PDF file - 522K, Experimental designs for DSS and AOM models

Background The introduction of electronic workflows has allowed for the flow of raw uncontextualized clinical data into medical documentation. As a result, many electronic notes have become replete of “noise” and deplete clinically significant “signals.” There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating. Objective This study aims to describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation. Methods This is a multihospital nonrandomized prospective improvement study conducted on the inpatient general internal medicine service across 3 hospital campuses at the New York University Langone Health System. A group of physician leaders representing each campus met biweekly for 6 months. The output of these meetings included (1) a conceptualization of the note bloat problem as a dysfunction in information flow, (2) a set of guiding principles for organizational documentation improvement, (3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations, and (4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience was measured using the System Usability Scale (SUS). Primary outcome measures after go-live include template utilization rate and note length in characters. Results In usability testing among 22 medicine providers, the new progress note template averaged a usability score of 90.6 out of 100 on the SUS. A total of 77% (17/22) of providers strongly agreed that the new template was easy to use, and 64% (14/22) strongly agreed that they would like to use the template frequently. In the 3 months after template implementation, general internal medicine providers wrote 67% (51,431/76,647) of all inpatient notes with the new templates. During this period, the organization saw a 46% (2768/6191), 47% (3505/7819), and 32% (3427/11,226) reduction in note length for general medicine progress notes, consults, and history and physical notes, respectively, when compared to a baseline measurement period prior to interventions. Conclusions A bundled intervention that included the deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency, and patient outcomes.

We have isolated a novel cDNA encoding macrophage colony-stimulating factor (M-CSF) from a murine stromal cell line, ST2. The cDNA included an entire coding sequence of the M-CSF gene but contained an additional sequence of 140 base pairs (bp). Northern blot analysis demonstrated that other murine cell lines such as a fibroblastic cell line (L) and a stromal cell line (PA6) also expressed the transcripts corresponding to the clone. The nucleotide sequence analyses of the cDNA and the cloned M-CSF genome revealed that the 140-bp insertion sequence was part of intron 1 which separated exon 1 and exon 2: the former contained part of the amino acid residues of the signal sequence and the latter the rest of the signal sequence and the first 22 amino acid residues of the mature protein. The insertion of the 140-bp intron sequence not only changed the amino acid sequence of the signal peptide but also generated an in-frame termination codon. However, instead of the dysfunction of the original initiation codon, the 140-bp insertion sequence contained a putative ATG initiation codon that preserved the original open reading frame. Finally, we found that the cDNA directed the expression of a secreted and biologically active M-CSF protein when it was introduced into COS7 cells and M-CSF activity in the culture supernatants was measured using an M-CSF-dependent cell line. These results indicate the presence of an alternatively spliced M-CSF transcript which utilizes an alternate initiation codon in order to specify active M-CSF protein.

Primary care physicians frequently evaluate patients with constipation. The history is crucial in uncovering warning symptoms and signs that warrant colonoscopy. Particular elements in the history and rectal examination also can provide clues regarding the underlying etiology. Regardless of etiology, lifestyle modifications, fiber, and laxatives are first-line therapies. Patients who fail first-line therapies can be offered second-line treatments and/or referred for testing of defecatory function. In those with severely refractory symptoms, referrals to a gastroenterologist and a surgeon should be considered.

Objective: New York City was the epicenter of the outbreak of the 2019 coronavirus disease (COVID-19) pandemic in the United States. As a large, quaternary care medical center, NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients during this time. Clinical leadership effectively identified, oriented, and rapidly deployed a “COVID Army,” consisting of non-hospitalist physicians, to meet the needs of the patient influx. We share feedback from our providers on our processes and offer specific recommendations for systems experiencing a similar influx in the current and future pandemics. Methods: To assess the experiences and perceived readiness of these physicians (n = 183), we distributed a 32-item survey between March and June of 2020. Thematic analyses and response rates were examined to develop results. Results: Responses highlighted varying experiences and attitudes of our frontline physicians during an emerging pandemic. Thematic analyses revealed a series of lessons learned, including the need to (1) provide orientations, (2) clarify roles/workflow, (3) balance team workload, (4) keep teams updated on evolving policies, (5) make team members feel valued, and (6) ensure they have necessary tools available. Conclusions: Lessons from our deployment and assessment are scalable at other institutions.

Introduction: Critically-ill patients with COVID-19 often require long-term enteral access due to prolonged ventilator support and slow recovery from neurologic injury. The outcomes of hospitalized patients with SARS-CoV-2 who received gastrostomy tubes (GTs) are unknown and limited guidance exists on how to safely triage GT placement in this population. The Enteral Access Team (EAT) is a multidisciplinary team led by an attending gastroenterologist (GI) hospitalist with advanced practice providers who collaborate with Palliative Care, Geriatrics, Speech-Language Pathology, and Nutrition to reduce unnecessary feeding tube placements at the end-of-life. The EAT reviews the appropriateness of GT placement and triages each case to the indicated procedural service. The EAT’s multidisciplinary approach was applied for patients with COVID-19. Methods: We performed a retrospective study of 135 hospitalized patients with positive PCR tests for SARS-CoV-2 who received GTs between 3/2020 and 4/2021. The GTs were placed by 3 services (gastroenterology, interventional radiology and surgery) at 3 hospitals within 1 health system in New York. One of the hospitals employed the multidisciplinary EAT approach to its triage of GT placement. Outcomes were compared between the EAT site and control sites where GT placement was decided through direct consultation by the primary team with one of the procedural services. Results: Demographics for the two groups, including overall numbers of COVID-19 admissions, can be seen in Table 1. At the EAT site (n = 43) 5% of patients expired prior to discharge following GT placement compared with 25% at the control sites (P < 0.05). Patients at the EAT site were older with a mean age of 70 years compared to the control sites with a mean age of 63 years (P = 0.01). There was no significant difference in the percentage of COVID-19 patients who received GTs, length-of-stay, or time from gastrostomy to discharge or death. Multivariable analysis showed the odds of in-hospital mortality were 10.1 times greater with the standard workflow than with the EAT workflow (OR 10.1, [95% CI: 1.7-60.6], P < 0.05). Conclusion: The EAT’s novel multidisciplinary team-based approach helps to appropriately select hospitalized patients with SARs-CoV-2 for long-term enteral access leading to reduced in-hospital mortality following GT placement. Additionally, this approach may help to mediate the national shortage of GTs and reduce the risk of exposure to providers involved in GT placement.Table 1.: Demographics and Outcomes of Patients with Gastrostomy Tube Placement through EAT Approach vs. Standard Approach.

Background: We aimed to characterize patients with inflammatory bowel disease (IBD) and novel coronavirus disease 2019 (COVID-19). Methods: We performed a case series of patients with IBD and confirmed or highly suspected COVID-19 to assess rates of severe outcomes. Results: We identified 83 patients with IBD with confirmed (54%) or highly suspected (46%) COVID-19. The overall hospitalization rate was 6%, generally comprising patients with active Crohn's disease or older men with comorbidities, and 1 patient expired. Discussion: In this series of patients with IBD, severe outcomes of COVID-19 were rare and comparable to similarly aged individuals in the general population.

In the spring of 2020, New York City became the epicenter of the Covid-19 pandemic in the United States. During the peak from March 10 to May 1, the hospitals of the Department of Medicine at New York University Grossman School of Medicine — including an academic, private hospital in a community setting, a private hospital, an affiliated public hospital, and an affiliated Veterans Affairs federal hospital — cared for more than 5,000 hospitalized patients with Covid-19. Each hospital encountered unique challenges based on its own resources, affiliations, size, and patient populations. However, with ongoing collaboration, leadership developed protocols applicable across sites. Despite these four hospitals being distinct, these collaborations resulted in many strategies that can be applied to a wide variety of medical centers that must rapidly respond to the unprecedented challenges created by the Covid-19 pandemic. In this article, the authors describe strategies for communication, surge planning, clinical care, and staff wellness.

For more than half of Crohn’s disease patients, strictures will cause bowel obstructions that require surgery within 10 years of their initial diagnosis. This study utilizes computed tomography imaging and clinical data obtained at the initial emergency room visit to create a prediction model for progression to surgery in Crohn’s disease patients with acute small bowel obstructions. A retrospective chart review was performed for patients who presented to the emergency room with an ICD-10 diagnosis for Crohn’s disease and visit diagnosis of small bowel obstruction. Two expert abdominal radiologists evaluated the CT scans for bowel wall thickness, maximal and minimal luminal diameters, length of diseased segment, passage of oral contrast, evidence of penetrating disease, bowel wall hyperenhancement or stratification, presence of a comb sign, fat hypertrophy, and small bowel feces sign. The primary outcome was progression to surgery within 6 months of presentation. The secondary outcome was time to readmission. Forty patients met the inclusion criteria, with 78% receiving medical treatment alone and 22% undergoing surgery within 6 months of presentation to the emergency room. Multivariable analysis produced a model with an AUC of 92% (95% CI 0.82–1.00), 78% sensitivity, and 97% specificity, using gender, body mass index, and the radiographic features of segment length, penetrating disease, and bowel wall hyperenhancement. The model demonstrates that routine clinical and radiographic data from an emergency room visit can predict progression to surgery, and has the potential to risk stratify patients, guide management in the acute setting, and predict readmission.

The COVID-19 pandemic has challenged front-line clinical decision-making, leading to numerous published prognostic tools. However, few models have been prospectively validated and none report implementation in practice. Here, we use 3345 retrospective and 474 prospective hospitalizations to develop and validate a parsimonious model to identify patients with favorable outcomes within 96 h of a prediction, based on real-time lab values, vital signs, and oxygen support variables. In retrospective and prospective validation, the model achieves high average precision (88.6% 95% CI: [88.4–88.7] and 90.8% [90.8–90.8]) and discrimination (95.1% [95.1–95.2] and 86.8% [86.8–86.9]) respectively. We implemented and integrated the model into the EHR, achieving a positive predictive value of 93.3% with 41% sensitivity. Preliminary results suggest clinicians are adopting these scores into their clinical workflows.

BACKGROUND:To create meaningful quality improvement (QI) curricula for graduate medical education (GME) trainees, institutions strive to improve coordination of QI curricula with hospital improvement infrastructure.OBJECTIVE:We created a curriculum to teach residents about QI and value-based medicine (VBM) and assessed curricular effectiveness.METHODS:We designed a 2-week required curriculum for internal medicine residents at a large academic program. After participating in basic skills workshops, trainees developed QI/VBM project ideas with faculty and nonclinical support and pitched them to hospital leaders at the end of the rotation. Pre-post and 1-year follow-up surveys were conducted for residents to self-assess knowledge, attitudes, and skills, participation in QI/VBM projects, and career intentions. We tracked QI/VBM project implementation.RESULTS:In the first 2 years (2017-2018), 92 trainees participated, and 71 of 76 (93%) recommended the curriculum. Surveys (76 of 92, 83%) show improvement in our learning objectives (12%-60% pre to 62%-97% post; P < .001 for all; Cohen's d effect size 0.7-1.2), which are sustained at 1-year follow-up (57%-95%; P < .01). Four of 19 projects have been implemented. At 1 year, 95% of residents had presented a quality/value poster presentation, 44% were involved in QI/VBM beyond required rotations, and 26% plan to pursue careers focused on improving quality, safety, or value.CONCLUSIONS:Our project-based curriculum culminating in a project pitch to hospital leadership was acceptable to GME trainees, improved self-assessed skills sustained at 1 year, and resulted in successfully implemented QI/VBM projects.

BACKGROUND AND PURPOSE:With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19. METHODS:We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls). RESULTS:During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P=0.003) and historical controls (25.0%, P<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls. CONCLUSIONS:We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.

INTRODUCTION: The outbreak of novel severe acute respiratory virus syndrome coronavirus 2 (SARS-CoV 2), the causative virus of coronavirus disease 2019 (COVID-19), has become a global pandemic. In the United States, cases exceed 2 million, with the New York City (NYC) metropolitan area at the epicenter. Patients with inflammatory bowel disease (IBD) are generally considered higher risk of infection due to immunosuppressive therapies, however, data are lacking regarding outcomes of COVID-19 in patients with IBD compared to the general population. We aim to investigate the impact of IBD on COVID-19 outcomes. METHODS: We prospectively collected data on all patients with IBD [Crohn’s disease (CD), ulcerative colitis (UC)] with confirmed or highly suspected COVID-19 (fever and/or close contact plus respiratory symptoms) and all non-IBD patients with confirmed COVID-19 from March 3 to May 10, 2020 at an academic medical center in NYC. Patient demographics, co-morbidities, and medication history were recorded. The endpoints were severe outcomes of COVID-19, including hospitalization, ventilator requirement, ICU admission and death. Adjusted analyses were performed for predictors of a composite endpoint of ventilator, ICU and death. RESULTS: We identified 83 patients with IBD [CD (n = 56, 67%) or UC (n = 27, 33%)] with confirmed or suspected COVID-19 and 8277 non-IBD patients with confirmed COVID-19 (Table 1). IBD patients had a lower median age (34 vs. 53 years; P < 0.001) and a higher proportion of Caucasians (69% vs. 41%; P < 0.001). IBD patients were less likely to have any co-morbidity (29% vs. 52%; P < 0.001), and had higher rates of immunomodulator (IMM) or biologic use. IBD patients with confirmed COVID-19 had lower rates of hospitalizations (14% vs. 51%; P < 0.001) and ICU admissions (2% vs. 13%; P = 0.04; Table 2). On multivariable analysis restricted to confirmed COVID-19, the presence of IBD was not associated with severe outcomes (OR 0.55, 95% CI 0.12-2.44, P = 0.43). Age, male gender, number of comorbidities, thiopurine and steroid use were significant predictors of severe COVID-19 outcomes, while TNF-antagonists had a protective effect (Table 3). CONCLUSION: In this large cohort study, IBD was not a risk factor for severe outcomes of COVID-19. Age, co-morbidities, and exposure to thiopurines and steroids were associated with severe outcomes of COVID-19. TNF-antagonists may be protective from severe outcomes of COVID-19, but this requires further study.Table 1.: Patient Demographics, Co-Morbidities and Medication HistoryTable 2.: Outcomes of COVID-19 PatientsTable 3.: Univariate and Multivariate Predictors of Composite Endpoint of Severe Outcome (Ventilator, ICU or Death) for Confirmed COVID-19 Patients

Introduction After infliximab (IFX), which was the first anti-TNF available in ulcerative colitis (UC), subcutaneous (SC) anti-TNF i.e. adalimumab (ADA) or golimumab (GOLI) were approved for moderate to severe UC.While it is well-known that SC anti-TNF were less effective after failure of IFX, there is no data on the efficacy of IFX after ADA or GOLI failure in UC.We aimed to evaluate the efficacity of IFX after failure or intolerance to one SC anti-TNF and to identify the factors associated with therapeutic efficacy.Methods This was a retrospective multicenter study (7centers), including all UC patients who received IFX after a SC anti-TNF.Efficacy was assessed according to physician's judgement as failure, partial response or complete response.Mucosal healing was defined as Mayo endoscopic subscore # 1. Clinical and biological response was defined as persistent response under IFX at week 52 without steroids or colectomy and with CRP < 5mg/L.Results Overall, 80 UC patients were included (E1=10.1 %), E2=36.7 % and E3 53.2 %).Among them, 70 were treated previously with ADA (87.5%), 63.9% discontinued ADA due to primary failure, 29.1% due to loss of response (LOR) and 7,1% due to adverse event.ADA was intensified in 42 patients (60.0%).Thirteen patients were treated with GOLI.Median Mayo score at inclusion was 9.5 [8.11].The patients were treated with IFX and concomitant use of 5-ASA (10.3 %), steroids (29.5%), thiopurines (46.2 %) or methotrexate (12.8 %).At week 12, the rate of clinical response was 78.4% (36.5% of complete response).IFX was intensified in 44.1% of the patients within the first 12 weeks.IFX was stopped in 17 patients, 13 because of primary failure and 4 due to adverse events.Mucosal healing was observed in 33.3% of the patients.In multivariate analysis, prior anti-TNF LOR rather than primary failure (OR=6, IC95% [1.2 -30.8], p=0.033) and concomitant use of thiopurines (OR=2.5 IC95 %[1.1-12.5])were predictive of clinical response at W12.At week 52, the remission rate was 29.2% (21/72).Clinical response was achieved in 61.1% of patients (40.3% of complete response).IFX was intensified in 2/3 of the patients.IFX was stopped in 24 patients due to failure (n=18) or adverse effects (n=6).Mucosal healing was achieved in 63.3% of patients (19/30).In multivariate analysis, clinical response at week 12 was associated with clinical remission at week 52 (OR=25 IC95% [1,0]).At last follow-up, (mean followup 44 months), the rate of clinical and biological response was 30.6% (22/72) and almost half of patients (47.2%) were still treated with IFX (73.6% with intensified doses).During this study, 11 patients (13.8%) required colectomy.Conclusion The results suggest that UC patients may be successfully treated with IFX after failure of SC anti-TNF, as approximately 50% of them maintained long-term clinical response.

Gastrointestinal symptoms and usage of proton pump inhibitors, probiotics, antibiotics, and psychotropic medications were also surveyed.Results: Overall, 98 pts who completed HBT agreed to participate.71 (72%) pts tested positive for SIBO.None of the pt demographics (age, gender, marital status, having children) differed significantly among SIBO + and SIBOsubgroups.There was no difference in the use of antibiotics, probiotics, PPI, and psychotropic medications among the groups.There was also no difference in GI symptoms among pts with and without SIBO.The survey for IBS was completed by 95 pts and 62 met criteria (65%).Presence of IBS was not significantly related to SIBO status.Only 2/62 (3.3%) pts with IBS were seeing a mental health provider.Pts with IBS were less likely to be seeing a psychiatrist than those without IBS (p=0.05).The survey to screen for underlying depression was completed by 95 pts and 32 screened positive (34%).Neither SIBO nor IBS was significantly associated with depression.The survey to screen for underlying anxiety was completed by 97 pts and 41 screened positive (42%).Neither SIBO nor IBS was significantly associated with anxiety.Quality of life (QoL) survey was completed by 97 pts.67 (69%) pts reported an impaired physical QoL, while 38 (39%) reported an impaired mental QoL.The presence of SIBO or IBS was not significantly associated with a decreased QoL.Pts with impaired mental QoL were more than four times likely to be taking anti-depressants (OR= 4.36, p=.002).Conclusions: The majority of pts who presented for HBT had SIBO, and IBS based on Rome III Criteria.Over one third of our pts screened positive for underlying depression, anxiety, and impaired QoL regardless of the presence of underlying IBS or SIBO.However the vast majority of these pts were not being seen by a mental health provider.Emphasis on utilization of mental health therapy may help optimize management.Multivariable logistic regression analysis with depression, anxiety, and impaired QoL as outcome and IBS, SIBO as predictors Tu1734

unusual.DISCUSSION Metastases of GIST are not a common occurrence.Moreover, only <1% of GISTs metastasize to subcutaneous tissue.Up to 85% of GISTs harbor activating mutations in KIT Tyrosine kinase /platelet derived growth factor receptor alpha (PDGFRA) gene.Our patient had KIT and exon 11 mutations.At present, Imatinib (Tyrosine kinase inhibitor) is the worldwide standard therapy for advanced/metastatic GIST and its efficacy in terms of progression free survival (PFS) and disease specific survival (DSS) has been widely demonstrated with 80% survival at 2 years.Nevertheless, after an initial response, a primary resistance can occur within 6 months of therapy and secondary resistance can develop within 2 years.Commonly, secondary resistance occurs with exon 11 mutation however, our case was peculiar because it demonstrated primary resistance which is more widespread with exon 9 mutation.CONCLUSION Additional research is needed on metastatic GIST and development of primary resistance to Imatinib with exon 11 mutation. Sa1679

Introduction: The optimal management of inflammatory bowel disease (IBD) has major physical, psychological and financial implications for our patients as well as our health care system. As IBD is a complex and chronic disease with symptoms that frequently require hospitalization, IBD patients are high utilizers of health care. The objectives of this study were to describe baseline features of patients and inpatient outcomes at an academic, comprehensive IBD center. Methods: We conducted a retrospective chart review of adult patients with IBD-related inpatient admissions at a tertiary referral, academic center between 2014 to 2016. We included patients who either had an IBD-related readmission within one year of index discharge or 12 months of clinical follow up. We analyzed data on patient demographics, medical history, IBD severity and management features, interventions during hospital admissions as well as readmission rates. Results: 102 patients were included. Overall, 43% were male, 76% white, 53% with Crohn's disease, 47% with ulcerative colitis (UC). The most prevalent co-morbidities included chronic pain (27%) and a mental health disorder (24%). 59% of patients had severe UC or stricturing, fistulizing, or perianal Crohns. The median duration of IBD prior to index admission was 7 years and 16% of patients had an IBD-related admission within the prior 2 years. 28 (27%) patients were readmitted within 1 year (11 (11%) readmitted within 30 days). Figure 1 shows indications for admission and readmission. The majority of indications for index admissions and readmission were IBD flare (82% and 75% respectively), defined as diarrhea and/or abdominal pain; and the median length of stay was 4 days. Table 1 shows diagnostic and therapeutic interventions. About 50% of patients underwent cross sectional imaging and endoscopic evaluation. Overall, 15% of patients underwent infusion (12% infliximab, 3% cyclosporine) and 12% of patients underwent surgery.593_A Figure 1. Indications for Admission and ReadmissionConclusion: Optimal management of IBD requires consideration of co-morbidities such as chronic pain and mental health as well as careful coordination of multiple inpatient services including gastroenterology, surgery and radiology. In our experience at NYU Langone, many of our patients required rescue infusions with infliximab or cyclosporine, complex surgical management, and psychosocial support. Based on these findings we have started a co-managed IBD service with GI and surgery to minimize hospital readmission and maximize patient outcomes.593_B Figure 2. Factors at Index Admission correlated with Readmission