Faculty Bibliography

BACKGROUND:CKD is associated with sudden cardiac death and atrial fibrillation (AF). However, other types of arrhythmia and different measures of the burden of arrhythmias, such as presence and frequency, have not been well characterized in CKD. METHODS:To quantify the burden of arrhythmias across CKD severity in 2257 community-dwelling adults aged 71-94 years, we examined associations of major arrhythmias with CKD measures (eGFR and albuminuria) among individuals in the Atherosclerosis Risk in Communities study. Participants underwent 2 weeks of noninvasive, single-lead electrocardiogram monitoring. We examined types of arrhythmia burden: presence and frequency of arrhythmias and percent time in arrhythmias. RESULTS:Of major arrhythmias, there was a higher prevalence of AF and nonsustained ventricular tachycardia among those with more severe CKD, followed by long pause (>30 seconds) and atrioventricular block. Nonsustained ventricular tachycardia was the most frequent major arrhythmia (with 4.2 episodes per person-month). Most participants had ventricular ectopy, supraventricular tachycardia, and supraventricular ectopy. Albuminuria consistently associated with higher AF prevalence and percent time in AF, and higher prevalence of nonsustained ventricular tachycardia. When other types of arrhythmic burden were examined, lower eGFR was associated with a lower frequency of atrioventricular block. Although CKD measures were not strongly associated with minor arrhythmias, higher albuminuria was associated with a higher frequency of ventricular ectopy. CONCLUSIONS:CKD, especially as measured by albuminuria, is associated with a higher burden of AF and nonsustained ventricular tachycardia. Additionally, eGFR is associated with less frequent atrioventricular block, whereas albuminuria is associated with more frequent ventricular ectopy. Use of a novel, 2-week monitoring approach demonstrated a broader range of arrhythmias associated with CKD than previously reported.

Obstructive azoospermia (OA) is a rare cause of male infertility, with Congenital Bilateral Absence of The Vas Deferens (CBAVD) being a major cause. A wealth of literature has established an irrefutable link between CFTR mutations and CBAVD, with CBAVD affecting almost all men with cystic fibrosis (CF) disease and a significant portion of men that are CFTR mutation carriers. In the past two decades, assisted reproductive technologies have made the prospect of fathering children a viable possibility in this subset of men, using a combination of sperm extraction techniques and intracystoplasmic sperm injection (ICSI). In order to assess techniques for sperm retrieval, as well as reproductive outcomes, a systemic search of the MEDLINE database was conducted for all articles pertaining to management options for CBAVD, and also all reports describing outcomes of these procedures in the CBAVD population. Both epididymal and testicular sperm extraction (TESE) are viable options for men with CBAVD, and though rigorous data are lacking, live birth rates range from 8% to 50% in most small retrospective series and subset analyses. In addition, there does not appear to be significant differences in the rate of live birth or complications and miscarriages between the various techniques, though further investigation into other factors that limit reproductive potential of men with CFTR mutations and CBAVD is warranted.

Objective/UNASSIGNED:The Mobile Universal Lexicon Evaluation System (MULES) is a rapid picture naming task that captures extensive brain networks involving neurocognitive, afferent/efferent visual, and language pathways. Many of the factors captured by MULES may be abnormal in sleep-deprived residents. This study investigates the effect of sleep deprivation in post-call residents on MULES performance. Methods/UNASSIGNED: = 18) and a group of similar-aged controls not taking call (n = 18). Differences in times between baseline and follow-up MULES scores were compared between the two groups. Results/UNASSIGNED: < 0.001, Wilcoxon rank sum test). The change in MULES time from baseline was significantly correlated to the change in subjective level of sleepiness for call residents and to the amount of sleep obtained in the 24 h prior to follow-up testing for the entire cohort. For call residents, the duration of sleep obtained during call did not significantly correlate with change in MULES scores. There was no significant correlation between MULES change and sleep quality questionnaire score for the entire cohort. Conclusion/UNASSIGNED:The MULES is a novel test for effects of sleep deprivation on neurocognition and vision pathways. Sleep deprivation significantly worsens MULES performance. Subjective sleepiness may also affect MULES performance. MULES may serve as a useful performance assessment tool for sleep deprivation in residents.

OBJECTIVE:) hospital discharge codes (eg, 440.2) among 8330 Black and White ARIC (Atherosclerosis Risk in Communities) participants (mean age 62.8 [SD 5.6] years) free of PAD at baseline (1996-1998) through 2015. Since lipid traits are biologically correlated to each other, we also conducted principal component analysis to identify underlying components for PAD risk. There were 246 incident PAD cases with a median follow-up of 17 years. After accounting for potential confounders, the following lipid measures were significantly associated with PAD (hazard ratio per 1-SD increment [decrement for HDL-C and Apo-E-HDL]): triglycerides, 1.21 (95% CI, 1.08-1.36); RLP-C, 1.18 (1.08-1.29); LDL-TG, 1.18 (1.05-1.33); HDL-C, 1.39 (1.16-1.67); and Apo-E-HDL, 1.27 (1.07-1.51). The principal component analysis identified 3 components (1: mainly loaded by triglycerides, RLP-C, LDL-TG, and sdLDL-C; 2: by HDL-C and Apo-E-HDL; and 3: by LDL-C and RLP-C). Components 1 and 2 showed independent associations with incident PAD. CONCLUSIONS:Triglyceride-related and HDL-related lipids were independently associated with incident PAD, which has implications on preventive strategies for PAD. However, none of the novel lipid measures outperformed conventional ones. Graphic Abstract: A graphic abstract is available for this article.

OBJECTIVE:We previously found that antibiotic use at <24 months of age was associated with slightly higher body weight at 5 years of age. In this study, we examine associations of early life antibiotic prescriptions with weight outcomes at 108 to 132 months of age ("10 years"). METHODS:We used electronic health record data from 2009 through 2016 from 10 health systems in PCORnet, a national distributed clinical research network. We examined associations of any (vs no) antibiotics at <24 months of age with body mass index z-score (BMI-z) at 10 years adjusted for confounders selected a priori. We further examined dose response (number of antibiotic episodes) and antibiotic spectrum (narrow and broad). RESULTS:Among 56,727 included children, 57% received any antibiotics at <24 months; at 10 years, mean (standard deviation) BMI-z was 0.54 (1.14), and 36% had overweight or obesity. Any versus no antibiotic use at <24 months was associated with a slightly higher BMI-z at 10 years among children without a complex chronic condition (β 0.03; 95% confidence interval [CI] 0.01, 0.05) or with a complex chronic condition (β 0.09; 95% CI 0.03, 0.15). Any versus no antibiotic use was not associated with odds of overweight or obesity at 10 years among children without (odds ratio 1.02; 95% CI 0.97, 1.07) or with a complex chronic condition (odds ratio 1.07; 95% CI 0.96, 1.19). CONCLUSIONS:The small and likely clinically insignificant associations in this study are consistent with our previous 5-year follow-up results, suggesting that, if this relationship is indeed causal, early increases in weight are small but maintained over time.

Objective Functional gastrointestinal disorders account for a large burden of disease in children. Specifically,constipation tends to comprise 25% or more of visits to Pediatric Gastroenterologists. With the publication ofthe ROME IV criteria, the recognition of functional constipation (FC) as a disease process has become morerefined, yet the pharmacotherapy and lifestyle modifications in the management of children with FC haveremained fairly static. Our aim was to conceptualize, design, and validate an evidence-based, personalizedconstipation action plan with pictograms to aid providers, parents, and patients in the management of FC inchildren. Methods We applied a stepwise approach for the validation of a pediatric Constipation Action Plan(CAP) with pictograms to manage FC. After reviewing available clinical practice guidelines and criterion, ourexpert team agreed on these key elements for inclusion: eating, play, belly pain, stool characteristics, negativesensations during defecation, and defecation accidents. In designing a tool for eventual implementation intothe patient-centered medical home model, we emphasized the concepts of transparency, translucency, and recall in judging the development of pictograms using digital survey analytics. Prior to the recall phase, adistraction test was performed using the Short assessment of health literacy-English version (SAHL-E) toassess respondent health literacy levels. The images were considered valid when: 1. The image demonstratedtransparency of at least 85% 2. The translucency score awarded to the image was >=5 3. The imagedemonstrated recall by at least 85% of the participants Readability of the CAP was assessed using thefollowing tools: Flesch Reading Ease score, Gunning Fog, Flesch-Kincaid Grade Level, The Coleman-Liau Index,The SMOG Index, Automated Readability Index, and Linsear Write Formula. Suitability of the CAP wasevaluated using a modified Suitability Assessment of Materials (SAM) instrument. Results The CAP wascompleted (Figure 1). Pictogram validation: 200 respondents (all with normal SAHL-E scores) completed thepictogram survey. All 12 pictograms demonstrated appropriate transparency, translucency and recall forinclusion in the CAP (Table 1). CAP validation: The CAP combined scores for readability were consistent with afourth grade level. 34 pediatricians responded to the SAM; the mean composite % score generated forsuitability was 90.5, consistent with superior material. Conclusion The Constipation Action Plan is a robustclinical action tool complete with validated pictograms, high readability, and high suitability for use in treatingFC in pediatric patients. The inherent flexibility of the CAP allows it to be tailored to meet the needs of anychild with functional constipation. The CAP represents the next step in the evolution of care for FC. Furtherinvestigation will confirm the CAP can increase caregiver confidence in home management, improvehealthcare related quality of life for the patient, and improve clinical outcomes

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.

Efforts to control the current coronavirus disease 2019 (COVID-19) pandemic have led to national lockdowns around the world. Reactions to the rapidly evolving outbreak were shared on social media platforms. We conducted a mixed-methods analysis of tweets collected from May 10 to May 24, 2020, using MAXQDA software in conjunction with Twitters search API using the keywords: "COVID-19," "coronavirus pandemic," "Covid19," "face masks," and included terms such as "Queens," "Bronx," "New York." A total of 7, 301 COVID-19-related tweets across the globe were analyzed. We used SAS Text Miner V.15.1 for descriptive text mining to uncover the primary topics in unstructured textual data. Content analysis of tweets revealed six themes: surveillance, prevention, treatments, testing and cure, symptoms and transmission, fear, and financial loss. Our study also demonstrates the feasibility of using Twitter to capture real-time data to assess the public's concerns and public health needs during the COVID-19 pandemic.

BACKGROUND:Cytokine storm is a marker of COVID-19 illness severity and increased mortality. Immunomodulatory treatments have been repurposed to improve mortality outcomes. RESEARCH QUESTION/OBJECTIVE:To identify if immunomodulatory therapies improve survival in patients with COVID-19 cytokine storm. STUDY DESIGN AND METHODS/METHODS:We conducted a retrospective analysis of electronic health records across the Northwell Health system. COVID-19 patients hospitalized between March 1, 2020 and April 24, 2020 were included. Cytokine storm was defined by inflammatory markers: ferritin >700ng/mL, C-reactive protein >30mg/dL or lactate dehydrogenase >300U/L. Patients were subdivided into six groups-no immunomodulatory treatment (standard of care) and five groups that received either corticosteroids, anti-interleukin 6 antibody (tocilizumab) or anti-interleukin-1 therapy (anakinra) alone or in combination with corticosteroids. The primary outcome was hospital mortality. RESULTS:5,776 patients met the inclusion criteria. The most common comorbidities were hypertension (44-59%), diabetes (32-46%) and cardiovascular disease (5-14%). Patients most frequently met criteria with high lactate dehydrogenase (76.2%) alone or in combination, followed by ferritin (63.2%) and C-reactive protein (8.4%). More than 80% of patients had an elevated D-dimer. Patients treated with corticosteroids and tocilizumab combination had lower mortality compared to standard of care (Hazard Ratio (HR):0.44, 95% confidence interval (CI): 0.35-0.55; p<0.0001) and when compared to corticosteroids alone (HR:0.66, 95%CI: 0.53-0.83; p-value=0.004), or in combination with anakinra (HR:0.64, 95%CI:0.50-0.81; p-value=0.003) . Corticosteroids when administered alone (HR:0.66, 95%CI:0.57-0.76; p<0.0001) or in combination with tocilizumab (HR:0.43, 95%CI:0.35-0.55; p<0.0001) or anakinra (HR:0.68, 95%CI:0.57-0.81; p<0.0001) improved hospital survival compared to standard of care. INTERPRETATION/CONCLUSIONS:The combination of corticosteroids with tocilizumab had superior survival outcome when compared to standard of care and corticosteroids alone or in combination with anakinra. Furthermore, corticosteroid use either alone or in combination with tocilizumab or anakinra was associated with reduced hospital mortality for patients with COVID-19 cytokine storm compared to standard of care.