Yale IM Traditional Residency Program
@TradIMYale
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X/Twitter Account of the Yale Traditional Internal Medicine Program. We post info relevant to the residency and also educational tidbits. Posts≠medical advice
New Haven, CT
Joined October 2023
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Why Yale?
A Thread by our Program Director Dr. Siegel
@MarkDSiegel1
We are sharing the whole letter here to make sure all our applicants will get a chance to read it.
🧵🧵
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To all our applicants,
You can join the general Open house tonight 9/16 at 7:30 PM EST for one more chance to meet our residents and learn about our program before the match deadline.
Event link:
#Match2025
#InternalMedicine
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Interested in learning more about our program?
We will host an open house soon to discuss why we love our program and answer some of your questions!
Stay tuned for the date!
@YaleIMed
@MarkDSiegel1
#Internalmedicine
#Match2025
#MedEd
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One of the best places to read & study on the
@YaleMed
campus, a few yards from the hospital:
The Cushing Historical Library 🏦, built 1941 in memory of Dr. Harvey Cushing, the famed neurosurgeon & Yale Professor.
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Another training opportunity Yale residents have is the POCUS Superuser track.
Under the supervision of Dr. Donroe, residents enrolled in this track are required to do 250 mentored POCUS scans & engage in POCUS teaching and research.
Photos: From Dr. Christopher Erb (LinkedIn).
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Shout out our brilliant
#InternalMedicine
residents presenting work at national conferences🎉! From cardiology to rheum, from GI to bioethics. Our residents can do it all! 🔬 Students and residents: check the thread for upcoming conferences that still are accepting abstracts!
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Ever seen a patient's med list grow and grow? Come read a case presented by Justin Dower, PGY-2 resident and CT-ACP awardee. Justin recently presented this case which showed a classic example of a phenomenon called the "prescribing cascade". Read on! 1/n
#PrimaryCare
#MedEd
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Highlights from our resident retreats so far this year ⛱️🖼️
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Coming soon to a hospital near you! 🌟 Big congratulations to all of our incredible Yale residents on this momentous Match Day. From fellowship to chief years, to hospitalist and primary care stars, we couldn't be prouder of our outstanding Internal Medicine crew! 🏥💙
#MatchDay
So happy for our
@TradIMYale
residents who matched into fellowship today! Here's our list of Traditional
@YaleIMed
residents who are entering fellowship and GIM fields. Congratulations to all!
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Yale20 is an online medical education initiative, led by our residents. Over the years, they produced many gems that showcase their potential as clinical teachers.
Here is one on ventilators. Check it out if you have an upcoming rotation in the ICU.
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Welcome home, future Trads! We look forward to having you!
Congratulations to the newly matched residents in our Internal Medicine Traditional Residency Program! Welcome to
@YaleMed
@Yale
@YNHH
!
🧵
#MatchDay2024
#Residency
#MedTwitter
#Match2024
@MarkDSiegel1
@TradIMYale
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What is the one disorder that can cause most known acid-base & electrolyte abnormalities?
The answer: Chronic alcohol use disorder (AUD).
Time for a tweetorial 🧵
1/14
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Do you have a conceptual understanding of hematuria? Check out an approach generated by one of our own residents compiled from a series of resources! It covers considerations for emergent hematuria, management differences between gross and microscopic hematuria, and more! 1/10
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If you have an upcoming ICU rotation, check these 10 ICU tips by our Program Director Dr.
@MarkDSiegel1
.
#8
is our favorite.
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A fantastic noon report today by
@ArcieriMichael
with an interesting case and clear algorithm on the DDx of Diplopia.
Algorithm/Image Source:
@CPSolvers
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Hi all! We lost access to the old Twitter account. Please follow us! We are the best resident-run Yale IM traditional residency program account on this entire app
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#Match2024
applicants! Meet one of our star residents Rachel! Why did she choose Yale IM? "The culture! The people...Yale is truly unique in that it is a highly respected academic program with vast amounts of world class research that maintains a welcoming, supportive community."
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Thank you Lara Rotter
@TradIMYale
PGY3 for sharing this heartbreaking story. A must read.
@TradIMYale
@annareisman
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Congratulations
@MaryamMooghali
on an incredible achievement 🎉👏🏻.
New study out in
@JAMANetworkOpen
led by
@YaleIMed
PGY-1
@MaryamMooghali
:
@US_FDA
Breakthrough Therapy Designation has been remarkably effective at reducing late-stage R&D times, but are these drugs getting to market faster also clinically meaningful? 🤔 1/
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One amazing opportunity our residents are exposed to is Yale's refugee clinic.
We work with local agencies to help refugees with resettlement & addressing their healthcare needs.
This is a part of our program's commitment to serving our local community.
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Looking forward to seeing you all!
In the sign-up form, you can drop your questions, and we will be happy to answer them during the events.
Join us for one of three webinars starting tonight for Yale Internal Medicine's Traditional Residency Training Program!
@TradIMYale
@MarkDSiegel1
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🩸Did you know studies show thrombophilias 🔼your DVT risk but not DVT recurrence? PFOs 🔼 stroke but not stroke recurrence? Smokers having a better prognosis post-MI than non-smokers 🤯? These observations can be partly explained by something called INDEX EVENT BIAS!
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What a view! 📸🏛️
Thanks
@XMichaelJonesMD
for the great picture!
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Congrats to our amazing former Chief
@kaushik_ramya
!!!!
What started out as a clinical ? ended up here!
@TradIMYale
@YaleIMed
Things We Do for No Reason™: Checking QTc on hospitalized adult patients before intravenous ondansetron administration - Kaushik - Journal of Hospital Medicine
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Some pearls on hyperkalemia: Do you have a framework for figuring out the etiologies? Things to consider: is it real (pseudohyperK), decreased excretion of K, cells breaking open, and things that influence compartmental distribution of K
#MedEd
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What a story!
Inspiring & Educational!
Another gym from Dr. Siegel.
Not the Call I Expected- A
#ProgramDirectorsNote
to my
@TradIMYale
residents.
You never really know, do you?
@YaleIMed
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Congrats Santiago!!!!! So proud of this incredible work
Excited to share our two research articles from the
@YaleVAMOS
team now out in
@JVascSurg
!!
Always grateful for the support and for learning every day from my mentors
@KimGSmolderen
@CarlosMenaYale
@GaelleRomain_Y
. Thankful every day to be training here at
@YaleIMed
@TradIMYale
!
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THUR 7 MAR | 6:30 pm | Join us IN PERSON for guest Senator Dr. Saud Anwar’s presentation on “Medicine and Public Policy: What do you need to know about public health policies in 2024?”
@YaleIMed
@YaleMed
@YaleSPH
@Yale
@SaudAnwarCT
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Congrats to our incredible resident Talal!!!!
After adjuvant immunotherapy what comes next in RCC? Check out our work in
@EUplatinum
as we try to answer some of the questions in this evolving field! Thread by
@KarlSemaan
below. A special thanks to our collaborators and
@DrChoueiri
@DrDanielHeng
for the mentorship & support!
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Another frustration is that, even after you replete electrolytes early during admission, alcohol-induced tubular dysfunction takes wks to resolve after abstinence, so deficits commonly recur.
So, it is important to keep monitoring & repleting electrolytes throughout.
13/14
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We hope you enjoyed this tweetorial. If you want to learn more, here are some suggested readings:
1.
2.
Until next time 🙂
14/14
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A common acid-base imbalance in AUD pts is anion-gap metabolic acidosis (AGMA), often named "alcoholic ketoacidosis".
Briefly, chronic AUD reduces insulin levels dt glycogen depletion. This, with ⬆️ sympathetic stimulation, cortisol & GH levels ⬆️ fatty acid mobilization.
4/14
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For a start, 10.2% of the US population >12 yo have alcohol dependence (per the NIH 2024 statistics).
The m/c abnormalities on presentation are metab acidosis and hyponatremia. The telltale sign of chronic AUD is rapid ⬇️in plasma PO4, Mg, K, and Ca in the first 24-36 hrs.
2/14
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@YaleMed
Take a 4K tour of the library and the Cushing Center Brain Exhibition beneath its floors.
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@ArdestaniBahar
@YaleIMed
@YaleRadiology
@khosravi_bardia
@YaleIM_Chiefs
@MarkDSiegel1
@MayoMrfa
@StoriesImg
@Inside_TheMatch
Congratulations you two! We look forward to working with you!
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In their paper, they point out three common examples of prescribing cascades.
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The prescribing cascade refers to a phenomenon where an adverse drug reaction is misinterpreted as a new medical condition. As a result, prescribers recommend an additional drug to treat the adverse reaction of a previous one.
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Patient develops symptomatic orthostatic hypotension. In order to make it easier for him to tolerate physical rehabilitation, the primary hospital team starts him on fludricortisone. He then develops scrotal edema and lower extremity swelling...
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Thanks for reading along and I hope you'll be more wary of considering adverse drug reactions as part of your differential and to think twice before prescribing a new med, especially in our geriatric populations!
#Polypharmacy
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Share your thoughts on this approach! How do you conceptualize this as an internist?
#MedEd
#MedTwitter
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One of the most influential papers on this topic was published in BMJ by Rochon and Gurwitz.
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We start with a case: Justin sees a patient in clinic. He recently presented to the hospital with systolic BP in the 220s with signs of stroke concerning for hypertensive emergency. For his chronic BP regimen he is started on carvedilol, and that's where the cascade commences...
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In his presentation, Justin points out that continuity of care and thorough primary care can serve as an additional layer of protection against this phenomenon. This is especially important because patients will often transfer between hospitals, subacute, and outpatient settings!
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As a result, he is thrown on furosemide -- this leads to a decline in his potassium levels and patient is started on a potassium supplementation tablet. This is a classic example of the prescribing cascade!
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Justin's resident primary care clinic is at the Fair Haven clinic, a FQHC that serves the multilingual communities in the surrounding areas regardless of ability to pay. This is one of multiple clinics that Yale residents can parttake in during their immersion blocks!
#match2024
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So what ended up happening? The patient was slowly deprescribed antihypertensives to good effect other than losartan (for which he was given a dose increase). At Justin's clinic, there is a remote BP monitoring program that helps faciliate this in conjunction with telehealth!
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The increased ADH level ⬇️ free water clearance ▶️ hyponatremia (in up to 17% of pts w AUD).
You may have heard the term "Beer potomania". Beer already has low Na levels. So, in pts w/o good PO intake, this ➕the ADH effect described above can lead to severe hyponatremia.
9/14
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@sacalle1
@CarlosMenaYale
@KimGSmolderen
@GaelleRomain_Y
We're excited to work with you,
@sacalle1
!
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Worth noting that despite acidosis, only 50% of pts have acidemia.
You can also get metabolic alkalosis (w protracted vomiting), respiratory alkalosis (w alcohol withdrawal) or respiratory acidosis (as very high alcohol levels can suppress the brainstem centers).
7/14
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But how does alcohol cause all of these changes?
Buckle up for a pathophysiology dive.
3/14
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So what's the solution? Rochon and Gurwitz point out some potential solutions to mitigate this phemenon.
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When ketoacids enter the EC space, they lose H ➡️+ HCO3=H2CO3 ➡️ CO2 (exhaled)+H2O. The acid salt is filtered in urine, pulling Na or K with it.
This can correct the AG but induces renal retention of dietary NaCl ➡️ hyperchloremic normal gap MA.
Palmer & Clegg. NEJM 2017
6/14
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Last, but not least, alcohol reduces your total body stores of PO4, K, Ca, and Mg.
This is often due to poor intake, malabsorption (steatorrhea/diarrhea), and renal loss (alcohol induced tubular dysfunction), etc.
Palmer & Clegg. NEJM 2017
11/14
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After admission, these deficits often reveal themselves with ⬆️ insulin release & correction of acidosis or development of alkalosis w withdrawal.
Specifically, the PO4 drop w AUD carries a high risk of rhabdomyolysis dt underlying alcohol-induced myopathy.
12/14
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The ⬆️ NADH from alcohol metabolism further enhances the ketogenic process. It also inhibits hepatic gluconeogenesis, which may lead to severe hypoglycemia.
So, the mainstay of correction is dextrose 5% in NS (and NEVER forget thiamine before that).
It does not stop here.
5/14
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The treatment of hyponatremia in chronic AUD pts is the same as other causes of hyponatremia.
And ALWAYS remember, avoid fast or overcorrection 😉.
10/14
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Read more about Rachel here:
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@ASanchez_PS
@Mark_Heslin
@GlassHealthHQ
Appears to be an evolving area! Check out this 2023 JAMA Review. It comes with proposed management algorithms and compiles different treatment approaches based on cases series/expert recommendations
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But enough acid base & let's move to something lighter; Na😅.
Interestingly, acute alcohol ingestion induces water diuresis by ⛔️ADH activity ▶️Hypernatremia.
But, on chronic exposure, the body overrides this effect dt ⬆️ plasma osmolality & ⬇️effective circulatory vol.
8/14
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Another schema is presented here from Lehnhardt et al using renal function and test reliability as the first step in your decision tree ()
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What meds can influence potassium levels in the blood?
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So no: we shouldn’t gasp a sigh of relief when our DVT patients actually have an underlying thrombophilia, we shouldn’t encourage people who just had a heart attack to smoke, and we shouldn’t puncture holes into hearts of people who just had a crypotogenic stroke…
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