Faculty Bibliography

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.

BACKGROUND: Race, ethnicity, and language have been identified as factors impacting uptake of HIV testing. This project sought to compare testing rates between predominant and non-predominant ethnic, racial, or language populations within neighborhood FQHCs.
METHOD(S): We identified Family Health Center network locations at which more than 50% of patients served identified as the same race, and/ or had the same preferred language, and focused our analysis on these sites. We used Excel and SPSS to compare HIV testing rates between predominant and non-predominant population groups at each clinic.
RESULT(S): At 2 of 5 sites with a predominant non-English preferred language, speakers of the predominant language were more likely to receive an HIV test than speakers of other languages (p<0.001 for both sites). The other sites showed no difference by language. Of 2 clinics with a predominant racial population, there was no difference between predominant and non-predominant populations in terms of HIV testing. At all included sites, with one exception, Hispanic ethnicity was associated with a significantly higher rate of HIV testing.
CONCLUSION(S): Predominant/non-predominant race did not affect HIV testing rates, but language and ethnicity did. One mechanism for this may be increased trust associated with patient-provider language concordance, resulting in greater uptake of tests. There is a need for future research to further explore the factors associated with these findings

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.

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.

BACKGROUND: Social determinants of health (SDoH) play a significant role in health outcomes, but little is known about care teams' attitudes about addressing SDoH. Our safety-net clinic has begun to implement SDoH screening and referral systems, but efforts to increase clinical responses to SDoH necessitates an understanding of how providers and clinical teams see their roles in responding to particular SDoH concerns.
METHOD(S): An annual survey was administered (anonymously) to clinical care teams in an urban safety-net clinic from 2017-2019, asking about ten SDoH conditions (mental health, health insurance, food, housing, transportation, finances, employment, child care, education and legal Aid). For each, respondents rated with a 4-point Likert-scale whether they agreed that health systems should address it (not at all, a little, somewhat, a great deal). They also indicated their agreement (using strongly disagree, somewhat disagree, somewhat agree, strongly agree) with two statements 1) resources are available for SDoH and 2) I can make appropriate referrals.
RESULT(S): 232 surveys were collected (103 residents, 125 faculty and staff (F/S), 5 unknown) over three years. Of note, mental health (84%) and health insurance (79%) were seen as very important for health systems to address, with other SDoH items seen as very important by fewer respondents. They reported little confidence that the health system had adequate resources (51%) and were unsure how to connect patients with services (39%). When these results were broken out by year, we found the following: In 2017 (n=77), approximately 35% of respondents thought the issues of employment, childcare, legal aid, and adult education should be addressed "a little," but in 2018 (n=81) and 2019 (n=74) respondents found the health system should be more responsible, with over 35% of respondents stating that these four issues should be addressed "somewhat" by health systems. In addition, half of respondents in 2019 felt that financial problems should be addressed "a great deal," up from 31% in 2017. Across all years, food, housing, mental health, and health insurance were seen as SDoH that should be addressed "a great deal". It is of note that respondents across all years reported limited understanding of referral methods and options available to their patients.
CONCLUSION(S): Many of the SDoH conditions were seen by respondents as outside the purview of health systems. However, over the three years, more members increased the number of SDoH conditions that should be addressed a "great deal." Responses also indicated that many of the team members do not feel prepared to deal with "unmet social needs". Additional examination of clinic SDoH coding, referral rates, resources, and team member perspectives will deepen our understanding of how we can cultivate a culture that enables team members to respond to SDoH in a way that is sensitive to their needs and patient needs

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the establishment of a Diabetes Prevention Clinic for veterans with prediabetes.

LEARNING OBJECTIVE #1: Recognize PVS as a sequela of severe chronic iron deficiency anemia LEARNING OBJECTIVE #2: Manage a patient with PVS using a multidisciplinary approach CASE: A 46yoF presented with subacute leg edema and exertional dyspnea. She had no medical history aside from two remote uncomplicated vaginal deliveries. She immigrated to theUnited States from Mexico 20 years ago and had limited contact with healthcare. On review of systems, she had mild esophageal reflux, abdominal swelling and heavy painfulmenses. Vitals were within normal limits with an exam notable for conjunctival pallor, systolic ejection murmur, jugular venous distension, bibasilar pulmonary crackles, palpable non-tender lower abdominal mass, and 1+ pitting edema of the lower extremities. Labs were notable for a hemoglobin (Hg) of 3.3 with MCV 54.2, iron 15, TIBC 416 and reticulocyte count 1.82. Transthoracic echocardiogram showed elevated right and left atrial pressures, grade II diastolic dysfunction and normal ejection fraction. Transvaginal Ultrasound (TVUS) showed multiple large fibroids. Esophagogastroduodenoscopy (EGD) revealed an anterior esophageal web below the upper esophageal sphincter, redemonstrated on esophagram, confirming the diagnosis of PVS. She received 3 units of RBCs with improvement of Hg to 8.3 with a rapid approach to euvolemia following intravenous diuresis. She was discharged with weekly intravenous iron infusions and follow-up with Primary Care, Hematology, Gastroenterology and Gynecology as well as the Legal Immigration Health Clinic to assist with obtaining insurance. IMPACT/DISCUSSION: For this patient, lack of access to healthcare and untreated menorrhagia led to a severe iron deficiency anemia (IDA) causing transient high-output heart failure and PVS. PVS is a rare condition characterized by a triad of dysphagia, IDA and post-cricoid esophageal webs. First described in 1912, the prevalence of PVS has declined worldwide paralleling IDA. It is nowmore common in developing nations and affects women more than men at a ratio of 8.5 to 1.Work-up includes EGD and esophagram to identify webs with a colonoscopy and TVUS to identify sources of blood loss. Iron supplementation improves dysphagia, though in severe cases, patients may require endoscopic dilation. While the prognosis of PVS is good, there is an association with esophageal squamous cell cancer and gastric adenocarcinoma, so annual surveillance is recommended. The primary care physician (PCP) is essential in coordinating a multidisciplinary approach in symptom management, identification and prevention of blood loss, malignancy screening, and involvement of social workers and legal services to ensure continued access to care.
CONCLUSION(S):While the causal relationship has not been proven, PVS is a rare sequela of severe chronic IDA and carries the potential for significant morbidity and risk of malignancy. The PCP has an important role in coordinating the multidisciplinary care of a patient with PVS including continued access to healthcare

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

BACKGROUND: A mature medical professional identity (PI) is a fundamental outcome of medical education (Irby and Hamstra, 2016) and medical schools across the country are developing approaches to support professional identity formation (PIF) in students. Reflective capacity, not just in the moment but as a broad skill, is key to core professional competency and may underlie PIF (Wald, 2015). Yet the relationship between reflective capacity and PIF is not well understood. Do these two concepts assess the same developmental capacity? Is reflective capacity a prerequisite for professional identity development? This pilot study is an initial attempt to explore this issue and to examine the relationship between written reflective capacity and professional identity development.
METHOD(S): As part of a professionalism curriculum medical students complete the Professional Identity Essay (PIE) at three time points: upon entrance to the school, after basic science courses, and after clinical rotations. The PIE (Bebeau and Lewis 2004), based on Kegan's developmental model (1982), requires responses to 9 prompts which elicit conceptions of the professional role. It is scored on a 5-point scale reflecting Kegan's 5 stages, with transitional stages captured by half-points. For this study, we randomly selected 20 PIE protocols from the 100 completed by the Class of 2020 after their basic science curriculum. These were scored by three raters (VM, AK, LA). Interrater reliability was established by reaching 100% agreement within one half stage on the PIE. The same raters scored the PIE protocols with the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT), following the scoring criteria (Wald 2010, Wald 2012). For both the PIE and REFLECT we averaged the three raters into a single score. A Pearson two-tailed correlation was then computed between the two scales.
RESULT(S): Completed scores on both measures were available for 19 of the 20 PIES. The range of PIE scores was 2.5-4, as would be expected of students at this point in their careers (Kalet 2018). REFLECT scores ranged 2-4. There was a statistically significant moderate positive correlation between the PIE and REFLECT (r=.628, p=.004), with REFLECT scores explaining 39% of the variance of PIE scores.
CONCLUSION(S): The correlation between PIE scores and REFLECT ratings suggests that the PIE captures and reflects some elements of learners' reflective capacity. However there remains a large component of the PIE score not explained by reflective capacity, which suggests that the PIE, as a standalone measure of PIF, demonstrates qualities beyond reflective capacity. Further investigation is warranted in order to tease out the interplay between these two concepts. Understanding the relationship between PIF and reflective capacity can inform educators in promoting a more nuanced and sophisticated PI development in students

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.