Faculty Bibliography

Purpose: Given recent evidence that the risk of renal toxicities with TDF may increase with coadministration of a pharmacoenhancer (Hill 2018), we assessed the risk of chronic kidney disease (CKD) associated with TDF and non- TDF containing regimens by D:A:D CKD risk and boosting.
Method(s): ART-naive adults initiating treatment with eGFR>=60 mL/min/ 1.73 m2 (last eGFR within 12 months pre-initiation) were identified in the OPERA cohort. CKD was defined as>=2 consecutive eGFR<60 mL/min/1.73 m2, >90 days apart. The associations between TDF use, baseline D:A:D CKD risk, and incident CKD were assessed with unadjusted incidence rates (IR, Poisson regression) and adjusted survival analyses (pooled logistic regression). Secondary analysis evaluated the contribution of pharmacoenhancers.
Result(s): Of 9,802 PLWH included, 6,222 initiated TDF (76% low-risk D:A:D CKD score, 16% medium-risk, 8% high-risk) and 3,580 did not (79% low-risk, 13% medium-risk, 8% high-risk; Table 1); 40-47% initiated a boosted regimen (Table 2). Overall, 125 incident CKD events occurred over 24,382 person-years of follow-up. Within strata of D:A:D risk score, IRs were similar by TDF exposure, with high baseline CKD risk associated with highest incidence regardless of TDF use (Figure 1). Compared to the low-risk group without TDF, there was no statistical difference in odds of incident CKD in the medium-risk group without TDF (aOR: 2.32, 95% CI: 0.72, 7.52) or the low-risk group with TDF (aOR: 0.55, 95% CI: 0.19, 1.54; Figure 2). Odds of incident CKD did not differ by pharmacoenhancer exposure, with or without TDF.
Conclusion(s): In this large cohort of ART-naive PLWH, incident CKD following ART initiation was relatively infrequent and was strongly associated with baseline CKD risk. TDF-containing regimens did not appear to increase the risk of CKD in those with a low baseline D:A:D CKD risk, the largest group of naive PLWH, and may remain a viable treatment option. (Figure Presented)

BACKGROUND:Age- and gender-adjusted percentiles of coronary artery calcium (CAC) score are commonly reported to compare a patient's coronary atherosclerosis burden to that of others of the same age and gender. The number of calcified plaques (numCP) detected on CAC scanning, a measure of plaque diffusivity, is associated with increased cardiovascular risk and, in the intermediate CAC range, adds to the CAC score in predicting mortality. This study aims to develop adjusted percentiles for numCP to provide a better context for understanding CAC scan findings. METHODS AND RESULTS/RESULTS:Using nonparametric modeling techniques, the distribution of numCP was analyzed in 70,320 consecutive, asymptomatic patients without prior clinically-diagnosed cardiovascular disease who were part of the Coronary Artery Calcium Consortium and supplemented by additional patients referred for clinical CAC scanning in a single center between 1998 and 2016. Nomograms for age-adjusted numCP percentiles for each gender were generated using quantile regression. The prevalence and average number of calcified coronary plaque were found to be higher in men than women. Distribution of numCP in women was found to closely mirror that of men approximately a decade younger. NumCP increased consistently across age groups in both men and women for each quantile category. CONCLUSIONS:A nomogram for age and gender-adjusted percentiles for the numCP on CAC scans has been developed in a large population of asymptomatic patients studied across multiple centers. This numCP nomogram may provide an additional tool for refining physician recommendations regarding treatment and expressing to patients how their CAC findings relate to others of similar age and gender. The numCP percentiles may also provide a meaningful way to evaluate and report the rate of progression of CAC on serial studies.

Serum amylase testing is not recommended for the workup of acute pancreatitis; yet it is commonly ordered in acute care settings. METHODS: This was a student-led quality improvement initiative with application of a pre-post study design at two urban hospitals: Mount Sinai Hospital, a 1,134-bed academic hospital, and Mount Sinai Queens, a 235-bed community hospital. The multifaceted intervention combined a targeted educational and awareness campaign with the decoupling of amylase from electronic order sets (at the academic hospital only), as well as a nonintrusive electronic medical record (EMR) advisory statement (at both hospitals). Monthly amylase orders were tracked for all emergency department visits and hospital admissions between January 2016 and May 2018 for both hospitals RESULTS: There was a significant and sustained decrease in amylase ordering at both the academic hospital (from 3,214 orders per month to 2,348 orders per month; p = 0.011) and the community hospital (from 100 orders per month to 23 orders per month; p = 0.001). Specifically, the nonintrusive EMR order advisory statement was independently associated with a significant reduction in serum amylase ordering. There was an estimated net annual cost reduction of $44,999. CONCLUSIONS: This student-led initiative was successful in reducing unnecessary amylase ordering across two diverse institutions through a combination of education, publicity, and EMR changes.

BACKGROUND: The EMulate Therapeutics Halo system is an investigational non-sterile, non-invasive, non-thermal, non-ionizing, portable, home-use medical device that uses a specific, localized ultra-low radio frequency energy (ulRFER) cognate for the treatment of pediatric brain tumors.
METHOD(S): Sixteen patients with brain tumors consisting of diffuse midline glioma/diffuse intrinsic pontine glioma (DMG/DIPG, n=14), recurrent medulloblastoma (n=1), or anaplastic astrocytoma (n=1) - were treated with the Halo under FDA's single-patient compassionate use pathway, as protocol deviations in a glioblastoma trial, or under TGA's Special Access Scheme. Baseline information and on-treatment safety and exposure data were collected.
RESULT(S): Patients ranged in age from 4 to 28 years (median = 8 years) and were diagnosed 91 - 1399 days (median = 397 days) prior to treatment with the Halo system. Patients were treated for 2 - 52 weeks (median = 15 weeks), with 4 patients still alive (all with a diagnosis of DMG/DIPG), and 3 still on treatment (ranging 18 - 52 weeks). Two out of the 16 patients reported mild-moderate adverse events - one patient reported nausea, fatigue, and excessive sleepiness, and one patient reported vomiting. No device-related serious adverse events were reported. Other adverse events reported were generally associated with progressive disease. Unsolicited, anecdotal reports from some parents/caregivers noted improvements in mobility, speech, and visual acuity while on treatment.
CONCLUSION(S): The Halo system appears to be safe and feasible for the treatment of pediatric brain tumors. Given that therapy is delivered non-invasively and no device-related serious adverse events were reported, further prospective study of the investigational device is warranted

To meet the United Nations Sustainable Development Goals (SDGs) in the United States, research by nurses and midwives has a real opportunity to make a significant impact. This paper identifies opportunities to strengthen research capacity in the United States amongst nurses and midwives in ways that will help meet the SDGs and ensure its sustainability. Research capacity means that in a country, there are individuals and teams capable of defining problems, setting priorities, establishing objectives for the goals of the research study, and following rigorous scientific procedures. By strengthening U.S. research capacity by addressing critical weaknesses in content expertise, nursing and midwifery's voices in policy dialogues, and global research initiatives will be have greater assurance of being included.

BACKGROUND:Heart failure is a heavy burden to the health care system in the United States. Once heart failure develops, the quality of life and longevity are dramatically affected. It is critical to prevent it. We evaluated the predictive ability of readily available clinical information to identify those likely to develop heart failure. METHODS:We used a CART model to determine the top predictors for heart failure incidence using the NHANES Epidemiologic Follow-up Study (NHEFS). The identified predictors were hypertension, diabetes, obesity, and myocardial infarction (MI). We evaluated the relationship between these variables and incident heart failure by the product-limit method and Cox models. All analyses incorporated the complex sample design to provide population estimates. RESULTS:We analyzed data from 14,407 adults in the NHEFS. Participants with diabetes, MI, hypertension, or obesity had a higher incidence of heart failure than those without risk factors, with diabetes and MI being the most potent predictors. Individuals with multiple risk factors had a higher incidence of heart failure as well as a higher hazard ratio than those with just one risk factor. Combinations that included diabetes and MI had the highest incidence rates of heart failure per 1000 person years and the highest hazard ratios for incident heart failure. CONCLUSIONS:Having diabetes, MI, hypertension or obesity significantly increased the risk for incident heart failure, especially combinations including diabetes and MI. This suggests that individuals with these conditions, singly or in combination, should be prioritized in efforts to predict and prevent heart failure incidence.

OBJECTIVE:Presenting the diagnosis of psychogenic nonepileptic seizures (PNES) can be a difficult task, but disclosing this information effectively is important to optimize patient outcomes. We sought to develop a standardized method to teach neurology residents how to introduce the diagnosis of PNES via an objective structured clinical examination (OSCE) with a standardized patient (SP). METHODS:In conjunction with the New York University School of Medicine Simulation Center (NYSIM), we designed an OSCE in which a resident had to inform a SP of her diagnosis of PNES and discuss a treatment plan. The SP was provided with details to gradually disclose depending on what the resident said about the history of her episodes, triggers for her episodes and her history of sexual abuse. Each encounter was observed by an attending physician who provided real-time feedback to the resident after the session. Additionally, the SP completed an objective written checklist of items the resident should have covered in the session and gave them verbal feedback. RESULTS:Twenty-six adult neurology (n = 22), child neurology (n = 3), and neuropsychiatry (n = 1) residents participated in this OSCE in 2018 and 2019, with full data available for 25 participants. Residents reported the OSCE was very useful (mean Likert score of 4.9/5). They felt moderately prepared (mean Likert score 3.8/5) and rated their performance as a mean of 3.3/5. On the SP's checklist, most residents were rated as Well Done in the domains of information gathering, relationship development, and education and counseling. Only in the domain of psychosocial assessment were most residents rated as Not Done (only 7/25 inquired about past trauma as a risk factor for PNES). SIGNIFICANCE/CONCLUSIONS:The OSCEs are a feasible and useful way to teach neurology residents about discussing PNES, as they allow for provision of real-time practice and feedback in a safe environment without real patients.

Since at least T. H. Marshall, scholars have recognized military service as a form of sacrifice that warrants compensation from the state. War-widow pensions, expansion of the franchise, and subsidized higher education are all examples of rights and benefits "bestowed" in return for wartime mobilization. Similarly, in the United States, governments have hired veterans preferentially for civilian public jobs as recompense for active military service. Although oft overlooked, those policies seem influential: the percentage of job holders identifying as veterans in the civilian US executive branch exceeds the proportion in the wider population by several multiples. This century-old pattern suggests another way that wartime mobilization has influenced the state. Yet, efforts to understand it have struggled to rule out the possibility that those who serve in the armed forces are predisposed to work for the state in both military and civilian capacities. Here, we rule out this possibility by examining whether birthdates randomly called for induction in the Vietnam-Era Selective Service Lotteries (VSSL) appear disproportionately in the population of nonsensitive personnel records of the civilian US executive branch. We find that birthdates called for induction appear with unusually high frequency among employees who were draft eligible and at risk for induction but not among other employees. This finding suggests a treatment effect from military service, thus dovetailing with the hypothesis that wartime mobilization has substantially and continually influenced who works in the contemporary administrative state.