Faculty Bibliography

OBJECTIVES/OBJECTIVE:To determine whether biomarkers of endothelial activation and inflammation provide added value for prediction of in-hospital mortality within 28 days when combined with physician judgment in critically ill emergency department patients. DESIGN/METHODS:Prospective, observational study. SETTING/METHODS:Two urban, academic emergency departments, with ≈80,000 combined annual visits, between June 2016 and December 2017. PATIENTS/METHODS:Admitted patients, greater than 17 years old, with two systemic inflammatory response syndrome criteria and organ dysfunction, systolic blood pressure less than 90 mm Hg, or lactate greater than 4.0 mmol/L. Patients with trauma, intracranial hemorrhage known prior to arrival, or without available blood samples were excluded. INTERVENTIONS/METHODS:Emergency department physicians reported likelihood of in-hospital mortality (0-100%) by survey at hospital admission. Remnant EDTA blood samples, drawn during the emergency department stay, were used to measure angiopoietin-1, angiopoietin-2, tumor necrosis factor receptor-1, interleukin-6, and interleukin-8. MEASUREMENTS AND MAIN RESULTS/RESULTS:We screened 421 patients and enrolled 314. The primary outcome of in-hospital mortality within 28 days occurred in 31 (9.9%). When predicting the primary outcome, the best biomarker model included angiopoietin-2 and interleukin-6 and performed moderately well (area under the curve, 0.72; 95% CI, 0.69-0.75), as did physician judgment (area under the curve, 0.78; 95% CI, 0.74-0.82). Combining physician judgment and biomarker models improved performance (area under the curve, 0.85; 95% CI, 0.82-0.87), with area under the curve change of 0.06 (95% CI, 0.04-0.09; p < 0.01) compared with physician judgment alone. CONCLUSIONS:Predicting in-hospital mortality within 28 days among critically ill emergency department patients may be improved by including biomarkers of endothelial activation and inflammation in combination with emergency department physician judgment.

Burnout among doctors appears to be at epidemic proportions these days, with concomitant gushing prescriptions for wellness and resilience. But in reality, most doctors are not burned out, in the traditional sense of the word: most love taking care of patients and want nothing more than to be able to do just that. The source of the agony is the profession-or rather the corporatization of the profession-that has so impinged upon the doctors' ability to practice medicine. Doctors placed their trust in the medical profession, but that trust has been roundly trounced. So, rather than prescribe Pilates classes for overstressed doctors, it is time for the medical profession-and the health care industry that has subsumed it-to get a check-up.

BACKGROUND:Hidradenitis suppurativa (HS) is a chronic inflammatory condition. OBJECTIVE:To measure emotional well-being in HS patients and compare to other populations, assess if there is an effect of disease severity on emotional well-being, and determine if emotional well-being is correlated with quality of life and depression. METHODS:A total of 153 HS subjects were recruited, and 66 Positive and Negative Affect Schedule (PANAS) surveys assessing emotional well-being were completed. Norms for comparison populations (disease-free undergraduates and adults) were used. A validated self-assessment tool was used to determine disease severity. Subjects completed the Patient Health Questionnaire-9 (PHQ-9) and Dermatology Life Quality Index (DLQI) to examine depression and quality of life, respectively. RESULTS:< 0.00001). CONCLUSION/CONCLUSIONS:HS patients have poor emotional well-being. PANAS scores correlated with worse quality of life and depression. Providing appropriate resources and treatments may be beneficial for HS patients.

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

Barriers to following dietary recommendations have been described; however, they remain poorly understood. The purpose of this qualitative study was to explore perceived barriers to adherence to dietary recommendations in a diverse hemodialysis patient population. Participants were eligible to participate in a semi-structured qualitative telephone interview prior to randomization for an ongoing clinical trial to evaluate the efficacy of an intervention designed to reduce dietary sodium intake. Interviews were digitally recorded, transcribed verbatim and coded using an iterative qualitative process. In total, 30 (37% females, 53% Caucasians) participants, 63.2 ± 13.3 years, were interviewed. Time, convenience, and financial constraints hindered dietary adherence. Dietary counseling efforts were rated positively but require individualization. Ability to follow recommended guidelines was challenging. Suggestions for addressing barriers include technology-based interventions that allow patients to improve food choices and real-time decision-making, and permit tailoring to individual barriers and preferences.

INTRODUCTION/BACKGROUND:The purpose of this study is to examine awareness, attitudes, and related knowledge of e-cigarettes, and JUUL specifically, among parents of middle and high school students. METHODS:Data were collected in October-November 2018 from a nationally representative sample of U.S. parents of middle and high school students aged 11-18 years (n=2,885) to examine e-cigarette and JUUL awareness, concern about e-cigarette use, and school communication regarding e-cigarettes. Weighted frequencies and percentages are reported; Rao-Scott chi-square tests examined differences by school level. Data were analyzed in 2019. RESULTS:Although most parents (96.2%) had seen or heard of e-cigarettes, only 55.9% had seen or heard of JUUL, and only 44.2% accurately identified an image of JUUL as a vaping device. Many parents reported concern about adolescent e-cigarette use (60.6%), but fewer reported concern about their own child's use (32.9%). Most parents (73.5%) reported receiving no communication from their child's school about e-cigarettes or JUUL. CONCLUSIONS:There are notable gaps in parents' awareness of JUUL. School-to-parent communication efforts are necessary to build parents' knowledge of e-cigarettes like JUUL to prevent the growing youth uptake of these novel and addictive products.

BACKGROUND:Advanced tumors of the thoracic spine are difficult to treat and can lead to complex pain syndromes. Following conventional oncologic treatments, pharmacologic therapy may be insufficient to manage pain. Minimally invasive interventional procedures offer alternatives to treat malignant thoracic spinal pain. METHODS:Thirteen patients with metastatic disease and poorly controlled thoracic axial and/or radicular pain were identified via a retrospective chart review. Patients were either treated with radiation, surgery, chemotherapy, or a combination of these. Then, the patients were organized into groups based on their diagnoses, anatomical disease locations, symptoms, prior treatments, and interventional pain procedures offered. RESULTS:All cases of intercostal nerve, costotransverse junction, erector spinae plane, and paravertebral blocks resulted in pain relief without any reported complications. A patient who received a thoracic epidural injection had a complete resolution of pain when combined with radiation therapy two weeks after the injection. One patient who underwent repeat thoracic epidurals eventually had an intrathecal pump placement resulting in reduced opioid usage. Finally, one patient who received a thoracic medial branch block with a relief of thoracic axial pain reported greater pain relief with a medial branch nerve cryoablation. CONCLUSION/CONCLUSIONS:We propose a treatment algorithm to manage patients with thoracic spinal tumor-related pain. Interventional thoracic axial procedures may be safe and efficacious pain treatments for cancer patients. This article is protected by copyright. All rights reserved.

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.

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.

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)