Faculty Bibliography

There are an estimated 3.5 million Muslims in North America. During the holy month of Ramadan, healthy adult Muslims are to fast from predawn to after sunset. While there are exemptions for older and sick adults, many adults with diabetes fast during Ramadan. However, there are risks associated with fasting and specific management considerations for patients with diabetes. We evaluated provider practices and knowledge regarding the management of patients with diabetes who fast during Ramadan. A 15-question quality improvement survey based on a literature review and the American Diabetes Association guidelines was developed and offered to providers at the outpatient primary care and geriatric clinics at an inner-city hospital in New York City. Forty-five providers completed the survey. Most respondents did not ask their Muslim patients with diabetes if they were fasting during the previous Ramadan. Knowledge of fasting practices during Ramadan was variable, and most felt uncomfortable managing patients with diabetes during Ramadan. There is room for improvement in educating providers about specific cultural and medical issues regarding fasting for patients with diabetes during Ramadan.

PURPOSE: To explore correlates of meeting recommended physical activity (PA) goals among middle-aged and older Korean Americans at risk for diabetes mellitus (DM). DESIGN AND METHODS: PA patterns and their correlates were assessed among 292 middle-aged and older Korean Americans at risk for DM living in New York City using cross-sectional design of baseline information from a diabetes prevention intervention. PA was assessed by self-report of moderate and vigorous activity, results were stratified by age group (45-64 and 65-75 years), and bivariate analyses compared individuals performing less than sufficient PA and individuals performing sufficient PA. Logistic regression was used to calculate adjusted odds ratios predicting sufficient PA. FINDINGS: After adjusting for sex, age group, years lived in the United States, marital status, health insurance, and body mass index (BMI), sufficient PA was associated with male sex, older age, lower BMI, eating vegetables daily, and many PA-specific questions (lack of barriers, confidence, and engagement). When stratified by age group, male sex and eating vegetables daily was no longer significant among Koreans 65 to 75 years of age, and BMI was not significant for either age group. CONCLUSIONS: PA interventions targeting this population may be beneficial and should consider the roles of sex, age, physical and social environment, motivation, and self-efficacy. CLINICAL RELEVANCE: Clinical providers should understand the unique motivations for PA among Korean Americans and recognize the importance of culturally driven strategies to enable lifestyle changes and support successful aging for diverse populations.

BACKGROUND:Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide. OBJECTIVES/OBJECTIVE:We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation. SEARCH METHODS/METHODS:We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature. SELECTION CRITERIA/METHODS:We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure. DATA COLLECTION AND ANALYSIS/METHODS:Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding. RESULTS:Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics. CONCLUSIONS:Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

BACKGROUND:Primary cesarean deliveries are a major contributor to the large increase in cesarean delivery rates in the United States over the past 2 decades and are an essential focus for the reduction of related morbidity and costs. Studies have shown that primary cesarean delivery rates among low-risk women in the United States vary 3-fold across hospitals and are not explained by differences in patient case-mix. However, the extent to which maternal vs hospital characteristics contribute to this variation remains poorly understood because previous studies were limited in scope and did not assess the influence of factors such as maternal ethnicity subgroups or prepregnancy obesity. OBJECTIVE:We assessed the contribution of individual- and hospital-level risk factors to the hospital variation in primary cesarean delivery rates among low-risk women in Florida. STUDY DESIGN/METHODS:Our population-based retrospective cohort study used Florida's linked birth certificate and hospital discharge records for the period of 2004-2011. The study population was comprised of 412,192 nulliparous, singleton, vertex, live births with labor at 37-40 weeks gestation in 122 nonmilitary delivery hospitals. Data were analyzed with logistic mixed-effects regression with cesarean delivery as the outcome. This approach provided adjusted risk estimates at an individual and hospital level and the estimated percent of hospital variation statewide that was explained by these factors. RESULTS:The primary cesarean delivery rate in the study population was 23.9%, with hospital-specific estimates that ranged from 12.8-47.3%. Leading risk factors for cesarean delivery were maternal age ≥35 years (adjusted relative risk, 2.22), prepregnancy obesity (body mass index, ≥30 kg/m(2); adjusted relative risk, 1.73), medical risk conditions (adjusted relative risk, 1.72), labor induction (adjusted relative risk, 1.52), and delivery in hospitals located in Miami-Dade County (adjusted relative risk, 1.73). Hospital geographic location was a significant effect modifier for prepregnancy obesity, medical conditions, and labor induction (P < .05), with a tendency towards lower adjusted relative risks for these factors in Miami-Dade County relative to other Florida regions. Conversely, Miami-Dade County had an increased prevalence of higher-risk ethnic subgroups, such as Cuban or Puerto Rican mothers, and also substantially higher adjusted relative risks that were associated with practice-related factors, such as delivery during weekday hours. Whereas hospital geographic location contributed to 39.6% of the observed variation statewide, the estimated contribution of maternal ethnicity ranged from 1.6-15.7% among Florida regions. CONCLUSIONS:Hospital geographic location contributes to hospital variation in primary cesarean delivery rates among low-risk women in Florida. In contrast to previous studies, our findings suggest that individual level risk factors such as maternal ethnicity also contribute to some of this variation, with differing extent by region. These individual factors likely interact with practice factors and add to the variation. This study was limited by not including maternal Bishop score before induction or obstetrics provider in the analysis. These were not available on the dataset but likely contribute to the variation. Our findings suggest potential issues to consider in quality improvement efforts, such as the need for future qualitative research that focuses on mothers in higher-risk ethnic subgroups and providers in high-rate hospitals, particularly those in Miami-Dade County. These studies may help to identify potential cultural differences in maternal beliefs and expectations for delivery and maternal reasons for differences in obstetrics practices.

PURPOSE/OBJECTIVE:Extant research indicates that some of the comorbidities associated with adult obesity may be adversely affected by the stress resulting from negative body image and weight-related stigma. This study examined the association between weight-related pressure and insulin sensitivity in adolescents, who are vulnerable to both weight-based teasing and the onset of metabolic dysregulation. METHODS:Participants were 215 adolescent healthy volunteers (55% female; 59% white; 35% overweight/obese; mean ± standard deviation age = 15.4 ± 1.4 year), who completed a self-report measure of pressure to be thin from parents, friends, and romantic partners. Fasting blood samples were obtained to assess serum insulin and glucose, which were used to calculate insulin sensitivity; fat mass (kg) and fat-free mass (%) were measured with air-displacement plethysmography. Pubertal stage was determined by physical examination. RESULTS:Pressure to be thin was positively associated with fasting insulin (p = .01) and negatively associated with insulin sensitivity (p = .02), after controlling for pubertal stage, sex, race, height, fat-free mass, and adiposity. Pressure to be thin was associated with a greater odds of having hyperinsulinemia (fasting insulin ≥ 15 μIU/mL; odds ratio (95% confidence interval): 1.65 [1.08-2.50], p = .02), adjusting for the same covariates. CONCLUSIONS:Results indicate that adolescents perceiving more pressure to be thin have greater elevations of fasting insulin and poorer insulin sensitivity above and beyond the effect of fat mass. Future research is warranted to elucidate the mechanisms responsible for this relationship.

BACKGROUND:β-Trace protein (BTP) and β2-microglobulin (B2M) are novel glomerular filtration markers that have stronger associations with adverse outcomes than creatinine. Comparisons of BTP and B2M to creatinine and cystatin C are limited by the absence of rigorously developed glomerular filtration rate (GFR) estimating equations for the novel markers. STUDY DESIGN/METHODS:Study of diagnostic test accuracy. SETTING & PARTICIPANTS/METHODS:Pooled database of 3 populations with chronic kidney disease (CKD) with mean measured GFR of 48 mL/min/1.73 m2 (N=3,551; MDRD [Modification of Diet in Renal Disease] Study, AASK [African American Study of Kidney Disease and Hypertension], and CRIC [Chronic Renal Insufficiency Cohort] Study). INDEX TESTS/METHODS:GFR estimated using creatinine, cystatin C, BTP, or B2M level. REFERENCE TEST/METHODS:GFR measured as the urinary clearance of iothalamate. RESULTS:For BTP and B2M, coefficients for age, sex, and race were smaller than for creatinine and were similar or smaller than for cystatin C. For B2M, coefficients for sex, age, and race were smaller than for creatinine and were similar (age and race) or smaller (sex) than for cystatin C. The final equations with BTP (BTP, age, and sex) or B2M (B2M alone) were less accurate than either the CKD-EPI (CKD Epidemiology Collaboration) creatinine or cystatin C equations. The combined BTP-B2M equation (BTP and B2M alone) had similar accuracy to the CKD-EPI creatinine or cystatin C equation. The average of the BTP-B2M equation and the CKD-EPI creatinine-cystatin C equation was not more accurate than the CKD-EPI creatinine-cystatin C equation. LIMITATIONS/CONCLUSIONS:No external validation population, study population was restricted to CKD, few participants older than 65 years, or nonblack nonwhite race. CONCLUSIONS:BTP and B2M are less influenced by age, sex, and race than creatinine and less influenced by race than cystatin C, but provide less accurate GFR estimates than the CKD-EPI creatinine and cystatin C equations. The CKD-EPI BTP and B2M equation provides a methodological advance for their study as filtration markers and in their associations with risk and adverse outcomes, but further study is required before clinical use.

In diabetes, low concentrations of the biomarker 1,5-anhydroglucitol (1,5-AG) reflect hyperglycemic excursions over the prior 1-2 weeks. To the extent that hyperglycemic excursions are important in atherogenesis, 1,5-AG may provide independent information regarding cardiovascular risk. Nonetheless, few studies have evaluated associations of 1,5-AG with long-term cardiovascular outcomes in a population-based setting. We measured 1,5-AG in 11,106 participants in the Atherosclerosis Risk in Communities (ARIC) study without cardiovascular disease at baseline (1990-1992) and examined prospective associations with coronary heart disease (n = 1,159 events), ischemic stroke (n = 637), heart failure (n = 1,553), and death (n = 3,120) over 20 years of follow-up. Cox proportional hazards models were adjusted for demographic and cardiovascular risk factors. Compared with persons with 1,5-AG ≥6 μg/mL and no history of diabetes, persons with diabetes and 1,5-AG <6.0 μg/mL had an increased risk of coronary heart disease (HR 3.85, 95% CI 3.11-4.78), stroke (HR 3.48, 95% CI 2.66-4.55), heart failure (HR 3.50, 95% CI 2.93-4.17), and death (HR 2.44, 95% CI 2.11-2.83). There was a threshold effect, with little evidence for associations at "nondiabetic" concentrations of 1,5-AG (e.g., >10 μg/mL). Associations remained but were attenuated with additional adjustment for fasting glucose or HbA1c. These data add to the growing evidence for the prognostic value of 1,5-AG for long-term complications in the setting of diabetes.

BACKGROUND:Many avenues have been proposed for a seamless transition between biomarker discovery data and selected reaction monitoring (SRM) assays for biomarker validation. Unfortunately, studies with the abundant urinary protein uromodulin have shown that these methods do not converge on a consistent set of surrogate peptides for targeted mass spectrometry. As an alternative, we present an empirical peptide selection work flow for robust protein quantification. METHODS:We compared the relative SRM signal intensity of 12 uromodulin-derived peptides between tryptic digests of 9 urine samples. Pairwise CVs between the 12 peptides were 0.19-0.99. We used a correlation matrix to identify peptides that reproducibly tracked the amount of uromodulin protein and selected 4 peptides with robust and highly correlated SRM signals. Absolute quantification was performed with stable isotope-labeled versions of these peptides as internal standards and a standard curve prepared from a tryptic digest of purified uromodulin. RESULTS:Absolute quantification of uromodulin in 40 clinical urine samples yielded interpeptide correlations of ≥0.984 and correlations of ≥0.912 with ELISA data. The SRM assays were linear over >3 orders of magnitude and had typical interdigest CVs of <10%, interinjection CVs of <7%, and intertransition CVs of <7%. CONCLUSIONS:Comparing the apparent abundance of a plurality of peptides derived from the same target protein makes it possible to select signature peptides that are unaffected by the unpredictable confounding factors inevitably present in biological samples.