Dorice Vieira

Overcoming barriers to hypertension control in African Americans.

Barriers to blood pressure control exist at the patient, physician, and system levels. We review the current evidence for interventions that target patient- and physician-related barriers, such as patient education, home blood pressure monitoring, and computerized decision-support systems for physicians, and we emphasize the need for more studies that address the effectiveness of these interventions in African American patients.

The failure of neuronal protective agents versus the success of thrombolysis in the treatment of ischemic stroke. The predictive value of animal models.

Abstract: Agents claimed to be neuroprotective in animal stroke models have all failed in human trials. Thrombolysis has been reported as beneficial in animal and human stroke. We explore the reasons for this disparity, using a review of published results of agents tested both in animal stroke models and in human stroke trials. In animals the effect of neuroprotective agents and of thrombolytic agents on infarct size is time‐dependent: early initiation of treatment works best; and benefit is progressively—and eventually totally—lost with increasing delay of time of first treatment. The animal data also show that, overall, the beneficial effects of the neuroprotective agents are weaker, and are totally lost sooner, than those of thrombolytics. The human data show that the failed trials of the neuroprotective agents had entry windows that went far beyond the windows of (any) success seen in tests of these agents in animals. By contrast, human thrombolysis trials uniformly restricted time of entry to windows in which these agents have shown beneficial effect in animals. In clinical stroke trials, neuroprotective agents failed to produce benefit because their effects at best are too weak, and they were used at times predictable from the animal models as too late. Thrombolytic therapy, which has a stronger effect than neuroprotective agents in animal models, was used clinically during the early window of optimal effectiveness, and produced beneficial results. “Too little/too late” is the recipe for failure in the treatment of ischemic stroke.

Colorectal Cancer in African Americans: An Update

This review is an update to the American College of Gastroenterology (ACG) Committee on Minority Affairs and Cultural Diversity’s paper on colorectal cancer (CRC) in African Americans published in 2005. Over the past 10 years, the incidence and mortality rates of CRC in the United States has steadily declined. However, reductions have been strikingly much slower among African Americans who continue to have the highest rate of mortality and lowest survival when compared with all other racial groups. The reasons for the health disparities are multifactorial and encompass physician and patient barriers. Patient factors that contribute to disparities include poor knowledge of benefits of CRC screening, limited access to health care, insurance status along with fear and anxiety. Physician factors include lack of knowledge of screening guidelines along with disparate recommendations for screening. Earlier screening has been recommended as an effective strategy to decrease observed disparities; currently the ACG and American Society of Gastrointestinal Endoscopists recommend CRC screening in African Americans to begin at age 45. Despite the decline in CRC deaths in all racial and ethnic groups, there still exists a significant burden of CRC in African Americans, thus other strategies including educational outreach for health care providers and patients and the utilization of patient navigation systems emphasizing the importance of screening are necessary. These strategies have been piloted in both local communities and Statewide resulting in notable significant decreases in observed disparities.

Clinical Implications of Referral Bias in the Diagnostic Performance of Exercise Testing for Coronary Artery Disease

Background Exercise testing with echocardiography or myocardial perfusion imaging is widely used to risk‐stratify patients with suspected coronary artery disease. However, reports of diagnostic performance rarely adjust for referral bias, and this practice may adversely influence patient care. Therefore, we evaluated the potential impact of referral bias on diagnostic effectiveness and clinical decision‐making. Methods and Results Searching PubMed and EMBASE (1990–2012), 2 investigators independently evaluated eligibility and abstracted data on study characteristics and referral patterns. Diagnostic performance reported in 4 previously published meta‐analyses of exercise echocardiography and myocardial perfusion imaging was adjusted using pooled referral rates and Bayesian methods. Twenty‐one studies reported referral patterns in 49 006 patients (mean age 60.7 years, 39.6% women, and 0.8% prior history of myocardial infarction). Catheterization referral rates after normal and abnormal exercise tests were 4.0% (95% CI, 2.9% to 5.0%) and 42.5% (36.2% to 48.9%), respectively, with odds ratio for referral after an abnormal test of 14.6 (10.7 to 19.9). After adjustment for referral, exercise echocardiography sensitivity fell from 84% (80% to 89%) to 34% (27% to 41%), and specificity rose from 77% (69% to 86%) to 99% (99% to 100%). Similarly, exercise myocardial perfusion imaging sensitivity fell from 85% (81% to 88%) to 38% (31% to 44%), and specificity rose from 69% (61% to 78%) to 99% (99% to 100%). Summary receiver operating curve analysis demonstrated only modest changes in overall discriminatory power but adjusting for referral increased positive‐predictive value and reduced negative‐predictive value. Conclusions Exercise echocardiography and myocardial perfusion imaging are considerably less sensitive and more specific for coronary artery disease after adjustment for referral. Given these findings, future work should assess the comparative ability of these and other tests to rule‐in versus rule‐out coronary artery disease.

Role of Bariatric Surgery as Treatment for Type 2 Diabetes in Patients Who Do Not Meet Current NIH Criteria: A Systematic Review and Meta-Analysis

Patients with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) >35 kg/m are currently eligible for bariatric surgery, according to the 1991 NIH Consensus Criteria for bariatric surgery. Up to 78% of patients with T2DM experience diabetes remission within 2 years after bariatric surgery. Evidence exists that changes in the gut hormonal milieu after gastric bypass can improve insulin resistance immediately after surgery and preceding substantial weight loss. In 2007, the American Society of Bariatric Surgery added “Metabolic Surgery” to its name. Patients with T2DM and BMI <35 kg/m are primarily offered intensive diabetes management, including pharmacotherapy and nonsurgical weight loss. The NIH is unlikely to change the bariatric surgery guidelines for patients with diabetes without additional evidence to support such a change. Although there is emerging evidence suggesting that using bariatric surgery to treat diabetes in less obese (BMI <35 kg/m) patients is highly effective, there are very few randomized trials. The objective of this report is to conduct a systematic review and meta-analysis of the literature about surgery in patients with T2DM and BMI <35 kg/m.

The Effects of Continuous Positive Airways Pressure Therapy on Cardiovascular End Points in Patients With Sleep-Disordered Breathing and Heart Failure: A Meta-Analysis of Randomized Controlled Trials

In patients with sleep‐disordered breathing and heart failure, continuous positive airway pressure has been found to be associated with an improvement in cardiovascular end points. We conducted a systematic review of the current literature and a meta‐analysis to pool data from 15 published randomized controlled trials. End points analyzed were left ventricular ejection fraction, diastolic blood pressure, systolic blood pressure, heart rate, and mortality. A fixed effects model was used for end points demonstrating homogeneity among included studies, whereas a random effects model was used for end points demonstrating heterogeneity among included studies. A significant improvement in left ventricular ejection fraction was noted with continuous positive airway pressure (mean difference, 5.05%; 95% confidence interval [CI]: 3.72 to 6.38), diastolic blood pressure (mean difference, −1.67; 95% CI: −3.09 to −0.25), and heart rate (mean difference, −5.92; 95% CI: −10.12 to −1.72). No significant changes in mortality (odds ratio, 0.63; 95% CI: 0.40 to 1.00) and systolic blood pressure were noted (mean difference, −6.35; 95% CI: −16.11 to 2.41). The analysis also revealed the need for additional studies to clarify the associations noted and the presence of publication bias with small studies with a paucity of small studies with negative results. In this meta‐analysis, treatment with continuous positive airways pressure was associated with improvements in ejection fraction, diastolic blood pressure, and heart rate in patients with sleep‐disordered breathing and congestive heart failure.

Mental Health, Psychosocial Challenges and Resilience in Older Adults Living with HIV

In addition to physical health challenges, older people living with HIV/AIDS (PLWHA) experience mental health burdens and challenges to their social well-being that diminish their overall health. These health states are synergistic and are driven by HIV and HIV treatments, the aging process itself, and psychosocial and structural conditions of their lives. However, resilience, which we understand as both a trait and a process, may serve to buffer the effects that HIV/HIV treatments, aging, and social/structural conditions may have on the overall well-being of the individual. In this chapter, we examine the extant literate on the mental health and psychosocial challenges experienced by older PLWHA as elements of the total health of the individual. We also provide a contextualization and conceptualization for understanding the significant role that resilience may play in empowering individuals to enact processes which buffer health from the stressors. In this perspective, the health of older PLWHA must be viewed through a lens of power and strength rather than one of deficit. We conclude by outlining a theoretical paradigm for the role of resilience in the health of older HIV-positive adults, which may serve as a guide to clinicians, public health practitioners, and researchers working with this population.

Adjuvant Human Papillomavirus Vaccination for Secondary Prevention: A Systematic Review

Importance Human papillomavirus (HPV) vaccination is recommended for children and younger adults but not older adults or those with prior HPV exposure, leaving a large portion of the population at risk for HPV-mediated disease. Emerging data suggest a possible role for vaccination as an adjuvant treatment for individuals with HPV-related clinical disease. Objective To systematically review the literature regarding HPV vaccination for secondary disease prevention after treatment of active clinical disease across disease sites to serve as a platform for the management of HPV-related disease of the head and neck. Evidence Review A systematic search from August 3 to 21, 2015, of the PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science, Biosis Citation Index, Current Contents Connect, Scientific Library Online, and Global Health databases used PRISMA guidelines to identify 326 relevant articles related to adjuvant use of HPV vaccination. Primary search terms were (HPV vaccine OR human papillomavirus vaccine OR papillomarvirus vaccines OR alphapapillomavirus vaccine) AND (HPV OR human papillomavirus OR alphapapillomavirus OR papillomaviridae OR virus warts OR wart virus) AND (recurrence OR relapse OR reoccurrence OR recurrences OR relapses OR relapsing). Forty-five full texts in English were reviewed, with 19 articles included in the final review. In some studies, subpopulations of individuals with HPV DNA positivity and/or seropositivity were extracted for inclusion. Included studies were assessed for bias and separated based on the presence of active clinical disease or HPV DNA positivity or seropositivity. Findings Nineteen studies with 22 474 unique patients were included in the review. When HPV vaccination was used as an adjuvant treatment for active clinical disease, 9 of 12 studies reported decreased disease recurrence, decreased disease burden, or increased intersurgical interval. In contrast, none of the 7 studies of vaccination in individuals with HPV DNA positivity and/or seropositivity without clinical disease reported improved outcomes. Conclusions and Relevance Differences between adjuvant vaccination in HPV-mediated clinical disease and vaccination in HPV DNA–positive and/or HPV-seropositive populations posit underlying differences in disease and immune processes. These data suggest that additional evaluation of adjuvant HPV vaccination in individuals with active clinical disease is warranted.

The Faculty Bibliography Project at the NYU School of Medicine

INTRODUCTION This paper describes the development of the New York University Health Sciences Library’s Faculty Bibliography. DESCRIPTION Since 2000, the NYU Health Sciences Library’s Faculty Bibliography project has systematically tracked publications of the NYU School of Medicine faculty. The project has grown to a significant institutional service making prominent contributions to the School of Medicine’s public web presence and to advanced productivity metrics. Migrating from Gopher to EndNote to MySQL, the Faculty Bibliography harvests data from multiple abstracting and indexing resources and uses sophisticated quality assurance methodologies. At present the Faculty Bibliography tracks over 228,000 publications of well over 13,000 faculty, including faculties of the NYU Colleges of Dentistry and Nursing. Both technical and social engineering aspects of the project’s success are discussed; the project’s role in deepening professional contact between the Library, clinical and research faculty, and School administration is stressed. NEXT STEPS The Library currently envisions broadening coverage to include faculty engaged in scientific and medical publishing from other schools and colleges at NYU. We also anticipate significant improvements in the project’s methodology once the ORCID initiative takes root.

Leveraging Technology and Staffing in Developing a New Liaison Program

With nearly all library resources and services delivered digitally, librarians working for the New York University Health Sciences Library struggled with maintaining awareness of changing user needs, understanding barriers faced in using library resources and services, and determining knowledge management challenges across the organization. A liaison program was created to provide opportunities for librarians to meaningfully engage with users. The program was directed toward a subset of high-priority user groups to provide focused engagement with these users. Responsibility for providing routine reference service was reduced for liaison librarians to provide maximum time to engage with their assigned user communities.