Faculty Bibliography

BACKGROUND Herpes simplex virus-2 (HSV-2) affects nearly 1 in 5 adults in the United States. Complications such as viral hepatitis and dissemination are rare in immunocompetent hosts. In this report, we describe a case of viral hepatitis secondary to disseminated HSV-2 in an immunocompetent patient with recurrent fevers and elevated aminotransferases. CASE REPORT A 57-year-old man with a history of type 2 diabetes and hypertension was admitted with a right index finger lesion concerning for an abscess. He underwent successful incision and drainage and was started on ampicillin-sulbactam. On Day 2 of hospitalization, he developed recurrent fevers and elevated aminotransferases and inflammatory markers. An extensive infectious, rheumatologic, and malignancy workup were pursued without immediate findings. Imaging demonstrated cirrhotic morphology of the liver and splenomegaly, but lab markers were intact for liver synthetic function. On Day 7 of hospitalization, fever frequency decreased, and HSV-2 titers resulted, with positive IgM and negative IgG. He subsequently developed erythematous, raised lesions in multiple dermatomes. Nucleic acid amplification testing of biopsied lesions was positive for HSV-2, confirming viral hepatitis secondary to disseminated HSV-2. He was started on intravenous acyclovir and discharged on valacyclovir following improvement in symptoms. CONCLUSIONS We report a case of viral hepatitis secondary to disseminated HSV-2 in an immunocompetent host. Up to 25% of cases occur in immunocompetent hosts and many patients do not develop characteristic skin lesions. Early diagnosis and treatment of viral hepatitis secondary to disseminated HSV remains vital to minimize morbidity and mortality.

Background: Hospital readmissions put older adults at risk for health complications and increase health system costs. Research shows post-discharge calls to patients and caregivers help improve transitional care and reduce readmission risk. The NYU inpatient geri-atric consult service provides post-discharge calls, but a triage method was needed to target patients at greatest risk for readmission. The HOSPITAL score is a validated prediction model to identify patients at risk for potentially avoidable 30-day readmissions. We present the first known application of the HOSPITAL score to risk stratify patients for post-discharge calls and review its feasibility.
Method(s): The HOSPITAL score was calculated for patients 65 years and older admitted to a medicine team with a geriatrics consult starting October 2018. The HOSPITAL score stands for Hemoglobin, Oncology service, Sodium level, Procedure, Index Type, Admissions in the past year, and Length of stay. HOSPITAL score 0-4 is low risk (5.8%), 5-6 is intermediate risk (11.9%), and >= 7 is high risk (22.8%) for potentially avoidable 30-day readmissions. A post-discharge call within 1 week of discharge was provided to patients with a HOSPITAL score >= 5 deemed intermediate or high risk to address their current condition, care plan, and medication adherence.
Result(s): Preliminary data showed a total of 50 patients on the inpatient geriatric consult service with a HOSPITAL score calculated in October 2018 and 64% meeting criteria for post-discharge calls. The average age was 86 and the average HOSPITAL score was 5 with a range from 1-11. The total all-cause 30-day readmission rate to NYU was 14%. The low risk HOSPITAL score group included 18 patients with a 2% readmission rate while the intermediate or high risk HOSPITAL score group included 32 patients with a 12% readmission rate.
Conclusion(s): The HOSPITAL score was a feasible tool to risk stratify patients for post-discharge calls given its use of readily avail-able data and quick calculation. The HOSPITAL score provided an effective triage method for post-discharge calls on the inpatient geriat-ric consult service and may be applicable to other medical teams who seek to allocate their transitional care services

Background: Antineutrophil cytoplasmic antibodies (ANCA) associated vasculitis is a necrotizing vasculitis which predominantly affects the small vessels. This disease usually manifests at age 64-75 and accounts for about 19% of renal failure in patients age>80. It is treated with immunosuppressive therapy with high dose corticoste-roids, rituximab and cyclophosphamide. Case presentation: We treated an 85-year-old woman who was sent to the emergency department from her nephrologist for acute kidney injury secondary to suspected ANCA. She had a prior admis-sion where she was noted to have an acute kidney injury with positive Myeloperoxidase (MPO), ANCA and antinuclear antibody (ANA). She had had fatigue and dyspnea for a few months. On exam her vitals were stable and pertinent findings included decreased breath sounds and 2+ pitting edema. Her creatinine was 3.4 (baseline of 1.0), and urinalysis was positive for blood and protein. Her inflammatory markers were elevated, C3: 103 mg/dL, C4: 24 mg/dL; serologies for Hep C and B were negative. She received high dose steroids, cyclophosphamide and plas-mapharesis was initiated. She underwent a left renal biopsy revealing necrotizing and crescentic glomerulonephritis which was complicated by a retroperitoneal bleed. She was transferred to the medical intensive care unit where she underwent a left renal artery embolization but developed acute hypoxic respiratory failure due to fluid overload requiring a brief intubation. Her renal function continued to decline but she could not tolerate hemodialysis due to hemodynamic insta-bility. Two weeks into the hospital course, we initiated goals of care discussions and she was transitioned to hospice care. There was a delay in this transition due to language banier, complex family dynamic, and unclear expectations regarding outcomes of therapy within this specifie patient population.
Discussion(s): This is a unique presentation of ANCA associated vasculitis in an older patient. The treatment and work up resulted in a poor outcome. Upon review of literature, there has been implication that ANCA associated disease diagnosed in an older patient may actu-ally carry a terminal prognosis, as older frail patients may not tolerate diagnostic work up and treatment, especially given the high morbidity within the first year of diagnosis. We recommend early goals of care discussions in frail elderly patients which may provide a better quality of life

Case Presentation: An 86 yo male with history of chronic sinusitis, HTN and DM came to the hospital with cough, exertional dyspnea, and unintentional weight loss for 3 months. Initial chest CT showed right middle lobe consolidation and pulmonary nodules. He was treated for pneumonia and discharged home. He returned 8 days later and repeat chest CT showed increased size of bilateral nodu-lar consolidations, and new small subsegmental pulmonary emboli. Despite treatment, he developed acute respiratory failure requiring intubation, acute kidney injury and hypotension requiring vasopres-sors. Geriatrics was involved to assist with family meetings, to under-stand the patient's goals of care, and to set realistic treatment plans. Due to the patient's lack of capacity, his friend as healthcare proxy (HCP) along with patient's niece and nephew made the decision to not resuscitate. Given patient's history of chronic sinusitis with rapidly progressive lung involvement, Granulomatosis with polyangiitis (GPA) was suspected and lung biopsy result confirmed the diagnosis. A multidis-ciplinary meeting was held with patient's HCP, niece, nephew, geriat-rics and rheumatology to discuss treatment options. After much debate, the family decided to pursue a trial of aggressive treatment with rituxin. However, rituxin infusion was stopped when patient further decom-pensated. After patient's condition stabilized, he firmly expressed his wish to go home. Another family meeting was held and treatment was shifted to comfort care to align with the patient's goals of care.
Discussion(s): GPA is a systemic necrotizing vasculitis affect-ing small-and medium-sized vessels. The reported peak incidence of GPA is between ages 65 to 70 years. Upper airway disease is the most common presenting feature of GPA. Our patient presented with typical features of GPA at an atypical age. Although early initiation of treatment has shown to improve patient survival in the average population, there is lack of evidence in frail older adults. Questions regarding treatment side effect, outcome and disease prognosis should be explored with patients at the earliest point of care possible in order to set a realistic treatment plan. Establishing rapport with patient and family, and involving them in management is crucial for making treat-ment decisions that align with their goals of care

CONTEXT: Low-income seniors frequently have multiple chronic medical conditions for which they often fail to receive the recommended standard of care. OBJECTIVES: To test the effectiveness of a geriatric care management model on improving the quality of care for low-income seniors in primary care. DESIGN, SETTING, AND PATIENTS: Controlled clinical trial of 951 adults 65 years or older with an annual income less than 200% of the federal poverty level, whose primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community-based health centers. INTERVENTION: Patients received 2 years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. MAIN OUTCOME MEASURES: The Medical Outcomes 36-Item Short-Form (SF-36) scales and summary measures; instrumental and basic activities of daily living (ADLs); and emergency department (ED) visits not resulting in hospitalization and hospitalizations. RESULTS: Intention-to-treat analysis revealed significant improvements for intervention patients compared with usual care at 24 months in 4 of 8 SF-36 scales: general health (0.2 vs -2.3, P = .045), vitality (2.6 vs -2.6, P < .001), social functioning (3.0 vs -2.3, P = .008), and mental health (3.6 vs -0.3, P = .001); and in the Mental Component Summary (2.1 vs -0.3, P < .001). No group differences were found for ADLs or death. The cumulative 2-year ED visit rate per 1000 was lower in the intervention group (1445 [n = 474] vs 1748 [n = 477], P = .03) but hospital admission rates per 1000 were not significantly different between groups (700 [n = 474] vs 740 [n = 477], P = .66). In a predefined group at high risk of hospitalization (comprising 112 intervention and 114 usual-care patients), ED visit and hospital admission rates were lower for intervention patients in the second year (848 [n = 106] vs 1314 [n = 105]; P = .03 and 396 [n = 106] vs 705 [n = 105]; P = .03, respectively). CONCLUSIONS: Integrated and home-based geriatric care management resulted in improved quality of care and reduced acute care utilization among a high-risk group. Improvements in health-related quality of life were mixed and physical function outcomes did not differ between groups. Future studies are needed to determine whether more specific targeting will improve the program's effectiveness and whether reductions in acute care utilization will offset program costs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00182962.

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

OBJECTIVE: Those aged <65 in nursing homes (NHs) are substantially different from elderly residents. This study uses data gathered from the Resident Assessment Instrument's Minimum Data Set (MDS) to describe these relatively rare residents. STUDY DESIGN AND SETTING: The study uses MDS assessments of close to three-quarter million residents in nine states from 1994 to 1996. Residents are described within chronological age group (0-4, 5-14, etc.). Factor analysis is used to develop diagnostic clusters, and the prevalence of these clusters, functional problems, other conditions, and treatments is described for each group. RESULTS: Thirteen diagnostic clusters describe nearly 85% of all NH residents and highlight differences between age groups. Pediatric residents are substantially more physically and cognitively impaired than young adult residents, and have the highest case mix burden of care. The youngest population primarily has diagnoses related to mental retardation and developmental disabilities, young adults have the highest prevalence of hemi- and quadriplegia, while older residents are typified by increasing prevalence of neurological diagnoses. CONCLUSION: This study offers an initial description of NH residents <65. The prevalence of residents with unique conditions may suggest the need to modify the MDS assessment instrument.