Poster Session 4

ABSTRACT:

Defects of the distal tibia, ranging from infectious to neoplastic origins, have often been treated with amputation of the affected limb. Surgical repair options have often been limited, as ankle replacements and ankle arthrodesis generally require more tibial bone stock to achieve positive outcomes and avoid loss of function in the affected joint. Here we present a case of a distal tibial defect being reconstructed using a pedicled fibula flap and ankle arthrodesis technique that allowed for full range of mobility of the joint post-operatively. Our patient was a 52 year old female with a history of myelodysplastic syndrome treated with a stem-cell transplant; fifteen months following the transplant, she was diagnosed with osteonecrosis of the distal tibia and calcaneus after developing severe swelling and pain in her left ankle. Despite conservative treatment measures, her symptoms continued to worsen and ankle reconstruction was chosen as the only viable option for recovery. She underwent distal tibial reconstruction and tibiotalar arthrodesis using an ipsilateral vascularized pedicled fibular flap. The patient was ambulating well eight weeks post-op; she reported being able to painlessly bear full weight on the left ankle 14 weeks post-op. One year post-op, the patient was able to demonstrate full range of motion of the affected joint. A 21-month post-op X-ray showed complete radiographic union of the distal tibia to the fibula flap and tibiotalar arthrodesis. As evidenced in our patient, an extremely positive postoperative outcome can be achieved with the utilization of this technique.

ABSTRACT:

Introduction: In elderly patients, altered mental status (AMS) is a nonspecific sign that commonly leads clinicians to suspect UTIs (urinary tract infections). Overlooking other causes of AMS can lead to more serious diagnoses being overlooked. We present a case of an elderly female with a six month history of recurrent UTIs who presented with AMS and was subsequently found to have a large frontal lobe meningioma.

Case Presentation: A 75-year-old female presented with a one day history of AMS. She denied recent trauma or illness, but she did report a six month history of recurrent UTIs and urinary incontinence requiring her to use an adult diaper. She was admitted for antibiotic treatment. The following day, she stated that she may have actually had a fall, but she was unsure. Imaging showed a 6 x 6.7 x 6.1 cm frontal lobe meningioma. Neurosurgery recommended a craniotomy, and the patient underwent tumor resection.

Discussion: Due to the patient’s age, recurrent UTI history, concomitant diaper rash, and notable urinalysis, the care team understandably remained focused on the UTI as the possible source of her AMS. Although imaging was eventually ordered, this visit could have easily been assumed to be just another, albeit severe, manifestation of her recurrent UTIs, and her large meningioma could have remained unfound. As the aging population continues to grow, the assumed association between UTI and AMS in elderly patients becomes an even larger threat to the appropriate care of older individuals.

ABSTRACT:

Background: Educational remediation addresses student deficits and creates additional opportunity to demonstrate competence before curriculum progression. In this study, we analyze the current pre-clinical remediation process at Kirk Kerkorian School of Medicine and compare student and faculty time utilized to the previously employed remediation process. We hypothesized that the current protocol would save more time.

Methods: Each semester, a comprehensive exam was administered representing relevant organ systems. A 75% passing threshold and demonstration of mastery of failed system examinations was required. Areas of deficiency were assessed for underachieving performances and a subsequent individualized exam was administered for remediation. Total student and faculty remediation time was analyzed and compared to the previous written assignment remediation method.

Results: Faculty spent an average 80-120 hours per semester remediating students using written assignments compared to an average 3 hours using comprehensive examinations. Twenty-six students failed one or more organ system exams in the fall semester of 2020. Four unsuccessfully demonstrated mastery using the comprehensive examination, requiring further remediation. Remediating students spent an average 20 hours per semester using written assignments versus 10 hours using comprehensive examinations.

Conclusion: Utilizing comprehensive end-of-semester examinations decreased faculty and student remediation time. Further evaluation is warranted to evaluate longitudinal effectiveness of content mastery.

ABSTRACT:

The surgical objective to maintain functionality and aesthetically favorable reconstructive goals is challenged when presented with large scalp defects with exposed calvarium, specifically post-Mohs Micrographic procedure. Standard reconstructive modalities (i.e. linear closure, tissue rearrangements, grafting, and tissue expansion) may not be well-tolerated in some patients. This results in failed healing via 2nd intention or artificial grafts, scaring, and alopecia. Double-layer undermining can improve wound closure compared to current standard techniques for large scalp defects. This technique provides additional laxity to facilitate closure of large scalp wounds and may be pre-planned or utilized following inability to approximate with galeal sutures alone.

ABSTRACT:

Medical students are often encouraged or required to carry out scholarly projects, which could include quality improvement (QI) studies. The aim of this submission is to discuss the medical student challenges and lessons learned from engaging in a QI study, which uses data from electronic health records (EHR), and the potential benefits and impact. These challenges were encountered during a feasibility study and an ongoing chart review from a current multiphase QI project in a family medicine practice. This project aims to improve obesity outcomes by studying the underdiagnosis and under-documentation of obesity in the EHR and to help build a framework for future QI projects involving students and EHR-based data. There are numerous challenges inherent in a QI study that uses EHR data for students. One of the initial barriers is student access to the EHRs (e.g., EPIC) in their preclinical years. Even with access, students may not be able to log on to the program remotely and are denied certain privileges such as leaving notes for providers. Furthermore, there is a steep learning curve to utilize programs like EPIC, and training is required. Data extraction from EPIC and similar programs also presents difficulties as there may be gaps in the extracted information or inability to find appropriate data due to numerous ways a diagnosis may be coded. Understanding the challenges involved in conducting a QI study using EHR data will allow for a logical approach to be developed that can mitigate these barriers in future studies.