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Item A Case of An Accessory Levator Scapulae Muscle(2020) Mong, Joy; Fisher, Cara; Wagner, LianneIntroduction: The levator scapulae is a posterior axioappendicular muscle that attaches the upper limb to the vertebral column. It originates from C1-C4 transverse processes and inserts on the margin of the superomedial angle of the scapula. This case report documents a variation of the musculature in the levator scapulae with a unilateral accessory muscle inserting into the trapezius instead of the scapula. Background: There have been some documented cases of anatomical variations of levator scapulae, however these variations were usually found to be of atypical origin or insertion. There have not been any documented cases of an accessory levator scapulae muscle belly matching the morphology noted here. The clinical implications of anatomical variants such as this one must be considered. Case Findings: During a detailed cadaver dissection of a 92 year-old female, a left unilateral accessory muscle of the levator scapulae was discovered. It originated just anterior to the bulk of the levator scapulae at the C2 level and inserted into the superior descending trapezius. This accessory levator scapulae measured 6.5 cm long and 0.5 cm wide. Conclusion: Knowledge of anatomical variants of levator scapulae is relevant to clinicians working in the fields of surgery, neurology, radiology and musculoskeletal medicine. This muscle is frequently implicated in the etiopathology of neck and shoulder pain and increased tension in levator scapulae has also been linked to increased cervicogenic headaches. Structural variations, such as this, may be a contributing factor to postural abnormalities leading to chronic myofascial pain and headaches.Item A DILATED, TORTUOUS UTERINE ARTERY: GROSS ANATOMICAL VARIANT AND CLINICAL SIGNIFICANCE(2020) Fisher, Cara; Clark, ChelseaPurpose: Dilated tortuous uterine arteries are associated with multipara, and the resultant decreased blood flow can lead to a multitude of pre- and post-partum complications. We report an anatomical variant, provide retrospective discussion on previous research, and advocate future efforts in identification specifically to aid in preeclampsia screening and prevention. Methods: A left hemisected pelvis of a 43-year-old embalmed female cadaver was dissected. It revealed a dilated tortuous ascending branch of the uterine artery. We used digital imaging measurement software (ImageJ NIH, Bethesda MD) to measure the artery. Results: The dilated tortuous segment contained a total of eighteen direction changes in a ~2cm span. Conclusions: This variant illustrates the substantial compression of uterine artery vasculature in the body to less than 1/3 of its true length, a common finding in multiparous women experiencing preeclampsia. We suggest research focusing on developing a reproducible, credible identification method for uterine artery variants in women presenting with associated symptoms in order to prevent dangerous clinical manifestations.Item A Literature Review of Velopharyngeal Insufficiency and Stress Velopharyngeal Insufficiency in Wind Players(2020) Behel, KensleyA literature review was conducted to evaluate diagnostic tools, as well as surgical and non-surgical reparative options used to diagnose and rehabilitate musicians suffering from velopharyngeal insufficiency (VPI) in musicians. Purpose: The purpose of this paper is to inform music educators and physicians of the prevalence, underlying causes, and possible manifestation of VPI in their students. Methods: Databases (PubMed and Web of Science), a scholarly search engine (Google Scholar), and journal archives (Medical Problems of Performing Artists) were searched yielding a total of 395 possible studies. After the exclusion criteria were applied (must include a minimum of one wind instrumentalist), 32 studies were selected for analysis. Results: As a result, 23 case studies from 1970 and 2018 were found to include relevant information about symptoms, diagnostic tools, and treatment options pertaining to VPI and SVPI in musicians. Conclusions: Nasal grunting, hypernasality, facial grimacing, decreased vocal intensity, fatigue, and maladaptive articulation were some of the side-effects of VPI in musicians. VPI under stress, known as SVPI, has been characterized as a potentially career-preventing or career-ending phenomenon. Medical intervention is often recommended to diagnose and treat VPI in musicians. To improve the quality of medical care for these musicians, more instrument-specific research is needed in this area.Item A Literature Review: The Role of Fenugreek in Diabetes Management(2020) Cherian, Aaron; Ramanathan, Meenakshi; Hoque, Sanjida; Villavicencio, MadeleinePurpose: This review's objective is to identify evidence regarding fenugreek's role in reducing blood glucose in patients with type 2 diabetes mellitus (T2DM) or pre-diabetes. Methods: PubMed and SCOPUS were utilized to find trials which included "fenugreek AND diabetes", "fenugreek AND glucose" and "Trigonella AND diabetes". Trials excluded were those published before 2003 and fenugreek's impact in disease states unrelated to diabetes. Results: Based on five trials describing fenugreek's effects of increased glucose uptake, increased insulin sensitivity and lowering fasting plasma glucose, fenugreek was proven to be efficacious with regards to diabetes and pre-diabetes. One trial showed fenugreek to have no statistical changes in fasting blood glucose, yet it statistically changed GIR. In addition, one study showed no statistical change in fasting blood glucose or A1c% compared with glibenclamide while another showed no change in fasting blood glucose when compared to diet and exercise. Five of the studies evaluated the safety of fenugreek and demonstrated a high safety profile and tolerability. Conclusion: Fenugreek has proven to have a role in the management of patients with diabetes or pre-diabetes via its ability to reduce insulin resistance and lower blood sugar. In order to establish the defined role in therapy, additional clinical trials with larger amounts of study subjects should be conducted. Gaining a USP approval for a fenugreek product and utilizing it in future trials would increase the validity of the results, making it more applicable to specific guidelines.Item A Non-Parametric Alternative to The Cochran-Armitage Trend Test in Genetic Case-Control Association Studies: The Two-sided Jonckheere's Test(2020) Zhou, Zhengyang; Ku, Hung-Chih; Xing, Chao; Manning, Sydney E.Purpose: In genetic association studies with case-control design, standard practice is to perform the Cochran-Armitage (CA) trend test under the assumption of additive genetic model. The CA trend test is a parametric statistical test, and under the null hypothesis of no association between the genetic variant and disease, the test statistic asymptotically follows a chi-square distribution with 1 degree-of-freedom. However, when the sample size and/or variant minor allele frequency are small, asymptotic properties may not hold, which can lead to reduced statistical power in detecting genetic associations. Methods: To improve statistical power in this case, we consider the two-sided Jonckheere's test, which is a rank-based nonparametric test. By not imposing assumptions on the distributions of the data, it is expected to have better statistical power than parametric tests for small sample sizes and/or rare variants. We conducted extensive simulations to compare the statistical power between the CA trend test and the two-sided Jonckheere's test under various scenarios. Results: We found for small sample size (e.g., n=200) and low minor allele frequency (e.g., p=0.05), the two-sided Jonckheere's test outpowered the CA trend test for all genetic models ranging from recessive to dominant. Conclusion: This finding provides an alternative to the CA trend test in genetic association studies under these circumstances. With higher statistical power from the two-sided Jonckheere's test, genetic epidemiologists will be able to detect more genetic associations for complex diseases, which may lead to better prevention and treatment strategies.Item A Presentation of a Rare Disorder: Hereditary Hemorrhagic Telangiectasia(2020) Smith, Michael; Elmore, Stephanie; Kannan, SrijaaBackground: The purpose of this case study is to describe a presentation of a rare disorder called Hereditary Hemorrhagic Telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. HHT is a rare autosomal dominant disorder that leads to malformed blood vessels in various body organs. Patients may be asymptomatic or have a wide range of clinical manifestations, thus making diagnosis of this condition difficult. Case Information: A 53-year-old Caucasian female with a history of intermittent epistaxis and multiple family members with HHT presented for a well woman visit and was found to be anemic with an H&H of 10.2 and 32.9 respectively. She was referred for a bidirectional endoscopy and was found to have multiple telangiectasias and polyps in her stomach and duodenum, some treated with argon plasma coagulation (APC). Since then, she has seen an HHT specialist biannually to rule out brain, heart, and lung involvement. She has had multiple colonoscopies and endoscopies with treatment of telangiectasias and arteriovenous malformations (AVMs) with APC since then. In 2018, she was treated for a left lower lung AVM. She requires parenteral iron therapy for her anemia every 3 months. Clinically, this patient presented with recurrent nosebleeds and anemia; however, her family history indicated a strong likelihood of HHT. Conclusion: Here I discuss the clinical features of this particular presentation of HHT as well as diagnostic criteria, management, and treatment with hopes of creating awareness in the scientific and medical community about how to diagnose and manage this rare condition.Item A Rare Case of Esophageal Stenosis in Behcet's Disease(2020) Faisal, AnnumBackground: Behcet's Disease (BD) is a multi-organ inflammatory disease characterized by aphthous oral ulcers, ocular manifestations and genital lesions. Various environmental and genetic factors contribute to the pathogenesis of BD, however the specific etiology remains unclear. Case:A 71-year-old female with a history of BD, pharyngeal ulcers, esophageal stenosis and tracheostomy presented to the emergency department with concerns of food being stuck in her throat for 4 days and inability to swallow. She has a history of dysphagia for many years, but was tolerant of thin liquids and soft foods. BD management consists of chronic steroids and previous dilation with balloon tracheoplasty. She is aphonic due to aphthous ulceration of the larynx. Fiberoptic nasal endoscopy and esophagogastroduodenoscopy were attempted with findings included a surgically absent larynx, unidentifiable upper esophageal sphincter and post-surgical scarring. These explorative studies were later aborted due to failure of scope advancement. A neck CT illustrated present trach and medially displaced carotid AA bilaterally without frank masses. Following recommendation of clinical swallow examination, contrast material passed into the pharynx and entered the upper portion of the airway; it appeared to remain in the glottis above the vocal folds. Patient attempted to swallow with minimal hyoid movement, however, a full swallow reflex was never achieved. Nutritional support with PEG tube was recommended and placed with no complications. Patient was subsequently discharged. Conclusion:This case illustrates the unique presentation of esophageal stenosis secondary to BD and warrants further investigation of the pharyngolaryngeal involvement in disease classification and progression.Item A rare case of nasal septum perforation in a breast cancer pt receiving Trastuzumab(2020) Mohanaselvan, ArvindselvanTrastuzumab is a monoclonal antibody that is used specifically in patients with metastatic breast cancer that is HER2 receptor positive, where it binds to the HER2 receptor and slows down cell multiplication. Human epidermal growth factor receptor 2 (HER2) is a tyrosine kinase receptor that facilitates signaling pathways of cell growth, division, motility and repair. ASCO, NCCN, ESMO currently recommend the administration of trastuzumab with chemotherapy for the management of HER2-positive early-stage breast cancer in adjuvant settings.In this report we present a case of spontaneous nasal perforation in a patient who received Trastuzumab but not Bevacizumab as part of her chemotherapy. Trastuzumab is the standard of care chemotherapy in patients with HER2 positive metastatic breast cancer. A literature review of nasal septum perforation as a complication of chemotherapy in breast cancer patients showed that Bevacizumab is a drug that is known to cause the said complication. Docataxel has also been shown to cause perforation in certain patients. In our patient, therapy did involve Docataxel but it was stopped 6 months before the pt developed the perforation. At the time of symptom development pt was only on Trastuzumab. This raises the question if the HER2 receptor attacking monoclonal antibody can cause mucosal breakdown leading to complications such as this. More case reports in the future might shed light on this peculiar phenomenon and help in devising methods to tackle such side effects.Item A Rare Case of Synchronous Gallbladder Metastasis Secondary to Gastric Adenocarcinoma(2020) Jackson, Terrence; Nagatomo, Kei; Osman, Houssam; Jeyarajah, Dhiresh; Cho, Edward; Lim, JosephBackground: Gallbladder metastasis is rare and usually presents in the end stage of a malignancy. When they do occur, most of the time it is secondary to melanoma. However, there have been case reports of gallbladder metastasis secondary to gastric cancer; this has been reported in Asian countries such as Japan, South Korea, and Turkey where gastric cancer rates are higher than western countries. This is the first case of gallbladder metastasis secondary to gastric cancer in the United States to ever be reported. Case Presentation: A 67-year-old female initially developed hematemesis, and further workup showed gastric cancer with initial pathology showing T3N0M0. Clinically she was asymptomatic. Patient underwent total gastrectomy with roux-en-y esophagojejunostomy and cholecystectomy. The final pathology showed T3N2M1 gastric adenocarcinoma with metastatic adenocarcinoma of the gallbladder. Conclusion: This is a very rare case adds to the limited literature on this topic. Due to lack of level one data on gallbladder metastasis in general, case reports such as this one provides a unique and valuable insight into this pathology.Item A Review of Resources and Accessibility for Alcohol Addiction in Tarrant County(2020) Ajaykumar, Sharanya; Bourgin, Sarah; Mahajan, Anisha; Sahu, Shweta; Hussain, SumeraPurpose: Alcoholism is a disorder that affects 14.4 million adults, ages 18 and older. Therefore, an understanding of alcoholism, its impact on the population, and resources available is crucial to help those suffering from this disease. This study serves as a systematic review of resources available to those suffering from alcoholism at a national, state, and local level with an emphasis on resources within Tarrant County, Texas. Methods: Online scientific archives were used to collect statistics on rates of alcoholism, associated behaviors, and options for treatment for those afflicted. Preliminary research for publicly available resources was done through Google. We chose to conduct our research in this manner to parallel the search behavior of those seeking treatment for alcoholism. We searched colloquial phrases such as "resources for alcohol addiction, Tarrant County" and "alcoholics anonymous Tarrant County" to compile our resources. Results: A plethora of resources are available to those seeking help to combat alcoholism or in need of withdrawal assistance at Tarrant County and beyond. Some of these resources include the National Association of Alcoholism and Drug Abuse Counselors, Alcoholics Anonymous, the Recovery Resource Council, MHMR Tarrant County, Mesa Springs, and Community Addiction Treatment Services. Conclusions: A number of resources are available to those suffering from alcoholism. These resources span a variety of services tailored across age, socioeconomic status, and insurance providers. However, as alcoholism becomes increasingly prevalent within society, the most significant barrier to receiving treatment is a lack of resources due to overcrowding.Item A Storm to be Reckoned With: Hemophagocytic Lymphohistiocytosis(2020) Henson, AmandaBackground: Hemophagocytic Lymphohistiocytosis (HLH) is a poorly understood disorder. There are primary (familial hemophagocytic lymphohistiocytosis) and secondary forms (reactive HLH) that are acquired from autoimmune disorders, malignancy, or infection. Although a specific diagnostic criteria exists for children, no such criteria exists for adults and that is why early recognition of clinical and lab signs is essential. Case Information: A 41 year old Vietnamese woman presented with unintentional 12 pound weight loss, odynophagia, anorexia, periumbilical pain, nausea, and dizziness. She also had a rash that spread from her axilla to her torso/extremities. Of note, she had a history of blood transfusions and travel to Vietnam. Labs revealed: pancytopenia, transaminits, elevated antinuclear antibody, Sjogren's A antibody, double stranded DNA antibody, hyperferritinemia, and hypertriglyceridemia. Bone marrow findings were insignificant. She was suspected to have HLH and treatment was promptly started with IV corticosteroids. Unfortunately, on day 5 of admission her condition acutely deteriorated and she expired. Conclusions: HLH is thought to be caused by uncontrolled macrophage and Th-1 lymphocyte activation. Excess production of cytokines such as IFN-γ, soluble IL-2 receptor, TNF-α, IL-1, IL-6, and IL-18 have been reported. This leads to a cytokine storm. Early diagnosis and treatment is very important in this disease since it carries a very high mortality rate of 50% despite appropriate treatment. Treatment consists of IV corticosteroids, IVIG, cyclosporin/anakinra/plasma exchange/etoposide, supportive care, transfusions, and blood pressure control.Item A Study of Diabetes Mellitus in Chronic Lower Back Pain Patients(2020) Powell, JakeThis study examined the association of diabetes mellitus and chronic lower back pain (CLBP) with chronic widespread pain (CWP). Differences in quality of life, disability, and opioid use between CLBP patients with and without diabetes mellitus were also measured. Methods: The study was a cross-sectional study to analyze the differences between groups using data acquired from patients within the PRECISION Pain Research Registry. Pain intensity was measured with an 11-point numerical rating scale. CWP was determined using an item from the NIH minimum data set. Quality of life was measured using 5 SPADE domains of the Patient-Reported Outcomes Measurement Information System (PROMIS-29). Disability was measured using the Roland Morris Disability Questionnaire (RMDQ). Current opioid use was assessed at the baseline encounter. Results: Of the 601 patients enrolled in the registry, 128 (21.3%) reported CLBP and comorbid diabetes. A total of 45 (35.2%) of these patients reported CWP. The mean SPADE score for CLBP patients with diabetes was 58.2 vs. 56.1 for those without diabetes (p< 0.001). Similarly, the mean RMDQ score for CLBP patients with diabetes was 16.0 vs. 13.7 for those without diabetes (p=0.003). A total of 61 (47.7%) CLBP patients with diabetes used opioids vs 159 (35.6%) CLBP patients without diabetes (OR, 1.65; 95% CI, 1.109-2.453; p=0.02). Conclusion: These results highlight the importance of diabetes as a comorbidity in patients with CLBP. Comorbid diabetes often confers CWP, and is significantly associated with poorer quality of life, greater disability, and more frequent opioid use.Item A Systematic Review of the Effectiveness Aquatic Exercises has for Individuals with Parkinson's Disease(2020) Salem, Yasser; Liu, Howe; Quiben, Myla; Holmes, Clayton; Aggarwal, SonaliPurpose: The aim of this systematic review was to examine the evidence regarding benefits of aquatic exercise for patients with Parkinson's disease. Methods: Electronic databases used were PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two individuals independently searched for relevant literature & sorted based on the inclusion criteria. Studies were included if they met the diagnosis criteria (Hoehn & Yagr scale or physician diagnosed) and aquatic exercise was the main intervention. Articles were excluded if they were not available in English. Results: Of 19 articles, there were eleven randomized controlled trials, one nonrandomized controlled trial, one case control study, five cohort studies, and one case study. Participant age ranged from 60 to 76 and overall inclusion criteria was 19-95 or older. Sample sizes ranged from 1 to 46 participants and 437 individuals were analyzed. Treatment duration was 3-4 up to 16 weeks with session frequency being 1-2 sessions up to 5 per week. Session length ranged from 35 to 60 minutes. A range of aquatic exercises and techniques were used to address multiple impairment areas. Various outcome measures were used to assess effectiveness of treatment. Conclusions: The evidence suggests an aquatic exercise program may effectively address deficits in quality of life, functional mobility, balance, posture, pain, and mood. Studies reported that aquatic activities are safe, enjoyable, & feasible interventions without adverse events or exacerbation of symptoms. Variability between studies was found with randomization, intervention parameters, population, and outcome measures for documenting changes.Item A Systemic Pharmacology Analysis of the Age-Related Eye Disease Study 2 (AREDS2) formula and its role in preventing Age-Related Macular Degeneration (AMD)(2020) Wu, Hongli; Yu, Yu; Lou, Alexander; Garcia, Luis; Tran, Myhoa; Duong, Anh; Wang, Miki; Brown, EricaPurpose: According to the major clinical trial sponsored by the National Eye Institute (NEI), oral supplementation with the Age-Related Eye Disease Study 2 (AREDS2) formulation (vitamins C and E, zinc, copper, lutein, and zeaxanthin) has been shown to delay the progression of advanced age-related macular degeneration (AMD). However, the detailed pharmacological mechanisms of AREDS2 have not been fully understood at the molecular level, other than its well-known antioxidative effects. In this study, we intend to develop a systemic approach to predict the AREDS2-associated targets and to build the drug-disease-target network. Methods: Genes of interest were identified via the NCBI database for all compounds in the AREDS2 formula. Cytoscape software was used to visually create a network of source and target nodes to analyze similarities between nodes. Cytoscape was again used to identify major pathways the AREDS2 formula targeted. Results: A total of 158 genes were identified to be targets of the AREDS2 formula. 27 out of 158 genes were a result of multiple components of the AREDS2 formula. The main pathways these genes affect were identified and mapped out to include adipogenesis, angiogenesis, apoptosis cascade, DNA damage response, fluid shear stress and atherosclerosis, glutathione metabolism, HIF1 signaling pathway, innate immune pathway, lipoprotein metabolism, Nrf2 pathway and oxidative stress pathway. The top 5 target genes were GSTP1, Nrf2, VEGFA, HIF1A, and CXCL8. Conclusion: The systemic pharmacology-based approach provides beneficial information for elucidating the potential mechanisms of action of the AREDS2 formula in treating AMD.Item A Systems Thinking Approach to the Prevention of Preterm Births(2020) Mupambo, TashingaBackground: Preterm birth is one of the leading causes of infant mortality in the United States every year. In 2017, 10.6% of Texas live births were preterm. The occurrence of preterm births is disproportionately higher in black women than other races. Looking at this issue from systems perspective will give us broader understanding how the behavioral, socio-economic and environmental risk factors interact and how organizations across different fields can work together to prevent or treat preterm births. Objective: The goal of this project was to identify organizations involved directly or indirectly in efforts to reduce preterm birth rates and to use the systems thinking approach to understand the role that each one plays and how they are connected using a concept map. Methods: The organizations were classified based on the stage of care they provide (preconception, prenatal or postpartum) and their level of reach (city-, county-, state-, or national-level). Information was collected from the organizations' websites and related web-based sources. Results: Selected organizations include Women with IMPACT, which provides preconception and inter-conception education and care; Live Tobacco Free, which offers smoking cessation programs and Great Expectation Doulas, which offers doula services. Conclusions: This perspective showed how women interact with these organizations and the potential for these organizations to form relationships which each other in order to make it easier for the women to be well-connected to necessary resources.Item A Unique Presentation of Intersection Syndrome(2020) Harris, PaytonIntersection syndrome is an underdiagnosed condition that many primary care and sports medicine physicians often miss. The reason for this may be due to its relative obscurity outside of the field of orthopedics, difficult to interpret presenting symptoms, or lack of access to proper diagnostic imaging. The goal of this case report is to educate physicians of the etiology, symptoms, and presentation of intersection syndrome in hopes that the effects this potentially debilitating condition can be minimized.Item Aberrant Extensor Digitorum Tendon Lies Superficial to Extensor Retinaculum(2020) Son, Benjamin; Paez-Espinoza, Monserrat; Brevell, Bailey; Fisher, Cara; Evans, ZacharyBACKGROUND: The extensor digitorum muscle (EDM) is located on the posterior aspect of the forearm. The tendons of this muscle typically run deep to the extensor retinaculum (ER) and a fibrous sheath that, not only stabilizes and aligns the extensor tendons but prevents them from bowstringing with extension of the wrist. The ER has been used in the past as a graft source to treat Boxer's knuckle, an injury of the metacarpophalangeal (MP) joint capsule. This indicates the minor role the ER plays in physiologic function. EDM is innervated by the posterior interosseous nerve, a branch of the radial nerve, and is used in extending digits 2 through 5. CASE INFORMATION: This case report documents an anatomical variant that was found during routine dissection of a 66-year-old male cadaver's EDM. The most medial tendon of the EDM, attached distally to digit 5, was discovered to be passing superficial to the ER. CONCLUSION: To our knowledge, this anatomic variation has yet to be documented. The donor's medical history reports no motor dysfunction to the phalanges; thus it is suspected that this variation likely resulted in little to no complications for the donor. The lack of previous documentation on this variant, both in scientific literature and the donor's personal medical history, leads us to suspect that the variant is either uncommon or not of mechanical significance. We have theorized that this anatomical variance would present itself in a similar manner as the palmaris longus tendon.Item Absolute Quantification of Mitochondrial DNA in Peripheral Blood from Women with Preeclampsia(2020) Silzer, Talisa; Phillips, Nicole; Goulopoulou, Styliani; Reid, Danielle; Sun, Jie; Scroggins, Sabrina; Santillan, Mark; Santillan, Donna; Cushen, SpencerIntroduction Mitochondrial DNA (mtDNA) in maternal blood has been proposed as a potential predictor of preeclampsia (PE). The objective of this study was to use an absolute PCR (abPCR) quantification protocol to determine concentrations of mtDNA in maternal plasma and peripheral blood mononuclear cells (PBMC) from normal and PE pregnancies. Methods Blood samples were collected from pregnant women with uncomplicated pregnancies and pregnancies with PE (University of Iowa IRB#200910784). abPCR quantification of mtDNA and nDNA was performed on DNA extracts from plasma (in the presence or absence of lysis buffer) and PBMCs using TaqMan(TM) probes and chemistry. Results When plasma DNA was extracted using lysis buffer, mtDNA concentrations were lower in women with PE than in controls (Control: 4.83 ± 1.09 vs. PE: 1.72 ± 0.38 pg/uL, n=19, P=0.017), while concentrations of nDNA did not differ (P=0.39). Without lysis buffer, plasma mtDNA remained lower in women with PE compared to controls (Control: 0.0106 ± 0.0019 vs PE: 0.0019 ± 0.0003 pg/uL, n=16-20, P< 0.0001). There were no group differences in PBMC mtDNA (P=0.66) and nDNA (P=0.13) concentrations. Conclusion mtDNA concentrations were lower in plasma of pregnant women with PE compared to controls. A significant amount of mtDNA was membrane bound as indicated by a 480-fold greater concentration in DNA isolated from plasma with lysis buffer vs. without. Use of this improved method of quantification of mtDNA in multiple blood fractions may allow for its development as a biomarker to detect PE prior to the onset of organ damage.Item Acute Acalculous Cholecystitis caused by the Epstein-Barr Virus in a Young Woman(2020) Siadati, Mohammad; Mandal, PrasunBackground: The Epstein-Barr Virus (EBV) is a common virus that causes infectious mononucleosis, which typically includes symptoms such as fever, pharyngitis, lymphadenopathy, hepatosplenomegaly, and elevated liver enzymes. However, acalculous cholecystitis has been reported as a rare complication of EBV. Acute acalculous cholecystitis only accounts for 10% of all acute cholecystitis cases. Case information: Here, we report a case of acalculous cholecystitis caused by EBV, which was treated successfully by medical treatment without surgery. An 18-year-old woman presented to the office for a four-day history of abdominal pain, nausea, vomiting, and dark urine. Physical exam showed scleral icterus and tenderness in the epigastric and right upper quadrant abdominal regions. Lab results indicated elevated LFTs, alkaline phosphatase, reactive lymphocytes, and hyperbilirubinemia. An ultrasound showed gallbladder wall thickening with no gallstones. Next, she was admitted and underwent an abdominopelvic CT, MRCP, viral hepatitis serology testing, and gastroenterology consultation. CT and MRCP showed hepatomegaly, splenomegaly, and gallbladder wall edema. Serology showed a positive EBV IgM. At this point, we diagnosed her with an acute EBV infection, causing acute acalculous cholecystitis. Subsequently, she improved with supportive care and was discharged home. Conclusion: Though acalculous cholecystitis rarely accompanies EBV, clinicians should be aware of this complication to avoid an unnecessary cholecystectomy.Item Acute Coronary Syndrome with Chief Complaint of Arm Pain: An Atypical Case Presentation(2020) Huber, Trevor; Puia, JustinIntroduction: Typically, Acute Coronary Syndrome (ACS) present with "pressure like, squeezing" substernal chest pain, with possible radiation to left jaw, arm, neck, and upper back. Additionally, autonomic symptoms, like diaphoresis, nausea and vomiting are also common. In the following ACS case, symptoms include localized left arm pain, mild muscle ache on the left chest, and mild dizziness without the typical symptoms of pressure-like chest pain, nausea, vomiting, or diaphoresis. Presentation: A 49-year-old male with history of 4 pack-years of tobacco smoke use presented to urgent care with left arm pain. He thought the pain to be related to history of left arm fracture as a child. This episode of left arm pain lasted 4 hours and did not improve with acetaminophen. He also reported a "muscle ache" over the left chest, and slight lightheadedness. He denied sub-sternal pressure, shortness of breath, nausea, vomiting, or diaphoresis. Initial EKG at urgent care showed lateral T-wave changes and point of care (POC) troponin test was 0.13 ng/ml. POC Troponin-I at hospital ED was 0.76 ng/ml. Cardiac catheterization revealed occlusion of 3 coronary arteries and 3 drug-eluting stents were subsequently placed. Conclusion: Patients with atypical presentation of ACS that are not initially diagnosed with ACS have greater morbidity and mortality. Keep atypical symptoms of ACS in mind when evaluating patients. High sensitivity POC Troponin I could reduce diagnostic time with potential for major benefits for patients and emergency departments.