with appropriate questions, 8-20% for providing clear explanations about diagnosis and treatment, 58-76% for managing the physical exam respectfully, 66-80% for using clear and easy to understand English, and 50-64% of students would be recommended or highly recommended to a friend, respectively (N=48 divided into two blocks). Students who failed scored poorly on medical English anchors (N=10). Students most strongly agreed that the OSCE helped them identify strengths and weaknesses and stimulated them to learn more (3.24 and 2.96 averages, Likert scale 1=strongly disagree, 4=strongly agree). Going Forward: KUSOM's OSCE pilot program exceeded expectations. Education and counseling was more challenging than information gathering or conducting physical examination. The second block performed better than the first block. The large increase in performance between blocks is likely explained by better attendance at bedside sessions. Offering OSCEs in both English and Turkish next year will help clarify whether their performance reflected clinical skills or English language alone. These findings inform expansion of curriculum and faculty development in bedside teaching at KUSOM

Executive functions are thinking skills that assist with reasoning, planning, problem solving, and managing one's life. The brain areas that underlie these skills are interconnected with and influenced by activity in many different brain areas, some of which are associated with emotion and stress. One consequence of the stress-specific connections is that executive functions, which help us to organize our thinking, tend to be disrupted when stimulation is too high and we are stressed out, or too low when we are bored and lethargic. Given their central role in reasoning and also in managing stress and emotion, scientists have conducted studies, primarily with adults, to determine whether executive functions can be improved by training. By and large, results have shown that they can be, in part through computer-based videogame-like activities. Evidence of wider, more general benefits from such computer-based training, however, is mixed. Accordingly, scientists have reasoned that training will have wider benefits if it is implemented early, with very young children as the neural circuitry of executive functions is developing, and that it will be most effective if embedded in children's everyday activities. Evidence produced by this research, however, is also mixed. In sum, much remains to be learned about executive function training. Without question, however, continued research on this important topic will yield valuable information about cognitive development. For further resources related to this article, please visit the WIREs website.

Early stress exposure is proposed to have significant lasting effects on cognitive development. The glucocorticoid hormone cortisol, a product of the hypothalamic-pituitary-adrenal (HPA) axis, is a particular focus of research, however, the majority of past research has been based on studies of older children and adults. Evidence linking cortisol levels in infancy with cognitive development is lacking. In a large cohort sample of infants (N = 1,091) oversampled for psychosocial risk, we tested whether basal cortisol levels and cortisol reactivity to emotional stressors administered at 7 and 15 months of age were associated with cognitive development measured at 15 months. Cognitive development was measured using the Mental Development Index of the Bayley Scales of Infant Development. Multiple regression analyses indicated that basal cortisol levels at 15 months, and to a lesser extent at 7 months, were inversely associated with infant cognitive development after adjusting for psychosocial and obstetric risk. The findings provide some of the first evidence that HPA axis activity in infancy is associated with early cognitive development.

As many as 50% of people satisfying diagnostic criteria for dementia are undiagnosed. A team-based training program for dementia screening and management was developed targeting four professions (medicine, nursing, pharmacy, social work) whose scope of practice involves dementia care. An interprofessional group of 10 faculty members was trained to facilitate four interactive competency stations on dementia screening, differential diagnoses, dementia management and team care planning, and screening for and managing caregiver stress. Registrants were organized into teams of five members, with at least one member of each profession per team. The teams rotated through all stations, completing assigned tasks through interprofessional collaboration. A total of 117 professionals (51 physicians, 11 nurses, 20 pharmacists, 24 social workers, 11 others) successfully completed the program. Change scores showed significant improvements in overall competence in dementia assessment and intervention (very low = 1; very high = 5; average change 1.12, P < .001), awareness of importance of dementia screening (average change 0.85, P < .001), and confidence in managing medication (average change 0.86, P < .001). Eighty-seven participants (82.9%) reported feeling confident or very confident using the dementia toolkit at their home institution. In a survey administered 3 months after the session, 48 respondents reported that they had changed their approach to administering the Mini-Cog test (78%), differential diagnosis (49%), assessment of caregiver stress (74%), and accessing community support and services (69%). In conclusion, team-based interprofessional competency training is a team teaching model that can be used to enhance competency in dementia screening and management in medical, nursing, pharmacy, and social work practitioners.

Few investigations have evaluated the incremental usefulness of tubular injury biomarkers for improved prediction of chronic kidney disease (CKD) progression. As such, we measured urinary kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, N-acetyl-ß-D-glucosaminidase and liver fatty acid binding protein under highly standardized conditions among 2466 enrollees of the prospective Chronic Renal Insufficiency Cohort Study. During 9433 person-years of follow-up, there were 581 cases of CKD progression defined as incident end-stage renal disease or halving of the estimated glomerular filtration rate. Levels of the urine injury biomarkers, normalized for urine creatinine, were strongly associated with CKD progression in unadjusted Cox proportional hazard models with hazard ratios in the range of 7 to 15 comparing the highest with the lowest quintiles. However, after controlling for the serum creatinine-based estimated glomerular filtration rate and urinary albumin/creatinine ratio, none of the normalized biomarkers was independently associated with CKD progression. None of the biomarkers improved on the high (0.89) C-statistic for the base clinical model. Thus, among patients with CKD, risk prediction with a clinical model that includes the serum creatinine-based estimated glomerular filtration rate and the urinary albumin/creatinine ratio is not improved on with the addition of renal tubular injury biomarkers.

Longitudinal studies of cognitive performance are sensitive to dropout, as participants experiencing cognitive deficits are less likely to attend study visits, which may bias estimated associations between exposures of interest and cognitive decline. Multiple imputation is a powerful tool for handling missing data, however its use for missing cognitive outcome measures in longitudinal analyses remains limited. We use multiple imputation by chained equations (MICE) to impute cognitive performance scores of participants who did not attend the 2011-2013 exam of the Atherosclerosis Risk in Communities Study. We examined the validity of imputed scores using observed and simulated data under varying assumptions. We examined differences in the estimated association between diabetes at baseline and 20-year cognitive decline with and without imputed values. Lastly, we discuss how different analytic methods (mixed models and models fit using generalized estimate equations) and choice of for whom to impute result in different estimands. Validation using observed data showed MICE produced unbiased imputations. Simulations showed a substantial reduction in the bias of the 20-year association between diabetes and cognitive decline comparing MICE (3-4 % bias) to analyses of available data only (16-23 % bias) in a construct where missingness was strongly informative but realistic. Associations between diabetes and 20-year cognitive decline were substantially stronger with MICE than in available-case analyses. Our study suggests when informative data are available for non-examined participants, MICE can be an effective tool for imputing cognitive performance and improving assessment of cognitive decline, though careful thought should be given to target imputation population and analytic model chosen, as they may yield different estimands.

Cardiovascular disease causes over 50% of the deaths in dialysis patients, and the risk of death is higher in white than in black patients. The underlying mechanisms for these findings are unknown. We determined the association of the proatherogenic metabolite trimethylamine N-oxide (TMAO) with cardiovascular outcomes in hemodialysis patients and assessed whether this association differs by race. We measured TMAO in stored serum samples obtained 3-6 months after randomization from a total of 1232 white and black patients of the Hemodialysis Study, and analyzed the association of TMAO with cardiovascular outcomes using Cox models adjusted for potential confounders (demographics, clinical characteristics, comorbidities, albumin, and residual kidney function). Mean age of the patients was 58 years; 35% of patients were white. TMAO concentration did not differ between whites and blacks. In whites, 2-fold higher TMAO associated with higher risk (hazard ratio [95% confidence interval]) of cardiac death (1.45 [1.24 to 1.69]), sudden cardiac death [1.70 (1.34 to 2.15)], first cardiovascular event (1.15 [1.01 to 1.32]), and any-cause death (1.22 [1.09 to 1.36]). In blacks, the association was nonlinear and significant only for cardiac death among patients with TMAO concentrations below the median (1.58 [1.03 to 2.44]). Compared with blacks in the same quintile, whites in the highest quintile for TMAO (≥135 μM) had a 4-fold higher risk of cardiac or sudden cardiac death and a 2-fold higher risk of any-cause death. We conclude that TMAO concentration associates with cardiovascular events in hemodialysis patients but the effects differ by race.