Discoveries & Impact (June 2022)

Discoveries & Impact highlights select scientific discoveries per section across the Department of Internal Medicine...

Initiative Calls on Insurers to Increase Availability, Intensity & Funding of Behavioral Counseling

Experts at the Yale School of Medicine and the Society of Behavioral Medicine (SBM) are urging insurers to increase the availability of behavioral counseling to prevent cardiovascular disease (CVD). The position statement “Increase Funding and Access for Intensive Behavioral Counseling to Reduce Cardiovascular Disease-Related Health Inequities,” was written to support prevention efforts in resource-limited-settings.

Health disparities and cardiovascular disease are closely linked. Nurses, registered dietitians, physical therapists, and both masters- and doctoral-level counselors can reduce systematic health inequities through behavioral counseling. Studies have suggested that behavioral medicine can improve clinical outcomes for patients with CVD. However, access to these services is underfunded and limited.

Co-authored by clinical psychologists Allison E. Gaffey, PhD, and Matthew Burg, PhD, the document recommends updating the Centers for Medicare and Medicaid Services (CMS) reimbursement procedures, which would allow providers to bill for behavioral counseling under primary and secondary CVD prevention codes.

SBM Recommendations for the Centers for Medicare and Medicaid Services (CMS)

• Expand reimbursement for intensive behavioral counseling.
• Include masters-and doctoral-level counselors trained in behavioral methods in the definition of qualified clinicians.
• Broaden coverage for intensive behavioral counseling to all health care settings.
• Maintain expanded coverage for telehealth and increase access to these services to adults at high risk for cardiovascular disease.

Download the SBM position statement.

Other authors on the position statement include Alyssa Vela, PhD, and Allison Carroll, PhD, Northwestern Feinberg School of Medicine; Casey Cavanagh, PhD, University of Virginia School of Medicine; Akilah Dulin, PhD, Brown University; Lisa Quintiliani, PhD, Boston University; Laura Hayman, MSN, PhD, FAAN, FAHA, University of Massachusetts Boston.

Vela, Alyssa, et al. “Position Statement: Increase Funding and Access for Intensive Behavioral Counseling to Reduce Cardiovascular Disease-Related Health Inequities.” Society of Behavioral Medicine, May 2022.

Pancreatic Branch duct -Intraductal Papillary Mucinous Neoplasms (BD-IPMNs) Monitored Beyond Five Years Showed Persistent Albeit Lower Pancreatic Cancer Risk

Pancreatic imaging results in increased diagnosis of presumed intraductal papillary mucinous neoplasms (IPMNs). IPMNs are pre-cancerous growths of the pancreas which undergo risk stratification for malignancy based morphological features. "Low-risk IPMNs" are those without worrisome features or high-risk stigmata. Among this cohort, imaging-based surveillance has been best practice, but the duration of follow-up is unclear.

In this study, a team from Yale School of Medicine and New York University led by Dr. James J. Farrell investigated the incidence of pancreatic malignancy during initial five years and beyond five years through systematically review and meta-analysis of forty-one studies.

This study demonstrated a persistent cancer risk in low-risk IPMNs surveilled beyond a five-year period, albeit a lower risk among cysts with initial size stability, supporting ongoing surveillance of these patients. Learn more in Clinical Gastroenterology and Hepatology.

Chhoda A, Singh S, Sheth AH, Grimshaw AA, Gunderson C, Sharma P, Kunstman JW, Sharma A, Ahuja N, Gonda T, Farrell JJ. BENEFIT OF EXTENDED SURVEILLANCE OF LOW-RISK PANCREATIC CYSTS AFTER FIVE-YEAR STABILITY: A SYSTEMATIC REVIEW AND META-ANALYSIS. Clin Gastroenterol Hepatol. 2022 May 11:S1542-3565(22)00450-5. doi: 10.1016/j.cgh.2022.04.025. Epub ahead of print. PMID: 35568304.

Ertugliflozin Reduces Sleep Apnea in T2D Patients

Obstructive sleep apnea (OSA) occurs when muscles in the throat relax and block one’s airway while asleep. This disruption in breathing causes the sufferer to awaken numerous times throughout the night. Untreated OSA can lead to heart and kidney problems, along with other health issues.

The benefits of empagliflozin, a sodium-glucose transporter 2 inhibitor, were demonstrated in previous trials in patients with type 2 diabetes, but researchers were curious to see if the cardiac and kidney improvements seen with a similar medication, ertugliflozin, could help patients with OSA.

In the new Yale-led study, “Ertugliflozin and incident obstructive sleep apnea: an analysis from the VERTIS CV trial,” the research team concluded that ertugliflozin reduced the occurrence of OSA in patients with type 2 diabetes. Learn more in Sleep Breathing Physiology and Disorders.

Wojeck BS, Inzucchi SE, Neeland IJ, Mancuso JP, Frederich R, Masiukiewicz U, Cater NB, McGuire DK, Cannon CP, Yaggi HK. Ertugliflozin and incident obstructive sleep apnea: an analysis from the VERTIS CV trial. Sleep & Breathing = Schlaf & Atmung 2022 doi: 10.1007/s11325-022-02594-2. PMID: 35596030.

Hospitalist Workload ≠ Increased Length of Stay

Hospitalist physicians’ workload – the total number of patients they care for daily – is rising in the U.S. Hospitalists report that increased workload negatively affects patients care, yet there has been little evidence to rigorously examine the relationship between workload and clinical outcomes. In a new study, investigators at the Yale School of Medicine and Yale New Haven Health System examined data from 38,141 hospitalizations at YNHH over a three-year period. They found a graded and statistically significant association between workload and length of stay. There were no associations between workload and ED visits or readmission within 7 and 30 days. Sarwat Chaudhry, MD, senior author of the study, noted that, “our study highlights the need for research assessing a range of outcomes, including those related to patient safety and satisfaction, to understand the impact of workload.”

Chaudhry also reflected on the interdisciplinary team who led this work, including William Cushing, PA-C, and Daniel Heacock, PA, with the NEMG clinical hospitalist group. “Every step in the design and analysis of this study benefitted from the insights of team members who have a real-world understanding of how hospital medicine is practiced. Those insights were critical in ensuring that our findings are robust and applicable in clinical practice.” Learn more in the Journal of Hospital Medicine.

Djulbegovic, M, Chen, K, Cohen, AB, et al. Associations between hospitalist physician workload, length of stay, and return to the hospital. J. Hosp. Med. 2022; 1- 11. doi:10.1002/jhm.12847

Physical Activity Preserves Mobility In Older Adults

In his recent editorial in the BMJ, Thomas Gill, MD, cites findings from the new SPRINTT (Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies) trial in which researchers found that a structured, moderate physical activity program can preserve mobility in older adults. The SPRINTT trial findings were consistent with the LIFE Study, in which Gill was a co-investigator and the site principal investigator at Yale School of Medicine.

He suggests that gait speed rather than short physical performance battery could be used to identify those at risk for mobility loss. Further, Gill recommends referring those at risk to a community physical activity program. Learn more in the BMJ.

Gill, T M. Preserving community mobility in vulnerable older people BMJ 2022; 377 :o1084 doi:10.1136/bmj.o1084

Use Molecular Interrogation for Myeloid Sarcoma

In this Letter to the Editor, Yale School of Medicine scientists present a case of a 47-year-old female who was diagnosed with acute myeloid leukemia (AML) and eventual relapse after allogeneic hematopoietic stem cell transplantation (alloHCT) with a new FLT3 mutation. Although achieving remission with further leukemia-directed therapy, her disease relapsed again with multi-focal myeloid sarcoma, which was confirmed to harbor a FLT3 mutation. FLT3-targeted therapy allowed another remission.

The authors urge that “molecular interrogation of myeloid sarcoma” should be strongly considered and can reveal therapeutic targets. Learn more in Annals Of Hematology.

Shallis RM, Pucar D, Perincheri S, Gore SD, Seropian SE, Podoltsev NA, Zeidan AM. Molecular testing of isolated myeloid sarcoma allows successful FLT3-targeted therapy. Annals Of Hematology 2022, 101(5): 1145-1147. doi: 10.1007/s00277-021-04702-w. PMID: 34686913.

Yale Researchers Design Sophisticated Computational Tool

Yale scientists and their colleagues from multiple institutions, with contributions from the Yale IMPACT Team, designed a new computational tool called Multiscale PHATE, a method that can learn and visualize abstract cellular features and groupings of data at all levels of granularity. In an article published in Nature Biotechnology, the authors explain how they applied Multiscale PHATE to a COVID-19 dataset with 54 million cells from 168 hospitalized patients. Cellular populations associated with patient outcome were identified. “While coarse grain analysis reveals that a cell type (e.g., T cells) may be broadly protective, fine-grain analysis reveals that cellular subsets can be pathogenic, highlighting the need for a multiresolution approach,” the authors said. To read the full article, go to Nature Biotechnology.

Kuchroo M, Huang J, Wong P, Grenier JC, Shung D, Tong A, Lucas C, Klein J, Burkhardt DB, Gigante S, Godavarthi A, Rieck B, Israelow B, Simonov M, Mao T, Oh JE, Silva J, Takahashi T, Odio CD, Casanovas-Massana A, Fournier J, Farhadian S, Dela Cruz CS, Ko AI, Hirn MJ, Wilson FP, Hussin JG, Wolf G, Iwasaki A, Krishnaswamy S. Multiscale PHATE identifies multimodal signatures of COVID-19. Nature Biotechnology 2022, 40(5): 681-691. doi: 10.1038/s41587-021-01186-x. PMID: 35228707.

Aligning Medical Care w/ a Patient’s Preferences & Values at End of Life

End of life (EOL) can result in less distress and fewer hospital admissions in the last month of life among cancer patients who are referred to hospice. Advance care planning (ACP) documents the patient’s preferences in the medical record and anticipates the complicated decisions that arise at the end of life. A retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice reviewed the association between billed ACP services and hospital admissions in the final 30 days of life. Read the article in the American Journal of Hospice and Palliative Medicine.

Prater LC, O'Rourke B, Schnell P, Xu W, Li Y, Gustin J, Lockwood B, Lustberg M, White S, Happ MB, Retchin SM, Wickizer TM, Bose-Brill S. Examining the Association of Billed Advance Care Planning With End-of-Life Hospital Admissions Among Advanced Cancer Patients in Hospice. The American Journal Of Hospice & Palliative Care 2022, 39(5): 504-510. doi: 10.1177/10499091211039449. PMID: 34427154.

Routine Use of Mycobacterial Cultures in Patients w/ Periprosthetic Joint Infections is Overused

Appropriate therapy of periprosthetic joint infection (PJI) hinges on accurate diagnosis. Since mycobacterial PJI is rare, routine testing is not cost-effective or necessary in most cases, say the authors of a report in Open Forum Infectious Diseases. The authors retrospectively reviewed operating room cultures for 97 patients admitted to Yale New Haven Hospital who met the criteria for first hip or knee periprosthetic joint infection. “We reviewed hip and knee PJI at our institution over 28 months. Mycobacterial cultures were routinely sent with rare positivity. Mycobacterial cultures should be sent only when there is clinical suspicion.” To read the study’s results, go here.

Golden M, Moffarah AS, Kerantzas C, Rubin L, O'Bryan J. Unnecessary Routine Use of Mycobacterial Cultures in Patients With Periprosthetic Joint Infections. Open Forum Infectious Diseases 2022, 9(5): ofac132. doi: 10.1093/ofid/ofac132. PMID: 35392456. PMCID: PMC8982768.

Revealing Extent of SARS–CoV-2 Infection in People w/ Rheumatic Diseases

Patients with rheumatic and musculoskeletal diseases (RMD) have higher rates of SARS-CoV-2 infection and an increased mortality rate. This was the conclusion of a systematic literature review using 14 databases from Jan. 1, 2019 to Feb. 13, 2021, as well as observational studies and experimental trials in RMD patients that described comparative rates of SARS-CoV-2 infection, hospitalization, oxygen supplementation, intensive care unit admission, mechanical ventilation or death attributed to COVID-19. The purpose of the study was to quantify the risk of COVID-19 infection in people with RMD and to describe the clinical outcomes of COVID-19 in these patients. Read more in Arthritis & Rheumatology.

Conway R, Grimshaw AA, Konig MF, Putman M, Duarte-García A, Tseng LY, Cabrera DM, Chock YPE, Degirmenci HB, Duff E, Egeli BH, Graef ER, Gupta A, Harkins P, Hoyer BF, Jayatilleke A, Jin S, Kasia C, Khilnani A, Kilian A, Kim AHJ, Lin CMA, Low C, Proulx L, Sattui SE, Singh N, Sparks JA, Tam H, Ugarte-Gil MF, Ung N, Wang K, Wise LM, Yang Z, Young KJ, Liew JW, Grainger R, Wallace ZS, Hsieh E. SARS-CoV-2 Infection and COVID-19 Outcomes in Rheumatic Diseases: A Systematic Literature Review and Meta-Analysis. Arthritis & Rheumatology (Hoboken, N.J.) 2022, 74(5): 766-775. doi: 10.1002/art.42030. PMID: 34807517. PMCID: PMC9011807.