Faculty Bibliography

BACKGROUND:Patients with aortic stenosis are nearly twice as likely to have a diagnosis of gout compared with individuals without aortic valve disease. METHODS:, and/or decrease in left ventricular ejection fraction due to aortic stenosis. RESULTS:/year [-0.16, -0.01], p=0.09); annualized change in peak velocity and mean gradient did not differ between groups. CONCLUSIONS:Progression to severe aortic stenosis was more frequent in patients with gout versus those without gout supporting the hypothesis that gout is a risk factor for aortic stenosis.

When patients are admitted to the hospital, they are generally expected to remain in or within close proximity to their assigned rooms in order to promote their safety and appropriate medical care. Although there are circumstances when patients may safely leave their hospital room or floor, guidance within the medical literature for the management of patient movement within the hospital are lacking. Excessive restrictions on patient movement may be seen as overly paternalistic, while lax requirements may interfere with high quality care, patient safety and efficient hospital practice. As a result, guidance in the form of institutional policy is warranted. Such policy development should take into consideration the potential clinical, legal, and ethical concerns in balancing the competing values of patients' preferences and respect for autonomy, while ensuring high quality, safe, and efficacious medical care. This paper will provide a framework for hospitals to create institution-specific patient movement policies that are fair, systematic, and transparent.

OBJECTIVES:To calculate the rate of hepatitis C virus (HCV) among HIV-infected men who have sex with men (MSM) with no reported history of injection drug use (IDU), and to assess whether disparities exist in HIV/HCV coinfection by race/ethnicity and neighbourhood poverty level within this population in New York City. METHODS:HIV-positive men who reported sex with men and did not report IDU at the time of HIV diagnosis, diagnosed through 2015 and alive as of 2000, were matched to people with HCV first reported to the New York City Department of Health and Mental Hygiene between 2000 and 2015. Those with HCV reported before or within 90 days of HIV infection were excluded. A multivariable Cox proportional hazards model was fit to compare the association between HCV diagnosis, race/ethnicity and neighbourhood poverty level. RESULTS:From 2000 to 2015, 54 488 non-IDU MSM were diagnosed with HIV, of whom 2762 (5.1%) were diagnosed with HCV after HIV diagnosis, yielding an overall age-adjusted HCV diagnosis rate of 512 per 100 000 person-years. HIV/HCV coinfection was significantly higher among non-Latino blacks (adjusted HR (aHR)=1.24, 95% CI 1.11 to 1.40) compared with non-Latino whites and among persons living in high-poverty neighbourhoods compared with those in low-poverty neighbourhoods (aHR=1.17, 95% CI 1.01 to 1.35) after stratification by year of HIV diagnosis. CONCLUSION:Disparities in HIV/HCV coinfection among HIV-positive MSM were observed by race/ethnicity and neighbourhood poverty level. Routine HCV screening is recommended for people infected with HIV. People coinfected with HIV and HCV should be linked to HCV care, treated and cured to reduce morbidity and mortality, and to avoid ongoing HCV transmission.

OBJECTIVE:Patients increasingly access radiology results through digital portals. We compared patient satisfaction and understanding of radiology results when received through an electronic patient portal versus direct communication from providers. METHODS:tests and logistic regression. RESULTS:Of 1,005 survey respondents, 87.8% (882 of 1,005) reported having received their imaging test results, with 486 (48.4%) first being notified through the patient portal and 396 (39.4%) via direct provider communication. Patients reported high levels of satisfaction with timing regardless of whether they first received the results through the patient portal or through direct provider communication (88.8%-89.9%). Patients who first received their results through the patient portal reported a lesser degree of perceived understanding than those who first received their results through direct provider communication (26.7% versus 47.8%; P < .001). Patients were less likely to report clear understanding for advanced imaging (CT or MRI) than ultrasound or x-rays (29.3% versus 40.3% versus 38.2%, respectively; P = .02). Patient characteristics showed no association with understanding in multivariable analysis. CONCLUSION/CONCLUSIONS:As online portal release of radiology results to patients becomes commonplace, efforts may be warranted to improve patient experience when first receiving their radiology results online.

BACKGROUND:Understanding how nutrient intake in older women compares with recommendations is important. The Academy of Nutrition and Dietetics position statement summarizes the nutrient needs of older adults (aged ≥60 years) based on a systematic review. OBJECTIVE:The objective of this study was to compare nutrient intake of Women's Health Initiative Long Life Study participants to the Dietary Reference Intakes for nutrients reviewed in the Academy of Nutrition and Dietetics position statement. DESIGN/METHODS:The study is a cross-sectional analysis. PARTICIPANTS/SETTING/METHODS:Participants (n=7,875) were mailed the General Nutrition Assessment Food Frequency Questionnaire during 2012-2013, of whom 77% (n=6,095) completed it, and 5,732 were included in the analytic sample after exclusion for implausible energy intakes. MAIN OUTCOME MEASURES/METHODS:Mean intake of energy and protein, calcium, fiber, folate, potassium, sodium, vitamins B-12, D, E, and K were described overall and compared with recommendations. STATISTICAL ANALYSES PERFORMED/METHODS:Demographic and lifestyle characteristics were summarized using descriptive statistics. The proportion of participants meeting recommendations was computed. RESULTS:Mean age of completers was 79±7 years and 53.5% were non-Hispanic white, 30% were non-Hispanic black, and 16.5% were Hispanic/Latina. Only one-third of women consumed ≥21 g/day fiber, whereas fewer met the Recommended Dietary Allowance for calcium (18.6%), vitamin E (16.9%), and vitamin D (1.7%). Just more than half (56%) of participants met the Recommended Dietary Allowance for protein of 0.8 g/kg body weight/day, and just less than half (47.0%) met potassium guidelines. CONCLUSIONS:These findings suggest older women within the Women's Health Initiative were generally not achieving recommended intake for several key nutrients highlighted by the Academy of Nutrition and Dietetics position statement. These findings underscore the need to identify effective approaches for improving the nutrient density of dietary intake in older women.

Background: Standard of care (SOC) regimens may contribute to immunosuppression by elevating intratumoral levels of adenosine, which activates the A2a and A2b receptors (R) on immune cells. Extracellular adenosine is primarily produced by the enzyme CD73. In prostate cancer, the activity of the highly expressed protein, prostatic acid phosphatase, produces additional adenosine. AB928, which is the first clinical-stage small molecule dual antagonist of both A2aR and A2bR, is highly potent, pharmacodynamically active, and well tolerated in dose escalation studies in combination with chemo/immunotherapy. Targeting the adenosine axis in combination with SOC regimens or immunotherapy may have a more profound effect on activating and inducing sustained antitumor immunity in patients (pts) with metastatic castrate-resistant prostate cancer (mCRPC). Trial design: This is a phase (Ph) 1b/2, open-label, multicenter platform trial to evaluate the antitumor activity and safety of AB928-based combination therapy in pts with mCRPC. Eligibility for a specific treatment arm will be informed by prior anticancer therapy. Treatment arms will independently evaluate AB928 + zimberelimab (AB122; anti-PD-1 antibody) alone or in combination with an SOC backbone (enzalutamide or docetaxel) in earlier-line pts or AB928 + AB680 (CD73 inhibitor) +/- zimberelimab in later-line pts. Treatment arms will be conducted in 2 stages: Stage 1 (Ph1b) and Stage 2 (Ph2). In Ph1b, up to 15 pts will receive investigational product(s) at the single agent recommended dose with SOC per label guidance. Provided safety and futility stopping criteria are not met, further accrual in the earlier-line arms will involve randomization to SOC alone; in the later-line arms, upfront randomization to the all-experimental regimens will continue in Ph2. Investigator-assessed antitumor response (radiologic, prostate specific antigen [PSA]) will follow PCWG3 criteria. New treatment arms may be added via protocol amendment. ARC-6 is actively recruiting in the United States, and results will be shared in upcoming scientific conferences (NCT04381832). Clinical trial identification: NCT04381832. Legal entity responsible for the study: Arcus Biosciences.
Funding(s): Arcus Biosciences. Disclosure: S.K. Subudhi: Advisory/Consultancy, Research grant/Funding (self): Janssen Oncology; Advisory/Consultancy: Polaris; Advisory/Consultancy: Dendreon; Advisory/Consultancy, Shareholder/Stockholder/Stock options: Apricity Health; Advisory/Consultancy: Amgen; Advisory/Consultancy: Bayer; Advisory/Consultancy: Exelixis; Advisory/Consultancy, Research grant/Funding (self): AstraZeneca; Advisory/Consultancy: Bristol-Myers Squibb; Advisory/Consultancy: Dava Oncology; Advisory/Consultancy: Cancer Now; Advisory/Consultancy: MEDACorp; Honoraria (self): Parker Institute of Cancer Immunotherapy; Honoraria (self): SITC. D. Wise: Advisory/Consultancy: ScientiaCME; Advisory/Consultancy: OncLIve; Advisory/Consultancy: Foundation Medicine; Honoraria (self), Advisory/Consultancy: Best Doctors; Advisory/Consultancy: Leap Therapeutics; Advisory/Consultancy: Guidepoint Consulting; Advisory/Consultancy: GLG Consulting; Advisory/Consultancy: Silverlight; Advisory/Consultancy: Alphasights; Advisory/Consultancy: Pfizer. S.T. Liu: Advisory/Consultancy: Merck; Advisory/Consultancy: Exelixis; Advisory/Consultancy: Esai; Advisory/Consultancy: Seattle Genetics. A. Chaudhry: Speaker Bureau/Expert testimony, Research grant/Funding (institution): Bayer; Advisory/Consultancy, Research grant/Funding (institution): Exelixis; Advisory/Consultancy: Astellas Pharma; Shareholder/Stockholder/Stock options: Novartis; Research grant/Funding (institution): Arcus Biosciences; Research grant/Funding (institution): Merck; Research grant/Funding (institution): Abbvie; Research grant/Funding (institution): AstraZeneca; Research grant/Funding (institution): BMS; Research grant/Funding (institution): Eli Lilly; Research grant/Funding (institution): Pfizer; Research grant/Funding (institution): Beigene; Research grant/Funding (institution): BerGenBio; Research grant/Funding (institution): Blueprint; Research grant/Funding (institution): Alkermes; Research grant/Funding (institution): Genentech; Research grant/Funding (institution): Gilead; Research grant/Funding (institution): Janssen; Research grant/Funding (institution): Millennium; Research grant/Funding (institution): Basilea; Research grant/Funding (institution): IunoCare; Research grant/Funding (institution): Amgen; Research grant/Funding (institution): Novartis. J. Kim: Advisory/Consultancy: Sanofi; Advisory/Consultancy: EMD Serono; Advisory/Consultancy: Voluntis; Research grant/Funding (self): Immune Design. O. Gardner: Shareholder/Stockholder/Stock options, Full/Part-time employment: Arcus Biosciences; Shareholder/Stockholder/Stock options, Full/Part-time employment: Bellicum Pharmaceuticals; Full/Part-time employment: Aduro Biotech; Shareholder/Stockholder/Stock options, Full/Part-time employment: Janssen. H. Gilbert: Shareholder/Stockholder/Stock options, Full/Part-time employment: Arcus Biosciences; Advisory/Consultancy, Full/Part-time employment: Bellicum; Shareholder/Stockholder/Stock options, Full/Part-time employment: Roche/Genentech; Shareholder/Stockholder/Stock options: Denali; Shareholder/Stockholder/Stock options: Celgene; Shareholder/Stockholder/Stock options: BMS. M. Grady: Shareholder/Stockholder/Stock options, Full/Part-time employment: Arcus Biosciences; Full/Part-time employment: Bellicum; Full/Part-time employment: Biothera. M. Paoloni: Leadership role, Shareholder/Stockholder/Stock options, Full/Part-time employment: Arcus Biosciences; Advisory/Consultancy: Eli Lilly; Advisory/Consultancy: Janssen Oncology; Advisory/Consultancy: Amgen. K. Krishnan: Leadership role, Shareholder/Stockholder/Stock options, Full/Part-time employment: Arcus Biosciences; Full/Part-time employment: Astex; Full/Part-time employment: Roche/Genentech; Full/Part-time employment: Five Prime. M. Carducci: Advisory/Consultancy, Research grant/Funding (institution): Pfizer; Advisory/Consultancy: Medivation; Advisory/Consultancy: Astellas; Advisory/Consultancy: Roche; Advisory/Consultancy: Abbvie; Advisory/Consultancy: Foundation Medicine; Advisory/Consultancy: Merck; Research grant/Funding (institution): EMD Serono; Research grant/Funding (institution): Exelixis; Research grant/Funding (institution): Gilead; Research grant/Funding (institution): Effector; Non-remunerated activity/ies: ECOG-ACRIN.
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To assess the impact of allopurinol on diabetes in a retrospective cohort of Veterans' Affairs patients with gout.The New York Harbor VA computerized patient record system was searched to identify patients with an ICD-9 code for gout meeting at least 4 modified 1977 American Rheumatology Association gout diagnostic criteria. Patients were divided into subgroups based on >30 continuous days of allopurinol, versus no allopurinol. New diagnoses of diabetes, defined according to American Diabetes Association diagnostic criteria or clinical documentation explicitly stating a new diagnosis of diabetes, were identified during an observation period from January 1, 2000 through December 31, 2015.Six hundred six gout patients used allopurinol >30 continuous days, and 478 patients never used allopurinol. Over an average 7.9 ± 4.8 years of follow-up, there was no significant difference in diabetes incidence between the allopurinol and non-allopurinol groups (11.7/1000 person-years vs 10.0/1000 person-years, P = .27). A lower diabetes incidence in the longest versus shortest quartiles of allopurinol use (6.3 per 1000 person-years vs 19.4 per 1000 person-years, P<.0001) was attributable to longer duration of medical follow-up.In this study, allopurinol use was not associated with decreased diabetes incidence. Prospective studies may further elucidate the relationship between hyperuricemia, gout, xanthine oxidase activity, and diabetes, and the potential impact of gout treatments on diabetes incidence.

Objectives While the need to address patients' social determinants of health (SDoH) is widely recognized, less is known about physicians' actual clinical problem-solving when it comes to SDoH. Do physicians include SDoH in their assessment strategy? Are SDoH incorporated into their diagnostic thinking and if so, do they document as part of their clinical reasoning? And do physicians directly address SDoH in their "solution" (treatment plan)? Methods We used Unannounced Standardized Patients (USPs) to assess internal medicine residents' clinical problem solving in response to a patient with asthma exacerbation and concern that her moldy apartment is contributing to symptoms - a case designed to represent a clear and direct link between a social determinant and patient health. Residents' clinical practices were assessed through a post-visit checklist and systematic chart review. Patterns of clinical problem solving were identified and then explored, in depth, through review of USP comments and history of present illness (HPI) and treatment plan documentation. Results Residents fell into three groups when it came to clinical problem-solving around a housing trigger for asthma: those who failed to ask about housing and therefore did not uncover mold as a potential trigger (neglectors - 21%; 14/68); those who asked about housing in negative ways that prevented disclosure and response (negative elicitors - 24%, 16/68); and those who elicited and explored the mold issue (full elicitors - 56%; 28/68). Of the full elicitors 53% took no further action, 26% only documented the mold; and 21% provided resources/referral. In-depth review of USP comments/explanations and residents' notes (HPI, treatment plan) revealed possible influences on clinical problem solving. Failure to ask about housing was associated with both contextual factors (rushed visit) and interpersonal skills (not fully engaging with patient) and with possible differences in attention ("known" vs. unknown/new triggers, usual symptoms vs. changes, not attending to relocation, etc.,). Use of close-ended questions often made it difficult for the patient to share mold concerns. Negative responses to sharing of housing information led to missing mold entirely or to the patient not realizing that the physician agreed with her concerns about mold. Residents who fully elicited the mold situation but did not take action seemed to either lack knowledge or feel that action on SDoH was outside their realm of responsibility. Those that took direct action to help the patient address mold appeared to be motivated by an enhanced sense of urgency. Conclusions Findings provide unique insight into residents' problem solving processes including external influences (e.g., time, distractions), the role of core communication and interpersonal skills (eliciting information, creating opportunities for patients to voice concerns, sharing clinical thinking with patients), how traditional cognitive biases operate in practice (premature closure, tunneling, and ascertainment bias), and the ways in which beliefs about expectancies and scope of practice may color clinical problem-solving strategies for addressing SDoH.