Faculty Bibliography

Needs and Objectives: Because of high patient turnover, decreased length of stay and onerous documentation requirements, today's clinician has great difficulty incorporating traditional learning into their day. Podcasts are a perfect medium to allow physicians and students to learn at a time and location of their choosing. Traditional podcasting is a passive endeavor. Even the most engaging podcasts haven't yet incorporated evidenced-based learning strategies. 1. We aim to create engaging, high-yield podcasts that use active learning strategies to boost retention over time. 2. Podcasts are augmented by artistic depictions and show notes, which offer mutually-reinforcing perspectives on each segment's key learning points. Setting and Participants: This educational innovation is internet-based and open to anyone. Thus, the setting is anywhere. Our listeners include medical students, residents, faculty and allied health professionals. Description: The typical CORE IM podcast runs 10-20 minutes. To ensure accuracy of the information, the podcast script is peer reviewed by a specialist in the field. Each podcast is augmented by drawings demonstrating key teaching points as well as show notes. Currently we are offering 2 bi-weekly segments: 5 pearls: Hosts explore 5 evidenced based pearls on a core internal medicine topic. Introductory questions prompt listeners to retrieve prior knowledge. A clinical pearl from a recent podcast is also reviewed based on the principle of spaced repetition. Mind the Gap: This segment takes a closer look at the evidence-or lack thereof-underpinning common clinical practices, in order to expose knowledge gaps and challenge dogma. Over the coming months we are planning new offerings: Hoofbeats: a case-based segment that will explore the reasoning techniques used by experienced diagnosticians discussing the case. Gamechangers: an appraisal of recent literature to determine if the results of a study ought to inform our clinical practice. Evaluation: From October to December 2017, we released six podcasts with more than 11, 000 total downloads. We have listeners in over 90 countries, from every discipline within medicine. Analysis of feedback on downloading platforms indicates that our listeners value the focus of the podcasts, the priming questions, and the review of take-away points at each segment's end. Discussion/Reflection/Lessons Learned: Incorporating evidence-based instructional strategies within podcasting allows learners to better retain new knowledge at their own time and pace. Visual learning also empowers learners to review teaching points from a different perspective. The feedback and growth of our listenership suggest that this combination can be a sustainable source of self-directed learning. Moreover, learning that occurs on platforms irrespective of training or field and beyond the physical borders of an institution unlocks the potential for exciting interdisciplinary discourse among all types of providers involved in patient care. Online Resource URL (Optional): https://urldefense.proofpoint.com/v2/url?u=http- 3A__bitly.com_2zHuixk&d=DwIBAg&c=j5oPpO0eBH1iio48DtsedbOBGmuw5jHLjgvtN2r4ehE&r=vQfPybH YMptZTsGTKf8YZN_ho-QhkqmSqA9bfoe84p4&m=dTRc5akIhNSA47ZIK1KHte11C- tDaMMQxvCxqAX06Ps&s=bKVMH_gnpa-ABH9jwRa_PeW-3W2bHq-BHl-6UCsiJIE&e=

Background: The New York University (NYU) internal medicine residency program converted to block schedule in July 2015. Sixty-five NYU residents have their continuity clinic site at New York Harbor VA (VA). Here, we practice in the medical home model (termed PACT), with NYU residents divided into 3 PACT teams. When we implement block scheduling, we also developed team-based group practices within these PACTs. Cohorts of resident providers serve as coverage for their fellow PACT residents when they are busy with inpatient responsibilities. Methods: This study evaluates the impact of a scheduling change and the implementation of group practices among residents at the VA from April 2015-June 2016; we surveyed residents from Bellevue Hospital over the same period for comparison. We estimated the impact of interventions on the following clinical outcomes: hypertension control, diabetes control, smoking cessation rates, influenza vaccination rates, and age-appropriate cancer screening rates for patients empaneled in the VA residents' clinics by comparing FY2014 data to FY2016 data. For each outcome, we estimated changes using linear regression models. We also estimated the impact of the intervention on residents' perceptions of self-efficacy, knowledge, and clinic workload & coordination. These were measured by factor scores generated from confirmatory factor analysis of answers to 23 survey questions administered before and after the intervention. The confirmatory factor model fit the data well according to standard metrics (RMSEA = 0.00; NNFI = 1.0). Results: Influenza vaccination rates and hypertension control increased significantly during the study period. Change in the other outcomes-smoking cessation, mammogram screening, colorectal cancer screening, hypertension control and diabetes control-was in the predicted direction but not significant. In terms of changesin attitudes over the study period, we used linear regression models from three specifications-the full sample with no controls, the full sample with a control for cohort, and the paired sample of pre-and post-tests. We found that the intervention positively impacted residents' perceptions of clinic workload & coordination as well as their perceptions of relevant knowledge. The impact on self-efficacy is less clear, since the difference was only significant among the full sample, but not in the other two specifications. Conclusions: The transition to block scheduling and the creation of group practices within the VA resident clinics has had a positive impact both on resident attitudes towards VA clinic and on clinical outcomes. Specifically, residents' knowledge of clinic functioning and perception of clinic workload & coordination improved. We also saw statistically significant improvements in influenza vaccination rates and hypertension control and no worsening in tobacco cessation rates, diabetes control, or age-appropriate cancer screening rates. Thus, this change improved training and had an impact on health outcomes

Background: In an effort to bolster medical student wellbeing and mitigate burnout, NYU School of Medicine (NYUSOM) launched a longitudinal resiliency curriculum, coupled with a wellbeing self-assessment tool. We aim to study its impact on the development of knowledge, self-awareness, and practices related to wellbeing and resiliency. Methods: MD AWARE (Medical Students Developing Awareness, Wellbeing, and Resilience) was launched in August 2017 for the incoming NYUSOM class. It involves six interactive sessions implemented at critical junctions over the first three years of medical school. Each session includes a short lecture, followed by a small group activity led by trained facilitators. At the start of each small group session, students are asked to complete an anonymous online survey (results only provided to student). The self-assessment includes 19 items adapted from three validated assessment tools measuring different aspects of wellbeing and burnout. Students immediately receive three scores with explanations of each and the opportunity to debrief in their small group. Thus far, the students have participated in the first two sessions. In the first, students were introduced to research on physician burnout, the protective effects of resilience, and practiced a gratitude exercise. In the second, students were introduced to mindful awareness to identifying cognitive distortions and practiced reframing negative inner dialogue. After each, students completed a retrospective pre/post survey, using a 4-point likert scale, assessing knowledge, self-awareness, and comfort/confidence in activities to promote wellbeing. Comparison between the survey results were calculated using pair t-test. Results: Survey results were available for 106/118 (90%) students participating in the first session and 55/114 (48%) participating in the second. Results of both pre/post surveys showed significant improvement (p=<.01) on every item. Notably, after the first session, students reported a substantial increase in their comfort acknowledging stressors (31.1% very comfortable pre-vs 61.1% post-) and seeking help when in need (18.1% very comfortable pre-vs 45.2% post-). After the second session, students reported increased comfort practicing mindful awareness (65.5% comfortable/very comfortable pre-vs 90.9% post-), increased confidence both identifying cognitive distortions (59.2% comfortable/very comfortable pre-vs 96.3% post-) and reframing negative responses (47.2% comfortable/very comfortable pre-vs 81.8% post-). Conclusions: While many schools have looked at ways to foster wellbeing in their medical students, our curriculum is unique in its longitudinal nature and use of repeated wellbeing self-assessments. Preliminary assessment demonstrates a positive impact on medical students' knowledge, self-awareness, and practices around wellbeing and resilience. Thus, our novel curriculum is a promising way to bolster resiliency skills and mitigate burnout in this vulnerable population

Learning Objective #1: Discuss typical, atypical clinical & laboratory presentations of acute mononucleosis Learning Objective #2: Review indications for treatment beyond supportive care CASE: A 33 year-old female with 1 prior spontaneous abortion presented with facial swelling, arthralgias and fevers to 102F for 2 weeks. The patient reported environmental exposures as a native of Australia such as outbreaks of Ross River Fever, encounters with flying foxes, a layover in Hong Kong, and a child with a febrile illness. She sought outpatient care and initial bloods revealed WBC 2.52K/uL, platelets 105K/uL and AST/ALT 88/70 ALP 117 U/L. She was prescribed antibiotics without effect. A week later, she developed pleuritic chest pain, was found to have a small pericardial effusion on outpatient echocardiogram and referred to the Emergency Department. Triage vitals were normal. Her exam was notable for periorbital edema, cervical lymphadenopathy and pain in bilateral wrists without effusion. Labs showed recovering blood counts (WBC 9.3K/uL Hgb 13.1g/dL Plt 157 K/uL), unremarkable UA, microalbumin/creatinine ratio and CK, but worsening LFTs with AST 505 ALT 578 ALP 788 U/L. She was admitted for further work-up with rheumatology and infectious disease input. While hospitalized, the patient developed new night sweats and a sore throat. Repeat echocar-diogram revealed a trace pericardial effusion and abdominal ultrasound was normal. C3/C4 levels, beta-2 glycoprotein, cardiolipin, Ro/La, lupus anticoagulant, histone, centromere, and mitochondrial antibodies all returned negative, as did respiratory viral panel, HIV, hepatitis serologies, thick and thin smears, Lyme, Anaplasma and Babesia serologies, Ross River fever, Dengue and Chikungunya. ANA titer and dsDNA Ab were < 1:40 and 9 respectively, but EBV viral capsid IgM returned positive consistent with acute mononucleosis. IMPACT: The triad of acute EBV is well known, but atypical presentations provide diagnostic challenges and warrant further evaluation DISCUSSION: The triad of acute Epstein-Barr viral infection involves high fevers, lymphadenopathy, and pharyngitis, all present in our patient. However, she also exhibited less typical disease features. Her periorbital edema, known as "Hoagland's sign," is caused by viral replication obstructing lymphatic drainage of the nasopharynx. Similarly, infected tonsillar B-cells instigate secretion of polyclonal antibodies (including heterophile and non-specific autoantibodies). This process is normally accompanied by leukocytosis with atypical lymphocytes, but our case presented initially with leukopenia. Further, her degree of transaminitis (levels > 10x) normal is usually restricted to the immunocompromised. Finally, EBV may also cause transient myo-or pericarditis as noted in select case reports. The mainstay of treatment is supportive, although steroids and acyclovir are used in cases of laryngeal edema, liver failure, or hemolytic anemia and thrombocytopenia. These agents have not been proven to reduce the length or severity of illness

L-selectin, a lectin-like receptor on all leukocyte classes, functions in adhesive and signaling roles in the recruitment of myeloid cells from the blood to sites of inflammation. Here, we consider L-selectin as a determinant of neurological recovery in a murine model of spinal cord injury (SCI). Spinal cord-injured, L-selectin knock-out (KO) mice (male) showed improved long-term recovery with greater white matter sparing relative to wild-type (WT) mice and reduced oxidative stress in the injured cord at 72 h post-SCI. There was a partial and transient reduction in accumulation of neutrophils in the injured spinal cords of KOs at 24 h post-injury. To complement these findings with KO mice, we sought a pharmacologic means for lowering L-selectin levels. We found that diclofenac, a nonsteroidal anti-inflammatory drug (NSAID), induced the shedding of L-selectin from the cell surface of myeloid subsets, specifically neutrophils and non-classical monocytes, in the blood and the injured spinal cord. Diclofenac administration to injured WT mice enhanced neurological recovery to a level comparable to that of KOs but did not improve recovery in KOs. While diclofenac treatment had no effect on myeloid cell accumulation, there was a reduction in oxidative stress at 72 h post-SCI. These findings implicate L-selectin in secondary pathogenesis beyond a role in leukocyte recruitment and raise the possibility of repurposing diclofenac for the treatment of SCI.

Background: Null mice raised by mating -/- with -/- showed sustained hyperglycemia & persistent hyperinsulinemia during glucose tolerance test (GTT) vs wild type (wt) raised by mating wt with wt . Insulin resistance by HOMA was increased 8 fold, but HOMA beta cell function was normal. As null mice ate & weighed more, & as caloric restriction abolished these differences, our data support the role of hyperphagia, possibly due to hypothalamic neuron leptin resistance without TRPC1 channels.
Method(s): We studied adipokines, environmental & genetic factors, including gene dosage, in this diabetic phenotype while minimizing epigenetics & hyperphagia in breeders & dams, using only littermates born to +/-breeders.
Result(s): 9-week-old null born to -/-breeders & nursed by -/-dams had severe random hyperglycemia (171 vs. 98 mg %) vs wt born to +/+ breeders & raised by +/+ dams. In contrast, null mice born to +/-breeders & nursed by +/-dams had minimal hyperglycemia (119 vs 171 mg %), implying anti-diabetic effects by a single maternal wt allele. Conversely, wt born to +/-breeders & nursed by +/-dams were hyperglycemic vs wt born to +/+ breeders & nursed by +/+ dams (118 vs 98 mg %), reflecting pro-diabetic effects of maternal haploid deficiency. These wt were as hyperglycemic as null littermates born to the same +/-breeders & nursed by the same +/-dams (118 vs 119 mg %). These data support the role of nongenetic parental influences. From 5th to 30th week, null but not +/-mice were obese vs wt. At 29 weeks, during GTT, both null & +/-mice were equally diabetic, with glucose (in mg %), respectively of 230 & 234 vs. 183 in wt at 20 min, 219 & 229 vs. 155 in wt at 60 min, & 179 & 188 vs 134 in wt at 90 min. These data support the role of both alleles in glucose homeostasis. In null mice, adiponectin was down (5.7) vs. wt (6.4) & +/-(6.2 mug/ml), but leptin up (2.3 vs. 1.3 in wt & 1.8 ng/ml in +/-).
Conclusion(s): We conclude: 1. Diploid TRPC1 gene deletion produces hyperphagia & obesity. 2. Haploid deficiency suffices to produce diabetes, associated with reduced adiponectin & increased leptin. 3. Non-genetic parental factors, via epigenetics & hyperphagia, markedly alter glucose homeostasis independent of genotypes