Clinical Reasoning Conference – July 2021

For our first Clinical Reasoning Conference of the academic year, our expert diagnostician was the incomparable Dr. Lori Daniels, cardiologist extraordinaire and a former chief resident of our program. Dr. Daniels walked us through the mystery case of a relatively healthy young woman who presented with acute-onset, sharp midsternal chest pain and was found to have dynamic EKG changes, elevated cardiac biomarkers, and apical hypokinesis on echocardiogram. A computed tomography of the coronary arteries showed abrupt tapering of the mid- to distal left anterior descending artery, which was consistent with spontaneous coronary artery dissection (SCAD). With treatment and cardiac rehabilitation, the patient had a good cardiac recovery. She was ultimately diagnosed with an arteriopathy.

We took this opportunity to discuss the uncommon but important diagnosis of SCAD, caused by hematoma formation within the tunica media, which then leads to intimal separation from the underlying vessel. Triggers include stress, Valsalva, intense exercise, hormonal changes, and medications. Most cases occur in young women with few traditional cardiac risk factors. SCAD can be associated with pregnancy and can occur in the postpartum setting. SCAD can present similarly to other causes of acute coronary syndrome (ACS), with typical chest pain, elevated cardiac biomarkers, EKG changes (including ST segment elevations), and wall motion abnormalities. Most cases are diagnosed through cardiac catheterization. Thrombolytics are generally avoided as they may cause extension of the dissection or hematoma. The role of antiplatelet agents and anticoagulants in SCAD is unclear, but these agents are often given. Neurohormonal block with β-blockers and ACE inhibitors (or ARBs) is also typically initiated. Percutaneous coronary intervention and coronary artery bypass graft surgery may be appropriate in select patients.

We were fortunate to have been joined by the patient, who shared her unique perspective on the experience. The classic teaching that women with ACS tend to present atypically is flawed. Studies suggest that women who have ACS report typical chest pain at similar rates as men who have ACS. Although women have higher rates of insurance and primary care than men, women who develop ACS report more difficulty receiving care than their male counterparts. In addition, despite having a higher cardiac risk burden and risk of severe myocardial infarction, women who have ACS are less likely to be appropriately diagnosed on presentation and less likely to be reperfused in a timely manner. Indeed, health inequities related to sex and other social determinants of health remain pervasive today.

Key Learning Points:

  1. SCAD is an important cause of acute coronary syndrome, particularly in young women who have few traditional cardiovascular risk factors.
  2. Not all chest pain is from atherosclerotic plaque rupture. Consider other diagnoses such as aortic dissection, pulmonary embolism, pneumothorax, and SCAD.
  3. In SCAD, most medications used to treat other causes of acute coronary syndrome can be delayed and administered after an angiogram without significant issues.
  4. Discrepancies related to sex and other social determinants of health in the management of individuals who present with chest pain remain commonplace.

Thank you to Dr. Daniels and our other expert discussants for participating in our conference today!

ACP presents- The Black Medical Experience: The Hidden Curriculum from Medical School to Attendinghood”

A VIRTUAL TOWN HALL WITH RYAN MIRE MD FACP PRESIDENT-ELECT OF THE ACP

WHEN: WED., JULY 28, 2021 4:00 PM-5:30 PM PST

The ACP Southern California III, Virginia, Washington, Tennessee, Georgia and Massachusetts Chapters are hosting a virtual town hall with Dr. Ryan Mire. Ryan Mire MD FACP is board certified in Internal Medicine and has an academic appointment as Assistant Clinical Professor of Clinical Medical Education for University of Tennessee Health Science Center. His professional membership includes the American College of Physicians, National Medical Association, and Alpha Omega Alpha Medical Honor Society. He has held leadership roles in medicine for the Heritage Medical Society and the Ascension St. Thomas West hospital along with national leadership for the ACP.

UCSD’s very own DJ Gaines will be serving as host for this event and it is open to everyone! A great opportunity to learn and discuss. There will be special guest panelists and a Q&A session following the speakers.

RSVP here by July 27

Fellowship Opportunity at University of Chicago in Primary Care Research

See below regarding a University of Chicago Fellowship opportunity for graduating residents who are interested in pursuing an academic career as a clinical investigator in internal medicine, pediatrics, ID/HIV, or geriatrics.

The goal of the HRSA T32 Primary care Investigators Training in Chronic disease & Health disparities (PITCH) Fellowship is to train the next generation of primary care clinical investigators to improve health outcomes and care delivery for patients with chronic diseases from underserved backgrounds. The PITCH Fellowship will recruit fellows from diverse backgrounds and train four (two first-year and two second-year) primary care fellows each year. Research projects will be aimed primarily at transforming the health care system through value-based care delivery and quality improvement initiatives, as well as improving mental health access and care, ending the crisis of opioid use disorder and overdose in America, and ending the HIV epidemic

Fellows will attain the core competencies for health services research and formal education addressing responsible conduct of research, oral and written presentation, manuscript and grant writing, leadership skills, and project management. Fellows will be offered the opportunity to complete Master of Science for Clinical Professionals or Master of Public Health, in addition to receiving dedicated, aligned mentorship with at least biweekly meetings and quarterly mentorship reviews. Through these activities, our fellows will become experts in the key principles of primary care research affecting vulnerable populations, the communication of their findings, leveraging policy to improve equity, and gain the fundamental skills that are required for rigorous academic research careers.

Eligibility:

All primary care clinicians with a commitment to a clinical investigator career will be considered for this two-year fellowship. Priority will be given to physician candidates from the specialties of internal medicine, geriatrics, pediatrics, and infectious disease (HIV) and/or those from underrepresented backgrounds.  For those individuals pursuing ID/HIV or geriatrics, acceptance into the PITCH fellowship and the clinical fellowships can be coordinated.

Applicants must be board-eligible or board-certified in internal medicine and/or pediatrics and eligible for licensure in the state of IL by July 1 of their first fellowship year. In addition, due to federal regulations based on our funding, applicants are required to be U.S. citizens or have permanent U.S. residence status at the time of the application.

Application Process:

Applying requires a 1) CV, 2) personal statement, and 3) brief Redcap survey.  The personal statement should explain why you are interested in this fellowship, your general area of research, name potential mentors, and describe your long-term goals including the position you think you would want after completing the fellowship.  The Fellowship has a particular interest in recruiting fellow from diverse backgrounds, so please also include information about your personal background.

If applicants move to the interview stage, then applicants will be asked to submit 3 letters of recommendation and an example of their research writing, if available.

Important dates:

Call for Applications: 4/1/2021-8/1/2021

Application Deadline: 8/1/2021

Invitation to Interview: 7/1/2021-8/22/2021

2nd Call for Applications (if necessary): 8/1/2021-8/31/2021

Applicant Interviews: 7/1/2021-9/30/2021

Deadline for Acceptance: 10/20/2021

Fellowship start date: 7/1/2022

To apply or if you have questions, please contact Morgan Ealey (Administrative Director) at mealey@medicine.bsd.uchicago.edu, Neda Laiteerapong, MD, MS (Program Director) at nlaiteer@medicine.bsd.uchicago.edu, and/or Elbert Huang, MD, MPH (Co-Director) at (ehuang@medicine.bsd.uchicagoe.du).

Celebrating Pride Month!

Today residents at Hillcrest and the VA took a moment to celebrate pride month and honor the LGBTQ+ Community. It is a privilege to care for LGBTQ+ identifying patients, and as physicians it is our responsibility to advocate for health equity for members of this community. This month, we take time to remember the origins of Pride Month with the Stonewall protests 52 years ago and remind ourselves of the inequities members of the LGBTQ+ Community still face today.

San Diego Pride organizes year-round events. The San Diego Pride Parade is on hold this year given the COVID19 pandemic, but there will be a smaller march on July 11th to demonstrate the resiliency of our LGBTQ+ Community.

Commemorating Juneteenth!

Tomorrow marks 156 years since Union troops arrived in Galveston Bay, Texas and announced that the more than 250,000 enslaved black people in the state were free. This event is widely considered the official end to slavery in the US and realization of the Emancipation Proclamation. Six months later, on December 6th, 1965, the 13th amendment would be ratified by the required number of states and forever abolished slavery in all US states and territories. This year, Juneteenth became a federal holiday, signifying that we as a society recognize the importance of this date in US history.

We hope you take time this weekend to reflect on the significance of this day and what it means to you, your colleagues, and your community. We recommend honoring the holiday by learning more about its history and what actions you can take to help further our country’s endeavors toward justice and equity for all.

To learn more about Juneteenth, visit the National Museum of African American History and Culture at https://nmaahc.si.edu/blog-post/celebrating-juneteenth.

Community Resources

·       African American Studies Program https://af-amstudies.ucsd.edu/ 

·       Black Resource Center https://brc.ucsd.edu/

·       Black Staff Association https://blink.ucsd.edu/sponsor/black/index.html

·       The DEI Shift Podcast https://www.thedeishift.com/

Reading Recommendation: How the Word Is Passed: Reckoning with the History of Slavery Across America by Clint Smith

UC Students/Alum/Faculty: Letter Objecting to Religious Hospital Mergers

UCLA’s Reproductive Health Interest Group (RHIG) Advocacy Committee has created a letter to UC President Michael Drake expressing opposition to UC affiliations with healthcare entities that use religious directives to prohibit the use of contraception, gender-affirming care for transgender people, abortion, and assisted reproductive technology (e.g. sperm/egg donors, IVF). Please click the following link to learn more. You can also sign the letter by clicking this link: https://www.protectcaliforniapatients.com/

Friday School 10/30–Rheum/Immunology, Disparities & Knee/Shoulder!

Resident Friday School

Transitions of Care within Rheumatology: Dr Chira, from the Rady Children’s Hospital Department of Rheumatology, gave a session on Transitions of Care! Dr Chira emphasized the importance of a transition process for all children transferring care from the pediatric to adult health care system. He highlighted the 6 Core Elements of Transition from GotTransitions.org! The second half of the session was spent in small groups working through cases and building models to help us transition and welcome our young adult patients in our Internal Medicine clinics.

Health Disparities in Asthma: Dr Akuthota, from our Pulmonary & Critical Care Department, highlighted the high proportion of asthma and ER visits related to asthma in Latinx and Black ethnicities. These discrepancies between races are most likely multifactorial- SES, genetics, Vitamin D status, history of violence/stress, access to healthcare, environmental exposures. 

Pregnancy and Autoimmunity: Dr Smith, from our Rheumatology Department, emphasized that a “planned pregnancy is the best pregnancy” with our patient with autoimmune diseases. Low risk medications during pregnancy include HCQ, NSAIDs, AZA, calcineurin inhibitors, sulfasalazine, TNF alpha inhibitors! Do NOT use MTX, MMF, cyclophosphamide in pregnancy! HCQ is also associated with better pregnancy outcome in patients with SLE!

Mystery Case: Today we interviewed a patient about his symptoms. He endorsed worsening back pain and stiffness starting in his early twenties. As time passed, his symptoms became worse and he started to notice decreased range of motion of his back. Pain was worse at night and was associated with considerable morning stiffness. What was the final diagnosis? Ankylosing Spondylitis! Thank you to Mr H for joining us and telling us your amazing story!

Intern Friday School

The interns had a separate session dedicated to the knee and shoulder exam! Dr Quan walked them through the exam with interactive videos with real patients to help illustrate many of the physical exam maneuvers we use in clinic!

Click our Rheumatology and Allergy/Immunology in our Friday School section on the blog to get access to presentations and articles presented during these sessions!