Faculty Bibliography

Objectives: In this study, we evaluated the effects of a Transtheoretical model (TTM)-based tailored behavioral intervention (TBI), a non-tailored intervention (NTI) or usual care (UC) on: (1) the Dietary Approaches to Stop Hypertension (DASH) dietary pattern in 533 individuals with uncontrolled hypertension; and (2) the change from baseline to 6 months in proportion of participants in action or maintenance stages of change (SOC). Methods: This was a randomized clinical trial. Diet was evaluated using the validated Harvard DASH score calculated from Willett Food Frequency Questionnaires (range 8-40). The randomized groups were compared using the Wilcoxon rank-sum test, with adjustment for clustering by physician and baseline DASH scores. Results: At 6 months, compared to UC, TBI had a 1.28 point increase in DASH score (p ≤ .01) while NTI was not significant. At 6-month follow-up, TBI was more effective in advancing dietary SOC when compared to UC (56% vs 43%, p < .01) and NTI was not effective (46% vs 43%, p = .64). Conclusions: A phone-delivered tailored TTM-based intervention achieved greater improvement in DASH score and dietary SOC, suggesting that TTM-based tailored interventions can increase patients' dietary adherence.

Patients with limited English proficiency skills are accessing health care services more frequently around the world. Language barriers increase patient vulnerability for adverse events, and health care interpreters may mitigate this risk. Nursing education regarding the effective and appropriate use of health care interpreters has been limited. Interpreters are natural partners for nurses as a strategy to bridge language barriers with patients and could be integrated more regularly into nursing education using clinical simulation strategies. This article offers an overview of the different types of interpreters in health care, proposes recommendations for integrating them into simulation education, and provides a case example to illustrate implementation.

Objectives - Inoperable or metastatic paragangliomas (PGL) and malignant pheochromocytomas (PCC) are rare tumours with limited options for systemic treatment. Aim of this study was to assess the safety and efficacy of the radiolabelled somatostatin analogue [177LutetiumDOTA0-Tyr3]octreotate (177Lu-DOTATATE) for the treatment of PGLs and PCCs. Methods - Patients with histologically proven inoperable or malignant PGLs and PCCs treated with 177Lu-DOTATATE at our centre were retrospectively analysed. Patients were treated with up to four cycles of 177Lu-DOTATATE with an intended dose of 7.4 Gb per cycle. Response was assessed with use of RECIST 1.1 Results - Thirty patients were included: 17 with parasympathetic, 10 with sympathetic PGLs and 3 with PCCs. Grade 3/4 subacute haematotoxicity occurred in 6 (20%) of patients. A reversible subacute adverse event due to cardiac failure following possible catecholamine release occurred in two patients. Best tumour response was partial response in 7 (23%) and stable disease in 20 (67%), whereas 3 (10%) patients had progressive disease. In 20 patients with baseline disease progression, tumour control was observed in 17 (85%); the median progression free survival was 91 months in patients with parasympathetic PGLs, 13 months in patients with sympathetic PGLs and 10 months in patients with metastatic PCCs. Conclusion - This study suggests that PRRT with 177Lu-DOTATATE is a safe and effective treatment option for patients with inoperable or malignant PGL and PCC.

[This corrects the article DOI: 10.1093/ofid/ofy209.142.].

Objective/UNASSIGNED:To assess the prognostic utility of serum albumin among elderly patients admitted for acute decompensated heart failure (ADHF) in terms of all-cause mortality and also to identify the predictors of hypoalbuminemia. Methods/UNASSIGNED:Retrospective cohort study of 119 elderly patients admitted for ADHF. Elderly patients were defined as patients over the age of 65 years. The patients were followed up for approximately 11 years. Patients with advanced renal failure, liver disease not due to HF, cancer and other causes of low life expectancy were excluded. Hypoalbuminemia was defined as serum albumin ≤ 2.9 g/dL. Results/UNASSIGNED:= 0.0357) was the only predictor of hypoalbuminemia following multiple linear regression. Conclusions/UNASSIGNED:Hypoalbuminemia may be an unrecognized marker of death in elderly patients with ADHF.

BACKGROUND:Accumulating data support a protective role of Helicobacter pylori against inflammatory bowel diseases (IBD), which might be mediated by strain-specific constituents, specifically cagA expression. AIM:To perform a systematic review and meta-analysis to more clearly define the association between CagA seropositivity and IBD. METHODS:We identified comparative studies that included sufficient detail to determine the odds or risk of IBD, Crohn's disease (CD) or ulcerative colitis (UC) amongst individuals with vs without evidence of cagA expression (eg CagA seropositivity). Estimates were pooled using a random effects model. RESULTS:Three clinical studies met inclusion criteria. cagA expression was represented by CagA seropositivity in all studies. Compared to CagA seronegativity overall, CagA seropositivity was associated with lower odds of IBD (OR 0.31, 95% CI 0.21-0.44) and CD (OR 0.25, 95% CI 0.17-0.38), and statistically nonsignificant lower odds for UC (OR 0.68, 95% CI 0.35-1.32). Similarly, compared to H pylori non-exposed individuals, H pylori exposed, CagA seropositive individuals had lower odds of IBD (OR 0.26, 95% CI 0.16-0.41) and CD (OR 0.23, 95% CI 0.15-0.35), but not UC (OR 0.66, 0.34-1.27). However, there was no significant difference in the odds of IBD, CD or UC between H pylori exposed, CagA seronegative and H pylori non-exposed individuals. CONCLUSION:We found evidence for a significant association between CagA seropositive H pylori exposure and reduced odds of IBD, particularly CD, but not for CagA seronegative H pylori exposure. Additional studies are needed to confirm these findings and define underlying mechanisms.

BACKGROUND: According to the 2017 American College of Gastroenterology (AGA) guidelines, therapeutic drug monitoring (TDM) of drug trough concentrations and anti-drug antibodies is recommended to optimize treatment with anti-tumor necrosis factor (TNF) agents and thiopurines1. Specifically, the AGA conditionally recommends reactive TDM in patients with active symptoms of inflammatory bowel disease (IBD) while on anti-TNF agents, as such testing is crucial for differentiating between mechanistic, non-immune mediated pharmacokinetic and immune-mediated pharmacokinetic drug failure, and allows providers to appropriately tailor treatment regimens. As such algorithms for monitoring therapies in IBD have evolved, it has become incumbent on physicians caring for these patients to develop techniques to engage in patient-centered care using the technique of shared decision making. Gastroenterology (GI) trainees may not be well versed in navigating these complex interpersonal skills. The Observed Structured Clinical Examination (OSCE) is a well-validated method of assessing core competencies of communication and professionalism. While it is traditionally used at the undergraduate medical education level, it has been used at the graduate level to address disease-specific competencies. Here, we discuss the use of an OSCE to assess the performance of GI fellows in engaging in shared decision-making on the topic of TDM for a patient with complex IBD refractory to treatment.
METHOD(S): Eleven second-year gastroenterology fellows from 4 GI fellowship programs participated in a 4 station OSCE. Previously validated OSCE checklists were used to assess the fellows' performance in IBD-specific cases, one of which will be discussed here. In the "Therapeutic Drug Monitoring" case, the objective for the fellows was to discuss the indications for infliximab trough and antibody testing and how results of this testing would impact treatment based on the AGA guidelines. Checklists were scored on a 3 and 5-point Likert Scale by the Standardized Patient (SP), mapped to the appropriate ACGME milestones by a GI medical educator and normalized on a scale from 0 to 9. Post-OSCE, the fellows were surveyed to assess their perspective on their performance as well as the exam's educational value.
RESULT(S): 6 ACGME milestones were assessed in this OSCE. Scores ranged from mean of 5.85 to 7.88. Fellows scored lowest on gathering and synthesizing essential and accurate information to define each patient's clinical problem(s) (PC1, mean score 5.85) with an average score of 5.85. They scored highest for overall clinical knowledge (MK1, mean score 7.88). Overall, 9/10 (90%) of fellows would be recommended for their interpersonal skills, but only 4/10 (40%) were deemed effective in their communication skills. The majority of fellows noted improvement in their understanding of when to use and how to interpret TDM after the exercise. CONCLUSION(S): This OSCE was designed to assess clinical and communication skills for gastroenterology surrounding the complex clinical arena of therapeutic drug monitoring utilizing crucial communication skills. The results suggest weaker performance linked to gathering and synthesizing clinical information, with stronger performance in clinical knowledge, developing management plans and various communication skills. This OSCE feedback and assessment can be used to develop targeted educational interventions to strengthen clinical and communication skills for providers

OBJECTIVES:To better understand indications for β-blocker (BB) prescriptions among older adults hospitalized with heart failure with preserved ejection fraction (HFpEF). DESIGN/SETTING:Retrospective observational study of hospitalizations derived from the geographically diverse Reasons for Geographic and Racial Differences in Stroke cohort. PARTICIPANTS:We examined Medicare beneficiaries aged 65 years or older with an expert-adjudicated hospitalization for HFpEF (left ventricular ejection fraction = 50% or greater). MEASUREMENTS:Discharge medications and indications for BBs were abstracted from medical records. RESULTS:Of 306 hospitalizations for HFpEF, BBs were prescribed at discharge in 68%. Among hospitalizations resulting in BB prescriptions, 60% had a compelling indication for BB-44% had arrhythmias, and 29% had myocardial infarction (MI) history. Among the 40% with neither indication, 57% had coronary artery disease (CAD) without MI and 38% had hypertension alone (without arrhythmia, MI, or CAD), both clinical scenarios with little supportive evidence of benefit of BBs. Among hospitalizations resulting in BB prescription at discharge, 69% had geriatric conditions (functional limitation, cognitive impairment, hypoalbuminemia, or history of falls). There were no significant differences in the prevalence of geriatric conditions between hospitalizations of individuals with compelling indications for BBs and hospitalizations of individuals with noncompelling indications. CONCLUSIONS:BBs are commonly prescribed following a hospitalization for HFpEF, even in the absence of compelling indications. This occurs even for hospitalizations of individuals with geriatric conditions, a subpopulation who may be at elevated risk for experiencing harm from BBs.

Intraductal papillary neoplasm of the bile duct is a rare bile duct tumor that displays a range of cytoarchitectural atypia and is recognized as a precursor of invasive carcinoma. We present a 71-year-old woman with a recent diagnosis of lung adenocarcinoma, who presented with acute cholangitis secondary to an obstructive intraductal papillary neoplasm of the bile duct. The patient underwent endoscopic retrograde cholangiopancreatography, which identified the lesion, and on biliary sweep, the polyp presented externally and she underwent successful polypectomy with resolution of the infection.

Background Sexually transmitted infection (STI) testing in hospital- based settings represents an opportunity to intervene and prescribe pre-exposure prophylaxis (PrEP) to prevent HIV infections. Methods Electronic health records of patient visits at NYC Health+Hospitals(H+H)/Bellevue between 1/1/14-7/30/17 were queried for positive STIs (gonorrhea (GC) and chlamydia (CT) & syphilis) results by hospital location and time. Visit data also included: patient demographic characteristics and PrEP prescriptions. Generalized estimating equations using a logit link, to account for repeated within patient measures, were used to explore the relationship between having a medical follow- up visit in <=30 and <=90 days following STI testing, which represents an opportunity to provide PrEP prescription, and demographic factors, controlling for key confounders. Results A total of 1,169 HIV-negative patients with 1+ STI diagnosis contributed 1,275 visits, of whom 700 (58%) were female with mean age of 32 yrs (SD=12.3)] and 532 (42%) were male with mean age of 44 yrs (SD 16.3). The majority of patients were Black (40%) or Hispanic/Latino (50%). In this sample, only 27 patients received PrEP. Overall, chlamydia was the most common (135/11%), followed by syphilis (476/ 38%) and gonorrhea (135/11%). Two-thirds of patients with a +STI diagnosis originated from the ED (33%) and OB/GYN clinics (32%); an additional 11% were diagnosed in Medicine clinics. 78% of patients did not have follow up <=30 days after +STI diagnosis. In adjusted analyses, the adjusted OR for follow up <=30 days after +STI diagnosis was lower for Black patients [0.39 (95%CI 0.21-0.72, p<0.01)] and higher for patients >=45 years old 2.20 [(95%CI 1.16-4.19, p= 0.02)]. Conclusion STI testing at a major, publicly-funded hospital within NYC H&H is an opportunity to discuss and prescribe PrEP. However, our findings suggest that there are significant missed opportunities for linkage to care after a +STI diagnosis and PrEP initiation, especially in the ED among young Black patients