Faculty Bibliography

Despite modern investigative innovations in the cutting edge field of gastroenterology, we are reminded of our contemporary limitations when we encounter the ever evasive Dieulafoy's lesion (DL). Ever since it has been initially described in 1884, its rare but frustrating presence creates a calamitous situation. Even more so when it presents atypically, much like it did in our patient. This review of DL delves into the history, epidemiology, characteristics, the most current and innovative diagnostic measures available, as well as treatment and prevention of recurrence of these obscure gastrointestinal (GI) bleeding sources.

BACKGROUND:Complementary and alternative medicines (CAM) are associated with poor asthma medication adherence, a major risk factor for asthma exacerbation. However, previous studies showed inconsistent relationships between CAM use and asthma control due to small sample sizes, demographic differences across populations studied, and poor differentiation of CAM types. METHODS:We examined associations between CAM use and asthma exacerbation using a cross-sectional analysis of the 2012 National Health Interview Survey. We included adults ≥18 years with current asthma (n = 2,736) to analyze racial/ethnic differences in CAM use as well as the association between CAM use and both asthma exacerbation and emergency department (ED) visit for asthma exacerbation across racial/ethnic groups. We ran descriptive statistics and multivariable logistic regressions. RESULT/RESULTS:Blacks (OR = 0.63 [0.49-0.81]) and Hispanics (OR = 0.66 [0.48-0.92]) had decreased odds of using CAM compared to Whites. Overall, there was no association between CAM use and asthma exacerbation (OR = 0.99 [0.79-1.25]) but the subgroup of 'other complementary approaches' was associated with increased odds of asthma exacerbation among all survey respondents (1.90 [1.21-2.97]), Whites (OR = 1.90 [1.21-2.97]), and Hispanics (OR = 1.43 [0.98-2.09). CAM use was associated with decreased odds of an ED visit for asthma exacerbation (OR = 0.65 [0.45-0.93]). These associations were different among racial/ethnic groups with decreased odds of ED visit among Whites (OR = 0.50 [0.32-0.78]) but no association among Blacks and Hispanics. CONCLUSION/CONCLUSIONS:We found that both CAM use and the association between CAM use and asthma exacerbation varied by racial/ethnic group. The different relationship may arise from how CAM is used to complement or to substitute for conventional asthma management.

Introduction Adrenocortical carcinoma (ACC) is a rare cancer that commonly spreads to the liver, lungs and lymph nodes. Bone metastases are infrequent. Objective The aim of this report was to describe the clinical characteristics, survival perspective, prognostic factors and frequency of adverse skeletal-related events (SREs) in patients with ACC who developed bone metastasis. Methods This is a retrospective, observational, multicenter, multinational study of patients diagnosed with bone metastases from ACC who were treated and followed up in three European countries (France, Italy and The Netherlands) and one center in the United States. Results Data of 156 patients were captured. The median overall survival was 11 months. SREs occurred in 47% of patients: 17% bone fractures, 17% spinal cord compression, 1% hypercalcemia, 12% developed more than one SRE. In multivariate analysis, cortisol hypersecretion was the only prognostic factor significantly associated with a higher mortality risk (hazard ratio (HR) 2.24, 95% confidence interval (CI): 1.19-4.23, P = 0.013) and with the development of a SREs (of border line significance). The administration of antiresorptive therapies (bisphosphonates and denosumab) was associated with a lower risk of death, even if not significant, and their survival benefit appeared confined in patients attaining serum mitotane levels within the therapeutic range. Conclusion Bone metastases in ACC patients are associated with poor prognosis and high risk of SREs. Cortisol hypersecretion was the only prognostic factor suggesting a potential benefit from antisecretory medications. The therapeutic role of bisphosphonates and denosumab to improve patient outcome deserves to be tested in a prospective clinical trial.

BACKGROUND:Primary care provider skills such as screening, longitudinal monitoring, and medication management are generalizable to prescribing alcohol use disorder (AUD) pharmacotherapy. The association between primary care engagement (i.e., longitudinal utilization of primary care services) and prescribing of AUD pharmacotherapy is unknown. METHODS:We examined a 5-year (2010-2014) retrospective cohort of patients with AUD, 18 years and older, at an urban academic medical center in the Bronx, NY, USA. Our main exposure was level of primary care engagement (no primary care, limited primary care, and engaged with primary care) and our outcome was any AUD pharmacotherapy prescription within 2 years of AUD diagnosis. Using multivariable logistic regression, we examined the association between primary care engagement and pharmacotherapy prescribing, accounting for demographic and clinical factors. RESULTS:Of 21,159 adults (28.9% female) with AUD, 2.1% (n = 449) were prescribed pharmacotherapy. After adjusting for confounders, the probability of receiving an AUD pharmacotherapy prescription for patients with no primary care was 1.61% (95% CI 1.39, 1.84). The probability of AUD pharmacotherapy prescribing was 2.56% (95% CI 2.06, 3.06) for patients with limited primary care and 2.89% (95% CI 2.44, 3.34%) for patients engaged with primary care. CONCLUSIONS:The percentage of AUD patients prescribed AUD pharmacotherapy was low; however, primary care engagement was associated with a higher, but modest, probability of receiving a prescription. Efforts to increase primary care engagement among patients with AUD may translate into increased AUD pharmacotherapy prescribing; however, strategies to increase prescribing across health care settings are needed.

Statement of Problem Or Question (One Sentence): As the lack of a 'face-to-face' interaction between the full team and the patient led to a downtrend in patient experience scores, we were inspired to design a patient centered communication tool that standardizes the multi-disciplinary bedside rounds. Objectives of Program/Intervention (No More Than Three Objectives): 1. To improve our patients' hospital experience in regards to care transitions and discharge planning by implementing standard bedside rounds that center around the patient's health care needs. 2. To create a daily scheduled opportunity for the patient to be involved in medical decisions and discharge planning which enhances patients' understanding of their own care plan. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): Our medical-surgical units did not have a standardized approach to ensure clear communication from a patient's multidisciplinary team, comprised of physicians, nurses, case managers and social workers. To this end, we implemented a communication plan based on the acronym "WE CARE" 1) Who was present (who was at bedside in addition to the patient); 2) Everyone on same page (language and literacy barriers); 3) Connect with patient and family (promote patient-centeredness and compassionate care through eye contact, introducing the full team); 4) Assessing understanding (explanation of changes to medications, key lab and test Results, and post-discharge plans); 5) Response from patient and/or caregivers (ensuring understanding); 6) Educate/empathy/end of conversation. Centered on the WE CARE model, we gathered all members of the care team and visited each patient at a standardized time every day. The intervention was started on one medical-surgical, unit 5600 on July 2018. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): HCAPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores for care transitions and discharge information pre and post intervention will be evaluated for the study group (unit 5600). We will also compare these scores to med/surg units who did not receive the intervention. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): We compared our pre-intervention 1/1/2018-4/31/2018 (approximately 54 surveys) and post-intervention (approximately 42 surveys) scores. In the domain of care transitions, e. g., patient had a good understanding of things patient was responsible for in managing his/her health; patient had a good understanding of purpose of each medication; staff consideration of patient and caregiver preferences post-discharge, there was an increase from 28% in our top-box (an answer of always) composite HCAHPS score to 58%. Scores for "discharge information delivered" remained high with a top-box response above 85% both pre-and post-intervention. In addition, during the post-intervention time, the study group unit had the highest "care transition" and "discharge information" top box responses compared to all control units. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): A focused, structured communication tool WE CARE, implemented as a part of daily standardized multidisciplinary bedside rounds led to an improvement in patient satisfaction scores around care transitions and discharge information delivered

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

Background: The core Entrustable Professional Activities medical school graduates should be able to perform on day 1 of residency provides a framework for readiness for residency. Communication skills are an essential foundation for these core EPAs and yet there have been few studies that describe communication competence across the UME-GME continuum. We report on our OSCE-based assessment of communication skills from the first few weeks of medical school to the first year of medicine residency.
Method(s): Assessment of communication is consistent in our OSCE program across UME and GME. Domains include Information Gathering (5 items), Relationship Development (6 items), and Patient Education (3 items) and these are assessed via a behaviorally anchored checklist (scores=% well done) that has strong reliability and validity evidence. In this study, we report on 3 multi-station OSCEs: the Introductory Clinical Experience (ICE) OSCE that occurs within the first weeks of medical school; the high-stakes, pass/fail Comprehensive Clinical Skills Examination (CCSE) OSCE that is fielded after clerkship year; and the Medicine Residency Program's PGY 1 OSCE. Across 3 classes of medical school (2014-2016) we have complete data for the 24 students who continued on in our Medicine Residency (and who provided consent to include their educational data in an IRB-approved registry). Analyses focus on differences in communication skills over time and between cohorts and the relationship between communication skills measured in medical school and those assessed in residency.
Result(s): Communication scores show significant improvement through medical school (but not into residency) in Information gathering (ICE mean=56%; CCSE mean=76%; PGY1 mean=77%) (F=11.54, p<.001, ICE< CCSE) and in relationship development (ICE=59%; CCSE=78%; PGY1= 74% (F=10.68, p<.001, ICE < CCSE). Mean patient education skills, however, increase significantly across all 3 time points (32% to 50% to 65%; F=31.00, p<.001). Patterns are similar across cohorts except that the Class of 2016 means increase from CCSE to PGY1. Regression analyses show that CCSE information gathering scores are more strongly associated with PGY performance than ICE scores (Std Beta=.32 vs.06), while for relationship development, it is the ICE scores that are more strongly associated (Std Beta=.40 vs.24). ICE and CCSE patient education skills have associations with PGY1 skill of similar size (Std Beta=.30 and.28).
Conclusion(s): Findings, despite the small sample, suggest a clear developmental trajectory for communication skills development and that information gathering and patient education skills may be more influenced by medical school than relationship development. That communication skills seem to level out in PGY1 highlights need for re-consolidation as clinical complexity increases. Results can inform theory development on how communication skills develop and point to transitions where skills practice/feedback may be particularly important

Background: Considerable resources are put into training physicians to be effective providers after residency. Practicing physicians are generally assumed to be more effective and more efficient than resident physicians who are still undergoing training. We capitalize on a unique opportunity to test that hypothesis using the controlled methodology of Unannounced Standardized Patients (USPs), Standardized Patients sent into clinical environments to systematically assess provider skills in the context of a standardized clinical scenario. Due to last minute scheduling changes, a small sample of attending physicians ended up seeing USPs we had intended to send to residents. In this study, we report on comparisons between how these attending physicians performed in terms of their patient centeredness, patient activation, assessment, and communication skills in comparison to residents.
Method(s): 6 USP visits were delivered to primary care clinics in an urban safety net hospital from 2009 to 2015. Of those 700+ visits, visits were completed inadvertently with 16 attendings. We selected the 16 attendings with at least 4 years of post-graduate experience and then matched them with 2 resident visits based on hospital, time period, and USP visit type (n=32 residents). In all visits, USPs completed a behav-iorally anchored post-visit checklist that assessed patient centeredness (4 items), patient activation (2 items), visit-specific assessment (10 items), and communication skills including information gathering (4 items), relationship development (5 items) and patient education (3 items). Items were rated as not done or partially done vs. well done and summary scores were calculated as % well done. Mean scores for attendings and matched residents were compared using t-tests.
Result(s): Resident and attending scores on patient centeredness (68% vs 73%), patient activation (44% vs 38%), assessment (53% vs 51%), patient education (49% vs 52%), information gathering (71% vs 78%) and relationship development (70% vs 73%) did not significantly differ (p>.05). Nor did we see any substantial differences in variances or find any outliers.
Conclusion(s): In our matched sample of residents and attendings, there were no significant differences by training level for any of the assessed clinical skills. While we viewed the inadvertent scheduling of USP visits with attendings as an opportunity to investigate the impact of training, our study is limited by the small sample size and whether we were able to create good matches. Findings may reflect ceiling effects (our checklists are too hard) or expertise-reversal effects (experts can skip some elements of the interaction and still arrive at the correct diagnosis and treatment plan). Further research, if our mistakenly-assessed attending sample increases, could explore the influence of PGY level and of patient load as attendings carry substantially heavier patient panels and see more (and probably more complex) patients per day then residents