Please join us on Tuesday, June 21st 2022 for an evening of outdoor food and fun as we welcome our new interns to the UCSD family! We will be meeting at Kate O. Sessions Memorial Park (5115 Soledad Road, San Diego, CA 92109) from 6pm-8pm. We will be serving tacos for dinner! Significant others, family and fur babies are welcome! It may get cool in the evening, so you may want to bring a jacket and consider bringing your own folding chairs or towels and blankets to sit on. Let the Chiefs know if you have any questions and we look forward to seeing you there!
Juneteenth is a holiday celebrating emancipation and the end of slavery that originated in Galveston, Texas in 1865. Juneteenth commemorates General Granger’s reading of General Order Number 3 on June 19th, 1865 which proclaimed freedom for all slaves. It is now a federally recognized holiday, and we will be observing Juneteenth on Monday, 6/20. Please see the above flyer for a community opportunity to celebrate!
Wrapping up the Hematology/Oncology block, our residents were treated to some great interactive sessions on breast cancer, colorectal cancer, and transfusion reactions.
Dr. Angelique Richardson, an amazing breast oncologist, taught us about breast cancer, which affects 1 in 8 women. Risk factors include age, genetics, low parity, estrogen exposure, dense breast tissue, radiation, obesity, and alcohol. Symptoms may include lumps in the breast, changes in the breast or skin overlying the breast (including peau d’orange), and discharge or bleeding from the nipple. For the general population, it is reasonable to start annual mammography at age 40, though guidelines differ. Treatment of breast cancer is determined by stage, grade, ER and HER2/neu status (most commonly ER+/HER2–), and sometimes molecular typing (e.g., Oncotype DX). We reviewed surgical treatment and common chemotherapy agents used to treat breast cancer—tamoxifen, aromatase inhibitors (e.g., anastrozole), anthracyclines (e.g., doxorubicin), anti-HER2 monoclonal antibodies (e.g., trastuzumab), CDK4/6 inhibitors (e.g., abemaciclib), and PARP inhibitors (e.g., olaparib)—including their indications and important toxicities to consider.
Switching gears, Dr. Greg Botta came to our Friday School to discuss the care of patients with colorectal cancer. Patients are often diagnosed on screening or after presenting with changes in bowel habits, pain or discomfort during bowel movements, bleeding, or anemia. Some patients may have a family history of colorectal cancer (e.g., familial adenomatous polyposis, Lynch syndrome). The stage, grade, location, microsatellite status, and molecular profile of the tumor (e.g., mismatch repair genes) inform management. Patients with nonmetastatic disease will generally undergo surgery; most patients with metastatic disease do not benefit from surgery. Observation is reasonable for stage I-II disease, curative chemotherapy is appropriate for stage II-III and now some stage IV disease, while palliative chemotherapy is an option for the remaining stage IV disease. Important chemotherapy agents to remember include 5-fluorouracil (5-FU), capecitabine, oxaliplatin, irinotecan, bevacizumab, and immune checkpoint inhibitors. Dr. Botta also briefly discussed how circulating tumor DNA (ctDNA) allowed us to management patients with colorectal cancer in a more nuanced manner.
During the last two hours, Dr. Elizabeth Allen, one of our blood bank faculty members, led our interns and residents through a whirlwind tour of transfusion reactions, including acute hemolytic transfusion reaction, acute febrile non-hemolytic transfusion reaction, transfusion-related acute lung injury (TRALI), urticarial and anaphylactic transfusion reactions, transfusion-associated circulatory overload (TACO), delayed hemolytic transfusion reaction, and transfusion-associated graft-versus-host disease (TA-GVHD). We then went through a number of practice cases that illustrated how to recognize, diagnose, and manage patients who experience each of these transfusion reactions.
Thank you all of our speakers for a very educational Friday School session!
We were very honored to have a special presentation today by Dr. Lucia Chambal from Maputo Central Hospital, discussing management of the COVID pandemic in Mozambique. We are so fortunate to be joined this week by Dr. Sam Patel, Dr. Lucia Chambal, and Dr. Ben Lauro Zavala from Mozambique this week!
This afternoon, our Jacobs residents were treated to a discussion of cancer therapy toxicities by our phenomenal lung and head & neck oncologist, Dr. Kate Gold. We reviewed the common types of cancer therapy: cytotoxic chemotherapy, targeted therapies, and immunotherapy. Cytotoxic chemotherapy attacks rapidly dividing cells and can cause side effects including hair loss, mucositis, nausea, vomiting, and myelosuppression. Targeted therapies comprise small molecular inhibitors and monoclonal antibodies that interfere with aberrant signaling pathways and often have more tolerable side effects; these may include diarrhea and pneumonitis. Immunotherapy takes advantage of patients’ intrinsic immune system and can lead to immune-related adverse effects, the most important of which include dermatitis, colitis, hepatitis, endocrinopathies (particularly hypothyroidism), and pneumonitis.
Dr. Gold suggested reviewing package inserts of these medications and communicating with the patient’s oncologist whenever a drug-related side effect is suspected. Drug-drug interactions are also common and can be investigated using physician aids such as Lexicomp. The National Comprehensive Cancer Network is another great resource and has guidelines on how various immune-related adverse events should be managed. Decisions on whether the implicated treatment should be continued will depend on the nature and severity of the adverse event and alternative cancer therapies available.
Thank you, Dr. Gold, for this very informative talk!
Our amazing resident Dr. Preethi Venkat presented a fascinating case of fulminant C. diff colitis coming to the ICU. We walked through the most recent IDSA 2021 guidelines for treatment of initial episode of C. diff colitis. Notably, oral fidaxomicin is preferred over oral vancomycin for both non-severe and severe cases, while oral vancomycin and IV metronidazole (plus or minus vancomycin per rectum) remains the mainstay for fulminant cases. Our expert discussant, infectious disease guru Dr. Sanjay Mehta, shared several clinical pearls, including the data behind the guidelines, role of fecal microbial transplant in fulminant disease and thinking about cost of therapy. Thanks to Dr. Venkat and Dr. Mehta for a great teaching conference!
This morning all-start resident and future chief Dr. Ben Yang shared a case of a elderly man with a history of diabetes who presented with acute right facial numbness and vision loss. On exam a swollen right face/eye with chemosis, cranial nerve II, III, IV and VI deficits, necrotic appearing palatal lesions. Further, on imaging he had orbital cellulitis involving the trigeminal nerve as well as cavernous sinus thrombosis. Our residents were quick to recognize this presentation was very worrisome for rhinocerebral mucormycosis. Our expert discussant Dr. Gabriel Wagner, ID specialist, shared valuable information regarding the aggressive nature of this disease, and recognizing the illness script and pursuing treatment early is crucial.
Thanks Dr. Wagner for your insights!
- Rhinocerebral mucormycosis is a medical emergency!
- Recognize potential complications of mucor including vision loss, cranial nerve deficits, destruction of sinuses/palate/orbit (*black eschar on nose/palate is a pathognomonic finding*) and cavernous sinus thrombosis
- Treatment includes EMERGENT surgical debridement as well as high dose liposomal amphotericin B.
Today for our DOM Grand Rounds, Dr. Edward Siew presented a fantastic and in-depth overview of acute kidney injury. Throughout his talk, Dr. Siew discussed how to reframe our approach to AKI, different barriers and challenges in the treatment of AKI, and challenged how we think about AKI. He finished his talk discussing next steps in the future of how we think of AKI and changes in diagnostic approach. Thank you so much to Dr. Siew for his insightful and comprehensive talk!
Dr. Deshpande presented a case of a pancreatitis from hypertriglyceridemia with Dr. Woods as our expert endocrinology discussant. Management was discussed with highlights below.
1. Conservative management with IV fluids, pain management, and bowel rest (NPO) are recommended.
2. Insulin therapy in non-diabetic patients is controversial and not routinely advised.
3. Plasmapheresis can be considered in severely ill patients on a case-by-case basis.
4. A strict no-fat diet should be initiated as diet is advanced.
5. Triglyceride-lowering therapy with fibrates and high-dose omega-3 should be initiated as pancreatitis resolves.
For our final noon conference of the Hematology/Oncology block, we were joined by skin cancer expert Dr. Greg Daniels. Melanomas are malignant tumors derived from melanocytes and may occur in response to UV light-induced DNA damage. These can be superficial spreading, lentigo maligna, acral lentiginous, nodular, and desmoplastic.
Immunotherapy with immune checkpoint inhibitors (e.g., pembrolizumab, nivolumab, combination ipilimumab/nivolumab) has significantly improved survival in patients with metastatic melanoma. Longer-term disease control, essentially a “cure,” is now a possibility for these patients. Other treatment options for metastatic disease include combination therapy targeting BRAF V600E (e.g., dabrafenib/trametinib).
Thank you, Dr. Daniels, for tackling this very tough topic!