Faculty Bibliography

PURPOSE/OBJECTIVE:Peptide receptor radionuclide therapy (PRRT) with the radiolabeled somatostatin analogue [Lutetium-177-DOTA0-Tyr3]octreotate (177Lu-DOTATATE) is widely applied for inoperable metastatic small intestinal and nonfunctioning pancreatic neuroendocrine tumors (pNETs). The aim of this study is to describe the safety and efficacy of the treatment of functioning pNETs. METHODS:Patients were treated with up to four cycles of 177Lu-DOTATATE with an intended dose of 7.4 Gbq per cycle. Radiological (Response Evaluation Criteria in Solid Tumors 1.1), symptomatic, and biochemical response were analyzed retrospectively for all patients with a functioning pNET (insulinoma, gastrinoma, VIPoma, and glucagonoma) treated with 177Lu-DOTATATE. Quality of life (QOL) was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core Module questionnaire. RESULTS:Thirty-four patients with a metastatic functioning pNET (European Neuroendocrine Tumor Society grade 1 or 2) were included: 14 insulinomas, 5 VIPomas, 7 gastrinomas, and 8 glucagonomas. Subacute hematological toxicity, grade 3 or 4 occurred in 4 patients (12%) and a hormonal crisis in 3 patients (9%). PRRT resulted in partial or complete response in 59% of patients and the disease control rate was 78% in patients with baseline progression. 71% of patients with uncontrolled symptoms had a reduction of symptoms and a more than 80% decrease of circulating hormone levels was measured during follow-up. After PRRT, median progression-free survival was 18.1 months (interquartile range: 3.3 to 35.7) with a concurrent increase in QOL. CONCLUSION/CONCLUSIONS:Treatment with 177Lu-DOTATATE is a safe and effective therapy resulting in radiological, symptomatic and biochemical response in a high percentage of patients with metastatic functioning pNETs. Hormonal crises occur relatively frequent and preventive therapy should be considered before and/or during PRRT.

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:Awareness of disease status has been identified as a factor in the treatment decision-making process. Women with recurrent ovarian cancer are facing the challenge of making treatment decisions throughout the disease trajectory. It is not understood how women with ovarian cancer perceive their disease and subsequently make treatment decisions. PURPOSE/OBJECTIVE:The purpose of this phenomenological study was to understand the lived experience of women with recurrent ovarian cancer, how they understood their disease and made their treatment decisions. METHODS:A qualitative design with a descriptive phenomenological method was used to conduct 2 in-depth interviews with 12 women (n = 24 interviews). Each interview was ∼60 minutes and was digitally recorded and professionally transcribed. Data collection focused on patients' understanding of their disease and how patients participated in treatment decisions. A modified version of Colaizzi's method of phenomenological reduction guided data analysis. RESULTS:Three themes emerged to describe the phenomenon of being aware of disease status: (1) perceiving recurrent ovarian cancer as a chronic illness, (2) perceived inability to make treatment decisions, and (3) enduring emotional distress. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:This study revealed how 12 women conceptualized recurrent ovarian cancer as a chronic disease and their perceived inability to make treatment decisions because of lack of information and professional qualifications, resulting in enduring emotional distress. Future research should replicate the study to confirm the persistence of the themes for racially, ethnically, and religiously diverse patient samples and to improve understanding of awareness of disease status and decision-making processes of patients.

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

Introduction: It is widely held that the likelihood of having a sleep disorder increases with age and that this is especially true of Insomnia, OSA, and RLS. Few studies, however, have been conducted that concurrently assess how symptoms vary with age while simultaneously taking into account multiple sleep disorders. The present analysis evaluates the prevalence of ten sleep disorders symptoms across four age cohorts.
Method(s): An archival analysis was conducted on an existing database of 4,206 individuals who completed an on-line screening survey at 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]). The sleep disorders symptoms assessed were for insomnia (problems with SL, WASO or EMA), snoring, [witnessed apneas], gasping, AM headaches, EDS, sleep attacks, muscular weakness with strong emotion, nightmares, and unpleasant sensations in the legs near bedtime. Contingency and Chi-Square analyses were used to assess for age group differences.
Result(s): Each age group was comprised of 180 subjects (total n=720, ~55% female). There were significant age related differences (and linear trends) for: Insomnia ([All:85.8%]; [YA:73.3%]<[A:87 .8%]=[MA:88.3%]<[OA:93.9%],p < 0.001); Snoring ([All:44.2%]; [YA:26.7%]<[A:41.1%]<[MA:55%]>[OA:53.9%],p < 0.001); and Witnessed apneas ([All: 28.1%]; [YA:17.8%]<[A:27.2%]=[MA:33. 3%]=[OA:33.9%],p = 0.002). There were age group differences (but not linear trends) for: Nightmares ([All: 50.7%]; [YA:57.2%]=[MA :57.2%]=[A:48.3%]>[OA:40%],p = 0.002); Headaches ([All:31.4%]; [A:43.3%]>[MA:32.2%]=[YA:29.4%]>[OA:20.6%], p < 0.001); and Muscular weakness ([All: 25.7%]; [A:30.6%)=[YA:28.9%)=[MA:25 .6%)>[OA:17.8%],p = 0.028). There were no significant age differences for EDS (All:53.6%), gasping (All:20.6%), RLS symptoms (All:22.1%), or sleep attacks (All:17.2%).
Conclusion(s): While sleep disorders symptoms vary with age, linear trends appear to be evident only for insomnia and the OSA symptoms of snoring and witnessed apneas. Note: One limitation of the present analysis is that the sample was populated by subjects with sleep complaints. This resulted in higher overall prevalence than is typical in population data

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.

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

Rising physician burnout has adverse effects on healthcare. This study aimed to identify remediable stressors associated with burnout using the 10-item Mini-Z and the Maslach Burnout Inventory (MBI), and to compare performance of the Mini-Z's single-item burnout metric against the 22-item MBI. Surveys were emailed to 4,118 clinicians affiliated with an academic health system; 1,252 clicked the link, and 557 responded (completion rate 44%). Four hundred seventy-five practicing physicians were included: academic faculty (372), hospital employed (52), and private practitioners (81). Prevalence of burnout via the MBI was 56.6%. Predictors of burnout were poor control over workload [OR = 8.24, 95% CI 4.(81, 14.11)], inefficient teamwork [OR = 7.61, 95% (CI 3.28, 17.67)], insufficient documentation time [OR = 5.83, 95% (CI 3.35, 10.15)], hectic-chaotic work atmosphere [OR = 3.49, 95% (CI 2.12, 5.74)], lack of value-alignment with leadership [OR = 3.27, 95% (CI 2.12, 5.74)], and excessive electronic medical record time at home [OR = 1.99, 95% CI (1.21, 3.27)]. Academic faculty experienced more burnout than private practitioners (59.9% vs. 42.0%, p = 0.013). Odds of burnout associated with stressors were generally concordant via Mini-Z's burnout metric versus the MBI. The Mini-Z is a brief, valid method to identify stressors associated with burnout and guide interventions.

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

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.