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Abstract
Oxalate is a metabolite consumed in nuts, beans and leaves, and excreted in urine. Oxalosis can cause nephropathy. We describe a rare case of a high-oxalate diet intended for irritable bowel syndrome (IBS) treatment causing oxalate nephropathy. A 59-year-old woman with a history of controlled hypertension presented with creatinine 1.8 mg/dL, increased from baseline 1.3 mg/dL. She denied recent illness, urinary stones, medication adjustments, herbal supplements and non-steroidal anti-inflammatory drugs use. Diet included six tablespoons of chia seeds and five handfuls of almonds daily to manage IBS symptoms. Her electrolytes, urinalysis and renal ultrasound were unremarkable. Her 24-hour urine output revealed increased oxalate and low citrate. Renal biopsy showed glomerulosclerosis, fibrosis and calcium oxalate deposition. She switched to a low-oxalate diet, with improvement in laboratory markers. An earlier dietary history could have raised concern for oxalosis prior to renal biopsy. Providers should be trained to identify at-risk patients and provide appropriate dietary counselling.
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Affiliation(s)
- Victoria Garland
- Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Leal Herlitz
- Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Renu Regunathan-Shenk
- Division of Kidney Disease and Hypertension, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Garland V, Cioffi J, Kirelik D, Pascual L, Borum ML. African-Americans Are Less Frequently Assessed For Hereditary Colon Cancer. J Natl Med Assoc 2020; 113:336-341. [PMID: 33092858 DOI: 10.1016/j.jnma.2020.09.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/03/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Colorectal cancer (CRC) is the third most common malignancy in the United States and disproportionately affects African-Americans. Approximately 5-10% of CRC results from hereditary cancer syndromes. A detailed family history is recommended as an initial component of cancer risk assessment to help determine initiation, frequency, screening method and genetic counselling referral. This study evaluated the rate of hereditary CRC risk assessment in African-American and white patients. METHODS A chart review of all patients referred for CRC screening in a university gastroenterology clinic during a 3 month period was performed. Patient self-described race/ethnicity, gender, age, documentation of multi-generational family medical history (3+ generations) were obtained. Amsterdam II Criteria, Bethesda Criteria and Colorectal Cancer Risk Assessment Tool were used to determine which patients with family histories should receive referrals for genetic counselling. Statistical analysis was performed using Fisher's Exact Test with significance set at p < 0.05. The study was IRB approved. RESULTS 872 medical records were reviewed, including 452 African-American (276 females, 176 males; mean age 60.2), 263 White (123 females, 140 males; mean age 59.4), 45 Hispanic, and 42 Asian. Multi-generational family history was obtained from 143 (16.4%); 62 African-American (13.7%; 47 females, 15 males), 58 White (22.1%; 37 females, 21 whites), 3 Hispanic (6.7%), and 4 Asian (9.5%). There was a significant difference (p = 0.0050) in the rate of detailed family history in African-Americans and whites. However, African-Americans and Whites similarly qualified for genetic counselling when family history was obtained (p = 0.7915); 58.1% African-Americans (36; 30 females, 6 males) and 50% Whites (29: 19 females, 10 males) qualified for genetic counselling. Overall referral rate to genetic counselling was 16.5% with no significant difference (p = 0.7586) between African-Americans and whites. CONCLUSIONS CRC risk assessment with detailed family medical history was inconsistently performed in all patients. There was significantly lower rate of obtaining multi-generational family medical histories in African-Americans. Referrals of all patients for genetic counselling and testing were also insufficient. Appropriate identification of individuals at increased risk for hereditary cancer syndromes, particularly African-Americans, is critical to prevention, early detection, and treatment of CRC and improving disparities in care.
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Affiliation(s)
- Victoria Garland
- Division of Gastroenterology and Liver Diseases, Department of Medicine, The George Washington University, Washington, DC, USA
| | - Joseph Cioffi
- Division of Gastroenterology and Liver Diseases, Department of Medicine, The George Washington University, Washington, DC, USA
| | | | - Lauren Pascual
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Marie L Borum
- Division of Gastroenterology and Liver Diseases, Department of Medicine, The George Washington University, Washington, DC, USA.
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Garland V, Kumar AB, Borum ML. Gastrointestinal and Hepatic Manifestations of COVID-19: Evolving Recognition and Need for Increased Understanding in Vulnerable Populations. J Natl Med Assoc 2020; 113:142-146. [PMID: 32807512 PMCID: PMC7428705 DOI: 10.1016/j.jnma.2020.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/24/2020] [Indexed: 02/06/2023]
Abstract
The novel coronavirus, SARS-CoV-2, has caused a global pandemic with high morbidity and mortality. It was first observed to cause a severe acute respiratory syndrome. However, gastrointestinal and hepatic manifestations have been increasingly recognized. Gastrointestinal symptoms include diarrhea, epigastric pain, nausea, and vomiting. Diarrhea is the most common GI manifestation of SARS-CoV-2 and can present without or without respiratory symptoms. Patients with GI symptoms have been associated with longer duration of illness and may be associated with more severe illness. Mechanism of diarrhea is thought to be related to direct viral cytotoxicity occurring when the SARS-CoV-3 enters GI cells via the ACE-2 receptor. Inflammatory response and cytokine release likely contributes to symptoms. SARS-CoV-2 can cause hepatic injury. Studies have shown mild to moderate elevation of liver enzymes. The pattern of liver abnormalities can be hepatocellular, cholestatic or mixed. Patients with severe infection have significantly higher rates of liver injury and worse outcomes. Proposed mechanisms for injury include immune mediated systemic inflammatory response, direct cytotoxicity from viral replication and hypoxia-reperfusion dysfunction. Recent data suggests that GI and hepatic injury may be under-recognized manifestation of SARS-CoV-2 infection. Patients with diarrhea and liver disease may have a worse prognosis. The rapidly evolving literature continues to reveal a growing body of information which enables updated guidance for management. More investigation is needed which focuses on vulnerable patients, including the elderly, those with underlying illness, as well as, racial and ethnic minorities.
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Affiliation(s)
- Victoria Garland
- Division of Gastroenterology and Liver Diseases, The George Washington University, Washington, DC
| | - Anita B Kumar
- Division of Gastroenterology and Liver Diseases, The George Washington University, Washington, DC
| | - Marie L Borum
- Division of Gastroenterology and Liver Diseases, The George Washington University, Washington, DC.
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Garland E, Garland V, Peters D, Doucette J, Thanik E, Rajupet S, Sanchez SH. Active design in affordable housing: A public health nudge. Prev Med Rep 2018; 10:9-14. [PMID: 29868352 PMCID: PMC5984212 DOI: 10.1016/j.pmedr.2018.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/23/2018] [Accepted: 01/29/2018] [Indexed: 12/01/2022] Open
Abstract
This pilot study investigates the impact of active design (AD) strategies on physical activity (PA) among adults living in two Leadership in Energy and Environmental Design (LEED) certified affordable housing developments in the South Bronx, New York. One building incorporates LEED Innovation in Design (ID) Credit: Design for Health through Increased Physical Activity. Tenants in an affordable housing building (AH) incorporating active design strategies completed PA self-assessments at their lease signing and one year later in 2015. Trained research assistants obtained body measurements. Residents of neighboring non-AD affordable housing (MCV) served as a comparison. Thirty four adults were recruited from AH and 29 from MCV, retention was 56% (n = 19) and 52% (n = 15) respectively at one year. The two groups' body mass index (BMI) and high-risk waist-to-hip ratio (WHR) were not statistically significantly different when analyzed as continuous variables, although BMI category had a greater decline at AH than at MCV (p = 0.054). There was a 31.5% increase in AH participants meeting MPA requirements and a statistically significant improvement in females (p = 0.031); while there was no change in the MCV participants overall or when stratified by gender. AH participants were significantly more likely to have reported increased stair use and less likely to have reported no change or decreased stair use than participants from MCV participants (p = 0.033). Housing has a role in individual health outcomes and behavior change, broad adoption of active design strategies in affordable housing is warranted to improve physical activity measures.
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Affiliation(s)
- Elizabeth Garland
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1043, New York, NY 10029, United States
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Asgary R, Alcabes A, Feldman R, Garland V, Naderi R, Ogedegbe G, Sckell B. Cervical Cancer Screening Among Homeless Women of New York City Shelters. Matern Child Health J 2017; 20:1143-50. [PMID: 26649876 DOI: 10.1007/s10995-015-1900-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction Homeless persons have minimal opportunities to complete recommended cancer screening. The rates and predictors of cervical cancer screening are understudied among homeless women in the US. Methods We enrolled 297 homeless women 21-65 years old residing in 6 major New York City shelters from 2012 to 2014. We used a validated national survey to determine the proportion and predictors of cervical cancer screening using cytology (Pap test). Results Mean age was 44.72 (±11.96) years. Majority was Black, heterosexual, single, with high school or lower education; 50.9 % were smokers and 41.7 % were homeless more than a year. Despite a 76.5 % proportion of self-reported Pap test within the past 3 years, 65 % of women assumed their Pap test results were normal or did not get proper follow up after abnormal results. Forty-five-point-nine percent of women did not know about frequency of Pap test or causes of cervical cancer. Lower proportion of up-to-date Pap test was associated with lack of knowledge of recommended Pap test frequency (p < 0.01) and relationship between HPV and an abnormal Pap test (p < 0.01). Conclusions Self-reported Pap testing in homeless women was similar to a national sample. However, the majority of women surveyed were not aware of their results, received limited if any follow up and had significant education gaps about cervical cancer screening. We recommend improved counseling and patient education, patient navigators to close screening loops, and consideration of alternative test-and-treat modalities to improve effective screening.
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Affiliation(s)
- Ramin Asgary
- Departments of Population Health and Medicine, New York University School of Medicine, 227 E30th Street, Room 639, New York, NY, 10016, USA. .,Community Medicine Program, NYU Lutheran Family Health Centers, 317 Bowery Street, New York, NY, 10003, USA.
| | - Analena Alcabes
- Community Medicine Program, NYU Lutheran Family Health Centers, 317 Bowery Street, New York, NY, 10003, USA
| | - Rebecca Feldman
- Department of OBGYN, The Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Victoria Garland
- Community Medicine Program, NYU Lutheran Family Health Centers, 317 Bowery Street, New York, NY, 10003, USA
| | - Ramesh Naderi
- New York University School of Medicine, 227 E30th Street, New York, NY, 10016, USA
| | - Gbenga Ogedegbe
- Departments of Population Health and Medicine, New York University School of Medicine, 227 E30th Street, Room 639, New York, NY, 10016, USA
| | - Blanca Sckell
- Community Medicine Program, NYU Lutheran Family Health Centers, 317 Bowery Street, New York, NY, 10003, USA
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Asgary R, Alcabes A, Feldman R, Garland V, Naderi R, Ogedegbe G, Sckell B. Human Papillomavirus Knowledge and Attitude among Homeless Women of New York City Shelters. Womens Health Issues 2015; 25:727-31. [PMID: 26329258 DOI: 10.1016/j.whi.2015.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Human papillomavirus (HPV) has not been studied among homeless women in the United States. We assessed knowledge and attitudes regarding HPV infection and the HPV vaccine among homeless women. METHODS We enrolled 300 homeless women age 19 to 65 residing in multiple New York City shelters from 2012 to 2014. We used a national survey to collect HPV data. RESULTS Mean age was 44.7 ± 12.16 years. The majority were Black, heterosexual, and single; 50.6% were smokers. Almost all HPV knowledge and attitudes data were considerably below the national averages; 41.9% never heard of HPV. Only 36.5% knew that HPV is a sexually transmitted disease; 41.5% knew that HPV causes cervical cancer; and only 19.5% and 17.3% received provider counseling regarding HPV testing and vaccine, respectively. Among participants, 65.4% reported that they would vaccinate their eligible daughters for HPV. Lower rates of up-to-date Pap tests were associated with a lack of knowledge regarding relationship between HPV and abnormal Pap test (p < .01). CONCLUSIONS We recommend improved HPV counseling by providers during any clinical encounter to reduce missed opportunities, coupled with employing patient teaching coach or navigators to improve health literacy and to connect patients to services regarding HPV and cervical cancer.
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Affiliation(s)
- Ramin Asgary
- Department of Population Health, New York University School of Medicine, New York, New York; Department of Medicine, New York University School of Medicine, New York, New York.
| | - Analena Alcabes
- Community Medicine Program, NYU Lutheran Family Health Centers, New York, New York
| | - Rebecca Feldman
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria Garland
- Community Medicine Program, NYU Lutheran Family Health Centers, New York, New York
| | - Ramesh Naderi
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Gbenga Ogedegbe
- Department of Population Health, New York University School of Medicine, New York, New York; Department of Medicine, New York University School of Medicine, New York, New York
| | - Blanca Sckell
- Community Medicine Program, NYU Lutheran Family Health Centers, New York, New York
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Asgary R, Garland V, Sckell B. Breast Cancer Screening Among Homeless Women of New York City Shelter-Based Clinics. Womens Health Issues 2014; 24:529-34. [DOI: 10.1016/j.whi.2014.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 05/07/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
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Asgary R, Garland V, Jakubowski A, Sckell B. Colorectal cancer screening among the homeless population of New York City shelter-based clinics. Am J Public Health 2014; 104:1307-13. [PMID: 24832144 DOI: 10.2105/ajph.2013.301792] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We determined colorectal cancer (CRC) screening rates, predictors, and barriers in 2 major New York City shelter-based clinics. METHODS We extracted screening rates, sociodemographic characteristics, and factors associated with homelessness from medical records of domiciled and homeless patients aged 50 years and older (n = 443) with at least 3 clinic visits between 2010 and 2012. RESULTS The majority of patients were African American or Hispanic, 76% were male, and 60.7% were homeless (mean = 2.4 years; SD = 2.8 years). Domiciled patients were more likely than homeless patients to be screened (41.3% vs 19.7%; P < .001). Homeless and domiciled patients received equal provider counseling, but more homeless patients declined screening (P < .001). In logistic regression, gender, race, duration of homelessness, insurance status, substance and alcohol abuse, chronic diseases, and mental health were not associated with screening, but housing, provider counseling, and older age were. CONCLUSIONS Proposed interventions to improve CRC screening include respite shelter rooms for colonoscopy prepping, patient navigators to help navigate the health system and accompany patients to and from the procedure, counseling at all clinical encounters, and tailored patient education to address misconceptions.
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Affiliation(s)
- Ramin Asgary
- Ramin Asgary is with the Department of Medicine, New York University School of Medicine, New York, NY. Victoria Garland and Blanca Sckell are with the Department of Community Medicine, Lutheran Family Health Centers, New York, NY. Andrea Jakubowski is with the Department of Medical Education, Mount Sinai School of Medicine, New York, NY
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