Faculty Bibliography

Needs and Objectives: Given the rise in mobile devices, it is critical that academic medical centers create new ways to support the educational, research, and patient care missions through mobile technology. Companion isa mobile app with a primary objective of promoting the use of evidence-based medicine at the point-of-care and enhancing the educational experience for medical students and residents through the rapid dissemination of knowledge. Setting and Participants:Companion launched in July 2017 across NYU Langone Health (NYULH), a tertiary-care academic medical center, and NYU School of Medicine. The Companion app was made available to all faculty, housestaff, and medical students for download on any Apple iPhone or iPad through NYULH's internal app catalog. Though available throughout the institution, special attention was given to the internal medicine residency program and medical students including dedicated training sessions on how to maximize the app's features for rounds and conferences. Description: Companion's core feature is a search function, similar to Google, where a user types in a keyword they are interested in looking up. For example, if a resident were admitting a patient with Congestive Heart Failure (CHF), and types "CHF" into the search box, the app will return NYULH institutional clinical guidelines related to CHF. From the results page, users can also use their finger to "swipe" into additional medical databases such as UpToDate and PubMed if they do not find what they are looking for in the institutional guidelines all from within the app. Once users find the document they are looking for they can "Favorite" the document for future reference, "Mark Up" the document with a virtual pen or highlighter, or "share" the document via QR code technology. Companion also utilizes location-aware technology for virtual "check-in" at conferences and pushing relevant clinical guidelines based on a user's physical location. Evaluation: Since launching in July 2017 our evaluation data is limited, but thus far, we have 747 active "60-day users" and over 5, 000 downloads of institutional clinical guidelines through the app. Further, there have been 5, 200 total "searches" performed within the app and over 10, 000 unique location check-ins at conference by medical students and residents. Discussion/Reflection/Lessons Learned: While still in the early stages of rolling out Companion, initial signs indicate that the app has potential to accomplish its goal of bringing evidence-based medicine to the bedside and enhancing the academic environment at our AMC. User feedback from front-line users has been instrumental in helping to refine the app and idenitfy new features that would improve the app. Since launching, we've pushed out 6 new version updates and recognize the importance of constantly iterating and adding new features to make the app as useful as possible. Next steps include integrating Companion with our electronic medical record and focusing on publicizing the app to other departments outside of internal medicine

Background: Clinical decision support (CDS) has been shown to im-prove compliance with evidence-based care but its impact is often diminished due to issues such as poor usability, insufficient integration into workflow, and alert fatigue. Non-interruptive CDS may be less subject to alert fatigue but there has been little assessment of its usability. The purpose of this study was to perform usability testing on interruptive and non-interruptive versions of a CDS. Methods: We conducted a usability study ofa CDS tool that recommended prescribing an angiotensin converting enzyme (ACE) inhibitor for inpatients with heart failure. We developed two versions of the CDS that varied in its format: an interruptive alert, in which the CDS popped-up at the time of order entry, and a non-interruptive alert, which was displayed in a checklist section of the Electronic Health Record (EHR). We recruited inpatient providers to use both versions in a laboratory setting. We randomly assigned providers to first trigger the interruptive or non-interruptive alert. Providers were given a clinical scenario and asked to " think aloud" as they worked through the CDS; we then conducted a brief semi-structured interview about usability. We used a constant comparative analysis informed by the Five Rights of CDS framework to analyze the interviews. Inpatient providers from different disciplines were recruited until thematic saturation was reached. Results: Of 12 providers who participated in usability testing, seven used the interruptive followed by the non-interruptive CDS and five used the non-interruptive CDS initially. We categorized codes into four themes related to the Five Rights of CDS and determined some codes to be general to the CDS while others were specific to the interruptive or non-interruptive version (Table). Providers noted that the interruptive alert was readily noticed but generally impeded workflow. Providers found the non-interruptive CDS to be less annoying but had lower visibility; although they liked the ability to address the non-interruptive CDS at any time, some providers questioned whether it would ultimately be used. Conclusions: Providers expressed annoyance in working with an inter-ruptive CDS. Although the non-interruptive CDS was more appealing, providers admitted that it may not be used unless integrated with workflow. One potential solution was a combination of the two formats: supplementing a non-interruptive alert with an occasional, well-timed interruptive alert if uptake was insufficient

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: 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: Null mice raised by mating -/- with -/- showed sustained hyperglycemia & persistent hyperinsulinemia during glucose tolerance test (GTT) vs wild type (wt) raised by mating wt with wt . Insulin resistance by HOMA was increased 8 fold, but HOMA beta cell function was normal. As null mice ate & weighed more, & as caloric restriction abolished these differences, our data support the role of hyperphagia, possibly due to hypothalamic neuron leptin resistance without TRPC1 channels.
Method(s): We studied adipokines, environmental & genetic factors, including gene dosage, in this diabetic phenotype while minimizing epigenetics & hyperphagia in breeders & dams, using only littermates born to +/-breeders.
Result(s): 9-week-old null born to -/-breeders & nursed by -/-dams had severe random hyperglycemia (171 vs. 98 mg %) vs wt born to +/+ breeders & raised by +/+ dams. In contrast, null mice born to +/-breeders & nursed by +/-dams had minimal hyperglycemia (119 vs 171 mg %), implying anti-diabetic effects by a single maternal wt allele. Conversely, wt born to +/-breeders & nursed by +/-dams were hyperglycemic vs wt born to +/+ breeders & nursed by +/+ dams (118 vs 98 mg %), reflecting pro-diabetic effects of maternal haploid deficiency. These wt were as hyperglycemic as null littermates born to the same +/-breeders & nursed by the same +/-dams (118 vs 119 mg %). These data support the role of nongenetic parental influences. From 5th to 30th week, null but not +/-mice were obese vs wt. At 29 weeks, during GTT, both null & +/-mice were equally diabetic, with glucose (in mg %), respectively of 230 & 234 vs. 183 in wt at 20 min, 219 & 229 vs. 155 in wt at 60 min, & 179 & 188 vs 134 in wt at 90 min. These data support the role of both alleles in glucose homeostasis. In null mice, adiponectin was down (5.7) vs. wt (6.4) & +/-(6.2 mug/ml), but leptin up (2.3 vs. 1.3 in wt & 1.8 ng/ml in +/-).
Conclusion(s): We conclude: 1. Diploid TRPC1 gene deletion produces hyperphagia & obesity. 2. Haploid deficiency suffices to produce diabetes, associated with reduced adiponectin & increased leptin. 3. Non-genetic parental factors, via epigenetics & hyperphagia, markedly alter glucose homeostasis independent of genotypes