2022 MSTAR Program at ISMMS Abstract Book

2022

Program Medical Student Training in Aging Research Icahn School of Medicine at Mount Sinai

ABSTRACT AND POSTER BOOK

The Medical Student Training in Aging Research (MSTAR) Program is sponsored by: The National Institute on Aging (NIA) The Brookdale Department of Geriatrics & Palliative Medicine The Leni and Peter May Department of Medical Education

MSTAR @ISMMS

The Program The Medical Student Training in Aging Research (MSTAR) at The Icahn School of Medicine at Mount Sinai is a T-32 program funded by The National Institute on Aging (NIA).

It is one of the 8 National Training Centers which includes Harvard Medical School (BU, UMass, UMiss and Brown) ★ Johns Hopkins University SOM ★ NYU ★ UCLA (UCSF and Univ of Washington) ★ UC San Diego ★ University of North Carolina ★ Augusta University (PR).

The MSTAR Program at ISMMS provides an enriching 8week experience in aging and palliative care related research under the mentorship of top experts in the field.

Aging-related research crosscuts many areas of scientific investigation from basic sciences, to clinical research, to health services research.

MSTAR @ISMMS Students gain a wealth of experiences they might not otherwise have during medical school, especially early in their training when most scholars participate in the program.

Program highlights include classes in research methodology, opportunities for research presentations and publications, clinical geriatrics experiences, information on medical careers and informal social gatherings and networking with fellow scholars and mentors.

Many former MSTAR scholars have pursued successful and varied careers. They have joined the growing number of dedicated scientists, innovative thinkers, and talented physicians whose specialized knowledge and skills in aging and palliative medicine are increasing in demand as our population ages.

MSTAR Program at ISMMS Leadership and Staff

Rainier P. Soriano, MD

Melissa Aldridge, PhD, MBA

MSTAR Program Co-Director

MSTAR Program Co-Director

Professor & Senior Associate Dean for Curricular Affairs The Leni & Peter May Department of Medical Education

Professor & Vice Chair of Research The Brookdale Department of Geriatrics & Palliative Medicine

Katelyn Ferreira, MPH

Jahriah Philip Hill

MSTAR Program Manager

MSTAR Program Coordinator

Research Program Manager The Brookdale Department of Geriatrics & Palliative Medicine

Department Coordinator The Leni & Peter May Department of Medical Education

2022 MSTAR Program at ISMMS Scholars

Aneesh Agarwal Icahn School of Medicine at Mount Sinai

Akiro Duey Icahn School of Medicine at Mount Sinai

William Gansa Icahn School of Medicine at Mount Sinai

Project: Impacts of the COVID-19 Pandemic on Skin Cancer Surgeries

Project: The Impact of Surgery on Mortality in Elderly Patients With Proximal Humerus Fractures: A Retrospective Analysis of Medicare Beneficiaries

Project: Regional Indicators Impact Proxy-reported Quality of Care During the Last Month of Life

Mentor: Jonathan Ungar, MD

Mentor: Claire Ankuda, MD

Mentor: Paul J. Cagle, MD

Mikayla Gordon-Wexler Icahn School of Medicine at Mount Sinai

Walter Jacob Icahn School of Medicine at Mount Sinai

Morgan (Mo) Kinsinger Northwestern University Feinberg School of Medicine

Project: Family Caregivers’ Challenges Navigating the Insurance Landscape for Family Members with Dementia

Project: Sleep Maintains Immune Homeostasis Limiting Murine Tauopathy

Project: Patients In Critical Care Without Family Re: A Rare, Vulnerable Group, For Whom Medical Decisionmaking Processes Are Not Well Understood

Mentor: Jennifer Reckrey, MD

Mentor: Cameron McAlpine, MD

Mentor: Bevin Cohen, PhD

2022 MSTAR Program at ISMMS Scholars

Gavin Li Icahn School of Medicine at Mount Sinai

Carolina Moreno-Alvarado University of Puerto Rico School of Medicine

Ian Odland Icahn School of Medicine at Mount Sinai

Project: Regional and Seasonal Variation in the Prevalence of Dry Eye and its Association with Psychiatric Comorbidity

Project: Decisions about Palliative and Hospice Care: The Effect of Caregiver and Patient Beliefs

Project: Artificial IntelligenceDriven Automated Intracerebral Hemorrhage Volume Calculation is More Accurate than Standard Clinical Method

Mentor: Sumayya Ahmad, MD

Mentor: Cardinale B. Smith MD, PhD

Mentor: Christopher P. Kellner, MD

Sungjae Park Icahn School of Medicine at Mount Sinai

Colby Parsons Icahn School of Medicine at Mount Sinai

Varun Subramaniam Icahn School of Medicine at Mount Sinai

Project: Variations in Hospital in Home Programs in Veteran Affairs Health System

Project: Use and Impact of Community Paramedicine on Healthcare Utilization among Homebound Patients

Project: Hospital readmissions after an epilepsy related surgical intervention in older adults in the US – a population-based study

Mentor: William Hung, MD

Mentor: Katherine Ornstein, PhD, MPH, Christian Escobar, MD

Mentor: Churl-Su Kwon, MD, PhD

2022 MSTAR Program at ISMMS Scholars

Vikram Vasan Icahn School of Medicine at Mount Sinai

Chinmayi Venkatram Icahn School of Medicine at Mount Sinai

Hannah Verma Icahn School of Medicine at Mount Sinai

Project: Risk Factors in Pituitary Surgery Amongst Octogenarians

Project: Home Care Clinicians’ Perspectives on Advance Care Planning for Patients who are Incapacitated with No Evident Advance Directives or Surrogates

Project: Risk Factors for Free Flap Complications for Head and Neck Cancer Defects in the Elderly

Mentor: Raj Shrivastava, MD

Mentor: Mingyang Gray, MD

Mentor: Bevin Cohen, PhD

Madeleine Villalba Icahn School of Medicine at Mount Sinai

Dragan Vujovic Icahn School of Medicine at Mount Sinai

Hadley Walsh Wake Forest School of Medicine

Project: Frameworks for the Relationship Between HIV and Aging Among HIV Clinic Providers

Project: Racial Disparities in Treatment Presentation, Modality, and Complications in Older Adults With Oropharyngeal Squamous Cell Carcinoma

Project: PDE4DIP is implicated in Progressive Supranuclear Palsy

Mentor: Abigail Baim-Lance, PhD

Mentor: Richard Bakst, MD

Mentor: John Crary, MD, PhD

Abstracts and Posters

Impacts of the COVID-19 Pandemic on Skin Cancer Surgeries A. Agarwal, S. Owji, B. Ungar MD, N. Gulati MD PhD and J. Ungar MD Department of Dermatology, Icahn School of Medicine at Mount Sinai

“In the year following COVID-19 pandemic start, basal cell carcinomas were treated later and with more stages of surgery; cancer dimensions and age at treatment remained similar; all skin cancer case volumes decreased in the immediate period following March 11, 2020.”

Introduction: Twenty percent of Americans will have skin cancer by age 70. During the March 2020 COVID-19 pandemic peak, skin cancer biopsies were down up to 85% and melanoma diagnoses were up to 60% fewer. This is particularly relevant among geriatric populations given that skin cancer prevalence is over 8% in this group. It is currently not well-documented whether these findings impacted surgical treatment of skin cancer during this period, and if there are any implications that providers/patients should be aware of during COVID-19 spikes or other public health emergencies.

Objective: To evaluate differences between pre- and post-COVID-19 cases of skin cancer of all varieties at a large academic medical center.

Methods: Single center, comparative cross-sectional retrospective study (3/2019 – 2/2021) of patients (N=549) undergoing skin cancer surgery: all encountered melanoma cases (94) and a random sample of 238 basal cell carcinomas (BCC) and 217 squamous cell carcinomas (SCC) at the Mount Sinai Department of Dermatology. By cancer type, cases were split into pre-pandemic (3/2019-2/2021) and post-pandemic start (3/11/2020-2/2021) groups. From medical record review, we collected lesion size, melanoma staging/depth, closure dimensions, zip code, age, biopsy/surgery dates, and biopsy/surgery locations. Overall departmental case volumes were also gathered.

Results: Average age of patients presenting for surgery was 67.58 years. Lesion and surgery closure sizes, along with melanoma stage/depth, remained the same for cases in both periods. Biopsy to treatment time increased among SCC (+4.82 days, +7.87%) and BCC (+26.14 days, +34.40%, p<0.05) but decreased for melanomas (-9.80 days, 24.81%). Required Mohs stages increased for BCC by 0.21 (13.01%, p<0.05) and SCC by 0.15 (9.15%). SCC surgery volume decreased to 1 in 04/2020 and 5 in 05/2020, BCC volumes similarly declined to 9 and 13, representing decreases of over 74% from the respective average monthly cases prior, and melanomas were not seen in 05/2020.

Conclusion: Delayed biopsies/diagnosis, as documented in literature, did translate to delayed surgical treatment significantly among BCC, requiring additional stages of Mohs surgery, suggesting possible poorer wound healing/recovery. However, overall cases were not more serious due to similar lesion characteristics in both pre- and post-periods, suggesting similar clinical outcomes. The more rapid treatment of melanomas, though not significant at the current level, may be reflective of the postponement of elective procedures during the pandemic and possibly more expedient emergent care; impacts on clinical outcomes in this period should be explored further among more rapidly treated melanomas. Case volume decreases for all skin cancer types in the immediate periods following public health crises may indicate a need for greater vigilance among at-risk groups, especially among geriatric populations, to ensure that cases are diagnosed, followed-up on, and treated, as well as backlogs cleared.

The Impact of Surgery on Mortality in Elderly Patients With Proximal Humerus Fractures: A Retrospective Analysis of Medicare Beneficiaries Akiro H. Duey, BS, Nicole Zubizarreta, MPH, Brocha Z. Stern, PhD, Jashvant Poeran, MD, PhD, Leesa M. Galatz, MD, Bradford O. Parsons, MD, Paul J. Cagle, MD Icahn School of Medicine at Mount Sinai, Department of Orthopedics

“Elderly patients undergoing surgery for a proximal humerus fracture had lower mortality rates than patients treated nonoperatively.”

Introduction: Proximal humerus fracture (PHF) is the third most common type of fracture in elderly patients and has been identified as a risk factor for 1-year mortality.

Depending on the severity of the fracture and patient comorbidities, PHF can be treated surgically or nonoperatively. The purpose of our study was to determine if surgical treatment for PHF in elderly patients is associated with higher mortality compared to nonoperative treatment.

Methods: This was a retrospective study using the Centers for Medicare and Medicaid Services Limited Data Set (CMS-LDS) between the years 2016-2020. All patients were over the age of 65. Patients were included based on a diagnosis of PHF which was identified by the International Classification of Diseases, 10th Revision (ICD-10) diagnosis code S42.2X. The surgical cohort was defined as any patient undergoing open reduction internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). Patients who did not undergo surgery within 30 days of initial PHF diagnosis were placed in the nonoperative treatment group. A multivariate logistic regression model was created to compare mortality between surgical and nonoperative groups while controlling for patient demographics and comorbidities.

Results: In total, 163,672 patients were included in the study. The mean age was 78.1 years, and 131,125 patients (80.1%) were female. Patients in the nonoperative group were older (78.5 years; p<0.001) and less likely to be female (79.7%; p<0.001). The most common type of PHF was a 2-part fracture, of which there were 127,434 (77.9%).

142,439 patients (87.0%) were treated nonoperatively, 6.3% underwent TSA, 5.9% underwent ORIF, and 0.8% underwent HA. The 30-day mortality rates were higher in the nonoperative group (3.8%; p<0.001) than in the TSA (1.0%), ORIF (1.4%), and HA (1.4%) groups. At one year after the initial PHF diagnosis, the nonoperative group had the highest mortality rate at 15.6% (p<0.001). The 1-year mortality rates were 6.0% for TSA, 7.0% for ORIF, and 8.6% for HA. Logistic regression analysis showed that TSA (OR: 0.43; 95% CI: [0.39, 0.47]; p<0.001), ORIF (OR: 0.55; 95% CI: [0.51, 0.60]; p<0.001), and HA (OR: 0.59; 95% CI: [0.48; 0.72]; p<0.001) remained associated with significantly lower 1-year mortality compared to nonoperative treatment.

Conclusions: When compared to nonoperative treatment of PHF, surgery was associated with lower mortality rates at thirty days and one-year post-diagnosis. Our findings suggest that in elderly patients, surgical treatment of PHF may reduce shortterm mortality.

Regional indicators impact proxy-reported Quality of Care (QoC) during the Last Month of Life (LML) Will Gansa, BA, Claire Ankuda, MD MPH, Subashini Rajagopalan, Hannah Kleijwegt, Mohamed Benyamine Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

“Proxies of decedents from persistent poverty, low education, and low employment counties report lower satisfaction with quality of care during the last month of life, independent of rural-urban status and traditional healthcare quality indicators.”

Introduction: End-of-life (EoL) healthcare provided to Americans in urban and rural settings is distinct in terms of both available and delivered services, which may influence patient and proxy reported outcomes. But much less is still known about which geographic, demographic, and healthcare market characteristics drive disparities in satisfaction with EoL care outcomes.

Objective: To assess how economic and demographic indicators affect proxy reported quality of EoL care across regional indicators and degrees of rurality.

Methods: This is a cross-sectional study of n=2878 decedents whose proxies completed the Last Month of Life questionnaire distributed by the National Health and Aging Trends Study (NHATS). The NHATs is a nationally representative cohort study of adults over the age of 65. The data was linked at the zip code level to USDA ERS Typology Codes, USDA Urban Influence Codes, and University of Wisconsin County Health Rankings. Metropolitan areas must have at least one urbanized area of 50,000 or more residents, micropolitan areas must have at least one urbanized area of 10-50,000 residents, and noncore areas do not contain an urbanized area of more than 10,000 residents. We tested association of individual and regional characteristics using two-way frequency tables and simple logistic regressions.

Results: County rurality index was not correlated with proxy reported quality of care during the LML. Proxies of decedents who lived in Persistent Poverty counties were less likely to rate the quality of care received during the LML as excellent (59.53% vs 51.46%, p=0.02), as were proxies of decedents who lived in Low Employment Counties (58.01% vs 51.29%, p=.02) and Low Education Counties (57.33% vs 51.06%, p=.01).

Proxies of non-white (p = .000) and less educated (p=0.01) decedents were less likely to rate the quality of care received during the LML as excellent.

Conclusions: Quantitative care disparities across rural and urban environments (i.e. access to hospice, number of nursing homes) may have less impact on proxy reported end of life care than downstream effects of high county poverty levels, low county education, and low county employment levels.

"It shouldn’t be like this”: Family Caregivers’ Challenges Navigating the Insurance Landscape for Family Members with Dementia Mikayla Gordon Wexler, BA and Jennifer Reckrey, MD Icahn School of Medicine at Mount Sinai, New York, NY, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.

“During the challenging initial transition to caregiving, family caregivers of people with dementia received limited support in navigating the insurance landscape.

The burden of insurance decision-making existed on top of other care responsibilities. Caregivers then described maintaining existing insurance without considering alternative plans despite clinically significant gaps in insurance coverage.”

Introduction: For the almost 11.3 million family and other unpaid caregivers in the United States caring for loved ones with dementia, navigating the health insurance landscape is shaded by the complex care needs of those with dementia and the need for both medical and long-term care at home. The goal of this study is to explore how caregivers make decisions around insurance for their family member with dementia and how these choices affect the care that people with dementia receive.

Methods: Semi-structured telephone or Zoom interviews were conducted from June 2022 to a projected end date of September 2022 with family caregivers of people with dementia who were enrolled in home-based primary care in New York City and who were dually eligible for Medicaid and Medicare. After obtaining sociodemographic and clinic data about participants and their family member with dementia, we asked a set of open-ended questions exploring caregivers’ perspectives on navigating their family member’s insurance plans and overall comfort with insurance landscape. Data will be analyzed using thematic analysis using both deductive and inductive coding using Dedoose.

Results: Participants (N=5; Goal of 18 participants by end of study) described the high burden of determining the needed insurance plans for their family member during the initial period of adjustment to their family members’ dementia diagnosis or decompensated medical status. During this period, participants identified medical and legal professionals (i.e., social workers, elder law attorneys, physicians) as providing necessary support in navigating health insurance decision-making. Attributes influencing choices included: family dynamics; previous plans in which their family member was enrolled; home care and medical supply needs. After this decision, participants did not report changing health insurance plans for their family member but rather advocating for their family member’s care within established health care plans. Overall, participants saw their insurance knowledge as specific to what they needed to know to best care for their family member.

Conclusions: This study highlights the challenges that family caregivers experience when seeking out information about needed insurance plans and receiving support in their decisions, especially when they are new to the caregiving role. These challenges may contribute to unwillingness to change plans even when challenges navigating current insurance plans exist. Ongoing insurance decision-making support may benefit both caregivers and people living in the community with dementia.

Sleep Maintains Immune Homeostasis Limiting Murine Tauopathy Walter Jacob, BS, Abi Yates, PhD, Pacific Huynh, PhD, Andrew Varga, MD, PhD, Cameron McAlpine, PhD The Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, The Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.

“A bi-directional relationship between sleep decline and tau burden in mice expressing mutant human tau.”

Introduction: Sleep declines in both quality and quantity with age. Inadequate sleep is associated with both cardiovascular and neurodegenerative diseases, such as atherosclerosis and Alzheimer’s disease (AD). The prevalence of insomnia in adults worldwide is estimated to be around 30%, whereas it is closer to 50% in patients with AD. Fewer than 35% of US adults get the recommended 7-8 hours of sleep per night. Poor and inadequate sleeps drive many disease sequalae including immune dysfunction and inflammation. However, despite the central importance of sleep, little is known about the molecular and cellular mechanisms that link sleep, the immune system, and disease. Two hallmarks of AD pathology are amyloid plaque deposition and tau tangle-like inclusions in brain parenchyma, which are believed to each seed via self-templating mechanisms. While mutations in either APP or MAPT (tau) can be causative in familial AD, tau aggregates correlate more with clinical disease and induce distinct inflammatory signatures in astrocytes and microglia. Systemic inflammation drives many disease processes, including cardiovascular disease, and may be involved in the development of AD. The contribution of circulating immune cells and their secreted factors to AD pathology remains unclear.

Given that sleep and circadian rhythm are key processes that maintain tight control over immune cell homeostasis, the role of sleep as a possible therapeutic target in preventing AD is greatly underexplored.

Objective: This study seeks to examine potential contributions of sleep and the immune system to AD pathology. It also explores whether augmentation of sleep is sufficient to decrease burden of disease.

Methods: PS19 (mutant human tau-overexpressing) and 5xFAD (mutant human APP-overexpressing) transgenic mice, which each harbor causative genetic mutations in familial AD, and wild type C57/B6 mice were used for this study. Sleep fragmentation was induced by in-cage sweep bars active every 2 minutes during the light phase. Sleep augmentation was achieved by antagonism of the orexin receptor using DORA-12. Mice implanted with EEG leads allowed for the analysis of sleep. Tau phosphorylation and microglial activation were determined by brain section immunohistochemistry and microscopy.

Immune cell profiling was done using spectral flow cytometry and all flow data were analyzed in FlowJo. Results: We show that 5xFAD mice demonstrate increased levels of bone marrow hematopoiesis and increased numbers of circulating immune cells. Additionally, we show that young PS19 mice exhibit increased leukocyte populations in the spleen compared to wild type mice well before clinical signs of AD are evident. Further, aged PS19 mice exhibit significantly impaired sleep compared to wild type mice and 8 weeks of sleep fragmentation greatly exacerbates tau phosphorylation in these mice, a marker of aggregate stability and burden of disease.

Discussion and Outlook: Our findings that mice harboring AD mutations have increased bone marrow hematopoiesis and increased leukocyte populations in the spleen suggest there is early activation of the innate immune system, which is known to elicit widespread inflammation and can disrupt resident immune cell functionality in the brain. We are still exploring whether systemic inflammation due to increased immune cell activation is a causative agent in AD. Through modulating innate immunity in both young and old PS19 mice, we hope to elucidate precise mechanisms by which peripheral immune cells mediate AD pathology in the brain. We also suggest a bi-directional relationship between tau burden and sleep fragmentation that may be mediated by the immune system. Ongoing experiments using drugs which promote sleep are examining whether rescue of sleep impairment and the associated return to immune homeostasis can ameliorate tau burden. While orexin receptor antagonists have already been identified as treatments for insomnia, we hope to decipher possible neuroprotective roles of these compounds in mitigating tau hyperphosphorylation and disruption of microglial architecture.

Conclusion: This study is ongoing and aims to reframe how we think about the pathogenesis of AD and potentially identify a new therapeutic axis (sleep) by which preventative interventions can be directed.

Patients In Critical Care Without Family Re A Rare, Vulnerable Group, For Whom Medical Decision-making Processes Are Not Well Understood Morgan Kinsinger, BA, Jiyoun Song, PhD, AGACNP-BC, RN, Bevin Cohen, PhD, MS, MPH, RN Northwestern Feinberg School of Medicine, Chicago, Illinois, Icahn School of Medicine at Mount Sinai, Brookdale Department of Geriatrics and Palliative Medicine, New York, New York

“Patients in critical care without family are a rare, vulnerable group. Right now, it’s not clear how medical decisions are made on their behalf.”

Introduction: Patients in critical care settings who are incapacitated with no evident advance directives or surrogates (INEADS) represent a growing and vulnerable patient population for whom it is often difficult to ensure ethical care concordant with their goals and preferences. Few state and institutional standards exist to guide medical decision-making on behalf of patients who are INEADs, especially at the end of life.

Objective: To better characterize the care of INEADs patients, this mixed-methods study investigated the demographics, illness courses, life-sustaining medical interventions, and narrative themes in the clinical notes of INEADs patients in critical care versus matched controls. The ultimate aim of this research is to aid development of future strategies to ensure that these patients receive ethical care concordant with their goals and preferences.

Methods: In a previous study, our research group utilized natural language processing (NLP) to identify patients at high risk of being INEADs (n = 81) from MIMIC-III, a publicly-available dataset of deidentified health-related data from patients hospitalized in intensive care units of Beth Israel Deaconess Medical Center from 2001 - 2012. A control cohort was assembled of patients which were matched to the high risk INEADs cohort for age, sex and ICD codes (n = 320). All clinical notes for both cohorts were individually reviewed for quantitative metrics of interest including length of stay, ICU service, opioid administration, mortality and discharge location. We utilized Dedoose qualitative analysis software to annotate all clinical notes for text relating decision-making processes, goals of care conversations, patients’ backgrounds and emotions or pain. Qualitative findings were reviewed and summarized by two study authors (MK, BC). In order to refine the tools to be utilized in this study, analysis was performed on a test cohort of patients (n = 8) who our research team has previously found to be genuinely INEADs based on chart review, the results of which are reported below.

Results: The percentage of true INEADs patients in the MIMIC-3 database (0.002%) was much smaller than previously reported. Among this cohort, patients were 75% male with a mean age of 60 (46 - 74) and mean number of days in the ICU of 15 (4 - 26). 3 patients were discharged to a rehab facility, 2 to home, 1 patient passed away, 1 left AMA, and 1 patients’ records lacked discharge data. The most common ICU service serving INEADs patients was cardiothoracic surgery, followed by medicine and neurology/neurosurgery. According to clinical notes, many patients came from vulnerable living situations such as incarceration or being elderly and living at home alone. Descriptions of decisionmaking moments were either lacking or written in passive language.

Conclusion: The care of INEADs patients often requires healthcare workers to face an ethical dilemma of making substituted medical decisions with no knowledge of what the patient would have preferred. In order to develop future guidelines, it is critical to understand how care is delivered under the current system and any biases or assumptions which may lead to healthcare disparities among this vulnerable population.

Regional and Seasonal Variation in the Prevalence of Dry Eye and Its Association with Psychiatric Comorbidity Gavin Li, BS, Janek Klawe, MS, Sumayya Ahmad, MD Icahn School of Medicine at Mount Sinai, New York, NY. Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY.

“There is a seasonal trend in the frequency of dry eye visits consistent throughout geographic regions, except for the Northern Rockies. Dry eye patients in the West are on average seen for dry eye more frequently than other regions.

The association between dry eye disease and depression or anxiety is strongest in younger patients and tends to decrease with age.”

Introduction: Dry eye is a common debilitating condition with prevalence in the U.S. ranging from 5-18%, which increases with age. Previous studies have identified an association between dry eye and psychiatric comorbidities such as depression and anxiety, which was strongest in the elderly population. There is also evidence that seasonal variation impacts dry eye severity. This study aims to further examine the impact of geography and seasonality on the diagnosis of dry eye, as well as to elucidate the association between dry eye with depression and anxiety, specifically in the geriatric population.

Methods: Using a 5% random sample of Medicare beneficiaries from 2011, 2,507,672 patients residing within the lower 48 states were identified. Dry eye patients were identified using international classification disease codes (ICD9) 375.15, 370.33.

Patients with a depression (major or minor) diagnosis (ICD9: 3000, 3000X, 3002X, 3003, 30030, or 3098X, with X signifying any number) or an anxiety disorder diagnosis (ICD: 2962, 2963, 3004, or 311) were likewise identified. Patients were grouped according to 3 age groups defined as 65-74, 75-84, and 85 and above. Demographic information include age, gender, race/ethnicity, state, and county code were collected.

Patients were grouped according to the 9 climate regions (Northeast, Upper Midwest, Ohio Valley, Southeast, Northern Rockies and Plains, South, Southwest, Northwest, West) as reported by the National Centers for Environmental Information. Separate logistic regression models were used to estimate associational odds ratios between dry eye and each of anxiety and depression for each age group.

Results: A total of 113,847 patients with dry eye were identified. The prevalence of dry eye was highest in the Northern Rockies and Plains (5.38%) and South (5.22%). The prevalence of dry eye was lowest in the Upper Midwest (3.79%) and Northwest (3.05%).

The majority of dry eye patients were women (71.3%). Logistic regression analyses revealed that depression (OR 2.12) and anxiety (OR 2.19) were most strongly associated with dry eye diagnosis in patients aged 65-74 and least strongly associated in patients aged 85 or older (depression OR 1.80, anxiety OR 1.53). There is a consistent seasonal trend in the frequency of dry eye claims throughout climate regions in the US, with patients in the West being seen for dry eye more frequently than in other regions.

Conclusion: Our findings demonstrate that the prevalence of dry eye varies by climate region and season. There is also a significant association between dry eye and each of depression and anxiety in the elderly population which decreases with age. Additional longitudinal studies evaluating dry eye association with psychiatric comorbidity are warranted.

Decisions about Palliative and Hospice Care: The Effect of Caregiver and Patient Beliefs Carolina M. Moreno, BS; Mayuri Jain, MPH; Jose Morillo, BA; Melissa B. Mazor, PhD, MS, RN; Lihua Li, PhD; Cardinale B. Smith MD, PhD University of Puerto Rico School of Medicine, Icahn School of Medicine at Mount Sinai, Brookdale Department of Geriatrics and Palliative Medicine, NY, NY

“Minoritized patients held more negative HC and PC beliefs. Regardless of race and ethnicity, patients held more negative beliefs than caregivers. Minoritized patients with advanced lung cancer had a higher usage of PC and HC than non-minoritized patients.”

Background: There is a need to expand hospice care (HC) and palliative care (PC) to optimize end of life (EOL) outcomes for the growing population of older adults with cancer. Recent evidence has listed socioeconomic status, the doctor-patient relationship, health insurance, and stigma of the name “palliative” as possible barriers that hinder patients from accepting HC and/or PC. Furthermore, there is a paucity of information on the impact of caregiver's knowledge, perceptions, and trust regarding utilization of HC and PC among patients and, particularly, minoritized populations.

Objective: The purpose of the study is to evaluate the impact of caregiver/patient agreement regarding HC and PC beliefs on patient utilization of HC and PC, and if this relationship differs between minoritized patients (Black and/or LatinX) and nonminoritized patients (non-Hispanic White and Asian).

Methods: We performed a prospective cohort study of newly diagnosed patients ≥18 years of age with advanced lung cancer (stage III and IV) and their caregivers at a single institution in New York City. Patients and caregivers had baseline interviews done within 3 months of their initial diagnosis and were followed over a period of 12 months.

Our primary outcome was the receipt of HC and/or PC determined through medical record review. We used validated instruments to assess HC and PC beliefs and created a composite score for positive, neutral, and negative beliefs, as well as medical mistrust.

We then measured the level of agreement among patients and caregivers. In future analysis, we plan to conduct a multivariable regression analysis to compare the impact of patients/caregivers agreement on PC and HC use, stratifying by minoritized status.

Results: We enrolled a total of 99 patients and 43 caregivers. The 43 dyads were included in the analyses. Among the racially/ethnically concordant dyadic pairs, 27 (63%) identified as minoritized and 16 (37%) were non-minoritized. Mean age was 65.2 ± 10.2 and 52.1 ± 15.2 years among patients and caregivers, respectively. Nonminoritized patients were more likely to use HC and PC (67% vs 25%; p=0.02).

Minoritized patients held more negative beliefs compared to non-minoritized patients (2.7±6.7 vs 7.1±4.9; p=0.02). There was no difference in beliefs between minoritized and non-minoritized caregivers (6.3±5.7 vs 6.1±5.6; p=0.94). Overall, patients reported more negative beliefs compared to caregivers (4.3±6.2 vs 6.4±5.7) and this difference in patient/caregiver agreement was larger for minoritized patients (3.6±6.2 vs 1.0±3.2).

Conclusion: The next step is to determine if the level of agreement between patients and caregivers about HC and PC beliefs impact receipt of PC and/or HC. A higher proportion of our minoritized population received HC and PC. Further work is needed to determine facilitators and barriers to minoritized patient’s use of HC and PC.

Artificial Intelligence Intracerebral Hemorrhage Volume Calculation is More Accurate Than mABC/2 Ian C. Odland BS, Braxton R. Schuldt BA, Trevor Hardigan MD, PhD, Denzel Falkner BS and Chistopher P. Kellner MD Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY, NY, Sinai Biodesign, Icahn School of Medicine at Mount Sinai, New York, NY, Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, NY

“VIZ ICH evaluated Intracerebral Hemorrhage Volume more accurately than mABC/2 compared to "ground truth" Semi-Autonomous Segmentation in 3D Slicer.”

Introduction: 75% of people who experience stroke are above the age of 65, making stroke the fourth highest contributor to mortality and second highest contributor to disability worldwide. The American Health Association (AHA) guidelines for stroke triage stress the importance of developing systems of care that facilitate the fastest achievable onset-to-treatment time for patients experiencing acute hemorrhagic stroke. Treatment of spontaneous intracerebral hemorrhage (ICH) requires rapid, accurate estimation of hemorrhage volume in Computed Tomography (CT) imaging to determine appropriate patient care. mABC/2 is the clinical gold standard for estimating ICH volume. While fast, this method is prone to observer variability and can be imprecise. Semi-Autonomous Segmentation (SAS), manually outlining hemorrhage at various cross-sections to compute volume, is the gold standard for clinical research applications. While accurate, SAS is not used clinically because it is slow, requires specialized software, and poorly suited for patient triage. In recent years, artificial intelligence platforms have been developed to analyze neuroimaging faster and more accurately.

Objective: Our goal is to validate the accuracy of VIZ ICH as a tool for determining hemorrhage volume and comparing its performance to both mABC/2 and SAS. Methods: A pre-study trial cohort of ten head CTs positive for ICH were segmented in 3D Slicer to determine ICH volume. SAS ICH volumes were adjudicated by a neurosurgical resident and treated as ground truth. The medical record was reviewed for mABC/2 ICH volumes. VIZ ICH volumes were collected from the VIZ mobile application.

Results: VIZ ICH volumes were more or equivalently accurate than mABC/2 in 70% of cases. Average difference between VIZ ICH volume and SAS ICH volume was 14.62 ± 14.47 mL. Average difference between mABC/2 ICH volume and SAS ICH volume was 22.26 ± 19.03 mL. A strong correlation between the VIZ hemorrhage volume and SAS hemorrhage volume was found (r = 0.96). This is indicative of a strong positive relationship with SAS ground truth.

Conclusion: This pilot study indicates that VIZ ICH may evaluate ICH volume more accurately than mABC/2 when compared to SAS. Our protocol will be expanded to a 200-patient cohort in the near future.

Variations in Hospital in Home Programs in Veteran Affairs Health System: A Need for Standardization?

Sungjae Park, BA and William Hung, MD Brookdale Department of Geriatrics and Palliative Medicine. Icahn School of Medicine at Mount Sinai, New York, NY,

“Early evaluation of VA HIH-programs reveal variations in key areas of staffing, catchment area, visit frequency, and acuity level. Each site collected different metrics to measure their clinical outcomes.”

Background: The Department of Veterans Affairs (VA’s) Hospital In Home (HIH) program is a model of care that delivers acute level hospital care at home. Since the first HIH program at a VA health facility, this model of care has spread throughout the VA health facilities across the nation. To meet the needs of its own unique patient demographics with specific geographic characteristics, each VA health facility started their own variations of the HIH program and have been modifying and maintaining them to improve patient care. In addition, with the recent COVID-19 pandemic, each VA health facility have been further modifying the care models of HIH programs to care for COVID patients at home. It is therefore unclear if HIH programs deliver uniform services across the country and whether these programs deliver care similar to what earlier studies of Hospital at Home program have described.

Therefore, we surveyed all 11 VA’s HIH programs across the nation, evaluate the necessity of federal level care model standardization to examine similarities and differences which ultimately may provide data to support guidelines for best practices. As the qualitative portion of this project, this study intends to evaluate and compare the VA’s HIH program care models and compare their effectiveness.

Methods: Hospital-in-home programs’ medical directors at 2 VA health facilities were interviewed for the characteristics of their HIH program care models and their clinical outcomes. Site 1 was the Southern and Site 2 was in the Northeastern United States of America. According to the self-reported data, the team mapped the implementation of Hospital-in-home model of care based on RE-AIM framework that assesses reach, staffing, effectiveness, adoption, implementation, and maintenance.

The remaining 9 programs’ medical directors will be interviewed in the future, and the data will be incorporated to this paper.

Results: The HIH programs at both sites received referrals from outpatient, inpatient, and ED services in the forms of both early discharge and replacement hospitalization services. Both sites also provided 24/7 emergency contact services. For staffing, both sites 1 and 2 had physicians, registered nurses, social workers, pharmacist. However, site 1 had a dietitian to discuss healthy diets with patients, while site 2 didn’t have a dietitian. Site 1 did not have physician assistants, while site 2 had physician assistants as providers. In Site 1, only registered nurses made home visits and performed clinical assessments while Site 2’s providers made home visits and performed clinical assessments in-person.

Site 1 limited their catchment area within 30-mile radius from its hospital while site 2 limited their catchment area within 23-mile radius or 45-minute driving due to high traffic. Site 1 temporarily created a special care model of HIH to care for patients with Covid infection at home, while site 2 admitted patients with Covid infection without any change in their care model. Patients in Site 2 was visited by a nursing staff in-person at least once a day. Depending on the needs of the patients nursing staff visited via phone or in-person at Site 1. Site 1 only provided acute care at home, but Site 1 provided both acute and subacute care. For tracking of its tracking of its clinical outcomes, 30-day re-admission rate and cost avoidance were tracked only at Site 1 and bed days saved at Site 2.

Discussion: Hospital-in-home programs at Veterans Affairs hospitals have variations in how each program is implemented and operated. Also, each site collected variations of metrics for the measurement of clinical outcomes; for comparison across sites, it would be important to have common metrics across these programs. There needs to be additional work looking into what standardized metrics should be to evaluate HIH program’s clinical effectiveness. Further data from additional sites will shed light on additional similarities and differences that may impact effectiveness of the programs.

This information will be necessary to guide practices and program development for HIH programs across the nation. As non-VA HIH programs in the nation also may lack standardized care model and metrics to measure clinical outcomes, the discussion of this paper will have implications for the non-VA HIH programs across the nation as well.

Use and Impact of Community Paramedicine on Healthcare Utilization among Homebound Patients Colby Parsons, AB, Sara Lubetsky, MS, Christian Escobar, MD, Peter Gliatto, MD, Katherine Ornstein, PhD, MPH Brookdale Department of Geriatrics and Palliative Medicine. Icahn School of Medicine at Mount Sinai, New York, NY, Center for Equity in Aging, Johns Hopkins School of Nursing, Baltimore, MD

“Homebound Patients who utilized Community Paramedicine are older and more chronically-ill than non-CP utilizing patients. Repeat utilizers of the Community Paramedicine have an even higher chronic disease burden than those who use the program only once.”

Background: Community Paramedicine (CP) programs have emerged as a novel model of hospital diversion for homebound patients. This model is designed to extend primary care provider capabilities by deploying paramedics to the home, who can virtually consult with a physician to coordinate treatment and assess if escalation is necessary. While a growing body of literature indicates that CP programs can safely manage many patients in their homes without escalation to the emergency department (ED), few studies have attempted to describe which clinical and demographic variables are predictive of patient outcomes following a CP encounter. Even fewer studies have examined potential concerns of equity and, as a result, little data exists describing patterns in utilization and outcomes based on the variables of income, race, and housing status.

Aim: Our research aims to compare CP utilization patterns and post-deployment outcomes across subpopulations of homebound patients at the Mount Sinai Visiting Doctors Program (MSVD). In doing so, we hope to better understand which patients are best served by this intervention.

Methods: This retrospective cohort study examines 256 unique MSVD patients who utilized CP between March 2017 and May 2022. The linked datasets from CP and MSVD include patient demographics, health status, social history, and encounterspecific information. We manually reviewed each CP encounter to abstract additional demographic and clinical variables of interest, such as: ACP status, hospice status, chief complaint, vital signs, and chronic disease burden. Automatedly-abstracted outcome variables from the EHR, such as rates of transport to ED, hospital admission following transport and healthcare utilization within 3 and 30 days, were also manually validated.

Instances of data mismatch or coding uncertainty were escalated to a physician researcher for adjudication. A multivariate logistic regression to evaluate the association between patient characteristics and utilization and outcome measures is still ongoing.

Results: Between 2017-2022, CP was deployed 366 times for 256 unique, MSVDenrolled patients. 15.4% of all MSVD patients used CP at least once during this period, and of those CP-utilizers, 28.1% utilized the service more than once. The average age of CP-utilizers was 86.2 years old, which was significantly older than the average of non-CP utilizers at 82.4 (p<0.001). CP-ulitizers also tend to have higher chronic disease burden, with an average Elixhauser score of 4.7, compared to the non-CP ulitizer mean of 3.8 (p<0.001). With an average score of 5.1, repeat utilizers of CP have an even higher disease burden than those who used the service only once (p<0.001).

Hospital Readmissions After Epilepsy Surgery In Older Adults in the US – A Population-based Study Varun Ramanan Subramaniam, BSH and Churl-Su Kwon, MD MPH FRSPH Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, Institute for Health Care Delivery Science and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York

“Age of 65+ increases readmission risk for epilepsy surgery by 1.42 times. Medicare status, hospital size, median household income, comorbidity index are significant predictors for readmission.”

Purpose: The incidence of epilepsy is highest in those over 65 years of age. In 2018, Medicare patients accounted for 60.3% of the $57 billion spent on readmissions.

Understanding causes for readmission in persons with epilepsy post-surgery is important to implement future quality improvement efforts. Identifying preventable causes of readmissions in this population will optimize treatment strategies and reduce healthcare costs. We investigated causes and readmission rates after cranial or epilepsy related neurosurgery in older adults.

Methods: A retrospective cohort study was performed using the 2019 Nationwide Readmissions Database (NRD), a population-based dataset capturing over 18 million hospitalizations in the US. Individuals 65 years or older with epilepsy were identified using previously validated ICD-10-CM codes in the 2019 NRD. ICD-10 procedure codes were used to identify surgical procedures: resective surgery, vagus nerve stimulation (VNS), deep brain stimulation (DBS), responsive neurostimulation (RNS), Laser interstitial Thermal Therapy (LiTT), intracranial EEG (iEEG) and radiosurgery at index admission. The primary outcome of interest was 30-day readmission following neurosurgical intervention in epilepsy. Descriptive statistics were used to determine weighted frequencies and cause of 30-day readmission. Predictors of readmission in older adults with epilepsy were identified using logistic regression.

Results: Of the 29092 patients with epilepsy who underwent surgery, 1842 were readmitted within 30-days post-surgery (6.35% readmission rate). Epilepsy readmission rate for patients 65+ was 8.60% while readmission rate for age 18-64 was 6.2% (OR: 1.42; 95% CI: 1.28 – 1.59; p < 0.0001) Readmission proportions for patients aged 65 and older were as follows: 1) resective surgery: 9.87%, 2) VNS: n/a, 3) RNS/DBS: 6.25%, 4) LiTT: 10.53%, 5) iEEG: 8.50%, 6) Radiosurgery: 0%. Factors significantly associated with 30-day readmission in a preliminary model included hospital size, median household income, Medicare status, and Elixhauser comorbidity index Conclusions: Older patients undergoing epilepsy related neurosurgery have an 8.60% frequency of readmission within 30-days. Primary reasons for readmission and preventable measures must be determined using regression models. Further emphasis on patient safety targeting these modifiable factors and optimization of discharge planning ggin the older population would likely reduce the occurrence of readmissions.

Risk Factors in Pituitary Surgery Amongst Octogenarians: A Comparative Study with Younger Patients Undergoing Pituitary Surgery Vikram Vasan, BA, Jonathan Dullea, MPH, Muhammad Ali, BA, Daniel Chaluts, BS, Varun Subramaniam, BS, Joshua Bederson, MD, Katelyn Ferreira, MPH, Melissa Aldridge, PhD, Rainier Soriano, MD, Raj K. Shrivastava, MD. Icahn School of Medicine at Mount Sinai, New York, NY

“Octogenarians experienced higher in-hospital mortality rates. They also experienced a longer hospital length of stay. Therefore, operative selectivity and sufficient preoperative preparation is required to optimize outcomes for octogenarians with pituitary adenomas.”

Introduction: As life expectancy has increased, the number of elderly patients has grown rapidly. Pituitary adenomas (PA) are known to occur more frequently in patients of increasing age. PA is also a common postmortem finding, and autopsy studies of octogenarians found a 14% prevalence of PA. Few previous studies have looked at national differences in octogenarians undergoing pituitary surgery for PA compared to younger patients.

Objective: To evaluate trends in pituitary surgery and characterize differences in comorbidities, length of stay, and in-hospital mortality between octogenarians and younger patients 65-79 and <65 years old.

Methods: The 2016-2019 National Inpatient Sample (NIS) dataset was utilized as a data-source for this analysis. Hospitalizations for PA surgery were distinguished by the appropriate diagnosis related group (drg) code. Comorbidities were classified based on the Elixhauser Comorbidity Index mapping of ICD-10 codes. Patients were stratified to age categories as follows: 80+, 65-79, <65. 1-way ANOVA tests accounting for the sampling design, were performed to determine differences in comorbidity prevalence, inhospital mortality, and length of stay between the three groups.

Results: Over the 4 years, the number of pituitary surgeries performed per year has increased (13,355, 14,414, 16,320, 17,015). Octogenarians were significantly more comorbid compared to patients 65-79 and <65: congestive heart failure (8.0% vs. 5.3% vs. 2.0%;p<0.001), peripheral vascular disease (14.1% vs. 4.3% vs. 1.5%;p<0.001), pulmonary disease (10.3% vs. 6.3% vs. 5.8%;p<0.001), and renal disease (14.9% vs.

11.2% vs. 3.9%;p<0.001). Octogenarians also significantly experienced more in-hospital mortality (1.5% vs. 0.4% vs. 0.3%;p=0.001) in unadjusted analysis. Though not statistically significant, octogenarians experienced a longer mean length of stay, (4.37 vs. 3.84 vs. 3.97;p=0.117).

Conclusions: The known higher incidence of PA with older age and increase in the aging population may contribute to the trend of increased pituitary surgery per year. As expected with older age, octogenarians had significantly more comorbid conditions compared to patients 65-79 and <65. Octogenarians also experienced higher in-hospital mortality rates, calling for identification of predictive comorbidities for octogenarians and operative selectivity for these patients.

Home Care Clinicians’ Perspectives on Advance Care Planning for Patients who are at risk of becoming Incapacitated with No Evident Advance Directives or Surrogates: A Qualitative Study Chinmayi Venkatram, BA, Aviv Y. Landau, PhD, MSW, Bevin Cohen, PhD, MS, MPH, RN Icahn School of Medicine at Mount Sinai, New York, NY, School of Social Work and Data Science Institute, Columbia University, New York, NY, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

“Clinicians identified 2 major themes regarding advanced care planning (ACP) among patients at risk of becoming INEADS in the community.”

Introduction: Patients who are Incapacitated with No Evident Advance Directives or Surrogates (INEADS) are vulnerable to receiving care that is unaligned with their preferences and values as they are unable to advocate for themselves when they are critically ill. To provide ethical end-of-life care and prevent patients from becoming INEADS, it is important that we understand the barriers patients at risk of becoming INEADS face when engaging in advance care planning (ACP).

Objectives: This qualitative study aimed to elicit home care clinicians' perspectives on barriers and facilitators to completing advance directives and appointing surrogate decision makers among patients at risk of becoming INEADS who are receiving home care services following acute care hospitalization.

Methods: We recruited home care social workers and nurses from Visiting Nurse Services of New York who had the experience of working with patients who were INEADS or at risk of becoming INEADS. We conducted 1:1 semi-structured interviews with 7 community social workers and 5 community nurses from August 2021 to July 2022. Interviews ranged from 30 to 90 minutes. The interview guide asked clinicians to recall their experiences with patients at risk of becoming INEADS, specifically conversations about advanced care planning and end of life. An example is “Tell me about any conversations you had with this patient about creating advance directives or appointing healthcare proxies.” All of the interviews were recorded, transcribed, and coded by two independent coders using Dedoose software. Thematic analysis was used to analyze the data.

Results: Two central themes emerged from the interviews: (1) Clinician barriers, and (2) Patient barriers. Clinician barriers included lack of sufficient training on engaging in ACP conversations, lack of time, shifting the responsibility of having ACP conversations to other clinicians, and the emotional nature of ACP conversations. Patient barriers included denial of health status, lack of education, mistrust of the medical and/or legal system, lack of support systems, and declining mental status.

Conclusions: Our findings highlight key challenges in ACP for patients who are at risk for becoming INEADS. Home care may uniquely facilitate ACP conversations due to the longitudinal and close relationships it fosters between providers and patients, and therefore may be an appropriate setting for interventions that address barriers to ACP for patients with no social support. Structural barriers such as lack of time, lack of training, and lack of clarity regarding roles and responsibilities related to ACP among clinicians across the continuum of care appear to be important areas for intervention.

Risk Factors for Free Flap Complications for Head and Neck Cancer Defects in the Elderly Hannah Verma, BA and Mingyang Gray, MD, MPH Icahn School of Medicine at Mount Sinai, New York, NY

“Although 70% of elderly adults experienced 1 or more surgical site complications, age is not a risk factor for re-operation or flap failure. Recipient site infection, history of previous H/N cancer resection, and history of previous H/N radiation have an additive effect on flap failure incidence.”

Background: Free flap tissue transfer is a complicated and highly invasive procedure that is performed in patients for reconstruction of defects after resection of head and neck cancer. It is often performed in older patients given the prevalence of head and neck cancer in the elderly population. The purpose of this study is to define risk factors for post-operative complications of free flaps in older adults.

Methods: Between 2016 and 2017, 40 free flaps with microvascular transfer were performed at a single institution as part of head and neck reconstruction for cancer patients aged 60 and older. Electronic medical records of these were reviewed, and demographics, medical history, and surgical history were recorded and analyzed using ANOVA and multiple linear regressions. Comorbidity status was graded using the Adult Comorbidity Evaluation-27 Index (ACE-27).

Results: The average age of the cohort was 73 and the flap failure rate was 7.5%. Age was not independently associated with overall surgical site complications or flap failure, although it was significantly associated with recipient site dehiscence. High ACE-27 score was a significant risk factor for systemic infection. Recipient site infection, a history of prior head and neck cancer excision, and a history of prior head and neck radiation exposure have an additive effect on incidence of flap failure.

Conclusion: Older age is not a predictor of flap failure. Patients’ prior history of radiation therapy and previous cancer excision should be taken into account during post-operative monitoring of free flaps.

Frameworks For The Relationship Between HIV And Aging Among HIV Clinic Providers: A Qualitative Study Madeline Villalba, Rachel Schenkel MD, Abigail Baim-Lance PhD Icahn School of Medicine at Mount Sinai, New York, NY; Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; GRECC, James J. Peters VAMC, Bronx, NY

“One of the dominant provider framings: for older PLWH regularly taking ARVs, comorbidities are comparatively more difficult to manage than HIV and constitute the primary driver of pathophysiology and/or mortality

Introduction: As a result of advancements in antiretroviral therapy (ART), people living with HIV (PLWH) are living longer: it is estimated that 70% of PLWH in the US will be over the age of 50 by 2030, raising questions of what it means to age with HIV and how to care for these individuals most effectively. Existing scientific literature often describes this relationship in terms of accelerated aging, defined as earlier than expected agerelated decline which increases progressively. Examining providers’ underlying attitudes and framings of the relationships between aging, HIV and comorbidities could yield valuable insights that inform interventions to best serve this growing and aging population.

Objective: To examine how providers who care for older PLWH and other comorbidities conceptualize the relationship between HIV and aging.

Methods: This study is situated within a larger investigation of experiences of and barriers to comorbidity management for older PLWH. To explore how providers frame the relationship between HIV and aging, we conducted 11 semi-structured interviews between November 2019 and July 2020 with physicians, RN case managers, and administrators at two health systems’ HIV clinics in New York City and the Hudson Valley. Topic guides revolved around providers’ ideas about aging with HIV; their experiences providing care to older PLWH; and barriers to comorbidity care for older PLWH. Multiple researchers coded the interviews, developing a codebook through an iterative process before performing a thematic analysis of the data.

Results: Analysis revealed a range of explanatory models that involved physiological, pathophysiological, and psychosocial dimensions of aging and HIV. While providers did employ frameworks describing HIV as a driver of “accelerated” aging, they also commonly espoused the framing that, for older PLWH, comorbidities are comparatively more difficult to manage than HIV and constitute the primary driver of pathophysiology and/or mortality. Participants frequently indicated that patients’ non-HIV chronic conditions pose a greater threat to their health than HIV. Paradoxically, though, providers view patients as regarding HIV as more deadly and engaging with HIV care more diligently, which providers related to patients’ experiences of the long-term effects of the HIV/AIDS epidemic.

Conclusion: Providers’ framing of the clinical relationship between HIV, aging, and comorbidities as comorbidity-driven marks a departure from HIV-dominant forms of thinking, while complicating a straightforward narrative of accelerated aging. This finding has important implications for interdisciplinary care management and supports the development of an asset-based approach to encourage patient engagement with comorbidity care.

Racial Disparities in Treatment Presentation, Modality, and Complications in Older Adults With Oropharyngeal Cancer Dragan Vujovic BA, Daniel Dickstein MD, Yingtong Chen, Richard Bakst, MD Icahn School of Medicine at Mount Sinai, New York, NY, Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, 1184 Fifth Avenue, New York, NY 10029, United States

“Hispanic patients had the longest time between oropharyngeal cancer diagnosis and treatment. Black non-Hispanic patients received a surgical approach to treatment least frequently.”

Introduction: The rise of HPV infections has caused an increase in oropharyngeal squamous cell carcinoma (OPSCC), despite the decreasing rate of tobacco usage. This cancer had been associated with the middle-aged population (45-65 years); however, as the HPV+ population ages the cancer burden will likely shift to the elderly cohort.

Additionally, white patients are more likely to have HPV+ disease which had limited research studies on other racial and ethnic groups with OPSCC. To our knowledge, this is the first study to investigate racial and ethnic disparities in treatment presentation, type, and complications for older adults with OPSCC. Methods: In this retrospective cohort study, we identified 140 elderly patients, aged ≥ 65 years, from a database in the Department of Radiation Oncology. All patients were newly diagnosed and treated at Mount Sinai Hospital between 2007 and 2020 for nonmetastatic, OPSCC. Patients were categorized according to race as identified in the electronic medical record (white, black, other/not specified) and ethnicity (non-Hispanic, Hispanic, other/non-specified). We excluded individuals with recurrent disease, prior history of OPSCC, or previous radiation therapy to the head and neck. Time to treatment initiation respective to race was analyzed using a non-parametric test for continuous variables (Kruskal-Wallis) and Scheffé test for post-hoc analysis. Treatment modality, pain levels, and PEG placement, were compared across races using the χ2 test and Fisher’s exact test.

Results: Patients of Hispanic ethnicity had the longest time from diagnosis to treatment (47 days) compared to patients from other races/ethnicities (white non-Hispanic= 25 days, black non-Hispanic= 32 days, other race/ethnicity= 23 days). This was statistically significant when compared to white non-Hispanic patients (p=0.037). Additionally, there was a significant association between races/ethnicities and treatment modality used (p=0.0044). There were no significant differences between races/ethnicities in treatment complications including levels of acute pain (3 months after RT), subacute pain (3-12 months after RT), and late pain (12 months after RT), as well as in the frequency of percutaneous endoscopic gastrostomy tube placement.

Conclusion: This is one of the first studies to investigate the impact of race/ethnicity on OPSCC presentation, treatment modalities, and complications in older adults with oropharyngeal squamous cell carcinoma. Preliminary analysis shows differences between racial and ethnic groups in length of time between diagnosis and treatment as well as in types of treatment modalities used. Further research is needed to elucidate the etiology of these disparities.

PDE4DIP is implicated in Progressive Supranuclear Palsy Hadley Walsh Ressler, BA, Kurt Farrell, PhD, Kristen Whitney, PhD, Ana C. Pereira, MD, John F. Crary, MD, PhD Wakeforest School of Medicine, Winston-Salem, NC, Icahn School of Medicine at Mount Sinai, New York, NY

“Single-nuclei RNA sequencing reveals astrocytic subtypes enriched in progressive supranuclear palsy, which may elucidate key markers of tau aggregation in PSP.”

Introduction: Neurodegenerative diseases represent a monumental public health crisis, with misfolded accumulation of tau protein as a prominent pathological disturbance.

Tauopathies comprise many neurodegenerative diseases including Alzheimer disease (AD) and progressive supranuclear palsy (PSP). PSP is distinct from other tauopathies in that it is characterized by essentially pathognomonic tufted astrocytes, which occur distinctively in certain subcortical brain regions, especially the subthalamic nucleus (STN) among others. Understanding the molecular changes in astrocytes in PSP has the potential to elucidate the pathogenesis and show how it overlaps and differs from other tauopathies.

Methods: To understand the unique astrocytic changes in patients with PSP, we employed single-nuclei RNA sequencing (snRNA-seq) on human post-mortem brain tissue in a cohort of autopsy-confirmed PSP cases and sex and age-matched controls (n=3 each). All subjects were male with a median age of death of 70 years (range 64-73) and median post-mortem interval of 18.1 hours (range 11.7-43.8). Single-nuclei RNA sequencing was performed on fresh frozen tissue from the STN region and analyzed using Seurat in R, and normalized using SCTransform. Data was validated using publicly available bulk RNA-sequencing.

Results: 7 clusters were identified using 40 principal components. Within the astrocyte cluster, 691 genes were differentially expressed, with130 genes upregulated and 561 genes downregulated in cases compared to controls. From our subclustering analysis, 7 major astrocytic subpopulations emerged. 3 were expressed preferentially in the diseased samples.

Conclusion: Subcluster analysis of the stressed astrocytic cluster revealed 3 astrocyte subpopulations highly enriched in PSP. Many markers of these 3 subclusters were differentially expressed between cases and controls, and top gene candidates were examined in a replication cohort. In addition to being upregulated in PSP astrocytes and marking an enriched astrocytic subcluster, PDE4DIP was also differentially expressed and spliced in both brain regions of the replication cohort. Pending further validation, these results may provide important mechanistic insight into the cellular changes underlying tau aggregation in PSP, and may one day be a target for future therapeutics.

ACKNOWLEDGMENTS 2022 MSTAR Program RESEARCH MENTORS

Sumayya Ahmad, MD Claire Ankuda, MD, MPH, MSc Abigail Baim-Lance, PhD Richard Bakst, MD Paul J. Cagle, MD Bevin Cohen, PhD, MS, MPH, RN John F. Crary, MD, PhD Christian Escobar, MD Mingyang Gray, MD William Hung, MD Christopher Kellner, MD Churl-Su Kwon, MD Cameron McAlpine, PhD Katherine Ornstein, PhD Jennifer Reckrey, MD Raj Shrivastava, MD Cardinale Smith, MD, PhD Jonathan Ungar, MD

2022 MSTAR Program Faculty

Claire Ankuda, MD, MPH, MSc Alex Federman, MD, MPH Helen Fernandez, MD, MPH Emily Franzosa, DrPH Rosanne Leipzig, MD, PhD Diane Meier, MD Charles Mobbs, PhD R.Sean Morrison, MD Albert Siu, MD, MSPH Cardinale Smith, MD, PhD

2022 MSTAR Program Research Presentation Poster Discussants

Claire Ankuda, MD, MPH, MSc Kenneth Boockvar, MD, MS Bevin Cohen, PhD, MS, MPH, RN Emily Franzosa, DrPH Julia Frydman, MD Talia Swartz, MD, PhD Support Team

Brendan Bullen Jacklyn Njegric Jennifer Woo