Faculty Bibliography

Purpose: Appropriateness criteria (AC) are important tools that could help inform decision making for elective surgical procedures. Available AC for elective total knee replacement (TKR) focus on pre-operative factors only. With recent availability of longitudinal outcome data on thousands of patients from patient registries and administrative databases, we aimed to develop new AC that also included predicted outcomes.
Method(s): To update the AC, we expanded these 16 hypothetical scenarios of the validated modified Escobar AC to include 3 predicted outcome factors: risk of serious complications (0%, 1-2%, 3-5%), time to revision (<5, 5-15, >15 years), and improvement in pain and function 2 years after surgery (little, some, a lot). The modified Escobar AC are based on 5 clinical factors: age, osteoarthritis radiographic severity, knee stability, symptoms severity, and number of knee compartments with osteoarthritis). A panel of clinician experts (3 orthopedic surgeons, 2 rheumatologists, 2 internists, 1 physical therapist, 1 experienced nurse practitioner) rated 432 written clinical scenarios for appropriateness on a 1-9 scale (1 being least appropriate and 9 being most appropriate), and the median score for each scenario was classified into one of 3 categories: inappropriate 1-3, maybe appropriate 4-6, and appropriate 7-9. Classification and Regression Tree (CART) analysis was applied to the TKR AC appropriateness categories to determine the contribution of the predicted outcomes variables to appropriateness classification.
Result(s): After orthopedic surgeons ruled out clinically implausible scenarios, the remaining 279 scenarios were classified as 71 inappropriate, 112 maybe appropriate, and 96 appropriate. Figure below shows the results of the CART analyses classification tree with the branches labeled with the key variables that discriminated among the classifications. The terminal nodes of each branch (highlighted in grey) indicate the final distribution of the ratings of appropriate (App), may be appropriate ( Maybe App) and inappropriate (Inapp). CART analyses showed that all 3 predicted outcome factors and 2 of the clinical presentation factors (knee symptom severity and X-ray findings) were the variables that discriminated among the classifications.
Conclusion(s): Our Results showed that predicted outcomes were utilized by clinicians when determining appropriateness for TKR. How these data influence the decision making of patients contemplating TKR should be investigated further. [Formula presented]
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OBJECTIVE:Increased utilization of CT pulmonary angiography (CTPA) for the evaluation of pulmonary embolism has been associated with decreasing diagnostic yields and rising concerns about the harms of unnecessary testing. The objective of this study was to determine whether clinical decision support (CDS) use would be associated with increased imaging yields after controlling for selection bias. METHODS:We performed a retrospective cohort study in the emergency departments of two tertiary care hospitals of all CTPAs performed between August 2015 and September 2018. Providers ordering a CTPA are routed to an optional CDS tool, which allows them to use Wells' Criteria for pulmonary embolism. After propensity score matching, CTPA yield was calculated for the CDS-use and CDS-dismissal groups and stratified by provider type. RESULTS:A total of 7,367 CTPAs were ordered during the study period. Of those, providers used the CDS tool in 2,568 (35%) cases and did not use the tool in 4,799 (65%) of cases. After propensity score matching, CTPA yield was 11.99% in the CDS-use group and 8.70% in the CDS-dismissal group (P < .001). Attending physicians, residents, and physician assistant CDS users demonstrated a 56.5% (P = .006), 38.7% (P = .01), and 16.7% (P = .03) increased yield compared with those who dismissed the tool, respectively. DISCUSSION/CONCLUSIONS:Diagnostic yield was 38% higher for CTPAs when the provider used the CDS tool, after controlling for selection bias. Yields were higher for every provider type. Further research is needed to discover successful strategies to increase provider use of these important tools.

Background: Delirium occurs commonly in hospitalized older adults. Clinicians investigate frequent causes of delirium such as infection, metabolic derangement, intracranial disorders, urinary and fecal disorders, and medication. The complexity in treating the underlying cause of delirium is the treatment of one contributing factor (e.g. infection), may in fact be the source of the confusion. Case report: We evaluated a 95 year old woman with atrial fibrillation, severe aortic stenosis, chronic kidney disease, heart failure, and clostridium difficile who presented to the hospital with shortness of breath. White blood cell count was elevated and CT chest revealed moderate patchy consolidation in the lung. The patient was started on Vancomycin, Aztreonam, and Cefepime for multidrug resistant pneumonia. At baseline she has no dementia and there was no concern for delirium on presentation. Hospital days 4-6 she became lethargic but remained clinically stable without a change in infectious markers. By hospital day 8 she completed the course of Cefepime but was nonverbal and opened her eyes only when directly stimulated. The only notable lab change was an uptrend of creatinine from 1.09 to 1.70 in the setting of diuresis for fluid overload. Mental status remained poor through hospital day 10. CT brain revealed moderate global volume loss. There was no evidence of a new infection, hypercarbia, or other metabolic derangements. EEG was not completed per family preference. By hospital day 12, 4 days after the cessation of Cefepime, her mental status began to improve and returned almost back to baseline before discharge.
Discussion(s): Cefepime is known to have neurotoxic effects that may include depressed consciousness, encephalopathy, aphasia, myoclonus, seizures, and coma. The primary risk factors for Cefepime neurotoxicity are renal impairment and blood-brain barrier dysfunction from systemic inflammation. Older age is a commonly reported clinical risk factor. Neurotoxic effects are noted a median of 4 days after initiation with reduced consciousness most commonly seen. The neurotoxic symptoms may resolve a median of 2 days after discontinuation. The literature findings mimic what was seen in this case. This case reinforces the need to consider the multifactorial contribution to delirium etiology. Cefepime induced neurotoxicity should be considered for infected patients with persistent hypoactive delirium

Background: Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders. The effectiveness of PPIs has led to overutilization, exposing patients to an increasing number of potential risks. Despite FDA safety warnings regarding the potential adverse effects of long-term PPI use, there has been a failure to re-evaluate the need for continued therapy. The VA Manhattan outpatient Geriatrics clinic, in collaboration with pharmacists and patients, conducted a quality improvement (QI) program using a shared decision-making approach to deprescribe inappropriate PPIs.
Method(s): Patients with PPIs ordered from April, 2017 to April, 2018 were identified using the VA database. Diagnoses were identified using ICD 10 codes. Patients without a clear indication for longterm PPI treatment were identified (long term PPI use is indicated in refractory GERD, Barrett's esophagus, Zollinger-Ellison syndrome, idiopathic chronic peptic ulcer, and bleeding prevention in selected patients). Patients were contacted telephonically by a physician or pharmacist, counseled regarding adverse effects of long-term PPI use and offered titration/discontinuation or change to an alternative agent. If patients consented, they were contacted for follow-up interviews at 1, 3, 6, 12 months after inclusion to assess symptoms and tolerance.
Result(s): Of the1230 patients in the Geriatrics clinic, 74 (6%) were on PPIs. Of these, 41/74 (55%) had no indication for chronic PPI use. 36 of 41 patients consented to participate. We were able to titrate and discontinue or switch to an H2 antagonist in 20 (55%) of the 36 patients but 15 (42%) were restarted on PPI for recurrence of GERD symptoms over the 12 months of follow-up. 1 patient died of natural causes.
Conclusion(s): This QI program successfully deprescribed inappropriate long-term PPIs in some patients without major adverse events by using an interdisciplinary approach and shared decision- making process with patients. However, a sizable proportion of patients required restarting of a PPI for GERD symptoms. Future work is needed to understand if GERD symptom control can be achieved by other means to further decrease PPI use

Racial minorities experience a high burden of food insecurity relative to non-Hispanic whites. Government-subsidized nutrition programs can positively impact food insecurity and nutritional risk among older adults. Yet, in New York City, where nearly 60% of people over 65 years are non-white, older minorities participate in government nutrition programs at very low rates. In this commentary, we focus on 2 programs: the Child and Adult Care Food Program and Older Americans Act Nutrition Services Programs. We identify opportunities for strengthening these programs to improve their reach and engagement with diverse older adults in New York City and similarly diverse urban communities.

Continuous positive airway pressure (CPAP) is highly effective in treating sleep-disordered breathing (SDB). However, unlike surgical interventions, this treatment modality relies heavily on patient acceptance and adherence. The current definition of adherence is largely arbitrary and is mainly used by third-party payers to determine CPAP reimbursement but CPAP adherence remains sub-optimal. Strategies to augment adherence, especially early in the course of a CPAP trial, are needed in the management of SDB. An understanding of the basis for observed differences in CPAP and oral appliance (OA) use is necessary in developing these strategies, but to date no single factor has been consistently identified. Consequently, a multidimensional approach using educational, behavioural, technological and potentially pharmacological strategies to target (i) disease characteristics, (ii) patient characteristics including psychosocial factors, (iii) treatment protocols and (iv) technological devices and side effects that may influence adherence, is likely required to augment the complex behaviour of CPAP and OA use. In the near future, we envision a personalized medicine approach to determine the risk of non-adherence and set individualized adherence goals aimed at treating specific symptoms (e.g. excessive daytime sleepiness) and reducing the risk of patient-specific SDB consequences (e.g. atherosclerosis). Resources for interventions to improve adherence such as educational programmes and telemedicine encounters could then be more efficiently allocated.

BACKGROUND:Cooking interventions have been linked to reductions in obesity and improvements in dietary intake in children. OBJECTIVE:To assess whether child cooking involvement (CCI) was associated with fruit intake (FI), vegetable intake (VI), vegetable preference (VP), and vegetable exposure (VE) in children participating in the Texas, Grow! Eat! Go! (TGEG) randomized controlled trial. METHODS:) CSH plus LGEG plus WAT (combined group). Height, weight, dietary intake, VE, VP, and CCI were collected at baseline and postintervention. Linear regressions were used to assess the relation between baseline CCI and fruit and vegetable (FV) intake, VE, and VP. A priori covariates included age, sex, race/ethnicity, and TGEG treatment group. RESULTS:< 0.01, respectively). CONCLUSIONS:Results show a positive relation between family cooking and FV intake and preference in high-risk, minority children.

Background Despite increased cardiovascular mortality in patients with HIV, studies have shown suboptimal rates of statin prescription among qualifying patients. Our initial trainee needs assessment survey revealed a lack of comfort and modifiable barriers to prescribing statins to patients with CAD and HIV on anti-retroviral therapy (ART). We sought to create a tool to mitigate these barriers and improve comfort and self-reported practice in prescribing statins to this population. Methods A 1-page tool detailing statin-ART co-administration regimens, common drug interactions and potential side effects was created and introduced to 24 cardiology and 8 infectious disease fellows at NYU School of Medicine. Ten weeks later, a post-intervention survey was conducted to assess comfort, barriers, and self-reported practice when prescribing statins to patients with HIV. Data was de-identified by a 3^rd party. Results were excluded for lack of consent for study participation and incomplete and/or duplicate survey responses. Results Of the included 11 cardiology and 6 infectious disease fellows, 53% report using the tool in clinical decision making over 10 weeks. Of these, 78% report the tool increased comfort initiating and/or adjusting statin therapy and 89% report the tool increased overall comfort managing statins in patients with HIV. In our prior needs assessment survey, the majority of fellows cited one or more barriers to prescribing statins to patients with HIV and a minority reported always considering HIV status when deciding to initiate statin therapy. After introduction of the tool, however, over half of fellows report no barriers to prescribing statins to this population and 100% report they will now always consider HIV status when deciding to initiate statin therapy. Ultimately, 65% of fellows plan to use the 1-page tool in the future and 82% recommend that it be provided to future trainees. Conclusion Introduction and use of our 1-page tool improved trainee comfort, reduced known barriers, and improved self-reported practice when prescribing statins to patients with HIV. Integration of such a tool into the curriculum can improve trainee education in caring for a vulnerable population.
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Background Arrhythmogenic cardiomyopathy (ACM) can mimic inflammatory processes. We present a complex patient with scleroderma (Sc)-dermatomyositis overlap syndrome (Sc-DM) and cardiac disease. Case A 57-year-old woman with family history of Sc presented with progressive weakness, dyspnea, edema, and Raynaud's (1A). Troponin was 1.6 ng/mL and CRP was 13.2 mg/L. EKGs revealed sinus rhythm with RBBB and AV sequential pacing with multifocal PVCs (1B-C). CT chest showed bibasilar fibrosis (1D). Echocardiography revealed biventricular dysfunction. Cardiac catheterization showed non-obstructive coronaries and a cardiac index of 1.8 L/min/m2. Cardiac MRI had diffuse biventricular subendocardial late gadolinium enhancement (1E). Electromyography revealed proximal myopathy. Rheumatologic workup was consistent with seronegative Sc-DM. Decision-making She was treated with steroids, mycophenolate, IV immunoglobulins, diuretics, and inotropes. Her course was complicated by recurrent VT cardiac arrests, prompting escalation to VA-ECMO. She underwent cardiac transplant on day 9 of ECMO. Pathology revealed biventricular fibrofatty replacement consistent with ACM (1F-G), patchy fibrosis of the pericardium, and mitral valve with thickened and fused chordae suggestive of inflammatory changes from Sc (1H-I). Conclusion This case highlights an atypical presentation of ACM in a patient with Sc-DM and the multidisciplinary approach necessary for proper diagnosis and management. [Figure presented]
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BACKGROUND:System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP. AIM/OBJECTIVE:To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE. METHODS:For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey. RESULTS:." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice. CONCLUSION/CONCLUSIONS:OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.