WIN OF THE WEEK: BESTSELLING AUTHOR

 Dr. Mansoor shares his gift with the world (as opposed to just OHSU IM Residents and students)

Dr. Mansoor shares his gift with the world (as opposed to just OHSU IM Residents and students)

CONGRATULATIONS to Dr. André Mansoor, OHSU DOM Faculty, Director of the Procedure Service, and now bestselling author of his acclaimed addition to the Internal Medicine Textbook Pantheon "Frameworks for Internal Medicine".

Any OHSU IM Resident or Student knows of Dr. Mansoor's reputation for producing high-quality, useful "frameworks" on the wards which can break down any overwhelming problem into bite-size chunks that are easy to understand, and this technique has become a hallmark of our teaching culture. Dr. Mansoor has combined all of his best Frameworks into a textbook format complete with annotations and figures to help Internal Medicine learners at ANY level improve their grasp on the subject matter.

Although it is now SOLD OUT on Amazon (thanks to some well-publicized tweets), you can still obtain it available directly from the publisher here.

CONGRATS ANDRÉ!

Weekly EBM Update: 12.7.2018 (Feat. Guest Star)

Welcome to the EBM Weekly Update!

This week we have an evidence update from the annual American Society of Hematology (ASH) meeting regarding the use of DOAC's for the treatment of cancer associated VTE. While in practice this had been done for sometime, this is one of the first trials (maybe the first?) showing superior efficacy with the use of a DOAC over LMWH. 

The second article review was selected and written by someone near and dear to many an IM residents’ heart- Dr. Daniel Green. Yes, we convinced this recent OHSU grad to make a cameo appearance from his Kaiser abode in sunny southern California and grace us with his EBM wisdom regarding the overzealous and potentially lethal use of oxygen therapy in nearly all hospitalized patients. We are forever grateful for his contribution! Thanks Dan ;) If any of you other current residents, alums, or faculty out there want to contribute to this effort, we’d love to have you!!


Apixaban, Dalteparin, in Active Cancer Associated Venous Thromboembolism, the ADAM VTE Trial (ASH 2018)

Historically, low molecular weight heparin (LMWH) was used for both prophylaxis and treatment of cancer associated DVT. Its superiority was demonstrated to coumadin in the CLOT trial (NEJM 2003), which demonstrated fewer episodes of venous thromboembolic disease (VTE) amongst patients receiving LMWH vs. oral anticoagulation with a coumadin derivative. However, with the advent of newer oral agents such as direct oral anticoagulants (DOAC’s), if LMWH remains superior remains to be seen. A non-inferiority trial published early this year in NEJM (2/2018) demonstrated that edoxaban was non-inferior to LMWH in patients with cancer associated DVT, however this was at the expense of increased bleeding, particularly amongst patients with GI malignancies. The authors of the above study evaluated the efficacy of 6 months of treatment with Apixaban (a DOAC) compared to dalteparin (LMWH) in the treatment of cancer associated VTE amongst 300 patients (287 included in primary analysis with colorectal, lung, pancreas, and breast the most prevalent cancer types). The authors found significantly fewer VTE’s in patients receiving apixaban compared to dalteparin (3.4% vs 14.1%, p-value: 0.0182). There was no difference in major bleeding between groups (0 and 2 patients, respectively), nor clinically relevant non-major bleeding.

Take Home: Among patients with cancer associated VTE, oral anticoagulation with apixaban appears to be a safe and effective treatment compared to LMWH. Further subgroup analysis is warranted to evaluate the safety of these agents amongst patients with GI malignancies.

Link to Conference Abstract Here


Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. (Lancet 4/2018) (By Contributor Dr. Daniel J. Green)

Background:  Most patients that are in the hospital will have a nasal cannula on whether they need it or not.  How do we know who needs supplemental oxygen therapy?

METHODS:  Systematic review and meta-analysis of randomized control trials in a variety of different databases comparing liberal versus conservative oxygen therapy in acutely ill adult inpatients (pts with chronic respiratory disease and a few other things like ECMO were excluded).  The outcome of interest was mortality (in hospital, 30-day, longest follow-up reported) and morbidity (hospital-acquired pneumonia, any infection, length of hospital stay, others).

Findings:  Twenty-five RCTs including ~16,000 patients with diseases such as sepsis, critical illness, stroke, trauma, myocardial infarction, cardiac arrest, and emergency surgery.  They compared conservative oxygen strategy (‘less is more’) verses liberal oxygen strategy (O2 sat median greater than 96%). More oxygen had a relative risk for in-hospital death of RR 1.2, 30-day mortality relative risk RR 1.14, all were statistically significant, and the I-square test for heterogeneity was low (favorable, meaning the studies were similar and easy to compare).

Critical Appraisal:  Broadly speaking, internally valid with high quality of evidence, low risk bias with low heterogeneity among numerous large randomized control trials.  Reasonably well generalized as the patient's included had a variety of different medical conditions.  Our veteran population has a high prevalence of chronic respiratory disease, I could not easily find what this term includes. If they excluded stable COPD, asthma patients etc., it would limit the generalization to our VA population.

 Take Home:  There is small but persistent risk of death, both short and long-term, from supplemental oxygen therapy titration to a saturation greater than ~96%.  Consider removing the nasal cannula to prevent death, prevent your patient from sitting in bed all day unnecessarily, and prevent dry nasal passages and discomfort.  But mostly death.

Link to Paper Here

Guide to the Incarcerated Patient

 Guidelines to help with the management of an incarcerated inpatient

Guidelines to help with the management of an incarcerated inpatient

Dr. Eddie Maldonado led us through a fascinating case on Monday that touched on multiple medicolegal and social themes that are encountered on the wards. We were also joined by two representatives from our wonderful OHSU social work team who assisted answering questions about complex issues.

Incarcerated patients, when admitted to our services, have certain considerations, rules, and legal protections that we should keep in mind. Remember, implicit and explicit biases by the entire care team must be carefully considered while administering treatment for this vulnerable populartion, and their incarcerated status can change (and often does!) during the course of a hospital stay.

Thank you, Eddie!

WIN OF THE WEEK: MATCH DAY!!!

 Congratulations to all of our hardworking residents!

Congratulations to all of our hardworking residents!

After years of preparation, months of interviewing and weeks of eager anticipation, our fellowship-bound senior residents and chief residents found out where they MATCHED to on Wednesday!!! Check out this incredible list of fellowship destinations and training programs and be sure to congratulate those matched when you see them!!

WIN OF THE WEEK: GIVING THANKS AND GIVING BACK

 Looking good while doing good!!

Looking good while doing good!!

Your friendly IM Res PDX crew teamed up to join a Habitat for Humanity build over the weekend before thanksgiving as we reflect on all that we are grateful for during this and all times of the year. Special thanks to the IM Residency Council, and in particular Dr. Whitney Elg-Salsman for organizing this trip!

Weekly EBM Update 11.16.18

Welcome to the EBM Weekly Update!

This week we chose one article highlighting an important shift in the epidemiology of mortality in the United States (attached above). The second is an opinion piece that finds itself where medicine, politics, policy abut. It is a response to the recent comments of the NRA directed at the medical community, written by Dr. Ester Choo here at OHSU.


Socioeconomic Differences in the Epidemiologic Transition From Heart Disease to Cancer as the Leading Cause of Death in the United States, 2003 to 2015: An Observational Study (Annals of Internal Medicine 11/2018)

Cardiovascular disease has long been known as the number one cause of mortality amongst women and men in the United States, with cancer coming in a close second. However, epidemiological data demonstrates a change in this pattern. Improved preventative cardiology with better control of risk factors such as smoking, hypertension, hyperlipidemia, and cholesterol in addition to improved management of acute coronary syndromes has greatly impacted mortality due to cardiovascular disease. While the CDC still lists cardiovascular disease as the leading cause of death based on 2015 data, due to the improvements listed above it is estimated that cancer will be the leading cause of death in the United States by 2020. The authors of this study evaluated socioeconomic and racial/ethnic factors influencing this epidemiological change.  The results indicated that cancer became the leading cause of death in 2015 amongst Asian Americans, Hispanics, and Non-Hispanic whites, in contrast to 2003, when heart disease was the leading cause of death. This shift was not evident for American Indians/Alaska Natives or blacks. Amongst the lowest-income counties, heart disease was the leading cause of death in 2015 across all racial groups. In the highest-income counties, Cancer was the leading cause of death amongst Hispanics, Asian Americans, and Non-Hispanic whites. Mortality was decreased for all racial groups except American Indians/Alaska Natives. Mortality rates decreased most across all racial groups in the highest income quintile. Blacks in the highest-income counties had cardiovascular mortality rates similar to Non-Hispanic whites in the lowest- income counties. 

Take home: An epidemiological shift appears to be occurring with cancer becoming the predominant cause of mortality amongst the United States population compared to heart disease. However, significant racial/ethnic and socioeconomic disparities remain, particularly in blacks, who had higher overall mortality than any other group, and American Indians/Alaska Natives- the one group with increased all-cause mortality over the study period, highlighting the need for improved advocacy, healthcare, and resource allocation for these populations. 

Link to article


Dr. Esther Choo: The NRA denies the reality of gun violence. Doctors like me know it all too well. ( NBC News 11/2018)

The second piece this week is not an original research piece, but rather is an article recently written by OHSU’s Dr. Esther Choo regarding the ongoing mass-shooting crisis. This is an excellent opinion piece highlighting recent events and the role and duty that we have as physicians in striving to provide a healthy, safe, and inclusive environment to all those around us. I encourage all to take a moment to read this well written- and well thought- article. 

Link to article

WIN OF THE WEEK: OHSU DOMINATES BEND ALE TRAIL 2K18

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A determined and mighty contingent of OHSU runners made the trek to Bend over the weekend and represented us proudly in the annual Bend Ale Trail. Dr. Claire Groth and Dr. Pat Liu placed in their respective categories!!! Give your congrats to all the runners and spectators when you see them around the hospital.

Give your regards to Francis! (a theatrical review of decision making capacity)

Watch out Broadway! Last week noon report took on a theatrical tone when Dr Francis Phan shook things up and added an element of role play.

While some our acting skills presented more as comedy, the content was that of pure drama. Inspired by a particularly challenging case of a woman with fluctuating goals of care in the setting of new Hungtington’s Disease and also brain metastases, Dr Phan's incentive for this role play session was to help our residents’ comfort and fluency with difficult capacity assessments.

To help us feel prepared going into our scripted interactions, Dr Phan provided his very own DMC (decision making capacity) mnemonic: Listen with “U-Ears” (TM)

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TAKE HOMES:

1) Decision making capacity assessments are hard, having a framework to fall back on can help. Use U-EARS!

2) Reach out for help, get additional input especially with higher stakes decisions

3) Establish SDMs (surrogate decision makers) early

*reference to the classic theater hit "Give My Regards to Broadway" from the 1904 hit musical, Little Johnny Jones