Project Title: Comparison of Pediatric Abscesses Management: Vessel Loop vs. Conventional Packing (Pediatric Abscesses Management Study)
Faculty Mentor’s Name: Dr. Saleem Islam
Student’s Name: Emma Djabali
Abscesses are a prevalent pediatric condition and often require surgical management for drainage. They are a common cause of ED visits and hospital stays and therefore place a substantial cost burden to children’s facilities. While straightforward, the most ideal technique to manage these has not been fully defined. While there are multiple surgical techniques described, we are using one of two methods here at our institution, conventional packing or vessel loops.
The use of vessel loops was introduced around 10 years ago and has proven safe and effective. It is preferred by some surgeons, as it eliminates the need for patients to repetitively pack their wound at home post-discharge and may cause less scarring. However, this method requires the patient to return to clinic for follow-up for removal of the loop. The other method is a single packing with slow removal at home by the parents or caregivers.
Our practice essentially provides a somewhat random observational study with 2 surgeons doing either one of them. A large retrospective observational trial comparing both methods’ outcomes would inform clinical practice.
Project Title: Culture vs. Evidence: Institutional Decision Making Surrounding Mode of Enteral Feeding in Critically Ill Pediatric Patients
Faculty Mentor’s Name: Dr. Robin Petroze
Student’s Name: Arianne Maya
Early nutrition is important in critically ill pediatric patients, and for those who cannot receive adequate nutrition orally, supplemental tube feeds are often initiated. Enteral feeds can be delivered to the stomach, usually through the nasogastric route, or directly to the small intestine by passing a transpyloric tube. While both methods have pros and cons, there is currently no empirical consensus on which method is best for pediatric patients who need supplemental feeding.
Benefits of nasogastric (NG) feeding include conservation of the stomach’s natural physiological processes, particularly when bolus feeds are used, which mimic the normal oral feeding process. When feeds enter the stomach, it continues to produce hormones and growth factors that target ongoing digestion in the small intestine. Acids in the stomach also provide defense against pathogens, and enteral nutrition plays an important role in maintenance of the microbiome.(1) Accessing the stomach with an NG tube may also be simpler than accessing the jejunum, which often requires more imaging assistance, such as endoscopy or fluoroscopy, which may be more resource and cost-intensive.(2) In many cases gastric feedings can be initiated sooner because they are more quickly placed than transpyloric tubes.(2,3)
Transpyloric feeding is often used in situations where gastric feeding has failed or empirically to prevent complications of gastric feedings. Transpyloric feeding is often used for patients with severe gastroesophageal reflux. It may also allow for higher caloric intake in patients with lower gastric motility or patients in whom gastric feeds need to be frequently held for procedures.(4) Yet, institutional practice varies widely, and in some institutions, routine transpyloric feeding is initiated in critically ill neonates and children in order to reduce the risk of aspiration. For example, the laxity of their esophageal sphincter can put preterm infants at greater risk for aspiration pneumonia, and in neonates with chronic lung disease, aspiration can be a life-threatening complication.(1) Transpyloric feeding can serve as a last resort for the management of very low birth weight infants experiencing gastroesophageal reflux.(5)
Most empirical studies to date do not find significant evidence for one feeding method over the other. One found that nasogastric feeding led to more gastric residual volumes and transpyloric feeding lead to infants reaching feeding goals more quickly, decreasing their hospital stay.(6) A meta-analysis of 9 trials and 359 preterm infants found that transpyloric access lead to more gastrointestinal disturbance, but did not find a significant difference in feeding tolerance, aspiration risk, or in hospital growth rates between each method. The author also cites a lack of data on the effect of transpyloric feeding on preventing or treating gastroesophageal reflux caused apnea.(1)
Overall, large gaps exist in research comparing the safety and efficacy of nasogastric and transpyloric feeding, but it has been shown that implementation of feeding guideline can improve growth of pediatric patients in critical care.(7,8) A recent clinical case in which empiric transpyloric tube placement in a patient with congenital heart disease led to a life-threatening small bowel perforation prompted us to evaluate our institutional practice with initial enteral feeding in critically ill neonates and children. Our goal is to evaluate decision-making and develop evidence-based protocols for care.
Project Title: How Does Glenoid Baseplate Migration Affect Outcomes in Reverse Shoulder Arthroplasty?
Faculty Mentor’s Name: Dr. Joseph King
Student’s Name: Robert Frantz
Shoulder arthroplasty is a procedure in which a damaged glenohumeral joint is replaced with a prosthetic device. There are a number of indications for such a procedure, but the most common indication is degenerative arthritis of the shoulder1. There are two major categories of total shoulder arthroplasty: anatomic total shoulder arthroplasty and reverse shoulder arthroplasty. The traditional method involves a prosthesis that mimics the natural anatomy of the shoulder and is effective for patients with normal rotator cuff function2. However, in patients with a non-functional rotator cuff or a rotator cuff tear, a reverse shoulder arthroplasty is indicated3. In this procedure, the typical “ball-and-socket” anatomy of the glenohumeral joint is reversed. Since FDA clearance of the reverse shoulder arthroplasty in 2003, its indications have been expanding and now include fracture sequelae, revision arthroplasty, instability arthropathy, and tumors around the shoulder girdle4. Many studies have shown promise for good functional outcomes of the later generation reverse shoulder arthroplasty implants and techniques5,6.
While complications with reverse shoulder arthroplasty have been decreasing with newer implants and techniques, complications still remain a concern. There are a number of different complications associated with reverse shoulder arthroplasty, and these include joint instability, implant loosening, scapular notching, and infection7,8. Adequate functional outcomes of the reverse shoulder arthroplasty rely on bony on-growth to the implant (both the humeral and glenoid components) as well as adequate force vectors across the joint to keep it stable. Typically, the glenoid component is held in place with a combination of locking and non-locking screws with different constructs depending on implant design with a bony on-growth surface. One implant also has the ability to allow bony in-growth due to the design of a hollow central press-fit cage that the bone can grow through in addition to several compression screws that become locking screws with the use of locking caps. While uncommon, in some cases there is observed migration of the glenoid component given the significant amount of force imparted on the glenoid baseplate during shoulder motion as well as the relatively small amount of bone available for fixation. Sometimes this migration leads to frank glenoid loosening and other times the baseplate stabilizes in the migrated position with bony in-growth and on-growth. As the incidence of reverse total shoulder arthroplasties increases9, it will be important to understand how migration of these baseplates impacts patient outcomes.
Project Title: Immuno-inflammatory response and secondary sepsis in post-splenectomy patients
Faculty Mentor’s Name: Dr. Scott Brakenridge
Student’s Name: Olgert Bardhi
One of the major leading causes of death in the United States is due to trauma . Polytraumatized patients who survive initial injuries often develop systemic inflammatory response syndrome (SIRS) due to a systemic immune reaction which is followed by a compensatory anti-inflammatory response syndrome (CARS) . SIRS can lead to alterations of the hosts immune system following injury which can lead to multi organ failure, severe infections, and sepsis . Thus, hospitalized patients are aggressively treated to maximize survival chances with fluid resuscitation, bleeding control, and surgery. Following the acute pro-inflammatory response, moderate to severe immuno-suppression post-trauma helps explain why polytraumatized patients are at risk for secondary infections and sepsis .
Among the most frequently injured organs in polytraumatized patients is the spleen. Splenectomy is a routine procedure in trauma centers, however, clinical evidence on the effects of spleen removal in trauma patients is lacking and ambiguous . The spleen is composed of lymphoid tissue and serves an important role in regulation of the immune system. Asplenic patients have historically been considered at a high risk of thrombosis and infection . Nonetheless, splenectomy has been shown to be beneficial and protective in different disease models of stroke and bacterial translocation after burn trauma [7,8]. Recent studies suggest that splenectomy modulates inflammatory response in trauma-hemorrhage and protects against secondary sepsis in a murine trauma model . Most of the studies have been completed in murine disease models and limited data exists on the effects of splenectomy in severe injury trauma patients. In this study we aim to elucidate the occurrence of secondary sepsis or infection in trauma patients with splenectomy and without. Additionally, we want to characterize the inflammatory response by measuring circulating cytokines in asplenic patients as well as leukocyte gene expression differences.
Project Title: Medical Student Use of the Online Surgical Clerkship Curriculum
Faculty Mentor’s Name: Dr. Janice Taylor
Student’s Name: Jonathan Arias
Online learning materials are used widely by medical students to develop their knowledge base. The third-year surgery clerkship at UF has a robust online curriculum that complements the 8-week small group and clinical experience. The content of the online curriculum is reviewed and updated at least annually by the clerkship director, with input from student feedback and the department’s executive education committee. Previous studies have analyzed material that medical students use to study, and have found that what they often use is not what is developed by their school. The purpose of this project will be to analyze use of the online curriculum platform (Canvas) at UF, and seek associations with use to objective measures. The student will perform statistical analysis on de-identified data that they organize from Canvas. The project results will be submitted to a national surgery education meeting.
1) Taylor JA, Shaw CM, Tan SA, Falcone JL. Are the kids alright? Review books and the Internet as the most common resources for the general surgery clerkship. Am J Surg. 2018;215:191-195.
2) Jayakumar N, Brunckhorst O, Dasgupta P, Khan M, Ahmed K. e-Learning in surgery education: A systematic review. J Surg Educ. 2015:72:1145-1157.
Project Title: Ncologic Outcomes in Patients with Clinical T1-3N1-2M0 Breast Cancer Undergoing Targeted Sentinel Lymph Node Biopsy Post-Neoadjuvant Chemotherapy
Faculty Mentor’s Name: Dr. Lisa Spiguel
Student’s Name: Morgan Cribbin
Axillary node staging is an important factor in breast cancer outcomes. Staging of lymph nodes guides both prognosis and treatment for patients with breast cancer. Lymph nodes are clinically staged prior to surgery based on clinical examination and pre-operative imaging, as well as pathologically following cancer resection. The standard of care in patients with clinically negative nodes is to perform a sentinel lymph node biopsy to determine pathologic nodal involvement and need for further nodal surgery. Patients with clinically positive nodes prior to surgery are not eligible for a sentinel node biopsy and instead undergo a complete axillary lymph node dissection.
There is a subgroup of patients with clinically positive nodes who are treated prior to surgery with neoadjuvant chemotherapy in hopes to downstage disease. In such patients with clinical T1-3N1-2M0 breast cancer who become clinically node negative after neoadjuvant chemotherapy, the use of performing sentinel lymph node biopsy prior to determining the need for axillary lymph node dissection has been demonstrated. However, these studies have not investigated the oncologic outcomes in patients who have pathologic negative nodes and are spared axillary node dissection. With this project we hope to demonstrate that sentinel lymph node biopsy is a safe and effective method of axillary node staging following the use of neoadjuvant chemotherapy with acceptable oncologic outcomes in patients who become clinically node negative following systemic therapy and are spared completion axillary dissection.
Project Title: Optimization of pediatric pain control and reduction of hepatoxicity risk – A quality improvement project to reduce the prevalent use of combination opioid/acetaminophen medications
Faculty Mentor’s Name: Dr. Kevin Shea
Student’s Name: Sunny Trivedi
The opioid epidemic is a prominent issue in the healthcare field; opioids are commonly prescribed for pain relief. In the United States, overall opioid consumption has quadrupled from 2000 to 2012.1 This problem extends beyond adults into the pediatric population. The pediatric population is a particularly vulnerable group, one that must be protected from unnecessary harm. In the post-operative setting, there is a heightened need for safe prescribing in pediatric patients to prevent abuse, addiction, and prolonged adverse effects.2 Hospitalizations from opioid poisoning in the pediatric population has increased two-fold from 1997 to 2002.3 From 1999 to 2016, there was a three-fold increase in pediatric mortality rate for opioid poisoning.4 In addition to opioids, acetaminophen is also commonly prescribed for pain relief. Although highly effective for pain relief, acetaminophen can cause significant hepatotoxicity if present above its toxic dose.5 It is critically important to be aware of the potential harm opioids and acetaminophen can cause when determining prescription practices for pain management.
Acetaminophen when prescribed with an opioid such as hydrocodone can be effective for managing pain. In fact, between 1998 and 2003, the combination of hydrocodone/acetaminophen was the most commonly prescribed medication.6 For postoperative analgesia, the routine practice at Lucile Packard Children’s Hospital Stanford is a combination prescription of acetaminophen and opioids. To combat the hepatotoxicity of acetaminophen, the daily consumption of acetaminophen in pediatric patients is capped at 2g. The combination prescription does not allow for the ability to titrate each medication individually to balance pain management and adverse effects. This is problematic as titration of the combination medication can potentiate hepatoxicity from acetaminophen, the risk of opioid overdose, and suboptimal pain control. Therefore, this project was created to shift the routine practice of prescribing combination acetaminophen and opioids to independent prescriptions.
Project Title: PICC lines vs Tunneled lines for Induction of Chemotherapy in Children
Faculty Mentor’s Name: Dr. Saleem Islam
Student’s Name: Alexandra Ilstad-Minnihan
Central venous catheters facilitate the long-term treatment of patients with cancer. In adults, studies have been done comparing the complication risk of peripherally inserted central catheters (PICC), and more long term central venous catheters such as tunneled external central venous catheters and subcutaneously implanted ports 1,2. Cancer patients are at an increased risk for catheter related complication due to their immunocompromised state as a result of underlying disease and treatment 3. For this reason, it is important to consider patient satisfaction, appropriateness of the timing of placement, and potential for downstream complications when choosing a central line for the initiation of chemotherapy.
Assessing catheter related complications in pediatrics is a challenge due to fewer cases. This often requires the inclusion of multiple illnesses in a study of effectiveness and outcomes and decreases the applicability of the studies to a particular population, for instance pediatric oncology patients 4. Those studies that have included pediatric oncology patients have failed to compare the long term central venous catheters to PICCs that may be indicated prior to insertion of a tunneled or subcutaneously implanted port or have focused on a single complication endpoint, such as catheter related blood stream infection 5,6,7. There are several factors implicated in choice of central venous line including physician preference, vein accessibility and proposed length of treatment therapy. If there are factors that confer increased risk of complication resulting from a particular central venous access, it is important to document this information to help guide clinical judgement when initiating central venous access for chemotherapy treatment in pediatric oncology patients.
Project Title: Psychosocial aspects of burnout and attrition among general surgery trainees
Faculty Mentor’s Name: Dr. Marie Crandall
Student’s Name: JohannaMcCracken
Background: Physician burnout and resident attrition are key concerns in modern healthcare. Previous research has demonstrated gender disparities in rates of attrition both in surgical training and also in attrition from academic medicine. Our goal is to examine specific gender-related psychosocial and sociodemographic factors that might be associated with burnout symptoms and might predict attrition from surgical residency.
Hypothesis: We hypothesize that having a supportive partner would be predictive of resilience and decrease the risk of burnout and attrition. We further hypothesize that “supportive” partners are gender specific, and that part of the reason women surgeons suffer higher burnout and attrition rates may be associated with traditional gender role affinity that persists despite choice of profession, and how that affects partner selection.
Methods: We will perform a multi-center, web-based survey of surgical residents, through the Research Committee of the Association of Program Directors in Surgery. Validated burnout and gender role agreement surveys will be coupled with demographic screening questions and our experimental questions about mate choice.
Role of Medical Student: The medical student will assist in survey creation, IRB application, survey dissemination, and data analysis. We expect that this will take all of the summer, but the student will be invited to contribute to research presentations and publications.
Funding: This project is unfunded.
Additional Notes: We are collaborating with investigators from the Department of Surgery at East Carolina University.
Project Title: Radiologic findings in craniosynostosis (O/S) papilledema and establishing gradations of imprinting
Faculty Mentor’s Name: Dr. Jessica Ching
Student’s Name: Nagashreyasu (Shreya) Chidarala
During normal infancy and development, the calvarium or skull of a newborn undergoes expansion to accommodate the growing brain. The growth occurs between the frontal, parietal and occipital bones of an infant at crevices of undifferentiated mesenchyme or sutures (Johnson 2011). Craniosynostosis is a condition that is characterized by the premature fusion of single or multiple cranial sutures either due to a syndromic or non-syndromic (environmental) events. As a result, the etiologies and presentation of craniosynostosis are diverse. Single gene mutations, chromosomal abnormalities contribute to syndromic causes, while intrauterine fetal head constraint or teratogenic exposure are non-syndromic causes. Classifications of craniosynostosis currently depend on the syndromic/non-syndromic etiology, and which suture or combination of sutures prematurely closed.
The most common presentation of craniosynostosis is an atypical face shape, often protruding and narrow. The functional defects of craniosynostosis effect the airway, feeding, orbit, and exhibit increased intracranial pressure (ICP). Increased ICP is one of the primary diagnostic tools to necessitate urgent surgical intervention. ICP can be measured directly and indirectly, however, it is far too invasive to perform in a routine follow-up (Kim 2019). The current non-invasive, indirect methods of ICP monitoring include a lumbar puncture, visual evoked potentials, fontanelle compression, and optic nerve sheath measurement, while direct assessment monitoring consists of ventricular cannulation, epidural, subdural, and intraparenchymal devices (Wiegand 2007).
Project Title: Retrospective Validation of the Brain Injury Guidelines in Pediatrics
Faculty Mentor’s Name: Dr. Brian Yorkgitis
Phone: (904) 244-3448
Student’s Name: Jamie Schwartz
Traumatic brain injury (TBI) is a leading cause of death and disability. It is a There has been an increase in pediatric TBI over the past decade. Management of pediatric TBI tasked to acute care surgeons (ACS) and neurosurgeons. Mild TBI managed by ACS has been proven to be safe. The Brain Injury Guidelines (BIG) developed by Joseph et al was successfully applied to the pediatric patients in a single-intuitional study. Their results concluded that the implementation of BIG reduced CT scans while showing similar outcomes.
A retrospective chart review of pediatric TBI patients cared for at a Level I Adult and Pediatric safety-net hospital will be performed to validate the previous authors’ work. Medical students will participate in data collection and analysis of the chart review along with preparation of abstracts and manuscripts resulting from the study. The results of this study will assist in validation of the BIG in pediatric patients to optimize the care of pediatric TBI.
Project Title: USE OF NANODIAMONDS FOR LOCALIZED IMMUNE MODULATION
Faculty Mentor’s Name: Dr. Ali Zarrinpar
Student’s Name: Clare Grady
Excessive hepatocellular damage incurred in the process of liver graft procurement, storage/preservation, and implantation/engraftment during liver transplantation can lead to graft non-function or delayed function and higher incidence of acute and chronic rejection. (2-4) This ultimately results in poor outcomes for patients and exacerbates the shortage of organs available for transplantation. Reperfusion of ischemic tissues lead to injury through a sterile inflammatory process in the absence of exogenous antigens. The resulting ischemia/reperfusion injury (IRI) initiates a cascade of innate immune-related responses that lead to local inflammation, cell death, organ injury, and failure. The mechanisms underlying IRI are complex and attempts have been made to resolve IRI by implicating and targeting multiple biological pathways. (5-10)
However, no current therapies are used to prevent or treat IRI in clinical practice. The absence of therapies is not necessarily due to a lack of druggable targets but rather the systemic side-effects and toxicities of the drugs. Conventional immunosuppression and immunomodulation inhibit the entire organism, not just the transplanted organ. Not only do patients suffer major side effects from these therapies, but these treatments usually have little impact on the immune cascade induced during IRI.
A potential approach to overcome the problems of systemic toxicity is the use of local or targeted treatment. Targeted delivery allows for selective treatment with drugs, which would lead to reduced local injury, inflammation, allopresentation, and systemic effects. (11) Nanodiamond (ND) particle therapy provides just such a means. (12) NDs can be functionalized with a wide variety of chemical groups; they can be loaded with a wide variety of compounds thus serving as an enhanced drug-delivery platform. (13-19) This application proposes the use of targeted drug delivery to focus the release of immunomodulatory medication within a specific organ, which would provide the potential for local modulation of organ physiology and even immune tolerance.
Success of the proposed studies will validate the use of treatment with NDs within the field of transplantation beyond their established application in chemotherapy. The drug selected for this demonstration is doxorubicin, a clinically useful antineoplastic which induces the expression of heme-oxygenase-1 (HO-1) in the liver and protects against oxidative injury and IRI. However, the free radical formation by doxorubicin leads to great toxicity, including cardiomyopathy and bone marrow suppression. Preclinical studies have shown that administration of ND-adsorbed doxorubicin (NDX), both systemic and localized, results in no apparent bone marrow suppression and leads to enhancement of drug tolerability and efficacy.
Project Title: Abdominal aortic aneurysms
Faculty Mentor’s Name: Dr. Gilbert Upchurch
Student’s Name: Seth Shanefield
Abdominal aortic aneurysms (AAAs) are the one of the leading causes of death in men of all races over 55 years and the number of deaths attributable to AAAs increased to 151,500 in 2013 (1,2). Despite numerous studies identifying multiple clinical risk factors for human AAA formation (i.e. male gender, smokers, COPD, hypertension) (3), aortic aneurysms continue to be a significant public health issue without any directed medical therapies. Accordingly, two pivotal unanswered questions are: (a) what are the endogenous mechanisms underlying dysregulated resolution pathways in aneurysm formation and, (b) what mechanism-based therapeutic strategies can be conceived to initiate resolution upon endogenous failure.
Recent studies have shown that the resolution of inflammation is regulated by specialized pro-resolving mediators (SPMs) that comprise omega-6 derived lipoxins as well as omega-3 derived resolvins, protectins and maresins. We have previously documented the role of NETs (4) and M1/M2 macrophage plasticity (5) in the pathological changes leading to extracellular matrix degradation and vascular remodeling in AAA, which can be effectively mitigated by specialized SPMs i.e. Resolvin D1 (6). However, the exact mechanism of NETosis formation during AAA formation remains to be deciphered. Recent studies have implicated mitochondrial reactive oxygen species (ROS) to drive NETosis in autoimmune diseases (7) but this associative role of mitochondrial (mt) DNA with NETs remains undescribed in vascular biology.