Faculty Bibliography

BACKGROUND AND PURPOSE/OBJECTIVE:With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19. METHODS:We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls). RESULTS:<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls. CONCLUSIONS:We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.

OBJECTIVE:To investigate the incidence and spectrum of neuroimaging findings and their prognostic role in hospitalized COVID-19 patients in New York City. METHODS:This is a retrospective cohort study of 3218 COVID-19 confirmed patients admitted to a major healthcare system (three hospitals) in New York City between March 1, 2020 and April 13, 2020. Clinical data were extracted from electronic medical records, and particularly data of all neurological symptoms were extracted from the imaging reports. Four neuroradiologists evaluated all neuroimaging studies for acute neuroimaging findings related to COVID-19. RESULTS:14.1% of admitted COVID-19 patients had neuroimaging and this accounted for only 5.5% of the total imaging studies. Acute stroke was the most common finding on neuro-imaging, seen in 92.5% of patients with positive neuro-imaging studies, and present in 1.1% of hospitalized COVID-19 patients. Patients with acute large ischemic and hemorrhagic stroke had much higher mortality risk adjusted for age, BMI and hypertension compared to those COVID-19 patients without neuroimaging. (Odds Ratio 6.02 by LR; Hazard Ratio 2.28 by CRR). CONCLUSIONS:Our study demonstrates acute stroke is the most common neuroimaging finding among hospitalized COVID-19 patients. Detection of an acute stroke is a strong prognostic marker of poor outcome. Our study also highlights the fact there is limited use of neuroimaging in these patients due to multiple logistical constraints.

The objective of this study was to utilize a co-culture hollow-fiber infection model (HFIM) to characterize the interplay between a small, difficult-to-detect, New Delhi metallo-β-lactamase-producing Klebsiella pneumoniae (NDM-Kp) minor population and a larger K. pneumoniae carbapenemase (KPC)-producing K. pneumoniae population in the presence of KPC-directed antibacterial therapy. Selective plating onto agar with ceftazidime-avibactam was used to track the density of the NDM-Kp population. Susceptibility testing and the Verigene System failed to identify the small initial NDM-Kp population. However, a ceftazidime-avibactam Etest detected resistant colonies that were confirmed to be NDM-Kp. In the HFIM, all of the investigated drug regimens caused regrowth within 24 h and resulted in >10⁹ CFU/mL of NDM-Kp. Our study demonstrates that the HFIM is a powerful tool for studying the population dynamics of multiple pathogens during antimicrobial exposure and also highlights that difficult-to-detect minor populations of drug-resistant bacteria may cause treatment failure without appropriate antibacterial therapy.

Objective: The interventions colleges use to help students be compliant with vaccinations is unknown. This study describes colleges' use of practices consistent with Centers for Disease Control and Prevention (CDC) recommendations to encourage student body vaccination.Participants: Participants were a convenience sample of 136 student health center (SHC) administrators from colleges across the U.S.Methods: An online survey assessed SHCs' use of various practices, policies and services to improve student body vaccination coverage.Results: There was wide variability in use of evidence-based interventions overall and with respect to specific vaccinations. While most SHCs (92.7%) coordinated vaccination outreach events on campus, only half (50%) accessed an immunization registry to verify vaccination histories. While 88.6% requested student vaccination histories for MMR, only 39.7% requested it for human papillomavirus (HPV).Conclusions: The discrepancies in SHC implementation of interventions to increase coverage of the recommended vaccinations for students suggest that helping colleges expand their capacity to intervene may decrease coverage rate disparities.

BACKGROUND:The seminal Dietary Approaches to Stopping Hypertension (DASH) study demonstrated the effectiveness of diet to control hypertension; however, the effective implementation and dissemination of its principles have been limited. OBJECTIVE:This study aimed to determine the feasibility and effectiveness of a DASH mobile health intervention. We hypothesized that combining Bluetooth-enabled data collection, social networks, and a human coach with a smartphone DASH app (DASH Mobile) would be an effective medium for the delivery of the DASH program. METHODS:We conducted a single-arm pilot study from August 2015 through August 2016, using a pre-post evaluation design to evaluate the feasibility and preliminary effectiveness of a smartphone version of DASH that incorporated a human health coach. Participants were recruited both online and offline. RESULTS:A total of 17 patients participated in this study; they had a mean age of 59 years (SD 6) and 10 (60%) were women. Participants were engaged with the app; in the 120 days of the study, the mean number of logged blood pressure measurements was 63 (SD 46), the mean number of recorded weight measurements was 52 (SD 45), and participants recorded a mean of 55 step counts (SD 36). Coaching phone calls had a high completion rate (74/102, 73%). The mean number of servings documented per patient for the dietary assessment was 709 (SD 541), and patients set a mean number of 5 (SD 2) goals. Mean systolic and diastolic blood pressure, heart rate, weight, body mass index, and step count did not significantly change over time (P>.10 for all parameters). CONCLUSIONS:In this pilot study, we found that participants were engaged with an interactive mobile app that promoted healthy behaviors to treat hypertension. We did not find a difference in the physiological outcomes, but were underpowered to identify such changes.

OBJECTIVE:To test the hypothesis that markers of coagulation and hemostatic activation (MOCHA) help identify causes of cryptogenic stroke, we obtained serum measurements on 132 patients and followed them up to identify causes of stroke. METHODS:Consecutive patients with cryptogenic stroke who met embolic stroke of undetermined source (ESUS) criteria from January 1, 2017, to October 31, 2018, underwent outpatient cardiac monitoring and the MOCHA profile (serum D-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer) obtained ≥2 weeks after the index stroke; abnormal MOCHA profile was defined as ≥2 elevated markers. Prespecified endpoints monitored during routine clinical visits included new atrial fibrillation (AF), malignancy, venous thromboembolism (VTE), or other defined hypercoagulable states (HS). RESULTS:= 0.79). The combination of 4 normal MOCHA and normal left atrial size (n = 30) had 100% sensitivity for ruling out the prespecified endpoints. CONCLUSION:The MOCHA profile identified patients with cryptogenic stroke more likely to have new malignancy, VTE, or HS during short-term follow-up and may be useful in direct evaluation for underlying causes of cryptogenic stroke.

: Globally, the proportion of older people living with HIV (PLWH) is growing and the burden of noncommunicable diseases, including cardiac and renal disease, is increasing. There are few studies of renal disease and cardiac risk in older PLWH. This study investigates the relationship between albuminuria and cardiac risk as estimated by the Atherosclerotic Cardiovascular Disease 10-year risk calculator. We report that albuminuria is associated with a higher Atherosclerotic Cardiovascular Disease risk score in both diabetic and nondiabetic older PLWH.

Objectives: Discharges against medical advice (AMA) occur when patients leave the hospital prior to a physician-recommended endpoint. It is unknown whether AMA discharges are associated with higher healthcare costs within 30 days of discharge. We examine healthcare costs following a hospital discharge in a commercially insured population.
Method(s): This retrospective cohort study examined individuals aged 18 to 64 with a hospitalization during 2007-2015 from a 10% random sample of enrollees in the IQVIA^TM Adjudicated Health Plan Claims Data. We included individuals with insurance coverage 6 months before and 30 days after their first hospitalization. Individuals with AMA and non-AMA discharges were matched on baseline covariates. Generalized linear models and cost ratios (CR) were used to quantify the association between AMA discharges and 30-day costs. We report CRs overall and by points of service (inpatient, emergency department (ED), physician office, non-physician outpatient encounter (NPOE) and prescription drug fill).
Result(s): Of the 467,746 individuals in the unmatched sample, 2,164 (0.46%) were discharged AMA. Mean (median) costs were 20% (5%) higher in the AMA group compared to the non-AMA group. In the matched sample and relative to those discharged routinely, individuals with an AMA discharge incurred 1.20 times (95% CI: 1.08, 1.34) higher costs. Similarly, individuals with an AMA discharge incurred higher inpatient (CR: 1.71, 95% CI: 1.45, 2.01) and ED (CR: 2.10, 95% CI: 1.84, 2.39) costs within 30 days post-discharge. Conversely, individuals with an AMA discharge incurred lower NPOE (CR: 0.84, 95% CI: 0.74, 0.95) and prescription drug fill (CR: 0.81; 95% CI: 0.73, 0.91) costs. There were no differences in physician office visit costs across the two groups.
Conclusion(s): An AMA discharge is associated with higher 30-day costs compared to those discharged routinely, particularly for acute care services. Future work should determine whether these findings extend to publicly-insured individuals.
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