Faculty Bibliography

Poor dietary choices are a leading cause of chronic disease, but nutrition is rarely discussed in clinical practice. Nutrition is taught in less than a third of medical schools and physicians in practice empirically report low levels of comfort and self-efficacy in discussing nutrition with patients. A two-part presentation was created and shared with second-year medical students at a college of medicine. Students were given pre-work that included a brief (15 minutes) pre-recorded presentation and an e-resource entitled "Practical Nutrition for the Primary Care Provider" and then engaged in a live virtual session with a brief lecture and question and answer period (45 minutes). A survey was administered following the live presentation to evaluate the extent to which the presentation met the stated objectives and could impact participants' future practice. One-hundred and six students participated in the live lecture. Eighty-eight students (83%) provided survey feedback. Over two-thirds of respondents indicated that the presentation completely met the objectives, 57% indicated that they would definitely talk to patients with chronic disease about nutrition, and 52% indicated they would incorporate diet assessment in visits with patients with chronic disease. Nutrition is integral to disease prevention and management. Many students provided comments on the importance of the topic and benefit of the information. Further research is necessary to determine the optimal time and place for nutrition education in medical training. This presentation and e-resource are evidence-based, brief, and provided tools for participants to access once in practice.

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

Background Prior studies of SLE clusters based on autoantibodies have utilized cross-sectional data from single centers. We applied clustering techniques to longitudinal and comprehensive autoantibody data from a large multinational, multiethnic inception cohort of well characterized SLE patients to identify clusters associated with disease outcomes. Methods We used demographic, clinical, and serological data at enrolment and follow-up visits years 3 and 5 from 805 patients who fulfilled the 1997 Updated ACR SLE criteria and were enrolled within 15 months of diagnosis. For each visit, ANA, dsDNA, Sm, U1-RNP, SSA/Ro60, SSB/La, Ro52/ TRIM21, histones, ribosomal P, Jo-1, centromere B, PCNA, anti-DFS70, lupus anticoagulant (LAC), IgG and IgM for anticardiolipin, anti-b2GP1, and aPS/PT, and IgG anti-b2GP1 D1 were performed at a single lab (except LAC). K-means clustering algorithm on principal component analysis (10 dimensions) transformed longitudinal ANA/autoantibody profiles was used. We compared cluster demographic/clinical outcomes, including longitudinal disease activity (total and adjusted mean SLEDAI- 2K), SLICC/ACR damage index and organ-specific domains, SLE therapies, and survival, using one-way ANOVA test and a Benjamini-Hochberg correction with false discovery rate alpha=0.05. Results were visualized using t-distributed stochastic neighbor embedding. Results Four unique patient clusters were identified (table 1). Cluster 1, characterized by high frequency of anti-Sm and anti-RNP over time, was the youngest group at disease onset with a high proportion of subjects of Asian and African ancestry. At year 5, they had the highest disease activity, were more likely to have active hematologic and mucocutaneous involvement, and to be on/exposed to immunosuppressants/ biologics. Cluster 2, the largest cluster, had low frequency of anti-dsDNA, were oldest at disease onset, and at year 5, had the lowest disease activity, and were least likely to have nephritis and be on/exposed to immunosuppressants/biologics. Cluster 3 had the highest frequency of antiphospholipid antibodies over time, were more likely to be of European ancestry, have an elevated BMI, be former smokers, and by year 5, to have nephritis, neuropsychiatric involvement, including strokes and seizures (SLICC/ACR damage index). Cluster 4 was characterized by anti-SSA/Ro60, SSB/La, Ro52/TRIM21, histone antibodies, and low complements at year 5. Overall, survival of the 805 subjects was 94% at 5 years, and none of the clusters predicted survival. Conclusions Four SLE patient clusters associated with disease activity, organ involvement, and treatment were identified in this analysis of longitudinal ANA/autoantibody profiles in relation to SLE outcomes, suggesting these subsets might be identifiable based on extended autoantibody profiles early in disease and carry prognostic information

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.

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