Faculty Bibliography

Type I interferon (IFN) is critical in our defense against viral infections. Increased type I IFN pathway activation is a genetic risk factor for systemic lupus erythematosus (SLE), and a number of common risk alleles contribute to the high IFN trait. We hypothesized that these common gain-of-function IFN pathway alleles may be associated with protection from mortality in acute COVID-19. We studied patients admitted with acute COVID-19 (756 European-American and 398 African-American ancestry). Ancestral backgrounds were analyzed separately, and mortality after acute COVID-19 was the primary outcome. In European-American ancestry, we found that a haplotype of interferon regulatory factor 5 (IRF5) and alleles of protein kinase cGMP-dependent 1 (PRKG1) were associated with mortality from COVID-19. Interestingly, these were much stronger risk factors in younger patients (OR=29.2 for PRKG1 in ages 45-54). Variants in the IRF7 and IRF8 genes were associated with mortality from COVID-19 in African-American subjects, and these genetic effects were more pronounced in older subjects. Combining genetic information with blood biomarker data such as C-reactive protein, troponin, and D-dimer resulted in significantly improved predictive capacity, and in both ancestral backgrounds the risk genotypes were most relevant in those with positive biomarkers (OR for death between 14 and 111 in high risk genetic/biomarker groups). This study confirms the critical role of the IFN pathway in defense against COVID-19 and viral infections, and supports the idea that some common SLE risk alleles exert protective effects in anti-viral immunity.

Importance:Accessing specialty care continues to be a persistent problem for patients who use safety-net health systems. To address this access barrier, hospital systems have begun to implement electronic referral systems using eConsults, which allow clinicians to submit referral requests to specialty clinics electronically and enable specialty reviewers to resolve referrals, if appropriate, through electronic dialogue without an in-person visit. Objective:Measure the effect of implementing an eConsult program on access to specialty care. Design Setting and Participants:Using an interrupted time series design with data from 2016 to 2020, this study analyzed 50 260 referral requests submitted during the year before and the year after eConsult implementation at 19 New York City Health + Hospitals (NYC H+H) specialty clinics that spanned 7 NYC H+H hospital facilities and 6 unique specialties. Exposures:Referral request was submitted to a specialty clinic in the year following eConsult implementation. Main Outcomes and Measures:Main outcomes included the fraction of referral requests resolved without an in-person visit following eConsult implementation; and, among requests triaged to have an in-person visit, the fraction of referrals with a successfully scheduled appointment, mean wait time to a specialty appointment, and the fraction of referral requests with a completed specialty visit. Changes associated with eConsult implementation were estimated using multivariate linear regression adjusting for patient age, gender, and specialty clinic fixed effects. Results: = .07). Changes in outcomes were mitigated during months when most clinics underwent an electronic health record transition after implementing eConsult. Conclusions and Relevance:In this quality improvement study, implementation of eConsults at a large multi-specialty safety-net system was associated with improvements in appointment scheduling rates and wait times. Despite an additional electronic health record transition, eConsults are a promising health care delivery tool for increasing access to specialty care.

PURPOSE:The aim of this study is to investigate the efficacy of a mobile platform that combines smartphone-based retinal imaging with automated grading for determining the presence of referral-warranted diabetic retinopathy (RWDR). METHODS:A smartphone-based camera (RetinaScope) was used by non-ophthalmic personnel to image the retina of patients with diabetes. Images were analyzed with the Eyenuk EyeArt® system, which generated referral recommendations based on presence of diabetic retinopathy (DR) and/or markers for clinically significant macular oedema. Images were independently evaluated by two masked readers and categorized as refer/no refer. The accuracies of the graders and automated interpretation were determined by comparing results to gold standard clinical diagnoses. RESULTS:A total of 119 eyes from 69 patients were included. RWDR was present in 88 eyes (73.9%) and in 54 patients (78.3%). At the patient-level, automated interpretation had a sensitivity of 87.0% and specificity of 78.6%; grader 1 had a sensitivity of 96.3% and specificity of 42.9%; grader 2 had a sensitivity of 92.5% and specificity of 50.0%. At the eye-level, automated interpretation had a sensitivity of 77.8% and specificity of 71.5%; grader 1 had a sensitivity of 94.0% and specificity of 52.2%; grader 2 had a sensitivity of 89.5% and specificity of 66.9%. DISCUSSION:Retinal photography with RetinaScope combined with automated interpretation by EyeArt achieved a lower sensitivity but higher specificity than trained expert graders. Feasibility testing was performed using non-ophthalmic personnel in a retina clinic with high disease burden. Additional studies are needed to assess efficacy of screening diabetic patients from general population.

Hepatitis B is a major public health threat which leads to serious liver disease or cancer and disproportionately impacts immigrants. Pregnant people are routinely tested for hepatitis B to prevent perinatal transmission but may themselves not receive appropriate education and referrals. People contacted as part of the local health department's perinatal hepatitis B prevention program were offered culturally appropriate telephone patient navigation services to test if this would improve adherence with postpartum hepatitis B care. Four-hundred and nine people were enrolled in the intervention. Using laboratory-reported surveillance data as the outcome measure, those receiving the intervention were 1.66 times as likely to see a hepatitis B care provider within 6 months of childbirth compared with those who did not. Culturally appropriate patient navigation can improve adherence with recommended hepatitis B care in the postpartum period. Health departments can use similar interventions to address liver health disparities in immigrant populations.

Bacterial infections represent a major cause of mortality and morbidity in patients with cirrhosis that can alter the clinical course of compensated cirrhosis. The most common infections are spontaneous bacterial peritonitis by gram-negative organisms, urinary-tract infection, and pneumonia. In this case report, we raise the question of considering infections in the prognosis scoring in this patient group.

Introduction:Instruction in implicit bias is becoming prevalent across the spectrum of medical training. Little education exists for preclinical students, and guidance for faculty to facilitate such education is minimal. To address these gaps, we designed and delivered a single session for incoming first-year medical students and developed a facilitator training program. Methods:One faculty member delivered a 1-hour, multimedia, interactive lecture to all first-year medical students. Students subsequently met in small groups with trained facilitators. Activities included reflection, guided debriefing, and strategy identification to become aware of when they might be making an assumption causing them to jump to a conclusion about someone. The program evaluation consisted of aggregated student strategies and facilitator feedback during postsession debriefs, both analyzed through thematic analysis. Results:We delivered instruction to 1,098 students. Student strategies resulted in three themes: (1) humility, (2) reflection, and (3) partnering. The postsession debriefs uncovered opportunities to enhance the session. Lessons learned included presenting material to an entire class at once, allowing students to engage in dynamic discussion in the small groups, eliminating anonymous polling in the small groups, and highlighting management of implicit bias as essential to professional development. Discussion:Our instructional design enabled first-year medical students to identify at least one strategy to use when implicit biases are activated. The large-group session was deliverable by one faculty member, and volunteers successfully facilitated small-group sessions after only one training session, making this model a feasible innovation to reach an entire medical school class at the same time.