Today during Jacobs Afternoon Conference, we continued our Hospital Medicine Pathway didactics with a case-based session on patient safety given by Dr. Komsoukaniants and Dr. Jenkins, two of our amazing hospital medicine attendings! We discussed several cases solicited from our residents and from our attendings. We focused on certain topics like overordering of imaging studies, the potential perils of ordering pharmacologic DVT prophylaxis in the hospital, delaying outpatient cancer and surgical care during an admission, handling delirium overnight, and potential adverse events from seemingly benign procedures such as feeding tube placement and urinary catheter placement. We ended the session with a few tips of advice for new hospital medicine attendings. Thanks to Dr. Komsoukaniants and Dr. Jenkins for leading the discussion!
This morning’s VA MTC touched upon a case of cannonball lesions on chest xray! We got to review some key points about hemoptysis, how to triage patients presenting with this complaint, and then rounded it out with a review of which conditions lead to this distinct CXR finding!
- Cannonball metastases are typically described as discrete, well-circumscribed nodules seen on CXR or CT, usually of relatively uniform size
- These lesions are most commonly from one of 2 metastatic malignancies:
- Renal Cell Carcinoma
- Something you can do when you see a CXR like this, is perform a testicular exam and consider lab tests associated with Choriocarcinoma (LDH, AFP, and beta-HCG)
- There are a few other malignancies that can cause this as well, but these are far less commonly associated:
- Endometrial Cancer
- Adrenal Cancer
- Prostate Cancer
- Synovial Sarcoma
Today during JMC afternoon conference we continued our Hospital Medicine Pathway didactics with a series of cases focused on oncologic emergencies. This session was mediated by Dr. Alex Truong and Dr. Jay Varughese, two of our fantastic hosptialists! We covered:
- Spinal cord compression due to spinal metastases: including the clinical presentation (weakness, saddle anesthesia), workup (MRI spinal imaging), and initial management steps (steroids, surgical consultation, and radiation treatment).
- Hypercalcemia of malignancy: including all the potential management options (cinacalcet, iHD, bisphosphonates, calcitonin, and their time courses for effect)
- SVC Syndrome: including how the chronicity and time course of presentation affect initial management (i.e. SVC stenting, chemotherapy, and radiation)
- Tumor lysis syndrome: including the management of TLS (Urate-lowering therapy, fluids, diuretics, and renal replacement therapy for anuria)
Our endocrine faculty have released a new Video Vault through their nonprofit diabetes support organization, Taking Control Of Your Diabetes (TCOYD)! The Video vault has a ton of free video lectures geared towards patients and addressing every diabetes topic you can imagine. Check out their website below to see some of their informative talks!
Today Dr. Heather Patton gave an excellent grand rounds on the topic of Integration of Palliative Care into Medicine Subspecialty Clinics: The Case for Cirrhosis. Dr. Patton is an Associate Clinical Professor of Medicine at UCSD in the division of Hepatology and she is the Director of Population Management and Hepatology at the VA San Diego Healthcare System.
Dr. Patton started with defining and reviewing barriers to palliative care. Palliative care can be introduced early in the course of an illness and can be give with active therapy. Palliative care is give to help alleviate suffering among patients facing life limiting illness. There has been a shift in the traditional algorithm towards trying to introduce palliative care earlier in the course of disease.
Dr. Patton also discussed the differences between primary care palliative care and speciality palliative care as described in the figure above. All physicians however should have the skills to assess palliative care concerns with their patients. Dr. Patton reviewed NCCN Distress thermometer and other functional assessments that can help us better evaluate palliative care needs in our patients.
Dr. Patton also discussed care giver burden and the important role that plays. She showed us some tools we can use to help measure and predict caregiver strain. Families of patients with cirrhosis also face significant burdens including loss of savings, loss of employment, sense of entrapment, deferred education.
She also highlighted the importance that communication plays in delivering palliative care to our patients. Prognosis is also important and should be evaluated in our patients and communicated. Associated with this she discussed the SPIKES model as a tool to help us deliver bad news to patients.
Dr. Patton reviewed health related quality of life and its impairment in patients with cirrhosis. It seems to be most impaired in those with HCV, PBC and NAFLD. It is associated with worse prognosis and increased hospitalization risk. She also reviewed where patients died among patients with cirrhosis. A large portion are still dying in the hospital and not at home or his a hospice setting. White patients are more likely to die in a hospice setting.
Dr. Patton discussed how to better improve advanced care planning in outpatients with cirrhosis including having a standardized note template and educational session and better identification of patients in need of AD. She also reviewed patient facing resources such as a website called prepare for your care.
Today Dr. Sheila Bhavsar (PGY3 and rising UCSD Geriatrics Fellow!!) shared a case she saw while working on our Owen’s consult service. This patient presented with fevers and new-onset focal weakness, and was found to have new ring-enhancing lesions on his CT scan. We also discovered that this patient had a new diagnosis of HIV, with a CD4 count of only 5!! We talked about our differential for CNS lesions, contrast enhancement, and brought in ID expert Dr. Darcy Wooten to help us focus on these things in the setting of the severely immunocompromised patient!! This patient ended up having Toxoplasma encephalitis!! Check out some of our key takeaways!!
- When it comes to CNS lesions, contrast enhancement means a space-occupying lesion causing mass effect and edema.
- Because steroids reduce swelling/edema, they can actually take away contrast-enhancement and give you a false-negative for this component of your imaging study!
- Toxoplasmosis makes it’s way to humans through cat feces (gross). People can get it from direct ingestion (didn’t wash your hands after cleaning the litterbox?), or from eating foods contaminated with cat feces (fresh fruits, vegetables, or even undercooked meats).
- Testing for this can be a little unsatisfying, usually without a slam dunk. Getting Toxo IgG, looking at the imaging findings, and considering your differential typically leads to empiric treatment for presumed Toxoplasma for 2 weeks (then reassessment) rather than jumping to brain biopsy straightaway.
Dear UCSD Family,
We want to take the opportunity, as we celebrate the birthday of Dr. Martin Luther King, Jr., to remember the importance of our mission of service to others, inclusiveness and mutual respect in our work, our community, and our lives. Dr. King said: “The arc of the moral universe is long, but it bends towards justice.” As physicians, we hold a privileged role, and a responsibility to help to bend this arc. This message is particularly important today, in the trying times our nation faces.
We are allowed into the lives of our patients in an incredibly intimate way, often at times when they are most vulnerable. They place their well-being in our hands. With this privilege comes an important responsibility: to treat all, regardless of their background, race, religion, gender, sexual orientation, legal status, or country of origin, with care, respect, and humility.
It is vital to remember that we also serve as role models for our students and the healthcare teams we lead. Our actions and the way in which we carry ourselves has a long reaching impact, shaping the way others will act. When we speak to our patients, students, teams, and one another, the words we choose matter; they set the tone for all of our interactions and enable us to effectively engage with one another and deliver the best care to our patients.
The events of the past year, the voices of the Black Lives Matter movement, and the horrific, hateful acts of domestic terrorism in our capitol earlier this month, remind us how much work there is still to be done. We must do this difficult but critical work. Civil Rights Leader John Lewis, wrote an essay shortly before his death on July 17, 2020. In it, he reminded us of our moral obligation to “stand up, speak up and speak out.” He said:
“Democracy is not a state. It is an act, and each generation must do its part to help build what we called the Beloved Community, a nation and world society at peace with itself. Ordinary people with extraordinary vision can redeem the soul of America….Now it is your turn to let freedom ring. When historians pick up their pens to write the story of the 21st century, let them say that it was your generation who laid down the heavy burdens of hate at last and that peace finally triumphed over violence, aggression and war. So I say to you, walk with the wind, brothers and sisters, and let the spirit of peace and the power of everlasting love be your guide.”
We welcome the opportunity to hear your thoughts about these important ideals and look forward to further discussions with you in the days, months, and years to come as we work towards our goal of becoming an anti-racist institution, advance equity and end disparities in care. Thank you for your service to our communities, each and every day. We take great comfort in our UCSD IM family and our shared vision of equity and peace for our families, our patients, our community and our nation.
I also wanted to take this opportunity, on this important day, to share with you a powerful piece written by members of our own UCSD IM family, Drs. Ian Simpson-Shelton and DJ Gaines. I have included it below.
simerjot (on behalf of the UCSD Internal Medicine Residency Program Leadership)
A Black Man’s Self-Worth in Medicine
Do you remember what you dreamed of becoming as an adult? I do, and I recall my father telling me I could be anything I wanted to be. My dreams were shattered as soon as I stepped into a prison and I am still trying to pick up the pieces of my self-worth.
“Wait, you’re a doctor?” “Nah, man he ain’t a doctor; he looks too much like us.” I am sitting in a high school classroom, it is late May 2018, full of young Black men and women. I know I am in the right place. It wasn’t the first time I have heard that, and surely will not be my last.
For those students, the concept of Blackness did not coincide with the possibilities of being a doctor. Who is telling these young men and women they can’t do what I do? Who is influencing their feelings of self-worth? Society? The educational system? Our government? Or perhaps the videos of young Black men and women losing their lives at the hands of law enforcement? I understand why they didn’t believe I was a physician, because I understand their perception of self-worth through the lens they are viewed in this world. Is anyone surprised they did not believe I was a physician?
I understand why the students couldn’t envision themselves as physicians. Personally, my sense of self-worth was stunted before I spent a decade of life on this earth. I was in New Jersey spending time with my mom, when I began to understand how I was viewed by society. My mom had recently been diagnosed with lupus, and she was going to the pharmacy to pick up her immunosuppressants. When we stepped outside, I was ready for some ice cream. Instead, we were greeted by the police, who accused my mother of being a thief and “a junkie.” Those medications to help suppress her immune system were slapped to the ground, and her pills were crushed. My mother and I were taken into custody, where we spent most of the evening in jail. Everyone in the neighboring cells was Black, and I recall thinking, “maybe this is where I belong.” I can’t tell you when I realized the jail cell wasn’t where I belonged. But, I can tell you that even as a physician, I struggle to believe medicine is where I belong.
Entering training, I was hopeful that I would find a sense of value and belonging. However, as I have advanced through the years, I have come to identify some systemic flaws that undermined my self-worth and sense of belonging as a Black man in medicine. One of the most glaring is that in contrast to the cell I once sat in, there are so few Black men in medicine. Despite composing 13.4 percent of the population, Black people only compose 3.6 percent of U.S. medical school faculty. Historically, our efforts to correct these inequities often result in disappointment. Black faculty experience lower rates of academic promotion (18.8 percent) compared to our white colleagues (30.2 percent) as well as higher rates of burnout. Still, my brothers and sisters have pressed on in hopes for a better future, putting countless hours of labor into addressing the structural integrity of our profession.
Like the high school students I mentor, I find it difficult to believe in my potential when the world tells me otherwise. The frustration I feel towards a system that compromises the self-worth of individuals at such a young age simply because of their appearance is indescribable. Nonetheless, I find solace through the interactions with my Black patients. “I’m so proud of you,” “I can’t tell you what it means for my son to see a Black doctor,” “Stay strong. I know you are making your family proud.” 20 years after sitting on a bench in a jail cell with my feet unable to even touch the ground, I found my purpose through the patients I am lucky enough to serve. I’m now proud to be able to serve as an example to help Black children believe in their dreams.
Black Lives Matter more than this country has ever truly accepted. African Americans built the backbone of this economy without asking for much in return except for justice and equity. We now need society and our partners in medicine to help support our push for equality, so one day our children can fulfill the dreams they deserve as human beings. The recent push by institutions to develop anti-racist policies has given me some hope. However, I hope these efforts are not just a fad. I hope that this will be the start of a fundamental shift in the backbone of our society, where people become advocates for all. Black lives will truly matter when Black children can see themselves beyond the “jail cell” that the world envisions for them, and their opportunities become equitable.
Dysautonomia International and University of California San Diego are holding a virtual workshop on dysautonomia, POTS, and related disorders. This workshop will feature leading experts in dysautonomia. It is open to all medical professionals, students, patients & caregivers for $20! Registration required!
Thursday morning, Brian Coburn, one of amazing second year Med/Peds residents, presented an interesting case of a 35-year-old patient who presented with hypoactive delirium. The patient’s medical history was significant for epilepsy and opioid use disorder. We started our investigation of possible causes of the patient’s encephalopathy by going through the AEIOUTIPS mnemonic of common causes of altered mental status that can be investigated with basic history, exam, labs, and imaging. Our expert discussants from the Toxicology services provided us a comprehensive overview of the approach to hypoactive toxidromes and judicious interpretation of urine tox screening. After the initial work-up was unrevealing, the team pursued additional investigation with lumbar puncture, EEG, and MRI without contrast that were also negative. The team asked our friends from psychiatry to help elucidate whether the patient’s symptoms may be due to an underlying psychiatric disorder, but the determination was made that a primary medical disease was still the most likely cause.
The patient’s condition continued to progress, and an MRI with contrast ultimately revealed acute, diffuse white matter lesions. Per our radiology colleagues, the differential for these findings included infection/post-infectious causes (viral encephalitis, acute disseminated encephalomyelitis, acute hemorrhagic leukoencephalitis), autoimmune encephalitis, and toxic leukoencephalopathy. Following a repeat LP that was negative for a broad array of infectious, autoimmune, and malignant/paraneoplastic studies, we were left with a diagnosis of opiate-induced toxic leukoencephalopathy. The disease presentation is extremely variable, ranging from minor cognitive impairment, easily confused with psychiatric illnesses, to severe neurological dysfunction. Our toxicologist reminded us that some of these findings can also be seen with potential transient, out-of-hospital anoxic episodes. While there is no proven treatment for toxic leukoencephalopathy, antioxidant therapy with Coenzyme Q10, Vitamin E, and Vitamin C has been used to treat some patients with variable results in the past. The patient received this treatment and spontaneously improved after several days of therapy.
Thank you to Brian, our expert discussants, and our residents for working through the differential of hypoactive delirium and the sequential investigations we needed to get to the bottom of this fascinating case.
This week for Friday School we had the opportunity to refresh our Ultrasound skills with Dr. Sweeney and Chief Nick! Given the ongoing pandemic and need for social distancing, our ultrasound curriculum was adapted to the virtual format with a case based series. In our first session, our PGY2-4s had the opportunity to work through workup and differential of shock and how to use ultrasound imaging to guide your diagnosis. We worked through various cases that highlighted different types of shock and how those various cases of shock present on Ultrasound! In the next block we had the opportunity to work with PGY1s. In this session we focused on the basics of the cardiac ultrasound, the views obtained under the cardiac exam as well as probes used. We would like to thank Dr. Sweeney and Nick for putting together these high yield cases! Slides will be posted at a future date once we can make them compatible with the blog! We look forward to transitioning back to in person as soon as we can!
For our second session, our senior residents had a chance to learn about Loneliness and Frailty by some of our amazing VA faculty, Dr. Nguyen and Dr. Thomas. Dr. Nguyen discussed her research and insights into Loneliness – which is the subjective sense of feeling alone regardless of objective social contact. It is a serious condition that especially affects older adults (approximately 1/3 of adults feel lonely), but seems to have spikes in the late 20s and early 50s. Beyond the sense of social isolation, loneliness is associated with multiple detrimental health effects including risk of premature death, a 50% increase in dementia, a 29% increase in heart disease, and a 32% increase in stroke. Dr. Ngyuen’s research has worked on modeling predictive algorithms that can detect patients suffering from loneliness based on words and phrases. In our clinics however, she recommends using a short 4 question questionnaire to help identify people. This should be done at every visit much in the same way that depression or diabetes is screened for. The best way to combat loneliness is wisdom, which can be sought by participating in altruistic acts (like volunteering) or participating in CBT. She recommends referring patients who screen positive for loneliness to counseling early, and once the pandemic is over, assisting them in finding a volunteer cause they are passionate about. Thank you Dr. Nguyen!
Lastly we had the opportunity to learn from one of our veteran geriatricians and our very on VA Chief of Medicine, Dr. Thomas about frailty. Frailty is defined “as an aging-related syndrome of physiological decline, characterized by marked vulnerability to adverse health outcomes” (Uptodate.com). Patients suffering from frailty are less likely to tolerate sickness or medical interventions and are more likely to require skilled care post hospitalization. The best tool to prevent this is to recognize it early! Encourage your patients to start resistance training to prevent muscle decline and walking to increase functional capacity! Don’t worry that its ever too late to start as patients can regain some function even if they start these interventions after relative frailty! Thank you Dr. Thomas for sharing your thoughts on this subject we will all encounter with our patients!