AMERICAN COLLEGE OF PHYSICIANS
MARYLAND REGIONANNUAL
ASSOCIATES MEETING
9 May 2019
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( ) Clinical Vignette
(x) Research Competition
( ) Basic Science
( ) Evidence based medicine
review
( ) Quality/Safety
(x) Clinical Research
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in research process (4 sentences or less): I directed the Solo Se Vive Una Vez (You Only Live Once) public health campaign, overseeing its implementation and evaluation. I submitted the IRB application, managed our team of research assistants, and organized survey and EMR data collection and entry through an online database. I conducted the research analysis and authored the project’s findings for dissemination.
First Author Information:
Name: Harita Shah MD
Institution: Johns Hopkins
Co-Author(s) Associates:
Suzanne Grieb PhD MSPH, Alejandra Flores-Miller, Kathleen Page MD
Program Director’s Name: Leonard Feldman MD
(indicating review of abstract)
SOLO SE VIVE UNA VEZ (YOU ONLY LIVE ONCE): A CAMPAIGN TO IMPROVE HIV TESTING AMONG IMMIGRANT LATINX IN BALTIMORE
Purpose: Of the 263,000 Latinx with HIV in the U.S., one fifth is unaware of their infection. Consistent with national trends, Baltimore City Health Department (BCHD) data show that HIV-infected Latinx are more likely to be diagnosed late than any other racial/ethnic groups. In prior studies, we demonstrated barriers to HIV testing among Latinx in Baltimore include HIV stigma, cultural/linguistic discordance, uninsured status, and fear of deportation. From July to December 2018, we implemented the Solo Se Vive Una Vez (You Only Live Once) campaign partnering with BCHD to increase HIV testing among Latinx in Baltimore by addressing these barriers. The purpose of the present study was to assess reach of the campaign and its impact on people’s decision to get tested.
Methods: The campaign included a website (solovive.org) and advertisements on social media, buses, billboards, radio, events, and dating apps. We conducted cross sectional surveys of Latinx adults obtaining HIV testing at the BCHD clinic and outreach before (n = 78) and after (n = 315) the campaign launch. Surveys assessed demographics, HIV testing history, exposure to the campaign, and influence of the campaign on the decision to get tested. Sexual risk behaviors and PrEP information were obtained from BCHD medical records by trained research assistants. Characteristics of the population exposed to the campaign versus not exposed were compared using t-test and chi squared analyses.
Results: 34% of respondents surveyed after campaign launch reported exposure to the Solo Se Vive Una Vez campaign, compared to 0% in the baseline surveys. 86% of those exposed reported that the campaign positively influenced their decision to get tested. Respondents with campaign exposure had significantly higher numbers of sexual partners and rates of paying drugs/money for sex (p < 0.05). The website has had 9,899 visitors, and 130 users requested testing through the website. 89% of Latinx surveyed never heard of PrEP and received PrEP information.
Conclusions: Solo Se Vive Una Vez is Baltimore’s first Spanish-language public health campaign promoting HIV screening. It achieved comparable exposure to other campaigns addressing HIV testing in Latinx. The campaign positively influenced the majority of testers exposed to it to get tested, including Latinx with high-risk sexual behaviors. BCHD data are currently being tabulated to measure change in testing rates.
AMERICAN COLLEGE OF PHYSICIANS
MARYLAND REGION
ANNUAL ASSOCIATES MEETING
9 May 2019
Please check one. First author is:
(X) RESIDENT
Please check only one. Abstract is submitted to.
( ) Poster
( ) Oral
(X) Either
General Classification:
(X) Clinical Vignette
( ) Research Competition
( ) Basic Science
( ) Evidence based medicine
review
( ) Quality/Safety
( ) Clinical Research
Indicate your participation
in research process (4 sentences or less): Involved in care of patient in case. Gathered information and wrote abstract.
First Author Information:
Name: George Kontogiannis, MD
Institution: Walter Reed National Military Medical Center, Bethesda MD
Co-Author(s) Associates:
Michael Casey Flanagan, MD
Program Director’s Name:
Joshua David Hartzell, MD
(indicating review of abstract)
PACED CORONARY VASOSPASM OCCURING DURING INTRAVENOUS NITROGLYCERIN, George Kontogiannis, MD, National Capital Consortium, Bethesda MD
Introduction: Classically known as Prinzmetal’s angina, vasospastic angina is a rest angina that responds well to sublingual nitrates. The Coronary Vasomotion Disorders International Study group diagnostic criteria describe a nitrate responsive angina with transient ischemic ECG changes without another obvious cause, and angiographic evidence of coronary artery spasm. However, the absence of nitrate responsiveness does not completely exclude the diagnosis. Patients with Prinzmetal’s angina are often of Japanese descent and smoke.
Case: We present a 45-year-old female with past medical history of right coronary artery vasospasm, associated with AV block status post dual chamber permanent pacemaker, who presented after ROSC from a syncopal episode. Her history of vasospasm was discovered a year prior when she had syncope secondary to an inferior STEMI and complete AV block. Cardiac catheterization showed no coronary artery disease but inducible spasm. Recurrent syncopal episodes led to a permanent pacemaker. In the ED, she was continued on her home isosorbide mononitrate and verapamil. She developed chest tightness with inferior ST elevations and ventricular pacing, was started on nitro drip, and her symptoms and ECG changes resolved after 10 min. She was admitted to the ICU and a few hours later had a recurrence, accompanied by symptomatic hypotension. Nitro was stopped and the patient was given a fluid bolus. Her symptoms resolved after 10 min. On history, the patient admitted to recently restarting tobacco abuse to cope with acute life stressors. She was started on Norvasc, and monitored with no recurrence.
Discussion: This case illustrates the diagnosis and treatment of refractory vasospasm with a unique consequence: complete heart block. It is refractory since it occurred while on a calcium channel blocker and a nitrate, as well as while on intravenous nitroglycerin. When such a patient presents, it is important to classify if they are a true non-responder, or if it is secondary to poor lifestyle adherence. Furthermore, the use of dual calcium channel blocker therapy is somewhat novel, having been described only in case reports. Her ECG is interesting as a learning point as well. When paced from an RV lead, the nidus of electrical impulse is inferior, and as such, the QRS waves should all be inferior. In her ECG however, the inferior leads were positively deflected, correlating with a right coronary vasospasm.
American College of Physicians
REGULATIONS FOR SUBMISSION OF
ABSTRACTS
AMERICAN COLLEGE OF PHYSICIANS
MARYLAND REGION
ANNUAL ASSOCIATES MEETING
9 May 2019
Please check one. First author is:
(X) RESIDENT
Please check only one. Abstract is submitted to.
(x) Poster
( ) Oral
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General Classification:
(x) Clinical Vignette
( ) Research Competition
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review
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Indicate your participation
in research process (4 sentences or less):
First Author Information:
Name: Kiran Motwani, MD
Institution: University of Maryland Medical Center and Baltimore VA Medical Center
Co-Author(s) Associates:
Program Director’s Name: Susan D. Wolfsthal, MD
(indicating review of abstract)
RHODOCOCCUS FASCIANS – A RARE CAUSE OF MENINGITIS IN A HUMAN HOST. Motwani K, MD. University of Maryland School of Medicine and VA Medical Center, Baltimore, MD.
Rhodococcus species are obligate aerobes, gram-positive bacilli, and partially acid-fast because of their mycolic acid-containing cell wall. They are isolated from a variety of sources including soil, ground water, plants, and animals. The microbe is generally considered to have low pathogenicity, however has been known to cause disease in immunocompromised hosts.
A 76-year-old male with a history of hypertension and alcohol abuse was admitted for altered mental status, which consisted of confusion, slurred speech, visual hallucinations, and ambulatory dysfunction. He had recently arrived from the Dominican Republic where he was exposed to poor living conditions. Magnetic resonance imaging (MRI) of the brain displayed mild meningeal enhancement and small embolic events. Further work-up revealed a ruptured pseudoaneurysm of his ascending aorta, and he underwent repair with a graft placement. The patient remained hemodynamically stable, however, 7 days post-operation there was no improvement in his mental status.
Cerebrospinal fluid (CSF) studies revealed: glucose 28 mg/dL, protein 474 mg/dL, white blood cell count 260 mcL with 48% polymorphonuclear leukocytes, 47% lymphocytes, and 5% monocytes. Cytology, gram stain, and cultures were all negative. He was started on ampicillin, ceftriaxone, and doxycycline empirically. Repeat CSF analysis revealed an increase in leukocytosis, with persistently low glucose and elevated protein. MRI brain showed worsening interval meningitis versus ventriculitis. Given his lack of improvement, his treatment regimen was changed to rifampin, isoniazid, pyrazinamide, and ethambutol for suspicion for tuberculosis meningitis. Additionally, a trial of steroids for sarcoidosis was attempted, without improvement.
The patient underwent a leptomeningeal biopsy, which displayed evidence of necrotizing granulomas and 16S rRNA cultures were positive for Rhodococcus fascians. He was started on a three-drug regimen with vancomycin, meropenem, and azithromycin for at least an 8-week course with plans to transition to oral antibiotics.
R. fascians is a rare cause of meningitis and not easily identified with routine microbial testing. Treatment regimens are currently unknown due to the rarity of the disease. Recognizing lack of improvement in disease course in an immunocompromised patient should lead providers to consider alternate pathologies and seek further testing with 16S rRNA gene sequencing.
AMERICAN COLLEGE OF PHYSICIANS
MARYLAND REGION
ANNUAL ASSOCIATES MEETING
9 May 2019
Please check one. First author is:
(X) RESIDENT
Please check only one. Abstract is submitted to.
(X) Poster
( ) Oral
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General Classification:
(X) Clinical Vignette
( ) Research Competition
( ) Basic Science
( ) Evidence based medicine
review
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Indicate your participation
in research process (4 sentences or less):
First Author Information:
Name: Hana Haver, MD
Institution: UMMC Midtown Campus
Co-Author(s) Associates:
Sam Knecht, MD
Program Director’s Name: R. Dobbin Chow, MD
(indicating review of abstract)
BILATERAL OCCIPITAL LOBE INFARCT NEGLECT DEFICIT (BLIND) SYNDROME
Introduction: Cortical blindness is loss of vision due to dysfunction of the visual cortices. Patients who suffer from cortical blindness, usually due to bilateral ischemic infarcts of the occipital lobes, tend to lack insight of their visual deficit. This phenomenon of unawareness, or denial of vision loss, is called visual anosognosia. Further, patients often claim to be able to see and will confabulate visual perceptions despite their lack of sight. Historically, visual anosognosia in cortical blindness has carried the eponym, Anton syndrome, named after the Austrian neurologist and psychiatrist, Gabriel Anton (1858–1933), who first described the syndrome in 1899.
Case presentation: A 76-year-old man was traveling to visit his daughter during the holidays when he suddenly experienced blurred vision while driving his car. Subsequently, he stayed in his car for 3 days because his visual deficit prevented him from using his phone to call for assistance. The police eventually found him, and brought him to medical attention. The patient reported several weeks of increasingly frequent ‘lightning-like’ bright flashes of green and yellow in his right eye, but denied the presence of floaters, curtain loss of vision, or diplopia. He reported that his last eye examination was 1 year prior, at which time his visual acuity was 20/30 bilaterally. Physical examination was significant for irregular rhythm and tachycardia. EKG revealed atrial flutter with 2 to 1 block and pulse of 150 beats per minute. Ophthalmologic exam demonstrated significantly diminished visual acuity – less than 20/200 bilaterally with 360-degree constriction of confrontational visual fields. Pupillary reflexes and ocular movements remained intact bilaterally. Dilated fundus exam revealed no evidence of retinal, macular, or choroidal pathology to explain the visual loss. Therefore, the patient was deemed cortically blind, prompting further evaluation for suspected stroke. CT brain without contrast revealed bilateral subacute parieto-occipital infarcts with local sulcal effacement. MRI of the brain without contrast showed acute to subacute bilateral PCA territory infarcts and additional small subacute infarcts in the bilateral cerebellar hemispheres. MRA of the head/neck without contrast showed no evidence of intracranial occlusion, stenosis, or aneurysm.
Conclusion: Here, we propose using the term, Bilateral occipital Lobe Infarct Neglect Deficit (BLIND) syndrome, to replace Anton syndrome for patients who develop cortical blindness with visual anosognosia associated with bilateral occipital lobe ischemic infarcts. In addition, consider BLIND syndrome in patients who present with visual deficits and denial of blindness in the setting of cardioembolism due to new onset atrial arrhythmia.
AMERICAN COLLEGE OF PHYSICIANS
MARYLAND REGION
ANNUAL ASSOCIATES MEETING
9 May 2019
Please check one. First author is:
(X) RESIDENT
Please check only one. Abstract is submitted to.
( ) Poster
( ) Oral
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( ) Clinical Vignette
(X) Research Competition
( ) Basic Science
( ) Evidence based medicine
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(X) Quality/Safety
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Indicate your participation
in research process (4 sentences or less): I developed this idea over the summer of 2018 and recruited faculty mentors and sponsors. Together with Dave Furfaro, I wrote our application for IRB exemption, adapted the survey, and developed our protocol for initiating buprenorphine maintenance. I co-led the educational conference with Dr. Graddy. I started and continue to manage the Buprenorphine Bridge team, and I am conducting data collection and data analysis with the assistance of my faculty mentors.
First Author Information:
Name: Ashish Thakrar, MD (Member)
Institution: Johns Hopkins Hospital
Co-Author(s) Associates: David Furfaro, MD (N/A, Johns Hopkins Hospital, Baltimore, MD); Ryan Graddy, MD (Member, Johns Hopkins Bayview, Baltimore, MD); Megan Buresh; MD (Member, Johns Hopkins Bayview, Baltimore, MD); Sara Keller (N/A, Johns Hopkins Hospital, Baltimore, MD); Leonard Feldman, MD (FACP, Johns Hopkins Hospital, Baltimore, MD)
Program Director’s Name: Leonard Feldman, MD FACP
(indicating review of abstract)
A QUALITY IMPROVEMENT PROJECT TO INCREASE INITIATION OF BUPRENORPHINE MAINTENANCE FOR INPATIENTS WITH OPIOID USE DISORDER
Background: Patients with opioid use disorder (OUD) are inconsistently initiated and discharged on opioid agonist therapy such as buprenorphine on internal medicine services at Johns Hopkins Hospital (JHH). This is a missed opportunity to save lives in the midst of the opioid overdose epidemic. Additionally, it contributes to patients leaving against medical advice and raises the risk for readmissions.
Purpose: The primary aim of this quality improvement project is to increase the number of patients initiated on buprenorphine maintenance therapy (BMT). Secondary aims are to understand barriers to initiation of BMT, to decrease perceived barriers, and to increase the number of providers with Buprenorphine ‘X’-waivers.
Methods: We have conducted four interventions: 1) administered an 18-question survey to all IM residents regarding barriers to initiating BMT; 2) developed/disseminated a protocol for initiating BMT with follow-up; 3) presented a 1-hour educational conference; and 4) started the JHH Buprenorphine Bridge Team of ‘X’-waivered physicians to prescribe bridging scripts of buprenorphine from discharge to follow-up. We will administer a follow-up survey in May after two additional educational conferences.
Results: 89 of 152 residents (59%) completed the baseline survey prior to implementation and identified the greatest barriers to initiating BMT as ‘don’t know how’ (67%), ‘medical team chooses a taper’ (49%), ‘no discharge plan’ (47%), and ‘discomfort with dosing’(40%). Over the first 30 days since implementation, 11 patients were initiated on BMT, the Buprenorphine Bridge team was consulted 13 times, and 4 new attending physicians obtained their Buprenorphine ‘X’-waiver.
Conclusions: Inpatient admissions offer a crucial opportunity to start buprenorphine maintenance treatment for patients with OUD. Residents identified a lack of education and discharge planning as the most important barriers to initiating BMT. We addressed these barriers through resident education, a protocol for prescribing BMT, a novel Buprenorphine Bridge Team, and development of a system for follow-up in partnership with Care Coordination teams.
American College of Physicians
REGULATIONS FOR SUBMISSION OF
ABSTRACTS
AMERICAN COLLEGE OF PHYSICIANS
MARYLAND REGION
ANNUAL ASSOCIATES MEETING
9 May 2019
Please check one. First author is:
(x) RESIDENT
Please check only one. Abstract is submitted to.
( ) Poster
( ) Oral
(x) Either
General Classification:
( ) Clinical Vignette
(x) Research Competition
( ) Basic Science
( ) Evidence based medicine
review
( ) Quality/Safety
(x) Clinical Research
Indicate your participation
in research process (4 sentences or less): study design, data gathering, data analysis, writing
First Author Information:
Name: Andrew Ma
Institution: University of Maryland Medical Center and Baltimore VA Medical Center
Co-Author(s) Associates:
John Morris, Jonah Rubin
Program Director’s Name: Susan D. Wolfsthal
(indicating review of abstract)
FEATURES AND CHARACTERISTICS OF GASTROINTESTINAL BLEEDING IN PATIENTS RECEIVING EXTRACORPOREAL MEMBRANE OXYGENATION. Ma AS, MD, Morris JD, MD, Rubin JN, MD, Herr DL, MD, Mazzeffi, MA, MD. The University of Maryland Medical Center and Baltimore VA Medical Center, Baltimore, MD.
Background: Extracorporeal membrane oxygenation (ECMO) is a form of prolonged cardiopulmonary support for cardiac and respiratory failure. The nature of the circuitry causes an acquired coagulopathy requiring use of continuous anticoagulation. Gastrointestinal (GI) bleeding is a common complication. Our aims are to investigate the incidence of GI bleeding in ECMO patients, identify risk factors for GI bleeding, and characterize the nature of such bleeds.
Methods: We performed a retrospective review of 269 patients who received ECMO from March 2010 to February 2015, identifying patients with overt GI bleeding. We reviewed consultations for endoscopic intervention and subsequent clinical courses. Using Stata I/C 15, a Cox proportional hazards analysis was performed to identify factors associated with GI bleeding.
Results: After analysis of 32 clinical variables, our univariate proportional hazards regression identified that post-cardiotomy shock (2.39, p = 0.01) and age (1.03, p = 0.002) exhibited significant hazard ratios. Other variables of increased but undetermined significance were hypertension, indication for ECMO, type of cannulation, and number of plasma transfusions. GI bleeding was associated with significant in-hospital mortality (3.30, p = 0.001). Of the 269 patients, 41 (15%) exhibited overt GI bleeding while receiving ECMO, most commonly as hematochezia (41%) and melena (37%). 19 underwent endoscopies. 79% of all bleeds were upper GI bleeds, with the most common source being gastroduodenitis without ulceration (47%) and esophagitis (42%). The most common source of lower GI bleeding was ischemic colitis (16%). Four endoscopies demonstrated lesions amenable to endoscopic or angiographic intervention, of which all were successful.
Discussion: Overt GI bleeding is a common complication after initiation of ECMO. It is a strong predictor of in-hospital mortality, with the greatest risk factors for bleeding being age and post-cardiotomy shock. When clinically appropriate, all endoscopies were able to identify a source of bleeding. Hematochezia was the most common presentation, but the majority of bleeding sources lay within the upper GI tract with the most common being gastroduodenitis. Limitations of this study include the retrospective design, but it remains the most extensive investigation of GI bleeding in ECMO patients to date.