From our Clinical Pathology Conference in May, we had a phenomenal overview of a rare, but aggressive syndrome of excessive immune activation – Hemophagocytic Lymphohistiocytosis.
Dr. Wysocki (Allergy) and Dr. Weina Chen (Pathology) presented a case and some great slides. See select slides and then the presentation online.
Another example of the amazing pathology we see at Parkland! A patient case in BMJ case reports has been making big news. Authors Nick Hendren, Senthil Sukumar and Dr. Glazer present a patient with significant alcohol use who went swimming in the Gulf of Mexico after a tattoo, and presented with Vibrio vulnificus sepsis.
Read the case abstract here.
UTSW residents have had great success publishing with BMJ case reports (http://casereports.bmj.com/). They accept both clinical images and case reports, are fast reviewers, and publish weekly. UTSW has a “fellowship” with them, allowing for free publication (membership number is 849366 which is needed during submission). They have their own template and formatting requirements explained on their website and require their own consent form (they will not accept an article without consent on their form).
This patient was in the ICU for a long time- unfortunately he did not make it despite a 2-month hospitalization. Thanks to the superb team of IM residents that cared for him:
A case challenge for you on this rainy Thursday.
I will present the case step by step with additional information provided every ~24-72h. Please leave your thoughts in the comments, or can submit to the anonymous link.
CASE: A 59yo with severe ischemic CM (most recent EF <20%) presents to CUH ED with DOE, orthopnea, bendopnea, and PND. He has had 3 hospitalizations in the last 4 months for heart failure exacerbations. His initial lab work is notable for normal K, CO2, AG, and creatinine, CBC is wnl, normal lactate, TSH. He is afebrile, BP 140/75, HR paced at 70, and satting well on RA. he has 2+ pitting edema b/l, JVP 15cm, +HJR, his extremities are moderately cool to touch. Overall he appears chronically ill but stable for the floor.
his EKG is below
His home medications are as follows
amiodarone 400 qday, furosemide 40mg BID, carvedilol 25mg BID, clopidogrel 75mg, pravastatin 10mg, diltiazem 30mg q6h, ranolazine 1000mg BID, ISMN 30mg BID, digoxin 125mcg qday, pradaxa 150mg BID
He is taken to RHC on HD1 with numbers below.
Right atrium: 14 mmHg
Right Ventricle: 40/8 mmHg
Pulmonary Artery: 39/18/26 mmHg
PCWP: 20 mmHg
NIBP: 114/ 75/ 88 mmHg
Heart Rate: 60
PA sat: 47 %
Pulse Ox: 96%
Hgb: 14.6 g/dL
Assumed Fick: cardiac output 2.8 L/min, index 1.37 L/min/m2
Thermodilution: cardiac output 2.8 L/min, index 1.36 L/min/m2
Day 1 questions- What Stevenson profile is this patient? What are your treatment options and how do his RHC numbers inform your decisions? What would you do with his home medicines? What conditions make thermodilution less accurate? What kind of device does have in place?
If you have further questions of the patient’s history or initial presentation please ask as well
Here are a couple of cool QI opportunities that can help you earn some $$$ as well.
1. AHRQ’s WebM&M
Submit cases of medical error/ patient safety to AHRQ’s WebM&M series. These cases are completely anonymous (no PHI, or information identifying the patient, institution or yourself). If selected, an expert will write a commentary on your case, and you will receive $300. Downside is that your identity is never revealed and you do not get credit/ a publication.
There is no strict deadline for this, but we never know when it will stop.
Please continue to report safety reports internally as well.
2. ACGME’s Back to Bedside Initiative
This aims to empower trainees to develop transformative projects that combat burnout by fostering meaning in their learning environments and engaging on a deeper level with patients. The purpose of Back to Bedside is to support the development of innovative ideas, clinical practices, or policies that will improve physician well-being and foster a sense of meaning in work while increasing the time physicians have to spend in the care of their patients.
Total funding: $10,000 per year renewable for up to two years.
Deadline for Proposals: August 5, 2017.
As the 2016-2017 academic year enters is last few weeks, the annual changes are afoot. A new year of interns are (hopefully) enjoying the end of their fourth year before the exciting journey of residency begins, current house staff prepare for new responsibilities and the perennial question of how well this whole system works for patients is asked anew.
Overall, recent answers seem encouraging. The May 23/30 JAMA includes a comparison of teaching and non-teaching hospitals. This review of millions of hospitalizations at thousands of US hospitals for patients suffering from many common conditions shows a small but consistent reduction in 30 day mortality for teaching hospitals compared with non-teaching hospitals.
Similarly, the BMJ recently published a study comparing outcomes for elderly patients depending on their physician’s age. Though published in BMJ, like the JAMA article it is a study of Medicare beneficiaries. It also showed a small but consistent reduction in 30 day mortality for younger physicians and what’s more, the younger cohort also delivered lower cost care. But one main caveat before our youngest physicians let out the ticker tape: if the older physicians had high clinical volumes (>201 admissions per year), the difference completely disappears.
So to our hardworking residents and faculty nationwide, thank you for your dedicated work – it seems to be paying off not just in the future but today and everyday in our busy teaching hospitals.
On May 4th, we held our 2nd annual Donald W. Seldin, MD Research Symposium showcasing the scholarly work of our housestaff.
Over 85 Interns, senior residents and fellows from the various Internal Medicine departments presented their work. The breadth and depth of the work was outstanding! Poster were presented on May 4th with judging taking place that afternoon. We thank all our judges, including our guest Grand Rounds speaker Dr. Rabinovitch (Stanford University) for joining us in the judging process. After intense probing into each poster and researcher’s work, the adjucation committee selected six finalists: our six Foster Fellows.
After Dr. Rabinovitch’s grand rounds lecture on May 5th, the six Foster Fellows were announced and scheduled to present their work on that following Friday, May 12th.
- Elizabeth McGehee (R2) Treatment and Outcomes of PrimaryPericardial Mesothelioma: A Systematic Review
- Jeanney Lew (R3) Understanding the Venus and Mars Effect: Sex-Based Differences in Cardiovascular Biomarkers
- Arjun Gupta (R3) Gastric Acid Suppression and Recurrent Clostridium difficile Infection: A Systematic Review and Meta-Analysis
- Justin Chen (Allergy Fellow) Reflexive Penicillin Allergy Testing with In-Hospital Aztreonam Use
- Glynnis Garry (R1) A Twist-Dependent Progenitor Cell Contributes to Adult Skeletal Muscle
- Jasmine Singh (R1) Homemade Silver Nanoparticle Pharmacology and Dramatic Activity in Highly Refractory Metastatic Head and Neck Squamous Cell Cancer
On May 12th, these six housestaff presented their work in a 5 minute short-oral form to the UTSW community, including Parkland, Clements and Texas Health. The D1.500 room was a packed house with great attendance from residents, faculty and researchers. Thank you also Dr. Podolsky for joining us! After 2 minutes of fast and furious questioning, including some tough questions by Dr. Helen Hobbes for Dr. Garry and Dr. James De Lemos for Dr. Gupta – it was time for all the audience to VOTE. The audience voted using their phones and paper ballots on the winning presentation and the chosen Seldin Scholar.
While votes were actively tallied, Dr. J ohnson took a moment to present a separate award that specifically recognized research in quality of care and education at Parkland Hospital (enabled by the Ron Anderson MD Professorship held by Dr. Carlos Girod, supported by a donation from the Hoblitzelle Foundation to UT Southwestern). Great way to our committment as a department and institution to research and care of those most in need in Dallas County.
This year’s Award for Research in Quality of Care at Parkland Memorial Hospital went to Deepika Satish, for her project, “Prescription Practices of Pancreatic Enzyme Replacement Therapy in a Public Health System.” Her mentor, Dr. Deepak Agrawal had a number of submissions.
And then, came the Finale! Votes were in! And in a close race with votes tallied from across all UTSW sites – the 2017 Seldin Scholar was:
Dr. Glynnis Gary and her mentor Dr. Rhonda Bassel-Duby
Congratulations to all our winners – and to all the housestaff and their fabulous mentors for their submissions.
We also would like thank all those that made this event possible, including Dr. Johnson and Dr. Towler along with the extraordinary team of Chris Huang, Shannon Carver, Beni Stewart, Mikki Ames and many others!
See you all in 2018 at next year’s symposium!
Shout out to R1 Dr. Pokala! You know you’re doing a great job when your attending tries to change your career path!! 🙂
“Dr. Pokala was placed on emergency residency on call for the CF/PH service. I thought he had a good attitude regarding losing a weekend day off, he prepared as if he would continue to follow the patients for several days, asked questions, followed up on lab test, and I felt he gave his best for my patients.
I feel this is a sign of an exemplary resident, and I want him to know it was greatly appreciated.
I know he is interested in heme/onc, but I hope he would consider pulmonary critical care instead one day. ”
54yo man with known a-fib presents to the ED with abdominal pain. You are on CCU overnight and get a call from J pod asking for help interpreting this ECG.
ECG credit Life in the fast lane
Today Dr. Kaldjian, Director of the Program in Bioethics and Humanities at the University of Iowa Carver College of Medicine and professor in the Department of Internal Medicine visited UTSW today.
After joining us at Morning Report today with resident Dr. Bryan Wilner presenting a very difficult and interesting ethical case.
Dr. Kaldjian then went on to give the Ethics Lecture during UTSW’s Update in Internal Medicine (lead by Dr. Weissler) entited “Ethics, Goals, and Role when Discussing Healthcare Costs with Patients.”
He spoke about the tension between patient-centered concerns and society-centered concerns. We were encouraged to think about which concern promotes the good of person vs. promotes justice.
Promoting the Good of Persons:
- beneficence (one patient at a time)
- utility (maximizing beneficience)
- commutative: giving to each what they are due as a person (in healthcare: to each according to their need)
- distributive: justice as fairness (similar treatment for similar cases)
Dr. Kaldjian also reminded the audience that as patient advocates, he encourages us to think about “intention.”
Some additional notes and references used in his talk. Enjoy!
Choosing your words wisely: stewardship vs. rationing
“Hospital-acquired bankrupcy” and a recent survey by the Kaiser Family Foundation: in order to pay the bills, what do patients?