Late last week at the VA, Dr. Nivi Arora (rising PGY3) asked the question “How do I handle prophylactic anticoagulation in my patient with acute myeloid leukemia undergoing induction therapy?”
This is a complicated question, weighing the risk of VTE in patients who are presumed to be hypercoagulable vs the risk of significant hemorrhage as these patients become pancytopenic. However, some studies do exist to assist us with our decision-making.
– The pathogenesis of VTE in acute leukemias is multifactorial and difficult to predict
– Venous thromboembolism occurs in 8-10% of patients with AML during induction chemotherapy with 7+3.
– Increased D-dimer >4.0 mg/L may be predictive of a thrombotic event.
– There is a wide variability in practice patterns with regards to VTE prophylaxis. Most who chose to order VTE prophylaxis used a platelet count of 50k/uL as the cutoff for discontinuing prophylaxis, although this was also variable. The most popular VTE prophylaxis method is SCDs, followed by heparin +/- SCDs
BLOOD, 6 OCTOBER 2016 x VOLUME 128, NUMBER 14
CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA, DECEMBER 2015, COLUME 15, NUMBER 12
This morning at the VA Quality Improvement Morning Report we discussed signout safety by using the illustrative case found here.
In this case, a patient received inappropriate full-dose anticoagulation instead of the intended DVT prophylaxis dosing of heparin. The authors described that ambiguous signout/handoff was the culprit. Specifically, the lack of descriptive contingencies regarding exact dosing of the intended medication and route of administration contributed greatly to the outcome.
The Joint Commission in 2016 identified that nearly 50% of all sentinel events reported to them involved handoff failures. As a result, improving the handoff process is a leading patient safety goal. However, several barriers exist that add difficulty to the handoff process, including the increasing complexity of hospitalized patients, work restrictions, and increasing frequency of handoffs. Improving the handoff process is both of incredible importance, and enormous difficulty.
Starmer and colleagues published a successful study in JAMA in 2013 describing their results after implementing a handoff “bundle”. The bundle consisted of an initial 2 hour training session, introduction of the SIGNOUT? mnemonic, and restructuring the institution signout to be a unified team handoff. Handoffs were occasionally supervised and a computerized tool automatically imported patient information, leaving the “Summary”, “To-Do”, and “Contingency” as the only free-form sections.
The authors tracked medical errors for 3 months prior to the intervention and 3 months after the intervention and found a significant decrease in the total number of errors from 33.8 per 100 admissions to 18.3 per 100 admissions.
- Handoff is a risky period. Taking the time to ensure signout is clear and thoughtful is something we all owe to our patients.
- Finding the appropriate level of detail to include in the signout takes experience, but erring on too much detail is better than not enough
- Standardized handoff method such as SIGNOUT? or I-PASS appear to reduce erros
- The electronic medical record and computer can help you, but cannot replace you.
Yesterday during morning report, Dr. Mirza presented a case of a patient who received ipilimumab then developed hypophysitis, a known adverse effect of ipilimumab.
Immune-related adverse events (IRAEs) are beginning to be recognized more frequently as the use of immunotherapy in cancer increases and reports of IRAEs continue to be reported. Recently, NEJM published a review of IRAEs associated with immune checkpoint inhibitors. A retrospective review of ipilimumab-induced hypophysitis (IIH) was also published in 2014.
IIH most frequently presents with headache and fatigue. Hyponatremia is also a frequent finding. Patients will present with laboratory findings of anterior hypopituitarism (low FT4 with low or normal TSH, low morning serum cortisol, low prolactin, low FSH/LH). On imaging, this patients have mild to moderate pituitary enlargement with enhancement in MRI.
The pathophysiology of IRAEs is unknown but is presumed to involve T-cells, antibodies, and cytokine responses. Similarly, optimal treatment is unknown; currently steroids are used to suppress inflammation temporarily in addition to holding the immunotherapy. They can occur at any time during treatment. Retreatment may be an option for some patients; the risk of recurrence is likely related to the severity of IRAE.
Rising third-year resident Dr Neil Keshvani published a Teachable Moment in the most recent issue of JAMA IM.
His case involved a patient who presented to the clinic with signs and symptoms of gonorrhea. He was successfully treated, however had the return of symptoms 3 weeks later, prompting a return to the clinic. Further history elucidated the symptoms were likely due to re-infection and illustrates the necessity for partner therapy to prevent re-infection.
Gonorrhea infections in the United States are increasing, with more than 468000 cases reported in 2016. Once an infection is identified, patients must be referred to the health department and an extensive history of all sexual partners within the last 60 days must be documented. Treatment is fairly simple, with dual ceftriaxone and azithromycin still recommended by the CDC. A test of cure should be performed within 3 months of completion of therapy. Novel strategies such as inSPOT to discretely notify possible infected partners and expedited partner therapy can potentially decrease the rates of re-infection. EPT in particular reduces rates of recurrent infection by 25% relative to asking the patient to refer partners.
The case can be viewed here.
Great work Neil!
Current PGY3 residents Drs Carolina De La Flor and Christina Yek recently presented research at the NIH.
Dr. Yek presented her study “Epidemiology of Invasive Fungal Disease in Lung Transplant Recipients”. In this study, Dr. Yek notes that risk factors for invasive fungal disease within a year after transplant include male gender and repeated bouts of CMV.
Current PGY3 and future MD Anderson Heme/Onc fellow Dr. Joe Moore publishes his research “Practice Patterns and Impact of PostchemotherpayRetroperitoneal Lymph Node Dissection on Testicular Cancer Outcomes”
in the European Urology Oncology journal. In this work, Dr. Moore and colleagues searched the National Cancer DataBase for all patients with testis cancer receiving multi-agent primary chemotherapy to determine patterns and outcomes among those who received post-chemotherapy retroperitoneal lymph node dissections (PC-RPLND) vs outcomes of those who did not.
Overall, they were able to analyze 5062 patients. In their cohort, 1230 received PC-RPLND, 32032 did not. The study authors ultimately demonstrate a survival benefit for PC-RPLND that was independent of other risk factors on multivariate analysis.
Great work Joe!
A narrow victory came down to the Final Jeopardy at the annual spring bowl Jeopardy competition.
Faculty and residents were going back-and-forth with questions such as “What is Kounis syndrome?” and “Who is Dr. Weiss-liraglutide”. The faculty entered Final Jeopardy with 8000 points and the residents had 7300 points. The faculty wagered 6,601 points and the residents wagered a single point.
The final answer was a composite of:
The sum of “The two-digit number in the antibody seen in diffuse scleroderma anti-SclXX + The absolute difference between the minimum systolic and diastolic blood pressure indicating stage 2 HTN in the new AHA guidelines + the minimum Glasgow coma scale + The CD4 count under which toxo prophylaxis should be given in patients with +IgG + ECOG grade of a healthy person + the number of current chief residents born outside the United States”
The final question is “What is 225?” however both faculty and residents answered “What is 226?” after miscalculating the number of chief residents born outside the United States.
As a result, the residents won by 5900 points!
Interns and PGY2s were given their teaching awards from the clerkship directors Drs Stephanie Brinker and Reeni Abraham. To win the award, residents had to be nominated by their medical students.
An astonishing 40% of the intern class was nominated for the award and 50% of the PGY2 class was nominated.
PGY1 Drs Danny Guidot, Nate Milburn, Kim Berger, and Megan Milne all received honorable mentions for their dedication to teaching on the wards. PGY2 Drs. Patrick Nolan (med-peds), Katie Gavinski, Danny Yang, and Jessica Barnes all received honorable mentions as well.
There was a four-way tie among the interns for the Teaching Excellence Award. Dr Bruno Alvarez was recognized for devoting time to teaching as well as demonstrating the art of medicine to his medical students. Dr. Stephane Buteau was noted by his medical students to be knowledgable beyond his training and calm under pressure with an amazing fund of knowledge. Dr. Geoffrey McCrossan was lauded for his maturity and support of his medical students. Dr. Andrew Sumarsono encourages his students to think independently and puts effort into teaching his medical students.
There was also a three-way tie for the second-year residents. Dr. Allison Lange was an amazing role model and physician. Dr. Nagendra Pokala is “PHENOMENAL” as stated on his medical student evaluations. Dr. Nate Meier is a “wonderful physician” and one students potential reason for choosing IM(!!!).
We congratulate our interns and residents for doing a great job teaching their students!
Yesterday at the VA, Dr. Ari Bennett presented a fascinating case of dysphagia and odynophagia in which the final diagnosis was a small retropharyngeal abscess.
In diagnosing disorders that result in dysphagia, the patient history is crucial. The first step is to localize the dysphagia. Dysphagia that localizes to the neck or results in nasal regurgitation or aspiration is termed “oropharyngeal dysphagia” while dysphagia localizing to the chest is termed “esophageal dysphagia”. Additional history on associated symptoms, time course of progression, and circumstances of dysphagia is critical to eliciting potential causes. Specific attention should be paid to the types of food that result in dysphagia.
The physical exam is important for eliciting signs of a systemic disease. In oropharyngeal dysphagia, neurogenic symptoms should be evaluated, as these can lead to diagnoses of ALS, Parkinson’s, or MS, in addition to other neuromuscular diseases. Thyromegaly or other causes of compressive symptoms should also be evaluated. Esophageal dysphagia is more difficult to evaluate by physical, but attention should be paid to signs of mucocutaneous disease that may also implicate the esophagus (scleroderma, epidermolysis bullosa, etc).
In oropharyngeal dysphagia, a swallow study or otolaryngoscopy can aid in diagnosis. Esophageal dysphagia will frequently require endoscopic and histologic examinations. Lastly, CT scans or endoscopic ultrasonography have narrow application but can be considered if a diagnosis remains elusive.
In Dr. Bennett’s case, the diagnosis was made by CT scan of the neck after a detailed history and physical was performed. The patient improved following a few days of clindamycin.
Source: Harrison’s Principles of Internal Medicine, 19e, Chapter 53.
Washington DC this past weekend was filled with residents from UTSW presenting their excellent work.
Current second-year residents Kristina Tzartzeva and Joseph Obi presented their research “Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients with Cirrhosis”. In this systematic review and meta-analysis, Drs Tzartzeva and Obi demonstrate the addition of AFP to ultrasound significantly increases the sensitivity for early HCC detection in patients with cirrhosis. This research was completed with Dr. Rich, a current GI fellow at UTSW, and the principal investigator Dr. Singal. Drs Parikh, Marrero, Yopp, and Waljee were also contributing authors on the study.
Second-year resident Ahana Sen presented her research “A Systematic Review of Failures Across the Colorectal Cancer Screening Process” in which she observes multiple causes for underuse and overuse and deviations from established guidelines for colorectal cancer screening. She postulates it would be possible to improve the effectiveness of CRC screening if these steps could be targeted. Dr Murphy was the principal investigator of this study, with significant contributions from Dr. Singal and Dr. Sigel.
Second-year resident Taylor Derousseau presented “Delayed Gastric Emptying in Pre-Lung Transplant Testing is Associated with Post-Transplant Acute Cellular Rejection Independent of Reflux”. In this study, Dr Derousseau retrospectively reviewed a database of prospectively collected data of patients undergoing lung transplant evaluation at UTSW. He finds an association with patients who had delayed gastric emptying also developing acute cellular rejection after lung transplant. Importantly, many of these patients with delayed gastric emptying were asymptomatic. Dr. Gavini was the principal investigator on this study, with contributions from Dr. Chan, Dr. Lo, and Dr. Kaza.
Intern Komal Patel presented her work “Use of Fresh Frozen Plasma to Correct Coagulopathy in Patients with Variceal Bleeding” with Dr. Agrawal and Dr. Sarode. She retrospectively reviewed cases of patients who presented with variceal hemorrhage to determine the effect of FFP on INR and outcomes, concluding this practice results in variable decreases in the INR and may be associated with rebleeding.
Lastly, third-year resident and rising Chief Resident Saroja Bangaru presented “Increased Use of Liver Transplantation as Therapeutic Option for Severe Alcoholic Hepatitis”. In this study, Dr. Bangaru surveyed transplant hepatologists about their practices and opinions with regards to liver transplantation in alcoholic hepatitis. Over half of respondents reported transplanting patients for severe AH, with excellent 1-year survival reported. Dr. Mufti was the principal investigator, with Dr. Pederson and Dr. Singal contributing to the work.
Help us congratulate our outstanding residents on their important work!