Faculty Bibliography

BACKGROUND: The Substance Abuse Research and Education Training (SARET) program is funded by the National Institutes of Drug Abuse in 2006 as a novel approach to spark interest in substance abuse research among medical, dental, nursing, and social work graduate students through a Web-based curriculum and research mentorships. This report presents the initial integration of the intervention in a Master of Social Work (MSW) program, the components of the program, and the mixed-methods evaluation of its effect on students' attitudes towards substance abuse research and treatment. METHODS: SARET comprises 2 main components: stipend-supported research mentorships and a Web-based module series, consisting of 6 interactive, multimedia modules addressing core SA research topics, delivered via course curricula and in the research mentorships. An initial evaluation was designed to assess SARET's acceptability and short-term impact on participants' interest in SA research. The components of this Web-based curriculum evaluation include focus group feedback on the relevance of the modules to SW students, number of courses into which the modules were integrated with number of module completions, changes in interest in SA research associated with module completion. RESULTS: The full series of Web-based modules has been integrated across several courses in the social work curriculum, and social work students have become integral participants in the summer mentored research experience. One hundred eighteen students completed at least 1 module and 42 students completed all 6 modules. Neurobiology, Screening, and Epidemiology were the most widely viewed modules. Students reported positive impact on their vision of SA-related clinical care, more positive attitudes about conducting research, and in some cases, change in career. CONCLUSIONS: The SARET program's modules and summer mentored research increased clinical and research interest related to SUDs, as well as interprofessional attitudes among social work students. Participants have shown some early research success. Longer-term follow-up will enable us to continue to assess the effectiveness of the program.

BACKGROUND: Opioid overdose deaths have reached epidemic proportions in the United States. This problem stems from both licit and illicit opioid use. Physicians play a role in prescribing opioids, recognizing risky use, and initiating prevention, including Opioid Overdose Prevention Training (OOPT). The American Heart Association (AHA) modified their basic life support (BLS) algorithms to consider naloxone in high risk populations and when a pulse is appreciated; however, the AHA did not provide OOPT. Our intervention filled this training deficiency by teaching medical students opioid overdose resuscitation with a Train-The-Trainer model as part of mandatory BLS training. METHODS: We introduced OOPT, following a Train-The-Trainer model, into the required Basic Life Support (BLS) training for first-year medical students at a single medical school in a large urban area. We administered pre- and post-evaluations to assess the effects of the training on opioid overdose knowledge, self-reported preparedness to respond to opioid overdoses, and attitudes towards patients with SUDS. RESULTS: In the fall 2014, 120 first-year medical students received OOPT. Seventy-three students completed both pre- and post-training evaluations. Improvements in knowledge about and preparedness to respond to opioid overdoses were statistically significant (p <.01) and large (Cohen's D = 2.70 and Cohen's D = 2.10 respectively). There was no statistically significant change in attitude toward patients with SUDs. CONCLUSIONS: We demonstrated the effectiveness of OOPT as an adjunct to BLS in increasing knowledge about and preparedness to respond to opioid overdoses; improving attitudes toward patients with SUDs likely requires additional intervention. We will characterize knowledge and preparedness durability, program sustainability, and long-term changes in attitudes in future evaluations. These results support dissemination of OOPT as a part of BLS training for all medical students, and potentially all BLS providers.

LEARNING OBJECTIVE #1: Diagnose cardiac sarcoidosis (CS) in a patient with complete heart block LEARNING OBJECTIVE #2: Management of cardiac sarcoidosis CASE: A 53-year-old female with no prior medical history presented to the ED with a few days of weakness. Initial ECG revealed sinus rhythm with complete heart block and junctional escape rhythm at a rate of 35 bpm. Patient was not on atrioventricular nodal blocking medications. Transthoracic echocardiogram showed normal bi-ventricular size/function without valvular disease. Laboratory workup including Lyme antibodies was unrevealing. Diagnosis of CS was considered and a cardiac MRI (CMR) was performed however, failed to definitively demonstrate late gadolinium enhancement suggestive of fibrosis. Positron emission tomography (PET) imaging was unavailable at the time. CT of the chest demonstrated bilateral hilar lymphadenopathy highly suggestive of sarcoidosis. A transvenous pacemaker was placed and an endobronchial ultrasound guided lymph node biopsy was performed which demonstrated non-caseating granulomas consistent with sarcoidosis. Given biopsy proven extra-cardiac sarcoidosis in combination with complete heart block without alternative explanation, a diagnosis of CS was established. Prednisone therapy was initiated and a dual chamber implantable cardioverter-defibrillator (ICD) was placed. Patient was discharged on oral steroids and planned for PET scan as an outpatient. IMPACT: Diagnosing CS in patient who presents with complete heart block whose cardiac imaging fails to demonstrate cardiac involvement is challenging. Internists should be aware that a negative CMR, despite high sensitivity, does not exclude cardiac involvement of sarcoidosis. A high index of suspicion should be maintained to pursue evidence of extra-cardiac involvement. If confirmed, the management changes significantly since an ICD should be considered instead of pacemaker along with need for immunosuppression. DISCUSSION: Cardiac involvement is seen in 5% of patients with sarcoidosis and presents with high-grade AV block, ventricular tachyarrhythmia, left ventricular dysfunction or heart failure. Chest imaging (X-ray or CT) is abnormal in 85-95% of patients. PET and/or CMR are imaging modalities of choice with PET having higher sensitivity compared toCMRbased on multiple studies (87% vs 75%). Endomyocardial biopsy (EMB) can be considered if extra cardiac targets are not available for biopsy; however, the sensitivity is low (25%) due to focal cardiac involvement. The American College of Cardiology recommends ICD implantation for primary prevention of sudden cardiac death in all patients with cardiac sarcoidosis due to high incidence of ventricular arrhythmias. Recovery of AV block following immunosuppression has been demonstrated in small studies however; predicting which patient population would recover their native conduction still remains an active area of investigation

BACKGROUND: As healthcare increases demands, primary care physicians need evidenced-based, patient-centered care coordination, effective use of information technology, interdisciplinary team functioning and shared decision-making skills more so in underserved areas. In 2008, we documented 20 years of the NYU/Bellevue Primary Care Internal Medicine Residency Program (NYUBPC) on readiness for practice1. In light of the recent primary care changes we assessed our recent training of Primary Care Residents in high quality, person-centered, systems-savvy, team-based care for the underserved. Specifically we aimed to: 1. Assess the NYUBPCP impact on graduate career choices, values and style 2. Elicit reflections that illustrate complexities in educating primary care physicians METHODS: We surveyed 56 graduates of the NYUBPCP from 2007-2014. The 44 question survey included 12 open-ended questions about career path, current practice, preparedness for practice and specifics about how aspects of training provided necessary skills and knowledge. Responses were unidentified. We received 37 responses, (66%). RESULTS: 36 respondents currently provide clinical care, with about 40% of their time spent in a primary care setting (S.D. 32%). On a 4- point scale 85% either agreed or strongly agreed with Primary Care as a career choice. 74% felt prepared for the challenges of a primary care practice, rating clinical experiences with underserved communities, and the psychosocial, clinical epidemiology and health policy focus as essential aspects of training. All but 4 provide care to medically underserved populations. They valued the community of peers and colleagues that the NYUBPCP provided. While 53% rated their clinical site as hectic/chaotic (4 or 5 on a 5 point scale), only 6% reported persistently feeling burnout. 19% reported at least one symptom of burnout. Qualitative analyses revealed overlapping themes in alumni perceptions of how residency influenced current practice, aspects of training that were difficult to implement and expectations for the future directions of primary care. Responses demonstrated a mismatch between the "purity" of primary care practice graduates strove to achieve after residency and the actuality of a practice influenced by external factors (e.g. time pressures, reimbursement issues and metric achievements). Some found it difficult to be involved with research or advocacy while in full-time clinical practice. Graduates believed the future of primary care lies in a team-based approach. CONCLUSIONS: A training program emphasizing rigorous curriculum, committed role modeling, care of the underserved, and strong residency community for support continues to document high rates of retention in primary care. They are well adapted entering physicians with the skills and attitudes necessary to succeed in primary care and become educators of the next generation

Ureaplasma is a significant cause of nongonococcal urethritis. This is a case of rectal Ureaplasma found on culture in a young man who has sex with men not previously reported in the literature. Nucleic acid amplification tests are now standard of care for sexually transmitted infection testing, but they do not test for Ureaplasma and, therefore, may be missing important infections. Ureaplasma could have important implications in urethritis and rectal HIV transmission among men who have sex with men engaging in condomless anal intercourse. Further study of Ureaplasma's role as a rectal pathogen may be warranted.

To date, various dimensions of body image and their associations with condom use have not been studied among men who have sex with men (MSM) who use geosocial-networking smartphone applications ("apps") to meet new sexual partners. The purpose of the current study was to evaluate associations between weight perception, body dissatisfaction, and self-objectification with sexual behaviors among a sample of MSM (n = 92) recruited from Grindr, an app popular among MSM, to complete an online survey. Obese participants scored significantly higher on measures of body dissatisfaction and lower on measures of sexual sensation seeking. Decreased propensities to seek sexual sensations were associated with fewer sexual partners. By assessing associations between dimensions of body dissatisfaction and sexual risk behaviors, this study adds support to a theory of syndemics among MSM, which suggests that synergistically related biological, psychological, social, and behavioral factors disproportionately affect health and health-related behaviors in this population.

LEARNING OBJECTIVE #1: Recognize clinical features of chronic eosinophilic pneumonia LEARNING OBJECTIVE #2: Diagnose eosinophilic pneumonia when imaging is atypical CASE: A 42-year-old male with history of hypertension and asthma presented with intermittent cough and progressive dyspnea over eight months. His symptoms were more pronounced in the two months leading to admission, during which time he had outpatient treatment with 5 courses of simultaneous oral antibiotics and steroids. Outpatient CT scan of the chest during this time showed diffuse bilateral ground glass opacities, interpreted as atypical infection and inflammatory changes. His symptoms temporarily improved with therapy; however, he was ultimately admitted due to progression of symptoms. On admission, he reported dyspnea at rest, cough productive of yellow sputum, and 20 lb unintentional weight loss over six months. He denied fevers, recent travel, or smoking. Initial vital signs and exam were normal. Labs were notable forWBC 14,000 with 5% eosinophils (750/muL) and elevated ESR and CRP. A repeat CT of the chest showed airspace consolidations primarily in a central and peribronchovascular distribution, with differential diagnosis including infection, organizing pneumonia, vasculitis, chronic eosinophilic pneumonia (CEP), and neoplasm. Blood cultures, HIV, 1,3 beta-d-glucan, galactomannan, ANA, p-ANCA, and c-ANCA were unremarkable. For tissue diagnosis, patient underwent video-assisted thoracoscopy with wedge resection, complicated by an apical pneumothorax requiring chest tube placement. Pathology showed numerous eosinophils in alveolar airspaces, consistent with CEP. Patient was started on high dose steroids with clinical improvement. He was discharged home with a chest tube and continued steroid treatment. IMPACT: In future practice, diagnoses other than infection should be considered earlier in patients with a history of atopy who fail multiple courses of outpatient antibiotics for presumed pneumonia. Furthermore, CEP can be diagnosed with elevated eosinophil count in broncho-alveolar lavage (BAL) fluid. For a patient with peripheral eosinophilia and symptoms consistent with CEP, BAL is the less invasive and more appropriate first diagnostic test over open lung biopsy. DISCUSSION: This patient's chronic dyspnea and cough, weight loss, lack of improvement with antibiotics, and unrevealing infectious and rheumatologic workup made CEP and cryptogenic organizing penumonia (COP) leading differential diagnoses. The classic radiographic appearance of eosinophilic pneumonia is peripheral upper-lobe ground glass infiltrates, which is seen in approximately two thirds of patients with this disease. About three quarters of patients have peripheral eosinophilia. While imaging of COP may appear similar to CEP, peripheral eosinophilia is not typically present, and open lung biopsy is required tomake the diagnosis. This patient's classic symptoms along with peripheral eosinophilia pointed toward a diagnosis of CEP even in the absence of typical radiographic findings

BACKGROUND: Entrustable Professional Activities (EPAs) and milestones are expert judgments made based on many formative assessments. Their validity is dependent on the number of assessments but attention is increasingly being paid to having a "fair" sample of observations equally distributed across residents and contexts. OSCEs provide such a consistent, fair sample of behavior assessed under controlled conditions but have mostly used been used to provide granular skills feedback. We explore how faculty judge the "entrustability" of residents based on observing OSCE cases and then how these entrustments relate to OSCE skills performance. METHODS: In an 11-case OSCE for primary care residents (n = 25; PGY1-3), SPs rated skills in communication (information gathering, relationship development, education/counseling), assessment, patient education (case-specific), physical exam, professionalism, treatment plan, patient satisfaction and patient activation. Summary scores were calculated as%items rated well done (vs not or partly done; internal consistency > .72). Faculty observers then judged how much supervision the resident would need in actual practice to handle the case: 1-requires direct supervision, 2-requires indirect supervision, 3-ready for unsupervised practice, or 4- can supervise others. Mean entrustment rating across cases was correlated with clinical skills. RESULTS: Mean entrustment =2.46 (SD .37), falling between requires indirect supervision and ready for unsupervised practice. On average, residents were judged to need direct supervision in .40 cases (SD .65), indirect supervision in 4.76 (SD 2.03), ready for unsupervised practice in 2.92 (SD 1.80), and able to supervise others in 1.07 cases (SD 1.15) with PGY1 residents needing direct and indirect supervision in more cases than PGY2 and 3 (p = .037). Associations between OSCE performance and faculty entrustment ranged from essentially zero (communication sub-domains of information gathering and education/counseling; case-specific patient education; patient satisfaction) to negative (communication sub-domain of relationship development r = -.25, p = .16; professionalism r = -.21, p = .22) to positive (case-specific assessment, r = .35, p = .07; physical exam r = .30, p = .13; treatment plan r = .40, p = .04; patient activation r = .51, p = .008). Associations between skills performance and entrustment ratings varied by case. CONCLUSIONS: OSCEs provide a valuable opportunity for faculty to make entrustment judgments based on observing the same, complete encounter across many trainees. Entrustment judgments appear to be capturing elements of competence related to but different from SP assessments of performance, including especially "bottom line" aspects of practice such as assessment, physical exam, treatment plans and patient activation. Interestingly, we consider patient activation skills to be an "educationally sensitive patient outcome" i because both teachable and associated with patient outcomes and our results support the importance of this skill set

BACKGROUND:: Recent methodological advancements should catalyze the evaluation of measurement invariance across groups, which is required for conducting meaningful cross-group comparisons. OBJECTIVE:: The aim of this study was to apply a state-of-the-art statistical method for comparing latent mean scores and evaluating measurement invariance across managers' and frontline workers' ratings of the organization of hospital care. METHODS:: On the 87 nursing units in a single institution, French-speaking and Dutch-speaking nursing unit managers' and staff nurses' ratings of their work environment were measured using the multidimensional 32-item practice environment scale of the nursing work index (PES-NWI). Measurement invariance and latent mean scores were evaluated in the form of a Bayesian 2-level multiple indicators multiple causes model with covariates at the individual nurse and nursing unit level. Role (manager, staff nurse) and language (French, Dutch) are of primary interest. RESULTS:: Language group membership accounted for 7 of 11 PES-NWI items showing measurement noninvariance. Cross-group comparisons also showed that covariates at both within-level and between-level had significant effects on PES-NWI latent mean scores. Most notably, nursing unit managers, when compared with staff nurses, hold more positive views of several PES-NWI dimensions. CONCLUSIONS:: Using a widely used instrument for measuring nurses' work environment, this study shows that precautions for the potential threat of measurement noninvariance are necessary in all stages of a study that relies on survey data to compare groups, particularly in multilingual settings. A Bayesian multilevel multiple indicators multiple causes approach can accommodate for detecting all possible instances of noninvariance for multiple covariates of interest at the within-level and between-level jointly.