Faculty Bibliography

The population of older adults is expanding rapidly, and aging predisposes to cardiovascular disease. The principle of patient-centered care must respond to the preponderance of cardiac disease that now occurs in combination with the complexities of old age. Geriatric cardiology melds cardiovascular perspectives with multimorbidity, polypharmacy, frailty, cognitive decline, and other clinical, social, financial, and psychological dimensions of aging. Although some assume that a cardiologist may instinctively cultivate some of these skills over the course of a career, we assert that the volume and complexity of older cardiovascular patients in contemporary practice warrants a more direct approach to achieve suitable training and a more reliable process of care. We present a rationale and vision for geriatric cardiology as a melding of primary cardiovascular and geriatrics skills, thereby infusing cardiology practice with expanded proficiencies in diagnosis, risks, care coordination, communications, end-of-life, and other competences required to best manage older cardiovascular patients.

OBJECTIVE: To educate physicians about appropriate acute migraine treatment guidelines by determining (1) where headache patients were first prescribed opioids and barbiturates, and (2) the characteristics of the patient population who had been prescribed opioids and barbiturates. BACKGROUND: Several specialty societies issued recommendations that caution against the indiscriminate use of opioids or barbiturate containing medications for the treatment of migraine. These medications are still being prescribed in various medical settings and could put headache specialists in a difficult position when patients request these agents. METHODS: Patients presenting to a headache center comprised of eight physicians were asked to complete a survey that assessed headache types, comorbid conditions, and whether they had ever been prescribed opioids or barbiturates. If they responded affirmatively to the latter question, they were asked about the prescribing doctor, medication effectiveness, and whether they were currently on the medication. Data collection took place over a one month period. RESULTS: Two hundred forty-four patients were given the survey and 218 of these patients completed it. The predominant diagnosis was migraine (83.9%). More than half of the patients reported having been prescribed an opioid (54.8%) or a barbiturate (56.7%). About one fifth were on opioids (19.4%) or barbiturates (20.7%) at the time of completing the survey. Most patients reported being on opioids for more than 2 years (24.6%) or less than one week (32.1%). The reasons most frequently cited for stopping opioids were that the medications did not help (30.9%) or that they saw a new doctor who would not prescribe them (29.4%). Among patients who had previously been on barbiturates, 32.2% had been on these for over 2 years. Most patients (61.8%) stopped barbiturates because they did not find the medication helpful, while 17.6% said they saw a new doctor who would not prescribe them. The physician specialty most frequently cited as being the first prescriber for opioids was emergency medicine (20.2%) with family doctors and general neurologists the next groups at 17.7% each. General neurologists were the most frequent (37.8%) first prescribers of barbiturates. CONCLUSIONS: Approximately 20% of patients presenting to a headache center reported current use of opioids and/or barbiturates. ED physicians were reported to be the most frequent first prescribers of opioids and general neurologists were the most frequent first prescribers of barbiturates. Taken as a whole, these data provide a useful snapshot of the wide variety of physician specialties that might benefit from additional education on the appropriate use of opioids and barbiturate-containing medications in patients with headaches.

BACKGROUND/PURPOSE: Group-based services can improve quality-of-life outcomes for oncology patients. We assessed preferences for supportive and educational programming to better meet patient needs and allocate resources. METHODS: Patients from three cancer centers in New York City completed a 15-item survey provided in English, Spanish, and Chinese about their interest in educational topics (wellness, nutrition, legal issues, etc.) and services (support groups, lectures, and exercise programs). Participants were recruited in the treatment and waiting areas by a patient navigator. Logistic regressions were used to assess associations between age, education, and gender on likelihood of attending each type of service. RESULTS: Three hundred eleven patients participated. Mean age was 59, and most were female (74%). The most common cancer was breast (40%), followed by genitourinary (15%). In terms of groups, women preferred wellness workshops followed by informative sessions; men preferred informative sessions, followed equally by post-treatment support and wellness workshops. Older age was related to reduced likelihood of group attendance, p =0.04. Overall, 68% of participants reported that they would be likely to attend groups. For lectures, nutrition was of greatest interest for both men (43%) and women (34%) followed by anxiety management (17% and 18%, respectively). Overall, 64% of participants reported that they would be likely to attend a lecture. More women (59%) than men (42%) reported interest in exercise programs, p = 0.02. A majority of respondents (54%) expressed desire for exercise programs at the cancer centers. CONCLUSIONS: This psychosocial needs assessment identified services most preferred by patients and can be used by cancer centers in developing programming to meet patient needs. These results may be useful to suggest ways that the healthcare team can respond most effectively to the psychosocial needs of cancer patients. Research Implications: The findings reflect gender, age, and educational level differences in terms of patient preferences for support programming; however, the generalizability is limited. Practice Implications: The psychosocial needs assessment provides a starting point for developing interventions. Therefore, this information should be helpful to clinicians planning new initiatives and refining existing psychoeducational and wellness programs and support groups

OBJECTIVE: The epidemiology of the incidence of sexually transmitted hepatitis C virus (HCV) infection in HIV-positive MSM is only partially understood. In the presence of HIV, HCV infection is more likely to become chronic and liver fibrosis progression is accelerated. DESIGN: A systematic review and meta-analysis was used to synthesize data characterizing sexually transmitted HCV in HIV-positive MSM. METHODS: Electronic and other searches of medical literature (including unpublished reports) were conducted. Eligible studies reported on HCV seroconversion or on reinfection postsuccessful HCV treatment in HIV-positive MSM who were not injecting drugs. Pooled incidence rates were calculated using random-effects meta-analysis, and meta-regression was used to assess study-level moderators. Attributable risk measures were calculated from statistically significant associations between exposures and HCV seroconversion. RESULTS: More than 13 000 HIV-positive MSM in 17 studies were followed for more than 91 000 person-years between 1984 and 2012; the pooled seroconversion rate was 0.53/100 person-years. Calendar time was a significant moderator of HCV seroconversion, increasing from an estimated rate of 0.42/100 person-years in 1991 to 1.09/100 person-years in 2010, and 1.34/100 person-years in 2012. Reinfection postsuccessful HCV treatment (n = 2 studies) was 20 times higher than initial seroconversion rates. Among the seroconverters, a large proportion of infections were attributable to high-risk behaviours including mucosally traumatic sex and sex while high on methamphetamine. CONCLUSION: The high reinfection rates and the attributable risk analysis suggest the existence of a subset of HIV-positive MSM with recurring sexual exposure to HCV. Approaches to HCV control in this population will need to consider the changing epidemiology of HCV infection in MSM.

BACKGROUND: Understanding HCV disease progression rates among people who inject drugs (PWID) is important to setting policy to expand access to detection, diagnosis and treatment, and in forecasting the burden of disease. In this paper we synthesize existing data on the natural history of HCV among PWID, including fibrosis progression rates (FPR) and the incidence of compensated cirrhosis (CC), decompensated cirrhosis (DC), and hepatocellular carcinoma (HCC). METHODS: We conducted electronic and manual searches for published and unpublished literature. Reports were eligible if they (i) included participants who were chronically infected with HCV and reported current or previous injection drug use; (ii) presented original data on disease progression in a study sample comprised of at least 90% PWID; (iii) published between January 1, 1990, and December 31, 2013; and (iv) included data from upper-middle- or high-income countries. Quality ratings were assigned using an adaptation of the Quality In Prognosis Studies (QUIPS) tool. We estimated pooled FPRs using the stage-constant and stage-specific methods, and pooled incidence rates of CC, DC, and HCC. RESULTS: Twenty-one reports met the study inclusion criteria. Based on random-effect models, the pooled stage-constant FPR was 0.117 METAVIR units per year (95% CI, 0.099-0.135), and the stage-specific FPRs were F0-->F1, 0.128 (95% CI 0.080, 0.176); F1-->F2, 0.059 (95% CI 0.035, 0.082); F2-->F3, 0.078 (95% CI 0.056, 0.100); and F3-->F4, 0.116 (95% CI 0.070, 0.161). The pooled incidence rates of CC, DC, and HCC were 6.6 (95% CI 4.8, 8.4), 1.1 (95% CI 0.8, 1.4), and 0.3 (95% CI -0.1, 0.6) events per 1000 person-years, respectively. Following the stage-constant estimate, average time to cirrhosis is 34 years post-infection, and time to METAVIR stage F3 is 26 years; using the stage-specific estimates, time to cirrhosis is 46 years and time to F3 is 38 years. CONCLUSION: Left untreated, PWID with chronic HCV infection will develop liver sequelae (including HCC) in mid- to late-adulthood. Delaying treatment with the new drug regimens until advanced fibrosis develops prolongs the period of infectiousness to perhaps thirty years. Scaling up of effective HCV prevention and early engagement in care and treatment will facilitate the elimination HCV as a source of serious disease in PWID.

Arterioenteric fistulas represent an infrequent but potentially fatal cause of gastrointestinal hemorrhage. Patients often present in extremis from shock and sepsis. This mandates a rapid diagnosis so that prompt, potentially life-saving interventions can be performed. We report the case of a 35 year-old male who presented with hematuria and hematochezia secondary to an iliac artery-uretero-colonic fistula that developed years following open common iliac artery aneurysm repair. His condition rapidly progressed to hemorrhagic shock and he underwent successful endovascular treatment with a covered stent graft as a bridge to definitive open surgery. Subsequently, graft explantation, extra-anatomic arterial bypass, bowel resection and ureter ligation was undertaken. A summary of the literature on iliac artery-enteric fistulas follows.