Faculty Bibliography

Tardive dyskinesia (TD) is a syndrome that causes chronic, involuntary, and disruptive movements of the body and/or face that is a severe, potentially irreversible adverse effect of long-term antipsychotic use. It has wide-reaching effects on patients' well-being, quality of life,¹ and treatment adherence.² Thus, TD is debilitating, leading to social withdrawal,³ and workplace absenteeism.¹ Current data on tardive dyskinesia treatment are limited, and prevention, primarily through the modification of antipsychotic regimens, remains the most effective strategy.⁴ Recent systematic review has shown valbenazine and vitamin E are the only treatments significantly more effective compared to placebo in treatment of TD, although valbenazine is associated with significant side effects.⁵ We present a case of a 76-year-old female with a diagnosis of Bipolar II Disorder (BD) who developed TD after treatment with lurasidone for 10 years. After struggling with both her BD and TD symptoms for 3 years, she sought care at our clinic where we prescribed 300 mg daily of lithium. At her follow-up visit 5 weeks later, her TD symptoms were greatly improved, with sustained benefits observed at following visits. This article reviews the literature discussing the interplay between lithium and TD and presents a case report of TD improvement after lithium augmentation for treatment-resistant depression. While this case suggests a potential role in TD treatment, the role of lithium in TD treatment remains controversial.

OBJECTIVE:To evaluate the early effects of Pathways to Success implementation on utilization, as measured by quarterly price-standardized Medicare spending per beneficiary. STUDY SETTING AND DESIGN/METHODS:This study was a nationwide retrospective cohort analysis of Traditional Medicare beneficiaries. The primary outcome was overall utilization, as measured by adjusted quarterly price standardized spending per beneficiary. Secondary outcomes included adjusted quarterly price standardized spending by component type (inpatient, outpatient institutional, Part B, and skilled nursing facility). The primary independent variable is Pathways to Success implementation on July 1, 2019. DATA SOURCES AND ANALYTIC SAMPLE/UNASSIGNED:A 20% sample of national Medicare data from January 1, 2018, through March 31, 2020, includes Traditional Medicare beneficiaries managed in ACOs (n = 1,368,523) and outside of ACOs ("controls," n = 1,476,982) prior to Pathways implementation. PRINCIPAL FINDINGS/RESULTS:Unadjusted quarterly spending among those in ACOs and controls decreased over the study period by $13.5 (from $2614.8 before Pathways implementation to $2601.3 after Pathways implementation) and $89.8 (from $2723.1 before Pathways implementation to $2633.3 after Pathways implementation), respectively. Adjusted quarterly spending per beneficiary decreased more slowly in ACOs compared to controls (differences-in-differences estimate +$46.8 (95% CI $19.2, $74.4) in ACOs vs. controls). This difference was largely driven by a more rapid decrease in the utilization of inpatient care. Adjusted quarterly spending per beneficiary for inpatient care decreased more slowly in ACOs compared to controls (differences-in-differences estimate +$43.6 [95% CI $27.2, $60.0] in ACOs vs. controls). CONCLUSIONS:After Pathways, reductions in utilization, as measured by price-standardized spending, by ACOs occurred less rapidly than for those managed outside of the Shared Savings Program. This effect was driven by a more rapid decrease in spending for inpatient care by nonparticipants.

Worldwide, nearly 40% of adults are overweight and 13% are obese. Health consequences of excess weight include cardiovascular diseases, type 2 diabetes, dyslipidemia, and increased mortality. Treating obesity is challenging and calorie restriction often leads to rebound weight gain. Treatments such as bariatric surgery create hesitancy among patients due to their invasiveness. GLP-1 medications have revolutionized weight loss and can reduce body weight in obese patients by between 15% and 25% on average after about 1 year. Their mode of action is to mimic the endogenous GLP-1, an intestinal hormone that regulates glucose metabolism and satiety. However, GLP-1 drugs carry known risks and, since their use for weight loss is recent, may carry unforeseen risks as well. They carry a boxed warning for people with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2. Gastrointestinal adverse events (nausea, vomiting, diarrhea) are fairly common while pancreatitis and intestinal obstruction are rarer. There may be a loss of lean body mass as well as premature facial aging. A significant disadvantage of using these medications is the high rate of weight regain when they are discontinued. Achieving success with pharmacologic treatment and then weaning to avoid future negative effects would be ideal.

BACKGROUND:EUS-guided gastroenterostomy (EUS-GE) is a minimally invasive therapy for the management of gastric outlet obstruction (GOO). EUS-GE has demonstrated excellent short-term efficacy without the risks of surgical bypass. However, there is limited data on follow-up outcomes. In this study, we collected 6-month follow-up data on patients who underwent EUS-GE for benign and malignant etiologies, to aim to show the shift in paradigm in their management algorithm. METHODS:This was a retrospective multicenter study across 7 international centers of consecutive patients undergoing EUS-GE over a 4-year period who were entered in a dedicated registry. Demographic characteristics, procedure-related information, and follow-up data were collected. Primary outcome was the 6-month data on clinical resolution of GOO. RESULTS:Ninety-one patients were included (71 malignant and 20 benign cases). Technical success was 99% due to high expertise and volume. Clinical success at 48 hours was 97% (88/90) with an average procedure time of 47 minutes and length of stay of 5.86 days. At 3 months, 87 (95.6%) patients had achieved clinical resolution. At 6 months, 48 (53%) subjects were alive, 40 (44%) were deceased, 3 were lost to follow-up (3.3%) and 1 (1%) had a recurrence of GOO. Clinical success at 6 months follow-up was 98% (47/48). CONCLUSIONS:The majority of patients with GOO who undergo EUS-GE showed clinical resolution at 6-month follow-up. Patients with malignant etiology are appropriately palliated during their life span. Further prospective studies are necessary to obtain long-term data regarding EUS-GE for benign etiologies.

The benefits and challenges of electronic health records (EHRs) as data sources for clinical and epidemiologic research have been well described. However, several factors are important to consider when using EHR data to study novel, emerging, and multifaceted conditions such as postacute sequelae of SARS-CoV-2 infection or long COVID. In this article, we present opportunities and challenges of using EHR data to improve our understanding of long COVID, based on lessons learned from the National Institutes of Health (NIH)-funded RECOVER (REsearching COVID to Enhance Recovery) Initiative, and suggest steps to maximize the usefulness of EHR data when performing long COVID research.

BACKGROUND:Results from national surveys indicate that many older adults reported delayed medical care during the acute phase of the COVID-19 pandemic, yet few studies have used objective data to characterize healthcare utilization among vulnerable older adults in that period. In this study, we characterized healthcare utilization during the acute pandemic phase (March 7-October 6, 2020) and examined risk factors for total disruption of care among older adults with multiple chronic conditions (MCC) in New York City. METHODS:This retrospective cohort study used electronic health record data from NYC patients aged ≥ 50 years with a diagnosis of either hypertension or diabetes and at least one other chronic condition seen within six months prior to pandemic onset and after the acute pandemic period at one of several major academic medical centers contributing to the NYC INSIGHT clinical research network (n=276,383). We characterized patients by baseline (pre-pandemic) health status using cutoffs of systolic blood pressure (SBP) < 140mmHg and hemoglobin A1C (HbA1c) < 8.0% as: controlled (below both cutoffs), moderately uncontrolled (below one), or poorly controlled (above both, SBP > 160, HbA1C > 9.0%). Patients were then assessed for total disruption versus some care during shutdown using recommended care schedules per baseline health status. We identified independent predictors for total disruption using logistic regression, including age, sex, race/ethnicity, baseline health status, neighborhood poverty, COVID infection, number of chronic conditions, and quartile of prior healthcare visits. RESULTS:Among patients, 52.9% were categorized as controlled at baseline, 31.4% moderately uncontrolled, and 15.7% poorly controlled. Patients with poor baseline control were more likely to be older, female, non-white and from higher poverty neighborhoods than controlled patients (P < 0.001). Having fewer pre-pandemic healthcare visits was associated with total disruption during the acute pandemic period (adjusted odds ratio [aOR], 8.61, 95% Confidence Interval [CI], 8.30-8.93, comparing lowest to highest quartile). Other predictors of total disruption included self-reported Asian race, and older age. CONCLUSIONS:This study identified patient groups at elevated risk for care disruption. Targeted outreach strategies during crises using prior healthcare utilization patterns and disease management measures from disease registries may improve care continuity.

BACKGROUND AND OBJECTIVE/OBJECTIVE:Alcohol withdrawal syndrome (AWS) is a serious complication of alcohol use disorder. Although benzodiazepines are the mainstay of treatment, some patients may be resistant to them, requiring rapidly escalating doses. Phenobarbital has emerged as an effective adjunct therapy in severe alcohol withdrawal, but studies have yielded inconsistent results and carry safety risks. The purpose of our study was to examine the effectiveness and the potential harm of phenobarbital in AWS. METHODS:In this multi-center, retrospective cohort study, patients who were admitted for AWS and received phenobarbital with benzodiazepine were compared to patients who received benzodiazepine monotherapy. The primary outcome was time to AWS resolution. Other secondary and safety outcomes included length of stay (LOS), rate of mechanical ventilation, and incidence of aspiration pneumonia. RESULTS:The phenobarbital group received significantly higher doses of benzodiazepines compared to the benzodiazepine monotherapy group (660 mg vs 340 mg, p < 0.0001). After adjustment, the use of phenobarbital was associated with significantly reduced time to AWS resolution (141.65 h vs 165.72 h, p < 0.0001). However, the use of phenobarbital was associated with the likelihood of mechanical ventilation (19.42 %vs. 0.96 %, p < 0.0001), aspiration pneumonia (22.33 % vs 5.77 %, p = 0.0006), and increased hospital LOS (8 days vs. 6 days, p = 0.0197). In the combination group, earlier phenobarbital initiation (within 24 h) was associated with significantly lower cumulative benzodiazepine dose (530 mg vs 887.50 mg, p = 0.002) and hospital LOS (6 days vs 10 days, p = 0.0017). CONCLUSION AND RELEVANCE/CONCLUSIONS:In our study, patients who received phenobarbital in combination with benzodiazepines had a quicker resolution of AWS but also had a higher incidence of mechanical ventilation, prolonged hospital LOS, and an increased risk of aspiration pneumonia. For patients at high risk of severe alcohol withdrawal, earlier initiation of phenobarbital appeared to yield the most optimal benefit.

Neoadjuvant therapy (NAT) is increasingly being used for pancreatic ductal adenocarcinoma (PDAC). This study investigates how NAT differentially impacts PDAC's carcinoma cells and the tumor microenvironment (TME). Spatial transcriptomics was used to compare gene expression profiles in carcinoma cells and the TME of 23 NAT-treated versus 13 NAT-naïve PDACs. Findings were validated by single-nucleus RNA sequencing (snRNA-seq) analysis. NAT induces apoptosis and inhibits proliferation of carcinoma cells and coordinately upregulates multiple complement genes (C1R, C1S, C3, C4B and C7) within the TME. Higher TME complement expression following NAT is associated with increased immunomodulatory and neurotrophic cancer-associated fibroblasts (CAFs); more CD4⁺ T cells; reduced immune exhaustion gene expression, and improved overall survival. snRNA-seq analysis demonstrates C3 complement is mainly upregulated in CAFs. These findings suggest that local complement dynamics could serve as a novel biomarker for prognosis, evaluating treatment response, and guiding therapeutic strategies in NAT-treated PDAC patients.

INTRODUCTION/BACKGROUND:Despite the well-documented safety of transesophageal echocardiograms (TEEs), inpatient gastroenterology (GI) services are called to clear patients for the procedure when they have GI symptoms or comorbidities ranging from mild to clinically significant. We aimed to assess the clinical utility of such consults in preventing TEE complications. METHODS:We performed a prospective cohort study of all inpatients at our institution who had a TEE ordered from 7/1/2021 through 7/1/2022. Patients' demographic information, indications for TEE, complications from TEE, 30-day readmission rates, GI team recommendations, and results of any GI-related interventions were collected and analyzed. RESULTS:There were 732 patients who had a TEE ordered during our study period, of whom 641 (87.51%) underwent the procedure. Of the 91 (12.49%) who did not have a TEE, none were canceled due to a GI-related concern. There were 23 of 641 patients (3.59%) with complications from the TEE, none of which were GI-related. The GI team was consulted on 36 patients (4.96% of TEEs ordered) and cleared 22 of 36 (61.11%) with no further testing while the remaining 14 of 36 patients (38.89%) underwent workups that were largely normal. Patients who had a GI consult before their TEE had a significantly longer time between their TEE being ordered and the TEE being performed compared with those who did not have a GI consult before their TEE (4.50 days vs 0.77 days, P < 0.01). DISCUSSION/CONCLUSIONS:Inpatient GI team workups to clear patients for a TEE found no contraindications to TEEs, did not change patient care plans, and led to increased hospital costs and lengths of stay.

This comprehensive review examines the effects of various infections on pregnancy, focusing on maternal symptoms, fetal outcomes, diagnostic methods, and placental pathology. The paper covers bacterial, viral, and parasitic infections, their mechanisms of transmission, clinical presentations, and histopathologic findings in the placenta. It emphasizes the importance of early detection and intervention, highlighting the challenges in diagnosis due to often asymptomatic presentations. The review also discusses the placenta's role as a protective barrier and its immune defense mechanisms against pathogens. Overall, this paper serves as a comprehensive resource for understanding the complex interplay between maternal infections, placental pathology, and fetal outcomes.