Faculty Bibliography

We previously reported the detection of Escherichia coli and Klebsiella pneumoniae that displayed in vitro piperacillin-tazobactam (TZP) resistance but were susceptible to third-generation cephalosporins (TZP-R/Ceph3-S). In this study, we assessed the phenotypic and genotypic profiles of 12 clinical non-clonal TZP-R/Ceph3-S E. coli and K. pneumoniae isolates derived from bloodstream infections. Whole-genome sequencing revealed that the majority of the TZP-R/Ceph3-S E. coli and K. pneumoniae isolates examined harbored bla_TEM-1 and bla_SHV-1 genes, respectively, but none harbored extended-spectrum β-lactamase, AmpC β-lactamase or carbapenemase genes. Increasing the tazobactam concentration from 4 mg/L to 16 mg/L restored TZP in vitro susceptibility among E. coli isolates expressing TEM-1, but had minimal impact on the susceptibility of K. pneumoniae to TZP. Real-time qPCR analysis showed that bla_TEM-1 expression was amplified in TZP-R E. coli upon incubation with sub-inhibitory TZP concentrations. Using an immunocompetent murine septicemia model, we assessed the efficacy of TZP against TZP-R/Ceph3-S isolates using TZP doses that mimicked human plasma exposures following the administration of TZP 4.5 g IV q6h over 0.5 h for 24h. Efficacy was assessed by survival through 96h. Untreated control mice exhibited high degree of mortality for all tested isolates. Compared with controls, TZP human-simulated exposure produced significant improvement in survival for all TZP-R/Ceph3-S E. coli and K. pneumoniae isolates examined (P<0.05). Thus, TZP resulted in remarkable in vivo activity against TZP-R/Ceph3-S E. coli and K. pneumoniae, despite the observed in vitro resistance.

PURPOSE OF REVIEW/OBJECTIVE:Plant-based diets have been used with growing popularity for the treatment of a wide range of lifestyle-related diseases, including diabetes, hypertension, and obesity. With the reinvigoration of the conservative and dietary management of chronic kidney disease (CKD) and the use of low protein diets for secondary prevention of CKD to delay or prevent dialysis therapy, there is an increasing interest in the potential role of plant-based diets for these patients. RECENT FINDINGS/RESULTS:Recently, a body of evidence related to the role of plant-based diet in preventing CKD has reemerged. Several observational studies have shown that red and processed meat have been associated with increased risk of CKD as well as faster progressing in those with preexisting CKD. In several substitution analyses, replacement of one serving of red and/or processed meat has been linked with sizable reductions in CKD risk as primary prevention. Although limited, experimental trials for the treatment of metabolic acidosis in CKD with fruits and vegetables show outcomes comparable to oral bicarbonate. The use of plant-based diets in CKD may have other benefits in the areas of hypertension, weight, hyperphosphatemia, reductions in hyperfiltration, and, possibly, mortality. The risk of potassium overload from plant-based diets appears overstated, mostly opinion-based, and not supported the evidence. Plant-based diets are generally well tolerated and provide adequate protein intake, including essential amino acids as long as the is correctly implemented. SUMMARY/CONCLUSIONS:Plant-based diets should be recommended for both primary and secondary prevention of CKD. Concerns of hyperkalemia and protein inadequacy related to plant-based diets may be outdated and unsupported by the current body of literature. Healthcare providers in general medicine and nephrology can consider plant-based diets as an important tool for prevention and management of CKD.

Patients living with end stage renal disease (ESRD) who are undergoing hemodialysis experience frequent hospitalizations associated with complications of care and exacerbations of illness. Efforts to reduce hospitalizations have had limited success. The purpose of this study was to explore why hospitalizations occur from the perspectives of patients undergoing hemodialysis treatment, their caregivers, and health care providers. Semi-structured interviews and focus groups were conducted with 21 patients living with ESRD, 10 caregivers, and three focus groups with health care professionals. Findings are discussed under four main themes: Graft site/Catheter/Access issues, "My resistance is low," "I could not breathe," and "The perfect storm." Results highlight the complexity of care and vulnerability of patients with ESRD. Further interprofessional research is needed to improve transitional care and care delivery for patient populations receiving hemodialysis.

Poor dietary quality is a leading contributor to mortality in the United States and to most cardiovascular risk factors. By providing education on lifestyle changes and specifically, dietary changes, hospitals have the opportunity to use the patient experience as a "teachable moment." The food options provided to inpatients and outpatients can be a paradigm for patients to follow upon discharge from the hospital. There are hospitals in the United States that are showcasing novel ways to increase awareness of optimal dietary patterns and can serve as a model for hospitals nationwide.

Background/UNASSIGNED:COVID-19 exposed undergraduate medical education curricular gaps in exploring historical pandemics, how to critically consume scientific literature and square it with the lay press, and how to grapple with emerging ethical issues. In addition, as medical students were dismissed from clinical environments, their capacity to build community and promote professional identity formation was compromised. Methods/UNASSIGNED:was developed using a modified guided inquiry approach. Students met daily for 2 weeks in groups of 15 to 18 with a process facilitator. During the first week, students reported on lessons learned from past pandemics; in the second week, students discussed ethical concerns surrounding COVID-19 clinical trials, heard from physicians who provided patient care in the HIV and COVID-19 pandemics, and concluded with an opportunity for reflection. Following the course, students were asked to complete an anonymous, voluntary survey to assess their perceptions of the course. Results/UNASSIGNED:With a response rate of 69%, an overwhelming majority of students agreed or strongly agreed that learning about historical pandemics helped them understand COVID-19 (72, 99%). The course successfully helped students understand current and potential COVID-19 management strategies as 66 (90%) agreed or strongly agreed they developed a better understanding of nonpharmacological interventions and new pharmacological treatments. Students also gained insight into the experiences of healthcare providers who cared for patients with HIV and COVID-19. Qualitative analysis of the open-ended comments yielded 5 main themes: critical appraisal of resources, responsibility of the physician, humanism, knowledge related to pandemics, and learning from history. Conclusions/UNASSIGNED:The onset of the COVID-19 crisis illustrated curricular gaps that could be remedied by introducing the history and biology of pandemics earlier in the curriculum. It was also apparent that learners need more practice in critically reviewing literature and comparing scientific literature with lay press. The flexible format of the course promotes the development of future iterations that could cover evolving topics related to COVID-19. The course could also be repurposed for a graduate or continuing medical education audience.

Internet-facilitated self-diagnosis and treatment is becoming more prevalent, putting individuals at risk of toxicity when drugs are acquired without medical oversight. We report a patient with delusional parasitosis who consumed veterinary albendazole purchased on the Internet, leading to pancytopenia, transaminase elevation, and alopecia. A 53-year-old man was sent to the emergency department (ED) by his gastroenterologist because of abnormal laboratory results. The patient had chronic abdominal pain and believed he was infected with parasites. He purchased two bottles of veterinary-grade albendazole on the Internet, and over the 3 weeks before his ED visit, he consumed 113.6 g of albendazole (a normal maximal daily dose is 800 mg). Five days before admission, he noticed hair loss and a rash on his face. His examination was notable for significant scalp hair loss and hyperpigmentation along the jaw line. Laboratory studies were remarkable for pancytopenia (most notably a WBC of 0.4 × 10³ cells/mm³, with an absolute neutrophil count (ANC) of 0 × 10³ cells/mm³) and transaminase elevation (AST 268 IU/L, ALT 89 IU/L). He developed a fever and was treated with antibiotics and colony-stimulating factors for presumed neutropenic bacteremia. Over the course of 1 week, his hepatic function normalized and his ANC increased to 3,000 × 10³ cells/mm³. Serial albendazole and albendazole sulfoxide concentrations were measured in serum and urine by liquid chromatography-quadruple time-of-flight mass spectrometry. On day 2, his serum concentrations were 20.7 ng/mL and 4,257.7 ng/mL for albendazole and albendazole sulfoxide, respectively. A typical peak therapeutic concentration for albendazole sulfoxide occuring at 2-5 hours post-ingestion is 220-1,580 ng/mL. Known adverse effects of albendazole include alopecia, transaminase elevation, and neutropenia. Pancytopenia leading to death from septic shock is reported. In our patient, prolonged use of high-dose albendazole resulted in a significant body burden of albendazole and albendazole sulfoxide, leading to pancytopenia, transaminase elevation, and alopecia. He recovered with supportive therapy.

Background/UNASSIGNED:Conventionally, endoscopic ultrasound-guided fine-needle aspiration and biopsy (EUS-FNA)/EUS-FNB) has been used for tissue diagnosis of upper gastrointestinal (GI) subepithelial tumors (SETs). However, deep biopsy (DB) via endoscopic submucosal dissection (ESD) is emerging as an alternative technique, given the inadequate tissue sampling with EUS-FNA/EUS-FNB. Our aim was to conduct a systematic review and meta-analysis to report the overall diagnostic yield of DB via ESD for upper GI SETs. Methods/UNASSIGNED:PubMed, Cochrane Library and Web of Science databases were searched to identify studies (from commencement to Oct 2017) that reported the DB via ESD technique for diagnosis of upper GI SETs. The primary outcome of interest was the method's overall diagnostic yield and the secondary outcome was to the occurrence of complications. The meta-analysis was performed using the DerSimonian and Laird random-effects model. Results/UNASSIGNED:=0%) respectively. Data regarding major bleeding and perforation rates were not reported in 2 studies. Substantial heterogeneity was observed in our meta-analysis. Conclusion/UNASSIGNED:DB via ESD is an effective and safe procedure for diagnosing upper GI SETs. Further multicenter randomized controlled trials are needed to validate these findings.

Student-run clinics are settings in which learners are empowered to design service delivery. Despite shared challenges faced by these clinics in improving clinical and educational programming, information exchange and collaboration between clinics of different institutions and professions are inefficiently facilitated by existing platforms. An abridged, one-hour hackathon event was piloted at the Society of Student-Run Free Clinics' 2018 Annual Conference. During the event, interprofessional teams were guided through defining a problem, ideating and prototyping possible solutions, and sharing them with the larger group. There were 23 participants representing 16 institutions and 5 professions; most had never discussed their clinic's problems with members of other institutions before. Teams generated novel ideas that culminated from a combination of existing local best practices or focused on developing infrastructure between clinics. Feedback of the event was positive; participants felt confident to design and implement solutions and collaborate with other clinics after the event. The abridged hackathon shows promise to facilitate communication and innovation among diverse groups across institutions.

Background/UNASSIGNED:There are limited data on the social and cultural determinants of dietary intake in Chinese Americans. Over 560,000 New York City residents are Chinese American, and there has been a growing trend over the past 30 y of permanent migration from China to the USA. Objectives/UNASSIGNED:The purpose of this secondary data analysis is to describe associations between diet, measured by self-report, and diet quality, with level of acculturation in a cross-sectional sample of urban-dwelling Chinese American immigrants. Methods/UNASSIGNED:This was a cross-sectional study involving 2071 foreign-born Chinese American adults. Acculturation was assessed using the Stephenson Multigroup Acculturation Scale, diet using a Chinese-adapted FFQ, and diet quality using the Alternative Healthy Eating Index (AHEI). Multivariable regression was used to assess associations between ethnic (ESI; Chinese) and dominant (DSI; American) society immersion scores with self-reported dietary measures. Results/UNASSIGNED: = 0.025) higher red and processed meat component score. Conclusions/UNASSIGNED:Assessment of acculturation level may help to tailor dietary strategies that are appropriate to what Chinese American immigrant communities are consuming to more effectively decrease the risk of chronic disease.