Publications by authors named "Martin Lesser"

132 Publications

The Association of Structural Inequities and Race with out-of-Hospital Sudden Death during the COVID-19 Pandemic.

Circ Arrhythm Electrophysiol 2021 Apr 9. Epub 2021 Apr 9.

Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead & Department of Cardiology, Northwell Health, New York & Center for Equity of Care, Northwell Health, Lake Success, NY.

- Social influencers of health (SIOH) namely race, ethnicity and structural inequities are known to affect the incidence of out of hospital sudden death (OHSD). We sought to examine the association between SIOH and the incidence of OHSD in the diverse neighborhoods of New York City (NYC) during the first wave of COVID-19 epidemic. - NYC ZIP stratified data on OHSD were obtained from the Fire Department of New York during the first wave of COVID-19 epidemic (March 1 - April 10, 2019) and the same period in 2020. To assess associates of OHSD, ZIP code-specific sociodemographic characteristics for 8,491,238 NYC residents were obtained via the US Census Bureau's 2018 American Community Survey and the New York Police Department's crime statistics. - Between March 1 and April 10, 2020, the number of OHSD rose to 4,334 from 1,112 compared to the year prior. Of the univariate ZIP code level variables evaluated, proportions of: Black race, Hispanic/Latino ethnicity, single parent household, unemployed inhabitants, people completing less than high school education, inhabitants with no health insurance, people financially struggling or living in poverty, percent of non-citizens and population density were associated with increased rates of OHSD within ZIP codes. In multivariable analysis, ZIP codes with higher proportions of inhabitants with less than high school education (p < 0.001) and higher proportions of Black race (p = 0.04) were independent predictors for increases in ZIP code rates of OHSD. - Educational attainment and the proportion of Black race in NYC ZIP codes remained independent predictors of increased rates of ZIP code level OHSD during the COVID-19 outbreak even after controlling for 2019 rates. To facilitate health equity, future research should focus on characterizing the impacts of structural inequities while exploring strategies to mitigate their effects.
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http://dx.doi.org/10.1161/CIRCEP.120.009646DOI Listing
April 2021

Treatment-dose LMWH versus prophylactic/intermediate dose heparins in high risk COVID-19 inpatients: Rationale and design of the HEP-COVID Trial.

Thromb Haemost 2021 Apr 6. Epub 2021 Apr 6.

Northwell Health, Feinstein Institutes for Medical Research, Manhasset, United States.

Coronavirus disease-2019 (COVID-19) has been associated with significant risk of venous thromboembolism (VTE), arterial thromboembolism (ATE), and mortality particularly among hospitalized patients with critical illness and elevated D-dimer (Dd) levels. Conflicting data have yet to elucidate optimal thromboprophylaxis dosing. HEP-COVID (NCT04401293) is a Phase 3, multicenter, pragmatic, prospective, randomized, pseudo-blinded, active control trial to evaluate efficacy and safety of therapeutic-dose low molecular weight heparin (LMWH) versus prophylactic-/intermediate-dose LMWH or unfractionated heparin (UFH) for prevention of a primary efficacy composite outcome of VTE, ATE, and all-cause mortality (ACM) 30 ± 2 days post-enrollment. Eligible patients have COVID-19 diagnosis by nasal swab or serologic testing, requirement for supplemental oxygen per investigator judgment, and Dd >4x upper limit of normal (ULN) or sepsis-induced coagulopathy (SIC) score ≥4. Subjects are randomized to enoxaparin 1 mg/kg SQ/BID (CrCl ≥ 30 ml/min) or 0.5 mg/kg (CrCl 15-30 ml/min) vs local institutional prophylactic regimens including: a) UFH up to 22,500 IU daily (divided BID or TID), b) enoxaparin 30mg and 40mg SQ QD or BID, or c) dalteparin 2500IU or 5000 IU QD. The principal safety outcome is major bleeding. Events are adjudicated locally. Based on expected 40% relative risk reduction (RRR) with treatment-dose compared with prophylactic-dose prophylaxis, 308 subjects will be enrolled (assuming 20% drop-out) to achieve 80% power. Distinguishing design features include an enriched population for the composite endpoint anchored on Dd >4x ULN, stratification by ICU vs non-ICU, and the ability to capture asymptomatic proximal deep venous thrombosis via screening ultrasonography prior to discharge.
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http://dx.doi.org/10.1055/a-1475-2351DOI Listing
April 2021

Incidence of Venous Thromboembolism and Mortality in Patients with Initial Presentation of COVID-19.

J Thromb Thrombolysis 2021 Mar 5. Epub 2021 Mar 5.

Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.

Venous thromboembolism (VTE) has emerged as an important issue in patients with COVID-19. The purpose of this study is to identify the incidence of VTE and mortality in COVID-19 patients initially presenting to a large health system. Our retrospective study included adult patients (excluding patients presenting with obstetric/gynecologic conditions) across a multihospital health system in the New York Metropolitan Region from March 1-April 27, 2020. VTE and mortality rates within 8 h of assessment were described. In 10,871 adults with COVID-19, 118 patients (1.09%) were diagnosed with symptomatic VTE (101 pulmonary embolism, 17 deep vein thrombosis events) and 28 patients (0.26%) died during initial assessment. Among these 146 patients, 64.4% were males, 56.8% were 60 years or older, 15.1% had a BMI > 35, and 11.6% were admitted to the intensive care unit. Comorbidities included hypertension (46.6%), diabetes (24.7%), hyperlipidemia (14.4%), chronic lung disease (12.3%), coronary artery disease (11.0%), and prior VTE (7.5%). Key medications included corticosteroids (22.6%), statins (21.2%), antiplatelets (20.6%), and anticoagulants (20.6%). Highest D-Dimer was greater than six times the upper limit of normal in 51.4%. Statin and antiplatelet use were associated with decreased VTE or mortality (each p < 0.01). In COVID-19 patients who initially presented to a large multihospital health system, the overall symptomatic VTE and mortality rate was over 1.0%. Statin and antiplatelet use were associated with decreased VTE or mortality. The potential benefits of antithrombotics in high risk COVID-19 patients during the pre-hospitalization period deserves study.
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http://dx.doi.org/10.1007/s11239-021-02413-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932762PMC
March 2021

Examination of patient characteristics and hydroxychloroquine use based on the US Food and Drug Administration's recommendation: a cross-sectional analysis in New York.

BMJ Open 2021 02 8;11(2):e042965. Epub 2021 Feb 8.

Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA

Objective: To describe the pattern of hydroxychloroquine use and examine the association between hydroxychloroquine use and clinical outcomes arising from changes in the US Food and Drug Administration (FDA)'s recommendation during the coronavirus disease 2019 (COVID-19) pandemic.

Design: A retrospective cross-sectional analysis.

Setting And Participants: We included hospitalised adult patients at Northwell Health hospitals with confirmed COVID-19 infections between 1 March 2020 and 11 May 2020. We categorised changes in the FDA's recommendation as pre-FDA approval (1 March 2020-27 March 2020), FDA approval (28 March 2020-23 April 2020), and FDA warning (24 April 2020-11 May 2020). The hydroxychloroquine-treated group received at least one dose within 48 hours of hospital admission.

Primary Outcome: A composite of intubation and inpatient death.

Results: The percentages of patients who were treated with hydroxychloroquine were 192/2202 (8.7%) pre-FDA approval, 2902/6741 (43.0%) FDA approval, and 176/1066 (16.5%) FDA warning period (p<0.001). Using propensity score matching, there was a higher rate of the composite outcome among patients treated with hydroxychloroquine (49/192, 25.5%) compared with no hydroxychloroquine (66/384, 17.2%) in the pre-FDA approval period (p=0.03) but not in the FDA approval period (25.5% vs 22.6%, p=0.08) or the FDA warning (21.0% vs 15.1%, p=0.11) periods. Coincidently, there was an increase in number of patients with COVID-19 and disease severity during the FDA approval period (24.1% during FDA approval vs 21.4% during pre-FDA approval period had the composite outcome). Hydroxychloroquine use was associated with increased odds of the composite outcome during the pre-FDA approval period (OR=1.65 (95% CI 1.09 to 2.51)) but not during the FDA approval (OR=1.17 (95% CI 0.99 to 1.39)) and FDA warning (OR=1.50 (95% CI 0.94 to 2.39)) periods.

Conclusions: Hydroxychloroquine use was associated with adverse clinical outcomes only during the pre-FDA approval period but not during the FDA approval and warning periods, even after adjusting for concurrent changes in the percentage of patients with COVID-19 treated with hydroxychloroquine and the number (and disease severity) of hospitalised patients with COVID-19 infections.
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http://dx.doi.org/10.1136/bmjopen-2020-042965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871686PMC
February 2021

Atrial fibrillation is an independent predictor for in-hospital mortality in patients admitted with SARS-CoV-2 infection.

Heart Rhythm 2021 04 22;18(4):501-507. Epub 2021 Jan 22.

Department of Cardiology, Northwell Health, New York, New York.

Background: Atrial fibrillation (AF) is the most encountered arrhythmia and has been associated with worse in-hospital outcomes.

Objective: This study was to determine the incidence of AF in patients hospitalized with coronavirus disease 2019 (COVID-19) as well as its impact on in-hospital mortality.

Methods: Patients hospitalized with a positive COVID-19 polymerase chain reaction test between March 1 and April 27, 2020, were identified from the common medical record system of 13 Northwell Health hospitals. Natural language processing search algorithms were used to identify and classify AF. Patients were classified as having AF or not. AF was further classified as new-onset AF vs history of AF.

Results: AF occurred in 1687 of 9564 patients (17.6%). Of those, 1109 patients (65.7%) had new-onset AF. Propensity score matching of 1238 pairs of patients with AF and without AF showed higher in-hospital mortality in the AF group (54.3% vs 37.2%; P < .0001). Within the AF group, propensity score matching of 500 pairs showed higher in-hospital mortality in patients with new-onset AF as compared with those with a history of AF (55.2% vs 46.8%; P = .009). The risk ratio of in-hospital mortality for new-onset AF in patients with sinus rhythm was 1.56 (95% confidence interval 1.42-1.71; P < .0001). The presence of cardiac disease was not associated with a higher risk of in-hospital mortality in patients with AF (P = .1).

Conclusion: In patients hospitalized with COVID-19, 17.6% experienced AF. AF, particularly new-onset, was an independent predictor of in-hospital mortality.
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http://dx.doi.org/10.1016/j.hrthm.2021.01.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825902PMC
April 2021

Prevalence and Predictors of Venous Thromboembolism or Mortality in Hospitalized COVID-19 Patients.

Thromb Haemost 2021 Jan 20. Epub 2021 Jan 20.

Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States.

Background:  We aimed to identify the prevalence and predictors of venous thromboembolism (VTE) or mortality in hospitalized coronavirus disease 2019 (COVID-19) patients.

Methods:  A retrospective cohort study of hospitalized adult patients admitted to an integrated health care network in the New York metropolitan region between March 1, 2020 and April 27, 2020. The final analysis included 9,407 patients with an overall VTE rate of 2.9% (2.4% in the medical ward and 4.9% in the intensive care unit [ICU]) and a VTE or mortality rate of 26.1%. Most patients received prophylactic-dose thromboprophylaxis. Multivariable analysis showed significantly reduced VTE or mortality with Black race, history of hypertension, angiotensin converting enzyme/angiotensin receptor blocker use, and initial prophylactic anticoagulation. It also showed significantly increased VTE or mortality with age 60 years or greater, Charlson Comorbidity Index (CCI) of 3 or greater, patients on Medicare, history of heart failure, history of cerebrovascular disease, body mass index greater than 35, steroid use, antirheumatologic medication use, hydroxychloroquine use, maximum D-dimer four times or greater than the upper limit of normal (ULN), ICU level of care, increasing creatinine, and decreasing platelet counts.

Conclusion:  In our large cohort of hospitalized COVID-19 patients, the overall in-hospital VTE rate was 2.9% (4.9% in the ICU) and a VTE or mortality rate of 26.1%. Key predictors of VTE or mortality included advanced age, increasing CCI, history of cardiovascular disease, ICU level of care, and elevated maximum D-dimer with a cutoff at least four times the ULN. Use of prophylactic-dose anticoagulation but not treatment-dose anticoagulation was associated with reduced VTE or mortality.
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http://dx.doi.org/10.1055/a-1366-9656DOI Listing
January 2021

The Effects of a Comprehensive Multidisciplinary Outpatient Diabetes Program on Hospital Readmission Rates in Patients with Diabetes: A Randomized Controlled Prospective Study.

Endocr Pract 2020 Nov;26(11):1331-1336

Division of Endocrinology, Friedman Diabetes Institute, Department of Medicine, Lenox Hill Hospital, Northwell Health, New York, New York. Electronic address:

Objective: The diagnosis of diabetes mellitus is associated with an increased risk of hospital readmissions. The goal of this study was to determine whether there was a difference in the rates of 30-day and 365-day hospital readmissions between diabetic patients who, upon their discharge, received diabetes care in a standard primary care setting and those who received their care in a specialized multidisciplinary diabetes program.

Methods: This was a randomized controlled prospective study.

Results: One hundred and ninety two consecutive patients were recruited into the study, 95 (49%) into standard care (control group) and 97 (51%) into a multidisciplinary diabetes program (intervention group). The 30-day overall hospital readmission rates (including both emergency department and hospital readmissions) were 19% in the control group and 7% in the intervention group (P = .02). The 365-day overall hospital readmission rates were 38% in the control group and 14% in the intervention group (P = .0002).

Conclusion: Patients with diabetes who are assigned to a specialized multidisciplinary diabetes program upon their discharge exhibit significantly reduced hospital readmission rates at 30 days and 365 days after discharge.
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http://dx.doi.org/10.4158/EP-2020-0261DOI Listing
November 2020

Estimating the predictive value of negative severe acute respiratory coronavirus virus 2 (SARS-CoV-2) results: A prospective study.

Infect Control Hosp Epidemiol 2020 Dec 10:1-3. Epub 2020 Dec 10.

Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.

We performed a prospective study of 501 patients, regardless of symptoms, admitted to the hospital, to estimate the predictive value of a negative nasopharyngeal swab for severe acute respiratory coronavirus virus 2 (SARS-CoV-2). At a positivity rate of 10.2%, the estimated negative predictive value (NPV) was 97.2% and the NPV rose as prevalence decreased during the study.
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http://dx.doi.org/10.1017/ice.2020.1362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783084PMC
December 2020

Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study.

BMC Med Inform Decis Mak 2020 12 7;20(1):324. Epub 2020 Dec 7.

Hispanic Counseling Center, Hempstead, NY, USA.

Background: Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes.

Methods: A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides.

Results: Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse.

Conclusions: These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes.

Trial Registration: NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.
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http://dx.doi.org/10.1186/s12911-020-01346-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720574PMC
December 2020

The Role of Duplex Ultrasound in Assessing AVF Maturation.

Ann Vasc Surg 2021 Apr 21;72:315-320. Epub 2020 Nov 21.

Division of Vascular Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY.

Background: Arteriovenous fistulas (AVFs) are favored for hemodialysis (HD) access. However, in many instances, AVFs fail to mature. We examined the utility of postoperative color duplex ultrasound (CDU) in assessing AVF maturation and determining the need for balloon-assisted maturation (BAM).

Methods: A total of 633 patients underwent AVF creation at a single institution from 2015 to 2018. A total of 339 patients (54%) underwent CDU at a median of 8 weeks postoperatively. We collected the following parameters: vein diameter, volume flow (VF), peak systolic velocities in arterial inflow and venous outflow, and presence of stealing branches. A peak systolic velocity ratio (SVR) of ≥2 correlated with ≥50% stenosis in venous outflow, and SVR ≥3 correlated with ≥50% stenosis at the anastomosis. AVFs were considered mature when they were successfully cannulated on dialysis. A generalized linear mixed model (GLMM) was created to compare duplex criteria associated with successful use of AVF (maturation) to those AVFs that required further intervention or failed to mature. Fistulography images, the current gold standard, were compared with findings from CDU studies to determine validity of the duplex ultrasound.

Results: Of the 339 AVFs with postoperative CDU, 31.3% matured without interventions, 38.3% required BAM, 9.7% thrombosed, and the remaining patients were not yet on HD. Based on GLMM analysis, the probability of AVF maturation increases if CDU demonstrated one of the following: the vein diameter is ≥ 6 (odds ratio [OR] = 38.7), no evidence of stenosis in the venous outflow tract (OR = 35.6), no stealing branches (OR = 21.6) and VF ≥ 675 (OR = 5.0). Fistulography was performed in 195 patents. Sensitivity and specificity for each are as follows: vein diameter (84.3%, 28.6%), stenosis (59.3%, 78.8%), and stealing branches (20.7%, 92.7%).

Conclusions: Postoperative CDU should be considered routine to correct anatomical findings that might limit AVF maturation and identify the need for further interventions.
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http://dx.doi.org/10.1016/j.avsg.2020.10.006DOI Listing
April 2021

Transcutaneous auricular vagus nerve stimulation reduces pain and fatigue in patients with systemic lupus erythematosus: a randomised, double-blind, sham-controlled pilot trial.

Ann Rheum Dis 2021 02 3;80(2):203-208. Epub 2020 Nov 3.

Feinstein Institutes for Medical Research, Manhasset, New York, USA.

Objectives: Musculoskeletal pain and fatigue are common features in systemic lupus erythematosus (SLE). The cholinergic anti-inflammatory pathway is a physiological mechanism diminishing inflammation, engaged by stimulating the vagus nerve. We evaluated the effects of non-invasive vagus nerve stimulation in patients with SLE and with musculoskeletal pain.

Methods: 18 patients with SLE and with musculoskeletal pain ≥4 on a 10 cm Visual Analogue Scale were randomised (2:1) in this double-blind study to receive transcutaneous auricular vagus nerve stimulation (taVNS) or sham stimulation (SS) for 4 consecutive days. Evaluations at baseline, day 5 and day 12 included patient assessments of pain, disease activity (PtGA) and fatigue. Tender and swollen joint counts and the Physician Global Assessment (PGA) were completed by a physician blinded to the patient's therapy. Potential biomarkers were evaluated.

Results: taVNS and SS were well tolerated. Subjects receiving taVNS had a significant decrease in pain and fatigue compared with SS and were more likely (OR=25, p=0.02) to experience a clinically significant reduction in pain. PtGA, joint counts and PGA also improved. Pain reduction and improvement of fatigue correlated with the cumulative current received. In general, responses were maintained through day 12. Plasma levels of substance P were significantly reduced at day 5 compared with baseline following taVNS but other neuropeptides, serum and whole blood-stimulated inflammatory mediators, and kynurenine metabolites showed no significant change at days 5 or 12 compared with baseline.

Conclusion: taVNS resulted in significantly reduced pain, fatigue and joint scores in SLE. Additional studies evaluating this intervention and its mechanisms are warranted.
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http://dx.doi.org/10.1136/annrheumdis-2020-217872DOI Listing
February 2021

Disseminated inflammation of the central nervous system associated with acute hepatitis E: a case report.

BMC Neurol 2020 Oct 27;20(1):391. Epub 2020 Oct 27.

Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.

Background: Hepatitis E infection affects over 20 million people worldwide. Reports of neurological manifestations are largely limited to the peripheral nervous system. We report a middle-aged genotype 3c male patient with acute hepatitis E virus (HEV) infection and severe neurological deficits with evidence of multiple disseminated inflammatory lesions of the central nervous system.

Case Presentation: A 42-year-old male patient presented to our emergency department with musculoskeletal weakness, bladder and bowel retention, blurred vision and ascending hypoesthesia up to the level of T8. Serology showed elevated liver enzymes and positive IgM-titers of hepatitis E. Analysis of cerebrospinal fluid (CSF) showed mild pleocytosis and normal levels of glucose, lactate and protein. HEV-RNA-copies were detected in the CSF and stool. Within 3 days after admission the patient became paraplegic, had complete visual loss and absent pupillary reflexes. MRI showed inflammatory demyelination of the optic nerve sheaths, multiple subcortical brain regions and the spinal cord. Electrophysiology revealed axonal damage of the peroneal nerve on both sides with absent F-waves. Treatment was performed with methylprednisolone, two cycles of plasma exchange (PLEX), one cycle of intravenous immunoglobulins (IVIG) and ribavirin which was used off-label. Liver enzymes normalized after 1 week and serology was negative for HEV-RNA after 3 weeks. Follow-up MRI showed progressive demyelination and new leptomeningeal enhancement at the thoracic spine and cauda equina 4 weeks after admission. Four months later, after rehabilitation was completed, repeated MRI showed gliotic transformation of the spinal cord without signs of an active inflammation. Treatment with rituximab was initiated. The patient remained paraplegic and hypoesthesia had ascended up to T5. Nevertheless, he regained full vision.

Conclusions: Our case indicates a possible association of acute HEV infection with widespread disseminated central nervous system inflammation. Up to now, no specific drugs have been approved for the treatment of acute HEV infection. We treated our patient off-label with ribavirin and escalated immunomodulatory therapy considering clinical progression and the possibility of an autoimmune response targeting nerve cell structures. While response to treatment was rather limited in our case, detection of HEV in patients with acute neurological deficits might help optimize individual treatment strategies.
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http://dx.doi.org/10.1186/s12883-020-01952-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7590485PMC
October 2020

Do Patients Regret Having Received Systemic Treatment for Advanced Non-Small Cell Lung Cancer: A Prospective Evaluation.

Oncologist 2021 Mar 10;26(3):224-230. Epub 2020 Nov 10.

Feinstein Institute for Medical Research, Manhasset, New York, USA.

Background: Thousands of patients annually receive treatment for advanced non-small cell lung cancer (NSCLC), but little is known about their views on the decision to receive that treatment, or regret. This trial prospectively evaluated the incidence of regret and whether baseline characteristics, patient decision-making parameters, or clinical progress early in the treatment course predicts regret.

Materials And Methods: Patients receiving systemic treatment for advanced NSCLC completed every 3-week patient reported outcome (PRO) assessment using the electronic Lung Cancer Symptom Scale (eLCSS-QL), including the 3-Item Global Index (3-IGI; assessing overall distress, activities, and quality of life [QL]). A prespecified secondary aim was to determine the frequency of regret evaluated at 3 months after starting treatment. Patients were randomized to usual care or enhanced care (which included use of the DecisionKEYS decision aid).

Results: Of 164 patients entered, 160 received treatment and 142 were evaluable for regret. In total, 11.5% of patients and 9% of their supporters expressed regret. Baseline characteristics did not predict regret; regret was rarely expressed by those who had a less than 20% decline or improvement in the 3-IGI PRO score after two treatment cycles. In contrast, when asked if they would make the same decision again, only 1% not having a 20% 3-IGI decline expressed regret, versus 14% with a 3-IGI decline (p = .01).

Conclusion: The majority of patients having regret were identified early using the PRO 3-IGI of the eLCSS-QL measure. Identifying patients at risk for regret allows for interventions, including frank discussions of progress and goals early in the treatment course, which could address regret in patients and their supporters.

Implications For Practice: This report documents prospectively, for the first time, the incidence of treatment-related regret in patients with advanced lung cancer and outlines that risk of regret is associated with patient-determined worsening health status early in the course of treatment. Identifying patients at risk for regret early in treatment (before the third cycle of treatment) appears to be crucial. Counseling at that time should include a discussion of consideration of treatment change and the reason for this change.
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http://dx.doi.org/10.1002/onco.13571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930410PMC
March 2021

Comparative Survival Analysis of Immunomodulatory Therapy for Coronavirus Disease 2019 Cytokine Storm.

Chest 2021 03 17;159(3):933-948. Epub 2020 Oct 17.

Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY; Institute of Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Northwell Health, Manhasset, NY.

Background: Cytokine storm is a marker of coronavirus disease 2019 (COVID-19) illness severity and increased mortality. Immunomodulatory treatments have been repurposed to improve mortality outcomes.

Research Question: Do immunomodulatory therapies improve survival in patients with COVID-19 cytokine storm (CCS)?

Study Design And 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. CCS was defined by inflammatory markers: ferritin, > 700 ng/mL; C-reactive protein (CRP), > 30 mg/dL; or lactate dehydrogenase (LDH), > 300 U/L. Patients were subdivided into six groups: no immunomodulatory treatment (standard of care) and five groups that received either corticosteroids, anti-IL-6 antibody (tocilizumab), or anti-IL-1 therapy (anakinra) alone or in combination with corticosteroids. The primary outcome was hospital mortality.

Results: Five thousand seven hundred seventy-six 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 LDH (76.2%) alone or in combination, followed by ferritin (63.2%) and CRP (8.4%). More than 80% of patients showed an elevated D-dimer. Patients treated with corticosteroids and tocilizumab combination showed lower mortality compared with patients receiving standard-of-care (SoC) treatment (hazard ratio [HR], 0.44; 95% CI, 0.35-0.55; P < .0001) and with patients treated with corticosteroids alone (HR, 0.66; 95% CI, 0.53-0.83; P = .004) or in combination with anakinra (HR, 0.64; 95% CI, 0.50-0.81; P = .003). Corticosteroids when administered alone (HR, 0.66; 95% CI, 0.57-0.76; P < .0001) or in combination with tocilizumab (HR, 0.43; 95% CI, 0.35-0.55; P < .0001) or anakinra (HR, 0.68; 95% CI, 0.57-0.81; P < .0001) improved hospital survival compared with SoC treatment.

Interpretation: The combination of corticosteroids with tocilizumab showed superior survival outcome when compared with SoC treatment as well as treatment with 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 CCS compared with patients receiving SoC treatment.
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http://dx.doi.org/10.1016/j.chest.2020.09.275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7567703PMC
March 2021

Glycosylated hemoglobin, but not advanced glycation end products, predicts severity of coronary artery disease in patients with or without diabetes.

Metabol Open 2020 Sep 16;7:100050. Epub 2020 Aug 16.

Division of Endocrinology and Friedman Diabetes Institute, Lenox Hill Hospital, Northwell Health, New York, NY, USA.

Background: The association between coronary artery disease (CAD) and diabetes mellitus (DM) is strong but the physiologic mechanisms responsible for this association remain unclear. Patients with DM exhibit high circulating levels of glycated proteins and lipoproteins called advanced glycation end products (AGEs) which have been implicated in the development of oxidative damage to vascular endothelium. We examined the relationships between the presence and extent of CAD and AGEs in patients undergoing elective coronary artery catheterization in an urban teaching hospital.

Methods: Patients with possible CAD (n = 364) were recruited prior to elective cardiac catheterization (52% male, 48% diabetic). Regression and correlation analyses were used to examine the relationship between serum AGE concentrations, soluble AGE receptor (sRAGE) concentration, HbA, LDL and the presence of obstructive CAD along with the burden of CAD measured by SYNTAX and SYNTAX II scores.

Results: AGE and sRAGE levels did not significantly correlate with any of the studied coronary artery disease parameters. HbA showed positive correlation with both SYNTAX and SYNTAX II scores in patients with and without diabetes.

Conclusion: In this cross-sectional study of patients with possible CAD, serum AGEs and sRAGE concentrations did not correlate with SYNTAX or SYNTAX II scores regardless of diabetic status. HbA1C correlated positively with the SYNTAX and SYNTAX II scores in both diabetic and non-diabetic populations.
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http://dx.doi.org/10.1016/j.metop.2020.100050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474000PMC
September 2020

Gefitinib Inhibits Invasion and Metastasis of Osteosarcoma via Inhibition of Macrophage Receptor Interacting Serine-Threonine Kinase 2.

Mol Cancer Ther 2020 06 5;19(6):1340-1350. Epub 2020 May 5.

The Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York.

Most patients with osteosarcoma have subclinical pulmonary micrometastases at diagnosis. Mounting evidence suggests that macrophages facilitate metastasis. As the EGFR has been implicated in carcinoma-macrophage cross-talk, in this study, we asked whether gefitinib, an EGFR inhibitor, reduces osteosarcoma invasion and metastatic outgrowth using the K7M2-Balb/c syngeneic murine model. Macrophages enhanced osteosarcoma invasion , which was suppressed by gefitinib. Oral gefitinib inhibited tumor extravasation in the lung and reduced the size of metastatic foci, resulting in reduced metastatic burden. Gefitinib also altered pulmonary macrophage phenotype, increasing MHCII and decreasing CD206 expression compared with controls. Surprisingly, these effects are mediated through inhibition of macrophage receptor interacting protein kinase 2 (RIPK2), rather than EGFR. Supporting this, lapatinib, a highly specific EGFR inhibitor that does not inhibit RIPK2, had no effect on macrophage-promoted invasion, and RIPK2 macrophages failed to promote invasion. The selective RIPK2 inhibitor WEHI-345 blocked tumor cell invasion and reduced metastatic burden In conclusion, our results indicate that gefitinib blocks macrophage-promoted invasion and metastatic extravasation by reprogramming macrophages through inhibition of RIPK2.
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http://dx.doi.org/10.1158/1535-7163.MCT-19-0903DOI Listing
June 2020

Transfusion in Elective Aortic Root Replacement: Analysis of the STS Adult Cardiac Surgery Database.

Ann Thorac Surg 2020 10 29;110(4):1225-1233. Epub 2020 Feb 29.

Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, New York. Electronic address:

Background: Data on blood use in proximal aortic surgery is limited. This study sought to establish quality benchmarks in the pattern of transfusion during elective aortic root replacement.

Methods: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried to identify all patients who underwent primary elective aortic root replacement between July 2014 and June 2017. Multivariable negative binomial regressions were used to determine whether perioperative transfusion was associated with demographic or procedural factors. Multivariable logistic regression analysis was performed for clinical outcomes.

Results: Of 5559 patients analyzed, 38.95% (n = 2165) received no blood products. Patients who had a valve-sparing root replacement were less likely to undergo transfusion than those who received composite roots (bioprosthetic or mechanical valves) or homografts. The 30-day mortality for all patients was 2.57% (n = 143). Transfusion was associated with an increased risk of death at 30 days (odds ratio [OR], 1.833; P = .012), more frequent reoperation for bleeding (OR, 1.766; P < .001), prolonged ventilation (OR, 1.935; P < .001), a longer postoperative hospital stay (OR, 1.056; P < .001), and a higher incidence of new dialysis-dependent renal failure (OR, 2.088; P = .003). There was no correlation between institutional case volume and transfusion practice.

Conclusions: Elective aortic root replacement can be performed with acceptable requirements for blood products. Composite root replacement has a greater likelihood of transfusion than does a valve-sparing procedure. Transfusion is independently associated with more complications after elective aortic root surgery, including 30-day mortality.
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http://dx.doi.org/10.1016/j.athoracsur.2020.01.035DOI Listing
October 2020

The Clinical Utility of Chest Radiography for Identifying Pneumonia: Accounting for Diagnostic Uncertainty in Radiology Reports.

AJR Am J Roentgenol 2019 12 11;213(6):1207-1212. Epub 2019 Sep 11.

Department of Medicine, Northwell Health and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.

Currently, chest radiography is the first-line imaging test for identifying pneumonia; chest CT is considered the reference standard. The purpose of this study was to calculate the statistical measures of performance of chest radiography for identifying pneumonia when taking into account uncertain results of both chest radiography and CT examinations. Statistical measures of performance of chest radiography, using CT as the reference standard, were calculated with 95% CIs by varying uncertain radiology report impressions of both chest radiography and CT to all negative or all positive. The resulting scenarios were as follows: scenario 1, uncertain chest radiography and CT impressions are considered positive for pneumonia; scenario 2, uncertain chest radiography impressions are positive but uncertain CT impressions are negative; scenario 3, uncertain chest radiography impressions are negative and uncertain CT impressions are positive; scenario 4, uncertain chest radiography and CT impressions are negative; and scenario 5, uncertain chest radiography and CT impressions are excluded. A retrospective analysis of 2411 patient visits revealed the prevalence of uncertain radiology report impressions to be 31.8% for chest radiography and 21.7% for CT. Scenario 1 yielded the following performance values: sensitivity, 51.9%; specificity, 71.3%; PPV, 59.4%; and NPV, 64.5%. Scenario 2 produced the following performance values: sensitivity, 59.6%; specificity, 67.1%; PPV, 59.6%; and NPV, 67.1%. Scenario 3 showed the following performance values: sensitivity, 13.4%; specificity, 97.7%; PPV, 82.6%; and NPV, 58.1%. Scenario 4 yielded the following performance values: sensitivity, 19.6%; specificity, 96.4%; PPV, 81.6%; and NPV, 59.5%. Scenario 5 produced the following performance values: sensitivity, 32.7%; specificity, 96.8%; PPV, 89.2%; and NPV, 63.8%. Uncertain chest radiography results for the evaluation of pneumonia are prevalent. A chest radiography impression using the strongest language in support of a pneumonia diagnosis is useful to rule in pneumonia radiographically, but a negative result performs poorly at ruling out disease.
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http://dx.doi.org/10.2214/AJR.19.21521DOI Listing
December 2019

Implementation and Validation of the 2013 Caprini Score for Risk Stratification of Arthroplasty Patients in the Prevention of Venous Thrombosis.

Clin Appl Thromb Hemost 2019 Jan-Dec;25:1076029619838066

3 Emeritus, NorthShore University Health System, Evanston, IL, USA.

Appropriate chemoprophylaxis choice following arthroplasty requires accurate patient risk assessment. We compared the results of our prospective department protocol to the Caprini risk assessment model (RAM) retrospectively in this study group. Our goal was to determine whether the department protocol or the Caprini score would identify venous thromboembolism (VTE) events after total joint replacement. A secondary purpose was to validate the 2013 Caprini RAM in joint arthroplasty and determine whether patients with VTE would be accurately identified using the Caprini score. A total of 1078 patients met inclusion criteria. A Caprini score of 10 or greater is considered high risk and a score of 9 or less is considered low risk. The 2013 version of the Caprini RAM retrospectively stratified 7 of the 8 VTE events correctly, while only 1 VTE was identified with the prospective department protocol. This tool provided a consistent, accurate, and efficacious method for risk stratification and selection of chemoprophylaxis.
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http://dx.doi.org/10.1177/1076029619838066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714918PMC
August 2019

Is vaginal misoprostol more effective than oral misoprostol for cervical ripening in obese women?

J Matern Fetal Neonatal Med 2020 Oct 10;33(20):3476-3483. Epub 2019 Feb 10.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Donald Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.

To determine if vaginal misoprostol is more effective than oral misoprostol for cervical ripening in obese women. A retrospective cohort study of obese women undergoing induction of labor from Jan 2013 to Dec 2016 with singleton, viable pregnancies beyond 37 completed weeks of gestational age. Women with an initial Bishop score of 7 or less, with a cervical dilatation of less than 2 cm, who received either vaginal or oral misoprostol as a cervical ripening agent, were included. Primary outcome was interval from the start of induction to the attainment of 3 cm cervical dilatation. Secondary outcomes included the interval from the start of induction to delivery and the rate of cesarean delivery (CD). Of women who met the inclusion criteria, 966 (75.5%) women received oral misoprostol and 314 (24.5%) received vaginal misoprostol. The mean time-interval from the start of induction to attainment of 3-cm dilatation was shorter in the vaginal group (10.5 ± 10.4 h) compared to the oral group (17.2 ± 11.5 h), ( < .0001). Significantly shorter times to delivery were also noted in the vaginal group (17.4 h for vaginal vs. 24.8 h for oral,  < .0001). In the subgroup analysis of nulliparous women, shorter time intervals from the start of induction to attainment of 3-cm dilatation, as well as to delivery, were noted in the vaginal misoprostol group ( < .0001 for both). Multiple linear regression model confirmed route of misoprostol administration as an independent variable in predicting the outcomes (time from start of induction to 3 cm as well as to delivery). Significant findings amongst neonatal outcomes included lower umbilical artery pH and higher rates of neonatal jaundice in the oral misoprostol group. In a population of obese women undergoing induction of labor, vaginal administration of misoprostol was associated shorter time intervals from the start of induction to the attainment of 3 cm of dilatation, as well as to delivery, without increasing the rate of cesarean deliveries or the incidence of adverse maternal and neonatal outcomes.
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http://dx.doi.org/10.1080/14767058.2019.1575684DOI Listing
October 2020

Home Telemonitoring In Heart Failure: A Systematic Review And Meta-Analysis.

Health Aff (Millwood) 2018 12;37(12):1983-1989

Andrzej Kozikowski is a senior analyst in the Division of Health Services Research and an assistant professor in the Department of Medicine, Northwell Health, in Manhasset.

We conducted a meta-analysis of twenty-six randomized controlled trials that tested the effectiveness of home telemonitoring in patients with heart failure for reducing mortality and hospital use. We used the PICOT framework as a tool to address an important variable not previously studied: the timing or duration of monitoring. Specifically, we found that home telemonitoring decreased the odds of all-cause mortality and heart failure-related mortality at 180 days but not at 365 days. Home telemonitoring did not significantly affect the odds of all-cause hospitalization at 90 or 180 days, or of heart failure-related hospitalization at 180 days. At 180 days, home telemonitoring significantly increased the odds of all-cause emergency department visits. Home care provision did not moderate the effects of home telemonitoring on all-cause hospitalization. Recent regulatory changes that relaxed Medicare restrictions on telehealth reimbursement make it imperative that studies fully describe outcomes (for example, heart failure-related versus all-cause hospitalizations) and deliberately test all essential intervention elements, such as intervention duration.
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http://dx.doi.org/10.1377/hlthaff.2018.05087DOI Listing
December 2018

A unique approach to faculty development using an Observed Structured Teaching Encounter (OSTE).

Med Educ Online 2018 Dec;23(1):1527627

e Department of Molecular Medicine and Population Health , Feinstein Institute for Medical Research Northwell Health System , Hempstead , NY , USA.

We have challenges with poor patient satisfaction scores (Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]) and internal medicine resident (IMR) evaluations of voluntary attending physicians. Using an Observed Structured Teaching Encounter (OSTE), we designed a faculty development project that focused on attendings' teaching and feedback skills. To assess attending communication with interns and improve attending teaching and feedback skills. All IM attendings on the Long Island Jewish Forest Hills (LIJFH) Emergency Department (ED) call schedule participated. OSTE simulation sessions included two clinical scenarios, standardized patients (SPs), fourth-year medical students trained as 'interns,' OSTE checklists, and debriefing. We analyzed 'intern' ratings of communication with attendings and attending self-assessment during the OSTE, and attending HCAHPS scores and IMR evaluations of attendings pre- and post-OSTE. Twenty-nine of 29 attendings completed the OSTE. Although an increase was demonstrated pre- to post- for 'intern' OSTE ratings of attendings and LIJFH attending self-assessment ratings, there was no statistically significant difference. Mean HCAHPS scores and resident evaluations of attendings also increased from pre- (22% and 3.59) to post-OSTE (30% and 3.87) but did not reach statistical significance. A statistically significant difference for both cases was demonstrated when comparing mean attending self-assessment ratings with 'intern' evaluation of attendings. Attending teaching/feedback skills improved between cases, attending self-ratings were higher than 'intern' ratings of attendings. HCAHPS and IMR evaluations of attendings improved post-OSTE. Regular intervention utilizing an OSTE may provide a sustained benefit for enhancing attendings' skills, patient satisfaction, and resident training.
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http://dx.doi.org/10.1080/10872981.2018.1527627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6201808PMC
December 2018

Thirty-day hospital readmission rate amongst older adults correlates with an increased number of medications, but not with Beers medications.

Geriatr Gerontol Int 2018 Oct 17;18(10):1513-1518. Epub 2018 Sep 17.

Department of Medicine, Hofstra-Northwell Health School of Medicine, Great Neck, New York, USA.

Aim: We sought to explore the relationship between the number of medications at hospital discharge and 30-day rehospitalization in older adults aged >65 years.

Methods: This was a multicenter cohort study to determine whether an increased number of medications was associated with 30-day rehospitalization in patients aged >65 years. We explored the relationship between rehospitalization and other risk factors. Data were collected from a large health system in the New York metropolitan area from September 2011 to January 2013. The primary outcome was 30-day hospital readmission from the index hospitalization.

Results: Patients had a mean ± SD age of 78 ± 9 years; 55% were women. The average length of stay after discharge from the hospital was 6 days. An increased number of medications was significantly associated with unplanned 30-day hospital readmission (P < 0.05). For each medication, the risk of rehospitalization increased by 4% (OR 1.04, 95% CI 1.03, 1.05). Patients discharged to rehabilitation centers were 32% more likely to be readmitted than patients discharged home (OR 1.39, 95% CI 1.27-1.51). Other risk factors significantly associated with 30-day rehospitalization were: cancer, intensive care unit, chronic heart failure, renal diseases and peripheral vascular diseases. Hypertension was negatively associated with 30-day unplanned rehospitalization (OR 0.88, 95% CI 0.82-0.95). No significant association between the number of Beers medications and 30-day rehospitalization was observed, after controlling for the number of medications and other covariates.

Conclusions: The number of discharge medications was significantly associated with 30-day hospital readmission among older adult patients. Important risk factors for 30-day rehospitalization were discharge location, cancer, intensive care unit, chronic heart failure, renal diseases and peripheral vascular diseases. Geriatr Gerontol Int 2018; 18: 1513-1518.
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http://dx.doi.org/10.1111/ggi.13518DOI Listing
October 2018

Establishing Surrogate Kidney End Points for Lupus Nephritis Clinical Trials: Development and Validation of a Novel Approach to Predict Future Kidney Outcomes.

Arthritis Rheumatol 2019 03 1;71(3):411-419. Epub 2019 Feb 1.

Ohio State University Wexner Medical Center, Columbus.

Objective: End points currently used in lupus nephritis (LN) clinical trials lack uniformity and questionably reflect long-term kidney survival. This study was undertaken to identify short-term end points that predict long-term kidney outcomes for use in clinical trials.

Methods: A database of 944 patients with LN was assembled from 3 clinical trials and 12 longitudinal cohorts. Variables from the first 12 months of treatment after diagnosis of active LN (prediction period) were assessed as potential predictors of long-term outcomes in a 36-month follow-up period. The long-term outcomes examined were new or progressive chronic kidney disease (CKD), severe kidney injury (SKI), and the need for permanent renal replacement therapy (RRT). To predict the risk for each outcome, hazard index tools (HITs) were derived using multivariable analysis with Cox proportional hazards regression.

Results: Among 550 eligible subjects, 54 CKD, 55 SKI, and 22 RRT events occurred. Variables in the final CKD HIT were prediction-period CKD status, 12-month proteinuria, and 12-month serum creatinine level. The SKI HIT variables included prediction-period CKD status, International Society of Nephrology (ISN)/Renal Pathology Society (RPS) class, 12-month proteinuria, 12-month serum creatinine level, race, and an interaction between ISN/RPS class and 12-month proteinuria. The RRT HIT included age at diagnosis, 12-month proteinuria, and 12-month serum creatinine level. Each HIT validated well internally (c-indices 0.84-0.92) and in an independent LN cohort (c-indices 0.89-0.92).

Conclusion: HITs, derived from short-term kidney responses to treatment, correlate with long-term kidney outcomes, and now must be validated as surrogate end points for LN clinical trials.
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http://dx.doi.org/10.1002/art.40724DOI Listing
March 2019

Belimumab promotes negative selection of activated autoreactive B cells in systemic lupus erythematosus patients.

JCI Insight 2018 09 6;3(17). Epub 2018 Sep 6.

Center for Autoimmunity and Musculoskeletal and Hematologic Diseases, and.

Belimumab has therapeutic benefit in active systemic lupus erythematosus (SLE), especially in patients with high-titer anti-dsDNA antibodies. We asked whether the profound B cell loss in belimumab-treated SLE patients is accompanied by shifts in the immunoglobulin repertoire. We enrolled 15 patients who had been continuously treated with belimumab for more than 7 years, 17 matched controls, and 5 patients who were studied before and after drug initiation. VH genes of sort-purified mature B cells and plasmablasts were subjected to next-generation sequencing. We found that B cell-activating factor (BAFF) regulates the transitional B cell checkpoint, with conservation of transitional 1 (T1) cells and approximately 90% loss of T3 and naive B cells after chronic belimumab treatment. Class-switched memory B cells, B1 B cells, and plasmablasts were also substantially depleted. Next-generation sequencing revealed no redistribution of VH, DH, or JH family usage and no effect of belimumab on representation of the autoreactive VH4-34 gene or CDR3 composition in unmutated IgM sequences, suggesting a minimal effect on selection of the naive B cell repertoire. Interestingly, a significantly greater loss of VH4-34 was observed among mutated IgM and plasmablast sequences in chronic belimumab-treated subjects than in controls, suggesting that belimumab promotes negative selection of activated autoreactive B cells.
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http://dx.doi.org/10.1172/jci.insight.122525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6171800PMC
September 2018

Serologic features of cohorts with variable genetic risk for systemic lupus erythematosus.

Mol Med 2018 06 1;24(1):24. Epub 2018 Jun 1.

The Feinstein Institute for Medical Research, Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases, 350 Community Dr, Manhasset, NY, 11030, USA.

Background: Systemic lupus erythematosus (SLE) is an autoimmune disease with genetic, hormonal, and environmental influences. In Western Europe and North America, individuals of West African descent have a 3-4 fold greater incidence of SLE than Caucasians. Paradoxically, West Africans in sub-Saharan Africa appear to have a low incidence of SLE, and some studies suggest a milder disease with less nephritis. In this study, we analyzed sera from African American female SLE patients and four other cohorts, one with SLE and others with varying degrees of risk for SLE in order to identify serologic factors that might correlate with risk of or protection against SLE.

Methods: Our cohorts included West African women with previous malaria infection assumed to be protected from development of SLE, clinically unaffected sisters of SLE patients with high risk of developing SLE, healthy African American women with intermediate risk, healthy Caucasian women with low risk of developing SLE, and women with a diagnosis of SLE. We developed a lupus risk index (LRI) based on titers of IgM and IgG anti-double stranded DNA antibodies and levels of C1q.

Results: The risk index was highest in SLE patients; second highest in unaffected sisters of SLE patients; third highest in healthy African-American women and lowest in healthy Caucasian women and malaria-exposed West African women.

Conclusion: This risk index may be useful in early interventions to prevent SLE. In addition, it suggests new therapeutic approaches for the treatment of SLE.
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http://dx.doi.org/10.1186/s10020-018-0019-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016868PMC
June 2018

Home Telemonitoring of Community-Dwelling Heart Failure Patients After Home Care Discharge.

Telemed J E Health 2019 06 23;25(6):447-454. Epub 2018 Jul 23.

1 Department of Medicine, Northwell Health, Manhasset, New York.

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http://dx.doi.org/10.1089/tmj.2018.0099DOI Listing
June 2019

Histopathologic characteristics of biopsies from dogs undergoing surgery with concurrent gross splenic and hepatic masses: 125 cases (2012-2016).

BMC Res Notes 2018 Feb 13;11(1):122. Epub 2018 Feb 13.

Biostatistics Unit, Feinstein Institute for Medical Research, Northwell Health, 350 Community Dr, Manhasset, NY, 11030, USA.

Objective: To investigate the histopathologic characteristics of concurrent splenic and liver masses in dogs undergoing splenectomy and liver mass biopsy/resection. Medical records of 125 client-owned dogs found to have splenic mass or masses and a liver mass or masses during surgery were examined. Signalment (age, sex, breed), body weight, and results of histopathology were recorded for all dogs.

Results: Twenty-seven percent (34/125) of the dogs in this study had no evidence of malignancy in either the liver or the spleen. Sixty of 125 dogs (48.0%) had malignancy in the spleen and liver, and 56 (56/60, 93.3%) of those dogs had the same malignancy in both organs. Signalment was similar to that in other reports of splenic pathology. In this clinical population of dogs, 27% of dogs with concurrent gross splenic and liver masses discovered intraoperatively had benign lesions in both locations and therefore had a favorable prognosis.
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http://dx.doi.org/10.1186/s13104-018-3220-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809889PMC
February 2018