October 2010

My Kind of Medicine: Real Lives of Practicing Internists: Dustin Engelken, MD

Dustin Engelken was new in town when the Mount Redoubt volcano erupted just 110 miles southwest of Anchorage. It was dead of winter, and the third longest subzero period on record. It was as he puts it, "not the best time to have moved there." A few days after the volcano went off, a local TV station came to the hospital where Dr. Engelken worked looking to interview someone about the health effects of volcanic ash. They chose him. He was a young physician with a new job in a strange town. He felt like a deer caught in headlights. "What did I know about falling ash from the sky?!" he says with a laugh.

Internal Medicine Interest Group of the Month: University of Alabama School of Medicine

The Internal Medicine Interest Group (IMIG) is one of the largest student medical interest groups at the University of Alabama School Of Medicine. We provide informative programming for medical students interested in learning more about careers in internal medicine and the array of subspecialty training opportunities following residency. We also educate students about the many benefits and opportunities for involvement in the medical community through the American College of Physicians.

Winning Abstracts from the 2010 Medical Student Abstract Competition: Assessing Potential Toxicities Of Gene Therapy: Insertional Mutagenesis Risk Following Aav Vector-mediated Gene Transfer

Hemophilia B is a severe bleeding disorder affecting 1 in 10,000 males. Gene therapy for Hemophilia B is a promising alternative to recombinant protein therapy. Long-term expression of coagulation factor IX (FIX) via stable gene transfer could reduce costs and risks associated with intravenous recombinant FIX infusions. In a human clinical trial (Manno, Nat Med 2006), our group has previously shown hepatic artery injection of an adenoassociated virus (AAV) vector expressing FIX (AAV-hFIX16) results in short-term efficacy and disease correction. A fundamental issue facing clinical gene transfer has to do with risk related to vector integration into the host genome. The consequences of AAV integration in in vivo systems is unknown. Here we present the results of a large-scale prospective study to determine whether integrated AAV vectors dysregulate nearby genes and increase cancer risk.

Subspecialty Careers: Highlights about Careers in Internal Medicine: Pulmonary Disease

Pulmonary medicine is the diagnosis and management of disorders of the lungs, upper airways, thoracic cavity, and chest wall. The pulmonary specialist has expertise in neoplastic, inflammatory, and infectious disorders of the lung parenchyma, pleura and airways; pulmonary vascular disease and its effect on the cardiovascular system; and detection and prevention of occupational and environmental causes of lung disease. Other specialized areas include respiratory failure and sleep-disordered breathing.

Did You Know You Can Enter the ACP's National Medical Student Abstract Competition?

The College sponsors local and national abstract competitions for medical students that offer monetary awards and the chance to win recognition. The winning entries in both the National Clinical Vignette and Research competitions are featured each year at the College's premier annual Internal Medicine meeting. National winners are awarded a monetary prize to offset the cost of attending the meeting, and finalists are invited to compete on-site in the poster competitions for monetary prizes.

The CDC Experience Applied Epidemiology Fellowship - Call for Applications

The CDC Experience Applied Epidemiology Fellowship is a one-year fellowship tailored for rising 3rd- and 4th-year medical students, designed to increase the pool of physicians with a population health perspective. Eight competitively selected fellows spend 10-12 months at the Centers for Disease Control and Prevention (CDC) offices in Atlanta, GA, where they carry out epidemiologic analyses in various areas of public health. Examples of previous and current areas of concentration include viral and bacterial diseases, cardiovascular health, obesity prevention, birth defects, STDs, injury prevention, and air pollution and respiratory health.

MKSAP for Students 4 Question 1

A 68-year-old man is evaluated in the emergency department because of a 5-day history of shortness of breath. He describes falling on the ice 5 days earlier and sustaining a large bruise on his right flank. That evening, he had trouble sleeping from the pain but finally managed to rest while sitting in a recliner. Over the past 5 days, he has had progressive shortness of breath; originally it was related to exertion, but it now occurs at rest. He continues to sleep in the recliner for comfort. He does not smoke.

On physical examination, an ecchymosis is evident on his right flank. He is mildly dyspneic during conversation. BMI is 25.7. Temperature is 37.6 °C (99.8 °F), heart rate is 112/min, respiration rate is 26/min, and blood pressure is 142/72 mm Hg. Oxygen saturation is 93% with the patient breathing room air. The trachea is in the midline, and jugular venous pressure is 6 cm H2O. The right posterior lung is dull to percussion, and there are decreased breath sounds on the right side of the chest. The cardiac point of maximal impulse is at the fifth intercostal space in the midclavicular line. No rubs, murmurs, or gallops are heard, and there is no evidence of edema.

Which of the following is the most likely diagnosis?
A. Chylothorx
B. Hemothorax
C. Pneumonia
D. Pulmonary embolism
E. Transudative pleural effusion

Answer

MKSAP for Students 4 Question 2

A 30-year-old woman is evaluated in the office during a routine examination. Her medical history is noncontributory, and her family history is unremarkable. Physical examination is normal.

The patient is fair skinned and freckled and seeks advice on how to avoid developing skin cancer.

Which of the following interventions is most likely to reduce this patient's risk for malignant melanoma?
A. ß-Carotene
B. Selenium
C. Sun-avoidance strategies
D. Sunscreen with sun-protection factor >30

Answer

Advocacy Update: The ABC's of Health Policy

If you are like us, your fellow medical students, family members, and non-medical friends have turned to you at some point in the last few months and said, "Hey, what do you think about the public option?" While you may be a policy whiz, I think we all know many medical students who are completely befuddled by the discussion currently underway nationally, as well as by the day-to-day issues involved in health insurance and billing.

Ask the Program Director

IMpact is developing a new feature that will focus on providing medical students practical advice to help them navigate the process of obtaining a residency position in internal medicine. Issues to be covered include CV development, writing a personal statement, the Match process, residency program interviews, and more. At this time, we are collecting questions and issues that medical students would like addressed by program directors. We will then recruit volunteer program directors to answer those questions in a series of monthly columns that will be included in upcoming newsletter editions. Please send your issues and questions to Kelly Lott, Programs Administrator, at klott@acponline.org.

In the Clinic: Chronic Obstructive Pulmonary Disease

In the Clinic is a monthly feature in Annals of Internal Medicine introduced in January 2007 that focuses on practical management of patients with common clinical conditions. It offers evidence-based answers to frequently asked questions about screening, prevention, diagnosis, therapy, and patient education and provides physicians with tools to improve the quality of care. Many internal medicine clerkship directors recommend this series of articles for students on the internal medicine ambulatory rotation. This month learn more about Chronic Obstructive Pulmonary Disease.

MKSAP for Students 4 Answer 1

Answer B: Hemothorax

The patient's history of trauma and the evidence of significant injury point to hemothorax as the most likely cause of his dyspnea. Hemothorax is most commonly due to trauma, either blunt or penetrating (including iatrogenic). Examination should include auscultation and percussion of the chest with the patient in the upright position. (Examination of the patient in the supine position will obscure findings.) Nontraumatic causes of blood in the pleural space are less common. They include malignancy, blood dyscrasias, pulmonary embolism, bullous emphysema, and necrotizing infections, including tuberculosis. Cases have been reported of endometriosis causing hemothorax.

Pneumonia usually presents with cough and evidence of infection (fever, chills, or sweats). Chest pain is common, as is abdominal pain in patients with lower-lobe pneumonias. Cough is also a strong clinical factor in patients with atypical pneumonias. This patient describes primarily dyspnea and orthopnea and shows no other evidence of pneumonia or infection. Pulmonary embolism must be considered in all patients with dyspnea and could have a similar presentation. However, this patient's symptoms began the night of the injury and progressively worsened, and he does not have the marked hypoxia associated with pulmonary embolism. This patient also has no known predisposing factors for pulmonary embolism (obesity, immobilization, recent surgery, or known cancer). Pleural effusion as a result of heart failure (transudative pleural effusion) must be considered because of the patient's orthopnea. However, his examination does not support such a diagnosis because of the absence of an S3 gallop, crackles, and elevated jugular venous pressure. Chylothorax is drainage of lymphatic fluid into the pleural space secondary to disruption or blockage of the thoracic duct. It is usually associated with malignancy (non-Hodgkin's lymphoma accounts for almost 60% of cases), but it can also be idiopathic or due to cirrhosis, tuberculosis, or filariasis. About 25% of cases of chylothorax are preceded by cardiothoracic procedures. Nonsurgical traumatic chylothorax is rare and not consistent with this patient's history of trauma followed by dyspnea.

Bibliography
1. Miller LA. Chest wall, lung, and pleural space trauma. Radiol Clin North Am. 2006;44:213-24, viii. [PMID: 16500204] [PubMed]

MKSAP for Students 4 Answer 2

Answer C: Sun-avoidance strategies

Avoiding the direct sunlight during peak hours and wearing broad-rimmed hats, long-sleeved shirts, and long pants are associated with a decreased risk for squamous cell carcinoma and its precursors, as well as malignant melanoma. The regular use of sunscreen has been shown to decrease the risk for developing solar keratoses, the precursors to squamous cell carcinoma; however, a meta-analysis found no association between melanoma risk and sunscreen use. The exact reasons for this surprising observation are not known, but it may be that fair-skinned people who are at increased risk for melanoma wear sunscreen more frequently than those who have a lower risk for melanoma. It is also possible that sunscreen does not filter the spectrum of solar radiation most responsible for melanoma initiation or promotion. One double-blind, randomized, placebo-controlled trial offers some insight: 87 young white adults were randomly assigned to use sunscreen with a sun-protection factor (SPF) of either 10 or 30 during their vacation. Those assigned to use sunscreen with an SPF of 30 spent a longer cumulative and average daily time sunbathing over the course of their vacation than those who used sunscreen with an SPF of 10. This finding suggests that although sunscreen may protect against the rays most responsible for sunburn, it may encourage more exposure to rays associated with melanoma formation. Because of this seeming paradox between sunscreen use and melanoma, countries such as Australia that have a very high incidence of skin cancer and melanoma emphasize sun avoidance and protective clothing more than sunscreen use.

Whereas ß-carotene has not been found to provide protection for the development of new skin cancer in patients with prior nonmelanoma skin cancer, selenium has been associated with a statistically significant increase in nonmelanoma skin cancer compared with placebo in patients who are at high risk for skin cancer.

Bibliography
1. Dennis LK, Beane Freeman LE, VanBeek MJ. Sunscreen use and the risk for melanoma: a quantitative review. Ann Intern Med. 2003;139:966-78. [PMID: 14678916] [PubMed]