Faculty Bibliography

The purpose of this study was to evaluate the efficacy of Mucograft (MG; a porcine-derived purified collagen membrane) to increase the thickness and height of the buccal soft tissue when placed at the time of implant placement in patients with thin or deficient keratinized tissue (KT). The primary endpoint of the study was the change in thickness and height of the buccal KT. Secondary endpoints included stability of the midbuccal soft tissue level; clinician rating of color, texture, and contour of treatment site; probing pocket depths (PPDs); assessment of satisfaction outcome; and patient assessment of pain/discomfort. Thirty-two patients were enrolled and 31 patients completed the study. There were no statistically significant (SS) differences between the MG and control groups for height measures. There was no SS difference for KT thickness (P = .117) between the groups at the final measurement (3 months postsurgery). However, there was an SS difference (P = .009) in favor of the MG group when comparing the difference in presurgical KT thickness to that 3 months postsurgery. Thus, MG was successful (compared to the control) in increasing the buccal KT. There were no SS differences between the groups for any of the other endpoints, including color, texture, contour, and pain assessment at any visit or successful outcome between the treatment group and the control. More cases and longer follow-up of implants placed with MG are needed to verify the results of this randomized prospective study.

PURPOSE: The adolescent and young adult (AYA) population is underserved because of unique late-effect issues, particularly future fertility. This study sought to establish rates of documentation of discussion of risk of infertility, fertility preservation (FP) options, and referrals to fertility specialists in AYA patients' medical records at four cancer centers. METHODS: All centers reviewed randomized records within the top four AYA disease sites (breast, leukemia/lymphoma, sarcoma, and testicular). Eligible records included those of patients: diagnosed in 2011, with no prior receipt of gonadotoxic therapy; age 18 to 45 years; with no multiple primary cancers; and for whom record was not second opinion. Quality Oncology Practice Initiative methods were used to evaluate documentation of discussion of risk of infertility, discussion of FP options, and referral to a fertility specialist. RESULTS: Of 231 records, 26% documented infertility risk discussion, 24% documented FP option discussion, and 13% documented referral to a fertility specialist. Records were less likely to contain evidence of infertility risk and FP option discussions for female patients (P = .030 and .004, respectively) and those with breast cancer (P = .021 and < .001, respectively). Records for Hispanic/Latino patients were less likely to contain evidence of infertility risk discussion (P = .037). Records were less likely to document infertility risk discussion, FP option discussion, and fertility specialist referral for patients age >/= 40 years (P < .001, < .001, and .002, respectively) and those who already had children (all P < .001). CONCLUSION: The overall rate of documentation of discussion of FP is low, and results show disparities among specific groups. Although greater numbers of discussions may be occurring, there is a need to create interventions to improve documentation.

Panel management, a set of tools and processes for proactively caring for patient populations, has potential to reduce morbidity and improve outcomes between office visits. We examined primary care staff's self-efficacy in implementing panel management, its correlates, and an intervention's impact on this self-efficacy. Primary care teams at two Veterans Health Administration (VA) hospitals were assigned to control or intervention conditions. Staff were surveyed at baseline and post-intervention, with a random subset interviewed post-intervention. Panel management self-efficacy was higher among staff participating in the panel management intervention. Self-efficacy was significantly correlated with sufficient training, aspects of team member interaction, and frequency of panel management use. Panel management self-efficacy was modest among primary care staff at two VA hospitals. Team level interventions may improve primary care staff's confidence in practicing panel management, with this greater confidence related to greater team involvement with, and use of panel management.

OBJECTIVE: There has been a rapid increase in the use of waterpipe tobacco and non-tobacco based shisha in many countries. Understanding the impact and effects of second-hand smoke (SHS) from cigarette was a crucial factor in reducing cigarette use, leading to clean indoor air laws and smoking bans. This article reviews what is known about the effects of SHS exposure from waterpipes. DATA SOURCES: We used PubMed and EMBASE to review the literature. Articles were grouped into quantitative measures of air quality and biological markers, health effects, exposure across different settings, different types of shisha and use in different countries. STUDY SELECTION: Criteria for study selection were based on the key words related to SHS: waterpipe, hookah, shisha and third-hand smoke. DATA EXTRACTION: Independent extraction with two reviewers was performed with inclusion criteria applied to articles on SHS and waterpipe/hookah/shisha. We excluded articles related to pregnancy or prenatal exposure to SHS, animal studies, and non-specific source of exposure as well as articles not written in English. DATA SYNTHESIS: A primary literature search yielded 54 articles, of which only 11 were included based on relevance to SHS from a waterpipe/hookah/shisha. CONCLUSIONS: The negative health consequences of second-hand waterpipe exposure have major implications for clean indoor air laws and for occupational safety. There exists an urgent need for public health campaigns about the effects on children and household members from smoking waterpipe at home, and for further development and implementation of regulations to protect the health of the public from this rapidly emerging threat.

BACKGROUND:Cesarean delivery may reduce placental-fetal transfusion and thus increase the risk of early childhood anemia compared with vaginal delivery, but this notion has not been carefully studied in longitudinal cohorts. OBJECTIVE:The aim was to assess the association of cesarean delivery with anemia in infants and children in 2 longitudinal Chinese birth cohorts from different socioeconomic settings. DESIGN/METHODS:Cohort 1 was recruited from 5 counties in northeastern China and cohort 2 from 21 counties or cities in southeastern China. Cohort 1 involved 17,423 infants born during 2006-2009 to mothers with early pregnancy baseline hemoglobin concentrations ranging from 100 to 177 g/L, whereas cohort 2 involved 122,777 children born during 1993-1996 to mothers with baseline hemoglobin concentrations ranging from 60 to 190 g/L. The main outcomes were anemia at 6 and 12 mo in cohort 1 and at 58 mo in cohort 2. Multiple logistic regressions were used to estimate adjusted ORs of anemia for cesarean compared with vaginal delivery. Stratified analyses were performed by pre- and postlabor cesarean delivery and according to maternal baseline hemoglobin concentration (≤109, 110-119, 120-129, and ≥130 g/L). RESULTS:Cesarean delivery was not associated with anemia at 6 mo in cohort 1 (adjusted OR: 1.05; 95% CI: 0.93, 1.19); however, cesarean delivery was associated with increased anemia at 12 mo in cohort 1 (adjusted OR: 1.19; 95% CI: 1.04, 1.37) and at 58 mo in cohort 2 (adjusted OR: 1.11; 95% CI: 1.08, 1.15). The positive associations for anemia at 12 and 58 mo were consistent across maternal hemoglobin subgroups and persisted for cesarean delivery subtypes. CONCLUSION/CONCLUSIONS:Cesarean delivery is likely associated with anemia in children, which suggests a possible need for exploring changes in obstetric care that might prevent anemia in cesarean-delivered children.

Newcomer elderly immigrants, defined as adults older than the age of 65 who have arrived in the United States in the last 10 years, represent a growing sector of the American population. Newcomers who experience limited English proficiency, financial strain, and acculturative stress are at considerable risk of developing poor health outcomes. Nursing's focus on healthy aging and aging in place has largely ignored the experiences of these older adults, who are said to be "aging out of place." This concept analysis uses Rodgers's evolutionary method to define "aging out of place" and illustrates why existing theories of elderly migration do not necessarily apply to this population. The challenge for nurses is incorporating the family, with whom conflict may arise, into the care of these elders. Community-based strategies that enable social integration and create a greater division of labor in the care of newcomer elders are called for.

BACKGROUND:Mobile health (mHealth) applications have recently proliferated, especially in low- and middle-income countries, complementing task-redistribution strategies with clinical decision support. Relatively few studies address usability and feasibility issues that may impact success or failure of implementation, and few have been conducted for non-communicable diseases such as hypertension. OBJECTIVE:To conduct iterative usability and feasibility testing of a tablet-based Decision Support and Integrated Record-keeping (DESIRE) tool, a technology intended to assist rural clinicians taking care of hypertension patients at the community level in a resource-limited setting in western Kenya. METHODS:Usability testing consisted of "think aloud" exercises and "mock patient encounters" with five nurses, as well as one focus group discussion. Feasibility testing consisted of semi-structured interviews of five nurses and two members of the implementation team, and one focus group discussion with nurses. Content analysis was performed using both deductive codes and significant inductive codes. Critical incidents were identified and ranked according to severity. A cause-of-error analysis was used to develop corresponding design change suggestions. RESULTS:Fifty-seven critical incidents were identified in usability testing, 21 of which were unique. The cause-of-error analysis yielded 23 design change suggestions. Feasibility themes included barriers to implementation along both human and technical axes, facilitators to implementation, provider issues, patient issues and feature requests. CONCLUSIONS:This participatory, iterative human-centered design process revealed previously unaddressed usability and feasibility issues affecting the implementation of the DESIRE tool in western Kenya. In addition to well-known technical issues, we highlight the importance of human factors that can impact implementation of mHealth interventions.

BACKGROUND: Approximately 65% of the United Arab Emirates (UAE) population are economic migrants from the low- and middle-income countries of South Asia. Emerging evidence suggests that expatriate populations from low or middle-income countries that migrate to high-income countries acculturate their lifestyle with the obesogenic behaviours of the host country. Previous research has focussed on migrant populations in the United States. The objective of this study was to assess the prevalence of obesity and explore the relationship between years of residency (surrogate measure for acculturation) and obesity among South Asian (from India, Pakistan and Bangladesh) male immigrants residing in the UAE. METHODS: A random sample of 1375 males was recruited from a mandatory residency visa health screening centre in Abu Dhabi (UAE). Employing a cross-sectional design, participants completed an interviewer-led adapted version of the World Health Organisation STEPS questionnaire, and anthropometric and blood pressure measurements were collected. Glycated haemoglobin (HbA1c) was measured in a random sub-sample (n = 100). Logistic regression was used to determine risk factors for being classified as obese, and to assess the relationship between years of residency and adiposity. RESULTS: The overall prevalence of body mass index-derived overweight and obesity estimates and waist-to-hip-derived central obesity rates was 615 (44.7%) and 917 (66.7%) males, respectively. Hypertension was present in 419 (30.5%) of the sample and diabetes in 9 (9.0%) of the sub-sample. Living in the UAE for six to 10 years or more than 10 years was independently associated with being classified with central obesity (adjusted odds ratio [AOR] 1.63 95% confidence intervals [CI] 1.13 - 2.35, p < 0.008; AOR 1.95 95% CI 1.26 - 3.01, p < 0.002; respectively) compared to residing in the UAE for one to five years. CONCLUSIONS: Our study revealed a high prevalence of overweight, central obesity and hypertension amongst a young South Asian male migrant population in the UAE. Study findings suggest a diminished 'Healthy Migrant Effect' with increased years of residency possibly due to greater acculturation and a transition in lifestyle behaviours. Health initiatives targeting the maintenance of a healthy body size, coupled with regular assessments of glucose control and blood pressure are urgently required in this population.

BACKGROUND: Advance care planning may help patients receive treatments that better align with their goals for care. We developed a Web-based decision aid called InformedTogether to facilitate shared advance care planning between chronic obstructive pulmonary disease (COPD) patients and their doctors. OBJECTIVE: Our objective was to assess the usability of the InformedTogether decision aid, including whether users could interact with the decision aid to engage in tasks required for shared decision making, whether users found the decision aid acceptable, and implications for redesign. METHODS: We conducted an observational study with 15 patients and 8 doctors at two ethnically and socioeconomically diverse outpatient clinics. Data included quantitative and qualitative observations of patients and doctors using the decision aid on tablet or laptop computers and data from semistructured interviews. Patients were shown the decision aid by a researcher acting as the doctor. Pulmonary doctors were observed using the decision aid independently and asked to think aloud (ie, verbalize their thoughts). A thematic analysis was implemented to explore key issues related to decision aid usability. RESULTS: Although patients and doctors found InformedTogether acceptable and would recommend that doctors use the decision aid with COPD patients, many patients had difficulty understanding the icon arrays that were used to communicate estimated prognoses and could not articulate the definitions of the two treatment choices-Full Code and Do Not Resuscitate (DNR). Minor usability problems regarding content, links, layout, and consistency were also identified and corresponding recommendations were outlined. In particular, participants suggested including more information about potential changes in quality of life resulting from the alternative advance directives. Some doctor participants thought the decision aid was too long and some thought it may cause nervousness among patients due to the topic area. CONCLUSIONS: A decision aid for shared advance care planning for severe COPD was found acceptable to most COPD patients and their doctors. However, many patient participants did not demonstrate understanding of the treatment options or prognostic estimates. Many participants endorsed the use of the decision aid between doctors and their patients with COPD, although they desired more information about quality of life. The design must optimize comprehensibility, including revising the presentation of statistical information in the icon array, and feasibility of integration into clinical workflow, including shortening the decision aid.

BACKGROUND: Data are sparse regarding the impacts of habitual physical activity (PA) and sedentary behavior on cardiovascular (CV) risk in older adults with mobility limitations. METHODS AND RESULTS: This study examined the baseline, cross-sectional association between CV risk and objectively measured PA among participants in the Lifestyle Interventions and Independence for Elders (LIFE) study. The relationship between accelerometry measures and predicted 10-year Hard Coronary Heart Disease (HCHD) risk was modeled by using linear regression, stratified according to CVD history. Participants (n=1170, 79+/-5 years) spent 642+/-111 min/day in sedentary behavior (ie, <100 accelerometry counts/min). They also spent 138+/-43 min/day engaging in PA registering 100 to 499 accelerometry counts/min and 54+/-37 min/day engaging in PA >/=500 counts/min. Each minute per day spent being sedentary was associated with increased HCHD risk among both those with (0.04%, 95% CI 0.02% to 0.05%) and those without (0.03%, 95% CI 0.02% to 0.03%) CVD. The time spent engaging in activities 100 to 499 as well as >/=500 counts/min was associated with decreased risk among both those with and without CVD (P<0.05). The mean number of counts per minute of daily PA was not significantly associated with HCHD risk in any model (P>0.05). However, a significant interaction was observed between sex and count frequency (P=0.036) for those without CVD, as counts per minute was related to HCHD risk in women (beta=-0.94, -1.48 to -0.41; P<0.001) but not in men (beta=-0.14, -0.59 to 0.88; P=0.704). CONCLUSIONS: Daily time spent being sedentary is positively associated with predicted 10-year HCHD risk among mobility-limited older adults. Duration, but not intensity (ie, mean counts/min), of daily PA is inversely associated with HCHD risk score in this population-although the association for intensity may be sex specific among persons without CVD. CLINICAL TRIAL REGISTRATION URL: www.clinicaltrials.gov Unique identifier: NCT01072500.