School of Medicine

The utilization of cervical spine instrumentation in the young pediatric patient in not well reported. This study presents outcomes and complications of cervical spine instrumentation in patients who underwent cervical spine fusion surgery before age 10. Radiographic and clinical data were collected on all patients who underwent cervical spine surgery with instrumentation at a single institution between January 1, 2006 and March 21, 2015. Patients were ≤ years of age at the time of surgery with any cervical spine deformity/injury diagnosis. Patient demographics, details on cervical spine diagnosis, procedural data, imaging data, and post-operative follow up data were collected. Twenty children met the criteria and were included in the study with a mean follow-up of 10.6 months (3 mo to 2 years). Initial indication for cervical spine correction surgery included: deformity (7 cases), trauma (6 cases), instability (3 cases), stenosis (2 cases), rotary subluxation (1 case), and infection (1 case). Fifteen cases were treated with adult 3.5mm cervical spine instrumentation, 3 with wiring (1 sublaminar and 2 spinous process), and 2 with cannulated screws. Postop immobilization included 16 Halo fixation, 3 collars, and 1 CTO. Overall there were 5 complications related to the surgery. two patients who had wiring (1 sublaminar and 1 spinous process) developed a non-union and required revision surgery (1 with cannulated screws and 1 with 3.5mm segmental cervical spine instrumentation). One patient developed a postop infection that required incision and drainage. Five patients developed superficial pin infections for their Halo. Tow deformity patients experienced neurological complications that were likely unrelated to the cervical instrumentation. Conclusions: rigid segmental fixation can be safe and efficacious when used in pediatric cervical spine patients. Whether used with Halo or orthosis, patients experience minimal to no complications from the instrumentation and achieve successful fusion. Cervical spine wiring had a high risk of non-union requiring revision surgery. The incidence of wound infection was low with one in 20 cases.

As the use of technology continues to increase in medical education, the utilization of video as a modality becomes apparent. This study is aimed at investigating the addition of video-guided anatomical discussions for the Mind, Brain and Behavior I (MBBI) course and its impact on student performance, specifically in the lab component, but also in the course as a whole. A series of videos were created that outlined a framework for how to approach neuroanatomy and then were provided on an online portal. An online survey was also provided to be used to assess use and provide a space for students to comment on the videos. Two successive classes (class of 2019 and 2020) were included in the data acquisition and analysis and compared with the class of 2018 (for which no videos existed). Performance was based on the mean score of each exam. "The class of 2020 (who had access to the videos) significantly outperformed the class of 2018 on the midterm and final (mean 85.0 +/- SD 11.1 vs. mean 86.9 +/- SD 9.3, p = 0.05) and (mean 87.9 +/- SD 7.9 vs. mean 90.5 +/- SD 6.1, p = 0.003), respectively. There was a trend toward improvement in the final exam between the class of 2018 and class of 2019 (mean 87.9 +/- SD 7.9 vs. 89.1 +/- 6.2, p = 0.31). All other comparisons were not significant. Further investigation into sectionspecific improvements as well as improving access to videos would further improve the utility of the video series

This medical education project sought to expand practical training at UCSD, School of Medicine. Specifically this was envisioned through creation of novel nasogastric intubation and urinary catheterization curriculum. Prior to the conception of this project, UCSD employed a wide range of simulated procedures for instructional use during the pre-clinical and clinical years: endotracheal intubation, central lines, arterial lines, etc. Anecdotally, these sessions were helpful for familiarization with the equipment and procedures that I would commonly encounter on the wards during my third and fourth years. Using these ideas as a framework, I planned to develop sessions to cover additional topics that I encountered in my clinical rotations but not in the classroom. Foley catheterization and nasogastric intubation were specifically chosen as they are both extremely common procedures.

The purpose of this project is to cut a window in the opaque edifice of medical liability for young and aspiring OBGYNs to peer through. In addition to reviewing a wealth of literature on medical liability, I interviewed a diverse collection of OBGYNs at UCSD about their experiences with and views of medical malpractice. By integrating these narratives with the literature. This paper attempts to capture three perspectives that, I hope, offer greater texture and deeper understanding to young clinicians trying to make sense of medical liability: 1) What it feels like to be sued and the challenges associated with coping on the job; 2) What advice physicians have to avoid being sued (and a note on attorneys); 3) Where our system of medical liability falls short and how it might be improved.

Distal forearm buckle fractures are common, inherently stable pediatric fractures. Immobilization, achieved with a removable splint is better tolerated, cheaper, and more efficient than cast treatment without increasing rates of re-fracture. Our children's hospital emergency department (ED) had no standardized protocol for the management of these fractures, resulting in varied immobilization methods, orthopedic consultations in the ED, and long lengths of stay.

Cystic Fibrosis (CF) is an autosomal recessive disease that affects thousands of individuals worldwide. The disease is caused by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene resulting in the dysregulation of apical ion channels. This disruption in ion transport leads to the production of the characteristic thick mucus seen in patients with CF. Although many organ systems are affected, the hallmark of the disease is viscous mucous plugs in the respiratory tracts leading to the disruption of mucociliary clearance and chronic bacterial colonization of the airways. Infections by organisms of the Burkholderia cepacia complex (BCC), a group of about 17 closely related species of Gram-negative bacteria, are associated with fulminant necrotizing pneumonia and severe decline in CF lung function. Acute exacerbations of CF are treated rapidly with antibiotics to halt further destruction of the lung. This repeating antibiotic exposure, however, has naturally led to the emergence of multidrug-resistant (MDR) organisms. Azithromycin, a macrolide antibiotic with anti-inflammatory properties is considered one of the standard-of-care therapies for patients colonized with Pseudomonas aeruginosa, and is commonly administered three times a week. Azithromycin treatment has been shown to decrease the frequency of exacerbations, and has largely been attributed to azithromycin's anti-inflammatory properties, since the drug does not show direct bacterial killing of the pathogen in standard minimum inhibitory concentration (MIC) tests in bacteriologic media. However, recent data from Lin and Nizet et al suggests that azithromycin may indeed have direct antimicrobial effects on P. aeruginosa and other Gram-negative bacteria, which are appreciated only under more physiological conditions (e.g. tissue culture media) and in synergy with cationic antimicrobial peptides of the host innate immune system. However, the effectiveness of azithromycin in patients with BCC is largely unknown. In this project, we investigate the effects of azithromycin against BCC in CF patients, with special attention to functional interactions with host defense factors. This research can lead to a better understanding of the future use of Azithromycin to reduce the development of MDR infections as well as its use as an anti-microbial agent against these infections.

The Affordable Care Act was implemented in 2014 and had a significant impact on the affordability and accessibility of healthcare for medically underserved populations within the United States. The UCSD Student-Run Free Clinic provides free and comprehensive medical care to underserved patients in San Diego County. The Free Clinic prioritizes providing healthcare to uninsured patients. Some Free Clinic patients gained insurance through the Affordable Care Act, and a subset of these insured patients continue to be cared for at the Free Clinic. Literature review suggested that patient navigators would be useful in helping these patients utilize their insurance and transition care to new medical homes.

To assess and compare the diagnostic performance of magnitude-reconstruction chemical-shift-encoded magnetic resonance imaging (MRI-M) and complex-reconstruction chemical-shift-encoded magnetic resonance imaging (MRI-C) for diagnosis of hepatic steatosis in subjects with severe obesity without known non-alcoholic fatty liver disease (NAFLD), using contemporaneous histology as reference. This is an IRB-approved, HIPAA-compliant, two-center, cross-sectional study of a larger prospective trail that recruited patients without known NAFLD consecutively between October 2010 and March 2015 to undergo research MRI exams 1-2 days prior to clinical-care weight-loss surgery. Proton denisty fat fraction (PDFF) was estimated using MRI-M and MRI-C. Liver biopsies were obtained intraoperatively. Using histologically-determined presence of steatosis as the reference standard, receiver operating characteristics (ROC) analyses were used to identify MRI-M- and MRI-C-derived PDFF thresholds for diagnosing steatosis. Bootstrapped-based tests were used to compare their diagnostic performace. A total of 81 patients (67 female, 14 maile, average age 48.2) were recruited for this study. MRI-M and MRI-C had areas under the ROC curve of 0.951 and 0.947, respectively, for diagnosing hepatic steatosis. for MRI-M, the Youden-index-based PDFF threshold of 6.5% provided 0.87 sensitivity (95% confidence internal: 0/75, 0.95), 0.96 specificity (0.81, 0.99), and 0.90 total accuracy (0.82, 0.96). For MRI-C, a PDFF threshold of 6.8%, provided a 0.90 sensitivity (0.77, 0.96), 0.96 specificity (0.81, 0.99), and 0.91 total accuracy (0.83, 0.97). Differences in performance parameters between MRI-M and MRI-C were not statistically significant. Conclusion: MRI-M- and MRI-C-derived PDFF is accurate for non-invasive diagnosis of hepatic steatosis in subjects with severe obesity.

Part 1: The University of California, San Diego (UCSD) Student-Run Free Clinic Project (SRFCP) serves a subset of complex patients who may benefit from additional levels of care coordination and support beyond the scope of what is currently provided in the clinic. The Complex Care Service (CCS) created a patient-centered care delivery system featuring medical students as case managers to address the needs of this population. A student-run elective (FPM 275) that developed from the CCS is seekign to enroll complex patients that would benefit from coordinated case managed care. Complex patients must first be identified. This project examines current practices of patient identification through 'hotspotting', finding that most selection is through subjective physican referrals or objective emergency medical services (EMS) utilization data. It then uses these heuristics as a guide to systematically rank free clinic patients by complexity and healthcare utilization, finding that SRFCP patients utilize EMS appropriately and that patients at risk for primary care breakdown are those with a greater degree of complexity. Finally, it uses these findings along with SRFCP physicians' subjective referrals to generate a list of patients and to develop an appropriate model for future patient enrollment in case managed care through FPM 275 at the SRFCP. Part 2: The University of California, San Diego (UCSD) Student-Run Free Clinic Project (SRFCP) serves a subset of patients who face the burden of multimorbid chronic disease, limited health literacy, and psychosocial barriers to health. Complex patients typically require high levels of healthcare resources and may benefit from additional levels of care coordination and support beyond the scope of what is currently provided at the SRFCP. The Complex Care Service (CCS) was created to address the needs of this population through a patient-centered care delivery system featuring medical students as case-managers. The primary goals of this service were two-fold: to improve outcomes for complex patients by developing their health literacy, self-management skills, and health related self-efficacy; and to develop medical students' ability to facilitate health behavior change and to provide collaborative case managed care to SRFCP patients. This project documents the creation of the CCS and its transformation into a student-run elective with the expansion of the service, the development and refinement of clinical tools, and the formalization of medical student training in motivational interviewing and health behavior change as a means to sustainably continue case managed care for complex patients identified at the SRFCP.