Faculty Bibliography

Background/UNASSIGNED:A growing body of research continues to elucidate health inequities experienced by transgender individuals and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that cause transgender health inequities as well as improve knowledge about transgender-specific care. Methods/UNASSIGNED:We conducted structured searches of five databases to identify literature related to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were deemed relevant to predefined criteria, medical education, and transgender health topics. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017. Results/UNASSIGNED:Transgender health has yet to gain widespread curricular exposure, but efforts toward incorporating transgender health into both undergraduate and graduate medical educations are nascent. There is no consensus on the exact educational interventions that should be used to address transgender health. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support. All published interventions proved effective in improving attitudes, knowledge, and/or skills necessary to achieve clinical competency with transgender patients. Conclusion/UNASSIGNED:Transgender populations experience health inequities in part due to the exclusion of transgender-specific health needs from medical school and residency curricula. Currently, transgender medical education is largely composed of one-time attitude and awareness-based interventions that show significant short-term improvements but suffer methodologically. Consensus in the existing literature supports educational efforts to shift toward pedagogical interventions that are longitudinally integrated and clinical skills based, and we include a series of recommendations to affirm and guide such an undertaking.

Background: The New York University (NYU) internal medicine residency program converted to block schedule in July 2015. Sixty-five NYU residents have their continuity clinic site at New York Harbor VA (VA). Here, we practice in the medical home model (termed PACT), with NYU residents divided into 3 PACT teams. When we implement block scheduling, we also developed team-based group practices within these PACTs. Cohorts of resident providers serve as coverage for their fellow PACT residents when they are busy with inpatient responsibilities. Methods: This study evaluates the impact of a scheduling change and the implementation of group practices among residents at the VA from April 2015-June 2016; we surveyed residents from Bellevue Hospital over the same period for comparison. We estimated the impact of interventions on the following clinical outcomes: hypertension control, diabetes control, smoking cessation rates, influenza vaccination rates, and age-appropriate cancer screening rates for patients empaneled in the VA residents' clinics by comparing FY2014 data to FY2016 data. For each outcome, we estimated changes using linear regression models. We also estimated the impact of the intervention on residents' perceptions of self-efficacy, knowledge, and clinic workload & coordination. These were measured by factor scores generated from confirmatory factor analysis of answers to 23 survey questions administered before and after the intervention. The confirmatory factor model fit the data well according to standard metrics (RMSEA = 0.00; NNFI = 1.0). Results: Influenza vaccination rates and hypertension control increased significantly during the study period. Change in the other outcomes-smoking cessation, mammogram screening, colorectal cancer screening, hypertension control and diabetes control-was in the predicted direction but not significant. In terms of changesin attitudes over the study period, we used linear regression models from three specifications-the full sample with no controls, the full sample with a control for cohort, and the paired sample of pre-and post-tests. We found that the intervention positively impacted residents' perceptions of clinic workload & coordination as well as their perceptions of relevant knowledge. The impact on self-efficacy is less clear, since the difference was only significant among the full sample, but not in the other two specifications. Conclusions: The transition to block scheduling and the creation of group practices within the VA resident clinics has had a positive impact both on resident attitudes towards VA clinic and on clinical outcomes. Specifically, residents' knowledge of clinic functioning and perception of clinic workload & coordination improved. We also saw statistically significant improvements in influenza vaccination rates and hypertension control and no worsening in tobacco cessation rates, diabetes control, or age-appropriate cancer screening rates. Thus, this change improved training and had an impact on health outcomes

Background: Many uremic retention solutes are products of gut bacterial metabolism. Protein-binding renders these solutes poorly dialyzable. In a prior study we observed that a single dose of 250 mg of vancomycin, given by mouth, resulted in a significant (40%) decrease in the plasma concentration of indoxyl sulfate and p-cresyl sulfate over a period of one week. In this study we compared the changes in plasma concentration of a panel of protein-bound uremic retention solutes in response to the once-weekly oral administration of 250 mg of vancomycin or placebo over a period of 8 weeks.
Method(s): Eight subjects with chronic, stable ESRD on thrice-weekly hemodialysis via AV fistula in the River Renal Dialysis Unit in Bellevue Hospital, were randomized to two groups, utilizing a single-blinded procedure. Baseline plasma samples were collected prior to the initial dose of vancomycin or placebo and at weeks one, two, three, four, and eight. Uremic retention solutes were measured by MS-HPLC.
Result(s): Six of the eight uremic retention solutes (Table 1) demonstrated a significant decline in concentration over the eight week period of once-weekly vancomycin administration. The magnitude of the decline makes it more likely that gut production was reduced rather than renal excretion increased. Solute concentrations remained unchanged over the same period of placebo administration.
Conclusion(s): The significant decline in the plasma concentrations of multiple uremic retention solutes provides evidence of the importance of the gut microbiome in the generation of these solutes. The reduction in concentrations of indoxyl sulfate, p-cresyl sulfate, and kynurenic acid, recognized as likely uremic toxins, suggests that altering the gut microbiome might provide a valuable therapeutic strategy in the management of ESRD