Faculty Bibliography
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department:Medicine. General Internal Medicine
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Incident type 2 diabetes mellitus after initiation of common HIV antiretroviral drugs
OBJECTIVES/OBJECTIVE:To describe the prevalence and incidence of prediabetes and type 2 diabetes mellitus (T2DM) among people living with HIV (PLHIV) and evaluate the association between antiretroviral therapy (ART) initiation with dolutegravir (DTG), elvitegravir/cobicistat (EVG/c), raltegravir (RAL), or boosted darunavir (bDRV) and incident T2DM. DESIGN/METHODS:Longitudinal study based on electronic health records of 29 674 PLHIV from the Observational Pharmaco-Epidemiology Research and Analysis (OPERA) cohort. METHODS:Calculate prevalence of prediabetes and T2DM at regimen initiation. Among PLHIV without prevalent disease, estimate prediabetes and T2DM incidence (Poisson regression) and association between regimen and incident T2DM (multivariate Cox proportional hazards regression). Analyses stratified by ART experience. RESULTS:Among ART-naive and ART-experienced/suppressed PLHIV, the estimated prevalence of prediabetes was 8 and 11%; that of T2DM was 4 and 10%, respectively. The T2DM incidence rate was 9 per 1000 person-years [95% confidence interval (CI): 8-11] among ART-naive and 13 per 1000 person-years (95% CI: 12-15) among ART-experienced/suppressed PLHIV, with no statistically significant differences between regimens. Compared with DTG, no statistically significant association between T2DM risk and regimen was observed among ART-naive on EVG/c [adjusted hazard ratios: 0.70 (95% CI: 0.47-1.05)] or bDRV [0.53 (0.26-1.04)] and ART-experienced/suppressed on EVG/c [0.96 (0.70-1.33)], RAL [1.17 (0.70-1.96)] or bDRV [0.90 (0.57-1.42)]. CONCLUSION/CONCLUSIONS:No increased risk of T2DM was observed with EVG/c, RAL or bDRV compared with DTG in ART-naive and experienced PLHIV. However, despite a large cohort, there was a small number of events and differential risk cannot be excluded.
PMID: 33048874
ISSN: 1473-5571
CID: 4712272
COVID-19 in New Orleans: A Nephrology Clinical and Education Perspective and Lessons Learned
New Orleans' first case of COVID-19 was reported on March 9, 2020 with a subsequent rapid rise in the number of cases throughout the state of Louisiana. Traditional educational efforts were no longer viable with social distancing and stay-at-home orders, therefore virtual didactics were integrated into our curriculum. Due to an exponential increase in the number of patients with acute kidney injury requiring kidney replacement therapy, the nephrology sections at Louisiana State University School of Medicine and Tulane University School of Medicine adapted their clinical workflows to accommodate these increased clinical volumes by utilizing prolonged intermittent kidney replacement therapies and acute peritoneal dialysis as well as other strategies to mitigate nursing burnout and decrease scarce resource utilization. Telehealth was implemented in outpatient clinics and dialysis units to protect vulnerable patients with kidney disease while maintaining access to care. Lessons learned from this pandemic and subsequent response may be utilized for future responses in similar situations.
PMCID:7708233
PMID: 33283183
ISSN: 2590-0595
CID: 4708532
A Model for Exploring Compatibility Between Applicants and Residency Programs: Right Resident, Right Program
Holistic review of residency applications is touted as the gold standard for selection, yet vast application numbers leave programs reliant on screening using filters such as United States Medical Licensing Examination scores that do not reliably predict resident performance and may threaten diversity. Applicants struggle to identify which programs to apply to, and devote attention to these processes throughout most of the fourth year, distracting from their clinical education. In this perspective, educators across the undergraduate and graduate medical education continuum propose new models for student-program compatibility based on design thinking sessions with stakeholders in obstetrics and gynecology education from a broad range of training environments. First, we describe a framework for applicant-program compatibility based on applicant priorities and program offerings, including clinical training, academic training, practice setting, residency culture, personal life, and professional goals. Second, a conceptual model for applicant screening based on metrics, experiences, attributes, and alignment with program priorities is presented that might facilitate holistic review. We call for design and validation of novel metrics, such as situational judgment tests for professionalism. Together, these steps could improve the transparency, efficiency and fidelity of the residency application process. The models presented can be adapted to the priorities and values of other specialties.
PMID: 33278296
ISSN: 1873-233x
CID: 4708352
Biomarkers of inflammation and repair in kidney disease progression
INTRODUCTION/BACKGROUND:Acute kidney injury and chronic kidney disease (CKD) are common in hospitalized patients. To inform clinical decision-making, more accurate information regarding risk of long-term progression to kidney failure is required. METHODS:We enrolled 1538 hospitalized patients in a multicenter, prospective cohort study. Monocyte chemoattractant protein-1 (MCP-1/CCL2), uromodulin (UMOD), and YKL-40 (CHI3L1) were measured in urine samples collected during outpatient follow-up at 3 months. We followed patients for a median of 4.3 years and assessed the relationship between biomarker levels and changes in estimated glomerular filtration rate (eGFR) over time and the development of a composite kidney outcome (CKD incidence, CKD progression, or end-stage renal disease). We paired these clinical studies with investigations in mouse models of renal atrophy and renal repair to further understand the molecular basis of these markers in kidney disease progression. RESULTS:Higher MCP-1 and YKL-40 levels were associated with greater eGFR decline and increased incidence of the composite renal outcome, whereas higher UMOD levels were associated with smaller eGFR declines and decreased incidence of the composite kidney outcome. A multimarker score increased prognostic accuracy and reclassification compared with traditional clinical variables alone. The mouse model of renal atrophy showed greater Ccl2 and Chi3l1 mRNA expression in infiltrating macrophages and neutrophils, respectively, and evidence of progressive renal fibrosis compared with the repair model. The repair model showed greater Umod expression in the loop of Henle and correspondingly less fibrosis. CONCLUSIONS:Biomarker levels at 3 months after hospitalization identify patients at risk for kidney disease progression. FUNDING/BACKGROUND:National Institutes of Health grants U01DK082223, U01DK082185, U01DK082192, U01DK082183, R01HL085757, R01DK098233, R01DK101507, R01DK114014, K23DK100468, R03DK111881, R01DK093771, K01DK120783, P30DK079310, P30DK114809.
PMID: 33290282
ISSN: 1558-8238
CID: 4708812
Canadian Internal Medicine Ultrasound (CIMUS) Expert Consensus Statement on the Use of Lung Ultrasound for the Assessment of Medical Inpatients With Known or Suspected Coronavirus Disease 2019
OBJECTIVES/OBJECTIVE:To develop a consensus statement on the use of lung ultrasound (LUS) in the assessment of symptomatic general medical inpatients with known or suspected coronavirus disease 2019 (COVID-19). METHODS:Our LUS expert panel consisted of 14 multidisciplinary international experts. Experts voted in 3 rounds on the strength of 26 recommendations as "strong," "weak," or "do not recommend." For recommendations that reached consensus for do not recommend, a fourth round was conducted to determine the strength of those recommendations, with 2 additional recommendations considered. RESULTS:Of the 26 recommendations, experts reached consensus on 6 in the first round, 13 in the second, and 7 in the third. Four recommendations were removed because of redundancy. In the fourth round, experts considered 4 recommendations that reached consensus for do not recommend and 2 additional scenarios; consensus was reached for 4 of these. Our final recommendations consist of 24 consensus statements; for 2 of these, the strength of the recommendations did not reach consensus. CONCLUSIONS:In symptomatic medical inpatients with known or suspected COVID-19, we recommend the use of LUS to: (1) support the diagnosis of pneumonitis but not diagnose COVID-19, (2) rule out concerning ultrasound features, (3) monitor patients with a change in the clinical status, and (4) avoid unnecessary additional imaging for patients whose pretest probability of an alternative or superimposed diagnosis is low. We do not recommend the use of LUS to guide admission and discharge decisions. We do not recommend routine serial LUS in patients without a change in their clinical condition.
PMID: 33274782
ISSN: 1550-9613
CID: 4694532
Entrustable Professional Activities (EPAs) for Global Health
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.
PMID: 33239533
ISSN: 1938-808x
CID: 4702422
Early Life Antibiotic Prescriptions and Weight Outcomes in Children 10 Years of Age
OBJECTIVE:We previously found that antibiotic use at <24 months of age was associated with slightly higher body weight at 5 years of age. In this study, we examine associations of early life antibiotic prescriptions with weight outcomes at 108 to 132 months of age ("10 years"). METHODS:We used electronic health record data from 2009 through 2016 from 10 health systems in PCORnet, a national distributed clinical research network. We examined associations of any (vs no) antibiotics at <24 months of age with body mass index z-score (BMI-z) at 10 years adjusted for confounders selected a priori. We further examined dose response (number of antibiotic episodes) and antibiotic spectrum (narrow and broad). RESULTS:Among 56,727 included children, 57% received any antibiotics at <24 months; at 10 years, mean (standard deviation) BMI-z was 0.54 (1.14), and 36% had overweight or obesity. Any versus no antibiotic use at <24 months was associated with a slightly higher BMI-z at 10 years among children without a complex chronic condition (β 0.03; 95% confidence interval [CI] 0.01, 0.05) or with a complex chronic condition (β 0.09; 95% CI 0.03, 0.15). Any versus no antibiotic use was not associated with odds of overweight or obesity at 10 years among children without (odds ratio 1.02; 95% CI 0.97, 1.07) or with a complex chronic condition (odds ratio 1.07; 95% CI 0.96, 1.19). CONCLUSIONS:The small and likely clinically insignificant associations in this study are consistent with our previous 5-year follow-up results, suggesting that, if this relationship is indeed causal, early increases in weight are small but maintained over time.
PMID: 33130067
ISSN: 1876-2867
CID: 4684082
The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease
BACKGROUND:The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. OBJECTIVE:To examine the effects of LSG on GERD symptoms. METHODS:One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). RESULTS:respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. CONCLUSION/CONCLUSIONS:These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.
PMID: 33244654
ISSN: 1708-0428
CID: 4681062
The case for simplifying and using absolute targets for viral hepatitis elimination goals
The 69th World Health Assembly endorsed the Global Health Sector Strategy for Viral Hepatitis, embracing a goal to eliminate hepatitis infection as a public health threat by 2030. This was followed by the World Health Organization's (WHO) global targets for the care and management of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. These announcements and targets were important in raising awareness and calling for action; however, tracking countries' progress towards these elimination goals has provided insights to the limitations of these targets. The existing targets compare a country's progress relative to its 2015 values, penalizing countries who started their programmes prior to 2015, countries with a young population, or countries with a low prevalence. We recommend that (1) WHO simplify the hepatitis elimination targets, (2) change to absolute targets and (3) allow countries to achieve these disease targets with their own service coverage initiatives that will have the maximum impact. The recommended targets are as follows: reduce HCV new chronic cases to ≤5 per 100 000, reduce HBV prevalence among 1-year-olds to ≤0.1%, reduce HBV and HCV mortality to ≤5 per 100 000, and demonstrate HBV and HCV year-to-year decrease in new HCV- and HBV-related HCC cases. The objective of our recommendations is not to lower expectations or diminish the hepatitis elimination standards, but to provide clearer targets that recognize the past and current elimination efforts by countries, help measure progress towards true elimination, and motivate other countries to follow suit.
PMID: 32979881
ISSN: 1365-2893
CID: 4679282
A Novel Method of Assessing Clinical Preparedness for COVID-19 and Other Disasters
QUALITY ISSUE:The emergence of COVID-19 highlights the necessity of rapidly identifying and isolating potentially infected individuals. Evaluating this preparedness requires an assessment of the full clinical system, from intake to isolation. INITIAL ASSESSMENT:Unannounced Standardized Patients (USPs) present a nimble, sensitive methodology for assessing this readiness. CHOICE OF SOLUTION:Pilot the Unannounced Standardized Patient methodology, which employs an actor trained to present as a standardized, incognito potentially infected patient, to assess clinical readiness for potential COVID-19 patients at an urban, community safety-net clinic. IMPLEMENTATION:The Unannounced Standardized Patient was trained to present at each team's front desk with the complaint of feeling unwell (reporting a fever of 101 degrees Fahrenheit in the past 24 hours) and exposure to a roommate recently returned from Beijing. The Unannounced Standardized Patient was trained to complete a behaviorally-anchored assessment of the care she received from the clinical system. EVALUATION:There was clear variation in care Unannounced Standardized Patients received; some frontline clerical staff followed best practices; others did not. Signage and information on disease spread prevention publicly available was inconsistent. Qualitative comments shared by the Unannounced Standardized Patients and those gathered during group debrief reinforced the experiences of the Unannounced Standardized Patients and hospital leadership. LESSONS LEARNED:Unannounced Standardized Patients revealed significant variation in care practices within a clinical system. Utilization of this assessment methodology can provide just-in-time clinical information about readiness and safety practices, particularly during emerging outbreaks. Unannounced Standardized Patients will prove especially powerful as clinicians and systems return to outpatient visits while remaining vigilant about potentially infected individuals.
PMCID:7543447
PMID: 32991675
ISSN: 1464-3677
CID: 4677192
