Faculty Bibliography

Gastrointestinal stromal tumor (GIST) is a common nonepithelial benign neoplasm involving the GI tract, most commonly located in the stomach. Here, we describe a challenging case of GIST that presented with acute GI bleed and syncope. A 53 year-old male with no significant past medical history presented to the ER with loss of consciousness for several minutes earlier in the day. He arrived in New York three days prior to admission after a long day of travel from Iowa during which he began to experience general malaise, chills, and had poor intake per os. On the day of presentation, the patient awoke feeling weak. He got out of bed and fell down with loss of consciousness for seconds to minutes, witnessed by his wife. Other review of systems was negative. Physical exam revealed normal vital signs and a well-appearing gentleman without obvious abnormalities. Initial labs were notable for a hemo- globin of 9.1, BUN/Cr ratio of 29/0.7, and a respiratory viral panel positive for influenza A. The syncope was initially attributed to hypovolemia from his influenza and the team planned to discharge the patient from the ER. He then had a bowel movement with a moderate amount of bright red blood. Vital signs and Hgb remained stable. The patient was then admitted to medicine for further work-up. The patient continued to have bright red blood followed by melenic stools in the morning and was taken urgently to the endoscopy suite. EGD revealed a large ulcerated mass oozing blood in the gastric body. Biopsies were non-diagnostic. Endoscopic ultrasound was subsequently performed showing a mass arising from the muscularis propria protruding 4-5 cm into the mid gastric body. The patient underwent a partial gastrectomy and resection of his mass. Pathology confirmed the diagnosis of gastrointestinal stromal tumor, mixed-type. The patient improved and was discharged on Hospital Day 11. While gastrointestinal stromal tumors tend to be benign, their presentations can be quite variable. In general, GISTs are characterized by non-specific symptoms like early satiety or bloating. In this case, our patient presented with an acute GI bleed and syncope from a GIST that had grown to be large and ulcerated. The patient's stable vital signs and his viral illness paved the way for anchoring bias, diverting the team from further investigating his anemia, and its potential role in his presentation

Obesity leads to an altered adipocytokine production negatively effecting the function of natural killer cells (NK cells), which are important effector cells of the innate immune system. NK cells provide a defence against tumour cells or virus infected cells and have different activating and inhibitory surface receptors to distinguish between normal and transformed cells. One group of the inhibitory receptors are the sialic acid-binding immunoglobulin-like lectins (Siglecs). The aim of this study was to compare the expression of Siglecs-7, -9 and -10 on NK cells from normal weight and obese subjects. Therefore peripheral blood mononuclear cells (PBMC) were isolated from 10 normal weight (BMI < 25 kg/m²) and 11 obese (BMI > 30 kg/m²) blood donors and analysed by flow cytometry. Moreover, the amount of sialic acid on NK cell was determined using a fluorescent labelled lectin that binds terminal sialic acids. Percentages of immune cells were not altered between normal weight and obese individuals. CD56^bright NK cells from obese subjects had a reduced expression of Siglec-7 while the expression of Siglec-9 was not altered. The reduction of Siglec-7 expression on CD56^bright NK cells might be a marker for their dysfunction. Moreover, Siglecs-7, -9 and -10 are not expressed on the NK cell lines NK-92 and NKL. When comparing the two NK cell subpopulations CD56^bright and CD56^dim, CD56^bright NK cells had a higher amount of sialic acids on their surface compared to CD56^dim NK cells regardless of body weight.

Study Objectives: To help address the growing opioid overdose epidemic and help teach a core toxicological emergency, the authors taught the use of naloxone as an antidote to an opioid overdose, for all first-year medical students as a part of first responder training using cardiopulmonary resuscitation, as an online and in-person training over three years. Previously we demonstrated that in-person opioid overdose prevention training as an adjunct to BLST improves knowledge and preparedness. To compare the educational outcomes; knowledge, preparedness, and attitudes, for online vs in-person opioid overdose prevention training. Methods: Opioid overdose prevention trainings were conducted in person in 2014 and 2015, and online in 2016. First year students completed pre-and post-training surveys covering three measures: knowledge (11-point scale), attitudes (66-point scale) towards patients with opioid use disorders, and self-reported preparedness (60-point scale) to respond to an opioid overdose. Online and in-person scores across all three measures were compared using analysis of covariance (ANCOVA) methods across two years of trainings. Results: After controlling for pre-test scores, there were very small and not meaningful differences in attitude and knowledge scores between in-person training and online training. The estimated difference for knowledge was-0.06 (95% CI-0.48-0.35) and for attitudes was 0.64 (95% CI-0.22-1.50). The average scores related to preparedness were higher for the students who took the course online, estimated at 2.10 points (95% CI 0.97-3.22). Feedback was generally positive, with 96% of the in-person group saying future classes should receive the training and 95% of the online group saying all medical schools should provide the training. Conclusions: Online training has become a more common method of medical education due to its many advantages including standardization, scalability and flexibility to accommodate asynchronous learning. However, few studies have performed analyses of online training vs in-person training for relative effectiveness. The authors have demonstrated that for training medical students to administer naloxone as an antidote to an opioid overdose, online training is comparable to in-person training. These results support the use of online training for adding training on administering naloxone

Introduction: Efficacy of colonoscopy is limited by inadequate preparation. A high social deprivation index has been identified as a risk factor for failure to repeat a colonoscopy when indicated. It is unknown whether or not split dose preparation increases adherence to recommendation for repeat colonoscopy. Few studies to date have evaluated the potential barriers to likelihood of repeating a bowel preparation in an underserved population. The purpose of this study was to identify factors associated with an increased likelihood of repeating a bowel preparation in a population with a high social deprivation index in a split-dose versus a single dose cohort Methods: Demographic, socioeconomic, medical, education and tolerability data were collected prospectively using a multi-language questionnaire. Descriptive statistics and multivariate analyses were performed on all variables assessed by our questionnaire to evaluate for differences in patients who were likely and unlikely to repeat the preparation. Results: Demographics are presented in table 1 (N=990). 336 (34%) completed single dose and 654 (66%) completed split dose colon preparation. Split dose patients were equally willing-to-repeat colonoscopy preparation compared to single dose patients (69.0% vs. 71.6%; P=0.45) (Table 2). Patients who were not willing to repeat split preparation complained of significantly more adverse gastrointestinal symptoms and difficulty completing dosing instructions due to social barriers and tolerability issues compared to single-dose cohort. Multivariable analysis revealed that concerns with time off work (OR: 0.48; 95% CI: 0.29-0.80), availability of appropriate food/drinks (OR: 0.59; CI: 0.36-0.97), tolerability (OR: 0.72; CI: 0.57-0.92), and colonoscopy scheduling (OR: 0.77; CI: 0.63- 0.94) were all factors independently associated with decreased willingness to repeat in the split dose cohort. Nurse's instruction in preferred language (OR: 2.69; CI: 1.22-5.91) and tolerability (OR: 0.71; CI: 0.55-0.92) were independently associated with patient willingness-to-repeat in the single-dose cohort. Conclusion: This study highlights that tolerability significantly effects repeatability in both single and split dose cohorts. It should be noted that patients with a high social deprivation index identify different barriers to single and split dose preparations. This observation could impact choice of preparation as it affects adherence to physician recommendations. (Figure Presented)

Hospital patients with serious mental illness (SMI) have high rates of smoking. There are few post-discharge treatment models available for this population and limited research on their treatment uptake following discharge. This study is a secondary analysis of an RCT that compared multi-session intensive telephone counseling versus referral to state quitline counseling at two safety net hospitals in New York City. For this analysis, we selected all trial participants with a history of schizophrenia, schizoaffective disorder or bipolar disorder (N = 384) and used multivariable logistic regression to compare groups on self-reported 30-day abstinence at 6 months and to identify patient factors associated with use of tobacco treatment. Analyses found no significant group differences in abstinence 6 months (28% quitline vs. 29% intervention, p > 0.05), use of cessation medications (42% quitline vs. 47% intervention, p > 0.05) or receipt of at least one counseling call (47% quitline vs. 42% intervention, p > 0.05). Patients with hazardous drinking (p = 0.04) or perceived good health (p = 0.03) were less likely to use cessation medications. Homeless patients were less likely to use counseling (p = 0.02). Most patients did not use cessation treatment after discharge, and the intensive intervention did not improve abstinence rates over quitline referral. Interventions are needed to improve use of cessation treatment and long-term abstinence in patients with SMI.

Cardiovascular disease (CVD) is the leading cause of mortality in the US and is largely preventable with lifestyle and medications. Statins are among the most prescribed medications in the United States. While several large trials have shown statins to be safe and effective, rare adverse events may be seen including the development or exacerbation of ulcerative colitis (UC). A 66-year-old woman with UC (diagnosed 5 years prior; well controlled on mesalamine with rare breakthrough symptoms), hypertension, hyperlipidemia, family history of premature CAD and 15+ pack year smoking history was evaluated for primary prevention of CVD and started on atorvastatin. Upon starting atorvastatin she noted myalgias and recurrence of proctitis. A colonoscopy at that time demonstrated active inflammation in the distal 5 cm of the rectum. All symptoms abated upon discontinuing the statin. Years later she was noted to be at increased risk for CVD, with an elevated coronary calcium score of 89 and an LDL of 149, and was re-challenged with low dose rosuvastatin. Soon after initiation, the patient again experienced a flare, this time requiring steroids to achieve remission despite stopping the statin. There is a paucity of data on statin-induced colitis. One reported case of pravastatin induced severe UC lead to colectomy and subsequent death, and several cases of statin-induced colitis have been reported to manufacturers. A RCT of 64 patients with UC and mild-moderate activity given atorvastatin vs. placebo for 8 weeks showed that patients on atorvastatin had worse outcomes (an increase of partial Mayo score by 1.5 points vs. decrease by 0.31 on placebo (p = 0.04)). However, a large retrospective, matched case-control study of 9,617 cases of IBD and 46,665 controls showed any statin exposure was associated with a significantly decreased risk of IBD (OR 0.68, 95% CI 0.64-0.72): CD (0.64, 95% CI 0.59-0.71), and UC (OR 0.70, 95% CI 0.65-0.76). This effect was similar for most statins and present regardless of the intensity of therapy. Given the known benefits of statin therapy in the prevention and treatment of CVD and conflicting data about its effects on IBD, patients with UC who are eligible for statin therapy should proceed with treatment but be counseled that they may be more susceptible to a flare. If UC symptoms are exacerbated, an alternative statin should not be employed. Instead, a different class of lipid-lowering therapy should be tried

BACKGROUND Liver abscesses represent a serious infection of hepatic parenchyma and are associated with significant morbidity and mortality. The emergence of a new hypervirulent variant of Klebsiella pneumoniae, which can cause serious infections in the Asian population, is under investigation. We report a case series of six Asian patients hospitalized at our institution from January 2013 to November 2015 for liver abscess due to Klebsiella pneumoniae. CASE REPORT Charts of six Asian patients were retrospectively reviewed. Four patients were male and two were female. The mean age was 53 years (range: 35-64 years). All patients had no known past medical history of immunodeficiency. Three patients had multiple liver abscesses at the time of initial presentation. In five patients, the source of entry of the pathogenic microorganism was unknown and in one patient the suspected source of entry was the gastrointestinal tract. In three patients there was also concomitant Klebsiella pneumoniae bacteremia. The mean duration of antibiotic treatment was seven weeks and the mean duration of hospital stay was 13.5 days. CONCLUSIONS Liver abscess should always be included in the differential diagnosis in cases of sepsis without obvious source and/or in the clinical scenarios of fever, abdominal pain, and liver lesions.

This article describes an innovative post-master's advanced certificate in gerontology program developed by the Hartford Institute for Geriatric Nursing at the New York University Rory Meyers College of Nursing. The program provides advanced practice registered nurses geriatric content to meet eligibility criteria for the Adult-Gerontology Primary Care NP certification exam and develops interprofessional care providers to care for complex older adults.