Faculty Bibliography
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department:Medicine. General Internal Medicine
recentyears:2
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14846
An Exploratory Study of Goals of Care Conversations Initiated with Seriously Ill Veterans in the Emergency Room
PMID: 33170071
ISSN: 1557-7740
CID: 4675912
Comparison of Clinical Features and Outcomes in Critically Ill Patients Hospitalized with COVID-19 versus Influenza
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.
PMID: 33183067
ISSN: 2325-6621
CID: 4671842
Journal of the American College of Radiology : JACR. 2021:18(2):324-333.DOI: 10.1016/j.jacr.2020.08.019
Impact on Participants of Family Connect, a Novel Program Linking COVID-19 Inpatients' Families With the Frontline Providers
PURPOSE/OBJECTIVE:With clinical volumes decreased, radiologists volunteered to participate virtually in daily clinical rounds and provide communication between frontline physicians and patients with coronavirus disease 2019 (COVID-19) and their families affected by restrictive hospital visitation policies. The purpose of this survey-based assessment was to demonstrate the beneficial effects of radiologist engagement during this pandemic and potentially in future crises if needed. METHODS:After the program's completion, a survey consisting of 13 multiple-choice and open-ended questions was distributed to the 69 radiologists who volunteered for a minimum of 7 days. The survey focused on how the experience would change future practice, the nature of interaction with medical students, and the motivation for volunteering. The electronic medical record system identified the patients who tested positive for or were suspected of having COVID-19 and the number of notes documenting family communication. RESULTS:In all, 69 radiologists signed or cosigned 7,027 notes. Of the 69 radiologists, 60 (87.0%) responded to the survey. All found the experience increased their understanding of COVID-19 and its effect on the health care system. Overall, 59.6% agreed that participation would result in future change in communication with patients and their families. Nearly all (98.1%) who worked with medical students agreed that their experience with medical students was rewarding. A majority (82.7%) chose to participate as a way to provide service to the patient population. CONCLUSION/CONCLUSIONS:This program provided support to frontline inpatient teams while also positively affecting the radiologist participants. If a similar situation arises in the future, this communication tool could be redeployed, especially with the collaboration of medical students.
PMCID:7534665
PMID: 33091384
ISSN: 1558-349x
CID: 4663492
Platelet Conditioned Media Induces an Anti-inflammatory Macrophage Phenotype through EP4
BACKGROUND:Platelets are increasingly recognized as immune cells. As such, they are commonly seen to induce and perpetuate inflammation, however, anti-inflammatory activities are increasingly attributed to them. Atherosclerosis is a chronic inflammatory condition. Similar to other inflammatory conditions, the resolution of atherosclerosis requires a shift in macrophages to an M2 phenotype, enhancing their efferocytosis and cholesterol efflux capabilities. OBJECTIVES/OBJECTIVE:To assess the effect of platelets on macrophage phenotype. METHODS:In several in vitro models employing murine (RAW264.7 and bone marrow derived macrophages) and human (THP-1 and monocyte-derived macrophages) cells, we exposed macrophages to media in which non-agonized human platelets were cultured for 60 minutes (platelet conditioned media; PCM) and assessed the impact on macrophage phenotype and function. RESULTS:). CONCLUSIONS:PCM induces an anti-inflammatory, pro-resolving phenotype in macrophages. Our findings suggest that therapies targeting hemostatic properties of platelets, while not influencing pro-resolving, immune-related activities, could be beneficial for the treatment of atherothrombotic disease.
PMID: 33171016
ISSN: 1538-7836
CID: 4662992
Trends in COVID-19 Risk-Adjusted Mortality Rates
Early reports showed high mortality from coronavirus disease 2019 (COVID-19). Mortality rates have recently been lower, raising hope that treatments have improved. However, patients are also now younger, with fewer comorbidities. We explored whether hospital mortality was associated with changing demographics at a 3-hospital academic health system in New York. We examined in-hospital mortality or discharge to hospice from March through August 2020, adjusted for demographic and clinical factors, including comorbidities, admission vital signs, and laboratory results. Among 5,121 hospitalizations, adjusted mortality dropped from 25.6% (95% CI, 23.2-28.1) in March to 7.6% (95% CI, 2.5-17.8) in August. The standardized mortality ratio dropped from 1.26 (95% CI, 1.15-1.39) in March to 0.38 (95% CI, 0.12-0.88) in August, at which time the average probability of death (average marginal effect) was 18.2 percentage points lower than in March. Data from one health system suggest that mortality from COVID-19 is decreasing even after accounting for patient characteristics.
PMID: 33147129
ISSN: 1553-5606
CID: 4664172
Use of patient-reported controls for secular trends to study disparities in cancer-related job loss
PURPOSE/OBJECTIVE:Racial/ethnic minorities experience greater job loss than whites during periods of economic downturn and after a cancer diagnosis. Therefore, race/ethnicity-matched controls are needed to distinguish the impact of illness on job loss from secular trends METHODS: Surveys were administered during and 4-month post-completion of breast cancer treatment. Patients were pre-diagnosis employed women aged 18-64, undergoing treatment for stage I-III breast cancers, who spoke English, Chinese, Korean, or Spanish. Each patient was asked to: (1) nominate peers who were surveyed in a corresponding timeframe (active controls), (2) report a friend's work status at baseline and follow-up (passive controls). Both types of controls were healthy, employed at baseline, and shared the nominating patient's race/ethnicity, language, and age. The primary outcome was number of evaluable patient-control pairs by type of control. A patient-control pair was evaluable if work status at follow-up was reported for both individuals. RESULTS:Of the 180 patients, 25% had evaluable active controls (45 patient-control pairs); 84% had evaluable passive controls (151 patient-control pairs). Although patients with controls differed from those without controls under each strategy, there was no difference in the percentage of controls who were working at follow-up (96% of active controls; 91% of passive controls). However, only 65% of patients were working at follow-up. CONCLUSIONS:The majority of patients had evaluable passive controls. There was no significant difference in outcome between controls ascertained through either method IMPLICATIONS FOR CANCER SURVIVORS: Passive controls are a low-cost, higher-yield option to control for secular trends in racially/ethnically diverse samples.
PMID: 33106995
ISSN: 1932-2267
CID: 4663572
Toward Understanding Movement-evoked Pain (MEP) and its Measurement: A Scoping Review
OBJECTIVE:Individuals with chronic pain conditions often report movement as exacerbating pain. An increasing number of researchers and clinicians have recognized the importance of measuring and distinguishing between movement-evoked pain (MEP) and pain at rest as an outcome. This scoping review maps the literature and describes MEP measurement techniques. METHOD/METHODS:The scoping review utilized six databases to identify original studies that targeted pain or movement-related outcomes. Our search returned 7,322 articles that were screened by title and abstract by two reviewers. The inclusion criteria focused on measurement of MEP before, during and after movement tasks in adults with chronic pain. Studies of children < 18 years of age or with non-human animals, case studies, qualitative studies, book chapters, cancer-related pain, non-English language and abstracts with no full publish text were excluded from the study. RESULTS:Results from 38 studies revealed great variation in the measurement of MEP, while almost all of the studies did not provide an explicit conceptual or operational definition for MEP. Additionally, studies collectively illuminated differences in MEP compared to rest pain, movement provocation methods, and pain intensity as the primary outcome. DISCUSSION/CONCLUSIONS:These results have clinically significant and research implications. To advance the study of MEP, we offer that consistent terminology, standardized measurement (appropriate for pain type/population), and clear methodological processes be provided in research publications. Based on the findings, we have put forth a preliminary definition MEP which may benefit from continued scholarly dialogue.
PMID: 33093342
ISSN: 1536-5409
CID: 4661002
Language barriers between nurses and patients: A scoping review
OBJECTIVE:Global migration and linguistic diversity are at record highs, making healthcare language barriers more prevalent. Nurses, often the first contact with patients in the healthcare system, can improve outcomes including safety and satisfaction through how they manage language barriers. This review aimed to explore how research has examined the nursing workforce with respect to language barriers. METHODS:A systematic scoping review of the literature was conducted using four databases. An iterative coding approach was used for data analysis. Study quality was appraised using the CASP checklists. RESULTS:48 studies representing 16 countries were included. Diverse healthcare settings were represented, with the inpatient setting most commonly studied. The majority of studies were qualitative. Coding produced 4 themes: (1) Interpreter Use/Misuse, (2) Barriers to and Facilitators of Quality Care, (3) Cultural Competence, and (4) Interventions. CONCLUSION/CONCLUSIONS:Generally, nurses noted like experiences and applied similar strategies regardless of setting, country, or language. Language barriers complicated care delivery while increasing stress and workload. PRACTICE IMPLICATIONS/CONCLUSIONS:This review identified gaps which future research can investigate to better support nurses working through language barriers. Similarly, healthcare and government leaders have opportunities to enact policies which address bilingual proficiency, workload, and interpreter use.
PMID: 32994104
ISSN: 1873-5134
CID: 4651722
IL-5 mediates monocyte phenotype and pain outcomes in fibromyalgia
Fibromyalgia (FM) is characterized by widespread chronic pain, fatigue, and somatic symptoms. The influence of phenotypic changes in monocytes on symptoms associated with FM are not fully understood. The primary aim of this study was to take a comprehensive whole-body to molecular approach in characterizing relationships between monocyte phenotype and FM symptoms in relevant clinical populations. LPS-evoked and spontaneous secretion of IL-5 and other select cytokines from circulating monocytes was higher in women with FM compared to women without pain. Additionally, greater secretion of IL-5 was significantly associated with pain and other clinically relevant psychological and somatic symptoms of FM. Further, higher levels of pain and pain-related symptoms were associated with a lower percentage of intermediate monocytes (CD14/CD16) and a greater percentage of non-classical monocytes (CD14/CD16) in women with FM. Based on findings from individuals with FM, we examined the role of IL-5, an atypical cytokine secreted from monocytes, in an animal model of widespread muscle pain. Results from the animal model show that IL-5 produces analgesia and polarizes monocytes toward an anti-inflammatory phenotype (CD206). Taken together, our data suggest that monocyte phenotype and their cytokine profiles are associated with pain-related symptoms in individuals with FM. Furthermore, our data show that IL-5 has a potential role in analgesia in an animal model of FM. Thus, targeting anti-inflammatory cytokines such as IL-5 in secreted by circulating leukocytes could serve as a promising intervention to control pain and other somatic symptoms associated with FM.
PMID: 33003107
ISSN: 1872-6623
CID: 4645192
Hospitalizations for Chronic Disease and Acute Conditions in the Time of COVID-19
PMID: 33104158
ISSN: 2168-6114
CID: 4645722
