T-cell/histiocyte-rich large B-cell lymphoma

Another month, another tumor board talk. The slides aren’t self-sufficient, I’m afraid, but the references might be a good starting point for learning more about TCHRLBCL[^wtf], or diffuse large B-cell lymphoma in general. I’d start with [this excellent review article on DLBCL treatment][ccr], written by several NCI attendings[^attnd].

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History of advance care planning in the US

Here is a slide show I had to make during my [pain and palliative rotation][ppc], which ended up being an updated rehash of [a review article I wrote for Cancer Journal on the history of end-of-life care][eolreview]. The article itself is behind a paywall, but you can find the PDF on [ResearchGate][rgate].

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Stem cell transplants, a slide show

As first-year fellows, we have to present a case at the Medical Oncology Service tumor board every four weeks. Obviously, I can’t share the details of those talks here. But I can post a sanitized version of my slides, with all identifying information removed.

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Pain. And Palliation.

I am not spiritual, or religious. Living in an atheist country that suddenly takes a turn towards militant Christian fundamentalism does that to you. I don’t believe in woo. I do believe that American doctors are overtreating their patients’ pain, and that American patients are too sensitized to it. Yes, the understaffed orthopedic VA surgery wards where post-op patients were screaming for their morphine may have led to the Kabuki of a nurse coming in every couple of hours to ask you about where your pain is, and what is the QUALITY of the pain, and howbadisitfromonetoten? But a cancer center is no VA. The ritual only reminds those with chronic cancer pain that yes, it is still there, and yes, it hurts more than it did 3 hours ago, and now they can’t finish reading their book because there is a twinge every couple of minutes while they are thinking about it.

Which is all a longwinded way of saying that I should not have enjoyed the pain and pallitavie rotation that much. There is spirituality, there is woo, there is a lot of pain. And yet I did.

These people know what they are doing. They have plenty of resources available to do it. And yes, they may “do Reiki”—nothing more than elaborate Kabuki for patients with advanced diseases—but there are times when that is exactly what the patients need. When 4am vital signs and checking for hepatomegaly every day just aren’t enough.

Some useful questions to ask your patients with any serious chronic disease, if and when you have some extra time in clinic:

  • Are you the same person now as you were before the diagnosis? How did you change?
  • What do you fear the most?
  • What do you hope for?
  • Who(m) do you rely on for support?1

The patients’ answers may surprise you.

  1. Whom” is gramaticaly correct, but interrpreted as pretentious by most patients. Use it judiciously. Yes, I realize that what I have written here is just as bad. 

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Posle USMLE-a: pozivi

Programi su pre nešto više od dve nedelje počeli da skidaju prijave sa ERAS-a. Ako vas je neko već pozvao, čestitam! Ako nije1, još nije vreme za brigu—većina programa pozivnice šalje u talasima, svake dve-tri nedelje, sve do kraja oktobra-sredine novembra.

Ako vam ni do tada ne stigne ništa, evo šta sigurno ne treba raditi—spemovati jadne direktore i njihove koordinatore generičkim molbama za intervju. U najboljem slučaju će ignorisati vaš mejl, u najgorem će vas skinuti sa spiska potencijalnih kandidata jer ne umete da pratite molbu sa sajta da ih ne kontaktirate za takve stvari.

Šta onda? Dve stvari: ako znate nekoga ko može garantovati za vas, zamolite ih da proslede vaše podatke koordinatoru ili direktoru koje poznaju2; i ako ste već u Americi, pošaljite mejl okolnim programima da ste dostupni u kratkom roku, za slučaj da neki kandidat otkaže razgovor dan-dva pre. Za tako nešto je dobro biti u mestima sa visokom koncentracijom programa koji primaju strance (čitaj: Istočna obala, Čikago). Naravno, prijavite se na te programa preko ERAS-a pre slanja mejla.

Ako ste završili sve stepove ali još niste dobili ECFMG sertifikat, slobodno se prijavite—programi to obično gledaju tek kad dođe vreme za rangiranje. Ako već morate da se prijavite bez svih stepova, Step 2 CK je najmanje bitan. CS je i dalje najlakši za prolaz, ali je njegovo padanje najveća crvena zastava koju nečija aplikacija može imati, tako da se stranci bez položenog CS-a obično ne pozivaju.

Sledeća bitna stavka su pisma preporuke. Nema svrhe plaćati prijavu za program koji na sajtu traži četiri pisma, a vi to četvrto još čekate. Srećom, većina je OK i sa tri, dok se poslednje može dodati naknadno. MSPE (“dekanovo pismo”) i transkript su neophodni, ali za strane kandidate nebitni pošto sistemi ocenjivanja nisu uporedivi. Na žalost, to je još jedna stavka za koju morati čekati na šalterima, hodnicima fakulteta, itd.


  1. Ili ako još niste poslali prijavu, u kom slučaju, šta kog đavola čekate‽ 

  2. Upozorenje: morate biti sigurni da su u dobrim odnosima. Postoje ljudi čija bi preporuka bila garancija za brisanje sa liste. 

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It’s well-known that most common knowledge is false

Did you hear the one about not prescribing angiotensin receptor blockers to patients with ACE inhibitor-induced angioedema? I’ve had heated debates with residents in my old clinic who did not want to even consider ARBs for a patient with worsening diabetic nephropathy who’s had lip swelling while on an ACE-I ten years ago.

Or the one about not giving these patients amlodipine, since there are two—yes, two—case reports on amlodipine-associated angioedema? Should we also stop giving them water?

Then there are shellfish allergies and iodine contrast, fever and atelectasis, morbid obesity and hypothyroidism… No matter how many studies show these associations to be too weak to be clinicaly significant, or just plain false, there will always be an attending somewhere giving them as his or her pearl of the day.

We need some medical mythbusting for physicians, not just the lay public.

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How to spend a Monday morning train ride

The GTD weekly review does a good of job keeping my task list managable, but not all tasks and projects are equal. It’s good to have a sense of when you might have time for deep thinking versus mindless task processing—-something GTD doesn’t trully account for. I had been doing a variant of weekly planning since high school, until internship destroyed any hope of having a daily, let alone weekly plan. It’s time to start again.

And if you are not following Cal Newport’s blog already, you should. The man is a machine.

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No, there’s nothing wrong with your attention span

After skimming through the fifth long-form article about the increase in bite-sized consumable writing made for the short-attention-span—-dare I say “millennial”—-crowd, I became scared for my own tenacity. Would the 15-year-old me, the one who had read the LotR cover to cover, be horrified by this balding humunculus with twice the age and—-if you’d believe the articles—-half the attention span?

No, he would not. I can write that with confidence of a man who has just burned through the first two Dark Tower books exclusively while riding the subway. Get in at Union Station, actually sit down to read at Gallery Place, blink and I’m done with a chapter or two and arriving at Bethesda.

Stephen King is a hell of a writer, you see, and most of what you can find online—-this blog post included—-is derivative crap at worst, well-written nonsense at best. My brain jumping from text to text was its way of saying Dude, why are you punishing me with this drivel? Just get us a good book. So I did, and the percieved length of my metro commute has decreased by two orders of magnitude. Which is a convoluted way of saying that time flies when you’re having fun1.

But if you’ve never read a book in your life and are now devouring Buzzfeed like a horsefly in a manure factory—-sorry, there is no help. It is you.

  1. See above re: quality of online writing. 

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Which opioids are safe in kidney and liver failure?

Many times during residency I looked for a table like this online. There weren’t any, so I decided to create one.

Ye’r welcome.

Source: Induru RR, et al. Managing Cancer Pain: Frequently Asked Questions. Cleveland Clinic Journal Of Medicine. 2011;78(7).

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