3/24/23 Friday School: Ultrasound, IBD and RACE4ALL—optimizing evals!

Our residents kicked the learning off with the next session in our longitudinal ultrasound curriculum, where seniors evaluated patients with ultrasound who had either normal or had interesting pathologic findings (pulmonary hypertension, polycystic kidney disease and screening for DVT/PE). Kudos to our PCCM fellows for helping our residents hone their skills and ace Dr. Sweeney’s pop quiz on impressive ultrasound findings! Our interns rotated through different stations to practice thoracentesis and ultrasound evaluation for pneumothorax and effusion.

We turned towards a gutsy session on IBD led by UCSD GI faculty and proud alum Dr. Brigid Boland. We reviewed the definition of ulcerative colitis, e.g. proctitis vs left-sided vs pancolitis (extending beyond the splenic flexure) as well as endoscopic spectrum of severity. Remember that there is increasing risk of colon cancer over time with UC, so surveillance should begin earlier after diagnosis. In contrast, Crohn’s disease can have different behaviors anywhere along the entire GI tract including inflammatory vs fibrostenotic vs fistulizing complications. IBD has many extraintestinal manifestations, including spondyloarthropathy, dermatologic, hepatobiliary, DVT, and osteoporosis. Dr. Boland delved into main classes of therapy for IBD and the changing paradigm of pursuing a top-down/treat-to-target approach. Watch out for non-Hodgkin’s and hepatosplenic T cell lymphoma with azathioprine and anti-TNF therapies!

Hospital medicine faculty Drs. Farkhondehpour and Sebasky then wrapped up the afternoon with a session from our RACE4ALL series with tips for filling out medical student evaluations, an important topic given residents serve as mentors and teachers to our amazing rotating medical students. The RIME (reporter, interpreter, manager, educator) scale is a useful framework for helping assess where learner’s progress towards independence and can be thought of as answering the what, why, and how questions.

Thanks to all of our incredible teaching faculty and rockstar residents for another amazing Friday School!

RACE Track — Senior Sign-Out Rounds 3/24/23 — Hepatic Lesions

For Senior Sign-Out Rounds at the VA today for RACE, PGY-3 Soumya Kurnool and PGY-2 Ariana Feuvrier-Rivera guided us through the case of a middle-aged woman that Ariana admitted overnight who presented with subacute epigastric pain and fatigue and was found to have elevated liver enzymes. RUQ US showed numerous hepatic lesions. Subsequent CT A/P with contrast again showed these lesions, along with duodenal thickening and multiple enlarged intra-abdominal lymph nodes.

We discussed Ariana’s differential on admission, which included malignancy and infection. To search for a possible primary and evidence of additional metastases, Ariana ordered a CT chest with contrast. She also ordered an MRI brain (patient reported recent worsening headaches) and consulted GI for EGD to evaluate the duodenal thickening and IR for liver biopsy. Ariana also considered infectious causes of hepatic lesions (including liver abscesses, TB, fungal infection, echinococcus, and Bartonellosis), took an extensive social history, and ordered quantiferon TB and fungal serologies.

Great job Ariana and Soumya!

3/24/23 Jacobs conference: your DESTINY awaits with Journal Club presenter Dr. Brian Ji!

Today at our weekly Friday morning Jacobs conference, our marvelous senior resident Dr. Brian Ji presented the DESTINY-Breast03 trial (https://www.nejm.org/doi/full/10.1056/NEJMoa2115022), exploring in a Phase 3 clinical trial a new HER2 antibody-drug conjugate trastuzumab deruxtecan (T-DXd) versus the standard of care trastuzumab emtansine (T-DM1) as second-line therapy for HER2+ breast cancer.

Dr. Ji walked us through the fascinating mechanism by which these new drugs work (image credit to chemoexperts.com), essentially being smart bombs delivering in a targeted fashion chemo payloads to HER2-expressing tumors. The Kaplan-Meier curves and waterfall plots tracking progression free survival were impressive, with significantly longer PFS (primary endpoint) with T-DXd compared to T-DM1 although median overall survival (secondary endpoint) not yet reached for both groups at interim analysis. Dr. Ji highlighted that an interesting side effect of both antibody-drug conjugates is interstitial lung disease, which was more common in T-DXd although the overall percentage of severe side effects was similar. We finished by reviewing the strengths and limitations of the study. Overall, this the subsequent DESTINY-Breast04 trial results also published in NEJM soon after were extremely exciting and practice-changing for the field! We look forward to hearing more from Dr. Ji as he starts heme/onc fellowship at UCSD this summer!

RACE Track — MS3 Teaching 3/23/23 — GI Bleeding

For MS3 teaching at the VA today for RACE, PGY-3 and future chief resident Mehul Trivedi gave an interactive talk on GI bleeding. Mehul’s inner artist emerged as he drew the GI tract from mouth to anus. He then led the medical students through the vast differential for GI bleeding from top to bottom. We even discussed bleeding due to Trichuris trichiura (or whipworm)!

Great job Mehul!

3/23/23 JMC heme/onc conference with Dr. Rebecca Shatsky!

Today at our weekly Jacobs heme/onc conference, we were joined by UCSD medical oncologist and breast cancer expert Dr. Rebecca Shatsky! She started by walking residents through principles of treatment for hormone receptor positive breast cancer, focusing on the two major classes of hormonal therapy: SERMs (e.g. tamoxifen) and aromatase inhibitors (e.g. anastrozole). Dr. Shatsky highlighted important differences in their mechanism of action and side effects of these drug classes, including multiple problematic drug interactions for tamoxifen (SSRIs, wellbutrin) on top of increased risk of DVT and endometrial cancer, contrasting with osteoporosis and arthalgias with AIs.

We further discussed that SERMs can be used in both pre-/post-menopausal women, while AIs are usually reserved for post-menopausal women but can be used in pre-menopausal women if ovarian suppression is concomitantly given. Dr. Shatsky then helped clarify terminology and management of ‘in situ’ versus invasive breast tumors (important distinctions given the definitive nature of surgery in the former vs the latter) and answered several questions on nuances in choosing SERMs vs AIs in select patients, finishing with a brief discussion on the treatment approach to male breast cancer which is interestingly predominantly hormone receptor positive.

Many thanks to our fantastic residents and the always incredible Dr. Shatsky for an engaging, high yield heme/onc conference!

RACEtrack Noon Teaching Conference: Help! It’s an insulin pump!

Today for noon conference, Soumya Kurnool (PGY3) and RACEtracker, presented about insulin pumps and continuous glucose monitors. And three brave volunteers Tally (PGY3), Kelly (PGY3), and Nikki (PGY1) tested out the Freestyle Libre! We learned that the most likely place for failure is the subcutaneous cannula and infusion set are the most likely places to fail. We were joined by Dr. Juang and Brittney from the Endocrinology department who served as our experts. See resources on pulse.ucsd.edu under Medication Resources for how to manage pumps inpatient.

RACE Track — Intern Report 3/22/23 — Long Call at the VA

At Intern Report at the VA today for RACE, PGY-3 and future chief resident Mehul Trivedi gave an instructive talk on the senior resident’s workflow while on long call at the VA. Mehul discussed how to triage pages from the ED and how to split admissions between non-teach, Short call, and Long call. He then walked us through several example scenarios. At the end of the talk, the interns all reported feeling more confident about being senior residents at the VA next year!

Thank you Mehul!

Grand Rounds 3/22/23 — Vitamin D: Where Do We Stand Now in 2023

At Grand Rounds today, UCSD Nephrologist Dr. Charles Ginsberg presented a fascinating talk on vitamin D supplementation. He walked us through several studies that showed that 25-OH vitamin D supplementation did not prevent fractures in older adults and demonstrated that routine screening and monitoring of 25-OH vitamin D is not beneficial and that supplementation may be unnecessary except in special circumstances. He also made the case for the use of vitamin D receptor agonists like calcitriol as a more effective form of vitamin D supplementation than 25-OH vitamin D.

HC NTC 3.21.23 – “Shocking” ST Elevations

Today, R3 and future cardiology fellow Dr. Kevin Sung presented a case of an elderly man who presented with progressive dyspnea on exertion, chest pain, fevers, chills, and myalgias over the course of weeks to months who was referred from urgent care for ST elevations on EKG. Patient underwent cardiac catheterization and did not have any evidence of coronary artery disease or Takotsubo cardiomyopathy on ventriculogram. However, cardiac biomarkers and inflammatory markers were markedly elevated. In the cath lab, the patient had a markedly elevated PCWP, decreased CO/CI, and decreased MvO2, consistent with cardiogenic shock. An intra-aortic balloon pump was placed and dobutamine and diuresis were started and format TTE confirmed global LV dysfunction (EF 35%). Cardiac biopsy demonstrated myocarditis with giant cells and eosinophils. Patient was started on immunosuppression and GDMT with marked improvement (EF 48% prior to discharge). Thank you to cardiologist Dr. Torres Barba for being an excellent expert discussant for this case!