Faculty Bibliography

Little is known regarding the impact of immigrant acculturation on the gut microbiome. We characterized differences in the gut microbiome between racially/ethnically diverse US immigrant and US-born groups, and determined the impact of dietary acculturation on the microbiome. Stool samples were collected from 863 US residents, including US-born (315 White, 93 Black, 40 Hispanic) and foreign-born (105 Hispanic, 264 Korean) groups. We determined dietary acculturation from dissimilarities based on food frequency questionnaires, and used 16S rRNA gene sequencing to characterize the microbiome. Gut microbiome composition differed across study groups, with the largest difference between foreign-born Koreans and US-born Whites, and significant differences also observed between foreign-born and US-born Hispanics. Differences in sub-operational taxonomic unit (s-OTU) abundance between foreign-born and US-born groups tended to be distinct from differences between US-born groups. Bacteroides plebeius, a seaweed-degrading bacterium, was strongly enriched in foreign-born Koreans, while Prevotella copri and Bifidobacterium adolescentis were strongly enriched in foreign-born Koreans and Hispanics, compared with US-born Whites. Dietary acculturation in foreign-born participants was associated with specific s-OTUs, resembling abundance in US-born Whites; e.g., a Bacteroides plebeius s-OTU was depleted in highly diet-acculturated Koreans. In summary, we observed that US nativity is a determinant of the gut microbiome in a US resident population. Dietary acculturation may result in loss of native species in immigrants, though further research is necessary to explore whether acculturation-related microbiome alterations have consequences for immigrant health.

There is minimal information on COVID-19 in immunocompromised individuals. We have studied 10 patients treated at 12 adult care hospitals. Ten kidney transplant recipients tested positive for SARS-CoV-2 by PCR, and 9 were admitted. The median age was 57 (IQR 47-67), 60% were male, 40% Caucasian, and 30% Black/African American. Median time from transplant to COVID-19 testing was 2822 days (IQR 1272-4592). The most common symptom was fever, followed by cough, myalgia, chills, and fatigue. The most common CXR and CT abnormality was multifocal patchy opacities. 3 patients had no abnormal findings. Leukopenia was seen in 20% of patients, and allograft function was stable in 50% of patients. 9 patients were on tacrolimus and a mycophenolic antimetabolite, and 70% were on prednisone. Hospitalized patients had their antimetabolite agent stopped. All hospitalized patients received hydroxychloroquine (HCQ) and azithromycin. 3 patients died (30%), five (50%) developed acute kidney injury. Kidney transplant recipients infected with COVID-19 should be monitored closely in the setting of lowered immunosuppression. Most individuals required hospitalization and presenting symptoms were similar to those of non-transplant individuals.

BACKGROUND: While much is known about the importance of addressing Social Determinants of Health, less is known about how members of the care team respond to patient-volunteered SDoH - especially when the determinant is related to financial insecurity. With increasing calls for universal screening for SDoH - what do teams do when a patient shares a financial concern? We report on the use of Unannounced Standardized Patients (USP) to assess how primary care teams respond to volunteered information about financial insecurity and whether an audit/ feedback intervention (with targeted education included) improved that response.
METHOD(S): Highly trained USPs (secret shoppers) portrayed six common scenarios (fatigue, asthma, Hepatitis B concern, shoulder pain, back pain, well visit). USPs volunteered a financial concern (fear of losing job, challenges with financially supporting parent, trouble meeting rent) to the medical assistant (MA) and then again to their provider and assessed the response of both the MA (did they acknowledge and/ or forward the information to the provider?) and the provider (did they acknowledge/ explore and/or provide resources/referrals?). A total of 383 USP visits were delivered to 5 care teams in 2 safety-net clinics. Providers were medicine residents. 123 visits were fielded during the baseline period (Feb 2017-Jan 2018); 185 visits during the intervention period (Jan 2018-Mar 2019) throughout which quarterly audit/feedback reports of the teams' response to the USPs' SDoH and targeted education on SDoH were distributed. 75 follow-up phase visits were fielded (Apr- Dec 2019). Analyses compared rates of MA and provider response to the volunteered financial insecurity issue across the 3 periods (chi-square, z-scores).
RESULT(S): The baseline rate of responding in some way to the volunteered information was high for both the MA (86% acknowledged) and the providers (100% responded). These overall rates of response did not change substantially or significantly across the three time periods (MA: Intervention period = 87%, Follow- Up period=90%; Provider: Intervention period=98%; Follow-Up period=98%). Rates of acting upon the volunteered information also remained quite consistent across the time periods: from 29 to 35% of MA forwarded the information to the provider across the 3 time periods and from 22 to 28% of providers in each intervention period gave the patient resources or a referral (mostly resources).
CONCLUSION(S): Our findings highlight the importance of patients directly telling team members about a financial concern. Future research should explore whether screening tools are effective in instigating a response. Audit/feedback reports with targeted educational components did not appear to influence the teams' response unlike what we found for housing and social concerns that had to be elicited. Whether this is due to differences in volunteered vs. elicited SDoH or to the nature of the SDoH (financial vs housing/social) warrants further investigation

BACKGROUND:Hepatitis C affects racial minorities disproportionately and is greatest among the black population. The incidence of hepatocellular carcinoma has increased with the largest increase observed in black and Hispanic populations, but limited data remain on whether hepatitis C hepatocellular carcinoma in racial-ethnic minorities have the same utilization of services compared with the white population. METHODS:We used the database of the National Inpatient Sample to identify hepatitis C-hepatocellular carcinoma patients (N = 200,163) who underwent liver transplantation (n = 11,491), liver resection (n = 4,896), or ablation of liver lesions (n = 6,933) from 2005 to 2015. We estimated utilization over time and assessed differences in utilization and inpatient mortality across patient characteristics. RESULTS:In multivariate analysis, factors associated with utilization of services included treatment year, sex, race, insurance status, hospital type, and comorbidity burden, with black and Hispanic patients having statistically significantly decreased utilization. Factors associated with inpatient mortality included treatment year, sex, race, insurance status, hospital type, hospital region, and comorbidity burden, with black patients having a statistically significantly greater risk of inpatient mortality. CONCLUSION/CONCLUSIONS:We identified racial and socioeconomic factors which were associated with utilization of services and inpatient mortality for patients with hepatitis C hepatocellular carcinoma. Blacks were especially disadvantaged in the receipt of care. Further work to abrogate these findings is imperative to ensure equitable provision of surgical therapies.

LEARNING OBJECTIVE #1: Recognize the acute neurologic manifestations of non-ketotic hyperglycemia in adults with type 2 diabetes. LEARNING OBJECTIVE #2: Management of chronic disease in non- English speaking patient populations with low health literacy. CASE: 44 year old Mandarin speaking male with a history of hypertension and type 2 diabetes (DM2) presented with five days of intermittent episodes of involuntary right arm movement associated with urinary incontinence. Episodes occurred at least ten times daily and were not associated with alteration of consciousness. Of note, he was diagnosed with DM2 in the past year, but had limited understanding of the disease and was not taking any medications. The patient takes no medication. He has no family history of seizures or other neurological problems. He smokes rarely and does not drink alcohol or use drugs. On presentation he had stable vital signs and physical exam revealed no focal neurological deficits and was otherwise normal. Labs including a blood count, hepatic panel, urine toxicology, and metabolic panel were normal apart from a glucose at 616 mg/dL with a HbA1C at 14.1%. After a normal non-contrast head CT, these episodes were confirmed as focal seizures on EEG and were refractory to 1500mg levetiracetamtwice daily. He was placed on a basal-bolus regimen of insulin, with improvement of his glucose and cessation of his seizures with no further abnormal activity on EEG. Before discharge, the patient was counseled on his diagnosis of DM2 with culturally appropriate, Mandarin based educational materials as well as individual teaching on glucose monitoring and insulin administration using an interpreter. IMPACT/DISCUSSION: Non-ketotic hyperglycemia (NKHG) is a complication of DM2, and often is triggered by metabolic stressors. Classically, this presents as polyuria, polydipsia, lethargy, confusion, and ataxia. Other neurologic findings such as increased motor tone, hemiparesis, or focal seizures are rare. The pathophysiology of focal seizures in NKHG is not fully understood. Hypertonicity is unlikely to be the cause as these seizures are not present in diabetic ketoacidosis, and serum osmolarity is normal during these seizures. A prominent theory is that there may be increased metabolism of the neurotransmitter GABA, decreasing the seizure threshold. Managing these focal seizures is often difficult due to delay in diagnosis and treatment. Focal seizures tend to be refractory to antiepileptic drugs, and phenytoin can worsen these seizures by reducing insulin secretion. Management of focal seizures in NKHG is control of the hyperglycemic state, with insulin and rehydration.
CONCLUSION(S): In our patient, treatment of hyperglycemia was successful in terminating seizure activity, representing a rare case of focal seizures presenting as a symptom NKHG. In addition, usage of culturally and language specific educational materials is vital for the proper management of chronic conditions such as DM2, in order to prevent further complications of chronic disease

BACKGROUND: Virtual Urgent Care (VUC) is a now a common modality for providing real-time assessment and treatment of common medical problems. However, most providers have not had formal telemedicine training or clinical experience. Faculty have little experience with this new modality of healthcare delivery. We created an experiential onboarding program in which standardized patients (SPs) are deployed into a VUC platform to assess and deliver feedback to physicians in an effort to provide individual- level quality assurance and identify programlevel areas for improvement.
METHOD(S): We simulated a synchronous urgent care evaluation of a 25- year-old man with lingering upper respiratory tract symptoms refractory to over-the-counter medications. The SP was trained to strongly request an antibiotic prescription. A mock entry in the electronic medical record, available to providers during the visit, provided demographic, prior medical, pharmacy and allergy information. The encounter was scheduled into a regular 30-minute appointment slot during a routine 8-hour shift. We developed a behaviorally- anchored assessment tool to evaluate core communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' SPs provided post-encounter verbal feedback to urgent care providers (UCPs), who received a summary report and had an opportunity provide structured feedback regarding the case. A single SP performed 20 / 21 visits.
RESULT(S): Twenty-one UCPs, with 2 to 23 years of clinical experience, participated in an announced scheduled visit. UCPs performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. All UCPs provided appropriate management plans and did not give antibiotics. In contrast, Education and Counseling skills were less strong (32% 'well done'). Within this domain, few received 'well done' for checking understanding (14%); conveying small bits of information and summarizing to ensure clarity (9%). Most (71% well done) collaborated with the SP in discussing next steps. Specific telemedicine skills were infrequently used: only 19% performed a virtual physical exam, 24% utilized the audio/video interface to augment information gathering, 14% optimized technical aspects by assessing sound, video or ensuring a backup plan should video fail. A subset of UCPs (n=9) provided structured feedback regarding the case. 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improved telehealth skills.
CONCLUSION(S): This experiential virtual urgent care onboarding program utilizing standardized announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. These findings form the basis for dedicated training for virtual urgent care providers to assure quality across the program

BACKGROUND:Despite the financial incentives to improve patient experience, measured through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, few interventions have led to sustained improvement. METHODS:A real-time survey (RTS) designed to capture multiple domains was conducted on medical inpatients in a tertiary care center from July 2017 to June 2018. Answers were reviewed by a multidisciplinary team, and interventions to improve experience were completed. RESULTS:A total of 235 RTSs resulted in 94 (40.0%) interventions. HCAHPS were compared 12 months pre-and postintervention, with an increase in the percentage of "always" for the responsiveness domain, 38.9% vs. 59.7%, p = 0.005. Several other domains showed an increase that did not reach statistical significance. CONCLUSION/CONCLUSIONS:Conducting RTSs may allow for a better understanding of patient experience and active service recovery.

PURPOSE OF REVIEW/OBJECTIVE:In this review article, we address emerging evidence for the medical and surgical treatment of the hospitalized patient with ulcerative colitis. RECENT FINDINGS/RESULTS:Ulcerative colitis is a chronic inflammatory disease involving the colon and rectum. About one-fifth of patients will be hospitalized from ulcerative colitis, and about 20-30%, experiencing an acute flare will undergo colectomy. Because of the significant clinical consequences, patients hospitalized need prompt evaluation for potential complications, stratification of disease severity, and a multidisciplinary team approach to therapy, which involves both the gastroenterologist and surgeon. Although corticosteroids remain first-line therapy, second-line medical rescue options, primarily infliximab or cyclosporine, are considered within 3-5 days of presentation. In conjunction, an early surgical consultation to present the possibility of a staged proctocolectomy as one of the therapeutic options is equally important. SUMMARY/CONCLUSIONS:A coordinated multidisciplinary, individualized approach to treatment, involving the patient preferences throughout the process, is optimal in providing patient-centered effective care.

LEARNING OBJECTIVE #1: Recognize the presentation of spontaneous coronary artery dissection (SCAD). LEARNING OBJECTIVE #2: Recognize amphetamine use as a potential risk factor for SCAD. CASE: A 33-year-old woman with a history of anxiety and ADHD on dextroamphetamine and amphetamine presented with acute onset sharp, substernal chest pain radiating to her left arm and neck since the morning. It felt similar to a "heartburn" episode a month ago. While in EMS, she felt nauseous, vomited, and described a "sensation of doom." She denied any dyspnea, cough, or lightheadedness. She endorsed a remote history of cocaine use and recent stressors at work causing increased anxiety. Her physical exam was unremarkable. EKG showed 0.5-mm STdepression in leads V4-V6, III and aVF with T-wave inversions in leads V1-V3. She received aspirin 325mg, aluminum-magnesium hydroxidesimethicone, and famotidine 20mg. Initial troponin I was 0.11ng/mL. Ddimer, urine drug screen, chest x-ray, and echocardiogram were normal. Repeat troponin 6 hours later was 11.3 and the EKG remained unchanged. Cardiac catheterization revealed a spontaneous coronary artery dissection (SCAD) in her distal left circumflex artery causing a 95% occlusion. No intervention was performed. She was discharged on aspirin and clopidogrel. Dextroamphetamine and amphetamine was discontinued. IMPACT/DISCUSSION: SCAD is a common cause of nonatherosclerotic coronary artery disease in women under age 50, accounting for 24% of myocardial infarctions [1] and recurrence is common. Young women with anxiety or GERD are often assumed to have noncardiac chest pain and may not be considered for coronary catheterization [2]. This may lead to underdiagnosis of SCAD. Pathophysiology of SCAD is not completely understood, but the proposed mechanism is an intimal tear or bleeding of vasa vasorum, causing a false lumen with an intramural hematoma. Early coronary angiography is critical for diagnosis. Risk factors include connective tissue disease, pregnancy, physical and emotional stress. Our patient was not pregnant and did not have a connective tissue disorder. While cocaine is typically associated with SCAD [3,4], her use was remote and urine test was negative. Interestingly, there are a few case reports showing an association between amphetamine use and risk of SCAD [5,6]. The scarcity of data could be due to rarity of the condition as well as under-diagnosis from lack of awareness that amphetamine use is a risk factor for SCAD. Appreciating amphetamine use as a possible risk factor for SCAD may prompt earlier recognition and treatment. Furthermore, heightening awareness among providers may trigger education of patients on the dangers of misusing or overusing amphetamines.
CONCLUSION(S): Patients with SCAD typically do not have risk factors for coronary artery disease; they are young, healthy and predominantly female. It is critical to maintain a high level of suspicion for SCAD in healthy patients who present with cardiac chest pain and to recognize stimulant medication use as a potential risk factor