Grand Rounds: The Life Changing Magic of Tidying Up: How to Optimize Medicine with Dr Ariel Green

We had an amazing Grand Rounds this morning with Dr Ariel Green, accomplished journalist and Geriatrician from John Hopkins Medical Center. Today she revealed the harmful effects of polypharmacy in the elderly and strategies to deprescribing.

Concerning Statistics for Older Adults: 36% of all adults take greater than 5 medications, with 17% of them taking over 10 medications! 20-30% of older adults are taking medications on lists of drugs to avoid, with 11% of ER visits are due to adverse drug events!

Medication Stewardship: A more thoughtful approach to prescribing includes prescribing based on best available benefit >> harm, goal aligned NOT guideline driven prescribing, using other therapies, ongoing monitoring and re-evaluation, and involve patient and caregivers in decisions.

What is Deprescribing: The structured and supervised process of withdrawal, dose reduction or substitution of an inappropriate medication with the goal of improving health outcomes and quality of life!

Deprescribing is Effective and Safe: A comprehensive meta-analysis has shown that deprescribing may reduce mortality and is safe! Deprescribing anti-hypertensives showed no increase in mortality, deprescribing psychotropics and benzo were associated with reduction in falls and improved cognition and daily function, and deprescribing statins with life limiting illness was safe and associated with better quality of life!

How to Deprescribe: This is a personalized approach that is specific to each patient. The overall approach however should incorporate the patient’s and caregiver’s goals. First identifying “what matters most” to the patient (ie what makes you happy, or what do you want to focus on?). Then find which medication to deprescribe addressing which medications have greatest harm to least benefit, are easiest to discontinue, and patient is most willing to discontinue. Deprescribing requires patient/caregiver buy in and should be framed in a positive light. It will need constant monitoring and communication.

Grand Rounds 3/31 – Filling the Gap: The Impact of International Medical Graduates

On Wednesday, Chief resident Alex Cypro presented on the role that International Medical Graduates (IMGs) serve in the U.S. healthcare system. The presentation started with a look at the robust participation of IMGs in the 2021 Match, along with a brief overview of the history of immigrant doctors working in the U.S. We learned about the realities of obtaining visas, as well as the de facto tax that these work permits can place on immigrant labor. 

Exploring some of the work patterns of IMGs, we learned that the majority train and work in Internal Medicine or one of its subspecialties. In terms of patient care, IMGs fill a real and present need in the US medical system. As a whole, IMGs are more likely to practice in areas of the U.S. with greater poverty and less education compared to U.S. medical graduates. They also work in greater proportion in communities of color. At the same time, the quality of patient care delivered by IMGs is the same as their U.S.-trained colleagues.

The talk also highlighted some of the challenges faced by IMGs during training, as well as ways for residency programs to support them through structured clinical and educational experiences. Looking to the future, we are likely to continue to benefit from immigrant doctors coming to work and live in America. The talk highlighted some of the advantages that immigrant individuals and communities add to the nation’s fabric. Finally, we touched on the potential opportunities for “brain circulation” of IMGs between their home and adopted countries. 

Grand Rounds: Transitions of Care for Youth with Special Healthcare Needs

Transition of Care is the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child centered to adult oriented health care systems. 

It is comprised of three phases: transition preparation starting in young adolescence in the pediatric setting, transfer from the child centered to adult oriented facilities, and adult care integration. 

Lack of structured transitions of care for patients between the pediatric to adult care setting are associated with: 

-Decreased clinic attendance rates, long lapses in care or complete loss of necessary follow: This has been shown in the Congenital Heart Disease Population that 63% of patients with moderate or severe CHD have a lapse in care between leaving the pediatric health system before seeing and adult cardiologist. Mean lapses of care were >10 years and were associated with worse clinical outcomes and need for urgent intervention.  

-Medication Non-Adherence: Young adult liver transplant patients who transfer to adult care had more fluctuation in tacrolimus levels, indicating medication non-adherence, and higher ALT values, indicating worse disease control, than adolescent liver transplant patients who remained in pediatric care.  

-Worsening Disease Control and Mortality: Young adults with T1DM have a 2.46 high likelihood of having poor glycemic control compared to young adult patients who are still in pediatric care. Sickle Cell patients have an unimodal spike in mortality associated with the transition period.

Barriers for successful Healthcare Transition involve: 

-Patient barriers:  lack of knowledge of disease or need for follow up 

-Provider Barriers: lack of interested providers to care for this population and lack of comfort/training revolving around pediatric onset diseases 

-Logistical Barriers: Lack of communication between healthcare systems, lack of time for clinic visits, changes in insurance coverage, lack of reimbursement for providers to address transition elements 

Pilot Interventions, including Transition Clinics for young adults and Transition programs run by a coordinator, have shown to increase matriculation to adult clinics, decrease lag time between pediatric to adult care visits, improve disease awareness and autonomy, as well as improve clinical outcomes.  

Future Steps include: 

-Including evidence based self-assessment tools to assess gaps in patient’s disease specific knowledge that need to be addressed 

-Increasing medical education and CME revolving around Healthcare Transition and pediatric onset diseases 

-Bidirectional communications between adult and pediatric providers 

-Creation of a payment structure that incentivizes collaboration between adult and pediatric providers 

Please check out Got Transition/National Center for Healthcare Transition for the national guidelines on healthcare transition for adolescents and young adults!

Medicine Grand Rounds 11/18

This morning we were treated to a fascinating Grand Rounds regarding the impact of inflammation on bone health by Dr. Ellen M. Gravallese of Harvard University and Brigham And Women’s Hospital. The talk discussed the mechanisms underlying the effect of inflammatory arthritis on bone physiology.  Dr. Gravallese shared studies of mouse models to highlight the inflammatory pathways that affect osteoclast and osteoblast biology. She also discussed how the change in focus to early and aggressive treatment of inflammatory arthritis is necessary to prevent joints from destruction. The talk dived into the details of RANKL and sclerostin pathophysiology and the role of innate immune DNA sensors in bone homeostasis. 

Missed the recording? You can view the recording of the presentation here:

Grand Rounds 10/28–Dr. Kimberly Manning on Bias

Today were very lucky to have renowned Med-Peds clinician educator, Dr Kimberly Manning, present Grand Rounds entitled “I May Be Biased:What Can I Do About It?” Dr. Manning is a professor of medicine at Emory University. Dr. Manning’s academic achievements include numerous teaching awards in both the School of Medicine and the Internal Medicine residency program, and her work has been published in such prestigious journals as the Annals of Internal Medicine, Academic Medicine and the Journal of the American Medical Association (JAMA.) 

Dr. Manning encouraged us to evaluate and acknowledge our explicit and implicit biases. Both can affect our behavior and attitude towards others but explicit biases are thoughts we are aware of verse implicit bias are often not in our conscious thoughts. She encouraged us to reflect on our own environments and the things that we do and don’t strongly consider each day. These are the factors that may be impacting our biases. She introduced us to Project Implicit which a self assessment tool that can help us to identify our biases. (link: https://implicit.harvard.edu/implicit/). Dr. Manning shared the results of her assessment with us and encouraged us all to take this excellent assessment. She also encouraged us to be aware of things that may magnify our biases such as distraction, fatigue, huger, high pressure and to be aware of these factors in our daily lives. Things we can do to help check our biases include checking our emotional state, manage known triggers, slow down, tell a trusted college our biases, adjust our schedule to mitigate biases and call ourselves out.

Dr. Manning’s grand rounds was very informative, inspiring and educational. It encouraged us all to evaluate our biases, identify them and she gave us tools to help work towards actively working to mitigate these biases in our daily lives.

DOM Grand Rounds – Resident Research with Dr. Ibrahim Selevany and Dr. Susan Seav

This morning we had the pleasure of hearing from two of our outstanding residents, Ibrahim Selevany and Susan Seav, who presented their research findings as part of the research elective.

Dr. Selevany presented findings from his research, titled “Stroke Volume Reserve Index (SVRI) is an Independent Predictor of Survival and Need for Advanced Therapies in Systolic Heart Failure Patients.” Dr. Selevany informed us of some of the indices currently used via Cardiopulmonary Exercise Testing (CPET) in order to help stratify the need for advanced therapies in patients with systolic heart failure, including peak VO2, which attempts to estimate peak cardiac output, however is limited by a number of physiologic factors including gender, age, deconditioning, obesity and anemia. SVRI, however, is an innovative measure, definted as the ratio of the calculated stroke volume at anaerobic threshold compared to rest. He explained that SVRI accounts for inotropic reserve and is less dependent on other patient factors. Dr. Selevany presented data from a retrospective study of 104 patients and demonstrated that abnormal SVRI in these patients was highly predictive of mortality at 1 year, compared to those individuals with normal SVRI. Furthermore, he demonstrated that SVRI is better than traditional CPET measures (Peak VO2, AT VO2, PCWP) via Receiver Operating Curve (ROC-AUC). Thus, SVRI is a novel parameter that provides additional insight into exercise physiology and may have a role in the evaluation of heart failure patients.

Next, Dr. Susan Seav presented her research, titled “Hyperoxia Kills: Overuse of Oxygen Therapy on the Medicine Wards.” Dr. Seav sought to conduct an observational study to identify the use/misuse of oxygen therapy in the inpatient setting, and better understand the disparities between prescription and delivery of inpatient oxygen protocols. She presented data from a systematic review of 25 RCTs comparing liberal vs conservative oxygen therapy in acute illness (IOTA), which demonstrated that in-hospital mortality and 30-d mortality was significantly higher in those receiving liberal O2. She also reviewed the 2018 BMJ Rapid Recommendations for oxygen use based on O2 saturation, and then presented data from a retrospective study from a UCSD experience of 1501 patients, and showed that only 12% of those patients who met inclusion criteria were meeting the standard of BMJ guidelines. She then outlined the reasons for hyperoxia of these patients, which appeared to be due to a variety of reasons including patient comfort, frequent desaturations, lack of time, or oxygen given during procedures. She then outlined potential changes to the order-set protocol in order help counteract the degree of hyperoxia, as well as proposed further nursing and physician education regarding updated BMJ guidelines on oxygen use in acutely ill patients.

Thank you to Dr. Selevany and Dr. Seav for these interesting and important research projects. Congratulations to you both for being winners of the Annual Research Symposium. For their full abstracts and video-poster presentations, please see https://www.ucsdimrrs20.org.

Dr. Susan Seav will be a third-year resident for the 2020-2021 academic year, and is slated to be a future Chief Medical Resident thereafter. Dr. Selevany will completing his Residency in Internal Medicine and will be a Cardiology Fellow at Montefiore Medical Center starting this summer.

Grand Rounds 5/13/20: Grit and Grace of the Thai Boys Trapped in the Cave – Lessons for Our Own Resilience and Well-being

Grand rounds continued today with our guest speaker, Dr. Mark Berelowitz from Royal Free Hospital, London, who spoke to us about resilience and well-being, through the metaphor of the experience from the trapped Thai soccer team (Wild Boars) in 2018. We started with an overview of the rescue itself and a brief discussion of the attitudes of the boys from the soccer team about their experience within the cave.

Dr. Berelowitz then shifted to a discussion of resilience itself. He highlighted several concepts of resilience – inoculation theory, exercise theory, intrinsic toughness theory, family relationships theory, situational vs lifetime resilience – all of which he feels are insufficient to actually capture the meaning and mechanism of resilience. Instead, he again brought up the metaphor of the Thai soccer team to establish points necessary for resilience, including optimism and gratitude.

We then discussed the challenges of building resilience, both as individuals and as a society. He highlighted the need for us as a society – similar to the soccer team in the cave – to promote a value based culture. As stated by the political philosopher Michael Sandell, “[We] must find a way to lean against purely privatized notions of the good life, and instead cultivate civic virtue.” In addition, he discussed the importance of cultivating this notion both in a top-down (e.g. our hospital administrators) and bottom-up (e.g. our small clinical teams) approach. Dr. Berelowitz finally discussed the need to make such concepts habitual and highlighted the need for both societal and individual mindfulness in our approach to a value based culture.

Resilience related Grand Rounds 5/13

Please join us for a special Resilience related Grand Rounds this coming Wednesday, May 13, 2020 from 7:30 – 8:30 am!

Grit and Grace of the Thai Boys Trapped In the Cave – Lessons for Our Own Resilience and Wellbeing

Mark Berelowitz, MD

Consultant Child and Adolescent Psychiatrist

Please use this ZOOM Webinar link to view it remotely: https://uchealth.zoom.us/j/530170932 

The recommended article is attached here:

Medicine Grand Rounds: May 6, 2020

Our own Dr. Jeremy Pettus gave an outstanding Grand Rounds this morning entitled “Moving Beyond Insulin Therapy: Novel Approaches to Treating Type 1 Diabetes.” Dr. Pettus described many of the issues related to patients’ management of Type 1 Diabetes (T1DM). These included the requirement of frequent testing, the dangers of insulin overdose and the need for constant vigilance, which can be overwhelming even in the most adherent patients.

The early diagnosis of T1DM has improved over the past several years and with that, new avenues for treatments, such as immunotherpaies have arisen. Recently, the use of teplizumab was shown to delay the development of T1DM by two years and is on track to be approved by the FDA later this year.

Dr. Pettus went through his experience with managing his own T1DM and the impact of improved technology and treatments. The current continuous glucose monitors have had the biggest impact on day-to-day management, as they do not require calibration, so do not require finger sticks. Now, in combination with insulin pumps, the “artificial pancreas” can be a reality with a closed loop system.

Glucagon receptor antagonists have also been shown to have significant improvement on glucose management and prevention of DKA.

The future is bright and research is ongoing!

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Grand Rounds 4/8: “Reviewing the Playbook: A Pregame Review of the UC San Diego Health COVID-19 Surge Readiness Plan”

Today our chief of Pulmonary Critical Care division, Dr. Jess Mandel, gave us an update on our surge planning during an All-Physician Town Hall meeting for UC San Diego Health System.

UC San Diego Health System CEO, Patty Maysent, first gave an update on the resources available, testing capabilities, and provider resources. Dr. Vaishal Tolia, director of the EM department, then talked about the ED efforts for planning specifically how they improved the flow of care, incorporated telehealth, secured adequate equipment, and expanded staffing. Dr. Dan Bouland, head of Hospital Medicine, then went over the tiered plan of service expansion to plan for increased census numbers during the surge.

Dr. Jess Mandel, then went over the plan for the critical care unit. He emphasized the need to have a team based approach and went over the 9 phase plan in regards to space expansion and materials required during the surge. He also went over the number of ventilators available, and the staff expansion plan. Next, he gave us some statistics on how San Diego’s number compare to other cities and how we prepared we look in the context of the projected models.

They ended with answering all questions from the multidisciplinary audience.

Thank you all for this overview of our surge planning.