Faculty Bibliography

Learning Objective #1: Recognize protein malnutrition and cirrhosis as potential complications of biliopancreatic diversion with duodenal switch (BPD-DS). CASE: A 37-year-old man with a history of severe obesity status post laparoscopic BPD-DS presented with diffuse swelling. The patient was admitted six months previously for severe protein-calorie malnutrition requiring initiation of total parental nutrition (TPN). During that admission, he was found to have elevated liver enzymes and ascites. Workup for autoimmune, infectious, and hereditary etiologies of cirrhosis was unremarkable; a liver biopsy showed steatosis without evidence of alcoholic hepatitis or cirrhosis. He now complained of abdominal distension and lower extremity edema that had progressed over several weeks, requiring multiple large-volume paracenteses. He endorsed past heavy alcohol use, but denied recent exposure. On physical examination, he was grossly anasarcic with a distended abdomen and appreciable fluid wave, 3+ pitting edema to the hips, and scrotal edema. His admission Model for End-Stage Liver Disease (MELD) score was 14. Repeat biopsy demonstrated prominent portal fibrosis and focal nodularity indicative of advanced-stage cirrhosis, with an interval decrease in steatosis from his previous biopsy. The rapidity of fibrosis and reversal of fatty change suggested the etiology was his bariatric surgery. He was treated with intravenous diuretics with improvement in his anasarca. At one-month follow-up, he had a stable MELD and diuretic-responsive ascites. He has been approved for liver transplant evaluation, with plans to reverse his bypass prior to transplant. IMPACT/DISCUSSION: BPD-DS is classically associated with improvement in hepatic function due to reversal of nonalcoholic steatohepatitis (NASH). However, case reports of hepatic failure following BPD-DS do exist. Clinicians should be alert to this complication and monitor post-surgical patients closely for signs of hepatic decompensation.
Conclusion(s): BPD-DS is the most effective bariatric surgery technique for sustained weight loss in the super-obese (BMI > 50 kg/m, ²). Nevertheless its widespread adoption has been limited by technical complexity and concerns over vitamin deficiencies and malnutrition. Loss of hepatotrophic factors due to protein malnutrition has been advanced as a mechanism to explain its contribution to the development of cirrhosis. With the increasing prevalence of obesity and the documented effectiveness of BPD-DS for sustained weight loss this surgery will likely become more commonplace. Awareness of this potential complication and vigilance to ensure adequate protein intake, with aggressive intervention-including the initiation of TPN-to preserve nutritional status is paramount to effective management of BPD-DS patients post-operatively

Background: Identifying and recruiting patients for clinical research remain major challenges for researchers. EHRs are playing larger roles in recruitment, from helping identify cohorts to alerting clinicians about potentially eligible patients. One major issue around using EHRs for recruitment is understanding the best way to manage the amount and type of messaging patients receive. Because research-related communications is a relatively new area, few institutions have set policies in this area. Before setting policy at NYU Langone Health, we chose to survey our patient population to better gauge their beliefs and to obtain data that would help us formulate a policy that aligns with patients' actual preferences rather than their hypothetical concerns.
Method(s): The NYU School of Medicine IRB determined that this project was exempt from review. We developed a 10-question survey in our institution's RedCAP system. The survey was developed with input from our institutional Research Governance Group, who gave input on both content and wording of the questions. We then obtained a random sample of 20,000 adult, active MyChart (our Epic patient portal) users, and sent a survey invitation to 10,000 patients per week for two weeks. The survey was completely anonymous, and the invitation contained a direct link to the RedCap survey. We closed the survey after 3 weeks.
Result(s): We received 2157 responses to the survey. 61.7% of respondents were female, 83% were white, and 11% identified as Hispanic/Latino. 2/3 of patients were within the 46-75 age range. 72% of patients responded that they would be interested in participating in research studies, and 87% of all patients responded that they would be interested in receiving research-related messages. Responses about limits on the number of messages that patients receive were nearly evenly split, with 46% responding that there should not be a limit on the number of research-related messages received, and 39% responding that there should be a limit. Over 90% wanted the option to opt-out of receiving further messages with each invitation. Opinion about the " right" number of research-related messages that a patient could receive in a particular time period was mixed, but were nearly evenly split between 1-2 times a month and no limit on messages.
Conclusion(s): Developing and distributing the survey through the patient portal was a relatively straightforward process and was relatively quick to implement after institutional approval. Our survey revealed engaged patients who are interested in finding out more about research, and who wish to have input into and control over the number and types of research-related messages they receive. Performing a similar survey in a larger, more diverse population would help give a more accurate picture of broader patient preferences. Digital messaging can be an effective tool for research-related communications, and could be added to the current toolbox of general recruitment techniques

We examined the utility of coronary artery calcium (CAC) for cardiovascular risk stratification among hypertensive adults, including those fitting eligibility for SPRINT (Systolic Blood Pressure Intervention Trial). Additionally, we used CAC to identify hypertensive adults with cardiovascular disease (CVD) mortality rates equivalent to those observed in SPRINT who may, therefore, benefit from the most intensive blood pressure therapy. Our study population included 16 167 hypertensive patients from the CAC Consortium, among whom 6375 constituted a "SPRINT-like" population. We compared multivariable-adjusted hazard ratios of coronary heart disease and CVD deaths by CAC category (0, 1-99, 100-399, ≥400). Additionally, we generated a CAC-CVD mortality curve for patients aged >50 years to determine what CAC scores were associated with CVD death rates observed in SPRINT. Mean age was 58.1±10.6 years. During a mean follow-up of 11.6±3.6 years, there were 409 CVD deaths and 207 coronary heart disease deaths. Increasing CAC scores were associated with increased coronary heart disease and CVD mortality (coronary heart disease-CAC 100-399: hazard ratio [95% CI] 1.88 [1.04-3.40], CAC ≥400: 4.16 [2.34-7.39]; CVD-CAC 100-399: 1.93 [1.31-2.83], CAC ≥400: 3.51 [2.40-5.13]). A similar increased risk was observed across 10-year atherosclerotic CVD risk categories and in the SPRINT-like population. A CAC score of 220 (confidence range, 165-270) was associated with the CVD mortality rate observed in SPRINT. CAC risk stratifies adults with hypertension, including those who are SPRINT eligible. A CAC score of 220 can identify hypertensive adults with SPRINT-level CVD mortality risk and, therefore, may be reasonable for identifying candidates for aggressive blood pressure therapy.

Learning Objective #1: Recognize, manage, and prevent hungry-bone syndrome (HBS) CASE: A 46-year-old male with a history of hypertension presented with urinary hesitancy and frequency for two months. His only other complaint was aching pain in his back and bilateral legs. Physical exam was significant for tenderness of his lower extremities. Labs were significant for creatinine of 3.9 mg/dL, calcium of 12.5 mg/dL, and an alkaline phospha-tase of 916 U/L. Parathyroid hormone (PTH) was 4393 pg/mL. Phosphate and 25-hydroxy vitamin D were normal, but 1,25-dihyrdoxy vitamin D was low at 9.1 pg/mL. Renal ultrasound demonstrated bilateral hydronephrosis. CT imaging revealed a left paratracheal soft tissue mass, extensive lytic bone lesions, and multiple renal calculi. Core biopsy of the mass was consistent with follicular parathyroid cancer. The patient received alendronate then underwent parathyroidectomy of the affected gland with post-operative perioral tingling and paresthesias and hypocalcemia with a nadir of 5.5 mg/dL. This patient then required 138g of oral calcium carbonate and 118g of intravenous calcium gluconate along with calcitriol and cholecalciferol over the course of thirteen days. IMPACT/DISCUSSION: This case exemplifies the potential severity of HBS. This patient's calcium requirement was 256g or an average of 20g/day, significantly higher than reported 6 to 12g/day that a typical HBS patient requires. HBS is defined as rapid and profound hypocalcemia due to an acute withdrawal of PTH after a parathyroidectomy. This is caused by a reduction of osteoclast activity and an increase in osteoblast activity leading to unopposed deposition of bone and resultant hypocalcemia. Hypophosphatemia and hypomagnesemia may also develop. These electrolyte abnormalities will last for weeks to months, but rarely have been reported to last for over a year. Patients who develop HBS are at risk of arrhythmias, heart failure, and seizures. These problems can be prevented with regular serum testing and repletion of calcium, phosphate, magnesium, and vitamin D. Preoperative bisphosphonates and vitamin D repletion have been shown to decrease the magnitude of hypocalcemia post operatively. Patients at risk of developing HBS include those with older age, higher preoperative serum calcium, alkaline phosphatase, and PTH levels, lower preoperative serum magnesium and albumin, parathyroid mass larger than 5 cm, ³ and those with evidence of brown tumors or osteitis fibrosa cystica. This patient's impressive calcium requirement may have stemmed from his preoperative kidney disease vitamin D deficiency, and extensive lytic bone lesions.
Conclusion(s): HBS is a life threatening complication that develops as a result of rapid withdrawal of PTH with subsequent electrolyte disturbances. Some evidence suggests that HBS can be prevented with preoperative administration of bisphosphonates and vitamin D. HBS can be managed with frequent electrolyte monitoring and aggressive repletion

Learning Objective #1: Identify non-HACEK gram-negative endocarditis early in its clinical course. Learning Objective #2: Recognize the morbidity and mortality of Escherichia coli endocarditis. CASE: A 54 year-old Hispanic man with no known past medical history presented with one month of constitutional symptoms: unintentional weight loss, anorexia, fatigue, and arthralgias. On admission, he was febrile, tachycardic, and breathing comfortably on room air. The exam was otherwise significant for a thin stature with temporal wasting, thrush, a lateral tongue ulcer, a raised non-blanching erythematous macular rash on sun-exposed areas of the extremities, and erythematous papules on the hands. There were no murmurs detected on cardiac auscultation. Initial labs were significant for anemia and leukopenia. A broad differential diagnosis initially included malignancy, rheumatologic disease, and systemic infection. Work-up revealed positive anti-Smith and anti ds-DNA antibodies, C3/C4 hypocomplementemia, and a pericardial effusion on transthoracic echocardiogram (TTE). He was diagnosed with systemic lupus erythematous (SLE), and started on hydroxychloroquine and steroids with improvement. On hospital day three, blood cultures grew Escherichia coli (E. coli) in four bottles, with an unclear source with aseptic urine and no localizing symptoms. CT scans of the head, chest, abdomen, and pelvis were notable for multiple peripherally located pulmonary airspace opacities concerning for septic emboli. A TTE was negative for vegetation, but given the high clinical suspicion for endocarditis, notwithstanding the rarity of E. coli as a pathologic organism, transesophageal echocardiogram (TEE) was pursued. TEE revealed a mobile echodensity on the aortic valve consistent with vegetation. The patient completed four weeks of ceftriaxone to treat E. coli endocarditis. IMPACT/DISCUSSION: E. coli bacteremia is common; however, due to decreased adherence of the organism to the endocardium, infective endocarditis from E. coli is rare, accounting for 0.51% of cases. Risk factors include immunocompromised states. Our patient was leukopenic from SLE. Sources of infection are often gastrointestinal and urinary. However, as in our patient, initial source is unclear in approximately half of cases. Murmur is often absent, and the disease is more common in native valves than prosthetic or degenerative valves. For these reasons, diagnosis is difficult. One study reported at least one month from onset to clinical diagnosis in 90% of patients with non-HACEK gram-negative endocarditis. However, given its high surgical intervention rate (42%), high complication rate (including heart failure and abscess), and high mortality rate of 21% (drastically higher than the 4% from HACEK gram-negative endocarditis), clinicians should maintain a high degree of suspicion to make this diagnosis early.
Conclusion(s): E. coli endocarditis is rare, occurs in immunocompro-mised patients, and is difficult to diagnose. However, given its high morbidity and mortality, timely recognition is critical

Needs and Objectives: Didactic training in motivation interviewing (MI) lacks efficacy, because opportunities to practice skills while being directly observed are rare. The goal of our educational innovation was to train interns in the advanced communication skills of motivation interviewing through a group observed standardized clinical experience (GOSCE). Our Learning Objectives were as follows: After an experiential learning session on MI, interns will be able to: 1. Identify opportunities to use MI with patients 2. Recognize "change talk" from a patient as an opportunity to use MI techniques 3. Use MI techniques when discussing behavior change with a patient Setting and Participants: 46 internal medicine interns in an academic internal medicine residency program. Description: Each session began with a 20 minute review of MI for behavior change given by a psychologist trained in Motivational Interviewing. Then, interns participated in a 3 station, one-hour long Group Observed Standardized Clinical Exercise (GOSCE). Interns worked in teams of 3, and for each station, one of the 3 interns was the active physician, while the other 2 observed the encounter. Each intern had an opportunity to be the active physician for a case. Each case was observed by one or two faculty members, one of whom was a psychologist trained in MI. After a 10 minute interaction with the standardized patient, the active physician received feedback on their MI skills and debriefed the encounter with the faculty and their peers. After the 3 cases, the session concluded with a group debrief and summary of the experience. Interns completed a retrospective pre/post survey to assess the impact of the session. Evaluation: Residents reported statistically significant improvement in all domains, including confidence with identifying opportunities to use MI, comfort using reflective and summary statements during MI, and likelihood of using motivational interviewing in future patient encounters. Qualitative comments after the session reflect that residents developed an appreciation for silence as a tool during MI, felt comfortable with tools such as decisional balance, and recognized the value of patient centered-ness during MI. Discussion/Reflection/Lessons Learned: Our interprofessional educational team (psychologists and internists) provided different perspective for both learners and our internal medicine faculty. Our residents appreciated practicing skills and receiving feedback in real time. This academic year (one year after the intern GOSCE), these same learners will participate in an OSCE that includes a case requiring motivational internviewing skills, and we will evaluate the durability of motivation interviewing skills taught during this session. We are interested in expanding opportunities to use GOSCE as a low stakes skills practice and development tool

BACKGROUND:The Society of Cardiovascular Computed Tomography (SCCT) recommends consideration of coronary artery calcium (CAC) scoring among individuals with a family history (FH) of coronary heart disease (CHD) and atherosclerotic cardiovascular disease (ASCVD) risk <5%. No dedicated study has examined the prognostic significance of CAC scoring among this population. METHODS:The CAC Consortium is a multi-center observational cohort study from four clinical centers linked to long-term follow-up for cause-specific mortality. All CAC scans were physician referred and performed in patients without a history of CHD. Our analysis includes 14,169 patients with ASCVD scores <5% and self-reported FH of CHD. RESULTS:This cohort had a mean age of 48.1 (SD 7.4), was 91.3% white, 47.4% female, had an average ASCVD score of 2.3% (SD 1.3), and 59.4% had a CAC = 0. The event rate for all-cause mortality was 1.2 per 1000 person-years, 0.3 per 1000 person-years for CVD-specific mortality, and 0.2 per 1000 person-years for CHD-specific mortality. In multivariable Cox proportional hazard models, those with CAC>100 had a 2.2 (95% CI 1.5-3.3) higher risk of all-cause mortality, 4.3 (95% CI 1.9-9.5) times higher risk of CVD-specific mortality, and a 10.4 (95% CI 3.2-33.7) times higher risk of CHD-specific mortality compared to individuals with CAC = 0. The NNS to detect CAC >100 in this sample was 9. CONCLUSION/CONCLUSIONS:In otherwise low risk patients with FH of CHD, CAC>100 were associated with increased risk of all-cause and CHD mortality with event rates in a range that may benefit with preventive pharmacotherapy. These data strongly support new SCCT recommendations regarding testing of patients with a family history of CHD.

Learning Objective #1: Explain how the hemodynamics of pericarditis can produce the clinical manifestations (signs and symptoms) seen in pericarditis. Learning Objective #2: Categorize the progressive electrocardiogram stages consistent with pericarditis. CASE: A 70 year-old female with hypertension and diabetes presented to the hospital with a one-day history of non-positional, left-sided chest pain associated with shortness of breath and subjective fevers. Physical exam and vitals were unremarkable. Work up included three negative troponins, EKG in normal sinus rhythm (Figure 1), and D-Dimer of 1100 ng/mL. CTA chest revealed a right subsegmental middle lobe filling defect consistent with pulmonary embolism for which patient was initiated on anticoagulation with resolution of chest pain. Approximately 24 hours after initial presentation the patient reported a new chest pain described as sharp, pleuritic, worse with lying flat and improved with sitting forward. Vitals revealed fever to 100. 5 F. Repeat EKG demonstrated diffuse ST elevations (Figure 2). Labs showed a negative troponin and ESR and CRP at 63 mm/hr and > 190 mg/L, respectively. Echo showed a trace pericardial effusion, normal ejection fraction, and no evidence of right heart strain. The patient was diagnosed with acute pericarditis and initiated on colchi-cine and NSAIDs with resolution of symptoms. Common causes for pericarditis including viral URI, TB, connective tissue disorders, and malignancy were ruled out with a negative review of symptoms, subsequent laboratory analysis and additional history from the patient's primary care provider. Given the unlikeliness of other etiologies, her acute pericarditis was felt to be secondary to her pulmonary embolism. IMPACT/DISCUSSION: Between 80-90% of pericarditis cases are idiopathic or presumed to be of viral etiology. Given the relatively benign course of the majority of causes of pericarditis a definitive work up is often not performed. However, this case highlights an additional "can't miss" cause of pericarditis-pulmonary embolism. Although rare, post-pulmonary embolism pericarditis is a well-documented phenomenon associated with elevated ESR, CRP, and low-grade fevers as in this patient's presentation. Proposed mechanisms include increased friction of an enlarged pulmonary artery and right ventricle against the pericardium and an immunologic response, similar to Dressler syndrome.
Conclusion(s): Despite being a known cause of pericarditis, pulmonary embolism is frequently overlooked or completely excluded from clinicians' differentials. Although the exact cause of pericarditis is often unknown, in patients with idiopathic pericarditis with no infectious signs, pulmonary embolism should always be considered based on history and physical exam findings to avoid missing a "can't miss" diagnosis

Background: It is well documented that few ordered tests are " high value" a significant percentage of those ordered are " low-value." Residency offers an opportunity to teach high-value care and educational interventions to do so have been effective. However, the relationship between high-value care and residents' ability to communicate effectively with patients has not been explored. Ability to establish rapport, gather information effectively, and be patient-centered may impact residents' use of tests. We hypothesize that residents with poor skills in these areas may order tests less efficiently.
Method(s): Unannounced Standardized Patients (USPs) were introduced into residents' primary care clinics in a large urban, safety net hospital to portray 3 clinical scenarios: a well visit, a chief complaint of fatigue, and a diagnosis of asthma. Orders were extracted via chart review. Appropriateness of orders was determined by reference to United States Preventive Services Task Force (USPSTF) and clinical practice guidelines. Excessive tests were defined as not explicitly indicated for the scenario-indicated tests were the converse. Number of excessive and % of indicated tests were calculated across the 3 visits for 48 residents. Communication skills in information gathering (5 items) and developing a relationship (6 items) and a patient-centeredness score (4 items: took a personal interest, answered all my questions) were computed as % of behaviorally anchored items rated as " well done" and included in regression models predicting test utilization.
Result(s): On average, residents ordered 15% of indicated tests (SD 9%, 0-38%) across the 3 visits and a mean of 1.3 unnecessary tests (SD 1.7, 0-6). In the regression model, the 3 skills explained 16% of variation in unnecessary tests (p=.047). Information gathering explained the greatest share (8%, p=.041). With all 3 variables in the model, patient-centeredness was positively associated with unnecessary tests (Std Be-ta=.42, p=.016) and information gathering was negatively associated with unnecessary tests (Std Beta=-.34, p=.041). Mirroring these Results, superutilizers (10 residents ordering > =3 excessive tests) had lower information gathering and relationship development scores than other residents (66% vs 75% and 72% vs 76%) but higher patient centeredness scores (80% vs 74%)-although differences were not significant.
Conclusion(s): Our findings suggest that information gathering skills may have a small influence on residents' ordering of excessive tests. Further research with larger samples (adequate power) will help clarify the effect sizes. If our Results stand, interventions for high-value care should include information gathering skills and residency programs should continue to reinforce core communication skills training. In addition, our finding that patient centeredness was associated with ordering unnecessary tests suggests that residency programs could caution residents about conflating ordering of tests with patient-centeredness

Background: Low-value tests, defined as inappropriate for a given clinical scenario, are ordered in one in five clinic visits. Residents tend to over-order diagnostic tests to "minimize uncertainty" of presenting cases, even though these tests are not useful according to Bayesian statistics; a pursuit deemed the "Ulysses syndrome". Simultaneously, evidence suggests residents misuse preventive tests in half of relevant clinical scenarios. We sought to quantify ordering behaviors in urban primary care clinics across three unannounced standardized cases.
Method(s): Unannounced standardized patients (USPs) were trained for standardized simulation of three clinical scenarios: a "Well" visit, a chief complaint of "Fatigue," and a diagnosis of "Asthma." USPs were introduced into medicine residents' clinics in an urban, safety-net hospital. All electronic orders were extracted via chart review. Scenario-specific appropriateness of diagnostic testing was determined by referencing United States Preventive Services Task Force (USPSTF) and society clinical practice guidelines (CPGs). "Preventive" tests (such as lipid panels or hemoglobin A1C) were derived from USPSTF guidelines whereas "Diagnostic" tests (such as pulmonary function testing for Asthma or heterophile antibodies for Fatigue) were from CPGs. "Excessive" tests were those not explicitly indicated for a given scenario in either USPSTF or CPGs (versus "indicated" tests).
Result(s): Indicated tests were ordered in 29% of Well (124 encounters), 16% of Fatigue (148 encounters), and 12% of Asthma (170 encounters) cases. One or more excessive tests were ordered in 44%, 22%, and 17% of Well, Fatigue, and Asthma encounters respectively. The distribution of indicated and excessive tests for preventive versus diagnostic purposes varied by case: In Well visits, the majority (71%) of excessive testing was in pursuit of a diagnosis, while three-quarters of indicated testing was for preventive purposes. In Fatigue and Asthma visits, the reverse patterns were true: the majority of indicated tests ordered were diagnostic (81% and 68%, respectively) while the majority of excessive tests were preventive (78% and 63%, respectively).
Conclusion(s): Introducing USPs to resident clinics revealed that, for patients presenting without a chief complaint (Well visit), residents successfully ordered less than one-third of indicated tests, and over 75% of inappropriately ordered tests pursued a diagnosis. For patients presenting with chief complaints (Fatigue and Asthma), rates of appropriate ordering were even lower (16% and 12%), and tended to overlook preventive care. In these cases, inappropriate tests tended to be ordered for preventive purposes. Awareness of resident mis-utilization of preventive and diagnostic testing in distinct clinical circumstances can guide educational efforts towards evidence-based care and resource stewardship