R2 Dr. Komal Patel and R1 Dr. Taylor Roberts had a manuscript published in Journal of Oncology Practice yesterday afternoon. Their paper details quality improvement methodology to reduce inappropriate rasburicase use at Parkland. After forming a committee to study the problem, interventions were designed to limit the inappropriate use, including changing the recommended dose and involving a pharmacy second review. Prior to implementing these changes, approximately 32% of all rasburicase orders, afterwards this rate dropped to 3.4%, with only a single inappropriate order in 8 months. Remarkably, this was accomplished without specialty-limiting the ordering of rasburicase or necessitating a consult prior to ordering.
Other authors on the study include past CMR Dr. Arjun Gupta, current CMR Dr. Tim Brown, Pharmacist Dr. Eileen Marley, and senior authors from the division of Hematology & Oncology Dr. Hsiao (Jenny) Li and Dr. Navid Sadeghi.
The full text of the article can be accessed here.
Congratulationss Dr. Patel and Dr. Roberts!
PGY2 Dr. Corbin Eule had his work published last week in BMC Cancer. Dr. Eule and colleagues looked at the published literature in palliative oncology to define the landscape of the literature as well as trends and areas that are absent or lacking in the field. Dr. Eule worked with APD Dr. Paulk on the study and the PI was Dr. Beg of hematology & oncology. The article is open access and can be found here.
Remember this pearl covered in CUH morning report last week regarding the sensitivity of the work-up for myeloma spectrum disorders:
- SPEP alone – sensitivity is 82%
- SPEP plus immunofixation– sensitivity is 92%
- SPEP plus immunofixation plus either Serum free light chains OR UPEP– sensitivity is 98%
At CUH & Parkland, the new SPEP always reflexes to immunofixation, so really what you should remember to do is send either the serum free light chains or the 24-hour UPEP, keeping in mind that SFLC is much easier logistically to do. If patients are admitted anyway, though, in practice, hematologists will recommend obtaining all 3 SPEP / SFLC / 24-hr UPEP.
This week at CUH MR, we talked about viral arthritis:
– Viral arthritis – responsible for about 1% of all cases of acute arthritis
– World-wide, parvovirus B19, hep B / C, HIV, and arboviruses (specifically alphaviruses, which includes chikungunya) are the most important causes of virally mediated arthritis
- Most commonly, viruses will cause a symmetric polyarthritis (similar in distribution to RA); HIV – arthralgias are more common than true arthritis
– Serologic testing may help the diagnosis but also helpful are associated clinical features that point to a specific virus (slapped cheek rash in parvovirus; jaundice related to hepatic injury in hepatitis viruses)
– Treatment goals are relief of symptoms and maintenance of function: acetaminophen / NSAIDs in doses typically used in inflammatory arthropathy like RA; steroids are discouraged because of limited utility in most viral arthritis; there is no role for anti-virals because the illness is self-limited in most cases
It’s been a big week for our second-year residents as two of them have had first author publications.
Dr. Corbin Eule had his publication “The Direct Antiglobulin Test for Evaluating Anemia” published in JAMA this week as part of their Diagnostic Test Interpretation series. Dr. Eule presents a patient case and the results of their labs and asks the reader to interpret them in a multiple-choice question. He then provides a nice overview of the DAT test. Co authors on the paper include Dr. Arjun Gupta (former chief resident and current hematology/oncology fellow at Johns Hopkins) and Dr. Srikanth Nagalla (hematology/oncology fellowship program director). Read the paper here.
Dr. Sumarsono had his publication “A 57 Year-Old Man With Subacute Progressive Hemoptysis and Fevers” published in CHEST. The paper details a case of a man presenting with hemoptysis and found to have an unusual diagnosis that was first considered after a specific physical exam finding. Co-authors on the paper include Dr. Timothy J Brown (current chief resident), Dr. Stan Atkin (former resident, current OHSU hospitalist), and Dr. Jason Clark (intensivist). Read the paper here.
From Dr. Cutrell’s antibiotic stewardship talk – see this helpful list of antibiotics with excellent PO bioavailability and take his advice to make the IV to PO switch when possible!
This week at morning report, we discussed TTP. Here is how you should think about the management of TTP:
Plasma Exchange: cornerstone of treatment. Perform daily until there is a complete response (see below).
Rituximab: beneficial to start early, there is data that suggests better remission rates when added to plasma exchange upfront.
Steroids: adjunctive because there is minimal data to back this up, but generally recommended if there is no contraindication.
These treatment modalities are initiated early and urgently in a patient with presumptive TTP. Treatment is continued until there is a complete response, which is defined by a platelet count above 150,000 for two consecutive days, together with normal or normalizing LDH and clinical recovery (ie end organ damage has resolved). After treatment, patients are most vulnerable to a recurrence within the first week after tapering of therapy. Patients are followed closely to assess for symptoms and for CBC/ADAMTS13 monitoring. What is unclear is what to do with patients who are asymptomatic but have a down trending/low ADAMTS13. In this situation, data suggests that treatment with rituximab can reduce the possibility of relapse, likely through decreasing the production of the antibodies inhibiting ADAMTS13.
Guidelines differ slightly between the different liver societies (AASLD & EASL & APASL) but most agree that we should screen the following high-risk groups:
- Patients with Child Pugh A or B cirrhosis
- Patients with Child Pugh C cirrhosis, only if awaiting liver transplant
- Non-cirrhotic patients with HBV infection & any of the following characteristics:
- Active hepatitis (ALT and/or high viral load)
- Family history of HCC
- Africans & African Americans (age does not matter)
- Asian males > 40
- Asian females > 50
- +/- Chronic HCV & advanced fibrosis (stage F3), rather than strict cirrhosis
Keep these in mind when you’re seeing your PCIM & PRIME patients!
Dr. Grodin gave us a terrific lecture on diuretic therapy in Acute Decompensated Heart Failure! Remember that when you admit patients with decompensated heart failure who are on diuretics at home, you should aim for about 2.5x the potency of their home diuretic regimen. Here is a helpful conversion table from today’s talk:
Last week at the VA, we discussed a case of MEN1 in morning report! Here are some pearls about MEN syndromes:
MEN1: The 3 Ps”
- Primary hyperparathyroidism – 90%
- (Anterior) Pituitary tumor – 40%
- MC prolactinoma à GH + prolactin à GH à non functioning
- ACTH / TSH secreting tumors are rare
- Pancreatic islet cell tumor
- Gastrinoma (ZES) – 30-40%
- Insulinoma – 10%
- Non-functioning – 20-55%
Caused by autosomal dominant mutation in MEN1 tumor suppressor gene
Clinical dx: 2+ MEN1 tumor types OR occurrence of 1 MEN tumor in a family member of a patient with diagnosis of MEN1
Who gets genetic testing? Any index patient with clinical MEN1, 1st degree relative of known MEN1 carrier regardless of symptoms, individuals with “suspicious or atypical MEN1”; if asymptomatic, offer genetic testing first to avoid extensive imaging / lab work-up
Who to screen: index patients & 1st degree relatives.
How to screen: Follow clinically for amenorrhea, galactorrhea, ED, growth abnormalities, nephrolithiasis, cushingoid changes, PUD / diarrhea, hypoglycemia, HA, visual changes. Labwork: annual Ca, PTH, gastrin (fasting), glucagon, VIP, pancreatic polypeptide, chromogranin A, insulin, fasting glucose, prolactin, IGF-1. Radiology: There is no consensus on radiologic screening guidelines – suggest annual pancreatic imaging with EUS/MRI/CT and MR pituitary q3-5 years
MEN2A & B:
- caused by autosomal dominant mutation in RET proto-oncogene
- MEN2A – has 4 variants, 60-90% of MEN2 syndromes
- MEN2B – 5% of all MEN variants
- Medullary thyroid carcinoma – typically earliest manifestation & almost all patients with MEN2 have it
- Pheochromocytoma – 50%
- Primary hyperparathyroidism – 10-50% of only MEN2A patients
- cutaneous lesions / mucosal neuromas, Hirschsprung’s disease
- thyroid, parathyroid, adrenal glands are at risk of developing tumors that reduce life expectancy –> importance of early diagnosis because of the excellent prognosis of medullary thyroid cancer if diagnosed early
- Who to screen: as a result, you screen first and second degree relatives of an index case.
- How to screen: plasma metanephrines, calcium / PTH, calcitonin and thyroid / neck US