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)

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.

PURPOSE/OBJECTIVE:To develop natural language processing (NLP) to identify incidental lung nodules (ILNs) in radiology reports for assessment of management recommendations. METHOD AND MATERIALS/METHODS:We searched the electronic health records for patients who underwent chest CT during 2014 and 2017, before and after implementation of a department-wide dictation macro of the Fleischner Society recommendations. We randomly selected 950 unstructured chest CT reports and reviewed manually for ILNs. An NLP tool was trained and validated against the manually reviewed set, for the task of automated detection of ILNs with exclusion of previously known or definitively benign nodules. For ILNs found in the training and validation sets, we assessed whether reported management recommendations agreed with Fleischner Society guidelines. The guideline concordance of management recommendations was compared between 2014 and 2017. RESULTS:The NLP tool identified ILNs with sensitivity and specificity of 91.1% and 82.2%, respectively, in the validation set. Positive and negative predictive values were 59.7% and 97.0%. In reports of ILNs in the training and validation sets before versus after introduction of a Fleischner reporting macro, there was no difference in the proportion of reports with ILNs (108 of 500 [21.6%] versus 101 of 450 [22.4%]; P = .8), or in the proportion of reports with ILNs containing follow-up recommendations (75 of 108 [69.4%] versus 80 of 101 [79.2%]; P = .2]. Rates of recommendation guideline concordance were not significantly different before and after implementation of the standardized macro (52 of 75 [69.3%] versus 60 of 80 [75.0%]; P = .43). CONCLUSION/CONCLUSIONS:NLP reliably automates identification of ILNs in unstructured reports, pertinent to quality improvement efforts for ILN management.

OBJECTIVES:Chronic hepatitis B virus (HBV) infection is a lifelong infection that can cause serious liver damage and liver cancer. The last surveillance-based prevalence estimate of chronic HBV infection in New York City was 1.2% in 2008; however, it did not account for persons with undiagnosed infection. The objective of this study was to calculate the prevalence of chronic HBV infection, including undiagnosed infection, for 2016 by using surveillance data and literature-based information. METHODS:We calculated the number of persons with diagnosed chronic HBV infection (2000-2016) who were alive and living in New York City in 2016 by using routine surveillance data. We estimated the percentage of persons with undiagnosed chronic HBV infection by using birth region-specific percentages from the literature, weighted by the proportion of the New York City population with diagnosed chronic HBV infection from the same birth region. We identified minimum, maximum, and most likely values for the percentage with undiagnosed chronic HBV infection to generate 95% certainty limits (CLs) of the prevalence estimate. RESULTS:The prevalence of chronic HBV infection in 2016, including undiagnosed infection, in New York City was 2.7% (95% CL, 2.2%-3.6%), representing approximately 230 000 persons. The prevalence of diagnosed chronic HBV infection was 1.5%. The estimated prevalence among non-US-born residents was 6.9% (95% CL, 5.4%-8.9%). CONCLUSIONS:The current burden of chronic HBV infection in New York City, especially for non-US-born residents, is substantial. A renewed focus and dedication of resources is required to increase the number of new diagnoses and improve provider capacity to care for the large number of persons with chronic HBV infection.

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.

The treatment of bacterial infections is hindered by the presence of biofilms and metabolically inactive persisters. Here, we report the synthesis of an enantiomeric block co-beta-peptide, poly(amido-D-glucose)-block-poly(beta-L-lysine), with high yield and purity by one-shot one-pot anionic-ring opening (co)polymerization. The co-beta-peptide is bactericidal against methicillin-resistant Staphylococcus aureus (MRSA), including replicating, biofilm and persister bacterial cells, and also disperses biofilm biomass. It is active towards community-acquired and hospital-associated MRSA strains which are resistant to multiple drugs including vancomycin and daptomycin. Its antibacterial activity is superior to that of vancomycin in MRSA mouse and human ex vivo skin infection models, with no acute in vivo toxicity in repeated dosing in mice at above therapeutic levels. The copolymer displays bacteria-activated surfactant-like properties, resulting from contact with the bacterial envelope. Our results indicate that this class of non-toxic molecule, effective against different bacterial sub-populations, has promising potential for the treatment of S. aureus infections.