1. < Cardiology/Epi

I am constantly amazed by the reach and impact of our faculty in mentoring and training graduates in our residency programs, pre-college students and undergraduates. This week I will highlight three unique programs that many of you might not be aware of, but which are yielding much fruit.

2023 Physical Medicine & Rehabilitation Residency Program Research Day

Since 1955, the Physical Medicine and Rehabilitation Residency (PM&R) Program, based at the VA Greater Los Angeles Health Care System, has trained over 400 physiatrists. I am pleased that PM&R is part of our larger department of medicine (DoM) family at UCLA. Their trainees have gone on to be superb clinicians, following a rigorous program that includes active participation in innovative research projects. The division of PM&R within the DoM was led by Dr. A. M. Erika Scremin from 1991 to 2016. Her bold vision of optimizing function for her patients was tirelessly matched by her drive to maximize academic standards for her trainees and peers. This culminated in a tradition of annually showcasing the team’s successful outcomes in clinical research.

On Tuesday, August 29th our colleagues in the PM&R Program celebrated their 30th Annual Physical Medicine and Rehabilitation Research Day. Honored guests convened at the UCLA Faculty Club to celebrate the accomplishments of our PM&R residents and faculty that took place during the 2022-2023 academic year.

Under the leadership of Chief of PM&R Dr. Blessen Eapen and Residency Program Director Dr. Dixie Aragaki, the PM&R program has had an outstanding year of research and scholarly output that includes 39+ published manuscripts, 31+ book chapters, 20+ conference presentations, 10+ funded projects, and 4 editorial roles.

The energy in the faculty club was electric as guests enjoyed an afternoon that included poster sessions and lunch with their peers. Guests heard from talented trainees who presented research which covered a wide range of studies with the goal of addressing the health care needs of our veteran population and broader community. I am happy to share with you highlights about each presentation as described by the presenters as well as pictures from the successful event! Enjoy!

Assessment of Sacroiliac Pain Etiology through Ultrasound Guided Diagnostic Injections

Ayana Taylor, MD; Brandon Kalasho, DO; Merideth Byl, DO, MBA; Michael Hernandez, MD; Majid Ashfaq, DO

The objective of this study is to delve into the underlying sources of sacroiliac (SI) pain, focusing on distinguishing between pain originating from the sacroiliac joint versus emanating from the supporting ligaments, particularly the transverse posterior sacroiliac ligament. The SI joint relies on a complex network of muscular and ligamentous attachments to bear vertical loads and accommodate weight shifts.

This is a prospective study that will enroll about 50 patients reporting SI pain. The investigative approach involves a series of SI pain provoking physical examination maneuvers, coupled with the use of a numeric pain rating scale. Subsequently, patients will undergo a diagnostic lidocaine injection into the posterior SI ligament utilizing ultrasound guidance. Following the injection, the same pain provoking physical examination maneuvers will be repeated, and the resultant pain levels assessed and graded. In the event that a patient does not experience a reduction of pain greater than 50% based on the initial pain grading, a second lidocaine injection will be administered into the SI joint. Once again, the pain-inducing physical examination maneuvers will be performed to evaluate the patient’s response to the injection, utilizing the pain grading scale.

Diagnosing the source of mechanical low back pain can be challenging. This proposed pilot study holds significant importance as it has the potential to enhance our understanding of the sources of sacroiliac pain, which can ultimately lead to more efficient patient treatment strategies.

A Comparison of Long-term Opioid Prescribing Practices between Care in the Community and Veterans Affairs Providers

Quinn Convery, PharmD, BCPS; Ariel Baria, PhD, MSN, GNP-BC; Jessie Bjella, MD, MS; Majid Mekany, MD, Paige Cronn, MD, Jeannie Zhang, MD, Calvin Ho, MD

In response to the opioid epidemic, extensive research has investigated patients appropriately indicated for long term opioid treatment in the setting of multiple risks and harms of therapy. Currently, there are no published studies assessing long term opioid prescribing patterns for Veterans receiving care at Veterans Affairs (VA) clinics compared to Veterans who qualify and seek care through Care in the Community (CITC). This retrospective chart review seeks to identify trends in long term opioid prescribing in patients with chronic pain receiving care from VA prescribers compared to patients who receive care from CITC prescribers. A secondary goal is to compare practices in performing opioid safety initiatives. To accomplish these goals, we collected data on 50 Veterans (in each group) over the age of 18 who have received 90 days or more of opioid prescriptions from a VA pharmacy from 7/1/18 to 6/30/19.

Preliminary data revealed higher rates of high morphine equivalent daily dose (MEDD) prescriptions (23% compared to 14% for the 61+ MEDD range) and naloxone prescribing (36% compared to 28%) in CITC compared to VA. There were higher rates of low MEDDs prescribing (64% compared to 57% for 1-30 MEDDs & 22% compared to 19% for 31-60 MEDDs), completing safety measures with the Prescription Drug Monitoring Program (PDMP) (96% compared to 85%), and performing Urine Drug Screens (92% compared to 64%) in VA compared to CITC. Analysis and interpretation of all parameters and outcomes must be obtained prior to commenting on clinical significance, though from preliminary data, there appears to be greater propensity for CITC to prescribe higher MEDDs than VA while VA performs more safety measures than CITC. Insight into opioid prescribing practices comparing VA and CITC providers is important as it generates discussion on why these differences exist and how they may inform future care.

Functional Outcomes of Mild Foot Drop Treated with Ankle Foot Orthoses

Miad Hadaegh, DO; Christopher Lee, MD; Gabriel Sanchez, DO;  Majid Ashfaq, DO; Resa Oshiro, MD

Ankle-foot orthoses (AFOs) are one of the most commonly prescribed orthoses to patients with foot drop, and ankle and/or foot problems. They are used to aid ambulation through the various stages of gait by assisting impaired ankle dorsiflexion or plantarflexion. Previous studies have demonstrated the functional benefit of AFOs when prescribed for treatment of moderate to severe foot drop. However, few studies have investigated the functional outcomes of mild foot drop treated with these orthoses. Mild foot drop is defined here as foot drop with at least 4 out of 5 manual muscle testing in ankle dorsiflexion or full strength with fatigue on short distances. This study intends to establish if there is functional benefit for treating mild foot drop with AFOs.

Typical standard of care considers AFO prescription when a patient suffers from severe foot drop or ankle instability that impedes their ability to ambulate safely. In our brace clinics, we have identified a population of patients who suffer from fatigue induced mild foot drop and/or pain that limits ambulation after moderate to long distances. Although these patients are not the typical AFO candidates, we believe that patients in this population can benefit from AFO prescriptions to improve their walking tolerance and/or reduce pain. Through this study, we hope to understand in depth the spectrum of patients who can benefit from AFO prescriptions and overall improve the decision-making process for clinicians treating foot drop of any severity.

Quality Improvement: Demographics, Co-morbidities and Symptoms in Veterans with Long COVID Syndrome

Harman Grewal, DO; Michelle Jin, MD; Jack Takahashi, MD; David Underhill, MD; Sara Flores, MD; Mike Tran, MD; Babak Darvish, MD

Our study was a retrospective chart review to determine the characteristics and symptoms of Long COVID patients in a large urban VA setting and if different variants of COVID had significantly different demographic, comorbidity, or symptom profiles. Patients in this study were evaluated in a Post COVID-19 Interdisciplinary Rehabilitation Clinic (“Long COVID Clinic”) and seen in the clinic with consults placed 1/20/22-1/6/23. Inclusion criteria were the presence of clinically defined Long COVID, data on the date of the first COVID-positive test, and completion of a Long COVID Clinic assessment. Patients with resolution of symptoms prior to clinic visit, failure to complete Long COVID assessment, and insufficient data were excluded. 132 patients were identified and 17 were excluded. 

Demographics and comorbidities collected from medical records included age, gender, vaccination status, BMI, DM, asthma, COPD, TBI, PAD, PVD, CAD, anxiety, and depression. Presenting symptoms of acute COVID infection obtained from a survey administered during the initial clinic visit included fever, cough, fatigue, myalgia, anosmia, ageusia, headache, nausea/vomiting, diarrhea, and rash. Subjects were assigned to COVID variant subgroups based upon date of the first positive test. Preliminary data indicates that different variants of initial COVID infection had significantly different percentages of presenting symptoms of diarrhea, nausea/vomiting, and headache symptoms. These findings may help local VA Post-COVID Rehab clinic providers improve assessment and steer treatment strategies.

The Role of Electromyography in Patients Undergoing Cervical Epidural Steroid Injections

Michael Davis, DO, MS; Andrew Lin, MD; Timothy Nguyen, MD, MBA; Melissa Phuphanich, MD; Mia Shan, MD; Andysheh Kamgar-Parsi, DO; Resa Oshiro, MD; Anne Nastasi, MD

The primary objective of our study was to determine if electromyography (EMG) confirmation of cervical radiculopathy predicts a positive treatment outcome following epidural steroid injections (ESI). A retrospective chart review study was performed on veteran patients who received transforaminal cervical ESIs between January 2010 and January 2020. Patients were categorized as “responders” and “non-responders.” Analysis was performed to determine if EMG findings, demographics, medical comorbidities, and magnetic resonance imaging (MRI) findings were associated with positive short-term outcomes following ESI.

The primary results of this study showed that patients with EMG confirmation for cervical radiculopathy were significantly more likely to be cervical ESI “responders” (p = 0.042). Age was also found to be negatively correlated with being an ESI "responder" (p=0.040). MRI findings (moderate to severe disc herniation/extrusion, moderate to severe neuroforaminal stenosis, nerve root compression or contact, and central canal stenosis) were not found to be significant predictors of being a "responder" (p>0.6). Based on our results, EMG-confirmed finding of cervical radiculopathy is a significant predictor of a positive short-term response to cervical ESI. This study helps clarify the role of EMGs in guiding treatment of cervical radiculopathy.

2023 Cultivating Interest in Research Careers (CIRC) Summer Symposium

I would like to congratulate Kenrik Duru, MD, MS and his team for hosting a successful end-of-summer symposium for their NHLBI-funded Cultivating Interest in Research Careers (CIRC) Project, which was held on August 16 at the James West Alumni Center. The aim of this R25 is to engage URM community college students in a summer research experience at UCLA with a research mentor, followed by a year-long support program to help them successfully transfer to a four-year institution. Four of their eight CIRC students last year successfully transferred to UCLA and are on campus now!

The students presented their work on a variety of projects that included: 

• Reliability of Self-Reported Age at Menarche as an Indicator for Breast Cancer Risk
• The Effect of a National Care Coordination Program on Processes of Care for High-Cost, High-Need Patients with Diabetes
• Treating Colitis Using Pomegranate Extract Dietary Supplement
• Characterization of Neural Crest-Derived Cells in Embryonic Mouse Hearts
• Analysis of Nerve Distribution in Porcine Model Affected with Arrhythmia
• Landscape Analysis of Mental Health Resources for Diverse Los Angeles County Residents
• p38/IRE1α/Xbp1 Signaling Regulates Chamber-specific Postnatal Heart Growth

The success of the CIRC Program is in part due to the faculty who volunteer as mentors to the participants. We would like to recognize the outstanding mentors from the DoM who provided a wonderful research opportunity for the CIRC students. They include:

Dr. Joann Elmore, Dr. Michelle L'Hommedieu, Dr. Jason Wang, Dr. O. Kenrik Duru, Dr. Carol Mangione, Dr. Tannaz Moin, Dr. Zhaoping Li, Dr. Jieping Yang, Dr. Maria Vega, Dr. Peng Zhao, Dr. Takanori Sato, Dr. Kalyanam Shivkumar, Ms. Amiksha Gandhi, Dr. Mona AuYoung, Dr. Tomohiro Yokota, Dr. Tzung Hsiai, Dr. Jijun Huang, and Dr. Yibin Wang.

2023 Biomedical Research Minor Symposium

Preparing future leaders in medicine for a successful career begins well before they set foot in a medical school. For the past 16 years, the biomedical research minor at UCLA has provided aspiring researchers at the undergraduate level, the opportunity to gain experience conducting research alongside UCLA faculty. This year, of the 16 students who participated in this program, four students worked in the labs of DoM faculty. I share with you highlights about the mentees as shared by their mentors.

Scott Kitchen, PhD, division of hematology-oncology
Mentee: Sarah Tei O’Malley
Project: “Investigating Promoter Usage to Optimize Anti-HIV CAR Function and Efficacy”

Martina McDermott, PhD, division of hematology-oncology
Mentee: Meghan Buddy
Project: “Triple Negative Breast Cancer: Cancer’s Deadliest Hat Trick”

Tamer Sallam, MD, PhD, division of cardiology
Mentee: Vivien Su
Project: “Integrative Multi-omics Profiling Identifies Dietary Stress Responsive Sex-Dimorphic Transcriptional Factors in Murine Liver”

I am very proud of Vivien Su, an undergraduate student who has been part of our group for 3 years. Vivien is an exceptional role model, who embodies all the outstanding qualities that we have come to expect from UCLA students. My lab is interested in investigating gene-phenotype relationships in cardiometabolic diseases. Viviaen was intrigued by the striking differences in the prevalence of many metabolic traits, such as fatty liver, between males and females. Under the guidance of another talented lab member, Dr. Zhengyi Zhang, Vivien started dissecting “the molecular play-by-play” of how a cholesterol-rich diet impacts chromatin dynamics and gene expression in the liver. Working along with Dr. Zhang, she was able to identify differences in chromatin dynamics and transcription factor motif preferences in response to dietary stress between the sexes. These studies deepen our understanding of sex-specific metabolic responses and nominate new pathways that may have implications in fatty liver development.

I am highly impressed by Vivien’s brilliance, tenacity, and contributions to our lab culture. This project required deep knowledge of computational approaches and extensive troubleshooting, which can be intimidating for any trainee. I am equally proud of Dr. Zhang’s mentorship of Vivien and commitment to teaching. Although Vivien is co-author on a manuscript in press and another in preparation, the ultimate goal of her lab experience is not necessarily a publication. The hope is to engage our students in an authentic research experience that can inspire a lifelong passion for discovery and scholarship. I am grateful that we have programs, like the Biomedical Research Minor, that fosters these opportunities at UCLA. 

Philip Scumpia, MD, PhD, division of dermatology
Mentee: Shengze Xu
Project: “Comparative Analysis of Signaling Pathways Induced by Ultraviolet Radiation and Ionizing Radiation”

I was very pleased to announce earlier this year the successful recruitment of Dr. Connie Rhee, as chief of nephrology at the VA Greater Los Angeles. We engaged her in a conversation to introduce you to our amazing colleague.

In Conversation with Connie Rhee, MD, MSc, Section Chief of Nephrology at VA Greater Los Angeles Health Care System (VA GLA)

What events in your life led you to pursue a career and/or research in medicine?

I unexpectedly discovered my passion for research during a hiatus from medical school while caring for my father as he battled for his life amidst a life-threatening CABG complication and a devastating diagnosis of gastric cancer. After his condition stabilized, I returned to school searching for ways to fill my time and was fortunate to meet Dr. Mark Molitch, a renowned endocrinologist at Northwestern University and nurturing mentor who invited me to join his inpatient diabetes research study team. This experience during my formative years was life-changing, as it introduced me to the value of patient-centered research, importance of working in teams, and joy of scientific writing, and also brought me focus, solace, and purpose during a tumultuous period of my life. In parallel, I witnessed the power of research in driving clinical decision-making, as we struggled with the decision to end my father’s radiation treatments prematurely due to painful radiation enteritis, then received reassurance from his oncologist that clinical trials showed minimal benefit of the last phases of radiation vs. earlier treatments he had completed. Now decades later, my research is centered on the interplay of endocrinology, metabolism/nutrition, and kidney disease, and my father is healthy and well at the youthful age of 81.

How have you seen the field of academic medicine evolve over the course of your career?

One of the most exciting developments in nephrology and academia overall includes the increasing representation of women in leadership. Years ago as a trainee, one of our faculty members cited in a lecture that less than a handful of Professors at our institution were women. I recently attended an outstanding Women in Nephrology (WIN) Leadership Conference led by the national WIN President, Dr. Susanne Nicholas, where we learned that over a quarter of nephrology division chiefs are now women! This is aligned with data from the AAMC showing that the proportion of women leading as division chiefs has nearly doubled since 2003 to 2018 from 16% to 29%. I am now embarking on a new role as the first female Editor-in-Chief of the Clinical Journal of the American Society of Nephrology (CJASN), and I am excited for what the future holds for both young women and men as we strive for greater diversity, equity, and inclusion in our field.

What are some of the challenges that are currently being faced in your field?

While in nephrology we have largely focused our efforts on the treatment of end stage kidney disease  (ESKD) via dialysis, our field is recognizing that we need greater emphasis on: 1) prevention of the development of CKD and its progression, 2) more patient-centered treatments for advanced CKD beyond that of in-center hemodialysis, and 3) increased access to kidney transplantation as the gold-standard treatment for ESKD, which are among the major goals of the federal Advancing American Kidney Health Initiative. Additionally, given that kidney disease disproportionately affects people who suffer from inequities in social determinants of health, working with stakeholders to eliminate these disparities is another major priority for our field.

What research question are you most interested in solving? How have you approached solving it?

With regards to CKD prevention, I am the Co-PI of a new NIH study (PLAFOND trial) examining plant-dominant low-protein diets to ameliorate the progression of diabetic kidney disease as the dominant cause of CKD globally. In terms of exploring non-dialytic treatment options for advanced CKD, I am also the Co-PI of an ongoing NIH study (OPTIMAL study) comparing the impact of conservative management vs. dialysis on hard outcomes and patient-centered endpoints. Collaborating with and learning from multi-disciplinary experts both within and outside of nephrology has been one of the most critical and rewarding aspects of our work together in tackling these major issues.

What is your vision and/or goals for addressing a few of these challenges in your new leadership role?

I look forward to partnering together with my UCLA and VA Greater Los Angeles colleagues to: 1) mentor, train, and support the next generation of clinicians and scientists, 2) inspire interest in patient-centered research within and outside of nephrology, and 3) use a team-based approach as we continue to grow, expand, and achieve new heights in the research, clinical, educational, and outreach arenas.

What inspires you to do the work that you do?

I have tremendous gratitude for the army of mentors, teachers, supervisors, collaborators, role models, and life-long friends who have inspired, encouraged, and supported me through the years, and for the wonderful opportunities I have been given in my career. I have a strong desire to pay this forward to support trainees aspiring to become clinicians and/or scientists both within and outside of nephrology.

What advice do you have for our aspiring physicians or physician-scientists?

I would like to encourage young clinicians and scientists to have resilience. Some of the greatest challenges we experience in life are those that refine us, make us stronger, inspire and motivate us to pursue higher goals, and teach us to have empathy for others.

Would you like to share anything else?

Two simple yet wise messages my father has consistently told me is to “Have fun” and “Make a lot of friends.” In both work and personal life, I have found that the journey and process are as important as the final destination and outcome, and that it is fulfilling to work in teams and within a community. In my new role, I look forward to re-connecting with old friends, meeting new friends, and enjoying our work and journeys together.

Round 2: HaPDy Hour - The Countdown to Fall Retreat Continues

Hanging out with out trainees was a wonderful way to bookend a long day. Last week, I visited with residents of firm D for this week's happy hour. I am impressed by the commitment of our trainees to ensure the best care of our patients, while benefiting from our strong learning environment. In conversations, I learned about the joys and challenging of parenting while a resident, discussed planned next steps in careers, celebrated when I heard of interests in some specialties such as infectious disease, while putting in a plug for endocrinology!

Best Wishes on Rosh Hashanah 

I would like to extend best wishes to our friends and colleagues who celebrated Rosh Hashanah, the Jewish New Year, which was at sundown on Friday, Sept. 15 to sundown on Sunday, Sept. 17. Rosh Hashanah commemorates the creation of the world and marks the beginning of the Days of Awe, a 10-day period of introspection and repentance that culminates in the Yom Kippur holiday, also known as the Day of Atonement. I hope the year is full of happiness, health and many blessings for all who celebrate.  Shanah Tovah!

Dale

P.S. 

Birthday season seems to have broken out in the DoM office. This was Gilma’s desk last week, and an unexpected party for me a few weeks earlier. I turned three this year.

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