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UCSF Resident Research Symposium
Sponsored by CTSI Resident Research Training Program,
Global Health Sciences and the Molecular Medicine Pathway
We are pleased to offer a combined clinical and translational, global health, and molecular medicine
research symposium dedicated to the research accomplishments of our residents. The mission of
CTST, the training component of CTSI, is to create a pipeline and training system that enhances the
number, quality, and cross-disciplinary skills of clinical and translational researchers at UCSF. Global
Health Sciences is dedicated to improving health and reducing the burden of disease in the world's
most vulnerable populations. The Molecular Medicine Pathway aims to enrich the residency
experience with opportunities to engage with clinician-scientists and peers, to engage with
current scientific literature, and to develop mentoring relationships in order to support career
development.
The primary goal of the CTSI Resident Research Training Program (RRTP) is to create
opportunities for all residents to gain fundamental knowledge in clinical and translational research
methods and evidence-based medicine skills. Additionally, we aim to inspire residents to pursue
future opportunities in investigation. CTST sponsors a one month course (Designing Clinical
Research) which provides residents with the opportunity to gain fundamental skills and to develop
their own research proposal in small group sessions with close guidance from the faculty. CTST also
offers two funding opportunities; the Resident Research Funding (RRF) award, which provides up
to $1500 per academic year to UCSF residents for qualified clinical and translational research
expenses not covered by their mentor or other sources; and the Resident Research Travel (RRT)
award, which provides $600 matching funds to support travel to present research findings at a
scientific meeting.
UCSF Global Health Sciences (GHS) is dedicated to improving health and reducing the burden of
disease in the world's most vulnerable populations. It integrates UCSF expertise in all of the health,
social, and biological sciences, and focuses that expertise on pressing issues in global health. GHS
works with partners in countries throughout the world to achieve these aims.
The main goal of the graduate medical education component of the Molecular Medicine Pathway
(MMP) is to create a community of and for basic science oriented residents across all specialties in
the UCSF School of Medicine and other professional schools. We are here to help these physicianscientists achieve their career goals in academia. Activities throughout the year include social
gatherings, a mentoring/career-development workshop, and the annual resident research symposium
co-sponsored with the CTSI.
We thank you for joining us today to celebrate the accomplishments of this year’s participants.
Miriam Kuppermann, PhD, MPH
Director, RRTP
Anna Bakardjiev, MD
Co-Director, MMP
Alison Huang, MD, MPhil, MAS
Co-Director, RRTP
Paul Volberding, MD
Director of Research, GHS
Ben Cheyette, MD, PhD
Co-Director, MMP
Schedule of Events
4:30 pm
Welcome & Resident Research Program Overview
Miriam Kuppermann, Director, CTSI Resident Research Training Program
Paul Volberding, Director, Global Health Sciences
Ben Cheyette and Anna Bakardjiev, Co-Directors, Molecular Medicine Pathway
4:45 pm
Comments by the Vice Dean
Catherine Lucey, Vice Dean of Education, School of Medicine
5:00 pm
Resident Oral Papers
Moderated by Miriam Kuppermann
Speaker Name: Melissa A. Bent, MD
Title: Comparison of Clinical Characteristics and Outcomes between Pediatric and
Adult Patients with Desmoplastic Small Round Cell Tumor
Residency Program: Pediatrics
Research Mentor: Steven DuBois, MD
Speaker Name: Blake R. Charlton, MD
Title: Length of Hospital Stay for Bleeding Among Adults with Atrial Fibrillation
Treated with Warfarin, Dabigatran, or Rivaroxaban
Residency Program: Categorical Internal Medicine
Research Mentor: Rita Redberg, MD, MS
Speaker Name: Kjeld A. Aamodt, DDS, MS
Title: Malocclusion and Caries vs. Oral Health Related Quality of Life in Latin
America
Residency Program: Dentistry
Research Mentor: Maria Orellana, DDS, PhD
Speaker Name: Stefana B. Morgan, MD
Title: MyPICS: Spiritual Care: Profiles of Three Core Spiritual Needs in Older
Patients with Advanced Cancer
Residency Program: Psychiatry
Research Mentor: Laura Dunn, MD
Speaker Name: Joseph T. Patterson, MD
Title: Anterior Versus Posterior Approaches for Surgical Odontoid Stabilization in
Patients Over 65 Years: 30-Day Morbidity and Mortality in a National
Database
Residency Program: Orthopaedic Surgery
Research Mentor: Bobby Tay, MD
6:15 pm
Mentors of the Year Awards
Clinical and Translational Recipient: Steven DuBois, MD,
Pediatric Hematology/Oncology
Global Health Recipient: R. Richard Coughlin, MD, MPH, Orthopaedic Surgery
Molecular Medicine Recipient: Vikaas Sohal, MD, PhD, Psychiatry
6:30 pm
Poster Viewing and Reception
Golden Gate Room
Mentors of the Year Award
It is well recognized that mentoring is a critical factor in academic success. The success of residents
embarking on a research project is highly influenced by the quality of their mentorship. Thus, we
would like to recognize the contributions of the many faculty who have assisted with the research
endeavors presented today.
Today we are recognizing three faculty mentors for outstanding excellence in mentoring. This year’s
awardees were selected from many outstanding nominations.
Clinical and Translational Mentor
Steven DuBois, MD
Nominating Residents’ Comments:
“Dr. DuBois is a phenomenal scientist, clinician and mentor. We devised a plan and schedule prior to
the course and consistently met weekly. He contacted various fellows and attendings to assist me with
navigating the SEER database and taught me to network. Since the TICR course, we have drafted a
manuscript for publication, meeting throughout the process and he hosted a Sarcoma Retreat where I
spoke about the project. He is energetic and inspiring. He has supported numerous trainees that have
completed the CTSI TICR course and has been an instructor in the past. He is most deserving of this
recognition.”
“Steve is an unparalleled mentor, able to take me from brainstorming about a research project to ready
for publication in one short year. We discuss the upcoming steps, then I am set loose to work on (and
re-work) statistics or an abstract draft; then we meet again and re-try whatever statistics were above
my head, or edit a paper draft. He is always available to help, but allows me to get my feet wet and gain
experience in the research process. In addition, his obvious excitement in the work he is doing
encourages my own.”
Global Health Mentor
R. Richard Coughlan, MD, MPH
Nominating Resident’s Comments:
“Dr. Coughlin inspires residents to reach out and teach orthopedics to developing nations in the US
and abroad. Without his support and encouragement, I would not have had the opportunity to start this
collaborative effort between UCSF orthopedics and the Hospital and Rehabilitation Centre for Disabled
Children in Nepal. After our efforts in 2013, 2 other orthopaedic residents have traveled to Nepal and
plans for collaborative research on hype displace, outreach centers, and educational conferences via
video conference are in process. His ideas, "do-not-give-up" and "do-the-right-thing" attitude are
unparalleled. He is truly an inspiration.”
Molecular Medicine Mentor
Vikaas Sohal, MD, PhD
Nominating Resident’s Comments:
“Vikaas has welcomed me into his laboratory along with a number of residents in other disciplines.
Having finished residency relatively recently himself, Vikaas is acutely aware of the challenges faced
by research track residents. Where these challenges are surmountable, Vikaas has been a steadfast
and vocal advocate. Where they are innate to residency training, he has been unfailingly supportive
and understanding. As a mentor, Vikaas inspires confidence that becoming a physician-scientist
remains both an achievable and worthy aspiration. Vikaas worked closely with me to develop a project
where progress was possible as a junior resident and continues to offer invaluable mentorship as the
research has evolved.”
Abstracts:
Oral Presentations
UCSF Resident Research Symposium
Wednesday, May 27th, 2015
Millberry Union Conference Rooms
Abstract title: Comparison of Clinical Characteristics and Outcomes between Pediatric and Adult
Patients with Desmoplastic Small Round Cell Tumor
Resident’s name: Melissa A. Bent, MD
Name of program: Pediatrics
Purpose: Desmoplastic small round cell tumor (DSRCT) is a rare, aggressive malignancy that
typically affects pediatric and young adult patients. Due to its rarity, there are limited data on potential
differences between pediatric and adult patients with DSRCT.
Methods: Patients aged 0–90 years at time of primary diagnosis with DSRCT and reported to the
Surveillance, Epidemiology and End Results (SEER) program between 1991 and 2011 were eligible
for inclusion in the cohort. We used Fisher exact tests and log-rank tests to compare clinical features
and overall survival for pediatric (age 0–21 years) and adult (age >21 years) patients. We performed
recursive partitioning to determine if a specific age group with more favorable outcomes could be
identified.
Results: The SEER database included 264 patients with DSRCT (95 pediatric / 169 adult patients).
The median age was 25 years (range: 0–90). Compared to adult patients, pediatric patients were
more likely to have pelvic tumors (p = 0.004), have distant metastatic disease (p = 0.041), and
receive radiation therapy (p = 0.004). Overall survival was poor and did not differ between pediatric
vs. adult patients (5-year overall survival: 18.1% vs. 16.9%; p = 0.51). The recursive partitioning
results demonstrated that no age group could be identified with a statistically significant difference in
the risk of death. Radiation therapy was associated with prolonged survival in pediatric but not adult
patients.
Conclusions: Clinical features and impact of radiation therapy differ between adult and pediatric
patients. Outcomes for children and adults are uniformly poor.
Abstract title: Length of Hospital Stay for Bleeding Among Adults with Atrial Fibrillation Treated with
Warfarin, Dabigatran, or Rivaroxaban
Resident’s name: Blake R. Charlton, MD
Name of Program: Categorical Internal Medicine
Purpose: Use of Novel Oral Anticoagulants (NOACs) for treatment of atrial fibrillation is increasing;
however, little is known about the hospital course of patients admitted for bleeding during treatment
with NOACs. The objective of this study is to compare length of stay for adults with atrial fibrillation
who were hospitalized for bleeding during treatment of warfarin, dabigatran, and rivaroxaban.
Methods: This retrospective, longitudinal cohort study used a commercial administrative claims
database of approximately 38 million members distributed across 14 US states from 1 November
2010 to 31 March 2014. Participants were adults with new atrial fibrillation who were hospitalized for
bleeding after initiating therapy on warfarin, dabigatran, or rivaroxaban. The main outcome was length
of stay. Secondary outcomes included transfusion of blood products, incidence of ICU stay, and
length of ICU stay. We used propensity scores for adjustment of a multivariate regression model. A
priori, we identified subgroup analysis for patients with chronic kidney disease, heart failure,
dementia, more than 7 comorbidities, hemorrhagic stroke, major gastrointestinal bleed, and those
over 75 years of age.
Results: Admissions for bleeding included 2,503 patients using warfarin, 461 using diabigatran, and
260 using rivaroxaban. Compared to dabigatran and rivaroxaban, warfarin patients were older and
had higher rates of chronic renal disease, heart failure, and higher average Deyo-Charlson
Comorbidity indexes. After adjustment for differences in baseline characteristics among the three
groups, average length of stay for was 9.1 days for patients on warfarin, 7.0 days on dabigatran, and
6.2 days on rivaroxaban. Compared to warfarin, dabigatran was associated with a 2.1 day decrease
(CI 1.8 - 2.4, p=0.05) in length of stay while rivaroxaban was associated with a 2.9 day decrease (CI
2.6 - 3.2, p=0.05) in length of stay. When compared to dabigatran, rivaroxaban was associated with a
0.8 days decrease (CI 0.4 - 1.3, p = 0.05) length of stay. Incidence of blood product transfusion was
not reliably captured. There were no significant differences in the incidence of ICU stay. Average
length of ICU stay was 9.0 days for patients on warfarin, 6.4 days for patients on dabigatran, and 5.7
days for patients on rivaroxaban. There was no significant difference in subgroups with heart failure,
chronic kidney disease, dementia, hemorrhagic stroke, or major gastrointestinal bleed. However,
warfarin’s association with increased length of stay was more pronounced for patients over the age of
75 or with more than 7 comorbidities. In these groups there was no difference in length of stay
between warfarin and dabigatran.
Conclusions: Among patients admitted for bleeding during systemic anticoagulation, warfarin was
associated with longer hospital and ICU stays when compared to dabigatran and rivaroxaban.
Dabigatran was associated with a longer length of stay compared to rivaroxaban. This study is limited
by its use of retrospective data, and its results do not affect estimations of bleeding instance or
mortality. Baseline characteristics did significantly differ between the warfarin and NOAC groups;
however, the large differences in length of stay after correction make it unlikely that the observed
differences are purely the result of residual confounding. Therefore, these results suggest that the
complications associated with bleeding during treatment with a warfarin are more severe than those
associated with bleeding during treatment with dabigatran or rivaroxaban.
Abstract title: Malocclusion and Caries vs. Oral Health Related Quality of Life in Latin America
Resident’s name: Kjeld A. Aamodt, DDS, MS
Name of program: Dentistry
Purpose: This multi-center study was aimed to assess how caries and malocclusion independently affect the
Oral Health Related Quality of Life (OHRQoL) of Latino children/adolescents living in Latin America.
Methods: A total of 2630 students (12 to 19y) were recruited from 6 different schools in Peru and Mexico. The
Child Oral Health Impact Profile (COHIP) was used to assess OHRQoL. Caries were quantified utilizing the
Decayed, Missing, and Filled Surface index (DMFS), and malocclusion using the Index of Complexity,
Outcome, and Need (ICON).
Results: Overall, the COHIP appears to be concurrently valid in each country (P).
Conclusions: This sample shows an effect of caries and malocclusion on OHRQoL of Latino students.
Rural/indigenous and urban samples respond differently to malocclusion assessment on the OHRQoL.
Abstract title: Spiritual Care: Profiles of Three Core Spiritual Needs in Older Patients with Advanced Cancer
Resident’s name: Stefana B. Morgan, MD
Name of program: Psychiatry
Purpose: Comprehensive multidisciplinary care for older adults requires attention not only to the physical and
psychological aspects of the individual, but also to the spiritual needs of each patient. There is substantial
evidence that the spiritual needs of individuals facing life-threatening illnesses, such as advanced cancer, often
go unmet. Professional healthcare chaplains are trained to assess and intervene to help patients with their
individual spiritual needs, regardless of the patient’s religious or spiritual beliefs or affiliation. However, minimal
research has documented how chaplains go about providing spiritual care to older adults with life- threatening
illnesses. Our team conducted a mixed-methods study of one well-articulated model of spiritual care (Spiritual
Assessment and Intervention Model, or Spiritual AIM), in the setting of outpatient palliative care for patients
with advanced cancer. Spiritual AIM posits that every individual has spirituality rooted in three core needs: the
need to seek meaning and direction, the need to find self-worth and to belong to community, and the need to
love and be loved, often facilitated through seeking reconciliation when relationships are broken. These mental
heuristics described by Spiritual AIM as the three core spiritual needs, are termed “Meaning and Direction,”
“Self-Worth/Belonging,” and “Reconciliation.” Chaplains have been trained to assess which one of these three
core spiritual needs is most apparent through their liaison with the patient. In previous work we have described
the Spiritual AIM model (including its conceptual, theological, and psychological underpinnings)(Shields et al.,
Palliative and Supportive Care, 2014). Here, we will illustrate the use of Spiritual AIM in three older adults (one
case exemplifying each core spiritual need). We will present the key signposts along the continuum of
assessment, embodiment and interventions, as well as response to the interventions, in order to better
characterize and explain the predominance of certain core needs over others.
Methods: Thirty-one patients were recruited through a comprehensive cancer center while receiving oncologic
and palliative care. Participants had three audiorecorded one-on-one sessions with a chaplain, as well as an
exit interview with a research assistant. Qualitative methods (iterative development of a codebook) were used
to characterize the Spiritual AIM model which provided a framework for the chaplain’s practice. In this study,
we used these codes to examine transcripts of all three chaplain sessions with three patients > 60 years old,
each of whom clearly manifests one core spiritual need.
Results: Mean age of participants was 65.9 (SD: 5.2 years, range: 60-80). Participants were diagnosed with a
variety of solid tumors and all had distant metastases. Participants were evenly divided between men and
women. Case 1 – Self-Worth and Belonging: C is a 60 year-old woman with metastatic solid tumor cancer. Her
core need is finding self-worth and belonging to a community, expressed to the chaplain as self-blame, fear of
burdening and guilt. Some of the chaplain’s interventions are valuing the patient and exploring her anger
toward others and towards God. Case 2 – Meaning and Direction: B is a 71 year-old man with colon cancer.
He struggles with re-forging his identity after facing physical disability and expresses ambivalence in navigating
decisions. The chaplain invites the patient to name sources of strength, provides blessing and rejoices in the
achievements of the patient. Case 3 – Reconciliation: J is a woman in her 60’s with a gynecologic cancer. She
struggles with tense relationships with her community and loved ones. The chaplain’s interventions include
acknowledging the brokenness in important relationships and challenging the patient to take responsibility.
Outcomes for each case will be discussed and examples of themes (quotations from participants) will be
presented.
Conclusions: This study provides a glimpse into a relatively sparsely studied area of comprehensive clinical
care for older patients – spiritual care by professional healthcare chaplains in the palliative care setting.
Additionally, it showcases the added value of spiritual care for geriatric patients and illustrates for other
healthcare professionals a theoretical model commonly used in chaplain practice. The implications of
enhanced understanding of the role of healthcare chaplains include improved interdisciplinary collaboration,
appropriate use of healthcare resources and augmented satisfaction for older patients and their providers alike.
Abstract title: Anterior Versus Posterior Approaches for Surgical Odontoid Stabilization in Patients
Over 65 Years: 30-Day Morbidity and Mortality in a National Database
Resident’s name: Joseph T. Patterson, MD
Name of program: Orthopaedic Surgery
Purpose: Surgical stabilization of odontoid fractures is superior to nonoperative management in
patients older than 65 years. Limited level III/IV data are available to guide the choice an anterior or
posterior approach to odontoid surgery in this population. The purpose of this study is to compare the
30-day morbidity and mortality of anterior versus posterior approaches for odontoid surgery in
patients over 65 years of age.
Methods: Surgical stabilization of odontoid fractures is superior to nonoperative management in
patients older than 65 years. Limited level III/IV data are available to guide the choice an anterior or
posterior approach to odontoid surgery in this population. The purpose of this study is to compare the
30-day morbidity and mortality of anterior versus posterior approaches for odontoid surgery in
patients over 65 years of age.
Results: Patients in the posterior group were significantly different with regard to lower incidence of
an odontoid nonunion and higher body mass index (BMI). There was a nonsignificant trend toward
older patients in the anterior group. All patients received general anesthesia. There were no
significant difference in days from admission to surgery or surgery to discharge. Operative time was
significantly greater, nearly twice as long, for posterior odontoid stabilization procedures. No patient in
either group had a documented fatal myocardial infarction, pulmonary embolism, renal failure,
neurologic deficit, wound dehiscence, renal insufficiency, or renal failure. On multivariate analysis
adjusted for baseline characteristics, there were no significant differences in the relative risk of the
composite outcome of any adverse event. Patients undergoing an anterior approach were more likely
to expire within 30 days of index surgery (RR = 2.75, 95% CI [1.03-7.34], p = 0.043), more likely to
have an unplanned hospital readmission (RR = 4.34, 95% CI [1.05-17.99], p = 0.043) and less likely
to discharge to facility other than home (RR = 0.64, 95% CI [0.42-0.96], p = 0.030). There were
nonsignificant trends toward greater relative of risk of revision surgery, cardiac or respiratory
failure/arrest, and major airway complication with an anterior odontoid surgery.
Conclusions: Anterior approach to surgical stabilization of the odontoid is associated with shorter
operative time as well as higher relative risk of mortality, discharge to home, and unplanned
readmission within 30 days of surgery relative to posterior surgery among patients 65 years or older
in a national surgical outcomes database. This study represents the highest level of available
evidence to support choice of surgical approach for odontoid fracture in this population, the first to
report validated surgical outcomes in odontoid surgery from a national prospective database, and the
first study to suggest a mortality benefit to a posterior surgical approach. Prospective, randomized
investigations are necessary to validate these findings, which are concordant with an observed
decline in the relative prevalence of anterior odontoid surgeries over the last two decades.
Resident Research Training Program
CTSI Resident Research Funding Award 2014 Recipients
Name
Program
Mentor
Emily Balkin
Pediatrics
Roberta Keller
Marie Beylin
Emergency Medicine
Steven Polevoi
Nicole Bui
Pediatrics
Roberta Keller
Heng Duong
Internal Medicine
Harold Collard
Marlys Fassett
Dermatology
Mark Ansel
Lindsay Hampson
Urology
Benjamin Breyer
Jeff Riddell
Emergency Medicine
Patil Armenian
Vivien Sun
Pediatrics
Shonul Jain
Abstracts:
Poster Presentations
UCSF Resident Research Symposium
Wednesday, May 27th, 2015
Selected Poster Presentations
Name
Residency Program
Mentor
Abstract Title
Bibhav Acharya
Psychiatry
Erick Hung
Needs-assessment for Mental Health Training Among
Primary Care Providers in Rural Nepal
Ben Alter
Anesthesia and
Perioperative Care
Howard Fields
Modeling expectation-induced analgesia
Jeffrey Barry
Orthopaedic Surgery
Eric Hansen
Perioperative Outcomes of Primary Total Hip Arthroplasy
after Lumbar Spinal Fusion
Maria Beylin
Emergency Medicine
Steven Polevoi
An emergency airway checklist is feasible to implement in
the emergency department but does not change self
reported first and second pass intubation success rates
Catherine Chen
Anesthesia and
Perioperative Care
Adams Dudley
Comparative prevalence of anesthesia use among
cataract surgery patients undergoing other low-risk
ambulatory procedures
Christine Chiu
Psychiatry
Julene Johnson
Preliminary Baseline Measures of Psychosocial Function in
the Community of Voices
Heng Duong
Internal Medicine,
Categorical
Hal Collard
Pulmonary artery to aortic diameter ratio predicts
mortality in IPF
Marlys Fassett
Dermatology
Mark Ansel
Expression and microRNA-mediated regulation of Th2type cytokines by inflammatory skin infiltrates in Atopic
Dermatitis
Sara Handley
Pediatrics
Henry Lee
Patterns of Inhaled Nitric Oxide use in California NICUs
Joseph Hippensteel
Internal Medicine,
UC Primary Care
Shuvo Roy
Characterization of a novel silicon micro-electromechanical systems (MEMS)-based extracorporeal
membrane oxygenator (ECMO).
Matthew Hirschtritt
Psychiatry
Carol Mathews
Latent class analysis of Tourette syndrome and common
comorbid disorders: Clinical and genetic implications
Myung Ko
Internal Medicine,
Categorical
Louise Walter
How Often are Elderly Veterans with Limited Life
Expectancy Diagnosed with Incidental Barrett’s
Esophagus?
Kelsey McEwan
Internal Medicine,
Categorical
Elizabeth Van Opstal
The Clinical Bridge
Claire Mulvey
Internal Medicine,
Categorical
Alka Kanaya
Sex differences in Lp(a) associations with atherosclerosis
in South Asians
Tyler Murray
Internal Medicine,
Categorical
Vijay Nambi
Postprandial effects on arterial stiffness parameters in
healthy young adults
Krystal Nizar
Psychiatry
Carol Mathews
Emotional dysregulation and error processing
characterizes individuals with Hoarding disorder
Name
Residency Program
Mentor
Abstract Title
Odayme Quesada
Internal Medicine,
Categorical
Rita Redberg
Assessing the Availability and Dissemination of Results
from Food and Drug Administration Mandated PostApproval Studies for Medical Devices
Molly Quinn
Obstetrics,
Gynecology and RS
Heather Huddleston
Ovarian volume as a non-linear predictor of metabolic
dysfunction in Polycystic Ovary Syndrome (PCOS)
Jeffrey Riddell
Emergency Medicine
Patil Armenian
A Prospective Observational Study Of Ketamine For
Sedation Of Acutely Agitated Emergency Department
Patients
Lindsey Sheffler
Orthopaedic Surgery
Michelle James
Long-term Outcomes of External Rotation Tendon
Transfers in Brachial Plexus Birth Palsy
Arjun Sinha
Internal Medicine,
Categorical
Nelson Schiller
Association of Resting RA Size and Function with Exercise
Capacity
Christopher Smitson
Internal Medicine,
Categorical
Carmen Peralta
Blood Pressure Trajectories in the Elderly: Clinical
Significance and Association with Poor Outcomes
Steven DuBois
Comprehensive Analysis of Clinical and Biological Features
that Correlate with MYCN Amplification in
Neuroblastoma: A Report from the International
Neuroblastoma Risk Group Project
Daria Thompson
Pediatrics
Julian Villar
Emergency Medicine
Clement Yeh
Video laryngoscopy and the use of supraglotic devices
improves time-to-definitive-airway, but does not improve
CPR quality, as compared to direct laryngoscopy in a
simulation model of cardiac arrest: a prospective,
simulation-based, randomized controlled trial.
Nicole Weiss
Pediatrics
Roberta Keller
Intestinal Atresias: Fetal Ultrasound Findings and
Duration of Parenteral Nutrition
Amanda Whitaker
Orthopaedic Surgery
Richard Coughlin
Evaluation of Nepali site for orthopaedic education and
training
Scott Wilke
Psychiatry
Vikaas Sohal
Identifying Prefrontal Cortex Endophenotypes of
Psychiatric Disorders in a Novel in vitro Assay
William Winkleman
Obstetrics,
Gynecology and RS
Tami Rowen
The Correlates of Female Sexual Dysfunction in Infertile
Women
Marron Wong
Obstetrics,
Gynecology and RS
Ben Li
Low Lying Placentas: Resolution Rates and Delivery
Outcomes Over a 13 Year Period
Abstract title: Needs-assessment for Mental Health Training Among Primary Care Providers in Rural
Nepal
Resident’s name: Bibhav Acharya, MD
Name of program: Psychiatry
Purpose: Low- and Middle-Income Countries (LMICs) face a large treatment gap in mental illness
because of high burden of disease and shortage of mental health specialists. Global initiatives place
Primary care providers (PCPs) at the center of scaling-up mental health services. If PCPs are to be
trained and supported in delivering mental health care, it is critical to begin by conducting a thorough
needs assessment.
Methods: This study utilized focus groups with PCPs in rural Nepal to understand PCPs’ reflections
on prior training and their current clinical practice with patients with mental illness. Transcripts were
translated from Nepali to English and coding and sorting of transcripts was facilitated using Dedoose
by two coders. One of the coders was not involved in conducting the focus groups. Inter-rater
reliability between the coders was calculated for 25% of the data using pooled Cohen’s Kappa16 and
determined to be 0.64, which is considered “good agreement”.
Results: All PCPs said that psychiatry was the most neglected topic in their clinical training. Clinical
rotation in psychiatry ranged from 0-15 days and everyone described learning very little. They felt illprepared to interview, diagnose and treat patients with mental illness. They described the importance
of treatment and counseling but were employing treatment methods that may cause patient
discomfort and would not improve psychiatric outcomes. Counseling was limited to advising patients
not to worry and providing others forms of reassurances.
Conclusions: Woefully inadequate mental health training in health professional schools has resulted
in challenges in knowledge (diagnostic criteria and evidence-based treatment), skills (conducting
patient-centered interviews and providing evidence-based counseling) and attitudes (beliefs about
gender, suicide and role of environmental stress). Results from needs-assessment will be used to
develop a training and education program for the PCPs in mental health.
Abstract title: Modeling expectation-induced analgesia
Resident’s name: Ben Alter, MD, PhD
Name of program: Anesthesia and Perioperative Care
Purpose: Expectation powerfully affects sensory experience. No clearer example of this can be
found than in the nociceptive sensory system. Predictions of impending pain can either decrease or
increase the described experience of that pain as part of placebo and nocebo phenomena. Although
these phenomena have been studied in human subjects, animals models are limited, leading to a
paucity of mechanistic understanding at the circuit, cellular, and molecular levels. To address this, we
sought to combine behavioral analysis techniques, including classical conditioning and sensory
testing, to develop a model of expectation-induced analgesia. We specifically set out to test the
hypothesis that, in the setting of ongoing pain, exposure to an environment previously associated with
analgesia will in itself cause analgesia.
Methods: Long-Evans rats were used in all experiments. Standard pain models were used to
establish hypersensitivity. Afterwards, animals went through a training phase in which contextual cues
were paired with pharmacologic agents that are analgesic in human and known to reduce
hypersensitivity in rats. Following conditioning, rats were exposed to contextual cues and sensory
thresholds measured.
Results: Custom behavioral equipment was designed and built in the lab. Conditioned place
preference was validated using morphine administration. Sensory threshold measurement techniques
were validated. Experiments using pain models in rats are ongoing.
Conclusions: Conditioned analgesia has been shown previously in humans and in naïve rodents.
The current study seeks to test whether conditioned analgesia occurs in rats with ongoing pain.
Methods developed and reported in this abstract will allow for the rigorous testing of this hypothesis. If
observed, conditioned analgesia in rats with ongoing pain could provide a model for placebo
analgesia in human.
Abstract title: Perioperative Outcomes of Primary Total Hip Arthroplasy after Lumbar Spinal Fusion
Resident’s name: Jeffrey Barry, MD
Name of program: Orthopaedic Surgery
Purpose: The coexistence of degenerative hip disease and spinal stenosis, coined “hip-spine
syndrome” by Fogel, is a recognized entity that may be as prevalent as 18% in patients ultimately
undergoing total hip arthroplasty (THA). The limited research to date suggests these patients
experience less pain relief and worse outcomes compared to other THA patients. We hypothesize
that primary THA patients who have undergone prior lumbar spinal fusion (LSF) experience worse
perioperative outcomes.
Methods: Retrospective case-control study. All primary THA patients who had undergone prior LSF
at our institution were identified and matched to a control group of primary THA patients who had not
undergone LSF (1:2) based on age, sex, and American Society of Anesthesiologists (ASA) score.
Perioperative outcomes were compared including complications, readmissions or reoperations within
90 days, anesthesia type, pain scores, narcotic usage, hospital length of stay, disposition, and
walking distance.
Results: From 2012-2014, 35 THA patients had prior LSF (17).
Conclusions: Preexisting LSF results in worse perioperative outcomes after primary THA including
higher rates of complications and reoperation. Decreased functional mobility, decreased rates of
neuraxial anesthesia, and higher narcotic usage likely all play roles in these findings. Hip-spine
syndrome warrants attention in THA patients and represents an area for further investigation.
Abstract title: An emergency airway checklist is feasible to implement in the emergency department
but does not change self reported first and second pass intubation success rates
Resident’s name: Maria Beylin, MD
Name of program: Emergency Medicine
Purpose: There is a recent trend in intubation checklist use in the Emergency Department (ED), but
limited literature is available to support or refute patient-related benefits. Within healthcare, checklist
use with central venous line insertion, intensive care unit rounding, and pre-operative evaluation has
led to improved patient outcomes. Intubations in the emergency department have high rates of
complications and require many steps. Such procedures tend to benefit from checklist use; however,
it is possible that due to the time constrained situation surrounding ED intubation, a checklist may not
improve outcomes and may even be detrimental. A landmark study by Sakles et al. found that each
subsequent intubation attempt in trauma patients is associated with a substantial increase in adverse
events, leading to an emphasis on first and second pass success rate as an important proxy for
decreased serious complications.
Methods: As part of a housestaff quality improvement project Emergency Medicine residents
implemented a real-time intubation checklist on July 1, 2013. A retrospective cohort study was
performed. Subjects were all consecutive adult patients intubated in a single academic ED one year
before and one year after implementation of the checklist. Two-tailed Fisher’s exact test was used for
statistical analysis to compare attempts before and after checklist implementation.
Results: There were a total of 173 adult patients intubated prior to checklist use (166 procedure
notes available) and 183 adult patients intubated after implementation of the checklist (N = 349). The
intubation checklist was used in 75% (137/183) of all intubations with increasing use after each
quarter. First or second pass success rate did not change after checklist implementation 96%
(159/166) vs 95%(173/183) (p = 0.627, Fisher’s exact test two-tailed). Similarly there was no
difference in the number of first or second pass attempts before and after checklist adoption.
Conclusions: An emergency airway checklist is feasible to implement in the emergency department
with rapid uptake and approval from residents, but does not change self reported first and second
pass intubation success rates. There may be other patient-related benefits of the checklist that were
not considered in this study.
Abstract title: Comparative prevalence of anesthesia use among cataract surgery patients
undergoing other low-risk ambulatory procedures
Resident’s name: Catherine L. Chen, MD, MPH
Name of program: Anasthesia and Perioperative Care
Purpose: Cataract surgery is the most common elective surgery among Medicare beneficiaries and
is considered very safe. Although patients are typically elderly with multiple coexisting conditions,
virtually all procedures are performed in an ambulatory setting with topical anesthesia. However, in
contrast to many other low-risk ambulatory procedures, cataract surgery is notable for the routine use
of anesthesiologists to provide sedation during surgery. We determined the prevalence of anesthesia
use in Medicare patients undergoing cataract surgery who also underwent other low-risk ambulatory
procedures.
Methods: Using an observational cohort of Medicare beneficiaries undergoing cataract surgery in
2011, we identified the percentage of cataract surgery patients who underwent other low-risk
ambulatory procedures in the same year. These procedures included bronchoscopy, upper
endoscopy, colonoscopy, cardiac catheterization, percutaneous coronary intervention (PCI),
pacemaker or implantable cardioverter/defibrillator placement (ICD), and electrophysiologic (EP)
procedures. We compared the prevalence of anesthesia use during cataract surgery with anesthesia
use during the other listed procedures. We defined a same-day hospital admission and death
occurring within 7 days after surgery as negative outcomes.
Results: Among 441,847 cataract surgery patients, 0.3% had bronchoscopy, 6% had upper
endoscopy, 10% had colonoscopy, 3% had cardiac catheterization, 0.7% had PCI, 0.8% had ICD,
and 0.4% had an EP procedure. Ninety percent of patients had an anesthesia provider during their
cataract surgery. The prevalence of anesthesia use during the other procedures were 22%, 40%,
46%, 0.3%, 0.4%, 15% and 34%, respectively. Cataract surgery patients had a 0.03% prevalence of
same-day hospital admission, compared to 17%, 2%, 0.5%, 24%, 46%, 17%, and 22% for the other
procedures, respectively. The prevalence of death was extremely low for all procedures during the
first 7 days after surgery.
Conclusions: Cataract surgery has the highest prevalence of anesthesia use and the lowest
prevalence of same-day hospital admission when compared to other low-risk ambulatory procedures.
Abstract title: Preliminary Baseline Measures of Psychosocial Function in the Community of Voices
Resident’s name: Christine C. Chiu, MD
Name of program: Psychiatry
Purpose: Community of Voices is a multi-site longitudinal study to investigate the effects of a
community choir on health and well being in ethnically diverse older adults.
Methods: The Community of Voices study is current recruiting older adults of diverse racial/ethnic
and socioeconomic status backgrounds from 12 existing Administration on Aging (AoA)-supported
senior centers to implement a multi-site, cluster-randomized clinical trial of a community choir
program to promote health and well-being. Participants age 60 or above sing in weekly 90-minute
choir for 44 weeks. Cognitive, physical and emotional domains are measured at baseline, 6 months
and12 months. Psychosocial outcomes include the PHQ-8 (Patient Health Questionnaire) as primary
outcome and NIH Toolbox Emotion measures of loneliness, social support, self-efficacy, apathy, fear,
positive affect as secondary outcomes. In our preliminary analysis of baseline data from 6 of the 12
sites for the psychosocial outcomes, we examine psychometric properties of the outcome measures.
Results: In 6 of the 12 sites, 65% of participants are African-American, Latino or Asian/Pacific
Islander and 36% are non-Hispanic white. The mean age is 71.5 years and the age range is 60-88
years. 70% of participants are women. 20% report less than high school education. The mean PHQ-8
score is 4.3 (SD = 3.8). Approximately 25% participants scored 0 on PHQ-8, and 11% participants
scored 10 or higher.
Spearman's test was used to examine inter-correlations between PHQ-8 and NIH Toolbox's
measures of emotion. Preliminary results suggest that there is moderate correlation between PHQ-8
and NIH Toolbox measures of sadness (r = 0.56), loneliness (r = 0.51) and fear affect (r = 0.59) (p’s <
0.001). There was a moderately strong correlation between NIH Toolbox sadness and loneliness (r =
0.71, p)
Conclusions: Baseline demographics data for 185 participants from 6 of the 12 senior centers
showed diversity in ethnicity and educational background. There is moderate correlation between
PHQ-8 and NIH Toolbox measures of negative affect (sadness, loneliness and fear affect), indicating
convergent validity of these tests. In contrast, there is low correlation between PHQ-8 and positive
affect measures (self-efficacy, positive affect), indicating divergent validity.
Abstract title: Pulmonary artery to aortic diameter ratio predicts mortality in IPF
Resident’s name: Heng T. Duong, MD
Name of program: Internal Medicine, Categorical
Purpose: Idiopathic pulmonary fibrosis (IPF) is a progressive, fibrotic interstitial lung disease with a poor
prognosis, but variable survival. CT measurement of pulmonary artery (PA) diameter and/or its ratio to
aorta (A) diameter is associated with pulmonary hypertension (PH) in several lung diseases. The
presence of PH correlates with increased mortality in IPF. We sought to determine whether there is an
association between PA diameter or PA:A diameter ratio and mortality in IPF.
Methods: Retrospective cohort study of patients enrolled between 2001-2010 at UCSF with a
multidisciplinary diagnosis of IPF based on 2000 American Thoracic Society criteria. Inclusion criteria
were availability of a high resolution CT (HRCT) or volumetric CT obtained within 12 months of the initial
clinic visit and complete pulmonary function testing (PFT). The primary outcome was time-to-death. Cox
proportional hazards regression modeling was performed to adjust for covariates. The added effect of
PA:A ratio to the predictive performance of the GAP score, a clinically validated scoring system to predict
survival in IPF, was assessed by change in the c-statistic.
Results: As of 4/1/2014, 659 patients had been assessed in total. 9.3% were current tobacco users,
35.1% were past users, and 55.7% were never users. Current smokers were more likely to be younger
and female (both p = 0.02). Past users were more likely to have a cancer diagnosis or tobacco-related
diagnosis (both p < 0.01). 79% of smokers underwent a tobacco cessation consult and there were no
predictors in univariate analysis that predicted likelihood of refusing a consult. Patients who had a consult
were significantly more likely to be prescribed nicotine-replacement therapy during their hospitalization
(97.4% vs. 40.0%, p < 0.01). The vast majority (81%) of patients receiving consults were also discharged
with nicotine-replacement therapy.
Prior to the initiative, 0% of our patients’ smoking status was assessed and no patients were ever referred
by our service to the inpatient smoking cessation consult service. Our department showed significant
improvement, achieving 59% assessment rate in quarter 1, 86% in quarter 2, and 100% by quarter 3.
Conclusions: As urologists, screening for tobacco use is important, as 1 in 11 patients undergoing
inpatient surgery are current smokers. Furthermore, these individuals are more likely than never smokers
to be younger and female, and we must avoid screening bias to identify these individuals. Our quality
improvement initiative has demonstrated drastic improvement in both identifying patients’ smoking status
and obtaining a perioperative smoking cessation intervention for current smokers, suggesting that this is a
fast, feasible, and easily-implemented assessment to identify smokers and obtain smoking cessation
counseling and treatment for patients at a time when they are perhaps most amenable to quitting. Further
analysis of smoking cessation rates is being conducted in a randomized trial to determine the success of
the perioperative smoking cessation intervention and predictors for successful cessation in this
population.
Abstract title: Expression and microRNA-mediated regulation of Th2-type cytokines by inflammatory
skin infiltrates in Atopic Dermatitis
Resident’s name: Marlys S. Fassett, MD, PhD
Name of program: Dermatology
Purpose: Atopic dermatitis (AD) is a highly prevalent T-cell mediated chronic skin disease. The skin
inflammation observed in AD results from a combination of keratinocyte barrier dysfunction plus
inflammatory cell migration and cytokine secretion into affected skin. There is a paucity of information
regarding the factors responsible for recruitment, retention and activation of T cells and other
leukocytes in skin during the subacute or chronic AD disease states, when most patients seek care.
Defining interrelationships between the heterogeneous infiltrating cell populations at different stages
of AD will be key to the development of pathophysiologically-informed therapies.
Methods: We optimized the MC903 mouse model of atopic dermatitis to be able examine T-helper 2
(Th2)-type cytokine production by skin-infiltrating Th2 cells, basophils, and type 2 innate-like cells
(ILC2s) by flow cytometry and RNAseq at serial time points during the transition from acute to chronic
dermatitis.
Results: We find that these three populations are all recruited to inflamed skin in sizable numbers,
and that they display distinct but complementary patterns of interleukin-4, -5 and -13 (Th2-type
cytokine) expression in dermatitic skin.
Conclusions: In addition, because we know that Th2 cytokine expression by T cells in vitro and in
other atopic diseases is post-transcriptionally regulated by microRNAs, we are profiling microRNA
expression in skin-infiltrating cell populations isolated from MC903-treated mouse skin. We are also
extending these studies to the AD patient population by profiling microRNA expression in lesional skin
biopsied from adults with chronic severe AD, in hopes of identifying causative pathways, therapeutic
targets, and biomarkers to guide future pharmacologic intervention.
Abstract title: Patterns of Inhaled Nitric Oxide use in California NICUs
Resident’s name: Sara C. Handley, MD
Name of program: Pediatrics
Purpose: To describe iNO exposure in a population-based cohort stratified by gestational age (GA)
over time and variation in iNO use across different levels of Neonatal Intensive Care Units (NICU).
Methods: In this cross-sectional, retrospective study utilizing the California Perinatal Quality Care
Collaborative (CPQCC), we examined iNO use from 2005 to 2013 for eligible infants 22+0/7 to
43+6/7 weeks GA admitted to one of 132 CPQCC NICUs. Analysis included a multivariable
regression model of characteristics of those who did and did not receive iNO, comparison of iNO
rates over time and variation between community and regional centers. Analysis was stratified by
gestational age.
Results: 4,850 of 136,113 infants received iNO (3.6%). Antenatal steroid use, delivery room
cardiopulmonary resuscitation and care in a regional level NICU were all associated with increased
iNO exposure. iNO use increased in all GA subgroups from 2005 to 2010, followed by modest
decreases in all GA groups from 2010 to 2012, however since 2012 use has again increased in all
GA groups, except for 31-33 week infants. iNO is used in both community and regional NICUs,
however use is significantly higher in regional centers and variation between centers.
Conclusions: iNO use in NICUs varies significantly with GA, with highest use at the extremes of GA.
Though there was a transient decreased after 2010, coinciding with the NIH Consensus Conference
that did not support the use of iNO in preterm infants, use in preterm and term infants in increasing.
The significant variation between centers suggests that additional work to standardize practice and
criteria for iNO use, particularly in preterm infants, is needed.
Abstract title: Characterization of a novel silicon micro-electro-mechanical systems (MEMS)-based
extracorporeal membrane oxygenator (ECMO).
Resident’s name: Joseph Hippensteel, MD, MS
Name of program: Internal Medicine, UC Primary Care
Purpose: We sought to determine oxygen and carbon dioxide exchange characteristics of a novel
polydimethylsiloxane/silicon membrane and demonstrate its feasibility for ECMO.
Methods: The MEMS-ECMO device was produced by combining rapid prototyping and
microfabrication techniques. The performance of the device was characterized ex vivo using
approximately 1L of citrate-phosphate-dextrose-adenine anticoagulated sheep blood. Blood gas
analyses from the in-flow and out-flow ports of the device were conducted every 6 minutes at variable
blood flow rates ranging from 0.1 mL/min to 1 mL/min. For the in vivo component of this work, an ewe
was anesthetized and bilateral saphenous catheters to supply blood to the device were placed by
trained veterinary staff. Equivalent to the ex vivo experiment, blood gases were analyzed from the inflow and out-flow ports every 6 minutes for a total of 3 hours at variable blood flow rates ranging from
0.1 to 1 mL/min. The oxygen flow across the device was maintained at an FiO2 of 100% at 520
mmHg for both experiments. Blood was propelled by an external peristaltic pump. All data was
compiled in and analyzed using Microsoft Excel (Redmond, WA).
Results: Ex vivo results demonstrated oxygen exchange at all flow rates except for 1 mL/min. The
oxygen exchange rate was four to five-fold lower than theoretical calculations. Carbon dioxide
exchange was not demonstrable beyond the initial blood flow rate of 0.5 mL/min. The in vivo
experiment demonstrated significant oxygen exchange at all flow rates, but at approximately 10-fold
lower than theoretical calculations. Carbon dioxide exchange was immeasurable beyond the first 30
minutes of the protocol. Microscopic analysis of the membranes showed significant cell adhesion,
which partially explains the difference between empirical and theoretical gas exchange rates.
Conclusions: We have shown that the MEMS-ECMO prototype is capable of exchanging oxygen
both ex vivo and in vivo albeit at lower rates than theoretical calculations. Nonetheless, our results
indicate that the polydimethylsiloxane/silicon membrane exhibits modestly superior oxygen exchange
characteristics when compared to membranes currently utilized in conventional ECMO systems. With
further optimization of the blood flow path and surface coatings, it should possible to increase oxygen
transfer and achieve meaningful CO2 exchange in future iterations of our device.
Abstract title: Latent class analysis of Tourette syndrome and common comorbid disorders: Clinical
and genetic implications
Resident’s name: Matthew Hirschtritt, MD. MPH
Name of program: Psychiatry
Purpose: Tourette syndrome (TS) is phenotypically complex and etiologically related to obsessivecompulsive disorder and attention-deficit/hyperactivity disorder (ADHD). Latent variable modeling can
reduce heterogenetity by identifying subgroups of individuals based on patterns of symptom
expression. The objectives of this study were to 1) analyze tic, obsessive-compulsive symptom
(OCS), and ADHD symptoms using exploratory factor (EFA) and latent class analyses (LCA) in TSaffected families, 2) clinically characterize the resulting subphenotypes, and 3) examine their utility for
genetic studies.
Methods: This study included 3494 individuals recruited for TS genetic studies. EFA and LCA of tic,
OCS, and ADHD symptom-level data were conducted. Heritability and TS-associated polygenic
burden were also estimated.
Results: The final EFA model for tics had 6 factors, including 3 organized somatotopically (e.g.,
body/trunk tics) and 3 by content (e.g., socially disinhibited tics). The final 4-class LCA tic model was
notable for 2 classes distinguished by low and high endorsement of disinhibited tics. When tic, OCS
and ADHD symptoms were combined, the final EFA solution separated symptoms by type (i.e., tic,
OCS, or ADHD symptoms) except for socially disinhibited/aggressive symptoms, which consisted of
both tics and OCS. The all-symptom LCA yielded a 5-class best-fit solution, including 1) high
endorsement across all symptoms, 2) tics only, 3) symmetry, 4) tics+ADHD, and 5) unaffected.
Heritability estimates ranged from .19 to .47; symmetry/exactness and socially disinhibited symptoms
had the highest heritability estimates (h2r=0.53, P).
Conclusions: We identified two novel TS-related phenotypes with high heritabilities, one of which
had a high polygenic load of TS associated genetic variants. These new phenotypes may reflect
underlying biological networks more accurately than traditional diagnoses, thus potentially aiding
future genetic, imaging and treatment studies.
Abstract title: How Often are Elderly Veterans with Limited Life Expectancy Diagnosed with
Incidental Barrett’s Esophagus?
Resident’s name: Myung S. Ko, MD
Name of program: Internal Medicine, Categorical
Purpose: Many older adults undergo esophagogastroduodenoscopies (EGDs) which may
incidentally diagnose Barrett’s Esophagus, an asymptomatic precursor lesion for esophageal
adenocarcinoma. However, it is unknown how often older adults with limited life expectancy are being
diagnosed with Barrett’s and national guidelines do not address when routine surveillance EGDs to
follow Barrett’s may be more harmful than helpful. Therefore, the objective of this study is to
determine how often older patients with limited life expectancy are diagnosed with Barrett’s in order to
determine the need for guidelines that specifically address how to individualize surveillance decisions
in older adults.
Methods: This is a cross-sectional study of 1206 male veterans 65 years or older who were
incidentally diagnosed with Barrett’s in 2011, using national VA and Medicare data. Patients with
concomitant diagnoses of esophagogastric disorders within 5 years prior to diagnosis of Barrett’s
were excluded. Descriptive statistics were performed to characterize demographics, Charlson-Deyo
Comorbidity scores and mortality. Limited life expectancy was defined as age > 85 and Charlson
comorbidity score > 1, or as age > 65 and Charlson comorbidity score > 4.
Results: Consistent with an older veteran population, 94 % were white, 68 % were married and 68 %
lived in a zip code where >25% had a college education. 20% of our cohort were over age 80 at the
time of Barrett’s diagnosis, and 17% were in poor health (Charlson score > 4). 266 patients (22%)
had limited life expectancy based on age and Charlson score. 248 patients (21 %) died within 4 years
after Barrett’s diagnosis.
Conclusions: A substantial proportion of older veterans who are incidentally diagnosed with Barrett’s
during EGD are over age 80 and many have a limited life expectancy. This suggests current practice
guidelines that recommend routine surveillance EGDs following a diagnosis of Barrett’s need to also
address when surveillance strategies may cause more harm than good. Individualized surveillance
strategies should consider health and life expectancy in order to minimize the harms after a diagnosis
of Barrett’s in patients with only a few years of life to live.
Abstract title: The Clinical Bridge
Resident’s name: Kelsey A. McEwen, MD, MPAS
Name of program: Internal Medicine, Categorical
Purpose: To develop a fourth year medical student course curriculum, designed primarily by medical
students, to increase graduate competence and confidence in skills and knowledge necessary for
internship training.
Methods: Recent medical literature suggests that medical school graduates often feel inadequately
prepared for the skills and knowledge required during their intern year. We sought to assess the need
for and implement an internship preparatory course at Rush Medical College.
A literature review via PubMed database search was conducted with search terms relating to our
aims. The search yielded 27 relevant publications between 1982 and 2014.
We then assessed measures of Rush Medical College graduates preparation for internship via review
of the Rush Medical College Graduation Questionnaire data from 2007-2011.
Results: We sought areas where Rush students rated their instruction inadequate relative to national
data (more than 5% higher inadequacy ratings compared with national ratings), rated themselves
inadequately prepared or less confident than other students nationally, and skill areas that program
directors rated Rush graduates less competent than Rush graduates rated themselves.
Conclusions: Based on this data, we designed ‘The Clinical Bridge’, a two week preparation for
internship course offered in the spring of the senior year of medical school. We plan to address
specific areas of inadequate internship preparation and skills and knowledge deficits through a variety
of core lectures, small group core sessions and subspecialty-specific small group sessions using
simulation, skill and case-based activities.
Fourth year medical students were the leaders in the development of the course, gaining valuable
experience in curriculum development. Our aim was to improve general competencies relevant to
entering residency, but also focus on our particular deficits. This multidisciplinary course offers core
lectures about health systems, communication and teaching, as well as small group simulation
sessions focusing on diagnostic test ordering and interpretation, acute emergency situations, blood
products, insulin management, antibiotic selection, ventilator basics and other intern topics.
Additionally, students select from a menu of interactive specialty specific sessions utilizing casebased teaching. Sessions use simulation techniques, practice of communication and technical skills,
as well as recognizing ‘must not miss’ diagnoses and managing issues encountered at night.
In order to implement this program at other medical schools, recruiting student leadership remains
essential, as well as recruiting residents and faculty to teach individual sessions. The needs
assessment method could be used by other medical schools for targeted curriculum development.
The course design, including teaching sessions, objectives, assessments and course map could be
shared as well.
Abstract title: Sex differences in Lp(a) associations with atherosclerosis in South Asians
Resident’s name: Claire Mulvey, MD
Name of program: Internal Medicine, Categorical
Purpose: South Asians have high rates of cardiovascular disease (CVD) that are incompletely
explained by traditional risk factors. Some studies have shown elevated lipoprotein(a) [Lp(a)], an
LDL-like particle that is a risk factor for CVD, in South Asians. We hypothesized that Lp(a) is
associated with subclinical atherosclerosis independent of traditional risk factors.
Methods: Metabolic syndrome and Atherosclerosis in South Asians Living in America is a
community-based cohort (N=146; age 57 ± 8 years; 51% male) free of CVD. Serum Lp(a) was
measured by immunonephelometry. Common carotid artery intima-media thickness (CIMT) was
measured by ultrasonography. We used multivariate linear regression to test associations of Lp(a)
with log-transformed CIMT after adjusting for age, sex, smoking, waist circumference, hypertension,
cholesterol medications, C-reactive protein, and fasting insulin and glucose. In additional models, we
further adjusted for LDL- and HDL-cholesterol, and triglycerides. We tested for interactions by sex,
stratifying our analyses as appropriate.
Results: Median Lp(a) levels were higher in women than men (0.18 vs. 0.13 g/L, respectively;
p=0.06), and higher in post-menopausal vs. pre-menopausal women (0.20 vs. 0.12 g/L; p=0.007).
However, median CIMT levels were lower in women compared to men (0.86 vs. 0.95 mm; p=0.002).
There was an interaction (p=0.04) by sex in the relationship between Lp(a) and CIMT. In women, this
relationship was significant (N=72, p=0.001), even after further adjustment for lipid parameters (β
coefficient 0.31, 95% CI 0.12 to 0.51; p=0.002). In contrast, there was no association in men between
Lp(a) and CIMT in either model (p=0.66 and p=0.32). In subgroup analysis, the association between
Lp(a) and CIMT was stronger in post-menopausal (N=52, β coefficient 0.35, 95% CI 0.08 to 0.62;
p=0.01) vs. pre-menopausal (p=0.62) women.
Conclusions: Lp(a) was an independent predictor of subclinical atherosclerosis in South Asian
women, but not men. This differs from other populations where associations tend to be stronger in
men.
Abstract title: Postprandial effects on arterial stiffness parameters in healthy young adults
Resident’s name: Tyler O. Murray, MD
Name of program: Internal Medicine, Categorical
Purpose: Postprandial lipemia has been associated with acute endothelial dysfunction. Endothelial
dysfunction, in turn, is associated with increased arterial stiffness. However, the relationship between
postprandial lipemia and acute changes in arterial stiffness has not been extensively investigated.
Therefore, we conducted a pilot study on the effects of postprandial lipemia on arterial stiffness in 19
healthy young adults before and after consumption of a high fat mixed meal.
Methods: Arterial stiffness was assessed locally with echo-tracking carotid arterial strain (CAS) and
globally with carotid-femoral pulse wave velocity (PWV).
Results: As assessed by these two benchmark parameters, arterial stiffness did not differ
significantly postprandially. However, arterial distension period (ADP) was significantly lower two
hours after mixed meal ingestion. In addition, slopes of carotid artery area (CAA) curves were
significantly steeper postprandially.
Conclusions: Therefore, we concluded that ADP may be a more sensitive marker of arterial stiffness
in healthy young adults when compared to PWV and CAS.
Abstract title: Emotional dysregulation and error processing characterizes individuals with Hoarding
disorder
Resident’s name: Krystal Nizar, MD. PhD
Name of program: Psychiatry
Purpose: Obsessive Compulsive disorder (OCD) and Hoarding disorder (HD) are syndromes that
have only relatively recently been separated within the DSM of psychiatry. Pathologic hoarding
symptoms co-occur with many neuropsychiatric disorders, and HD remains significantly disabling and
understudied. Inefficient error monitoring and impaired insight into symptom severity and impact may
underlie the HD core behavioral symptom of difficulty discarding. Anecdotally, patients with HD report
more anxiety associated with the possibility of making an error than do those with OCD.
Methods: Self-report of emotional response to prospect of making an error, prediction of error
making, as well as physiological reactivity was recorded in individuals performing a Go/Go visualspatial task that allows participants to recognize and correct their errors.
Results: Preliminary data suggest that those with HD do not make substantially more errors than
controls, but do exhibit reduced accuracy in error tracking, as well as heightened emotional reactivity
in response to errors. Prior EEG findings found diminished error-related negativity (ERN) in HD (as
opposed to hyperactive ERN in those with OCD), and this constellation of emotional dysregulation in
response to error making, consistent with the core behavioral symptoms of HD, may represent a
potential syndrome-specific markers of HD.
Conclusions: Systems for monitoring performance, registering deviations from expected
performance, attributing emotional significance to error events, and remembering those events, all
contribute to an individual’s ability to form a concept of and update knowledge about functioning. This
type of metacognition is potentially important across a wide spectrum of neuropsychiatric disorders.
This study pilots a standardized approach to studying insight into errors, and emotional reactivity to
errors. Long-term, the goal is to assess feasibility of quantitatively tracking insight into illness and its
relation to motivation for treatment, particularly in specialty psychiatric clinical populations.
Abstract title: Assessing the Availability and Dissemination of Results from Food and Drug
Administration Mandated Post-Approval Studies for Medical Devices
Resident’s name: Odayme Quesada, MD
Name of program: Internal Medicine, Categorical
Purpose: One of the U.S Food and Drug Administration’s (FDA) most important
tools in post-market surveillance of medical devices are Post-Approval Studies (PAS). We sough to
determine the availability PAS results outside the FDA website as dissemination of results is
necessary to inform clinical practice.
Methods: We examined what proportion of PAS ordered from 2005-2014 for medical devices were
completed and what proportion of completed PAS were published in peer-reviewed journals or
available to the public in other formats. We searched via ClinicalTrials.gov, PubMed, and Google.
Results: Of the 309 PAS ordered from 2005 to 2014, 92 (30%) were completed among which 14
nonclinical studies were excluded from further analysis. Of the remaining 78 completed clinical PAS,
61.5 % were published in a peer-reviewed journal, and 15.4% had made results publically available,
primarily through device labeling. About a quarter (23.1%) of the completed PAS were not reported
outside the FDA website, which summarily provides partial or all results under each PAS. Higher
quality PAS (larger cohorts, more research sites, higher follow-up rate) were more likely to be
published. Also studies that were published were more likely to lead to labeling changes.
Conclusions: High quality data from PAS could greatly inform clinical care and optimal
use of medical devices if widely disseminated. We note opportunities to improve the availability and
transparency of findings from post-market studies, which are increasingly important currently as
Congress and FDA propose to shorten pre-market approval times.
Abstract title: Ovarian volume as a non-linear predictor of metabolic dysfunction in Polycystic Ovary
Syndrome (PCOS)
Resident’s name: Molly Quinn, MD
Name of program: Obstetrics, Gynecology and RS
Purpose: PCOS is a heterogeneous disorder associated with metabolic dysfunction. We aim to
characterize the relationship between ovarian morphology and markers of metabolic dysfunction in
PCOS.
Methods: The study design is a cross-sectional cohort study at a subspecialty clinic within a tertiary
referral center. Patients evaluated between 2007-2013 in a multi-disciplinary clinic for PCOS were
consecutively enrolled in a research database. PCOS was diagnosed by Rotterdam Criteria.
Transvaginal ultrasound, physical exam and laboratory investigation of metabolic function were
systematically performed.
Logistic regression models were employed to determine the effect of ovarian volume, follicle number,
age and BMI on Homeostatic model assessment-insulin resistance (HOMA-IR) of >2.5 and >4.
Receiver operating characteristic (ROC) analyses investigated the area under the ROC (AUC) for a
logistic regression model using ovarian volume and follicle number as binary (ovarian volume
>10cm3, follicle number >12) or continuous variables for prediction of elevated HOMA-IR.
Results: Ovarian volume is associated with elevated HOMA-IR with ovarian volume >10cm3 best
predicting HOMA-IR >2.5 and >4 (logistic regression coefficient 1.024 and 1.442, respectively).
Including the ovarian volume as a continuous variable in a prediction model using age and BMI to
predict HOMA-IR >4 improved the AUC by 1% over a model using age and BMI alone (AUC 0.79, CI
0.73-0.85 vs. 0.78, CI 0.72-0.84) while a binary measure of ovarian volume improved the prediction
by 5% (AUC 0.83, CI 0.77-0.89 vs. 0.78, CI 0.72-0.84). An area under the ROC for a logistic
regression using follicle number did not improve prediction model over age and BMI alone (AUC 0.79
CI 0.72-0.85 vs. 0.79 CI 0.73-0.85).
Conclusions: There exists a non-linear relationship between HOMA-IR and ovarian volume. Follicle
number is not predictive of HOMA-IR. Ovarian volume > 10cm3 improves prediction of metabolic
dysfunction as manifest by elevated HOMA-IR.
Abstract title: A Prospective Observational Study Of Ketamine For Sedation Of Acutely Agitated
Emergency Department Patients
Resident’s name: Jeffrey C. Riddell, MD
Name of program: Emergency Medicine
Purpose: Benzodiazepines and typical antipsychotics have long been used to sedate agitated ED
patients. Slow onset of action, need for dose titration, respiratory depression, and long recovery time
are significant limitations that necessitate the study of other agents such as ketamine. The objective
of this study was to determine whether ketamine is faster than benzodiazepines and typical
antipsychotics in sedating agitated ED patients. Secondary objectives were to determine the adverse
events and necessity for re-dosing of sedative medications.
Methods: This prospective observational study took place in an urban academic ED. Subjects were
between age 18-65 requiring chemical sedation for acute agitation. Medication, dose, and route were
chosen by the treating physician. Each provider documented a subjective time that agitation was
controlled and sedation levels at 0, 5, 10, and 15 minutes using a previously validated 6-pt sedation
scale. Information was entered into a spreadsheet and descriptive statistics were calculated.
Results: 83 patients were included. Adequate sedation was achieved most quickly with ketamine
alone, with a median time to sedation more than twice as fast as the next fastest medication. 75%
(95%CI 60-86%) of those receiving benzodiazepines alone, 55% (95%CI 32-72%) of those given
ketamine alone, and 33% (95%CI 12-65%) of those given haloperidol alone required subsequent
medication doses. 11 patients (13.4%, 95%CI 8-23%) had adverse events, 4 had hypotension (2
benzodiazepine, 1 ketamine, 1 haloperidol) and 4 required intubation (2 haloperidol, 1
benzodiazepine, 1 ketamine). Adverse events occurred in 4 (17%, 95%CI 7-37%) patients receiving
haloperidol, 3 (14%, 95%CI 5-35%) receiving ketamine, and 4 (10%, 95%CI 4-24%) receiving
benzodiazepines.
Conclusions: Ketamine provided rapid sedation for violent and agitated ED patients with an adverse
event rate similar to other agents. A large randomized trial is warranted to compare the safety and
efficacy of different sedation agents.
Abstract title: Long-term Outcomes of External Rotation Tendon Transfers in Brachial Plexus Birth
Palsy
Resident’s name: Lindsey C. Sheffler, MD, MAS
Name of program: Orthopaedic Surgery
Purpose: Limitations in shoulder external rotation (ER) and abduction are well-known consequences
of brachial plexus birth palsy (BPBP). ER tendon transfer (ERTT), in which the teres major and
latissimus dorsi muscles are transferred to the rotator cuff, may increase abduction and ER and
improve upper extremity function in children with BPBP. The long-term outcomes of ERTT are not
well established.
Methods: The medical records from a case series of 117 children with BPBP who underwent ERTT
between 1994 and 2007 by a single surgeon were retrospectively reviewed. All subjects had
standardized pre- and post-operative assessments by an occupational therapist, including active and
passive shoulder range of motion, and standardized intensive post-operative therapy. Subjects were
followed at 2, 4, 6 and 12 months post-operatively, and annually thereafter. The median length of
post-operative follow-up was 7 years (range, 2-13 years).
Results: Post-operative active abduction and ER improved by 28 degrees (p)
Conclusions: In children with BPBP, ERTT improves active range of motion and upper extremity
function. Initial post-operative gains in ER and abduction decrease over time but are statistically
significant at up to 8 years of follow-up. Pectoralis major tendon lengthening and/or subscapularis
release may improve post-operative gains in active ER over ERTT alone.
Abstract title: Association of Resting RA Size and Function with Exercise Capacity
Resident’s name: Arjun Sinha, MD, MS
Name of program: Internal Medicine, Categorical
Purpose: The right atrium is a key contributor to right ventricular preload but its association with
exercise capacity has not been well studied. We sought to determine the association of resting right
atrial structure and function with exercise capacity.
Methods: Thirty nine healthy subjects (48 ± 16 years; 49% female), recruited from the Health eHeart
cohort, underwent graded supine bicycle exercise in 30 watt stages. Imaging and analysis were
performed with GE Vivid E9 system and EchoPAC software. Right atrium (RA) maximum (RAESVI)
and minimum (RAEDVI) biplane indexed volumes, RA emptying fraction (RAEF = RAESVIRAEDVI/RAESVI), and RA function index (RAFI = RAEF x RVOT-VTI/RAESVI) were measured at
rest, where RVOT-VTI is the velocity time integral of the right ventricular outflow tract. Unadjusted
and multivariate adjusted linear regression models were used to evaluate the association of each of
these resting RA predictors with maximum METs achieved.
Results: In demographically adjusted models, only RAEDVI (β=0.14, 95% C.I., p=0.04) was
associated with exercise capacity. In the fully adjusted model with parameters of LV structure and
function and pulmonary artery systolic pressure as covariates, both RAEDVI (β=0.13, 95% C.I.,
p=0.02) and RAEF (β= -0.06, 95% C.I., p=0.01) were associated with exercise capacity. Neither
RAESVI nor RAFI was associated with exercise capacity.
Conclusions: In healthy individuals, there is a significant association of resting RAEDVI and RAEF
with exercise capacity. The positive association of RAEDVI suggests that subjects who maintain a
fuller RA at rest have increased exercise capacity, thus supporting the primacy of the thoracic pump
over other mechanisms in augmenting right-sided cardiac filling. The negative association with RAEF
and exercise capacity is not unexpected given the positive association with RAEDVI (minimal RA
volume) and lack of association with RAESVI (maximal RA volume).
Abstract title: Blood Pressure Trajectories in the Elderly: Clinical Significance and Association with
Poor Outcomes
Resident’s name: Christopher C. Smitson, MD
Name of program: Internal Medicine, Categorical
Purpose: Blood pressure (BP) trajectories in the elderly are not well characterized, and their
association with clinical outcomes is not well established.
Methods: Among 4,067 participants in the Cardiovascular Health Study (CHS), we used repeated
blood pressure (BP) measurements from the first 7 years to identify discrete trajectories of systolic
(SBP), diastolic (DBP) and joint SBP/DBP by latent class analysis. We examined the associations of
BP trajectory group membership with all-cause mortality, incident congestive heart failure (CHF) and
incident cardiovascular disease (CVD), independently of risk factors, one-time BP measures and antihypertensive therapy. We used multivariable Cox models with follow up beginning after the 7th year
visit. Incident CVD was defined as having myocardial infarction, cardiac arrest, stroke or
cardiovascular death.
Results: A median of 7 BP measures were used to identify three distinct BP trajectory groups:(1)
Increasing SBP and DBP, (2) stable SBP with decreasing DBP, and (3) both SBP and DBP
decreasing. Average age at the 7th year visit was 78, and median follow-up time was 9.3 years.
Compared with increasing SBP and DBP, a decreasing SBP and DBP had the highest risk for death.
Adjusted hazard ratios (HR) for death were 1.16 (95% CI, 1.03-1.31) for stable SBP with decreasing
DBP and 1.20 (95% CI, 1.06-1.36) when both SBP and DBP were decreasing. Findings did not differ
when we stratified by anti-hypertensive medication use. Persons with declining SBP and DBP were
also at increased risk for incident CVD and CHF, compared with rising SBP and DBP. The adjusted
HR for incident CVD was 1.26 (95% CI, 1.01-1.58), and it was 1.18 (95% CI 0.99-1.42) for incident
CHF.
Conclusions: Among community-dwelling elders, a declining SBP and DBP trajectory is
independently associated with higher risk for death, CVD and CHF. These findings indicate the
clinical importance of blood pressure changes over time in the elderly.
Abstract title: Comprehensive Analysis of Clinical and Biological Features that Correlate with MYCN
Amplification in Neuroblastoma: A Report from the International Neuroblastoma Risk Group Project
Resident’s name: Daria L. Thompson, MD, MPH
Name of program: Pediatrics
Purpose: MYCN amplification is a hallmark of aggressive neuroblastoma and is one of the strongest
independent adverse prognostic factors in this disease. However, a comprehensive analysis of the
predictors of MYCN amplification itself has not been reported. The purpose of this work is to identify
groups of clinical and/or biologic factors that distinguish patients with a high likelihood of having
MYCN gene amplification from those having a low likelihood.
Methods: INRG data were analyzed from 7,102 patients diagnosed with neuroblastoma from 19902002 with known MYCN status. Descriptive statistics and chi-squared tests were used to analyze
univariate clinical (age at diagnosis, ferritin and LDH level, INSS stage, primary tumor site) and
biologic (DNA ploidy, MKI, tumor differentiation, segmental chromosomal aberrations) variables.
Univariate logistic regression was used to identify variables that were most highly predictive of MYCN
amplification status. Manual multivariate recursive partitioning was used to identify subgroups of
patients with maximal difference in rates of MYCN amplification.
Results: 7,102 out of 8,800 patients had known MYCN status. All clinical and biologic variables were
statistically significant univariate predictors of MYCN amplification. The odds of MYCN amplification
were 8.4 fold greater for high LDH (vs. low LDH), and the odds were 19.8 greater for 1p deletion (vs.
normal 1p). Recursive partitioning that incorporated both clinical and biological variables identified
subgroups of patients with disparate rates of MYCN amplification. The most extreme subgroups were:
Patients with high LDH who had adrenal primary tumors that were poorly differentiated and harbored
a chromosome 1p deletion (85.7% had MYCN amplification) compared to those with localized tumors
with hyperdiploidy, low MKI, and lacking chromosome 1p aberration (0.6% had MYCN amplification).
Age and ferritin level were not significant predictors of MYCN status in this model.
Conclusions: Recursive partitioning identifies subgroups of neuroblastoma patients who have highly
disparate rates of MYCN amplification. These findings can be used to inform investigations of
molecular mechanisms of MYCN amplification and support the importance of having tumor tissue
available at diagnosis to provide biological data that may inform diagnosis, prognosis, and selection
of therapy.
Abstract title: Video laryngoscopy and the use of supraglotic devices improves time-to-definitiveairway, but does not improve CPR quality, as compared to direct laryngoscopy in a simulation model
of cardiac arrest: a prospective, simulation-based, randomized controlled trial
Resident’s name: Julian Villar, MD, MPH
Name of program: Emergency Medicine
Purpose: Greater chest compression fraction (CCF) is associated with a trend toward increased
return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA). Endotracheal
intubation (ETI) attempts may diminish CCF and quality of compressions that would be detrimental to
survival probability. We hypothesize that the use of supraglottic airways (SGA) by residents increases
CCF, quality of chest compressions, and time-to-airway, when compared to video laryngoscopy (VL)
and direct laryngoscopy (DL).
Methods: A prospective, simulation-based, randomized trial with EM residents at the Kanbar Center.
Participants were separated into groups of two with one randomly assigned to an airway maneuver
and the other to chest compressions. Compressor and airway roles switched after each maneuver
was completed.
Primary outcomes were CCF and “Target Fraction” (TF), percentage of compressions with optimal
depth and rate. Secondary outcome was time to airway maneuver completion.
Results: We have enrolled 50% of our anticipated sample size. This preliminary analysis is based on
the data collected to date.
CCF for SGA was 0.995 (95% CI 0.992 -0.998); for DL 0.992 (95% CI 0.986 – 0.999); and VL 0.994
(95% CI 0.990 – 0.998); ANOVA p = 0.707. TF for SGA was 0.603 (95% CI 0.403 – 0.803); for DL
0.634 (95% CI 0.419 – 0.850); and for VL 0.564 (95% CI 0.357 – 0.771). Average time-to-airway for
SGA was 19.79 seconds (95% CI 17.07 – 22.50); for DL 46.43 seconds (95% CI 25.68 – 67.18); and
for VL 27.21 seconds (95% CI 23.22 – 31.21). ANOVA p = 0.0130.
Conclusions: The type of airway maneuver does not affect CCF or TF. SGA has already been found
to be statistically significantly faster than DL. VL also appears to be faster than DL, though not yet
statistically significant. In summary, based on these preliminary results, residents should use SGA or
perform ETI with VL to during cardiac arrest.
Abstract title: Intestinal Atresias: Fetal Ultrasound Findings and Duration of Parenteral Nutrition
Resident’s name: Nicole Weiss, MD
Name of program: Pediatrics
Purpose: Intestinal atresias are a common cause of intestinal failure (IF), which is associated with a
high morbidity and mortality. While fetal diagnosis is possible, there are limited data available to
counsel families regarding the broad range of clinical outcomes. This study’s aim was to determine
whether fetal ultrasound findings are associated with PN duration and the incidence of PN associated
liver disease (PNALD), IF, and length of hospital stay in a neonatal population with jejunal and/or ileal
atresias.
Methods: This is a single site retrospective study of neonates with surgically confirmed jejunal and/or
ileal atresia (years 2000-2013) with available fetal ultrasounds. Infants with gastroschisis, congenital
diaphragmatic hernia, significant congenital heart defects, and genetic or metabolic disorders were
excluded. Images were reviewed by a radiologist masked to the surgical diagnosis and study
outcomes.
Results: The study group (n=25, 20 jejunal, 4 ileal, 1 jejunoileal) was premature with a GA (± SD) of
35 ± 3 weeks. 3 (12% subjects died, 9 (41%) survivors developed PNALD, and 7 (32%) survivors
developed IF. PN days, length of stay, and IF incidence were not significantly (p)
Conclusions: Ascites and abdominal cysts appear to be more commonly associated with ileal rather
than jejunal atresias, likely due to higher incidence of in utero bowel perforation in ileal atresias. While
this study is limited by sample size and heterogeneity, we are expanding this cohort in collaboration
with additional centers to potentially uncover clinically relevant information.
Abstract title: Evaluation of Nepali site for orthopaedic education and training
Resident’s name: Amanda T. Whitaker, MD
Name of program: Orthopaedic Surgery
Purpose: To evaluate the Hospital and Rehabilitation Centre in Banepa, Nepal for UCSF orthopaedic
resident education, and the current educational/research system for Nepali residents.
Methods: This is an observational evaluation of 2 hospitals in Nepal, the non-profit Hospital and
Rehabilitation Centre for Disabled Children (HRDC) in Benepa and Baidya and Banskota (B&B)
Hospital in Kathmandu with a literature review of studies on the pediatric orthopaedic patient
population in Nepal.
Results: The complexity and breadth of surgical and non-surgical cases at HRDC and B&B
supplement the educational objectives of UCSF orthopaedic surgery residency training, with unique
learning opportunities regarding polio, neglected clubfoot, tuberculosis, and osteomyelitis. Current
growing educational programs, such as the cerebral palsy workshop and Ponseti clubfoot expertise,
allow for education and research collaboration. The mobile camps countrywide each month see on
average 260 pediatric patients within a week’s time. Each year, approximately 800 major pediatric
surgical procedures take place in 5 operating rooms with 6 orthopaedic surgeons. There are 2 house
staff and 1 resident at HRDC with the main education being informal teaching in clinic and in the
operating room. They have 1 visiting resident research coordinator assisting in ongoing longitudinal
studies. Their goals are to improve their knowledge of the burden of cerebral palsy and improve
access to care throughout the country.
Conclusions: HRDC and B&B offer collaborative opportunity for education and research with UCSF
department of orthopaedic surgery. They offer unique orthopaedic conditions and education not able
to be provided in the US. We can assist with improving research and educational curriculum. The
connection between HRDC/B&B and the Institute for Global Orthopaedics and Traumatology
(IGOT)/UCSF orthopaedic surgery residency supports IGOT’s fundamental mission of developing
solutions for the large burden of orthopaedic conditions across the world through reseach,
collaboration, and capacity building.
Abstract title: Identifying Prefrontal Cortex Endophenotypes of Psychiatric Disorders in a Novel in
vitro Assay
Resident’s name: Scott A. Wilke, MD, PhD
Name of program: Psychiatry
Purpose: Most psychiatric disorders are complex, but highly heritable conditions. For those such as
schizophrenia or mood disorders, a large number of gene variants have been linked to an increased
risk profile. Many of these genes have normal functions in brain development and the formation and
function of synapses. Thus a prominent hypothesis has been that a large number of genetic lesions
may converge at the level of neural circuits, giving rise to a relatively more restricted set of behavioral
abnormalities. To investigate this hypothesis, our lab has developed an isolated preparation for both
analyzing and manipulating network level dynamics in rodent prefrontal cortex (PFC) microcircuits.
Methods: To study the functional organization of PFC microcircuits, our lab developed a method to
image the simultaneous activity of 50-100 layer 5 PFC neurons using the virally expressed calcium
indicator GCaMP6 in a live slice preparation. The experiments presented here compare control mice
with a Disc1 dominant negative (Disc1-DN) transgenic line which is a model of increased genetic risk
for schizophrenia and other psychiatric disorders. At ~3 weeks of age, layer 5 of medial PFC was
injected with an adeno-associated virus which expresses GCaMP6 under the control of the synapsin
promoter. At ~8 weeks of age, 350 micron thick live coronal slices were cut using a vibratome for
imaging under fluorescence microscopy. One hour movies were recorded under two conditions which
enhance spontaneous activity, high potassium media and 2 uM carbachol (a cholinergic agonist). To
assess the impact of dopaminergic stimulation, a dopamine type 2 (D2) receptor agonist (10 uM
quinpirole) was washed on after 20 minutes of baseline activity. An existing algorithm was adapted to
determine regions of interest and convert calcium signals to binary firing patterns for each active
neuron. Matlab was used to analyze these data to determine a variety of parameters relevant to
network activity and compare them between conditions.
Results: This assay can be used to examine the effects of pharmacologic manipulations on
microcircuit activity patterns in mouse models of psychiatric disorders. Spontaneous activity in layer 5
microcircuits of medial PFC respond differently to D2 receptor stimulation depending on whether
slices are exposed to high potassium or simulated cholinergic tone. Disc1 mPFC slices had lower
mean activity compared to controls in high potassium media, but did not exhibit a change in activity
level when exposed to quinpirole. In contrast, washing on quinpirole in slices which had been
exposed to carbachol resulted in significant increases in mean activity level in layer 5 mPFC
microcircuits.
Conclusions: We have developed an isolated preparation for investigating the effect of specific
genetic manipulations on emergent network level phenomenon in a high throughput screening assay.
Using this assay we have demonstrated that layer 5 mPFC microcircuits from Disc1 mice are less
active in high potassium media compared to controls. Further, we have shown that cholinergic tone
unmasks the ability of layer 5 medial PFC microcircuits to respond to D2 receptor stimulation with
increased activity. This assay will be a valuable tool for both dissecting circuit level mechanisms of
specific genetic manipulations and informing hypotheses which can be tested in vivo.
Abstract title: The Correlates of Female Sexual Dysfunction in Infertile Women
Resident’s name: William D. Winkleman, MD
Name of program: Obstetrics, Gynecology and RS
Purpose: To measure the sexual, personal, marital and social impact of infertility on females.
Methods: Cross-sectional analysis of 383 women from eight reproductive endocrinology clinics.
Participants received an extensive questionnaire and face-to-face and telephone interviews.
Respondents classified the underlying cause of infertility (i.e. male factor only, male and female
factors, female factor only, unexplained). Each respondent was assessed for the sexual impact,
personal impact, marital impact and social impact of infertility. Sexual impact is a composite score of
five questions originally taken from Fertility Problem Inventory. Personal impact is a composite score
of five items, social impact is a composite score of 25 questions and marital impact is a composite
score of seven questions. Each scale has a range from 0 to 100 and higher scores represent greater
dysfunction/impact.
Results: Among 383 respondents, 23.2% were married one year or less and 24.5% had at least one
previous child. Caucasians comprised 70.5% of the respondents and 71.9% had at least a college
degree. The majority (58.5%) attributed infertility to only female factors, 30.4% attributed infertility to a
combination of male and female factors, 7.3% attributed infertility to only male factors and 2.5%
thought the etiology was unexplained. In the multivariate analysis, female factor infertility was
independently associated with worse sexual impact scores (mean=40, CI=32-48) relative to couples
with both male and female factors (mean=35, CI=32-39, p=0.046). Similarly, female factor infertility
was independently associated with worse personal impact scores (mean=61, CI=50-71) compared
with couples with both male and female factors (mean=55, CI=51-60, p=0.030). Respondents with
unexplained infertility reported higher levels of marital and social distress. On adjusted analysis,
having a previous child and older age were significantly associated with worse sexual, social and
personal impact.
Conclusions: Females who perceive their infertility to be due to female factors only are at higher risk
for sexual dysfunction and personal distress. These results can be used to identify those patients with
infertility who are at the greatest risk of sexual dysfunction so we can more accurately target
interventions and provide support.
Abstract title: Low Lying Placentas: Resolution Rates and Delivery Outcomes Over a 13 Year Period
Resident’s name: Marron C. Wong, MD
Name of program: Obstetrics, Gynecology and RS
Purpose: For patients diagnosed with low lying placentas during routine prenatal ultrasound, there
are no standard guidelines for the time of subsequent follow up ultrasounds, nor are there
standardized recommendations about the safety of vaginal delivery for those with persistent low lying
placentas. Our aim was to evaluate the eventual placenta location and delivery outcome of patients
diagnosed with low lying placentas.
Methods: This was a retrospective cohort study at an academic medical center of patients diagnosed
with low lying placentas (placental edge 0-2 cm from the internal os) from 2002 to 7/2014 who had at
least one follow up ultrasound. We excluded patients initially diagnosed with placenta previa. We
determined placental location in follow up ultrasounds and ultimate route of delivery.
Results: 963 patients met criteria. 918 (95.3%) had resolution of their low lying placentas. 38 (3.9%)
had persistent low lying placentas. The remaining patients ultimately were diagnosed with vasa
previas (2 patients, 0.2%) and placenta previas (5 patients, 0.5%). 526 patients had available delivery
information. In this group, 513 (97.5%) had resolved low lying placentas; of those, 381 (74%)
delivered vaginally and 132 (25.7%) delivered by cesarean. Seven patients had persistent low lying
placentas. One of those seven labored (placenta 1.7 cm from the os). She delivered vaginally, but
had an intrapartum course complicated by hemorrhage requiring blood transfusion. Six delivered by
cesarean: one by patient preference for low lying placenta and five for indications unrelated to
placental location. The final five patients delivered by cesarean for vasa previa (1 patient) and
placenta previa (4 patients).
Conclusions: At our institution, most low lying placentas resolve on ultrasound surveillance. The
single patient with a persistent low lying placenta who labored had significant intrapartum bleeding.
Other patients with persistent low lying placentas delivered by cesarean either by patient choice or for
indications unrelated to their placenta. This study suggests that it is prudent to exercise caution in
trials of labor for patients with low lying placentas.
NOTES
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