Faculty Bibliography

Learning Objective #1: Recognize the presentation and management of adrenal insufficiency (AI). Learning Objective #2: Express the importance of preventing premature closure and reevaluating clinical findings in an inadequately explained illness. CASE: A 19 year-old man with history of anorexia nervosa presented after collapse with pre-syncopal symptoms. He endorsed poor oral intake and a prodrome of weakness, lightheadedness, and vomiting without loss of consciousness. Additionally, he endorsed months of anorexia, fatigue, and weakness leading to several hospitalizations and a psychiatric admission for an eating disorder. On admission he had hypothermia, tachycardia, and hypotension minimally responsive to fluid. He was thin with signs of hypovolemia without objective weakness, focal findings of infection, or hyperpigmentation. Labs were notable for hyponatremia, hyperkalemia, and hypoglycemia. On admission he was diagnosed with hypovolemia and metabolic derangements secondary to an underlying eating disorder. A random serum cortisol level was found to be undetectable, as was a morning level. Adrenocorticotropin (ACTH) stimulation test revealed elevated ACTH with persistently suppressed serum cortisol, confirming primary AI. Intravenous (IV) corticosteroids were initiated with a rapid clinical response. An adrenal antibody titer returned positive. IMPACT: As is often the case, our team was presented with a patient with a provisional diagnosis. The challenge in such instances is to recognize incon-gruent data and to consider alternative explanations. We utilized the approach of "thinking-out-loud, "broadening our differential, and identifying features better explained by other conditions, including AI. The case reminds us of the pitfalls of premature closure and encourages the practice of "thinking-out-loud." DISCUSSION: Pre-syncope presents with a constellation of non-specific symptoms commonly encountered by general internists. Our patient's presentation yielded a broad differential spanning cardiovascular, infectious, and malignant etiologies, as well as hypovolemia secondary to anorexia nervosa, which anchored on the patient's prior diagnosis. By "thinking-out-loud, "our team recognized the electrolyte abnormalities and hypoglycemia to be consistent with AI. The Endocrine Society Clinical Practice Guidelines recommends sending diagnostic tests to exclude AI in all patients with compatible findings: volume depletion, hypotension, fever, abdominal pain, hyperpigmentation, hypoglyce-mia, or hyponatremia and hyperkalemia. Initial testing should include a morning cortisol which reflects peak levels, however, an undetectable level at any time is abnormal. In patients with symptoms consistent with severe AI or adrenal crisis, stress dose IV steroids should be initiated pending cortisol level results. In this case, IV steroids were not immediately initiated partly due to premature closure. It is important to maintain a low threshold to initiate stress dose steroids in patients with hemodynamic instability without a clear cause

Background: Conflicting data exists on the relationship between outpatient visits and emergency department (ED) visit and admission rates. While some have shown outpatient access prevents ED visits and admissions, others show that factors such as continuity are more important. A mental health diagnosis is consistently cited as a factor associated with increased inpatient utilization. There is little published data about resident-run outpatient clinics and their outcomes, including how these ambulatory contacts affect ED visit and admission rates. Methods: The medical record was used to collect data for all patients seen at least once in the primary care resident clinic at a large, public New York City hospital over the course of 1 academic year. We counted the number of outpatient visits per patient, regardless of type, including both primary care visits and clinic visits for all medical and surgical subspecialties. We controlled for the level of health of each patient using locally developed scores. Our primary outcomes were total number of ED visits and total number of inpatient admissions; secondary outcomes were inpatient length of stay (LOS) and admissions for ambulatory care sensitive conditions (ACSC). We conducted bivariate analyses, using T-Tests and ANOVA, and multivariate analysis, using ordinary least of squares regression, to determine whether increased contact with outpatient clinics was associated with ED visit and admission rates. A separate analysis was conducted for patients with a mental health diagnosis. Results: Our sample consisted of 2,988 patients, seen at least once in the resident-run primary care clinic, averaging 7 outpatient visits across all sub-specialties. There were 2,544 ED visits (1317 unique patients), 571 inpatient admissions (368 unique patients), and 126 ACSC admissions (97 unique patients). Patients who were hospitalized averaged 2 admissions; average LOS was 9.5 days. Multivariate analysis, controlling for sociodemographic and health factors, found more ambulatory care visits were associated with more ED visits and more inpatient admissions (p < 0.01). There was no statistically significant association between ambulatory care visits and LOS or ACSC admissions. A mental health diagnosis was associated with increased ambulatory care visits, and increased ED visits and inpatient admissions, and a 4 day longer LOS. Conclusions: Among patients seen in the resident internal medicine clinic, we were surprised to find that more outpatient visits were positively associated with more ED visits and admissions when controlling for all sociodemographic factors and health status. Our study adds to the body of literature, as there has been little previously published about resident clinic outcomes. Further studies are needed on how to improve these resident run clinics in order to help prevent ED visits and admission. Our study also showed that a mental health diagnosis was positively associated with ambulatory care visits, consistent with the previous literature

BACKGROUND:Mechanisms underlying the heightened myocardial infarction risk among HIV-infected women (versus non-HIV-infected women) remain unclear. Our objectives were to assess epicardial adipose tissue (EAT) volume and its associations among asymptomatic women with and without HIV. METHODS:A total of 55 HIV-infected and 27 non-HIV-infected women without known cardiovascular disease who underwent cardiac CT and metabolic/immune phenotyping were included. EAT volume derived from CT was compared among women with and without HIV, and within-group EAT associations were assessed. Next, immune and atherosclerotic plaque parameters were compared among groups stratified by HIV serostatus and high/low EAT (defined in reference to median EAT for each serostatus group). RESULTS:[P=0.04]; P for overall ANOVA) and were highest among HIV-infected women with excess EAT (versus HIV-infected women without excess EAT, non-HIV-infected women with excess EAT and non-HIV-infected women without excess EAT). The percentage of segments with non-calcified coronary plaque also differed by HIV serostatus/EAT volume subgroup and was highest among HIV-infected women with excess EAT. CONCLUSIONS:Asymptomatic women with and without HIV have similar volumes of EAT, but drivers of EAT may differ between groups. HIV-infected women with excess EAT have highest-level immune activation and the highest percentage of non-calcified plaque. Future studies are needed to determine whether EAT contributes pathogenetically to HIV-associated cardiovascular disease in women.