Faculty Bibliography

INTRODUCTION/BACKGROUND:Necrotizing fasciitis is a rapidly progressive infection associated with high mortality and complications. It mainly involves subcutaneous tissue and fascia. More quality data on disparities in clinical outcomes of necrotizing fasciitis must be provided. Our study aims to identify gender and racial disparities in necrotizing fasciitis outcomes. METHODS:We used data from the Nationwide Inpatient Sample database from 2016 to 2020. As appropriate, the Chi-square and t-test were used to test for associations between categorical and continuous variables. Multivariate logistic regression models, adjusted for key confounders, were used to obtain odds ratios for in-hospital mortality and various complications. Similarly, multivariate linear regression models were created for continuous outcome variables. RESULTS:Among 118,775 patients with necrotizing fasciitis, women (adjusted odds ratio [aOR] 1.18, 95 ​% confidence interval [CI]: 1.07-1.30, p ​= ​0.001), Asian (aOR 1.49 (95 ​% CI: 1.10-2.02, p ​= ​0.01), and Hispanic (aOR: 1.16; 95 ​% CI: 1.0-1.35; p ​= ​0.045) patients had significantly higher in-hospital mortality than White patients. In comparison with men, women were more likely to require invasive mechanical ventilation and blood transfusions and develop ARDS. They are less likely to develop AKI, acute myocardial infarction, or venous thromboembolism and require non-invasive mechanical ventilation (p ​< ​0.05 for all comparisons). Similarly, certain racial minority groups were also at a heightened risk for complications, such as AKI requiring hemodialysis, ARDS, venous thromboembolism, sudden cardiac arrest, and need for blood transfusion, among others (p ​< ​0.05 for all comparisons). As compared to white patients, African American (1.7 days longer, p ​< ​0.001), Asian (4.3 days longer, p ​< ​0.001), and Hispanic (0.6 days longer, p ​= ​0.048) patients had a significantly longer length of hospital stay. Asian, African American, and Hispanic patients also had substantially higher hospitalization costs, amounting to an additional $17,596.07 (p ​< ​0.001), $5899.60 (p ​< ​0.001), and $4356.55 (p ​< ​0.01), respectively, versus White patients. Native American patients did not have any significant difference in the cost of hospitalization as compared to White patients. CONCLUSION/CONCLUSIONS:Females and racial minorities are at increased risk of mortality and higher healthcare resource utilization in necrotizing fasciitis. There is a need to develop equitable management strategies and health policy interventions to address these disparities effectively.

Spinocerebellar ataxia type 14 (SCA14) is an autosomal dominant neurodegenerative disorder characterized by adult-onset cerebellar ataxia, and occasionally pyramidal signs, cognitive changes, sensory changes, myoclonus, and tremor. SCA14 results from heterozygous gain-of-function pathogenic variants in PRKCG, which encodes protein kinase Cγ. The aim was to elucidate the molecular mechanism of disease in a 60-year-old man with SCA14 due to a novel heterozygous variant in PRKCG c.154T > C p.(C52R). Next-generation sequencing was completed in the proband, targeted variant analysis was conducted in his family, and biochemical functional assays were performed. The C52R variant segregated with disease. Like other C1A domain variants, it had increased basal activity yet was unresponsive to agonist stimulation and was relatively resistant to down-regulation. This expands the genetic landscape of SCA14 and supports the condition as a gain-of-function disease, with variants in the C1A domain having leaky activity yet unresponsiveness to agonist stimulation.

OBJECTIVE:To assess the association between skilled nursing facility (SNF) utilization and Alzheimer's disease and related dementias (ADRD) both before and during the COVID-19 pandemic. DESIGN/METHODS:An observational cohort study. SETTING AND PARTICIPANTS/METHODS:The study included community-dwelling respondents aged 65 or older. METHODS:This study analyzed data from 3 waves of the Health and Retirement Study and employed multivariable, individual-level regressions. The primary outcomes were any SNF stays, the number of SNF stays, and the total number of SNF days, in the past 2 years of the survey. Respondents were classified as cognitively normal, having cognitive impairment but not dementia (CIND), or having ADRD. RESULTS:The study included 23,654 respondent-years, representing 12,529 unique respondents. Before the pandemic, differences in any SNF stays, and the number of SNF stays between the cognitively normal and CIND and ADRD groups were statistically insignificant in multivariable regressions. During the pandemic, compared with respondents with normal cognition, those with CIND had higher odds of any SNF stays (OR, 1.53; 95% CI, 1.06-2.20) and more SNF stays (incidence rate ratio [IRR], 2.40; 95% CI, 1.30-4.40); similarly, the ADRD group showed higher odds of any SNF stays (OR, 1.68; 95% CI, 1.08-2.59) and more SNF stays (IRR, 2.48; 95% CI, 1.36-4.47) than cognitively normal older adults. The total number of SNF days for CIND and ADRD respondents remained statistically insignificantly different from those of the cognitively normal group, both before and during the pandemic, in regression analyses. CONCLUSIONS AND IMPLICATIONS/CONCLUSIONS:This cohort study suggests that the pandemic was associated with increased differences in any SNF stays and number of transitions to SNFs between cognitively normal individuals and those with CIND or ADRD. These findings provide a foundation for understanding the potential impact of a public health emergency on post-acute care utilization among older adults with varying degrees of cognitive impairment.

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.

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.

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.

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.