WIN OF THE WEEK: COURAGE TO TEACH

Screen Shot 2018-10-19 at 10.49.04 AM.png

Congratulations!!!

to our beloved program director, Dr. Sima Desai, for being awarded the HIGHLY prestigious Parker J. Palmer Courage to Teach Award for 2019. This honor is bestowed upon several GME program directors around the country who truly go out of their way in their dedication to their programs and the people therein. As we all know, Sima is incredibly deserving of this award. Please congratulate her when you get a chance! (PS it was also her birthday last week!!!)

Link to official announcement and other awardees: https://www.acgme.org/Portals/0/PDFs/AwardRecipientsAnnouncement.pdf

WIN OF THE WEEK: ANNUAL R2 LEADERSHIP RETREAT

On Thursday 10/4, the 2nd year OHSU IM residents gathered at the South Waterfront for a day of workshops designed to push them as team leaders and help them further their career goals. They talked candidly about leadership experiences they have had thus far, including difficult situations, unresolved anxieties, and dilemmas.

In the afternoon, for the first time, we presented 3 separate career panels, which were staffed by recent graduates who have chosen careers in primary care, hospitalist medicine, and subspecialty fellowships, to give our new residents the chance to ask probing questions about their own career choices and trajectories.

For our residents- how did you think the session went? Let us know in the comments! (or preferably your evaluation forms)

 Happy and engaged R2s excited for a day off the wards and ready to push their leadership skills to the next level!

Happy and engaged R2s excited for a day off the wards and ready to push their leadership skills to the next level!

WIN OF THE WEEK: OHSU IM RESIDENCY SCHOLARSHIP NEWSLETTER

This week, our program released the SIXTH edition of the OHSU Internal Medicine Residency Program's Quarterly Scholarship Newsletter. As usual, our residents' hard work was rewarded with publications in a multitude of high-impact journals.

The newsletter is part of ongoing efforts by Dr. Avital O'Glasser, one of our assistant program directors, along with the SPeAR (Scholarship Peer Advice and Resources Group) to solidify our scholarship infrastructure. Reach out to Avi or the SPeAR group if you have any questions about getting more involved in research!

Screen Shot 2018-09-27 at 10.39.23 PM.png

FEATURED RESIDENT PUBLICATIONS FROM THE SUMMER QUARTER 2018 (Resident name in bold):

1.        Bien JY, Hegarty R, Chan B. Anemia in Scurvy. J Gen Intern Med. 2018 Jul 27.

2.       Haraga J, LeBlanc M, Chiovaro J. Not All It's CrAg-ed Up to Be: Disseminated Cryptococcosis. Am J Med. 2018 Jul 31.

3.       Ketterer B, Montanaro A, Hunter A. So Much More than Bald and Bloated. J Hosp Med, published online September 28, 2018.

4.       Keyserling K, Koprowski SSpur-Cell Anemia. N Engl J Med. 2018 Aug 23;379(8):774.

5.        Koprowski S, VanLue MJ, McCormick ME. Treatment of Stress Velopharyngeal Incompetence With Injection of Hyaluronic Acid. Cleft Palate Craniofac J. 2018 Apr;55(4):615-618.

6.       Dua A, Koprowski S, Ali F, Desai SS. Factors that Predict Failure to Meet Merit-Based Incentive Payment System Quality Measures for Asymptomatic Carotid Endarterectomy. Ann Vasc Surg. 2018 Apr;48:127-132.

7.        Lachowiez C, White K, Spurgeon S. Exaggerated arthropod assault: Eosinophilic dermatosis in a patient with small lymphocytic lymphoma. Clin Case Rep. 2018;00:1–3. 

8.       Larson E, German DM, Shatzel J, DeLoughery TG. Anticoagulation in the Cardiac Patient: A Concise Review. Eur J Haematol. 2018 Sep 10. 

9.       Lu E, Thomas GV, Chen Y, Wyatt AW, Lloyd P, Youngren J, Quigley D, Bergan R, Bailey S, Beer TM, Feng FY, Small EJ, Alumkal JJ. DNA Repair Gene Alterations and PARP Inhibitor Response in Patients With Metastatic Castration-Resistant Prostate Cancer. J Natl Compr Canc Netw. 2018 Aug;16(8):933-937. doi: 10.6004/jnccn.2018.7020.

10.     Nishikawa G, Luo J, Prasad V. A comprehensive review of exceptional responders to anticancer drugs in the biomedical literature. European Journal of Cancer 101 (2018) 143e151.

11.      O'Donnell M, Shatzel JJ, Olson SR, Daughety MM, Nguyen KP, Hum J, DeLoughery TG. Arterial Thrombosis in Unusual Sites: A practical review. Eur J Haematol. 2018 Aug 21.

12.     Olson SR, Lu E, Sulpizio E, Shatzel JJ, Rueda JF, DeLoughery TG. When to Stop Eculizumab in Complement-Mediated Thrombotic Microangiopathies. Am J Nephrol. 2018 Aug 15;48(2):96-107.

13.     Scharman C, Mansoor A, O'Glasser A. Occam's Razor Vs. Hickam's Dictum: Headache in an Immunocompromised Patient. SGIM Forum 41 (9): 8-9, 11.

14.     Tao D, Prasad V. Choice of control group in randomised trials of cancer medicine: are we testing trivialities? Lancet Oncol. 2018 Sep;19(9):1150-1152.

15.     Tao D, Schott S, Prasad V. The tradeoff of cancer drug regulatory policy: Faster approvals for one means less knowledge for another. Am J Med. 2018 Sep 7.

Don’t forget to email Avital O’Glasser (oglassera@ohsu.edu) or IM SPeAR (imscholarship@ohsu.edu) with any recent publications, presentations, or interest in participating in scholarly work or having a resident work with you!

Flozin down that river of knowledge: a wild case of undifferentiated shock!

This afternoon Dr Cara Levin brought us on an exciting journey of a middle aged man with a significant cardiovascular history (prior CABG, DES, TAVR) who was transferred to OHSU for ongoing management of shock initially felt secondary to acute GIB and acute hypoxic respiratory failure, who, when presenting to our institution, demonstrated difficult to explain labs: significant mixed AG and non-AG metabolic acidosis with respiratory acidosis, profound neutrophil predominant leukocytosis (to the 50,000s), mildly elevated lactate and then stable Hg.

What was the cause of his shock if we now couldn’t blame it on hypovolemia from his GIB bleed? Could it be cardiogenic? Was he septic? Were his new vent settings causes obstruction?

We turned to the lab abnormalities we did observe in search of other clues for our unifying diagnosis, namely… his acid base status!

In true internal medicine form, we broke down those labs in a step-wise fashion. Find below a helpful diagram courtesy of Dr Joel Topf (@kidney_boy), as featured on the hit IM podcast, “The Curbsiders”.

acidbase.png

Through these steps we arrived at our multifactorial mixed AG and non-AG metabolic acidosis with respiratory acidosis and grew our differential through expoloring causes for a MAGA (metabolic anion gap acidosis) with the helpful mnemonic “Goldmark”.

goldmark 2.jpg
goldmark 2.jpg

In this case, it turns out that our patient had been on Empagliflozin, an SGLT-2 inhibitor agent used in management of type 2 diabetes. While the SLGT-2 inhibitors have shown great promise in terms of reducing important cardiovascular outcomes in patients at high risk fo CV events (like our patient!), they unfortunately have a known side effect of increased risk of euglycemic DKA.

Euglycemic DKA can present with an MAGA, leukomoid reaction, and elevated lactate, like this patient. More so, acidosis is a direct cause of hypotension and shock. Per one source " Cardiac contractility and cardiac output are reduced and arterial vasodilatation develops, which contributes to the development of hypotension". (source below) After appropriate treatment with insulin and glucose, this patient’s gap closed.

In full disclosure about this case, although his labs have improved, the etiology of his initial hypotension and shock picture is not yet clear. This is, however, often the case in medicine, and shock in particular, that a single, clear, elegant explanation doesn’t exist. And as such, we again thank Dr Levin for this honest and exciting case that allowed us to walk down the often confusing paths of shock and its attedant management in a real “choose your own adventure” fashion.

Citations: -https://img.ma-shops.com/hild/pic/image01646.jpg -https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/4eb58c5284bc04a8a9c4325f003add3d36b4e18a/7-Table2-1.png -https://thecurbsiders.com/show-notes/88-acid-base-boy-bands-grandfather-clocks-joel-topf-md -https://www.medscape.org/viewarticle/718583_6

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!