The StethoSCOOP

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The StethoSCOOP
UCMC
INTERNAL
MEDICINE
The StethoSCOOP
RESIDENCY
V O L U M E
3 ,
I S S U E
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A U G U S T
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Weekly Calendar
SPECIAL
POINTS OF
INTEREST:
8/24: Noon Report: GI Team
 VP and MTP noon
reports
8/25: Noon Report: Renal Team
 Epic Phone Book!
8/26: Grand Rounds: Arun Sanyal, MD (Schiff Lecture): “NASH”
 Anemia bonanza
8/27: Weesner Prep: AKI with Li’
Academic Half-Day: NONE (Change day)
8/28: NONE (Change day)
Wishing Dr. Warm a
“T”-rrific “B”-day!
INSIDE
If you don’t know what all
those ligands, receptors,
and interleukins are, you
better eat...er, read up! :)
THIS ISSUE:
Epic Phone
Book
2
Powerpoint
Power
2
Open Door
Policy
2
IVDU at UCMC
3
Anemia tidbits
3
Board Review
4
VA Updates
4
Weekend to-do 5
Medical Trivia
5
Shoutouts
5
Anonymous Feedback
Our website has a section for anonymous feedback. Think of this like an electronic suggestion box that you can use at any time. The message will be sent directly to Dr. Warm, and is
completely anonymous. If you have constructive feedback that you would like to share,
please use this tool. The link is: http://intmed.uc.edu/education/residency/feedback.aspx
VOLUME
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2
Epic Phonebook
Did you know there is a Phone Book in Epic?
A phone book where you can find pagers and cell
phones for providers at UC??? Now you have no
excuse not to call attendings for assistance and
you can track down subspecialists at your whim.
Did you know YOU are listed in the phone book?
To access Phone Book, go to Epic menu
(top left), click on Tools, and find Phone
Book (see screen shot at right)
Powerpoint Power
Top tips:
Ben Kinnear with the Master Teacher
 Simplify the slides: More diagrams/visuals, less words.
Program and the Blue Team
People should be listening to your words and it’s confusing
demonstrated some how-tos and what-notto read at the same time
to-dos in Powerpoint presentations for

Give a few active learning objectives at the
noon report on Tuesday. Thanks to
beginning: audience can focus on what they should be
everyone for their feedback and discussion.
able to DO after the presentation
 Make it visible: be certain your audience can read text,
see graphs—no point in having it up there if they can’t see it
 Deliver the presentation: YOUR VOICE is the
presentation. The slides are for effect. Know the material
and rehearse, rehearse, rehearse. You will catch your
blunders and can practice timing to avoid awkwardness.
Open Door Policy
We know sometimes our door is closed and
we are sorry about that. Often we are
away, usually precepting in clinic or
attending on wards, or in meetings or
roaming the hospital getting miscellaneous
work done and trying to solve the problems
and address the concerns brought to us.
Sometimes we shut the door when we are
here having private discussions—please
keep in mind that if it was your business or
you were in the office with us, you
wouldn’t want the door open either.
THE
STETHOSCOOP
Even if we aren’t physically sitting
behind an open door, we ALWAYS
have a virtual open door policy
and you should know we are
ALWAYS available to you.
3 tips:
1. Always knock (we may be here)
2. Email at any time
3. Call at any time (our cell
phones are in the Epic phone
book!)
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3
Managing IVDU at UCMC
Recap:
Caroline Lee with the Vulnerable Populations
Pathway and the Green Team, along with guest
 Withdrawal: treat early with clonidine and antispeaker Dr. Feinberg, discussed and advised on
emetics. Acute withdrawal will directly worsen pain
topics related to heroin use in Cincinnati at Monday’s
and result in frustration and poorer patient outcomes.
noon report. Thanks to everyone for their discussion.
 Preventing overdose: Consider prescribing naloxone
for your patients being discharged on narcotics.
 Harm Reduction: Clean needle exchange can
effectively reduce transmission rates of HIV and HCV.
 Breaking the habit: If you have a IVDU who is
interested in quitting, contact Libby at 513-377-7114.
Mechanisms of Adaptation to Iron Deficiency
 Mediated by tissue hypoxia and suppression of the
hepatic hormone hepcidin
 hypoxia-inducible factor 2α (HIF-2α) stimulates
production of EPO by kidney. Erythropoiesis is increased,
senescent RBCs are destroyed and iron recycled by
macrophages.
 HIF-2α increases expression of the duodenal divalent
metal transporter 1 (DMT1)22 on enterocytes to increase
the absorption of dietary iron
 Hepcidin levels are depressed in response to a reduction
in the physiologic signals and erythropoiesis.
 Ferroportin (FPN), which is no longer being degraded
because of the low levels of hepcidin, facilitates dietary
iron absorption and iron release from macrophages.
 Reduced levels of iron in the liver trigger increases in the
synthesis of the iron carrier transferrin further decreasing
levels of iron-bound transferrin.
Adapted from: Camaschella C. Iron deficiency anemia. N
Engl J Med. 2015 May7;372(19):1832-43 PMID: 25946282
ITP
TTP
Thrombocytopenia: Yes
Yes
Increased PT/INR: No
No
MAHA:
No
YES
Fibrin/Fibrinogen: Normal Normal
Ok to give Platelets:
Clots?
Bleeding?
Treatment
THE
HUS
Yes
No
YES
Normal
HIT
Yes
+/No
Normal
Anemia Tidbits
DIC
Yes
YES
Yes
ABNL
Why don’t you give platelet transfusions in TTP?
It increases thrombosis. Only give platelets if patient
is having serious bleeding.
How is TTP different from HUS?
Acquired TTP is due to auto-antibody to ADAMTS13.
HUS is due to shiga toxin producing bacterial
Yes
No
No
No
Yes
infection, usually EHEC O157:H7. Toxin binds to
endothelial cells and inactivates ADAMTS13. Usually
+++
+++
++++
++
preceeded by bloody diarrhea, but not always. TTP
+
++++
+
has increased neurologic symptoms vs HUS has
IVIG Plasma- Supportive, D/c
Supportive, increased renal symptoms. Very hard to distinguish
Ster- pheresis antibiotics Heparin Cryo if fibrin- clinically. Usually treat patient as if it were TTP oids
can worsen
ogen <100
plasma exchange
STETHOSCOOP
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BOARD REVIEW WITH THE CHIEFS
DUST OFF THOSE OLD STETHOSCOPES, FOLKS. IT’S TIME TO START GEARING UP FOR
BOARDS. HERE IS A QUICK PEARL WE LEARNED THIS WEEK:
Q:A 54-year-old woman is seen in the office for routine
Hgb 8.9
follow up. She has diabetes mellitus and RA. Her only
MCV 82
complaints are mild fatigue and mild morning joint
WBC 6900, normal diff
discomfort. She denies fevers, dyspnea, and weight loss.
She is able to perform duties and home and work. Family Platelets 459,000
and medical history are noncontributory. Her medications Reticulocyte Ct normal
include metformin and hydroxychloroquine.
Iron: 48 (50-212)
PE: Afebrile, BP 123/69, pulse 98, RR 16. Exam is
TIBC: 220 (265-497)
unremarkable.
Ferritin: 250 (11-306)
Labs are obtained and shown at right.
What would a bone marrow biopsy most likely show?
A: Bone marrow biopsy would show dense iron staining in macrophages but no staining in
erythrocyte precursors. The most likely diagnosis is anemia of chronic disease which is the
second most common cause of anemia after iron deficiency. The pathophysiology is complex
but increased hepcidin appears to play a major role. Hepcidin, a peptide hormone, inhibits
iron uptake in the duodenum as well as iron release from hepatocytes and macrophages.
When hepcidin is increased in states of inflammation (which would be protective in situations
such as sepsis), iron becomes trapped in bone marrow macrophages and hepatocytes. On
serum testing, anemia of chronic disease is characterized by normal to high ferritin with low
serum iron and low to normal TIBC. The RBC morphology may be normocytic or microcytic.
Gangat N, Wolanskyj AP.Anemia of chronic disease. Semin Hematol. 2013 Jul;50(3):232-8 PMID: 23953340
VA Updates
Monday Aaron Mulhall and Adam Cole kindly volunteered to teach Ultrasound-guided IJ
and Subclavian central lines. The residents were then able to practice placing central
lines on ultrasound compatible mannequins. We plan on practicing other procedures
over the next several months including lumbar punctures, thoracentesis and intubation.
THE
STETHOSCOOP
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Weekend To-Do: Tennis! Festivals!!!
Aug. 22: Brew Ha-Ha, 4p.m.-midnight. Sawyer Point, Pete Rose Way, Downtown. Features 50 comedians on four
stages and more than 120 beers and wine. Food trucks. Drinks wristband $5. Benefits The Cure Starts Now Foundation and other charities. Entry free. www.cincybrewhaha.com.
Aug. 22: Bootyard Bash, 3-10 p.m., Washington Park, 1230 Elm St., Over-the-Rhine. For one day only park transforms into real-live honky-tonk. Western-themed games, face painting, stilt walkers and more. Will Hoge, Carter
Winter, The Black Lillies and Jeremy Pinnell will perform. Free. 513-621-4400;washingtonpark.org/event/bootyardbash.
Aug. 22: Shakespeare in the Park, 7 p.m., Miami Whitewater Forest, 9001 Mount Hope Road, Crosby Township.
New production of “Romeo and Juliet.” Bring lawn chairs or blankets. Presented by Cincinnati Shakespeare Company. Free. 513-521-7275; www.cincyshakes.com.
Aug. 15-23: Western & Southern Open, Saturday-Aug. 23, Lindner Family Tennis Center, 5460 Courseview
Drive, Mason. Professional tennis tournament. 513-651-0303; www.cincytennis.com.
Aug. 23: Cincy Summer Streets, 11 a.m.-3 p.m., Hamilton Avenue, Northside. On Hamilton between Pullan and
Spring Grove Ave. Car-free space for everyone to walk, run, skate, dance, create art and more. Free. 513-4364990;www.cincysummerstreets.org.
TRIVIA
A month after swimming at
Cape Maclear, Lake Malawi, a
traveler develops fevers,
lethargy, and the rash shown
at right. What is the
eponymous name of this
condition and where did that
name originate? Hint: it’s not
malaria
Congratulations to Casey
Philipsborn for
identifying reticulocytes
and spherocytes in
autoimmune hemolytic
anemia.
First correct answer
to Rachel wins a $5
Starbucks gift card!
SHOUT OUTS!!! (Let us know who Rocks)
-shout out to the VA teams for their discharge efficiency. Joanna Marco did 7 discharges in
one day with no senior! Cody Lebeck-Lee did 7 to bring his team to a total of 11 in one
day! These must be records!
-shout out to Javier Baez for writing MICU notes so beautiful Dr. Norton should be jealous.
-shout out to Greg Wigger and Grace Escamilla for rocking night float.
-shout out to Joel Gabre from a seasoned past chief for doing an awesome job stepping up
to run a code.
-shout out to Erin Connolly for taking VA night float beatings like a champ, smile and all.
THE
STETHOSCOOP
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