Faculty Bibliography

BACKGROUND:Obesity is associated with higher risk for coronary artery calcium (CAC), but the relationship between body mass index (BMI) and mortality is complex and frequently paradoxical. METHODS:We analyzed BMI, CAC, and subsequent mortality using data from the CAC Consortium, a multi-centered cohort of individuals free of established cardiovascular disease (CVD) who underwent CAC testing. Mortality was assessed through linkage to the Social Security Death Index and cause of death from the National Death Index. Multivariable logistic regression was used to determine odds ratios for the association of clinically relevant BMI categories and prevalent CAC. Cox proportional hazards regression modeling was used to determine hazard ratios for coronary heart disease, CVD, and all-cause mortality according to categories of BMI and CAC. RESULTS:Our sample included 36 509 individuals, mean age 54.1 (10.3) years, 34.4% female, median BMI 26.6 (interquartile range, 24.1-30.1), 46.6% had zero CAC, and 10.5% had CAC ≥400. Compared with individuals with normal BMI, the multivariable adjusted odds of CAC >0 were increased in those overweight (odds ratio, 1.13 [95% CI, 1.1-1.2]) and obese (odds ratio, 1.5 [95% CI, 1.4-1.6]). Over a median follow-up of 11.4 years, there were 1550 deaths (4.3%). Compared with normal BMI, obese individuals had a higher risk of coronary heart disease, CVD, and all-cause mortality while overweight individuals, despite a higher odds of CAC, showed no significant increase in mortality. In a sex-stratified analysis, the increase in coronary heart disease, CVD, and all-cause mortality in obese individuals appeared largely limited to men, and there was a lower risk of all-cause mortality in overweight women (hazard ratio, 0.79 [95% CI, 0.63-0.98]). CONCLUSIONS:In a large sample undergoing CAC scoring, obesity was associated with a higher risk of CAC and subsequent coronary heart disease, CVD, and all-cause mortality. However, overweight individuals did not have a higher risk of mortality despite a higher risk for CAC.

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.

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

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

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: Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). However, readmissions from SNFs and immediately after SNF discharge are common. In this study, we examined whether patients with a primary hospital discharge diagnosis of HF may benefit from a HF disease management program (HF-DMP) while undergoing post-acute rehabilitation in SNFs.
METHOD(S): This is a sub-group analysis of a cluster-randomized controlled trial of HF-DMP vs usual care (UC) for patients in SNF (n=671) with a HF diagnosis, regardless of ejection fraction (EF), conducted in 47 SNFs in the Denver-metropolitan area. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by a HF nurse advocate (HFNA). The HFNA directed a 7- component intervention focused on optimizing HF disease management through the following: documentation of EF, symptom and activity assessment, weights 3 times a week with dietary surveillance, recommendations for medication titration, patient/caregiver education, discharge instructions, and 7-day post- SNF discharge follow-up. This sub-group analysis examined patients discharged from hospital to SNF with a primary hospital discharge diagnosis of HF (n=125). The primary outcome was a composite of all-cause hospitalization, emergency department visits, and mortality at 60 days post-SNF admission. The etiology (HF related, non-HF cardiovascular (CV) related, or "other") of the first event was adjudicated by a Clinical Endpoints committee that was blinded to treatment group. Secondary outcomes were the composite outcome at 30 days, and change in health status and self-management from baseline to 60 days measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Self-care of HF Index (SCHFI).
RESULT(S): Of the 125 patients with a primary hospital discharge diagnosis of HF, 50were in the HF-DMP and 75 in UC. Overallmean age was 79+/-10, 53% were women, mean EF was 46+/-15%. At 60 days, the rate of the composite outcome was lower in the HF-DMP group (30%) compared to UC (52%) (p=0.02). Adjudicated events in the HF-DMP group revealed one HF related event, one CV related event, and 12 events classified as "other" within 60 days. In contrast, the UC group had 12 HF related events, 5 CV related events, and 19 events classified as "other" within 60 days. The rate of the composite outcome at 30 days for the HFDMP group was 18% versus 31% in the UC group (p=0.11). Change in KCCQ and SCHFI measures were not significantly different between groups at 60 days.
CONCLUSION(S): Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while receiving rehabilitation in a SNF had lower rates of the composite outcome at 60 days and less HF related events. Standardized HF management during SNF stays may be particularly important for patients with a primary discharge diagnosis of HF