Faculty Bibliography

Pinworm infections are usually under the spectrum of the Infectious Diseases department, however, they can fall into a gastroenterologist's lap when found incidentally during a screening colonoscopy. This case expands on the epidemiology, clinical presentation, diagnosis, and treatment of pinworms in the patient and household.

Patient management is not based on a single decision. Rather it is dynamic, based on a sequence of decisions with therapeutic adjustments made over time. Adjustments are personalized, tailored to individual patients as new information becomes available. However strategies allowing for such adjustments are infrequently studied. Traditional antibiotic trials are often nonpragmatic, comparing drugs for definitive therapy when drug susceptibilities are known. COMparing Personalized Antibiotic StrategieS (COMPASS) is a trial design that compares strategies consistent with clinical practice, decision-rules that guides empiric and definitive therapy decisions. Sequential multiple assignment randomized (SMART) COMPASS allows evaluation when there are multiple definitive therapy options. SMART COMPASS is pragmatic, mirroring clinical antibiotic treatment decision-making and addressing the most relevant issue for treating patients: identification of the patient-management strategy that optimizes ultimate patient outcomes. SMART COMPASS is valuable in the setting of antibiotic resistance when therapeutic adjustments may be necessary due to resistance.

Background/UNASSIGNED:Overcoming-lactam resistance in pathogens such as Pseudomonas aeruginosa is a major clinical challenge. Rapid molecular diagnostics (RMDs) have the potential to inform selection of empiric therapy in patients infected by P. aeruginosa. Methods/UNASSIGNED:In this study, we used a heterogeneous collection of 197 P. aeruginosa that included multidrug-resistant (MDR) isolates to investigate whether two representative RMDs (Acuitas Resistome Test and VERIGENE Gram-Negative Blood Culture Test) could identify susceptibility to two newer -lactam/-lactamase inhibitor (BL-BLI) combinations, ceftazidime/avibactam (CZA) and ceftolozane/tazobactam (TOL/TAZO). Results/UNASSIGNED:We found that the studied RMD platforms were able to correctly identify BL-BLI susceptibility [susceptibility sensitivity 100% (95% CI: 97%, 100%)] for both BL-BLIs. However, their ability to detect resistance to these BL-BLIs was lower [resistance sensitivity 66% (95% CI: 52%, 78%) for TOL/TAZO and 33% (95% CI: 20%, 49%) for CZA]. Conclusions/UNASSIGNED:The diagnostic platforms studied showed the most potential in scenarios where a resistance gene was detected or in scenarios where a resistance gene was not detected and the prevalence of resistance to TOL/TAZO or CZA is known to be low. Clinicians need to be mindful of the benefits and risks resulting from empiric treatment decisions based on resistance gene detection in P.aeruginosa, acknowledging that such decisions are impacted by the prevalence of resistance which varies temporally and geographically.

In acute pancreatitis, the most crucial aspect of management falls within the first 48-72 hours, which should be approached in a step-wise order. When steps are skipped or rushed, such as the early use of computed tomography (CT) with contrast in the setting of poor oral intake, the risk of morbidity increases. This is a case when the deleterious effects of contrast worsened the severity of the clinical course, resulting in a higher rate of mortality and longer hospital stay, and escalated the healthcare cost burden.

Xanthomas within the gastrointestinal tract occur secondary to a mucosal insult. When enough cells accumulate, their appearance can range from small nodules studding the intestinal mucosa to bandlike infiltrations to pseudotumor-like masses within the intestine with fibrosis and inflammation resembling malignancy. When large enough, they can produce symptoms of obstruction such as vomiting, abdominal pain, distention, and dysmotility. This case demonstrates the epidemiology, clinical presentation, diagnosis, and treatment of duodenal xanthomas.

OBJECTIVES/OBJECTIVE:We explored patient perceptions regarding physician attire in different clinical contexts and resultant effects on the physician-patient relationship. SETTING/METHODS:The 900-bed University Hospital Zurich, Switzerland. PARTICIPANTS/METHODS:A convenience sample of patients receiving care in dermatology, infectious diseases and neurology ambulatory clinics of the University Hospital Zurich participated in a paper-based survey. PRIMARY AND SECONDARY OUTCOME MEASURES/UNASSIGNED:The survey instrument was randomised and showed photographs of male or female physicians wearing various forms of attire. On the basis of the respondents' ratings of how the physician's attire affected perceptions across five domains (knowledgeable, trustworthy, caring, approachable and comfort with the physician), a composite preference score for attire was calculated as the primary outcome. Secondary outcomes included variation in preferences by respondent characteristics and context in which care was provided. RESULTS:Of 834 patient respondents (140 in dermatology, 422 in infectious diseases and 272 in neurology), 298 (36%) agreed that physician attire was important. When compared with all available choices, the combination of white scrubs with white coat was rated highest while a business suit ranked lowest. Variation in preferences and opinions for attire were noted relative to respondent demographics and the clinical setting in which the survey was administered. For example, compared with younger patients, respondents ≥65 years of age more often reported that physician dress was both important to them and influenced how happy they were with their care (p=0.047 and p=0.001, respectively). CONCLUSIONS:Outpatients at a large Swiss University hospital prefer their physicians to be dressed in white scrubs with white coat. Substantial variation among respondents based on demographics, type of physician and clinical setting were observed. Healthcare systems should consider context of care when defining policies related to dress code.

Background It is uncertain whether there is an association between left ventricular (LV) ejection fraction ( LVEF ) or LV wall motion abnormality and embolic stroke of undetermined source ( ESUS ). Methods and Results We performed a retrospective, cross-sectional study of patients with acute ischemic stroke enrolled in the CAESAR (Cornell Acute Stroke Academic Registry) from 2011 to 2016. We restricted this study to patients with ESUS and, as controls, those with small- and large-artery ischemic strokes. LVEF had to be above 35% to be considered ESUS . In a secondary analysis, we excluded patients with ESUS who had any evidence of ipsilateral carotid atherosclerosis. Multiple logistic regression was used to evaluate whether LVEF or LV wall motion abnormality was associated with ESUS . We performed a confirmatory study at another tertiary-care center. We identified 885 patients with ESUS (n=503) or small- or large-artery strokes (n=382). Among the entire cohort, LVEF was not associated with ESUS (odds ratio per 5% decrement in LVEF , 1.0; 95% CI, 1.0-1.1) and LV wall motion abnormality was not associated with ESUS (odds ratio, 0.9; 95% CI, 0.5-1.6). The results were identical in our confirmatory study. In our secondary analysis excluding ESUS patients with any evidence of ipsilateral carotid atherosclerosis, there was an association between LVEF and ESUS (odds ratio per 5% decrement in LVEF , 1.2; 95% CI, 1.0-1.5; P=0.04). Conclusions Among the entire cohort, no association existed between LVEF or LV wall motion abnormality and ESUS ; however, after excluding ESUS patients with any evidence of ipsilateral carotid atherosclerosis, lower LVEF appeared to be associated with ESUS .

In this needs assessment, gathered patient perceptions on how telemedicine video visits might influence their care. Patients in this study (n = 13) were all diagnosed with end-stage cancer and were receiving palliative care at an urban academic medical center. Interview themes addressed: 1. impact on patient's health management, 2. user experience, 3. technical issues and 4. cost and time. Ultimately, despite concerns over truncated physical exams and prescription limits, the majority of patients favored having the opportunity for telemedicine video visits, felt that the doctor-patient relationship would not suffer, had confidence in their or their surrogate's technical abilities to navigate the video visit, had privacy concerns on par with other technologies, had few cost concerns, and believed a video alternative to an in-person visit might increase access, save time as well as increase comfort and safety by avoiding a trip to the office. These results suggest potential for acceptance of video-based telemedicine by an urban population of oncology patients receiving palliative care.