Faculty Bibliography

Background: Delirium occurs commonly in hospitalized older adults. Clinicians investigate frequent causes of delirium such as infection, metabolic derangement, intracranial disorders, urinary and fecal disorders, and medication. The complexity in treating the underlying cause of delirium is the treatment of one contributing factor (e.g. infection), may in fact be the source of the confusion. Case report: We evaluated a 95 year old woman with atrial fibrillation, severe aortic stenosis, chronic kidney disease, heart failure, and clostridium difficile who presented to the hospital with shortness of breath. White blood cell count was elevated and CT chest revealed moderate patchy consolidation in the lung. The patient was started on Vancomycin, Aztreonam, and Cefepime for multidrug resistant pneumonia. At baseline she has no dementia and there was no concern for delirium on presentation. Hospital days 4-6 she became lethargic but remained clinically stable without a change in infectious markers. By hospital day 8 she completed the course of Cefepime but was nonverbal and opened her eyes only when directly stimulated. The only notable lab change was an uptrend of creatinine from 1.09 to 1.70 in the setting of diuresis for fluid overload. Mental status remained poor through hospital day 10. CT brain revealed moderate global volume loss. There was no evidence of a new infection, hypercarbia, or other metabolic derangements. EEG was not completed per family preference. By hospital day 12, 4 days after the cessation of Cefepime, her mental status began to improve and returned almost back to baseline before discharge.
Discussion(s): Cefepime is known to have neurotoxic effects that may include depressed consciousness, encephalopathy, aphasia, myoclonus, seizures, and coma. The primary risk factors for Cefepime neurotoxicity are renal impairment and blood-brain barrier dysfunction from systemic inflammation. Older age is a commonly reported clinical risk factor. Neurotoxic effects are noted a median of 4 days after initiation with reduced consciousness most commonly seen. The neurotoxic symptoms may resolve a median of 2 days after discontinuation. The literature findings mimic what was seen in this case. This case reinforces the need to consider the multifactorial contribution to delirium etiology. Cefepime induced neurotoxicity should be considered for infected patients with persistent hypoactive delirium

Background: Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders. The effectiveness of PPIs has led to overutilization, exposing patients to an increasing number of potential risks. Despite FDA safety warnings regarding the potential adverse effects of long-term PPI use, there has been a failure to re-evaluate the need for continued therapy. The VA Manhattan outpatient Geriatrics clinic, in collaboration with pharmacists and patients, conducted a quality improvement (QI) program using a shared decision-making approach to deprescribe inappropriate PPIs.
Method(s): Patients with PPIs ordered from April, 2017 to April, 2018 were identified using the VA database. Diagnoses were identified using ICD 10 codes. Patients without a clear indication for longterm PPI treatment were identified (long term PPI use is indicated in refractory GERD, Barrett's esophagus, Zollinger-Ellison syndrome, idiopathic chronic peptic ulcer, and bleeding prevention in selected patients). Patients were contacted telephonically by a physician or pharmacist, counseled regarding adverse effects of long-term PPI use and offered titration/discontinuation or change to an alternative agent. If patients consented, they were contacted for follow-up interviews at 1, 3, 6, 12 months after inclusion to assess symptoms and tolerance.
Result(s): Of the1230 patients in the Geriatrics clinic, 74 (6%) were on PPIs. Of these, 41/74 (55%) had no indication for chronic PPI use. 36 of 41 patients consented to participate. We were able to titrate and discontinue or switch to an H2 antagonist in 20 (55%) of the 36 patients but 15 (42%) were restarted on PPI for recurrence of GERD symptoms over the 12 months of follow-up. 1 patient died of natural causes.
Conclusion(s): This QI program successfully deprescribed inappropriate long-term PPIs in some patients without major adverse events by using an interdisciplinary approach and shared decision- making process with patients. However, a sizable proportion of patients required restarting of a PPI for GERD symptoms. Future work is needed to understand if GERD symptom control can be achieved by other means to further decrease PPI use

Background: Patients with respiratory failure who require prone positioning are not considered good candidates for PD due to the concerns for increased intra-abdominal pressure, impaired diaphragmatic movement, and leaking of peritoneal fluid. We addressed the COVID-related AKI (CRAKI) surge for renal replacement therapy (RRT) by initiating an acute PD program at Bellevue Hospital including prone patients.
Method(s): All patients were in the ICU with COVID related hypoxic respiratory failure and acute kidney injury (AKI). 6/35 patients who received PD were treated for 16 hours per day in the prone position to improve oxygenation. The mean age was 54.6. The average BMI was 35.5. Patients were on mechanical ventilation 12-33 days. 3/6 patients were on CVVH however, switched to PD due to clotting. Patients were on PD for an average of 9.3 days. All PD catheters were placed at the bedside using an open cut down technique. PD was started the same day using manual exchanges. Dwell volume was gradually increased to 2 L. Exchanges were performed q1h while supine and q2h while prone, a total of 4-6 exchanges/day. The PD team coordinated timing with the prone team and ICU nurses to allow the continuation of the PD treatment. Patients were monitored clinically for abdominal distention and changes in respiratory mechanics.
Result(s): All 6 patients remained on PD for the duration of the hospitalization. There were no incidences of bowel injury, hemorrhage, exit-site infections, or peritonitis. None of the patients had any catheter malfunction. Leaking was addressed with temporarily reducing the dwell volume. Patients experienced slow draining which was due to kinking of the tubing during prone positioning. All patients were able to continue receiving PD without interruptions. Either no change or improvement in ABG and ventilator settings was noted after prone positioning and PD.
Conclusion(s): Due to COVID related surge, we saw a significant number of patients in the ICU with severe acute respiratory failure requiring prone positioning who also developed AKI requiring RRT. We were able to successfully provide acute PD in ventilator-dependent prone patients suffering from CRAKI. This required a team effort and some modifications in the conventional PD prescription. (Figure Presented)

BACKGROUND:Relevant clinical information is often missing when a patient sees a specialist after being referred by another physician in the ambulatory setting. This can result in missed or delayed diagnoses, delayed treatment, unnecessary testing, and drug interactions. Residents' attitudes toward providing clinical information at the time of referral and their perspectives toward training on referral skills are not clear. We sought to assess internal medicine residents' attitudes toward and experiences with outpatient referrals. METHODS:We conducted a cross-sectional survey in October-December 2018 of all internal medicine interns and residents affiliated with a large, urban internal medicine residency program in New York, NY. We used a novel survey instrument that included 13 questions about attitudes toward and experiences with outpatient referrals. We used descriptive statistics to characterize the results. RESULTS:Overall, 122 of 132 residents participated (92% response rate). Respondents were approximately equally distributed across post-graduate years 1-3. Although 83% of residents reported that it is "always" important to provide the clinical reason for a referral, only 11% stated that they "always" provide a sufficient amount of clinical information for the consulting provider when making a referral. Only 9% of residents "strongly agree" that residency provides sufficient training in knowing when to refer patients, and only 8% "strongly agree" that residency provides sufficient training in what information to provide the consulting physician. CONCLUSIONS:These results suggest a substantial discrepancy between the amount of information residents believe they should provide at the time of a referral and the amount they actually provide. Many residents report not receiving adequate training during residency on when to refer patients and what clinical information to provide at the time of referral. Improvements to medical education regarding outpatient referrals are urgently needed.

Background/UNASSIGNED:Telemedicine holds promise to bridge the transition of care between inpatient and outpatient settings. Despite this, the unique communication and technical skills required for virtual encounters are not routinely taught or practiced in graduate medical education (GME) programs. Objective/UNASSIGNED:To develop an objective structured clinical examination (OSCE) case to assess residents' telemedicine-specific skills and identify potential gaps in our residency program's curriculum. Methods/UNASSIGNED:As part of a multi-station OSCE in 2019, we developed a case simulating a remote encounter between a resident and a recently discharged standardized patient. We developed an assessment tool comprising specific behaviors anchored to "not done," "partly done," and "well done" descriptors to evaluate core communication and telemedicine-specific skills. Results/UNASSIGNED:Seventy-eight NYU internal medicine residents participated in the case. Evaluations from 100% of participants were obtained. Residents performed well in Information Gathering and Relationship Development domains. A mean 95% (SD 3.3%) and 91% (SD 4.9%) of residents received "well done" evaluations across these domains. A mean 78% (SD 14%) received "well done" within Education/Counseling domain. However, only 46% (SD 45%) received "well done" evaluations within the Telemedicine domain; specific weak areas included performing a virtual physical examination (18% well done) and leveraging video to augment history gathering (17% well done). There were no differences in telemedicine-specific skill evaluations when stratified by training track or postgraduate year. Conclusions/UNASSIGNED:We simulate a post-discharge virtual encounter and present a novel assessment tool that uncovers telemedicine-specific knowledge gaps in GME trainees.

Background/UNASSIGNED:Montefiore Medical Center (MMC) is a large tertiary care center in the Bronx, New York City, with 245 internal medicine residents. Beginning on February 29, 2020, residents became ill with COVID-19-like illness (CLI), which required absence from work. There was initially a shortage of personal protective equipment and delays in SARS-CoV-2 testing, which gradually improved during March and April 2020. Objective/UNASSIGNED:We evaluated the relationship between CLI-related work absence rates of internal medicine residents and MMC's COVID-19 hospital census over time. Methods/UNASSIGNED:Data on resident work absence between February 29 and May 22 were reviewed along with MMC's COVID-19 hospital census data. To determine the effect of patient exposure on resident CLI incidence, we compared the mean incidence of CLI per patient exposure days (PED = daily hospital census × days pre- or post-peak) before and after peak COVID-19 hospital census. Results/UNASSIGNED:= .003). Conclusions/UNASSIGNED:At the beginning of the COVID-19 pandemic in New York City, a large portion of internal medicine residents at this single center became ill. However, the incidence of CLI decreased over time, despite ongoing exposure to patients with COVID-19.

Aims/UNASSIGNED:To define outcomes of patients with COVID-19 compared to patients without COVID-19 suffering in-hospital cardiac arrest (IHCA). Materials and methods/UNASSIGNED:We performed a single-center retrospective study of IHCA cases. Patients with COVID-19 were compared to consecutive patients without COVID-19 from the prior year. Return of spontaneous circulation (ROSC), 30-day survival, and cerebral performance category (CPC) at 30-days were assessed. Results/UNASSIGNED:Fifty-five patients with COVID-19 suffering IHCA were identified and compared to 55 consecutive IHCA patients in 2019. The COVID-19 cohort was more likely to require vasoactive agents (67.3% v 32.7%, p = 0.001), invasive mechanical ventilation (76.4% v 23.6%, p < 0.001), renal replacement therapy (18.2% v 3.6%, p = 0.029) and intensive care unit care (83.6% v 50.9%, p = 0.001) prior to IHCA. Patients with COVID-19 had shorter CPR duration (10 min v 22 min, p = 0.002). ROSC (38.2% v 49.1%, p = 0.336) and 30-day survival (20% v 32.7%, p = 0.194) did not differ. A 30-day cerebral performance category of 1 or 2 was more common among non-COVID patients (27.3% v 9.1%, p = 0.048). Conclusions/UNASSIGNED:Return of spontaneous circulation and 30-day survival were similar between IHCA patients with and without COVID-19. Compared to previously published data, we report greater ROSC and 30-day survival after IHCA in COVID-19.

Fifty-six percent of high-needs NYC cancer patients are food insecure, at times choosing between medical treatment and food. We describe FOOD (Food to Overcome Outcome Disparities), an innovative intervention, which has established eleven medically tailored food pantries in NYC cancer centers and distributed the equivalent of 307,080 meals since 2011.

PURPOSE:To describe the effect of transgender health-related objective structured clinical examination (THOSCE) case exposure on learner activation regarding gender-affirming care. METHOD:A modified grounded theory approach was applied to identify the educational value of THOSCE cases. Focus groups with current and former primary care internal medicine residents who participated in THOSCE cases were conducted in 2018-2019. Transcripts were analyzed and coded until saturation to identify themes. RESULTS:Eighteen (72%) eligible learners participated in the focus groups. Themes were identified relating to gender-affirming care, and modified grounded theory analysis was used as a framework to organize the themes into 4 stages of learner activation: (1) believing the learner role is important, (2) having the confidence and knowledge necessary to take action, (3) taking action to maintain and improve one's skills, and (4) staying the course even under stress. CONCLUSIONS:Residents were grateful for the opportunity to practice the skills involved in transgender health in a simulation. Many felt unprepared and were concerned about how they were perceived by the standardized patient and faculty. Residents identified feeling more comfortable with gender-affirming language in the inpatient setting, which may provide an opportunity for learning in the future. Residents identified the psychosocial skills of gender-affirming care as more directly relevant while biomedical aspects of gender-affirming care seemed less accessible to residents, given the lack of outpatient experience. The authors propose a staged approach to teaching the skills of gender-affirming care using simulation to address learners of all levels.