Faculty Bibliography

BACKGROUND:Visceral infarctions appear to be more common in patients with embolic stroke subtypes, but their relation to troponin elevation remains uncertain. METHODS:Among patients with acute ischemic stroke enrolled in the Cornell AcutE Stroke Academic Registry (CAESAR) from 2011 to 2016, we included those with troponin measured within 24 hours from stroke onset and a contrast-enhanced abdominal computed tomographic scan within 1 year of admission. A troponin elevation was defined as a value exceeding our laboratory's upper limit of normal (.04 ng/ mL) in the absence of a clinically recognized acute ST-segment elevation myocardial infarction. Visceral infarction was defined as a renal or splenic infarction as ascertained by a single radiologist blinded to patients' other characteristics. Multivariable logistic regression was used to evaluate the association between elevated troponin and visceral infarction. RESULTS:Among 2116 patients registered in CAESAR from 2011 to 2016, 153 patients had both a troponin assay and a contrast-enhanced abdominal computed tomographic scan, of whom 33 (21%) had an elevated troponin and 22 (14%) had a visceral infarction. The prevalence of visceral infarction was higher among patients with an elevated troponin (30%; 95% confidence interval [CI], 16%-49%) than among patients without an elevated troponin (10%; 95% CI, 5%-17%) (P = .003). After adjustment for demographics and comorbidities, we found a significant association between elevated troponin and visceral infarction (odds ratio, 3.9; 95% CI, 1.5-10.4). CONCLUSIONS:Among patients with acute ischemic stroke, elevated troponin was associated with visceral infarction. Our results demonstrate that poststroke troponin elevation may indicate the presence of underlying embolic sources.

Purpose of review/UNASSIGNED:Antiretroviral therapy has enabled many people with HIV to live long lives with their infection, but the literature suggests that long term survivors are developing comorbidities and aging-related syndromes at earlier ages than their non-infected counterparts. In addition, there is evidence or sex-based differences in comorbidity risk. Recent findings/UNASSIGNED:How to best care for people aging with HIV is not known, but the tools of comprehensive geriatric assessment can identify people at risk for decline. Newer antiretroviral therapies offer promise of fewer side effects and drug interactions. We will also discuss special needs of women aging with HIV. Summary/UNASSIGNED:People with HIV and their providers are often unprepared to confront issues of aging, and each clinical program must develop methods to assess older patient and manage age-related complications and syndromes.

BACKGROUND/OBJECTIVE/OBJECTIVE:The connection between gout and various cancers remains unclear. We assessed the relationship between gout and colorectal cancer in a population of veterans. METHODS:We reviewed the Computerized Patient Record System of the VA New York Harbor Health Care System to assess the 10-year occurrence of colorectal cancer in patients with gout undergoing colonoscopy, versus patients with osteoarthritis but no gout. RESULTS:Gout and osteoarthritis subjects were similar in age, ethnicity, body mass index, and smoking history. Among 581 gout and 598 osteoarthritis subjects with documented colonoscopies, the 10-year prevalence of colorectal cancer was significantly lower in gout (0.8%) versus osteoarthritis (3.7%) (p = 0.0008) patients. Differences in colorectal cancer rates remained significant after stratifying for nonsteroidal anti-inflammatory drug use. Among gout subjects, use of colchicine and/or allopurinol, as well as the presence/absence of concomitant osteoarthritis, did not influence colorectal cancer occurrence. On subanalysis, differences in colorectal cancer occurrence between gout and osteoarthritis subjects persisted among those who underwent diagnostic (0.5% in gout vs 4.6% in osteoarthritis subjects, p < 0.001) but not screening (0.9% in gout subjects vs 1% in osteoarthritis subjects, p = 1.0) colonoscopy. There was no significant difference in nonmalignant colorectal polyp occurrence between gout and osteoarthritis subjects. CONCLUSIONS:Subjects with gout had decreased colonoscopy-documented occurrence of colorectal cancer compared with osteoarthritis subjects, suggesting a possible protective effect.

BACKGROUND:Coronary artery calcium (CAC) has been shown in multiple populations to predict atherosclerotic cardiovascular disease. However, its predictive value in Asian-Americans is poorly described. PATIENTS AND METHODS/METHODS:We studied 1621 asymptomatic Asian-Americans in the CAC Consortium, a large multicenter retrospective cohort. CAC was modeled in categorical (CAC = 0; CAC = 1-99; CAC = 100-399; CAC ≥ 400) and continuous [ln (CAC + 1)] forms. Participants were followed over a mean follow-up of 12 ± 4 years for coronary heart disease (CHD) death, cardiovascular disease (CVD) death, and all-cause mortality. The predictive value of CAC for individual outcomes was assessed using multivariable-adjusted Cox regression models adjusted for traditional cardiovascular risk factors and reported as hazard ratios (95% confidence interval). RESULTS:The mean (SD) age of the population was 54 (11.2) years and 64% were men. The mean 10-year atherosclerotic cardiovascular disease risk score was 8%. Approximately half had a CAC score of 0, whereas 22.5% had a CAC score of greater than 100. A total of 56 deaths (16 CVD and 8 CHD) were recorded, with no CVD or CHD deaths in the CAC = 0 group. We noted a significantly increased risk of CHD [hazard ratio (HR): 2.6 (1.5-4.3)] and CVD [HR: 2.3 (1.8-2.9)] mortality per unit increase in In (CAC + 1). Compared to those with CAC scores of 0, individuals with CAC scores of at least 400 had over a three-fold increased risk of all-cause mortality [HR: 3.3 (1.3-8.6)]. CONCLUSION/CONCLUSIONS:Although Asian-Americans are a relatively low-risk group, CAC strongly predicts CHD, CVD, and all-cause mortality beyond traditional risk factors. These findings may help address existing knowledge gaps in CVD risk prediction in Asian-Americans.

Curricular revision efforts have resulted in learner-centered programs that value content integration and active learning. Yet, less attention has been placed on assessment methods that are learner-centered and promote assessment for learning. The use of context rich short answer question (CR-SAQ) exams in the preclinical years of medical school was evaluated to determine if this format aligns with the criteria for assessment for learning. Medical students and preclinical faculty members were sent a survey comprised of closed and open-ended questions about their experience using CR-SAQ exams. Data were analyzed using a mixed-method design. Open-ended responses were evaluated using thematic analysis within the framework of criteria for assessment for learning. A total of 274 students (94%) and 24 faculty (75%) completed the survey. Fifty four percent of students reported preferring a CR-SAQ exam format over multiple choice questions (MCQ) format. Quantitative data and qualitative comments by students supported that CR-SAQ exams aligned with criteria for assessment for learning, including acceptability, authenticity, educational effect, and the cueing effect. Student concerns included preparation for USMLE Step 1 exam, as well as the validity and reproducibility of CR-SAQ assessments. Faculty largely agreed with the benefits of the CR-SAQ, but were concerned about feasibility, acceptability and reproducibility. The CR-SAQ exam format assessment strategy supports assessment for learning in an undergraduate medical education setting. Both benefits and drawbacks of this method are presented, however students and faculty describe a broader impact that this assessment method has on their development as a physician.

BACKGROUND:Intraductal papillary mucinous neoplasm (IPMN) is premalignant pancreatic lesion. International guidelines offer limited predictors of individual risk. A nomogram to predict individual IPMN malignancy risk was released, with good diagnostic performance based on a large cohort of Asian patients with IPMN. The present study validated a nomogram to predict malignancy risk and invasiveness of IPMN using both Eastern and Western cohorts. METHODS:Clinicopathological and radiological data from patients who underwent pancreatic resection for IPMN at four centres each in Eastern and Western countries were collected. After excluding patients with missing data for at least one malignancy predictor in the nomogram (main pancreatic duct diameter, cyst size, presence of mural nodule, serum carcinoembryonic antigen and carbohydrate antigen (CA) 19-9 levels, and age). RESULTS:In total, data from 393 patients who fit the criteria were analysed, of whom 265 were from Eastern and 128 from Western institutions. Although mean age, sex, log value of serum CA19-9 level, tumour location, main duct diameter, cyst size and presence of mural nodule differed between the Korean/Japanese, Eastern and Western cohorts, rates of malignancy and invasive cancer did not differ significantly. Areas under the receiver operating characteristic (ROC) curve values for the nomogram predicting malignancy were 0·745 for Eastern, 0·856 for Western and 0·776 for combined cohorts; respective values for the nomogram predicting invasiveness were 0·736, 0·891 and 0·788. CONCLUSIONS:External validation of the nomogram showed good performance in predicting cancer in both Eastern and Western patients with IPMN lesions.