School of Medicine

Multiple theories about the association between Post Traumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been proposed, but there is yet to be a common consensus on their exact relationship. Regardless of the etiology of their association, it is reasonable to suggest that the interaction between SUD and comorbid PTSD is complex. The intention of this project was not to dive deeper into the suggested theoretical models, but rather to focus on understanding how these conditions affect patients and on a pragmatic approach to treatment. This was based largely in principle on two observations from prior studies. One of which was the fact that patients with the SUD/PTSD are more likley to struggle with treatment for substance use disorder in regards to retention and periods of abstinence. Second was the realization that patients with comorbid disease have higher rates of homelessness, physical health problems, psychiatric cormorbities, and psychosocial impairment when compared to individuals with a single disorder. As such, the goal of this project was to gain a better understanding of the challenges associated with treating these patients and to also develop a greater understanding of the "best" practice approach to treatment.

Bone metastases of prostate cancer continue to elude effective clinical management world-wide. A newly developed xenograft model, PCSD1, is a pre-clinical therapeutic development and testing platform to understand the mechanisms of resistance to androgen deprivation therapy of bone metastatic prostate cancer. Prostate cancer is a heterogeneous disease for which it is especially important to study models that represent the range of different patients. However, of the patient samples investigated by Christina Jamieson’s lab at UCSD, only 5 out of 20 (25%) were able to successfully create xenografts. The hypothesis I tested is that metastatic cells that have failed to xenograft into a patient-derived tumor xenograft mouse model will be able to successfully survive in vitro in an organoid culture system. The goals of my research were twofold: to successfully develop organoid cultures for both cells that have successfully and unsuccessfully xenografted into the mouse model and to perform imaging and genetic analysis on these organoids.

The purpose of this study was to define a novel angle measure (theta) characterizing true slipped capital femoral epiphysis (SCFE) deformity; use theta to differentiate between SCFE hips, contralateral unaffected hips, and normal hips; and to compare theta to the Southwick slip angle (SSA). 3DCT reconstructions of the pelvis and femurs were obtained and pelvic position was standardized. The center point and direction vector of the femoral epiphysis was determined. The femoral neck axis was defined. The angle between the femoral neck axis and epiphysis vector defined the 3D angle of deformity (theta). The 3D translation of the femoral epiphysis, measured as a percentage of femoral neck diameter, was measured in three planes. The average theta angle was significantly greater in SCFE hips (44.9±22.5°) compared to control (14.5±8.8°) or normal (14.0±6.5°) hips (p<0.001). There was no significant difference in theta angle between control and normal hips (p=0.83). Theta angle correlated strongly with SSA (rs=0.774, p<0.001). Its high but imperfect correlation with SSA may indicate theta as a better measure, implicating SSA as underestimating the true deformity in nearly 25% of cases.

In a recent study, 74% of 430 UCSD Student-Run Free Clinic (UCSDSRFC) patients were food insecure using the 6-item USDA food insecurity screening questionnaire. 30% of the 430 had "very low food security". Since the pubilcation of this study, a robust Food Rx program has been instituted. All patients now receive a "food prescription" consisting of two 5-10 lb bags of healthy food at clinic. Additionally, food insecure patients at UCSDSRFC are often referred to food pantries. At most clinics where a Food Rx program has not or cannot be implemented, referrals to food pantries are one of few interventions available for food insecure patients. However, there is little research that addresses who is most interested in going to a food pantry and if referred patients actually go. This survey study includes 292 patients surveyed during a 3-month period. This survey included the 6-item USDA food insecurity-screening questionnaire and additional questions about food pantry utilization. 31.8% (84/264) patients reported previously going to a food pantry. The most common concerns about food pantry use were transportation and fear of being asked about documentation status. The survey results suggest that there is a weak but statistically significant relationship between food insecurity score and interest in going to a food pantry. This suggests clinical resources directed towards addressing food insecurity through food pantry referrals will be more effective among more food insecure patients. Additionally, previous food pantry visits also appear to hae an effects on interest in going again. Among the interested patients who have reached for follow-up, nearly 40% (14/34) have gone to a food pantry and 85.7% (12/14) plan to go again. More than half (8/14) of these patients had not previously been to a food pantry. Future studies at the UCSDSRFC will include the on-going follow-up of individuals referred to food pantries and comparison of food insecurity and clinical outcomes between individuals using food pantries and those who are not.

The Brain Trauma Foundation recommends intracranial pressure (ICP) monitor placement for patients with severe traumatic brain injury (TBI). Adherence with these guidelines in elderly patients is unknown. We hypothesized that disparities in ICP monitor placement would exist based on patient age.

Military members are required to carry heavy loads frequently during training and active duty combat. We investigated if operationally relevant axial loads affect lumbar disc kinematics in forty-one male active duty Marines with no previous clinically diagnosed pathology. Marines were imaged standing upright with and without load. From T2-weighted magnetic resonance images, IVD health and kinematic changes between loading conditions and across lumbar levels were evaluated using two-way repeated measures analysis of variance tests. IVD kinematics with loading were compared between individuals with and without signs of degeneration on imaging. Linear regression analyses were performed to determine associations between IVD position and kinematic changes with loading. Fifty-eight percent (118/205) of IVDs showed evidence of degeneration and 3% (7/205) demonstrated a disc bulge. IVD degeneration was not related to posterior annular position (p>0.205). Changes in sagittal intervertebral angle were not associated with changes in posterior annular position between baseline and loaded conditions at any lumbar level (r<0.267; p=.091-0.746). Intervertebral angles were significantly larger in the lower regions of the spine (p<0.001), indicating increased local lordosis when moving in the caudal direction Disc height at the L5/S1 level was significantly smaller (6.3mm, mean difference =1.20) than all other levels (p<0.001) and baseline posterior disc heights tended to be larger at baseline (7.43mm ± 1.46) than after loading (7.18 ±1.57, p=0.071). Individuals with a larger baseline posterior annular position demonstrated greater reduction with load at all levels (p<0.002), with the largest reductions at L5/S1 level. Overall, while this population demonstrated some signs of disc degeneration, operationally relevant loading did not significantly affect disc kinematics.

To explore the topic of gender micro‐inequities, both on a personal level and on a professional level. To evaluate literature on the topic. This includes evaluating the different ways to study this topic (survey, focus group, longitudinal interviews, etc), as well as the specific populations studied and critically consider the positives and negatives of the different methods. To plan and give a professional lecture/webinar, including seeking feedback and evaluation.

Clinical reasoning (CR) is essential to a physician's practice of medicine. Although there have clear efforts to incorporate CR into the pre-clinical curriculum at UCSD-SOM, there is a lack of formal CR education during rotations. Thus, the Clinical Reasoning Exercise (CRE) was designed for third year medical students on the inpatient internal medicine service. The CRE is an educational exercise that provides step-by-step guidance through the diagnostic process by utilizing three principles--problem representation, diagnostic schema, and illness scrips. Supplementary materials include narrated PowerPoint/YouTube tutorials (for both students and faculty) as well as an example completed CRE for student reference. The CRE was piloted with six students rotating the Veteran's Association (VA) in February 2019. Students were met in small groups (2-3) to review general aspects and logistics. After the one-month long inpatient rotation, students were sent the link to an anonymous survey. The overall respondent rate was 66% (N=4/6). All four students reported completing one CRE during the 4-week block. Overall, students felt the CRE was a useful exercise that helped educate them on CR/CR principles and helped them systematically approach a clinical problem. However, there was a mixed response as to whether the CRE should be implemented in the future curriculum. The students' main concerns included increasing the number of requirements for the rotation and redundancy with a pre-existing requirement. Going forward, the CRE itself will need to be modified and its position in the curriculum closely reassessed. In addition, a larger sample size is needed to adequately obtain generalizability to the remainder of the third-year class.

Palliative care and advanced health directives, particularly the Physician’s Orders for Life Sustaining Treatment (POLST), play significant roles in the management of seriously ill children and those with chronic medical conditions. Multiple studies have demonstrated improved patient quality of life and family sense of autonomy and control when advance health directives are implemented, yet little is known about actual end‐of-life‐care choices parents make. The goal of this project was to examine parental preferences for end‐of‐life care among patients enrolled in a pediatric palliative home care program (PPHCP) or hospice who have completed a POLST. .

Simulation has become an integral part of learning new procedures and staying adept at skills already learned. Ultrasound (US) guided peripheral IV (PIV) needle insertion is a skill necessary for EM, Anesthesia, and general practice nurses and physicians. Medical schools, teaching hospitals, and community hospitals universally use simulation amongst their practitioners. Ultrasound POC use is increasing in Emergency Department (ED) and other hospital areas. Most institutions have formalized training to teach residents and nurses proper techniques for POC US use. Training models can vary from commercially available ones costing thousands of dollars to home-made ones that have a short life-span and suboptimal viewing characteristics. 1 Patient safety has been a driving force in changing medical training. "To Err is Human", a landmark study published in 1999 estimated 3% of injuries to hospital patients are caused by medical errors, resulting in between 44,000-98,000 deaths per year. The traditional teaching mantra of "See one, Do one, Teach one" apprenticeship model has been replaced with proficiency-based teaching methods to improve physician training and patient safety.