Are you feeling CLINICLE?

Our very own Praneet Mylvarapu (UCSD IM class of 2022, incoming UCSD Cardiology fellow) has created a fun, clinical, semantic medical diagnosis guessing game (similar to Wordle!). Introducing Clinicle, which brings you daily clinical puzzles to figure out!

Clinicle Game

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1/26/23 VA NTC: HIT or miss?

Today at NTC, our fantastic resident and rising chief Dr. Ben Yang shared an incredible case of an older male presenting with asymptomatic acute thrombocytopenia. After we discussed an initial differential for acute thrombocytopenia, we discovered he was found to have a recent heparin exposure in the setting of recurrent embolic phenomena raising concern for HIT. We reviewed in depth the workup and initial management of HIT, including weighing options for anticoagulation such as argatroban, bivalirudin, fondaparinux, DOACs and warfarin. In the end, the patient tested negative for HIT but later developed TTP requiring PLEX. Thanks to our amazing hospitalists Dr. Kenmore and Dr. Jassal for sharing their clinical pearls on this complex case!

1/25/23 Grand Rounds: Dr. Pradipta Ghosh on cancer stem cells

Today at Department of Medicine Grand Rounds, Dr. Pradipta Ghosh gave an incredible talk on tracking and killing cancer stem cells. As Director of the Institute for Network Medicine, Dr. Ghosh described the unique transdisciplinary approach iNetMed takes to identifying and validating new therapeutic targets, highlighting seminal advances her lab has made in understanding the role of CDX2 in colorectal cancer stem cell biology as well as uncovering strategies for differentiation therapy in colon cancer. We’re so proud of Dr. Ghosh as a graduate of the UCSD internal medicine residency & GI fellowship and thank the Department of Medicine for hosting another spectacular Grand Rounds!

1/24/23 EM/IM Conference

At noon today, we had our second EM/IM Conference of the academic year! We were joined by Dr. Gillian Schmitz, Dr. Nikita Joshi, and Dr. Megan Heeney, who gave a comprehensive presentation on workplace violence in hospitals.

Thank you to our EM colleagues, Dr. Nicolas Kahl and Dr. Kristy Schwartz, for planning this great talk!

NTC 1/23/23 — Disseminated MAC and IRIS

At noon teaching conference today, Matthew Tan (one of our fantastic interns), Dr. Riggs, and Dr. Blumenthal, led us through the case of a middle-aged man with a history of poorly controlled HIV/AIDS with recent initiation of ART, disseminated cryptococcosis with pneumonia and meningitis, and disseminated MAC, who presented with acute-onset generalized weakness, RLQ abdominal pain, nausea, and vomiting, and was found to have a small bowel obstruction 2/2 an intra-abdominal mass, calcitriol-mediated hypercalcemia, and primary adrenal insufficiency. These issues were ultimately attributed to MAC-associated IRIS manifesting as mesenteric lymphadenitis, granulomatous disease-related hypercalcemia, and infectious adrenalitis. The patient was treated with corticosteroids, with subsequent resolution of SBO and normalization of electrolyte abnormalities.

We used the case to discuss immune reconstitution inflammatory syndrome (IRIS), which is inflammation from worsening of a pre-existing infection after initiation of antiretroviral therapy. IRIS is referred to as “paradoxical” when a known infection worsens after ART or as “unmasking” when a previously unknown infection reveals itself after ART. We then talked about infection due to Mycobacterium avium-intracellulare complex (MAC), which usually causes disseminated disease in patients with HIV not on ART (constitutional symptoms with MAC in blood) and localized disease with lymphadenitis in patients with MAC-associated IRIS.

VA NTC 1.23.23

Today we took a deep dive into infectious diarrheal illnesses. We discussed an older patient who presented with 10 days of diarrhea that had worsened after exposure to poulty. The patient was hemodynamically stable but met sepsis criteria with a significant bandemia. Dr. Kaplan helped us know when to consider antibiotic treatment in infectious diarrhea as well as learn more about which workup to order at the VA.

Ultimately the patient was diagnosed with Campylobacter jejuni and treated with 3 days of Azithromycin. He improved significantly and on discharge was counseled on warning signs of Guillain-Barré Syndrome which can occur after Campylobacter enteritis. Don’t forget to report it to the Public Health department!

HC NTC 1/19/23

Today, we discussed a case of progressive, subacute altered mentation in a middle-aged previously healthy patient. Patient presented to multiple emergency rooms 3 times prior to admission for headache and dizziness. He was admitted and workup revealed CSF with a lymphocytic predominance. He was diagnosed coccidioides meningitis and started on appropriate treatment. Thank you to expert discussant, Dr. Deiss, for aiding our discussion about meningitis and encephalitis.

X-Waiver Elimination for Prescribing Buprenorphine

On January 12, 2023, the DEA and SAMHSA eliminated the requirement of X-Waiver training for prescribing buprenorphine for opioid use disorder. All clinicians with a current DEA registration that includes Schedule III authority (ability to prescribe narcotics) can prescribe buprenorphine for OUD!