Faculty Bibliography

LEARNING OBJECTIVE #1: Know the possible drug interactions of HMG CoA reductase inhibitor (statin) and commonly used antiplatelet agents LEARNING OBJECTIVE #2: Understand options for statin therapy in people with statin induced myopathy CASE: A 75-year-old man presented to his primary care physician (PCP) with two weeks of progressively worsening bilateral anterior thigh pain causing difficulty with ambulation. One month prior to presentation, he had been hospitalized for non-ST elevation myocardial infarction and in-stent thrombosis after he self-discontinued aspirin therapy. Upon discharge, he was switched to ticagrelor after he was found to be a non-responder to clopidogrel on platelet function tests. One day prior to admission his PCP discovered AST and ALT elevations to over 400 U/L (normal ranges 11-39 U/L and 11-35 U/L) and instructed the patient to present to the emergency room for further workup. In the emergency room (ED), the patient reported his symptoms started after he started taking ticagrelor, and he denied alcohol use. Past medical history includes hypertension and coronary artery disease treated with five drug eluting stents. He reported adherence medication regimen, which consisted of aspirin, ticagrelor, atorvastatin, amlodipine, hydrochlorothiazide, losartan, and metoprolol. He denied shortness of breath, dyspnea on exertion, abdominal pain, and leg edema. Vital signs were normal. Physical exam was most notable for tenderness to palpation of the thighs bilaterally. AST and ALT were 228 U/L and 158 U/L respectively, and CK was 4600 U/L (normal range: 45-245 U/L). Urinalysis revealed small blood with 0-4 red blood cells; urine culture produced no growth. Liver ultrasound found a normal liver and biliary tree. Hepatitis B and C serologies were negative. Troponin I was 0.07 ng/mL (normal range: <0.06 ng/mL), though there were no EKG changes from his prior admission. Once admitted to the floor, his atorvastatin was discontinued. The next day his AST and ALT decreased to 57 U/L and 121 U/L, and his CK fell to 715 U/L. IMPACT/DISCUSSION: Both myopathy and hepatitis occurred in this patient after initiation of ticagrelor, which is a known inhibitor of CYP P450 3A4. The levels of atorvastatin, which is metabolized by CYP P450 3A4, likely increased and caused a dose dependent toxicity, causing the patient's symptoms and lab abnormalities. He was subsequently discharged with improvement of thigh pain.
CONCLUSION(S): The drug-drug interaction of atorvastatin and ticagrelor has been established. This submission focuses on increasing knowledge of this common interaction. In this case, atorvastatin was discontinued and rosuvastatin was started as it is not metabolized by CYP P450 3A4. This combination is often better tolerated when combined with ticagrelor. The patient returned for outpatient follow-up and was started on rosuvastatin 5 mg with repeat liver function tests ordered with plans titrate as tolerated

BACKGROUND: Patients who are immigrants, notably those with undocumented status, face challenges to equitable healthcare access. By understanding immigration status as a social determinant of health (SDOH), physicians can begin to address such disparities. However, few undergraduate medical curricula include formal longitudinal instruction addressing immigration. We conducted a needs assessment of a medical school's curricular content in teaching medical students to address immigration as a SDOH.
METHOD(S): MS1-3 students from a school in Bronx, NY where 35% of the patient population are immigrants, received a 13-question email survey via surveymonkey.com. Students were assessed on three primary areas based on a literature review on sanctuary doctoring and SDOH: 1) Knowledge of immigrants' barriers to care (4-point scale, strongly disagree to strongly agree); 2) Confidence in assessing patient immigration status, taking an immigration history, and advocating for patients at risk of deportation (3-point scale, not confident to very confident); and 3) Frequency of assessing patients' immigration status, identifying immigration status when presenting cases, and referring undocumented patients to social/legal resources (4-point scale, never to always). Outcomes were compared between pre-clinical (MS1-2) and clinical (MS3) students.
RESULT(S): Among 539 students, 159 (29.5%) responded, with 104 preclinical and 55 clinical students. 79.2% strongly agreed that undocumented immigration status limits healthcare access. Few students reported being very confident in asking about immigration status (8.8%), taking an immigration history (12.6%), providing legal information (2.5%) and advocating for patients at risk of deportation (6.3%). Compared to the pre-clinical cohort, clinical students were significantly more confident in taking an immigration history (p=0.04) but not in other skills. Few students endorsed frequently or always asking patients about immigration status (3.2%), identifying immigration status when presenting patients (4.5%), and referring undocumented patients to appropriate resources (8.3%). There were no significant differences in frequencies of use of clinical skills pertaining to care of immigrant patients in the pre- and clinical cohorts.
CONCLUSION(S): Students are aware of barriers that immigrant patients face but lack confidence and experience in identifying and supporting undocumented patients. Our results will inform a revision of the longitudinal curriculum, including didactics and practical activities. LEARNING OBJECTIVE #1: 1. Assess students' skills and confidence in identifying and advocating for undocumented immigrant patients in clinical practice LEARNING OBJECTIVE #2: 2. Assess students' knowledge of immigrants' barriers to care

Purpose/UNASSIGNED:People with HIV (PWH) are living longer lives and likely experiencing accentuated aging. Comprehensive geriatric assessment (CGA) has been proposed as a way to identify and help meet each individual patient's needs. Patients and Methods/UNASSIGNED:We performed a retrospective review of the results of CGA in an HIV clinic in New York City. CGA included assessment of basic and instrumental activities of daily living, screens for depression, anxiety, frailty, cognition, and quality of life, along with general discussion of concerns and goals. We compared the group of PWH referred for CGA to those of comparable age who were not referred to determine the factors that were associated with referral. We carried out a descriptive analysis of those undergoing CGA, along with regression to determine factors associated with poorer PHQ-2 depression scores and higher VACS score. Results/UNASSIGNED:A total of 105 patients underwent full CGA during the study period. Mean age of referred patients was 66.5 years, ranging from 50 to 84 years (SD 7.99). More than 92% were virally suppressed. Compared with their non-referred counterparts over 50, referred patients were older and had more functional comorbidities like cerebrovascular disease, neuropathy, and urinary incontinence. More than half complained of fatigue, and 2/3 noted poor memory. Almost 60% were frail or prefrail. Ninety patients were asked about their goals, and the most commonly cited were related to health or finances; fifteen patients were unable to articulate any goals. Having fewer goals and noting weight loss or fatigue were predictive of higher scores on the PHQ-2 depression screen. Conclusion/UNASSIGNED:Although most older PWH undergoing CGA can manage their ADL, many have concerns and deficits beyond their comorbidities. CGA offers an important window into the psychosocial concerns and needs of older PWH.

LEARNINGOBJECTIVES 1: Interpersonal /Communication Skill: 1) Identify communication skills needed to recruit older adults LEARNING OBJECTIVES 2: 2) Assess feasibility of GOSCEs to enhance recruitment skills in RAs. SETTING AND PARTICIPANTS: Convenience sample of 18 (5 male, 13 female) Research Assistants (RAs) at an urban hospital who recruit older adults for clinical trials. DESCRIPTION: Increasing older adults' participation in clinical trials is urgently needed. We developed a remote, three station simulation (Group Objective Structured Clinical Exam - GOSCE) to teach RAs communication skills. This 2-hour course included a discussion of challenges in recruiting older adults; skills practice with Standardized Participants (SPs); and a debrief to review experiences, highlight best practices. After discussion, RAs rotated (3 per group) through the stations, each with SP and faculty observer who provided immediate feedback. Thus, learners had opportunities for active and observational learning.Scenarios were: 1) an older white woman with hearing impairment; 2) an older white woman and family member together; and 3) an older Black man mistrustful due to history of racism in medical research. SPs completed behaviorally anchored checklists (11 communication skills across all cases, and 5-7 case-specific questions). Learners completed a 36- item survey of self-assessed change in skill after the workshop; insights on recruitment practice; and educational value. EVALUATION: The communication checklist across all cases included: relationship development (5 items, mean of 58% well done (range: 50-75%), patient education (3 items, 44% (42-58%)), patient satisfaction (2 items, 54% (50-58%)), and information gathering (1 item, 92%). Seventeen RAs completed the survey, 100% felt the workshop provided valuable feedback and taught relevant material, 88% would participate again and 52%reported that the workshop improved their recruitment skills. All RAs reported encountering situations similar to hearing impairment and family member cases, and the majority rated the cases as high in educational value. Just 45% reported experiencing a case similar to the Black male case, and 100% rate it as high in educational value. Key points identified by RAs included the value of building a trusting relationship with potential subjects, recognizing possible barriers to communication early on and addressing these directly in a supportive and respectful style. DISCUSSION / REFLECTION / LESSONS LEARNED: Remote GOSCEs are a feasible mechanism for training RAs in subject recruitment focused on the unique needs of older adults. Responses to the RA survey suggest that GOSCEs are feasible for training RAs in simulated clinical scenarios with which participants are familiar and unfamiliar. SP assessment of RAs identified areas for further reinforcement to improve recruitment skills. This innovation is a feasible, high yield strategy for training research staff. It is highly adaptable to the specific recruitment needs and skills of a clinical trials and will add to the literature on educating RAs

Coronavirus disease 2019 (COVID-19) was first identified at the end of 2019 as a cluster of pneumonia cases in Wuhan, China. By February 2020, this virus quickly spread, becoming a global pandemic. The spectrum of symptomatic infection severity can range from mild, severe, and critical disease. Many correlated comorbidities were established, including smoking, socioeconomic background, gender (male prevalence), hypertension, obesity, cardiovascular disease, chronic lung disease, diabetes mellitus, cancer, and chronic kidney disease. In an extensive literature search, post-COVID-19 necrotizing Staphylococcus aureus pneumonia with pneumothorax has not been recorded. We present a case about a 62-year-old male who presented with symptoms of COVID-19 with many underlying comorbidities, including hypertension and hyperlipidemia. He was on ventilatory support during his first week in the hospital and then received supplemental oxygenation as he recovered from his COVID-19 pneumonia. Nearly a month and a half after his initial presentation, he quickly decompensated and was started on supplemental oxygen and the necessary treatments. It was then, with the aid of lab work and imaging, that we determined that he had developed necrotizing Staphylococcus aureus pneumonia with pneumothorax. He was adequately treated, and once he was stable, he was discharged home and was told to continue his therapy.