Faculty Bibliography

BACKGROUND: Systemic inflammation has emerged as a promising marker and potential mechanism underlying post-traumatic stress disorder (PTSD). The relationship between posttraumatic stress pathology and systemic inflammation has not, however, been consistently replicated and is potentially confounded by comorbid illness or injury, common complications of trauma exposure. METHODS: We analyzed a large naturalistic cohort sharing a discrete physical and mental health trauma from the destruction of the World Trade Center (WTC) towers on September 11, 2001 (n = 641). We evaluated the relationship between multiple physical and mental health related indices collected through routine evaluations at the WTC Environmental Health Center (WTC EHC), a treatment program for community members exposed to the disaster. C-Reactive Protein (CRP), a marker of systemic inflammation, was examined in relation to scores for PTSD, PTSD symptom clusters (re-experiencing, avoidance, negative cognitions/mood, arousal), depression and anxiety, while controlling for WTC exposures, lower respiratory symptoms, age, sex, BMI and smoking as potential risks or confounders. RESULTS: CRP was positively associated with PTSD severity (p < 0.001), trending toward association with depression (p = 0.06), but not with anxiety (p = 0.27). CRP was positively associated with re-experiencing (p < 0.001) and avoidance (p < 0.05) symptom clusters, and trended toward associations with negative cognitions/mood (p = 0.06) and arousal (p = 0.08). CONCLUSIONS: In this large study of the relationship between CRP and posttraumatic stress pathology, we demonstrated an association between systemic inflammation and stress pathology (PTSD; trending with depression), which remained after adjusting for potentially confounding variables. These results contribute to research findings suggesting a salient relationship between inflammation and posttraumatic stress pathology.

Identifying the earliest time point on the prediabetic continuum is critical to avoid progressive deterioration in beta-cell function. Progressively rising glucose levels even within the "normal range" occur considerably late in the evolution to diabetes thus presenting an important opportunity for earlier diagnosis, treatment, and possible reversal. An elevated 1 h postprandial glucose level, not detected by current diagnostic standards, may provide an opportunity for the early identification of those at risk. When the 1 h post-load glucose level is elevated, lifestyle intervention may have the greatest benefit for preserving beta-cell function and prevent further progression to prediabetes and diabetes. In view of the considerable consistent epidemiologic data in large disparate populations supporting the predictive capacity of the1 h post-load value for predicting progression to diabetes and mortality, the time is therefore ripe to evaluate this hypothesis in a large, prospective multicenter randomized trial with lifestyle intervention.

BACKGROUND: Technology-delivered interventions are useful tools for addressing unhealthy alcohol use. Smartphones in particular offer opportunities to deliver interventions at the user's convenience. We developed a smartphone application with 5 modules (personal feedback, self-monitoring of drinking, designated driver tool, blood alcohol content calculator, information). We assessed its acceptability and associations between use and drinking outcomes. METHODS: 130 adults with unhealthy alcohol use (>14 (men)/ >7 (women) drinks/week or > = 1 episode/month with 6 or more drinks) recruited in Switzerland (n = 70) and Canada (n = 60) were offered to use the application. Follow-up occurred after 3 months. We assessed appreciation, usefulness and self-reported frequency of use of the modules, and drinking outcomes (drinks/week, binge drinking). Associations between application use and drinking at 3 months were evaluated with negative binomial and logistic regression models, adjusted for baseline values and gender. RESULTS: 48% of participants were women, mean (SD) age: 32.8(10.0). Follow-up rate: 86.2%. There were changes from baseline (BL) to follow-up (FU) in number of drinks/week, BL: 15.0(16.5); FU: 10.9(10.5), p = 0.01, and binge drinking, BL: 95.4%; FU: 64.3%, p<0.0001. All modules had median ratings between 6 and 8 (scale of 1-10). 77% of participants used the application; 76% used the personal feedback module, 41% the self-monitoring of drinking, 22% the designated driver tool, 53% the BAC calculator, and 31% the information module. Participants using the application more than once reported significantly fewer drinks/week at follow up: IRR (number of drinks per week) 0.70 (0.51; 0.96). CONCLUSIONS: A smartphone application for unhealthy alcohol use appears acceptable and useful (although there is room for improvement). Without prompting, its use is infrequent. Those who used the application more than once reported less weekly drinking than those who did not. Efficacy of the application should be tested in a randomized trial with strategies to increase frequency of its use.

BACKGROUND: Increasing use of emergency departments among older patients with palliative needs has led to the development of several service-level interventions intended to improve care quality. There is little evidence of patient and family involvement in developmental processes, and little is known about the experiences of - and preferences for - palliative care delivery in this setting. Participatory action research seeking to enable collaborative working between patients and staff should enhance the impact of local quality improvement work but has not been widely implemented in such a complex setting. OBJECTIVES: To critique the feasibility of this methodology as a quality improvement intervention in complex healthcare settings, laying a foundation for future work. SETTING: an Emergency Department in a large teaching hospital in the United Kingdom. METHODS: Experience-based Co-design incorporating: 150h of nonparticipant observation; semi-structured interviews with 15 staff members about their experiences of palliative care delivery; 5 focus groups with 64 staff members to explore challenges in delivering palliative care; 10 filmed semi-structured interviews with palliative care patients or their family members; a co-design event involving staff, patients and family members. FINDINGS: the study successfully identified quality improvement priorities leading to changes in Emergency Department-palliative care processes. Further outputs were the creation of a patient-family-staff experience training DVD to encourage reflective discussion and the identification and application of generic design principles for improving palliative care in the Emergency Department. There were benefits and challenges associated with using Experience-based Co-design in this setting. Benefits included the flexibility of the approach, the high levels of engagement and responsiveness of patients, families and staff, and the impact of using filmed narrative interviews to enhance the 'voice' of seldom heard patients and families. Challenges included high levels of staff turnover during the 19 month project, significant time constraints in the Emergency Department and the ability of older patients and their families to fully participate in the co-design process. CONCLUSION: Experience-based Co-design is a useful approach for encouraging collaborative working between vulnerable patients, family and staff in complex healthcare environments. The flexibility of the approach allows the specific needs of participants to be accounted for, enabling fuller engagement with those who typically may not be invited to contribute to quality improvement work. Recommendations for future studies in this and similar settings include testing the 'accelerated' form of the approach and experimenting with alternative ways of increasing involvement of patients/families in the co-design phase.

The objective was to detect geospatial clustering of sugar-sweetened beverage (SSB) intake in Boston adolescents (age = 16.3 +/- 1.3 years [range: 13-19]; female = 56.1%; White = 10.4%, Black = 42.6%, Hispanics = 32.4%, and others = 14.6%) using spatial scan statistics. We used data on self-reported SSB intake from the 2008 Boston Youth Survey Geospatial Dataset (n = 1292). Two binary variables were created: consumption of SSB (never versus any) on (1) soda and (2) other sugary drinks (e.g., lemonade). A Bernoulli spatial scan statistic was used to identify geospatial clusters of soda and other sugary drinks in unadjusted models and models adjusted for age, gender, and race/ethnicity. There was no statistically significant clustering of soda consumption in the unadjusted model. In contrast, a cluster of non-soda SSB consumption emerged in the middle of Boston (relative risk = 1.20, p = .005), indicating that adolescents within the cluster had a 20% higher probability of reporting non-soda SSB intake than outside the cluster. The cluster was no longer significant in the adjusted model, suggesting spatial variation in non-soda SSB drink intake correlates with the geographic distribution of students by race/ethnicity, age, and gender.

BACKGROUND: Encapsulated non-invasive follicular variant papillary thyroid cancer (ENIFVPTC) has recently been re-termed noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). This designation specifically omits the word "cancer" to encourage conservative management since patients with NIFTP tumors have been shown to derive no benefit from completion thyroidectomy or adjuvant radioactive iodine (RAI) therapy. METHODS: IRB approved retrospective study of consecutive cases of tumors from 2007 to 2015 that met pathologic criteria for NIFTP. The Conservative Management (CM) group included patients managed with lobectomy alone or appropriately indicated total thyroidectomy. Those included in the Aggressive Management (AM) group received either completion thyroidectomy or radioactive iodine or both. RESULTS: From 100 consecutive cases of ENIFVPTC reviewed, 40 NIFTP were included for the final analysis. Of these, 10 (27%) patients treated with initial lobectomy received completion thyroidectomy and 6 of 37 (16%) also received post-surgical adjuvant RAI. The mean per-patient cost of care in the AM group was $17629+/-2865 nearly twice the $8637+/- 309 costs in the CM group, and was largely driven by the cost of completion thyroidectomy and RAI. CONCLUSIONS: The term NIFTP has been recently promulgated to identify a type of thyroid neoplasm, formerly identified as a low-grade cancer, for which initial surgery represents adequate treatment. We believe that since the new NIFTP nomenclature intentionally omits the word "cancer" the clinical indolence of these tumors will be better appreciated, and cost savings will result from a more conservative and appropriate clinical management.

The World Trade Center (WTC) disaster released large amounts of various chemical substances into the environment, including perfluoroalkyl substances (PFASs). Yet, no studies have examined exposures in children living or attending schools near the disaster site. We measured serum PFASs in WTC Health Registry (WTCHR) respondents who were