Faculty Bibliography

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.

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.

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.

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.

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: Stethoscopes are recognized as a culprit of microbes that has been conclusively demonstrated to transmit microbes from one patient to another and from health care worker to patient. To curb infections, hospitals need to set more rigorous hygiene standards, identify Methods to interrupt transmission and develop strategies on sterilizing the diaphragms of the stethoscopes. Furthermore, studies have shown that providers infrequently clean their stethoscopes. In one study, only 48% of providers cleaned their stethoscopes daily or weekly, 37% monthly and 7% reported that they had never cleaned their stethoscope. The objective of this study was to conduct a pilot study comparing efficacy of disposable diaphragm covers to no intervention, defined as their ability to reduce colony count of Methicillin Resistant Staphylococcus Aureus (MRSA) and reduce bacterial contamination on stethoscope diaphragm surfaces.
Method(s): This was a prospective pilot study using a randomized, controlled, single-blinded, crossover trial design, evaluating the effect of daily stethoscope disposable diaphragm covers vs. uncovered stethoscopes. Upon recruitment, residents on clinical rotations were randomized to receive one of two sealed opaque boxes. If a resident was randomized to the intervention arm, the package included instructions to begin with the covers. If a resident was randomized to the control arm, instructions were to begin with no covers. We instructed the participants to switch arms at 7 days. Laboratory Methods: A sterile swab was rolled over the surface of the stethoscope's diaphragm from side to side in a streaking method. We used the chromagar MRSA plates (MRSASelectTM II agar plates) to grow oxacillin resistant, non-enterococal gram positives and the non-selective blood agar plate. Cultures were obtained from each resident's stethoscope diaphragm at the end of every 7 day period. We performed a colony count in 24 hours and 48 hours of incubation.
Result(s): We enrolled 37 residents, of whom 29 (70%) completed both weeks of the trial. On the log-10 scale, the mean (range) colony count on plain agar was 1.5 (0.0-3.7) during control and 1.6 (0.0-3.0) using covers. For MRSA, the mean (range) log-10 colony count during control was 0.1 (0.0-2.7) and 0.1 (0.0-1.2) under covers. Overall, 7 (11%) cultures were positive for MRSA during control and 6 (9%) using covers. Using mixed models to account for within-subject and within-culture correlation, the covers increased colony count by 0.47 (95% confidence interval,-0.37-1.31) in mean log-10 overall colony count, and increased risk of MRSA+ culture by 0.2 percent (95% confidence interval,-10.0-10.3).
Conclusion(s): This well designed study shows disposable diaphragm covers inadequate in reducing bacterial load. It is likely that this study was hindered by a small sample size, therefore a larger study to evaluate the ability of other Methods to prevent cross transmission of MRSA and subsequent infections from the stethoscope diaphragm is needed