Friday School 9/10 – COPD, Screening and Disparities in Lung Cancer, and NTM Lung Infections

We had an amazing lineup of lecturers for our final PCCM Friday School!

To start off the afternoon, Dr. Erica Lin reviewed COPD. She taught us an awesome trick for remembering the mMRC dyspnea scale: one vertical line for grade 1 (difficulty walking up a hill), two vertical lines for grade 2 (slower than other people), three horizontal lines for grade 3 (short of breath after 100 meters), and a square for grade 4 (short of breath inside the four walls of your home).

You can download a copy of her slides here:

Dr. Luda Bazhenova, UCSD’s hem/onc program director and pulmonary oncologist, then went through an excellent review of lung cancer from epidemiology to treatment.

Lung Cancer Pearls:

  • If there are multiple sites of metastases, avoid getting a bone biopsy, because molecular testing is more challenging on bone than soft tissue.
  • Stage IV NSCLC is not in itself an indication for hospice, and neither is age!
  • 95% of small cell lung cancer cases are associated with smoking.

You can download a copy of her slides here:

We were then joined by Dr. Wael Elmaraachli for a review of NTM lung infections. He highlighted the importance of confirming and working up a patient for NTM prior to initiating treatment and that generally, the treatment does not need to be initiated urgently. He also highlighted that the prevalence of NTM lung infection is increasing!

For the last hour of Friday School, we were joined by Dr. Mark Fuster and Dr. Brinda Desai, who walked us through an amazing discussion of disparities in lung cancer screening. Although the new guidelines now encompass a larger group of people, there are still a lot of gaps in screening. Additional research and advocacy is needed to improve equitable care.

Thank you so much to all of our amazing lecturers today!

Friday School 9/3: O2 Delivery, Vents, Asthma, Chest Imaging, and Debriefing!

We started out this awesome PCCM Friday School with an amazing talk by one of our respiratory therapists, Jaycee Custodio! He brought all sorts of respiratory devices from a venturi mask to chest physiotherapy devices for the residents to checkout in person. He reviewed low flow oxygen delivery devices followed by high flow oxygen devices. He also showed us the amazing effects of PEEP with an actual set of lungs!

We were then joined by two of the awesome PCCM fellows, Dr. Alex Pearce and Dr. Sean DeWolf, for an interactive talk on vents! They reviewed various scenarios that a resident may be called to troubleshoot overnight, discussed important principles of each vent mode, and practiced making adjustments based on ABGs.

Lastly, the senior residents had a session on debriefing led by our very own chief resident, Dr. Ashley Scanlon. We were joined by our extraordinary palliative care fellow, Dr. Kevin Yang, and Chaplain Gordan DeBever. The residents had the opportunity to practice leading a debrief after discussing a framework for holding one!

Meanwhile, the residents had two PCCM lectures this afternoon. First, Dr. Jennifer Karunamuni gave them her renowned lecture on chest imaging and then Dr. Praveen Akuthota discussed asthma!

It was an amazing line-up this afternoon, and we cannot thank the facilitators enough for teaching the residents!

Friday School 8/27: Pulmonary HTN, CTEPH, Vents, Chest Imaging, and ILD

Today was packed full of PCCM learning! The seniors started with a session on pulmonary hypertension by Dr. Jenny Yang. The residents were tasked with figuring out the WHO group for 8 different cases!

We were then joined by the amazing Dr. Kim Kerr for an excellent discussion on CTEPH. She highlighted the incredible work being done at UCSD in CTEPH. We were extremely lucky to be joined by a patient who shared their own personal experience with CTEPH.

Our pulmonology series continued with a lecture on chest imaging with one of our amazing radiologists, Dr. Elizabeth Weihe, and then a lecture on interstitial lung disease with Dr. Bernie Sunwoo.

The interns also had an introductory lecture on vents with one of our amazing PCCM fellows, Dr. Cameron McGuire.

Thank you so much to all of the amazing facilitators today and for all of the residents for their participation! It was a fabulous afternoon of learning!

Friday School 8/20: ECMO, Journal Club, and Shock!

Today, we continued our PCCM Friday School block with a fun filled day of ECMO and shock! To start one of the amazing PCCM fellows, Dr. Cameron McGuire, taught us about ECMO. The residents’ skills were put to the test with an ECMO simulation competition.

Check out THIS amazing ECMO simulation developed the University of Washington to test your own skills!

Team Mazen took the gold! Dr. Mazen Odish would be proud!

For today’s journal club, the residents presented two journals on ECMO: the EOLIA and CESAR trials.

We were then joined by one of our amazing hospitalists, Dr. Meghan Sebasky, for a quick RACE4All session on medical student evaluations.

For the last two hours of the afternoon, we were joined by an incredible team of PCCM fellows and attendings to discuss shock! Dr. Lam, Dr. Sweeney, Dr. McGuire, Dr. Sullivan, Dr. Barnes, Dr. Bond, and Dr. Bailey let the residents through four cases of shock discussing the differential diagnosis, initial work-up, and management.

Dr. Cameron McGuire summarized the cases to end the day! He emphasized the importance of keeping a broad differential and treating septic shock early with antibiotics.

You can access a copy of his slides here:

Thank you to all of the facilitators today, especially Dr. McGuire, for all of the amazing teaching today!

Friday School 8/13 – O2 delivery, vents, chest imaging, and debriefing!

On this Friday the 13th, we continued the PCCM Friday School block with an excellent array of sessions! To begin, one of our fabulous respiratory therapists, Jaycee Custodio, did a rapid fire review of the many different oxygen delivery methods available in the hospital. He even brought real lungs to show the effects of PEEP!

We continued our discussion of oxygenation and ventilation with a review of vent settings with one of our pulmonary critical care fellows, Dr. Lauren Sullivan. The interns and seniors put their knowledge to the test with some “Non-Bar” Trivia! The interns also had an excellent lecture by one of our phenomenal radiologists, Dr. Jennifer Karunamuni.

To finish up the afternoon, we were joined by our amazing palliative care providers, Chris Onderdonk, palliative care social worker, and Dr. Kevin Yang, palliative care fellow to discuss a framework for debriefing. The residents then had the opportunity to practice leading a debrief session themselves! One of the biggest take away from the sessions was that debriefing does not need to take a lot of time!

Thank you to all the amazing facilitators for teaching the residents today!

Friday School 8/6: Clinical Reasoning, Chest Imaging, Asthma, and Disparities in Lung Cancer Screening

Today’s PCCM Friday School was packed full of great learning! For the first two hours, the senior residents took part in a cough clinical reasoning conference. As the experts, they were given aliquots of information and were tasked with developing a hypothesis and discussing how the data supported or refuted their differential. These expert clinicians did a great job keying into the diagnoses! Thank you to Dr. Cameron McGuire and Dr. Allen Aiyang for joining us as PCCM expert fellows. Dr. Sell rounded out the session with a review of chronic cough, her favorite diagnosis!

The seniors were then taken through a review of chest imaging with Dr. Liz Weihe while the interns were taught about asthma with Dr. Praveen Akuthota.

For the last hour of the afternoon, PCCM fellow extraordinary, Dr. Brinda Desai, joined us to discuss lung cancer screening and disparities in lung cancer screening. While the new guidelines capture a wider population, the screening guidelines miss a large population of patients at high risk for lung cancer. An important component of lung cancer screening is assessing the challenges and barriers a patient may face from the initial discussion (language barrier and health literacy) to acceptance of screening (guilt or shame they feel about smoking and mistrust of the health care system) to ability to screen and follow-up on any abnormal results (insurance and transportation). We practiced using this great tool to predict lung cancer risk that can be used with patients to help inform their care.

We finished off the day by submitting a letter to congress to encourage increased funding for lung cancer screening. You can fill this form out here!

Thank you to everyone who participated today!

PCCM Friday School 7/30 – Pulmonary hypertension, CTEPH, NTM pulmonary disease, and ILD

We continued the PCCM Friday School block today with four great sessions on pulmonary disease! To start off the afternoon, Dr. Jenny Yang discussed the different types of pulmonary hypertension. The residents were tasked with the challenging job of matching 8 different case presentation to pulmonary hypertension group and right heart catheterization group. Though difficult, they all did a great job, and the winners (above) took home a COVID-19 plush.

For the next hour, Dr. Kim Kerr taught us about CTEPH and the amazing CTEPH team we have here at UCSD. A guest speaker joined us to share her personal experience with CTEPH. We cannot thank her enough for taking the time to share her story!

Once the interns arrived, we jumped into NTM pulmonary disease. The incredible Dr. Rebecca Sell and Dr. Annie Cowell went through a patient case and then Dr. Wael Elmaraachli discussed his approached to work-up and management of NTM pulmonary disease. Dr. Elmaraachli emphasized the importance of distinguishing NTM pulmonary disease versus infection since NTM can be a contaminant and is found in the environment.

Lastly, Dr. Bernie Sunwoo discussed interstitial lung disease. Her biggest take away, history is key!!

Thank you to all the amazing experts and the guest speaker today!

PCCM Friday School – 7/23

For the first PCCM Friday School of the year, we started off with an ECMO Journal Club. Eight of our awesome senior residents presented a review of the CESAR and EOLIA ECMO trials. Dr. Mazen Odish also joined us for a review of the ECMO circuit. He brought with him one of the ECMO machines for some hands on teaching and troubleshooting. Huge shout out to Dr. Odish for his amazing teaching!

Dr. Meghan Sebasky then joined us for a RACE4all session on evaluations. She reviewed updates to the medical student evaluations and reminded us of the RIME framework for giving evaluations. Thank you much to Dr. Sebasky for helping us give informative and valuable evaluations!

Lastly, Dr. Erica Lin and six PCCM fellows joined us for a session on shock management. In small groups, the residents tackled 4 different cases of shock discussing differential diagnoses, and initial and advanced management. The cases were summed up by a quick lecture by Dr. Erica Lin and Dr. Cameron McGuire including some myths and pitfalls in the management of shock! The slides for this lecture will be posted here once updated.

Remember: Keep a broad differential! Premature closure occurs!

Thank you to all the fellows who helped today: Dr. Michelle Zhang, Dr. Laura Barnes, Dr. Sean DeWolf, Dr. Jacob Bailey, and Dr. Dan Bond. And thank you to all the residents for your participation!

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!

Rheumatology Friday School– 10/23/20

This Friday at Friday school, in addition to the amazing journal fight club on the use of plasmapheresis for ANCA-associated vasculitis affecting the kidney (see Justin’s separate, awesome post), we ALSO learned about diagnosing and managing common musculoskeletal complaints (with Dr. Ken Vitale from sports medicine), crystal arthropathy (with gout guru and guideline author Dr. Robert Terkeltaub) and rheumatoid arthritis (with gifted clinician-educator Dr. Katherine Nguyen). YAY Rheumatology! The “smart guy” consult for multi-system disease!

Here are a few key take home points!

Sports Med

  1. In the world of sports medicine age >40 (and in some cases >35) is OLD, and impacts the epidemiology of common causes for knee pain
  2. Iliotibial band syndrome presents with diffuse, poorly localized lateral knee and distal thigh pain at the end of exercise involving knee flexion and extension . Running outdoors or downhill may worsen symptoms. On exam, there is often tenderness ~ 2-3 cm proximal to the lateral femoral condyle. Treat with abstinence from inciting activity, ice, followed by gradual return to activity, stretching, strengthening, and local massage.
  3. Consider radial tunnel syndrome in patients with burning or numbness on the outside forearm and elbow, just distal to the lateral epicondyle.

Gout

  1. Gold standard for diagnosis of acute gout is negatively birefringent, needle-like uric acid crystals within neutrophils in joint fluid.
  2. Colchicine, NSAIDs, and glucocorticoids (intra-articular or systemic) are all options for treatment of acute gout; consider patient comorbidities (diabetes, kidney disease) and drug interactions when choosing.
  3. The American College of Rheumatology recommends a “treat-to-target” approach, with a target serum urate <6.0 mg/dL . Allopurinol, started at a low dose (100mg/day for normal kidney function) and titrated up, is the 1st line therapy; check an HLAB58*01 first in those from high risk ethnic groups (Black & Asian) to avoid severe hypersensitivity skin reaction. Start anti-inflammatory prophylaxis to prevent flares.

Rheumatoid Arthritis (RA)

  1. The most useful lab tests in the diagnosis of rheumatoid arthritis (RA) are rheumatoid factor and anti–cyclic citrullinated peptide (CCP) antibodies; anti-CCP antibodies have a specificity of 95% for RA.
  2. Methotrexate is the anchor drug in rheumatoid arthritis; it is used as monotherapy and as a component of combination therapy.
  3. Tumor necrosis factor α inhibitors are the most frequently used biologics to treat rheumatoid arthritis; they have a rapid onset of action and synergy with methotrexate.