Faculty Bibliography

Introduction: Gastrointestinal follicular lymphoma (FL) is a rare, but distinct extra-nodal variant of non-Hodgkin's lymphoma. Its incidence has grown outside of known genetic inheritance, due to epigenetic mutations from increased toxic exposure to benzene and pesticides, expanded life spans, and widespread standardized screening efforts. Diagnosis is by colonoscopy-obtained tissue staining and can be missed if alternative CRC screening methods are used in lieu. Case Description/Methods: A 54-year-old Ukranian male with a past medical history of HTN and GERD came in for an asymptomatic screening colonoscopy. One 8 mm polyp in the transverse colon was positive for FL. IHC staining demonstrated atypical small B-lymphocytes, positive for CD451, CD201, PAX51, CD101, and BCL-21. Bloodwork, including LDH, beta-2-microglobulin, were normal. A staging PET scan was negative indicating an isolated disease within the colonic polyp. As the patient was asymptomatic, no further treatment was indicated and the patient was scheduled for regular follow-up.
Discussion(s): GI FL is a B-cell lymphoma with an incidence slightly higher in women and a median age of 65. Occurrence outside of the bone marrow, spleen, or liver is uncommon. Descending incidence within the GI tract is the duodenum, ileum, stomach, and rarely colon. Within the colon, it presents asymptomatically. Definitive diagnosis is by a colonoscopy-obtained tissue staining. Colonoscopy adherence is generally high after the age of 65, given the median age of colorectal cancer incidence is 67 and the availability of Medicare coverage. However, if alternatively approved screening modalities are utilized such as the gFOBT, FIT, FIT-DNA, or flexible sigmoidoscopy, then the diagnosis of a FL might be missed until either mass or metastatic effects become apparent. Diagnostic work-up includes IHC staining for CD-20, CD-36, a follicular cell pattern, increase in B cells, bcl-2, bcl-6, and a 14:18 translocation by FISH or PCR (85% of cases). Investigation into a primary NHL, leukemia, or MDS includes flow cytometry, bone marrow biopsy, and cytogenetics. Increased LDH indicates rapid progression with staging done by PET or pan CTs. Colonic FL have a 10-year survival rate of 80% and an indolent course, so treatment is only indicated if the patient is symptomatic. Treatment for stage 1 is radiation, stages 2-4 is CHO P-R chemotherapy. Adjuvant or refractory treatments include anti-CD20 monoclonal antibodies, such as rituximab or obinutuzumab.

In 2021, Delta has become the predominant SARS-CoV-2 variant worldwide. While vaccines effectively prevent COVID-19 hospitalization and death, vaccine breakthrough infections increasingly occur. The precise role of clinical and genomic determinants in Delta infections is not known, and whether they contribute to increased rates of breakthrough infections compared to unvaccinated controls. Here, we show a steep and near complete replacement of circulating variants with Delta between May and August 2021 in metropolitan New York. We observed an increase of the Delta sublineage AY.25, its spike mutation S112L, and nsp12 mutation F192V in breakthroughs. Delta infections were associated with younger age and lower hospitalization rates than Alpha. Delta breakthroughs increased significantly with time since vaccination, and, after adjusting for confounders, they rose at similar rates as in unvaccinated individuals. Our data indicate a limited impact of vaccine escape in favor of Delta's increased epidemic growth in times of waning vaccine protection.

Introduction: The objective structured clinical examination (OSCE) has been shown to not only assess but also improve the performance of trainees. Our group has previously demonstrated the benefits of OSCEs to assess gastroenterology (GI) fellows. We have successfully assessed performance across numerous milestones. Typically, OSCEs are held in person, however the COVID-19 pandemic has precipitated the need for virtual learning. We accordingly transitioned to a virtual zoom OSCE (Z-OSCE) and evaluated trainees' perception of this program.
Method(s): Fourteen first- and second-year GI fellows from five programs across multiple states participated in a four-station virtual OSCE on Zoom. Afterwards, participants answered a survey to share their perspectives and provide feedback. Learners were asked to rate the usefulness of the virtual OSCE and compare it to other in-person and virtual educational modalities. These questions were rated on a 10-point Likert scale (Figure 1). Additionally, free-text responses regarding any aspect of the OSCE were evaluated for comments on the virtual format.
Result(s): In comparing the usefulness of the virtual OSCE to other in-person modalities, trainees rated it a mean of 7.15 (range 5-10), and 31% of respondents rated it a 9 or 10. Trainees rated the virtual OSCE compared to other virtual learning modalities a mean of 8.15 (range 5-10), and 43% rated it 9 or 10. When asked whether they would recommend this OSCE as a training tool, the trainees gave a mean recommendation of 7.77 (range 5-10), and 38% gave a 9 or 10. General feedback regarding the nature of the OSCE noted the virtual format worked well, orientation to the format was important and could be improved by providing it in an email beforehand.
Conclusion(s): Virtual learning has been necessary during the COVID-19 pandemic, and it is crucial to evaluate the value of the novel Z-OSCE. Participants found the virtual OSCE may be more useful than in-person learning modalities and it compared favorably to other virtual learning modalities. One benefit of this modality was the easier inclusion of fellows from geographically disparate areas negating the need to travel for this program, a benefit given lack of universal access to simulation using standardized patients. To improve future exams, orientation prior to the day of the OSCE may improve trainees' experiences.

Introduction: The objective structured clinical examination (OSCE) is a common educational strategy to assess interpersonal skills and knowledge gaps, and we have previously shown its benefits in inflammatory bowel disease (IBD) education. As a result of the COVID-19 pandemic, there has been explosive growth in telehealth. Currently, we lack methods to teach and evaluate trainees' related skillset and no telehealth-specific milestones exist. We assessed the telehealth proficiency of gastroenterology (GI) fellows as part of an annual IBD OSCE over Zoom (Z-OSCE).
Method(s): Seven GI fellows from four programs participated in Z-OSCE featuring four clinical scenarios. We used previously validated OSCE checklists to assess the fellows' performance in IBDspecific cases. Telehealth communication skills were also assessed. One of the scenarios required the trainees to conduct a televisit focusing on preventative care for a Crohn's disease patient based on the ACG guideline. Checklists were scored on a 3-point Likert scale by the Standardized Patient (SP).
Result(s): The telehealth behavioral anchored checklist items included: maintaining proper computer etiquette, use of non-verbal communication and positioning to optimize the encounter, optimized technical aspects, and exhibiting comfort and confidence with the virtual platform. In these domains 5 or 6 (out of 7) fellows received 3 points. In contrast less than half of the fellows asked questions of the SP to make sure they understood or acknowledged emotion, and 3 out 7 fellows did not make appropriate eye contact. Despite high performance in the telehealth aspects of the encounter, the SP did not fully recommend fellows for their communication skills without reservations to friends/ family, with all fellows receiving 2 points.
Conclusion(s): Telehealth has quickly become a fixture of our profession, and merits educational opportunities and assessment to improve clinicians' competency, as it will likely outlast the COVID- 19 pandemic. To our knowledge, this is the first OSCE designed to assess telehealth performance in the delivery of IBD care. Z-OSCEs can play a unique role in simulating realistic telehealth visits and this pilot program helps us identify future educational needs. Assessment of fellows' performance during this virtual program can provide an opportunity for learning, growth and reflection as well as prepare trainees for future patient encounters

The onset of the coronavirus 2019 (COVID-19) pandemic prompted unique public health measures including stay-at-home (SAH) orders that provoked altered dietary and exercise patterns and may have affected medication access and use. Although these impacts have the potential to influence lipid levels, little is known of the consequences of COVID-19 SAH on objective atherosclerotic cardiovascular disease (ASCVD) risk factors. We performed a patient-level analysis of the primary measure of atherogenic lipid-associated risk, nonHDL-C during the 2020 SAH period and the same time period in 2019, in patients within a large health system in New York City. We found that women and racial and ethnic minority group members were more likely to exhibit substantial worsening of atherogenic lipid profile (≥38 mg/dL increase in nonHDL-C) during this period. Our results suggest that the pandemic and subsequent public health measures may have produced unintended negative consequences on already at-risk groups.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

OBJECTIVES/OBJECTIVE:Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. CASE PRESENTATION/METHODS:This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1-2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. CONCLUSIONS:Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

INTRODUCTION/BACKGROUND:The attitudes of healthcare staff towards patients' safety, including awareness of the risk for adverse events, are significant elements of an organization's safety culture. AIM OF RESEARCH/UNASSIGNED:To evaluate nurses and physicians' attitudes towards factors influencing hospitalized patient safety. MATERIALS AND METHODS/METHODS:The research included 606 nurses and 527 physicians employed in surgical and medical wards in 21 Polish hospitals around the country. The Polish adaptation of the Safety Attitudes Questionnaire (SAQ) was used to evaluate the factors influencing attitudes towards patient safety. RESULTS:Both nurses and physicians scored highest in stress recognition (SR) (71.6 and 80.86), while they evaluated working conditions (WC) the lowest (45.82 and 52,09). Nurses achieved statistically significantly lower scores compared to physicians in every aspect of the safety attitudes evaluation (p<0.05). The staff working in surgical wards obtained higher scores within stress recognition (SR) compared to the staff working in medical wards (78.12 vs. 73.72; p = 0.001). Overall, positive working conditions and effective teamwork can contribute to improving employees' attitudes towards patient safety. CONCLUSIONS:The results help identify unit level vulnerabilities associated with staff attitudes toward patient safety. They underscore the importance of management strategies that account for staff coping with occupational stressors to improve patient safety.

Background/UNASSIGNED:Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana's Upper East Region. Objective/UNASSIGNED:This study sought to identify non-physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana's current primary health care structure. Methods/UNASSIGNED:Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants. Findings/UNASSIGNED:Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies. Conclusions/UNASSIGNED:Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.