Faculty Bibliography

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:The effects of breastfeeding (BF) on metabolic syndrome (MetS) and diabetes mellitus in children exposed to gestational diabetes mellitus (GDM) in utero have rarely been evaluated. OBJECTIVE:This study assessed BF and GDM in relation to the prevalence of prediabetes and MetS in Hispanic children and adolescents (8-19 y). METHODS:This is a longitudinal study with 229 Hispanic children (8-13 y) with overweight/obesity, family history of diabetes, and an average of four annual visits (AV). Participants were categorized as follows: never (negative for prediabetes/MetS at all AVs), ever (positive for prediabetes/MetS at any visit), intermittent (positive for prediabetes/MetS at 1-2 AVs), and persistent (positive for prediabetes/MetS at greater than or equal to 3 AVs). RESULTS:Compared with GDM offspring who were not BF (referent), GDM offspring who were BF had lower odds of persistent prediabetes (OR = 0.18; 95% CI, 0.04-0.82; P = 0.02) and MetS (OR = 0.10; 95% CI, 0.02-0.55; P = 0.008). Compared with referent group, non-GDM offspring who were BF, and non-GDM offspring not BF had lower odds of persistent prediabetes (OR = 0.10; 95% CI, 0.03-0.39; P = 0.001; OR = 0.05; 95% CI, 0.01-0.11; P < 0.001) and MetS (OR = 0.14; 95% CI, 0.04-0.59; P = 0.01 and OR = 0.04; 95% CI, 0.01-0.11; P < 0.001). CONCLUSIONS:These results show BF is protective against prediabetes and MetS in offspring regardless of GDM status.

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.

PURPOSE OF REVIEW/OBJECTIVE:The effect of the intestinal microbiome on urine chemistry and lithogenicity has been a popular topic. Here we review the evidence for exposure to antibiotics increasing the risk of nephrolithiasis. RECENT FINDINGS/RESULTS:Studies of the intestinal microbiome have focused on Oxalobacter formigenes, an anaerobe that frequently colonizes the human colon. As a degrader of fecal oxalate its presence is associated with lower urinary oxalate, which would be protective against calcium oxalate stone formation. It also appears capable of stimulating colonic oxalate secretion. A recent study showed that antibiotics can eliminate colonization with O. formigenes. In a case-control study, exposure to sulfa drugs, cephalosporins, fluoroquinolones, nitrofurantoin/methenamine, and broad spectrum penicillins prospectively increased the odds of nephrolithiasis. The effect was greatest for those exposed at younger ages and 3-6 months before being diagnosed with nephrolithiasis. SUMMARY/CONCLUSIONS:Recent evidence suggests a possible, causal role of antibiotics in the development of kidney stones. A possible explanation for this finding includes alterations in the microbiome, especially effects on oxalate-degrading bacteria like O. formigenes. Ample reasons to encourage antibiotic stewardship already exist, but the possible role of antibiotic exposure in contributing to the increasing prevalence of kidney stones in children and adults is another rationale.

Background Understanding the relationships between demographic, healthcare-related and psychosocial factors with STI vulnerability will provide information that can guide development of STI prevention efforts tailored to the lived realities of YMSM. Methods Between 2009-2011, n=600 YMSM were enrolled at age 18 in a prospective cohort study examining psychosocial and physical health during semi-annual visits conducted over a 36-month period. Reports of recent STIs were collected by self-report and a composite outcome variable was created: self-report of any STI (CT, GC, and/or syphilis) in the prior 90 days (hereafter called STI diagnoses). Bivariate analysis was conducted to examine relationships between STI diagnoses and 3 domains of covariates: demographic factors, psychosocial factors, and healthcare system related factors. Generalized estimating equations (GEE) with link logit was used to model factors from each domain associated with STI diagnoses. Results Over the course of the study period, these 597 participants contributed a total of 2,765 visits and self-reported n=205 STI diagnoses (composite variable detailed above). Increased age was associated with increased likelihood of STI diagnoses (aOR=1.22 per year, 95% CI 1.04-1.43) after adjustment for SES, race, #insertive/receptive anal intercourse acts, type of healthcare obtained (private clinic, public clinic, VA), and insurance status. Black/African YMSM were more likely to self-report an STI (aOR=2.90, 95% CI 1.50-5.61), compared to White (non-hispanic) peers (adjusted for age, SES, #sex acts, clinic type, and insurance). Participants receiving healthcare at public clinics (aOR= 1.89, 95% CI 1.30- 2.77) and VA facilities (aOR= 4.13 95% CI 2.24-7.60) were more likely to report STI diagnoses than those attending private clinics (adjusted for age, race, SES, #sex acts, insurance). Depression score, gay-related stigma, internalized homophobia were not associated with STI diagnoses. Conclusion Older black/african YMSM were more likely to self-report an STI, perhaps because they participant in a different core mixing group of sexual contacts than other participants

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

Mesenchymal origin of primary thyroid angiosarcomas (TAS) is extremely rare and comprises less than 1% of primary thyroid cancer worldwide. While TAS are most commonly occurring in the Alpine region, there are multiple reported cases of TAS in non-Alpine regions. Diagnosis of TAS is commonly made after thyroidectomy as cytologic diagnosis can be challenging due to paucity of cells, presence of necrosis and unawareness of the disease due to rarity. We report a case of primary TAS diagnosed by cytology in a 56-year-old man who presented with a sudden onset of left neck pain, swelling and haemoptysis. He was later noted to have suspicious nodules on both lobes of thyroid on ultrasound. Fine needle aspiration of thyroid nodules showed malignant epithelioid cells. The diagnosis of TAS was made based on positive endothelial markers such as thrombomodulin and CD31, with many pertinent negatives, including negative cytokeratins,thyroid transcription factor (TTF1), thyroglobulin, calcitonin and carcinoembryonic antigen (CEA).

Background Clinical reasoning (CR) is a core competency in medical education. Few studies have examined efforts to train faculty to teach CR and lead CR curricula in medical schools and residencies. In this report, we describe the development and preliminary evaluation of a faculty development workshop to teach CR grounded in CR theory. Methods Twenty-six medicine faculty (nine hospitalists and 17 subspecialists) participated in a workshop that introduced a framework to teach CR using an interactive, case-based didactic followed by role-play exercises. Faculty participated in pre- and post-Group Observed Structured Teaching Exercises (GOSTE), completed retrospective pre-post assessments (RPPs), and made commitment to change statements (CTCs). Results In the post-GOSTE, participants significantly improved in their use of problem representation and illness scripts to teach CR. RPPs revealed that faculty were more confident in their ability and more likely to teach CR using educational strategies grounded in CR educational theory. At 2-month follow-up, 81% of participants reported partially implementing these teaching techniques. Conclusions After participating in this 3-h workshop, faculty demonstrated increased ability to use these teaching techniques and expressed greater confidence and an increased likelihood to teach CR. The majority of faculty reported implementing these newly learned educational strategies into practice.

Fluridone is widely used as a herbicide for controlling invasive aquatic plants such as hydrilla in surface water bodies. When applied on surface waters fluridone can attach to bed sediment, requiring rigorous extraction methods prior to analysis. Currently, very limited information exists in terms of fluridone residue detection in delta sediment. In this study, we researched fluridone detection in both water and sediment. To extract fluridone from sediment, here we have tested two extraction methods: (1) a rotavapor method (RM); and (2) a quick, easy, cheap, effective, rugged and safe (QuEChERS) method (QM). The extraction results of RM were compared with those of QM. To quantify fluridone concentrations in extracts, a high-performance liquid chromatography (HPLC)-UV detector was used. HPLC separation was achieved using an Allure C18 5 µm 150 × 4.6 mm column with a mobile phase composed of acetonitrile and water (60:40, v/v). The UV detector was operated at 237 nm. The method was tested and validated using a series of water and sediment samples taken from Sacramento-San Joaquin Delta in California. The average recovery of fluridone was 73% and 78% using RM and QM respectively. The proposed method can be used for testing fluridone in water and sediment samples.