Hail Mary, Full of Haze : Physicalism and the Knowledge Argument

This project aims to provide a clear and compelling reason for rejecting dualism with respect to the mind, by undermining the support dualist positions receive from so-called knowledge arguments. In particular, I will show the error present in the many forms of what is variously called the “Mary’s Room” or “Mary the Brilliant Color Scientist” thought experiment

Soft Rock – When Blasting It Doesn’t Work

Soft Rock – When Blasting It Doesn’t Work Mark Schneider, MD Providence Portland Medical Center – Portland, OR Additional Authors: Jesse Powell, MD Case-History of Present Illness: 68-year-old female presents with several days of malodorous urine and fevers. Brought to the ED by her daughter who diagnosed urinary tract infection (UTI) due to the distinct urine odor. No hematuria, dysuria, retention, or incontinence. Past Medical History: Recent hospitalization for UTI with culture that grew P.mirabilis, completed course of cefdinir, with follow-up culture ordered by PCP that grew extended-spectrum beta lactamase (ESBL) E.coli. Physical Exam and Vital Signs: Vitals: 115/48, 101, 38°C, 18, 93% without supplemental oxygen. • Lumbar spine tenderness, no CVA tenderness. Large area of erythema of right inner thigh and chronic lower extremity edema. Otherwise a non-focal exam. Labs and Imaging: Procalcitonin 2.3, UA - packed bacteria/WBCs/3+ leukocyte esterase, WBC - 17.5, and urine culture with \u3e100,000 CFU/mL ESBL E.coli. CT abdomen : Staghorn calculus within the lower pole calyces and renal pelvis of the right kidney. Heterogenous low density material within the mid and upper pole calyces suspicious for xanthogranulomatous deposits. Renal function evaluated via nuclear medicine kidney flow and function with diuretic showing: No urinary obstruction. Asymmetrical renal activity with 73% left kidney and 27% right kidney. Clinical Course: IV antibiotics while undergoing work-up. Urology consulted and recommended stone removal due to recurrent UTIs with same organisms despite treatment. Went to OR for stone removal. Procedure abandoned due to unexpected finding of “white exudate renal collecting system mass” with concern for an organized abscess or fungal ball. Tissue sample sent for culture and pathology. Culture grew Proteus mirabilis/penneri. Pathology report stated degenerative amorphous material with rare inflammatory exudate and fibrinoid hemorrhagic exudate. Macroscopic appearance similar to picture at right. Patient readmitted for planned percutaneous nephrolithotomy. The stone was successfully removed by manual grasping and removal in pieces. Renal Matrix (Proteinaceous) Stones. Rare: First described in 1908. 50 published cases between 1908-1981. Risk Factors: Female. History of urinary tract infections, chronic renal failure, hemodialysis. • Infection with P.mirabilis or E.coli. Proteinuria. Presentation: Similar to those with calcium nephrolithiasis – flank pain and UTI. Diagnosis: Possible to suspect/diagnose by imaging. Usually made at the time of surgery. Treatment Surgery: Surgical removal is necessary – emergently if obstruction or urgently for source control when associated with a UTI. Percutaneous or uteroscopic approach – Shockwave lithotripsy does not work. Prevention of recurrence: Prophylactic antibiotic use. Acidification of the urine. Conclusions • Rare and easily overlooked/mistaken for calcium based renal calculi • Diagnosis often at the time of surgery • Can cause obstruction and renal failure • Surgical/urologic intervention is needed for removal. Refractory to shockwave lithotripsy. • Antibiotics and/or acidification of the urine may help prevent recurrence.https://digitalcommons.psjhealth.org/ppmc_internal/1014/thumbnail.jp

Chronic Hepatitis B Reactivation: Deadly, But Preventable

Chronic Hepatitis B Reactivation: Deadly, But Preventable Sarah Xie, DO Providence Portland Medical Center – Portland, OR Additional Authors: Andrea Roast, MD, FACP; Jesse Powell, MD A 51-year-old Vietnamese male with chronic hepatitis B presents with symptoms of acute hepatitis. 2 months prior, his PCP had discontinued Tenofovir, for which he had been taking for the past decade, based on an undetectable viral load and a negative HBeAg. 1 month later, his viral load soared to 796 million so Tenofovir was restarted. On admission a few days later, the patient had scleral icterus and jaundiced skin. He had severe transaminitis, coagulopathy, and a total bilirubin of 7.7. His CT showed hepatitis, but no cirrhosis. With other etiologies ruled out, he was diagnosed with acute on chronic hepatitis B reactivation due to discontinuation of Tenofovir. He was discharged once his LFTs improved though his total bilirubin continued to rise. The liver transplant team followed the patient post discharge and one month later, he represented with decompensated liver cirrhosis which progressed to fulminant hepatic failure requiring a liver transplant. An estimated 350 million people in the US live with chronic hepatitis B, though only a third are aware of their diagnosis. Untreated hep B accounts for over 600,000 deaths per year from HCC and end stage liver disease. There is no cure because hep B virus remains in hepatocytes by integrating its DNA into our own and by turning its DNA into stable mini-chromosomes. Tenofovir AF, the 1st line treatment, works only by inhibiting viral replication outside the nucleus, but does not eradicate viral DNA (point). A negative viral load, as seen in our patient, indicates only medication adherence and not a cure. Only 1% of patients achieve “seroclearance of HBsAg,” constituting a functional cure and can discontinue medications at that point, but 99% of patient require indefinite treatment. Our patient did not have labs consistent with a functional cure. Tenofovir has a black box warning that if discontinued, can cause hepatitis B reactivation leading to severe hepatic injury and even fulminant hepatic failure. It took only one month of discontinued Tenofovir to set in motion our patient’s path for a liver transplant. Fortunately, he is doing well now. The take home points are that, unlike Hepatitis C, 99% of hep B patients require indefinite treatment to minimize the risk of premature death. Physicians should recognize that only seroclearance of HBsAg suggests a functional cure. Undetectable viral loads indicate successful treatment adherence. Discontinuation of treatment can result in hepatitis B reactivation and even fulminant hepatic failure. From a broader perspective, clinicians need to be vigilant of undiagnosed chronic hepatitis B carriers, especially in patients immigrating from countries with high prevalence or patient with high risk behaviors. These patients are at risk for reactivation with any immunosuppressive therapy such as steroids or cancer therapies.https://digitalcommons.psjhealth.org/ppmc_internal/1015/thumbnail.jp

Be Careful What You Screen For: An Incidental Finding Of Tracheobronchial Amyloidosis

Introduction: The 2011 National Lung Screening Trial (NLST) demonstrated a reduction in morbidity and mortality with LDCT compared to CXR. In 2013 the USPSTF began recommending CT scan for lung cancer screening in appropriate patients but, the 2015 National Health Interview Survey (NHIS) demonstrated that less than 5% of eligible patients received screening. The NLST also demonstrated a high rate of false positives, incidental findings, and the need for further invasive testing. When deciding to screen, patients and providers are tasked with reconciling these risks and benefits. In this case, we explore one patient’s incidental findings, and the work-up that ensued. Our Case: Our patient is a 70-year old female with PMHX of COPD (GOLD 1) who suffers from dyspnea with exertion, and cough. The patient did not tolerate LAMA therapy but her symptoms improved with the addition of an ICS/LABA inhaler. She has had 1-2 COPD exacerbations per year. She has a 54-pack year smoking history and quit smoking 2 years ago. In accordance with USPSTF guidelines and with shared decision making, the patient was referred for lung cancer screening with LDCT. LDCT revealed thickening of the patient’s right and mainstem bronchi, and trachea. In light of this, the patient was referred to pulmonology for bronchoscopy. Bronchoscopy demonstrated irregular thickening and heaped pink mucosa. Biopsies were examined by a pathologist who determined the tissue to be amyloid. Upon follow up in primary care clinic, the tissue samples were located and again sent for amyloid sub-typing which identified AL amyloid. With this finding, the patient required subsequent testing with free light chains, SPEP, and UPEP to rule out a plasma cell dyscrasia. Finally, a fat pad biopsy was ordered to evaluate for systemic amyloidosis. With all of these tests negative, the patient could be diagnosed with localized pulmonary AL amyloidosis & specifically tracheobronchial amyloidosis. This condition is managed symptomatically and does not require systemic chemotherapy. Discussion: In this case, we explored the diagnosis of a patient with central airway obstruction due to amyloidosis found incidentally during lung cancer screening. In our patient, the incidental finding of central airway obstruction required further testing with bronchoscopy, pathology, mass spectrometry, SPEP, UPEP, serum free light chains, and a fat pad biopsy which were ultimately negative. The high rate of false positive screens and the need for subsequent testing are concerns physicians must address with their patients when recommending lung cancer screening CT. This should be balanced with the potential for reduced mortality and morbidity with CT screening, through higher cure rates, less invasive lung resection, and increased rates of smoking cessation.https://digitalcommons.psjhealth.org/ppmc_internal/1009/thumbnail.jp

Recommendations for Implementing Hepatitis C Virus Care in Homeless Shelters: The Stakeholder Perspective.

Compared with the general population, homeless individuals are at higher risk of hepatitis C infection (HCV) and may face unique barriers in receipt of HCV care. This study sought the perspectives of key stakeholders toward establishing a universal HCV screening, testing, and treatment protocol for individuals accessing homeless shelters. Four focus groups were conducted with homeless shelter staff, practice providers, and social service outreach workers (n = 27) in San Francisco, California, and Minneapolis, Minnesota. Focus groups evaluated key societal, system, and individual-level facilitators and barriers to HCV testing and management. Interviews were transcribed and analyzed thematically. The societal-level barriers identified were lack of insurance, high-out-of-pocket expenses, restriction of access to HCV treatment due to active drug and/or alcohol use, and excessive paperwork required for HCV treatment authorization from payers. System-level barriers included workforce constraints and limited health care infrastructure, HCV stigma, low knowledge of HCV treatment, and existing shelter policies. At the individual level, client barriers included competing priorities, behavioral health concerns, and health attitudes. Facilitators at the system level for HCV care service integration in the shelter setting included high acceptability and buy in, and linkage with social service providers. Conclusion: Despite societal, system, and individual-level barriers identified with respect to the scale-up of HCV services in homeless shelters, there was broad support from key stakeholders for increasing capacity for the provision of HCV services in shelter settings. Recommendations for the scale-up of HCV services in homeless shelter settings are discussed

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Koinonia

Spotlight FeatureThinking Globally in a Local Context, Jolene Cassellius Family and Balance, Shannon Schans Cultivating Philanthropy in the Co-Curriculum: An Alternative to the Narcissism of the iGeneration, Brian Powell InterviewThe Ministry of Reconciliation: A Conversation with Brenda Salter McNeil, Glen Kinoshita Thinking TheologicallyThought About Thinking Lately? How About Thinking Christianly?, Michael Santarosa Book ReviewHush: Moving From Silence to Healing After Childhood Sexual Abuse, reviewed by Carol Harding I\u27m the Teacher, You\u27re the Student: A Semester in the University Classroom, reviewed by Ryan K. Giffin Reconciliation Blues: A Black Evangelical\u27s Inside View of White Christianity, reviewed by Jesse Brown FeaturesThe President\u27s Corner Editor\u27s Desk Regional Updateshttps://pillars.taylor.edu/acsd_koinonia/1080/thumbnail.jp

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