Faculty Bibliography

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

Background: In an effort to bolster medical student wellbeing and mitigate burnout, NYU School of Medicine (NYUSOM) launched a longitudinal resiliency curriculum, coupled with a wellbeing self-assessment tool. We aim to study its impact on the development of knowledge, self-awareness, and practices related to wellbeing and resiliency. Methods: MD AWARE (Medical Students Developing Awareness, Wellbeing, and Resilience) was launched in August 2017 for the incoming NYUSOM class. It involves six interactive sessions implemented at critical junctions over the first three years of medical school. Each session includes a short lecture, followed by a small group activity led by trained facilitators. At the start of each small group session, students are asked to complete an anonymous online survey (results only provided to student). The self-assessment includes 19 items adapted from three validated assessment tools measuring different aspects of wellbeing and burnout. Students immediately receive three scores with explanations of each and the opportunity to debrief in their small group. Thus far, the students have participated in the first two sessions. In the first, students were introduced to research on physician burnout, the protective effects of resilience, and practiced a gratitude exercise. In the second, students were introduced to mindful awareness to identifying cognitive distortions and practiced reframing negative inner dialogue. After each, students completed a retrospective pre/post survey, using a 4-point likert scale, assessing knowledge, self-awareness, and comfort/confidence in activities to promote wellbeing. Comparison between the survey results were calculated using pair t-test. Results: Survey results were available for 106/118 (90%) students participating in the first session and 55/114 (48%) participating in the second. Results of both pre/post surveys showed significant improvement (p=<.01) on every item. Notably, after the first session, students reported a substantial increase in their comfort acknowledging stressors (31.1% very comfortable pre-vs 61.1% post-) and seeking help when in need (18.1% very comfortable pre-vs 45.2% post-). After the second session, students reported increased comfort practicing mindful awareness (65.5% comfortable/very comfortable pre-vs 90.9% post-), increased confidence both identifying cognitive distortions (59.2% comfortable/very comfortable pre-vs 96.3% post-) and reframing negative responses (47.2% comfortable/very comfortable pre-vs 81.8% post-). Conclusions: While many schools have looked at ways to foster wellbeing in their medical students, our curriculum is unique in its longitudinal nature and use of repeated wellbeing self-assessments. Preliminary assessment demonstrates a positive impact on medical students' knowledge, self-awareness, and practices around wellbeing and resilience. Thus, our novel curriculum is a promising way to bolster resiliency skills and mitigate burnout in this vulnerable population

Background: Conflicting data exists on the relationship between outpatient visits and emergency department (ED) visit and admission rates. While some have shown outpatient access prevents ED visits and admissions, others show that factors such as continuity are more important. A mental health diagnosis is consistently cited as a factor associated with increased inpatient utilization. There is little published data about resident-run outpatient clinics and their outcomes, including how these ambulatory contacts affect ED visit and admission rates. Methods: The medical record was used to collect data for all patients seen at least once in the primary care resident clinic at a large, public New York City hospital over the course of 1 academic year. We counted the number of outpatient visits per patient, regardless of type, including both primary care visits and clinic visits for all medical and surgical subspecialties. We controlled for the level of health of each patient using locally developed scores. Our primary outcomes were total number of ED visits and total number of inpatient admissions; secondary outcomes were inpatient length of stay (LOS) and admissions for ambulatory care sensitive conditions (ACSC). We conducted bivariate analyses, using T-Tests and ANOVA, and multivariate analysis, using ordinary least of squares regression, to determine whether increased contact with outpatient clinics was associated with ED visit and admission rates. A separate analysis was conducted for patients with a mental health diagnosis. Results: Our sample consisted of 2,988 patients, seen at least once in the resident-run primary care clinic, averaging 7 outpatient visits across all sub-specialties. There were 2,544 ED visits (1317 unique patients), 571 inpatient admissions (368 unique patients), and 126 ACSC admissions (97 unique patients). Patients who were hospitalized averaged 2 admissions; average LOS was 9.5 days. Multivariate analysis, controlling for sociodemographic and health factors, found more ambulatory care visits were associated with more ED visits and more inpatient admissions (p < 0.01). There was no statistically significant association between ambulatory care visits and LOS or ACSC admissions. A mental health diagnosis was associated with increased ambulatory care visits, and increased ED visits and inpatient admissions, and a 4 day longer LOS. Conclusions: Among patients seen in the resident internal medicine clinic, we were surprised to find that more outpatient visits were positively associated with more ED visits and admissions when controlling for all sociodemographic factors and health status. Our study adds to the body of literature, as there has been little previously published about resident clinic outcomes. Further studies are needed on how to improve these resident run clinics in order to help prevent ED visits and admission. Our study also showed that a mental health diagnosis was positively associated with ambulatory care visits, consistent with the previous literature

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