Faculty Bibliography

OBJECTIVES/OBJECTIVE:People detained in correctional facilities are at high risk for infection with severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease 2019 (COVID-19). We described the epidemiology of the COVID-19 outbreak in a large urban jail system, including signs and symptoms at time of testing and risk factors for hospitalization. METHODS:This retrospective observational cohort study included all patients aged ≥18 years who were tested for COVID-19 during March 11-April 28, 2020, while in custody in the New York City jail system (N = 978). We described demographic characteristics and signs and symptoms at the time of testing and performed Cox regression analysis to identify factors associated with hospitalization among those with a positive test result. RESULTS:Of 978 people tested for COVID-19, 568 received a positive test result. Among symptomatic patients, the most common symptoms among those who received a positive test result were cough (n = 293 of 510, 57%) and objective fever (n = 288 of 510, 56%). Of 257 asymptomatic patients who were tested, 58 (23%) received a positive test result. Forty-five (8%) people who received a positive test result were hospitalized for COVID-19. Older age (aged ≥55 vs 18-34) (adjusted hazard ratio [aHR] = 13.41; 95% CI, 3.80-47.33) and diabetes mellitus (aHR = 1.99; 95% CI, 1.00-3.95) were significantly associated with hospitalization. CONCLUSIONS:A substantial proportion of people tested in New York City jails received a positive test result for COVID-19, including a large proportion of people tested while asymptomatic. During periods of ongoing transmission, asymptomatic screening should complement symptom-driven COVID-19 testing in correctional facilities. Older patients and people with diabetes mellitus should be closely monitored after COVID-19 diagnosis because of their increased risk for hospitalization.

Medical students provide clinical teaching faculty with feedback on their skills as educators through anonymous surveys at the end of their clerkship rotation. Because faculty are in a position of power, students are hesitant to provide candid feedback. Our objective was to determine if medical students were willing to provide negative upward feedback to clinical faculty and describe how they conveyed their feedback. A qualitative analysis of third year medical students' open-ended comments from evaluations of six clerkships was performed using politeness theory as a conceptual framework. Students were asked to describe how the clerkship enhanced their learning and how it could be improved. Midway through the academic year, instructions to provide full names of faculty/residents was added. Overall, there were significantly more comments on what worked well than suggestions for improvement regarding faculty/residents. Instructing students to name-names increased the rate of naming from 35% to 75% for what worked well and from 13% to 39% for suggestions for improvement. Hedging language was included in 61% of suggestions for improvement, but only 2% of what worked well. Students described the variability of their experience, used passive language and qualified negative experiences with positive ones. Medical students may use linguistic strategies, such as impersonalizing and hedging, to mitigate the impact of negative upward feedback. Working towards a culture that supports upward feedback would allow students to feel more comfortable providing candid comments about their experience.

PURPOSE OF REVIEW/OBJECTIVE:The use of POCUS has grown tremendously with the introduction of innovative, easy-to-carry and maneuver hand-held devices. This review focuses on nephrology-centric applications of POCUS that can be incorporated on a daily basis to make impactful and prompt clinical decisions. RECENT FINDINGS/RESULTS:We review articles covering use of POCUS in the dialysis unit, the Emergency Department, office, and ICU for assessment of volume status, access issues, stones, obstruction, and to help manage patients with AKI, shock, and heart failure. SUMMARY/CONCLUSIONS:POCUS is a welcome addition to our bedside diagnostic armamentarium and has great utility in nephrology. Trials are ongoing in evaluating outcomes with POCUS and physicians' clinical experience using it has been extremely positive.

PURPOSE OF REVIEW/OBJECTIVE:The purpose of this review was to assess the prevalence of United States chronic kidney disease (CKD) health disparities, focusing on racial/ethnic groups, immigrants and refugees, sex or gender, and older adults. RECENT FINDINGS/RESULTS:There are major racial/ethnic disparities in CKD, with possible contributions from the social determinants of health, socioeconomics, and racial discrimination. Racial/ethnic minority patients experience faster progression to end-stage kidney disease (ESKD) and higher mortality predialysis, however, once on dialysis, appear to live longer. Similarly, men are quicker to progress to ESKD than women, with potential biological, behavioral, and measurement error factors. There is a lack of substantial evidence for intersex, nonbinary, or transgender patients. There are also strikingly few studies about US immigrants or older adults with CKD despite the fact that they are at high risk for CKD due to a variety of factors. SUMMARY/CONCLUSIONS:As providers and scientists, we must combat both conscious and unconscious biases, advocate for minority patient populations, and be inclusive and diverse in our treatment regimens and provision of care. We need to acknowledge that sufficient evidence exists to change treatment guidelines, and that more is required to support the diversity of our patient population.

PURPOSE/OBJECTIVE:As global health education and training shifts towards competency-based approaches, academic institutions and organizations must define appropriate assessment strategies for use across health professions. The authors of this study aim to develop entrustable professional activities (EPAs) for global health to apply across academic and workplace settings. METHOD/METHODS:In 2019, the authors invited 55 global health experts from medicine, nursing, pharmacy, and public health to participate in a multi-round, online Delphi process; 30 (55%) agreed. Experts averaged 17 years of global health experience, and 12 (40%) were from low-to-middle-income countries. In round one participants listed essential global health activities. The authors used in-vivo coding for round one responses to develop initial EPA statements. In subsequent rounds, participants used a 5-point Likert-type scale to evaluate EPA statements for importance and relevance to global health across health professions. The authors elevated statements that were rated 4 (important/relevant to most) or 5 (very important/relevant to all) by a minimum of 70% of participants (decided a priori) to the final round, during which participants evaluated whether each statement represented an observable unit of work that could be assigned to a trainee. Descriptive statistics were used for quantitative data analysis. The authors used participant comments to categorize EPA statements into role domains. RESULTS:Twenty-two EPA statements reached at least 70% consensus, and the authors categorized them into 5 role domains: partnership developer, capacity builder, data analyzer, equity advocate, and health promoter. Statements in the equity advocate and partnership developer domains had the highest agreement for importance and relevance. Several statements achieved 100% agreement CONCLUSIONS:: EPAs for global health may be useful to academic institutions and other organizations to guide the assessment of trainees within education and training programs across health professions.

PURPOSE OF REVIEW/OBJECTIVE:Several nontraditional risk factors have been the focus of research in an attempt to understand the disproportionately high cardiovascular morbidity and mortality in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) populations. One such category of risk factors is cardiovascular autonomic dysfunction. Its true prevalence in the CKD/ESKD population is unknown but existing evidence suggests it is common. Due to lack of standardized diagnostic and treatment options, this condition remains undiagnosed and untreated in many patients. In this review, we discuss current evidence pointing toward the role of autonomic nervous system (ANS) dysfunction in CKD, building off of crucial historical evidence and thereby highlighting the areas in need for future research interest. RECENT FINDINGS/RESULTS:There are several key mediators and pathways leading to cardiovascular autonomic dysfunction in CKD and ESKD. We review studies exploring the mechanisms involved and discuss the current measurement tools and indices to evaluate the ANS and their pitfalls. There is a strong line of evidence establishing the temporal sequence of worsening autonomic function and kidney function and vice versa. Evidence linking ANS dysfunction and arrhythmia, sudden cardiac death, intradialytic hypotension, heart failure and hypertension are discussed. SUMMARY/CONCLUSIONS:There is a need for early recognition and referral of CKD and ESKD patients suspected of cardiovascular ANS dysfunction to prevent the downstream effects described in this review.There are many unknowns in this area and a clear need for further research.

INTRODUCTION:The proportion of women editorial board members and authors of editorials in major gastroenterology journals is not known. METHODS:We determined the sex of editorial board members (n = 2,282) and authors of editorials (n = 1,705) across 6 journals from 1985 to 2020 at 5-year intervals. RESULTS:The proportion of women editorial board members increased from 2.9% in 1985 to 19.8% in 2020 (P < 0.0001) and women authors of editorials increased from 0% in 1985 to 22.2% in 2020 (P < 0.0001). DISCUSSION:The proportion of women represented over time has improved, but opportunities likely exist to improve further.

Corticosteroids, anti-CD20 agents, immunotherapies, and cytotoxic chemotherapy are commonly used in the treatment of patients with cancer. It is unclear how these agents affect patients with cancer who are infected with SARS-CoV-2. We retrospectively investigated associations between SARS-CoV-2-associated respiratory failure or death with receipt of the aforementioned medications and with pre-COVID-19 neutropenia. The study included all cancer patients diagnosed with SARS-CoV-2 at Memorial Sloan Kettering Cancer Center until June 2, 2020 (N = 820). We controlled for cancer-related characteristics known to predispose to worse COVID-19 as well as level of respiratory support during corticosteroid administration. Corticosteroid administration was associated with worse outcomes prior to use of supplemental oxygen; no statistically significant difference was observed in sicker cohorts. In patients with metastatic thoracic cancer, 9 of 25 (36%) and 10 of 31 (32%) had respiratory failure or death among those who did and did not receive immunotherapy, respectively. Seven of 23 (30%) and 52 of 187 (28%) patients with hematologic cancer had respiratory failure or death among those who did and did not receive anti-CD20 therapy, respectively. Chemotherapy itself was not associated with worse outcomes, but pre-COVID-19 neutropenia was associated with worse COVID-19 course. Relative prevalence of chemotherapy-associated neutropenia in previous studies may account for different conclusions regarding the risks of chemotherapy in patients with COVID-19. In the absence of prospective studies and evidence-based guidelines, our data may aid providers looking to assess the risks and benefits of these agents in caring for cancer patients in the COVID-19 era.

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.

Objectives/UNASSIGNED:The aim of this study was to test the mediating role of perceived discrimination and stress on associations between perceived neighborhood social environment (PNSE) and TV viewing. Methods/UNASSIGNED:Baseline data were used for 4716 participants (mean age = 55.1 y; 63.4% female) in the Jackson Heart Study (JHS), a large prospective cohort study of African Americans in Jackson, Mississippi. One binary TV viewing outcome was created: ≥4 h/day versus <4 h/day. PNSE variables included neighborhood violence, problems (higher value = more violence/problems), and social cohesion (higher value = more cohesion). Mediators included perceived lifetime discrimination, daily discrimination, and chronic stress (higher value = greater discrimination/stress). Multivariable regression was used with bootstrap-generated 95% bias-corrected confidence intervals (BC CIs) to test for mediation adjusting for demographics, health-related and psychosocial factors, and population density. Results/UNASSIGNED: = 1.01, 1.10, respectively). Daily discrimination was neither directly nor indirectly associated with TV viewing. Conclusions/UNASSIGNED:Each PNSE variable was indirectly associated with TV viewing via lifetime discrimination and perceived stress, but not with daily discrimination among JHS participants. Unexpected directionality of mediating effects of lifetime discrimination and chronic stress should be replicated in future studies. Further research is also needed to pinpoint effective community efforts and physical environmental policies (e.g., installing bright street lights, community policing) to reduce adverse neighborhood conditions and psychosocial factors, and decrease TV viewing and subsequent cardiovascular disease risk.