Faculty Bibliography

Introduction/UNASSIGNED:Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological intervention clinically used for pain relief. The importance of utilizing the adequate stimulation intensity is well documented; however, clinical methods to achieve the highest possible intensity are not established. Objectives/UNASSIGNED:Our primary aim was to determine if exposure to the full range of clinical levels of stimulation, from sensory threshold to noxious, would result in higher final stimulation intensities. A secondary aim explored the association of pain, disease severity, and psychological variables with the ability to achieve higher final stimulation intensity. Methods/UNASSIGNED:Women with fibromyalgia (N=143) were recruited for a dual-site randomized controlled trial - Fibromyalgia Activity Study with TENS (FAST). TENS electrodes and stimulation were applied to the lumbar area, and intensity was increased to sensory threshold (ST), then to "strong but comfortable" (SC1), then to "noxious" (N). This was followed by a reduction to the final stimulation intensity of "strong but comfortable" (SC2). We called this the Setting of Intensity of TENS (SIT) test. Results/UNASSIGNED:<0.0001) with a mean increase of 1.7 mA (95% CI: 1.5, 2.2). Linear regression analysis showed that those with the largest increase between SC1 and N had the largest increase in SC2-SC1. Further, those with older age and higher anxiety were able to achieve greater increases in intensity (SC2-SC1) using the SIT test. Conclusion/UNASSIGNED:The SC2-SC1 increase was significantly associated with age and anxiety, with greater mean increases associated with older age and higher anxiety. Thus, although all patients may benefit from this protocol, older women and women with elevated anxiety receive the greatest benefit.

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.

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/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.