Faculty Bibliography

The overall nutritional quality of foods/drinks available at urban food pantries is not well established. In a study of 50 pantries listed as operating in the Bronx, NY, data on food/drink type (fresh, shelf-stable, refrigerated/frozen) came from direct observation. Data on food/drink sourcing (food bank or other) and distribution (prefilled bag vs. client choice for a given client's position in line) came from semi-structured interviews with pantry workers. Overall nutritional quality was determined using NuVal® scores (range 1-100; higher score indicates higher nutritional quality). Twenty-nine pantries offered zero nutrition at listed times (actually being closed or having no food/drinks in stock). Of the 21 pantries that were open as listed and had foods/drinks to offer, 12 distributed items in prefilled bags (traditional pantries), 9 allowed for client choice. Mean NuVal® scores were higher for foods/drinks available from client-choice pantries than traditional pantries (69.3 vs. 57.4), driven mostly by sourcing fresh items (at 28.3% of client-choice pantries vs. 4.8% of traditional pantries). For a hypothetical 'balanced basket' of one of each fruit, vegetable, grain, dairy and protein item, highest-NuVal® items had a mean score of 98.8 across client-choice pantries versus 96.6 across traditional pantries; lowest-NuVal® items had mean scores of 16.4 and 35.4 respectively. Pantry workers reported lower-scoring items (e.g., white rice) were more popular-appeared in early bags or were selected first-leaving higher-scoring items (e.g., brown rice) for clients later in line. Fewer than 50% of sampled pantries were open and had food/drink to offer at listed times. Nutritional quality varied by item type and sourcing and could also vary by distribution method and client position in line. Findings suggest opportunities for pantry operation, client and staff education, and additional research.

Cushing's syndrome is associated with multisystem morbidity and, when suboptimally treated, increased mortality. Medical therapy is an option for patients if surgery is not successful and can be classified into pituitary-directed drugs, steroid synthesis inhibitors, and glucocorticoid receptor antagonists. In the last decade there have been new developments in each drug category. Targeting dopamine and somatostatin receptors on corticotroph adenomas with cabergoline or pasireotide, or both, controls cortisol production in up to 40% of patients. Potential new targets in corticotroph adenomas include the epidermal growth factor receptor, cyclin-dependent kinases, and heat shock protein 90. Osilodrostat and levoketoconazole are new inhibitors of steroidogenesis and are currently being evaluated in multicentre trials. CORT125134 is a new selective glucocorticoid receptor antagonist under investigation. We summarise the drug therapies for various forms of Cushing's syndrome and focus on emerging drugs and drug targets that have the potential for new and effective tailor-made pharmacotherapy for patients with Cushing's syndrome.

Klebsiella pneumoniae sequence type (ST) 307 is an emerging global antimicrobial drug-resistant clone. We used whole-genome sequencing and PCR to characterize K. pneumoniae ST307 with oxacillinase (OXA) 181 carbapenemase across several private hospitals in South Africa during 2014-2016. The South Africa ST307 belonged to a different clade (clade VI) with unique genomic characteristics when compared with global ST307 (clades I-V). Bayesian evolution analysis showed that clade VI emerged around March 2013 in Gauteng Province, South Africa, and then evolved during 2014 into 2 distinct lineages. K. pneumoniae ST307 clade VI with OXA-181 disseminated over a 15-month period within 42 hospitals in 23 cities across 6 northeastern provinces, affecting 350 patients. The rapid expansion of ST307 was most likely due to intrahospital, interhospital, intercity, and interprovince movements of patients. This study highlights the importance of molecular surveillance for tracking emerging antimicrobial clones.

Following a 1983 chromic acid (hexavalent chromium [CrVI]) spill from a Garfield, NJ electroplating plant, CrVI-contaminated water was found in a local firehouse basement in 1993. An ATSDR public health advisory was issued for the plant site in 2010, and from 2008-2015, fourteen residential properties have required remediation to address CrVI-contaminated dust in the basements. As part of the Community Outreach and Engagement Core of the NYU NIEHS Center, seventytwo Garfield residents aged 18-65 years, participated in a community survey with the goal of identifying concerns related to environmental and community health. Thirty-two percent responded that they 'didn't know' if they were exposed to chemicals or pollutants where they live. This finding suggests a limited awareness of environmental chemical exposures, chromium contamination and/or potential exposure to CrVI. Furthermore, toenail clippings were collected from forty-seven Garfield residents and analyzed for total chromium levels to assess potential long-term exposure. On average, residents living on/inside the contaminated plume area had higher total chromium levels in their toenail clippings than residents living outside the plume area. However, chromium levels for all participants were within the range of historical normal. This study highlights the value of partnerships between environmentally-impacted community's and academic scientists working together to identify potential contaminant exposures and address public health concerns through research and environmental health education.

Background: Although the population of older adults is rising rapidly, the number of physicians seeking specialty training in geriat-rics is decreasing. This study of fellows in geriatrics training programs across the United States explored motivating factors that led fellows to pursue geriatrics as a career in order to inform the recruiting of more trainees to the field.
Method(s): 10-15 fellows were sought for interviews, until satu-ration was reached. 30-minute semi-structured telephone interviews were conducted by the primary investigator with fifteen geriatrics fellows from academic medical centers across the United States, 14 of whom were at Claude D. Pepper Older Americans Independence Centers. This qualitative study involved interviews that were tran-scribed and descriptively coded by two independent reviewers. A thematic analysis of the codes was summarized.
Result(s): Fifteen geriatrics fellows in seven different states partic-ipated in the study, and they revealed that mentorship and early clin-ical exposure to geriatrics were some of the most influential factors affecting career choice. Having positive attitudes and close relation-ships with older adults prior to medical school are other critical factors in influencing trainees to pursue careers in geriatrics.
Conclusion(s): The results of this study have the potential for a large impact, helping to inform best practices in encouraging trainees to enter the field, and enhancing medical student and resident exposure to geriatrics and mentorship from geriatricians. As the number of older individuals rises, we need innovative ways to draw medical students and residents to geriatrics. This study demonstrates the need for geri-atricians to serve not only as mentors to trainees but also as proactive ambassadors to the field

OBJECTIVE:Tildrakizumab, an inhibitor of the p19 subunit of interleukin (IL)-23, was recently Food and Drug Administration (FDA) approved for patients with moderate to severe psoriasis. This article will review the phase II and III clinical trial data of tildrakizumab. DATA SOURCES:A PubMed search from January 2000 to September 2018 was done with the search terms tildrakizumab, guselkumab, risankizumab, p19, interleukin-23, and psoriasis. STUDY SELECTION AND DATA EXTRACTION:Articles discussing phase II and III clinical trial data for tildrakizumab were selected. DATA SYNTHESIS:In phase II and phase III trials, tildrakizumab was safe and efficacious compared with placebo and etanercept. More patients achieved Psoriasis Area and Severity Index 75 receiving tildrakizumab (200 mg, 62%-74%; 100 mg, 61%-66%; 25 mg, 64%; 5 mg, 33%) compared with placebo (4%-6%, P < 0.0001) and etanercept (48%, P = 0.01). More patients achieved Physician Global Assessment (PGA) response of "clear" or "minimal" receiving tildrakizumab (200 mg, 59%; 100 mg, 55%-58%) than the placebo group (4%-7%, P < 0.0001). 59% of patients who received tildrakizumab 200 mg achieved a PGA response of "clear" or "minimal" compared with etanercept (48%, P = 0.0031). The most common adverse effect was infection. Relevance to Patient Care and Clinical Practice: Tildrakizumab is a new, FDA-approved, physician-administered biological therapy for patients with moderate to severe psoriasis. It appears to be efficacious and safe so far. CONCLUSION:Tildrakizumab is efficacious and safe for the treatment of patients with moderate to severe psoriasis. IL-23/p19 inhibitors are a promising class of biological therapy.

OBJECTIVE:Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less. DESIGN/METHODS:Retrospective cohort study. SETTING AND PARTICIPANTS/METHODS:All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home. MEASURES/METHODS:Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge. RESULTS:Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78). CONCLUSIONS/IMPLICATIONS/CONCLUSIONS:The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition.

Introduction: Older adults are thought to be particularly prone to insomnia. What is less clear is the extent to which this general observation 1) applies to specific measures and 2) corresponds to sleep dissatisfaction. The aim of the present analysis was to evaluate how sleep continuity disturbance (SCD) and problem endorsement vary by age.
Method(s): An archival analysis was conducted with an existing database of 4,206 individuals who completed an online screening survey (https://urldefense.proofpoint.com/v2/url?u=http- 3A__www.sleeplessinphilly.com&d=DwIBAg&c=j5oPpO0eBH1iio48DtsedeElZfc04rx3ExJHeIIZuCs&r=CY_ mkeBghQnUPnp2mckgsNSbUXISJaiBQUhM-Uz9W58&m=_icVcFoc7ulJmPF3ojT4VQ- keh3a2N4OhtHGRLx7AN4&s=GRc5DD1Hlq9WkqeVHjBH7X9hXNa8mcKsHyVAl9iK8QI&e=). Subjects were grouped into four age categories (matched for race, BMI, and gender): Young Adults (YA[18-29]), Adults (A[30-44]), Middle Aged Adults (MA[45-65]) and Older Adults (OA[65-89]). One-way ANOVA's were utilized to evaluate differences between groups for sleep latency (SL), number of awakenings (NWAK), wake after sleep onset (WASO), early morning awakenings (EMA), and total sleep time (TST). Problem endorsements (i.e., "do you consider this a problem?") were assessed with Contingency and/or Chi-Square analyses for each SCD variable.
Result(s): Each group was comprised of 180 subjects (total n=720, ~55% female). Sleep initiation problems did not become more severe with age. In contrast, sleep maintenance problems worsened with age (> WASO, > EMA, < TST). Problem endorsements appeared to parallel severity trends. Mean severity data are as follows. SL ([All: 42.2min]; [YA:43.2]=[A:45.6]=[MA:39.9]=[OA:40.0 ],p = 0.213); NWAK ([All: 2.6]; [YA:2.2]<[A:2.8]=[MA:2.8]=[OA:2.7 ],p = 0.001); WASO ([All: 37.6min]; [YA:22.6]<[A:36.1]=[MA:40.9]=[OA:45.7 ],p < 0.001); EMA ([All: 61.8min]; [YA:53.1]=[A:57.5]=[MA:63.8]=[OA:71.2],p < 0.001); and TST ([All: 342.1min]; [YA:365.7]>[A:334.7]=[MA:326.3]=[OA:34 1.7],p < 0.001). Percent problem endorsement data are as follows. SL ([All: 76.4%]; [YA:69.9%]<[A:82.8%]=[MA:75.0%]=[OA:78.0% ],p = 0.045); NWAK ([All: 77.3%]; [YA:62.2%]<[A:83.8%]=[MA:80.9%]=[OA: 81.4%],p < 0.001); WASO ([All: 85.5%]; [YA:69.7%]<[A:87.4%]=[MA:91.6%]=[OA:8 9.6%],p < 0.001); EMA ([All: 76.6%]; [YA:58.4%]<[A:82.8%]=[MA:78.4%]<[OA:84 .9%],p < 0.001); and TST ([All: 72.4%]; [YA:56.1%]<[A:76.1%]=[MA:78.9%]=[OA:78.3 %],p < 0.001).
Conclusion(s): More sophisticated analyses are on-going to determine the degree to which SCD symptom severity predicts the likelihood of problem endorsement, and what other factors may influence the report of sleep satisfaction, and whether these vary with age

Background/Purpose: Despite the increasing trend toward ambulatory surgery rate in general, for cleft lip repair, 72.1% of patients in the United States are still hospitalized. Multiple centers have been studying this and with the very recent publishing of 2 large volume studies published in Plastic and Reconstructive Surgery supporting the safety of outpatient cleft lip surgery, it has become a high-profile debatable topic in cleft management. Last year at ACPA in the plastic surgery breakout session there was a heated debate on the topic between surgeons. And just this summer, one of the authors articles was featured as the PRS Journal Club article of the month via Social media, where there were 68 comments, 11 shares, and 40 likes, which placed the article in the TOP 15 most viewed article in PRS Journal's website. So this is a topic that more and more surgeons and craniofacial teams are thinking about and considering changing practice management but that deserves being brought into the spotlight to discuss all the pros and cons. The goal of the presentation are to present a literature review up to date on inpatient versus outpatient cleft lip surgery and have members of the panel share their and data behind their approach to postoperative cleft lip management. We would like to focus on what has been studied and reported versus what people practice because "that is how they were trained" or that is how they "historically" have always done it. Methods/Description: We will start with an overview of the literature surrounding inpatient versus outpatient cleft lip surgery and epidemiology about the numbers of institutions that do inpatients versus outpatient. If possible, we would like to include an audience poll to get an idea of practice patterns in the room. Then based on the recent published studies, each panelist will share different protocols that have been successful for outpatient cleft lip management and how that could be implemented if a center wants to consider outpatient cleft lip surgery. This includes: preoperative education that can be done by the team or nurse managers, perioperative management before, during, and after the operation, and postoperative care after they go home. All are very key components to a successful outpatient cleft lip management. We will also discuss the barriers to doing outpatient cleft lip surgery as well as having a panelist who consistently does inpatient cleft lip surgery to present the rationale behind their practice management and also their barriers to outpatient cleft lip surgery. I have reached out to a few people and will be discussing with them at the upcoming ASPS meeting to see who may be interested in joining the panel to discuss that. We will discuss the economic impact overall of practice changes to a predominantly outpatient surgery and also potential insurance policy impact. We think this will be a very useful topic for any team member participating in the care of a cleft lip patient

We examined the prevalence of infection with human papillomavirus (HPV) and HIV in a cohort of young gay, bisexual, and other men who have sex with men [sexual minority men (SMM)]. HPV vaccination uptake was assessed; HIV antibody testing was performed and genetic testing for oral and anal HPV infection was undertaken. We examined both HPV vaccination and infection in relation to key demographic and structural variables. Participants (n = 486) were on average 23 years old; 70% identified as a member of a racial/ethnic minority group, and 7% identified as transgender females. Only 18.1% of the participants indicated having received the full dosage of HPV vaccination and 45.1% were unvaccinated. Slightly over half the participants (58.6%) were infected with HPV, with 58.1% testing positive for anal infection and 8.8% for oral infection. HIV seropositivity was associated with infection to oral HPV [adjusted odds ratio (AOR) = 4.03] and vaccine-preventable HPV, whereas both neighborhood-level poverty (AOR = 1.68) and HIV infection (AOR = 31.13) were associated with anal infection to HPV (AOR = 1.68). Prevalence of HPV infection is high among unvaccinated young SMM, despite the availability and eligibility for vaccination. HPV infection adds further health burden to these populations and is particularly concerning for those who are HIV positive as HIV infection increases the risk of developing HPV-related cancers. These findings underscore a missed prevention opportunity for an at-risk and underserved population and suggest the need for active strategies to increase HPV vaccination uptake in young SMM before the onset of sexual behavior.