Beth Israel Medical Center Research Articles

Health Related Quality of Life Outcomes Among Patients with Sickle Cell Disease during the Transition Period from Pediatric to Adult Care in Newark, NJ

Background: Sickle Cell Disease (SCD) is a genetic condition associated with painful vaso-occlusion episodes (VOE), chronic pain, and organ damage. Painful VOE and chronic pain can hinder daily activities and thus affect Quality of Life (QoL). The transition period of SCD patients from pediatric to adult care is often marked by frequent hospitalizations, complications and higher mortality. Our study evaluated patient reported health related QoL outcomes in SCD patients who transitioned from pediatric to adult care. Methods: This is a descriptive study of SCD patients receiving medical care at Newark Beth Israel Medical Center. The informed consent and assent were obtained from patients and/or legal guardians. Enrolled patients filled out a questionnaire using seven domains from the Adult Sickle Cell Quality of Life Measurement Information System (ASCQ-Me): pain episodes, medical history, pain impact, sleep impact, social functioning, stiffness, and emotional impacts. Eligible patients were aged 16-25 years, presenting to the pediatric or adult hematology clinic for their well visit. Recruitment took place from December 2021 to April 2023. Results: Seventy-six individuals were enrolled and questionnaire was administered. Most were aged 16-21 years with homozygous sickle cell disease. Pain episodes: 10-18% of 16-20 year-olds reported pain attacks in the previous year, while 43-100% of 21-25 year-olds reported pain attacks. Among 22-25 year-olds, 25-50% could not do most things that they usually did or relied on family or friends compared to 40-83% of 16-21 year-olds. Pain impact: 50-100% of 22-24 year-olds struggled all day due to pain, while most younger patients were unaffected. About 25-60% of 20-25 year-olds were occasionally, rarely, or never pain-free. In the sleep impact domain, 29-60% of 20-25 year-olds did not get enough sleep, and 20-60% of all ages stayed up most of the night due to difficulty falling asleep. Medical history: 17-36% of 16-20 year-olds and 40-100% of 21-25 year-olds used daily pain medicine. Sickle cell complications affected 8-40% of patients in all age groups. Social functioning domain: 25-60% of 20-25 year-olds often or always had their health that kept them away from doing something fun. Also, 16-17 year-olds (21%) and 20-22 year-olds (25-60%) reported that their family felt that they were a burden. No significant findings were noted in stiffness impact across all age ranges. Emotional impact: 25-83% of all patients were often or always sad about their health (70% of 16 year-olds and 83% of 21 year-olds). Nine % (19 year olds) to 83% (21 year olds) were depressed about their health problems and 21 year olds seemed most affected by emotional impact of their disease. Conclusion: Our cross-sectional study revealed a significant impact of SCD on HRQoL during the transition years from childhood to adulthood. Therefore, screening for mental health in patients aged 16-25 years is crucial, offering support to those at risk. Disease-modifying therapy adherence should be emphasized. Limitations of our study include a small sample size, especially in the older age group. Further studies may be needed to assess age and genotype stratified HRQoL outcomes for 16-25-year-old SCD patients and potential improvement measures.

Harvard Hospital Names Chair in Nadelson’s Honor

Back to table of contents Previous article Next article APA & MeetingsFull AccessHarvard Hospital Names Chair in Nadelson’s HonorKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:29 Nov 2022https://doi.org/10.1176/appi.pn.2022.12.12.5AbstractBrigham and Women’s Hospital established the Carol C. Nadelson, M.D., Distinguished Chair in Psychiatry in honor of APA’s first woman president. Hemioni Amonoo, M.D., M.P.P., was appointed the chair’s inaugural incumbent.For past APA President Carol Nadelson, M.D., it all began in Brooklyn, N.Y. As a little girl, she announced to her parents that she wanted to be a doctor. She was told, “But girls don’t do that.”While completing her training at Beth Israel Medical Center, Carol Nadelson, M.D., and her peers opened the first daycare center for women faculty, as well as a rape crisis center.Yet now, Harvard Medical School’s Brigham and Women’s Hospital has established the Carol C. Nadelson, M.D., Distinguished Chair in Psychiatry as an enduring tribute to the profound impact Nadelson has had on generations of patients, trainees, women clinicians, and colleagues, said Robert Higgins, M.D., M.S.H.A., president of Brigham and Women’s Hospital and executive vice president at Mass General Brigham. Higgins spoke at an event last June to honor Nadelson and the chair’s inaugural incumbent, Hermioni Amonoo, M.D., M.P.P.“This is an enormous honor and quite a surprise to me,” Nadelson told Psychiatric News. She was APA’s first woman president, serving in that position for the 1985-1986 term. She was also the first editor in chief of APA Publishing (Psychiatric News https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2019.8a20).Nationally, 41, or 35%, of the 116 chairs of psychiatry departments were women in 2021, the year for which the most recent data are available, according to the Association of American Medical Colleges. That percentage is higher than the national average of women who are department chairs in the clinical sciences, which is 24%. Comparatively, 22% of the chairs were women in internal medicine departments, 43% were women in pediatric departments, and 1% were women in surgery departments.The experience for women in medicine has changed drastically since Nadelson completed her training. During her speech at the June event, she shared how, as the only woman in her pre-med program, she was not taken seriously and was harassed and mercilessly teased. She experienced the same treatment in medical school, where there were, at most, only two women in each of her classes. “The landscape for women at that point was not promising,” Nadelson said during her speech, noting that the changes for women that were taking place in the rest of culture and society were not evident in medical education.She completed her training at Beth Israel Medical Center in Boston, where the chair of psychiatry was a woman. “That was incredibly reassuring, and it gave the women a chance to live in a community that was open,” Nadelson said.In 1998, Nadelson was asked to develop the Office for Women’s Careers at Brigham and Women’s Hospital. Upon taking that position, she met with every department chair and division chief to review their women faculty and learn why they were not getting promoted. She helped the women faculty write the papers and get into the positions necessary to advance their careers, helping to develop a fellowship program that offered support for women who were also juggling other responsibilities, like taking care of their children.Eventually, Nadelson would return to teaching and mentoring residents. During the June event, David A. Silbersweig, M.D., noted that Nadelson is still involved in supporting her mentees and their projects. “Carol is a pioneer in the true sense of the word in psychiatry and for women in medicine,” said Silbersweig, who is chair of the Department of Psychiatry and Institute for the Neurosciences at Brigham and Women’s and Faulkner hospitals.During her remarks, Amonoo called Nadelson “an illustrious woman, pacesetter, and a true role model.”“We all have so much to learn from you,” she continued, speaking to Nadelson. “Being named the inaugural incumbent of this chair that bears your name is such an honor.” ■“Recording of the celebration of the creation of the Carol C. Nadelson, M.D., Distinguished Chair in Psychiatry” ISSUES NewArchived

Predicting Mechanical Ventilation and Mortality in COVID-19 Using Radiomics and Deep Learning on Chest Radiographs: A Multi-Institutional Study

In this study, we aimed to predict mechanical ventilation requirement and mortality using computational modeling of chest radiographs (CXRs) for coronavirus disease 2019 (COVID-19) patients. This two-center, retrospective study analyzed 530 deidentified CXRs from 515 COVID-19 patients treated at Stony Brook University Hospital and Newark Beth Israel Medical Center between March and August 2020. Linear discriminant analysis (LDA), quadratic discriminant analysis (QDA), and random forest (RF) machine learning classifiers to predict mechanical ventilation requirement and mortality were trained and evaluated using radiomic features extracted from patients’ CXRs. Deep learning (DL) approaches were also explored for the clinical outcome prediction task and a novel radiomic embedding framework was introduced. All results are compared against radiologist grading of CXRs (zone-wise expert severity scores). Radiomic classification models had mean area under the receiver operating characteristic curve (mAUCs) of 0.78 ± 0.05 (sensitivity = 0.72 ± 0.07, specificity = 0.72 ± 0.06) and 0.78 ± 0.06 (sensitivity = 0.70 ± 0.09, specificity = 0.73 ± 0.09), compared with expert scores mAUCs of 0.75 ± 0.02 (sensitivity = 0.67 ± 0.08, specificity = 0.69 ± 0.07) and 0.79 ± 0.05 (sensitivity = 0.69 ± 0.08, specificity = 0.76 ± 0.08) for mechanical ventilation requirement and mortality prediction, respectively. Classifiers using both expert severity scores and radiomic features for mechanical ventilation (mAUC = 0.79 ± 0.04, sensitivity = 0.71 ± 0.06, specificity = 0.71 ± 0.08) and mortality (mAUC = 0.83 ± 0.04, sensitivity = 0.79 ± 0.07, specificity = 0.74 ± 0.09) demonstrated improvement over either artificial intelligence or radiologist interpretation alone. Our results also suggest instances in which the inclusion of radiomic features in DL improves model predictions over DL alone. The models proposed in this study and the prognostic information they provide might aid physician decision making and efficient resource allocation during the COVID-19 pandemic.

Abstract P043: Distance And Clinical Outcomes Of Patients Admitted For Covid-19: Lessons Learned From The Neighbors Of An Inner-city Hospital.

Background: In rural areas, the distance factor has been identified as key in the utilization of health services. We aim to determine whether distance to an inner-city hospital in Newark, was associated with mortality in patients admitted for COVID-19 during the peak of the pandemic. Methods: Patients who were admitted for COVID-19 at the Newark Beth Israel Medical Center (NBIMC) were stratified into two groups based on distance between the zip codes of their primary residence and the hospital. Baseline demographics, clinical characteristics and in-hospital outcomes were compared between subjects living within a 2-mile radius of the zip code of the hospital [Neighbors] and those living further than 2 miles [Distant]. The primary outcome was in-hospital mortality. Secondary outcomes were admission to the intensive care unit (ICU), length of hospitalization, and discharge disposition. Results: Between March 09 and May 04, 2020, a total of 769 patients were admitted for COVID-19 at NBIMC. 406 (53%) resided within a 2-mile radius of the hospital location. Of these 44% were obese. History of hypertension, diabetes mellitus and coronary artery disease was documented in 69%, 48% and 23% respectively. Compared with distant patients, neighbors were older (59 vs. 69 yrs. P=0.048), mostly of Black/African American race (64% vs. 82%; p<0.001) and had a higher incidence of diabetes mellitus (40% vs. 48%; p=0.025) or coronary artery disease (17% vs. 23%; p=0.039). Visitors were more likely to report an exposure history to a COVID-19 patient than neighbors (31% vs. 21%, p=0.001). In-hospital death rate were significantly higher in neighbors than visitors (32% vs. 22%, p=0.007). Admission to the ICU was similar between both groups (p=0.438). Among those who survived to discharge, distant patients had longer length of hospitalization (12 vs. 10 days; p=0.006), than neighbors. Discharge disposition was comparable in both groups (p=0.249) Conclusions: In this cross-sectional study of patients admitted to an inner-city hospital for COVID-19, majority of patients living within a 2-mile radius were of Blacks/African Americans who had a higher incidence of DM and CAD. A paradoxical association between distance to the hospital and in-hospital mortality was observed. Based on these findings, targeted interventions aimed at Impacting social determinants of health seem prudent.

Impact of the COVID19 Pandemic on Admissions and Emergency Department Visits of Adults with Sickle Cell Disease

Background: The most common complication of sickle cell disease (SCD) in adults is vaso-occlusive crisis that is characterized by severe pain. These events can often be managed at home with oral analgesics, but if the pain is not controlled or the patient develops other associated problems, they seek care in an emergency department (ED). In the ED, they receive initial treatment with pain medications and are assessed for other complications such as infection and acute chest syndrome. If an individual's pain is not controlled in a short period of time, the majority of these patients are admitted to the hospital for inpatient management or placed in an observation unit (OBs) for 6-47 hours. The COVID-19 pandemic affected the Greater Newark community starting in mid March with the majority of all inpatient admissions (Ads) being COVID related through the end of May. It has been observed both at our medical center and nationally that during this time period and even afterwards, the number of ED visits and Ads had significantly fallen. The reasons for this finding may include fear of contracting COVID infection at the hospital, regular telemedicine (TM) calls to facilitate outpatient management, and an increase in the number of prescriptions of home pain medications. The purpose of this analysis was to examine patterns of ED visits, Ads, outpatient visits, prescription renewals and nurse (RN) and social worker (MSW) calls in order to determine the impact of COVID-19 infection on the local SCD community.Methodology: A retrospective review was undertaken of billing data and the EMR of all patients with SCD treated at Newark Beth Israel Medical Center (a 450 bed community-based academic tertiary care medical center) between January 2020 and June 2020. Data collected included the number of and reason for ED and OBs, Ads, the number of TM and outpatient visits, and MSW and RN telephone contacts. All patients 18 years of age and older were included. Overall, 100 adults with SCD received care between January and June.Results: Peak hospital COVID Ads, ED and OBs for all patients (SCD and non-SCD) occurred during the weeks between March 25 and May 24, 2020 with a daily inpatient census over 200 between April 7 and 24. SCD Ads at peak COVID (April-May) were significantly lower at 26±2/month compared to 64±11/month pre-COVID (January-February) (p= 0.04). ED and OBs were unchanged. During the peak of COVID, 10/93 (11%) SCD Ads (1 death) were COVID related with 80/96 (86%) for uncomplicated pain crises. MSW and RN called all patients proactively to offer support at onset of COVID pandemic. During this same time period, the number of MSW telephone contacts increased from 138±37/month pre-COVID to 372±21/month during COVID (p=0.02). RN contacts with SCD patients were stable and mostly were for pain prescription renewals. TM was initiated in March 2020 and an increase in these visits correlated with a fall in face to face physician visits: 83.5±11/month pre-COVID to 39.5±8/month peak COVID (p= 0.04), and TM 0/month pre-COVID and 31±4/month peak COVID (0.01).Conclusion: The outbreak of COVID-19 in the community reduced the number of Ads for patients with SCD without an increase in ED and OBs visits. MD face-to-face encounters were reduced but outpatient care continued with the initiation of TM, regular RN contact with maintenance of pain medication prescriptions and a greater numbers of MSW calls for psychosocial support. Further investigation and understanding of the use of Ads for SCD care, and the reduction during COVID, may have implications for current SCD management.DisclosuresCohen:GBT: Speakers Bureau.

Clinical outcomes of patients with COVID-19 and HIV coinfection.

BackgroundPatients with human immunodeficiency virus (HIV) infection may be at an increased risk for morbidity and mortality from the coronavirus disease 2019 (COVID‐19). We present the clinical outcomes of HIV patients hospitalized for COVID‐19 in a matched comparison with historical controls.MethodsWe conducted a retrospective cohort study of HIV patients admitted for COVID‐19 between March 2020 and April 2020 to Newark Beth Israel Medical Center. Data on baseline clinical characteristics and hospital course were documented and compared with that of a matched control group of COVID‐19 patients who had no history of HIV. Kaplan–Meier survival curves and the log‐rank tests were used to estimate and compare in‐hospital survival between both unmatched and matched groups.ResultsTwenty‐three patients with HIV were hospitalized with COVID‐19. The median age was 59 years. The rates of in‐hospital death, the need for mechanical ventilation, and intensive care unit (ICU) admission were 13% (n = 3), 9% (n = 2), and 9% (n = 2), respectively. The HIV infection was well‐controlled in all patients except for three patients presented with acquired immune deficiency syndrome (AIDS). All AIDS patients were discharged home uneventfully. A one‐to‐one propensity matching identified 23 COVID‐19 patients who served as a control group. In both pre‐ and post‐match cohorts, survival between HIV and control groups were comparable.ConclusionsIn our cohort of HIV‐infected patients hospitalized for COVID‐19, there was no difference in mortality, ICU admission, and the need for mechanical ventilation when compared with a matched control of COVID‐19 patients with HIV.

Abstract P466: Health and Healthcare Disparities in the Management of Systemic Hypertension and Cardiovascular Disease: The Critical Role of Insurance Status

Background: Minority populations are two to three times as likely to die of preventable cardiovascular events. Two main forces behind the challenge in managing hypertension among minority populations are disparities in health and healthcare. Aims: To identify the common health and healthcare disparities (HHD) among hypertensive patients who presented to a community medical center and propose a collaborative alliance for improvement. Methods: Internal medicine residents at the Newark Beth Israel Medical Center utilized a (P: Provider, I: Insurance, F: Food, E: Economic stability, N: Neighborhood, C: Culture and Language, E: Education, S: Social (PI-FENCES) model to identify health and health care disparities in hypertensive patients who presented to the ambulatory and inpatient settings over a 12-week-period. Demographic and baseline clinical characteristics were recorded. The distribution of each of the elements of PI-FENCES was documented and their association with respective demographics was determined. A protocol for usability study was designed based on preliminary data collected. Results: Between May 2019 and July 2019, a total of 86 hypertensive patients (mean ± SD age: 54 ± 12 years, BMI: 31± 8 kg/m 2 ) were identified. Seventy-one (83%) of them were African Americans. Of the patients identified, 51 (59%), presented to the ambulatory setting, 24 (28%) were seen in the in-patient setting and 11 (13%) were admitted to the Intensive care unit. According to the PI-FENCES model, distribution of HHD were as follows: n(%); P: 6 (6.9%), I: 40 (47%), F: 8(9.3%), E: 10 (11.6%), N: 1 (1.2%), C: 10 (14%), E: 26 (30.2%), S: 17 (19.7%). While 61 (71%) patients had at least 1 element of HHD, 9 (1.1%) had more than 2 elements of HHD. Associated cardiovascular conditions noted among admitted patients (n=35) were heart failure exacerbation (n=8) (22%) and cerebrovascular accident (n=4) (11%). Compared to patients with insurance, patients with no insurance were more likely to be admitted to the inpatient service or intensive care unit (Insurance: 31% vs. No insurance: 69%, p<0.0001). Based on the preliminary data, a Reducing ReAdmission Secondary to Hypertension (RRaSH) proposal will be implemented. RRaSH will focus on developing follow-up and referral plans for all uninsured hypertensive patients who present to the in-patient setting. The program will also encourage free health screening of families and friends of this uninsured population. Conclusion: About one out of every two patients who presented with systemic hypertension to a community medical center had no insurance. Compared to patients with insurance, patients with no insurance were more likely to be admitted to the inpatient service or intensive care unit. RRaSH will be a follow-up and referral plan to help reduce readmissions secondary to hypertension.

Jeremy David Safran (1952–2018).

Present an obituary for Jeremy David Safran (1952-2018). In 1993, Safran became full professor and director of clinical training at the New School for Social Research. At the New School, he developed the program with an affiliation to Beth Israel Medical Center, where he was a principal consultant on a psychotherapy research program founded by Arnold Winston and directed by me. In 2001, Jeremy completed psychoanalytic training at the New York University Postdoctoral Program. Subsequently, he cofounded (with Lewis Aron and Adrienne Harris) the Sandor Ferenczi Center at the New School, became president of the International Association for Relational Psychoanalysis and Psychotherapy, and served as associate editor for Psychoanalytic Dialogues. Jeremy's efforts and collaborations regarding emotion and interpersonal process laid the foundation for our own collaboration regarding ruptures in the therapeutic alliance. Our aim was to promote a "second generation" of alliance research that went beyond demonstrating its predictive validity and could be applied across treatment orientations to redress failure rates. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Hypertensive emergencies in diabetic patients from predominantly African American urban communities

ABSTRACTAim: The aim of this study was to identify risk factors for hypertensive emergencies in diabetic patients presenting with severely elevated blood pressure.Methods: Using electronic medical records, this study identified diabetic patients with hypertensive crisis who presented to the emergency department of Newark Beth Israel Medical Center, Newark, NJ from June 2013 to May 2016. Diabetic patients with hypertensive emergencies were compared with non-diabetic patients based on important demographic and clinical characteristics.Results: Patients with diabetes accounted for 52.27% of all hypertensive emergencies during the study period. There were 264 diabetic patients with hypertensive emergencies and 519 diabetic patients with hypertensive urgencies. The majority of patients were African Americans (88.6%). The odds of hypertensive emergencies were strikingly higher in diabetic patients with hyperlipidemia (OR 1.66, 95% CI 1.23–2.24), coronary artery disease (OR 2.95, 95% CI 2.15–4.05), congestive heart failure (OR 6.28, 95% CI 4.49–8.80), renal insufficiency (OR 2.84, 95% CI 2.10–3.86) and low hemoglobin (OR 0.9, 95% CI 0.84–0.97). Acute or worsening heart failure was the most frequent acute target organ injury (49.6%) followed by non-ST elevation myocardial infarction (41.7%). Diabetic and non-diabetic patients had similar rates of target organ injuries.Conclusion: The development of hypertensive emergencies in patients with diabetes was not because of diabetes per se but because of coexisting highly elevated blood pressure. Tight blood pressure control may decrease the risk of hypertensive emergencies in this patient population.

Music Related Sensibilities in Trauma Treatment: An interview with Janina Fisher

Janina Fisher PhD has collaborated with many of the pillars in the field of trauma theory and treatment – including Judith Herman, Bessel van der Kolk, and Pat Ogden – and she is a pioneering force and innovator in her own right. A prominent clinician and consultant, Dr. Fisher is a licensed clinical psychologist and instructor at the Trauma Center, an outpatient clinic and research center founded by Bessel van der Kolk. The opportunity to interview Dr. Fisher stemmed from her participation in the conference Trauma Theory & Treatment: Somatosensorial Implications of Resilience, hosted by the Louis Armstrong Center for Music & Medicine at Mount Sinai Beth Israel Medical Center in New York City. The conference lectures included mental healthcare professionals ranging from a broad spectrum of disciplines, with a strong showing of music therapists with specialties in trauma treatment with diverse populations. As conference co-chair I took the opportunity to interview Dr. Fisher, who graciously agreed to sit down with me and answer some questions. As a music psychotherapist whose work centers on pre-emptive strategies in fragile hospital populations such as newly diagnosed cancer patients receiving radiation therapy, her in-depth and thoughtful responses to my probing questions offered unique insight. At various junctures, I provide some commentary to contextualize some of the salient themes. Her comments expand upon the growth and ‘interdisciplinarization’ of the evolving field of trauma. We are indeed fortunate to have her share her knowledge and expertise on its inner workings and perspectives within these pages. The following is a candid exchange in which Dr. Fisher provides insight not only on her ideas on the neurobiological nature of trauma, but also how musical concepts, and her own musical training in her youth informs her clinical approach in working with victims of emotional trauma. I am grateful to Marija Pranjic for transcribing the interview. Keywords: Trauma, PTSD, Music Therapy, Dissociation, Safety

Single Center Experience of a New Endoscopic Clip in Managing Nonvariceal Upper Gastrointestinal Bleeding.

To assess the safety and efficacy of the Instinct clip in the acute endoscopic treatment of upper gastrointestinal bleeding (UGIB). This is the first large series reporting this clip in achieving hemostasis. A retrospective descriptive chart review was performed on patients presenting with recent overt GI bleeding treated with endoclip therapy at Mount Sinai Beth Israel Medical Center between May 2013 and January 2016. Results are expressed in absolute numbers, percentages, and trends. In total, 178 consecutive patients with UGIB were included. Source of bleeding was identified as duodenal ulcer (29.2%), gastric ulcer (22.5%), gastro-esophageal junction tear (8.4%), anastomosis (5.6%), erosive gastropathy (5.6%), Dieulafoy (5.1%), gastric polyp (4.5%), postendoscopic procedure (3.9%), angioectasia (3.4%), esophageal ulcer (2.8%), benign duodenal mass (2.8%), peg tube site (2.3%), gastric neoplasm (1.7%), esophagitis (1.1%), and small bowel ulcer (1.1%). Lesions demonstrated active bleeding in 47.5% (11.3% spurting and 36.2% oozing) and nonbleeding lesions in 52.5% (25.0% visible vessel, 11.9% hematin in ulcer base, 10.0% adherent clot, 5.6% flat spot). Initial hemostasis was achieved in 96.6%. Additional methods were used in 24.1% (argon plasma coagulation and epinephrine injection in 21.3%, surgery in 0.6%, and interventional radiology in 2.2%). There were no adverse events. In-hospital rebleeding was 7.3% and 3.9% presented with rebleeding within 30 days. Average procedure duration was 22.9 minutes and average length of hospital stay was 11.3 days. The Instinct clip, when used for UGIB, seems to be safe and effective with similar rebleeding rates compared with other modalities.

The aging methadone maintenance patient: Treatment adjustment, long-term success, and quality of life

To evaluate the features and modes of adaptation to aging among Methadone Maintenance Treatment (MMT) enrollees. Beth Israel Medical Center in New York City. A sample of 156 MMT enrollees (103/66 percent males and 53/34 percent females) age 24-68 years. Twenty-nine percent of participants were aged 55 or older. A cross-sectional, multivariate, correlational design. Participants were administered the MMSE, ASI, BSI, as well as measures of impulsiveness and quality of life (QOL). Older adults were more likely to have had longer periods of treatment (p < 0.01), less likely to report current heroin use (p < 0.05) and overall drug use (p < 0.05), but were more likely to have a history of comorbid alcohol misuse (p < 0.01). Advanced age was also associated with less impulsiveness, hostility, paranoia, and interpersonal sensitivity (p < 0.01), more chronic medical problems (p < 0.05), greater use of medication for medical problems (p < 0.05), and more liberal take home medicine schedules (p < 0.01). However, no differences were found between older and younger participants with respect to their scores on the Overall Social Support scale (p > 0.05), the Personal Well-Being Index (p > 0.05) and the Satisfaction with Life Scale (p > 0.05), suggesting comparable levels of QOL. Furthermore, the rate of contact for older participants with medical professionals did not differ significantly from that of younger participants (p > 0.05). Only 7.1 percent of older participants reported regular contact with a primary care physician; a rate that is slightly lower than the rate in the overall population. The findings from the present study highlight at least two underappreciated challenges that clinicians are increasingly likely encounter in their work with the aging MMT population. These challenges are: (1) that despite numerous medical and psychiatric complaints, only a small proportion of MMT patients have regular contact with a primary care physician and the rate of contact does not appear to increase with age and (2) even with age-related declines in psychiatric comorbidity and illicit substance use, the suboptimal level of QOL that is characteristic of the MMT population as a whole does not improve with aging and length of tenure in MMT.

A Single Center Experience of Endoscopic Submucosal Dissection

Introduction: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique used for the resection of superficial gastrointestinal tumors with data showing high en bloc and curative resection rates in early gastric cancer. While it has been widely employed in East Asia, its adoption in the West has been slow due to the increased technical difficulty, higher rate of complications, longer procedure times and lower candidate populations. Methods: A retrospective review of the clinical and technical characteristics of ESD for superficial lesions of the gastrointestinal tract treated at Mount Sinai Beth Israel Medical Center, New York between May 2012 and December 2016. Results: We reviewed 59 cases of ESD - 46 gastric, 7 esophageal and 6 colorectal lesions. There were 21 cases of early malignancy, all in the upper GI tract (20 gastric, 1 esophageal). The overall en bloc resection rate was 70% (15/21) and R0 resection rate was 85% (18/21). Among the early gastric cancers, 7 were adenocarcinomas without invasion beyond the submucosa (T1), 3 were intramucosal carcinomas and 10 were cases of high grade dysplasia (HGD). There were 8 cases of low grade dysplasia with endoscopically-visible mucosal abnormalities, all of which were en bloc R0 resections. Eleven of the cases of gastric ESD were for submucosal tumors - 5 GISTs, 3 carcinoid tumors, 1 leiomyoma and 2 pancreatic rests. The seven esophageal lesions were 3 granular cell tumors, 2 dysplastic lesions in the setting of Barrett's esophagus, one case of HGD and one case of lymphoepithelioma-like carcinoma (curative R0 resection). Six of these cases were en bloc resections. Complete resection of 6 colorectal polyps were performed by ESD. Two of these polyps had previously undergone partial mucosal resection limiting en bloc resection. The average procedure time in the esophagus, stomach and colon was 76, 106 and 83 minutes respectively. The average resection sizes were 2, 3 and 2 cm respectively. There was one complication, in a patient who underwent ESD in the proximal stomach for a lesion with LGD, of delayed bleeding requiring hospitalization and endoscopic therapy. Conclusion: In this small single center series, ESD appears to be effective and safe with resection rates comparable to published data. With further experience, specialized training and development of dedicated instruments, ESD should become integrated into specialized endoscopic practice in the West for the treatment of GI tract neoplasms.

Functional and quality of life outcomes after partial glossectomy: a multi-institutional longitudinal study of the head and neck research network

BackgroundWhile aggressive treatment for oral cancer may optimize survival, decrements in speech and swallowing function and quality of life often result. This exploratory study investigated how patients recover their communicative function, swallowing ability, and quality of life after primary surgery [with or without adjuvant (chemo)radiation therapy] for tongue cancer over the course of the first year post-operation.MethodsPatients treated for oral cancer at three institutions (University of Alberta Hospital, Mount Sinai Beth Israel Medical Center, and Turku University Hospital) were administered patient-reported outcomes assessing speech [Speech Handicap Index (SHI)], swallowing [(M.D. Anderson Dysphagia Inventory (MDADI)] and quality of life [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC-H&N35)]. Outcome measures were completed pre-operatively and at 1-, 6-, and 12-months post-operatively.ResultsOne hundred and seventeen patients undergoing partial glossectomy with reconstruction participated in this study. Results indicated no significant differences in swallowing function (MDADI and EORTC-H&N35 subscales) between baseline and 6 months post-surgery and no significant differences in speech function (SHI subscales) between baseline and 1 year post-surgery. Most quality of life domains (EORTC-H&N35 subscales) returned to baseline levels by 1 year post-operation, while difficulties with dry mouth and sticky saliva persisted. A clear time trend of adjuvant (chemo)radiation therapy negatively affecting dry mouth scores over time was identified in this study, while negative independent effects of chemoradiation on MDADI swallowing, and EORTC-H&N35 swallowing, eating, and opening mouth subscales were found.ConclusionsAssessment time influenced patient-reported speech, swallowing, and quality of life outcomes, while treatment (by time) effects were found for only swallowing and quality of life outcomes. Results of the present study will help guide clinical care and will be useful for patient counseling on expected short and long-term functional and quality of life outcomes of surgical and adjuvant treatment for oral cavity cancer.

Wound Care: What the Medical Director Needs to Know

Wound Care: What the Medical Director Needs to Know

Inter-Observer Variation in the Pathologic Identification of Extranodal Extension in Nodal Metastasis from Papillary Thyroid Carcinoma

Extranodal extension (ENE) in lymph node metastases has been shown to worsen the prognosis of papillary thyroid cancer (PTC). Despite the clinical significance of ENE, there are no stringent criteria for its microscopic diagnosis, and its identification is subject to inter-observer variability. The objective of this study was to determine the level of agreement among expert pathologists in the identification of ENE in PTC cases. Eleven expert pathologists from the United States, Italy, and Canada were asked to review 61 scanned slides of representative permanent sections of PTC specimens from Mount Sinai Beth Israel Medical Center in New York. Each slide was evaluated for the presence of ENE. The pathologists were also asked to report the criteria they use to identify ENE. The overall strength of agreement in identifying ENE was only fair (κ = 0.35), and the proportion of observed agreement was 0.68. The proportions of observed agreement for the identification of perinodal structures (fat, nerve, skeletal, and thick-walled vessel involvement) ranged from 0.61 to 0.997. Overall agreement for the identification of ENE is poor. The lack of agreement results from both variation in pathologists' identification of features and disagreement on the histologic criteria for ENE. This lack of concordance may help explain some of the discordant information regarding prognosis in clinical studies when this feature is identified.

Prognostic values of 18F-FDG PET/CT parameters in patients with nasopharyngeal carcinoma

Objective At present, nasopharyngeal carcinoma (NPC) is a head and neck cancer with special geographical distribution and biological behavior. Studies have shown that 18F-FDG PET/CT parameters have certain prognostic values in patients with NPC in high-incidence areas. The aim of this study is to investigate the prognostic values of 18F-FDG PET/CT parameters in patients with NPC in low-incidence areas. Methods The clinical data of 83 NPC patients who were diagnosed and treated in Beth Israel Medical Center, Albert Einstein Medical College from January 2003 to December 2013 were analyzed retrospectively. Based on 18F-FDG PET/CT images, gross tumor volume (GTV) was delineated using the gradient method to obtain 18F-FDG PET/CT parameters: maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Results The number of patients followed was 37 at 3-years time. For all patients, the 3-year failure-free survival, locoregional relapse-free survival, and metastasis-free survival rates were 74%, 88%, and 85%, respectively. The univariate analysis showed that SUVmax of the primary tumor (P=0.004) and TLG (P=0.014) were prognostic factors for 3-year locoregional relapse-free survival rate, and SUVmax of the primary tumor (P=0.024) and TLG (P=0.033) were prognostic factors for 3-year failure-free survival rate. The multivariate analysis showed that SUVmax of the primary tumor was the independent prognostic factor for 3-year failure-free survival rate. Conclusion SUVmax of the primary tumor before treatment is the independent prognostic factor for failure-free survival in patients with NPC. Key words: Tomography, positron emission; Maximum standardized uptake value; Total lesion glycolysis; Nasopharyngeal neoplasms/radiotherapy; Nasopharyngeal neoplasms/chemotherapy; Prognosis

Abstract P6-02-01: Screening mammography in women over age 75: Is it beneficial?

Abstract Background: In 2015 the U.S. Preventive Services Task Force (USPSTF) stated that there was insufficient evidence for the use of screening mammography in women aged 75 and older. This statement was based on the lack of randomized controlled trials demonstrating survival benefit in this population. As per the American College of Radiology, the acceptable cancer detection rate via screening mammography is at least 2.5 cases per 1000 examinations for an institution, with reported rates as high as 4.7 cases per 1000. Aim: In this study, we sought to examine our institution's practice of screening mammography for women 75 years and older. We aimed to determine the incidence of cancer detection in this age group through screening mammography. Methods: A search was performed to identify women aged 75 and above who underwent screening mammography at Mount Sinai Beth Israel Medical Center between January 1, 2013 and December 31, 2014. Patients classified as BIRADS 0 on initial screening were reclassified based on their subsequent diagnostic imaging, if performed. A chart review was performed for those patients who underwent breast biopsies to obtain their pathology results. Results: In this two year period, 2057 patients aged 75 and older underwent screening mammography. The majority of women in this age group had non-actionable results of their screening mammography, and were classified as BIRADS 1 or 2 (96%). There were a total of 49 patients who had BIRADS 3 final results (2.4%). Twenty-two patients had screening mammograms that were classified as BIRADS 4 (1.1%). Biopsies revealed 6 invasive ductal carcinomas, 4 cases of in situ carcinoma, 2 cases of duct ectasia, 2 intraductal papillomas, 3 fibrocystic biopsies, and 3 fibroadenomas. In total, 10 of 2057 patients were diagnosed with breast cancer (0.5%). Mammography results from 2013-2014Final radiologic classificationNumber of patientsPercent of populationBIRADS 182940.3%BIRADS 2114755.7%BIRADS 3492.4%BIRADS 4221.1%BIRADS 500%BIRADS 0100.5%Total screening mammograms2057 Conclusions: In our institution, 98.4% of women aged 75 and older had screening mammography with benign results. Ten women in this group were found to have breast cancer. The breast cancer detection rate in this cohort was 4.9 per 1000 screening examinations, which is nearly double the cited recommendation put forth by the American College of Radiology. These results are certainly relevant when considering appropriateness of annual screening mammography in this age group. Citation Format: Cate SP, Kohli MK, Gillego A, Chadha M, Fulop T, Boolbol SK. Screening mammography in women over age 75: Is it beneficial?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-01.

Hepatic stem cells and cancers: a pathologist's view.

Neil Theise speaks to Georgia Patey, Commissioning Editor: Neil Theise is a diagnostic liver pathologist, adult stem cell researcher and complexity theorist in New York City, where he is a Professor of Pathology at the Mount Sinai Beth Israel Medical Center of Icahn School of Medicine at Mount Sinai. He received his medical degree from Columbia University College of Physicians and Surgeons, where he also received his training in Anatomic Pathology. Subspecialty training was pursued in gastrointestinal (NYU), liver (Royal Free Hospital) and liver transplant (Mount Sinai, NYC) pathology. His earliest research focus was on defining the premalignant dysplastic nodules in human chronic liver disease. He revised understandings of human liver microanatomy, which in turn, led directly to identification of possible liver stem cell niches and the marrow-to-liver regeneration pathway. He is considered a pioneer of multiorgan adult stem cell plasticity. His publications on these topics in model systems and human liver stem cells have been highlighted on a record five covers of Hepatology.

Hurricane Sandy: Impact on Emergency Department and Hospital Utilization by Older Adults in Lower Manhattan, New York (USA).

On October 29th, 2012, Hurricane Sandy caused a storm surge interrupting electricity with disruption to Manhattan's (New York, USA) health care infrastructure. Beth Israel Medical Center (BIMC) was the only fully functioning major hospital in lower Manhattan during and after Hurricane Sandy. The impact on emergency department (ED) and hospital use by geriatric patients in lower Manhattan was studied. The trends of ED visits and hospitalizations in the immediate post-Sandy phase (IPS) during the actual blackout (October 29 through November 4, 2012), and the extended post-Sandy phase (EPS), when neighboring hospitals were still incapacitated (November 5, 2012 through February 10, 2013), were analyzed with baseline. The analysis was broken down by age groups (18-64, 65-79, and 80+ years old) and included the reasons for ED visits and admissions. During the IPS, there was a significant increase in geriatric visits (from 11% to 16.5% in the 65-79 age group, and from 6.5% to 13% in the 80+ age group) as well as in hospitalizations (from 22.7% to 25.2% in the 65-79 age group, and from 17.6% to 33.8% in the 80+ age group). However, these proportions returned to baseline during the EPS. The proportions of the categories "dialysis," "respiratory device," "social," and "syncope" in geriatric patients in ED visits were significantly higher than younger patients. The increases of the categories "medication," "dialysis," "respiratory device," and "social" represented two-thirds of absolute increase in both ED visits and admissions for the 65-79 age group, and half of the absolute increase in ED visits for the 80+ age group. The categories "social" and "respiratory device" peaked one day after the disaster, "dialysis" peaked two days after, and "medication" peaked three days after in ED visit analysis. There was a disproportionate increase in ED visits and hospitalizations in the geriatric population compared with the younger population during the IPS. The primary factor of the disproportionate impact on the geriatric population appears to be from indirect effects of the hurricane, mainly due to the subsequent power outages, such as "dialysis," "respiratory device," and "social." Further investigation by chart review may provide more insights to better aid with future disaster preparedness.