Faculty Bibliography

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Importance: While statin therapy for primary cardiovascular prevention has been associated with reductions in cardiovascular morbidity, the effect on all-cause mortality has been variable. There is little evidence to guide the use of statins for primary prevention in adults 75 years and older. Objectives: To examine statin treatment among adults aged 65 to 74 years and 75 years and older when used for primary prevention in the Lipid-Lowering Trial (LLT) component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT). Design, Setting, and Participants: Post hoc secondary data analyses were conducted of participants 65 years and older without evidence of atherosclerotic cardiovascular disease; 2867 ambulatory adults with hypertension and without baseline atherosclerotic cardiovascular disease were included. The ALLHAT-LLT was conducted from February 1994 to March 2002 at 513 clinical sites. Interventions: Pravastatin sodium (40 mg/d) vs usual care (UC). Main Outcomes and Measures: The primary outcome in the ALLHAT-LLT was all-cause mortality. Secondary outcomes included cause-specific mortality and nonfatal myocardial infarction or fatal coronary heart disease combined (coronary heart disease events). Results: There were 1467 participants (mean [SD] age, 71.3 [5.2] years) in the pravastatin group (48.0% [n = 704] female) and 1400 participants (mean [SD] age, 71.2 [5.2] years) in the UC group (50.8% [n = 711] female). The baseline mean (SD) low-density lipoprotein cholesterol levels were 147.7 (19.8) mg/dL in the pravastatin group and 147.6 (19.4) mg/dL in the UC group; by year 6, the mean (SD) low-density lipoprotein cholesterol levels were 109.1 (35.4) mg/dL in the pravastatin group and 128.8 (27.5) mg/dL in the UC group. At year 6, of the participants assigned to pravastatin, 42 of 253 (16.6%) were not taking any statin; 71.0% in the UC group were not taking any statin. The hazard ratios for all-cause mortality in the pravastatin group vs the UC group were 1.18 (95% CI, 0.97-1.42; P = .09) for all adults 65 years and older, 1.08 (95% CI, 0.85-1.37; P = .55) for adults aged 65 to 74 years, and 1.34 (95% CI, 0.98-1.84; P = .07) for adults 75 years and older. Coronary heart disease event rates were not significantly different among the groups. In multivariable regression, the results remained nonsignificant, and there was no significant interaction between treatment group and age. Conclusions and Relevance: No benefit was found when pravastatin was given for primary prevention to older adults with moderate hyperlipidemia and hypertension, and a nonsignificant direction toward increased all-cause mortality with pravastatin was observed among adults 75 years and older. Trial Registration: clinicaltrials.gov Identifier: NCT00000542.

OBJECTIVE: To assess whether a correlation exists between newsworthiness (Altmetric score) and scientific impact markers, such as citation analysis, impact factors, and levels of evidence. METHODS: The top five most cited articles for the year 2014 and 2015 from the top 10 ranking urology journals (Scientific Impact Group) were identified. The top 50 articles each in 2014 and 2015 were identified from Altmetric support based on media activity (Media Impact Group). We determined the number of citations that these articles received in the scientific literature, and calculated correlations between citations with Altmetric scores. RESULTS: In the Scientific Impact Group, the mean number of citations per article was 37.6, and the most highly cited articles were oncology guidelines. The mean Altmetric score in these articles was 14.8. There was a weak positive correlation between citations and Altmetric score (rs = 0.35, 95% confidence interval 0.16-0.52, P < 0.001). In the Media Impact Group, the mean Altmetric score was 121.1 and most widely shared articles all related to sexual medicine. In this group, the mean number of citations was 9.7 and there was a weak negative correlation between Altmetric score and citations (rs = -0.20, P = 0.046). CONCLUSION: The top articles based on Altmetric scores were not highly cited, suggesting that publications receiving the most media attention may not be the most scientifically rigorous, or that this audience places greater value on different subjects than the scientific community.

BACKGROUND: In 2012 The Joint Commission implemented new Tobacco Treatment (TOB) performance measures for hospitals. A study evaluated the impact of a hospital-based electronic health record (EHR) intervention on adherence to the revised TOB measures. METHODS: The study was conducted in two acute care hospitals in New York City. Data abstracted from the EHR were analyzed retrospectively from 4,871 smokers discharged between December 2012 and March 2015 to evaluate the impact of two interventions: an order set to prompt clinicians to prescribe pharmacotherapy and a nurse-delivered counseling module that automatically populated the nursing care plan for all smokers. The study estimated the relative odds of a patient being prescribed medication and/or receiving smoking cessation counseling in the intervention period compared to the baseline time period. RESULTS: There was a modest increase in medication orders (odds ratio [OR], 1.35). In contrast, rates of counseling increased 10-fold (OR, 10.54). Patients admitted through surgery were less likely to receive both counseling and medication compared with the medicine service. CONCLUSION: Hospitalization presents an important opportunity to engage smokers in treatment for primary and secondary prevention of tobacco-related illnesses. EHRs can be leveraged to facilitate integration of TOB measure requirements into routine inpatient care; however, the smaller effect on prescribing patterns suggests limitations in this approach alone in changing clinician behavior to meet this measure. The success of the nurse-focused EHR-driven intervention suggests an effective tool for integrating the cessation counseling component of the new measures and the importance of nursing's role in achieving the Joint Commission measure targets.

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: The National Committee for Quality Assurance (NCQA) developed the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures to evaluate health plan performance against benchmarks or other plans. The Center for Medicare and Medicaid Services (CMS) requires insurance plans to submit HEDIS data to qualify as a Medicare Advantage Plan (MAP) or a MAP that includes Medicare Part D (MAPD). Our MAPD selected and tested HEDIS and other 5-Star measures comparing the quality of care for MAPD members who did and did not use a Geriatric Assessment Center (GAC) serving MAPD members within a markedly impoverished region in the western US. Members visit the GAC typically once per year. Methods: We selected eight measures reflecting preventive care, chronic disease management, and continuity of care (See Table). Within one Medical Group, we compared the performance of these measures for Plan Members having attended the GAC in 2014 with Plan members who did not but had at least one primary care provider (PCP) visit. We used exact match procedures to identify a comparison group based on age, gender, Low-Income Subsidy Level, Risk Adjustment Factor and Special Needs Plan. Results: We identified 258 members who used the GAC in 2014 and 258 as the matched control group (See Table). Preventive care but not chronic disease management performance measures were significantly better for members who used the GAC. GAC users had better care continuity performance (measured by readmission rates) but this was not statistically significant. Conclusions: The GAC is well suited to achieving high quality preventive care due to the ease of completion in one visit. Chronic disease management care continuity is likely better suited to a repeated visit care structure. (Table Presented)

Background: A comprehensive geriatric assessment clinic (GAC) was established in collaboration with a health plan within a markedly impoverished region in the US. Evaluation objectives were to assess the quality of chronic illness care from the perspective of member-patients and providers. Methods: We abstracted medical records of patients attending the GAC during one quarter of 2014 and administered the 20-item Patient Assessment of Chronic Illness Care (PACIC) survey in English and Spanish in 2015. We anonymously surveyed patients before and directly after visits. Survey questions, modified for low health literacy, used a 1-to-5-likert scale (1=none of the time to 5=always) for 5 domains: patient activation, decision support, goal setting, problem solving, and care coordination. We administered a 7-item quality assessment survey to providers for: relevance, ease of use, ability to apply findings, and agreement with diagnostic findings and recommendations, using a 1-to-5-likert scale (1=strongly disagree to 5=strongly agree). Results: Abstracted data for 193 patients demonstrated 51% had not finished high school and their chronic condition burden was high (mean: 7.2 conditions; 31% with diabetes). For patient surveys (n=165; 19% Spanish), post-visit PACIC domain scores ranged from 4.0-4.5 and post-visit ratings were higher across all domains (1.4 to 1.7 higher; p<0.001 for each). For each of 20 questions, aggregate post scores improved, indicating higher quality. For provider surveys, respondents (n=14) felt the GAC provided useful (50%) and relevant (64%) information for their practices, taught them how to provide better care for other patients (64%), and made it easier to provide care (50%). Less than one third (29%) felt their experience discouraged them from using the service again. Discussion: The AC greatly improved member-perceived care quality and facilitated provider care among patients with high chronic condition burden, suggesting a useful strategy for patients with high need. Since some providers did not find this service useful, provider focus groups are underway to understand and improve unmet provider needs

Limbic encephalitis presents as altered mood, memory loss and confusion. Clinical features may include psychiatric symptoms and seizures. In contrast to paraneoplastic disorders, non-paraneoplastic autoimmune encephalitis often responds to immunotherapy and sometimes with marked recovery. However, relapse can occur. An 82-year-old male presented with subacute episodes of memory loss over a few days. The patient was unable to recognize his own home and family members. Physical exam was unremarkable. Neuropsychological assessment revealed deficits in cognitive performance that could be consistent with moderate dementia or a more rapidly progressive encephalopathy. Agitated behavior and anxiety were also noted. Laboratory evaluation included hyponatremia, which was corrected with no symptom improvement. B12, TSH, and HIV were normal. CSF analysis revealed 10 WBCs/muL, Glucose-52 mg/dl, Protein-62 mg/dl and was negative for infectious, neoplastic causes, varicella, VDRL, viral cultures, NMDA receptor antibody, GAD 65 antibody and Anti-Hu antibody. Occult malignancy work up with CT scan of chest and abdomen and colonoscopy was normal. Serum for voltage-gated potassium channel antibodies was positive at 849 pmol/l (>88). EEG showed occasional focal left fronto-temporal slowing without epileptiform activity. MRI revealed focal enhancement of the medial left temporal lobe consistent with limbic encephalitis. The patient started high dose steroids with improvement in memory and complete resolution of focal abnormality within the left hippocampal/parahippocampal region suggestive of resolving encephalitis. At seven months after tapering steroids the patient presented with myoclonus and recurrent memory loss. MRI demonstrated recurrent encephalitis with gyral swelling and FLAIR hyperintensity in the left temporal lobe. The patient was restarted on high dose steroids with addition of Rituximab. This case illustrates that limbic encephalitis can present as a rapidly progressive dementia. Differential diagnosis should include more unusual forms of rapidly progressive dementia such as Jakob-Creutzfeldt disease if myoclonus is present, Lewy body dementia if waxing and waning memory, and Alzheimer's dementia with acute delirium if presenting over a period of months. In this patient, MRI changes were crucial to recognizing a potentially reversible limbic encephalitis. Early recognition and treatment may decrease relapse and reduce functional impairment

BACKGROUND: Associations between sleep duration and cardiovascular disease (CVD) risk factors have been demonstrated in past studies. However, previous studies have not investigated these relationships using objective sleep measures in sub-Saharan Africa. Our objective was to investigate the association between sleep duration and cardiovascular risk factors in a sample of community-dwelling Ghanaian adults. METHODS: We used wrist actigraphy along with a seven-day sleep diary to measure sleep duration, wake after sleep onset, sleep latency, and sleep quality. Participants were randomly selected from among those participating in the RODAM study in rural and urban Ghana. Outcome measurements included 10-year risk of CVD events, prevalent CVD, and metabolic syndrome. Additional participant characteristics were assessed using a structured questionnaire. Linear and logistic regression analyses were used to assess the relationships between sleep measures and CVD risk. RESULTS: A total of 263 participants from rural and urban Ghana participated. Total sleep time was positively associated with a 10-year CVD risk; this association remained after adjusting for age, sex, urban vs rural location, socio-economic status, physical activity, and sleep disturbance (beta = 0.990, p = 0.015). Short sleep, defined as sleeping less than seven hours per night on average, was negatively associated with a 10-year CVD risk, and this relationship remained in the fully adjusted model (beta = -2.100, p = 0.011). Sleep duration was not associated with prevalence of CVD or metabolic syndrome. CONCLUSION: Using actigraphy to measure sleep duration among a population of community-dwelling adults in sub-Saharan Africa is feasible. We found a positive association between sleep and CVD risk. No association was found between sleep duration and prevalent CVD or metabolic syndrome. The implications and new directions relating to these findings are stated.

BACKGROUND: There is a pressing workforce shortage and leadership scarcity in palliative care to adequately meet the demands of individuals with serious illness and their families. To address this gap, the Cambia Health Foundation launched its Sojourns Scholars Leadership Program in 2014, an initiative designed to identify, cultivate, and advance the next generation of palliative care leaders. This report intends to summarize the second cohort of Sojourns Scholars' projects and their reflection on their leadership needs. OBJECTIVE: This report summarizes the second cohort of sojourns scholars' project and their reflection on leadership needs. METHODS: After providing a written reflection on their own projects, the second cohort participated in a group interview (fireside chat) to elicit their perspectives on barriers and facilitators in providing palliative care, issues facing leadership in palliative care in the United States, and lessons from personal and professional growth as leaders in palliative care. They analyzed the transcript of the group interview using qualitative content analysis methodology. RESULTS: Three themes emerged from descriptions of the scholars' project experience: challenges in palliative care practice, leadership strategies in palliative care, and three lessons learned to be a leader were identified. Challenges included perceptions of palliative care, payment and policy, and workforce development. Educating and collaborating with other clinicians and influencing policy change are important strategies used to advance palliative care. Time management, leading team effort, and inspiring others are important skills that promote effectiveness as a leader. DISCUSSION: Emerging leaders have a unique view of conceptualizing contemporary palliative care and shaping the future. CONCLUSIONS: Providing comprehensive, coordinated care that is high quality, patient and family centered, and readily available depends on strong leadership in palliative care. The Cambia Scholars Program represents a unique opportunity.