A recording of this presentation is available HERE.
Thanks to Omi Patel, PharmD for an excellent presentation on Empiric Antibiotics, Antibiotic Stewardship and Diagnostic Stewardship in the Hospital. We are so lucky to have a close working relationship with our pharmacists who offer interdisciplinary team care.
A summary will be posted here soon. Check back!
A recording of this presentation is available HERE.
Dr. Rob Mejia Powell gave a really awesome talk this week about Anal Cancer Screening. He reminded us that, while anal squamous cell carcinoma-- almost entirely HPV-related -- is rare in the overall population (1-2 cases/100K person years). While most people are not high risk and should NOT be screened, there are higher risk populations who should definitely be screened with anal pap smears and referred to high resolution anoscopy (HRA), which is available through SRCH for internal and external referrals. Take a look at his presentation for some really great info. If you just want the brief notes, you'll miss out on the butt jokes.
Here's a reminder of what patients with anal cancer "look like", survivors of anal cancer: https://youtu.be/QYR3GWWAmjE?si=kolJuD1TrdgWXMBU
"Say the word 'anal anal anal' a million times until your friends get used to it."
Take a look at this table to see the relative incidence in certain risk categories:
Known risk factors include age, HPV infection (especially vulvar neoplasia in women), receptive anal intercourse, and immunosuppression (e.g. HIV, chronic steroid/immunosuppressants). Also note that the highest growing group in women.
Pathogenesis of anal cancer is similar to cervical cancer: Exposure to HPV > persistent infection > precancerous high-grade squamous intraepithelial lesions (HSIL, anal intraepithelial neoplasia (AIN grades 2 or 3)) > invasion to ASCC
Who should be screened?
The ANCHOR Trial, published in NEJM 2022 was a multi-site RCT that showed that, YES, screening at risk populations does work to prevent anal cancer. Primary outcome: anal cancer. Test subjects: Men with HIV age >35. Study found 9 anal cancers in the treatment group (those screened>> HRA>> treatment) vs. 21 cancers in the observation group. This equates to a 60% decrease in anal cancer.
A recording of this presentation is available HERE.
This week's Grand Rounds, by Dr. Alison Ohringer, was so phenomenal that I have literally been thinking about it nonstop since she finished. The topic-- Ehlers-Danlos Syndrome, Dysautonomia, and MCAS-- doesn't exactly sound titillating, but after years in primary care taking care of patients with chronic symptoms that I don't always know what to do with -- I had a serious physician "AHA moment".
Dr. Ohringer started with a silly meme that has now become an earworm for me: "If you cannot connect the issues, think connective tissues."
I have long thought of rheumatology and/or autoimmunity as a linking factor for non-specific symptoms in patients, particularly in women with fatigue, dizziness, and other systemic malfunctions. I also have long dreamed of studying how our enteric nervous system interacts with the central nervous system (leading to diarrhea, constipation, and anxiety), but I cannot say I had specifically tied in connective tissues to the issues-- until yesterday.
If you are a primary care provider, I definitely recommend watching this one! If you just want my notes, here goes. . .
Hypermobility= the ability of a joint to move beyond the normal range (can be isolated and/or benign (e.g. gymnasts) or generalized and/or symptomatic, impacting multiple joints and leading to pain, fatigue and can be associated with other symptoms)
Spectrum of severity of hypermobility:
Hypermobile Ehlers-Danlos Syndrome (hEDS), previously referred to as EDS type III, the most common subtype, is diagnosed by hx and clinical criteria. There is no genetic test. Many experience symptoms of Mast Cell Activation Syndrome (MCAS), Postural Orthostatic Tachycardia Syndrome (POTS) and related dysautonomia, small fiber neuropathy, and migraine
Hypermobility Spectrum Disorder (HSD) is diagnosed by history and clinical criteria, on a spectrum ranging from asymptomatic to chronic pain. Some may have some of the hEDS comorbidities, though they may be less severe
Prevalence:
Symptoms of mast cell activation include a variety of organ systems, including not only allergy, but also cardiologic (hypotension, tachycardia), GI (diarrhea, cramping), and constitutional (fatigue and even memory/concentration problems).
MCAS (mast cell activation syndrome) = MCAD + abnormal labs
Dysautonomia: all disorders of the autonomic nervous system resulting from imbalanced sympathetic/parasympathetic activation - can be a clinical diagnosis, can be diagnosed with certain tests
POTS: a form of dysautonomia meeting 2 specific diagnostic criteria: - History of orthostatic intolerance with or without systemic symptoms - Correlation of symptoms with a sustained increase in upright HR by at least 30 bpm (40 bpm if pt <20yo) within 10 minutes of standing or head-up tilt, without orthostatic hypotension
Common symptoms in patients with MCAD and POTS/dysautonomia
General: fatigue, night sweats, anaphylaxis, weight changes
HEENT: itchy/watery eyes, nasal congestion, itchy throat
Cardiac: light headedness, pre-syncope, palpitations, tachycardia, labile BP
Pulm: shortness of breath, wheeze, cough
GI: refractory acid reflux, intermittent abdominal pain, nausea, vomiting, diarrhea
GU: bladder irritability and frequent voiding, uterine cramps, heavy menstrual bleeding
Derm: hives, itch, flushing, rash MSK: long bone pain
Neuro: LH/dizziness, brain fog, neuropathy
Diagnosis and Evaluation:
