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Managing Asthma with Your Smartphone

Montefiore allergy and immunology specialist Sunit Jariwala, MD, is betting on technology to help patients manage their asthma in between doctor’s visits.

Research Stories

Elucidating Hepatitis C virus-related knowledge, attitudes, behaviors, and transmission networks among people who inject drugs (PWID’s) in Kenya – Dr. Matthew Akiyama

Hepatitis C virus (HCV) is a global pandemic with an estimated 71 million individuals infected worldwide. Direct acting antiviral therapies now available with high cure rates and few side effects; however, global access remains a challenge. The World Health Organization (WHO) has outlined global HCV elimination targets to be enacted by 2030, but few nations are on target to achieve this goal.

Sub-Saharan Africa is an important geographic region since it is home to a large number of people living with HCV. People who inject drugs (PWID) are central to HCV elimination efforts since they are the group with the highest HCV prevalence in most countries and may have ongoing risk factors for HCV transmission. Yet, little is known about PWID in sub-Saharan Africa. Comprising a growing proportion of HCV and HIV transmissions in the region, PWID have lacked access to addiction treatment and prevention services such as needle and syringe exchange and faced persecution and stigma from police and communities.

With the goal of establishing collaborative partnerships, Dr. Matthew Akiyama undertook a project funded by the Einstein Global Health Center to 1) elucidate Hepatitis C virus (HCV)-related knowledge, attitudes, behaviors, and transmission networks among PWID in Kenya, and 2) provide HCV treatment support for emerging HCV providers in the Nairobi and the coastal regions of Kenya.

Household air pollution (HAP) and cancer – Dr. Dean Hosgood

Solid fuels (i.e., coal, wood) are often used for heating and cooking in unventilated situations within the home (i.e., rooms without a vent or stoves without a chimney), leading to substantial household air pollution (HAP) exposures, including to known carcinogens. HAP exposure is (1) experienced by ~3 billion people, (2) a leading cause of disease, and (3) causes >3.5 million deaths per year globally. Dr. Hosgood is recognized as one of the leading researchers in the world with respect to cancer risks attributed to HAP. He has published the definitive systematic reviews and meta-analyses evaluating the risk of lung cancer associated with HAP exposures. Some of the strongest literature evaluating lung cancer susceptibility attributed to HAP is based on studies in Xuanwei, China. Dr. Hosgood’s analysis of the Xuanwei residents’ coal burning has led to seminal findings on lung cancer and HAP. In a retrospective cohort study, Dr. Hosgood found that improving stoves to mitigate HAP exposure is associated with significant reductions in lung cancer mortality, even after accounting for exposure to second hand tobacco smoke. Largely influenced by this body of literature from Xuanwei, the International Agency for Research on Cancer (IARC) has concluded that indoor emissions from household combustion of coal are a lung carcinogen (Group 1).

A major focus of Dr. Hosgood’s research has been to elucidate the complex mechanisms underlying HAP-induced tumorigenesis. In case-control studies conducted in Xuanwei, Dr. Hosgood has observed that genetic variation in candidate immune, cell cycle, and telomere maintenance genes was associated with lung cancer risk. Dr. Hosgood and colleagues, though their research within the Female Lung Cancer Consortium in Asia (FLCCA), have also shown that lung cancer in nonsmokers (LCINS: ~25% of all lung cancer cases; 53% of those in women, 15% of those in men) has unique genetic risk factors when compared to lung cancer cases attributed to smoking tobacco. Notably, genome-wide association studies (GWAS), consisting primarily of smokers, identified susceptibility variants on 5p15 and 15q25, providing insights into the underlying mechanism(s) of lung cancer susceptibility. Dr. Hosgood and colleagues’ have shown that the nicotine receptor coding region on 15q25 was not associated with LCINS, and they have identified novel susceptibility loci, including HLA Class II, which were not associated with lung cancer risk (i.e., p≤10-8) in the GWAS consisting primarily of smokers. The risk of lung cancer associated with coal exposure varied with these novel loci, providing evidence that genetic variation in HLA Class II and TP63 may modify the association between HAP and lung cancer risk (i.e., gene x environment interaction). In addition to genetic variation, Dr. Hosgood was the first to report that populations with substantial HAP exposures experience unique tumor-based EGFR and KRAS mutations patterns, as well as novel respiratory tract microbiota profiles, compared to other urban and rural populations.

Recently, Dr. Hosgood’s research has expanded into lung cancer-attributed to HAP in populations with low-dose, chronic exposures such as those in rural regions in the Northern United States, parts of Africa, and Chile. Dr. Hosgood has also built a global consortium of 13 prospective cohorts (HAPCO: Household Air Pollution Consortium) that have site- and disease-specific mortality and solid fuel use data, for a combined sample size of 587,257 participants across 8 countries, to date. HAPCO provides a novel opportunity to assess the risks associated with cancers other than lung as well as non-malignant respiratory and cardiometabolic outcomes, for which prospective epidemiologic research is limited.

Outreach Stories

Montefiore Hepatitis B Starfish Program – Dr. Samuel Sigal

More than 75 million people with HBV infection currently live on the African continent, and 10-12% of all people have the infection in West Africa. The West African community is vibrant and rapidly growing in the Bronx, and approximately 120,000 people from West Africa call the Bronx home.

The majority of infections in West Africa occur from mother to baby at the time of birth, but transmission and infection can easily be prevented through screening with a simple blood test and vaccination. Effective therapy for patients with active infection is available. Untreated infection commonly leads to severe liver disease and cancer. Treatment can prevent both the development of severe liver disease and cancer. Unfortunately, most West Africans in the Bronx are not being screened for the infection, vaccinated, and treated for this potentially deadly infection.

Because of the importance of West Africans to the Montefiore and Bronx community, the Liver Disease Division at Montefiore Medical Center is conducting an outreach program for Hepatitis B awareness. The first stage of the program is education. On-site educational seminar at church, mosque, community organization have been conducted, reaching approximately 3000 people date. Beginning November 2018, we have also offer free testing.

We have named our program the “Montefiore Hepatitis B Starfish Program” based on a story in which a man was observed throwing starfish which had washed ashore back into the ocean so that they would not dry out and die. When confronted with the observation that there were too many for him to make a difference, “He smiled as he picked up the next starfish. Hurling it far into the sea he said, "It makes a difference for this one." We realize that our task is enormous. If we can prevent only one newborn from getting infected, however, we would have potentially saved the world for that child, and we will consider our efforts a success.

3D printing as a solution to the shortage of durable medical equipment (DME) in developing countries – Dr. Stephanie Rand

Through our 3D printing program, we aim to provide a comprehensive solution to the shortage of durable medical equipment (DME) in developing countries. With with minimal initial technology savvy, we aim to train local medical communities in specific developing countries to produce and customize DME. In 2018, we delivered the first 3D printer to the English-speaking Caribbean, to the Sir John Golding Rehabilitation Centre in Kingston, Jamaica. Along with the printer, we provided CAD files with easily customizable designs for DME costing between $5 to $260 when printed (opposed to $50 to $20,000 for similar standard production DME models), and training. With a small markup built into the price that the local medical center will charge for these services, profits can be reinvested into providing subsidized products and supporting community driven development. Within the first week, the Rehabilitation Centre delivered over 10 orthotics printed on site on demand for patients.

International NRP (Neonatal Resuscitation Program) training in the Caribbean region – Dr. Orna Rosen

Two neonatologist from the Children Hospital at Montefiore and one pediatrician that was trained in the USA who is a Grenadian citizen travelled to Grenada as part of The International NRP Initiative for the tri-island state of Grenada, Carriacou and Petite Martinique . The above physicians taught an NRP course that was held from Monday, May 22nd until Friday, May 26th 2017.

During the course ten senior health care professionals were trained to be NRP Instructors and one hundred health care professionals were trained to be NRP providers. This included staff from the Grenada General Hospital, Princess Alice Hospital and rural Birthing Centers in Grenada, The Princess Royal Hospital in Carriacou and Birthing Centers in Petite Martinique.

The purpose of this course was to make sure that midwives and nurses can use an ambu bag giving positive pressure ventilation in case of need which is a lifesaving procedure. We trained doctors to become NRP instructors that they can maintain the skills and knowledge of the other medical providers by repeating the course periodically. We are intended to go in the fall to teach NRP and medical emergency procedures in the newborn.

Featured Stories

Managing Asthma with Your Smartphone

Montefiore allergy and immunology specialist Sunit Jariwala, MD, is betting on technology to help patients manage their asthma in between doctor’s visits.

In an effort to convince patients to stick with guideline-based recommendations, Dr. Jariwala and his colleagues have devised ASTHMAXcel, an interactive and personalized smartphone app that combines asthma education with games that challenge the user’s asthma knowledge and encourage healthier behaviors.

“We’ve ‘gamified’ asthma management,” says Dr. Jariwala, an associate professor of medicine at Einstein and the lead adult allergist/immunologist at the Montefiore Asthma Center.

The app, which is available for both Android and iOS phones and tablets, gives patients an ever-present virtual assistant to teach them about asthma, including when and how to use their asthma control and rescue medications and how to minimize exposure to possible triggers. A future version of the app will include personalized text messages.