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Item Mechanical performance of dual and single locking plate constructs for fixation of humeral mid- diaphyseal fractures: a finite element study with Retrospective Case Series(2015-03) Luedke, ColtenPurpose: To compare the mechanical performance of four different locking plate constructs (three single and one dual plate) for mid-diaphyseal humeral fracture fixation and present our clinical case series Materials and Methods: Five humeral shaft finite element models (1 intact and 4 fixation) were loaded in torsion, compression, posterior-anterior (PA) bending, and lateral-medial (LM) bending. A comminuted fracture was simulated by a 1-cm fracture gap. Fracture fixation was consistsed of: (A) 4.5-mm 9-hole large fragment plate (wide), (B) 4.5-mm 9-hole large fragment plate (narrow), (C) 3.5- mm 9-hole small fragment plate, and (D) one 3.5-mm 9-hole small fragment plate and one 3.5-mm 7- hole small fragment plate. Outcome measures include construct stiffness, and hardware stresses. The clinical series of patients include 41 patients having undergone dual plating of humeral shaft fractures with primary outcomes of time to healing, nonunion and failures. Results: Model A showed the best outcomes in torsion and PA bending, whereas Model D outperformed the others in compression and LM bending. Stress concentrations were located near and around the unused screw holes for each of the single plate models and at the neck of the screws just below the plates for all the models studied. Of the 41 patients included in our clinical series, 26 were available at final follow up. All 26 patients showed clinical and radiographic healing. 2 complications were noted: 1 hardware failure due to infection, 1 infection at an olecranon plate. Conclusions: The results support using a dual small fragment locking plate construct as an alternative in cases where crutch weight-bearing (compression) tolerance may be important and where anatomy limits the size of the bone segment available for plate fixation. Our clinical series show the 26 patients available at final follow-up all demonstrate clinical and radiographic healing.Item The use of virtual reality and a sub-threshold vibratory noise as a tool to enhance sensory reintegration and postural control among patients with diabetic peripheral neuropathy.(2015-03) Pair, Brad; Bugnariu, NicoletaPurpose: Peripheral neuropathy frequently occurs among patients with diabetes and can result in many complications, including plantar sensory loss. Diminished sensation alters the sensory weighting mechanism, causing individuals to become increasingly reliant on visual stimuli to maintain adequate balance and postural control. The purpose of this study was to evaluate the clinical usefulness of a virtual reality- (VR) based sensory reweighting and balance training program that incorporates principles of the stochastic resonance theory in subjects with diabetic peripheral neuropathy. Methods: Seven subjects, ages 63 to 69 years old, with peripheral neuropathy due to type II diabetes have completed the study; enrollment is ongoing. This study was conducted using a V-Gait CAREN system. Subjects were fitted with vibratory devices placed around both ankles and underwent increasingly challenging postural stability activities over the course of 6 one-hour sessions. Visual dependency was reduced by manipulating the lighting conditions and applying visual distractions from the VR. Subjects received an acute application of a sub-threshold vibration throughout the duration of each session. Pre- and post- measurements of fall risk and standing balance were assessed at visits 1 and 8 using the Activity Balance Confidence (ABC), Falls Efficacy, and Clinical Test of Sensory Interaction for Balance (CTSIB). Data was analyzed using paired t-tests. Results: Post training analysis showed a significant improvement in ABC score (p=0.02) but not with Fall Efficacy score (p Conclusions: Subjects improved overall balance and sensory selection strategy as indicated by an improved ability to control both the amplitude and velocity of their sway during conditions of altered visual and somatosensory information. Preliminary results support the use of a sub-threshold background noise as an adjunct to a VR- based balance and sensory re-integration training program for individuals at risk for falls due to diabetic peripheral neuropathy.Item Anatomical observation of the dorsal scapular nerve- A series of cadaver study.(2015-03) Nguyen, Vuvi H.; Liu, Howe; Rosales, Armando; Reeves, RustinPurpose: The impingement of the dorsal scapular nerve (DSN) often leads to shoulder weakness and scapular pain radiating to the upper limb. This nerve originates from a branch of the root of C5 in the brachial plexus and typically pierces the middle scalene muscle to innervate the levator scapulae, rhomboid minor, and rhomboid major muscles. Due to its anatomical location, the DSN is difficult to dissect and thus, is not often shown to medical students in lab. The purpose of this study is to show and educate medical students on the variable anatomy of the DSN. Materials and Methods: Studies were conducted on 3 embalmed adult Caucasian cadavers in which the origin, anatomical route, and muscular innervations of the DSN were dissected and documented. Results: It was found that the DSN originated from C5 spinal nerve root in two cadavers whereas in one cadaver, the DSN branches from C4. The route of the DSN varies either by passing anteriorly to the scalene muscles or piercing through the middle scalene muscle in order to travel posteroinferiorly to its targeted muscles. The DSN innervated only the rhomboid muscles in one cadaver and in the other two cadavers, this nerve innervated the rhomboid muscles as well as the levator scapulae muscle. Conclusions: The variations of the DSN spinal contribution, route, and muscle innervations are identified in this study. Such variations will help clinicians become better aware of its anatomy in order to make the appropriate diagnosis and treatment plan to patients with pain related to DSN impingement.Item Injury Patterns and Treatment in Functional Fitness Competitions: A Case Report(2015-03) Schulte, Adam P.Introduction: High-intensity functional fitness regimes, popularized by programs such as CrossFit, have produced a large population of regularly active participants in a short span of time1. The evolution of such exercise programs into formal competitions has allowed athletes to pursue further athletic achievement, and, in some cases, earn monetary and other prizes for placing highly. The CrossFit® Games and CrossFit® Regionals events are annual sanctioned competitions organized by CrossFit, Inc. which hosts the top athletes from around the world. As the pool of competing athletes continues to grow, a greater number of local-level events hosted by individual gyms, known as affiliates, have begun to emerge. While incident reporting by medical staff is implemented at CrossFit-sanctioned events, local level event hosts inconsistently take all necessary steps to ensure sufficient medical care is available for the participating athletes, which places athletes at greater risk of harm2. This as well as proper antisepsis measures are of the utmost importance, as blood-borne exposure secondary to superficial hand abrasions, commonly referred to “hand rips”, in competition is very common. Methods: Injury report data was collected during at the 2014 Dallas All Cities Open, a one-day local event hosted by CrossFit Dallas Central at the Texas State Fairgrounds Fair Park Coliseum. Athlete information was recorded upon their presentation to the medical station, including name, gender, age, affiliate, and a brief description of their injury. Results: A total of 248 athletes representing 50 gyms and CrossFit affiliates participated, 8 of whom were unaffiliated (M=3, W=5), and placed into four divisions: Mens (M) Womens (W) Masters Men (MM) and Masters Women (MW), a Masters designation given to those age 40 or older. There were 134 M, 90 W, 13 MM, and 11 MW. A total of 43 athletes presented for injury treatment (17 M, 24 W, 2MW), and all injuries recorded were hand-related. Injury types were unilateral hand rips (HR, n=16), bilateral hand rips (HRB, n=19), simple blister (B, n=1), blood blister (BB, n=5), and combined type blister + hand rip (B+HR, n=2). Treatment predominantly consisted of triple antibiotic ointment, nonadherent dressing, and kinesiotape. Conclusion: This is the first known documented account to detail injury types, treatment, and medical coverage of local-level functional fitness competitions. With the number of these events steadily increasing, the need for medical coverage, standardized treatment and antisepsis protocols, and education of event coordinators and athletes is of central importance to ensuring participant safety and injury prevention. Beers, Emily. “Virtuosity Goes Viral”. The CrossFit Journal (30 June 2014). Hall, Landon. “Accident puts the spotlight on CrossFit's safety”. http://www.ocregister.com/articles/crossfit-602474-last-ogar.html (19 Feb 2014).Item Iodine: a Catalyst for Transient Congenital Hypothyroidism(2015-03) Wilson, Don; Dallas, John; Baby, NayanaAbstract Introduction: Iodine plays a key role in thyroid hormone metabolism. Excess iodine is an unusual cause of hypothyroidism. We report an infant with iodine induced abnormal newborn screen for congenital hypothyroidism. Case report: A Korean infant female was found to have an abnormal newborn screen for congenital hypothyroidism (CH) at 2 weeks of age. Investigation revealed markedly elevated urinary iodine. The infant’s diet consisted of breast milk alone, and her mother admitted to a diet rich in seaweed soup. It was recommended that the mother discontinue use of seaweed soup. The infant was initially treated with thyroid hormone replacement. Following withdrawal of the thyroid hormone replacement, the child remained euthyroid and developmentally normal. Discussion: Seaweed: a dietary staple of certain cultures is rich in iodine and maternal consumption of products with high iodine content while breastfeeding has been associated with congenital hypothyroidism. In the present case, the infant’s initial New Born Screen (NBS) was normal. The second newborn screen showed an elevated TSH with normal free T4. Conclusion: Iodine excess should be considered as a cause of an abnormal newborn congenital hypothyroidism screen, especially in the Asian culture.Item Skin Health on Our Team: Prevention of Pressure Ulcers in Athletic Individuals with Spinal Cord Injuries(2015-03) Garner, Becky; Spohr, Stephanie; Bhavsar, Margi; Kitzman-Ulrich, HeatherOBJECTIVE: Focus group data were collected as a means to gather participant attitudes, beliefs, feelings and opinions in regards to informing the design of a pressure ulcer prevention study. BACKGROUND: Little research has been done on pressure ulcers (PU) in healthy, active individuals with spinal cord injuries (SCI). Athletes, in particular, may be at greater risk for developing PUs due to prolonged vigorous movement. Despite this risk only 30.8% of all wheelchair athletes seek medical assistance for PUs. METHODS: Participants were recruited following collegiate sports practices to participate in a focus group that assessed attitudes, beliefs, and feelings about PU prevention and intervention delivery preferences. Classic content analysis methods were used to determine frequencies of important themes. Basic demographics, sports involvement, and previous PU history were also collected. RESULTS: Participants were male (N=8) with a mean age of 23 (SD) years; Caucasian (55%), and Hispanic/Latino (33%). All participants were actively competing in various wheelchair sports. Forty-four percent had a history of PUs but only 28% sought medical treatment. Focus group themes included: awareness, risk, prevention, and program solutions. Within PU awareness, 72% of comments concerned intrapersonal topics (e.g., beliefs, attitudes) followed by participants’ comments on past experiences (15%). Participants expressed a sense of isolation with PU occurrence resulting in frustration and a lack of ability to face the challenges coinciding with PUs. CONCLUSIONS: This group of athletes with SCI believes skin health is crucial for overall health, ability to participate in sports, and quality of life. Although PU occurrence may not necessarily be due to laziness or lack of attention, that impression seems to be general consensus of other team members and society. Future recommendations include providing athletes with direct access to a wound care specialist, while interventions should emphasize best practices in compliance, motivation, and development of protective lifestyle behaviors.Item Potential health effects from exposure to Xylene (Dimethylbenzene) in residential communities experiencing unconventional shale gas extraction and processing operations(2015-03) Igenoza, Oluwatosin P.; Akintunde, Kikelomo M.; Rich, AlisaPotential health effects from exposure to Xylene (Dimethylbenzene) in residential communities experiencing unconventional shale gas extraction and processing operations. Introduction: Xylene, a product of combustion is found in emissions from unconventional shale gas extraction and processing operations. Residential communities experiencing urban drilling may have an increased risk of exposure to Xylene from inhalation of emissions. Routes of entry into the human body are inhalation, ingestion and absorption. Xylene rapidly spreads throughout the body due to its high solubility in blood. It is highly lipophilic and may be retained in fatty tissues. It can cross the placental and blood-brain barriers (BBB). Objective: To identify potential health effects from Xylene exposure in residential communities experiencing unconventional shale gas extraction and processing. Materials and Methods: A meta-analysis of published literature was performed and articles retrieved from Pubmed (388), Scopus (353), EBSCO, Science Direct and Pneumonet (25). Keywords searched include xylene, dimethylbenzene and health effects of xylene. Abstracts were reviewed and articles pertaining to health effects retrieved in full text. No date restriction on publications was made for articles searched. Xylene was found in mixtures with other volatile organic compounds (Benzene, Toluene and Ethylbenzene), with literature referencing BTEX rather than the individual compounds. Articles that included combined effects of BTEX were excluded. Results: Ambient air monitoring studies identified high concentrations of Xylene at various distances from unconventional shale gas operations. Published literature confirmed exposure to isomers of Xylene was associated with adverse health effects. Residential communities in close proximity to natural gas emissions may experience similar health effects. Short- and long-term health effects associated with Xylene exposure included neurological, respiratory and hematological impairment. Conclusion Short- and long-term exposure to Xylene among residents in close proximity to emissions from unconventional shale gas extraction may have an increased risk of neurological, respiratory and hematological adverse health effects. Children may be at an increased risk due to their unique physiological demand and high body fat.Item The Perfect Storm: Predicting Injuries in Professional Ballet Dancers(2015-03) Gray, Melanie; Talari, Deepika; Nejtek, VickiHypothesis: Injuries in a professional or semi-professional ballet dancer are significantly associated with perfectionism and fewer rehabilitation hours as measured by the Multidimensional Perfectionism Scale (MDS). Injuries will be treated more often with osteopathic manipulative therapy (OMT) than other interventions (e.g. physical therapy, chiropractic, and other.) Method: University institutional review board approval was obtained to conduct this prospective, cross-sectional pilot study to examine the prevalence, severity, and predictors of musculoskeletal injuries. Ballet dancers between the ages of 20-60 with a past professional or semi-professional ballet performance history of 5-years or longer with a history of one or more performance injuries during their careers were recruited. MDS scores, the number of lifetime dance injuries, and whether or not OMT was utilized were analyzed. Results: Forty-eight ballet dancers (mean age + SD = 30.15 + 7.48) chose to participate in the survey. ‘ Total lifetime moderate injuries (requiring recovery time of 1-4 weeks) were significantly associated with MDS items “My parents set very high standards for me” (F=4.90, p=0.033); “If I do not do as well as other people, it means I am an inferior human being.” (F=6.61, p=0.014). Fewer rehabilitation hours were associated with more lifetime injuries (F=187.84, p=0.000). Dancers with a higher number of lifetime ‘overuse’ injuries sought OMT (mean=6.3) more often than physical therapy (mean=4.4), chiropractic (mean=4.8) or ‘other’ interventions such as acupuncture or massage (mean=3.5) [F=4.08, p = 0.05]. After controlling for pre-existing health conditions such as anxiety, arthritis, asthma, depression, osteoporosis, a trend in seeking OMT more often for overuse injuries was noted [F=3.70, p=0.06]. Conclusion: In support of our hypotheses, ballet dancers may experience more musculoskeletal injuries due to high levels of perfectionism, feelings of inferiority, and fewer hours of necessary rehabilitation. Dancers with a history of multiple overuse injuries sought OMT more than other therapies, although pre-existing illnesses may have influenced the results.Item A Direct Observational Study Evaluating Prehospital Medical Documentation of a Simulated Combat Casualty by Military Medical Providers(2015-03) Mott, Jeffrey; McGarry, Adam B.; Kotwal, Russ S.BACKGROUND: In order to reduce preventable prehospital death on the battlefield there needs to be an increase in prehospital medical documentation. The purpose of this study was to determine if there is a lack of training on utilizing Department of the Army Form 7656/Tactical Combat Casualty Care card during pre-deployment medical training at Tactical Combat Medical Care course, at the Center for Predeployment Medicine and the AMEDD Center and School. This form captures prehospital injury and intervention data from point of injury to definitive medical treatment. METHODS: A direct observational study of prehospital medical documentation was conducted on simulated Combat Casualties by Military Medical Providers, utilizing Department of the Army Form 7656/Tactical Combat Casualty Care card. Completion of one form during trauma lane training, per simulated combat casualty satisfied the inclusion criteria for qualitative results. Our hypothesis was there is no training deficit on Department of the Army Form 7656/Tactical Combat Casualty Care card at Tactical Combat Medical Care course. RESULTS: During the period studied, every other week over four months January – April 2013, 130 Department of the Army (DA) Form 7656/Tactical Combat Casualty Care (TCCC) cards were collected and evaluated from 131 simulated combat casualties. The quantity of the form completed was 99.20% with an accuracy of completed prehospital medical documentation at 80.70%. CONCLUSION: Leaders enforcing standards will be the driving force for increased prehospital medical documentation. This study demonstrates there is not a lack of training at Tactical Combat Medical Care course on completing Department of the Army Form 7656/Tactical Combat Casualty Care card. Keywords: DA Form 7656, Prehospital Medical documentation, Prehospital battlefield death.Item Differences in physical and psychological outcomes among patients who were and were not admitted to an inpatient physical rehabilitation facility 3 months after acute traumatic injury(2015-03) Christiansen, Jacob D.; Driver, Simon; Bennett, Monica; Hamilton, Rita; Warren, Ann MariePurpose: After experiencing a traumatic injury, many patients are recommended to receive inpatient physical rehabilitation to continue their recovery. Even with recommendations from the acute care therapy team to continue care at an inpatient rehabilitation facility, some patients are unable to be admitted for a variety of reasons. The objective of the current analysis was to examine differences in perceived functional and psychological outcomes between (1) individuals who were admitted to an inpatient physical rehabilitation hospital after an acute traumatic injury, and (2) patients who were recommended and but not admitted to inpatient rehabilitation. Methods: After obtaining hospital IRB approval, patients admitted to a Level I trauma center for acute injury were approached to participate in this prospective, longitudinal study. After meeting inclusion criteria, 505 patients completed informed consent and were enrolled into the study during hospitalization. Of these, 60 (8.4%) patients were identified with recommendations by the therapy team to continue care in inpatient rehabilitation; 50 patients subsequently were admitted to an inpatient rehabilitation facility and 10 were not. Eight of ten subjects that did not admit to an inpatient rehabilitation facility as recommended completed a three month follow up. Patient-perceived physical and emotional function was evaluated three months after initial injury using the Veterans RAND 12 Item Health Survey (VR12); all individuals were also screened for depression, posttraumatic stress disorder (PTSD), pain, and return to work. Wilcoxon and Fisher’s tests were conducted to identify differences between the two groups. Results: There were no differences in functional and psychological outcomes between the two groups during initial hospitalization. However, at three month follow up, a significant difference was found between groups for both emotional health and depression. No significant differences between groups were found for PTSD, pain, and physical function at three month follow up. Though not significant, patients who were admitted to an inpatient rehabilitation facility reported greater pain improvement at three month follow up when compared to patients who did not go to inpatient rehabilitation. Conclusion: Patients receiving inpatient physical rehabilitation appear to fare better emotionally and psychologically three months after initial injury. These results suggest that admission to inpatient rehabilitation is an important factor in optimizing psychological health after injury. As such, recommendations across disciplines should be strongly considered when making discharge decisions from the acute care setting. Future research to provide evidence regarding the importance of inpatient rehabilitation in later outcomes post injury should be conducted to maximize later quality of life.Item Don't Hang Up the White Coats Just Yet: A Systematic Review for Patient Preferences(2015-03) Mozejko, Lisa; Brock, Crissie; Davis, Carissa; Gentry, AshleyPurpose: The objective of this systematic review was to assess the question, “Do patients have a preference for their physicians to wear white coats?” Methods: The criteria for article selection included (1) primary research articles that (2) had patient-reported data (3) for patient preference or patient attitudes toward (4) physicians wearing white coats. Data was extracted using individual articles review forms that assessed the research level, quality, and results for each article. Evidence base rating was assigned based on the results across articles. Results: Fifteen articles met inclusion criteria for this systematic review and were divided into two categories: (1) articles that assessed patient preferences for or attitudes toward white coats in primary care (n=5) and (2) those in specialty areas (n=10). Of the 5 articles that assessed patient preferences or attitudes in primary practice, 3 indicated that patients had a preference for white coats and that white coats were related to patient confidence, comfort, trust, and expectations. Across the 10 articles that assessed patient preferences or attitudes in specialty areas, 3 articles indicated a positive patient preference for white coats. Conclusions: The evidence base across the 5 articles for patient preference for or attitudes toward white coats in primary care indicates that patients do prefer the white coat; however, the evidence base across the 10 articles in specialty areas does not. Studies addressing preferences and attitudes toward white coats in the U.S. are limited. Future research should include prospective cohort studies, various patient groups in various settings, and controls for extraneous influences that may relate to preferences or attitudes.Item Internal Iliac Artery Branching Pattern Variation(2015-03) Pombo, Matthew A.; Tran, Toan; Kirchhoff, ClaireTextbooks emphasize the number and order of arteries that arise from the anterior and posterior divisions of the internal iliac artery. However, common trunks for internal iliac artery branches occur with varying frequency, which may lead to a decrease in the confidence level of an identification in cases of unexpected branching patterns. We present a cadaveric study on variations in the branching pattern of the iliac arteries. All cadavers (N = 47: 28 females, 19 males, 94 hemipelves) were donated to the UNTHSC Willed Body Program. We report frequencies of shared trunks between branches of internal iliac and compare them with previous studies. The rate at which internal pudendal and inferior gluteal share a trunk differs statistically between studies: 31.9% of cases in our study, and 60.9% of cases reported by Braithwaite (1952) (p = 0.0001). Other branches such as the middle rectal and internal pudendal shared a trunk in 24.5% of cases; middle rectal and inferior gluteal shared a trunk in 7.4% of cases. These values are similar to the findings reported by Parsons & Keith (1897). Students are encouraged to memorize the order of arterial branching patterns, but shared trunks, as well as their varying incidence across studies, emphasize the need for students to identify arteries based on target organ rather than memorizing a branching pattern. Research supported by Department of Integrative Physiology & Anatomy.Item Can cadaver racial disparity affect medical education?(2015-03) Chen, George S.; Xiong, Yi; Nguyen, Bao X.; Fraser, Patrick R.; Reeves, Rustin E.; Chen, Shande; Rosales, Armando A.Purpose (a): The study of anatomy is a cornerstone of clinical knowledge. Human pathology is known to have different presentation across different races. In this study, we decided to elucidate the racial disparities of willed-body donors (WBDs) at UNTHSC. Methods (b): Demographic data was collected from 222 WBDs from the UNTHSC Department of Anatomy. Information such as age, race, sex, residence zip code, birthplace, education level, marital status, place of death, cause of death, military statues, and occupation were all examined. All data were compiled and analyzed using SAS 9.3 and Microsoft Excel. Results (c): Our analysis of the WBDs (n=222) demonstrated racial proportions as 96.43%, 2.23%, 1.34%, and 0.00% for Caucasian, African-American, Latino, and all other races respectively. Conclusions (d): Our findings suggest that many racial groups are essentially excluded from anatomical studies at the University of North Texas Health Science Center. We also believe that the level of education obtained may influence the decision for body donation, as our donors have higher average education levels compared to the average US population. The results of this study have important implications for medical education at a time when more minorities, as well as people with low socioeconomic status, are gaining access to our healthcare system.Item Metaphyseal Distal Tibia Fractures: Cohort Study Comparing Outcomes of Patients Treated with Minimally-Invasive Plating vs. Intramedullary Nailing(2015-03) Barcak, Eric A.; Collinge, Cory A.Purpose: The optimal treatment of non-or minimally articular distal tibia fractures has been debated in the literature. In recent years, minimally invasive plate osteosynthesis (MIPO) and intramedullary nail (IMN) fixation have been commonly used to treat this injury pattern. Both treatment modalities use biology-preserving (indirect) techniques for fracture reduction but the implants’ designs and their application are very different. There are few, limited studies that compare the clinical results and outcomes in patients with metaphyseal distal tibia fractures treated with MIPO vs. IMN. We hypothesized that there would be no difference in clinical or functional outcomes between these treatment modalities in a similar population. Methods: We evaluated all patients with metaphyseal distal fractures (=4cm from the plafond) treated with MIPO or IMN at a busy urban trauma center by a single fellowship trained orthopedic trauma surgeon from 2003 to 2013. The senior surgeon treated this type of injury almost exclusively with MIPO technique until 2009, when technique and design improvements of IMN yielded a potentially superior alternative treatment method. Since then, we have used IMN almost exclusively for this problem. This has created two distinct cohorts of patients treated for a like problem by very different surgical methods. Clinical and radiographic evaluation at a minimum of one year follow up was obtained along with visual analog (VAS) pain scales, limb specific assessments (Olerud and Molander’s ankle score, American Orthopaedic Foot and Ankle Surgeon’s [AOFAS] ankle-hindfoot instrument), and whole-person assessment with the Short Form 36 (SF-36) tool. Results: We studied 86 patients (43 MIPO and 43IMN) with distal tibia fractures within 4 cm of the plafond with minimal or no articular involvement. Thirty-eight of 43 patients in the MIPO group and 26 of 43 patients in the IMN group met inclusion criteria for the study including greater than 1 year follow up. Complications of MIPO included three nonunions, two with malunion [greater than] 5 degrees, no infections, one major wound complication, and four patients who had plates removed. Complications in the IMN group included 2 nonunions (both type 3 open fractures), one delayed union (type 3 open fracture, healed without surgical intervention at 65 weeks), 3 with malunion [greater than] 5 degrees, two deep infections, and three patients undergoing removal of distal locking screws. Pain scores were similar between MIPO and IMN groups. Average AAOS ankle scores were similar between the two groups, but the Olerud and Molander ankle scores were significantly better in the MIPO group (86.6 vs. 77, respectively; P Conclusions: Similar clinical results and functional outcomes were obtained when treating non- or minimally articular metaphyseal distal tibia fractures with MIPO or IMN except for one of two ankle scores that favored MIPO. Complications appeared to correlate with open fracture and high-energy injuries.Item Role of Physical Therapy in the Interdisciplinary Team for Safe Transitions for Elderly Persons (STEP)(2015-03) Camp, Kathlene E.; Johnson, Valerie; Bugnariu, Nicoleta; Lardner, Dana; Knebl, JaniceBackground: Managing an effective transition from hospital to home is challenging due to the medical complexity of multiple diagnoses and care needs, especially in low income seniors. Early hospital readmission has been linked with many factors, including impaired mobility and ineffective management of diseases. Physical therapy (PT) can have an impactful role on addressing safety with mobility and supporting education on disease management. Purpose: The purpose of this report is to describe the role of PT on an interdisciplinary care team, describe the PT intervention, highlight fall risk assessments and results, and identify leading environmental hazards and supports that can impact fall risk. Methods: The STEP care team was comprised of a medical director, nurse practitioner or physician assistant, social worker, physical therapist, pharmacist and registered dietician. PT performed a comprehensive evaluation, appropriate fall risk assessment, and home safety evaluation. Recommendations and assistance were provided to improve home safety, education and intervention were implemented to address specific needs to improve safety with mobility, care was coordinated with home health resources, and community resources were utilized to access additional needs not met by insurer coverage. Final assessments were made at time period of 30+ days in accordance with successful transition in medical care. Results: 126 out of 161 patients enrolled into the STEP program received PT. Patients were in the STEP program for an average of 42 days and received an average of 3 PT visits. The most prevalent home safety hazards identified were lack of grab bars (45%), lack of supportive equipment for shower/tub (42%), unsafe bathroom tub/shower surfaces (30%), narrow/cluttered pathways (33%), and cluttered/soiled living areas (30%). The most common supports were adequate lighting (39%), appropriate commode height (58%), stable/supportive seating (40%), clear/accessible walkways (44%), and secure floor coverings (38%). Home modification opportunities were greatest for adjustment of commode and seating heights (79%, & 2%), providing adequate lighting and chair dressing support (60%), securing floor coverings (50%), and installing night lights (50%). For ambulatory clients, fall risk assessments indicated 96% were at risk for falls. There was an average of 9% of hospitalizations in the first 30 days; however none were related to falls. Conclusion: Reasons for falls are multifactorial and require an interdisciplinary approach to have effective reduction in risk. PT has a significant role in this reduction by addressing both the physical impairments and the environmental factors. Interprofessional collaboration on patient performance in the home can be instrumental in avoiding falls and preventing early hospital readmissions for this high risk population.Item A STEP in the Right Direction: An Interdisciplinary Transitional Care Approach to Preventing Hospital Readmissions (2015)(2015-03) Loewen, Ashlee; Knebl, Janice; Yarabinec, Ashley; Camp, Kathlene E.; Johnson, Valerie; Stafford, Ashley; Allen, John G.; Shoukry, Emad; Wagner, Teresa; Greenlee, Quante; Turpin, ShirleyPurpose: The Affordable Care Act, calls for more focus on finding “innovative delivery systems that improve care, increase efficiency, and reduce costs” (Centers for Medicare and Medicaid Services, n.d., para. 4). The Safe Transitions for the Elderly Patients (STEP) program is a hybrid transitional care model developed to reduce readmission rates for Medicaid patients over 50 years of age in Tarrant County. Background: The STEP Program provides high quality transition of care services for discharged Medicaid elders of Tarrant County. A medical director, nurse practitioner, physician assistant, physical therapies, social workers, pharmacist, and nutritionist make up the in home care team. The foundation of the STEP Program was developed by the University of North Texas Health Science Center (UNTHSC) as part of an 1115 Waiver approved by CMS in 2012. The STEP Program is designed to improve the coordination and continuity of care for Medicaid patients 50 years of age and older transitioning from the hospital to the home setting following discharge. The primary goal of the STEP program is to identify discrepancies in transitional care and find solutions toward reducing all-cause 30-day hospital readmissions. Through the CMS 1115 waiver guidelines, we are also tracking patient BMI, smoking status, and pneumococcal vaccine status. Methods: The STEP Program will provide care transition services for 750 patients from October 1, 2013, to September 30, 2016, via referrals received from local hospital partners. STEP faculty and staff have developed evidence-based protocols and communication strategies aimed at meeting or exceeding performance metrics for reducing hospital readmission. The NextGen EMR is the primary means for gathering data for these metrics and assessing the impact of the evidence based protocols and communication strategies. Plan-Do-Study-Act methodology is used to regularly to evaluate and re-evaluate STEP Program practices to meet and exceed performance metrics, while improving overall performance. Current Results: The current 30-day readmission rate for patients enrolled in the STEP program is 9%, which is a significant improvement from the recent national readmission rate at 18.5% and Texas at 18.4% for Medicare specific beneficiaries (CMS, 2012). Conclusion: By reducing hospital readmission, the STEP Program can contribute to improving the quality of transitional care services as a sustainable practice model. This example of transitional care services can serve as a model to help reduce hospital expenditures, decrease hospital penalization for readmissions, and help provide quality outpatient management and coordinated care for this vulnerable patient population. Centers for Medicare and Medicaid Services. (n.d.). Section 1115 demonstrations. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/Section-1115-Demonstrations.html Centers for Medicare and Medicaid Services. (2012). National Medicare readmission findings: Recent data and trends. Retrieved from http://www.academyhealth.org/files/2012/sunday/brennan.pdfItem Tactical Emergency Medical Support(2015-03) Mott, Jeffrey; Callaway, DavidPurpose: The scene of a law enforcement special operation presents numerous barriers to traditional Emergency Medical Services access; thus, there is a need for medical support of law enforcement special operations to be performed by well-trained and properly equipped tactical medics who can operate effectively within the perimeter. Though military and law enforcement special operations are unique, similarities exist in the realm of tactical medical. Therefore, the purpose of this translational research project was to adopt the US military’s Tactical Combat Casualty Care guidelines, which are currently considered to be the standard of care for military prehospital medicine, to civilian tactical law enforcement. Methods: In 2005, the TCCC guidelines were adopted by US Army Special Operations for use in the Global War on Terrorism and training began at the Center for Predeployment Medicine, Fort Sam Houston, TX. When later considering adaptation of the guidelines to civilian special operation use, the Committee on Tactical Emergency Casualty Care was formed to determine the extent to which the three phases of tactical care—Care under fire (Direct threat care), Tactical field care (Indirect threat care), and Tactical Evacuation Care (Evacuation care)—needed to be modified. Results: Some specific content areas and provider competencies were amended; otherwise, each phase was determined applicable and modified in name change only. In addition, the overall structure and decision-making of the TCCC model was applicable to civilian special operation use. The austerity and danger of the operational environment require that the tactical medic be trained with a unique set of decision-making skills to be able to constantly balance the benefit of a particular intervention against the special risks inherent in performing the intervention in the environment. Modification of techniques, establishing priorities, and ongoing assessment of risk permit the tactical medic to provide the greatest good for the most people without exposing himself to unnecessary risk. Conclusion: The principles of medical care in the military tactical care environment are similar to those in the civilian tactical care environment. Although some TCCC content needed to be adapted for the civilian law enforcement, the phases of tactical care and the principles and flexibility of the system were efficiently and effectively incorporated.Item Treating the Homeless Patient: Different Attitudes Among Pre-Clinical Medical Students(2015-03) Patel, Tarang Mukeshbhai; Talari, Deepika; Nejtek, Vicki; Kaushal, DeepikaBackground: Locally, ~2,123 people are homeless. Most of these have multiple physical and mental illnesses requiring consistent medical treatment that is delivered intermittently. Inadequate medical treatment for the indigent and homeless could potentially be a function of biased healthcare professional attitudes toward the homeless patient. Our previous research examined treatment attitudes of medical students (MS1-4), residents, and physicians and showed that MS3-4 students were cynical and judgmental about the homeless condition and they resented treating the homeless patients more than any other group. Here, we examined if there were any changes in attitudes towards treating the homeless in 2nd year medical students assessed in 2013 in comparison to a different group of 2nd year medical students assessed in 2014. Hypothesis: Attitudes about treating the homeless will significantly differ between two groups of of 2nd year medical students. Methods: A cross-sectional between-group comparison of attitudes toward treating homeless patients was conducted in 2nd year medical students MS2_1 (n=66) and MS2_2 (n=72). All ages and race/ethnic groups were eligible to participate. The Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI) and the Attitudes Toward the Homeless Questionnaire (ATHQ) were used to quantify attitudes. Socio-demographic data were analyzed using frequency distributions and chi-square analyses. Group differences in HPATHI and ATHQ scores were analyzed using general linear modeling to correct for unequal group sizes. Statistical significance was determined using a 95% CI and a p-value of 0.05. Results: We found the MS2_1 group was significantly more judgmental in that they reported that ‘homelessness was self-inflicted’ (p=0.013), and that they believed that ‘alcoholism is a personal weakness’ (p=0.001). The MS2_1 thought that ‘homelessness was not related to health issues’ (p=0.038). The MS2_2 rated themselves significantly higher than the MS2-1 group as ‘going into medicine to help the needy’ and that ‘social injustice is an important healthcare issue.’ Gender and race were not influencing factors on these results. Conclusion: These results suggest that 2nd year medical students assessed in 2013 had a substantial bias towards treating homeless patients and had very poor insight on the biological basis for addiction. These data warrant a larger investigation to determine if this was just a cohort effect that has since been resolved, or if the educational requirement and coursework that the 2013 group of medical students experienced was different than that received by the 2014 students. Nevertheless, curriculum that adequately prepares students to practice real-world community medicine in special needs populations like the homeless is important, as is the need for more in-depth curriculum to teach the biological basis for addiction.Item Changes in Health Knowledge and Lifestyles After Participating in a Research Study.(2015-03) Resendes, Erica M.; Fulda, Kimberly; Habiba, NusrathBackground Clinical research plays an instrumental role in the advancement of health care by opening doors to new and improved treatments, prevention procedures, and methods of diagnoses. It is, therefore, important to tackle issues that may negatively impact the completion of a study. This includes problematic recruitment, which can result in costly economic consequences, inefficient collection of data, and even closure of a study. Research shows that the major driving force behind an individual’s decision to participate is due to the benefits received while enrolled in a study. These benefits are usually the primary aim of a study and include helping out future patients, receiving new/improved treatments and getting better care for various illnesses. The purpose of this study was to assess the participant’s self-reported benefits and/or lifestyle changes subsequent to participating in a research study. Methods A telephone survey was administered to parents/legal guardians of children who participated in two initial studies conducted at the UNT Health Science Center (UNTHSC). The survey assessed if the parents/legal guardians became more aware of their child’s health after participating and whether they made a change in the child’s lifestyle. Questions used in the initial study were re-administered in this study. In the initial study, children were sent a report characterizing the child’s lab results as normal or abnormal. Wilcoxon-Signed Rank test was used to compare means pre and post, and Fisher’s Exact Test was used to compare willingness to participate in future studies between parents of children who received normal and abnormal results. A total of 61 surveys were completed. Results Since completing the study, 55.7% of the parents/legal guardians reported a change in their child’s diet, while 70.5% reported a change in their child’s physical activity. Parents/legal guardians of children who received both normal and abnormal results were more likely to report making their child eat healthy and exercise regularly as well as describe their child as not being overweight during the follow-up data collection as compared to the original study (Abnormal p Discussion/Conclusion By highlighting such benefits, the public’s perceptions of clinical research can be broadened, encouraging more individuals to consider participating. The goal was to show that by participating in research, individuals can learn more about their own health, or more importantly, their child’s health. This knowledge can then translate to lifestyle changes beyond the scope of a study.Item Effects of Cervicothoracic Junction Manipulation on Shoulder Strength and Electromyography Amplitude in Asymptomatic Adults(2015-03) Connors, Michael; Wang-Price, Sharon S.; Nichols, Charles; Austin, Niva; Canales, Jessica; Nwosu, Onyekachukwu; Littenberg, AlanPURPOSE: Recent studies have examined the relationship between spinal mobility restriction and upper quadrant muscle function in patients with shoulder pain with limited results. Little research has been conducted to examine the effects of cervicothoracic junction manipulation (CTJ) on shoulder strength and electromyography (EMG). The primary purpose of this study was to examine the immediate and carry-over effects of CTJ manipulation on shoulder strength of shoulder abduction (ABD) and external rotation (ER), as well as EMG amplitude of the anterior deltoid (ADELT), mid-deltoid (MDELT), supraspinatus (SUPR), and infraspinatus (INFR) muscles. The secondary purpose was to determine the reliability of the strength and EMG testing protocol used in the study. METHODS: Twenty-four adults (7 men, 17 women, aged 29.8 +/- 9.8 years) were randomly assigned into two groups: manipulation group that received a sham CTJ manipulation (3 men, 9 women). A hand-held dynamometer (HHD) was used to determine shoulder strength, and EMG activity was recorded using a wired EMG unit and four tethered surface electrodes. Shoulder ABD and ER strength and EMG activity of the ADELT, MDELT, SUPR, and INFR muscles were collected simultaneously during maximal voluntary isometric contraction (MVIC) of shoulder ABD and ER. Two trials of MVIC were performed for shoulder ABD and ER, and the average of the two trials was used for statistical analysis. All participants were asked to come in two separate days. The within-day and between-day reliability of shoulder strength and EMG measurements was determined in the first two visits. The intervention was delivered during the second visit, which was within 24-48 hours of the first visit. To assess immediate and carry-over effects of CTJ manipulation (either manipulation or sham manipulation), the shoulder strength and EMG were collected before intervention, immediately post intervention, 15 minutes post intervention, and 30 minutes post intervention. To assess within-day intra-tester reliability, the shoulder strength and EMG activity were collected twice on the first visit, and again during the second visit before the intervention to determine the between-day reliability. Outcome measures consisted of shoulder abduction and ER strength in kilograms*force (kgf) and EMG root mean square (RMS) of the ADELT, MDELT, SUPR, and INFR muscles. Intra-class correlation coefficients (ICC) were used to determine intra-tester within-day and between-day reliability. Six separate 2x4 ANOVAs with repeated measures were used to analyze HHD and EMG data for between and within group comparison. Alpha level was set at 0.05 for all analyses. RESULTS: The results showed excellent within-day and between-day reliability for both HHD and EMG measurements (within-day reliability: ICC = 0.97-0.99 for HHD, ICC = 0.97-0.99 for EMG, and between-day: ICC = 0.96-0.99 for HHD, ICC = 0.94-0.96 for EMG). The ANOVA results revolted a significant group by time interaction for ER strength (p = 0.047), EMG RMS of SUPR (p = 0.041), and EMG RMS of INFR (p = 0.001), but not for shoulder ABD strength or the rest of the EMG data. Post-hoc analysis showed a significant decrease (p CONCLUSIONS: The results of this study suggest that a potential immediate inhibition carryover effect exists on shoulder EMG and HHD for shoulder ER post spinal manipulation and is possibly maintained for a period up to 30 minutes post technique.