Faculty Bibliography

We assessed purchases made, motivations for shopping, and frequency of shopping at four New York City corner stores (bodegas). Surveys and purchase inventories (n = 779) were collected from consumers at four bodegas in Bronx, NY. We use Chi square tests to compare types of consumers, items purchased and characteristics of purchases based on how frequently the consumer shops at the specific store and the time of day the purchase was made. Most consumers shopped at the bodega because it was close to their home (52 %). The majority (68 %) reported shopping at the bodega at least once per day. The five most commonly purchased items were sugary beverages, (29.27 %), sugary snacks (22.34 %), coffee, (13.99 %), sandwiches, (13.09 %) and non-baked potato chips (12.2 %). Nearly 60 % of bodega customers reported their purchase to be healthy. Most of the participants shopped at the bodega frequently, valued its convenient location, and purchased unhealthy items. Work is needed to discover ways to encourage healthier choices at these stores.

Diagnostic imaging is integral to the evaluation of many emergency department (ED) patients. However, relatively little effort has been devoted to patient-centered outcomes research (PCOR) in emergency diagnostic imaging. This article provides background on this topic and the conclusions of the 2015 Academic Emergency Medicine consensus conference PCOR work group regarding "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The goal was to determine a prioritized research agenda to establish which outcomes related to emergency diagnostic imaging are most important to patients, caregivers, and other key stakeholders and which methods will most optimally engage patients in the decision to undergo imaging. Case vignettes are used to emphasize these concepts as they relate to a patient's decision to seek care at an ED and the care received there. The authors discuss applicable research methods and approaches such as shared decision-making that could facilitate better integration of patient-centered outcomes and patient-reported outcomes into decisions regarding emergency diagnostic imaging. Finally, based on a modified Delphi process involving members of the PCOR work group, prioritized research questions are proposed to advance the science of patient-centered outcomes in ED diagnostic imaging.

BACKGROUND: Although shared decision making (SDM) is the preferred model of making complex treatment decisions with patients, patients' and doctors' attitudes towards SDM for advance care planning are unknown. OBJECTIVE: We sought to: (i) gain general insights into the current practice of SDM and attitudes about patient involvement, and (ii) gain specific insights into experience with, and attitudes about, SDM for advance care planning. DESIGN: Qualitative analysis of face-to-face semi-structured interviews. SETTING AND PARTICIPANTS: Patients with chronic lung disease and their doctors at a New York City public hospital. RESULTS: Although patients described participation in decision making, many deferred the final decision to their doctors. Doctors indicated a preference for SDM but expressed barriers including perceived lack of patient understanding and lack of patient empowerment. With regard to end-of-life discussions, patients were generally open to having these discussions with their doctors, although their openness sometimes depended on the circumstance (i.e. end-of-life discussions may be more acceptable to patients for whom the chance of dying is high). Doctors reported engaging in end-of-life treatment decisions with their patients, although expressed the need for conversations to take place earlier, in advance of acute illness, and identified a lack of prognostic estimates as one barrier to engaging in this discussion. CONCLUSIONS: Doctors should explore their patients' attitudes regarding end-of-life discussions and preferences for decision-making styles. There is a need for tools such as decision aids which can empower patients to participate in decision making and can support doctors with prognostic estimates pertinent to individual patients.

Given the heightened risk for HIV and other STIs among young men who have sex with men (YMSM) as well as the racial/ethnic disparities in HIV/STI risk, an understanding of longitudinal trends in sexual behaviors is warranted as YMSM emerge into adulthood. Drawing from an ongoing prospective cohort study, the present analysis employed latent growth curve modeling to examine trends in distinct types of sexual activity without condoms over time in sample of YMSM and examine differences by race/ethnicity and perceived familial socioeconomic status (SES). Overall, White and Mixed race YMSM reported more instances of oral sex without condoms as compared to other racial/ethnic groups with rates of decline over time noted in Black YMSM. White YMSM also reported more receptive and insertive anal sex acts without a condom than Black YMSM. Declines over time in both types of anal sex acts without condoms among Black men were noted when compared to White men, while increases over time were noted for mixed race YMSM for condomless insertive anal sex. The effects for race/ethnicity were attenuated with the inclusion of perceived familial SES in these models. These findings build on previous cross sectional studies showing less frequent sex without condoms among Black YMSM despite higher rates of HIV incidence in emerging adulthood, as well as the importance of considering economic conditions in such models. Efforts to understand racial/ethnic disparities in HIV/STIs among YMSM must move beyond examination of individual-level sexual behaviors and consider both race/ethnicity and socioeconomic conditions in order to evaluate how these factors shape the sexual behaviors of YMSM.

Adolescent obesity continues to be a major public health issue with a third of American adolescents being overweight or obese. Excess weight is associated with cardiovascular risk factors and pre-diabetes. High school students identified as carrying excess weight [body mass index (BMI) >/=25 kg/m2, or BMI percentile >/=85 %] were invited to participate in The BODY Project, an intervention that included a medical evaluation and a personalized medical report of the results of that evaluation sent to the parent/guardian at home. The medical evaluation and report was repeated 12 months later. The reports also contained advice on how the individual student could modify their lifestyle to improve the specific medical parameters showing abnormalities. Outcomes were change in BMI, blood pressure, high-density lipoprotein (HDL), low-density lipoprotein (LDL), fasting glucose, and fasting insulin. Students participating in The BODY Project intervention demonstrated modest, yet significant, reductions in BMI (p < 0.001) 1 year later, and also had significant improvements in systolic blood pressure (p < 0.001) and cholesterol profile (HDL p = 0.002; LDL p < 0.001) at follow-up. The BODY Project, by means of a minimal educational program anchored on the principle of teachable moments around the students' increased perception of their own risk for disease from the medical abnormalities uncovered, demonstrates evidence of potential effectiveness in addressing adolescent obesity.

Emergency visits are rising nationally, whereas the number of emergency departments is shrinking. However, volume has not increased uniformly at all emergency departments. It is unclear what factors account for this variability in emergency volume growth rates. The objective of this study was to test the association of hospital and population characteristics and the effect of hospital closures with increases in emergency department volume. The study team analyzed emergency department volume at New York State hospitals from 2004 to 2010 using data from cost reports and administrative databases. Multivariate regression was used to evaluate characteristics associated with emergency volume growth. Spatial analytics and distances between hospitals were used in calculating the predicted impact of hospital closures on emergency department use. Among the 192 New York hospitals open from 2004 to 2010, the mean annual increase in emergency department visits was 2.7%, but the range was wide (-5.5% to 11.3%). Emergency volume increased nearly twice as fast at tertiary referral centers (4.8%) and nonurban hospitals (3.7% versus urban at 2.1%) after adjusting for other characteristics. The effect of hospital closures also strongly predicted variation in growth. Emergency volume is increasing faster at specific hospitals: tertiary referral centers, nonurban hospitals, and those near hospital closures. This study provides an understanding of how emergency volume varies among hospitals and predicts the effect of hospital closures in a statewide region. Understanding the impact of these factors on emergency department use is essential to ensure that these populations have access to critical emergency services. (Population Health Management 2015;xx:xxx-xxx).

CONTEXT: Given the highly variable behavior and clinical course of prostate cancer (PCa) and the multiple available treatment options, a personalized approach to oncologic risk stratification is important. Novel genetic approaches offer additional information to improve clinical decision making. OBJECTIVE: To review the use of genomic biomarkers in the prognostication of PCa outcome and prediction of therapeutic response. EVIDENCE ACQUISITION: Systematic literature review focused on human clinical studies reporting outcome measures with external validation. The literature search included all Medline, Embase, and Scopus articles from inception through July 2014. EVIDENCE SYNTHESIS: An improved understanding of the genetic basis of prostate carcinogenesis has produced an increasing number of potential prognostic and predictive tools, such as transmembrane protease, serine2:v-ets avian erythroblastosis virus E26 oncogene homolog (TMPRSS2:ERG) gene fusion status, loss of the phosphatase and tensin homolog (PTEN) gene, and gene expression signatures utilizing messenger RNA from tumor tissue. Several commercially available gene panels with external validation are now available, although most have yet to be widely used. The most studied commercially available gene panels, Prolaris, Oncotype DX Genomic Prostate Score, and Decipher, may be used to estimate disease outcome in addition to clinical parameters or clinical nomograms. ConfirmMDx is an epigenetic test used to predict the results of repeat prostate biopsy after an initial negative biopsy. Additional future strategies include using genetic information from circulating tumor cells in the peripheral blood to guide treatment decisions at the initial diagnosis and at subsequent decision points. CONCLUSIONS: Major advances have been made in our understanding of PCa biology in recent years. Our field is currently exploring the early stages of a personalized approach to augment traditional clinical decision making using commercially available genomic tools. A more comprehensive appreciation of value, limitations, and cost is important. PATIENT SUMMARY: We summarized current advances in genomic testing in prostate cancer with a special focus on the estimation of disease outcome. Several commercial tests are currently available, but further understanding is needed to appreciate the potential benefits and limitations of these novel tests.

BACKGROUND: Very brief single-item screening questions (SISQs) for alcohol and other drug use can facilitate screening in health care settings, but are not widely used. Self-administered versions of the SISQs could ease barriers to their implementation. OBJECTIVE: We sought to validate SISQs for self-administration in primary care patients. DESIGN: Participants completed SISQs for alcohol and drugs (illicit and prescription misuse) on touchscreen tablet computers. Self-reported reference standard measures of unhealthy use, and more specifically of risky consumption, problem use, and substance use disorders, were then administered by an interviewer, and saliva drug tests were collected. PARTICIPANTS: Adult patients aged 21-65 years were consecutively enrolled from two urban safety-net primary care clinics. MAIN MEASURES: The SISQs were compared against reference standards to determine sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for alcohol and drug use. KEY RESULTS: Among the 459 participants, 22 % reported unhealthy alcohol use and 25 % reported drug use in the past year. The SISQ-alcohol had sensitivity of 73.3 % (95 % CI 65.3-80.3) and specificity of 84.7 % (95 % CI 80.2-88.5), AUC = 0.79 (95 % CI 0.75-0.83), for detecting unhealthy alcohol use, and sensitivity of 86.7 % (95 % CI 75.4-94.1) and specificity of 74.2 % (95 % CI 69.6-78.4), AUC = 0.80 (95 % CI 0.76-0.85), for alcohol use disorder. The SISQ-drug had sensitivity of 71.3 % (95 % CI 62.4-79.1) and specificity of 94.3 % (95 % CI 91.3-96.6), AUC = 0.83 (95 % CI 0.79-0.87), for detecting unhealthy drug use, and sensitivity of 85.1 (95 % CI 75.0-92.3) and specificity of 88.6 % (95 % CI 85.0-91.6), AUC = 0.87 (95 % CI 0.83-0.91), for drug use disorder. CONCLUSIONS: The self-administered SISQs are a valid approach to detecting unhealthy alcohol and other drug use in primary care patients. Although self-administered SISQs may be less accurate than the previously validated interviewer-administered versions, they are potentially easier to implement and more likely to retain their fidelity in real-world practice settings.