Faculty Bibliography

Background While there is overwhelming evidence for the beneficial role of hydroxychloroquine (HCQ) in SLE, little is known about its economic impact. We estimated annual direct, indirect, and total costs (DC, IC, TC) associated with HCQ use. Methods A subset of patients from the Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) inception cohort were assessed annually between 2014 and 2019 for health resource use, lost work-force/non-work-force productivity and concurrent HCQ use. Resource use was costed using 2021 Canadian prices and lost productivity using Statistics Canada age-and-sex specific wages. At each assessment, HCQ dose over the past year and weight were documented and patients were stratified into 1 of 3 HCQ dosage groups: nonusers (0 mg/kg/day), low-intensity users (<= 5 mg/kg/day), or high-intensity users (>5 mg/kg/day). Costs associated with HCQ dose were calculated by averaging all observations within each dosage group. Multiple random effects linear regressions adjusted for the possible confounding of age at diagnosis, sex, race/ethnicity, disease duration, geographic region, education, alcohol use, and smoking on the association between annual DC and IC and HCQ dose. A possible mediating effect of disease damage (SLICC/ACR DI) on these associations was also investigated. Results 661 patients (89.4% female, 59.3% non-Caucasian race/ethnicity, mean age and mean disease duration at the start of economic assessments was 42.1 years and 9.5 years, respectively) were followed over a mean of 2.8 years. Across 1536 annual assessments, 36.1% of observations were provided by HCQ non-users, 43.1% by low-intensity users (mean dosage 3.4 mg/kg/day), and 20.8% by high-intensity users (mean dosage 5.9 mg/kg/day). Annual adjusted DC were higher in nonusers ($9599) versus low-intensity users ($6344) and highintensity users ($6333) (table 1). When disease damage was included in the regression, there were no significant differences in DC between dosage groups. While unadjusted IC were higher in non-users ($37,610) versus low-intensity users ($32,480) and high-intensity users ($31,418), adjusted IC did not differ. Adjusted TC were higher in non-users ($46,157) versus low-intensity users ($39,257) and high-intensity users ($37,634). Conclusion SLE patients reported higher adjusted annual DC and TC during periods of HCQ non-use versus periods of use, regardless of the intensity of use. There was no additional cost savings in those using high intensity dosages. The cost-savings effect of HCQ could potentially be partially mediated through reduced damage. In addition to its well-established therapeutic potential, there may be an economic imperative for HCQ use in SLE patients

LEARNING OBJECTIVES 1: Describe a longitudinal curriculum to train internal medicine (IM) residents in point-of-care ultrasound (POCUS). LEARNING OBJECTIVES 2: Recognize the impact of decreased patient contact on residents' retention of POCUS skills. SETTINGAND PARTICIPANTS:Despite thewell-documented benefits of POCUS, internal medicine residents receive little formal training. We implemented a curriculumin the 2019 academic year to train 55 PGY-2 IMresidents in POCUS across four urban teaching hospitals and a method to evaluate its efficacy. As the COVID pandemic hit, we additionally sought to understand the impact of COVID on the efficacy of our curriculum and to ascertain from IM residents their barriers to using POCUS during the COVID pandemic. DESCRIPTION: The curriculum was composed of three workshops, consisting of lectures and hands-on practice covering lung, cardiac, abdominal, and lower extremity vascular views. Following the workshops, we sought to consolidate learners' knowledge with a subsequent year-long skill building phase. The skill-building phase was truncated due to the pandemic.A hands-on assessment was performed prior to the course and not repeated at course conclusion due to social distancing concerns. An online knowledge test was administered before the course, immediately following the course, and at one year. A survey assessing attitudes and barriers to POCUS was administered before the course and at one year. EVALUATION: No resident passed the pre-course hands-on assessment. Prior to the course, the average resident score was 54% on the online knowledge quiz; directly after the workshop series, the average rose to 78%. At one year, the average score on the online knowledge quiz was 74%, a statistically significant decrease (p=0.04). Ninety-one percent of residents reported performing POCUS at least once/month prior to the pandemic. During the pandemic, scanning activity decreased; 67% residents reported they scanned rarely or never. DISCUSSION/ REFLECTION / LESSONS LEARNED: Our course led to significant improvement of knowledge regarding ultrasound technology and image interpretation, however this decayed at one year, likely due to lack of skill reinforcement. Though POCUS was widely used prior to the pandemic, usage dropped at the pandemic's peak, despite its utility as both a diagnostic and therapeutic tool. The most commonly cited reason for lack of use was concern regarding contamination and infectious exposure. While the COVID pandemic disrupted our curriculum, it also highlighted opportunities to incorporate POCUS into clinical practice and reinforced the importance of continued longitudinal practice to retain learned skills

LEARNING OBJECTIVE #1: Recognize hemoptysis as a symptom of alveolar hemorrhage in COVID19 LEARNING OBJECTIVE #2: Recognize the complexity of managing simultaneous pulmonary embolism and hemoptysis in worsening COVID19 pneumonia CASE: A 69-year-old man with hypertension, mild emphysema and gastritis presented for a week of fatigue, dyspnea and fever. On arrival to ED, T 100.4F, tachycardic, hypoxic to 86% on room air and improved to 94% on nasal cannula (NC). No cough, anosmia/ageusia or gastrointestinal (GI) symptoms. Nasopharyngeal swab detected SARS-CoV-2. Chest xray showed bilateral multifocal patchy airspace opacities and prominent interstitial markings. Ddimer was 470. 'Do not intubate (DNI)' status was affirmed. The next day, he required 100% fraction of inspired oxygen with high-flow NC despite initiation of high-dose dexamethasone and remdesivir. Twice-daily proton pump inhibitor (PPI) was begun in tandem with steroid. Procalcitonin of 0.31 prompted addition of ceftriaxone and azithromycin. On day 4, Ddimer jump from 861 to 3099 raised suspicion for pulmonary embolism (PE). CT confirmed bilateral PE. Heparin drip was started and later changed to apixaban. On day 18, he had a large episode of hemoptysis. No hemoglobin (Hgb) drop. Repeat CT showed decreased clot burden but increased bilateral airspace opacity consistent with atypical pneumonia, ARDS and hemorrhage. Interventional Radiology (IR) did not intervene due to lack of target on CT. Once hemodynamically stable with no further bleed, heparin drip was restarted. On day 22, he had another episode of moderate hemoptysis with an isolated episode of melena. Repeat Hgb was again stable, but a unit of packed red blood cells was given preemptively. IMPACT/DISCUSSION: COVID19 is associated with hypercoagulability and increased risk for thrombotic events such as PE. Hemoptysis occurs in 13% of PE cases but has so far rarely been reported in COVID19. There are a few case reports of COVID19 pneumonia, acute PE and underlying emphysema that developed hemoptysis and had worse outcomes. Our case is unique in that his hemoptyses were on hospital days 18 and 22 after starting therapeutic anticoagulation. So, his hemoptysis was unlikely to be caused by PE. Upper GI bleed (GIB) was also less likely; he was on a PPI, and Hgb was low but stable throughout. The most likely etiology was alveolar hemorrhage and ARDS secondary to COVID19. Concurrence of venous thromboembolism and alveolar hemorrhage can create a therapeutic dilemma. Our patient's DNI status precluded procedures requiring general anesthesia, e.g. endoscopy to visualize GIB or bronchoscopy to identify vessels for IR embolization. Apixaban reversal with andexanet alfa was deferred given his known PE. IVC filter was considered in case he could not tolerate anticoagulation. Heparin drip was restarted for easier anticoagulant reversal.
CONCLUSION(S): Hemoptysis can present as a late-onset complication of COVID19 in the hospitalized patient. Heparin drip for pulmonary embolism in COVID19 can be easily discontinued if hemoptysis develops

Background: Heart failure (HF) is an important contributor to the increased cardiovascular (CV) mortality incidence in ESKD. Therapies targeting HF's unique pathophysiology in ESKD are lacking. Hydralazine-isosorbide dinitrate (H-ISDN) targets reduced nitric oxide bioavailability and could improve CV mortality in ESKD Methods: Adult patients with HF on maintenance dialysis between January 2011 and December 31, 2016 were identified using the United States Renal Data System. There were 6306 patients with at least one prescription for H-ISDN and 75,851 non-users. The primary outcome was death from any cause. Secondary outcomes included cardiovascular death and sudden death. Treatment effects were estimated using stabilized inverse probability weights in Cox proportional hazards regression. Because H-ISDN has been shown to improve outcomes in Black HF patients, we investigated effect modification by race Results: Age was similar in H-ISDN users (66 +/- 13 years) and non-users (69 +/- 13 years) with 50% and 51% men, respectively. H-ISDN (51%) users were more likely to be of Black race than non-users (27%). Dialysis vintage was longer in H-ISDN (25 months) users compared with non-users (15 months). All characteristics were well balanced in weighted models. Risks of all-cause mortality, cardiovascular death, and sudden death were significantly reduced in H-ISDN users compared to non-users (Table). We did not identify significant effect modification by race (Figure)
Conclusion(s): To our knowledge, this is the first analysis of the impact of H-ISDN on mortality in ESKD. Our results suggest that combination H-ISDN improves survival in dialysis patients with HF

Psychosocial stressors are prevalent and linked to worse health outcomes, but are less frequently addressed than physically apparent medical conditions at primary care visits. Through a community-academic partnership between an art museum and a federally qualified health center, we developed an innovative museum-based intervention and evaluated its feasibility and acceptability among diverse, underserved patients and its perceived effects on psychosocial stressors. Guided by experiential learning and constructivist approaches, the intervention consisted of a single, three-hour session that incorporated group discussions and interactive components, including art-viewing, sketching, and object-handling. We used post-intervention focus groups to elicit feedback qualitatively. From July 2017 to January 2018, 25 patients participated. Focus groups revealed that the intervention exhibited therapeutic qualities, fostered self-reflection, catalyzed social connectivity, and functioned as a gateway to community resources. These findings can guide future research and development of community-based interventions to target the growing burden of psychosocial stressors among the underserved.