Pathway Applications – 2020

Hi everyone,

We are excited to announce that the applications for all our pathways are open!

This includes the following pathways:

– Global Medicine Pathway

– Hospital Medicine Pathway

– Integrative Medicine Pathway.

– Primary Care Pathway

– RACE (Residents As Clinician Educators) Track

The deadline is November 20th at 11:59pm PST. You may apply to as many of them as you would like, and we will work with you to match into one of them based on competitiveness, interest, and fit. Please note that you may do the Integrative Medicine Pathway concurrently with another pathway.

Please read the application requirements carefully (listed at the bottom of each google form) to ensure that you submit the required documents before the application deadline!

Global Medicine Pathway:

https://docs.google.com/forms/d/e/1FAIpQLScTh3Bb6CkBTGWTkvNyxx-EmeBi-IqDPRTSy1xNCtVOV9aRqw/viewform?usp=sf_link

Hospital Medicine Pathway:

https://docs.google.com/forms/d/e/1FAIpQLSec4P4abWlv3cGYMLCQuIgqeCHGNOg0eARC6SAgs45VAXFLLg/viewform?usp=sf_link

Integrative Medicine Pathway:

https://docs.google.com/forms/d/e/1FAIpQLSc2SCFqNVAe4pMxxG18L9GF61KKFJfkKaajhY-O83ibx4Nh3g/viewform?usp=sf_link

Primary Care Pathway:

https://docs.google.com/forms/d/e/1FAIpQLSeTKML9e9HKzEv77TxgJjmBkXxnO1gC1F-zxNAREp0sVaQJRA/viewform?usp=sf_link

Residents As Clinician Educators (RACE) Track

https://docs.google.com/forms/d/e/1FAIpQLSevIszRLhqoOh0s-Bewaj9jpXT863pXzNySuWxoaI9KtsnsNg/viewform?usp=sf_link

If you missed the pathway interest meeting, you can hear a bit about each pathway https://ucsdim.com/pathway-interest-session/ or review more on our blog under the ‘prospective residents’ heading, then ‘residency pathways’ here: https://ucsdim.com/residency-pathways/.

Feel free to reach out with any questions. Thank you!

Luke Webster, CMR

Pathway Interest Meeting–10/21/20

Thank you to everyone who joined us last night for the Pathway Interest Meeting! I have attached a link to the 30 minute introduction video as well as documents that were presented during the meeting for those of you who were not able to attend. 

Applications are being finalized as we speak! We will send a consolidated email in the next 1-2 weeks containing all pathway application forms and final application details. 

If you have any questions regarding specific pathways, please reach out to the chief in charge of your pathway!

Hospital Medicine: DJ

Global Health: Alex

Integrative Medicine: Samantha

Primary Care: Luke

RACE track: Nick

Pathway Session Video: 

Pathway Information on the Blog:

Please reach out with any questions!

Sincerely, 

Luke Webster

Global Health Simulation!

Mandy Mohindra and Ian Drobish, our inaugural Global Health Pathway residents, participated in an interdepartmental simulation with fellow Emergency, Surgery, and OB/GYN residents. The simulation centered on a patient presenting with profound dehydration from a diarrheal illness. The resident teams had to manage the resuscitation while figuring out the underlying etiology (cholera!) and overcoming a twist – the patient was also pregnant. 

The teams then participated in a socially distanced debrief and dinner while discussing the realities of providing medical care in under-resourced settings. The session ended with skills stations which taught trainees how to establish intraosseous access (without an EZ-IO device!), calculate fluid drip rates for IV medications, and mix-up homemade oral rehydration solution. Thank you, Ian and Mandy, for representing our program and bringing your A game!

MTC 4/21: Diarrhea in HIV patients

Today our amazing Med/Peds PGY3, Jack Strutner, led us through a case he saw in Mozambique at his time at Maputo General Hospital.  His patient was a young man with HIV who came in with subacute diarrhea with profuse bloody bowel movements and a fever. He was found to be severely volume depleted and with an AKI on exam. We worked through our diagnostic schema and work-up of diarrhea in an HIV patient, focusing on infectious etiologies. Our expert discussant from Infectious Diseases, Dr. Stephen Rawlings, helped further flesh out our differential for these patients and discussed ARV side effects. We then discussed the differences in work-up approaches for patients in resource poor settings vs here in the US, with the main difference being more focus on stabilization and resuscitation with empiric antibiotics and less so on diagnostic tests. The patient unfortunately passed which we discovered is sadly a common scenario on a global scale, highlighting the importance of ongoing global efforts to improve water supply and sanitation in disease prevention.

Take away points:

1) Remember to take a thorough history regarding diarrhea onset, characteristics (volume, content, frequency) and associated symptoms

2) ARVs, particularly protease inhibitors, integrase inhibitors and  Zidovudine (causing acute pancreatitis) may be the cause of diarrhea in some HIV patients

3) Diarrheal illness is still a leading cause of death worldwide, particularly in resource poor nations

Thank you again to Dr. Strutner for a thought provoking case, and to Dr. Rawlings for always providing great teaching! We hope to hear from our colleagues in Maputo sometime again soon!

Global Medicine Volunteer Opportunity! 3/7/20

The International Health Collective is looking for residents to volunteer at their monthly clinic in Tijuana on Saturday, March 7th. Providers meet in Otay Mesa at 8am, and are back on this side of the border by 4pm. This is an amazing global health opportunity to deliver primary care to an underserved community in a low-resource setting. You will have a lot of autonomy, but also plenty of support from Dr. Jia Shen (cardiology) and Dr. Weena Joshi (pediatrics). Interpreters are available, so no Spanish is required. Please email Janet (janetma@ucsd.edu) if you are interested!

HC MTC 2/27: Chagas cardiomyopathy

Today in Hillcrest, we discussed a patient with end-stage heart failure who was found to have RBBB+LAFB and an EF of 13%. We took this opportunity to review the conduction system, and EKG findings for bundle branch pathologies. After ruling out ischemic disease, we also explored possible etiologies for his non-ischemic cardiomyopathy with the acronym HIVEMIND (coined by CMR Gary Ma). A thorough history was key in eliminating many of the possible etiologies, and the key was his immigration from El Salvador which prompted testing for Chagas! He was ultimately diagnosed with Chagas cardiomyopathy and underwent cardiac transplantation. However, his story did not end there. After reviewing the illness script for cardiac manifestations of Chagas, which include arrhythmias, cardiomyopathy, and aneurysms, we learned that post-transplant patients still need to be regularly monitored the disease given the possibility of reactivation. This patient had not one, but two recurrences of his Chagas disease with significant conduction system disease (RBBB, 2:1 AV block) requiring multiple treatments with benznidazole and pacemaker placement!

Thank you to our discussant Dr. Anna McDivit for her insights on approaching bundle branch blocks, and for reminding us to have a lower threshold for ICD implantation in Chagas cardiomyopathy patients given their high risk for fatal arrhythmias! Thanks also to Dr. Gary Ma for his clever acronym for NICM.

Takeaway points:

  1. Prolonged QRS intervals should prompt consideration of a bundle branch block, while axis deviations should prompt consideration of fascicular blocks.
  2. The differential for non-ischemic cardiomyopathy is broad (think HIVEMIND!) – start with a comprehensive history to guide further testing.
  3. Chagas disease is the most common etiology of non-ischemic cardiomyopathy in Central America. Consider Chagas disease in any patient with cardiac symptoms or EKG abnormalities from a Chagas-endemic area (particularly immigrants from El Salvador or southern Mexico). RBBB+LAFB is the most common conduction abnormality, though any can occur.
  4. Chagas disease has an acute and chronic phase. First-line treatment for Chagas disease is benznidazole, although treatment is less effective for chronic infections.
  5. Cardiac transplant is indicated in patients with Chagas cardiomyopathy and end-stage heart failure. Post-transplant patients must be monitored for disease reactivation.

HC MTC 2/24: Severe falciparum malaria

Today, Ian Drobish presented not one but two cases of severe malaria this morning – the first was a case that he saw during his rotation in Kenya, and the second case was just recently admitted to the Hillcrest MICU after visiting relatives in Subsaharan Africa! Both patients presented with fever, nausea, vomiting, had traveled to high-transmission areas, and were found to be both anemic and thrombocytopenic. We took this opportunity to dive into the illness script for malaria, a disease we see rarely in the United States but one that causes significant morbidity and mortality in many other parts of the world.

First, we reviewed the epidemiology of malaria and identified malaria-endemic areas. Remember that malaria is caused by the female Anopheles mosquito and is therefore found in tropical areas.  Transmission also varies by region, with Subsaharan Africa generally considered high transmission and Latin America and Asia are considered low transmission. In the United States, “VFR” (visiting friends and relatives) travelers such as our MICU patient are at highest risk for acquiring disease as they often return to their home country for longer duration and may not take prophylaxis due to presumed immunity.

We then discussed the pathophysiology of malaria, which is caused by the Plasmodium parasite. P. falciparum is responsible for the majority of malaria disease burden, and especially severe malaria cases due to its virulence factor pfEMP and ability to infect RBCs of any age. We followed the life cycle of the parasite, which starts with a mosquito bite (usually at night), travels to the liver in 1-2 hours, and then into the RBCs with ruptured schizonts causing symptoms 1-4 weeks after the initial bite.

Both of our patients met criteria for severe malaria, defined by any one of 12 WHO criteria which include organ failure, shock, and high parasitemia. Diagnosis was made with rapid antigen testing, and both thick and thin peripheral smear. Severe malaria can cause rapid deterioration with mortality rate highest in the first 24 hours of presentation and need IV artesunate with close monitoring.

For malaria patients in United States, providers must call the CDC malaria hotline to deliver this medication as it is not FDA approved or commercially available. Cinchona alkaloids (quinidine/quinine) were previously used, but have less efficacy and higher toxicity including QTc prolongation. Quinidine is also no longer stocked in US hospitals as of last year! Our MICU patient had her IV artesunate delivered from LAX, received 3 doses over 24 hours, and was discharged with oral artesunate after her peripheral smears showed parasitemia <1%. Both she and our patient in Kenya responded quickly to treatment and were discharged after 3 days.

Finally, our ID discussants Dr. Michael Tang, Dr. Thaidra Gaufin, and Dr. Samuel Penziner discussed malaria prophylaxis for travelers. Medication selection, which typically includes atovaquone-proguanil, mefloquine, or doxycycline, is dependent on resistance patterns of the region as well as co-morbidities. Thank you to our discussants (and Dr. Annie Cowell) for their insights, and to Ian Drobish for adding some global health learning to our morning reports!

Takeaway points:

  1. Any patient with a fever and recent travel to malaria-endemic region should be tested for malaria. “VFR” (visiting friends/relatives) travelers are at greatest risk.
  2. Use WHO criteria to determine severe malaria, which can lead to rapid deterioration and needs STAT treatment with IV artesunate.
  3. Call the CDC Malaria hotline to obtain IV artesunate, which is not commercially available in the United States. Quinidine is no longer stocked in the US, so use PO artesunate through an NGT while awaiting IV formulation.

https://www.cdc.gov/malaria/diagnosis_treatment/treatment.html