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Objective Patients with coronavirus disease 2019 (COVID-19) can progress to a state of unregulated inflammation called cytokine storm syndrome (CSS). We describe formation and operation of a COVID-19 multidisciplinary consultation service that was allowed to individualize treatment for critically ill patients with COVID-19 during the pandemic. Methods Institutional experts from different subspecialties formed a COVID-19 CSS task force at Montefiore Medical Center, Bronx, NY. They agreed on a set of four clinical and six laboratory parameters that can help early identify COVID-19 CSS. We describe the formation and implementation of the COVID-19 task force. The case series description of the COVID-19 CSS consultation cohort highlights consultation volume, baseline characteristics, clinical and laboratory parameters, and how biologic treatments were allocated to these patients. Results Between April 4,2020, and May 7,2020, the COVID-19 CSS task force was formed, consisting of adult and pediatric rheumatologists and allergy and immunology physicians. The task force evaluated a total of 288 patients, of whom 197 (68%) were male, the median (interquartile range [IQR]) age was 62 (51-70) years, 122 (42%) were Hispanic, and 88 (31%) were Black or African American. The common presenting symptoms in all referred patients were dyspnea (85%) and diarrhea (80%). Thirty-one patients who received biologic therapy were younger, with a median (IQR) age of 53 (32-63) years, as opposed to 62.5 (52-70) years in the nonbiologic group (P = 0.008). A higher proportion receiving biologics was in the critical care setting (26 [84%] vs 151 [59%]; P = 0.006). Conclusion To the best of our knowledge, this is the first multidisciplinary collaborative effort to provide individualized patient recommendations for evaluation and treatment of patients with COVID-19 who may have CSS. This working model helped to devise an approach that may have identified patients who were most likely to benefit from biologic therapy in the absence of evidence-based guidelines.

The efficacy of glucocorticoids in COVID-19 is unclear. This study was designed to determine whether systemic glucocorticoid treatment in COVID-19 patients is associated with reduced mortality or mechanical ventilation. This observational study included 1,806 hospitalized COVID-19 patients; 140 were treated with glucocorticoids within 48 hours of admission. Early use of glucocorticoids was not associated with mortality or mechanical ventilation. However, glucocorticoid treatment of patients with initial C-reactive protein (CRP) ≥20 mg/dL was associated with significantly reduced risk of mortality or mechanical ventilation (odds ratio, 0.23; 95% CI, 0.08- 0.70), while glucocorticoid treatment of patients with CRP

The first Covid-19 patient was admitted to Montefiore Medical Center (MMC) on March 10, 2020. Soon thereafter there was a rapid and exponential surge of Covid-19 admissions to MMC that could have resulted in catastrophic consequences if MMC had been overwhelmed, as happened in Europe. To adjust to this crisis our institution, under the inspiring leadership of Dr. Philip Ozuah, President and CEO of Montefiore Medicine, adopted an “all hands on deck” approach, mobilizing our entire workforce to expand our units to accommodate the growing number of patients being admitted. Given that the internal medicine (IM) and ICU units are part of the department of medicine (DOM), the DOM was at the center of this mobilization. The DOM is the largest department at MMC and mobilizing it required careful planning, seamless teamwork, and strong leadership. To achieve that goal, we applied a framework that we designate the “3C framework,” denoting Coordination, Communication, and Collaboration. In this report we describe the many initiatives the Montefiore Einstein DOM implemented during the Covid-19 pandemic using the 3C framework. These included establishing the Medicine Covid-19 Taskforce to lead our efforts, starting a daily newsletter for up-to-date communications, rapidly expanding the ICU and IM units, converting most specialty inpatient consults to eConsults, coordinating research studies, and more. The goal of this report is to serve as a guide on how the 3C framework helped us organize, mobilize, and energize the department of medicine effectively and efficiently during this unprecedented crisis.

A 47-year-old woman presented with sicca symptoms, polyarthralgias, polymyalgias and dysphagia. She was found to have positive antinuclear, anti-SSA-Ro and anti-SSB-La antibodies. Slit lamp exam confirmed the presence of keratoconjunctivitis sicca, and the patient was diagnosed with Sjögren’s syndrome. Three years later, she was referred for evaluation of gait instability associated with recent falls. On physical examination, the patient was found to have bilateral ptosis, percussion myotonia, distal upper and lower extremity weakness, and a steppage gait. Electromyography demonstrated electrical myotonia. Genetic testing revealed expanded CTG repeats (733 and 533) in the myotonic dystrophy type 1 (DM1) protein kinase gene, confirming the diagnosis of DM1. Dysphagia, pain and eye discomfort may occur in both Sjögren’s syndrome and DM1, and in this case, may have delayed the diagnosis of muscular dystrophy.

OBJECTIVES/SPECIFIC AIMS: The goal of this study was to evaluate the effect of a junior faculty mentoring program on change in confidence in key academic skills. METHODS/STUDY POPULATION: The Department of Medicine at the Albert Einstein College of Medicine/Montefiore Medical Center enrolled 33 mentees over three years (2015-2018) in a mentoring program that consisted of monthly interactive seminars focused on topics related to building academic careers, works-in-progress, and pairing of each mentee with a mentor. Mentees were asked about their confidence in key academic skills prior to and after completing the program. Confidence levels were assessed on a seven point scale, ranging from 1 (weak) to 7 (strong). Mean confidence levels were compared between pre and post surveys using independent samples t-test. Matching was not accounted for because not all individuals who completed the pre survey also completed the post survey and vice-versa. Of those mentees who completed both pre and post surveys, confidence scores were analyzed using Wilcoxon matched pairs signed rank test, with similar results to those reported here. Each mentoring session was evaluated by those in attendance at the end of each particular session with possible scores of 1 (unsatisfactory) to 5 (excellent). RESULTS/ANTICIPATED RESULTS: On average the mentees had a fair level of confidence in all nine areas assessed at baseline, with the exception of how to get funding (2.4 ± 1.7). Confidence increased in all areas assessed, and except for how to write a paper (p=.05) all represented a significant increase in confidence (Table 1). Evaluations of each of the mentoring sessions were high, with mean values ranging from 4.3 to 4.9 on the five point scale. DISCUSSION/SIGNIFICANCE OF IMPACT: This mentoring program significantly improved mentees’ confidence in identifying their own professional values and goals, as well as knowing how to turn education into scholarship, work with a mentor, integrate work and life, and give a presentation.

Premedical students commonly shadow physicians to gain an understanding of what careers in medicine entail. The authors reviewed the literature to explore (1) whether shadowing achieves this goal consistently and effectively, (2) the ethical issues involved, and (3) other reasons that individuals shadow physicians.The authors searched the MEDLINE database via Ovid for English-language articles published from 1948 to March 2011. Eligible articles described physician shadowing programs and/or assessed the value of physician shadowing independently or in comparison with other educational methods.Of 770 articles identified, 13 articles about physician shadowing programs met inclusion criteria. Two of the 13 programs involved shadowing only, whereas 11 included other educational initiatives. Participants varied; shadowers included students (high school, college, medical school), recent medical school graduates, or international medical graduates. Few studies addressed shadowing by premedical students. Most studies involved programs outside the United States. Shadowing program objectives and characteristics differed. Data reported from focus groups, interviews, and surveys suggest that shadowing experiences generally increased participants' interest in medicine (or a specialty) or improved participants' confidence in transitioning to a new position. Some articles raised ethical and practical concerns related to shadowing.The few shadowing programs described in the literature were heterogeneous and often involved other activities. Further research is warranted; objective outcomes measures would be useful. The authors propose developing guidelines and introducing a code of conduct for premedical students, to enhance the consistency of shadowing experiences and address ethical and practical considerations.

Pharmaceutical companies are guilty of moral misconduct. They stretch the definitions of illnesses, such as bipolar disorder, in order to expand markets. (1) They sponsor seeding studies, such as Merck's ADVANTAGE trial (Assessment of Differences between Vioxx and Naproxen to Ascertain Gastrointestinal Tolerability and Effectiveness), in order to facilitate the rapid uptake of a new drug at the time of its launch. (2) They promote unapproved uses of drugs, such as Lilly's "Viva Zyprexa" campaign, in which sales representatives recommended the drug for dementia. (3) These activities all aim to maximize sales. Yet drug companies have translated scientific discoveries into products that have improved and extended the lives of millions of people. For example, statins prolong survival in patients with coronary artery disease, (4) tumor necrosis factor inhibitors retard joint destruction in patients with rheumatoid arthritis, (5) and imatinib induces remission in most patients with chronic myeloid leukemia. (6) Sometimes alone and sometimes in collaboration with investigators from academia or government, the pharmaceutical industry has helped people live longer, better lives. Drug companies are also a source of crucial research funding. The U.S. pharmaceutical industry invested $47.9 billion in research and development in 2007. (7) If the current level of productivity and investment from the private sector is to continue without repeating the pitfalls of the past, we must collaborate with industry to find better ways of ensuring ethical drug development. Multiple changes will be necessary to achieve this end. External reforms so far have come from the government, (8) academia, (9) and journal editors. (10) Internal ethics initiatives have also been introduced at several companies. (11) For example, Roche established an external Science and Ethics Advisory Group. (12) Merck and Abbott have established ethics offices. (13) GlaxoSmithKline, Lilly, Merck, and Abbott maintain confidential "helplines" that employees may call to report potential violations. (14) The industry deserves credit for taking these steps. Whether they actually have a positive impact or serve simply as window-dressing intended to disarm critics remains to be seen. What else can be done to bridge the gap between the industry's key role in producing important products and the parade of unethical actions that plague it? As a physician and a former vice-president of Pfizer, I believe that a previously unrecognized way of addressing the problem may already exist inside the pharmaceutical industry itself, in the form of the physicians who work there. In order for industry physicians to ensure ethical behavior, it is necessary that they: 1) make decisions about ethical issues; 2) acknowledge they have a moral duty to ensure that their company behaves ethically; 3) possess the knowledge and skills required to perform their jobs; 4) have the responsibility and the incentive to conduct clinical research ethically, rather than just to increase revenue; and 5) work in a culture that recognizes and supports their expertise and their role. Roles and Obligations of Physicians in Industry Approximately eighty-six thousand medical and scientific professionals work in drug companies in the United States. (15) Pharmaceutical physicians are deployed throughout the industry in many positions--as bench researchers, focusing on the discovery of new drugs; as clinical researchers, designing, implementing, and overseeing phase I--IV trials; and as safety experts, focusing on "pharmacovigilance," which refers to monitoring the side effects of a drug. Others compile medical information, review promotional materials, create speakers bureaus, and review independent medical grants. Many work with marketers and other colleagues to create product development plans, launch new products, and implement strategies to support approved compounds. Given the diversity of jobs carried out by physicians in industry, it is not surprising that they participate in making many ethically laden decisions, ranging from the selection of disease targets to the proper conduct of trials in the third world to the monitoring and management of potential safety issues. …

Background Social media use by physicians offers potential benefits but may also be associated with professionalism problems. The objectives of this study were: 1) to examine and compare characteristics of social media use by medical students and faculty; 2) to explore the scope of self- and peer-posting of unprofessional online content; and 3) to determine what actions were taken when unprofessional content was viewed. Methods An anonymous, web-based survey was sent to medical students and faculty in October, 2013 at the Albert Einstein College of Medicine in Bronx, New York. Results Three-quarters of medical students reported using social media “very frequently” (several times a day), whereas less than one-third of faculty did so (p

The Internet revolution continues to affect all facets of society, and health care is no exception. Eighty-one percent of adults in the United States use the Internet, and 59% have searched online ...

Objective Despite the frequency of ethical issues arising in patient care, ethical discourse in the rheumatology literature is negligible. To better understand the scope of ethical problems occurring in our specialty, the American College of Rheumatology (ACR) Committee on Ethics and Conflict of Interest surveyed ACR members. Specific objectives of the survey were 1) to learn the perceived frequency of ethical issues in rheumatology, 2) to identify activities that pose ethical problems in rheumatologic practice, 3) to determine the extent of education on, and self-perceived knowledge about, ethics among ACR members, and 4) to determine member interest in, and suggest content for, future ACR-sponsored educational activities related to bioethics. Methods The survey included 12 non–open-ended questions addressing 5 core areas: 1) ethical dilemmas in daily practice, 2) ethical concerns in basic and clinical research, 3) influence of industry, 4) ethics of regulatory policies, potential conflicts, and disclosure, and 5) personal education on and interest in ethics. Two open-ended questions were also included, asking respondents to list the ethical issues most relevant to rheumatology and to provide any comments. Data analysis was descriptive. Results Seven hundred seventy-one responses were received. Respondents believed that ethical issues arise most frequently in practice and in clinical research. The most common ethical issues cited were the high cost of treatment for patients (51% of respondents) and for society (48%), and the practice of defensive medicine (45%). Conclusion The survey results suggest that ethical problems in rheumatology are of concern to the ACR membership. Further, there is a perceived need for educational programs targeted at helping members address such professional challenges.

The pharmaceutical industry's influence on the process of defining illness can be positive, as when drug companies increase public awareness of disease and develop effective therapies, or negative, if it pushes the boundaries of illness too far in pursuit of profit.

SHADOWING PHYSICIANS HAS BECOME AN ACCEPTED WAY for college students to learn what it is like to be a physician. Students follow practicing physicians in their daily activities that almost always include patient care; indeed patient interactions seem to be the high point of the experience. But there are ethical concerns about physician shadowing by college students. Shadowing is not a new idea in medical education. Historically, learning through observation has been a central component of training physicians and remains an important mechanism for medical students to learn history taking and physical examination skills, as well as to become familiar with various aspects of a physician’s life. Currently, firstand second-year medical students are routinely assigned to shadow physicians. Medical students are also introduced to various specialties through shadowing experiences. However, shadowing of physicians by college students is a relatively new practice, and it is difficult to measure the frequency with which it occurs. Students do not necessarily list physician shadowing per se as an extracurricular activity on their medical school applications, but may describe the experience in other terms, such as volunteering, acting as a medical assistant, or working in a physician’s office. One survey of 317 students who requested to be on the premedical advisor’s e-mail list at a small liberal arts college revealed that of the 101 respondents, 80.2% reported some experience with physician shadowing. According to one premedical society Web site, “Hospital shadowing is a must for aspiring MDs—not just because med school admissions committees won’t take an applicant seriously if he or she has never been inside a hospital before, but because hospital experience will help you decide whether you even want to be a doctor, and provide you much-needed exposure to hospital life, physicians, and patients.” Some undergraduate premedical programs actively sponsor physician shadowing programs so students can “see what it means to be a practicing physician.” Participation in at least 1 shadowing experience is often recommended. Other schools use their career networks to enable students “to experience some period of time in the shoes of health care professionals.” Shadowing is also touted as a way to enhance medical school applications because it shows that students have “taken the time to investigate your career choice and to learn about professionals in your career field.” Yet physicians have multiple ethical obligations to their patients that might be violated by allowing college students to shadow their work. First, the relationship between a professional and a client is considered fiduciary, meaning that it is based on trust, and shadowing may be a breach of the physician’s fiduciary obligation to the patient. Physicians, as fiduciaries, must always act in their patients’ best interests, and subordinate their own selfinterests and the interests of others. How is a patient’s welfare served by having a college student present during an appointment with his or her physician? If physician shadowing by a college student may not be in a patient’s best interest, why is shadowing by medical students acceptable? Shadowing by medical students may ultimately benefit society by providing a valuable educational experience that produces more humane, competent physicians. In addition, college students differ from medical students in several fundamental ways: medical students have committed themselves to the study and practice of medicine, whereas college students have not; medical students have been evaluated and admitted into training for the medical profession, whereas college students have not; the primary purpose of shadowing by medical students is to learn medicine, whereas the purposes of shadowing by college students are to help them choose a career and gain admission to medical school; and medical students, from day 1 of medical school, are expected to behave in a professional manner. Many medical schools hold rituals to acknowledge admission into the profession for entering students; some involve the recitation of oaths of professionalism. In addition to their fiduciary obligations, physicians have other duties to their patients that are breached by college student shadowing, including maintaining privacy

PURPOSE This review was undertaken (1) to determine the antitumor activity of agents studied in phase II trials in small-cell lung cancer (SCLC) patients, (2) to evaluate the adequacy of published trials, (3) to determine if previously treated patients are suitable for phase II trials in SCLC, and (4) to develop an improved design for phase II trials. DESIGN English-language, single-agent efficacy trials in SCLC, published from 1970 to 1990, were reviewed. Study design and reporting of results were assessed for clinical and statistical methodology. Response rates observed in previously treated patients were compared with those observed in previously untreated patients. RESULTS One hundred forty-one articles evaluating 57 agents in 3,042 patients were reviewed. Eleven drugs were active (defined as a response rate greater than or equal to 20% in a trial with greater than or equal to 14 assessable patients), and 12 were inactive. Due to methodologic problems with the clinical trials, the usefulness of the remaining 34 drugs (60%) remains uncertain. Deficiencies identified in trials include inappropriate sample sizes, poorly defined response criteria, and failure to report important prognostic factors. When studied in adequate trials, all agents known to be active in SCLC had an observed response rate greater than or equal to 10% in previously treated patients. CONCLUSIONS Over the past 2 decades, phase II trials in SCLC have failed in their primary task of effectively identifying agents that warrant further clinical study and rejecting inactive agents. If only previously treated patients had been entered into these trials, no useful agent would have been missed provided that a lower observed response rate had been used as evidence of antitumor activity. We propose a two-stage sequential study design, entering previously treated patients, for future phase II trials in SCLC.

Current definitions of conflict of interest in medicine are unwieldy, impractical, and difficult to apply. Although well intentioned, Brody's (2011) approach to clarifying conflict of interest as i...

Neutrophils acquire lysosomal granules and assembly systems for producing soluble mediators of inflammation during the process of maturation in the bone marrow. Subsequently, they emigrate from the circulation when they become attracted to joint spaces of rheumatoid arthritis patients by chemoattractants such as the complement split product, C5a, and leukotriene B4. Exposure to immune complexes, rheumatoid factor, and cytokines in the synovial fluid results in neutrophil activation with release of granule contents, toxic oxygen metabolites, and proinflammatory products of the arachidonic acid cascade. This process is analogous to a local Arthus reaction in which activation of the complement system is a central event. Some of the inflammatory materials released by this reaction contribute to the cartilage destruction seen in rheumatoid arthritis. Because others are chemoattractants themselves, they perpetuate intraarticular inflammation and permit the predominance of acute inflammatory cells in lesions maintained by chronic inflammation.