Faculty Bibliography

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: 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

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

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.

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

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/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.