School of Medicine

Undergraduate medical education is constantly evolving to develop new, effective, engaging teaching methods. An integrated medical school curriculum correlates the basic and clinical sciences beginning in the first year in order to engage students, develop clinical reasoning skills, and prepare them for their clinical experiences. Contextualization, in which clinical case examples are used to illustrate basic science principles, is one strategy used to achieve this goal. In addition to changes in the structure of medical school curricula, the platforms by which educational material is delivered are also rapidly changing. Web-based applications, including podcasts and virtual interactive cases, provide endless opportunities to present information in efficient and interesting formats and encourage self-directed learning by students. Pharmacology is an area of preclerkship education that is particularly challenging to medical students. One reason for this is the fact that students begin learning clinical pharmacology in the first year, prior to learning detailed pathophysiology of the diseases being treated; without clinical context, learning pharmacology can feel little more than memorization of names and mechanisms. The UCSD School of Medicine Integrated Scientific Curriculum addresses these challenges by through a two-pass curriculum, whereby pharmacology is introduced with physiology and basic pathophysiology in Year 1, and reiterated with pathophysiology as the focus in Year 2; however, pharmacology still remains a difficult subject for many medical students. Cardiovascular System 1 (CS1) and Renal System 1 (RS1) have been identified as courses in the first-year curriculum that would benefit from additional supplemental pharmacology resources.

With a rapidly growing older adult population in the United States, the importance of age-appropriate care in the emergency department (ED) is becoming increasingly recognized. The University of California, San Diego (UCSD) La Jolla ED has adopted the use of a specialized health and welfare screening and referral system in its Senior Emergency Care Unit (SECU) to address the unique needs of older adult patients. Trained geriatric nurses screen patients and positive screens generate automatic referrals. Between December 1, 2016 and October 31, 2018 a total of 974 eligible patients were screened. Of these, 354 patients had one or more positive screens and received referrals. A retrospective chart review was used to examine clinical and demographic characteristics of patients to evaluate outcomes of the screening and referral system. Statistical analysis include: two sample t-tests to compare average age between groups; chi-square and likelihood ratio tests to compare demographic characteristics in patients who did and did not receive a referral, follow through with referrals, and return to the ED within 30-days; and logistic regression to asses if referral generation or follow-up predicted 30-day return to the ED. Patients receiving one or more referrals were older (M = 80, SD = 9.2) than those who did not receive any referrals [(M = 77, SD = 8.3), t(674) = 5.07, p<0.01] and patients who followed through with referrals were older (M = 81, SD = 9.2) than those who did not attend any referral follow-up [(M = 78, SD = 9.0), t(151) = 2.67, p<0.05]. Patients who were discharged received referrals at higher rates than expected compared to those who were admitted (χ² LR (13) 27.096, p=0.012) and patients reporting Black or African American race attended follow-up at lower than expected rates compared to patients reporting other races (χ² LR (6) =13.575, p= 0.035). Across all referrals, follow-up was less than 50% suggesting a need for quality improvement in the system.

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.

Gastrointestinal stromal tumors (GIST) are increasingly recognized as having diverse biology. With the development of tyrosine kinase inhibitors molecularly matched to oncogenic KIT and PDGFRA mutations, GIST have become a quintessential model for precision oncology. However, about 5-10% of GIST lack these driver mutations and are deficient in succinate dehydrogenase (SDH), an enzyme that converts succinate to fumarate. SDH deficiency leads to accumulation of succinate, an oncometabolite that promotes tumorigenesis. SDH- deficient GIST are clinically unique in that they generally affect younger patients and are associated with GIST- paraganglioma hereditary syndrome, also known as Carney-Stratakis Syndrome. SDH-deficient GIST are generally resistant to tyrosine-kinase inhibitors, the standard treatment for advanced or metastatic GIST. Thus, surgical resection is the mainstay of treatment for localized disease, but recurrence is common. Clinical trials are currently underway investigating systemic agents for treatment of advanced SDH-deficient GIST. However, further studies are warranted to improve our understanding of SDH-deficient GIST disease biology, natural history, surgical approaches, and novel therapeutics.

Post-laminectomy pain syndrome refers to persistent leg and/or lumbar back pain after a surgical procedure. The pathophysiology of this syndrome is complex, as often the operation was technically successful. Evaluation with MRI plays a crucial role in the assessment of post- laminectomy pain syndrome, as it provides soft tissue resolution for evaluation for common post- surgical pain generators, including recurrent posterior disc disease and associated narrowing of the spinal canal, lateral recess or neural foramina.

As information technology continues to improve, patients are given access to increasing amounts of their health data. Health applications such as Epic MyChart provide an easily accessible archive of information for both patients and, in the case of pediatrics, parents. With increasing amounts of available information there is a concurrent need to provide education about interpretation. This study aimed to create a short, parent-focused, educational video to convey high-yield information regarding growth chart data. A pre- and post-survey were administered in conjunction with the educational video using QR codes at pediatric offices in La Jolla. We found, in general, parents felt well-equipped to be active participants in their child’s health, but identified some areas for improvement regarding perceptions of health.

Danon disease is a congenital X-linked hypertrophic cardiomyopathy that results from mutations in LAMP2, a transmembrane lysosomal protein necessary for autophagy. The disease presents in childhood or adolescence, and life expectancy is 19 for men and 34 for women. Although Danon disease is rare, no specific therapy based on its biology is currently known. Recent in vitro studies using mouse by the Cherqui Lab have shown evidence supporting hematopoetic stem cell transplant as a novel treatment option for cystinosis. Cystinosis is a metabolic disease that arises from mutations in a transmembrane lysosomal protein - cystinosin (CTNS gene). Detailed in vitro and in vivo studies have shown that rescue of the phenotype occurs because wildtype macrophages derived from the transplanted wildtype hematopoietic stem cells can transfer lysosomes containing wildtype cystinosin directly to Ctns-deficient cells in multiple organs of the host Ctns -/- mice. Because Danon disease also arises from mutations in a transmembrane lysosomal protein, LAMP2, a similar approach could be effective in rescuing the phenotype of LAMP2 mutant mice. The Adler Lab has recently developed an in vitro cell model for Danon disease using skin fibroblasts expanded from skin biopsies from two identified patients diagnosed with Danon disease, confirmed by RT-PCR. These in vitro and in vivo models can be used show efficacy of hematopoietic stem cell transplant for Danon disease.

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.

Background: opioid overdose and abuse have reaches epidemic rates in the United States. Legitimate prescriptions are a large source of opioid misuse in adults and adolescents. The goal of this quality improvement project was to reduce opioid exposure from our pediatric emergency department (ED).

Slides presenting a top-down, not "pattern-recognition," approach to decision-making in a clinical neurology setting.