Faculty Bibliography

Aims: We conducted a descriptive, cross-sectional survey exploring mobile phone and TM use patterns and preferences pertaining to their substance treatment in a public sector, office-based buprenorphine program. Methods: A 28-item, quantitative and qualitative semistructured survey was administered to 71 patients enrolled in a public sector, office-based buprenorphine program between June and September 2013. Survey domains included: demographic characteristics, mobile phone and TM use patterns, and mobile phone and TM use patterns and preferences pertaining to their substance treatment. Results: Mobile phone ownership was common (93%) with no significant differences in ownership among self-reported homeless, recently incarcerated, and unemployed respondents. Most reported sending or receiving TM (93%) and reporting 'very much' or 'somewhat' comfort sending TM (79%). Contacting buprenorphine providers by phone (30%) or TM (17%) was uncommon, however most preferred to use either form of communication to reach their provider (67%). Older patients received less TM (25) compared to younger age groups (128) yet were as interested as the rest of the clinic population to have their provider's mobile phone number (96%) and send TM if at risk of relapse (78%). Conclusions: Our findings highlight the acceptability of enhancing patient-provider mobile phone and TM communications in a public sector, office-based buprenorphine clinic, even among respondents that were not comfortable in using TM. Although mobile phone ownership was very common, frequent turnover in phone ownership and changing phone numbers highlights challenges in feasibility for any future m health interventions in this clinical setting

The inability of current recommendations to control the epidemic of diabetes, the specific failure of the prevailing low-fat diets to improve obesity, cardiovascular risk, or general health and the persistent reports of some serious side effects of commonly prescribed diabetic medications, in combination with the continued success of low-carbohydrate diets in the treatment of diabetes and metabolic syndrome without significant side effects, point to the need for a reappraisal of dietary guidelines. The benefits of carbohydrate restriction in diabetes are immediate and well documented. Concerns about the efficacy and safety are long term and conjectural rather than data driven. Dietary carbohydrate restriction reliably reduces high blood glucose, does not require weight loss (although is still best for weight loss), and leads to the reduction or elimination of medication. It has never shown side effects comparable with those seen in many drugs. Here we present 12 points of evidence supporting the use of low-carbohydrate diets as the first approach to treating type 2 diabetes and as the most effective adjunct to pharmacology in type 1. They represent the best-documented, least controversial results. The insistence on long-term randomized controlled trials as the only kind of data that will be accepted is without precedent in science. The seriousness of diabetes requires that we evaluate all of the evidence that is available. The 12 points are sufficiently compelling that we feel that the burden of proof rests with those who are opposed.

Physiological responses to threat occur through both the autonomic nervous system (ANS) and the hypothalamic pituitary adrenal (HPA) axis. Activity in these systems can be measured through salivary alpha-amylase (sAA) and salivary cortisol, respectively. Theoretical work and empirical studies have suggested the importance of examining the coordination of these systems in relation to cognitive functioning and behavior problems. Less is known, however, about whether these systems interactively predict more automatic aspects of attention processing such as attention toward emotionally salient threatening stimuli. We used a dot probe task to assess attention bias toward threatening stimuli in 347 kindergarten children. Cortisol and sAA were assayed from saliva samples collected prior to children's participation in assessments on a subsequent day. Using regression analyses, we examined relations of sAA and cortisol to attention bias. Results indicate that cortisol and sAA interact in predicting attention bias. Higher levels of cortisol predicted greater bias toward threat for children who had high levels of sAA, but predicted greater bias away from threat for children who had low levels of sAA. These results suggest that greater symmetry in HPA and ANS functioning is associated with greater reliance on automatic attention processes in the face of threat.

Visual impairment is a key manifestation of multiple sclerosis. Acute optic neuritis is a common, often presenting manifestation, but visual deficits and structural loss of retinal axonal and neuronal integrity can occur even without a history of optic neuritis. Interest in vision in multiple sclerosis is growing, partially in response to the development of sensitive visual function tests, structural markers such as optical coherence tomography and magnetic resonance imaging, and quality of life measures that give clinical meaning to the structure-function correlations that are unique to the afferent visual pathway. Abnormal eye movements also are common in multiple sclerosis, but quantitative assessment methods that can be applied in practice and clinical trials are not readily available. We summarize here a comprehensive literature search and the discussion at a recent international meeting of investigators involved in the development and study of visual outcomes in multiple sclerosis, which had, as its overriding goals, to review the state of the field and identify areas for future research. We review data and principles to help us understand the importance of vision as a model for outcomes assessment in clinical practice and therapeutic trials in multiple sclerosis.

BACKGROUND:Decreased kidney function and kidney damage may predate hypertension, but only a few studies have investigated both types of markers simultaneously, and these studies have obtained conflicting results. STUDY DESIGN/METHODS:Cross-sectional for prevalent and prospective observational study for incident hypertension. SETTING & PARTICIPANTS/METHODS:9,593 participants from the ARIC (Atherosclerosis Risk in Communities) Study, aged 53-75 years in 1996-1998. PREDICTORS/METHODS:Several markers of kidney function (estimated glomerular filtration rate using serum creatinine and/or cystatin C and 2 novel markers [β-trace protein and β2-microglobulin]) and 1 marker of kidney damage (urinary albumin-creatinine ratio [ACR]). Every kidney marker was categorized by its quintiles (top quintile as a reference for estimated glomerular filtration rates and bottom quintile for the rest). OUTCOMES/RESULTS:Prevalent and incident hypertension. MEASUREMENTS/METHODS:Prevalence ratios and HRs of hypertension based on modified Poisson regression and Cox proportional hazards models, respectively. RESULTS:There were 4,378 participants (45.6%) with prevalent hypertension at baseline and 2,175 incident hypertension cases during a median follow-up of 9.8 years. Although all 5 kidney function markers were associated significantly with prevalent hypertension, prevalent hypertension was associated most notably with higher ACR (adjusted prevalence ratio, 1.60 [95% CI, 1.50-1.71] for the highest vs lowest ACR quintile). Similarly, ACR was associated consistently with incident hypertension in all models tested (adjusted HR, 1.28 [95% CI, 1.10-1.49] for top quintile), while kidney function markers demonstrated significant associations in some, but not all, models. Even mildly increased ACR (9.14-14.0mg/g) was associated significantly with incident hypertension. LIMITATIONS/CONCLUSIONS:Self-reported use of antihypertensive medication for defining incident hypertension, single assessment of kidney markers, and relatively narrow age range. CONCLUSIONS:Although all kidney markers were associated with prevalent hypertension, only elevated albuminuria was associated consistently with incident hypertension, suggesting that kidney damage is related more closely to hypertension than moderate reduction in overall kidney function.

Program/Project Purpose: Inter professional education is increasingly recognized as fundamental for health education worldwide. Although effective management is essential for health care improvement, business schools have been underrepresented in global health education. Here we report the Health Innovation Fellowship (HIF), a new training program created for practicing health professionals offered by the Central American Healthcare Initiative (CAHI) and INCAE Business School, Costa Rica. The initial period for this annual program is July 2014 to February 2015. HIF aims to catalyze improvements in the quality, efficiency, and delivery of healthcare for Central Americans in greatest need. Structure/Method/Design: HIF's goal is to provide training in management and leadership for fellows, in order to carry out an innovative health care improvement project in their local region. Participants are selected based on a submitted outline for their proposed project, and why it is innovative and relevant within their current local health care system. The initial cohort of 16 fellows represent eight health-related professions in six Central American countries. HIF is supported by CAHI stakeholders. Desired outcomes for HIF include successful completion of each fellow's project, and providing a positive impact on achieving their goals. All fellows attend four one-week on-site modular training sessions, receive ongoing mentorship, and stay connected through formal and informal networks and webinars to exchange knowledge and support each other. Viability is encouraged by creating a network of increasingly sustainable projects and health professional leaders across Central America, with each successive annual training program. Outcomes & Evaluation: Preliminary data are positive. During each on-site training module, fellows present updated project profiles, which are compared to their earlier project profiles to track progress. A "check-out" process has fellows set concrete goals and timelines to accomplish by the next module, and a "check-in" process reports whether they achieved their previous goals. After the first and second modules, 100% of the fellows considered HIF and its training sessions as "very good" or "excellent" toward meeting their project's goals. More than 50% of the projects have found either financial or political support for their implementation. Upon completion of HIF, fellows complete a quantitative-qualitative exit interview to measure 1) project outcomes and 2) the fellowship's impact on their project design, implementation, quality and effectiveness. Going Forward: Strengths include that both leadership and trainees come from the Global South, and that HIF offers a Global South platform to collaborate with partners in the Global North. Across sites, common themes are defined and unique lessons are learned. The seven-month period is a challenge, which is short for health system improvement efforts. By focusing on innovation and management within a Central American school of business, HIF is a novel capacity-building effort within global health education efforts

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.

Over the past three decades, there has been an increase in the number of empirical investigations of the phenomenology of eating disorders among African American adolescents. Despite efforts to understand racial/ethnic differences, relatively few eating disorder models address the important sociocultural factors that exert powerful influences on beliefs and behaviors related to weight status and eating patterns in this population. Nevertheless, researchers must be culturally competent in order to develop appropriate models. Therefore, we propose an approach to developing researcher cultural competence by addressing potential barriers that may hinder efforts to explore relevant, culturally appropriate factors that contribute to eating disturbance in African American girls. In this regard, we highlight the importance of integrative collaboration that can assist in identification and exploration of potential risk factors that may lead to model generation. We believe such information will lead to the development of culturally appropriate assessments, models, and, ultimately, interventions.

This study evaluated continuity and change in maternal-child hypothalamic-pituitary-adrenal axis attunement in early childhood. Participants were drawn from a prospective study of 1,292 mother-child dyads, which were racially diverse, predominantly low-income, and non-urban. Child focused stress tasks designed to elicit anger, fear, and frustration were administered during early infancy, later infancy, and toddlerhood. Mothers' and children's saliva samples (later assayed for cortisol) were collected before and after the tasks. The strength of mother-child adrenocortical attunement was conserved across infancy and toddlerhood. The magnitude of maternal-child adrenocortical attunement decreased in response to the child-focused stress tasks. Maternal sensitivity and the child's task-related emotional reactivity moderated adrenocortical attunement across the task, with greater maternal sensitivity during a free-play, and lower levels of child emotional reactivity during the stress tasks, stabilizing attunement from pre- to post-task levels. The findings advance our understanding of individual differences in the social regulation of adrenocortical activity in early childhood.

Fibroblast growth factor-23 is a bone-derived hormone that increases urinary phosphate excretion and inhibits hydroxylation of 25-hydroxyvitamin D. Recent studies suggest that fibroblast growth factor-23 may be an early biomarker of CKD progression. However, its role in kidney function decline in the general population is unknown. We assessed the relationship between baseline (1990-1992) serum levels of intact fibroblast growth factor-23 and incident ESRD in 13,448 Atherosclerosis Risk in Communities study participants (56.1% women, 74.7% white) followed until December 31, 2010. At baseline, the mean age of participants was 56.9 years and the mean eGFR was 97 ml/min per 1.73 m(2). During a median follow-up of 19 years, 267 participants (2.0%) developed ESRD. After adjustment for demographic characteristics, baseline eGFR, traditional CKD risk factors, and markers of mineral metabolism, the highest fibroblast growth factor-23 quintile (>54.6 pg/ml) compared with the lowest quintile (<32.0 pg/ml) was associated with risk of developing ESRD (hazard ratio, 2.10; 95% confidence interval, 1.31 to 3.36; trend P<0.001). In a large, community-based study comprising a broad range of kidney function, higher baseline fibroblast growth factor-23 levels were associated with increased risk of incident ESRD independent of the baseline level of kidney function and a number of other risk factors.