Faculty Bibliography

Remote patient monitoring (RPM) has been shown to support adults with treated but uncontrolled hypertension (HTN) outside the clinic setting, yielding significant benefits in the treatment and control of blood pressure (BP). Despite its proven efficacy and recommendation as guideline-concordant care, adoption of RPM is suboptimal, particularly among marginalized populations, who face structural barriers to HTN control. A barrier to equitable adoption among marginalized populations is the lack of digital inclusivity in the design and deployment of RPM. Digitally inclusive tools consider factors such as affordability, access, digital literacy, and skills. To address this challenge, the authors describe a digitally inclusive model of RPM for HTN management within the Family Health Centers (FHCs) at NYU Langone, a federally qualified health center (FQHC) that serves more than 110,000 patients each year. The model uses protocols from the Target: BP initiative in combination with team-based care and digitally inclusive strategies to improve HTN control. Specifically, care teams work collaboratively to identify patients with uncontrolled HTN and order RPM using electronic health record-embedded clinical decision support; provide patients with free home BP monitors and training in accurate BP measurement; deliver language-concordant health coaching and optimize the antihypertensive regimen via a virtual high-risk clinic (VHRC); and monitor patient progress through shared communications. Patients also receive support from community health workers (CHWs) to address digital barriers and unmet social needs. The authors present utilization and preliminary outcome data of their model, involving 429 patients who were enrolled in RPM and the VHRC across five FHC practices between January 1, 2022, and December 31, 2023. Enrolled patients attended a mean of 4.9 (standard deviation [SD]: 0.5) visits with a nurse practitioner for medication adjustments and counseling; 5.7 (SD: 0.5) health coaching visits with a nurse; and 1 visit (SD: 0.2) with a CHW for digital and social needs over a mean of 5.7 months (SD: 0.8). Enrolled patients sent a mean number of 65 BP readings (SD: 96.4) over their period of participation. On average, enrolled patients exhibited a -13.5/-8.0 mmHg reduction from their enrollment date to the date that they were discharged from the VHRC (approximately 5.7 months). This is in comparison to a -0.5/+0.6 mmHg change in mean BP exhibited by patients with uncontrolled HTN not enrolled in the Advancing Long-term Improvements in Hypertension Outcomes through a Team-based Care Approach (ALTA) program and receiving care at the practices during the same period (n=2,843). Across the practices, BP control had also increased from the pre-ALTA baseline period (January 1, 2021, to December 31, 2021) of 68.44%-82.99%, by the end of December 31, 2023, among all patients with uncontrolled HTN. While the implementation of this digitally inclusive RPM model has shown success in a large FQHC that cares for a diverse population of patients, there remain digital inequity barriers that must be addressed at the policy level to ensure this efficacious approach reaches all patients.

CONTEXT/UNASSIGNED:Minoritized populations such as racial and ethnic minorities and individuals of less privileged socioeconomic status experience a disproportionate burden of poor hypertension (HTN) control in the United States. Multilevel systems interventions have been shown to improve patient-level outcomes in minoritized populations; however, there remains a large translational gap in implementing these approaches into federally qualified health centers (FQHC), which serve those at highest risk of HTN-related morbidity and mortality. The paucity of purposeful collaborations between academic researchers and practice staff throughout the research process remains a significant roadblock to the timely translation of evidence to practice. DESIGN/UNASSIGNED:This commentary describes the key principles and best practices that underlie the development and sustainment of an equitable research-practice alignment, which is supporting the implementation of multilevel systems intervention for improved HTN care in a large FQHC in Brooklyn, New York. The key principles, which are derived from the central tenants of relationship development and maintenance in community-engaged participatory research, patient-centered outcomes research, and organizational alignment theory include (1) cocreation of a shared mental model, (2) bridging multilevel communication, (3) ensuring mutual accountability, and (4) creating a culture of continuous improvement. CONCLUSIONS/UNASSIGNED:Together, the principles guide how the research and practice teams work together to achieve a shared goal of improving the health and well-being of minoritized patients through the provision of high quality, community-oriented HTN care. Best practices to sustain our alignment require an ongoing and deliberate investment in honest and transparent communication by all members.

Covid-19 is a new highly contagious RNA viral disease that has caused a global pandemic. Human-to-human transmission occurs primarily through oral and nasal droplets and possibly through the airborne route. The disease may be asymptomatic or the course may be mild with upper respiratory symptoms, moderate with non-life-threatening pneumonia, or severe with pneumonia and acute respiratory distress syndrome. The severe form is associated with significant morbidity and mortality. While patients who are unstable and in acute distress need immediate in-person attention, many patients can be evaluated at home by telemedicine or videoconferencing. The more benign manifestations of Covid-19 may be managed from home to maintain quarantine, thus avoiding spread to other patients and health care workers. This document provides an overview of the clinical presentation of Covid-19, emphasizing telemedicine strategies for assessment and triage of patients. Advantages of the virtual visit during this time of social distancing are highlighted.

Primary myelofibrosis (PMF) is a disease that affects the bone marrow. It presents with cytopenias, hepatospleomegaly accompanied with extramedullary hematopoiesis, and often with constitutional symptoms. Cytotoxic gamma-delta T-cells are considered a distinct hepatosplenic lymohoma. This is a case presentation of a 43-year-old male with an initial diagnosis of PMF who underwent allogeneic stem cell transplantation complicated by primary graft failure. He subsequently underwent a partial splenic embolization; however, he quickly developed a fulminant hepatosplenic gamma-delta T-cell lymphoma which led to his death that was diagnosed posthumously. PMF has been known to transform into an acute myeloid leukemia, but there has been no established link with gamma-delta T-cell lymphoma.

Background. With over 100,000 unique lives and 600,000 visits in 2018, The Family Health Centers at NYU Langone (FHC) is one of the largest Federally Qualified Health Center network based primarily in Southwest Brooklyn New York. Within the catchment area 48% of the population report being born out of the United States, with 30% of the population describing themselves of Asian ethnicity and 42% as Latino [1]. Effective January 1, 2014 New York State law mandated hepatitis C screening to be offered to every individual born between 1945 and 1965 receiving health services. Now five years later, with the advancements in treatment options and increased access for patients where cost has become prohibitive we retrospectively reviewed how our performance has been prior to embarking on a goal of 60% screening compliance. Methods. We performed a retrospective chart review looking at a denominator of patients born between 1945 and 1965 who were seen in the FHC for a visit in 2018. Patients who were previously screened since 2016, have a diagnosis of hepatitis C, history of hepatitis C documented in either past medical history, problem list or ICD code were excluded. Data abstraction for compliance in the numerator included patients who have a resulted hepatitis C antibody or have indicated current treatment (with a hepatitis C viral load). Results. 51% of patients based on the aforementioned methodology have been screened in 2018. 11,577 patients were eligible with 650 patients having a documented refusal. 261 new diagnosis were made in 2018 and compliance for non-screened patients without any prior screening was 35%. Regarding racial/ethnic composition of the practice sites compared with patients screened, one practice site with an 87% Asian non-Hispanic population had a 35% compliance rate with screening where as the most predominate Hispanic population site (81% of total patients seen) had a 54% compliance rate. Conclusion. Overall screening rates within the network are commendable, yet more work is being done to drive provider awareness on the need for compliance. Differences in racial/ethnic backgrounds and compliance of screening completion can be seen within the FHC network. Current efforts are focused on increasing culturally appropriate awareness amongst the patient population as well as the providers

Tranexamic acid (TXA) is an anti-fibrinolytic agent that inhibits plasminogen activation by binding to its lysine receptor sites and preventing its conversion to plasmin. It stabilizes clots to reduce bleeding and has been used in the setting of trauma, heavy menstrual bleeding, and hematologic malignancies. To our knowledge, there is no mention in the literature of medical management with TXA to treat a life-threatening hemorrhage in the setting of non-operative, endoleakage-induced, chronic disseminated intravascular coagulation (DIC). This case report summarizes the successful use of TXA in a patient with DIC secondary to multiple aortic aneurysms and endoleakage in an effort to stop the expansion of a life-threatening gluteal hematoma not amenable to surgical or vascular intervention.