Faculty Bibliography

OBJECTIVE:New York City was the epicenter of the outbreak of the 2019 coronavirus disease (COVID-19) pandemic in the United States. As a large, quaternary care medical center, NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients during this time. Clinical leadership effectively identified, oriented, and rapidly deployed a "COVID Army," consisting of non-hospitalist physicians, to meet the needs of the patient influx. We share feedback from our providers on our processes and offer specific recommendations for systems experiencing a similar influx in the current and future pandemics. METHODS:To assess the experiences and perceived readiness of these physicians (n = 183), we distributed a 32-item survey between March and June of 2020. Thematic analyses and response rates were examined to develop results. RESULTS:Responses highlighted varying experiences and attitudes of our frontline physicians during an emerging pandemic. Thematic analyses revealed a series of lessons learned, including the need to (1) provide orientations, (2) clarify roles/workflow, (3) balance team workload, (4) keep teams updated on evolving policies, (5) make team members feel valued, and (6) ensure they have necessary tools available. CONCLUSIONS:Lessons from our deployment and assessment are scalable at other institutions.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The Nurses Improving Care for Healthsystem Elders (NICHE) is a nurse-led education and consultation program designed to help health care organizations improve the quality of care for older adults. To conduct a scoping review of the evidence associated with the NICHE program to (a) understand how it influences patient outcomes through specialized care of the older adult and (b) provide an overview of implementation of the NICHE program across organizations as well as its impact on nursing professionals and the work environment. RESEARCH DESIGN AND METHODS/METHODS:Six databases were searched to identify NICHE-related articles between January 1992 and April 2019. After critical appraisal, 43 articles were included. RESULTS:Four thematic categories were identified including specialized older adult care, geriatric resource nurse (GRN) model, work environment, and NICHE program adoption and refinement. Specialized older adult care, a key feature of NICHE programs, resulted in improved quality of care, patient safety, lower complications, and decreased length of stay. The GRN model emphasizes specialized geriatric care education and consultation. Improvements in the geriatric nurse work environment as measured by perceptions of the practice environment, quality of care, and aging-sensitive care delivery have been reported. NICHE program adoption and refinement focuses on the methods used to improve care, implementation and adoption of the NICHE program, and measuring its impact. DISCUSSION AND IMPLICATIONS/UNASSIGNED:The evidence about the NICHE program in caring for older adults is promising but more studies examining patient outcomes and the impact on health care professionals are needed.

Background: Home blood pressure measurement (HBPM) has been a time-honored supplement to periodic in-office measurement to facilitate primary care physician (PCP) diagnosis of hypertension (HTN), its ongoing control and medication management. PCPs, in response to COVID-19, adopted telemedicine as the sole means of care, elevating HBPM as the essential HTN surveillance tool. We assessed the feasibility of this approach in a Veteran Affairs (VA) geriatric clinic.
Method(s): Study subjects included all the Veterans seen by New York Harbor VA geriatrics fellows' clinic between January 1, 2019 and March 1, 2020 and who have HTN listed as an electronic health record (EHR) diagnosis. Those with systolic blood pressure (SBP) > 140 mmHg were prioritized. We called these patients to assess adherence to BP self-care and reconcile medications, to identify reasons for poor adherence and to offer solutions. Patients were called again within two months to re-assess adherence, collect BP measures and adjust medications as needed.
Result(s): Among 102 patients diagnosed with HTN, 41 had not achieved the goal of SBP <140 mmHg prior to this intervention. We reached 78% (n=32) of these 41 patients (requiring 1-3 phone calls). All reported medical adherence, but none were found to consistently check BP at home with any frequency or proper technique. For the 14 patients having no BP monitor at home, we sent a monitor to 10 through prescription and enrolled 4 in a home telehealth (HT) program that uses daily remote measurement. We provided detailed instruction of proper HBPM during the initial interview. At follow-up, 47% (n=15) practiced HBPM and reported BP readings within goal, indicating no need for change in care. Of these 15, 11 had their own BP monitors; 2 achieved control through the HT program. However, only 2 of the 10 patients who received the prescribed BP monitor started HBPM and demonstrated good control.
Conclusion(s): Given our reliance on telemedicine, HBPM is feasible for outpatient HTN management. Close PCP follow-up to encourage consistent HBPM practice may improve and sustain the success of this strategy. The quality of self-reported data should be assessed during office visits

AIMS/OBJECTIVE:Sacubitril/valsartan combines renin-angiotensin-aldosterone system inhibition with amplification of natriuretic peptides. In addition to well-described effects, natriuretic peptides exert direct effects on pulmonary vasculature. The effect of sacubitril/valsartan on pulmonary artery pressure (PAP) has not been fully defined. METHODS AND RESULTS/RESULTS:This was a retrospective case-series of PAP changes following transition from angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) to sacubitril/valsartan in patients with heart failure reduced ejection fraction and a previously implanted CardioMEMS™ sensor. Pre-sacubitril/valsartan and post-sacubitril/valsartan PAPs were compared for each patient by examining averaged consecutive daily pressure readings from 1 to 5 days before and after sacubitril/valsartan exposure. PAP changes were also compared between patients based on elevated trans-pulmonary gradients (trans-pulmonary gradient ≥ 12 mmHg) at time of CardioMEMS™ sensor implantation. The cohort included 18 patients, 72% male, mean age 60.1 ± 13.6 years. There was a significant decrease in PAPs associated with transition from ACEI/ARB to sacubitril/valsartan. The median (interquartile range) pre-treatment and post-treatment change in mean, systolic and diastolic PAPs were -3.6 (-9.8, -0.7) mmHg (P < 0.001), -6.5 (-15.0, -2.0) mmHg (P = 0.001), and -2.5 (-5.7, -0.7) (P = 0.001), respectively. The decrease in PAPs was independent of trans-pulmonary gradient (F(1,16) = 0.49, P = 0.49). CONCLUSIONS:In this retrospective case series, transition from ACEI/ARB to sacubitril/valsartan was associated with an early and significant decrease in PAPs.

BACKGROUND:There is limited understanding about why sarcopenia is happening in bladder cancer, and which modifiable and nonmodifiable patient-level factors affect its occurrence. OBJECTIVE:The objective is to determine the extent to which nonmodifiable risk factors, modifiable lifestyle risk factors, or cancer-related factors are determining body composition changes and sarcopenia in bladder cancer survivors. DESIGN, SETTING, AND PARTICIPANTS:Patients above 18 yr of age with a histologically confirmed diagnosis of bladder cancer and a history of receiving care at Duke University Medical Center between January 1, 1996 and June 30, 2017 were included in this study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:Bladder cancer survivors from our institution were assessed for their dietary intake patterns utilizing the Diet History Questionnaire II (DHQ-II) and physical activity utilizing the International Physical Activity Questionnaire long form (IPAQ-L) tools. Healthy Eating Index 2010 (HEI2010) scores were calculated from DHQ-II results. Body composition was evaluated using Slice-O-Matic computed tomography scan image analysis at L3 level and the skeletal muscle index (SMI) calculated by three independent raters. RESULTS AND LIMITATIONS:A total of 285 patients were evaluated in the study, and the intraclass correlation for smooth muscle area was 0.97 (95% confidence interval: 0.94-0.98) between raters. The proportions of patients who met the definition of sarcopenia were 72% for men and 55% of women. Univariate linear regression analysis demonstrated that older age, male gender, and black race were highly significant predictors of SMI, whereas tumor stage and grade, chemotherapy, and surgical procedures were not predictors of SMI. Multivariate linear regression analysis demonstrated that modifiable lifestyle factors, including total physical activity (p=0.830), strenuousness (high, moderate, and low) of physical activity (p=0.874), individual nutritional components (daily calories, p=0.739; fat, p=0.259; carbohydrates, p=0.983; and protein, p=0.341), and HEI2010 diet quality (p=0.822) were not associated with SMI. CONCLUSIONS:Lifestyle factors including diet quality and physical activity are not associated with SMI and therefore appear to have limited impact on sarcopenia. Sarcopenia may largely be affected by nonmodifiable risk factors. PATIENT SUMMARY:In this report, we aim to determine whether lifestyle factors such as diet and physical activity were the primary drivers of body composition changes and sarcopenia in bladder cancer survivors. We found that lifestyle factors including dietary habits, individual nutritional components, and physical activity do not demonstrate an association with skeletal muscle mass, and therefore may have limited impact on sarcopenia.

SOURCE CITATION:N Engl J Med. 2021;384:216-28. 33186492.

Introduction Most persons on hemodialysis (HD) are older, and many have trouble with walking and self-care. Yet data are sparse on how mobility is shaped by personal factors such as motivation in this group. Our goal was to identify what personal factors impact the mobility of older adults on HD. Methods We included 1) older adults on HD (inclusion criteria: >=60 years; on outpatient HD) and 2) care partners (inclusion criteria: >=18 years; routinely helping an older adult on HD). Each had a single in-person assessment. We administered the Short Physical Performance Battery (SPPB, range 0-12 points) to assess mobility, and audio-recorded one-on-one semi-structured key informant interviews regarding personal factors for mobility. Unless requested, older adults and care partners were interviewed separately. Transcripts underwent descriptive and focused coding; the codebook was revised iteratively until consensus on all code definitions was reached. We identified codes that were personal factors using International Classification of Function criteria. A combined inductive and deductive approach extracted major themes. Results We enrolled 31 older adults on HD (42% female, 50% Black) with a mean age of 72.5+/-8.1(S.D.) years and a mean history on HD for 4.6+/-3.5 years. For the older adults on HD, mean SPPB was 3.6+/-2.8 points. Twelve care partners enrolled (75% female, 50% Black) with a mean age of 53.8+/-15.7 years. TheTable lists the themes that emerged. Conclusion Our diverse sample of older adults on HD had poor mobility, and had a mean SPPB score that is associated with 20% one-year mortality in other groups. They want mobility and independence, but mobility frequently flutuates, causing distress. They and their care partners have learned to be flexible in their expectations. Future studies should incorporate these insights in interventions to improve the mobility of older adults on HD

Transplantation-associated thrombotic microangiopathy (TA-TMA) is a complication of allogeneic hematopoietic cell transplantation (HCT) that often occurs following the development of acute graft-versus-host disease (aGVHD). In this study, we aimed to identify early TMA biomarkers among patients with aGVHD. We performed a nested-case-control study from a prospective cohort of allogeneic HCT recipients, matching on the timing and severity of antecedent aGVHD. We identified 13 TMA cases and 25 non-TMA controls from 208 patients in the cohort. Using multivariable conditional logistic regression, the odds ratio for TMA compared with non-TMA was 2.65 (95% confidence interval [CI], 1.00 to 7.04) for every 100 ng/mL increase in terminal complement complex sC5b9 and 2.62 (95% CI, 1.56 to 4.38) for every 1000 pg/mL increase in angiopoietin-2 (ANG2) at the onset of aGVHD. ADAMTS13 and von Willebrand factor (VWF) antigens were not appreciably associated with TMA. Using a Cox regression model incorporating sC5b9 >300 ng/mL and ANG2 >3000 pg/mL at the onset of aGVHD, the adjusted hazard ratio for mortality was 5.33 (95% CI, 1.57 to 18.03) for the high-risk group (both elevated) and 4.40 (95% CI, 1.60 to 12.07) for the intermediate-risk group (one elevated) compared with the low-risk group (neither elevated). In conclusion, we found that elevated sC5b9 and ANG2 levels at the onset of aGVHD were associated with the development of TMA and possibly mortality after accounting for the timing and severity of aGVHD. The results suggest important roles of complement activation and endothelial dysfunction in the pathogenesis of TMA. Measurement of these biomarkers at the onset of aGVHD may inform prognostic enrichment for preventive trials and improve clinical care.

RATIONALE/BACKGROUND:No direct comparisons of clinical features, laboratory values, and outcomes between critically ill patients with COVID-19 and influenza in the United States have been reported. OBJECTIVE:To evaluate the risk of mortality comparing critically ill patients with COVID-19 to seasonal influenza. METHODS:We retrospectively identified patients admitted to the intensive care units (ICUs) at two academic medical centers with laboratory confirmed SARS-CoV-2 or influenza A or B infections between January 1, 2019 and April 15, 2020. Clinical data were obtained by medical record review. All patients except one had follow-up to hospital discharge or death. We used relative risk regression adjusting for age, sex, number of comorbidities, and maximum sequential organ failure scores (SOFA) on ICU day 1 to determine the risk of hospital mortality and organ dysfunction in patients with COVID-19 compared to influenza. RESULTS:We identified 65 critically ill patients with COVID-19 and 74 with influenza. The mean (± standard deviation) age in each group was 60.4 +/- 15.7 and 56.8 +/- 17.6 years, respectively. Patients with COVID-19 were more likely to be male, have higher body mass index and higher rates of chronic kidney disease and diabetes. Thirty-seven percent of COVID-19 patients identified as Hispanic, compared to 10% of influenza patients. A similar proportion of patients had fever (~40%) and lymphopenia (~80%) on hospital presentation. Rates of acute kidney injury and shock requiring vasopressors were similar between the groups. While need for invasive mechanical ventilation was also similar in both groups, patients with COVID-19 had slower improvements in oxygenation, longer durations of mechanical ventilation, and lower rates of extubation compared to patients with influenza. Hospital mortality was 40% in COVID-19 patients and 19% in influenza patients (adjusted relative risk 2.13, 95% confidence interval 1.24 to 3.63; p = 0.006). CONCLUSIONS:Need for invasive mechanical ventilation was common in ICU patients with COVID-19 or influenza. Compared to those with influenza, ICU patients with COVID-19 had worse respiratory outcomes, including longer duration of mechanical ventilation. Additionally, patients with COVID-19 were at greater risk for in-hospital mortality, independent of age, sex, co-morbidities, and ICU severity of illness.