Image of the Week 07/01/2014

A patient with poorly controlled type-2 diabetes comes in with complaints of pain, swelling and erythema in both feet. What is the diagnosis and what tests should be done to confirm?

The Crimson Care Collaborative: Reviving the Pipeline for Primary Care

Christine Bishundat

Med Ed Committee

            The Benjamin Lipson Memorial Lecture was held at the Simches Research Center on June 19. The speakers included Marya Cohen, MD, MPH, Jessica Zeidman, MD, Talia Kraower, MD, Charlotte Ward, MPH, and medical students Tomi Jun, Simin Lee, and Katherine Schiavoni, who each addressed different aspects of the CCC model at HMS.

            Simin Lee's talk described the founding and evolution of CCC at HMS. In 2006, universal healthcare coverage became law in Massachusetts, transforming the landscape of healthcare and medicine in the state. While the number of uninsured patients has fallen following healthcare reform, there remains an insufficient number of primary care providers to meet the growing need.  In addition, between 1999-2009 the number of medical students matching into primary care dropped substantially [1]. 

            Recognizing the need for more primary care providers in Massachusetts, a group of students at HMS sought to expand primary care opportunities by creating the first CCC site at MGH IMA in 2010. The CCC mission emphasized a desire to provide excellent care while developing the next generation of primary care leaders. Currently, five CCC sites exist, treating a variety of patients including immigrants, refugees, youth, and those with chronic illness.

            Charlotte Ward, a researcher at the Stoekle Center and Benjamin Lipson Memorial Lecture speaker, analyzed data on the relationships between CCC and primary care match rates. She published an article in the New England Journal of Medicine in 2010 suggesting that CCC at HMS had, in fact, increased the number of graduating students matching into primary care.

The remaining speakers highlighted additional projects underway at CCC which are summarized here:

Interprofessional Education (IPE): Since modern medicine requires working in a team, CCC has nurse practitioner students, pharmacy students, medical students, interpreters, social workers, faculty preceptors, and undergraduates provide care as a unit. The students and faculty address medical concerns as well as social needs.

Longitudinal mental healthcare: A care manager enhances communication between the patients and PCPs around issues related to mental health.

Patient-reported outcomes: iPads are distributed to patients at their appointments to assess what outcomes are important to them and how well CCC addresses these needs.

Longitudinal care teams: CCC hopes to follow-up with patients and build lasting relationships through phone calls, text messages, and home visits.

Patient outreach: CCC is posting information in the communities it serves regarding workshops on nutrition labels reading and exercise habits.

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1. Ganguli, Inshani. The Case for Primary Care- A Medical Student’s Perspective. NEJM. Available online at: http://www.ishaniganguli.com/pdfs/GanguliPerspectiveNEJM.pdf

Image of the Week 06/17/2014

A patient presents with burning, stinging vesicles at the vermilion border of the lip.  What may have caused this lesion and what is the treatment?

Image of the Week 06/10/2014

How is ophthalmia neonatorum prevented in newborns in the US? What organism causes this condition? 

Live Blog: Cutaneous Manifestations of Chronic Disease

Christine Bishundat
Medical Education Committee

Our talk today was given by Jeffrey Cohen, MSIV, on cutaneous manifestations of chronic disease.

The three main chronic diseases we see in clinic are diabetes, hypertension, and obesity.  Today, Jeff discussed common skin conditions associated with diabetes and obesity.

Diabetes: The most common skin condition associated with diabetes is acanthosis nigricans, a velvety hyperpigmentation found in the folds of the skin. Acanthosis nigricans is a product of insulin resistance.

Diabetic patients also have an increased risk of bacterial and fungal infections. Generally, bacterial and fungal infections are differentiated by appearance: green pigment is indicative of bacterial infection with pseudomonas, while central clearing in red patches and flaky edges indicate fungal infection.

Diabetic ulcers are present in 15-25% of patients with Type 2 Diabetes.  These are a result of vasculitides and neuropathies due to chronically elevated blood glucose.

Diabetic bullae (blistering), dermopathy, and pigmented purpuric dermatosis are less common but notable because they correlate with high levels of hemoglobin A1C.

Obesity:

Patients with obesity are at increased risk of developing intertrigo, psoriasis, and stasis dermatitis.

Intertrigo is skin inflammation due to rubbing and abrasion in intertriginous zones.  Intertrigo can be complicated by candida infection.

Psoriasis is a common inflammatory skin disease characterized by scaly plaques.

Stasis dermatitis is a chronic inflammatory skin condition that typically presents on the lower extremities.  The hemostasis that causes stasis dermatitis is the result of venous hypertension and venous valve insufficiency.

Take Home Points:
- Diabetes and obesity put patients at increased risk of developing certain skin conditions.
- It is important to perform a thorough physical exam in order to prevent and treat cutaneous lesions, some of which (like diabetic ulcers) can be life-threatening.

Image of the Week 6/03/2014

A 23-year-old woman presents with a fever of 103°F, headache, nausea, vomiting, photophobia, and meningismus.  In the ED, she becomes increasingly lethargic.  What condition is she likely to have, and what is the causative organism in the Gram stain of her CSF, shown above?