Faculty Bibliography

Student-run clinics are settings in which learners are empowered to design service delivery. Despite shared challenges faced by these clinics in improving clinical and educational programming, information exchange and collaboration between clinics of different institutions and professions are inefficiently facilitated by existing platforms. An abridged, one-hour hackathon event was piloted at the Society of Student-Run Free Clinics' 2018 Annual Conference. During the event, interprofessional teams were guided through defining a problem, ideating and prototyping possible solutions, and sharing them with the larger group. There were 23 participants representing 16 institutions and 5 professions; most had never discussed their clinic's problems with members of other institutions before. Teams generated novel ideas that culminated from a combination of existing local best practices or focused on developing infrastructure between clinics. Feedback of the event was positive; participants felt confident to design and implement solutions and collaborate with other clinics after the event. The abridged hackathon shows promise to facilitate communication and innovation among diverse groups across institutions.

OBJECTIVES:This study thoroughly explored the demographic and imaging characteristics, as well as the all-cause and cause-specific mortality risks of patients with a coronary artery calcium (CAC) score ≥1,000 in the largest dataset of this population to date. BACKGROUND:CAC is commonly used to quantify cardiovascular risk. Current guidelines classify a CAC score of >300 or 400 as the highest risk group, yet little is known about the potentially unique imaging characteristics and mortality risk in individuals with a CAC score ≥1,000. METHODS:A total of 66,636 asymptomatic adults were included from the CAC consortium, a large retrospective multicenter clinical cohort. Mean patient follow-up was 12.3 ± 3.9 years for patients with cardiovascular disease (CVD), coronary heart disease (CHD), cancer, and all-cause mortality. Multivariate Cox proportional hazards regression models adjusted for age, sex, and conventional risk factors were used to assess the relative mortality hazard of individuals with CAC ≥1,000 compared with, first, a CAC reference of 0, and second, with patients with a CAC score of 400 to 999. RESULTS:There were 2,869 patients with CAC ≥1,000 (86.3% male, mean 66.3 ± 9.7 years of age). Most patients with CAC ≥1,000 had 4-vessel CAC (mean: 3.5 ± 0.6 vessels) and had greater total CAC area, higher mean CAC density, and more extracoronary calcium (79% with thoracic artery calcium, 46% with aortic valve calcium, and 21% with mitral valve calcium) than those with CAC scores of 400 to 999. After full adjustment, those with CAC ≥1,000 had a 5.04- (95% confidence interval [CI]: 3.92 to 6.48), 6.79- (95% CI: 4.74 to 9.73), 1.55- (95% CI:1.23 to 1.95), and 2.89-fold (95% CI: 2.53 to 3.31) risk of CVD, CHD, cancer, and all-cause mortality, respectively, compared to those with CAC score of 0. The CAC ≥1,000 group had a 1.71- (95% CI: 1.41 to 2.08), 1.84- (95% CI: 1.43 to 2.36), 1.36- (95% CI:1.07 to 1.73), and 1.51-fold (95% CI: 1.33 to 1.70) increased risk of CVD, CHD, cancer, and all-cause mortality compared to those with CAC scores 400 to 999. Graphic analysis of CAC ≥1,000 patients revealed continued logarithmic increase in risk, with no clear evidence of a risk plateau. CONCLUSIONS:Patients with extensive CAC (CAC ≥1,000) represent a unique very high-risk phenotype with mortality outcomes commensurate with high-risk secondary prevention patients. Future guidelines should consider CAC ≥1,000 patients to be a distinct risk group who may benefit from the most aggressive preventive therapy.

OBJECTIVE:Cardiovascular responses to hypovolemia and hypotension are depressed during general anesthesia. A considerable number of anesthetized and critically ill animals may not benefit hemodynamically from a fluid bolus; therefore, it is important to have measures for accurate prediction of fluid responsiveness. Static measures of preload, such as central venous pressure, do not provide accurate prediction of fluid responsiveness, whereas dynamic measures of cardiovascular function, obtained during positive pressure ventilation, are highly predictive. This review describes key physiological concepts behind heart-lung interactions during positive pressure ventilation, factors that can modify this relationship and provides the basis for a rational interpretation of the information obtained from dynamic measurements, with a focus on pulse pressure variation (PPV). DATABASE USED/UNASSIGNED:PubMed. Search items used were: heart-lung interaction, positive pressure ventilation, pulse pressure variation, dynamic index of fluid therapy, goal-directed hemodynamic therapy, dogs, cats, pigs, horses and rabbits. CONCLUSIONS:The veterinary literature suggests that targeting specific PPV thresholds should guide fluid therapy in lieu of conventional assessments. Understanding the physiology of heart-lung interactions during intermittent positive pressure ventilation provides a rational basis for interpreting the literature on dynamic indices of fluid responsiveness, including PPV. Clinical trials are needed to evaluate whether goal-directed fluid therapy based on PPV results in improved outcomes in veterinary patient populations.

BACKGROUND:The Coronary Artery Calcium Data and Reporting System (CAC-DRS), which takes into account the Agatston score category (A) and the number of calcified vessels (N) has not yet been validated in terms of its prognostic significance. METHODS:We included 54,678 patients from the CAC Consortium, a large retrospective clinical cohort of asymptomatic individuals free of baseline cardiovascular disease (CVD). CAC-DRS groups were derived from routine, cardiac-gated CAC scans. Cox proportional hazards regression models, adjusted for traditional CVD risk factors, were used to assess the association between CAC-DRS groups and CHD, CVD, and all-cause mortality. CAC-DRS was then compared to CAC score groups and regional CAC distribution using area under the curve (AUC) analysis. RESULTS:The study population had a mean age of 54.2 ± 10.7, 34.4% female, and mean ASCVD score 7.3% ± 9.0. Over a mean follow-up of 12 ± 4 years, a total of 2,469 deaths (including 398 CHD deaths and 762 CVD deaths) were recorded. There was a graded risk for CHD, CVD and all-cause mortality with increasing CAC-DRS groups ranging from an all-cause mortality rate of 1.2 per 1,000 person-years for A0 to 15.4 per 1,000 person-years for A3/N4. In multivariable-adjusted models, those with CAC-DRS A3/N4 had significantly higher risk for CHD mortality (HR 5.9 (95% CI 3.6-9.9), CVD mortality (HR4.0 (95% CI 2.8-5.7), and all-cause mortality a (HR 2.5 (95% CI 2.1-3.0) compared to CAC-DRS A0. CAC-DRS had higher AUC than CAC score groups (0.762 vs 0.754, P < 0.001) and CAC distribution (0.762 vs 0.748, P < 0.001). CONCLUSION/CONCLUSIONS:The CAC-DRS system, combining the Agatston score and the number of vessels with CAC provides better stratification of risk for CHD, CVD, and all-cause death than the Agatston score alone. These prognostic data strongly support new SCCT guidelines recommending the use CAC-DRS scoring.

Internet-facilitated self-diagnosis and treatment is becoming more prevalent, putting individuals at risk of toxicity when drugs are acquired without medical oversight. We report a patient with delusional parasitosis who consumed veterinary albendazole purchased on the Internet, leading to pancytopenia, transaminase elevation, and alopecia. A 53-year-old man was sent to the emergency department (ED) by his gastroenterologist because of abnormal laboratory results. The patient had chronic abdominal pain and believed he was infected with parasites. He purchased two bottles of veterinary-grade albendazole on the Internet, and over the 3 weeks before his ED visit, he consumed 113.6 g of albendazole (a normal maximal daily dose is 800 mg). Five days before admission, he noticed hair loss and a rash on his face. His examination was notable for significant scalp hair loss and hyperpigmentation along the jaw line. Laboratory studies were remarkable for pancytopenia (most notably a WBC of 0.4 × 10³ cells/mm³, with an absolute neutrophil count (ANC) of 0 × 10³ cells/mm³) and transaminase elevation (AST 268 IU/L, ALT 89 IU/L). He developed a fever and was treated with antibiotics and colony-stimulating factors for presumed neutropenic bacteremia. Over the course of 1 week, his hepatic function normalized and his ANC increased to 3,000 × 10³ cells/mm³. Serial albendazole and albendazole sulfoxide concentrations were measured in serum and urine by liquid chromatography-quadruple time-of-flight mass spectrometry. On day 2, his serum concentrations were 20.7 ng/mL and 4,257.7 ng/mL for albendazole and albendazole sulfoxide, respectively. A typical peak therapeutic concentration for albendazole sulfoxide occuring at 2-5 hours post-ingestion is 220-1,580 ng/mL. Known adverse effects of albendazole include alopecia, transaminase elevation, and neutropenia. Pancytopenia leading to death from septic shock is reported. In our patient, prolonged use of high-dose albendazole resulted in a significant body burden of albendazole and albendazole sulfoxide, leading to pancytopenia, transaminase elevation, and alopecia. He recovered with supportive therapy.

Objectives/UNASSIGNED:Detecting instantaneous stroke volume change in response to altered cardiac preload is the physiologic foundation for determining preload responsiveness. Design/UNASSIGNED:Proof-of-concept physiology study. Setting/UNASSIGNED:Research simulation laboratory. Subjects/UNASSIGNED:Twelve healthy volunteers. Interventions/UNASSIGNED:A wireless continuous wave Doppler ultrasound patch was used to measure carotid velocity time integral and carotid corrected flow time during a squat maneuver. The Doppler patch measurements were compared with simultaneous stroke volume measurements obtained from a noninvasive cardiac output monitor. Measurements and Main Results/UNASSIGNED:= 0.81 and 0.62, respectively). The four-quadrant plot found a 100% concordance rate between changes in stroke volume and both changes in carotid velocity time integral and changes in corrected flow time. A change in carotid velocity time integral greater than 15% predicted a change in stroke volume greater than 10% with a sensitivity of 95% and a specificity of 92%. A change in carotid corrected flow time greater than 4% predicted a change in stroke volume greater than 10% with a sensitivity of 90% and a specificity of 92%. Conclusions/UNASSIGNED:In healthy volunteers, both carotid velocity time integral and carotid corrected flow time measured by a wireless Doppler patch were useful to track changes in stroke volume induced by a preload-modifying maneuver with high sensitivity and specificity.

PURPOSE OF REVIEW/OBJECTIVE:Plant-based diets have been used with growing popularity for the treatment of a wide range of lifestyle-related diseases, including diabetes, hypertension, and obesity. With the reinvigoration of the conservative and dietary management of chronic kidney disease (CKD) and the use of low protein diets for secondary prevention of CKD to delay or prevent dialysis therapy, there is an increasing interest in the potential role of plant-based diets for these patients. RECENT FINDINGS/RESULTS:Recently, a body of evidence related to the role of plant-based diet in preventing CKD has reemerged. Several observational studies have shown that red and processed meat have been associated with increased risk of CKD as well as faster progressing in those with preexisting CKD. In several substitution analyses, replacement of one serving of red and/or processed meat has been linked with sizable reductions in CKD risk as primary prevention. Although limited, experimental trials for the treatment of metabolic acidosis in CKD with fruits and vegetables show outcomes comparable to oral bicarbonate. The use of plant-based diets in CKD may have other benefits in the areas of hypertension, weight, hyperphosphatemia, reductions in hyperfiltration, and, possibly, mortality. The risk of potassium overload from plant-based diets appears overstated, mostly opinion-based, and not supported the evidence. Plant-based diets are generally well tolerated and provide adequate protein intake, including essential amino acids as long as the is correctly implemented. SUMMARY/CONCLUSIONS:Plant-based diets should be recommended for both primary and secondary prevention of CKD. Concerns of hyperkalemia and protein inadequacy related to plant-based diets may be outdated and unsupported by the current body of literature. Healthcare providers in general medicine and nephrology can consider plant-based diets as an important tool for prevention and management of CKD.

Background/UNASSIGNED:There are limited data on the social and cultural determinants of dietary intake in Chinese Americans. Over 560,000 New York City residents are Chinese American, and there has been a growing trend over the past 30 y of permanent migration from China to the USA. Objectives/UNASSIGNED:The purpose of this secondary data analysis is to describe associations between diet, measured by self-report, and diet quality, with level of acculturation in a cross-sectional sample of urban-dwelling Chinese American immigrants. Methods/UNASSIGNED:This was a cross-sectional study involving 2071 foreign-born Chinese American adults. Acculturation was assessed using the Stephenson Multigroup Acculturation Scale, diet using a Chinese-adapted FFQ, and diet quality using the Alternative Healthy Eating Index (AHEI). Multivariable regression was used to assess associations between ethnic (ESI; Chinese) and dominant (DSI; American) society immersion scores with self-reported dietary measures. Results/UNASSIGNED: = 0.025) higher red and processed meat component score. Conclusions/UNASSIGNED:Assessment of acculturation level may help to tailor dietary strategies that are appropriate to what Chinese American immigrant communities are consuming to more effectively decrease the risk of chronic disease.