Faculty Bibliography

PRCIS/UNASSIGNED:The Manhattan Vision Screening and Follow-up Study in Vulnerable Populations is a 5-year prospective, cluster-randomized study to improve detection and management of glaucoma and other eye diseases in vulnerable populations living in affordable housing developments. PURPOSE/OBJECTIVE:To describe the study design and methodology of the Manhattan Vision Screening and Follow-up Study in Vulnerable Populations, which aims to investigate whether community-based vision screenings can improve detection and management of glaucoma, vision impairment, cataract, and other eye diseases among vulnerable populations living in affordable housing developments in upper Manhattan. METHODS:This 5-year prospective, cluster-randomized, controlled trial consists of vision screening and referral for follow-up eye care among eligible residents aged 40 and older. Visual acuity, intraocular pressure (IOP), and fundus photography are measured. Participants with visual worse than 20/40, or IOP 23-29▒mmHg, or unreadable fundus images fail the screening and are scheduled with the on-site optometrist. If IOP is ≥30▒mmHg, participants are assigned as "fast-track" and referred to ophthalmology. Participants living in seven developments randomized to the Enhanced Intervention Group who fail the screening and need vision correction receive complimentary eyeglasses. Those referred to ophthalmology receive enhanced support with patient navigators to assist with follow-up eye care. Participants living in three developments randomized to the Usual Care Group who fail the screening and need vision correction are given an eyeglasses prescription only and a list of optical shops. No enhanced support is given to the Usual Care Group. All participants referred to ophthalmology are assisted in making their initial eye exam appointment. CONCLUSION/CONCLUSIONS:This study targets vulnerable populations where they live to ensure improved access to and utilization of eye-care services in those who are least likely to seek eye care.

PURPOSE/AIM/UNASSIGNED:In the United States, high rates of vision impairment and eye disease disproportionately impact those who lack access to eye care, specifically vulnerable populations. The objective of our study was to test instruments, implement protocols, and collect preliminary data for a larger 5-year study, which aims to improve detection of eye diseases and follow-up eye care in vulnerable populations using community health workers (CHW) and patient navigators. In the study, trained CHWs conducted vision screening and patient navigators scheduled on-site eye exams and arranged appointments for those referred to ophthalmology to improve adherence to follow-up eye care. MATERIALS AND METHODS/UNASSIGNED:Eligible individuals age 40-and-older were recruited from the Riverstone Senior Center in upper Manhattan, New York City. Participants underwent on-site vision screening (visual acuity with correction, intraocular pressure measurements, and fundus photography). Individuals who failed the vision screening were scheduled with an on-site optometrist for an eye exam; those with ocular pathologies were referred to an ophthalmologist. Participants were also administered the National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ-8) and Stopping Elderly Accidents, Deaths, and Injuries (STEADI) test by community health workers. RESULTS/UNASSIGNED:Participants (n=42) were predominantly older adults, with a mean age of 70.0 ± 9.8, female (61.9%), and Hispanic (78.6%). Most individuals (78.6%, n=33) failed vision screening. Of those who failed, 84.8% (n=28) attended the on-site eye exam with the optometrist. Ocular diagnoses: refractive error 13/28 (46.4%), glaucoma/glaucoma suspect 9/28 (32.1%), cataract 7/28 (25.0%), retina abnormalities 6/28 (21.4%); 13 people required eyeglasses. CONCLUSION/UNASSIGNED:This study demonstrates the feasibility of using CHWs and patient navigators for reducing barriers to vision screening and optometrist-based eye exams in vulnerable populations, ultimately improving early detection of eye disease and linking individuals to additional eye care appointments. The full five-year study aims to further examine these outcomes.

Background: Alterations in cell-mediated immunity have been associated with cancer risk for people living with HIV (PLWH). Circulating levels of T regulatory cells (Tregs), and activated and senescent T cells have been linked to cancer risk and outcomes in HIV uninfected persons but there has been limited study of T cell subset alterations and cancer development unique to PLWH. We therefore aimed to determine whether the proportions of these T cell phenotypes predicted the incidence of non-AIDS cancers that have been associated with responses to immunotherapy (lung, anus, kidney).
Method(s): We used longitudinal data from 1,429 PLWH and 765 uninfected persons from the Veterans Aging Cohort Study Biomarker Cohort linked to VA cancer registry data to identify 75 incident lung, anus, and kidney cancers (the most common cancers arising in the cohort with known immunotherapy link). Subjects were followed from enrollment (2005-2006) until cancer incidence, death or were censored on 9/31/2017 (10 years of median follow-up). We measured the proportion of seven subpopulations of T cells, including Tregs (CD4+CD25+FOXP3+), activated (CD4+CD38+ and CD8+CD38+) and senescent (CD4+CD28-, CD4+CD57+, and CD8+CD28-, CD8+CD57+) CD4 and CD8 phenotypes. We used Cox proportional hazard regression to model associations between these immune cells and the risk of cancer while adjusting for age, sex, race/ethnicity and smoking status.
Result(s): The cohort was mostly male (95%) of median age 52 years. PLWH accounted for the majority (75%) of the cancer cases. Among PLWH, lower overall CD4 count was associated with greater proportions of Tregs, senescent CD4 and activated CD8 phenotypes. Of the included T cell subpopulations, greater proportions of circulating Tregs were significantly associated with increased incidence of the combined group of lung, anus and kidney cancers for the overall combined cohort and for PLWH only (see Table). Alterations in the proportion of subsets of CD4 and CD8 cells expressing markers of senescence or activation were not significantly associated with cancer risk during follow-up.
Conclusion(s): Among PWH increased circulating Tregs as a proportion of CD4 cells were associated with increased risk of lung, anus and kidney cancers. Correlation of these findings with the precancerous tumor microenvironment may provide greater insight into the role of HIV infection as an increased risk for some cancers (Table Presented)

Statement of Problem Or Question (One Sentence): Underutilization of clinical prediction rules and poor uptake of provider-oriented clinical decision support (CDS) has contributed to overuse of antibiotics for sore throat. Objectives of Program/Intervention (No More Than Three Objectives): 1. Adapt CDS for registered nurses (RNs) to evaluate and treat patients with sore throat 2. Demonstrate the feasibility of RN visits using CDS to evaluate and treat patients with sore throat Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We performed a 12-week pilot study to evaluate the feasibility of RN visits using an integrated clinical prediction rule (iCPR) tool to determine patient risk for strep throat and provide appropriate treatment at a family medicine clinic in a Midwest academic healthcare system. iCPR, originally developed for use by primary care physicians (PCPS), includes a risk calculator using Centor strep throat criteria and ordersets based on patient's risk for strep throat: education for low-risk, testing for intermediate-risk, and testing or antibiotics for high-risk. To adapt the process for RN visits, we developed triage protocols so appropriate patients received nurse visits, very low risk received education and more complex patients received provider visits. No major changes were made to the risk calculator or ordersets. Four RNs, with 2-24 years of experience, received a 10-minute online training session on sore throat evaluation followed by a 45-minute in-person training on physical examination and iCPR use. RNs triaged patients by phone and conducted RN visits using iCPR and following orderset recommendations. RNs could transition to a PCP visit if they were uncomfortable evaluating the patient. Measures of Success (DISCUSS QUALITATIVE AND/OR QUANTITATIVE METRICS WHICH WILL BE USED TO EVALUATE PROGRAM/INTERVENTION): Electronic health record data was used to determine the number of nurse visits, frequency of tool use and antibiotic and diagnostic test ordering. RNs completed a self-efficacy survey prior to training and 8-weeks after implementation. At 12 weeks, we interviewed RNs to understand barriers and facilitators to using the tool. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): 162 triage calls for sore throat resulted in 77(48%) patients with RN-only visits, 45(28%) with provider visits, 38(23%) with no visit. Only 2 RN visits (< 3%) converted to provider visit due to patient complexity. RNs completed the risk calculator for 99% of visits and followed recommendations in all cases except for ordering antibiotics in 1 high-risk patient with a negative rapid strep. RN confidence in their ability to evaluate and treat a patient with sore throat was 85 (SD 5.8) (0 cannot do at all; 100 highly certain I can do) prior to training and 97.5 (SD 5.0) at 8-weeks. RNs felt the tool decreased provider visits and strep testing in patients. RN's also felt that the tool increased patient and RN satisfaction. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): This pilot study demonstrates that RNs can use CDS to appropriately triage, evaluate and treat acute low-complexity sore throat patients. Implementation of an RN-driven iCPR tool shows promise to reduce inappropriate antibiotic prescribing and represents a potential model for expanding RN practice using CDS

Background: Clinical decision support (CDS) tools which incorporate clinical prediction rules (CPRs) have the potential to successfully deliver accurate information and guide decision-making at the point of care. Our previously validated integrated clinical prediction rule (iCPR) was designed to guide evidence-based treatment within an electronic health record for streptococcal pharyngitis and pneumonia based on chief complaints of sore throat, cough or upper respiratory infection. In initial testing at a single site, it resulted in high provider tool adoption (58%) and decreased antibiotic prescribing rates (35%) for acute respiratory infections. Our objective for this study was to assess the impact of this tool when adapted and implemented in diverse primary care settings.
Method(s): This was a randomized controlled trial including 33 primary care practices at two large academic health systems in Wisconsin and Utah. Between October 2015 and June 2018 providers in the intervention group were prompted to complete either Centor Score or Heckerling Rule for Pneumonia based onthe chief complaint of the patient encounter. EHR data on provider and patient demographics, tool use rates, and antibiotic order rates from 541 providers and 100,573 monitored patient encounters were collected for analysis. Risk ratios, CIs, and P values are calculated from a generalized estimating equation log-binomial model adjusting for clustering of orders or visits by provider and using robust standard error estimators.
Result(s): The tool was triggered 42,126 times among 214 intervention providers and was completed in 6.9% of eligible visits. The intervention and control groups prescribed antibiotics in 35% and 36% of visits respectively and were not significantly different. There were no differences in rates for rapid streptococcal test or chest X-ray orders between groups (Strep: relative risk, 1.0; P=.11; Pneumonia: relative risk, 1.8; P=.64).
Conclusion(s): In diverse primary care settings, the tool was not effective at reducing unnecessary antibiotic prescription and diagnostic testing. This outcome was possibly driven by low overall use of CDS tools highlighting the growing impact of " alert fatigue" and the need for new approaches to enhance provider engagement with CDS tools. New strategies for reducing the persistently high rates of inappropriate antibiotic prescribing for acute respiratory infections are needed. Novel approaches in future studies are necessary for reducing barriers to CDS tools in order to increase use and engagement

Purpose: The tremendous popularity of the new integrated interventional radiology (IR) and diagnostic radiology residency highlights the importance of medical student outreach to promote a diverse new generation of trainees. In order to promote women in IR, and attract female applicants directly from medical school, the Women in IR committee (WIR) of the Resident Fellow and Student Section (RFS) of the Society of Interventional Radiology (SIR) started accepting female and honorary male medical student members in March 2018. We aimed to assess the interests and goals of medical students joining WIR to better address their needs and to guide future recruitment. Materials: This retrospective study analyzed the WIR registration form responses during a 4-week recruitment period. Prior to medical student recruitment, WIR had 38 active female resident and fellow members. Recruitment banners were sent to the RFS medical students and posted on the RFS website and social media accounts.
Result(s): Among 43 students who registered, 7%, 28%, 37% and 28% were first, second, third and fourth year students, respectively. 19% were males. When asked to select any committee activities in which they were interested, the majority indicated research (93%), educational activities (86%), publishing articles online (60%), organizing events (58%), and leading new projects (53%). When asked their goals in joining WIR, female students wanted to promote WIR (69%), network (63%), build mentorship (31%), seek more opportunities (26%), address barriers for women (23%), and make an impact in IR (23%); male students wanted to support WIR (100%), address barriers (50%), and advance IR with diversity and inclusion (50%).
Conclusion(s): Medical students showed robust interests in joining WIR. Both female and male students expressed interests in promoting WIR and addressing barriers for the gender gap. Female students expressed interests in increasing networking, mentorship, and opportunities in IR. Male students emphasized the importance of diversity and inclusion. Recruiting medical students into SIR committees and providing networking, mentorship, and projects may attract both more female and male medical students into the field.
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Background: The potential of the electronic health record (EHR) and clinical decision support (CDS) to improve the practice of medicine have been significantly tempered by poor design and the resulting burden they place on health care providers. CDS is rarely tested in the real clinical environment. As a result many tools are hard to use, placing strain on providers and resulting in low adoption rates. This is the first study to evaluate CDS usability and the provider-computer-patient interaction in the real clinical environment. The objective of this study was to further understand barriers and facilitators of meaningful CDS usage within a real clinical context. Methods: This qualitative observational study was conducted with three primary care providers during a total of six patient care sessions. In patients with the chief complaint of sore throat the Centor Score was used to stratify the risk of group A strep pharyngitis. In patients with a chief complaint of cough or upper respiratory infection the Heckerling Rule was used to stratify the risk of pneumonia. During usability testing all human-computer interactions, including audio and continuous screen capture, were recorded using Camtasia software. Participants' comments and interactions with the tool during patient care sessions and participant comments during a post-session brief interview were placed into coding categories and analyzed for generalizable themes. Results: In the 6 encounters observed, primary care providers toggled between addressing either the computer or the patient during the visit. Minimal time was spent listening to the patient without engaging the EHR. Participants almost always used the CDS tool with the patient, asking questions to populate the calculator and discussing the results of the risk assessment; they reported the ability to do this as the major benefit of the tool. All primary care providers were interrupted during their use of the CDS tool by the need to refer to other sections of the chart. In half of the visits, patient's clinical symptoms challenged the applicability of the clinical prediction rule to calculate the risk of bacterial infection. Primary care providers rarely used the incorporated incentives for CDS usage, including progress notes and patient instructions/documentation. Conclusions: Live usability testing of these CDS tools generated insights about their role in the patient-provider interaction. CDS may contribute to the interaction by being simultaneously viewed by provider and patient. CDS can improve usability and lessen the strain it places on providers by being short, flexible and customizable to unique provider workflow. A useful component of CDS is being as widely applicable as possible and ensuring that its functions represent the fastest way to perform a particular task

Purpose: Pseudoexfoliation (PXF) syndrome is known to be associated with glaucoma, zonular weakness, reduced pupil dilation, and cataract progression. This retrospective study presents two-year follow-up of a Guatemalan population undergoing cataract surgery. Methods: 279 eyes of 259 patients who underwent cataract surgery at Hospital de la Familia in Guatemala in 2014 and 2015 were reviewed retrospectively. Eyes necessitating combined glaucoma filtration procedures and traumatic subluxed lenses were excluded. Records were reviewed for presence of PXF material, pre-operative visual acuity, cataract density, intraocular pressure (IOP), cataract extraction technique, intraocular lens (IOL) placement site, and surgical complications. Fisher exact test and chi-square test were used for categorical variables, and two-tailed T test was used for continuous variables. Statistical significance was defined as p <= 0.05. Results: 233 eyes (83%) had vision worse than 20/200 preoperatively. Phacoemulsification and extracapsular extraction were performed in 60 eyes (22%) and 219 eyes (78%), respectively. The most common complications were elevated IOP (>30 mmHg) on postoperative day 1 (19%), poor intraoperative pupil dilation (13%), zonular abnormalities (10%), vitreous loss (10%), posterior capsular tear (8%), incomplete cortex removal (8%), and iris trauma (5%). Other complications included post-operative hyphema (3%), dropped nucleus (3%), suprachoroidal hemorrhage (0.3%), and retrobulbar hemorrhage (0.3%). 41 eyes (15%) had documented PXF preoperatively. Eyes with PXF were more likely to result in poor dilation (p = 0.004), zonular abnormalities (p < 0.001), and vitreous loss (p = 0.04). The location of IOL placement in eyes with PXF was significantly different (p = 0.003), specifically that more anterior chamber intraocular lenses were placed in eyes with PXF (p < 0.001). Eyes with PXF also were more likely to have elevated post-operative IOP (p = 0.09), however this did not reach statistical significance. Conclusions: This study confirms our previously reported incidence of PXF in this Central American population of 15%. PXF is associated with increased likelihood of intraoperative and post-operative complications from cataract surgery. Detailed preoperative exam and preparation are warranted to anticipate such complications

Purpose: There is currently much debate about the utility of routine ophthalmology consults to rule out intraocular involvement in fungemic patients, especially in the age of modern antifungals with improved ocular penetration. This retrospective observational clinical study aims to evaluate the incidence of intraocular involvement in patients with fungemia and identify predisposing risk factors in our population at an urban tertiary care hospital. Methods: A retrospective review was performed using clinical records for all inpatient ophthalmology consults for 'fungemia', 'candidemia', and 'rule out fungal endophthalmitis' between the dates of January 1, 2010 and December 31, 2015. Results: Of 94 patients (51.6 years, 75.5% male) with fungemia, 9/94 (9.6%) had chorioretinal involvement with one patient (1.1%) developing vitreous opacities. Another five (5.3%) demonstrated non-specific retinal lesions of which an infectious etiology could not be ruled out but were deemed inactive due to failure to progress over multiple examinations. Of those diagnosed with intraocular involvement, no patients communicated visual disturbances as they were either asymptomatic or intubated. 7/9 (78%) had a history of intra-abdominal surgery within the past year, 6/9 (67%) were receiving total parenteral nutrition (TPN), and 6/9 (67%) had concomitant bacteremia. All fungal isolates were subspecies of Candida with C. albicans being the most common (found in 6/9 patients [67%]). Change in management due to intraocular findings occurred in 2/9 cases (22%) and consisted mainly of optimization of antimicrobial therapy. Conclusions: Ocular involvement in fungemia is uncommon, but if present may result in devastating visual loss. In this study, an incidence of 9.6% is consistent with prior reports. However, in our series, all patients with intraocular involvement were asymptomatic or unable to communicate suggesting that routine examination remains necessary to detect early changes and modify treatment as necessary. These results also suggest that risk factors for ocular involvement in fungemia include history of abdominal surgery, total parenteral nutrition and concomitant bacteremia