Faculty Bibliography

BACKGROUND/UNASSIGNED:Hospitalized patients with serious illness have significant symptom burden and face complex medical decisions that often require goals of care discussions. Given the shortage of specialty palliative care providers, there is a pressing need to improve the palliative care skills of internal medicine (IM) residents, who have a central role in the care of seriously ill patients hospitalized at academic medical centers. METHODS/UNASSIGNED:We conducted an anonymous survey of IM residents at a large, urban, academic medical center to identify which aspects of palliative care trainees find most important and their knowledge gaps in palliative care. The survey measured trainees' self-assessed degree of importance and knowledge of core palliative care skills and evaluated frequency of completing advance care planning documentation. RESULTS/UNASSIGNED:Overall, 51 (23%) IM residents completed the survey. The majority of trainees considered multiple palliative care skills to be "very important/important": symptom management, prognostication, introducing the palliative care approach, discussing code status, and breaking serious news. Across these same skills, trainees reported variable levels of knowledge. In our sample, trainees reported completing healthcare proxy forms and Medical Orders for Life-Sustaining Treatment infrequently. CONCLUSIONS/UNASSIGNED:IM trainees rated core palliative care skills as important to their practice. Yet, they reported knowledge gaps across multiple core palliative care skills that should be addressed given their role as frontline providers for patients with serious illness.

PURPOSE/UNASSIGNED:Hospital at home (HaH) is a means of providing inpatient-level care at home. Selection of admissions potentially suitable for HaH in oncology is not well studied. We sought to create a predictive model for identifying admissions of patients with cancer, specifically solid-tumor malignancies, potentially suitable for HaH. METHODS/UNASSIGNED:In this observational study, we analyzed admissions of patients with solid-tumor malignancies and unplanned admissions (January 1, 2015, to June 12, 2019) at an academic, urban cancer hospital. Potential suitability for HaH was the primary outcome. Admissions were considered potentially suitable if they did not involve escalation of care, rapid response evaluation, in-hospital death, telemetry, surgical procedure, consultation to a procedural service, advanced imaging, transfusion, restraints, and nasogastric tube placement. Admission source, patient demographics, vital signs, laboratory test results, comorbidities, admission and active cancer diagnoses, and recent hospital utilization were included as candidate variables in a multivariable logistic regression model. RESULTS/UNASSIGNED:Of 3,322 admissions, 905 (27.2%) patients were potentially suitable for HaH. After variable selection in the derivation cohort (n = 1,097), thirteen factors predicted potential suitability: admission source; temperature and respiratory rate at presentation; hemoglobin; breast cancer, GI cancer, or malignancy of secondary or ill-defined origin; admission for genitourinary, musculoskeletal, or neurologic symptoms, intestinal obstruction or ileus, or evaluation of secondary malignancy; and emergency department visit in prior 90 days. Model c-statistics were 0.71 (95% CI, 0.68 to 0.75) and 0.63 (0.59 to 0.67) in the derivation and validation (n = 1,095) cohorts. CONCLUSION/UNASSIGNED:Hospital admissions of patients potentially suitable for HaH may be identifiable using data available at admission.

The dermatology application process is grueling, that is tough to navigate without the proper guidance. This commentary is meant to shed light on the factors that can help applicants stand out in order to be successful in the match. It includes observations from successful applicants from the most recent match process.

BACKGROUND Lyme borreliosis, caused by spirochetes of the Borrelia burgdorferi genospecies complex, is the most commonly reported tickborne infection in North America and those infected may present with cutaneous, cardiac, articular, and neuropsychiatric abnormalities. The protean nature of many of its clinical manifestations presents a diagnostic conundrum. Lyme disease can affect the heart, albeit rarely, with cardiac abnormalities usually manifesting as varying degrees of heart block or arrhythmias. CASE REPORT We present a case of complete heart block in a young man who participated in outdoor activities in a Lyme-endemic area and developed fatigue and palpitations weeks after a flu-like illness. He noticed that his heart rate was low; he had an intermediate suspicious index in Lyme carditis (SILC) score with positive Lyme serologies. His initial electrocardiogram when he presented to the emergency department showed a complete heart block. In this case, he was successfully managed with intravenous ceftriaxone, amoxicillin, and a transcutaneous pacemaker, obviating the need for a permanent pacemaker. CONCLUSIONS Electrocardiographic changes such as heart block and arrhythmias with or without symptoms may be the initial manifestation of Lyme carditis in a patient who may or may not remember a tick bite or have a typical skin rash. The SILC score may assist in recognizing these cases and prompt initiation of antibiotics usually leads to the resolution of these electrocardiographic abnormalities and symptoms that may be present.

Patients with kidney failure and acute respiratory distress syndrome (ARDS) requiring prone position have not been candidates for peritoneal dialysis (PD) due to concern with increased intra-abdominal pressure, reduction in respiratory system compliance and risks of peritoneal fluid leaks. We describe our experience in delivering acute PD during the surge in Covid-19 acute kidney injury (AKI) in the subset of patients requiring prone positioning. All seven patients included in this report were admitted to the intensive care unit with SARS-CoV-2 infection leading to ARDS, AKI and multisystem organ failure. All required renal replacement therapy, and prone positioning to improve ventilation/perfusion mismatch. All seven were able to continue PD despite prone positioning without any detrimental effects on respiratory mechanics or the need to switch to a different modality. Fluid leakage was noted in 71% of patients, but mild and readily resolved. We were able to successfully implement acute PD in ventilator-dependent prone patients suffering from Covid-19-related AKI. This required a team effort and some modifications in the conventional PD prescription and delivery.

BACKGROUND:Point-of-care ultrasound (POCUS) is becoming widely adopted with increasing accessibility of courses. Little is known about the optimal design of the introductory course or longitudinal training programs targeting hospitalists that are critical to success. METHODS:Hospitalists at four academic sites participated in a two-day introductory course and a longitudinal phase comprising clinical POCUS practice, clip uploading with online feedback, hands-on teaching, and monthly ultrasound conferences. Assessments were performed immediately before and after the two-day course and after 1 year. RESULTS:Knowledge increased from baseline to post two-day course (median score 58 and 85%, respectively, p < 0.001) and decreased slightly at 1 year (median score 81%, p = 0.012). After the two-day introductory course, the median score for hands-on image acquisition skills, the principal metric of participant success, was 75%. After 1 year, scores were similar (median score 74%). Confidence increased from baseline to post two-day course (1.5 to 3.1 on a 4 point Likert scale from Not at all confident (1) to Very confident (4), p < 0.001), and remained unchanged after 1 year (2.73). Course elements correlating with a passing score on the final hands-on test included number of clip uploads (r = 0.85, p,0.001), attendance at hands-on sessions (r = 0.7, p = 0.001), and attendance at monthly conferences (r = 0.50, p = 0.03). CONCLUSIONS:The I-ScaN POCUS training program increased hospitalist knowledge, skill and confidence with maintained skill and confidence after 1 year. Uploading clips and attending hands-on teaching sessions were most correlative with participant success.

BACKGROUND:Interdisciplinary research teams can increase productivity among academic researchers, yet many junior investigators do not have the training or financial resources to build productive teams. We developed and tested the acceptability and feasibility of three low-cost services to help junior faculty build and maintain their own research teams. METHODS:At an urban academic medical centre, we implemented three types of consultation services: 1) giving talks on evidence-based best practices for building teams; 2) providing easy-to-use team building resources via email; and 3) offering a year-long consultation service-co-led by students-that taught faculty to build and maintain research teams. Our primary outcome was the number of faculty who used each service. For the yearlong consultation service, we asked faculty participants to complete three online self-assessments to rate their leadership confidence, the team's performance, and which of the consultation components were most helpful. We used descriptive statistics to evaluate faculty assessment scores at three timepoints by comparing median scores and interquartile ranges. RESULTS:We gave 31 talks on team building to 328 faculty and postdoctoral fellows from 2014 to 2020. Separately, 26 faculty heard about our research team building expertise and requested materials via email. For the consultation service, we helped build or enhance 45 research teams from 2014 to 2020. By the end of the consultation, 100% of the faculty reported they were still maintaining their team. In the initial survey, the majority of participants (95.7%, n = 22) reported having no or few experiences in building teams. Further, when asked to rate their team's performance at 12-months, faculty highly rated many elements of both teamwork and taskwork, specifically their team's productivity (6/7 points), morale (6/7 points), and motivation (6/7 points). By the end of the program, faculty participants also highly rated two components of the consultation program: recruitment assistance (7/10 points) and provision of team management tools (7/10 points). CONCLUSIONS:For participating faculty, our program provided valued guidance on recruitment assistance and team management tools. The high demand for team-building resources suggests that junior faculty urgently need better training on how to develop and manage their own team.