Faculty Bibliography

Background/UNASSIGNED:High patient turnover presents challenges and opportunity to provide hepatitis C virus (HCV) care in US jails (remand facilities). This study describes the HCV care cascade in the New York City (NYC) jail system during the direct-acting antiviral (DAA) treatment era. Methods/UNASSIGNED:Patients admitted to the NYC jail system from January 2014 through December 2017 were included in this retrospective cohort analysis. We describe rates of screening, diagnosis, linkage to jail-based care, and treatment among the overall cohort, and among subgroups with long jail stays (≥120 days) or frequent stays (≥10 admissions). The study protocol was approved by a third-party institutional review board (BRANY, Lake Success, NY). Findings/UNASSIGNED:Among the 121,371 patients in our analysis, HCV screening was performed in 40,219 (33%), 4665 (12%) of whom were viremic, 1813 (39%) seen by an HCV clinician in jail, and 248 (5% of viremic patients) started on treatment in jail. Having a long stay (adjusted risk ratio [aRR] 8·11, 95% confidence interval [CI] 6·98, 9·42) or frequent stays (aRR 1·51, 95% CI 1·04, 2·18) were significantly associated with being seen by an HCV clinician. Patients with long stays had a higher rate of treatment (14% of viremic patients). Sustained virologic response at 12 weeks was achieved in 147/164 (90%) of patients with available virologic data. Interpretation/UNASSIGNED:Jail health systems can reach large numbers of HCV-infected individuals. The high burden of HCV argues for universal screening in jail settings. Length of stay was strongly associated with being seen by an HCV clinician in jail. Treatment is feasible among those with longer lengths of stay. Funding/UNASSIGNED:None.

BACKGROUND:Coronary artery calcium (CAC) is a guideline recommended cardiovascular disease (CVD) risk stratification tool that increases with age and is associated with non-cardiovascular disease outcomes including cancer. We sought to define the age-specific change in the association between CAC and cause-specific mortality. METHODS:The Coronary Artery Calcium Consortium includes 59,502 asymptomatic patients age 40-75 without known CVD. Age-stratified mortality rates and parametric survival regression modeling was performed to estimate the age-specific CAC score at which CVD and cancer mortality risk were equal. RESULTS:The mean age was 54±8 years (67% men) and there were 2,423 deaths over a mean 12±3 years follow-up. Among individuals with CAC = 0, cancer was the leading cause of death, with low CVD mortality rates for both younger (40-54 years) 0.2/1,000 person-years and older participants (65-75 years) 1.3/1,000 person-years. When CAC ≥400, CVD was consistently the leading cause of death among younger (71% of deaths) and older participants (56% of deaths). The CAC score at which CVD overtook cancer as the leading cause of death increased exponentially with age and was approximately 115 at age 50 and 380 at age 65. CONCLUSIONS:Regardless of age, when CAC = 0 cancer was the leading cause of death and the cardiovascular disease mortality rate was low. Our age-specific estimate for the CAC score at which CVD overtakes cancer mortality allows for a more precise approach to synergistic prediction and prevention strategies for CVD and cancer.

BACKGROUND:The impact of COVID-19 on heart transplant (HTx) recipients remains unclear, particularly in the early post-transplant period. METHODS:We share novel insights from our experience in five HTx patients with COVID-19 (three within 2 months post-transplant) from our institution at the epicenter of the pandemic. RESULTS:All five exhibited moderate (requiring hospitalization, n = 3) or severe (requiring ICU and/or mechanical ventilation, n = 2) illness. Both cases with severe illness were transplanted approximately 6 weeks before presentation and acquired COVID-19 through community spread. All five patients were on immunosuppressive therapy with mycophenolate mofetil (MMF) and tacrolimus, and three that were transplanted within the prior 2 months were additionally on prednisone. The two cases with severe illness had profound lymphopenia with markedly elevated C-reactive protein, procalcitonin, and ferritin. All had bilateral ground-glass opacities on chest imaging. MMF was discontinued in all five, and both severe cases received convalescent plasma. All three recent transplants underwent routine endomyocardial biopsies, revealing mild (n = 1) or no acute cellular rejection (n = 2), and no visible viral particles on electron microscopy. Within 30 days of admission, the two cases with severe illness remain hospitalized but have clinically improved, while the other three have been discharged. CONCLUSIONS:COVID-19 appears to negatively impact outcomes early after heart transplantation.

Introduction. COVID-19 has rapidly emerged as a pandemic infection that has caused significant mortality and economic losses. Potential therapies and prophylaxis against COVID-19 are urgently needed to combat this novel infection. As a result of in vitro evidence suggesting zinc sulphate may be efficacious against COVID-19, our hospitals began using zinc sulphate as add-on therapy to hydroxychloroquine and azithromycin.Aim. To compare outcomes among hospitalized COVID-19 patients ordered to receive hydroxychloroquine and azithromycin plus zinc sulphate versus hydroxychloroquine and azithromycin alone.Methodology. This was a retrospective observational study. Data was collected from medical records for all patients with admission dates ranging from 2 March 2020 through to 11 April 2020. Initial clinical characteristics on presentation, medications given during the hospitalization, and hospital outcomes were recorded. The study included patients admitted to any of four acute care NYU Langone Health Hospitals in New York City. Patients included were admitted to the hospital with at least one positive COVID-19 test and had completed their hospitalization. Patients were excluded from the study if they were never admitted to the hospital or if there was an order for other investigational therapies for COVID-19.Results. Patients taking zinc sulphate in addition to hydroxychloroquine and azithromycin (n=411) and patients taking hydroxychloroquine and azithromycin alone (n=521) did not differ in age, race, sex, tobacco use or relevant comorbidities. The addition of zinc sulphate did not impact the length of hospitalization, duration of ventilation or intensive care unit (ICU) duration. In univariate analyses, zinc sulphate increased the frequency of patients being discharged home, and decreased the need for ventilation, admission to the ICU and mortality or transfer to hospice for patients who were never admitted to the ICU. After adjusting for the time at which zinc sulphate was added to our protocol, an increased frequency of being discharged home (OR 1.53, 95 % CI 1.12-2.09) and reduction in mortality or transfer to hospice among patients who did not require ICU level of care remained significant (OR 0.449, 95 % CI 0.271-0.744).Conclusion. This study provides the first in vivo evidence that zinc sulphate may play a role in therapeutic management for COVID-19.

OBJECTIVE:The global prevalence of obesity is increasing and has nearly doubled in the last decade, disproportionately impacting less-developed countries. The aim of this cross-sectional study was to analyse health-related quality of life (HRQOL) in morbidly obese women attending a bariatric clinic in India, and assess potential obesity indicators that can be utilised in under-resourced settings, to better understand HRQOL of individual patients. METHODS:Anthropometric measurements were collected, including waist circumference, hip circumference, waist-hip ratio, waist-height ratio and body mass index (BMI). HRQOL was assessed using an obesity-related quality-of-life questionnaire focused on the impact of obesity on physical distress, self-esteem, sexual life and work life. RESULTS:The average BMI of study participants was 39.6 kg/m2, with an average HRQOL of 40.2%. The strongest correlation was noted between BMI and HRQOL (R2=0.16). Exploratory analyses demonstrated that patients with higher BMI quartiles had lower scores for physical impact and psychosocial impact, and higher scores for sexual health, comfort with food, and experience with dieting compared to patients in lower quartiles. CONCLUSION/CONCLUSIONS:In South Indian, middle-aged, morbidly obese women, HRQOL is lower than average and is highly correlated with BMI, with different BMI levels having higher impacts in different subcategories, supporting the need for an individualised therapeutic focus for each patient.

INTRODUCTION: Endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) are therapeutic alternatives to surgery for resection of colon and rectal lesions. In regards to large colon and rectal polyps and tumors, both ESD and EFTR have high en bloc resection rates and low recurrence rates, but are limited by training, procedure length, stability, and instrumentation. The Robotic System (RS) is a new robot-assisted endoscopic platform with multiple degrees of freedom allowing improved visualization, dexterity, and tissue manipulation with traction. This is the first U.S. experience assessing the feasibility and safety of robot-assisted ESD and EFTR in resection of distal colon and rectal lesions and its implication for polyps and tumors.
METHOD(S): This is a multicenter retrospective study from five institutions. Patients with distal colon or rectal lesions who underwent either ESD or EFTR with the RS were included. Each patient's clinical history, endoscopic findings, procedural records, and pathology records were reviewed.
RESULT(S): Forty-one patients underwent either ESD or EFTR with the RS for distal colon or rectal lesions, with an average total resection time of 135.0 minutes (s 62.8, n = 24). On average, lesions were 9.3 cm from the anal verge (range: 2 cm to 17 cm, n = 35) and were 30.0 mm in max diameter (range: 9 to 77 mm, n = 28). There were 13 (31.7%) neoplasms and 23 (56.1%) adenomatous polyps; other lesions included inflammatory polyps, diffuse nodular lymphoid hyperplasia, and granulation tissue-all were suspicious for malignancy. Neoplasms included 11 adenocarcinomas and 2 GISTs. Adenomatous polyps included 11 tubular adenomas and 11 tubulovillous adenomas. Twenty-nine out of 34 patients (85.3%) with either adenomatous polyps or adenocarcinoma were successfully removed with the RS alone. Of these, 23 (79.3%) demonstrated clean margins on pathology. Post-endoscopic complications included rectal pain and bleeding.
CONCLUSION(S): This report demonstrates a role of robotic endoscopy for the safe and effective treatment of natural orifice endoscopic surgical resection, with its benefits including traction and triangulation. As endoscopic surgery in the form of ESD evolves, refinement of the tools and techniques of the robotic platform will allow endoscopists to have shorter learning curves and resection of distal colon and rectal polyps and tumors to have higher negative margin rates, potentially allowing more endoscopists the ability to perform ESD

Background and study aims  Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) can be used in patients with unresectable pancreatic ductal adenocarcinoma (PDAC). We performed a systematic review and meta-analysis to evaluate the efficacy of EUS-RFA in treatment of locally advanced unresectable PDAC and other pancreatic tumors. Patients and methods  A comprehensive search was done of multiple electronic databases and conference proceedings including PubMed, EMBASE, Web of Science databases, Google Scholar and manual search of references (from inception through May 2019) to identify the studies reporting use of EUS-RFA for pancreatic lesions. The primary outcome was to evaluate technical and clinical success of the procedure. The secondary outcome was to study overall adverse events (AEs). Results  Thirteen studies reporting 165 EUS-RFA procedures on 134 patients were included. Of 134 patients, 27.94 % (38) had unresectable locally advanced PDAC, 40 % (53) had PNETs, 3 % (4) had metastasis to the pancreas and 30 % (41) had other lesions. The pooled technical success rate calculated out of the total number of procedures was 100 % (95 % CI [99.18 - 100], I2 = 0 %). The pooled clinical success rate calculated out of the total number of patients was 91.58 % (95 % CI [82.5 - 98.08], I2 = 21.5 %). The pooled overall AE rates were 14.67 % (95 % CI [4.77 - 27.46], I2 = 56.19 %) out of which abdominal pain was the most common with 9.82 % (95 % CI [3.34 - 18.24], I2 = 23.76 %). Low to moderate heterogeneity was noted. Conclusion  EUS-RFA has high technical (100 %) and clinical success (91.5 %) rates. Further multicenter trials are needed to further validate our findings.

Background/UNASSIGNED:Effective therapies to combat coronavirus 2019 (COVID-19) are urgently needed. Hydroxychloroquine (HCQ) has in vitro antiviral activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but the clinical benefit of HCQ in treating COVID-19 is unclear. Randomized controlled trials are needed to determine the safety and efficacy of HCQ for the treatment of hospitalized patients with COVID-19. Methods/UNASSIGNED:We conducted a multicenter, double-blind randomized clinical trial of HCQ among patients hospitalized with laboratory-confirmed COVID-19. Subjects were randomized in a 1:1 ratio to HCQ or placebo for 5 days and followed for 30 days. The primary efficacy outcome was a severe disease progression composite end point (death, intensive care unit admission, mechanical ventilation, extracorporeal membrane oxygenation, and/or vasopressor use) at day 14. Results/UNASSIGNED: = .350). There were no significant differences in COVID-19 clinical scores, number of oxygen-free days, SARS-CoV-2 clearance, or adverse events between HCQ and placebo. HCQ was associated with a slight increase in mean corrected QT interval, an increased D-dimer, and a trend toward an increased length of stay. Conclusions/UNASSIGNED:In hospitalized patients with COVID-19, our data suggest that HCQ does not prevent severe outcomes or improve clinical scores. However, our conclusions are limited by a relatively small sample size, and larger randomized controlled trials or pooled analyses are needed.

BACKGROUND:Chinese-Americans are a fast-growing immigrant group with worse rheumatic disease outcomes compared to Caucasians and frequent use of Traditional Chinese Medicine (TCM). Whether TCM use is associated with lower adherence to western rheumatic medications is unknown. METHODS:Chinese-Americans actively treated for a systemic rheumatic disease were recruited from two Chinatown clinics. Socio-demographic, TCM use, and clinical data were gathered. Self-reported health status was assessed using Patient-Reported Outcome Measurement Information System (PROMIS®) short forms. Adherence was stratified using the 8-item Morisky Medication Adherence Scale. Factors independently associated with high adherence were identified using multivariable logistic regression. RESULTS:Among 230 subjects, median age was 55 (range 20-97), 65% were female, 71% had ≤ high school education, 70% were on Medicaid, and 22% reported English fluency. The most common rheumatic diagnoses were rheumatoid arthritis (41%), systemic lupus erythematosus (17%), and seronegative spondyloarthropathies (15%). Half reported TCM use in the past year, and 28% reported high adherence to western rheumatic medications. In multivariable analysis, high adherence was associated with TCM use (OR 3.96, p<0.001), being married (OR 3.69, p=0.004), medication regimen complexity (OR 1.13, p=0.004), older age (OR 1.06, p<0.001), and was negatively associated with anxiety (OR 0.94, p=0.001). CONCLUSIONS:While adherence to western rheumatic medications was low in this cohort, interestingly, it was higher among TCM users compared to non-users. TCM use appears to represent a complementary rather than an alternate approach to disease management for these patients. Future studies should evaluate whether TCM use is associated with better disease outcomes. This article is protected by copyright. All rights reserved.