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

Evidence on the association between vitamin D status and pancreatic cancer risk is inconsistent. This inconsistency may be partially attributable to variation in vitamin D regulating genes. We selected 11 vitamin D-related genes (GC, DHCR7, CYP2R1, VDR, CYP27B1, CYP24A1, CYP27A1, RXRA, CRP2, CASR and CUBN) totaling 213 single nucleotide polymorphisms (SNPs), and examined associations with pancreatic adenocarcinoma. Our study included 3,583 pancreatic cancer cases and 7,053 controls from the genome-wide association studies of pancreatic cancer PanScans-I-III. We used the Adaptive Joint Test and the Adaptive Rank Truncated Product statistic for pathway and gene analyses, and unconditional logistic regression for SNP analyses, adjusting for age, sex, study and population stratification. We examined effect modification by circulating vitamin D concentration (50 nmol/L) for the most significant SNPs using a subset of cohort cases (n = 713) and controls (n = 878). The vitamin D metabolic pathway was not associated with pancreatic cancer risk (p = 0.830). Of the individual genes, none were associated with pancreatic cancer risk at a significance level of p<0.05. SNPs near the VDR (rs2239186), LRP2 (rs4668123), CYP24A1 (rs2762932), GC (rs2282679), and CUBN (rs1810205) genes were the top SNPs associated with pancreatic cancer (p-values 0.008-0.037), but none were statistically significant after adjusting for multiple comparisons. Associations between these SNPs and pancreatic cancer were not modified by circulating concentrations of vitamin D. These findings do not support an association between vitamin D-related genes and pancreatic cancer risk. Future research should explore other pathways through which vitamin D status might be associated with pancreatic cancer risk.

BACKGROUND: Inorganic arsenic exposure has been related to the risk of increased blood pressure based largely on cross-sectional studies, conducted in highly exposed populations. Pregnancy is a period of particular vulnerability to environmental insults. However, little is known about the cardiovascular impacts of arsenic exposure during pregnancy. OBJECTIVES: To evaluate the association between prenatal arsenic exposure and maternal blood pressure over the course of pregnancy in a US population. METHODS: The New Hampshire Birth Cohort Study is an ongoing prospective cohort study, in which over 10% of participant household wells exceed the arsenic maximum contaminant level of 10 mug/L established by the US EPA. Total urinary arsenic measured at 24-28 weeks gestation was measured in 514 pregnant women, ages 18-45, who used a private well in their household and used as a biomarker of exposure during pregnancy. Outcomes were repeated blood pressure measurements (systolic, diastolic and pulse pressure) recorded during pregnancy. RESULTS: Using linear mixed effects models, we estimated that, on average, each 5 microg/L increase in urinary As was associated with a 0.15 mmHg (95% CI: 0.02, 0.29, p = 0.022) increase in systolic blood pressure per month and a 0.14 mmHg (95% CI: 0.02, 0.25; p=0.021) increase in pulse pressure per month over the course of pregnancy. CONCLUSIONS: In our US cohort of pregnant women, arsenic exposure was associated with greater increases in blood pressure over the course of pregnancy. These findings may have important implications as even modest increases in blood pressure impact cardiovascular disease risk.

PURPOSE: Delivering the recommended care is an important quality measure that has been insufficiently studied in urology. Obstructive pyelonephritis is a suitable case study for this focus because many patients do not receive such care, although guidelines advocate decompression. We determined the influence of hospital factors, particularly familiarity with urolithiasis, on the likelihood of decompression in such patients. MATERIALS AND METHODS: We used the NIS from 2002 to 2011 to retrospectively identify patients admitted to community hospitals with severe infection and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (the decompression rate in patients with ureteral calculi and no infection). After calculating national estimates we performed logistic regression to determine the association between the receipt of decompression and hospital stone volume, controlling for treatment intensity and other covariates thought to be associated with receiving recommended care. RESULTS: Of an estimated 107,848 patients with obstructive pyelonephritis 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs 25%, OR 2.77, 95% CI 1.94-3.96, p <0.01) as well as high and low treatment intensity (78% vs 37%, p <0.01). CONCLUSIONS: High hospital stone volume and treatment intensity were associated with an increased likelihood of receiving decompression. Such findings might be useful to identify hospitals and regions where access to quality urological care should be augmented.

Racial/ethnic disparities in the prevalence of type 2 diabetes mellitus (T2DM) are well documented and until recently, research has focused almost exclusively on individual-based determinants as potential contributors to these disparities (health behaviors, biological/genetic factors, and individual-level socio-demographics). Research on the role of neighborhood characteristics in relation to racial/ethnic disparities in T2DM is very limited. Therefore, the aim of this research is to identify and estimate the contribution of specific aspects of neighborhoods that may be associated with racial/ethnic disparities in T2DM. Data from the Boston Area Community Health III Survey (N = 2764) was used in this study, which is a community-based random-sample survey of adults in Boston, Massachusetts from three racial/ethnic groups (Black, Hispanic, and White). We applied two-level random intercepts logistic regression to assess the associations between race/ethnicity, neighborhood characteristics (census tract socioeconomic status, racial composition, property and violent crime, open space, geographic proximity to grocery stores, convenience stores, and fast food, and neighborhood disorder) and prevalent T2DM (fasting glucose > 125 mg/dL, HbA1c >/= 6.5%, or self-report of a T2DM diagnosis). Black and Hispanic participants had 2.89 times and 1.48 times the odds of T2DM as White participants, respectively. Multilevel models indicated a significant between-neighborhood variance estimate of 0.943, providing evidence of neighborhood variation. Individual demographics (race/ethnicity, age and gender) explained 22.3% of the neighborhood variability in T2DM. The addition of neighborhood-level variables to the model had very little effect on the magnitude of the racial/ethnic disparities and on the between-neighborhood variability. For example, census tract poverty explained less than 1% and 6% of the excess odds of T2DM among Blacks and Hispanics and only 1.8% of the neighborhood variance in T2DM. While the findings of this study overall suggest that neighborhood factors are not a major contributor to racial/ethnic disparities in T2DM, further research is needed including data from other geographic locations.

OBJECTIVES: To characterize caregiver strain, depressive symptoms, and self-efficacy for managing dementia-related problems and the relationship between these and referring provider type. DESIGN: Cross-sectional observational cohort. SETTING: Urban academic medical center. PARTICIPANTS: Caregivers of community-dwelling adults with dementia referred to a dementia care management program. MEASUREMENTS: Caregivers were surveyed and completed the Patient Health Questionnaire (PHQ-9) about themselves; the Modified Caregiver Strain Index; the Neuropsychiatric Inventory Questionnaire, which measures patient symptom severity and related caregiver distress; and a nine-item caregiver self-efficacy scale developed for the study. RESULTS: Of 307 patient-caregiver dyads surveyed over a 1-year period, 32% of caregivers reported confidence in managing dementia-related problems, 19% knew how to access community services to help provide care, and 28% agreed that the individual's provider helped them work through dementia care problems. Thirty-eight percent reported high levels of caregiver strain, and 15% reported moderate to severe depressive symptoms. Caregivers of individuals referred by geriatricians more often reported having a healthcare professional to help work through dementia care problems than those referred by internists, family physicians, or other specialists, but self-efficacy did not differ. Low caregiver self-efficacy was associated with higher caregiver strain, more caregiver depressive symptoms, and caring for an individual with more-severe behavioral symptoms. CONCLUSION: Most caregivers perceived inadequate support from the individual's provider in managing dementia-related problems, reported strain, and had low confidence in managing caregiving. New models of care are needed to address the complex care needs of individuals with dementia and their caregivers.

OBJECTIVES: To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. METHODS: We randomized 151 patient-caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient-caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. RESULTS: Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. DISCUSSION: Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected.

Sudden hospital closures displace patients from usual sources of care and force them to access facilities that lack their prior medical records. For patients with complex needs and for nearby hospitals already strained by high volume, disaster-related hospital closures induce a public health emergency. Our objective was to analyze responses of patients from public versus private emergency departments after closure of their usual hospital after Hurricane Sandy. Using a statewide database of emergency visits, we followed patients with an established pattern of accessing 1 of 2 hospitals that closed after Hurricane Sandy: Bellevue Hospital Center and NYU Langone Medical Center. We determined how these patients redistributed for emergency care after the storm. We found that proximity strongly predicted patient redistribution to nearby open hospitals. However, for patients from the closed public hospital, this redistribution was also influenced by hospital ownership, because patients redistributed to other public hospitals at rates higher than expected by proximity alone. This differential response to hospital closures demonstrates significant differences in how public and private patients respond to changes in health care access during disasters. Public health response must consider these differences to meet the needs of all patients affected by disasters and other public health emergencies. (Disaster Med Public Health Preparedness. 2015;00:1-9).