Faculty Bibliography

BACKGROUND:Treatment of asymptomatic bacteriuria (ASB) is common. Overtreatment of ASB leads to harm, including adverse effects from antibiotics, antibiotic resistance, and increased length of stay. METHODS:This quality improvement initiative targeted inappropriate urine cultures (UC) across 11 hospitals and 70 ambulatory clinics in a safety-net setting. A mandatory prompt for appropriate indications for UC orders and a best practice advisory (BPA) for UC on patients with urinary catheters were created. UC ordering was compared preintervention (June 2020-October 2021) to postintervention (December 2021-August 2022). Variation in hospitals and clinics were assessed, as well as BPA responses by clinician type and specialty. RESULTS:Inpatient UCs decreased 20.9% (p < .001), and outpatient UCs was unchanged (2.6% increase, nonsignificant). Inpatient UCs on patients with urinary catheters decreased 21.6% (p < .001). Temporal trends were also assessed. High variation was seen among hospitals and clinics. Low BPA acceptance rates were seen in internal medicine and family medicine clinicians. Attendings showed high acceptance to the BPA compared to other clinicians. CONCLUSIONS:This initiative successfully decreased UCs in a large, safety-net system. Further study is needed in assessing variation among hospitals and clinics, as well as among clinician types and specialties.

Thymomas are rare anterior mediastinal masses that present with local or paraneoplastic symptoms. Definitive diagnosis requires tissue sampling but early detection leads to early intervention and improved outcomes. We present a case where routine cardiovascular risk assessment identified an incidental and rare thymoma. Final specimen pathology revealed a Thymoma WHO Type AB (30% A, 70% B). Routine cardiovascular risk assessment which often includes coronary artery calcium scanning and cardiovascular computed tomographic angiography may reveal pathology beyond the coronary arteries. Early detection of asymptomatic mediastinal masses facilitates early intervention and can improve outcomes.

BACKGROUND:The use of immune checkpoint inhibitors (ICIs) in the front-line treatment of advanced non-small-cell lung cancer (NSCLC) is currently the standard of care. However, as clinical trials include a very limited number of elderly patients, evidence on the safety and efficacy of using ICI-based regimens is still limited. METHODS:A virtual International Expert Panel took place in July 2022 to review the available evidence on the use of ICI-based regimens in the first-line setting in elderly patients with NSCLC and provide a position paper on the field both in clinical practice and in a research setting. RESULTS:All panelists agreed that age per se is not a limitation for ICI treatments, as the elderly should be considered only as a surrogate for other clinical factors of frailty. Overall, ICI efficacy in the elderly population is supported by reviewed data. In addition, the panelists were confident that available data support the safety of single-agent immunotherapy in elderly patients with NSCLC. Conversely, concerns were expressed on the safety of chemo + ICI-based combination, which were considered mainly related to the toxicities of chemotherapy components. Therefore, suggestions were proposed to tailor combined approaches in the elderly patients with NSCLC. The panelists defined high, medium, and low priorities in clinical research. High priority was attributed to implementing the real-world assessment of elderly patients treated with ICIs, who are mostly underrepresented in pivotal clinical trials. CONCLUSIONS:Based on the current evidence, the panelists outlined the significant limitations affecting the clinical practice in elderly patients affected by NSCLC, and reached common considerations on the feasibility, safety, and effectiveness of ICI monotherapy and ICI combinations in the first-line setting.

Coronavirus disease (COVID)-related misinformation is prevalent online, including on social media. The purpose of this study was to explore factors associated with user engagement with COVID-related misinformation on the social media platform, TikTok. A sample of TikTok videos associated with the hashtag #coronavirus was downloaded on September 20, 2020. Misinformation was evaluated on a scale (low, medium, and high) using a codebook developed by experts in infectious diseases. Multivariable modeling was used to evaluate factors associated with number of views and presence of user comments indicating intention to change behavior. One hundred and sixty-six TikTok videos were identified and reviewed. Moderate misinformation was present in 36 (22%) videos viewed a median of 6.8 million times (interquartile range [IQR] 3.6-16 million), and high-level misinformation was present in 11 (7%) videos viewed a median of 9.4 million times (IQR 5.1-18 million). After controlling for characteristics and content, videos containing moderate misinformation were less likely to generate a user response indicating intended behavior change. By contrast, videos containing high-level misinformation were less likely to be viewed but demonstrated a nonsignificant trend towards higher engagement among viewers. COVID-related misinformation is less frequently viewed on TikTok but more likely to engage viewers. Public health authorities can combat misinformation on social media by posting informative content of their own.

INTRODUCTION/UNASSIGNED:Immigration has been identified as an important social determinant of health (SDH), embodying structures and policies that reinforce positions of poverty, stress, and limited social and economic mobility. In the public health literature with regard to diet, immigration is often characterized as an individual-level process (dietary acculturation) and is largely examined in one racial/ethnic subgroup at a time. For this narrative review, we aim to broaden the research discussion by describing SDH common to the immigrant experience and that may serve as barriers to healthy diets. METHODS/UNASSIGNED:A narrative review of peer-reviewed quantitative, qualitative, and mixed methods studies on cardiometabolic health disparities, diet, and immigration was conducted. RESULTS/UNASSIGNED:Cardiometabolic disease disparities were frequently described by racial/ethnic subgroups instead of country of origin. While cardiovascular disease and obesity risk differed by country of origin, diabetes prevalence was typically higher for immigrant groups vs United States (US)-born individuals. Common barriers to achieving a healthy diet were food insecurity; lack of familiarity with US food procurement practices, food preparation methods, and dietary guidelines; lack of familiarity and distrust of US food processing and storage methods; alternative priorities for food purchasing (eg, freshness, cultural relevance); logistical obstacles (eg, transportation); stress; and ethnic identity maintenance. CONCLUSIONS/UNASSIGNED:To improve the health of immigrant populations, understanding similarities in cardiometabolic health disparities, diet, and barriers to health across immigrant communities-traversing racial/ethnic subgroups-may serve as a useful framework. This framework can guide research, policy, and public health practices to be more cohesive, generalizable, and meaningfully inclusive.

BACKGROUND:It is critical to assess implementation fidelity of evidence-based interventions and factors moderating fidelity, to understand the reasons for their success or failure. However, fidelity and fidelity moderators are seldom systematically reported. The study objective was to conduct a concurrent implementation fidelity evaluation and examine fidelity moderators of CHORD (Community Health Outreach to Reduce Diabetes), a pragmatic, cluster-randomized, controlled trial to test the impact of a Community Health Workers (CHW)-led health coaching intervention to prevent incident type 2 Diabetes Mellitus in New York (NY). METHODS:We applied the Conceptual Framework for Implementation Fidelity to assess implementation fidelity and factors moderating it across the four core intervention components: patient goal setting, education topic coaching, primary care (PC) visits, and referrals to address social determinants of health (SDH), using descriptive statistics and regression models. PC patients with prediabetes receiving care from safety-net patient-centered medical homes (PCMHs) at either, VA NY Harbor or at Bellevue Hospital (BH) were eligible to be randomized into the CHW-led CHORD intervention or usual care. Among 559 patients randomized and enrolled in the intervention group, 79.4% completed the intake survey and were included in the analytic sample for fidelity assessment. Fidelity was measured as coverage, content adherence and frequency of each core component, and the moderators assessed were implementation site and patient activation measure. RESULTS:Content adherence was high for three components with nearly 80.0% of patients setting ≥ 1 goal, having ≥ 1 PC visit and receiving ≥ 1 education session. Only 45.0% patients received ≥ 1 SDH referral. After adjusting for patient gender, language, race, ethnicity, and age, the implementation site moderated adherence to goal setting (77.4% BH vs. 87.7% VA), educational coaching (78.9% BH vs. 88.3% VA), number of successful CHW-patient encounters (6 BH vs 4 VA) and percent of patients receiving all four components (41.1% BH vs. 25.7% VA). CONCLUSIONS:The fidelity to the four CHORD intervention components differed between the two implementation sites, demonstrating the challenges in implementing complex evidence-based interventions in different settings. Our findings underscore the importance of measuring implementation fidelity in contextualizing the outcomes of randomized trials of complex multi-site behavioral interventions. TRIAL REGISTRATION:The trial was registered with ClinicalTrials.gov on 30/12/2016 and the registration number is NCT03006666 .

BACKGROUND:Peripherally inserted central catheters (PICCs) are increasingly used for vascular access in inpatient settings. Compared to multilumen PICCs, single-lumen PICCs carry a lower rate of complications, including central-line-associated bloodstream infection and thrombosis. Despite this, multilumen PICCs are still overused. METHODS:This quality improvement initiative was implemented across 11 hospitals at New York City Health + Hospitals safety net system. The electronic health record (EHR) interventional radiology or vascular access team consultation orders were modified to allow for lumen choice, with default selection to a single-lumen PICC. RESULTS:= .255). Among provider types in the postintervention period, single-lumen PICC utilization ranged from 67.7% for advanced practice providers to 82.4%-94.6% for physicians. Among provider specialties, utilization ranged from 31.8% for neurology to 97.7% for orthopedics. Additionally, there was large variation in pre- and postintervention differences in utilization by hospital. CONCLUSIONS:We successfully increased single-lumen PICC utilization across all 11 safety net hospitals. This expands on previous work on improving single-lumen PICC use and use of default nudges in large, resource-limited settings. Further study is needed to examine variation among provider types, specialties, and hospitals.

Untreated sleep disorders form a risk of coronary artery disease, hypertension, obesity, and diabetes mellitus. Access to polysomnography is limited, especially during the COVID-19 pandemic, with home sleep apnea testing (HSAT) being a potentially viable alternative. We describe an HSAT protocol in patients with advanced heart failure (HF). In a single-center, observational analysis between 2019 and 2021 in patients with advanced HF and heart transplant (HT), 135 screened positive on the STOP-Bang sleep survey and underwent a validated HSAT (WatchPAT, ZOLL-Itamar). HSAT was successful in 123 patients (97.6%), of whom 112 (91.1%; 84 HF and 28 HT) tested positive for sleep apnea. A total of 91% of sleep apnea cases were obstructive, and 63% were moderate to severe. Multivariable linear regression showed that the apnea hypopnea index was 34% lower in the HT group than in the HF group (p = 0.046) after adjusting for gender, and that this effect persisted in White patients but not among African-Americans. Patient characteristics were similar between groups, with coronary artery disease, diabetes mellitus, and hypertension as the most prevalent co-morbidities. In conclusion, sleep apnea remains prevalent in patients with HF with a high co-morbidity burden. HSAT is a feasible and effective tool for screening and diagnosis in this population.