Faculty Bibliography

BACKGROUND:The link of low estimated glomerular filtration rate (eGFR) and high proteinuria to cardiovascular disease (CVD) mortality is well known. However, its link to mortality due to other causes is less clear. METHODS:We studied 367,932 adults (20-93 years old) in the Korean Heart Study (baseline between 1996-2004 and follow-up until 2011) and assessed the associations of creatinine-based eGFR and dipstick proteinuria with mortality due to CVD (1,608 cases), cancer (4,035 cases), and other (non-CVD/non-cancer) causes (3,152 cases) after adjusting for potential confounders. RESULTS:Although cancer was overall the most common cause of mortality, in participants with chronic kidney disease (CKD), non-CVD/non-cancer mortality accounted for approximately half of cause of death (47.0%for eGFR <60 ml/min/1.73 m2 and 54.3% for proteinuria ≥1+). Lower eGFR (<60 vs. ≥60 ml/min/1.73 m2) was significantly associated with mortality due to CVD (adjusted hazard ratio 1.49 [95% CI, 1.24-1.78]) and non-CVD/non-cancer causes (1.78 [1.54-2.05]). The risk of cancer mortality only reached significance at eGFR <45 ml/min/1.73 m2 when eGFR 45-59 ml/min/1.73 m2 was set as a reference (1.62 [1.10-2.39]). High proteinuria (dipstick ≥1+ vs. negative/trace) was consistently associated with mortality due to CVD (1.93 [1.66-2.25]), cancer (1.49 [1.32-1.68]), and other causes (2.19 [1.96-2.45]). Examining finer mortality causes, low eGFR and high proteinuria were commonly associated with mortality due to coronary heart disease, any infectious disease, diabetes, and renal failure. In addition, proteinuria was also related to death from stroke, cancers of stomach, liver, pancreas, and lung, myeloma, pneumonia, and viral hepatitis. CONCLUSION/CONCLUSIONS:Low eGFR was associated with CVD and non-CVD/non-cancer mortality, whereas higher proteinuria was consistently related to mortality due to CVD, cancer, and other causes. These findings suggest the need for multidisciplinary prevention and management strategies in individuals with CKD, particularly when proteinuria is present.

Few studies have evaluated text message (TM) content preferences to support evidence-based treatment approaches for opioid use disorders, and none in primary care office-based buprenorphine treatment (OBOT) settings. This study assessed the acceptability and preferences for a tailored TM intervention in support of core OBOT medical management components (e.g., treatment adherence, encouraging abstinence, 12-step group participation, motivational interviewing, and patient-provider communication as needed). 97 patients enrolled in a safety net OBOT program completed a 24 item survey instrument and consisted of multiple choice responses, 7-point Likert-type scales, binomial "Yes/No" questions, and open-ended responses. The sample was predominately male (81%), had an average age of 46 years, and was diverse (64% ethnic/racial minorities); 56% lacked stable employment. Respondents were interested in receiving TM appointment reminders (90%), information pertaining to their buprenorphine treatment (76%), supportive content (70%), and messages to reduce the risk of relapse (88%). Participants preferred to receive relapse prevention TM during all phases of treatment: immediately after induction into buprenorphine treatment (81%), a 'few months' into treatment (57%), and after discontinuing buprenorphine treatment (72%). Respondents also expressed interest in TM content enhancing self-efficacy, social support, and frequent provider communication to facilitate unobserved "home" induction with buprenorphine. Older participants were significantly less receptive to receiving TM appointment reminders, however were as interested in receiving supportive, informational, and relapse prevention components compared to younger respondents. Implications for integrating a TM support system in OBOT are discussed.

Diagnosis of type 2 diabetes and prediabetes is mandatory. Chronic hyperglycemia in diabetes is associated with long-term micro- and macrovascular as well as with neurological complications. Prediabetes predisposes patients to develop diabetes and macrovascular disease. Diagnosis of diabetes is established on (at least) one of the following criteria: a fasting plasma glucose >/= 126 mg/dl (7.0 mmol/l), a casual plasma glucose >/= 200 mg/dl (11.1 mmol/l) in the presence of symptoms, a 2-h plasma glucose during the 75-g oral glucose tolerance test (OGTT) >/= 200 mg/dl (11.1 mmol/l) and/or an HbA1c >/= 6.5%. Prediabetes is defined by the Position Statement of the American Diabetes Association as a fasting plasma glucose between 100 and 125 mg/dl (5.6 - 6.9 mmol/l) [a condition called Impaired Fasting Glucose] and/or by a 2-h plasma glucose during OGTT 140 - 199 mg/dl (7.8 - 11.0 mmol) [Impaired Glucose Tolerance] and/or a HbA1c level 5.7 - 6.4%, with however some potential discordance between tests. The threshold of fasting plasma glucose defining Impaired Fasting Glucose as well as the adequacy of HbA1c as a correct diagnostic tool for prediabetes is still debated.

Program/Project Purpose: Although, the internist plays a central role in the hospital, as the coordinator of interdisciplinary diagnostic and therapeutic care, they may function differently in different parts of the world. This project aims to compare the general structure of internal medicine clinical services at hospitals in USA and Turkey. Structure/Method/Design: The study was conducted in Koc University Hospital in Istanbul, Turkey, and Bellevue Hospital in New York, USA, in 2015, by trainees participating in an academic exchange. At Bellevue Hospital, approximately 80% of internal medicine beds are managed by internal medicine attendings and hospitalists. In United States (US), general internists provide comprehensive and organized care for both acute and chronic diseases. In comparison, in Koc University Hospital, Istanbul, all internal medicine beds are managed by nine different subspecialties, with general internal medicine as its own subspecialty, and not a primary hospitalist team. Outcome and Evaluation: In New York, once the patient is admitted and stabilized, the primary hospitalist teams provide medical care. Thereafter, the primary internist team may request a subspecialty consult considering medical condition of the patient. On the other hand, in Istanbul, transfer of patients are triaged from the first point of contact to subspecialty service that is related to their medical condition. This subspecialty team manages the patient's condition and provides appropriate medical care until discharge. When there is a need to consult, the primary subspecialty team would consult other subspecialties. Going Forward: These two different ecoles have their own advantages and disadvantages. While a central role for internists in US offers important advantages such as high patient-population satisfaction and cost effectiveness, it also has been associated with discontinuity of care, patient dissatisfaction, loss of acute care skills by primary care physicians, and burnout among hospitalists. In Turkey, although subspecialized services may provide better-focused medical care, they may sometimesmiss the big picture and are over-used. In future exchanges, the division of care between generalist/hospitalist and consultant/ subspecialist care will be studied, which can include type of ward patient is assigned, stratification by chief complaint, percentage of consults requested, length of stay, and patient satisfaction

Background: The number of asylum seekers in the US has risen dramatically over the past 10 years. This study aimed to measure the prevalence of selected infectious, non-communicable and psychiatric illnesses within this population and to evaluate the success of a program for asylum seekers in screening for these conditions. Methods: Two hundred ten new clients from 51 countries, plus Tibet, who were accepted into an urban hospital-based program for asylum seekers from 2012-2014 were included. Screening rates and outcomes for infectious, non-communicable, and mental illnesses were evaluated based on intake data and review of the medical record. Informed written consent was obtained during the intake process. Findings: 71% percent of patients screened positive for depression (n=144 positive/204 total screened) and 55% screened positive for PTSD (n=111/193), followed by latent tuberculosis (41%, n=65/ 159), hypertension (10%, n=21/210), hepatitis B (9.4%, n=19/ 202), and HIV (0.8%, n=1/124). Rates of completed screenings were highest for PTSD, depression, hepatitis B and latent tuberculosis. Interpretation: This population is at very high risk of PTSD, depression, and latent tuberculosis, and at increased risk of hepatitis B. Screening rates for these diseases were high at this dedicated program for asylum seekers. Point of care testing was more effective than testing that required repeat visits. These findings call for special attention to the primary care needs for asylum seekers in the US