Faculty Bibliography

Learning Objective #1: Recgonizing hemophagocytic lymphohistiocytosis (HLH) in septic patients with ferritin levels greater than 20,000 CASE: A 35-year-old woman with a history of recurrent urinary tract infections (UTIs) complicated by nephrolithiasis presented with four days of fever and a sore throat. She was febrile to 103.1, blood pressure 99/62, and heart rate 100. WBC was 12, Hgb 8.6, creatinine 1.8, AST 304, ALT 92, and HIV, streptococcus, mononucleosis and EBV IgM testing were all negative. Urinalysis was consistent with a UTI, she was admitted, and started on antibiotics. A CTscan of the abdomen revealeda right, staghorn calculi with surrounding, ill-defined lesions in the parenchyma. Urology placed a right nephrostomy tube which drained frank pus. Other work-up revealed an LDH of 2,502, triglycerides of 474, ferritin of 31,000. An Interleukin 2 Receptor (CD25) soluble test was sent but bone marrow biopsy was deferred given improvement in clinical symptoms and laboratory data. Twelve days into her admission, the patient clinically deteriorated. Lactate was elevated to 5.7, LFTs and LDH began to rise, and ferritin was 24,000 from a nadir of 8,000. Repeat triglycerides were 1,210. She was transferred to the intensive care unit for septic shock, placed on vasopressors and was subsequently intubated. A bone marrow biopsy revealed histiocytosis in a scattered and cluster pattern and hemophagocytosis and hemophagocytic lymphohistiocytosis (HLH) was diagnosed. Treatment with dexamethasone and etoposide was initiated on day fourteen based on the modified HLH 94 protocol. Her CD25 soluble test later came back elevated. She was weaned of vasopressors, extubated and completed chemotherapy inpatient. She was discharged three months after presentation. IMPACT/DISCUSSION: HLH is a rare, life-threating condition characterized by excessive immune activation that is most common in the pediatric population but can occur at any age. There are pre-disposing genetic defects and/or an immunological trigger such as infection, malignancy or rheumatologic disorder that have been linked to the development of HLH. Most commonly infectious HLH is reported in viral infections-commonly EBV-but it is possible the diagnosis is being overlooked in bacterial infections that lead to sepsis. It is easy in sepsis to attribute cytopenia and rising LFTs to end organ damage from the sepsis itself, making it difficult to distinguish from HLH. Infection itself is also commonly associated with high ferritin levels making it even more difficult to distinguish from HLH. Without treatment, patients often only survive a few months and overall mortality is as high as 75%. Appropriate, early treatment have shown remission rates up to 71%.
Conclusion(s): Thus, this case report exemplifies the importance of investigating HLH as a possible contributor to end-organ damage in septic shock when extremely high ferritins are noted. Mortality is high in patients with HLH which makes timely diagnosis of the utmost importance

Needs and Objectives: In the changing landscape of healthcare, physicians must be adaptive, visionary and evidence-based in their approach to care Medical education must be adjusted to allow learners to gain skills that prepare them to function effectively in this new paradigm. In order to meet these needs, we developed a community based curriculum with emphasis on transitions of care, population health and innovation of care. Setting and Participants: Curriculum was developed as part of a new NYU Internal Medicine Residency Community Health Track, housed at NYU Langone Hospital-Brooklyn, a community based, academic teaching hospital. Ambulatory training is based at the Family Health Centers at NYU Langone, a network of FQHCs. Both the hospital and FQHCs serve a vulnerable, diverse community in south Brooklyn. To date we have recruited one class of 10 interns. As of July 2020 we anticipate having a full track consisting of 30 residents. Description: Our first year curriculum aims to develop a framework for thinking about community health introducing key concepts such as population-based care, novel delivery of care, and interdisciplinary collaboration. Early in their training, residents completed a community assessment using observational data, interviews and census track data. These assessments paired with collaboration with CHW and community organizations gave them first hand exposure to our area's specific challenges and gaps in care. The residents began to develop skills in home care by working with an interdisciplinary team of doctors, nurses and CHWs. Additionally, they participated in a transitions of care workshop, examining their own hospital patients who had been readmitted and identifying best practices for hospital discharge. Evaluation: A multi-method evaluation plan is essential as we evaluate and strengthen the curriculum. Qualitative feedback is gathered at regular intervals throughout the year along with surveys of trainees. Initial Results suggest that curricula is well-received by residents. Aggregated longitudinal educational data including resident self-report, 360^oevaluations and performance-based assessment, (OSCEs, USP visits) will contribute to program evaluation. The most important outcome will be how these trainees practice once they have graduated. We plan to use postgraduate surveys to judge the impact of the curriculum. Discussion/Reflection/Lessons Learned: We adapted curriculum to focus on our particular community and created innovative programs to improve the population's health. Essential to these accomplishments was our partnership with learners and our reliance on their feedback to guide curriculum development. Allowing trainees to explore their interests has lead to visionary projects. We have learned that by being flexible and adapting to the learners' needs and interests we can serve our community in deeper ways than we had initially anticipated. However, structural limitations of the clinic coupled with institutional changes resulted in a slower time frame for clinical adaptations

Learning Objective #1: Recognize risks of hypoglycemia associated with sulfonylureas and thiazolidinediones Learning Objective #2: Apply evidence-based guidelines for appropriate management of diabetes in elderly patients CASE: A 72 year-old Spanish-speaking man with poorly controlled type 2 diabetes, hypertension, and newly diagnosed prostate cancer was bought by ambulance with confusion and weakness. He was found to have a fingerstick glucose of 30 mg/dl. Additional workup was unremarkable and symptoms resolved with 50% dextrose. He was admitted for symptomatic hypoglycemia. The patient reported taking multiple oral hypoglycemic agents, including glipizide twice daily, pioglitazone, metformin, and sitagliptan. Four months prior, pioglitazone was tripled due to A1c 10.4%. He also revealed unintentional weight loss (possibly due to his cancer), and multiple home fingersticks in the 60s. Repeat A1c was 6.7%. The sulfo-nylurea and pioglitazone were discontinued. The patient was educated on his medications, glucose targets, and symptoms of hypoglycemia. He was discharged with advice to follow with his primary physician. IMPACT/DISCUSSION: Nearly 25% of patients over age 65 have diabetes. Elderly diabetics are uniquely vulnerable, with higher risks of symptomatic hypoglycemia, increased hospitalizations, and higher overall associated morbidity and mortality. Polypharmacy, low health literacy, and language barriers contribute to their complex medical management. Recent studies have shown that tighter A1c control (< 7.0%) is associated with additional harms in geriatric patients, including a higher mortality rate. As a result, medical organizations have revised their glycemic control guidelines towards more personalized, patient-centered management. These guidelines include differential A1c goals (from 7.0-9.0%) based on overall health, comorbidities, and life expectancy. Guidelines for geriatric diabetes care were updated in 2018 to include recommendations that overtreatment of diabetes should be avoided, medication classes at low risk of hypoglycemia are preferred, and complex medication regimens should be simplified to reduce hypoglycemia. Our patient illustrates the importance of each of these guidelines. With his age and comorbid-ities, including newly diagnosed cancer, he had indications for looser A1c goals. He was also at high-risk for medication-related adverse events, given his polypharmacy and limited health literacy. Metformin and sitagliptin would have been favored agents. Education on symptoms of hypoglycemia, as well as interpreting fingersticks, was crucial to prevent rehospitalization and improve health literacy.
Conclusion(s): Geriatric patients with diabetes represent a unique and vulnerable population. Guidelines for diabetes management in these patients are evolving, with increased emphasis on personalized, patient-centered management, including looser A1c goals for those with comorbidities or shorter life expectancy. Providers are encouraged to simplify medications and avoid polypharmacy to improve outcomes and save lives

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

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: Recognize and manage opioid overdose in a community health center setting Learning Objective #2: Improve linkage to effective treatment for opioid use disorder after overdose CASE: A 54 yo man was found unresponsive at the door of our community health center. Rapid Response was called and the patient was found to be unresponsive to sternal rub, with 6 breaths per minute, and pinpoint pupils. One dose of 4mg of intranasal naloxone was administered, and soon the patient was alert and oriented. He declined transfer to the ED but was amenable to observation, stating that he had just purchased his usual 3 bags and used them outside of his primary care clinic. His PMH was notable for 36 years of IV/intranasal heroin use, prior stroke, GERD, glaucoma, hyperlipidemia, lumbar radiculopathy, and tobacco use. He had one overdose in the 1990s, attempted detox several times and tried self-treating himself with methadone and buprenorphine. He lived with his girlfriend and was unemployed. His medications included cyclobenzaprine and ranitidine. The medical assistant from our addiction medicine clinic engaged the patient, who reported that the overdose scared him, and offered medication treatment which he accepted. The addiction clinic nurse and physician saw the patient that day and gave an initial buprenorphine prescription, instructions and follow-up appointment. He is now stable on buprenorphine 8mg daily. IMPACT/DISCUSSION: The overdose described in this case represents one of three overdoses in the past month at our NYC health center. Urban health centers often serve as community hubs and may be seen as a safer place to use opioids. Overdoses at community health centers represent an important point of patient engagement in treatment for OUD. Treatment with opioid agonist therapy after overdose has been shown to reduce all-cause and opioid-related mortality. However, only a small percentage of patients receive medication therapy after overdose. (Larochelle et al. Annals of Internal Medicine. 2018) Initiation of medication treatment for OUD at the time of ED presentation has also been shown to improve engagement in treatment. (DOnofrio et al. JAMA 2015.) Institutional commitment to training all providers and staff to recognize the signs of opioid overdose and administer intranasal naloxone has direct impact on patient outcomes. Our experience with this case has demonstrated the importance of immediate engagement in care at the time of overdose. Having a team available at the time of overdose that cares for patients with addiction enabled us to quickly engage this patient in care and start medication therapy when he felt most receptive to treatment.
Conclusion(s): Our case demonstrates two crucial steps for improving outcomes in opioid overdose: widespread availability of and training for intranasal naloxone use, along with community health sites equipped to treat patients with opioid use disorder at the time of overdose

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

Background: There is an increased awareness among healthcare professionals to discuss social determinant of health (SDOH) information with patients. However, the awareness does not necessarily translate into effective response to the situation. In order to better understand the nuances in such conversations between patients and providers, we reviewed qualitative responses from Unannounced Standardized Patient (USP) portraying patients with SDOH concerns who were seen as part of a study to investigate healthcare teams' management of SDOH information.
Method(s): USPs, representing six different clinical cases, were seen by residents at an urban safety-net hospital. Each case had SDOH issues (financial and housing insecurity, social isolation), and USPs were trained to provide such information in a systematic fashion in response to provider questioning. After the encounter, USPs completed a behaviorally-anchored, standardized checklist, and also entered their impressions of the encounter in free text. The focus of this study was to evaluate these comments using a qualitative approach, focusing only on those that addressed SDOH. 258 visits occurred from 2017-present, and 209 relevant comments were analyzed.
Result(s): Three general themes emerged: residents' openness to discussion of SDOH, their understanding of how these issues related to presenting concerns, and how they responded to those concerns. Some providers did not explore SDOH prompts, e.g. " I don't think she cut me off, but she quickly moved on to her next question without further delving deeper", while others were more responsive and supportive e.g., the provider " is very open to hearing my situation, I was able to fully explain my situation clearly." Such provider behavior impacted trust and connection, e.g., " Doctor X had good communication skills, but I felt like he didn't really hear my full story" There were variations in how well providers related SDOH to medical symptoms, e.g. " he completely ignored my concerns about mold at home" [asthma case] vs. " His questions centered around possible anxiety this (housing issue) might be causing me." After acknowledgement, fewer providers provided specific information or referrals to address the problem. This lack of follow-up seemed to leave USPs feeling uncomfortable. Both empathic comments and suggestions for actions influenced their sense of activation to manage their health post-visit.
Conclusion(s): Data from the USP visits indicate that there is a range of attention to and follow up on patient presentation of SDOH needs by trainees in clinical settings. Issues of both general communication skills, awareness of connection between SDOH and health, and awareness of local resources impacted provider behavior, which then had an effect on relationship with patients. The complex issues involved in addressing SDOH highlights the diverse training needs for learners

Needs and Objectives: There is an increasing need for resident education on substance use disorders (SUDs). The purpose of our curriculum was to improve residents' knowledge, skills, and attitudes on treating patients with SUDs. Setting and Participants: First and second year residents from NYU's Primary Care, Internal Medicine program participated in the Block of Addiction Medicine (BAM!) curriculum. Clinical settings included buprenorphine/methadone clinics and outpatient treatment programs in a large, urban safety net hospital system. Description: BAMis an intensive two week curriculum focused on SUDs. To improve residents' knowledge, we included didactic sessions on substances, including alcohol, opiates, and tobacco. Sessions covered epidemiology, biology, and treatment, including pharmacologic options, with all residents receiving buprenorphine prescribing waiver training. BAMwas delivered by an interdisciplinary faculty that included addiction medicine specialists, department of health officials, and general practitioners, nurses, and social workers who have worked extensively with patients with SUDs. Workshops built skills including screening, brief interventions, and referral to treatment (SBIRT) and motivational interviewing. Residents attended buprenorphine/methadone clinics, outpatient treatment programs, and 12-step (AA/NA) meetings. Residents shared lunch in a non-clinical setting with patients in recovery to understand their perspectives on living with addiction. Evaluation: Residents' attitudes and self-perceived efficacy in treating SUDs were surveyed. Pre and post data was obtained on 15 of 16 participants. Using the medical condition regard scale (MCRS), an 11 item questionnaire on biases/emotions/expectations for treating patients with SUD, we found a statistically significant improvement in the composite score, from 44.46 to 47.0 (p=0.026). Of 15 residents, 11 reported improved ability to effectively screen for SUD, 10 reported improved comfort in screening patients for SUD, 12 reported improved knowledge in using medically assisted treatment (MAT), and 14 reported improved ability to effectively treat patients with MAT (all p<.001 in Wilcoxon signed rank test). Qualitative feedback showed residents felt this curriculum was an essential part of their education; one participant commented: "this is a course that should be offered to every medical care provider." Discussion/Reflection/Lessons Learned: BAMincluded a varied curriculum delivered by inter-professional faculty. Residents reported improved comfort in treating patients with SUDs and demonstrated a significant improvement on the MCRS in their already positive attitudes towards treating this patient population. Qualitative feedback indicated that residents enjoyed BAMand found it important to their training. Given the increasing need for providers who are able to effectively treat SUDs, courses such as BAMare an effective and essential part of residency. Further studies are needed to assess if the changes in residents' attitudes persist and whether we influenced practice

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