Faculty Bibliography

Antithrombotic therapy for stroke prevention in patients with atrial fibrillation (AF) has dramatically shifted from warfarin, a vitamin K antagonist, to the direct oral anticoagulants (DOACs) such as dabigatran, apixaban, and rivaroxaban. In patients with contraindications to oral anticoagulation, left atrial appendage occlusion (LAAO) devices, such as the Watchmanâ„¢ device, may be considered; however, temporary postimplantation antithrombotic therapy is still a recommended practice. We present a case of complex antithrombotic management, post LAAO device implantation, designed to avoid drug interactions with concomitant rifampin use and remained necessary secondary to subsequent device leak. This case highlights the challenges of antithrombotic therapy post LAAO device placement in a complex, but representative, patient.

BACKGROUND:Because of the strong link between childhood obesity and adulthood obesity comorbidities, and the difficulty in decreasing body mass index (BMI) later in life, effective strategies are needed to address this condition in early childhood. The ability to predict obesity before age five could be a useful tool, allowing prevention strategies to focus on high risk children. The few existing prediction models for obesity in childhood have primarily employed data from longitudinal cohort studies, relying on difficult to collect data that are not readily available to all practitioners. Instead, we utilized real-world unaugmented electronic health record (EHR) data from the first two years of life to predict obesity status at age five, an approach not yet taken in pediatric obesity research. METHODS AND FINDINGS/RESULTS:We trained a variety of machine learning algorithms to perform both binary classification and regression. Following previous studies demonstrating different obesity determinants for boys and girls, we similarly developed separate models for both groups. In each of the separate models for boys and girls we found that weight for length z-score, BMI between 19 and 24 months, and the last BMI measure recorded before age two were the most important features for prediction. The best performing models were able to predict obesity with an Area Under the Receiver Operator Characteristic Curve (AUC) of 81.7% for girls and 76.1% for boys. CONCLUSIONS:We were able to predict obesity at age five using EHR data with an AUC comparable to cohort-based studies, reducing the need for investment in additional data collection. Our results suggest that machine learning approaches for predicting future childhood obesity using EHR data could improve the ability of clinicians and researchers to drive future policy, intervention design, and the decision-making process in a clinical setting.

In this clinical vignette, we present a case of a 59-year-old woman with catastrophic antiphospholipid syndrome likely triggered by polymicrobial sepsis. The diagnostic criteria and clinical manifestations of catastrophic antiphospholipid syndrome are reviewed. We also compare diagnostic criteria and clinical manifestations with other clinical entities in the differential diagnosis, including thrombotic thrombocytopenic purpura-hemolytic-uremic syndrome, disseminated intravascular coagulation, sepsis, and inflammatory bowel disease. Catastrophic antiphospholipid syndrome is a rare, but lethal condition, and treatment recommendations are based on expert consensus and analyses of the international Catastrophic Antiphospholipid Syndrome Registry. Current management guidelines recommend triple therapy, with anticoagulation, glucocorticoids, and plasma exchange or intravenous immunoglobulins. This case brings this rare clinical entity to the attention of clinicians and emphasizes the need for more research to understand the best management. It also raises the question of whether high-dose steroids should be continued for treatment of catastrophic antiphospholipid syndrome in the setting of a severe sepsis.

Problem: Much of the medical education literature on clinical reasoning (CR) comes from primarily English-speaking countries. It is less clear how these educational interventions translate to environments with non-native English speakers, and in clinical systems where there is higher patient volumes.
Purpose(s): To implement a CR session for 6th year medical students at a university hospital in Istanbul, Turkey. Description of Program: In November, 2018 we conducted a 3-hour session on CR at Koc University in Istanbul developed from a curriculum at our home institution in the United States. In an interactive case-based didactic, students were introduced to the CR concepts of problem representation (PR), illness scripts, and diagnostic time outs. Students then applied these concepts to a case during facilitated small group breakouts. Outcomes Twenty-four 6th year medical students participated. Retrospective pre-post self-assessments of confidence in and likelihood of using CR concepts on an eight-point Likert scale were completed, and qualitative data on use in clinical practice were obtained. Results were analyzed using a paired t-test. After participating in this session, students were more confident in and more likely to use all domains of the CR framework taught with large effect sizes in eight of ten domains (Figure 1). A common theme in the qualitative data was that the use of PR would be helpful to communicate about patients efficiently in the busy clinical environment.
Discussion(s): Teaching CR skills translated well to an international setting. Critical to the session's success was demonstrating relevance to the local institution's clinical environment, in particular taking into account the higher patient volume experienced by providers, and changing the attitude that better decision-making does not necessarily take longer. The impact of culture and environment was evidenced by what the students found to be most effective-use of PR to communicate efficiently about patients in a busy clinical environment-which is different from our experiences teaching this in the US where learners often highlight the utility of the diagnostic time out. Significance of Findings Our findings speak to the need to contextualize CR concepts within the local learning culture to define relevance and meet the learners' needs. (Figure Presented)

Background: The risk-benefit ratio of ACE-I/ARB therapy after an AKI episode is unclear.
Method(s): We studied 1570 patients recently discharged from hospital and enrolled in a multi-center prospective cohort study (ASSESS-AKI). Follow-up began 3 months after index hospitalization and continued through November 2018. Half of the participants had AKI during the index hospitalization. ACE-I/ARB use and covariates were ascertained 3 months after discharge from the index hospitalization. We used multivariable Cox regression adjusting for demographics, cardiovascular disease, diabetes mellitus, heart failure (HF), blood pressure, urine protein to creatinine ratio, and eGFR to examine the association between ACE-I/ARB use and subsequent death, AKI (>=50% difference between peak and nadir inpatient serum creatinine), renal progression (ESRD or halving of eGFR), and adjudicated HF events.
Result(s): Among study participants who did not have AKI during index hospitalization (N=806), mean age was 65 years, mean eGFR 74 ml/min/1.73m2, and 45% self-reported use of ACE-I/ARB 3 months after hospitalization. Among study participants who did have AKI during index hospitalization (N=764), mean age was 64 years, mean eGFR 65 ml/min/1.73m2, and 50% self-reported use of ACE-I/ARB 3 months after hospitalization. Mean follow-up time was 3.6 years. ACE-I/ARB therapy 3 months after an AKI hospitalization was associated with a lower risk of another hospitalized AKI event and a lower risk of death (Table).
Conclusion(s): Use of ACE-I/ARB in survivors of hospitalized AKI was not associated with increased risk of subsequent AKI but was associated with lower risk of death

BACKGROUND/AIMS/OBJECTIVE:The current diagnostic workup of Cushing's syndrome (CS) requires various tests which only capture short-term cortisol exposure, whereas patients with endogenous CS generally have elevated long-term cortisol levels. Scalp hair assessment has emerged as a convenient test in capturing glucocorticoid concentrations over long periods of time. The aim of this multicenter, multinational, prospective, case-control study was to evaluate the diagnostic efficacy of scalp hair glucocorticoids in screening of endogenous CS. <br>Methods: We assessed the diagnostic performances of hair cortisol (HairF), hair cortisone (HairE), and sum of both (sumHairF+E), as measured by state-of-the-art LC-MS/MS technique, in untreated patients with confirmed endogenous CS (n=89), and community controls (n=295) from the population-based Lifelines cohort study. <br>Results: Both glucocorticoids were significantly elevated in CS patients when compared to controls. High diagnostic efficacy was found for HairF (area under the curve (AUC), 0.87 [95% CI, 0.83 to 0.92]), HairE (0.93 [0.89 to 0.96]) and sumHairF+E (0.92 [0.88 to 0.96]; all P<.001). Participants were accurately classified at optimal cut-off threshold in 86% of cases (81% sensitivity, 88% specificity, 94% negative predictive value (NPV)) for HairF, in 90% of cases (87% sensitivity, 90% specificity, 96% NPV) for HairE, and 87% of cases (86% sensitivity, 88% specificity, 95% NPV) for the sum. HairE was shown to be most accurate in differentiating CS patients from controls. <br>Conclusion: Scalp hair glucocorticoids, especially hair cortisone, can be seen as a promising biomarker in screening of CS. Its convenience in collection and workup additionally makes this feasible for first-line screening <br>.

Purpose: To explore the experiences of transgender and gender nonbinary (TGNB) medical students and physicians in the United States. Methods: The authors conducted a 79-item online survey using Likert-type and open-ended questions to assess the experiences of TGNB-identified U.S. medical students and physicians. Variables included demographic data, disclosure of TGNB status, exposure to transphobia, and descriptions of educational and professional experiences. Recruitment was conducted using snowball sampling through Lesbian, Gay, Bisexual, Transgender, Queer professional groups, list-servs, and social media. The survey was open from June 2017 through November 2017. Results: Respondents included 21 students and 15 physicians (10 transgender women, 10 transgender men, and 16 nonbinary participants). Half (50%; 18) of the participants and 60% (9) of physicians had not disclosed their TGNB identity to their medical school or residency program, respectively. Respondents faced barriers on the basis of gender identity/expression when applying to medical school (22%; 11) and residency (43%; 6). More than three-quarters (78%; 28) of participants censored speech and/or mannerisms half of the time or more at work/school to avoid unintentional disclosure of their TGNB status. More than two-thirds (69%; 25) heard derogatory comments about TGNB individuals at medical school, in residency, or in practice, while 33% (12) witnessed discriminatory care of a TGNB patient. Conclusion: TGNB medical students and physicians faced significant barriers during medical training, including having to hide their identities and witnessing anti-TGNB stigma and discrimination. This study, the first to exclusively assess experiences of TGNB medical students and physicians, reveals that significant disparities still exist on the basis of gender identity.