Faculty Bibliography

Program/Project Purpose: Although, the internist plays a central role in the hospital, as the coordinator of interdisciplinary diagnostic and therapeutic care, they may function differently in different parts of the world. This project aims to compare the general structure of internal medicine clinical services at hospitals in USA and Turkey. Structure/Method/Design: The study was conducted in Koc University Hospital in Istanbul, Turkey, and Bellevue Hospital in New York, USA, in 2015, by trainees participating in an academic exchange. At Bellevue Hospital, approximately 80% of internal medicine beds are managed by internal medicine attendings and hospitalists. In United States (US), general internists provide comprehensive and organized care for both acute and chronic diseases. In comparison, in Koc University Hospital, Istanbul, all internal medicine beds are managed by nine different subspecialties, with general internal medicine as its own subspecialty, and not a primary hospitalist team. Outcome and Evaluation: In New York, once the patient is admitted and stabilized, the primary hospitalist teams provide medical care. Thereafter, the primary internist team may request a subspecialty consult considering medical condition of the patient. On the other hand, in Istanbul, transfer of patients are triaged from the first point of contact to subspecialty service that is related to their medical condition. This subspecialty team manages the patient's condition and provides appropriate medical care until discharge. When there is a need to consult, the primary subspecialty team would consult other subspecialties. Going Forward: These two different ecoles have their own advantages and disadvantages. While a central role for internists in US offers important advantages such as high patient-population satisfaction and cost effectiveness, it also has been associated with discontinuity of care, patient dissatisfaction, loss of acute care skills by primary care physicians, and burnout among hospitalists. In Turkey, although subspecialized services may provide better-focused medical care, they may sometimesmiss the big picture and are over-used. In future exchanges, the division of care between generalist/hospitalist and consultant/ subspecialist care will be studied, which can include type of ward patient is assigned, stratification by chief complaint, percentage of consults requested, length of stay, and patient satisfaction

Background: The number of asylum seekers in the US has risen dramatically over the past 10 years. This study aimed to measure the prevalence of selected infectious, non-communicable and psychiatric illnesses within this population and to evaluate the success of a program for asylum seekers in screening for these conditions. Methods: Two hundred ten new clients from 51 countries, plus Tibet, who were accepted into an urban hospital-based program for asylum seekers from 2012-2014 were included. Screening rates and outcomes for infectious, non-communicable, and mental illnesses were evaluated based on intake data and review of the medical record. Informed written consent was obtained during the intake process. Findings: 71% percent of patients screened positive for depression (n=144 positive/204 total screened) and 55% screened positive for PTSD (n=111/193), followed by latent tuberculosis (41%, n=65/ 159), hypertension (10%, n=21/210), hepatitis B (9.4%, n=19/ 202), and HIV (0.8%, n=1/124). Rates of completed screenings were highest for PTSD, depression, hepatitis B and latent tuberculosis. Interpretation: This population is at very high risk of PTSD, depression, and latent tuberculosis, and at increased risk of hepatitis B. Screening rates for these diseases were high at this dedicated program for asylum seekers. Point of care testing was more effective than testing that required repeat visits. These findings call for special attention to the primary care needs for asylum seekers in the US

BACKGROUND: Outcome measures to capture disability, such as the Multiple Sclerosis Functional Composite (MSFC), were developed to enhance outcome measurements for clinical trials in adults with multiple sclerosis (MS). The MSFC initially included three components: a timed 25-foot walk [T25FW], 9-hole peg test [9HPT], and the Paced Auditory Serial Addition Task [PASAT]. Modifications to the original MSFC, such as adding binocular low-contrast letter acuity (LCLA) or substituting the symbol digit modalities test (SDMT) for the PASAT, improved the capacity to capture neurologic impairment in adults. Similar outcome scales for pediatric MS have not yet been established. OBJECTIVE: To determine whether the three-component MSFC or a modified MSFC with LCLA and the SDMT better identifies neurological deficits in pediatric MS. METHODS: We evaluated 5 measures (T25FW, 9HPT, Children's PASAT [ChiPASAT], SDMT, and binocular LCLA [Sloan charts, 1.25% contrast]) in children with MS (disease onset <18 years) and healthy controls. To be able to compare measures whose scores have different scales, Z-scores were also created for each test based on the numbers of standard deviations from a control group mean, and these individual scale scores were combined to create composite scores. Logistic regression models, accounting for age, were used to determine whether the standard 3-component MSFC or modified versions (including 4 or 5 metrics) best distinguished children with MS from controls. RESULTS: Twenty pediatric-onset MS subjects, aged 6-21 years, and thirteen healthy controls, aged 6-19 years, were enrolled. MS subjects demonstrated worse scores on the 9HPT (p=0.004) and SDMT (p=0.001), but not the 25FTW (adjusted for height, p=0.63) or the ChiPASAT (p=0.10): all comparisons adjusted for age. Decreased (worse) binocular LCLA scores were associated with MS (vs. control status, p=0.03, logistic regression; p=0.08, accounting for age). The MSFC composite score for the traditional 3 components did not differ between the groups (p=0.28). Replacing the ChiPASAT with the SDMT (OR 0.72, p=0.05) better distinguished MS from controls. A modified MSFC-4 with the SDMT replacing the ChiPASAT and including binocular 1.25% LCLA had the greatest capacity to distinguish pediatric MS from controls (OR 0.89, p=0.04, logistic regression). Including all 5 metrics as a composite MSFC-5 did not improve the model (p=0.18). CONCLUSIONS: A modified MSFC (25FTW, 9HPT, SMDT, and binocular 1.25% LCLA) is more sensitive than the traditional MSFC or its components to capture the subtle impairments that characterize pediatric MS and should be validated in order to be considered for future pediatric MS trials.

INTRODUCTION: Resistant hypertension (RHTN) is an important condition affecting 29% of the hypertensive population in the U.S., especially among blacks. Sleep disturbances, like obstructive sleep apnea, insomnia, and short sleep duration, are increasingly recognized as underlying modifiable factors for RHTN. We evaluated associations of RHTN with short sleep duration among blacks with metabolic syndrome. METHODS: Data from the Metabolic Syndrome Outcome Study (MetSO), a NIH-funded cohort study characterizing metabolic syndrome (MetS) among blacks were analyzed. MetS was defined according to criteria from the Adult Treatment Panel (ATP III). RHTN was defined according to guidelines from the American Heart Association. Short sleep was defined as self-reported sleep duration <7 hrs experienced during a 24-hour period. RESULTS: Analysis was based on 1,035 patients (mean age: 62+/-14years; female: 69.2%). Of the sample, 90.4% were overweight /obese; 61.4% had diabetes; 74.8% had dyslipidemia; 30.2% had a history of heart disease; and 48% were at high risk for obstructive sleep apnea. Overall, 92.6% reported physician-diagnosed hypertension (HTN) and 20.8% met criteria for RHTN. Analyses showed those with RHTN were more likely to be short sleepers (26.8% vs. 14.9%, p< 0.001). Based on logistic regression analysis, adjusting for effects of age, sex, and medical comorbidities, patients with metabolic syndrome and RHTN had increased odds of being short sleepers (OR = 1.95, 95% CI: 1.28-2.97, p = 0.002). CONCLUSION: Among blacks with metabolic syndrome, patients meeting criteria for resistant hypertension showed a twofold greater likelihood of being short sleepers, prompting the need for sleep screening in this vulnerable population.

The peak troponin level has been associated with cardiovascular (CV) mortality and adverse CV events. The association of peak troponin with CV risk factors and severity and complexity of coronary artery disease remains unknown. We assessed the predictors of peak troponin in patients with acute coronary syndrome (ACS). This study aims to determine the predictors of peak troponin in ACS. Cardiac catheterization (CC) reports and electronic medical records from 2010 to 2013 were retrospectively reviewed. A total of 219 patients were eligible for the study. All major CV risk factors, comorbidities, laboratory data, CC indications, and coronary lesion characteristics were included. Univariate and multivariate regression analyses were done. On multivariate linear regression analysis, ST-elevation myocardial infarction (p = 0.001, beta = 65.16) and increasing synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) score (p = 0.002, beta = 1.15) were associated with higher peak troponin. The Pearson correlation between SYNTAX score and peak troponin was r = 0.257, p = 0.001. History of daily aspirin use was associated with lower peak troponin (p = 0.002, beta = -24.32). Prior statin use (p = 0.321, beta = -8.98) and the presence of CV risk factors were not associated with peak troponin. Coronary artery disease severity and complexity, urgency of CC, and prior aspirin use are associated with peak troponin levels in ACS. Our findings may help predict patient population with ACS who would be at a greater risk for short- and long-term CV morbidity and mortality due to elevated peak troponin.

Dissection of the ascending aorta, type A aortic dissection (TAAD), represents a surgical emergency with high morbidity and mortality. Current open surgical techniques, although state-of-the-art procedures and having improved outcomes for patients with TAAD over the last decades, confer significant risk of complications and death. Recently, endovascular techniques for repair of both the abdominal and thoracic aorta have gained acceptance within the vascular and cardiovascular surgical communities as a useful tool in select pathologies and patient populations. As development of endovascular technology proceeds ever closer to the aortic valve, thoracic endovascular repair for TAAD deserves special investigation. A comprehensive literature search for studies reporting outcomes of endovascular repair in the ascending aorta was performed. In this review, we compile the worldwide experience of thoracic endovascular repair for TAAD as well as imaging studies for patient selection and the use of hybrid (open plus endovascular) techniques. The authors discuss the remaining challenges that preclude its broader adoption in this role, namely patient selection and device specificity.