Faculty Bibliography

Learning Objective #1: Recognize how to diagnose tick-borne co-infections based on clinical presentation and lab findings. CASE: A 43-year-old man presented with one month of progressively worsening malaise and polyarthralgias to the point that he could not walk or hold utensils. He reported that shortly after removing a tick from his thigh while in upstate New York he developed fevers, anorexia, dizziness, and memory problems in addition to the rheumatic symptoms above. He denied any rashes or inflamed joints. On exam he was ill-appearing, had a fever of 102F but had no rashes, no joint erythema or effusions, and no cardiac murmurs. Laboratory values were significant for a hemoglobin of 9.2 g/dL, iron level of 55mu g/dL, total iron binding capacity of 247mu g/dL, a ferritin of 372 ng/mL, an erythrocyte sedimentation rate of 124 mm/hr, and a c-reactive protein of 116 mg/L. A peripheral smear was negative for hemolysis or Maltese crosses suggestive of babesiosis. EKG and imaging studies were unremarkable. On admission, he was started empirically on doxycycline for presumed tick-borne illness without coverage for babesiosis due to the negative peripheral smear and hemolysis labs. Over the course of his hospitalization the patient's fatigue slowly improved and by follow up one week later he was completely asymptomatic. His Lyme and anaplasma titers both returned positive. IMPACT: Rates of co-infection with babesiosis and anaplasmosis range from 4-28 percent in endemic regions of the United States. Lyme disease is a tick-borne illness transmitted by the Ixodes scapularis tick in Eastern and North Central regions of North America. I. scapularis is also the vector for Babesia microti and Anaplasma phagocytophilum. Those who are co-infected have similar clinical manifestations including malaise, fever, myalgias, and arthral-gias, but can have more prolonged courses and severe symptoms. DISCUSSION: Our patient presented with non-specific malaise, a largely unremarkable physical exam and an isolated anemia without any evidence of hemolysis. Babesiosis may cause hemolysis and anaplasmosis may cause leukopenia, thrombocytopenia, and elevated transaminases. Typically patients present with the rash of erythema migrans without remembering a tick bite, however the rash is only present in 80% of cases. Absence of rash and unusually severe rheumatic complaints should not decrease the suspicion for tick-borne illnesses under otherwise typical circumstances. Serologic testing was warranted due to the absence of an erythema migrans rash, and a history of travel to an endemic region with possible exposure to multiple tick-borne illnesses. Empiric therapy is indicated while definitive testing is pending

BACKGROUND:Despite decreasing rates of HIV among many populations, HIV-related health disparities among gay, bisexual and other men who have sex with men persist, with disproportional percentages of new HIV diagnoses among racial and ethnic minority men. Despite increasing awareness of HIV pre-exposure prophylaxis (PrEP), PrEP use remains low. In addition to exploring individual-level factors for this slow uptake, structural drivers of PrEP use must also be identified in order to maximize the effectiveness of biomedical HIV prevention strategies. METHOD/METHODS:Using cross-sectional data from an ongoing cohort study of young sexual minority men (N=492), we examine the extent to which structural-level barriers, including access to health care, medication logistics, counseling support, and stigma are related to PrEP use. RESULTS:While almost all participants indicated awareness of PrEP, only 14% had ever used PrEP. PrEP use was associated with lower concerns about health care access, particularly paying for PrEP. Those with greater concerns talking with their provider about their sexual behaviors were less likely to use PrEP. CONCLUSION/CONCLUSIONS:Paying for PrEP and talking to one's provider about sexual behaviors are concerns for young sexual minority men. In particular, stigma from healthcare providers poses a significant barrier to PrEP use in this population. Providers need not only to increase their own awareness of and advocacy for PrEP as an effective risk-management strategy for HIV prevention, but also must work to create open and non-judgmental spaces in which patients can discuss sexual behaviors without the fear of stigma.

Background/UNASSIGNED:A growing body of research continues to elucidate health inequities experienced by transgender individuals and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that cause transgender health inequities as well as improve knowledge about transgender-specific care. Methods/UNASSIGNED:We conducted structured searches of five databases to identify literature related to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were deemed relevant to predefined criteria, medical education, and transgender health topics. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017. Results/UNASSIGNED:Transgender health has yet to gain widespread curricular exposure, but efforts toward incorporating transgender health into both undergraduate and graduate medical educations are nascent. There is no consensus on the exact educational interventions that should be used to address transgender health. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support. All published interventions proved effective in improving attitudes, knowledge, and/or skills necessary to achieve clinical competency with transgender patients. Conclusion/UNASSIGNED:Transgender populations experience health inequities in part due to the exclusion of transgender-specific health needs from medical school and residency curricula. Currently, transgender medical education is largely composed of one-time attitude and awareness-based interventions that show significant short-term improvements but suffer methodologically. Consensus in the existing literature supports educational efforts to shift toward pedagogical interventions that are longitudinally integrated and clinical skills based, and we include a series of recommendations to affirm and guide such an undertaking.

Learning Objective #1: Recognize the incidence of posterior circulation stroke after cardiac catheterization Learning Objective #2: Recognize how cognitive biases affect clinical decision making CASE: A 57 year old man with hypertension, type 2 diabetes, depression, coronary artery disease s/p PCI and 4-vessel CABG presented with nausea, vomiting, and syncope. He was found to be in complete heart block and underwent emergent pacemaker placement and cardiac catheterization with stent placement to the left circumflex artery. After catheterization, patient reported lightheadedness and cloudiness when walking. He was transferred to the medicine service with sign-out to follow up with physical therapy given "deconditioning" after his acute illness. PT sessions were limited by his hesitancy to walk beyond a few steps. Four days after downgrade, patient reported left sided visual changes. Physical exam was notable for left homon-ymous hemianopia without somatosensory deficits. A non-contrast head CT revealed a new acute to sub-acute right posterior cerebral artery infarction. He was determined to have had an embolic ischemic stroke secondary to cardiac catheterization. His lightheadedness and cloudiness were believed to be secondary to hemianopia. He was medically managed and discharged to SAR. IMPACT: This case involves a common post-catheterization complication as an unusual presentation described as lightheadedness and cloudiness. We attributed the symptoms to overall deconditioning secondary to diagnostic momentum. Furthermore, visual fields were not accurately assessed in this post-procedure patient. Our personal practice now includes exam maneuvers to evaluate posterior circulation on patients post-cardiac catheterization given the high incidence of these strokes in cardiac patients. DISCUSSION: Post-cardiac catheterization strokes are common, with most occurring within 24 hours of the procedure. Of these, approximately 25% involve the posterior circulation often leading to visual field deficits without gross somatosensory deficits. As a result, neurological deficits may often go unnoticed if visual fields are not accurately assessed. Furthermore, patients may not realize a true visual field deficit as they can compensate with neck rotation; initial descriptors may be vague such as lightheadedness or cloudiness. Our case was further complicated by cognitive biases that influenced our decision making; namely, the case was framed as overall deconditioning. As a result, we anchored to a single diagnosis and did not consider neurological deficit as an explanation for our patient's symptoms. We encourage all medical professionals to be cognizant of variability in presentation of visual field deficits and also be keen to their own cognitive biases