Faculty Bibliography

Little is known about the dietary patterns of Chinese Americans. Understanding their dietary patterns can provide insights for addressing cardiovascular disease (CVD) risk among Chinese American immigrants. The objective of this study was to identify dietary patterns among Chinese American immigrants living in New York City (NYC) and to describe associations with demographic and CVD risk factors. A validated Food Frequency Questionnaire assessed usual dietary intake in Chinese American immigrants living in NYC as part of the Chinese American Cardiovascular Health Assessment (CHA CHA) in 2010-2011 (n = 1973, age range 21-89 years). Principal components analysis with varimax rotation retaining three factors with eigenvalues > 1.5 identified dietary patterns. Multivariable linear regression models tested associations between CVD risk factors and dietary pattern scores. In multivariable analyses, each unit of increase in the Sweets factor was associated with 0.76 ± 0.33 (mean ± SD) mg/dL higher HDL cholesterol and a 6.2 ± 2.7% increase in HOMA-IR. In contrast, each unit increase in the Fried Noodles factor was associated with a 0.27 ± 0.11 inch greater waist circumference, - 0.89 ± 0.40 mg/dL lower HDL cholesterol, and also a 6.9 ± 2.6% increase in HOMA-IR. Each unit increase in the Vegetables factor was associated with a - 1.40 ± 0.43 mmHg and - 0.95 ± 0.27 mm Hg decrease in systolic and diastolic blood pressure, respectively. Dietary patterns are significantly associated with CVD risk factors among Chinese American immigrants in NYC. Future work will inform how dietary patterns relate to level of acculturation in order to guide the development of dietary interventions to reduce CVD risk.

Graft-versus-host disease (GVHD) is an adverse immunologic phenomenon following allogenic hematopoietic stem cell transplant. Cutaneous manifestations are the earliest and most common presentation of the disease. This article describes the pathophysiology, clinical presentation, diagnosis, and treatment options available for acute and chronic GVHD. Acute and chronic GVHD result from an initial insult triggering an exaggerated inflammatory cascade. Clinical presentation for cutaneous acute GVHD is limited to maculopapular rash and oral mucosal lesions, whereas chronic GVHD can also include nail, scalp, and genitalia changes. Diagnosis is often made clinically and supported by biopsy, laboratory and radiology findings.

The small bowel is an uncommon site for cancer metastasis. Despite this, cases have reported the duodenum as a metastatic site from local organs. However, duodenal involvement from more distant organs, such as the ovaries, has rarely been reported. Herein, we present a case of a 68-year-old female who developed duodenal metastatic disease from a primary ovarian serous adenocarcinoma. The goal of this report is to encourage clinicians to keep a broad differential in patients complaining of abdominal pain, especially in those with a history of primary ovarian malignancy.

INTRODUCTION: Maternal TDF treatment during the third trimester has been shown to reduce perinatal transmission of the hepatitis B virus (HBV) in highly viremic women in several RCTs. However, the data is limited on the effectiveness of TDF in the real-world setting. With this real-world study, we aimed to assess the efficacy and safety of TDF therapy for these mothers in a single center in the US.
METHOD(S): All Hepatitis B e-antigen positive mothers with HBV DNA .6log10 copies/mL who received TDF in the third trimester and delivered from July 2010 to September 2018 were retrospectively analyzed. All infants received hepatitis B immunoglobulin and vaccination at birth and subsequently. Primary endpoints were the safety of TDF use and mother-to-child transmission rates. Secondary outcomes were maternal HBV DNA level suppression at delivery.
RESULT(S): Among the 75 patients enrolled, the mean (6SD) age of the patients was 30.47+/-4.49 years, mean (6SD) gestational age was 37.87+/-2.95 weeks, and the mean (6SD) treatment duration before delivery was 9.60+/-3.36 weeks. A significantly lower level of the mean (6SD) serum HBV DNA was achieved at delivery vs. baseline (4.2+/-1.2 vs. 7.6+/-0.80 log10 copies/mL, respectively; P- < 0.01). Additionally, 80% (60/75) of mothers achieved HBV DNA < 6log10 copies/mL at delivery. The median (Interquartile range) alanine aminotransferase (ALT) level before treatment was 26 (20) IU/L, and at delivery was 27 (20) IU/L respectively. Vertical transmission rate among infants was 0%, and all infants were hepatitis B surface antigen negative between 28 -52 weeks after birth. Fatigue was the most common complaint reported by 52% (39/75) of mothers. No infants had a birth defect. On treatment, ALT flares were observed in 4.5% (6/75) of mothers.
CONCLUSION(S): In this US cohort of real-world practice, TDF therapy for highly viremic mothers was well tolerated and reduced vertical transmission effectively. No severe adverse effects were reported in both mothers and infants. Our study supports the use of TDF treatment for highly viremic mothers in a real-world setting. (Figure Presented)

BACKGROUND & AIMS:Previous or current infection with Helicobacter pylori (exposure) has been reported to protect against eosinophilic esophagitis (EoE), perhaps owing to H pylori-induced immunomodulation. However, findings vary. We performed a systematic review and meta-analysis of comparative studies to define the association between H pylori exposure and EoE more clearly. METHODS:We searched 4 large databases to identify comparative clinical studies that included sufficient detail to determine the odds or risk of EoE (primary outcome) or esophageal eosinophilia (secondary outcome) among individuals exposed to H pylori (exposed) vs individuals who were tested and found to be unexposed. Estimates were pooled using a random-effects model. Meta-regression and sensitivity analyses were planned a priori. Studies were evaluated for quality, risk of bias, publication bias, and heterogeneity. RESULTS:We analyzed 11 observational studies comprising data on 377,795 individuals worldwide. H pylori exposure vs nonexposure was associated with a 37% reduction in odds of EoE (odds ratio, 0.63; 95% CI, 0.51-0.78) and a 38% reduction in odds of esophageal eosinophilia (odds ratio, 0.62; 95% CI, 0.52-0.76). Fewer prospective studies found a significant association between H pylori exposure and EoE (P = .06) than retrospective studies. Effect estimates were not affected by study location, whether the studies were performed in pediatric or adult populations, time period (before vs after 2007), or prevalence of H pylori in the study population. CONCLUSIONS:In a comprehensive meta-analysis, we found evidence for a significant association between H pylori exposure and reduced odds of EoE. Studies are needed to determine the mechanisms of this association.

INTRODUCTION: Fecal microbiota transplant (FMT) is an effective treatment for recurrent Clostridioides difficile infection (rCDI), but its precise mechanism remains unknown (1-2). Recent studies suggest that the restoration of gut bacteria, which carry necessary enzymes to convert primary bile acids (PBAs) to secondary bile acids (SBAs), may play a key role in rCDI risk (3, Figure 1). For example, in vitro studies have demonstrated that PBAs stimulate C. difficile spore germination and that deoxycholic acid, a SBA, inhibits toxin-producing C. difficile (4). As normal fecal bile acid pools consist predominantly of SBAs, we hypothesize that a contributor of rCDI risk is the decrease in SBAs from enteric bacteria loss following antibiotic use (5-8).We present the first case enrolled in our clinical trial using ursodeoxycholic acid (UDCA), a SBA, as an adjunct treatment to prevent future rCDI. CASE DESCRIPTION/METHODS: An otherwise healthy 46-year-old man presented with S. aureusbacteremia secondary to septic knee arthritis. While on an extended course of cefazolin, he developed profuse, watery diarrhea and stool C. difficile toxin PCR was positive. He was then treated with intravenous metronidazole for one week and oral vancomycin for two weeks, with resolution of symptoms. Six weeks later, CDI recurred and was successfully treated with oral vancomycin for two weeks, in conjunction with concurrent UDCA 300 mg twice daily for eight weeks. Stool samples were collected at two-week intervals and fecal bile acid compositions were assessed via liquid chromatography - mass spectrometry. Fecal bile acid analyses demonstrated a shift towards protective SBAs by the end of the 8-week course of ursodiol (Figure 2). This profile of increased SBAs remained consistent despite subsequent retreatment with cefazolin at 5 months for recurrent septic arthritis. The patient has been without rCDI now for almost 2 years. DISCUSSION: The findings in this case are consistent with our hypothesis that increasing SBAs through adjunct treatment with UDCA can be effective in breaking the rCDI cycle. While some CDI patients have adequate enteric bacteria to produce SBAs after antibiotic treatment, others may have a delayed normalization of their gut microbiome, and may therefore require ?bridge therapy? with supplementary SBAs (e.g., UDCA) until their endogenous microbial community is restored. Treatment and analysis of additional patients with rCDI in this clinical trial are in progress. (Figure Presented)

Fatty acids derived from fish oil are long chain omega-3 (n-3) polyunsaturated fatty acids. The important polyunsaturated fatty acids of fish oil are eicosapentaenoic acid, and docosahexaenoic acid. For decades, there has been a debate about the use of omega-3 fatty acid supplements and their benefits on cardiovascular health. The more recent trials including the JELIS, REDUCE-IT, VITAL, STRENGTH, and the ASCEND trials addressed the paucity of data of omega-3 Fatty acids on primary as well as secondary prevention of cardiovascular events and risk-benefit balance of these supplements. Prior to these studies, many large randomized controlled trials have shown conflicting results on the effect of polyunsaturated fatty acids in patients with prior coronary artery disease, stroke or major vascular events. These inconsistent results warrant a better understanding of the effects of omega-3 fatty acids on the subtypes of cardiovascular diseases, and their use in primary and secondary prevention. More recently, the REDUCE-IT study showed a possible protective benefit of fish oil supplements (in purified form and higher than normal doses) in the reduction of Triglyceride levels. It is also noteworthy that omega-3 fatty acids have found their mention in the most recent American College of Cardiology guidelines for the management of hypertriglyceridemia as an adjunct to statins and fibrates. The aim of this review is to discuss these recent updates on use of fish oil in cardiometabolic diseases, and their surrounding controversies.

Background. With over 100,000 unique lives and 600,000 visits in 2018, The Family Health Centers at NYU Langone (FHC) is one of the largest Federally Qualified Health Center network based primarily in Southwest Brooklyn New York. Within the catchment area 48% of the population report being born out of the United States, with 30% of the population describing themselves of Asian ethnicity and 42% as Latino [1]. Effective January 1, 2014 New York State law mandated hepatitis C screening to be offered to every individual born between 1945 and 1965 receiving health services. Now five years later, with the advancements in treatment options and increased access for patients where cost has become prohibitive we retrospectively reviewed how our performance has been prior to embarking on a goal of 60% screening compliance. Methods. We performed a retrospective chart review looking at a denominator of patients born between 1945 and 1965 who were seen in the FHC for a visit in 2018. Patients who were previously screened since 2016, have a diagnosis of hepatitis C, history of hepatitis C documented in either past medical history, problem list or ICD code were excluded. Data abstraction for compliance in the numerator included patients who have a resulted hepatitis C antibody or have indicated current treatment (with a hepatitis C viral load). Results. 51% of patients based on the aforementioned methodology have been screened in 2018. 11,577 patients were eligible with 650 patients having a documented refusal. 261 new diagnosis were made in 2018 and compliance for non-screened patients without any prior screening was 35%. Regarding racial/ethnic composition of the practice sites compared with patients screened, one practice site with an 87% Asian non-Hispanic population had a 35% compliance rate with screening where as the most predominate Hispanic population site (81% of total patients seen) had a 54% compliance rate. Conclusion. Overall screening rates within the network are commendable, yet more work is being done to drive provider awareness on the need for compliance. Differences in racial/ethnic backgrounds and compliance of screening completion can be seen within the FHC network. Current efforts are focused on increasing culturally appropriate awareness amongst the patient population as well as the providers

Background/Purpose : The impact of glucocorticoid (GC) use on major organ damage in SLE patients has not been formally studied by amalgamating the relevant data published in the literature over the past 40 years. We aimed to study the association between GC use and the occurrence of major organ damage in SLE patients by performing meta-analyses of observational studies published between 1970 and December 2018. Methods : Literature search on PubMed (from 1966 to December 2018) for prevalence and longitudinal studies which reported GC exposure (proportion of GC users in the cohort [%GC use] and/or GC use in defined doses) and the occurrence (prevalence/incidence) of major organ damage in SLE patients using the keywords cataract, cerebrovascular (CVA), stroke, cardiovascular (CVS), angina, myocardial infarction (MI), coronary artery bypass, osteoporosis, avascular necrosis (AVN) and osteonecrosis in respective combinations with lupus was conducted. Studies with sample size < 50 and observation duration < 12 months were excluded. The logit of the proportion of patients with disease damage was modelled as a random effect in the meta-analysis, which was employed to study the association between the proportion of patients with organ damage and variables of GC use (mean daily [mg/day] and cumulative [gm] prednisone [PDN] doses and %GC use). A 2-stage estimation of the random-effects logistic regression models was used with restricted maximum likelihood estimation. Univariate associations between organ damage and moderators were examined for statistical significance, and variables related to GC use were adjusted for SLE disease duration in multivariate models if their univariate P values were < 0.2. Results : Out of 8,882 publications screened, 212 articles involving 205,619 SLE patients were eligible for the metaanalyses (Figure 1), of which 97 were prevalence and 115 were longitudinal studies. Univariate analyses of prevalence studies revealed that mean daily PDN dose (odds ratio [OR]=1.10, p=0.007) and lower proportion of female in the cohort (OR=0.002, p=0.002) were associated with the prevalence of overall CVS events. Mean daily PDN dose (OR=1.52, p< 0.001) and %GC use (OR=2,255.2, p< 0.001) were associated with the prevalence of AVN. A significant association between cumulative PDN dose and prevalence of CVA was found after multivariate adjustment for SLE disease duration (OR=1.07, p=0.017). In longitudinal studies, a significant association was identified between cumulative PDN dose and incidence of cataracts after adjustment for SLE disease duration (OR=1.04, p=0.013). While the incidence of MI in SLE patients has dropped over the past 40 years (OR=0.94, p=0.002), it was associated with % GC use after adjustment for SLE disease duration (OR=8.18, p=0.012). Interestingly, significant univariate associations were found between antimalarial use and lower prevalence of MI (OR=0.05, p=0.002) and lower incidence of CVA (OR=0.20, p=0.032). Conclusion : Independent of SLE disease duration, cumulative PDN dose was associated with higher prevalence of CVA and incidence of cataracts, and higher incidence of MI was associated with overall GC use