WIN OF THE WEEK: 2018 INTERN INTENSIVE

 Snapshots from our 2018 Intern Intensive Curriculum

Snapshots from our 2018 Intern Intensive Curriculum

The 5th annual OHSU Internal Medicine Intern Intensive has kicked off strong this week! We have assessmbled an all-star faculty cast to deliver a number of workshops geared towards advanced topics and skills for our PGY1's to master.

Our topics this week include: IM-procedures led by Dr. Andre Mansoor and crew, advanced point-of-care ultrasound featuring Dr. Renee Dversdal and Dr. Kevin Piro, EHR topics by Dr. Jeff Gold, vent training with Dr. Jonathan Pak, EKG training with Dr. Aya Mayo and our cardiology fellows, communications training led by Dr. Megan Moody, and simulation training at our state of the art sim-center led by Dr. Joe Chiovaro and Dr. Bailey Pope.

Your friendly 2018-2019 IM Chief Residents hope this experience continues to enrich the work and lives of our resident family, and look forward to the fantastic results to come! We will resume our regularly-scheduled programming of blog posts and noon conferences next week.

Win of the Week: Dr. Choo Talks Gender and Race Bias

 Dr. Choo and Dr. Baig-Lewis discuss before the internal medicine program

Dr. Choo and Dr. Baig-Lewis discuss before the internal medicine program

Dr. Esther Choo, OHSU Emergency Medicine faculty and national thought-leader on issues of gender and racial bias in medicine dropped by our internal medicine program last week to deliver an extremely relevant Q&A session moderated by rising chief resident Dr. Shahana Baig-Lewis.

Dr. Esther Choo published (today!) a powerful perspective piece in the New England Journal of Medicine on a similar topic, bringing both her recent celebrity and substantial insight to bear against a problem affecting our society at large by declaring "Time's Up" for such problems in medicine.

We are fortunate to have a speaker with Dr. Choo's experience and voice on our hilltop, and we always glad to have her stop by and share with the IM residents!

Adult Henoch-Schonlein Purpura

Dr. Kiefer presented a fascinating case of Henoch-Schonlein Purpura presenting in a patient with a complex medical history who received antibiotics and presented with new renal failure, unique “palpable purpura” rash, and hypotension. While more common in pediatric populations, HSP occurs in adults as well, and can be a result of drug reaction. While a trigger is only found in a minority of patients, in addition to medications, triggers for adult onset HSP can include infections.

 representative image courtesy of  Brown EM res blog

representative image courtesy of Brown EM res blog

We used this as an opportunity to review our most commonly discussed vasculidities. Please note that this below chart is not meant to be exhaustive! It may however be useful for board prep or when thinking of a differential when a vascular inflammatory process is considered.

 schema courtesy of your friendly ohsu im chief resident

schema courtesy of your friendly ohsu im chief resident

NUT Midline Carcinoma

 NUTs

NUTs

Earlier this week we heard from Dr. LeBlanc about a very unique case of NUT Midline Carcinoma. NUT carcinoma is an exceedingly rare, highly aggressive form of squamous cell carcinoma, attributed to chromosomal rearrangement in the NUT gene. While only several hundred cases have ever been recorded, it is thought more prevalent than diagnosed given that it may often be misdiagnosed or mischaracterized upon presentation.

In our case, the patient was a young woman without much medical history, who had been worked up by oral surgery at an outside institution for a cheek abscess bizarrely refractory to antibiotics for months. Upon presentation, biopsy was obtained and pathology was notable for sheets of “small, round, blue cells” which is suggestive of an aggressive, poorly differentiated malignancy. While surgical resection is primarily indicated in these cases, this patient’s tumor size was too large, and thus a plan for chemoradiation was selected and the team is investigating the possibility of clinical trial.

 Sheet of “small round blue cells”

Sheet of “small round blue cells”

Classic Differential of Small Round Blue Cells

  • Neuroblastoma

  • Nephroblastoma

  • Rhabdomyosarcoma

  • Ewing’s sarcoma

  • Medulloblastoma

  • Retinoblastoma

  • Lymphoma

  • NUT Carcinoma

Thanks to Dr. Missy LeBlanc for this fascinating case!

Weekly EBM Update 9.3.18

Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus (ASCEND Trial NEJM 9/2018)

Aspirin has long been touted as primary preventative therapy for individuals at increased risk of cardiovascular events, historically defined as a man over age 45 and a woman over age 55. However, these recommendations have been tempered in recent years due to the increasingly highlighted adverse bleeding risk associated with aspirin. This paradigm shift can be seen in the most recent United States Preventative Service Task Force update on aspirin for primary prevention- now recommended (level B) for individuals age 50-59 with 10% 10-year ASCVD risk for the prevention both cardiovascular events and colorectal cancer in adults who are able to remain on it for 10 years. Aspirin is also a component of preventative measures in patients with diabetes, however recent studies have brought its benefit into question. The authors of this multicenter, randomized controlled trial (ASCEND) aimed to evaluate the effectiveness of aspirin in primary prevention of cardiovascular events in patients with diabetes but without overt clinical coronary disease. Patients were randomized to 100 mg of aspirin daily or placebo. The primary outcome was the occurrence of a first serious vascular event: a composite of non-fatal MI, non-fatal stroke (excluding intracerebral hemorrhage (ICH)) or TIA, or death due to a vascular cause. The safety outcome was the composite of confirmed ICH, sight threatening bleeding, GI bleeding, or bleeding that resulted in hospitalization, transfusion, or death. After a mean follow up of 7.4 years, the primary composite cardiovascular outcome occurred in 658 patients in the aspirin group vs 743 in the placebo group (rate ratio: 0.88, p-value: 0.01). The primary safety (bleeding) outcome occurred in 314 patients in the aspirin group compared to 245 in the control group (rate ratio: 1.29, p-value: 0.003). The reduction in cardiovascular events due to aspirin was driven largely in part due to a reduction in TIA.

Take home: Aspirin use led to a significant decrease in the rate of adverse cardiovascular events, however this came a significant increase risk of bleeding. The number needed to treat and harm respectively were: 91, and 112. Aspirin led to a risk reduction of cardiovascular events of 12%, but at a 29% increased risk of bleeding. Aspirin use for primary prevention of cardiovascular events may be outweighed, or at the least- counterbalanced, by its risk for serious bleeding.

Read the article here

A Single, Post-ACTH Cortisol Measurement to Screen for Adrenal Insufficiency in the Hospitalized Patient (Journal of Hospital Medicine 8/2018)

Adrenal insufficiency is a diagnosis frequently considered amongst hospitalized patients. Initial screening for adrenal insufficiency commonly employs stimulation testing using the high dose (250 mcg) cosyntropin stimulation test (CST). The traditional test involves measuring cortisol levels at 0, 30, and 60 minutes after the administration of cosyntropin, with a cortisol level > 18 mcg/dL at any time point confirming adequate adrenal function. However, the inpatient administration of this test can be complex, requiring coordination from nursing staff to ensure that the samples are drawn at the appropriate time points. The authors of this retrospective cohort study sought to identify the accuracy of testing cortisol levels at a single time point- 30 minutes or 60 minutes- compared to the standard CST method of testing both time points amongst patients in the ICU or medical wards, respectively. The authors found that cortisol levels at 60 minutes had higher concordance with traditional CST compared to the 30-minute level (99.7% vs. 88.0%, respectively) in both ICU and ward patients. Testing at 30 minutes alone lead to a significantly higher rate of false positives (42.7% of positive tests (ie. < 18 mcg/dL) at 30 minutes were negative at 60 minutes (ie. > 18 mcg/dL)), compared to testing at 60 minutes, where 1.8% of tests were false positives at 60 minutes and negative at 30 minutes.

Take Home: It appears that an initial screening approach for adrenal insufficiency with the high dose cosyntropin test followed by a single 60-minute cortisol level has high concordance with traditional (baseline, 30- minute, and 60-minute testing), and leads to significantly fewer false positives than single 30-minute cortisol levels. Simplifying this testing algorithm could lead to better utilization of hospital staff and resources while remaining highly sensitive for adrenal insufficiency. Such implications should be validated in prospective studies.

Read the article here

WIN OF THE WEEK: RETURN OF THE PROCEDURE SERVICE

Procedure Services.PNG

The beloved IM Procedure service is back in business!!!

Contact this team with any of your inpatient paracentesis, thoracentesis, arthrocentesis, or lumbar puncture needs by paging 17269.

This is a win for the whole IM program, with special credit due to Dr. Jacoby for his committment to resident education, the procedure team leadership Drs. Mansoor, Harmon, Hendricks, and Riquelme, and Internal Medicine Residency Council advocacy spearheaded by Drs. Matt O'Donnell, Dave Ellis, and Kim Chesteen.

THANKS TO EVERYONE INVOLVED!

Classification of Hypotension and Shock

Dr. Beth Collins gave a great noon report Wednesday highlighting the workup of undifferentiated hypotension.

When approaching the hypotensive patient, it is important to keep in mind the main physiologic categories that contribute to the development of shock- defined as inadequate perfusion to sustain metabolic activities of end organ tissue (e.g. inadequate oxygen utilization)- as these will help guide the clinicians diagnostic and therapeutic plan.

Below is a diagram from a recent NEJM review on circulatory shock:

Screen Shot 2018-09-01 at 9.33.23 AM.png

Want to keep reading? Find the article here

Weekly EBM Update 8.27.18

Association of Broad-Based Genomic Sequencing With Survival Among Patients With Advanced Non–Small Cell Lung Cancer in the Community Oncology Setting (JAMA 8/2018)

The concept of broad-based genomic sequencing has made up an integral component of what is known as “precision” medicine—use of biomarker assessment to tailor cancer therapy to an individual. This concept is particularly attractive in an era where specific genetic mutations are identified and targeted with benefit to clinically relevant patient outcomes. In the specific case of advanced non-small cell lung cancer, for example, testing for mutations in EGFR and ALK are now standard of care as they predict efficacy of potential therapeutic options. Broad-based genetic screening, then, is an attempt to test many cancer genes (in this case, >30) that may have additional predictive or prognostic benefit. The National Comprehensive Cancer Network recommends such broad-based genomic sequencing as a method to uncover rare driver mutations and/or candidates for clinical trials. Nevertheless, in NSCLC populations, prior studies have failed to produce convincing evidence that routine use of broad-based genomic screening improves survival in a population, except for one retrospective study for which EGFR/ALK were included in the study group.

The study conducted by Presley, et. al, in JAMA therefore set out to assess whether the use of a broad-based genomic screen connotes any mortality benefit above the standard-of-care EGFR and ALK mutation testing. Consistent with past results, the authors were unable to find any statistically significant survival benefit in the population. They identified that less than 5% of patients who underwent broad-based genomic sequencing-informed treatment for a non-EGFR or ALK mutation. They did acknowledge that the initial, unadjusted survival estimates favored broad-based genomic sequencing, but found that immunotherapy use was independently associated with both factors and may have served as a confounder. Criticism of broad genomic sequencing includes the assertion that simply being assigned to genetic-directed therapy is not a proof of benefit, and that high costs associated with widespread use of these genomic screens and then subsequent targeted therapies may be out-of-reach for many community-treated patients and unsustainable in the long run.

Take Home: At the present, broad based genomic sequencing to identify additional mutations associated with NSCLC does not appear to have an effect on overall mortality in patients with non-small cell lung cancer.

Find the article here

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit A Multicenter Population-Based Cohort Study (JAMA IM 8/2018)

We have all been faced with difficult discharge and disposition decisions in the past, but one of the most difficult decisions is whether or not a patient in the intensive care unit is ready for direct discharge home, or needs to be first transferred to the medical ward prior to discharge. For many patients, transfer to the ward is necessary for issues related to rehabilitation, continued medical therapy, or to observe the trajectory of the frail patient. However, a select subgroup of patients may be able to discharge directly from the ICU. The Authors of this study evaluated the healthcare utilization and clinical outcomes of select patients admitted to the ICU who were discharged directly from the unit, compared to a control cohort of patients who were first transferred to the floor prior to discharge. The patients were matched based on propensity scores in an attempt to minimize the effects of confounding. The authors analyzed 6,732 patients admitted to 9 ICU’s. 14% of patients were discharged home, while 86% were transferred to the ward. The most common admitting diagnoses discharged home were overdose, pneumonia, and trauma/orthopedic injuries. The most common ICU admitting diagnoses discharged home were overdose, withdrawal, seizures, or metabolic coma. Patients discharged home had a significantly shorter length of hospital stay compared to those transferred to the ward (3.3 days vs. 9.2 days, p-value: < 0.001). Additionally, there was no difference in 30-day hospital readmission rates between groups (discharged home: 10% vs. transferred to ward: 11%). 4% of patients in both groups died in the year following discharge. The only factors with statistically significant increased risk for hospital readmission were being discharged from a hospital where ≥ 1 patient was directly discharged per week, and leaving against medical advice (HR 1.17, and 1.79 respectively)

Take Home: For select patients admitted to the ICU (notably those with admission diagnoses of overdose, withdrawal, seizures, or metabolic coma), direct discharge home may be reasonable. Direct discharge home for these diagnoses is associated with a 30-day readmission and 1-year mortality similar to propensity score matched controls who were transferred to the floor prior to discharge.

Find the article here