Faculty Bibliography

Statins are the cornerstone of lipid-lowering therapy for cardiovascular disease prevention. The 2013 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines represent a fundamental shift in how statins will be prescribed. The new guidelines recommend statins for nearly all older patients up to age 75 years, including healthy adults with low normal lipid levels and no atherosclerotic cardiovascular disease (ASCVD) risk factors other than age. Under the 2013 guidelines, age becomes a main determinant for initiating statin therapy for primary prevention among older adults. Specifically, according to the new guidelines, white males aged 63-75, white females aged 71-75, African American males aged 66-75, and African American females aged 70-75 with optimal risk factors would be recommended for statin treatment for primary prevention. Based on the new guidelines, one could term these older adults as having "statin deficiency," a condition warranting statin treatment. We call this putative condition of age-related statin deficiency "statinopause." After careful examination of the trial evidence, we find very little support for the new recommendations for primary prevention. The lack of evidence underscores the need for clinical trials to determine the risks and benefits of statin therapy for primary prevention among older adults.

BACKGROUND: The epidemiology of aortic dissection (AD) has not been well described among older persons in the United States. It is not known whether advancements in AD care over the last decade have been accompanied by changes in outcomes. METHODS AND RESULTS: The Inpatient Medicare data from 2000 to 2011 were used to determine trends in hospitalization rates for AD. Mortality rates were ascertained through corresponding vital status files. A total of 32 057 initial AD hospitalizations were identified. The overall hospitalization rate for AD remained unchanged at 10 per 100 000 person-years. For 30-day and 1-year mortality associated with AD, the observed rate decreased from 31.8% to 25.4% (difference, 6.4%; 95% confidence interval [CI], 6.2-6.5; adjusted, 6.4%; 95% CI, 5.7-6.9) and from 42.6% to 37.4% (difference, 5.2%; 95% CI, 5.1-5.2; adjusted, 6.2%; 95% CI, 5.3-6.7), respectively. For patients undergoing surgical repair for type A dissections, the observed 30-day mortality decreased from 30.7% to 21.4% (difference, 9.3%; 95% CI, 8.3-10.2; adjusted, 7.3%; 95% CI, 5.8-7.8) and the observed 1-year mortality decreased from 39.9% to 31.6% (difference, 8.3%; 95% CI, 7.5-9.1%; adjusted, 8.2%; 95% CI, 6.7-9.1). The 30-day mortality decreased from 24.9% to 21% (difference, 3.9%; 95% CI, 3.5-4.2; adjusted, 2.9%; 95% CI, 0.7-4.4) and 1-year decreased from 36.4% to 32.5% (difference, 3.9%; 95% CI, 3.3-4.3; adjusted, 3.9%; 95% CI, 2.5-6.3) for surgical repair of type B dissection. CONCLUSIONS: Although AD hospitalization rates remained stable, improvement in mortality was noted, particularly in patients undergoing surgical repair.

INTRODUCTION: Dental visits represent an opportunity to identify and help patients quit smoking, yet dental settings remain an untapped venue for treatment of tobacco dependence. The purpose of this analysis was to assess factors that may influence patterns of tobacco-use-related practice among a national sample of dental providers. METHODS: We surveyed a representative sample of general dentists practicing in the United States (N = 1,802). Multivariable analysis was used to assess correlates of adherence to tobacco use treatment guidelines and to analyze factors that influence providers' willingness to offer tobacco cessation assistance if reimbursed for this service. RESULTS: More than 90% of dental providers reported that they routinely ask patients about tobacco use, 76% counsel patients, and 45% routinely offer cessation assistance, defined as referring patients for cessation counseling, providing a cessation prescription, or both. Results from multivariable analysis indicated that cessation assistance was associated with having a practice with 1 or more hygienists, having a chart system that includes a tobacco use question, having received training on treating tobacco dependence, and having positive attitudes toward treating tobacco use. Providers who did not offer assistance but who reported that they would change their practice patterns if sufficiently reimbursed were more likely to be in a group practice, treat patients insured through Medicaid, and have positive attitudes toward treating tobacco dependence. CONCLUSION: Findings indicate the potential benefit of increasing training opportunities and promoting system changes to increase involvement of dental providers in conducting tobacco use treatment. Reimbursement models should be tested to assess the effect on dental provider practice patterns.

OBJECTIVE. The objective of this study was to quantify the effects of radiation-induced cancer risks in patients with Bosniak category IIF lesions undergoing CT versus MRI surveillance. MATERIALS AND METHODS. We developed a Markov-Monte Carlo model to determine life expectancy losses attributable to radiation-induced cancers in hypothetical patients undergoing CT versus MRI surveillance of Bosniak IIF lesions. Our model tracked hypothetical patients as they underwent imaging surveillance for up to 5 years, accounting for potential lesion progression and treatment. Estimates of radiation-induced cancer mortality were generated using a published organ-specific radiation-risk model based on Biological Effects of Ionizing Radiation VII methods. The model also incorporated surgical mortality and renal cancer-specific mortality. Our primary outcome was life expectancy loss attributable to radiation-induced cancers. A sensitivity analysis was performed to assess the stability of the results with variability in key parameters. RESULTS. The mean number of examinations per patient was 6.3. In the base case, assuming 13 mSv per multiphase CT examination, 64-year-old men experienced an average life expectancy decrease of 5.5 days attributable to radiation-induced cancers from CT; 64-year-old women experienced a corresponding life expectancy loss of 6.9 days. The results were most sensitive to patient age: Life expectancy loss attributable to radiation-induced cancers increased to 21.6 days in 20-year-old women and 20.0 days in 20-year-old men. Varied assumptions of each modality's (CT vs MRI) depiction of lesion complexity also impacted life expectancy losses. CONCLUSION. Microsimulation modeling shows that radiation-induced cancer risks from CT surveillance for Bosniak IIF lesions minimally affect life expectancy. However, as progressively younger patients are considered, increasing radiation risks merit stronger consideration of MRI surveillance.

INTRODUCTION: The impaired host defense system in HIV infection impacts the oral and gastrointestinal microbiota and associated opportunistic infections. Antiretroviral treatment is predicted to partially restore host defenses and decrease the oral manifestation of HIV/AIDS. Well-designed longitudinal studies are needed to better understand the interactions of soluble host defense proteins with bacteria and virus in HIV/AIDS. "Crosstalk" was designed as a longitudinal study of host responses along the gastrointestinal (GI) tract and interactions between defense molecules and bacteria in HIV infection and subsequent therapy. PURPOSE: The clinical core formed the infrastructure for the study of the interactions between the proteome, microbiome and innate immune system. The core recruited and retained study subjects, scheduled visits, obtained demographic and medical data, assessed oral health status, collected samples, and guided analysis of the hypotheses. This manuscript presents a well-designed clinical core that may serve as a model for studies that combine clinical and laboratory data. METHODS: Crosstalk was a case-control longitudinal clinical study an initial planned enrollment of 170 subjects. HIV+ antiretroviral naive subjects were followed for 9 visits over 96 weeks and HIV uninfected subjects for 3 visits over 24 weeks. Clinical prevalence of oral mucosal lesions, dental caries and periodontal disease were assessed. RESULTS: During the study, 116 subjects (47 HIV+, 69 HIV-) were enrolled. Cohorts of HIV+ and HIV- were demographically similar except for a larger proportion of women in the HIV- group. The most prevalent oral mucosal lesions were oral candidiasis and hairy leukoplakia in the HIV+ group. DISCUSSION: The clinical core was essential to enable the links between clinical and laboratory data. The study aims to determine specific differences between oral and GI tissues that account for unique patterns of opportunistic infections and to delineate the differences in their susceptibility to infection by HIV and their responses post-HAART.

BACKGROUND: Case managers are employed in medical homes to coordinate care for clinically complex patients. OBJECTIVE: To measure the association of patient perceptions of case manager performance with overall satisfaction and subsequent health care utilization. DESIGN: Retrospective cohort study. SETTING: Integrated health system in Pennsylvania. PATIENTS: Members of the health system-owned health plan who 1) received primary care in the health system's clinics, 2) were exposed to clinic-embedded case managers, and 3) completed a survey of satisfaction with care. MEASUREMENTS: Survey assessment of case manager performance and overall satisfaction with care and claims-based assessment of case manager performance and subsequent hospitalizations or emergency department visits. Survey measures were dichotomized into very good versus less than very good. RESULTS: A total of 1755 patients (44%) completed the survey and 1415 met study criteria. Survey respondents who reported very good ratings of case manager performance across all items had a higher probability of reporting very good overall satisfaction with care (92.2% vs. 62.5%; P < 0.001) and had a lower incidence of subsequent emergency department visits (incidence rate ratio, 0.79 [95% CI, 0.64 to 0.98]; P = 0.029) but not hospitalizations (incidence rate ratio, 0.92 [CI, 0.75 to 1.11]; P = 0.37) up to 2 years after the survey compared with survey respondents who reported less-than-very good case manager performance on 1 or more questions on the survey. LIMITATIONS: Satisfaction data demonstrated substantial ceiling effects. Survey nonresponse may have introduced bias in the results. CONCLUSION: Patients' favorable perceptions of case managers are associated with higher overall satisfaction with care and may lower risk for future acute care use. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation and the U.S. Department of Veterans Affairs.

The New York City (NYC) subway is the main mode of transport for over 5 million passengers on an average weekday. Therefore, airborne pollutants in the subway stations could have a significant impact on commuters and subway workers. This study looked at black carbon (BC) and particulate matter concentrations (PM2.5) in selected subway stations in Manhattan. BC and PM2.5 levels were measured in real time using a Micro-Aethalometer and a PDR-1500 Data RAM, respectively. Simultaneous samples were also collected on quartz filters for Organic and Elemental carbon (OC/EC) analysis and on Teflon filters for gravimetric and trace element analysis. In the underground subway stations, mean real time BC concentrations ranged from 5 to 23 microg/m3, with 1 minute average peaks >100 microg/m3, while real time PM2.5 levels ranged from 35 to 200 microg/m3. Mean EC levels ranged from 9 to 12.5 microg/m3. At street level on the same days, the mean BC and PM2.5 concentrations were below 3 microg/m3 and 10 microg/m3, respectively. This study shows that both BC soot and PM levels in NYC's subways are considerably higher than ambient urban street levels, and further monitoring and investigation of BC and PM subway exposures are warranted.

Falls are common events that threaten the independence and health of older adults. Studies have found a wide range of fall statistics in different ethnic and racial groups throughout the world. These studies suggest that fall rates may differ between different racial and ethnic groups. Studies also suggest that the location of falls, circumstances of falls, and particular behaviors may also be different by population. Also migration to new locations may alter an individual's fall risk. However, there are few studies that directly compare ethnic and racial differences in falls statistics or examine how known fall risk factors change based on race and ethnicity. This paper reviews the existing literature on how falls may differ between different racial and ethnic groups, highlights gaps in the literature, and explores directions for future research. The focus of this paper is community dwelling older adults and immigrant populations in the United States.

Obesity is a challenging public health problem that affects millions of Americans. Increasingly policy makers are seeking environmental and policy-based solutions to combat and prevent its serious health effects. Calorie labeling mandates, including the provision in the 2010 Patient Protection and Affordable Care Act that is set to begin in 2014, have been one of the most popular and most studied approaches. This review examines 31 studies published from January 1, 2007 through July 19, 2013. It builds on Harnack and French's 2008 review and assesses the evidence on the effectiveness of calorie labeling at the point of purchase. We find that, while there are some positive results reported from studies examining the effects of calorie labeling, overall the best designed studies (real world studies, with a comparison group) show that calorie labels do not have the desired effect in reducing total calories ordered at the population level. Moving forward, researchers should consider novel, more effective ways of presenting nutrition information, while keeping a focus on particular subgroups that may be differentially affected by nutrition policies.

Abstract Support for marijuana (cannabis) legalization is increasing in the US, and state-level marijuana policies are rapidly changing. Research is needed to examine correlates of opinions toward legalization among adolescents approaching adulthood as they are at high risk for use. Data were examined from a national representative sample of high school seniors in the Monitoring the Future study (years 2007-2011; N = 11,594) to delineate correlates of opinions toward legalization. A third of students felt marijuana should be entirely legal and 28.5% felt it should be treated as a minor violation; 48.0% felt that if legal to sell it should be sold to adults only, and 10.4% felt it should be sold to anyone. Females, conservatives, religious students, and those with friends who disapprove of marijuana use tended to be at lower odds for supporting legalization, and Black, liberal, and urban students were at higher odds for supporting more liberal policies. Recent and frequent marijuana use strongly increased odds for support for legalization; however, 16.7% of non-lifetime marijuana users also reported support for legalization. Findings should be interpreted with caution as state-level data were not available, but results suggest that support for marijuana legalization is common among specific subgroups of adolescents.