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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 Age and sex differences in childhood and adulthood obesity association with phthalates: Analyses of NHANES 2011–2014(2018-03-14) Moore, Jonathan; Huang, Yuhan; Aryal, Subhash; Uche, Uloma I.Purpose: To examine the relationship between urinary phthalates and obesity in children/adolescents and in adults using data from NHANES 2011-2014. Methods: Using the National Health and Nutrition Examination Surveys (NHANES) 2011-2014, data files on ten urinary phthalates and obesity in children/adolescents (aged 6-19 years old) and in adults (20 years and older) were retrieved. Urinary phthalates were grouped as low molecular weight (LMW) phthalates, High Molecular Weight (HMW) phthalates, Di-2-ethylhexyl phthalates (DEHP) and categorized using weighted quartiles. Children/adolescents were classified as underweight/normal, overweight and obese using the BMI z-score. Adults were classified similarly using BMI measures of29.9, respectively. A multinomial logistic regression was conducted to determine the association of urinary phthalates and obesity while controlling for covariates. Participants with missing covariates, pregnant women and breastfeeding women were excluded. Results: Using multinomial logistic regression, the 3rd quartile for LMW and the 4th quartile for DEHP had statistically significant associations with being overweight in children/adolescents. The 3rd quartile for LMW was associated with being overweight in female children/adolescents and the 4th quartile for DEHP was associated with being overweight in male children/adolescents. The 4th quartile of individual phthalate MECPP was found to result in increased odds of being overweight in the female group and in children overall. The highest quartile for MEHHP was also significantly associated with obesity for children overall and for males. There were no statistically significant associations between urinary LMW, HMW and DEHP concentrations and obesity in adults, even when stratified by gender. Analyses of the individual phthalate components of LMW indicated an association between the 4th quartile of MnBP and overweight among female adults. No association was found in other individual phthalates and prevalence of obesity in adults. Conclusion: Urinary concentrations of LMW and DEHP are associated with increased rates of overweight in children/adolescents and there is a sex difference in this association. There is no apparent association between urinary phthalates and obesity in adults.Item An 11-Year-Old Female with Short Stature, Developmental Delay, and Bilateral Cataracts(2018-03-14) Swanson, Larry; Hamby, Tyler; Hamilton, Luke; Wilson, Don; Tran, MartinPseudohypoparathyroidism (PHP) is a rare, autosomal dominant disorder characterized by an end-organ insensitivity to parathyroid hormone (PTH). 1,2,3 Children with PHP typically present with symptoms of hypocalcemia, such as tetany and seizures. The most common form of PHP is 1A, caused by a loss of function mutation in the GNAS gene, which primarily affects PTH and possibly other hormones that share the same signal transduction. 3,4 In addition to symptoms of hypocalcemia and hormonal resistance, patients with PHP1A present with one or more features of Albright hereditary osteodystrophy (AHO), including short stature, subcutaneous ossifications, obesity, rounded face, mental deficit, and brachydactyly of either the 4th or 5th phalanges of the hands, feet, or both. We report a child who presented with features of PHP1A, discuss the diagnosis, and current recommendation of this rare condition.Item Analysis of the UNTHSC Teen Clinic(2018-03-14) Bui, Priya; Moses, MichelleBackground: The UNTHSC Teen Clinic was established in June 2015 by Dr. Priya Bui as a result of her experiences working with teens in the UNTHSC pediatric clinic. The clinic is run ½ day per week by Dr. Bui and PA Lauren Dobbs. Typical visits include taking a thorough history and physical, screening for psychiatric problems, running special labs (for STIs, lipids, etc.) when indicated, and conducting an in-depth confidential interview to explore the teen’s environment and any risky or dangerous behavior or thoughts. The aim of this project is to analyze the first year of teen clinic so as to show others who may be interested in starting a clinic of this kind what exactly it may entail. Specifically, the research objectives were to create a raw database of information from the first year of UNTHSC’s Teen Clinic (stripped of identifiers); discover the population served; and analyze the depression and risky sexual behavior populations and the interventions used for them. Methods: Retrospective data collection and analysis. Created a raw database of all cases seen in teen clinic from 06/04/15 to 06/24/16. Collected and placed the following coded information into a protected Excel file: Age, Sex/gender, Referral Source, Chief Complaint (CC), History of Present Illness (HPI), Assessment, Medical Intervention, Psychiatric Intervention, Outcomes, Provider, and any Miscellaneous Information. Total of 196 encounters and 116 patients were included in the present study with no exclusion criteria. Analyzed chief complaint (CC), history of present illness (HPI), and assessment. Separately analyzed CC, HPI, assessments, and interventions of the Depression/Adjustment Disorder and Hypersexual Behavior populations. Preliminary Results: The top four CC, HPI, and assessments seen were determined. CC: Well child check (80), follow up (44), establish teen clinic (27), and depression (17); HPI: depressive symptoms (56), family instability (45), acute symptoms (31), well child check (29); Assessment: well child check within normal limits (72), depression (49), asthma/allergies (22), obesity (21). Populations with depression/adjustment disorder and hypersexual behavior were analyzed. In the small hypersexual group, there was successful intervention in 44% of females seen (i.e. Nexplanon placement). We found that in the depressive group 54.8% followed up. Conclusions: In its first year alone, Teen Clinic addressed a variety of unique issues not often explored in a typical pediatrician’s visit- most importantly (indicated by the frequency seen) symptoms of depression and adjustment disorder. Additionally, many teens were recommended for follow up, and many actually came back, successfully establishing a medical home. There are many possibilities for future studies, including, but not limited to: correlational analysis between family issues and risk taking behavior; analysis of patient compliance (by tracking follow up visits); analysis of outcomes from various interventions; and continuing the analysis of interventions in the hypersexual and depressed groups.Item Are Activity Limitations Related to Mental Health in Veterans Aged 25 and Older?(2018-03-14) McElroy, Juliana; Hartos, Jessica; Knickerbocker, JenniferPurpose: Many veterans face difficulties such as physical limitations and mental health disorders, but little is known about how these are related within the veteran population. This study will examine the association between activity limitations and mental health in veterans aged 25 and older. Methods: This cross-sectional analysis used 2015 BRFSS data for veterans aged 25 and older from Oklahoma, Virginia, and Washington. Multiple logistic regression analysis was used to assess the relationship between mental health and activity limitations after controlling for psychosocial and demographic variables. Results: About one-fourth of veterans aged 25 and older reported having less than 30 days of good mental health in the past month (19-23%), and similar amounts reported having serious difficulty walking or climbing stairs (17-28%). After controlling for lifestyle and demographic factors, mental health was inversely related to activity limitations and to chronic health conditions in all three states with moderate to high effect sizes. Conclusion: These findings indicate there is a significant relationship between activity limitations, chronic health conditions, and mental health among veterans 25 years and older. Limitations of this study include the low prevalence of female veterans which made it difficult to assess gender differences. Due to the significant relationship, it is recommended that primary care practitioners screen for activity limitations, chronic health conditions, and poor mental health if a veteran presents with any of these, and then educate and provide referral services as necessary.Item Bleeding diathesis in a patient with a novel mutation in SERPINF2: A case study of alpha-2 antiplasmin deficiency(2018-03-14) Drummond-Borg, Margaret; Adcock, Dorothy; Dunlap, Elissa; Torres, MarcelaBackground: Alpha-2 antiplasmin is a serine protease inhibitor that inactivates plasmin and prevents premature breakdown of fibrin clots. Deficiency of this enzyme can lead to spontaneous bleeding and hemophilia-like symptoms, despite normal coagulation and platelet function studies. We present a case of congenital alpha-2 antiplasmin deficiency to emphasize the importance of recognizing a patient with bleeding symptoms despite normal coagulation assays and to report a novel SERPINF2 gene mutation as a cause of this disorder. Case Information: A 7-month-old patient presented with a hemarthrosis of the right knee that was assumed to be septic arthritis, despite negative cultures of the bloody synovial fluid. She experienced significant bruising and spontaneous hematomas, necessitating a hematologic consultation. Complete blood count (CBC), Von Willebrand Factor (VWF) activity and antigen, prothrombin time (PT), partial thromboplastin time (PTT), thrombin time, platelet function analysis, and fibrinogen levels were all normal. At 3 years of age, she had a second suspected hemarthrosis of the right knee, prompting the following tests: plasminogen activator inhibitor-1 levels, euglobulin lysis time, factor XIII activity and platelet aggregation studies. All tests showed normal results. In addition, she had two episodes of hemorrhage after a tooth extraction, both instances required red blood cell and fresh frozen plasma transfusions. Whole exome sequencing revealed a novel homozygous mutation in the SERPINF2 gene. Alpha-2 antiplasmin activity was then measured atA), has not been previously reported in patients with alpha-2 antiplasmin deficiency. Family history was positive for consanguinity. These findings suggest that this mutation has likely been present in several generations of this patient’s family and follows the pattern of an autosomal recessive disorder. Conclusions: This case highlights the difficulties in diagnosing bleeding disorders that involve the fibrinolytic pathway. The previously unreported pathogenic mutation of the SERPINF2 gene may provide valuable insight into the molecular mechanisms of alpha-2 antiplasmin deficiency.Item Congenital and Hematologic Abnormalities in an Infant with a Novel GATA1 Mutation: A Case Study(2018-03-14) McCavit, Timothy; Bowman, W. Paul; Hamby, Tyler; Hunter, AbigailBackground: The GATA genes encode a family of transcription factors that are important for the development and differentiation of different cell lines. GATA1 is required for the development of cells of myeloid lineage and has been implicated in many diseases including transient myeloproliferative disorder, acute megakaryoblastic leukemia, and Diamond Blackfan anemia. This case study explores the clinical presentation of a novel GATA1 mutation. Case Presentation: A Caucasian male was born at 36 weeks gestation with a prenatal history significant for pericardial effusion, restrictive patent ductus arteriosus and polyhydramnios. Due to these anomalies, amniocentesis was performed which revealed normal chromosomes. At birth, he presented with decreased tone and respiratory distress so he was placed on continuous positive airway pressure and was transferred to Cook Children’s Medical Center. On physical exam, he had micropenis, hypospadias, bilateral clubfoot and blueberry muffin spots on the abdomen. Persistent leukocytosis, anemia and thrombocytopenia during the first month of life prompted consideration of a primary hematologic condition. A bone marrow exam was performed which showed a small increase in blasts, a significant decrease in erythroid precursors and few megakaryocytes. Subsequently whole exome sequencing (sent during the birth hospitalization) found the patient to be hemizygous for variant p.R307C in exon 6 of the GATA1 gene – a previously unreported mutation. The patient has been free from transfusions since 3 months of age although mild hemolytic anemia and leukocytosis have persisted. Currently he is being monitored for changes in blood counts and developmental milestones. Conclusion: The patient’s congenital anomalies and hematologic abnormalities have not been explained by another cause. His bone marrow has been sent to a research lab in Boston for functional analysis of the mutation. Additionally, the missense mutation discovered in sequencing has not been reported in the medical literature, but a mutation of the same exon of GATA1 has been previously described. The phenotype similarities between these two patients suggest that the congenital and blood anomalies are related to the missense mutation in exon 6 of the GATA1 gene. It is unclear why the mutation seems to affect mature red blood cells but not erythropoiesis. Work is ongoing to identify which targets are being modified by this mutation and how those changes impact phenotype.Item Contamination Rates in Urine Collection at Cook Children’s Pediatric Urgent Care Centers(2018-03-14) Fulton, Audra; Hamby, Tyler; Akkad, Rana; Coplin, Bradley; Martin, Parul; Henson, RobinBackground: Over $180 million in health care costs are spent annually on pediatric urinary tract infections (UTIs). Pediatric UTI symptoms are often non-specific causing physicians to rely on the results of a urine dip stick to assess appropriate follow up and treatment. Improper urine collections can result in bacterial contaminations and can mask true urinary tract infections. This would lead to inaccurate diagnosis, unnecessary treatment, and/or obtaining additional specimens, all adding to the burden of increased costs and patient/parental anxiety. Hypothesis: Cook Children’s Urgent Care Clinics (UCCs) have significant contamination rates from patients who gave mid-stream urine. Methods: Data collection consisted of a six-week retrospective chart review on patients with suspected UTI at each UCC location. Included in this study were patients five years and older and able to collect a mid-stream urine. Data was placed into Red Cap database. Contamination was defined as culture results= 12 yrs) on the assumption that adult supervision was needed in the former group. Contamination rates were then calculated for age, gender, and UCC location. Results: Of the 258 charts reviewed, 202 met the criteria for this study. The sample size was significantly smaller for males (13%) than females (87%). Total contamination rate was 30% (p=). Based on age, contamination rates showed 54% for 5-11 yrs and 46% for 12 yrs and older (p=0.0069). Females were more likely than males to have contamination, 33% vs 11.5%, respectively (p=0.026). There was no significant relationship between UCC location and contamination (p=0.52). Small, moderate, and large amounts of leukocyte esterase were associated with infection (p= 0.0006), however, trace results were not. Conclusions: The results from this preliminary study reinforce significant urine collection contamination rates. Chart reviews will be completed to provide a more robust sample size, but steps need to be taken to determine what is causing this high rate. To elucidate these variable(s), surveys (patient/family and provider) will be obtained to assess collection methods: how the urine is collected (parent/patient perspective), how it is thought to be collected in the clinic (provider perspective), and financial burdens to the family and institution (administrative perspective).Item Deconstructing Dogma: Non-Operative Management of Small Bowel Obstruction in the Virgin Abdomen(2018-03-14) Duane, Therese; Ray-Zack, Mohamed; Campbell-Furtick, Mackenzie; Moore, Billy; Haddad, Nadeem; Zielinski, Martin; Yeh, Daniel; Collom, MorganPurpose: Management of small bowel obstruction (SBO) has become more conservative, especially in those patients with previous abdominal surgery (PAS). However, surgical dogma continues to recommend operative exploration for SBO with no PAS. With the increased use of CT imaging resulting in more SBO diagnoses, it is important to reevaluate the role of mandatory operative exploration. Gastrografin administration decreases the need for operative exploration and may be an option for SBO without PAS. We hypothesized that the use of GG for SBO without PAS will be equally effective in reducing the operative exploration rate compared to that for SBO with PAS. Methods: A post-hoc analysis of prospectively collected data was conducted for patients with SBO from February 2015 through December 2016. Patients Results: Overall, 601 patients with SBO were included in the study, 500 with PAS and 101 patients without PAS. The two groups were similar except for age, gender, prior abdominal surgery including colon surgery, prior SBO admission and history of cancer. Multivariate analysis showed that PAS (OR = 0.47, p=0.03) and the use of GG (OR = 0.11, p Conclusion: Patients with and without PAS who received GG had lower rates of operative exploration for SBO compared to those that did not receive GG. Patients with a diagnosis of SBO without PAS should be considered for the non-operative management approach using GG.Item Effect of Nicotine Consumption in Auto-Brewery Syndrome(2018-03-14) DeMoss, Dustin; Khan, Samir; Hogan, Sean; AlFarra, TariqPurpose: Auto-Brewery Syndrome (ABS) is a rare condition defined by a proliferation of yeast species in the gut, where they enter the bloodstream. Patients typically show signs of intoxication upon carbohydrate ingestion as a result of yeast fermentation. A literature review reveals several cases of patients with diagnosed ABS who were admitted to the hospital for psychosis and agitation. In addition to ABS, patients often present with several comorbidities, including Chronic Traumatic Encephalopathy (CTE) and a history of e-cigarette or tobacco consumption. Given the temporal relationship between nicotine consumption and the onset of psychotic episodes in these patients, there may be a link between nicotine consumption and worsening psychosis in patients with CTE and ABS. Question/hypothesis: Could nicotine consumption exacerbate Auto-Brewery Syndrome to induce psychotic episodes in the setting of Chronic Traumatic Encephalopathy? Methods: An English literature review of case reports involving patients who are smokers with concurrent ABS and CTE and an English literature review on the effects of nicotine in the body Results: The literature suggests a connection between nicotine consumption and increased catecholamine levels, which can increase glucose production and blood glucose levels. The proposed mechanism involves activation of the nicotinic acetylcholine receptors in the adrenal medulla, which increase the production and release of catecholamines, namely epinephrine. Epinephrine then binds B2 receptors on the liver and skeletal muscles, upregulating glucose production and release. The glucose may then be fermented by yeast in the bloodstream, resulting in alcohol toxicity and/or psychotic episodes. Conclusion: Our review shows that patients experienced an increase in psychotic episodes while staying at a psychiatric hospital where they were provided with cigarettes and produced elevated BAC measurements during these events. The mechanism by which nicotine increases glucose production in the body led us to believe that these patients were experiencing ABS exacerbations secondary to nicotine consumption, inducing psychotic events in the CTE setting.Item Factors Influencing Patient Willingness to Participate in an Outpatient Pharmacy Transition of Care Program(2018-03-14) Cohen, Lawrence; Palmer, Tony; Weinland, Jessie; Poe, DonovanPurpose: The purpose of this study is to identify any inpatient hospital controllable factors that influence a patient's willingness to participate in an outpatient transition of care program. Methods: A qualitative debrief analysis was conducted to identify strengths and weaknesses of recruitment efforts after the conclusion of a study into a transition of care program. All recruitment personnel involved this study conducted at Medical City Fort Worth were asked to complete a survey battery. It consisted of ten questions designed to elucidate a full picture of the challenges and successes the recruiters encountered during patient interaction experiences. Researchers then read the responses three times. During the first reading the researchers took no notes. On the second reading researchers marked instances of prevailing ideas. On the third reading researchers transferred the most prevalent ideas to separate notes. Researchers then compared all noted ideas identified by the group. From those ideas, three themes pertinent to the profession of pharmacy emerged. Results: The first theme was timeliness. Recruiters unanimously reported requiring multiple visits to obtain patient consent for study participation. Multiple recruiters reported that newly admitted patients were more likely to be overwhelmed by their circumstances while patients who had been scheduled for discharge were willing to discuss medication related programs and services. The second theme was concern about changing pharmacies. More than eighty percent of recruiters reported encountering patient objections related to changing their existing pharmacy provider. One prevailing idea included in this theme is that the community pharmacist is seen as a trusted health-care provider. Recruiters reported that once patients understood that a program pharmacist was going to take personal responsibility for managing their medications that they became more willing to participate. The third theme was ensuring caregiver or family involvement in the decision-making process. Recruiters unanimously reported the need for the patient's social support network to be included in the discussion and decision regarding outpatient health-care. Conclusions: When designing voluntary outpatient medication management programs three themes should be considered to ensure patient involvement: 1. Reduce redundant and non-productive patient encounters by discussing programs closer to discharge or as part of the discharge medication counseling, 2. Be prepared to address concerns over changing, and pharmacies by describing the personal role the pharmacist will be playing in the patient's care. 3. Lastly, ensure that the patient's primary caregiver or social support person in present to discuss changes to outpatient medical care.Item Health Status, Healthy Lifestyle Practices, and Attitudes toward Lifestyle Counseling among Medical Students at the Osteopathic Medical School and Allopathic Medical School in DFW: A Cross-Sectional Analysis(2018-03-14) Lee, Jenny; Mason, David; Seals, Ryan; Jetpuri, Zaiba; Bridges, Katie; Crenshaw, AubreyPurpose: By 2020, the World Health Organization predicts that 63% of all worldwide diseases and deaths will be associated with poor lifestyle choices which individuals, families, or groups make every day. It is imperative that health care providers adopt and demonstrate evidence-based and patient-centered competent approaches to improving patients’ lifestyle habits for health promotion, disease prevention, and therapeutic effects. Since medical students are the future of medicine, it is important to investigate their health status, health habits practice, and readiness to engage in lifestyle counseling. Further, it is interesting to investigate if any difference exists between osteopathic and allopathic medical students. Methods: A survey is the key instrument in this cross-sectional study to assess the health status, health habits practice, and attitudes towards engagement in lifestyle counseling among medical students. The survey contains questionnaires, which are in the multiple choice and closed-ended formats. The survey will be sent out via email separately to each TCOM class and each UT Southwestern (UTSW) class. The survey being sent out to TCOM is through Qualtrics and the survey for UTSW is through REDCap. Data: Data is in the process of being collected through Qualtrics for TCOM and REDCap for UTSW. All data at UTSW will be sent to the researcher at TCOM and analyzed. The analysis will be conducted using Statistical Analysis System version 9.4. Hypotheses: The primary hypothesis is that there will be a relationship between health status, health lifestyle practice, and attitude to engage in lifestyle counseling and years spent in medical education. The secondary hypothesis is that there will be a difference in health status, healthy lifestyle practice, and attitude to engage in lifestyle counseling among medical students in different levels of medical education. The tertiary hypothesis is that there will be a difference in health status, healthy lifestyle practice, and attitude to engage in lifestyle counseling among osteopathic medical students and allopathic medical students.Item How bamboo has shaped the anatomy and physiology of Hapalemur(2018-03-14) Muchlinski, Magdalena; Hemingway, HoldenPurpose Hapalemur spps. and Prolemur simus (bamboo lemurs) stand out among the relatively homogeneous lemurids because they are bamboo feeders and vertical clingers and leapers. This unique diet presents equally unique challenges, like its verticality, toughness, and toxicity. The bamboo lemurs share the generalized anatomy of the other lemurids, but also display some well-documented adaptations in their limb proportions to overcome the problems presented by bamboo. Soft tissue adaptations, however, remain largely unexplored. Here we begin to explore possible soft tissue adaptations in Hapalemur griseus. Based on the available anatomical and physiological data obtained from other Hapalemur and Prolemur species, we predict that H. griseus will have differences in hindlimb morphology when compared to other lemurids. We further predict that H. griseus will have more hindlimb muscle mass and will amplify muscle mass differences with increased type II muscle fibers. Methods We compared regional muscle mass, relative to total muscle mass, in mainland African, Malagasy, and Asian prosimians and a tree shrew (n = 11). Raw regional muscle mass values (e.g., hindlimb and sural) were divided by total muscle mass for a particular species to compare relative muscle mass. We then used immunohistochemistry to evaluate the fiber profile (the relative amount of type I/type II fibers) of muscles of significance, based on the results of the comparison of muscle masses. Results Relative hindlimb muscle mass in H. griseus is no different than other lemurids (p = 0.26). However, relative sural muscle mass is significantly heavier (p H. griseus than other lemurids. When the fiber profiles of primary foot plantar flexors were evaluated, the soleus muscle of H. griseus displayed a higher amount of type II (fast) fibers than any other species. Conclusions These findings indicate that although H. griseus shares some generalized lemurid morphology, its diet of bamboo has pushed this generalized lemurid to an anatomical extreme. We suspect that based on the diameter of the bamboo stalk and the bamboo lemurs body size, bamboo lemurs may be leaping in a unique fashion that does not easily fit with small-bodied “foot-powered” leapers or large-bodied “hip-powered” leapers. Although the results are preliminary, we suspect additional bamboo-specific adaptations in their anatomy and physiology will be uncovered with further examination into the anatomy of the bamboo lemurs.Item Incorporation of pharmacy personnel into medical mission trips: Benefits of an interprofessional team(2018-03-14) White, Annesha; Cobern, BriannaThere is a multitude of literature discussing the benefits of having pharmacy services incorporated into the medical mission team, however very few articles discuss in detail how pharmacists provide those services. The UNTHSC Christian Medical Association organizes an annual trip to various countries in Central America and has recently started incorporating pharmacists. The objective of this research was to review the literature within the last decade on the contribution of a pharmacist on the medical mission team. A secondary aim was to identify specific areas for consideration, such as medication acquisition, formulary development and pediatric dosing. A review of the literature was conducted identifying articles by searching PubMed, Scopus and Academic Search Complete, using the keywords ‘pharmacy’, ‘mission trips’, ‘medical missions’, ‘formulary’, and ‘religious missions.’ Articles that were published between 2007 and 2017 were included in the analysis. A summary was provided based on eight subtopics: acquiring medications; formulary development; work flow; transportation; packaging, labeling and medication setup; medication data collection; counseling; and pediatrics. A template was developed reflecting medical mission trip workflow. The search yielded a total of 10 articles for review. Findings revealed that medication acquisition and formulary development are key pre-trip roles for pharmacists. If medication is being brought outside the country where the trip is taking place, pharmacists should research the foreign country’s policies beforehand to ensure there are no issues with customs during travel. Counseling and work flow were the most common roles in terms of impact. Packaging and labeling improved efficiency for patients when customized to their language preference. Few studies thoroughly examined pediatric dosing, and none of the studies highlighted the pharmacist’s role in pediatric dosing. Previous literature has shown that pharmacy services are beneficial, but developing more standardized methods of how to utilize pharmacy services will help increase pharmacist contributions on mission trips. Since pharmacist involvement is a newer idea, there are a lack of empirical studies to measure the success of pharmacist involvement. More research using randomized control trials or specific outcome measures would benefit the existing body of literature. An opportunity exists for pharmacists to effectively contribute on an interprofessional team.Item Kinematic Analysis of Sagittal Plane Stability of Delta Frame External Fixation(2018-03-14) Beck, Cameron; Tran, Apollo; Hoy, Austin; Barcak, Eric; Wood, AddisonPurpose: External fixation with a delta frame construct is the most common construct used for temporizing patient distal tibia and ankle injuries. While these constructs may be the most common there are numerous variations that are often performed based on surgeon preference. The inclusion or exclusion of a posterior slab or 1st metatarsal pin to the construct is variable amongst surgeons and have little data to support their use aside from anecdotal evidence. Methods: 10 Fresh Frozen Cadavers were secured to a custom-made rig that held the tibia rigid and allowed the application of a standard delta frame external fixator. The specimens had a 2 cm segment of bone resected near the ankle plafond to simulate a highly unstable distal tibia or pilon fracture. The ankle was then loaded with a 10 lb weight from the great toe and 3D kinematics were recorded using an electromagnetic tracking system with 6 degrees of freedom. The 4 construct comparisons were: 1. Delta frame 2. Delta frame with 1st metatarsal pin 3. Delta frame with posterior slab 4. Delta frame with 1st metatarsal pin and posterior slab Results: The delta frame construct without any additions was less stable than all other constructs with statistical significance in the sagittal plane with regards to flexion/extension rotation. The most stable construct was a delta frame with 1st metatarsal pin and posterior slab. The most cost-effective measure to add sagittal plane stability was the addition of the posterior slab splint. Conclusion: Delta frame stability in the sagittal plane can be cost effectively augmented by the addition of a posterior slab. The addition of both a posterior slab or 1st metatarsal pin were able to significantly add stability to the base construct and the combination of the 2 were able to achieve highest stability.Item Major Mental Illness: Resources in Tarrant County(2018-03-14) Hmaidan, Sarah; Samal, Akanksha; Jiwani, Sonia; Abrams, Stephanie; Petrus-Jones, MichaelPurpose: Our project sought to present patient resources in Fort Worth and Tarrant County that focus on major mental illness, which affects 1 in 5 adults yearly in the United States. This includes, but is not limited to: major depressive disorder, bipolar disorder, post-traumatic stress disorder, schizophrenia, eating disorders, and substance abuse disorders. There is a higher prevalence of major mental illness among homeless, prisoner, and veteran populations, and in Tarrant County high poverty and uninsured rates contribute to prevalence rates higher than the national averages. Additionally, there are shortages of mental health care providers in Tarrant County and Texas overall. Methods & Results: A thorough investigation and review of resources in Tarrant County was conducted. Among the resources found in Tarrant County, several are branches of larger state or national organizations that provide extensive support and advocacy for, and education about mental illness. In addition to providing information on Tarrant County resources, we included information on resources for medical and health professions students on the UNT Health Science Center campus who may be living with one of these illnesses. High prevalence of physician burnout and maximal stress contributes to mental instability and increased mental illness prevalence among physicians and providers. Conclusions: Based on what we found in our search for resources, we concluded that there needs to be an increase in the number of mental health providers, an increased focus on advocacy and awareness about mental illness and health care, and an open dialogue about the real consequences of untreated mental illness in all populations.Item PATIENT SAFETY CULTURE IN SKILLED NURSING FACILITIES(2018-03-14) Oderberg, Jane; Severance, Jennifer; Agena, Valerie; Ross, SarahPURPOSE Skilled nursing facilities (SNF) have an increasingly frailer and more dependent patient population with a high risk of re-hospitalization from preventable adverse events. Developing a culture of safety is a core component to clinician and staff behaviors that affect safety, quality, and patient outcomes, although little is known about improving patient safety in long term care settings. With a goal of improving the safety culture and quality of care provided in SNF settings, UNTHSC Center for Geriatrics developed and implemented the evidence-based interprofessional Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) to address falls risk reduction at skilled nursing facilities in Fort Worth, Texas. METHODS We administered the Agency for Healthcare Research and Quality (AHRQ) Nursing Home Survey on Patient Safety Culture Brookdale Broadway Plaza (n=36), the Stayton (n=26) between August and October 2017. Survey results across twelve composites of patient safety culture were used to inform the development and delivery of a TeamSTEPPS Long Term Care 2.0 training series focused on falls risk reduction. The first training session delivered in October 2017 for direct care staff (n=47) provided an overview of the TeamSTEPPS model and communication tools, and an introduction to falls risk reduction in long term care settings. A second session for direct care staff (n=37) delivered in December and January provided additional training in TeamSTEPPS strategies and development of a communication tool to aid in fall risk reduction. Initial evaluation of knowledge and skills of trainees included a Likert scale survey. RESULTS Survey analysis identified that most staff believed their residents were safe in their facility (89% Brookdale,91% Stayton,82%Trinity) and they would recommend their facility to others (76% Brookdale; 80% Stayton). The lack of communication regarding residents (Brookdale 60%; Stayton 48%) was prevalent in both facilities and most direct care staff felt they were not considered members of the care team (61% Brookdale; 50% Stayton). Initial evaluation of TeamSTEPPS training showed that a majority (92-100%) were highly confident they could describe objectives related to the TeamSTEPPS program and falls awareness and prevention. As a result of the training, an action plan and communication tool was developed with input from the trainees to ensure continuity of care, improve communication, and decrease falls. Using a Plan-Do-Study-Act continuous improvement cycle, this checklist will be implemented by designated facility personnel. A post evaluation using the patient safety culture survey will be administered. CONCLUSIONS The implementation of TeamSTEPPS at SNF facilities demonstrated benefits to staff in improving their quality of care and ability to work collaboratively for the good of the patients. We anticipate that SNF will utilize TeamSTEPPS principles to develop, implement and sustain effective patient safety interventions.Item Patient Surveys Referring to Urine Sample Collection Methods: A Quality Improvement Study at Cook Children’s Urgent Care Centers(2018-03-14) Akkad, Rana; Henson, Robin; Fulton, Audra; Hamby, Tyler; Martin, Parul; Coplin, BradleyBackground:Urinary Tract Infections (UTIs) are a common problem amongst Pediatric Urgent Care Centers (UCCs) and are usually the result of various bacterial species. While many factors are considered when diagnosing a UTI, the urinalysis remains the most important screening tool and a urine culture gives diagnostic confirmation. The sensitivity and reliability of a urinalysis is affected by many factors including the urine collection method. A previous retrospective study found that Cook Children’s UCCs had high rates of urine contamination (defined as Hypothesis: We hypothesize that Cook Children’s midstream urine collection policy is not being followed/enforced. Methods: A quality improvement (QI) study was designed and conducted at Cook Children’s Pediatric UCC in Fort Worth. The Fort Worth site was chosen because of its historically high patient volume. A survey was developed with questions that modeled Cook Children’s midstream urine collection policy. Surveys were given verbally to patients who gave a urine sample and met the inclusion criteria: potty trained. Families could follow along with a provided copy of the survey. The data were collected over a four-week period, placed into REDCap, and analyzed according to survey questions. Results: Of those surveyed (n=24) less than 10% received gloves; 35% of female patients and 66% of uncircumcised male patients were properly instructed to clean their genitalia. Midstream urine collection instructions were given to 26% of patients, and more than 50% of patients claimed to not collect urine midstream. Conclusions: The results from this preliminary study demonstrate that Cook Children’s midstream urine collection policy is not properly followed by the UCC staff. There is evidence that rates of urine contamination and improper UTI diagnosis are high. As such, future interventions will focus on educating the UCC staff on Cook Children’s policy and employing a check off to make sure all members of the staff are properly trained on giving patient instructions for midstream urine collection.Item POST-OP BLEEDING IN A PATIENT WITH NOONAN SYNDROME AND FACTOR XIII DEFICIENCY: A CASE STUDY(2018-03-14) Baker, Austin; Marcincuk, Michelle; Torres, Marcela; Homewood, TylerBackground: Factor XIII, also known as fibrin stabilizing factor, strengthens the final stages of hemostasis. It plays a pivotal role in angiogenesis, maintenance of pregnancy, wound healing, bone metabolism and cardio protection. A deficiency in this factor is inherited in an autosomal recessive fashion or an antibody against the factor can be developed. Noonan syndrome is a common genetic abnormality that is characterized by webbed neck, short stature, characteristic facies, congenital heart defects, and developmental delay. It is inherited in an autosomal dominant fashion. Commonly, patients with this disease present with a proclivity for bleeding diathesis due to platelet and coagulation factor abnormalities. Case Information: We present a 13-year old boy with known Noonan syndrome who experienced profuse bleeding from the left ear and a large hematoma formation after an otologic procedure. Although Noonan patients are known to experience bleeding complications, our patient had undergone various surgical procedures without prior hemorrhagic events. Due to retained ear tubes and chronic suppurative otitis media, the patient developed conductive hearing loss and was recommended to receive surgical intervention. The patient presented the following day to the emergency department with bleeding from the left ear and hematoma of the left side of his face and neck. He was discharged after bleeding was stopped; but once home, the bleeding started again, and he was re-admitted for an exploratory exam under general anesthesia. Diffuse oozing was discovered, and a platelet transfusion was provided to stop the bleeding. A bleeding disorder workup was sent including a factor XIII activity assay. Preliminary coagulation tests proved normal, however factor XIII deficiency was confirmed. Conclusions: This is the first described case of factor XIII deficiency presenting in a patient with Noonan syndrome. Noonan patients have a proclivity for bleeding diathesis, but much more commonly due to other factor and platelet abnormalities. Noonan syndrome is common enough that many clinicians and surgeons will see these patients in their practice. It is important to be aware of the common bleeding disorders associated with Noonan syndrome, but also to be aware that they can have other rare bleeding disorders despite normal basic coagulation tests.Item Postural control and use of eye movements differ during quiet standing in Autism Spectrum Disorder and Typical Development(2018-03-14) Gray, Jaimie; Dangelmayr, Kalyn; Sherrod, Gabriela; Bugnariu, Nicoleta; Miller, Haylie; Bolinger, ErinPURPOSE: Individuals with Autism Spectrum Disorder (ASD) have clinically-significant difficulty with postural stability and motor coordination. However, few studies quantitatively examine differences in postural stability and eye movement between ASD and typical development (TD). Individuals with ASD have atypical eye movements, and emerging evidence suggests that they also have difficulty using vision to support postural control. This study aimed to quantify differences in eye movement and postural stability between individuals with ASD and TD. METHODS: 18 individuals with ASD (Mage = 15.3) and 23 TD (Mage = 14.3) participated in this study. Participants stood on a force plate while wearing eye-tracking glasses. The force plate monitored their center of pressure, a common metric used to assess balance and stability. The eye-tracking glasses monitored their fixation and saccadic eye movements. Participants completed a quiet standing task with three conditions: eyes open (EO), eyes closed (EC), and EO while wearing a translucent dome on the head, obscuring visual context (Dome). Each condition lasted 30 seconds, and participants were monitored for compliance by a member of the research team. RESULTS: Participants in the ASD group had greater overall postural instability than the TD group across all conditions. Notable differences also occurred between the groups for anterior-posterior sway and sway in the EO condition. The two groups also differed in proportion of fixations versus saccadic eye movements used to support postural stability. CONCLUSIONS: These data suggest that the specific profile of postural instability and contributing eye movements differs between ASD and TD. The ASD group had markedly increased instability when visual context was eliminated (EC) or obscured (Dome), suggesting an important influence of visual information and potential failure to engage in sensory reweighting. Sensory reweighting is critical function, increasing flexibility in the strategies a person uses to maintain balance in situations where one dominant source of sensory input (e.g., vision) is unreliable or unavailable. Data collection is ongoing, and additional studies are necessary to investigate the mechanisms responsible for postural instability in ASD.