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!
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!
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
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.
Consider radial tunnel syndrome in patients with burning or numbness on the outside forearm and elbow, just distal to the lateral epicondyle.
Gold standard for diagnosis of acute gout is negatively birefringent, needle-like uric acid crystals within neutrophils in joint fluid.
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.
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)
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.
Methotrexate is the anchor drug in rheumatoid arthritis; it is used as monotherapy and as a component of combination therapy.
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.
Today was our first day of the Rheumatology Friday School Block and part of our Resident As Clinician Educator for All (RACE 4 All) curriculum!
From 1-3pm, RACE Track Director, Dr. Supraja Thota shared tips on how to be an amazing team leader and teach on rounds. She included a mini-workshop on the “holdover game,” helping residents to make holdovers into a rich, interactive cognitive reasoning exercise that can help avoid anchoring!
From 3-5pm, residents and interns gathered in small groups to come up with creative questions to test their co-residents on the clinical manifestations, work up and treatment of SLE! Dr Maripat Corr from our Rheumatology Department then reviewed SLE with us! With her help, and the help of our new resident experts in SLE, we were able to answer all the fun (but difficult) questions made by each small group! While we were able to cover a lot, learning about SLE is not restricted to Friday School! Check out this amazing article on SLE for the internist in the Annals of Internal Medicine! Click Here!
We were lead today through some interesting high yield Osteoporosis learning objectives by our RACE track resident Dr. Kusuma Pokala and endocrinologist Dr. Gina Woods. Our residents took on the challenge of teaching each other and we took our newfound knowledge through a Jeopardy game to solidify this information! We then learned about common dermatologic conditions that general internists may encounter with the help of Drs. Natasha Carter, Laura Romero and Joyce Yuan. Thank you all for helping our residents with our virtual learning experiences!
Today we had a multitude of interesting talks covering a range of GIM topics. Dr. Eduardo Gruvald led us through medical management of Obesity. Then Dr. Chad Wadell gave us some insight into what to be aware of for job contract negotiations. Finally Dr. Anna Quan reminded us of the components of the knee and shoulder exam and led us through some high yield cases!
For our last neurology/emergency medicine Friday school session, our residents and interns tested their knowledge of neurology by working through several simulation sessions, courtesy of NCC expert Dr. Cynthia Gonzalez! We then learned about stroke syndromes and management! Check out the link below for some of the pearls from the sim sessions!
YAY Friday School! This Friday, Dr. Dan Sweeney (PCCM) and our awesome PCCM fellows (Mazen Odish, Jacob Bailey, Erica Lin, Jeff Barry) taught us how to perform a FAST exam, and how image the aorta, the IVC, the femoral and popliteal veins to look for DVT. We practiced on a simulator, and on LIVE models, including a very nice volunteer with Polycystic Kidney Disease.
Our residents then participated in a workshop facilitated by our multi-disciplinary Palliative Care team and members of the HEAR (Healer Evaluation Assessment and Referral) program (including Rachel Accardi, Courtney Sanchez, Chris Onderdunk, Dr. Maria Tiamson-Kassab) on how to lead a debrief following a difficult patient event. Critical leadership skills and part of our RACE (Resident As Clinician Educator) Curriculum!
I want to take this opportunity to stress that if any of you are struggling with the impact of a difficult patient encounter, a loss or medical error, I urge you to seek help to process this important event. Being a physician is an incredibly rewarding, but also difficult job! The program is here to support and help you. You can also come to any of the chief residents, or program leadership with your concerns about yourself or your colleagues. I promise they will be addressed with sensitivity and confidentiality. I have included some resources below for the Healer Education Assessment and Referral (HEAR) Program.
We had a terrific Friday school this afternoon! First a panel of patients who had undergone renal transplant shared their experiences with our residents, facilitated by transplant nephrologist Dr. Mita Shah. Next, Residents worked through advanced cases of Acute Kidney Injury with Dr. Tyler Woodell, while Interns talked through Acute Kidney Injury with Dr. Scott Mullaney.
Finally, UCSD Med/Peds 2019 graduate Dr. Grant Meyer, Med/Peds R2 Dr. Nicky Herrick, and UCSD GIM (4th & Lewis) attending Dr. Julie Sierra spoke to us about the important role physicians can play in Advocacy efforts.
The Cardiology Friday School block continues with a great afternoon didactic session!
Our senior residents received a discussion by Dr. Lori Daniels (Cardiology) regarding the use and interpretation of cardiac biomarkers, specifically highly sensitive Troponin-T (hsTnT) and NT-proBNP. UCSD was one of the first sites to adopt the use of hsTnT, which has led to drastic reductions in ED length of stay during ACS rule outs.
Katrina Derry, PharmD gave a fantastic talk regarding the pharmacoeconomics of cardiac medications. She highlighted tenets of pharmacoeconomic analysis and discussed the basis of utilizing Incremental Cost-Effectiveness Ratio (ICER). We also discussed real world examples of SGLT2 inhibitors compared to GLP-1 agonists.
In our combined resident and intern didactic session, Dr. Howie Tran (Heart Failure/Transplant/Mechanical Circulatory Support) gave a great primer on guideline directed medical therapy, the evidence to support the use of each agent, as well as a discussion on CardioMEMs, a remote pulmonary artery pressure sensor that has led to drastic reductions in heart failure readmissions at UCSD and other sites. We also broke up into small groups to do case-based learning about the indications and study results for SGLT2 inhibitors, angiotensin receptor-neprilysin inhibitors (ANRI) and CardioMEMs. We also used the opportunity to discuss recent trial results from DAPA-HF and PARAGON-HF that had been just presented at the European Society of Cardiology conference in Paris.
Thank you to all our expert discussants for an exciting and educational afternoon!
Today, we learned about dementia, how to disclose the diagnosis, and the challenges around this disease. This is HIGH YIELD stuff. Dementia is like the last frontier, where clinical acumen is necessary. We do not have one test that gives a slam dunk diagnosis. To start if you are thinking about dementia, you need to consider depression and delirium. According to Dr. Sladek, these are the three a”D”go’s! You also should think about the reversible causes. Reversible causes make up <1% of dementia but you can save someone’s life. Alzheimer’s disease is the most common, but there are other types of dementia you need to know. Check out this list: