Faculty Bibliography

: Globally, the proportion of older people living with HIV (PLWH) is growing and the burden of noncommunicable diseases, including cardiac and renal disease, is increasing. There are few studies of renal disease and cardiac risk in older PLWH. This study investigates the relationship between albuminuria and cardiac risk as estimated by the Atherosclerotic Cardiovascular Disease 10-year risk calculator. We report that albuminuria is associated with a higher Atherosclerotic Cardiovascular Disease risk score in both diabetic and nondiabetic older PLWH.

Purpose: Appropriateness criteria (AC) are important tools that could help inform decision making for elective surgical procedures. Available AC for elective total knee replacement (TKR) focus on pre-operative factors only. With recent availability of longitudinal outcome data on thousands of patients from patient registries and administrative databases, we aimed to develop new AC that also included predicted outcomes.
Method(s): To update the AC, we expanded these 16 hypothetical scenarios of the validated modified Escobar AC to include 3 predicted outcome factors: risk of serious complications (0%, 1-2%, 3-5%), time to revision (<5, 5-15, >15 years), and improvement in pain and function 2 years after surgery (little, some, a lot). The modified Escobar AC are based on 5 clinical factors: age, osteoarthritis radiographic severity, knee stability, symptoms severity, and number of knee compartments with osteoarthritis). A panel of clinician experts (3 orthopedic surgeons, 2 rheumatologists, 2 internists, 1 physical therapist, 1 experienced nurse practitioner) rated 432 written clinical scenarios for appropriateness on a 1-9 scale (1 being least appropriate and 9 being most appropriate), and the median score for each scenario was classified into one of 3 categories: inappropriate 1-3, maybe appropriate 4-6, and appropriate 7-9. Classification and Regression Tree (CART) analysis was applied to the TKR AC appropriateness categories to determine the contribution of the predicted outcomes variables to appropriateness classification.
Result(s): After orthopedic surgeons ruled out clinically implausible scenarios, the remaining 279 scenarios were classified as 71 inappropriate, 112 maybe appropriate, and 96 appropriate. Figure below shows the results of the CART analyses classification tree with the branches labeled with the key variables that discriminated among the classifications. The terminal nodes of each branch (highlighted in grey) indicate the final distribution of the ratings of appropriate (App), may be appropriate ( Maybe App) and inappropriate (Inapp). CART analyses showed that all 3 predicted outcome factors and 2 of the clinical presentation factors (knee symptom severity and X-ray findings) were the variables that discriminated among the classifications.
Conclusion(s): Our Results showed that predicted outcomes were utilized by clinicians when determining appropriateness for TKR. How these data influence the decision making of patients contemplating TKR should be investigated further. [Formula presented]
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Introduction: The role of medical students in catalyzing and leading curricular change in US medical schools is not well described. Here, American Medical Association student and physician leaders in the Accelerating Change in Medical Education initiative use qualitative methods to better define student leadership in curricular change.Methods: The authors developed case studies describing student leadership in curricular change efforts. Case studies were presented at a national medical education workshop; participants provided worksheet reflections and were surveyed, and responses were transcribed. Kotter's change management framework was used to categorize reported student roles in curricular change. Thematic analysis was used to identify barriers to student engagement and activators to overcome these barriers.Results: Student roles spanned all eight steps of Kotter's change management framework. Barriers to student engagement were related to faculty (e.g. view student roles narrowly), students (e.g. fear change or expect faculty-led curricula), or both (e.g. lack leadership training). Activators were: (1) recruiting collaborative faculty, staff, and students; (2) broadening student leadership roles; (3) empowering student leaders; and (4) recognizing student successes.Conclusions: By applying these activators, medical schools can build robust student-faculty partnerships that maximize collaboration, moving students beyond passive educational consumption to change agency and curricular co-creation.

When patients are admitted to the hospital, they are generally expected to remain in or within close proximity to their assigned rooms in order to promote their safety and appropriate medical care. Although there are circumstances when patients may safely leave their hospital room or floor, guidance within the medical literature for the management of patient movement within the hospital are lacking. Excessive restrictions on patient movement may be seen as overly paternalistic, while lax requirements may interfere with high quality care, patient safety and efficient hospital practice. As a result, guidance in the form of institutional policy is warranted. Such policy development should take into consideration the potential clinical, legal, and ethical concerns in balancing the competing values of patients' preferences and respect for autonomy, while ensuring high quality, safe, and efficacious medical care. This paper will provide a framework for hospitals to create institution-specific patient movement policies that are fair, systematic, and transparent.

BACKGROUND:System based practice (SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless, structured assessment is required for training programs. We hypothesized that objective structured clinical examination (OSCE) would be an effective tool for assessment of SBP. AIM/OBJECTIVE:To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE. METHODS:For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twenty-six first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey. RESULTS:." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice. CONCLUSION/CONCLUSIONS:OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.

Objective/UNASSIGNED:activity of apramycin against clinical CR-hvKp along with carbapenem-resistant non-hvKp (CR-non-hvKp) isolates. Methods/UNASSIGNED:sequencing) and antimicrobial resistance genes were examined by PCR and Sanger sequencing. Pulsed-field gel electrophoresis and next generation sequencing were conducted on selected isolates. Results/UNASSIGNED:. Conclusion/UNASSIGNED:activity against CR-hvKp isolates, including those were resistant to amikacin or gentamicin. Further studies are needed to evaluate the applicability of apramycin to be used as a therapeutic antibiotic against CR-hvKp infections.

BACKGROUND:Community transmission of coronavirus 2019 (Covid-19) was detected in the state of Washington in February 2020. METHODS:We identified patients from nine Seattle-area hospitals who were admitted to the intensive care unit (ICU) with confirmed infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Clinical data were obtained through review of medical records. The data reported here are those available through March 23, 2020. Each patient had at least 14 days of follow-up. RESULTS:We identified 24 patients with confirmed Covid-19. The mean (±SD) age of the patients was 64±18 years, 63% were men, and symptoms began 7±4 days before admission. The most common symptoms were cough and shortness of breath; 50% of patients had fever on admission, and 58% had diabetes mellitus. All the patients were admitted for hypoxemic respiratory failure; 75% (18 patients) needed mechanical ventilation. Most of the patients (17) also had hypotension and needed vasopressors. No patient tested positive for influenza A, influenza B, or other respiratory viruses. Half the patients (12) died between ICU day 1 and day 18, including 4 patients who had a do-not-resuscitate order on admission. Of the 12 surviving patients, 5 were discharged home, 4 were discharged from the ICU but remained in the hospital, and 3 continued to receive mechanical ventilation in the ICU. CONCLUSIONS:During the first 3 weeks of the Covid-19 outbreak in the Seattle area, the most common reasons for admission to the ICU were hypoxemic respiratory failure leading to mechanical ventilation, hypotension requiring vasopressor treatment, or both. Mortality among these critically ill patients was high. (Funded by the National Institutes of Health.).

Background Arrhythmogenic cardiomyopathy (ACM) can mimic inflammatory processes. We present a complex patient with scleroderma (Sc)-dermatomyositis overlap syndrome (Sc-DM) and cardiac disease. Case A 57-year-old woman with family history of Sc presented with progressive weakness, dyspnea, edema, and Raynaud's (1A). Troponin was 1.6 ng/mL and CRP was 13.2 mg/L. EKGs revealed sinus rhythm with RBBB and AV sequential pacing with multifocal PVCs (1B-C). CT chest showed bibasilar fibrosis (1D). Echocardiography revealed biventricular dysfunction. Cardiac catheterization showed non-obstructive coronaries and a cardiac index of 1.8 L/min/m2. Cardiac MRI had diffuse biventricular subendocardial late gadolinium enhancement (1E). Electromyography revealed proximal myopathy. Rheumatologic workup was consistent with seronegative Sc-DM. Decision-making She was treated with steroids, mycophenolate, IV immunoglobulins, diuretics, and inotropes. Her course was complicated by recurrent VT cardiac arrests, prompting escalation to VA-ECMO. She underwent cardiac transplant on day 9 of ECMO. Pathology revealed biventricular fibrofatty replacement consistent with ACM (1F-G), patchy fibrosis of the pericardium, and mitral valve with thickened and fused chordae suggestive of inflammatory changes from Sc (1H-I). Conclusion This case highlights an atypical presentation of ACM in a patient with Sc-DM and the multidisciplinary approach necessary for proper diagnosis and management. [Figure presented]
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Background Despite increased cardiovascular mortality in patients with HIV, studies have shown suboptimal rates of statin prescription among qualifying patients. Our initial trainee needs assessment survey revealed a lack of comfort and modifiable barriers to prescribing statins to patients with CAD and HIV on anti-retroviral therapy (ART). We sought to create a tool to mitigate these barriers and improve comfort and self-reported practice in prescribing statins to this population. Methods A 1-page tool detailing statin-ART co-administration regimens, common drug interactions and potential side effects was created and introduced to 24 cardiology and 8 infectious disease fellows at NYU School of Medicine. Ten weeks later, a post-intervention survey was conducted to assess comfort, barriers, and self-reported practice when prescribing statins to patients with HIV. Data was de-identified by a 3^rd party. Results were excluded for lack of consent for study participation and incomplete and/or duplicate survey responses. Results Of the included 11 cardiology and 6 infectious disease fellows, 53% report using the tool in clinical decision making over 10 weeks. Of these, 78% report the tool increased comfort initiating and/or adjusting statin therapy and 89% report the tool increased overall comfort managing statins in patients with HIV. In our prior needs assessment survey, the majority of fellows cited one or more barriers to prescribing statins to patients with HIV and a minority reported always considering HIV status when deciding to initiate statin therapy. After introduction of the tool, however, over half of fellows report no barriers to prescribing statins to this population and 100% report they will now always consider HIV status when deciding to initiate statin therapy. Ultimately, 65% of fellows plan to use the 1-page tool in the future and 82% recommend that it be provided to future trainees. Conclusion Introduction and use of our 1-page tool improved trainee comfort, reduced known barriers, and improved self-reported practice when prescribing statins to patients with HIV. Integration of such a tool into the curriculum can improve trainee education in caring for a vulnerable population.
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