Faculty Bibliography

Receptive anal intercourse and its association with sexually transmitted infections and human papillomavirus-related anal dysplasia has been well studied in various at-risk groups including men who have sex with men. However, the relationship between receptive anal intercourse and its potential complications in patients with inflammatory bowel disease is not fully understood. This narrative review discusses sexually transmitted infections and anal dysplasia in patients with inflammatory bowel disease who engage in receptive anal intercourse and the lack of evidence-based data to guide clinical practice. It addresses the psychosocial effects of stigmatization in these patients and its consequences in the clinical encounter. We review the need for sufficient data on infection, cancer prevention, and precoital and postcoital hygienic practices with hopes that future studies establish standardized guidelines and recommendations.

The number of new HIV infections continues to be on the rise in many high-income countries, most notably among men who have sex with men (MSM). Despite recent attention to the use of antiretroviral medications as pre-exposure prophylaxis (PrEP) among MSM, considerably less research has been devoted to examining the awareness and use of post-exposure prophylaxis (PEP). Based on a convenience sample of 179 self-reported HIV-uninfected MSM using a geosocial-networking smartphone application, this study is among the first to examine the awareness and use of PEP and their demographic and behavioral correlates among MSM in London. Most respondents (88.3%) had heard of PEP, where 27.4% reported having used it. In multivariable models, the disclosure of one's sexual orientation to their general practitioner (Prevalence ratio [PR]: 3.49; 95% confidence interval (CI): 1.14, 10.70; p = .029) and reporting one's HIV status as negative (rather than unknown) (PR: 11.49; 95% CI: 1.68, 76.92; p = .013) were associated with having heard of PEP; while the recent use of club drugs (PR: 3.02; 95% CI: 1.42, 6.43; p = .004) was associated with having ever used PEP. High awareness and use in this sample suggest that PEP is a valuable risk-reduction strategy that should be capitalized on, be it in addition to or in the absence of PrEP.

NEEDS AND OBJECTIVES: Team-based primary care (PC) is seen as the best way to provide proactive, patient-centered quality care. However, developing these team-based skills is difficult in the ever-shifting, stressful healthcare environment. We sought to develop effective training to enhance team functioning at an urban safety-net hospital, with the goal of clinical transformation (e.g. improving clinic flow, enhancing care for patients with diabetes). SETTING AND PARTICIPANTS: Team training intervention at Bellevue Hospital's Adult Ambulatory Care Center, flagship of the NYC Health & Hospitals (H +H), serving poor, diverse patients with complex medical and social needs. There are 4 adult PC teams, each with 8 attending physicians, 20 residents, 1-2 physician assistants, 2 nurses, 5 patient care associates (PCA), and 2 clerical associates (CA), all caring for a panel of ~7,500 patients. To date, we have completed a training cycle for one team, with 26 members: 10 providers (7 MDs, 2 PAs, and 1 NP), 4 RNs, 5 PCAs, 3 CAs, and 4 residents participating. We are scheduled to complete training of a second team in February 2017, with the other 2 to follow. DESCRIPTION: We partnered with a parallel NYC H + H effort, enabling a seamless NYU-HRSA/NYC H + H program with increased time allotted. This includes 4 three-hour workshops co-led by NYC H + H and NYU-HRSA faculty. Each workshop blends activating, team-building exercises for teams; mini-lectures on topics like roles and responsibilities, communication skills, huddles, and experiential activities using the team's patient data. This is reinforced with seven, 30-min biweekly meetings to follow up on teamidentified topics and facilitate team members' quality improvement projects. EVALUATION: A 31-item (each item rated 0-3), retrospective pre/post survey was administered to trainees after training, addressing individual skills and attitudes (16 items) and team functioning (15 items)14 of 26 participants (54%) in team 1 completed the survey, and Team 2 participants will complete the survey in Feb. 2017. Training resulted in increased rating of individual skills t = 4.86, p < .0001) and team functioning (t = 4.02, p = .003). Additional metrics, including tracking teams' QI efforts and assessing patient experience (e.g. Unannounced Standardized Patient reports) and administrative and panel level data, are ongoing. DISCUSSION/REFLECTION/LESSONS LEARNED: Implementation of successful team training in an under-resourced, urban primary care setting is challenging. It demands flexibility, tailoring to participants' concerns; and responding to changing clinical and administrative circumstances. Essential to success was partnering with team members to guide the training

Ureaplasma is a significant cause of nongonococcal urethritis. This is a case of rectal Ureaplasma found on culture in a young man who has sex with men not previously reported in the literature. Nucleic acid amplification tests are now standard of care for sexually transmitted infection testing, but they do not test for Ureaplasma and, therefore, may be missing important infections. Ureaplasma could have important implications in urethritis and rectal HIV transmission among men who have sex with men engaging in condomless anal intercourse. Further study of Ureaplasma's role as a rectal pathogen may be warranted.

To date, various dimensions of body image and their associations with condom use have not been studied among men who have sex with men (MSM) who use geosocial-networking smartphone applications ("apps") to meet new sexual partners. The purpose of the current study was to evaluate associations between weight perception, body dissatisfaction, and self-objectification with sexual behaviors among a sample of MSM (n = 92) recruited from Grindr, an app popular among MSM, to complete an online survey. Obese participants scored significantly higher on measures of body dissatisfaction and lower on measures of sexual sensation seeking. Decreased propensities to seek sexual sensations were associated with fewer sexual partners. By assessing associations between dimensions of body dissatisfaction and sexual risk behaviors, this study adds support to a theory of syndemics among MSM, which suggests that synergistically related biological, psychological, social, and behavioral factors disproportionately affect health and health-related behaviors in this population.

BACKGROUND: Patient experience is an important quality indicator, and healthcare organizations spend considerable resources assessing patient satisfaction. Yet a view of patient experience gleaned from patient satisfaction measures tends to show high levels of reported satisfaction, with little variation. Unannounced standardized patients (USPs) have been used to assess providers' clinical skills, but can also provide other information about the healthcare encounter. This study examined the concordance between USP and patient reports of care at the same site. METHODS: Data was gathered at Bellevue Hospital Primary Care Clinic, a city safety-net hospital. USPs assess internal medicine residents training there, and complete a behaviorally anchored checklist of resident skills and interactions with other staff, wait times, ease of clinic navigation, and perceptions of team functioning. Data from 155 USP visits from July 2015-Oct 2016 was used in this study. Independently, as part of team-training efforts in the Primary Care Clinic, patient satisfaction surveys were collected, addressing similar issues. At the end of a clinic visit, research assistants unrelated to patient care asked patients to complete a 30-item survey. 118 surveys were completed between July-November 2016. 11 items appeared on both scales (though worded slightly different) and were used in this comparison. These included questions about clerical (CA) and patient care associates (PCA), and providers (MDs, NPs, PAs), provision of information, team functioning and clinic environment. Of the 11 items, 4 had the same response choices. 7 had differing numbers of responses (eg 4 vs 3 point Likert scales), evenly distributed across patient and USP scales. For each of these items, we collapsed items so to maximize positive ratings (eg. on a 4 point scale from poor to excellent, "good" and "excellent" were combined rather than "good" and "fair"). Chi-square analyses were computed to examine group differences. RESULTS: On chi-square analyses, 9 of the 11 items significantly differed between the USP and patient groups, with patients more likely to have positive ratings. These included rating PCAs as friendlier (x² = 8.67(1,206), p = .003) and providers better at answering questions (x² = 11.75 (2,265), p = .003); reporting that they received sufficient/clear instructions about medication refills and follow-up (x² = 29.5(2,264), p = .0001); finding the clinic atmosphere calmer than did USPs (x² = 10.5 (2,265), p=.005) and noting that the team functioned better (x² = 7.31(2,268), p = .026). There were no significant differences in willingness to recommend the clinic or on clarity of CAs' communication. CONCLUSIONS: Results of this study document the differing perspectives of patients and USPs. Consistent with previous work, patients in our study tended to rate most items higher than did the USPs. USPs provide a different, and likely a more critical look at the clinical setting and this information can enhance efforts to improve patient experience. (Table Presented)

BACKGROUND: As healthcare increases demands, primary care physicians need evidenced-based, patient-centered care coordination, effective use of information technology, interdisciplinary team functioning and shared decision-making skills more so in underserved areas. In 2008, we documented 20 years of the NYU/Bellevue Primary Care Internal Medicine Residency Program (NYUBPC) on readiness for practice1. In light of the recent primary care changes we assessed our recent training of Primary Care Residents in high quality, person-centered, systems-savvy, team-based care for the underserved. Specifically we aimed to: 1. Assess the NYUBPCP impact on graduate career choices, values and style 2. Elicit reflections that illustrate complexities in educating primary care physicians METHODS: We surveyed 56 graduates of the NYUBPCP from 2007-2014. The 44 question survey included 12 open-ended questions about career path, current practice, preparedness for practice and specifics about how aspects of training provided necessary skills and knowledge. Responses were unidentified. We received 37 responses, (66%). RESULTS: 36 respondents currently provide clinical care, with about 40% of their time spent in a primary care setting (S.D. 32%). On a 4- point scale 85% either agreed or strongly agreed with Primary Care as a career choice. 74% felt prepared for the challenges of a primary care practice, rating clinical experiences with underserved communities, and the psychosocial, clinical epidemiology and health policy focus as essential aspects of training. All but 4 provide care to medically underserved populations. They valued the community of peers and colleagues that the NYUBPCP provided. While 53% rated their clinical site as hectic/chaotic (4 or 5 on a 5 point scale), only 6% reported persistently feeling burnout. 19% reported at least one symptom of burnout. Qualitative analyses revealed overlapping themes in alumni perceptions of how residency influenced current practice, aspects of training that were difficult to implement and expectations for the future directions of primary care. Responses demonstrated a mismatch between the "purity" of primary care practice graduates strove to achieve after residency and the actuality of a practice influenced by external factors (e.g. time pressures, reimbursement issues and metric achievements). Some found it difficult to be involved with research or advocacy while in full-time clinical practice. Graduates believed the future of primary care lies in a team-based approach. CONCLUSIONS: A training program emphasizing rigorous curriculum, committed role modeling, care of the underserved, and strong residency community for support continues to document high rates of retention in primary care. They are well adapted entering physicians with the skills and attitudes necessary to succeed in primary care and become educators of the next generation

Data from a cross-sectional study of a clinic-based sample of older people living with HIV (PLWH; n = 100) were used to examine associations between biomarkers of physical health and neurocognitive impairment (NCI). In this sample, anemia, chronic kidney disease (CKD) stages 4-5, and hypocalcemia were associated with impairment in executive functioning or processing speed. Furthermore, participants with anemia were more likely to have CD4+ T cell counts <200 cells/mm3 (chi2 [1] = 19.57, p < .001); hypocalcemia (chi2 [1] = 17.55, p < .001); and CKD 4-5 (chi2 [2] = 10.12, p = .006). Black and Hispanic participants were more likely to be anemic compared to other races and ethnicities (chi2 [3] = 12.76, p = .005). Common medical conditions (e.g., anemia, hypocalcemia, CKD) should be investigated as potential contributors to NCI in older PLWH. Additionally, laboratory testing in racial/ethnic minority PLWH may help inform NCI screening.

Parental mental health may be a critical component in understanding the overlapping health burdens of mental health symptomatology and drug use in young men who have sex with men (YMSM), yet studies of YMSM have not fully examined these associations. To understand these relationships, data drawn from a study of gay, bisexual, and other YMSM were used examine associations between perceived parental psychopathology and the mental health symptomatology and drug use of YMSM. Findings suggest that YMSM reporting at least one parent with perceived depression, manic depression, schizophrenia, or antisocial behavior anytime during their childhoods were more likely to report higher levels of both depressive symptomatology and post-traumatic stress disorder (PTSD) than those reporting no perception of any of these psychopathologies in their parents. Number of different drugs uses in one's were higher among participants who perceived at least one parent as depressed. Mediation analyses indicated that the relationship between perceived parental depression and lifetime drug use of YMSM was mediated both by YMSM depression and YMSM PTSD. These results suggest that parental psychopathology plays an important role in the health of sexual minority men, a population with elevated levels of mental health burden and drug use across the lifespan.