Faculty Bibliography

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.

BACKGROUND: There's been a recent shift toward addressing social determinants of health (SDoH) during the clinical encounter through discussion and documentation. SDoH documentation in the problem list and through billing-related z-code use is necessary for accurate, individual patient and population level tracking andmay improve quality of care.We sought to better understand if/how providers document their patient's SDoH when elicited during a clinical visit.
METHOD(S): Unannounced Standardized Patients (USPs) were sent to two safety-net clinics to assess how medicine residents care for a new patient presenting with one of six unique chief complaints, and accompanying underlying financial, housing, and social concerns. USPs assessed resident practices after the encounter through a behaviorally anchored checklist and systematic chart review. USPs volunteered financial concerns while housing insecurity and social isolation needed to be elicited by the provider. Checklist items assessed if the USP was able to fully disclose their SDoH to the provider. Provider documentation in the electronic medical record (EMR) in one of three spaces: the history of present illness (HPI), the problem list, or through use of a social determinant-specific Zcode was examined when a USP was able to share their concerns.
RESULT(S): 384 USP visits were sent to medical residents from 2017 to 2019. USPs were able to share their financial concerns during 84% of the encounters, but were less likely to be able to share their housing or social concerns with providers (35% and 28%, respectively). Documentation in the HPI and treatment list remained low across cases (<15%) and only one Z-code was used across all visits. On an individual case level, providers addressed housing insecurity most frequently in the asthma case (discussion 65%; documentation: HPI 39%, Plan 16%) and social isolation in the fatigue case (discussion 57%; documentation: HPI 49%, Plan 2%). Providers were least likely to discuss and document SDoH for patients presenting with acute pain.
CONCLUSION(S): In clinical scenarios where SDoH concerns were elicited, residents documented SDoH in less than half of visits. Omission of SDoH not only effects clinical care but also panel management and SDoH population-level estimations. New education strategies are needed to address resident's ability to elicit and accurately document SDoH

BACKGROUND: The importance of addressing patients' social determinants of health (SDoH) is widely recognized, but less is known about how physicians specifically elicit, respond to, and document these determinants. We sought to describe resident practices when caring for a patient whose SDoH is integral to accurate diagnosis and treatment using Unannounced Standardized Patients (USPs).
METHOD(S): USPs were used (n=68) to assess how medicine residents responded to the consistent portrayal of a patient with asthma exacerbation and concern that her living situation (moldy, dilapidated housing) might be contributing to her symptoms. USPs, or "secret shoppers", were sent to two of New York's safety-net hospitals. Resident practices were assessed by the USP during a post-visit behaviorally-anchored checklist (7 items) and through a systematic chart review (3 items). Checklist items included whether or not a provider explored and fully elicited the USPs concerns, how they responded once shared, and what the provider actually did in response. Chart review items included whether or not a provider documented their patient's housing concerns in the history of present illness (HPI), problem list, or through use of a billingrelated Z-code.
RESULT(S): 68/79 consented residents participated: 11 PGY1 (16%), 31 PGY2 (46%), and 26 PGY3 (38%). 65% (44/68) of residents elicited the patient's housing SDoH and of those, 75% (33/44) responded by acknowledging/exploring and providing notes/practical support. 30% (10/33) connected the patient to informative resources or direct referral. Less than half (14/33; 42%) of those who acknowledge/explored documented appropriately in the EMR. No residents documented housing in the problem list or with a housing-related ICD10 Z-code. Of the 14 high performers, 6 successfully elicited, acknowledged, and documented housing concerns for one of our other five SDoH cases. More than half (55%) of the residents who elicited housing information connected the mold to the asthma exacerbation as a possible trigger, either during clinical interaction or in documentation. All but one (93%) of those who el icited, acknowledged, and documented made this connection.
CONCLUSION(S): Using USPs to directly observe resident practice behaviors in gathering information about, documenting and taking action on a consistently portrayed SDoH case closely linked to clinical symptoms is the first piece of the puzzle needed to better understand education and training that prepares physicians to address SDoH. Our study identifies practice gaps at all stages - adequately collecting information, understanding the clinical/ treatment consequences of, effectively responding to needs, and in documentation of SDoH. Future research should explore the influence of the clinical microsystem (e.g., SDoH screening tools, available resources and referrals, and workflows) on physician SDoH-related practices

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

OBJECTIVE:This analysis examined whether specific social, physical, and financial factors were associated with diet quality among older, community-dwelling women. METHODS:This cross-sectional analysis was conducted in a subset of 6,094 community-dwelling Women's Health Initiative participants who completed a food frequency questionnaire, administered from 2012 to 2013, and a self-administered supplemental questionnaire, administered approximately 1 year later. The supplemental questionnaire included five questions assessing social, physical, and financial factors related to eating. Diet quality was assessed with the Healthy Eating Index-2010 (HEI-2010; range of 0-100; higher score indicates a higher quality diet). The total HEI-2010 score was calculated by summing individual scores representing the intake of nine adequacy components (beneficial food groups) and three moderation components (food groups to limit). Associations of responses to the five questions on the supplemental questionnaire with HEI-2010 scores were examined with multiple linear regression, adjusting for relevant covariates. RESULTS:Mean ± standard deviation age of participants was 78.8 ± 6.7 years. Reporting eating fewer than two meals per day, having dental or other mouth problems causing problems with eating, and not always being able to shop, cook, or feed oneself were associated with statistically significantly lower HEI-2010 scores, compared with those not reporting these issues, after multivariable adjustment: 5.37, 2.98, and 2.39 lower scores, respectively (all P values <0.0001). Reporting eating alone most of the time and not always having enough money to buy food were not associated with HEI-2010 scores. CONCLUSIONS:Among older, community-dwelling women, eating fewer than two meals per day, dental and other mouth problems, and diminished ability to shop for food, prepare meals, and feed oneself were associated with lower diet quality. These are potential targets for interventions to improve diet quality in older women. : Video Summary:http://links.lww.com/MENO/A561.

LEARNING OBJECTIVE #1: Recognize the presentation of pure red cell aplasia caused from Azathioprine LEARNING OBJECTIVE #2: Distinguish key parts of history and lab findings that help diagnose pure red cell aplasia CASE: A 42-year-old female with a medical history of Crohn's disease, mixed connective tissue disease (MCTD), hypertension, and stage 3 chronic kidney disease, presented to the hospital with a complaint of fatigue and weakness for the previous two weeks. She was taking azathioprine, vedolizumab, and prednisone 5 mg for her Crohn's disease and MCTD. In addition, allopurinol was added 1.5 months prior. Initial lab workup revealed a macrocytic anemia with a hemoglobin of 7.5 mg/dl and a mean corpuscular volume of 100.9 fl. Previous CBCs showed a hemoglobin around 14 mg/dl with normal mean corpuscular volume. She reported no history concerning for bleed. She had normal ESR and CRP levels and an unremarkable CT abdomen. Folate and B12 levels were normal. She had a haptoglobin of 152 mg/dl, an LDH of 218 units/liter, and total bilirubin of .3 mg/dL, inconsistent with hemolysis. A peripheral smear did not reveal hypersegmented neutrophils. Her reticulocyte count was 0.58%, and absolute count of 0.013, which suggested bone marrow suppression. Her white blood cell count and platelets were both normal. A 6- thioguanine nucleotides RBC level was elevated at 559 pmol/8x10(8)RBC (normal 235-400). Her azathioprine was subsequently discontinued, and her symptoms improved. A CBC on follow up visit approximately 3.5 months after discharge showed a hemoglobin of 13 mg/dl. IMPACT/DISCUSSION: Azathioprine is a purine analogue that interferes with DNA synthesis and inhibits proliferation of rapidly growing cells. 6-mercaptopurine (6-MP) is a drug metabolite of azathioprine that is used in the treatment of autoimmune diseases such as Crohn's disease. This occurs in part by the active metabolite, 6-Thioguanine nucleotide (6- TGN). Bone marrow suppression has been documented as a possible adverse effect of azathioprine, which is thought to occur via 6-TGN. Rarely, the suppression can be specific for erythrocyte generation and lead to a pure red cell aplasia (PRCA). Of note, our patient recently began allopurinol treatment to attempt to increase efficacy of the azathioprine. This occurs in part due to the inhibition of one of the metabolic pathways of 6-MP via Xanthine oxidase which will lead to increased therapeutically active 6-TGN. This simultaneous use likely contributed to the elevated 6-TGN metabolites and myelosuppression. This occurs more commonly in patients with low levels of Thiopurine methyl transferase (TPMT), however, aplastic anemia secondary to azathioprine can occur in patients with normal TPMT activity.
CONCLUSION(S): Allopurinol is often added in combination with azathioprine in the treatment for Crohn's disease. If these patients present with fatigue and macrocytic anemia, drug induced pure red cell anemia must be considered

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

BACKGROUND: Internalizing a strong medical professional identity (PI) is a critical part of medical education. Recent studies of medical students have documented that students' PI, measured by the Professional Identity Essay (PIE), a reflective writing assessment of PI based on Kegan's theory of adult development and Bebeau's developmental model of PI, vary and are impacted by education. Little is known about the PI of exemplary professional physicians. We sought to: 1) describe the PI of physicians who exemplify the highest principles of the medical profession, and 2) evaluate NYU faculty identified as professional exemplars by peers to provide data and demonstrate clear role models for learners METHODS: We elicited nominations for professional exemplar physicians from NYU faculty, chief residents, and 4th-year students, using the definition of professionalism developed by Colby and Damon (1992). Participants were recruited after receiving at least 3 nominations; select participants who received 1 or 2 nominations were also recruited to diversify the participants in terms of specialty, years of practice, gender and race.We also used snowball techniques to get nominations fromstudy participants. After consenting, faculty received the 11-question PIE. We analyzed demographic data of nominated faculty and completed a content analysis of the PIE.
RESULT(S): 206 individual faculty were nominated at least one time by 70 community members. 32 individuals were recruited to the study; to date 22 have completed the PIE. The 206 nominees/22 participants represent: 34/12 specialties, average years in practice 17.6/23.8, range of years in practice 62 for nominees/44 for participants. We identified 3 primary themes through the content analysis: (1) Response to Expectations, "Everything. The profession demands everything.As much as this profession takes fromme, it is dwarfed by what I have received in return." (2) Response to Failure: "I fail to live up to expectations every day. Some days thismotivatesme, other days I disappoint myself." (3) Learning from Others: "I view teaching as integral to medical professionalism." There was a range of developmental levels in the responses with some focusing more on external rather than internal motivations: "I can say that the [malpractice] process for me was very threatening, emotionally consuming and had the potential to alter professional behavior in the wrong way."
CONCLUSION(S): Nominated faculty represented a diverse group with respect to PI. Many participants demonstrated great professionalism and a sense of internal PI in responses to the PIE questions, while others focused onmore externalmotivations to drive their professional behaviors. Further analysis is needed to define the qualities of a true exemplary professional. The range of responses of the exemplars can both serve as role models for learners and provide multiple pathways for learners and faculty to strengthen their own professional identities

Background/UNASSIGNED:The population detained in the New York City (NYC) jail system bears a high burden of hepatitis C virus (HCV) infection. Challenges to scaling up treatment include short and unpredictable lengths of stay. We report on the clinical outcomes of direct-acting antiviral (DAA) treatment delivered by NYC Health + Hospitals/Correctional Health Services in NYC jails from 2014 to 2017. Methods/UNASSIGNED:We performed a retrospective observational cohort study of HCV patients with detectable HCV ribonucleic acid treated with DAA therapy while in NYC jails. Some patients initiated treatment in jail, whereas others initiated treatment in the community and were later incarcerated. Our primary outcome was sustained virologic response at 12 weeks (SVR12). Results/UNASSIGNED:There were 269 patients included in our cohort, with 181 (67%) initiating treatment in jail and 88 (33%) continuing treatment started in the community. The SVR12 virologic outcome data were available for 195 (72%) individuals. Of these, 172 (88%) achieved SVR12. Patients who completed treatment in jail were more likely to achieve SVR12 relative to those who were released on treatment (adjusted risk ratio, 2.93; 95% confidence interval, 1.35-6.34). Of those who achieved SVR12, 114 (66%) had a subsequent viral load checked. We detected recurrent viremia in 18 (16%) of these individuals, which corresponded to 10.6 cases per 100 person-years of follow-up. Conclusions/UNASSIGNED:Hepatitis C virus treatment with DAA therapy is effective in a jail environment. Future work should address challenges related to discharging patients while they are on treatment, loss to follow-up, and a high incidence of probable reinfection.