Faculty Bibliography

INTRODUCTION/UNASSIGNED:Urogynecology and Reconstructive Pelvic Surgery (URPS) became an accredited fellowship in 2013. Our objective was to assess the landscape of URPS procedures performed by URPS fellowship-trained (FT) and non-FT urologists (NFT) since accreditation. MATERIALS AND METHODS/UNASSIGNED:A retrospective cohort study of American Board of Urology case logs of urologists performing URPS procedures from January 2013 through August 2024 was conducted. The annual case volumes of FT and NFT urologists were compared. Multivariable mixed-effects Poisson regression models assessed the impact of covariates on annual case volume. RESULTS/UNASSIGNED:5,816 urologists (393 FT, 5,423 NFT) performing URPS procedures were included, with 513 FT and 5,818 NFT case log submissions. Compared to NFT, FT urologists were predominantly female (48% vs 13%, p<0.01), practiced in metropolitan areas (52% vs 23%, p<0.01) and academic settings (41% vs 7%, p<0.01). FT performed 24% of annual URPS cases on average, rising to 34% when excluding benign prostate hypertrophy (BPH) procedures. Modelling demonstrated that FT performed URPS cases at 4.2 times the annual rate of NFT (RR 4.2, 95% CI 3.6-4.6) on average, rising to 7.6 times when BPH was excluded (RR 7.6, 95% CI 6.7-8.6), controlling for other covariates. Independent of FT status, women performed non-BPH URPS at a 62% higher rate than men, with higher rates also seen among urologists that are younger, recertifying and outside the Northeast. CONCLUSIONS/UNASSIGNED:Although NFT outnumber FT by 14 to one, FT performed eight times more non-BPH URPS cases annually on average and accounted for 34% of total non-BPH volume.

OBJECTIVE:During the COVID-19 pandemic, telemental health (TMH) use rapidly increased. Though patients report satisfaction with TMH, acceptability among different psychiatric providers (inpatient, outpatient, nurses) and for various diagnoses is less understood. This study aimed to expand understanding by examining TMH acceptability, benefits, and barriers for providers and patients during the early transition to TMH in the COVID-19 pandemic. METHODS:Online anonymous surveys evaluated patient (n = 64) and provider (n = 39) satisfaction with and perceived benefits and challenges to TMH from October-December 2020 on 5-point Likert scales. Qualitative data was collected and themes identified. RESULTS:Outpatient (3.97 ± 1.05) and inpatient (3.11 ± 1.6) providers, including nurses, reported high satisfaction with TMH, despite over 50% never having used TMH prior to the pandemic. TMH was viewed as acceptable across diagnoses, including serious mental illness and substance use. Provider-rated benefits of outpatient TMH versus in-person visits included COVID safety (mean difference[MD] = 3.05), travel (MD = 2.95), and reduced cancellations (MD = 1.81). Inpatient TMH similarly included COVID safety benefits (MD = 3.31), but also challenges related to team-based service provision (MD = 1.68) and working with trainees (MD = 1.19). Qualitative themes identified TMH challenges (e.g., technological: 56.7% patients, 66.7% providers) and benefits (e.g., convenience/flexibility: 80% patients, 81.5% providers). CONCLUSIONS:TMH was associated with high satisfaction for patients and across provider types and patient diagnoses. This study provides further support that TMH across clinical settings allows for greater flexibility and accessibility to evidence-based care, and ongoing benefits even outside the context of the COVID-19 pandemic. It suggests the benefits of ongoing training of staff and trainees in TMH.

Background: Data that demonstrates productivity, value or quality in clinical practice are high priority in healthcare systems but are less developed for the field of C-L Psychiatry. Recent work has focused on qualitative metrics (Kovacs et al., 2021) and service effectiveness (Wood, et al., 2014) but there is no consensus on what operational or safety metrics CL teams should track. Without reliable metrics, it can be challenging to illustrate daily CL service operations or provide quantitative support to justify expansion of staffing to hospital leadership. In response to an administrative need, our service started an ongoing collaboration with departmental leadership, administrative support staff, and medical center information technology to develop CL operational and safety metrics.
Method(s): We developed 17 monthly and 9 daily metrics to describe our operations. These metrics cluster into the following groups: clinical volume and encounters; behavioral emergency response activations (BERTs) and bedside safety huddles for patients with recent violence; length of stay; proactive Addiction CL service; behavioral acuity highlights (ex: 1:1s for suicide risk); and "CL Dwell Time" which is the time from medical clearance to discharge to inpatient psychiatry (if applicable). From this data, we selected key metrics to display on a quarterly basis to senior hospital leadership in the form of a "metrics card" to parallel our medicine and surgical colleagues who present High Reliability Organization score cards.
Result(s): Our service demonstrated increases in consultation requests, completed consultations, total clinical encounters and activation of BERTs. We compared trends for total length of stay by ultimate discharge destination, such as psychiatric admission vs acute rehabilitation vs home. The data allowed for deeper dives into concerning trends, such as the problem of escalating violence in the general medical hospital as evidenced by the increasing BERTs per month over several years. We examined the number of unique patients with BERTs, BERTs per patient, BERTs per patient by psychiatric diagnoses, and BERT total per medical unit or service. The data has allowed for the development of interventions to reduce BERTs for specific populations and medical units.
Discussion(s): The creation of comprehensive CL service operational metrics has provided our team with the ability to analyze clinical, acuity, and safety trends over the past 2 years. This ability has led to improved advocacy for service needs (i.e. expansion of FTE and fellowship lines), data-informed communication with hospital leadership, and identification of clinical care gaps needing quality improvement. References: 1. Kovacs Z, Asztalos M, et al. Quality assessment of a consultation-liaison psychiatry service. BMC Psychiatry. 2021 Jun 1;21(1):281. 2. Wood R, Wand AP. The effectiveness of consultation-liaison psychiatry in the general hospital setting: a systematic review. J Psychosom Res. 2014 Mar;76(3):175-92.
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Background/Significance: During the COVID-19 pandemic, people with substance use disorders have experienced increased rates of overdose, decreased access to substance use disorder treatment, and increased risk for adverse COVID outcomes (NIDA, 2020). Throughout the pandemic, NYU Langone Health has continued using the Tobacco, Alcohol, and Prescription Substance (TAPS) screening tool for all inpatient admissions in order to identify and provide proactive consultation to hospitalized patients at risk for substance use disorders.
Method(s): We conducted a retrospective review of adult inpatient medical and surgical admissions to NYU Langone Health, using data collected from a pre-defined Epic report based on TAPS documentation. We compared groups pre-COVID-19 pandemic (defined as 9/2018-9/2019) and during COVID-19 pandemic (defined as 3/2020-3/2021) for the following outcomes: (1) nursing compliance rate with TAPS administration, (2) prevalence of patients with substance use disorders as measured by positive TAPS screen, and (3) severity of alcohol use disorder among patients with TAPS positive for alcohol.
Result(s): During the pre-COVID-19 period, 24,057 patients were screened with a compliance rate of 90% and a positivity rate of 6% (N=1673). ICU compliance was 84%. Prevalence of patients at risk for various substance use disorders was as follows: 4.3% (N=1027) alcohol, 1.5% (N=357) cannabis, 0.32% (N=78) heroin, 0.24% (N=57) opiates, 0.15% (N=35) sedatives, 0.48% (N=116) stimulants, and 0.01% (N=3) prescription stimulants. Of positive alcohol screens, 26.7% (274/1027) represented the highest severity of use (Alcohol Score 4). During the COVID-19 period, 17,931 patients were screened with a compliance rate of 82% and positivity rate of 6% (N=1374). ICU compliance was 74%. Prevalence of patients at risk for various substance use disorders was as follows: 4.3% (N=772) alcohol, 1.5% (N=272) cannabis, 0.60% (N=108) heroin, 0.26% (N=46) opiates, 0.20% (N=35) sedatives, 0.69% (N=124) stimulants, and 0.04% (N=7) prescription stimulants. Of positive alcohol screens, 41.2% (318/772) were highest severity. We were unable to meaningfully test for significant given limitations of Epic datasets and variability in unit composition and staffing throughout COVID-19 period.
Discussion(s): There was decreased compliance with TAPS administration during COVID-19 as compared to pre-COVID-19, as well as overall low compliance in ICUs during both time periods. There were similar rates of positive screens for all substance use disorders pre-COVID-19 and during COVID-19, with an increase in positive heroin and other opiate screens during COVID-19. Among patients with positive alcohol screens, there was increased severity of alcohol scores during COVID-19 relative to pre-COVID-19. Conclusion/Implications: These results suggest a change in patterns of substance use during the COVID-19 pandemic, consistent with findings from prior studies of increased opioid overdoses (Slavova 2020, Georgia Department of Public Health 2020) and severity of substance use (NIDA 2020). Poor ICU compliance suggests increased barriers to TAPS administration in patients with critical illness and/or altered mental status, which may lead to decreased identification and treatment of patients at increased risk for substance use disorders. These results may inform clinical practice and future studies regarding utilization of TAPS screen and proactive addiction psychiatry consultation service in acute care settings. References: 1. NIDA. 2020, September 14. Addressing the Unique Challenges of COVID-19 for People in Recovery. Retrieved from https://www.drugabuse.gov/about-nida/noras-blog/2020/09/addressing-u nique-challenges-covid-19-people-in-recovery on 2021, March 15 2. Slavova, S., Rock, P., Bush, H. M., Quesinberry, D., & Walsh, S. L. (2020). Signal of increased opioid overdose during COVID-19 from emergency medical services data. Drug and alcohol dependence, 214, 108176. 3. Georgia Department of Public Health. 2020, June 19. Suspected Drug Overdose Increases in Georgia Amid COVID-19. Retrieved from https://www.drugabuse.gov/sites/default/files/suspected_drug_overdos e_increases_in_georgia_amid_covid-19_1.pdf
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BACKGROUND:New York City's first case of SARS-associated coronavirus (SARS-CoV-2) disease 2019 (COVID-19) was identified on 1 March 2020, prompting rapid restructuring of hospital-based services to accommodate the increasing numbers of medical admissions. Non-essential services were eliminated but in-patient treatment of psychiatric illnesses was necessarily maintained. AIMS/OBJECTIVE:To detail the response of the NYU Langone Health in-patient psychiatric services to the COVID-19 outbreak from 1 March to 1 May 2020. METHOD/METHODS:Process improvement/quality improvement study. RESULTS:Over this time period, our two in-patient psychiatric units (57 total beds) treated 238 patients, including COVID-19-positive and -negative individuals. Testing for COVID-19 was initially limited to symptomatic patients but expanded over the 62-day time frame. In total, 122 SARS-CoV-2 polymerase chain reaction (PCR) tests were performed in 98 patients. We observed an overall rate of COVID-19 infection of 15.6% in the patients who were tested, with an asymptomatic positive rate of 13.7%. Although phased roll-out of testing impaired the ability to fully track on-unit transmission of COVID-19, 3% of cases were clearly identified as results of on-unit transmission. CONCLUSIONS:Our experience indicates that, with appropriate precautions, patients in need of in-patient psychiatric admission who have COVID-19 can be safely managed. We provide suggested guidelines for COVID-19 management on in-patient psychiatric units which incorporate our own experiences as well as published recommendations.

A 37-year-old woman with an eating disorder and major depressive disorder, initially presented in 2005 to the University of New Mexico Mental Health Center when she was forced into treatment by her probation officer after a routine urine drug screen was positive for methamphetamine. The patient adamantly denied having ever used methamphetamine but did acknowledge a 20-year history of abusing over-the-counter medications to maintain her weight. Subsequent hair analysis confirmed the presence of ephedrine but not methamphetamine. The patient had limited insight into the problems associated with her ephedrine dependence. She refused to consider the risk of cardiac complications that could result from excessive ephedrine intake. Moreover, she continued to use ephedrine despite having to spend 3 nights in the county jail after a second urine drug screen was positive for methamphetamine. Subsequent hair analysis demonstrated this to be a false positive.

Modafinil is a novel psychostimulant that is Food and Drug Administration-approved for the treatment of excessive daytime somnolence associated with narcolepsy, obstructive sleep apnea/hypopnea syndrome, or shift work sleep disorder. Among its pharmacologic properties, modafinil enhances glutamate neurotransmission. In contrast to other stimulants, modafinil does not cause elation or euphoria in healthy volunteers or in substance abusers. In fact, one report suggests that modafinil may be effective for the treatment of amphetamine craving and dependence, while another report indicates that it may be useful in the treatment of cocaine dependence. Because of this lower abuse potential, modafinil is a Schedule IV prescription, allowing multiple refills and prescriptions by phone. Among the most common side effects associated with modafinil in premarketing trials were headache, nausea, anxiety, and insomnia. (journal abstract)

While currently available treatments, such as selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT), are efficacious in obsessive-compulsive disorder (OCD), only approximately 40% to 60% of patients experience significant reduction of symptoms, with many others demonstrating either partial or no response. Little practical advice is available to clinicians on next-step treatment strategies for patients who have not responded to >=2 trials of SSRIs. Augmentation with various agents, including dopamine antagonists, typically are recommended. In severe, resistant cases, neurosurgery may even be used. The following is a report on the successful use of the atypical antipsychotic aripiprazole in combination with the serotonergic tricyclic antidepressant clomipramine in a patient with severe, refractory OCD.