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Dr. Nicole Relke and Dr. Fiona Milne

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!

 

References

 

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-…

Comments

Name
Kiera Liblik

Mon, 03/28/2022 - 11:30

Hello Lubnaa,
Thank you for your summary and discussion of last week's MGR - you did a wonderful job encompassing two very different, but important, topics. In reading a bit about malnourishment in the hospital setting, I came across an interesting article about the Hospital Food Experience Questionnaire (HFEQ).(1) This questionnaire was developed by a Canadian group in order to predict in-hospital malnutrition and patient preferences.(1)

The HFEQ had good internal reliability and seems like an interesting way to guide patient nutrition in the hospital.(1) Of course, it is important to acknowledge that the administration of a questionnaire takes time, and may not always be feasible/practical for all patients. I would love to hear your thoughts and whether you think the HFEQ will be implemented nationally in the future.
Warm regards,
Kiera

1) Trinca, V., Iraniparast, M., Morrison-Koechl, J., Duizer, L., & Keller, H. (2021). Hospital Food Experience Questionnaire (HFEQ): Reliable, valid and predicts food intake in adult patients. Clinical Nutrition, 40(6), 4011-4021.

Name
Kiera Liblik

Hi Kiera,

Thanks for your kind words and for sharing your findings on the HFEQ.

I think the collection of feedback on patients' food experiences in the hospital is valuable. It seems to be a fairly straightforward questionnaire, with three subscales focusing on 1) Food Priorities, 2) Food-Related Priorities, and 3) Meal Ratings, so I do imagine that it would be fairly easy to implement in many different hospitals. There is the full-form questionnaire that has 22 items as well as a shorter 11-item version, so it appears to be versatile in terms of how a hospital may wish to use it. Given this, it certainly has the potential to be implemented nationally!

Lubnaa

Name
Lubnaa Hossenbaccus

Name
Cassie Brand

Mon, 03/28/2022 - 11:52

Hi Lubnaa,
Great job facilitating last weeks discussion, especially with the challenging hybrid format! I really enjoyed reading your post and think you did a great job of summarizing our time with Dr. Milne and Dr. Relke. One thing I found really interesting was being introduced to the upcoming genra of illustrated reviews. As a visual learner, I am very excited about this prospect and think that use of this style would benefit my personal learning. It is suggested that a large proportion of the population are visual learners, and I am wondering how you personally see this benefiting the translation of knowledge in both the scientific and lay community. Do you think that these types of reviews will make information more accessible to a larger population? Or do you think there will be challenges associated with interpretation of visuals that could possibly make them less effective?

Best,
Cassie

Name
Cassie Brand

Name
Kyla Tozer

Tue, 03/29/2022 - 08:19

In reply to by Anonymous (not verified)

Hi, Lubnaa,
You did such a wonderful job navigating this online/in person MGR with Dr. Milne and Dr. Relke. Both topics were vastly different and extremely interesting. One of the major take away's I had was the visual reviews and how many people could benefit from this type of analysis. I wondered the same thing has Cassie, as to the challenges associated with interpreting the visualization, and the efficacy associated with personal interpretation. I would love to hear your thoughts on that. Secondly, I was blow away by the costs associated with Transexamic acid. Do you think there should be a regulation on costs for drugs like this? I always think of the costs associated with opioids, versus life changing drugs, like Tansexamic acid.
Thank you again, Lubnaa,
You did a wonderful job and I look forward to hearing your responses.
Kyla

Name
Kyla Tozer

Hi Kyla,

I've shared my thoughts on potential challenges of illustrated reviews as a response to Cassie's post and would encourage you to take a look - I'd be interested on your thoughts on the topic as well!

As for your question on TXA, I was also surprised at the costs of it, especially as a WHO "essential drug". Dr. Relke mentioned that it is mainly a concern in the out-patient setting in the absence of insurance, often in cases of heavy menstrual bleeding (HMB). I do wonder if government regulations could be put in place to better support these individuals, as it is well-known that HMB has a significant impact on quality of life and a heavy economic burden (1).

Lubnaa

(1) https://pubmed.ncbi.nlm.nih.gov/24266506/

Name
Lubnaa Hossenbaccus

Name
Lubnaa Hossenbaccus

Sat, 04/02/2022 - 14:03

In reply to by Anonymous (not verified)

Hi Cassie,

Thanks for this interesting question! I do think that illustrated reviews have the potential to be translational and more accessible, however, I think the actual content will also impact their relatability to various audiences. A highly technical illustrated review, such as with many graphs and specialized scientific terminology, will still require knowledge synthesis and critical appraisal as would a written review. As such, I think the illustrated medium may facilitate knowledge translational, though the authors' considerations of who their audience is will also be necessary.

Lubnaa

Name
Lubnaa Hossenbaccus

Name
Alyssa Burrows

Mon, 03/28/2022 - 11:53

Hi Lubnaa,

Excellent post succinctly summarizing two excellent talks, I appreciated the enthusiastic energy that you brought to the grand rounds discussion last week. Something that piqued my interest was the use of tranexamic acid (TXA) for people with menorrhagia which is described as excessive (>80mL/ cycle) or prolonged bleeding (>7 days) during menses (1). An early studied published in the British Journal of Medicine in 1970 established that four 1 gram tablets of TXA given four times daily for the first for days of menstruation significantly reduced menstrual blood lose (2). Four interventions have been shown to effectively reduce heavy menstrual bleeding in double blind placebo controlled randomized controlled trials (RCTs) levonorgestrel-releasing intrauterine system (LNG-IUS), tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDs), and danazol. In a meta-analysis of 4 placebo-controlled RCTs, TXA reduced menstrual bleeding by about 53 mL, roughly a 40% to 50% decrease. LNG-IUS, TXA, were superior to NSAIDs and danazol was found to be equivalent to NSAIDs. Another study highlighted that TXA was preferred to LNG-IUS as they reduce blood loss while conserving cycle patterns and fertility, and were better tolerated (4). In contrast to LNG-IUS which have shown to decrease menstrual bleeding, copper intrauterine devices (IUDs) sometimes have side effects of increasing menstrual bleeding. TXA and Ibuprofen (an NSAID) were both found to effectively reduce volume of blood lose and duration of copper IUD induced menorrhagia (5) Overall, as you mentioned, the treatment method used to treat heavy menstrual bleeding depends on patient goals and shared-decision making. In your research did you identify an gaps in TXA use or access for menorrhagia?

Looking forward to hearing your thoughts,

Alyssa

Citations:

Apgar BS, Kaufman AH, George-Nwogu U, Kittendorf AL. Treatment of menorrhagia. American Family Physician. 2007 Jun 15;75(12):1813-9.

Callender SL, Warner GT, Cope E. Treatment of menorrhagia with tranexamic acid. A double-blind trial. Br Med J. 1970 Oct 24;4(5729):214-6.

Lale A, Halajian E, Guthmann R, Nashelsky J. Which medications work best for menorrhagia?.

ERDOĞDU E, Necdet SU. Comparison of the Levonorgestrel-releasing intrauterine system and oral tranexamic acid in the treatment of dysfunctional uterine bleeding. Zeynep Kamil Tıp Bülteni. 2020;51(3):159-64.

Shahin MS, Ahmed AK, Galal SK. A comparative study between the efficacy of tranexamic acid and ibuprofen for treatment of menorrhagia induced by copper T-380A intrauterine device. Al-Azhar Assiut Medical Journal. 2021 Apr 1;19(2):279.

Name
Alyssa Burrows

Hi Alyssa,

Thanks for your kind words.

Dr. Relke mentioned that as an essential medication, TXA is available in hospitals, but a limiting factor to it's access may be cost-related in an out-patient setting when a patient does not have insurance, commonly in cases of heavy menstrual bleeding. Similar to my thoughts to Kyla's question, I think the maybe government regulations may be able to remove some of the financial burden from these patients to allow them access to such therapies.

As well, I think first and foremost, the proper identification that a patient may have a bleeding disorder that results in menorrhagia is important. many women are left undiagnosed, hence do not have access to the appropriate care that they need, including TXA (1).

Lubnaa

(1) https://pubmed.ncbi.nlm.nih.gov/33275722/

Name
Lubnaa Hossenbaccus

Name
Georgia Kersche

Mon, 03/28/2022 - 13:59

Hi Lubnaa,

Thank you for your excellent facilitation of our last Grand Rounds discussion! I really enjoyed reading your summary as well. During the presentation I was most surprised by the malnourishment screening questions and found myself with many questions about the kinds of patients these questions would miss. As you mentioned in your post, the questions are not sensitive or specific enough to correctly identify all undernourished patients (1). In particular, I think the questions and screening strategy neglects overweight and obese patients who we may not think are capable of being undernourished. In reality, it has been found that overweight and obese patients are actually more likely to have nutritional deficiencies due to their diet, attempts to lose weight, and concurrent chronic conditions (2, 3). Malnutrition is commonly found in people of all BMIs (4). One study found that up to 60% of obese critical care patients were malnourished (4). Do you think that moving away from weight- and appearance-based screening for malnutrition is an effective move to improve our detection of all malnourished patients? Looking forward to hearing your thoughts!

Best wishes,
Georgia

References
1. Ng, W. L., Collins, P. F., Hickling, D. F., & Bell, J. J. (2019). Evaluating the concurrent validity of Body Mass Index (BMI) in the identification of malnutrition in older hospital inpatients. Clinical Nutrition, 38(5), 2417–2422. https://doi.org/10.1016/j.clnu.2018.10.025
2. Brown, N. (2018). Overweight but Undernourished: The Leading Global Health Crisis.
African Journal of Food, Agriculture, Nutrition and Development,
18(1), 1A+. https://link.gale.com/apps/doc/A540601303/AONE?u=queensulaw&sid=bookmar…
3. Astrup, A., & Bügel, S. (2018). Overfed but undernourished: Recognizing nutritional inadequacies/deficiencies in patients with overweight or obesity. International Journal of Obesity, 43(2), 219–232. https://doi.org/10.1038/s41366-018-0143-9
Robinson, M. K., Mogensen, K. M., Casey, J. D., McKane, C. K., Moromizato, T., Rawn, J. D., & Christopher, K. B. (2015). The relationship among obesity, nutritional status, and mortality in the critically ill*. Critical Care Medicine, 43(1), 87–100. https://doi.org/10.1097/ccm.0000000000000602

Name
Georgia Kersche

Hi Georgia,

Thanks for this great question.

Evidence in the literature does suggest that it may be beneficial to move away from BMI-dependent screening tools as these may result in the underestimation of malnutrition risk of obese patients.

A team from the Netherlands (1) compared results from the Malnutrition Universal Screening Tool (MUST), a BMI-dependent tool, with the Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), which does not rely on BMI. They reported that more than one third of obese patients who were at risk of malnutrition were identified using the PG-SGA SF but were missed using the MUST.

Lubnaa

(1) https://pubmed.ncbi.nlm.nih.gov/33589809/

Name
Lubnaa Hossenbaccus

Hi Lubnaa and Georgia,

Georgia, I think you raise a very important point about screening for malnourishment in obese patients. We often associate eating disorders with malnourishment and significant weight loss. Asking patients about whether they have lost weight may help to identify patients with eating disorders such as bulimia or anorexia and help them to find appropriate psychiatric resources. However, binge eating disorder is believed to be the most common eating disorder (1). Binge eating disorder is an episode of eating, in succinct time period, an amount that is definitely larger than what most people would eat in a similar period of time. People with binge eating disorder feel a lack of control over eating during the episode and this can lead to obesity and malnutrition. The current screening questions would miss those with binge-eating disorder and their struggles would be overlooked. This is just another reason why we should move away from weight- and appearance-based screening to identify malnutrition.

Best,
Bethany
1. Smink, F. R., Van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current psychiatry reports, 14(4), 406-414.

Name
Bethany Wilken

Hi Georgia and Lubnaa,

Thank you for this great summary of the MGR! You bring up a great point that this screening may miss patients who are overweight or obese and undernourished. A recent study with patients with acute coronary syndrome found that 9-40% of patients were moderately to severely malnourished, and 48-58% of malnourished patients were overweight or obese. (1) In hospitalized patients, 23-25% of overweight or obese patients are at increased risk for malnutrition. This increased the duration of their hospital stay, from an average of 5 to 10-15 days. Malnutrition also increased risk of death, with an odds ratio of 6.4, including after controlling for BMI. (2) Many screening tools for undernourished patients include low BMI as a criteria, such as the Nutritional Risk Screening tool, which may cause healthcare providers to overlook overweight patients who are malnourished. (3) I think that using more inclusive tools to screen for malnutrition may help physicians identify patients who are overweight/obese and at risk of malnutrition. This is very important, as malnutrition is harmful to health outcomes, at all BMIs. The Nutritional Risk Screening tool uses BMI, decrease in food intake, and recent weight loss as criteria to determine malnutrition. Do you know of any other criteria not affected by weight that could be used to identify malnutrition? I look forward to hearing everyone’s thoughts!

Samantha

References
1. Freeman, A. M., & Aggarwal, M. (2020). Malnutrition in the Obese: Commonly Overlooked But With Serious Consequences. Journal of the American College of Cardiology, 76(7), 841–843. https://doi.org/10.1016/j.jacc.2020.06.059
2. Leibovitz, E., Giryes, S., Makhline, R., Zikri Ditch, M., Berlovitz, Y., & Boaz, M. (2013). Malnutrition risk in newly hospitalized overweight and obese individuals: Mr NOI. European journal of clinical nutrition, 67(6), 620–624. https://doi.org/10.1038/ejcn.2013.45
3. Reber, E., Gomes, F., Vasiloglou, M. F., Schuetz, P., & Stanga, Z. (2019). Nutritional Risk Screening and Assessment. Journal of clinical medicine, 8(7), 1065. https://doi.org/10.3390/jcm8071065

Name
Samantha

Name
Trinity Vey

Mon, 03/28/2022 - 20:15

Hi Lubnaa,

I think you did a fantastic job facilitating our discussion last week and have provided a very well-written summary. What an excellent discussion to end off our TMED 801 classes!

During the discussion portion, Asish asked an interesting question about biomarkers for malnutrition. I think that as scientists, we sometimes have a hard time with more subjective and context-dependent tools such as the Canadian Nutrition Screening Tool and Subjective Global Assessment. Dr. Milne was adamant that albumin is not a biomarker for malnutrition. Interestingly, hepatic proteins such as albumin and pre-albumin have been used for decades to evaluate nutritional status, however, evidence has shown they are not accurate indicators of nutritional status, and rather, are more greatly affected by other factors (1). Other potential biomarkers of nutritional status such as IGF-1 or 3-methylhistidine have been explored but to date, none have found widespread clinical use (2). I’m wondering if anyone has come across any other potential objective measures of malnutrition in the literature? Is this an area worth investing further research?

Thanks again!

Best,

Trinity

1. Marcason W. Should Albumin and Prealbumin Be Used as Indicators for Malnutrition?. J Acad Nutr Diet. 2017;117(7):1144. doi:10.1016/j.jand.2017.04.018
2. Keller U. Nutritional Laboratory Markers in Malnutrition. J Clin Med. 2019;8(6):775. Published 2019 May 31. doi:10.3390/jcm8060775

Name
Trinity Vey

Hi all,

Thanks Lubnaa for the fantastic recap of last week's discussion. It's been great to read everyone's thoughts on the interesting topics we learned about! Thinking of biomarkers, I am reminded of a discussion that we had in class about other indicators of malnutrition that have more to do with social determinants of health. With the movement towards electronic medical records systems, there are several built-in tools to assess and better understand malnutrition in patients. For example, the Junum app in the EPIC EMR looks at several indicators such as changes in grip strength, weight loss, body composition changes, energy and fluid intake to signal malnutrition in a patient's chart (https://apporchard.epic.com/Gallery?id=2580). As we move forward with technological innovation in healthcare, we can move towards an integrated approach to identifying and addressing malnutrition with data that's already available in the patient's chart for other reasons.

Name
Katie Lindale

Hi Katie,

That's really interesting; thanks for sharing this! I've also heard of "smart scales" that are linked to an app on one's phone, which record body weight. I recall that Dr. Milne mentioned that a record of a patient's changes in weight would be useful for potential diagnosis so I wonder if there may be a way to link up app-related data to a patient's health records. This may also be a means of empowering patients.

Lubnaa

Name
Lubnaa Hossenbaccus

Hi Trinity,

Thanks for your kind words and this interesting question.

I do think that a biomarker for malnutrition would be really useful, though the underlying cause or deficiency may be complex, so I'm not sure of the feasibility of a single marker. I've also come across hemoglobin and total cholesterol as useful biomarkers in older adults (1). It appears that many laboratory markers are not reliable on their own and should be complemented other data, such as a physical exam (2). With the SGA being a well-validated screening tool, I wonder if biomarker testing may be validated to be complemented with SGA results.

Lubnaa

(1) https://pubmed.ncbi.nlm.nih.gov/28771192/
(2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5193064/

Name
Lubnaa Hossenbaccus

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