Faculty Bibliography

40% of Medicare beneficiaries with diabetes (DM) are >76 years. This group is not included in clinical trials, so we have poor understanding of DM's natural history in this population and limited evidence to guide its treatment. We hypothesized that 1) clinical databases can provide valuable information about this group and 2) compared to other ages, DM patients >76 years have differing trajectories for hemoglobin A1c (A1c), LDL cholesterol, and systolic/ diastolic blood pressures (SBP/

Background: Care of limited English proficiency (LEP) patients in the emergency department (ED) is challenging. Objectives: We set out to determine the association between patient LEP status and unplanned ED revisit within 72 hours-a widely used metric of ED quality of care. Recognizing that physicians may choose to admit LEP patients if uncertain about diagnosis or follow-up, we also examined the association between LEP status and hospital admission rate. Methods: We used ED electronic data to perform a retrospective cohort study of patients presenting to an adult ED in 2012. Admission analysis was performed after excluding patients with psychiatric complaints, altered mental status, non-verbal states, and patients with more than four ED visits in 12 months. For the ED revisit within 72 hours analysis, we further excluded patients with planned ED revisits, and those who presented to the ED within 30 days of a hospital admission. We used generalized estimating equation (GEE) multivariate models to control for patient's age, sex, insurance, race, ethnicity, triage category, and Charlson Comorbidity Score. Results: 41,772 patients with 56,821 ED visits were included in the hospital admission analysis. 7.1% of all patients (n=2,943) had LEP; professional interpreter use was documented in 23.9%. While LEP patients appeared more likely than English speakers to be admitted (32.0% vs. 27.2%, OR 1.20, 95% CI 1.11-1.30, p<0.001), this association became non-significant after adjustments (OR=1.04, 95% CI 0.95-1.15, p=0.42). 32,857 patients with 45,546 ED visits were included in the ED revisit within 72 hours analysis. 4.2% of all patients (n=1,380) had at least one unplanned revisit. LEP patients were more likely than English speakers to have unplanned visits (5.0% vs. 4.1%, OR=1.19, 95% CI 1.02-1.45, p=0.07). This association persisted (OR=1.24, 95% CI 1.02-1.53, p=0.04) after adjustment for potential confounders. Conclusion: We found that while LEP patients were no less likely to be admitted to the hos!

Background: ED patients with acute drug overdose have been shown to suffer adverse cardiovascular events, but prediction of these events is difficult. Objectives: To validate previously derived features of the initial ECG associated with adverse cardiovascular events in this population. Methods: We performed a prospective validation cohort study to evaluate adult ED patients with acute drug overdose at two urban university hospitals over 5 years in whom ED admission ECGs were performed. Excluded were patients with alternate diagnoses, anaphylaxis, chronic drug toxicity, and missing outcome data. Adverse cardiovascular events were defined as any of the following: shock (vasopressor requirement), myocardial injury (MI, elevated troponin), ventricular dysrythmia, or cardiac arrest (pulseless). Blinded cardiologists interpreted ECGs for rhythm, intervals, QT dispersion, ischemia (T wave inversion, ST depression), and infarction (ST elevation, Q waves). Diagnostic test characteristics of the previously derived ECG rule (ectopy, non-sinus rhythm, QTc), as well as univariate statistics, odds ratios (OR), and 95% confidence intervals (CI) were calculated. Assuming 10% prevalence of predictor variables and baseline 8% adverse cardiovascular event rate in the population, we calculated the need to enroll 552 patients to show three-fold increased risk per factor with 80% power and 5% alpha. Results: Of 589 acute drug overdose patients who met inclusion criteria (48% male, mean age 42), there were 95 adverse cardiovascular events (39 shock, 64 MI, 26 dysrhythmia, 16 cardiac arrest). The most common drug exposures were benzodiazepines, opioids, and acetaminophen. All previously derived criteria were highly predictive of adverse events, with QTc >500 ms the highest risk feature associated with over 10-fold increased adverse cardiovascular event risk (OR 11.2, CI 4.6-27). All high-risk ECG features as well as diagnostic test characteristics of the ECG rule are presented in Table 217. Conclusion: This study val!

Children who become overweight by age 2 years have significantly greater risks of long-term health problems, and children in low-income communities, where rates of low adult literacy are highest, are at increased risk of developing obesity. The objective of the Greenlight Intervention Study is to assess the effectiveness of a low-literacy, primary-care intervention on the reduction of early childhood obesity. At 4 primary-care pediatric residency training sites across the US, 865 infant-parent dyads were enrolled at the 2-month well-child checkup and are being followed through the 24-month well-child checkup. Two sites were randomly assigned to the intervention, and the other sites were assigned to an attention-control arm, implementing the American Academy of Pediatrics' The Injury Prevention Program. The intervention consists of an interactive educational toolkit, including low-literacy materials designed for use during well-child visits, and a clinician-centered curriculum for providing low-literacy guidance on obesity prevention. The study is powered to detect a 10% difference in the number of children overweight (BMI > 85%) at 24 months. Other outcome measures include observed physician-parent communication, as well as parent-reported information on child dietary intake, physical activity, and injury-prevention behaviors. The study is designed to inform evidence-based standards for early childhood obesity prevention, and more generally to inform optimal approaches for low-literacy messages and health literacy training in primary preventive care. This article describes the conceptual model, study design, intervention content, and baseline characteristics of the study population.

OBJECTIVE: Describe the attitudes, beliefs, and practices of U.S. obstetricians on the topic of prenatal environmental exposures. STUDY DESIGN: A national online survey of American Congress of Obstetricians and Gynecologists (ACOG) fellows and 3 focus groups of obstetricians. RESULTS: We received 2,514 eligible survey responses, for a response rate of 14%. The majority (78%) of obstetricians agreed that they can reduce patient exposures to environmental health hazards by counseling patients; but 50% reported that they rarely take an environmental health history; less than 20% reported routinely asking about environmental exposures commonly found in pregnant women in the U.S.; and only 1 in 15 reported any training on the topic. Barriers to counseling included: a lack of knowledge of and uncertainty about the evidence; concerns that patients lack the capacity to reduce harmful exposures; and fear of causing anxiety among patients. CONCLUSION: U.S. obstetricians in our study recognized the potential impact of the environment on reproductive health, and the role that physicians could play in prevention, but reported numerous barriers to counseling patients. Medical education and training, evidence-based guidelines, and tools for communicating risks to patients are needed to support the clinical role in preventing environmental exposures that threaten patient health.

OBJECTIVE: We investigated the King-Devick (K-D) test of rapid number naming as a visual performance measure in a cohort of patients with multiple sclerosis (MS). METHODS: In this cross-sectional study, 81 patients with MS and 20 disease-free controls from an ongoing study of visual outcomes underwent K-D testing. A test of rapid number naming, K-D requires saccadic eye movements as well as intact vision, attention and concentration. To perform the K-D test, participants are asked to read numbers aloud as quickly as possible from three test cards; the sum of the three test card times in seconds constitutes the summary score. High-contrast visual acuity (VA), low-contrast letter acuity (1.25% and 2.5% levels), retinal nerve fiber layer (RNFL) thickness by optical coherence tomography (OCT), MS Functional Composite (MSFC) and vision-specific quality of life (QOL) measures (25-Item NEI Visual Functioning Questionnaire [NEI-VFQ-25] and 10-Item Neuro-Ophthalmic Supplement) were also assessed. RESULTS: K-D time scores in the MS cohort (total time to read the three test cards) were significantly higher (worse) compared to those for disease-free controls (P=0.003, linear regression, accounting for age). Within the MS cohort, higher K-D scores were associated with worse scores for the NEI-VFQ-25 composite (P<0.001), 10-Item Neuro-Ophthalmic Supplement (P<0.001), binocular low-contrast acuity (2.5%, 1.25%, P<0.001, and high-contrast VA (P=0.003). Monocular low-contrast vision scores (P=0.001-0.009) and RNFL thickness (P=0.001) were also reduced in eyes of patients with worse K-D scores (GEE models accounting for age and within-patient, inter-eye correlations). Patients with a history of optic neuritis (ON) had increased (worse) K-D scores. Patients who classified their work disability status as disabled (receiving disability pension) did worse on K-D testing compared to those working full-time (P=0.001, accounting for age). CONCLUSIONS: The K-D test, a <2minute bedside test of rapid number naming, is associated with visual dysfunction, neurologic impairment, and reduced vision-specific QOL in patients with MS. Scores reflect work disability as well as structural changes as measured by OCT imaging. History of ON and abnormal binocular acuities were associated with worse K-D scores, suggesting that abnormalities detected by K-D may go along with afferent dysfunction in MS patients. A brief test that requires saccadic eye movements, K-D should be considered for future MS trials as a rapid visual performance measure.

Background: Although ecstasy (MDMA) use is not as prevalent in the United States (US) as it was in the early 2000s, use remains popular among adolescents and young adults. Few recent studies have examined ecstasy use in national samples among those at particularly high risk for use-adolescents approaching adulthood. Research is needed to delineate sociodemographic correlates of use in this group. Methods: Data were examined from a nationally representative sample of high school seniors in the US (modal age = 18) from the Monitoring the Future study (years 2007-2012; weighted N = 26,504). Data from all cohorts were aggregated and correlates of recent (last 12-month) use of ecstasy were examined. Results: Roughly 4.4% of high school seniors reported use of ecstasy within the last year. Females and religious students were consistently at lower odds for use. Black and Hispanic students, and students residing with two parents, were at lower odds for ecstasy use, until controlling for other drug use. Odds of use were consistently increased for those residing in a city, students with weekly income of >$50 from a job, and students earning >$10 weekly from other sources. Lifetime use of alcohol, cigarettes, marijuana, and other illicit drugs each robustly increased odds of ecstasy use. Conclusion: Subgroups of high school seniors, defined by specific sociodemographic factors, and those who have used other drugs, are currently at high risk for ecstasy initiation and use. Since ecstasy is regaining popularity in the US, prevention efforts should consider these factors.

BACKGROUND: For patients with advanced cancer, visits to the emergency department (ED) are common. Such patients present to the ED with a specific profile of palliative care needs, including burdensome symptoms such as pain, dyspnea, or vomiting that cannot be controlled in other settings and a lack of well-defined goals of care. The goals of this study are: i) to test the feasibility of recruiting, enrolling, and randomizing patients with serious illness in the ED; and ii) to evaluate the impact of ED-initiated palliative care on health care utilization, quality of life, and survival.Methods/design: This is a protocol for a single center parallel, two-arm randomized controlled trial in ED patients with metastatic solid tumors comparing ED-initiated palliative care referral to a control group receiving usual care. We plan to enroll 125 to 150 ED-advanced cancer patients at Mount Sinai Hospital in New York, USA, who meet the following criteria: i) pass a brief cognitive screen; ii) speak fluent English or Spanish; and iii) have never been seen by palliative care. We will use balanced block randomization in groups of 50 to assign patients to the intervention or control group after completion of a baseline questionnaire. All research staff performing assessment or analysis will be blinded to patient assignment. We will measure the impact of the palliative care intervention on the following outcomes: i) timing and rate of palliative care consultation; ii) quality of life and depression at 12 weeks, measured using the FACT-G and PHQ-9; iii) health care utilization; and iv) length of survival. The primary analysis will be based on intention-to-treat. DISCUSSION: This pilot randomized controlled trial will test the feasibility of recruiting, enrolling, and randomizing patients with advanced cancer in the ED, and provide a preliminary estimate of the impact of palliative care referral on health care utilization, quality of life, and survival.Trial registration: Clinical Trials.gov identifier: NCT01358110 (Entered 5/19/2011).

BACKGROUND: Patients with advanced cancer often visit the emergency department (ED). Little is known about their willingness or ability to engage in palliative care research, although enrollment in clinical trials of other seriously ill ED patientsthose with stroke, for examplehas been shown to be feasible. OBJECTIVE: To identify barriers to the enrollment of ED patients with advanced cancer in palliative care research. METHODS: We prospectively tracked factors that affected patient accrual into a trial of palliative care for adults with metastatic solid tumors at an urban, academic ED. Research staff screened the electronic medical records for patients admitted to the hospital with metastatic solid tumors 8-12 hours a day, Monday through Friday. The ED attending of record and the patient's medical oncologist had to agree before research staff invited the patient to participate. Informed consent was obtained at the bedside in the ED, and patients were offered a $20 incentive to participate. RESULTS: Attempts were made to enroll 150 eligible patients in the study, and 73 were enrolled (49% enrollment rate). Barriers to enrollment for the 77 patients who did not participate were deduced from the field notes and placed into the following categories: patient refusal (n = 38, 49%), diagnostic uncertainty regarding cancer stage (n = 11, 14%), symptom burden (n = 9, 12%), family refusal (n = 7, 9%), physician refusal (n = 7, 9%), and/or patient unaware of illness or stage (n = 5, 7%). LIMITATIONS: The findings are descriptive and do not test predetermined hypotheses. CONCLUSION: Patient refusal, symptom burden, and diagnostic disparities are common barriers encountered when recruiting ED patients with advanced cancer. Despite the barriers, recruitment was feasible for such ED patients. FUNDING/SPONSOR: This study was funded by a Mentored Research Scholar Grant from the American Cancer Society (Dr Grudzen), a Medical Student Training in Aging Research Grant from the American Federation on Aging (Mr Kandarian), and by a Mid- Career Investigator Award in Patient Oriented Research (K24 AG022345) from the National Institute on Aging (Dr Morrison).

BACKGROUND: Standardized Patients (SPs) are actors trained to portray health care patients during the training and assessment of health care providers. This paper describes the methods and costs associated with using SPs to evaluate the skills of telephone counselors working on a clinical trial that evaluated a telephone smoking cessation program tailored for smokers using Department of Veterans Affairs mental health clinics. FINDINGS: Conducting the SP exercises required five main steps: (1) Write a SP case description detailing patient demographics, demeanor, clinical symptoms and history, and instructions on how to respond to counseling, (2) Identify, select and train actors to portray the SP cases; (3) Conduct audio-taped counseling encounters between the SPs and counselors, (4) Rate the counselors on their core counseling competencies, (5) Provide feedback to counselors. The SPs and study supervisors reported that the checklist was easy to use when rating the counselors. Counselors reported that the SP encounters were realistic and helpful for practicing their clinical work and for building self-efficacy for working with real patients. The labor costs of developing two SP cases and training two SP actors was approximately $1,475. The per-session labor cost of conducting a 1-hour counseling session between one SP and one counselor was approximately $314. CONCLUSIONS: Using SPs to train telephone counselors working on a clinical trial was feasible and offered training benefits beyond those provided by didactic instruction and role plays. Our research group is now routinely using SPs for the training of incoming telephone counselors.