Medical Grand Rounds Featuring Internal Medicine Chief Residents - Dr. Nicole Relke and Dr. Fiona Milne
Lubnaa Hossenbaccus, PhD Student (Translational Medicine)
On March 24th, 2022, our class excitedly welcomed the 2021 Internal Medicine Chief Residents, Dr. Nicole Relke and Dr. Fiona Milne, to our final TMED 801 class. We attended their Medical Grand Rounds presentations and had the chance to ask them questions in our discussion session.
We first heard from Dr. Relke who presented on tranexamic acid (TXA), based on her recently published illustrated review in the Research and Practice in Thrombosis and Haemostasis (RPTH) (1). TXA is a synthetic lysine analog that binds to plasminogen and stabilizes fibrin-rich clots to reduce bleeding (2,3). It has been on the World Health Organization’s Essential Medicine List since 2011 (4,5), after a landmark trial which reported that early TXA use in adult patients with trauma injury resulted in reduced risk of death (6). Despite its usefulness, systemic TXA can cause side effects and has a dose-related association with the occurrence of seizures (7). Dr. Relke addressed controversies about the increased risk of thromboembolic events with the combined use of CHC and TXA, stressing the importance of shared decision making for patients with heavy menstrual bleeding.
Based on the altimetric score, Dr. Relke’s illustrated review was ranked the RPTH’s #1 paper of 2021. The review was very well-received, and she shared that illustrated reviews are more easily integrated into teaching resources and allow for better social media engagement. Dr. Relke also mentioned that it was a fun experience to create the review; she believes that there is a need for further creative and translational dissemination of scientific knowledge.
Dr. Milne’s talk, on the other hand, focused on the assessment of malnourished patients in the hospital, an aptly timed presentation with March being Nutrition Month. She discussed malnutrition, undernutrition specifically, and shared that malnourished patients are 7 times more likely to die (8). In an acute care setting, the “Integrated Nutrition Pathway for Acute Care” (INPAC) set the minimum standards for meeting the nutritional needs of in-patients (9). It involves 1) Screening, 2) Risk Identification, and 3) Formal Assessment. Screening is important to minimize the chance of missing malnourished patients as it does not rely on the recognition of symptoms by a healthcare worker, as would a referral process. The “Canadian Nutrition Screening Tool” (CNST) (10) includes two questions: “Have you lost weight in the past 6 months without trying to lose weight?” and “Have you been eating less than usual for more than a week?” If patients answer yes to both questions, they are flagged. Following risk identification, the “Subjective Global Assessment” (SGA) is the gold-standard assessment tool (11). It comprises considerations related to a patient’s medical history and physical exam, and can be classified as A (well-nourished), B (moderately malnourished), or C (severely malnourished). While the screening and assessment tools are useful, they do come with limitations. We discussed how some patients may be missed, such as those who are intentionally trying to lose weight. Dr. Milne highlighted the benefit of careful and creative question choices when asking patients about their weight, such as whether their clothing fits differently or whether the number of belt notches they use has changed.
There are also new initiatives that aim to tackle this problem. In 2021, the “Malnutrition Prevention, Detection, and Treatment Standard” was released, however it has not yet been fully implemented (12). The MedPass program for in-patients allows for small volumes of high calorie and high protein supplementation to be given to patients while passing medications. While in hospital and despite having the desire to eat, some patients have trouble eating; KHSC is launching an Adaptive Feeding Program, which will provide patients with adaptive utensils to ensure that they are better able to feed themselves. Dr. Milne talked about how good weight monitoring systems would be helpful for assessing nutritional status, which affects all aspects of patient care. There remains the need for further research and better resources.
We ended our conversation with Drs. Milne and Relke on their role as Chief Residents. They reflected on how a large part of their role involved conflict resolution and being adaptable. They highlighted how providing validation and support went a long way during this challenging time. They are both continuing with their subspeciality trainings – Dr. Relke will be pursuing Haematology at the University of Toronto and Dr. Milne will be pursuing Gastroenterology at Queen’s University. We wish them both the best in their future endeavours and are grateful for their time and insights!
1. Relke N, Chornenki NLJ, Sholzberg M. Tranexamic acid evidence and controversies: An illustrated review. Res Pract Thromb Haemost [Internet]. 2021 Jul 1 [cited 2022 Mar 27];5(5). Available from: /pmc/articles/PMC8279901/
2. Lin H, Xu L, Yu S, Hong W, Huang M, Xu P. Therapeutics targeting the fibrinolytic system. Exp Mol Med [Internet]. 2020 Mar 1 [cited 2022 Mar 28];52(3):367–79. Available from: https://pubmed.ncbi.nlm.nih.gov/32152451/
3. Chapin JC, Hajjar KA. Fibrinolysis and the control of blood coagulation. Blood Rev [Internet]. 2015 Jan 1 [cited 2022 Mar 28];29(1):17–24. Available from: https://pubmed.ncbi.nlm.nih.gov/25294122/
4. Gill R, Ganatra B, Althabe F. WHO essential medicines for reproductive health. BMJ Glob Heal [Internet]. 2019 Dec 1 [cited 2022 Mar 27];4(6):e002150. Available from: https://gh.bmj.com/content/4/6/e002150
5. World Health Organization. eEML - Electronic Essential Medicines List [Internet]. [cited 2022 Mar 27]. Available from: https://list.essentialmeds.org/?query=tranexamic acid
6. Olldashi F, Kerçi M, Zhurda T, Ruçi K, Banushi A, Traverso MS, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet (London, England) [Internet]. 2010 [cited 2022 Mar 27];376(9734):23–32. Available from: https://pubmed-ncbi-nlm-nih-gov.proxy.queensu.ca/20554319/
7. HIGHLIGHTS OF PRESCRIBING INFORMATION. [cited 2022 Mar 28]; Available from: www.fda.gov/medwatch.
8. Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen DR, Gramlich L, et al. Decline in nutritional status is associated with prolonged length of stay in hospitalized patients admitted for 7 days or more: A prospective cohort study. Clin Nutr [Internet]. 2016 Feb 1 [cited 2022 Mar 28];35(1):144–52. Available from: https://pubmed.ncbi.nlm.nih.gov/25660316/
9. INPAC - CMTF - Canadian Malnutrition Task Force [Internet]. [cited 2022 Mar 28]. Available from: https://nutritioncareincanada.ca/resources-and-tools/hospital-care-inpa…
10. Identify patients who are at risk for malnutrition.
11. Assessment (SGA) - CMTF - Canadian Malnutrition Task Force [Internet]. [cited 2022 Mar 28]. Available from: https://nutritioncareincanada.ca/resources-and-tools/hospital-care-inpa…
12. Malnutrition Prevention, Detection and Treatment Standard - CMTF - Canadian Malnutrition Task Force [Internet]. [cited 2022 Mar 28]. Available from: https://nutritioncareincanada.ca/prevention-and-awareness/malnutrition-…