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.

Grand Rounds 4/1: Ventilator Management for the Non-Critical Care Physicians!

Today for Grand Rounds, Dr. Papamatheakis presented a very high yield discussion of mechanical ventilation, designed to assist non-critical care physicians to feel more comfortable with the ventilator and with treatment of patients who develop respiratory failure. Before starting the talk, however, he did stress that the likelihood of non-critical care physicians actually needing to management ventilators at UCSD during the COVID-19 pandemic is very low; UCSD is well-prepared with both critical care attending, ICU beds, and ventilators!

Dr. Papamatheakis introduced the history of mechanical ventilation (no good vent talk is complete without an iron lung shout-out!). This was followed by an overview by the main indications for intubation and mechanical ventilation: hypoxemic and hypercapnic respiratory failure. He used this to discuss the main adjustable ventilator settings and the modes of mechanical ventilation. He rounded out the talk with an overview of ARDS and some case-based scenarios/troubleshooting strategies aimed at some of the issues seen with patients infected by COVID-19.

  • SCCM also has excellent resources aimed at providing critical care (including mechanical ventilation) for the non-critical care physician. More details can be found here: https://covid19.sccm.org/nonicu.htm

DOM Grand Rounds – The Ethics of New Technology with Dr. Sonia Ramamoorthy

This morning, we had the pleasure of hearing from Dr. Sonia Ramamoorthy, a UCSD Colorectal Surgeon who utilizes innovative robotic surgical techniques,  who spoke today about the ethical issues involved in medical innovation. As a surgeon, Dr. Ramamoorthy expressed that while standard of care has a proven track record in many cases, surgical interventions in a diverse patient population inherently brings a bevy of sometimes unexpected intra-operative challenges that must be met with adaptive techniques and innovative thinking. This sentiment of adapting SOP to the real world is something that physicians in internal medicine encounter frequently as well, particularly given that no two patients are exactly alike.

Dr. Ramamoorthy expounded on innovation in the surgical world further, and recounted the a time in UCSD’s recent history, where an interest in natural orificial surgery was gaining popularity internationally. In the time where such surgical techniques were considered “fringe,” or “non-standard,” multiple ethical dilemmas were presented, particularly surrounding whether it was ethical for US physicians to perform such surgeries internationally in countries where the enthusiasm for such unproven techniques was greater. During this time, a surgical team from UCSD, under a temporary appointment with an international hospital, went to perform 25 of such surgeries. The same group then came back performed the first set of transgastric appendectomies in the United States, which then led to a watershed moment for UCSD in the press– an example of when the willingness to adopt innovative approaches can be beneficial.

However, the risk with such willingness to adopt new approaches is the occurrence of  acts that transgress major ethical boundaries, such as in the case of the He Jiankui, the Chinese scientist who performed genetic manipulation of human embryos. She went on to explain that in order to systematically consider the risks/benefits of adopting new/innovative approaches in medicine, one must have both personal as well as institutional checklists of questions to ask in order to maintain ethical steadfastness.

Dr. Ramamoorthy explained that the challenges of new technologies are that it must have purpose, identification of winners and losers, must be integrated well, and must have regulatory potential. Questions regarding whether new technologies and techniques should be adopted include an assessment of the population that benefits, who takes the risk, whether the practitioner would utilize the innovation on a loved one, patient preference/understanding. Dr. Ramamoorthy also highlighted a framework to assist in a systematic method of adopting innovative ideas and techniques with the IDEAL framework – idea, development, exploration, assessment, and long-term study.

Finally, she highlighted the need for didactic lessons in ethics in the next generation of medical staff/learners. While such teaching at the moment is not mandatory, the importance of instilling ethical awareness in an era of a “build-it-first” mentality will be of increasingly importance as medical innovation continues to accelerate. We thank Dr. Ramamoorthy for an insightful and thought provoking presentation!

Grand Rounds 2/26: Glucose Monitoring for the Internist!

Today our very own APD and endocrinologist extraordinaire Dr. Trish Santos presented an amazing talk on “Glucose Monitoring for the Internist: A Growth Mindset.”

We started with a discussion of the history of glucose monitoring since the 1950s into the current state of continuous glucose monitors (CGMs). This lead to a review of the use of hemoglobin A1c as a screening and monitoring tool for diabetes mellitus. Dr. Santos highlighted that the A1c is especially helpful from a population level and for predicting microvascular damage, but has some issues for individual patients. Current assays have a margin of error of 0.5%, and with data provided by CGM, it has been shown that the previous assumed fasting blood glucose (BG) levels may not actually reflect the true range of daily glucose variability in an individual. We reviewed some of this variability by looking at two patient examples and also discussed some of the reasons for variability in hemoglobin A1c.

We then started discussing the role of self-monitored blood glucose (SMBG) checks, which really only seems to have a role in patients on insulin therapy. Dr. Santos highlighted many of the challenges that patients face when using SMBG, which can be extensive! In addition to the challenges, we also discussed that the SMBG can give people false assurance about the true value of BG levels – it is not the gold standard for BG levels (plasma BG is the gold standard)!

Dr. Santos then completed her talk with a discussion of the CGM specifically. The CGM has 3 components: a subcutaneous glucose sensor, a transmitter, and a receiver (usually via a smart phone/device). Between devices, the mean absolute relative difference (MARD) is used, which assesses the accuracy between devices for BG monitoring. Dr. Santos then reviewed the most common devices available for our patients, with some important distinctions and caveats between devices (check out the summary table below). We discussed that the likely future of CGM will be an implantable sensing device that lasts for up to 90 days (newly available at UCSD)! Finally, we reviewed how CGMs can be used for data acquisition and for therapeutic intervention for type 2 diabetics. The use of CGM has been shown to improve both average BG levels and has lead to improved patient satisfaction as well! We are also slowly working on how to utilize the data provided by these devices, which is an ongoing, but exciting prospect!