Faculty Bibliography

Learning Objective #1: HSP is an uncommon small vasculitis in adults, often occurring after an infectious illness CASE: A 49 year old female presented to the emergency room with a progressive, painful rash in her lower extremities and abdominal pain over the past 10 days. Patient was in her usual state of health until 10 days prior to admission when she began to notice a skin eruption in her lower extremities associated with pain. The rash spread upwards and patient was seen by a dermatologist as an outpatient, where a biopsy was taken. Patient was prescribed a topical steroid without improvement in symptoms. She also developed a generalized intermittent abdominal pain without hematochezia. No recent upper respiratory infections/other infectious symptoms. Upon arrival to the hospital, patient was in stable condition. Exam was notable for diffuse, palpable purpura in her lower extremities and abdomen. Patient's urinalysis was significant for proteinuria and microscopic hematuria. Chemistries demonstrating baseline renal function. Given her significant abdominal pain, patient was started on prednisone for a presumed diagnosis of Henoch-Schonelin Purpura (HSP). Skin biopsy returned showing small vessel leukocytoclastic vasculitis with IgA, C3 deposition. Patient was maintained on oral steroids for 48 hours with significant improvement in her abdominal pain and rash. As her abdominal ceased, patient was transitioned to colchicine and discharged home. IMPACT: Recognition of this uncommon small vasculitis as a disease that also affects adults. HSP is typically self-limited, but glucocorticoid therapy is warranted in patients with significant gastrointestinal or renal involvement. DISCUSSION: HSP, a predominantly pediatric condition, is a small vessel vasculitis characterized by IgA complex deposition the smaller venules, capillaries, and arterioles of various organ systms. HSP typically occurs after an infectious illness, which our patient did not appear to have. The typical tetrad of symptoms include: skin, arthralgias, gastrointestinal symptoms, and renal disease. Palpable purpura occurs in nearly every patient, typically in the lower extremities and the buttocks. Abdominal pain occurs in 65% of cases. Renal disease is common, more often affecting adults than children. Typical manifestation is hematuria. Significant proteinuria and elevated creatinine occur in a minority of patients, with < 1% of cases progressing to ESRD. HSP is usually a benign, self-limited disease. Patients with mild arthralgias and abdominal pain may be treated with acetaminophen. If severe abdominal pain occurs, steroids are the recommended initial therapy, and have been shown to improve abdom-inal pain, but not otherwise improve overall progression of disease. Colchicine can be considered for mild abdominal symptoms. Additional indication for glucocorticoid therapy includes significant renal involvement (proteinuria > 1g/day). If refractory symptoms, cyclophosphamide or mycophenolate there may be considered

Learning Objective #1: Recognize the complications of Legionella Pneumonia CASE: A 40 yo woman with well-controlled HIV (last CD4 in the 700's uL with, an undetectable viral load) and CKD (Cr of 1.5 mg/dL) presented with fevers, productive cough, and diarrhea for 10 days. On presentation, she was febrile to 102.9F, tachycardic to 104 bpm, and hypoxic to SpO2 of 90-92%. Physical exam was notable for decreased breath sounds in the right lower lobe. Initial studies revealed a sodium of 125 mEq/L, AST/ALT elevation to 1200 IU/L/400s IU/L, BUN/Creatinine of 81md/dL/8.6 mg/dL, and positive Urine Legionella. Her creatinine continued to uptrend, with a creatinine phosphoki-nase (CPK) of 8580 U/L on HOD3. She was treated with IV hydration and urine alkalization. Urgent dialysis and kidney biopsy were considered, however, patient's creatinine stabilized. Patient completed a 14 day course of Azithromycin, with improvement in her AKI, with her creatine downtrending to 3.7 mg/dL and her CPK to 372 U/L. IMPACT: The wide ranging consequences of Legionnaires' Disease (LD) on the lungs, liver, and kidneys is well documented. However, the prevalence and severity of the broad spectrum of LD in HIV patients has not been thoroughly investigated. Our patient was infected with HIV. We believe that this fact contributed to the severe clinical course, characterized by rhabdomyolysis and acute renal failure. DISCUSSION: This is a case of LD in an HIV+ patient characterized by pneumonia, hyponatremia, transaminitis, and acute reversible renal failure from non-traumatic rhabdomyolysis. LD is a bacterial pneumonia, with multi-organ complications. ARF, specifically rhabdomyolysis is an infrequently recognized complication of LD; which is associated with increased mortality. Risk factors for LD include chronic lung disease, cigarette smoking, and immunosuppression. HIV-infected individuals are at an increased risk for pulmonary infections. Legionella pneumonia is estimated to be responsible for 20% of all adult HIV-associated pneumonias as compared to 15% in the general population. HIV-infected patients present with a more severe clinical presentation compared to HIV-negative individuals. One retrospective study, compares the clinical features and outcome of LD between 64 HIV-negative and 15 HIV-positive patients (mean CD4 count 340 uL). In the HIV patient group, there were higher reports of laboratory abnormalities (CPK, hyponatremia, LFTs), bilateral lung involvement on imaging, and an increase in respiratory failure and mortality. One proposed theory includes a blunted TH1 response in the setting of HIV infection. Legionella pneumophila is a facultative intracellular pathogen, which replicates inside macrophages. Cell mediated immunity or TH1-CD4 helper cells are essential in clearing the infection from the body. TH1-CD4 helper cells are the primary source of interferon alpha, which helps decrease cellular nutrients, including iron, leading to apoptosis and cellular lysis, ultimately preventing Legionella from thriving

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.

BACKGROUND:Interprofessional education is increasingly recognized as essential for health education worldwide. Although effective management, innovation, and entrepreneurship are necessary to improve health systems, business schools have been underrepresented in global health education. Central America needs more health professionals trained in health management and innovation to respond to health disparities, especially in rural communities. OBJECTIVE:This paper explores the impact of the Health Innovation Fellowship (HIF), a new training program for practicing health professionals offered jointly by the Central American Healthcare Initiative and INCAE Business School, Costa Rica. Launched in 2014, HIF's goal is to create a network of highly trained interdisciplinary health professionals in competencies to improve health of Central American communities through better health management. METHODS:The program's fellows carried out innovative healthcare projects in their local regions. The first three annual cohorts (total of 43 fellows) represented all health-related professions and sectors (private, public, and civil society) from six Central American countries. All fellows attended four 1-week, on-site modular training sessions, received ongoing mentorship, and stayed connected through formal and informal networks and webinars through which they exchange knowledge and support each other. CAHI stakeholders supported HIF financially. RESULTS:Impact evaluation of the three-year pilot training program is positive: fellows improved their health management skills and more than 50% of the projects found either financial or political support for their implementation. CONCLUSIONS:HIF's strengths include that both program leaders and trainees come from the Global South, and that HIF offers a platform to collaborate with partners in the Global North. By focusing on promoting innovation and management at a top business school in the region, HIF constitutes a novel capacity-building effort within global health education. HIF is a capacity-building effort that can be scaled up in the region and other low- and middle-income countries.