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Item A Case of Symptomatic Angiomyolipoma(2019-03-05) Young, Todd; Eskildsen, DaneBackground: Renal angiomyolipoma (AML) are benign soft tissue neoplasms classically composed of blood vessels, smooth muscle cells and adipocytes. These masses are found in .3 to 2.1% of the population and can be strongly associated with genetic syndromes such as the Tuberous Sclerosis Complex. While most of these masses are found incidentally, they can, in rare cases, become symptomatic. Patients with symptomatic AML most commonly present with hematuria, flank pain and renal hemorrhage. Case Presentations: A.H. is a 51-year-old obese female who presented 7 months ago to the emergency department with sudden onset left upper quadrant pain, nausea and emesis. On admission, her hemoglobin was found to be 9.1. Due to continued anemia she was transfused with 2 units of blood. CT scan of the abdomen and pelvis showed massive hemorrhage in the retroperitoneum surrounding the left kidney and a focus of fatty tissue likely representing a large AML. After Urological consult, left renal pole artery embolization was performed by interventional radiology. Over the next several months, after resolution of the hemorrhage, subsequent scans found that the symptomatic mass measured 4 cm and another 1.2 cm AML was found in the ipsilateral kidney. 6 months’ post presentation it was determined that, due to size and history of hemorrhage that the patient would undergo a radical left nephrectomy. Upon surgical exploration of the abdomen the tissue around the kidney was found to still be incredibly inflamed and thick. Despite this, the surgery proceeded without complications. Conclusion: Classic AML are the only benign renal masses that can confidently be diagnosed using imaging. As such, confirmed asymptomatic AML are often left untreated and actively observed over time. The consensus in literature indicates a size 4 cm as the cutoff for when AML are suspicious for symptomatic manifestation. Indeed, the risk of significant symptoms directly increases with size of the mass. This same 4cm size cutoff is used as a guideline for when treatment is warranted. Modern first line treatment includes embolization, with partial or radical nephrectomy coming into play when embolization fails to control symptoms or with excessively large masses. In this case, although embolization initially controlled the bleeding, patient comorbidities and tumor size warranted definitive removal of the mass.Item A Case Series Comparison of Treatment Techniques for Blount’s Disease(2019-03-05) Mayfield, Matthew; DeRon, Nathan Jr.Background: Blount’s disease is disordered growth at the proximal tibial physis of pediatric patients causing leg bowing known as genu vara. Diminished growth of the medial physis causes leg bowing without natural correction. The high prevalence of comorbid obesity in patients is thought to contribute to destruction of growth cells at the physis. There are two common treatments: hemiepiphysiodesis involves arresting the lateral proximal tibial physis to allow increased growth at the medial proximal tibia. Osteotomy includes realigning the tibia and fibula such that the lower extremity mechanical axis becomes increasingly linear. This case series analyzes the optimal treatment choice based on patient age. Case Descriptions: Case 1 A 10-year-old male presented with bilateral leg bowing, bilateral knee pain, and obesity (BMI = 53.8). Treatment was bilateral hemiepiphysiodesis at the lateral tibial physis using eight-plates. This correction was insufficient. Bilateral tibia-fibula osteotomies with external fixation (ex-fix) were then performed with successful correction. Case 2 An 8-year-old female presented with bilateral leg bowing, limp, knee pain, and obesity (BMI = 44.7). Treatment was bilateral hemiepiphysiodesis at the lateral tibial physis. The left hemiepiphysiodesis proved sufficient for correction, but the right hemiepiphysiodesis did not. A subsequent tibia-fibula osteotomy with ex-fix was performed and proved successful. Case 3 A 12-year-old male presented with leg bowing, knee pain, and obesity (BMI = 38.6). Treatment was bilateral hemiepiphysiodesis at the lateral tibial physis. This proved insufficient, and treatment proceeded to a left tibia-fibula osteotomy with ex-fix and a right tibial osteotomy with internal fixation. These osteotomies were sufficient for correction. Conclusion: This case series shows an indication for osteotomy as first-line treatment for Blount’s disease in patients at a relative advanced age. The study also identified further potential research targets. A retrospective look at success rates of treatments in various age groups may help determine the age at which each treatment is preferred. A retrospective analysis may be performed to determine the infection rates in both types of treatment. Finally, additional research may be performed to determine the obesity threshold required to increase risk for Blount’s disease. This data is potentially useful to pediatricians for patient education and prevention.Item A comparison of Social Responsiveness Scores in patients aged 0-24 with Autism Spectrum Disorder or schizophrenia.(2019-03-05) Miller, Haylie; Shahub, Nur-AlhudaPurpose: Autism Spectrum Disorder (ASD) and schizophrenia share common features; past research demonstrates that these features include pathophysiology, social-cognitive impairments, possible genetic underpinnings, and risk factors. In both disorders, social cognition presents a key barrier to quality of life. One measure of social cognition designed for use in ASD, the Social Responsiveness Score (SRS), is also commonly used to assess social cognition and plan interventions in schizophrenia. We aimed to determine whether people with ASD and schizophrenia differ in the mean and range of their SRS scores. Methods: We identified an age-matched sample of fifteen individuals with Autism Spectrum Disorder (Male = 13, Female = 2; MAge= 22.71, SDAge= 3.24) from the National Database of Autism Research and thirteen individuals with schizophrenia (Male = 10, Female = 3; MAge= 22.07, SDAge= 2.99) from the SchizConnect database. All individuals were between the ages of 0 and 24 years. Data were analyzed using Microsoft Excel and the Statistical Package for Social Sciences software. SRS T-scores Results: Mean SRS scores did not differ between the ASD (M = 80.50, SD = 14.32) and the schizophrenia (M = 89.78, SD = 39.37) groups (p = 0.22). Although the group means were not significantly different, the schizophrenia group had a notably wider range of SRS scores than the ASD group. Conclusions: Although our groups did not differ in their mean SRS scores, there was wide variability in the schizophrenia group. The SRS was designed for ASD, and may not be an adequate measure of social dysfunction in other populations. At minimum, this wide variability suggests that when using the SRS as a tool for assessing social-communication skills in schizophrenia, the influence of other factors (such as age, behavior, or language) must also be considered. Further study is required to fully assess the clinical utility of this tool for non-ASD populations.Item A Novel Mutation of APOB in Two Siblings with Hypercholesterolemia(2019-03-05) Hamilton, Luke; Hamby, Tyler; Wilson, Don; Sprunger, AbigailA Novel Mutation of APOB in Two Siblings with Hypercholesterolemia 1 Abigail Sprunger, BS; 2L. Hamilton, MS; 3T. Hamby, PhD; and 2D. P. Wilson, MD, FNLA 1University of North Texas Health Science Center, Ft Worth, TX, and the Departments of 2Pediatric Endocrinology and Diabetes and 3Research Administration, Cook Children’s Medical Center, Ft Worth, TX, USA. Abstract Background: Familial hypercholesterolemia (FH) is a common genetic disorder cause of premature atherosclerosis due to chronically elevated low-density lipoprotein cholesterol (LDL-C) levels from birth. Individuals with FH experience an increased risk of premature cardiovascular disease (CVD), and lack of early identification and treatment increases the risk of CVD-related coronary events later in life. We report two siblings with FH caused by a novel mutation in APOB. Methods: Electronic medical records were reviewed for two patients with FH. Case Information: Two biologically related siblings (male age 9, female age 11) were found to have LDL-C levels [greater than] 95th centile for respective age and gender. Neither sibling had preexisting medical conditions nor a history of chronic medications. Both siblings were found to have the same missense variant in the APOB gene, a novel mutation causing hypercholesterolemia. Because of parental concerns regarding use of statins, both were treated with a cholesterol absorption inhibitor. Conclusions: Despite the benefits of early identification of those at moderate-to-severe risk, several knowledge gaps impede successful cholesterol screening of children: misunderstanding goals of screening, the best screening method, and ideal age for screening and for intervention. Current guidelines recommend universal cholesterol screening and selective screening starting at 10 and 2 years of age, respectively. Although not routinely preformed, identification of a genetic mutation helps to 1) confirm the diagnosis of FH; and 2) serves as an additional risk factor for CVD, aids risk stratification and clinical-decision making, and helps determine the timing and intensity of treatment that would provide the best long-term health benefits. In addition to lipid-lowering medications, treatment should include global reduction of all CVD risk factors through health education, and adoption of life-long, heart-healthy living with a goal to reduce LDL-C levels toItem A Systems Approach to Postpartum Depression: Opportunities for Prevention and Treatment(2019-03-05) Thompson, Erika; Adhikari, SujitaA Systems Approach to Postpartum Depression: Opportunities for Prevention and Treatment Sujita Adhikari MPH Candidate, Erika L. Thompson, PhD, MPH, CPH Dept. of Health Behavior and Health Systems, UNT Health Science Center, Fort Worth TX,76107 Background Postpartum Depression (PPD) is a common mental health issue that occurs in women after childbirth. The depressive symptoms in affected mother are often manifested as a feeling of extreme sadness, guilt, helplessness, insomnia, excessive crying, extreme concern about child, fatigue and suicidal thoughts. Biological factors (e.g. hormonal changes) and psychological factors (e.g. stress, lack of social support, low socio-economic status, abusive relationships, greater work pressure, the occurrence of adverse life events, previous history of depression) are risk factors for PPD. In 2018, 14.7% of women in Texas who gave live birth experienced postpartum depression. Due to the complexity of this health issue, systems thinking is necessary to identify organizations aligned with addressing PPD, which can then help design effective interventions to minimize the potentially harmful effects of PPD. Objective The main objective is to identify organizations in the Fort Worth region that are involved in postpartum depression prevention or treatment and map organization connections. Methodology A web search was conducted in November 2018 to identify organizations and government bodies who address postpartum depression. Interconnection was established amongst these organizations to analyze using a system thinking approach. Results Three national-level organizations (e.g. Medicaid), four state-level organizations (e.g. Texas Department of Health and Human Services) and three local level organizations (e.g. MHMR of Tarrant County) were identified in the Fort Worth region. These organizations when analyzed were found connected with each other forming a system which operated to address PPD in this region. Conclusion These major ten organizations that are dedicated to working on postpartum depression are interconnected. The organizations operate at different levels to form a complex system. While organizations are making a positive impact on this issue, it is still necessary to dive deeper and understand the underlying factors for this problem. By understanding the complex system for PPD prevention and opportunities for integration, better mental health outcomes can be achieved.Item An ERP study on attention bias in experimental pain individuals under different cognitive loads.(2019-03-05) Liu, Howe; Salem, Yasser; Wu, Wen; wang, kanglingPurpose: The aim of the present study was to investigate the behavioral and electrophysiological differences between experimental pain persons and healthy controls when conducting attention bias task under different cognitive load conditions. Methods: 30 healthy subjects were recruited from the Southern medical university of China, into which equally divided the experimental pain group and healthy control group (7 female/15 and 8 female /15; mean age ± SD: 22.53±2.35 and 21.69±3.25 respectively; mean years of education ± SD:16.30 ±3.58 and 15.78 ±3.65 respectively). All subjects underwent ERP examination when completing an attention bias task. The experimental pain subjects simulated pain by spraying capsaicin on the inner side of the upper arm with an average pain score of 6.08±2.33. Healthy control group reported no pain. Results: Behavioral results showed that the main effect of load was significant, with a longer respond time and lower correct rate under high cognitive load compared with low one, suggesting that the task we used could well distinguish different loads. Further ERP results revealed that the main effect of wave peaks (N1 and P2) between groups was significant. Experimental pain subjects responded to all word interferences with a smaller amplitude than that of the normal group. A significantly synergistic effect of interference word * load, with a significantly smaller amplitude induced by pain words and negative words of early components P2 and N3 under the condition of high cognitive load, and interference word*group, with a smaller amplitude of N1 and N3 elicited by various interference words, were found. Conclusion: Experimental pain subjects’ response to the words of external stimulus was weakened as a result of the disturbance of pain. We believed that cognitive load mainly affected and regulated the early components of attention, that the processing mode of interference words (especially pain words and negative words) was different under high cognitive load compared with low one, which could provid electrophysiological evidence for cognitive load theory.Item Avascular Necrosis of the Femoral Head in a Healthy, Young, Adult Male(2019-03-05) Neelakantan, Suguna MD; Burghul, SunaBackground: Avascular necrosis (AVN) of the femoral head can be caused by a variety of factors including tobacco use, traumatic injury, or hypercoagulability. Hypercoagulability in the body can lead to the formation of thrombi in the microcirculation, resulting in many possible complications. This report will discuss a case of a healthy, young male who developed avascular necrosis of the femoral head as a result of Factor V Leiden. Case Information: A 30-year-old previously healthy male presented to the outpatient family medicine clinic with a chief complaint of severe pain in his right hip. The pain had been present for eight months and was progressively getting worse. The patient’s only past medical history was hyperlipidemia. He was not taking any medications, he exercised regularly, he worked as a sales representative, and he did not have any family history of clotting disorders. He had no history of trauma, tobacco use, alcohol consumption, or steroid use. On physical exam, he had extreme pain upon flexion of the right hip. An X-ray of the right hip showed equivocal broadening of the superolateral femoral head-neck junction suggesting mechanical impingement. He then presented two weeks later with more intense pain in his hip and was unable to walk. He was referred to orthopedic surgery, where an MRI was performed and showed Stage 3 avascular necrosis of the femoral head. He then saw hematology and testing revealed that he was heterozygous for a mutation in the r506q gene responsible for factor V, confirming his diagnosis to be Factor V Leiden. The patient had a right total hip arthroplasty and is doing well. Conclusions: AVN of the femoral head is a debilitating condition. When left untreated, it is estimated that between 70-80% of patients will progress to bilateral AVN, making diagnosing the underlying cause vital. Hypercoagulability is believed to be a major and common cause of AVN; thus, systemic anticoagulation therapy should be considered to prevent further complications, especially when a patient is homozygous for the mutation on Factor V. While other treatment options for AVN of the femoral head are available, when the necrotic lesion has become too large or the femoral head has collapsed, total hip arthroplasty remains the best option. Although many patients discover that they have Factor V Leiden due to family history, this patient was unusual in that he presented with an irreversible complication of the disease.Item Biomechanic Evaluation of AC Joint Reconstruction Techniques: A Systematic Review(2019-03-05) Mong, Joy; Wagner, Lianne; Schultz, Matthew; Hoelscher, Skyler MD; Webb, Brian MD; Tran, ApolloBackground. Acromioclavicular (AC) joint disruption comprises 3.2% of all shoulder injuries, yet there is still broad debate on the optimal surgical approach. Over 150 surgical variations have been proposed, however the lack of common terminology and experimental standards make it challenging to draw any conclusions. For such predicaments, systematic reviews that provide a methodical approach for navigating the literature and have proven useful for identifying areas for improvement, standardizing protocols, and providing direction for a comprehensive analysis. Objective. The purpose of this review is to: 1) systematically evaluate the current state of the literature concerning the biomechanical testing of AC reconstruction; 2) to summarize the surgical techniques and testing procedures; and 3) to identify biomechanical areas that are not well represented in the existing literature. Methods. We completed a literature search to identify biomechanical studies on AC joint fixation using Medline, Scopus, and Excerpta Medica Database (EMBASE) following the 2009 PRISMA statement. Articles were independently reviewed by two investigators and any disagreements were reconciled by consensus in consultation with a third investigator. Investigators independently abstracted data from each study, focusing on surgical techniques and characteristics of the testing protocol. Results. The most popular techniques were the Modified Weaver Dunn and suture button techniques with a tunnel through or looping under the coracoid. To assess construct performance, 28 out of 39 studies included a load to failure protocol to evaluate strength and stiffness of the construct. 18 studies measured vertical plane translation, 16 studies measured horizontal motion, and 5 studies measured rotation. Conclusion. Overall, the most common techniques involved graft with suture augmentation. Techniques looping under the coracoid decreased the likelihood of fracture whereas techniques going through the coracoid improved stability and better maintained reduction. Free graft and hookplates have been found to be biomechanically or clinically inferior. Elastic stiffness serves as a reliable indicator for quantifying early construct stability while strength and translation better represent long-term functional stability. While general conclusions can be made from current biomechanic literature, a more objective verdict requires better standardization of terminology and testing procedures.Item Chronic Dislocation of Radiocarpal Joint in two patients with Down Syndrome(2019-03-05) Roberts, Tyler; Sherman, Pamela; Robinson, JacobChronic Dislocation of Radiocarpal Joint in two patients with Down Syndrome Authors: Jacob Robinson, OMS-II UNTHSC-TCOM; Tyler Roberts, PGY III JPS Orthopedic Resident; Pamela J Sherman, MD Cook Children’s Medical Center Background: Down syndrome (Trisomy 21) is regarded as the most common human genetic disorder with a prevalence of about 1 in 660 live births. With the main effect being mental retardation, there are several orthopedic concerns that have raised awareness with this population. While subluxation at the atlantoaxial and hip joints have been more common orthopedic issues in patients with Down syndrome, chronic subluxation or dislocations at the wrist are not so frequently reported. Cases: We present two cases of non-traumatic volar mid-carpal dislocations occurring in two separate patients with Down syndrome. The 12-year-old female patient presented with unilateral left sided pain and bilateral dislocations, while the 13-year-old male presented with unilateral pain and dislocation on the left. Of note, several commonalities aside from an extra chromosome exist between the patients. They were of similar age, showed arthritic changes on x-ray, and were previously diagnosed with hypothyroidism. One orthopedic condition of particular interest that could be related to the cases is arthropathy of down syndrome . A study investigating this condition reported a prevalence up to 6 times greater than that of juvenile idiopathic arthritis in the general population. Conclusion: It’s likely that many cases similar to those presented are more common that currently recognized or reported. With participation of Down syndrome patients worldwide in Special Olympic Sports and other activities, this raises the question is additional screening necessary for the safety of these individuals. Sponsor: Cook Children’s/UNTHSC Pediatric Research ProgramItem Coordinated Movement of Diaphragm and Pelvic Floor Muscles in Relation to Respiratory Function(2019-03-05) Lu, Crystal; Beasley, Stephanie; Nichols, Charles; Liu, Howe; Coleman, AudreyBackground: It is known that the diaphragm affects pulmonary function, trunk stabilization, and other systems found in the thoracic and abdominal cavities. The pelvic floor muscles (PFM) aid in function and stabilization of the urinary, excretory, and reproductive organs. The purpose of this literature review is to determine the connection between the function of the diaphragm and PFM and the role that the PFM may play in common thoracic and abdominal diagnoses. Methods: The review was conducted using databases and specific keywords from peer-review articles between 2008 and 2018. Many of the studies used real time magnetic resonance imaging (MRI) and electromyography (EMG) to determine activation and function of the diaphragm and PFM during different activities. Results: The diaphragm and pelvic floor muscles (PFM) have been shown to work together in many aspects of respiration and postural control and move in parallel during quiet breathing. It was noted that stronger PFM resulted in faster respiratory rates due to increased muscle recruitment and strength of respiratory muscles. In a different study, EMG results showed that the anterior diaphragm contributes more to respiratory function, while the middle and posterior diaphragm assist with trunk stabilization. Subjects with larger and stronger diaphragms had better postural stability and experienced less low back pain. The diaphragm and PFM also contribute to intra-abdominal pressure (IAP). When the diaphragm and PFM move cranially during expiration, abdominal muscles contract and thicken causing an increase in IAP. Discussion: The results showed that the diaphragm and PFM are vital in respiration, organ support, bladder and bowel control, and postural support. The diaphragm and PFM move synchronously in healthy individuals but can become dysfunctional with many pathologies. These two muscle groups, along with abdominal muscles, form a bridge and work synergistically, which could explain the association of symptoms between the three. Clinical Implications: It is important during diagnosis and treatment of the thoracic and abdominal cavity that the diaphragm and pelvic floor muscles should be assessed. Use of real time MRI and EMG can help increase strength and decrease irregular contractions in the bridge of the abdominal muscles, the diaphragm, and PFM. Focusing on all three muscles as a group instead of isolating one can increase postural stability in patients.Item Current research status on the treatment of veisalgia using Silybum marianum(2019-03-05) Powell, Jake; Nguyen, Thuy; Tran, ApolloBackground. There is abundant anecdotal evidence for products claiming to reduce veisalgia after alcohol consumption. Among these products is milk thistle (Silybum marianum), a plant that has been widely touted for its hepatoprotective properties against toxins such as alcohol, venom and plant poisons. Companies commonly promote the use of milk thistle proactively and/or actively as a treatment to attenuate symptoms of veisalgia. However, none of these claims are substantiated by research. Purpose. The purpose of this study is to evaluate the current state of the literature concerning the use of milk thistle for treating veisalgia. The supplement is commercially promoted as a cure for hangovers and we aim to assess the validity of these claims. Methods. We completed a literature search on milk thistle and veisalgia using Medline, Scopus, and Excerpta Medica Database (EMBASE). Because there are currently no studies directly linking milk thistle with hangovers, we identified the main pathophysiological pathways implicated with veisalgia to cross examine the validity of using milk thistle for treatment. Results. No studies directly examined the treatment of veisalgia with milk thistle. However, several studies demonstrated milk thistle to have antioxidant and antitoxin effects in the liver, small intestine, and stomach. Animal studies have found that milk thistle may contribute to hepatocyte regeneration and reduce inflammatory processes. Multiple clinical trials using milk thistle as treatment for a variety of liver diseases suggest that milk thistle may be a viable and biologically active supplement. However, most clinical trials assessed milk thistle’s effects on liver related diseases such as hepatitis. Conclusions. Veisalgia is a multifactorial pathological state that has been implicated with liver damage and inflammation. Milk thistle has been found to provide benefits for a variety of liver diseases, which share several pathophysiological processes that cause veisalgia. Based on this evidence it is possible that milk thistle could be effective in alleviating veisalgia symptoms in common with liver disease. However, there is not enough evidence in the current literature to definitively indicate milk thistle for the treatment of veisalgia.Item De Garengeot Hernia, Déjà Vu : A Unique Report(2019-03-05) Coleman, Cathryn; Still, Sasha; Rodriguez, Carlos; Alavi, MichaelBACKGROUND The presence of a vermiform appendix incarcerated within a femoral hernia is known as a de Garengeot hernia (DGH). These hernias are extremely rare entities with less than 100 documented cases uploaded to PubMed’s database. Most develop sporadically with no prior history of femoral herniation. We present the unique case of a 59-year-old female with a retrospectively suspected two-year history of a femoral hernia, who developed an acutely incarcerated and strangulated DGH requiring prompt surgical management. CASE INFORMATION A 59-year-old female presented to the Emergency Department complaining of a three-day history of a painful right groin lump. She was clinically diagnosed with a right inguinal hernia two years prior. On presentation, she stated that she coughed and felt her hernia ‘pop out’ but was unable to reduce it. A round, firm mass was appreciated caudal to her inguinal ligament and was tender, irreducible and non-fluctuant. Overlying erythema and skin changes were identified. She had a low-grade fever (99°F), with a WBC of 13.73 x109/L and lipase of 162. CT imaging revealed a right groin hernia containing the appendix with significant inflammatory changes and suspicions for strangulation and superimposed primary acute appendicitis. The radiologist interpreted the groin hernia as inguinal (Amyand hernia), while the surgeon interpreted it as femoral (DGH). Intraoperatively, a femoral hernia was identified containing murky fluid surrounding an inflamed and necrotic appendix. An appendectomy followed by a natural tissue hernia repair (McVay) was performed. Histopathologic examination of the excised specimen revealed acute suppurative appendicitis with severe peri-appendicitis. CONCLUSIONS De Garengeot hernias are very rare entities and account for less than 1% of all femoral hernias. Though effective in other conditions, imaging plays a limited role in diagnosis and treatment of DGH due to its low sensitivity and specificity. These factors may result in varying interpretations of a single scan as seen by the radiologist and surgeon in this case. There are various surgical management options available. However, in this case an appendectomy followed by primary repair was performed as the strangulated appendix posed a high risk for post-operative complications. When evaluating a patient with a groin hernia and controversial CT result, it is important to use one’s clinical suspicion to help guide the surgical approach and management options.Item Does General Health Differ by Number of Health Conditions and Use of Special Equipment in Veterans Ages 35-64?(2019-03-05) Brion, Alyssa; Comrie, Justin; Michalak, Grant; Mott, Jeffrey; Hartos, Jessica; Camacho, GabrielaPurpose: About one third of veterans return to the Veterans Affairs (VA) from war with health issues. The purpose of this study was to assess the relationship between health conditions and use of special equipment with general, mental, and physical health of veterans ages 35-64 in the general population. Method: This cross-sectional analysis utilized data from the 2016 Behavioral Risk Factor Surveillance System (BRFFS) for veterans ages 35-64, from Florida, Maryland, New York, Texas and Washington. Ordered logistic regression analysis by state and outcome was used to determine the relationship between general, physical, and mental health by number of health conditions and activity limitations after controlling for demographic factors and substance use. Results: A low proportion of veterans reported poor/fair general health, low physical health, and low mental health. Additionally, about one-third reported having 1 or more health conditions, and a low proportion reported medical conditions that required special equipment. Adjusted statistics showed that across states, general health, physical health, and mental health were all significantly related to number of health conditions and use of special equipment after controlling for all other variables in the model. Conclusion: The purpose of this study was to assess the relationship between health conditions and use of special equipment with general, physical, and mental health of veterans ages 35-64 in the general population. The results may generalize to veterans ages 35-64 in primary care settings. A low proportion of veterans may have poor or fair general health, low physical health, or low mental health, which were all moderately to highly related to number of health conditions and use of special equipment. If veterans present with one, they should be screened for all and treated concurrently.Item Effects of Strength Training on Bone Mineral Density in Adult Women: A Systematic Review(2019-03-05) Rokayak, Natalee; Yasser, Salem; Liu, Howe; Paez, GeneTitle: Effects of Strength Training on Bone Mineral in Adult Women – A Systematic Review In the recent years, exercise has been proposed as a treatment strategy for obtaining an optimal peak bone mass. Moreover, several studies have shown that participating in exercise program can prevent osteoporosis and decrease the risk of fracture. High load exercises such as weight lifting, and strength training provide loading exercises that may improve bone mineral density. To our knowledge, there is no study that have compiled the evidence for the role of strengthening exercises in the prevention and treatment of osteoporosis. Purpose The purpose of this systematic review is to evaluate the effectiveness of strengthening exercises on bone mineral density in adult women. Subjects: This systematic review of literature included 17 published studies that met our inclusion criteria. In total, 1210 adult women participated in those articles and were studied in our final included studies. Methods Electronic databases used were PubMed, Physiotherapy Evidence Database (PEDro), CINAHL, Web of Science Search and Scopus. Key words included osteoporosis, bone mineral density, and strength. Our inclusion criteria included population (adult women 18 years and older), and intervention (strength training is the main exercise program). The initial search yielded 1073 potential articles. These studies were then screened for duplications and selection criteria. Of those 1073 studies, 17 studies were considered to meet all of the required inclusion criteria. Data Analysis This is a systematic review study. Quality of the included studies was rated using the Centre of Evidence-Based Medicine: Levels of Evidence and the PEDro scale. Results In total, 17 research studies were examined and met our inclusion criteria. All of the included studies were randomized controlled trials. Across all 17 studies, 1210 adult women were participants. Sample size for each study ranged between 20 and 226 adult women. The age range of the participants was between 18 and 70 years old. All studies showed beneficial effects of strength training in bone mineral density in adult women. No adverse effects were reported in those studies. Dosing of intervention varied in terms of frequency (ranged 2 to 5 sessions per week), duration (ranged from 15 to 75 minutes), length of the exercise program (ranged from 6 weeks to 2 years) and mode/type of strength training used. Conclusion The results of this study showed that strength training programs are safe and effective to improve bone mineral density in adult women and can be used as a treatment strategy to prevent Osteopenia and Osteoporosis in postmenopausal women. Further studies are needed to determine the appropriate mode and dosage of the exercise program. Relevance: The findings of this study suggest that strength training has beneficial effects on bone mineral density in adult women and can be used as a strategy to prevent and minimize osteoporosis in postmenopausal women.Item Efficacy of Sympathetic Nerve Blocks in Pediatric Outpatients with Central Sensitization of Pain(2019-03-05) Blackham, Sterling; Gandhi, Artee; Brooks, Meredith; Hamby, Tyler; Romney, ColePurpose: Central sensitization (CS) is distinguished by an increased sensitivity to painful stimuli, due to a lower pain threshold or an altered response to pain. Clinically, CS frequently presents as enhanced sensitivity to a painful stimulus, triggering of pain by nonpainful events, and expansion of the receptive field. There is currently no standardized treatment for CS. Therapy is normally attempted through medications, lifestyle modifications, stress management, cognitive-behavioral therapy, physical therapy, interventional pain procedures, and occasionally surgery but evidence supporting specific treatments is lacking. Interventional nerve blocks are relatively common for the relief of chronic pain in adults but not in pediatric patients. To the best of our knowledge, this is the largest report examining the use of sympathetic nerve blocks for the relief of chronic pain in children. Methods: This study was a retrospective, chart review of pediatric patients treated between January 2009 and March 2018 for conditions that cause CS at Cook Children’s Medical Center. Patients included were between ages 0-21 years at the time of the procedure. Demographics, diagnoses, pain scores (FACES, VAS, NAS, FLACC; each measured on 10-point Likert scales), patient report of complications, activities of daily living and improvements in limb function were reviewed for each patient. Though each patient had 1-5 procedures, study analysis was limited to the first procedure. Results: There were 69 distinct patients (56 female; 63 white; median age 14.68 years, range 3.54-19.27). Common diagnoses treated include complex regional pain syndrome (45 patients) and abdominal pain (15 patients). Most patients demonstrated improvements in leg functionality (77%), hand functionality (76%), and overall functionality (71%). Pain scores improved after intervention for 74% of patients, and on average, patients reported a statistically significant improvement in the pain score from before (Mean=5.39; SD=3.02) to after (Mean=1.38; SD=2.08) intervention, P Conclusions: Sympathetic nerve blocks are both effective and safe for the short-term treatment of CS in children. Additional research should be done to determine long-term effectiveness and safety in this population.Item Imaging viscosity of intragranular mucin matrix in cystic fibrosis cells(2019-03-05) Ponomarchuk, Olga; Castillo, Marlius; Rebik, Jonathan; Brochiero, Emmanuelle; Borejdo, Julian; Gryczynski, Ignacy; Dzyuba, Sergei; Gryczynski, Zygmunt; Grygorczyk, Ryszard; Fudala, Rafal; Requena, SebastianPurpose: Abnormalities of mucus viscosity play a critical role in the athogenesis of several respiratory diseases, including cystic fibrosis (CF). Currently, there are no approaches to assess the rheological properties of mucin granule matrices in live cells. This is the first example of the use of a molecular rotor, a BODIPY dye, to quantitatively visualize the viscosity of intragranular mucin matrices in a large population of individual granules in differentiated primary bronchial epithelial cells using fluorescence lifetime imaging microscopy. Methods: We use a simple fluorescent phenyl-BODIPY rotor molecule which is readily uptaken into mucin granules and exhibits dramatic changes in its fluorescent lifetime as a function of its environments viscosity. To measure the distribution of viscosities in intracellular mucin, we use fluorescence lifetime microscopy (FLIM) to image the non-CF and CF. We employ a machine learning algorithm to analyze the pictures and use a combination of Python and ImageJ to compute the size and viscosity distribution of intracellular mucin granules. Results: In this work, we demonstrate the use of a simple BODIPY rotor to measure the apparent viscosity of intracellular mucin granules in human bronchial epithelial cells with and without CF. The molecular rotor is readily taken up into mucin granules and can be used to quantify the intracellular viscosity of mucin granules. Additionally, as a control, we use a non-rotor analog of the phenyl-BODIPY probe which is demonstrates little or no change in its fluorescent lifetime. Our results indicate the molecular rotor can be a valuable tool to study and quantify mucus pathology in diseased cells. Conclusion: We demonstrated that BODIPY-rotor could probe intragranular viscosities of CF and non-CF cells. Importantly, two different populations of viscosities were identified in the CF granules as opposed to a single population of viscosities in non-CF granules. This indicates a heterogeneous nature of the CF granules, which might be related to the pathology. Overall, our results suggest that BODIPY viscometers could be viable tools for assessing the viscoelastic properties of mucin matrix within intact granules in live cells. Combining FLIM studies with such molecular viscometers should provide valuable insight into various stages of CF mucus pathogenesis, and potentially could aid in the development of efficient therapeutic approaches to combat the disease.Item Opportunities for Tuberculosis Prevention in Private Sector Healthcare: Health Insurance and Usual Sources of Healthcare in Foreign-Born Persons with Latent Tuberculosis Infection(2019-03-05) Stockbridge, Erica L.; Miller, Thaddeus; Mun, Eun-Young; Annan, EstherOpportunities for Tuberculosis Prevention in Private Sector Healthcare: Health Insurance and Usual Sources of Healthcare in Foreign-Born Persons with Latent Tuberculosis Infection E. Annan 1, E. L. Stockbridge 2, T. L. Miller 2, E.Y. Mun2 1Department of Biostatistics & Epidemiology, University of North Texas Health Science Center, Fort Worth, TX, United States. 2 Department of Health Behavior & Health Systems, University of North Texas Health Science Center, Fort Worth, TX, United States. Abstract Background: Preventing TB in the foreign-born US population is a priority, as over two-thirds of active TB cases in the US occur among foreign-born persons. With 90% of incident active TB cases among foreign-born persons stemming from reactivation of latent TB infections (LTBI), there is a need to increase targeted LTBI testing and treatment in foreign-born persons. It may be feasible to conduct these activities within the US private healthcare sector, but LTBI-positive foreign-born persons' use of healthcare and ability to pay for care will facilitate or impede such a strategy. These characteristics are not well-described in current literature. Aims: (1) Estimate LTBI prevalence among foreign-born individuals by health insurance status and usual source of healthcare (USHC); and (2) examine patterns of insurance coverage and USHC among foreign-born persons with LTBI. Methods: We analyzed 2011-12 National Health and Nutrition Examination Survey (NHANES) self-reported health insurance and USHC data for foreign-born individuals in combination with markers for LTBI. The sample was restricted to civilian, noninstitutionalized, foreign-born persons ages 6 years or older with interferon gamma release assay (IGRA) results and self-reported insurance and USHC data (N=1,793). We used Stata /SE 15.1 to conduct analyses and adjust for complex sampling design. Results: Overall, 15.9% of our sample were LTBI-positive. Of LTBI-positive persons, 37.0% had some form of insurance and 76.9% had a USHC. LTBI prevalence was highest in persons who used a clinic or health center as a USHC (17.3%), but 44.6% of persons with LTBI use a physician’s office or HMO as a USHC. Insured persons had a slightly higher prevalence of LTBI than uninsured persons (16.2% and 15.3%, respectively). While LTBI prevalence was highest in persons with Medicare, persons with LTBI were most likely to be uninsured (37.0%) or have private insurance (33.1%). In total, 56.7% of persons with LTBI had both health insurance and a USHC, while 20.2% had neither insurance nor a USHC. Conclusion: Both health insurance and USHC were common within foreign-born individuals with LTBI residing in the US. Although different strategies are needed to address LTBI within the vulnerable population of foreign-born persons without health insurance or USHC, our results suggest that targeted LTBI testing and treatment within the US private healthcare sector could reach the majority of foreign-born individuals with LTBI.Item Patellar Component Fixation Strength with Varying Bone Defect Following Revision Total Knee Arthroplasty(2019-03-05) St. Louis, Blake; Nwannunu, Brian; Kosmopoulos, Victor; Powell, Jake; Wagner, Russell; Beck, CameronPurpose: Total knee arthroplasty (TKA) is an effective surgical treatment with only an 8.2% revision rate. A revision TKA can be initiated for several reasons including prosthetic loosening, infection, and pain. During a revision TKA, the three pronged “patellar button” may need to be removed and replaced from the posterior aspect of the patella. After removal, the quality of the remaining patellar bone is evaluated to determine if another patellar component is a viable option. Anecdotally, orthopedic surgeons visually inspect the patella to evaluate the amount of bone defect present. They then have to decide whether to replace the patellar button or pursue another path of repair. Currently there is no scientific basis to assist them in deciding how to best proceed. This study aims to determine the maximum shear force prior to failure of a cemented patellar component with varying degrees of bone defect. Methods: 60 pairs of patellae were harvested from embalmed cadavers. Each patella pair was visually inspected by an orthopedic surgeon and separated based on bone quality into a control (better bone quality) and experimental group (worse bone quality). Those within the experimental group were further divided into three groups, of 20 each, consisting of either a single defect, double defect, or triple defect. The patellae were then prepared as if performing an intraoperative revision TKA. Before cementing the patellar component, defects were created in each patella according to their experimental group (single, double, or triple defect) using a Dremel tool and metal washer to ensure each defect was the same size. A patellar component was then cemented to each patella using the same surgical procedure used during a revision TKA. After allowing the cement to cure, the patellae were potted into a mold using fiber glass resin. Maximum shear force was then tested with a material testing system (MTS). Results: The 60 pairs of patella range in age from 56 years old to 99 years old with an average age of 80. Thirty-one patella pairs were male (51.67%) and 29 pairs were female (48.33%). Data is currently being collected and analyzed regarding the shear force of the patellar component with the 3 different varying bone defect sizes. Conclusions: The further evaluation of the data will serve to provide physicians with clarity when faced with the question of what to do with the patella in the case of a revision TKA.Item Pediatric Midstream Urine Collection Methods in the UCC: Post-Intervention Surveys(2019-03-05) Henson, Robin; Collins, Audra; Hamby, Tyler; Zia, SamadPurpose Urinary tract infections (UTIs) are one of the most common bacterial infections in the pediatric population. Diagnosing UTIs requires a urinalysis and often a urine culture. Diagnosing a UTI in the toilet trained child requires consistent staff education and materials for specimen collection to avoid risk of contamination. Contamination of a urine sample can be reduced with a policy which includes consistent instructions to patients and provision of the correct materials. A quality improvement (QI) project conducted in June 2017 at Cook Children’s Pediatric Urgent Care Center (UCC) in Fort Worth surveyed patients and parents regarding midstream urine collection (MSUC), and it showed that the MSUC policy was not consistently followed by the UCC staff. Online education and training were then provided to clinical staff to reinforce this policy. The objective of this QI project is to conduct the same patient/parent survey to determine if the staff education improved adherence to the MSUC policy. Methods The patient/parent survey, which was used in June 2017, was again administered to patients in June 2018. The survey included questions concerning Cook Children’s MSUC policy. Patients (ages 4-18) who presented with signs of UTI were given the survey after staff instruction was given and urine was collected. The surveys were conducted at Cook Children’s Pediatric UCC in Fort Worth, Texas. Results A total of 20 (2017) and 19 (2018) patients were surveyed. Patients in 2018 were significantly more likely to receive instructions to use 3 wipes, receive 3 or more wipes, and actually use 3 wipes. There was no significant difference in the likelihood of receiving gender-specific instructions, receiving MSUC instructions, following gender-specific instructions, or following MSUC instructions. Conclusions The distribution of pre-assembled packets of materials enabled all patients to receive the proper number or wipes. However, staff should be encouraged to provide pre-assembled packets as well as verbal instructions to each patient. Educational interventions for UCC staff should be re-evaluated and repeated throughout the year. Further educational interventions for the UCC staff may result in a greater adherence to the Cook Children’s MSUC policy and a decrease in midstream urine contamination rates.Item Perceived Fatigue May Be an Overlooked Barrier to Successful Therapeutic Lifestyle Change(2019-03-05) Hamby, Tyler; Jarvis, Todd; Wilson, Don; Hamilton, Luke; Bopp, BenPurpose Children and adolescents at-risk of developing premature cardiovascular disease (CVD) due to genetic disorders and acquired conditions, such as obesity and insulin resistance, are often referred to a pediatric lipid clinic. While adoption of a lifelong, heart-hearty lifestyle is encouraged, those with genetic disorders may benefit from lipid-lowering medications. Recommendations for therapeutic lifestyle change in those who are obese, especially the need for less sedentary time and 30-60 min/d of moderate-to-vigorous physical activity, may be hindered by a perception of fatigue. An increased perception of fatigue in obese youth vs healthy controls has previously been reported in those referred to an obesity clinic. The purpose of this study was to examine perceived fatigue in a sample of obese youth (age; BMI ³95th percentile) with acquired CVD risk factors, who were referred to a pediatric lipid clinic. METHODS This study was a retrospective chart review of 237 youth referred to the Risk Evaluation to Achieve Cardiovascular Health (REACH) clinic at Cook Children’s Medical Center between January 1, 2014 and August 31, 2018. During the initial clinic visit, each subject and the child’s parent independently completed the PedsQL Multidimensional Fatigue Scale, a validated survey with 18 items divided into 3 subscales – General, Sleep/Rest, and Cognitive – each containing 6 questions. A total score was computed, the range of possible scores ranging from 0 to 100 for each subscale. Higher scores indicate less perception of fatigue. A t-test was used to compare study subjects to previously reported obese youth (N=43) referred to an obesity clinic and normal weight, healthy controls (N=157). A p-value RESULTS The study population consisted of 200 subjects, 50.5% of whom were morbidly obese (³99th percentile). Study subjects had statistically significantly more perception of fatigue for each sub- and total scale for both self- and parent-reported scales (p CONCLUSION Obese youth with and without reported acquired CVD risk-factors experience greater perceived fatigue than healthy controls. It is important to consider barriers to implementation, such as perception of fatigue, when recommending lifestyle modification.