Faculty Bibliography

BACKGROUND: Characterization of health conditions in recent immigrant subgroups, including foreign-born whites and Asians, is limited but important for identifying emerging health disparities. Hypertension, a major modifiable risk factor for cardiovascular disease, has been shown to be associated with acculturation, but the acculturative experience varies for different racial/ethnic groups. Assessing the impact of race/ethnicity on the relationship between acculturation-related factors and hypertension is therefore of interest. METHODS: Data from the 2005-2008 waves (n = 36,550) of the NYC Community Health Survey were combined to estimate self-reported hypertension prevalence by nativity, language spoken at home, and time spent in the United States. Multivariable analyses were used to assess (i) the independent associations of acculturation-related factors and hypertension and (ii) potential effect modification by race/ethnicity. Sensitivity analysis recalibrating self-reported hypertension using measured blood pressures from a prior NYC population-based survey was performed. Prevalence was also explored by country of origin. RESULTS: Being foreign vs. US born was associated with higher self-reported hypertension in whites only. Speaking Russian vs. English at home was associated with a 2-fold adjusted odds of self-reported hypertension. Living in the United States for >/=10 years vs. less time was associated with higher self-reported hypertension prevalence in blacks and Hispanics. Hypertension prevalence in Hispanics was slightly lower when using a recalibrated definition, but other results did not change substantively. CONCLUSIONS: Race/ethnicity modifies the relationship between acculturation-related factors and hypertension. Consideration of disease prevalence in origin countries is critical to understanding health patterns in immigrant populations. Validation of self-reported hypertension in Hispanic populations is indicated.

Objectives. We estimated sodium intake, which is associated with elevated blood pressure, a major risk factor for cardiovascular disease, and assessed its association with related variables among New York City adults. Methods. In 2010 we conducted a cross-sectional, population-based survey of 1656 adults, the Heart Follow-Up Study, that collected self-reported health information, measured blood pressure, and obtained sodium, potassium, and creatinine values from 24-hour urine collections. Results. Mean daily sodium intake was 3239 milligrams per day; 81% of participants exceeded their recommended limit. Sodium intake was higher in non-Hispanic Blacks (3477 mg/d) and Hispanics (3395 mg/d) than in non-Hispanic Whites (3066 mg/d; both P < .05). Higher sodium intake was associated with higher blood pressure in adjusted models, and this association varied by race/ethnicity. Conclusions. Higher sodium intake among non-Hispanic Blacks and Hispanics than among Whites was not previously documented in population surveys relying on self-report. These results demonstrate the feasibility of 24-hour urine collection for the purposes of research, surveillance, and program evaluation. (Am J Public Health. Published online ahead of print January 16, 2014: e1-e8. doi:10.2105/AJPH.2013.301542).

PURPOSE: The prevalence of lower urinary tract symptoms increases with age and impairs quality of life. Radical prostatectomy has been shown to relieve lower urinary tract symptoms at short-term followup but the long-term effect of radical prostatectomy on lower urinary tract symptoms is unclear. MATERIALS AND METHODS: We performed a prospective cohort study of 1,788 men undergoing radical prostatectomy. The progression of scores from the self-administered AUASS (American Urological Association symptom score) preoperatively, and at 3, 6, 12, 24, 48, 60, 84, 96 and 120 months was analyzed using models controlling for preoperative AUASS, age, prostate specific antigen, pathological Gleason score and stage, nerve sparing, race and marital status. This model was also applied to patients stratified by baseline clinically significant (AUASS greater than 7) and insignificant (AUASS 7 or less) lower urinary tract symptoms. RESULTS: Men exhibited an immediate worsening of lower urinary tract symptoms that improved between 3 months and 2 years after radical prostatectomy. Overall the difference between mean AUASS at baseline and at 10 years was not statistically or clinically significant. Men with baseline clinically significant lower urinary tract symptoms experienced immediate improvements in lower urinary tract symptoms that lasted until 10 years after radical prostatectomy (13.5 vs 8.81, p <0.001). Men with baseline clinically insignificant lower urinary tract symptoms experienced a statistically significant but clinically insignificant increase in mean AUASS after 10 years (3.09 to 4.94, p <0.001). The percentage of men with clinically significant lower urinary tract symptoms decreased from baseline to 10 years after radical prostatectomy (p = 0.02). CONCLUSIONS: Radical prostatectomy is the only treatment for prostate cancer shown to improve and prevent the development of lower urinary tract symptoms at long-term followup. This previously unrecognized long-term benefit argues in favor of the prostate as the primary contributor to male lower urinary tract symptoms.

PURPOSE: Approximately a third of prostate cancer cases with a Gleason score of 6 are upgraded at radical prostatectomy. We studied trends and predictors of upgrading and up staging among men with Gleason 6 prostate cancer who were potential candidates for active surveillance in a population based cohort. MATERIALS AND METHODS: From 2007 to 2011, 13,159 men were diagnosed with Gleason 6, clinical stage T1c/T2 prostate cancer in the NPCR (National Prostate Cancer Register of Sweden). Of these men 4,500 underwent radical prostatectomy, including 2,205 with data on the extent of prostate cancer in the biopsy cores. Logistic regression was used to examine variables associated with adverse pathology (defined as upgrading to Gleason 7 or greater, or up staging to pT3 or greater) in the full group and in potential candidates for active surveillance using 6 current published protocols. RESULTS: Among Swedish men with clinically localized Gleason 6 prostate cancer approximately 50% had adverse pathology at radical prostatectomy. Of the men who met the study inclusion criteria of 6 different active surveillance protocols, adverse pathology was present in 33% to 45%. Predictors of adverse pathology were older age, higher prostate specific antigen, prostate specific antigen density greater than 0.15 ng/ml/cm(3), palpable disease and extent of cancer greater than 4 mm on biopsy. Larger prostate volume had an inverse relationship with adverse pathology. CONCLUSIONS: More than a third of men meeting the most stringent active surveillance criteria had adverse pathology at radical prostatectomy in this population based cohort. Active surveillance programs should consider prostate specific antigen density and extent of cancer on biopsy for patient selection.

The interpretation of images obtained in patients who have recently undergone abdominal or pelvic surgery is challenging, in part because procedures that were previously performed with open surgical techniques are increasingly being performed with minimally invasive (laparoscopic) techniques. Thus, it is important to be familiar with the normal approach used for laparoscopic surgeries. The authors describe the indications for various laparoscopic surgical procedures (eg, cholecystectomy, appendectomy, hernia repair) as well as normal postoperative findings. For example, port site hernias are more commonly encountered in patients with trocar sites greater than 10 mm and occur at classic entry sites (eg, the periumbilical region). Similarly, preperitoneal air can be encountered postoperatively, often secondary to trocar dislodgement during difficult entry or positioning. In addition, intraperitoneal placement of mesh during commonly performed ventral or incisional hernia repairs typically leads to postoperative seroma formation. Familiarity with normal findings after commonly performed laparoscopic surgical procedures in the abdomen and pelvis allows accurate diagnosis of common complications and avoidance of diagnostic pitfalls. (c) RSNA, 2014.

The aim of this study was to determine heritability estimates of treatment responses to a 10% hydrogen peroxide strip-based whitening system in twins. Eighty-five twin pairs were randomly assigned to 10% hydrogen peroxide whitening strips or placebo strips without peroxide. Both twins (monozygotic or dizygotic) received the same treatment. Maxillary teeth were treated for 30 minutes twice daily for 7 days. Efficacy was measured objectively as L* (light-dark), a* (red-green), and b* (yellow-blue) color change from digital images at baseline () and day 8. Heritability estimates for tooth whitening treatment responses for changes from day 8 to baseline were obtained using variance-component methodologies. Whitening treatment responses were highly heritable (h2 = 71.0) for b* and a*(p < .0001), but not for L* (h2 = 27.0), which was essentially modulated by environmental factors. This study has demonstrated that both genetic and environmental factors significantly contributed to seven-day whitening treatment responses achieved with 10% hydrogen peroxide strips.

Objective: Thoracic endovascular aortic repair (TEVAR) for acute uncomplicated type B aortic dissection (TBAD) remains controversial. This study aims to evaluate the impact of TEVAR on mortality, morbidity, length of stay (LOS), and discharge status in patients with acute uncomplicated TBAD.Methods: We analyzed the National Inpatient Sample from 2009 and 2010. Patients were categorized according to the type of treatment: TEVAR or medical management. Outcomes, including mortality, stroke, myocardial infarction (MI), acute renal failure, discharge disposition, and LOS, were compared between the treatment groups.Results: We identified 4706 patients with TBAD. Mean age was 67 years and 55% were male. Treatment options included TEVAR in 504 and medical management in 4202. The overall adjusted in-hospital mortality was similar for both the groups (8.5% for TEVAR vs 10.3% for medical management, P = .224). The TEVAR carried higher risk of stroke (odds ratio [OR] = 1.61, 95% confidence interval [CI] = [1.14-2.27]; P = .0073). The TEVAR was associated with prolonged LOS (12 vs 5.6 days, P < .0001) and patients were less likely to be discharged home (OR 0.73, 95% CI 0.54-0.99; P = .013). When stratified by age, all outcomes were similar between the 2 groups, with the exception of longer LOS with TEVAR.Conclusions: Thoracic endovascular aortic repair for acute uncomplicated TBAD was associated with similar in-hospital mortality, MI, and renal failure as compared to medical management. The TEVAR had higher rate of stroke up to the age 70 years and longer LOS. Because extending TEVAR to less complicated patients could only decrease TEVAR mortality rates, these findings support the more widespread use of TEVAR to treat patients with uncomplicated TBAD.

PURPOSE: Pain, fatigue, dyspnea, and distress are commonly reported cancer-related symptoms, but few studies have examined the effects of multiple concurrent symptoms in longer-term cancer survivors. We examined the impact of varying degrees of symptom burden on health-related quality of life (HRQOL) and performance status in surgically treated non-small cell lung cancer (NSCLC) survivors. METHODS: A sample of 183 NSCLC survivors 1-6 years post-surgical treatment completed questionnaires assessing five specific symptoms (pain, fatigue, dyspnea, depression, and anxiety), HRQOL, and performance status. The number of concurrent clinically significant symptoms was calculated as an indicator of symptom burden. RESULTS: Most survivors (79.8 %) had some degree of symptom burden, with 30.6 % reporting one clinically significant symptom, 27.9 % reporting two symptoms, and 21.3 % reporting three or more symptoms. Physical HRQOL significantly decreased as the degree of symptom burden increased, but mental HRQOL was only significantly decreased in those with three or more symptoms. Receiver-operating characteristic (ROC) curves showed that having multiple concurrent symptoms (two or more) was most likely associated with limitations in functioning (area under a ROC curve = 0.75, sensitivity = 0.81, specificity = 0.54). CONCLUSIONS: Two or more clinically significant symptoms are identified as the "tipping point" for showing adverse effects on HRQOL and functioning. This highlights the need for incorporating multiple-symptom assessment into routine clinical practice. Comprehensive symptom management remains an important target of intervention for improved post-treatment HRQOL and functioning among lung cancer survivors.

BACKGROUND: Low-grade albuminuria is an indicator of endothelial dysfunction and is associated with an increased risk of cardiovascular disease. A graded level of exposure to bisphenol A was recently identified to be associated with increased risk of low-grade albuminuria in children and adults. Because bisphenol A and phthalates coexist as dietary contaminants, this study investigated whether exposure to phthalates is also associated with low-grade albuminuria. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data were examined from 667 children who participated in the 2009-2010 National Health and Nutrition Examination Survey and who had results for urinary phthalate metabolites and albumin excretion. Urinary albumin and creatinine concentrations were measured in a first morning specimen using a solid-phase fluorescent immunoassay and a Roche/Hitachi Modular P Chemistry Analyzer with an enzymatic method, respectively. Phthalate metabolites were analyzed in a separate spot urine sample from each participant, using high-performance liquid chromatography and tandem mass spectroscopy. RESULTS: For each (roughly) 3-fold increase in metabolites of di-2-ethylhexylphthalate (a high molecular weight phthalate commonly found in foods), a 0.55 mg/g increase in albumin/creatinine ratio (ACR) was identified (P=0.02), whereas a 1.30-fold odds of a higher ACR quartile was also identified for each (roughly) 3-fold increase (P=0.02). Higher ACR was not identified in relationship to metabolites of lower molecular phthalates commonly found in lotions or shampoos, suggesting specificity. CONCLUSIONS: Although reverse causation and unmeasured confounders represent alternative explanations, these findings, in conjunction with our earlier data on bisphenol A, indicate that a wide array of environmental toxins may adversely affect albuminuria and potentially increase the risk of cardiovascular disease. In view of the potential long-term health implications of ongoing exposure in this vulnerable subpopulation, our data support both further study and renewed regulatory efforts to limit exposure during childhood.