SAVE THE DATE! If you have the day off next Sunday, March 7, meet us at 9am at the trailhead at Lake Poway. 14644 Lake Poway Rd, Poway, CA 92064. $10 for parking (consider carpooling). 8 miles round trip; 2,000 feet of elevation gain, no shade, great views and photo op! Bring your mask and plenty of water! For more details, contact Christine Sonners (firstname.lastname@example.org).
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Today in Jacobs Oncology Conference, we learned about a 71 year-old woman who presented with nausea, headache and confusion who was found to be severely hyponatremic to 113. CT of her thorax showed a large, R middle lobe lesion with biopsy showing small-cell lung cancer. Her subsequent scans and staging workup also showed involvement of the liver, thoracic spine, abdominal lymph nodes, and bone marrow. She underwent induction chemoimmunotherapy with carboplatin, etoposide, and atezolizumab with significant initial reduction of her disease burden. She unfortunately developed cerebral mets about 4 months later as well as rapidly progressive thoracic disease and passed away. Special thanks to Dr. Luda Bazhenova, her thoracic oncologist, for teaching us about a few key points regarding small-cell lung cancer.
1.) Small-cell lung cancer (SCLC) cancer accounts for ~15-20% of newly diagnosed lung cancers in the U.S and is heavily associated with smoking. It is a rapidly-growing tumor that, if untreated, will lead to death within a matter of weeks to months.
2.) SCLC is staged into limited stage and extensive stage disease. About 20% of limited -stage patients are potentially curable with chemotherapy +/- radiation. Surgery has no role in treatment of SCLC.
3.) Chemotherapy (platinum + etoposide) with immunotherapy remains the mainstay of treatment for extensive-stage SCLC. Most patients (~80%) respond but will have recurrence of disease. Overall survival time for extensive stage disease is about 10-12 months.
4.) SCLC is associated with several paraneoplastic syndromes, including SIADH, Lambert-Eaton Myasthenic Syndrome, and Cushing syndrome caused by tumor ACTH production.
Check out our Cards-loving PGY2 Dr. Sonya John, getting to hop into the OR for a heart transplant in a patient with Amyloid while on her Heart Failure rotation! Dr. John is here holding the patient’s original amyloid-infiltrated heart!! So cool!!
Today we had our last Senior RACE Track morning report of the season! Dr. Hemali Batra-Sharma taught us about something we don’t see so often, but can have a big impact on patients: angioedema!! Former resident and current Allergy/Immunology Fellow Dr. Jessica Galant-Swafford joined us to highlight some of the big takeaways as they distinguished histamine-mediated and bradykinin-mediated angioedema. Check out Hemali’s worksheet and some of their key takeaways!!
- Histamine-Mediated Angioedema presents FAST (minutes), typically due to atopic triggers, with urticaria, itchiness, flushing, and is treated FIRST with Epinephrine (with steroids/antihistamines after that)
- Bradykinin-Mediated Angioedema presents SLOW (hours/days), most commonly caused by ACEi (but also Gliptins, Risperidone, other drugs) but can also just be hereditary. There is NOT urticaria/pruritis/flushing, and the treatment is primarily either C1 inhibitor replacement or the bradykinin inhibitor: Icatibant!
- YOUNG patients with Bradykinin-Mediated Angioedema likely have hereditary angioedema. There are 3 flavors:
- Type 1 Hereditary Angioedema: low C1 inhibitor levels
- Type 2 Hereditary Angioedema: low C1 inhibitor function
- Hereditary Angioedema with normal C1 inhibitor: other heterogenous causes involved in the pathway. Most commonly this is due to Factor XII mutations.
- OLDER patients with Bradykinin-Mediated Angioedema likely have acquired angioedema. This is typically due to antibodies to C1 inhibitor, and is associated with autoimmune or lymphoproliferative disorders.
- YOUNG patients with Bradykinin-Mediated Angioedema likely have hereditary angioedema. There are 3 flavors:
Inspiring and thought provoking session this evening with Dr. Kendi, author of How to Be an Antiracist!
Congratulations to all our pathway participants for our upcoming academic year!
- Stacy Han (R1)
- Jessica Hansen (R1)
- Allison Yip (R1)
- Nick Flores (R1)
- Thejas Kamath (R1)
- Jed Bell (M/P R1)
- Randall Blankers (R1)
- Elena Cutting (R1)
- David Hibbert (R1)
- Samara Sorus (M/P R1)
- Tally Buckstaff (R1)
- Soumya Kurnool (R1)
- Mehul Trivedi (R1)
- Edward Wang (R1)
- Kendel Flegenheimer (R2)
- Erin Roberts (R2)
- Revathy Sampath-Kumar (R2)
- Anna Armitage (R1)
- Amy Guzdar (R1)
- Allison Ibarra (R1)
- Annie Ondracek (M/P R1)
- Kevin Sung (R1)
- Allison Yip (R1)
- Neena Iyer (R2)
- Ambika Munaganuru (R3)
Today during Jacobs afternoon conference, one of our wonderful R3’s, Mary Brooks, presented an EBM addressing optimal anticoagulation therapy (P2Y12i vs. ASA + VKA or DOAC) for patients with atrial fibrillation and medical management for CAD. She found three studies that showed varying data, including that antiplatelet (single vs. dual) + DOAC had fewer bleeding events than VKA + DAPT; that P2Y12i + DOAC is associated with lower bleeding risk than standard triple therapy (VKA + P2Y12i + ASA) and was shown to be non-inferior; and that dual antithrombotic therapy had significantly lower risk of major bleeding without any difference in any ischemic events. Unfortunately, data is insufficient about the safety of a P2Y12i vs. ASA as the antiplatelet agent.
For the second part of conference, we examined an article from the Things We Do For No Reason (TWDFNR) series addressing oxygen therapy for patients without true hypoxia. The recommendations from the article are listed below:
- For most acutely ill patients, do not administer supplemental oxygen when SpO2 >92%. If supplemental oxygen is used, the SpO2 should not exceed 94%-96%.
- For patients with suspected MI, only start supplemental oxygen for SpO2 <90%.
- For patients at risk for hypercapnic respiratory failure (eg, COPD patients), target SpO2 of 88%-92%.
- Provide supplemental oxygen to normoxemic patients with carbon monoxide poisoning, decompression injury, gas embolism, cluster headache, sickle cell crisis, and pneumothorax.
- Review and revise institutional practices and policies that contribute to unnecessary use of supplemental oxygen.
Today during Medicine Grand Rounds we were very fortunate to hear from Dr. Caroline S. Blaum, a Geriatrics Professor at New York University and a senior research scientist for the National Center for Quality Assurance. Dr. Blaum gave us a very informative perspective on aging with multiple chronic conditions and the efforts to improve care for these patients.
She first defined patients with multiple chronic conditions (MCC) as those with >1 condition that adversely affects quality of life. This has significant implications for the delivering of care as well as the costs of care. These patients disproportionately account for most of the spending in on our patient population. The greatest risk factor in a majority of chronic diseases is aging, and it contributes to the significant morbidity and mortality of our patients.
We then spoke about the Pillars of Aging, which include several different mechanisms, including inflammation, proteostasis, adaptation to stress, and macomolecular damage. These mechanisms lead unfortunately to disease and loss of independence. The mechanisms lead to different rates of aging and significant heterogeneity in activity and independence in our geriatric population. When multiple chronic conditions occur in the same patient, they tend to synergize in their adverse effects, increasing other conditions that limit independence, including falls, frailty, and strokes.
Dr. Blaum then spoke about Alzheimer disease and how this interacts with multiple comorbidities. The probability of higher cognitive impairment increases with increased risk of heart failure, diabetes. Conversely, heart failure and diabetes have a significant positive association with cognitive impairment and cause significant morbidity and mortality. Dr. Blaum spoke about the significant QI initiatives surrounding diabetes care in the cognitively impaired population, centered on interventions such as telephonic “phone panel” based-calls for diabetes education.
We then discussed multimorbidity and how that leads to poor-value care. Older adults with MCC get care that is fragmented, not evidence-based, expensive, and potentially not patient-centered as a result. Older adults are often excluded from clinical trials and when they are not, the trials have minimal information on outcomes that are relevant to this population. Additionally, guideline-based medications designed to treat one condition can exacerbate another comorbid condition with its side effects. Finally, the increase in intensity of treatment is sometimes not within the patient’s goals of care. All these interventions lead to increasing healthcare-based burden on patients, who spend a significant part of their day keeping rack of their activity, their medications, and their appointments, which again may not be within their goals of care.
To address all this, Dr. Blaum was part of a large, multidisciplinary working group that developed a working framework for care of patients with MCC. This is a three-part framework designed to identify health priorities, stop harmful or unhelpful treatments, start interventions that help health priorities, and to communicate with the patient to continue to reassess and adjust care to focus on the patient’s priorities. With these interventions, Dr. Blaum laid out a path where patient-centered and patient-prioritized care is not only possible, but feasible and achievable.
Special Kudos to our CVC team this past month: Stacy Han, April Butler, George Villatoro, Allison Ibarra, Armando Martinez, Ana Lucia Fuentes, Revathy Sampath-Kumar, and Priya Sharma!
From Harpreet Bhatia, the cardiology Chief Fellow: “I was recently working at CVC on the ICU rotation and just wanted to give a shout out to the resident team that was on. They were awesome – smart, hardworking (handling a particularly busy time on the service), and they worked really well as a team, helping each other out and supporting each other. Best team I’ve worked with.”
Congratulations CVC team and thank you all so much for your hard work!
Today we were lucky to have RACE Track Senior Dr. Alex Cours, and her expert Dr. EB Sladek talk us through a case of a patient presenting for “memory issues”. Alex walked us through a focused differential for altered mental status, specifically honing in on memory impairment. Her patient was concerned because some recent genetic testing had shown her that she was (+) for ApoE, had an MRI consistent with “cognitive impairment”, and had an aunt diagnosed with some type of dementia. Ultimately the patient was not showing any signs of memory issues, but rather her concerns and fears drove her to present for further evaluation after a misleading workup outside of our system. Check out below for some key takeaways from Alex’s talk and teaching!!
- ApoE testing is NOT recommended for workup of AMS, Memory Impairment, or Major Cognitive Disorder. Unless it is necessary for a research protocol, it is ultimately not particularly useful diagnostically, and only those homozygous for E4 have an increased susceptibility (not certainty) to develop dementia.
- Neuroimaging is useful for the following populations, but otherwise is not generally helpful for memory or cognitive assessments:
- Symptoms in those < 65
- Those with focal neurological defects
- Sudden or rapid progression of symptoms
- Specific concern for NPH
- History of fall or other head trauma
- Assessments that are helpful, particularly in screening for dementia in patients who are not acutely ill, are the MoCA (Montreal Cognitive Assessment) and the SLUMS examination (used primarily at the VA).
Great job Alex and Dr. Sladek!! Thanks for all the excellent teaching!!
The Harvard Medical School Fellowship in General Medicine and Primary Care is soliciting applications for the class entering in July 2022! From their website:
“The fellowship program is a collaboration of major clinical institutions of HMS (Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Cambridge Health Alliance, the Department of Population Medicine, Massachusetts General Hospital) and the Harvard T.H. Chan School of Public Health. The aim of the program is to prepare general internists for successful and rewarding careers as academic leaders. The research focus of the program includes priority topics identified in Healthy People 2020 such as reducing racial/ ethnic and socioeconomic disparities in care, improving access to care and the treatment of patients with common medical problems.”
Residents interested in this opportunity can learn more at https://www.hmsgenmedfellowship.org/ or contact Dr. Stacy Charat for more details!