Publications
Prediction of COVID-19 Social Distancing Adherence (soda) on the US County-Level
Myles Ingram, Ashley Zahabian, & Chin Hur
From Unacast Social Distancing Dataset between March 16, 2020 - April 24, 2020
SoDA model predicted social distancing scores with 91.6% accuracy
Red is negative correlation with SoDA and blue is positive correlation
From Unacast Social Distancing Dataset between March 16, 2020 - April 24, 2020
We used social distancing adherence (SoDA) estimated from mobile phone data and population-based demographics/statistics of 3054 counties in the United States to determine which demographics features correlate to adherence on a countywide level. 45 predictor features were evaluated using univariable regression to determine their level of correlation with SoDA and used to form a prediction model. Persons who work from home prior to the COVID-19 pandemic and owner-occupied housing unit rate were the most positively correlated and negatively correlated features to SoDA, respectively. Our results indicate that economic features, health features, and other features, such as political affiliation, race, and the time since the first case/death, impact SoDA on a countywide level.
Cost‐effectiveness of neoadjuvant FOLFIRINOX versus gemcitabine plus nab‐paclitaxel in borderline resectable/locally advanced pancreatic cancer patients.
Myles Ingram, Brianna Lauren, Yoanna Pumpalova, Jiheum park, Francesca Lim, Susan Bates, Fay Kastrinos, Gulam Manji, Chunh Yin Kong, Chin Hur
The 2020 National Comprehensive Cancer Network guidelines recommend neoadjuvant FOLFIRINOX or neoadjuvant gemcitabine plus nab-paclitaxel (G-nP) for borderline resectable/locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC). The purpose of our study was to compare treatment outcomes, toxicity profiles, costs, and quality-of-life measures between these two treatments to further inform clinical decision-making. We developed a decision-analytic mathematical model to compare the total cost and health outcomes of neoadjuvant FOLFIRINOX against G-nP over 12 years. Our modeling analysis suggests that FOLFIRNOX is the cost-effective treatment compared to G-nP for BR/LA PDAC despite having a higher cost of total care due to TRAE costs. Trial data with sufficient follow-up are needed to confirm our findings.
Boxes represent health states, circles represent temporary states. Arrows denote transitions
G-nP, Gemcitabine plus nab-paclitaxel; QALYs, quality-adjusted life-years
Boxes represent health states, circles represent temporary states. Arrows denote transitions
Gene-Specific Variation in Colorectal Cancer Surveillance Strategies for Lynch Syndrome
Fay Kastrinos, Myles Ingram, Elisabeth Silver, Aaron Oh, Monica Laszkowska, Anil Rutsgi, Chin Hur
Strategies are on efficiency frontier. (A) MLH1, (B) MSH2, (C) MSH6, (D) PMS2. CSY, colonoscopy.
(A) MLH1, (B) MSH2, (C) MSH6, (D) PMS2. QALYs, quality-adjusted life-years.
Arrows denote transitions
Strategies are on efficiency frontier. (A) MLH1, (B) MSH2, (C) MSH6, (D) PMS2. CSY, colonoscopy.
Lynch syndrome is associated with pathogenic variants in 4 mismatch repair (MMR) genes that increase lifetime risk of colorectal cancer. Guidelines recommend intensive colorectal cancer surveillance with colonoscopy every 1–2 years starting at age 25 years for all carriers of Lynch syndrome, regardless of gene product. We constructed a simulation model to analyze the effects of different ages of colonoscopy initiation and surveillance intervals for each MMR gene (MLH1, MSH2, MSH6, and PMS2) on colorectal cancer incidence and mortality, quality-adjusted life-years, and cost. The model supports recommendations for intensive surveillance of patients with Lynch syndrome–associated variants in MLH1 or MSH2. However, for patients with Lynch syndrome–associated variants of MSH6 or PMS2, later initiation of surveillance at 35 and 40 years, respectively, and at 3-year intervals, can be considered.
Cost-effectiveness of universal screening for germline BRCA mutations in metastatic pancreatic cancer
Myles Ingram, Yoanna Pumpalova, Jiheum Park, Francesca Lim, Jennifer Ferris, Susan Bates, Gulam Manji, Chung Yin Kong, Chin Hur
Germline BRCA1/2 mutations (gBRCAm) increase the risk of pancreatic ductal adenocarcinoma (PDAC). The NCCN 2022 guidelines recommend genetic testing for gBRCAm in all newly diagnosed metastatic PDAC patients. Previously, gBRCAm screening in PDAC patients was done selectively for patients with a familial history of PDAC. We developed a decision-analytic mathematical model comparing the cost and health outcomes of universal gBRCAm screening against selective gBRCAm screening. Universal gBRCAm screening was found to be the optimal strategy compared to selective gBRCAm screening.
QALYs, quality-adjusted life years.
Left: universal screening arm. Right: selective screening arm.
Deep Reinforcement Learning for Optimal Critical Care Pain Management with Morphine using Dueling Double-Deep Q Networks
Daniel Lopez-Martinex, Patrick Eschenfeldt, Sassan Ostvar, Myles Ingram
Patient physiological data and pain scores, along with morphine administrations.
Histogram of physician against dueling DDQN actions for those instances in which both physician and dueling DDQN recommended administration of morphine
Histogram of morphine administration doses (top) and time between administrations (bottom) for both physicians (left) and the dueling DDQN algorithm (right).
Patient physiological data and pain scores, along with morphine administrations.
Opioids are the preferred medications for the treatment of pain in the intensive care unit. While undertreatment leads to unrelieved pain and poor clinical outcomes, excessive use of opioids puts patients at risk of experiencing multiple adverse effects. In this work, we present a sequential decision making framework for opioid dosing based on deep reinforcement learning. It provides real-time clinically interpretable dosing recommendations, personalized according to each patient's evolving pain and physiological condition. We focus on morphine, one of the most commonly prescribed opioids. To train and evaluate the model, we used retrospective data from the publicly available MIMIC-3 database. Our results demonstrate that reinforcement learning may be used to aid decision making in the intensive care setting by providing personalized pain management interventions.
Prevalence of Clostridioides difficile and Other Gastrointestinal Pathogens in Patients with COVID-19
Monika Laszkowska, Judy Kim, Adam Faye, Myles Ingram, Han Truong, Elisabeth Silver, Benjamin May, William Greendyke,
Jason Zucker, Benjamin Lebwohl, Chin Hur, Daniel Freedberg
Gastrointestinal symptoms are common in patients with COVID-19, but prevalence of co-infection with enteric pathogens is unknown. This study assessed the prevalence of enteric infections among hospitalized patients with COVID-19. We evaluated 4973 hospitalized patients ≥ 18 years of age tested for COVID-19 from March 11 through April 28, 2020, at two academic hospitals. Among 4973 hospitalized individuals, 311 were tested for gastrointestinal infections (204 COVID-19 positive, 107 COVID-19 negative). Patients with COVID-19 were less likely to test positive compared to patients without COVID-19. This trend was driven by lower rates of non-C.difficile infections , but not C. difficile infection. On multivariable analysis, infection with COVID-19 remained significantly associated with lower odds of concurrent GI infection, again driven by reduced non-C.difficile infection. Pathogens aside from C.difficile do not appear to be a significant contributor to diarrhea in COVID-19 positive patients.
Trends in stool testing and results over time during COVID-19 pandemic (2/1/2020–4/11/2020) for C. difficile testing
Trends in stool testing and results over time during COVID-19 pandemic (2/1/2020–4/11/2020) for gastrointestinal PCR testing
Trends in stool testing and results over time during COVID-19 pandemic (2/1/2020–4/11/2020) for C. difficile testing
Disease course and outcomes of COVID-19 among hospitalized patients with gastrointestinal manifestations
Monika Laszkowska, Adam Faye, Judith Kim, Han Truong, Elisabeth Silver, Myles Ingram, Benjamin May, Benjamin Ascherman, Logan Bartram, Jason Zucker, Magdalena Sobieszczyk, Julian Abrams, Benjamin Lebwohl, Daniel Freedberg, Chin HuR
Survival Analysis among 2804 COVID-19 positive patients, comparing 30-day mortality from time of admission.
Time-to-event analysis from symptom onset to discharge among the 769 patients who survived to discharge and had known time of symptom onset.
Time-to-event analysis from hospitalization to discharge.
Survival Analysis among 2804 COVID-19 positive patients, comparing 30-day mortality from time of admission.
In this study we characterize the disease course and severity of COVID-19 among hospitalized patients with gastrointestinal manifestations in a large, diverse cohort from the Unites States. This retrospective study evaluated hospitalized individuals with COVID-19 between March 11 and April 28, 2020 at two affiliated hospitals in New York City. We evaluated the association between GI symptoms and death, and also explored disease duration, from symptom onset to death or discharge. Of 2804 patients hospitalized with COVID-19, the 1,084 (38.7%) patients with GI symptoms were younger and had more co-morbidities compared to those without GI symptoms. Individuals with GI symptoms had better outcomes, with a lower likelihood of intubation and death, after adjusting for clinical factors. Hospitalized patients with GI manifestations of COVID-19 have a reduced risk of intubation and death, but may have a longer overall disease course driven by duration of symptoms prior to hospitalization.
Cost-Effectiveness Analysis of Biomarker-Guided Treatment for Metastatic Gastric Cancer in the Second-Line Setting
Brianna Lauren, Sassan Ostvar, Elisabeth Silver, Myles Ingram, Aaron Oh, Lindsay Kumble, Monika Laszkowska, Jacqueline Chu, Dawn Hershman, Gulam Manji, Alfred Neugut, Chin Hur
The 5-year survival rate of patients with metastatic gastric cancer (GC) is only 5%. However, trials have demonstrated promising antitumor activity for targeted therapies/immunotherapies among chemorefractory metastatic GC patients. We constructed a Markov decision-analytic model using clinical trial data. Our model compared pembrolizumab monotherapy and ramucirumab/paclitaxel combination therapy for all patients and pembrolizumab for patients based on MSI status or PD-L1 expression. The most effective strategy was pembrolizumab for MSI-H patients and ramucirumab/paclitaxel for all other patients, Biomarker-based treatments with targeted therapies/immunotherapies for second-line metastatic GC patients substantially improve unadjusted and quality-adjusted survival but are not cost-effective at current drug prices.
Treatment strategies with all patients receiving the same treatment.
Personalized treatment based on biomarker status. Biomarkers are programmed death ligand - 1 (PD-L1) or high microsatellite instability (MSI-H)
This tornado diagram illustrates the results of a one-way sensitivity analysis of key input parameters. The ranges of incremental cost-effectiveness ratios (ICERs) for the MSI-H: PEM/MSS: PAC strategy compared to the PAC for all patients’ strategy are plotted
Treatment strategies with all patients receiving the same treatment.
Where have all the emergencies gone? The impact of the COVID-19 pandemic on obstetric and gynecologic procedures and consults at a New York City hospital
Emily Spurlin, Esther Han, Elisabeth Silver, Benjamin May, Nicholas Tatonetti, Myles Ingram, Zhezhen Jin, Chin Hur, Arnold Advincula, Hye-Chun Hur
This figure shows the total volume of OB-GYN consults per week over the course of the early coronavirus disease 2019 pandemic. The dotted line indicates the date of the mandated ban on elective cases. ED = emergency department; GYN = gynecology; OB = obstetric.
This figure shows the total volume of OB-GYN surgeries per week over the course of the early coronavirus disease 2019 pandemic. The dotted line indicates the date of the mandated ban on elective cases. GYN = gynecology; OB = obstetric.
This figure shows the total volume of OB-GYN consults per week over the course of the early coronavirus disease 2019 pandemic. The dotted line indicates the date of the mandated ban on elective cases. ED = emergency department; GYN = gynecology; OB = obstetric.
The purpose of this study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical volume and emergency department (ED) consults across obstetrics-gynecology (OB-GYN) services at a New York City hospital. The volume and types of surgeries and ED consults were compared before and after the COVID-19 moratorium. During the pandemic, the average weekly volume of ED consults and gynecology (GYN) surgeries decreased, whereas obstetric (OB) surgeries remained stable. The proportions of OB-GYN ED consults, GYN surgeries, and OB surgeries relative to all ED consults, all surgeries, and all labor and delivery patients were 1.87%, 13.8%, 54.6% in the pre–COVID-19 time frame (February 1–March 15) vs 1.53%, 21.3%, 79.7% in the COVID-19 time frame (March 16–April 15), representing no significant difference in proportions of OB-GYN ED consults and GYN surgeries before and during COVID-19 This study highlights how the pandemic has affected the ways that patients in OB-GYN access and receive care. Institutional policies suspending elective surgeries during the pandemic decreased GYN surgical volume and affected the types of cases performed.