Art of Innovation: 3rd Annual Interventional Endoscopy Course 6/6

FREE WEBINAR Saturday June 6th

This educational program is hosted by the West Coast Chapter
of Women in Interventional Endoscopy and supported by the UCSD
Divisions of Gastroenterology.

This Course aims to promote the knowledge of recent and cutting- edge approaches in interventional Gastroenterology, in both current and emerging practice; addressing not only technological and procedural
advances but also factors affecting endoscopists’ wellbeing

Registration LINK

2019-2020 Six Word Stories

During the 2019-2020 academic year, our family of residents responded to three 6-word story prompts.

My pandemic silver lining is…

  • Zooming with friends, zoomies with doggies
  • gratitude for snail mail and amazonprime
  • Residents who inspire me every day!
  • A crisis without precedent or president
  • my dog loves me even more
  • relearning how to read leisure books.
  • wearing jammies and blankies to work.
  • online church any day, any time.
  • memes, online dance workouts, virtual concerts.
  • Innovative collaborative scientific medical staff worldwide
  • less plans, free time, slow down
  • Time to reconnect with support system
  • more snuggles with the best pup
  • Almost a PGY2; no more prerounding
  • no cars no traffic smooth drive
  • parents finally learned how to facetime 
  • the tiger king is outrageous and addicting

New Year, New Me- This year I am looking forward to…

  • finally getting around to PDSAs…maybe
  • Making new memories with old friends 
  • counting to six without making any errors
  • First job, long vacation, celebrating friends!
  • Finally achieving better work life fit
  • Vegas bod inspired by Jon Chung.
  • Being done with intern year yay
  • Starting fellowship, new city, mksap first!
  • Super seniors finally graduating from residency
  • The birth of my first baby!
  • Trying a new taco every month
  • Publishing my first author research paper!
  • Becoming an ultrasound guru, like Gary
  • Finally mastering the art of mealprep
  • Watching my baby learn to walk

Today I am grateful for….

  • Light rain, comfy sweaters, Jassal hugs.
  • The chance to serve through medicine.
  • My Family, My Patients, My Residents.
  • The last parking spot in Gilman
  • warm drinks, lights, things merry/bright
  • Not being a patient in hospital
  • F Words: Family, Friends, Food, Festivities
  • Compassionate co-workers who keep me sane.
  • EDIS is all green. I sleep
  • Rain in the desert, no fires
  • My amazing va interns and attending
  • No wards, no call, no problem 
  • A good night’s sleep without interruption
  • Happy hour after Friday School, yeah!
  • Turkey Turkey Gobble Gobble Yummy Tummy


HEROES- Humpday Hopkins (PEAC) Modules Highlights

Below are some highlights from today’s session!

Echinacea: possible use in prevention/treatment of respiratory tract infections. A number of clinical trials have demonstrated a positive effect on prevention and treatment of upper respiratory tract infections. Yet, definitive conclusions regarding efficacy have been difficult to make, owing to study limitations. There exists great variation in species of plant studied, parts of the plant used (root, leaf, flower, seed), and extraction methods further complicating interpretation of trials. Echinacea is thought to be quite safe for short-term use. No serious side effects have been reported, although hypersensitivity reactions can occur. Because of its ability to stimulate the immune system, echinacea is not recommended for patients with autoimmune disease or human immunodeficiency virus infection for fear of worsening disease.

Emergency contraception
– Levonorgestrel (Plan B)
-Most effective <24 hr, up to 5 days
– Ulipristal (Ella)
– Up to 5 days
-Superior to levonorgestrel, especially >72 hr
-Can’t be used with recent hormonal contraception use
– Urgent insertion of copper IUD (Paraguard)
-Up to 7 days

HEROES- Humpday Hopkins (PEAC) Modules Highlights

RESIDENTS ON THE HEROES OUTPATIENT BLOCK SHARED PEARLS FROM THEIR HOPKINS/PEAC MODULE STUDY SESSION.

A RANDOM SAMPLE OF HIGH YIELD POINTS FROM THIS WEEK AND LAST WEEK BELOW!

Key figures from the October 2019 ATS/IDSA guidelines for CAP:

Vertigo:

  1. The importance of open-ended history questions:  If patients volunteer a description of spinning or movement, the positive predictive value of this finding for diagnosing vertigo is 95%.  If one asks a patient if they feel spinning directly, the positive predictive value for diagnosing vertigo drops to 75%. 
  2. The indications for neuroimaging:
    – Symptoms of central vertigo (e.g., falls to either side while walking; no change throughout day
    -Any focal neurologic signs on physical exam
    -Risk factors for stroke (particularly hypertension) when the history and physical exam are not classic for a peripheral source of vertigo
    – New or severe headache accompanying vertigo
    MRI is preferable to CT scan because the posterior fossa needs to be adequately visualized to eliminate the most worrisome etiologies that cause central vertigo, and MRI is superior at visualizing the posterior fossa
  3. Drugs can cause central vertigo. The most common culprits are anticonvulsants, antidepressants, HCTZ, alpha-blockers, beta-blockers, calcium-channel blockers, NSAIDs, benzodiazepines, and muscle relaxants. Drugs can cause both persistent or acute intermittent forms of vertigo.

Dementia

  1. For people who are at risk of dementia such as those with subclinical Alzheimers, it is unclear if control of vascular risk factors  such as HTN and cholesterol affects the incidence of dementia. In 4 studies, only 1 study showed clear benefit and 1 other study showed less impressive benefit.
  2. To diagnose NPH, need significant gait improvement after a single large volume LP (30cc drained) or more prolonged indwelling CSF catheter monitoring and drainage up to 3 days. Usually treatment is placement of a diversion catheter, but this typically only helps gait, not cognition.
  3. Treatment of AD- cholinesterase inhibitors in minor stage and add NMDA receptor modifiers (memantine) in moderate stage.

Anemia

  1. Multiple myeloma can cause a hypoproliferative normocytic anemia.
  2. Spherocytes on peripheral smear in patient with anemia should make you think of hereditary spherocytosis or immune-mediated hemolysis. To distinguish between these, a direct antibody test can be ordered – it is positive in immune-mediated hemolysis and negative in hereditary spherocytosis. 
  3. Patients with beta thalessemia minor have increased Hbg A2 and Hgb F levels compared to normal patients on hemoglobin electrophoresis.
  4. Thymoma should be excluded in all patients presenting with idiopathic pure red cell aplasia, since about 10% of PRCA cases have been associated with this disorder.

Back Pain

  1. Red flag signs of back pain – lasting more than 4-6 weeks, unresponsive to therapy, worse at night, worse when lying down, unexplained weight loss
  2. Spinal stenosis is relieved by sitting or leaning forward and made worse by lying back. Classic symptom of spinal stenosis is pseudo claudication (pain in calves).
  3. Causes of anterior/inguinal hip pain include iliopsoas bursitis, inguinal hernia, vascular insufficiency, and renal colic
  4. NEJM study of asymptomatic patients with no back pain demonstrated that 52% of patients have at least one bulging desk and 27% had protruding discs.
  5. 90% of cases will resolve in 4-6 weeks so based on these two stats we really shouldn’t be imaging until 6 weeks out
  6. Interestingly. They also discussed how physical therapy was not shown to be better than handed out pamphlets in reduction of pain. It was really only helpful if there were asymmetries noted. Like gait, posture, balance etc. I find that commonly we are referring patients to physical therapy when we don’t have an answer for their back pain but unfortunately it doesn’t seem like the data is really there to support that being a good use of the patient’s time

Podcast Highlight: The DEI Shift

By our own fantastic residents Maggie Kozman, DJ Gaines, and Pooja Jaeel- an enlightening (non-COVID) podcast! This podcast focuses on shifting the way we think and talk about diversity, equity, and inclusion in the medical field.

The title, The DEI Shift, uses a common acronym DEI (standing for diversity, equity, and inclusion) as a play on the idea of a “day shift”, the time in the hospital when the daytime teams come in, bring fresh perspectives to the issues that arose overnight, and progress patient care forward. This podcast is aimed at: 1) bringing new perspectives and a more inclusive approach to the discussions of diversity issues in healthcare, 2) shifting us away from avoidance, fatigue, and negative connotations that have become attached to these topics, and 3) transitioning these discussions from mere classroom didactics into relevant, day-to-day, organic conversation and application.

Apple: https://podcasts.apple.com/…/po…/the-dei-shift/id1502320722…

Spotify: https://open.spotify.com/show/12PUDntuHNwxZlEYftUFGH

Google Podcasts: https://podcasts.google.com/…‎Society & Culture · 2020

PS- Have a great learning tool that you use outside of work hours? I am compiling a list of high yield resources people use to satisfy their thirst for knowledge (all things medical and non-medical!). Send Holly Greenwald (HGreenwald@health.ucsd.edu) your awesome podcasts, youtube channels, instagram, twitter, blogs, or books – anything that stimulates your minds. 

HEROES- Humpday Hopkins (PEAC) Modules Highlights

RESIDENTS ON THE HEROES OUTPATIENT BLOCK SHARED PEARLS FROM THEIR HOPKINS/PEAC MODULE STUDY SESSION. A RANDOM SAMPLE OF HIGH YIELD POINTS BELOW!

Statins:
When a certain intensity of statins is indicated (e.g., high-intensity) but not tolerated, the next lower intensity statin therapy should be tried (e.g., moderate-intensity). Those most likely to have statin intolerance include those with impaired renal or hepatic function, ALT > 3X the upper limit of normal, age >75, Asian ancestry, or on drugs that affect statin metabolism. When a high intensity statin is indicated but not tolerated and a moderate intensity statin is used, further LDL lowering may be achieved with ezetimibe or a bile acid sequestrant.

Nephrolithiasis:
For recurrent stone formers, collect 24 hour urine with measurement of volume, calcium, oxalate, citrate, uric acid, and sodium in addition to straining urine to identify type of stone. If hypercalciuria is present, thiazide diuretics can decrease calcium exertion

CKD Pearls
In addition to ACE-I/ARBs, calcium channel blockers (verapamil and diltiazem) can reduce proteinuria and progression of CKD
Initiation of EPO can be considered once Hgb falls <10 (although guidelines from NKF recommend target Hgb of 11-12)
Although it’s recommended to avoid NSAIDs in AKI or CKD, apparently aspirin (compared to other NSAIDS) may be the most sparing of renal damage

Cutaneous Anthrax: spores in skin (after skin trauma)
– not painful
          – A papule that ulcerates after a couple days
          – Vesicles around ulcer, edematous
          – 4 days later crusts over -> black eschar
         – Falls off after a couple weeks

Foods that are high in Phosphorus

HEROES- Humpday Hopkins (PEAC) Modules Highlights

Residents on the HEROES Outpatient block shared pearls from their Hopkins/PEAC Module study session. A Random Sample of High Yield Points Below!

Cardiotoxicity related to chemotherapy:
– 2 broad categories of cardiac toxicity from chemotx: type 1 (dose-depending, irreversible ultrastructural necrosis) and type II (not dose dependent, often reversible)
– Type 1 injury is associated with doxorubicin, daunorubicin, and epirubicin (anthracyclines). Usually presents with dilated cardiomyopathy
– Type 2 injury more common with targeted therapy, such as trastuzumab (results in HFrEF), multi targeted TKI (sunitinib HTN and HFrEF), and anti endothelial growth factor antibodies (bevacizumab associated with reversible HTN). 
– If receiving chemotx known to have cardiotox, EKG/TTE at baseline. Repeat TTE after total cumulative antrhacycle dose of 300 mg/m2, and q3 months if on trastuzumab.

GERD Learning Points: Indications for PPI
a. Uncomplicated GERD – short term use ideally (8 weeks)
b. GERD related complications (cough, dysphonia, esophageal stricture, etc) – for short term use or long term magement of symptomsa. Uncomplicated GERD – short term use ideally (8 weeks)
c.  Symptomatic GERD + Barretts – long term
d. Asymptomatic GERD + Barretts – “consider” long term PPI
e. High risk for ulcer related bleeding from NSAIDS – long term IF continuing to take NSAIDS
f.      **NOTE:  Patients with uncomplicated GERD, should attempt to discontinue or transition to H2 blocker after 8 weeks
g.     **NOTE:  Should periodically attempt to identify lowest effective dose for patients on long term PPI
h.     **NOTE:  Should consider esophageal pH monitoring for patients unable to wean PPI dose, to ensure true presence of GERD before committing to long term therapy

Gender Medicine: STI and screening for immunocompromised
1. Trichomonas infection is considered an STD and partners should be treated. Treatment is 2g of PO metronidazole or tinidazole one time.
2. The CDC recommends re-testing of trichomoniasis 3 months after treatment.
3. For cervical cancer screening in immunocompromised, it is recommend for HIV 2 pap smears in year of diagnosis, then annually, for immunosuppressed (such as transplant) to do annual pap, and there is no clear guideline for intermittently immunosuppressed (i.e., rheum patients).

Dizziness:
1. Don’t forget that those who have had gastric bypass are at risk for B12 deficiency which can cause peripheral neuropathy and dizziness
2. Medications can be the cause of peripheral vertigo ie. antidepressants
3. Eye closure increases the amplitude of nystagmus in peripheral vertigo and has no effect on the nystagmus of central vertigo (ask them to open their eyes)
4. HINTS: In 2009, Kattah et al. examined the diagnostic accuracy of combining 3 previously established bedside diagnostic tests:
1: Horizontal head impulse testing (Head Impulse)
2: Direction-changing nystagmus in eccentric gaze (Nystagmus)
3: Vertical skew (Test of Skew)
https://www.emra.org/emresident/article/hints-exam/

“These tests were combined and have since been used as a tool to identify posterior circulation stroke: the Head Impulse, Nystagmus, Test of Skew (HINTS).2 A single central finding on any of the 3 components “rules-in” a posterior circulation stroke, and further testing/treatment is indicated. The Kattah study demonstrated the HINTS exam was more sensitive than an MRI in the first 24 hours. “

UCSD Celebrates Women’s Herstory Month!

Faculty, staff, and students are invited to participate in UC San
Diego’s Women’s Herstory Month Celebration throughout March.  This
important observance and celebration of diversity will feature a
wide-range of programs focused on women’s contributions to American
society and the world. This year’s theme is “Untold Stories: The 19th
Amendment and Beyond.”
  
We invite you to join us for programs that explore the 100th anniversary
of the passage of the 19th Amendment, with a specific focus on the
“Untold Stories” of the movement that highlight the voting rights
activism of women of color. In addition, this year’s theme has been
expanded to include Untold Stories of women’s activism and achievements
more broadly.

Lifelong Learning: Infectious Disease

Want to impress your friends and colleagues with the latest and greatest in infectious disease? This week’s Lifelong Learning Thread is highlighting a few podcasts that will allow you to do just that! From up to date info on the Coronavirus to the latest literature in Infectious Disease. Check out these podcasts and stay up to date while on the go!

podcastkillyou

This Podcast Will Kill You: https://podcasts.apple.com/us/podcast/this-podcast-will-kill-you/id1299915173 and http://thispodcastwillkillyou.com/

Check out the timely Episode 43 M-m-m-my Coronaviruses! Grad students studying disease ecology, Erin and Erin found themselves disenchanted with the insular world of academia. They wanted a way to share their love of epidemics and weird medical mysteries with the world, not just colleagues. Plus, who doesn’t love an excuse to have a cocktail while chatting about pus and poop?

puscast

Infectious Disease Puscast:
https://podcasts.apple.com/us/podcast/id1153935086
Mark Crislip condenses up to date literature and packs it into 30 minute segments!

 

PS- Have a great learning tool that you use outside of work hours? I am compiling a list of high yield resources people use to satisfy their thirst for knowledge (all things medical and non-medical!). Send Holly Greenwald (HGreenwald@health.ucsd.edu) your awesome podcasts, youtube channels, instagram, twitter, blogs, or books – anything that stimulates your minds.