Faculty Bibliography

INTRODUCTION: Gastrointestinal symptoms of SARS-CoV-2 infection common, but usually mild in severity. We describe a case of severe gastrointestinal bleeding (GIB) in a patient with a COVID-19 associated hyperinflammatory response. CASE DESCRIPTION/METHODS: A 25-year-old man with no significant medical history presented with 2 weeks of fevers, cough, dyspnea, and diarrhea. He tested positive for COVID-19 on nasopharyngeal PCR and imaging showed multifocal pneumonia. Initial labs were notable for markedly elevated CRP and ferritin, pancytopenia and acute kidney injury. He was treated for suspected COVID-19 associated hyperinflammatory syndrome with anakinra (5 mg/kg twice daily) and hydroxychloroquine. He became anuric requiring hemodialysis and renal biopsy complicated by retroperitoneal bleeding and emergent embolization of the left renal artery. He was intubated for worsening acute respiratory distress syndrome (ARDS) and developed hematemesis and melena leading to hemorrhagic shock. EGD showed diffuse inflammation, erosions and oozing from the esophagus to the proximal duodenum, non-bleeding gastric ulcers and petechiae (Figure 1A, B). Given clinical suspicion for COVID-19 associated macrophage activation syndrome (MAS)/ secondary hemophagocytic lymphohistiocytosis (sHLH), anakinra was restarted and intravenous immunoglobulin (IVIG, 1mg/kg) was given with clinical improvement. The patient continued to have melena. Repeat EGD showed severe esophagitis with large clots and sloughing mucosa, a focal 3-4 cm area of necrosis in the fundus, unresolved non-bleeding stomach ulcers and improved duodenitis from prior (Figure 1C, D). DISCUSSION: We describe a case of a young adult who developed catastrophic GIB as a complication of COVID-19. The pathogenesis of SARS-CoV2 infection is incompletely understood, but there is mounting evidence that it can induce a MAS/sHLH-like hyperinflammatory response. Several laboratory hallmarks of COVID-19 infection are also seen in MAS/sHLH including elevated CRP, ferritin, IL-1, and IL-6. This hyperinflammatory response can manifest in a variety of ways, including a Kawasaki-like presentation in pediatric patients responsive to IVIG and IL-1 antagonism. GIB is rare in COVID-19, occurring in 4% of cases, but can occur in up to 20% of MAS/sHLH cases. Clinicians should recognize that COVID-19 can provoke a MAS/sHLH-like hyperinflammatory syndrome with gastrointestinal involvement

Introduction/UNASSIGNED:As global travel becomes more prevalent, medical students may be asked to care for patients with unforeseen exposures. We developed a simulation where clerkship medical students interviewed and examined a patient with recent travel who presented with bloody diarrhea and abdominal pain and was diagnosed with amebic colitis. The students had the opportunity to develop a differential diagnosis and discuss the workup of the patient. Methods/UNASSIGNED:We divided students into two groups. Each group took a turn participating in the simulation while the other group observed. Students were expected to interview and examine the patient as well as treat any urgent findings and develop a differential diagnosis. After each simulation, we reconvened with both groups for a faculty-led debriefing session to discuss the learning objectives, including approaches to caring for a patient with diarrhea and the differential diagnosis and workup of bloody diarrhea. Results/UNASSIGNED:To date, five different groups of six to 12 students have completed this simulation. The module has been well received, and 100% of survey respondents have agreed that after completing the activity, they had a better understanding of how to approach a recent traveler with diarrhea and abdominal pain. Discussion/UNASSIGNED:While most medical students will not travel abroad for traditional global health experiences, many will encounter patients with recent travel or immigration and must therefore be prepared to treat diseases typically categorized as global health. We developed this simulation and successfully incorporated workup of a returning traveler into the medical school curriculum for clerkship students.

Background: Gastric cancer is the third most common cause of cancer death worldwide. In the US, gastric cancer incidence for Chinese Americans is nearly twice that for non-Hispanic whites. Cancer is the leading cause of death among Chinese New Yorkers who experience higher mortality for gastric cancer than other New Yorkers overall. The bacterium Helicobacter pylori (H. pylori) is the strongest risk factor for gastric cancer, and eradication of H. pylori through triple antibiotic therapy is the most effective prevention strategy for gastric cancer. Despite the elevated burden, there are no culturally and linguistically tailored evidence-based intervention strategies to address H. pylori medication adherence and gastric cancer prevention for Chinese Americans in NYC, a largely foreign-born (72%), limited English proficient (61%), and low-income (21% living in poverty) population.
Objective(s): The study objective was to develop and pilot a community health worker (CHW)-delivered linguistically and culturally adapted gastric cancer prevention intervention to improve H. pylori treatment adherence and address modifiable cancer prevention risk factors, including improved nutrition for low-income, LEP, Chinese American immigrants.
Method(s): We used a mixed methods and community-engaged research approach to develop and pilot the intervention curriculum and materials. Methods included: 1) a comprehensive scoping review of the peer-reviewed and grey literature on gastric cancer prevention programs and strategies targeting Chinese Americans; 2) 15 key informant interviews with gatekeepers and stakeholders serving the New York Chinese immigrant community to assess the knowledge and perception of H. pylori infection and gastric cancer among Chinese New Yorkers; and 3) pilot implementation of the collaboratively developed intervention with H. pylori-infected LEP Chinese immigrant participants (n=7).
Result(s): Study process findings and pilot results will be presented. Preliminary results indicate high patient- and community-level need and acceptability for the intervention. Baseline and 1-month post-treatment outcomes and survey data, qualitative data analysis of the CHW session notes, and key informant interviews will be presented.
Conclusion(s): Findings suggest that a CHW-delivered culturally adapted gastric cancer prevention intervention can result in meaningful health information and treatment adherence for at-risk, low-income Chinese immigrant communities. Study findings are being applied to inform a randomized controlled trial being implemented in safety net hospital settings

BACKGROUND:System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP. AIM/OBJECTIVE:To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE. METHODS:For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey. RESULTS:." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice. CONCLUSION/CONCLUSIONS:OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.