Jacobs Afternoon Conference 6/23 – PCN Allergies

This afternoon we were fortunate to have Dr. Taremi, infectious diseases specialist, give us a talk about penicillin (PCN) allergies. She noted that about 10% of the population have reported PCN allergies (even higher in hospitalized patients), however an estimated >95% of those can tolerate PCN. Further, it’s estimated that the prevalence of true life-threatening anaphylactic PCN allergies in somewhere between 0.02 – 0.04%. She emphasized the importance of obtaining a detailed history of allergic reactions and to classify the type and severity of the reaction paying particular attention to any IgE-mediated reactions (e.g., anaphylaxis, hives, angioedema, etc.).

Takeaways:

• Alternative antibiotics usage due to reported penicillin allergy has been shown to result in higher costs, increased risk of antibiotic resistance, and worse patient outcomes

• Cross-reactivity between truly penicillin allergic patients and later generation cephalosporins or carbapenems is rare

• Patients who have low-risk history (i.e. pruritus without rash, >10 years from reaction without IgE features or family history of PCN allergy),

• Consider referring to allergy clinic for skin testing in appropriate candidates (those with a medium risk history, i.e. urticaria or reactions with features of IgE but not anaphylaxis)

VA Outpatient MTC 6/23: Male gynecomastia

For today’s outpatient morning teaching conference, we discussed initial workup of male gynecomastia in the outpatient clinic setting. As this may not be a common chief complaint, we reviewed the definition of true gynecomastia versus pseudo-gynecomastia then used resources widely available to us including UpToDate to formulate a differential diagnosis on the spot to help tailor interview questions and the exam. Our fabulous expert discussant, primary care clinician extraordinaire and our very own program director Dr. Simerjot Jassal shared many clinical pearls, including:

  1. Doing a thorough medication reconciliation, including OTC meds, herbs and supplements — and don’t be afraid to ask your friendly clinic pharmacist for help with this! Surprisingly, many common medications such as H2 blockers, omeprazole, statins, ACE inhibitors can be culprits, in addition to spironolactone and antipsychotics.
  2. Screening for underlying disease such as cirrhosis, hyperthyroidism, malignancy including testicular tumors and breast cancer along with any family history of enzymatic hormonal disorders, childhood mumps and cryptorchidism.
  3. Evaluating on breast exam for discrete masses, noting location, size, texture, mobilization and checking for axillary lymphadenopathy.

Thanks to everyone for a great conference and stay tuned for part 2 of the case where we’ll cover laboratory and imaging workup!

MTC 6/23 Myxedema Coma

This morning we were joined by endocrinologist Dr. Patricia Wu and learned about myxedema coma! Major signs of myxedema coma rather than just severe hypothyroidism are hypothermia and altered mental status. Patient’s are usually able to tolerate low levels of thyroid hormone but when something disrupts the balance it precipitates crisis. So look for underlying causes like infection or myocardial infarction!

Major takeaways

  1. Treatment – stress dose steroids before levothyroxine
    • Avoid precipitating adrenal crisis – patient may have coexisting adrenal insufficiency as result of suppressed HPA axis from severe hypothyroidism or concomitant primary or secondary adrenal insufficiency. And if don’t treat and patient does have AI then increases cortisol clearance and precipitates an adrenal crisis.
    • IV hydrocortisone 100mg, can then decrease to 50 q8, then 25 q12
    • Can discontinue once cortisol results as normal
  2. IV levothyroxine + T3 – IV
    • Commonly these patients have gut edema that makes PO absorption difficult. PO should also be avoided as patient’s are commonly altered.
    • 200mcg-400mcg initially and then transition to 50-100mcg daily
  3. These patients should be admitted to ICU and monitor T4 daily
    • Mortality is very high!
    • Usually see improvement within one week and can start transitioning to PO weight based

Also, check out Martin Johnson house for a beautiful sunset view!

Jacobs Afternoon Conference 6/22 – EBMs

Today our amazing and soon to be done with residency R3’s Dr. Crisp and Dr. Song each gave very interesting Evidence-Based Medicine presentations.

Dr. Song presented first about use of midodrine in the ICU (fun fact – midodrine is “off-label use” in the ICU as it is only FDA approved for orthostatic hypotension). He discussed three studies that examined whether the addition of midodrine to IV vasopressors reduces duration of IV vasopressor therapy and decreases length of stay in the ICU. The first two studies were retrospective (275 and 1119 patients, respectively) and showed that addition of midodrine had significant reductions in IV vasopressor duration and ICU LOS. However, an RCT (‘MIDAS trial, 132 total randomized patients, 66% post-op/surgical), showed no difference in LOS (ICU and hospital), and there was a significant difference in bradycardic events with midodrine use.

Next, Dr. Crisp discussed the use of multivitamin and thiamine in hospitalized patients with alcohol use disorder. Firstly, a cross-sectional study of 83 ED patients found that no patients had B12/folate deficiency, and only 6/39 had borderline low thiamine levels. Then she talked about a large retrospective single hospital study of 5507 patients which showed the number of discharge medications (when viewed as an independent variable) was associated with higher readmission rates. The takeaways are that there may be little utility in discharging patients with AUD with a multivitamin/folate/thiamine supplement(s), and if concern for symptomatic thiamine deficiency, use IV thiamine instead.

Thank you Alex and Ali for the interesting talks!

Resident Research Award

Congratulations to R2 Dr. Gourisree Dharmavaram for being selected to receive the UCSD internal medicine Outstanding Resident Research Award! She was selected from 40 posters presented at our resident research symposium and from 4 finalists who presented at UCSD DOM grand rounds. Her project is entitled: “The Heart Will Go On: Association of Frailty and Sarcopenia with Outcomes after Heart Transplantation.” GREAT JOB GOURI!!!

Medical student teaching awards!

Congratulations to our amazing residents Dr. Zoya Qureshy and Dr. Morgan Birabaharan for receiving this year’s coveted medical student teaching awards! They were recognized as outstanding teachers and showed exemplary dedication, support and commitment to educating third year medical students. Way to go, Zoya and Morgan!

Owen MTC 6/21 Acute Hepatitis C

Today, Dr. Yang presented a case of a patient with uncontrolled HIV and severe hepatocellular acute liver injury. Workup was significant for a new Hepatitis C diagnosis from 6 months prior, and liver biopsy demonstrated acute severe hepatic injury consistent with Hepatitis C. The patient was started on Epclusa inpatient with improvement of transaminases and synthetic liver function.

MTC 06/21/22: ICU Cases

Today for Morning Teaching Conference, our interns and residents walked us through their management of complex ICU cases. We covered COPD, septic shock, bradycardia, an unstable GI bleed, and more. The interns led the way, showing off all the knowledge they have acquired over the past year and proving they are ready to take on nights in the ICU. We were joined by our amazing expert, Dr. Mark Hepokoski, who shared some fantastic pearls and management suggestions.