Faculty Bibliography

Altman revisits the 1982 AIDS Epidemic. Thirty years after scientists gave a frightening new disease its name, AIDS still afflicts millions of men and women around the world. AIDS has infected more than 60 million people worldwide and has killed at least half that number in one of the worst epidemics in history

The world of HIV in the US just changed dramatically - for the better. In a major development for public health that went almost unnoticed, Orasure Technologies just received FDA approval for an over-the-counter home HIV test, Oraquick. A patient will simply be able to swab the inside of their mouth or gums and know with over 90% certainty whether they are HIV positive within 30 minutes. At the same time, the false positive rate is extremely low, meaning you are very unlikely to be told that you have HIV if you don't

NEEDS AND OBJECTIVES: Despite an increasing need for physicians trained in Internal Medicine (IM), the number of medical students entering residencies in IM has declined. Misconceptions about careers in IM, pay differentials between disciplines, student debt and work hours are thought to contribute to this decline. We developed an "IM Speed Dating Event" to increase first year medical student's awareness of the breadth and richness of IM training and careers. SETTING AND PARTICIPANTS: Faculty members from each Division within the Department of Medicine at our institution were asked to participate to emphasize the diversity of careers paths after IM training. Medical Students were recruited via email, flyers and word-of-mouth. Over 3 years of the event (2009-2011), 51 medical students participated (14-19/year). DESCRIPTION: This "speed dating" event was structured so that students rotated, in timed, five-minute blocks, speaking to a total of 10 faculty. Faculty members were organized to optimize diversity of disciplines to which students were exposed. Students asked questions about faculty members' career and training paths, current roles/responsibilities, work life, and work/life balance. The event was very informal, easy to set up and organize, and the speed dating format encouraged friendly, compelling and direct, but brief, discussions. EVALUATION: All 51 participants (n=18 in 2009, 19 in 2010, and 14 in 2011), completed a pre-event anonymous assessment of their attitudes toward and understanding of IM residency and career pathways and practices as well as their specialty and career intentions. After the event, 47 completed an evaluation of the "Speed Dating" event including listing 3 things they learned and the degree to which the event led them to become more interested in exploring IM. Pre-event assessment results suggest that medical students are quite unsure about IM careers (e.g., 45% reported being not sure whether faculty within IM Departments have all done IM residencies and 58% rep!

NEEDS AND OBJECTIVES: Our annual residency retreat brainstorms innovations to meet needs. In 2010 needs were: to introduce foundation concepts and enable primary care (PC) residents to feel/be competent in clinic earlier; to spiral learning of core concepts, skills and attitudes from the start; and to have residents and faculty connect from the outset.We aim to equip PC clinicians to deliver bio-psychosocial, comprehensive, best evidence-based systems savvy care and to become change agents, leaders, and scholars. To meet these aims we designed a learner centered, team oriented, skills-based Essentials for PC Clinicians (EPIC) curriculum utilizing an initial, rigorous 4 week block with spiral reinforcement through 3 years. The innovation is a comprehensive, reproducible, effective method to ensure residents' progress on paths of clinical, humanistic, and intellectual excellence consistent with the generalist paradigm. SETTING AND PARTICIPANTS: EPIC is part of the NYU Internal Medicine PC Residency. Residents attend public hospital and community continuity clinics. 8 interns take the EPIC block and 24 residents spiral through the curriculum. DESCRIPTION: EPIC begins with a 4 week intern block dedicated to core topics in PC; is reinforced in precepting and subsequent blocks; and has a weekly EPIC conference where these topics are deepened and extended. EPIC Block: The overarching themes throughout the 4 weeks focus on understanding and practice of core skills: workshops/precepting on time management, efficient use of EHR, obtaining best practices, consultation, how one learns best, practice in the medical home and engaging community resources. Week 1 focuses on diabetes, and introduces the pillars: psychosocial medicine, evidence-based practice, and systems-based policy awareness and skill. The second week focuses on hypertension. The last 2 weeks introduce 7 common, high-risk high gain conditions from smoking to hepatitis B. Teaching methods combine group learning and reflective written exercises!

BACKGROUND: The discipline of health care ethics consultation (EC) has been limited by the lack of both high quality data and quality standards. To promote high quality ethics consultation practices, staff at the National Center for Ethics in Health Care within the Veterans Health Administration (VHA) developed 2 specific EC tools, ECWeb and the EC Feedback Tool. ECWeb is a web-based database tool that promotes process standards consistent with "CASES," VA's systematic approach to ethics consultation. The EC Feedback Tool, which links to ECWeb records, enables consultation participants to rate their experience on various aspects of EC. This paper describes the ethics consultation requests, processes, and evaluations from all facilities in our system. METHODS: We analyzed data from completed ethics consultations from ECWeb records initiated between October 2008 and September 2011. For each consultation record, users documented in ECWeb the data related to utilization of the EC service (e.g., type of consultation request, requester role (i.e., physician, nurse, patient). Additionally, ECWeb users documented, as applicable, various processes performed during the ethics consultation (e.g., capacity assessment (y/n), a face-to-face patient visit (y/n), and if the consult was identified as being symptomatic of underlying issues that are best addressed at the systems level). The EC Feedback Tool asked respondents to rate the ethics consultant(s) on 12 specific ethics knowledge and skill areas as well as their overall experience with ethics consultation, both on a 5 point Likert scale. RESULTS: We analyzed ECWeb data for 4628 completed consults from 140 facilities across theVHAhealth system .Median consultation volume per facility was 7 in 2009 (mean=9.6, range=0-60), 8 in 2010 (mean=12.4, range=0-106), and 8 in 2011 (mean =12.1, range=0-119). The majority of consultations were classified by the consultants as related to shared decision making (73%). Most consultations (63%) related to patients in the !

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): To determine how adding a non-clinical member to primary care teams can improve hypertension and smoking cessation outcomes in Veteran Affairs New York Harbor Healthcare System's (VA NYHHS) implementation of the VA's Patient Centered Medical Home (PCMH) model, known as Patient Aligned Care Teams (PACT). OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): As part of the Program for Research on Outcomes of VA Education (PROVE) study, we sought to define a toolkit of panel management strategies that Panel Management Assistants (PMAs) will use to improve outcomes in smoking cessation and hypertension across patient panels. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENTVS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): Coincident with the nation-wide implementation of PACT across the VA system, PROVE explores the incremental impact of panel management and clinical microsystem education on hypertension and smoking outcomes. Two-thirds of randomly selected PACT teams in ambulatory care clinics at the Brooklyn and Manhattan campuses of the VA NYHHS had a PMA added to the team. Based on literature review and qualitative interviews of clinicians and key stakeholders at VA NYHHS, we developed a core toolkit of strategies utilizing clinical databases to target subsets of smokers and hypertensive patients that could benefit from specialized panel management interventions outside of the patient visit, such as identifying smokers who have not recently received tobacco cessation medications. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICH WILL BE USED TOEVALUATE PROGRAM/INTERVENTION): Prior to PROVE's intervention, we determined baseline rates of hypertension (uncontrolled and controlled) and smoking for all PACT panels. To assess PROVE's effectiveness of integrating panel management strategies by PACT teams, we will survey providers and nurses at baseline, 6 and 12 months to me!

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): Primary care providers need a way to formalize and simplify complicated follow-up instructions so patients can successfully navigate the health-care system in between visits with their doctor. OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): The individualized Electronic Primary Care Follow-up Plan is designed to maximize the efficiency and utility of face-to-face visits; encourage patient participation; and facilitate communication between the patient and health care team. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): Using the Veterans Affairs (VA) electronic medical record we designed a Follow-up Plan that translates physician follow-up orders into a single page, individualized instruction sheet for the patient to take home at the end of each primary-care visit. This templated note not only supplies the patient with an instruction tool; it also provides the physician with the convenience of ordering all referrals from one place. Physicians view a checklist of all possible relevant follow-up orders, expandable when prompted to offer additional, more specific options. For instance, if a physician orders imaging, a menu box of options appears with different imaging modalities; if a referral is required, a list of specialty clinics appears. The selected follow-up then automatically links to electronic orders. The final chart note pulls in only patient-relevant data. The patient leaves the primary care visit with a one-page personalized instruction sheet explaining how, when and why to accomplish each follow-up task. Checkout lines are minimized as patients no longer wait in line to schedule appointments. The note, which documents that patient communication took place with an electronic signature, remains in the medical record and can be consulted and reprinted at any time between visits by any member of Patient Aligned Care Team (PACT!

LEARNING OBJECTIVE 1: Distinguish clinical clues to assess for Lemierre's Syndrome. LEARNING OBJECTIVE 2: Manage Lemierre's Syndrome when appropriate anaerobic antibiotics are not sufficient. CASE: A 24-year-old healthy female was admitted after presenting with fever, sore throat, neck and pleuritic chest pain that started 3 days prior to admission. On physical examination, the patient appeared in mild respiratory distress requiring supplemental oxygen, and noted to have swelling and tenderness along the left sternocleidomastoid muscle with associated left tonsillar exudate and bibasilar pulmonary rales. Her initial complete blood count revealed isolated mild thrombocytopenia and a bandemia of 79%. A rapid strep test returned negative and a rapid influenza A/B RNA test also was negative. Following admission, a CT scan of the neck with contrast showed left peritonsillar abscess extending into the hypopharyngeal region with extensive lymphadenopathy. The patient was subsequently started on piperacillin-tazobactam and metronidazole after her admission blood culture began growing gram-negative anaerobes, which later speciated as Fusobacterium necrophorum. As the patient continued to spike high grade fevers, metronidazole was switched to intravenous sulbactam-ampicillin. On appropriate antibiotic coverage, the patient continued to complain of worsening dyspnea requiring increased supplemental oxygen by nasal cannula. A CT scan of the chest then showed multifocal pneumonia and multiple lung nodules concerning for septic emboli. In search for the source of her septic emboli, an echocardiogram showed normal findings, while a repeat CT of the neck with contrast revealed new findings of multiple necrotic lymph nodes and left internal jugular vein thrombus leading to a diagnosis of Lemierre's Syndrome. Subsequently, given clinical deterioration, patient was initiated on intravenous anticoagulation and the left internal jugular vein was resected. Over the ensuing several days, the patient's clinical pictur!

LEARNING OBJECTIVE 1: Recognize that TMP/SMX can induce a severe, potentially life-threatening, isolated thrombocytopenia. CASE: A 50-year-old healthy female without significant medical history presented with a day history of non-pruritic red rash on her torso. The patient was in her usual state of good health until three days prior to admission when she starting trimethoprim/sulfamethoxazole (TMP/SMX) for a possible dental infection. Except TMP/SMX, she was not taking any other prescribed or over the counter medication. Two days after starting taking TMP/SMX, she noticed the rash and presented to the hospital. On initial physical examination, the patient noted to have scattered nonblanching red petechial rash over her torso extending down to the bilateral lower extremities. The rest of her physical exam and review of systems were unremarkable. Her initial complete blood count (CBC) revealed an isolated thrombocytopenia with a platelet count of 4.000/mm3. The rest of her blood work including chemistry, coagulation, liver function and hemolysis panels were all within normal range. A subsequent peripheral smear confirmed thrombocytopenia with large platelets, but otherwise was normal. Bactrim was held off as a possible causative agent, and the patient was being evaluated for possible idiopathic thrombocytopenic purpura (ITP). Patient's platelet count responded poorly to the first unit of single donor platelets (SDP) transfusion, while a second unit of SDP tranfusion led to appropriate increase in platelet count. Within 36 hours of her hospital stay, the platelet count recovered to a normal range without any further transfusion requirement or glucocorticoids for initially presumed ITP. This led to a diagnosis of TMP/SMX-induced severe thrombocytopenia. Her presenting petechial rash also gradually resolved over hospital course. Patient was discharged on hospital day 3 with a platelet count of 202.000/ mm3. A week after discharge, her repeat platelet count was 425.000/mm3. DISCUSSION: Based on the N!

OBJECTIVE: Postoperative bleeding is a major cause of morbidity and mortality after complex aortic surgery. Intraoperative coagulopathy is a well-known culprit in this process. Recombinant activated factor VII is increasingly used for the postoperative management of such bleeding. We report our experience with the intraoperative use of this agent. METHODS: We performed a propensity-matched analysis on 376 retrospectively identified patients who underwent aortic root, arch, or ascending aortic replacement surgeries from 1999 to 2010. We matched a total of 58 patients: recombinant activated factor VII-treated group (n = 29) and nonrecombinant activated factor VII-treated group (n = 29). We compared the matched patients on re-exploration, mortality, bleeding-related events, use of blood and blood products, length of intensive care unit stay, duration of hospitalization, and thrombotic complications. RESULTS: Propensity-matched patients had similar preoperative and intraoperative characteristics. The mean dose of recombinant activated factor VII group was 23 +/- 12 mug/kg. We found significantly lower rates of surgical re-exploration (P = .004), fewer prolonged intubations (P = .004), less total chest tube output (P = .01), and fewer units of packed red blood cells (P = .01) and fresh-frozen plasma (P = .04) transfused postoperatively in the recombinant activated factor VII group. There was no significant difference in mortality (P = 1), duration of intensive care unit stay (P = .44) or hospital stay (P = .32), or thrombotic complications between the groups (P = .5). CONCLUSIONS: We recommend the intraoperative administration of low-dose recombinant activated factor VII but limited to the management of persistent, nonsurgical, mediastinal bleeding in aortic surgery. Further prospective randomized studies and larger cohorts are needed to verify these findings.