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Item Management of Type Two Diabetes with Chronic Kidney Disease(2018-03-14) Monk, Nicole; Smith, AllieManagement of Type Two Diabetes with Chronic Kidney Disease Allie Smith MS-III, Nicole Monk MS-III, Long Wong M.D. Chronic kidney disease is a complex disease that occurs in over 200 million people worldwide. There are multiple causes, including: chronic hypertension, arteriolosclerosis and diabetes. Diabetic kidney disease occurs in about 40% of all patients with type two diabetes. Due to the insidious nature of renal damage and the high risk of both secondary hypertension and diabetic nephropathy caused by type two diabetes, early intervention and tight glycemic control are crucial to slowing the progression of renal disease. Renal disease in these patients also poses a complicated problem due to the fact that the effects and concentrations of typical drugs use to control type two diabetes, are partially dependent on renal function as are the unique side effects of each drug. Therefore, close monitoring and frequent adjustment of these medications is needed when managing a type two diabetic with chronic kidney disease. In this report, we offer a brief overview of management of patients with type two diabetes that also have chronic kidney disease and present the case of a 71 year old female with type two diabetes and recently diagnosed chronic kidney disease.Item Does Alcohol Misuse Differ by Gender and Veteran Status in Adults Ages 25 and Older?(2018-03-14) Goodell, Haley; Van Noy, Aubry; Kotulek, Shelby; Diver, Thomas; Hartos, Jessica; Zarker, KourtneyPurpose: There are conflicting findings across previous studies regarding prevalence of alcohol use, binge drinking, and heavy drinking between veteran males and females, and compared to civilians. The purpose of this study was to assess whether alcohol misuse differs by gender and veteran status in adults 25 and older. Methods: Data from the 2015 BRFSS for Maine, Montana, Oregon, South Carolina, and Alaska for veteran and non-veteran males and females ages 25 and older were used in this cross sectional analysis. Multiple logistic regression analysis was used to assess the relationship between alcohol misuse (use, binge, heavy) and veteran status by gender after controlling for age, education level, income level, marital status, race, depression, and smoking status. Results: For adults ages 25 and older, about half (44-59%) reported alcohol use, and about one-tenth reported binge drinking (10-15%) or heavy drinking (5-7%) in the past 30 days. After controlling for demographic and lifestyle factors, alcohol use and binge drinking were directly related (small to moderate effect sizes) to gender and veteran status, with males, both veteran and non-veteran, showing more than female non-veterans in Maine, Montana, Oregon, South Carolina, and Alaska. There was no overall pattern across states for heavy drinking. Conclusion: Overall, alcohol use, binge drinking, and heavy drinking were related to gender and veteran status. Binge drinking and heavy drinking were also related to smoking. For veteran and non-veteran adults ages 25 years and older in a primary care setting, a moderate prevalence of alcohol use may be expected, while a low prevalence of binge drinking, heavy drinking, and smoking may be expected. Although these prevalences may be low, standard of care is to automatically screen for alcohol use and smoking in all patients, both veteran and non-veteran. Therefore, in a primary care setting if signs of binge or heavy drinking are present, providers should consider a more in depth screen for alcohol misuse. Additionally, if signs of either alcohol misuse or smoking are present, providers should consider a more in depth screen for both. Patient education and referrals for alcohol misuse treatment programs and/or smoking cessation counseling should be provided to patients as needed.Item MASSIVE RIGHT-SIDED HIATAL HERNIA VARIATION: A Case Report(2018-03-14) Dhume, Mahima; Fisher, Cara; Reeves, Rustin; Farrell, MollyBackground: A hiatal hernia describes a herniation of abdominal contents, typically the stomach, through the esophageal hiatus into the mediastinum. The majority of reported paraesophageal hernias (PEH) are left-sided; although, right-sided hiatal hernias have a better prognosis, there is little mention of them in current literature. Case Information: During a routine cadaver dissection for academic purposes, a massive hiatal hernia was identified in an 84-year-old female. This anatomic variant case presents with the abdominal contents of the entire stomach, pyloric sphincter, and portions of the greater and lesser omentums displaced into the right thoracic cavity. Such hernias can have acute symptoms, chronic symptoms, or present as asymptomatic. In this case report, the donor was thought to have no significant functional abnormalities, although there were reports of gastrointestinal bleeding. Conclusions: We believe this case to be a rare variant due to two factors: the size of the hiatus, and the displacement of the hernia into the right side of the mediastinum. The hiatal surface area (HSA) in this case report was calculated to be 17.41cm2, which is almost three times the established average HSA in normal patients. This case report attempts to add to the body of literature detailing right-sided hiatal hernias. Looking forward, we believe that there is great scope for future research specific to right-sided hiatal hernias and improvement in the quality of life for those who undergo elective PEH repair.Item Are Smokers More Likely to be Non-Compliant with their Medications? An Examination of Permanent Supportive Housing (PSH) Residents in Fort Worth, Texas(2018-03-14) Walters, Scott; Moore, Jonathan; Moore, JonathanPurpose: People with a history of chronic homelessness are disproportionately more likely to smoke and have problems with medication compliance. Moreover, smoking and medication adherence are often related; people who smoke tend to have more trouble taking their medications. However, no studies to our knowledge have investigated this relationship among a group of formerly homeless individuals who have mental health symptoms. The current study utilized a sample of permanent supportive housing (PSH) residents in Ft. Worth, TX who were participating in a health coaching program. It was hypothesized that people who smoked would have more difficulties adhering to their medication regimens. Methods: Data were from m.chat, a technology-enhanced health coaching program for PSH residents with mental health symptoms. Data from November 2014 - March 2017, which consisted of 567 participants, were included. Baseline smoking status was determined by the following question: do you currently smoke cigarettes, or use other forms of tobacco? (yes vs. no). Medication adherence was identified using a modified Morisky Medication Adherence Scale, which categorized people as low vs. medium/high adherence. Covariates were selected based on prior literature and the information available in our data. Logistic regression was used for the analysis. Results: Medication adherence was similar between smokers and non-smokers (aOR: 0.78, 95% CI: 0.41, 1.49). However, drug abuse was significantly associated with medication adherence; people who reported consuming any illicit drug or abusing a prescription medication in the past 90 days had 73% lower odds (aOR: 0.27, 95% CI: 0.12, 0.65) of adhering to medications compared to those who reported no drug abuse. Alcohol consumption was significant in the unadjusted analysis, but was not significant after adjusting for other factors. Conclusions: Among a group of PSH residents with a history of homelessness, smokers and non-smokers had similar rates of medication adherence. Although smoking was not associated with medication adherence, other forms of substance use were related to a poorer medication adherence. This research highlights the role of illicit drug use in predicting medication adherence; programs that attempt to improve rates of medication adherence should take drug use into account as a key predictor of compliance.Item Diagnostic Validation of Dynamic Ultrasound Evaluation of Supination-External Rotation Ankle Injuries(2018-03-14) Fisher, Cara; Johnson, Katelyn; Reeves, Rustin; Wood, Addison; Rabbani, TebyanAbstract Purpose: Definitive diagnosis of syndesmosis injuries can be made with plain film radiographs if the injury is severe enough, but often is missed when severity or image quality is low. Ultrasound diagnosis may circumvent many of these disadvantages by being inexpensive, efficient, and able to detect subtle injuries without radiation exposure. This study evaluates the ability of ultrasound to detect subtle SER ankle syndesmosis injuries with a dynamic external rotational stress test. Methods: Nine male fresh frozen specimens were secured to an ankle rig and stress tested to 10 Nm of external rotational torque with ultrasound monitoring at the tibiofibular clear space. The ankles were subjected to syndesmosis ligament sectioning and repeat stress measurements of the tibiofibular clear space at peak torque. Ankle States Examined: 1. Intact State 2. 75% of AITFL Cut 3. 100% of AITFL Cut 4. Fibula Fx - Cut 8 cm proximal 5. 75% PITFL Cut 6. 100% PITFL Cut Results: Dynamic external rotation stress evaluation using ultrasound was able to detect a significant difference between the uninjured ankle tibiofibular clear space of 4.5 mm and the injured ankle with 100% of anterior inferior tibiofibular ligament cut 6.0 mm (P=.017). Additionally, this method was able to detect significant differences between the uninjured ankle and the injured states. Conclusion: Dynamic external rotational stress evaluation using ultrasound was able to detect stage 1 Lauge-Hansen SER injuries with statistical significance and corroborates criteria for diagnosing a syndesmosis injury at ≥ 6.0 mm of tibiofibular clear space widening.Item Sympathetic Chain Schwannoma Masquerading as a Vagus Nerve Schwannoma Complicated by Postoperative Horner’s Syndrome and Facial Neuralgia: A Case Report(2018-03-14) Homewood, Tyler; Baker, Terry; Baker, AustinBackground: Schwannomas of the carotid sheath are rare neoplasms and schwannomas of the cervical sympathetic chain are the least common subtype. Despite predictive radiologic patterns, Cervical sympathetic chain schwannomas (CSCS) have been known to masquerade as other neoplasms on CT and MRI making preoperative diagnosis difficult. Postoperative complications are common. We present a rare case of a misdiagnosed CSCS with unusual complications of permanent Horner’s syndrome and facial neuralgia. Case Information: A 36-year-old female presented with a right neck mass. CT and MRI confirmed the mass in the parapharyngeal space. The positioning of the mass in conjunction with the common carotid artery and the internal jugular vein lead to a diagnosis of vagus nerve schwannoma (VNS). During surgical treatment, dissection to the mass revealed the preoperative diagnosis of VNS to be incorrect as the mass was found to be involved with the cervical sympathetic chain. A new diagnosis of CSCS was made and the nerve was enucleated along with the mass. The patient presented postoperatively with Horner’s syndrome and severe facial neuralgia. Despite maximal medical management for two years, these complications have proved permanent. Conclusions: Imaging is the mainstay for preoperative diagnosis of CSCS. While imaging trends allowing distinction between VNS, CSCS, and other tumors are helpful, recent studies have shown considerable variability in these trends making preoperative diagnosis difficult. Our case reflects this difficulty as preoperative imaging led to an incorrect diagnosis. In addition, post-operative complications, such as temporary Horner’s syndrome are common in CSCS. The patient in our case presented with more severe and unique complications of facial neuralgia and permanent Horner’s syndrome. These complications are not often seen in the literature. Future research should be undertaken to determine if a link between an incorrect preoperative diagnosis and an increased complication rate exists. In addition, this case serves to heighten clinician consciousness of a rare but important diagnosis and the difficulties involved with initial diagnosis and potential complications. We hope that such knowledge will prompt physicians to prepare thoroughly for possibly alternative diagnoses during surgical intervention which may lead to improved patient outcomes.Item Histoplasmosis Mistaken for Lung Neoplasm During Immunosuppression Therapy(2018-03-14) Liu, Luna; Sisay, Emnat; Machaiah, Madhrira; Bohra, HemaBackground TNFα antagonists such as Cimzia use large immunogenic protein molecules to induce deviations in normal host immunity and inflammatory response. Most warnings address alert providers to seriously consider initiating immunologics, because TNF plays an important role in immunity, notably against mycobacteria. Cimzia is different than other prior agents targeting TNF, because it does not fix, complement or induce cell-mediated cytotoxicity that is antibody-dependent from not having an immunologic Fc portion. Case information A sixty year-old female with psoriasis, hypertension and greater than fifteen year history of Crohn's disease on Cimzia presented after four months of cough, night sweats, weight loss and generalized weakness. Her productive chronic cough evolved from brownish and bloody phlegm to a greenish color. Initial imaging from her PCP revealed a right upper lung mass thought to be a malignant tumor. Social history did not endorse any use of tobacco products or prior history of COPD, asthma or pneumonia. Family history for cancer was unremarkable. Patient describes that she was a teacher for many years in an older school building that had multiple past infestations, including possum. The initial attempt at bronchoscopy was inadequate for pathology, but repeated procedure denoted an exophytic and fungating mass. Cardiothoracic surgery performed an elective right partial right pneumonectomy and mediastinoscopy. Pathology performed on brushings were negative for malignancy, but endorsed a granuloma with acute inflammation. Final biopsy from the procedure revealed a granulomatous inflammation with a methenamine silver stain revealing histoplasmosis. Urine histoplasma antigen was negative, but antibody was high at 1:1, which can be seen with disseminated or diffuse pulmonary histoplasmosis. Patient began a short inpatient course of liposomal Amphotericin B transitioning to oral itraconazole prior to discharge. Conclusions Histoplasmosis mimics many common respiratory infections and neoplastic processes with symptom presentation and radiologic findings that have led to surgical resections of non-malignant pulmonary granulomatous nodules initially thought to be carcinomas. Patients on certolizumab should be closely monitored for the development of disseminated disease such histoplasmosis and warned about participating in activities that can expose them to inhalation of airborne microconidia.Item Neuroleptic Malignant Syndrome caused by Cyclobenzaprine(2018-03-14) Aftabizadeh, Som; Patel, Harsh; Herekar, Amar; Machaiah, Madhrira; Reddy, PrashanthBackground/Abstract: Neuroleptic malignant syndrome is a disorder characterized by a triad of fever, muscle rigidity and altered mental status and classically associated with dopamine antagonists. It is rare and potentially fatal if not diagnosed and treated in the correct manner. There is no specific diagnostic test to rule in the disorder and a high suspicion and detailed list of home medications are needed as it is essentially a clinical diagnosis. A patients course usually begins with muscle rigidity followed by a fever within several hours, as well as mental status changes that range from drowsiness, agitation, or confusion to a severe delirium or coma. Here we present a unique case of a patient with NMS secondary to cyclobenzaprine. To our knowledge, it is only the third case reported in literature.1-3 Case Report: A 70 year old male with a past medical history of left-sided ischemic stroke, hypertension, type II diabetes, and chronic back pain presented to our emergency department with altered mental status (AMS). His last known normal was the previous evening around 10pm where the wife admitted to a verbal argument over the patient’s frequent overuse of prescribed Norco and Flexeril for his chronic back pain. Upon waking up the following morning the patient’s wife immediately noticed AMS, unsteady gait, and loss of bladder control. Upon arrival to our ED the patient was febrile with a max temperature of 104.9, profusely diaphoretic, tachypneic, tachycardic, with muscle rigidity. Pupils were equal and reactive and reflexes were intact. The patient’s altered mentation and labored breathing continued to decline requiring intubation and mechanical ventilation. Computed tomography and magnetic resonance imaging of the brain were normal. Continuous EEG was negative for seizure activity. CSF analysis, blood, and urine cultures were negative for infection. Creatine kinase was elevated at 1,963 U/L and WBC elevated at 21.9 k/mm3. Urine triage screen was positive for opiates. The patient was treated with dantrolene and lorazepam with good response in temperature. Slowly, over the course of the next few days, the patient’s symptoms resolved and he was weaned of the ventilator and eventually discharged with no complications. Discussion/Conclusion: Our patient’s clinical presentation and diagnostic work-up were classic for NMS. Treatment is largely supportive including cessation of the offending agent and pharmacologic interventions in more severe cases such as ours. NSM is thought to be caused by abrupt dopamine receptor blockage and the typical causative agents are antipsychotics. NMS caused by cyclobenzaprine is extremely rare and to the best of our knowledge only two other case reports have been reported in literature. While our case points to an overdose as the most likely pathogenesis, other reports have described a possible idiosyncratic reaction, i.e., immune-mediated reactions that occur rarely and in unpredictable fashion among the population. This case questions if medications other than antipsychotics such as muscle relaxers should be kept in mind when working up a cause for NMS. The fact that a muscle relaxant can actually potentiate muscle rigidity makes this a unique phenomenon and we feel it should be further investigated. References: Berman BD. Neuroleptic malignant syndrome: a review for neurohospitalists. Neurohospitalist. 2011;1(1):41-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726098/ http://journal.chestnet.org/article/S0012-3692(16)53939-7/fulltext Fink M. Response to "Neuroleptic malignant-like syndrome due to cyclobenzaprine?". J Clin Psychopharmacol. 1996;16(1):97-9. https://emedicine.medscape.com/article/816018-overview#a4Item Epigenetic Risk Factors for Mild Cognitive Impairment, Alzheimer’s Disease and Metabolic Dysfunction in Mexican Americans(2018-03-14) Silzer, Talisa; Sun, Jie; Phillips, Nicole; Johnson, Leigh; O'Bryant, Sid; Barber, Robert C.; Abraham Daniel, AnnPurpose: Alzheimer’s is the most common form of dementia and the 5th leading cause of death for those over 651. The population of Mexican American elders will grow seven-fold by 20502 with rates of mild cognitive decline (MCI) and Alzheimer’s disease (AD) increasing exponentially1. Mexican Americans are diagnosed with MCI and AD at younger ages than non-Hispanic whites3; 4. In addition, Mexican Americans who are diagnosed with AD are 1) less likely to carry the ApoEε4 genotype3-5., 2) suffer a greater burden of type 2 diabetes3; 6, 3) experience greater metabolic-related cognitive decline7; 8 and 4) display a proteomic signature of AD that is heavily metabolic in nature4; 9, compared to non-Hispanic whites, whose proteomic signature for AD is dominated by inflammatory proteins. We hypothesized that differentially methylated regions of DNA (DMRs) are associated with age at onset of cognitive decline (MCI/AD) and metabolic dysfunction (metabolic syndrome/type 2 diabetes) in Mexican Americans. Methods: To test this hypothesis, we assayed genomic DNA methylation in samples from 14 female Mexican American participants enrolled in the Health and Aging Brain study in Latino Elders (HABLE). Participants were diagnosed with cognitive decline (n=4), metabolic dysfunction (n=3), both (n=4), or as a control (n=3). We isolated DNA from leukocytes and bisulfite treated the samples before running them on an Illumina MethylationEPIC chip in accordance with manufacturer’s recommendations to assay genomic DNA methylation. Results: Several interesting biological pathways showed significantly different methylation status between groups. When the participants were split on cognitive decline, DNA in the amyloid secretase, EGF receptor signaling, PDGF signaling, gonadotropin-releasing hormone receptor and Wnt signaling pathways were significantly hypermethylated in cases. In comparison, analyses based on metabolic dysfunction showed significant DNA hypomethylation in the beta1 and beta2 adrenergic receptor signaling pathways and hypomethylation of the gonadotropin releasing hormone receptor pathway in cases. Conclusions: The etiology of cognitive decline appears to differ between Mexican Americans and non-Hispanic whites. Future work will resolve how dementia risk differs between these and other ethnic groups. The knowledge gained from these studies will be critical to a better understanding of AD pathophysiology and the development of ethnicity-focused AD treatment options. Acknowledgements: Research reported here was supported by the National Institute On Aging of the National Institutes of Health under Award Number R01AG054073. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The research team also thanks the local Fort Worth community and participants of the Health & Aging Brain Study.Item Orthopedic Implants With Imaging Correlation(2018-03-14) Choi, Woongsoon; Smith, Spencer; Tran, JohnsonAbstract Title: Orthopedic Implants With Imaging Correlation Presenter name: Johnson Tran, MS-III; Woongsoon Choi, MS-IV; Spencer Smith, M.D. Purpose: Orthopedic surgery is an important discipline that encompasses numerous procedures that entail placement of various pins, screws, plates, rods, prostheses, and other hardware. Virtually every healthcare provider will encounter many patients with orthopedic implants; however, medical students at the Texas College of Osteopathic Medicine have minimal hands-on exposure to such implants. Presented here are 16 orthopedic implants matched with corresponding radiographic images. This exhibit allows students to personally handle different pieces of hardware while visualizing how and where they are used in orthopedic procedures. Methods: The surplus orthopedic hardware on display was donated to our team by the Baylor Surgical Hospital at Fort Worth. We then identified each implant and searched the internet for matching radiographic images that demonstrate their in vivo utilization in actual patients. Results and Conclusion: We successfully identified 16 orthopedic implants and obtained correlative radiographs. This poster, which will remain accessible to students on permanent display in a school laboratory, is a unique educational tool which allows students to directly interact with real orthopedic implants while comprehending their utility through via correlative imaging. Research Area: Education Presentation Type: PosterItem Establishing Experimental Sample Uniformity Prior to Patella Component Fixation Testing(2018-03-14) Wagner, Russell; Kosmopoulos, Victor; Beck, Cameron; Hogsett, Cameron; Nestlerode, Christina; Nwannunu, BrianPurpose: It is imperative to perform quality control studies to validate experimental sample quality prior to testing. Due to the inherent inconsistency when using cadaveric bone as a means to test clinically relevant hypotheses, one such quality check is to geometrically study the variability present in the bone samples. Thus, as a quality control step prior to investing resources to undertake the overall aim of studying patella component fixation in total knee arthroplasty (TKA), this study aims to establish sample uniformity by analyzing patella length, width, and depth. Methods: Ten random pairs of patellae were harvested from a possible 39 embalmed cadavers. Each patella was then prepared by an orthopaedic surgeon, as if performing an intraoperative TKA, for fixation of a patella implant component. After preparation but before adding a patellar component and cement, the surgeon visually inspected each patella and separated each pair with the better bone quality sample as part of the control group and the other as part of the treatment group. Measurements were then taken by two independent observers using a caliper to determine the superior-inferior patellar length (SIL), medial-lateral width (MLW), and the sectioned patellar thickness (TH). T-tests were performed to establish interobserver measurement reliability and the geometric uniformity between the control and treatment groups and between the left and right samples. Results: There was no significant difference between readers in the SIL (p=0.48), MLW (p=0.58) and TH (p=0.23) measurements. No significant differences were found when comparing between the control and experimental groups for any of the three measures (SIL p=0.21, MLW p=0.44, TH p=0.90). There was however, a significant difference observed in the sectioned preparation TH (p=0.007) when comparing left and right knee patellae. Conclusions: Based on the geometric outcomes measured (SIL, MLW, TH) the results of this study validate the sample uniformity when comparing patellae based on control and treatment groups rather than right verses left. Doing so helps control sample quality for completing the overall aim to study cement fixation methods of the patellar component in TKA.Item The Potential Role of E-Cigarettes In Diffuse Alveolar Damage(2018-03-14) Khan, Samir; Bakre, Sulaimon; Al-Farra, Sherif; AlFarra, TariqPurpose: The prevalence of e-cigarette usage has increased in non-smokers and those planning to quit smoking. Although the potential long term adverse effects have not been studied in humans, studies have shown that certain components of e-cigarette fluid may lead to the release of cytotoxic components implicated in the pathogenesis of diffuse alveolar damage (DAD), a histopathological diagnosis that is commonly associated with acute respiratory distress syndrome (ARDS). This literature review describes the potential association between e-cigarettes and diffuse alveolar damage while making reference to relevant associated studies. Methods: An English literature review of studies that examine the potential cytotoxic effects of E-cigarette fluid components in relation to the pathophysiology of diffuse alveolar damage. Results: To date, no longitudinal studies have been performed on humans to show the toxicity of e-cigarette vapor on the human lung. However, studies have shown different mechanisms by which the compounds in e-cigarette vapor lead to the destruction of alveolar epithelial cells in-vitro. The major component of e-cigarette vapor, propylene glycol, has been shown by in-vitro studies to be cytotoxic to alveolar type II epithelial cells. Glycerol, another component of e-cigarettes, was also found to be cytotoxic in a dose-dependent pattern. Moreover, lactate dehydrogenase, a common byproduct of cell death, was found elevated in alveolar cells exposed to e-cigarette vapor when compared to alveolar cell controls exposed to clean air, suggestive of cell death. Interleukin-6 (IL-6), a proinflammatory cytokine, was found to be elevated in a dose dependent pattern after young healthy non-smokers hTBE cells (human tracheobronchial epithelial cells) were exposed to e-cigarette fluid. Furthermore, there was an increase in fibroblast growth factor (FGF) in alveolar cells, which is also part of the pathogenesis of DAD. Conclusion: Diffuse alveolar damage is a life-threatening condition with a high mortality rate. The evidence of adverse effects demonstrated by the in-vitro studies described above suggests an association between e-cigarette use and diffuse alveolar damage. Just as studies were able to reveal the harmful effects of tobacco products in the past, this literature review introduces a new avenue of investigation to assess the long-term effects of e-cigarettes on humans.Item A Case of Osteosarcoma in Concurrent Sickle Cell Disease(2018-03-14) Bowman, William; Berry, Stacey; Hamby, Tyler; MacGregor, TheresaBackground: Osteosarcoma is an aggressive bone cancer with a poor prognosis. When this disease is coupled with a concurrent diagnosis of Sickle Cell Disease (SCD), very careful management of the treatment is necessary, due to complications that may arise. This case study will explore some of the complications that were faced in a patient with these two diseases. Case Information: An 11-year-old male with SCD presented to the hospital with leg pain. He was mistakenly believed to have osteomyelitis, a known complication of SCD. Imaging supported this initial diagnosis but further evaluation was ordered. A biopsy of the proximal tibia showed pleomorphic malignant cells and malignant osteoid, confirming a diagnosis of osteosarcoma. Treatment following the Children’s Oncology Group Protocol: AOST0331 was initiated. This protocol includes 29 weeks of chemotherapy consisting of alternating Methotrexate (MTX) once a week for two weeks, followed by Doxorubicin/Cisplatin one week. This is repeated until week 10, when a surgical resection of the tumor is performed, followed by 17 more weeks of chemotherapy. During treatment, several incidents that are attributable to complications of SCD occurred. Two instances of delayed MTX clearance and the formation of two intra-cardiac thrombi were the most troubling of these complications. The patient remained in the hospital during the prolonged MTX clearance, and was monitored closely until clearance was achieved. The patient also received tPA and Lovenox to dissolve the intra-cardiac thrombus and reduce the likelihood of the formation of another thrombus. Conclusions: SCD with a diagnosis of osteosarcoma presents unique challenges to a physician. SCD induces a hypercoagulable state and often leads to end-organ damage, and osteosarcoma is a cancer that must be dealt with aggressively to achieve remission. A diagnosis of osteosarcoma in a patient who already has SCD has the potential to be masked by the complications of SCD. Osteosarcoma must be considered a differential in someone who presents with bone pain, even if they are already known to have SCD. Once a diagnosis of osteosarcoma is made, the implications of the concurrent diagnosis of SCD requires that physicians very carefully consider the possibilities of severe complications that may arise. Managing physicians must have awareness of the effects chemotherapy can have on an individual that is both in a hypercoagulable state and may also have end-organ damage.Item Does Physical Activity Level Differ Between Those With and Without Diagnosed Arthritis in Middle Aged Females?(2018-03-14) Hartos, Jessica; DeBerry, Sara; Welch, Jayton; Carroll, AmandaPurpose: Current clinical guidelines regarding the recommended physical activity levels for middle aged females with arthritis are unclear. Therefore, the purpose of this study was to assess whether physical activity levels differ between those with and without diagnosed arthritis in middle-aged females. Methods: This cross-sectional analysis used 2015 BRFSS data for females ages 45-64 from Arkansas, Mississippi, and Alabama. Multiple logistic regression was used to assess the relationship between physical activity levels and arthritis while controlling for weight status, fruit consumption, vegetable consumption, activity limitations, heart disease, depression, educational level, and ethnicity/race. Results: Approximately half of females 45-65 years-old reported a diagnosis of arthritis (44-49%) and less than half reported being physically inactive (38-45%). Overall, physical activity levels did not significantly differ between those with and without arthritis. However, arthritis was significantly related to activity limitations, heart disease, and depression. Conclusion: Overall, physical activity levels did not differ between those with and without arthritis in females ages 45-64 years old. Across 2 or 3 states, an arthritis diagnosis was significantly related to activity limitations, a diagnosis of angina or coronary heart disease, and a diagnosis of depression. However, no information was available regarding patient medications, compliance, or current management of arthritis. Based on the results of this study, it is recommended that if a patient presents with arthritis, activity limitations, coronary heart disease, or depression, primary care providers should screen for all four conditions, provide education, and treat accordingly.Item The Involvement of S6 Kinase-2 in Breast Cancer(2018-03-14) Basu, Alakananda; Joshi, RohanPurpose: Breast cancer is the second leading cause of cancer death in women. Triple negative breast cancer is characterized by the lack of estrogen receptor, progesterone receptor, and HER2/neu and hence poses a problem for targeted therapy. Thus there is an urgent need to identify a suitable molecular target. The 40S ribosomal protein S6 kinase (S6K) acts downstream of mTOR, which plays important roles in cell proliferation, protein translation, and cell survival and is a potential target for cancer therapy. S6K exists as two homologues, S6K-1 and S6K-2, but little is known about the function of S6K-2. Although Akt is believed to act upstream of mTOR, persistent inhibition of S6K-1 can activate Akt via a negative feedback loop. In the present study, we have examined the effects of S6K-2 on Bcl-2. Bcl-2 is in the Bcl-2 family of proteins and is an anti-apoptotic protein. Methods: The breast cancer cell lines ZR-75 and MCF-7 were used. These cells were transfected using siRNAs which were either control non-targeting or target-specific. The extent of gene knockdown was determined by Western blot analysis. The proteins from the cell extract were visualized using SDS-PAGE gel electrophoresis and enhanced chemiluminescence. Yo-Pro staining was used to visualize apoptotic cells. Results: It was noted that S6K-2 knockdown lead to a decrease in Bcl-2, this occurred concurrently with an increase in cell death. Silencing of S6K-2 caused a decrease in Bcl-2 via Akt. Conclusion: Targeting S6K-2 may be an effective therapeutic strategy to treat breast cancer.Item Recurrence of Sub-Acute Methotrexate Neurotoxicity in a 16-year-old Female Undergoing Therapy for Precursor B-cell ALL(2018-03-14) Torres, Jordan; Chaphekar, Anita V.Introduction: Methotrexate, an anti-folate, is commonly used in treatment for acute lymphoblastic leukemia. Neurotoxicity is a known complication of methotrexate and can present as acute, sub-acute, and long-term neurotoxicities. Sub-acute methotrexate neurotoxicity can be seen as late as two weeks after methotrexate administration and can present as stroke-like symptoms, seizures, aphasia, and encephalopathy.Patients who develop methotrexate neurotoxicity can be safely re-challenged with the drug, although there are reports of recurrent neurotoxicity occurring. Patients who develop methotrexate neurotoxicity often have MRI findings of white matter hyper-intensities known as leukoencephalopathy. These changes are usually transient and can be present in an asymptomatic patient being treated with methotrexate. Case Presentation: This case was identified and reviewed using electronic medical records and imaging. Details of the case were also supplied by the patient herself during interview. A 16-year-old female presented to her outside pediatrician with several months of headaches, one week history of loose stools, and two-day history of bruising to the back of the hands. A complete blood count revealed anemia, thrombocytopenia, and leukocytosis. The patient was sent to Cook Children’s Emergency Room. A diagnosis of precursor B-cell Acute Lymphoblastic Leukemia, High Risk was established. Patient was enrolled in the COG protocol AALLO8B1 for biology and tissue banking and treatment protocol AALL1131. Induction began as planned. The patient was given intrathecal methotrexate on day 8 and 29 without problems. However, her minimal residual disease at the end of induction was 0.2%. Due to this, the patient was switched to the very high-risk arm of protocol AALL1131.The Consolidation phase consisted of weekly intrathecal methotrexate, intravenous cyclophosphamide, intravenous cytarabine, and 6-mercaptopurine. During the first few days of consolidation the patient began complaining of trouble with concentration and memory. Approximately eleven days after intrathecal methotrexate administration, the patient reported to the Cook Children’s Emergency Department with complaints of pain in her mouth, difficulty swallowing, and a fever of 101.9 degrees Fahrenheit. The patient also had weakness in her right upper extremity, slurred speech, and she could not write with her right hand. Physical exam in the emergency department was remarkable for right facial hemiparesis and asymmetry. She was somnolent and lethargic. The right upper extremity had decreased tone and strength compared to the left upper extremity. The patient exhibited aphasia. Cranial nerve seven demonstrated a right central palsy, but all other cranial nerves were intact. Blood cultures were negative. The patient had to be intubated and transferred to the PICU due to loss of gag reflex and inability to keep her airway open. MRI showed bilateral periventricular white matter and centrum semiovale diffusion restriction with no mass effect consistent with acute methotrexate toxicity. Decadron and Leucovorin were started. She was extubated on PICU day 4. The patient returned to the oncology clinic a few days after discharge and was doing well overall. During this clinic visit, she received a re-challenge of 15 mg of intrathecal methotrexate. Approximately one week after this methotrexate administration, the patient returned to the emergency department with recurrent methotrexate encephalopathy. She complained of a left lower facial palsy, left arm weakness, and difficulty with speech. She was afebrile and physical exam did not show any major neurological abnormalities, An MRI of the brain showed diffusion restriction in bilateral centrum semiovale and supratentorial periventricular white matter with right more than left side. This was deemed to be consistent with methotrexate neurotoxicity. MRA showed no vascular deficit. The patient was switched from intrathecal methotrexate to intrathecal cytarabine for maintenance therapy. She tolerated this well, although she did have some delayed clearance of the methotrexate requiring a longer hospital stay. Conclusion: Although re-challenge is considered safe, it is important to be aware of the possibility of a second episode of methotrexate neurotoxicity occurring as seen in this patient. The patient had stroke-like symptoms that resolved in a few days in both instances. Additionally, her MRI findings are consistent with leukoencephalopathy. She continues to receive intravenous methotrexate but is given intrathecal cytarabine rather than intrathecal methotrexate.Item Combination of Mithramycin and Standard Chemotherapeutic Agents Induces Anti-proliferative activity in Ewing Sarcoma cell lines(2018-03-14) Hunter, Abigail; Lout, Holly; Dunlap, Elissa; Sankpal, Umesh; Bowman, W. Paul; Basha, Riyaz; Ray, Anish; Albeer, LinaBackground/Hypothesis: Ewing sarcoma (ES) is a small, round, blue cell tumor found primarily in bones of adolescents. The EWS-FLI1 transcription factor is associated with proliferation of cancer cells and is over-expressed in [greater than] 85% of Ewing sarcoma cases. Mithramycin (MIT) is an antibiotic with antineoplastic properties and has been shown to inhibit EWS-FLI1. A recent trial of MIT treatment in ES patients found that hepatotoxicity precluded the administration of MIT at a dose required to inhibit EWS-FLI1 ([greater than]50nmol/L). We hypothesize that the efficacy of adjunct treatment can be enhanced if MIT is used along with standard chemotherapeutic agents such as Vincristine (VIN) and Etoposide (ETO). Combination treatment will reduce the effective dose of both Mithramycin and the standard agent thereby decreasing the therapeutic dose range and side effects. Methods: ES cells, CHLA10 and TC205 were cultured in the presence of vehicle or MIT or VIN or ETO or in combinations (MIT+VIN or MIT+ETO). After 2 days, cell viability was measured using The CellTiter-Glo® Luminescent Cell Viability Assay kit. The apoptosis induced by each of the above-mentioned treatments on the ES cells was measured by Flow cytometry using Annexin V Apoptosis Detection Kit. The expression of cleaved-Poly (ADP-ribose) polymerase (c-PARP), a marker for apoptosis was determined by Western blot analysis. Results: While all treatments showed ES cell growth inhibition, the combination treatment of MIT+ETO was more effective (significant at p Conclusion: The combination MIT+ETO caused more cell growth inhibition when compared to individual treatments in the TC205 and CHLA10 cell lines. These results demonstrate that MIT in combination with standard chemotherapeutic agents potentially increases therapeutic efficacy in ES. However, these results are limited to in vitro studies and need to be tested in an animal model to determine reproducibility and assess the toxicity.Item Influence of exogenous oxidative stress on the resilience of aged glutathione-deficient mice(2018-03-14) Sumien, Nathalie; Mock, J.; Davis, DelaneyInfluence of exogenous oxidative stress on the resilience of aged glutathione-deficient mice Delaney L. Davis, J. Thomas Mock and Nathalie Sumien Introduction With age, individuals become less resilient against stressors, rendering them more susceptible to diseases and leading to exacerbated brain impairments. Aging also involves a shift in redox state that can be associated with the key molecule, glutathione. To determine the importance of glutathione in stress resilience, we sought to study the effect of an oxidative stressor (paraquat) in an animal model of chronic glutathione deficiency. Glutathione deficiency can be achieved by the genetic knockout of the modifier subunit of the enzyme, glutamate cysteine ligase (gclm). Our hypothesis was that chronic glutathione deficiency will render mice less resilient to the oxidative stress induced by paraquat and will cause further impairments in motor and cognitive function. Methods Old (18 months) male and female gclm+/+ and gclm-/- mice received one to two intraperitoneal injections of 10 mg/kg of paraquat (PQ) or saline for one week. Four days following the last injection, animals underwent behavioral tests measuring affective, cognitive and motor function (locomotor activity, elevated zero maze, bridge walking, wire suspension, fear conditioning, rotorod, and active avoidance). After the completion of behavioral testing, brain regions, skeletal muscle, liver, heart, and kidney tissues were harvested and will be used to examine biochemical changes in oxidative damage and redox signaling. The data were analyzed using 2 or 3-way ANOVAs followed by pairwise comparisons. Results Body weights in male and female mice dropped immediately after PQ injection, with the gclm-/-treatment group having a greater decrease in percentage of body weight than the gclm+/+. PQ injections appeared to decrease overall activity of both gclm+/+ and gclm -/-. PQ-treated mice seemed to spend less time in open arms, indicating increased anxiety levels. Overall, PQ-treated mice appeared to perform better on motor skills and worse on cognitive tests. Conclusions These preliminary data suggest a trend that paraquat may have differential effects depending on the task (cognitive vs. motor), and gclm -/- mice may be more susceptible to an oxidative stressor.Item Mapping, Characterization and Description of HIV-APPE Rotations at ACPE Accredited Colleges of Pharmacy(2018-03-14) Hall, Brenton; Thomas, Drew; Suzuki, Sumihiro; Clay, Patrick; Rivera, MivielisBackground: Despite aggressive HIV testing programs and the introduction of preventative antiretroviral regimens (PrEP), the number of persons living with HIV in the United States (US) continues to increase by over 30,000 every year. As over 50% of PLWH are now over the age of 50, they represent an especially challenging population to provide care as they develop co-morbid conditions consistent with their non-PLWH counterparts of the same age, gender, race and ethnicity. In order for healthcare teams to optimally care for this population, pharmacists with focused training in this disease state are required. Accredited colleges of pharmacy, federal training programs and other large healthcare systems must first be knowledgeable of where to send trainees, yet no comprehensive database of HIV-specialized pharmacist training sites currently exists. Objective: This study's primary aims were to (1) create a map of US-based pharmacy student training sites, then describe (2) the training environment and (3) qualifications of the trainer present. Methods/Materials: A forced-choice, logic, algorithm based, Qualtrics™ survey was developed, validated, IRB-approved and deployed using a four-pronged approach. From October to November 2017, this anonymous survey was distributed through (1) professional organizations membership lists (pharmacy and medicine, HIV and non-HIV focused), (2) ACPE accredited pharmacy schools' experiential coordinators, and (3) a nationwide pharmacy chain. The 4th prong was via grassroots, snowball distribution whereby recipients forwarded it to their contacts. Results: Of 170 survey respondents, 143 consented to participate. Not all responded to each question. Results reflect proportion of question responses. Respondents reported 65% (n=94) primarily provide care for PLWH, 48% have at least 100 HIV patients served annually, and 79% (n=143) receive some form of government funding. Of the 143, 78 (59%) are APPE sites, 55 of which take over 6 students annually. Most students (93%) engaged 10 patients per week and 8 of 10 patients were PLWH. While 60 (42%) of these APPE sites report affiliation with at least 1 college of pharmacy, 18 states were not captured, including areas with high prevalence of PLWH. Conclusion: The survey successfully identified predominantly high patient volume HIV training sites, with experienced preceptors in 32 states. Serial deployment with enhanced marketing is needed to identify the regions not represented. Research Area: HIV Training Presentation Type: PosterItem A Case of Ovarian Torsion in the 3rd Trimester of Pregnancy(2018-03-14) Nguyen, Bao-Quyen; Combs, ShannaBackground Ovarian torsion is a rare occurrence during pregnancy, especially in the third trimester. It is a gynecological emergency and needs to be promptly reversed in order to preserve ovarian function. Unfortunately, ovarian torsion is difficult to diagnose due to non-specific abdominal symptoms. It is especially difficult to diagnose in pregnancy due to the enlarged uterus which leads to trouble visualizing anatomy as well as similar symptom presentation that occurs in pregnancy. Case Information An unusual case of ovarian torsion in the third trimester presented with late onset of abdominal pain and non-reassuring fetal heart tones. The ovarian torsion was unable to be clearly visualized with ultrasound and was found upon emergent Cesarean delivery that was performed due to non-reassuring fetal heart tones. The ovary was found to be necrotic and a right salpingo-oophorectomy was performed. Conclusion It is rare for ovarian torsion to occur in pregnancy and even more rare to have an effect on the fetal status as presented in this case. Upon review of the literature, this case was found to be truly unique in the rarity of occurrence of ovarian torsion late in pregnancy, as well as the effect on the fetal status. Only 2 other case reports of intra-abdominal inflammatory conditions in the third trimester were identified to have caused fetal distress, resulting in an emergent Caesarian delivery.