Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/30818


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    Bowel Associated Dermatosis Arthritis Syndrome
    (2022) Hasan, Aya
    Background: Bariatric surgery is the most effective weight loss therapy available for patients with morbid obesity and can be considered when non-operative means such as diet and exercise, nutritional counseling, and weight loss programs have failed. Gastric bypass surgery may produce malabsorptive or surgical complications, which can result in nutritional deficiencies as well as syndromes related to bacterial overgrowth in the blind loops of bowel created, known as Bowel Associated Dermatosis Arthritis. Case Presentation: A 37-year-old female presented with a pruritic rash for 3 months. It was initially located on her inner thighs and spread to involve her feet, groin, abdomen, arms, and hands. She complained of intense vaginal itching as well. She had been treated unsuccessfully with multiple agents that included oral and topical antifungals, permethrin 5% cream, triamcinolone cream, and cetirizine without improvement in her itching. She had a history of gastric bypass surgery for obesity 6 months prior to onset of the symptoms. Her past medical history was significant for type 1 diabetes mellitus, diabetic neuropathy, hypertension, hyperlipidemia, rheumatoid arthritis, depression, and hypothyroidism secondary to I131 ablation for Graves disease. Examination revealed eczematous plaques on her hands, feet, and ankles with confluent erythema on the lower legs that partially blanched. Erythema and edema of the tongue, and fissures of the oral commissure with erythema were noted as well. The findings were consistent with a nutritional deficiency. She was started on crushed B vitamins, Zinc, and Vitamin C. Improvement of the glossitis, angular cheilitis, and rashes were noted with no new petechiae seen at one-week follow-up. Nine months later, we were again consulted on this patient for a recent onset of painful skin abscesses that were being treated with incision and drainage, intravenous vancomycin, and topical mupirocin. After incision and drainage, the lesions were noted to be healing poorly and were more painful. Examination revealed eczematous plaques with sharply defined borders on the upper and lower extremities, including the palms and soles, and trunk. An exquisitely tender erythematous nodule with central pustule and crust was seen on the left occipital scalp. Histopathologic examination of the scalp nodule showed psoriasiform hyperplasia with a focal area of ulceration along with a diffuse infiltrate of neutrophils throughout the dermis. PAS, Fite, and Brown-Brenn stains were negative. The histopathology was consistent with bowel-associated dermatosis-arthritis syndrome. She was treated with broad-spectrum antibiotics and colchicine. Following successful treatment of this patient's skin manifestations caused by complications secondary to her bariatric surgical procedure, the patient continued to lose weight despite adequate dietary caloric and protein intake. Her bypass procedure was reversed, and the patient's skin eruptions completely resolved. Conclusion: This case demonstrates the complications that can arise because of alterations made in the gastrointestinal anatomy. With a limited number of cases, bowel-associated dermatosis-arthritis is a clinically important syndrome to recognize because these patients, as was our patient, can be subjected to non-therapeutic repeated incision and drainage procedures.
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    Patellar Fracture Non-Union with Patella Baja Treated with Repeat Open Reduction Internal fixation and Tibial Tubercle Osteotomy: A Case Report
    (2022) Ver Hoef, John M.
    The following case explores a possible treatment modality for instances of patellar non-union with patellar Baja after fracture. The incidence of patellar non-union is rare, and review of treatment possibilities is limited to a few case series. In this case, a 59-year-old male presents with anterior knee pain and a dysfunctional extensor mechanism. It was found that the patient had patellar non-union after a failed patellar fracture reconstruction four years prior to presentation. The pain was restricting his mobility and reducing his ability to carry out his activities of daily living, and he was seeking definitive treatment. After careful consideration, it was decided a tibial tubercle osteotomy and lift was necessary to ascend the patella Baja, and the patella would be approximated and fixed with k-wire. The procedure was successful and one year later the patient returned for hardware removal. The patient healed well and had regained function in his extensor mechanism. The patient was lost to follow up and did not complete physical therapy. Three years later the patient had returned for checkup and reports significant reduction in pain but is still having difficulty with extension. The patient was found to have atrophied quadriceps muscles in the affected leg leading to weakness and suboptimal knee extension. Though the original reconstruction model had merit, the tibial tubercle osteotomy was elevated slightly too far leading to hyperflexion in the knee and a weak extensor mechanism. This case report serves to review the causation of the patient's outcome and the possible merit in the procedure to treat patellar non-union with Baja. By reviewing cases like these the literature base is increased to help guide clinical decision making in similar situations.
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    Comparative Analysis of Same-Day Surgery Cancellations for Total Joint Arthroplasty Patients at JPS between 2018 and 2019
    (2022) Lyons, Cody; Wagner, Russell
    Background Same-day surgery cancellations create an enormous financial burden by wasting hospital resources such as healthcare professional labor hours, operating room time, and underutilizing surgical equipment. The aim of this study was to follow-up a previous study investigating reasons for same-day surgery cancellations, and to determine if there has been a decrease in same-day surgery cancellations in 2019 compared to 2018 after the implementation of an optimization clinic. Methods This is an incidence study comparing knee and hip replacement surgical candidates between two years. We will review the reasons for cancellations during 2018 and compare those with our data collected for 2019 knee and hip replacement same-day surgery cancellations. Results We are awaiting data collection and analysis for same-day surgery cancellations in 2019, but the top three reasons for cancellation in 2018 included the discovery or development of a new medical condition and/or contraindication to surgery, abnormal pre-operative test results, and the lack of beds being available. An optimization clinic for all preoperative arthroplasty patients was instituted after collection of the 2018 data. The data collected should reveal if the optimization clinic has led to a decrease in same-day surgery cancellations, and therefore, hospital losses. Conclusions In the 2018 data collection, two areas were identified as having potential for immediate improvement, availability of hospital beds and problems with surgical equipment, implant, or supply. Based on 2018 findings, implementation of strategies to eliminate these issues could decrease the yearly cancellation rate by an additional 30%. With new information on 2019 cancellations, we will not only compare 2018 vs. 2019, but we could follow the data longitudinally to see where JPS could potentially save hundreds of thousands of dollars in the future.
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    Diaphragmatic breathing impacts on biophysiological systems
    (2022) Thomas, Prince
    Anxiety and stress has been at an all-time high in recent years for various reasons. With added anxiety and stress comes a plethora of preventable diseases such as heart disease, asthma, diabetes, Alzheimer's disease, etc. The purpose of this study was to examine diaphragmatic breathing as an underutilized tool that may result in body relaxation and help with physical and mental health. Specifically, we are looking at the biophysiological changes that can be monitored, and how they are impacted by diaphragmatic breathing practices. This systematic review utilized PubMed and Scopus databases to identify 10 articles that met our inclusion criteria. Key words used were diaphragmatic breathing; mental health; real-time feedback; relaxation; sustained attention; DASS-21; HbA1c; diaphragmatic breathing; stress management; systematic relaxation; type 2 diabetes mellitus. The results displayed that Diaphragmatic breathing has an impact on multiple factors that correlate with overall health and well-being. We saw that diaphragmatic breathing interventions resulted in cortisol levels decreasing, Beck anxiety inventory scores decreasing, Dass-21 showing less depression, peripheral temperature decreasing, heart rate decreasing, blood pressure decreases, and decreased breathing rate. Studies have also shown better glycemic control for individuals with type 2 diabetes who participated in a diaphragmatic breathing protocol. The data that we looked at suggested that diaphragmatic breathing has positive implications for overall health and wellness. Stress management in the United States are often pharmacological interventions that can be costly and difficult for some to access. Diaphragmatic breathing is a free practice that has shown to provide positive results for individuals to improve their mental and physical health with minimal side effects.
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    Burnout and Emotional Intelligence in Neurosurgical Advanced Practice Providers Across the United States: A Cross-Sectional Analysis
    (2022) Richards, Alexandra E.; Neal, Matthew; Curley, Kara; Zhang, Nan; Bendok, Bernard; Zimmerman, Richard; Patel, Naresh; Kalani, Maziyar; Lyons, Mark
    Purpose: Although much research has examined nursing and physician burnout, the advanced practice provider (APP) population has not yet been studied. The goal of the present study was to survey APPs in neurosurgery to determine whether greater emotional intelligence (EI) is protective against burnout. Methods: An 80-item survey was created that incorporated the Maslach Burnout Inventory Human Services Survey for Medical Personnel, the Trait Emotional Intelligence Questionnaire-short form, and original questions developed by us. The collective survey was distributed, administered, and collected using the web-based REDCap (Research Electronic Data Capture) platform. Statistical analyses were completed using a comparison between participants with and without burnout. Results: A total of 106 neurosurgical APPs (26 men, 80 women) completed the survey, of whom, 57 (54%) reported current burnout. High average scores for personal accomplishment and global EI were inversely related to burnout (P = 0.034 and P = 0.003, respectively). In addition, the following factors were associated with burnout: inadequate support staff in the work place (P = 0.008), inadequate time off work (P < 0.001), inadequate administrative time (P = 0.009), not experiencing support from one's supervisor (P = 0.017), insufficient time for continuing medical education (P < 0.001), an inability to separate work from personal time (P < 0.001), and an inability to advance within one's professional field (P = 0.043). Conclusions: For neurosurgical APPs, EI is protective against burnout. Many opportunities exist at the individual and organizational level to alleviate burnout among neurosurgical APPs. Targeted strategies to improve work-life balance, EI, support systems, and opportunities for career development among neurosurgical APPs might enhance employment satisfaction and reduce burnout.
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    Early Axial Interfragmentary Motion and its Impact on the Fracture Healing Environment: A Scoping Review
    (2022) Rechter, Griffin; Anthony, Ryan; Rennard, Justin; Kellam, James; Warner, Stephen
    Purpose: The initial interfragmentary motion (IFM) at a fracture site determines the mode of fracture healing. Controlled axial IFM is thought to promote successful fracture healing, however the effects of minimal and excessive IFM can be detrimental to osteogenesis. Understanding the consequences of altering the fracture environment is important to advance our comprehension of fracture healing and has implications for surgical interventions. This review aims to consolidate information from the literature to assess our understanding of the effects of early axial IFM on fracture healing outcomes. Methods: PubMed and Medline databases were queried to identify studies from inception until June 2021 assessing axial IFM on fracture healing outcomes. 4,972 studies were initially identified. Following recommendations from PRISMA guidelines, two independent reviewers screened all studies, and data was extracted into a standardized spreadsheet. All outcome measures were recorded, including histomorphometric and radiographic analysis of the callus, biomechanical testing of callus strength, and time to union. Data synthesis is presented as a narrative review of our findings. Results: Fifteen studies met inclusion criteria totaling 605 fractures and osteotomies in skeletally mature participants. 423 animal and 182 human subjects were examined. Nine studies investigated IFM at the tibia, 4 at the metatarsus, and 2 at the femur. The gap size did not exceed 6mm in any study. The range of IFM in investigated tibias, metatarsi, and femurs was 0.32-2.0mm, 0.1-2.4mm, and 0.03-1.0mm, respectively. The median time to analysis was 9 weeks. Notable findings included no statistically significant association between early IFM and healing outcomes in experimental femur studies. All experimental tibial studies showed positive effects on callus formation with small-to-moderate axial IFM. Most studies found that allowing early micromovement produced superior callus stiffness and rigidity compared to rigid fixation, however continuing to increase the IFM negatively impacted biomechanical outcomes despite producing a larger callus. While increasing IFM often led to an enlarged callus size, the callus quality was compromised. Conclusions: The range of initial axial IFM conducive to a favorable fracture healing environment remains elusive. Preliminary evidence suggests an association between small-to-moderate initial axial IFM for stimulating successful fracture healing. However, heterogeneity in results and methodology precluded meta-analysis and comparability amongst studies. The cumulative evidence in the literature is insufficient to determine a definite correlation between the axial IFM and fracture healing outcomes. Future research should be directed at controlled trials and investigation of human subjects to understand the implications of orthopedic interventions on fracture healing outcomes.
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    Rethinking the dose response and risk-benefit relation for health benefits of exercise
    (2022) Craig, Ryan; Paris, Sorrel; Biggerstaff, Matthew; Thakkar, Harsh; Smith, Michael
    Purpose: The dose response relationship between exercise and all-cause mortality has been well documented. The current Health and Human Services (HHS) guidelines recommend 150 minutes of moderate intensity exercise per week. This presents a barrier to entry for many patients, as demonstrated by nearly half of all Americans not meeting the HHS guidelines for daily aerobic activity. Methods: Using data from cohort studies, randomized control trials, and case control studies, we evaluated health outcomes at exercise volumes lower than the current recommendations. We used the 2011 Compendium of Physical Activities to quantify the contributions of daily activities and exercises to achieve activity level recommendations. Results: Despite current guidelines suggesting a minimum amount of 150 minutes of moderate intensity exercise to achieve benefit, we found there was statistically significant benefit occurring at much lower volumes of exercise. The largest change in overall mortality is often seen when comparing groups of no or minimal amounts of exercise to those engaging in low amounts of activity. This low level of energy expenditure can often be achieved without engaging in classical "exercise" regimens. Conclusion: The current exercise recommendations can challenge patients' time, resources, physical capability, and self-efficacy. While current guidelines emphasize 150 minutes of moderately intense activity per week, patients benefit from much lower weekly physical activity volumes. A reframing of what is considered exercise would allow patients to subjectively feel more confident in their ability to influence their health through movement. Patients can also be challenged by the specific recommendations of aerobic exercise. This may be remedied by guiding patients to consider daily, non-exercise modalities as sources of weekly activity. Ultimately, assessing the risk-benefit relation to total exercise workload may provide a novel approach to determining optimal targets for exercise that provide the safest and most efficacious exercise regimen. Therefore, clinical discussions focused on prescribing exercise should begin with acknowledgement of normal daily activities that promote energy expenditure and encouraging patients to increase overall weekly movement.
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    Memorial Medical Clinic Fall Risk Assesment: Quality Improvement Project
    (2022) Ibarra-Aleman, Victoria; Crowley, William
    Purpose: For patients 65 and older, injuries sustained from falls can lead serious injuries and can cause a decrease in the elderly individual's quality of life. Therefore, screening for fall risks is important in the prevention of future falls and the consequences associated with those falls. Memorial Medical Clinic did not assess for fall risk in patients 65 or older; however, the clinic was now positioned to do fall risk screenings because they had the resources and the staff needed to perform this. This project looked at the correlation between increased fall risk assessments and increased screening of fall risk in the clinic. Methods: Data was gathered from November 9-30, 2021, using convenient sampling. Patients were screened with the "Stay Independent-STEADI" questionnaire. Patients were given the questionnaire by the medical assistant on intake, and the patient filled out the survey while they waited for the provider to arrive. The average number of patients who were screened for fall risk and total number of patients who fit into the sampling population was evaluated. Results: With the implementation of the screening, using the STEADI questionnaire, fall risk screening increased from 0% to 83.9% and 19 individuals with risk of falling were identified (4 or more points on the STEADI questionnaire). Throughout the study, only 1 person was excluded because they were deaf, mute, illiterate, and did not know sign language. Conclusions: Through the study, it was found that many of the elderly patients with risk of falling were already being seen at the clinic for the factors that placed them at risk. Additionally, with a system in place, the clinic was now positioned to continue performing fall risk screenings using the STEADI questionnaire. Throughout this quality improvement project, it was also identified that patient flow in the clinic needed to be improved to be more efficient in the handing out of the STEADI questionnaire. The need for more training in newly hired staff was also encountered. Both would be great areas for future quality improvement projects.
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    Ultrasound Guided Cervical Plexus Block Cadaver Training
    (2022) Banh, Debini; Quach, Shanon; Crawford, Lakiesha
    Background Ultrasound guided techniques have become increasingly used in medicine to increase success rates and decrease complications of procedures such as central line placements, paracentesis, and regional nerve blocks. Ultrasound guided brachial plexus blocks are commonly used in surgeries and procedures involving the distal clavicle, shoulder, and proximal humerus. A majority of the training for nerve blocks were previously done on the job with live patients. There is limited research behind training on human cadavers. Ultrasound guided nerve block training on cadavers would enhance training for any medical education that involves such skill sets. Methods Fresh human cadavers were imaged using a Butterfly ultrasound on the nerve imaging preset. The brachial plexus was imaged in the transverse plane superior to the clavicle. The supraclavicular artery was used as the initial landmark. The probe was then moved superiorly until the anterior and middle scalenes came into view. A 25 gauge 1 inch needle was inserted in the transverse plane between the anterior and middle scalenes. Saline was then used to simulate local anesthetics and injected between the anterior and middle scalenes to simulate a brachial plexus nerve block. Results The images obtained from fresh human cadavers provided a more realistic image of the brachial plexus and surrounding structures such as the anterior and middle scalenes, the sternocleidomastoid, and the surrounding fascia compared to a phantom model of a nerve plexus. A fresh human cadaver was adequately able to simulate a nerve block in a live patient. Conclusion Cadaver ultrasound guided nerve block training would be an effective model to provide both medical students and interns to enhance their skills outside of the clinical setting. The realistic experience through cadavers would decrease the patient's procedural discomfort and increase confidence and the success rate of providing regional anesthesia including a brachial plexus block.
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    An Examination of the Importance of Electromyography (EMG) and Nerve Conduction Studies (NCS) Studies in the Evaluation of Persistent Paresthesia of the Hand Through Two Clinical Cases
    (2022) Grice, Amy; Pedersen, Brandon
    Background: Provocative clinical tests are often performed during the physical exam when patients present with paresthesia of one or both hands. Although Tinel's test is commonly done at the wrist and elbow for suspected neuropathy, studies have shown that this test does not have a high sensitivity or specificity. Electrodiagnostic testing can be used to accurately determine the cause of suspected neuropathy and provide useful information not provided by provocative testing. Case Information: The first patient was a 90-year-old male who presented with a six month history of progressively worsening numbness and tingling in the right fourth and fifth digits. The second patient was a 52-year-old male who presented with persistent numbness and tingling in the fourth and fifth digits of the hands bilaterally. On physical exam, Tinel's test was performed at the wrists and elbows with both patients testing negative bilaterally for both. Nerve conduction studies revealed that the 90 year-old patient had a significant drop in conduction velocity across the elbow for the right ulnar nerve. For the 52 year-old male, nerve conduction studies showed prolonged latency and diminished amplitude of the left ulnar sensory nerve across the wrist. Conclusions: Despite both patients having similar presentations, electrodiagnostic testing showed that the cause of their symptoms was different. Consistent with the recent literature, our negative Tinel's test and positive NCS findings in two cases of patients with ulnar neuropathy further support that physicians cannot rely on special tests alone to pinpoint the location or clarify the cause of symptoms consistent with neuropathy. Additional testing is needed, particularly in the form of EMG and NCS studies, to further elucidate the cause of the pathology to better direct care and find the patient proper treatment to restore function.
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    A Novel Approach for Stent Removal After Migration
    (2022) Sahu, Shweta; Roberts, Jay
    Background: Bariatric surgeries, including Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch, are becoming increasingly prevalent in not only the US, but in the world as a whole. Though rare, complications after bariatric surgery can occur, with the most feared complication being gastric/ anastamotic leaks. One well known, safe and efficacious treatment of these leaks includes the placement of self-expandable metal stents (SEMS). Unfortunately, these SEMS have been known to move to a location other than where they were originally placed, a phenomenon known as "stent migration." Case Presentation: A 33-year-old Caucasian female with morbid obesity presented to clinic to pursue Roux-en-Y gastric bypass surgery after numerous failed attempts to lose weight. Though she was asymptomatic at the time, the patient elected to pursue the surgical weight loss management option after a trial of medical treatment for obesity, in which she was unable to maintain the weight loss for an extended period of time. This, in conjunction with her growing risk of medical comorbidities associated with her pre-existing morbid obesity, determined the management with laparoscopic Roux-en-Y gastric bypass, which proceeded with no complications during the time of surgery. Nine months later, the patient presented with dysphagia and epigastric pain, which prompted the need for esophagogastroduodenoscopy (EGD) which revealed erosive gastritis and a large marginal ulcer traversing the anastomosis. Though the patient tolerated robotic revision of the gastrojejunostomy (GJ) well, she developed another gastric perforation that required placement of a 12mm x 24 mm SEMS in order to close the leak at the GJ anastomosis. The patient presented to clinic with discomfort yet again, and this time, imaging revealed the stent had migrated distally, and was located just proximal to the jejunostomy. A typical endoscope (approximately 2.5 feet in length) is not sufficiently long enough to reach this area, and thus a unique 2 surgeon approach was taken to retrieve the migrated stent using a colonoscope, typically 5 feet in length. Conclusion: This case illustrates an innovative approach to removing a distally migrated stent, a known complication of endoscopic stent placement in the management of gastric/ anastamotic leaks after bariatric surgery.
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    An Intraoperative Diagnosis of Intrathyroid Parathyroid Adenoma in a 34-year-old Hispanic Female: A Case Report
    (2022) Shirai, Ren; Przybyla, Jeffery
    Background: Up to 85% of primary hyperparathyroidism is caused by a single parathyroid adenoma, which most commonly occurs in the external aspect of the inferior pole of the thyroid. In rare cases, they are found within the thyroid gland. Even with recent advancements in ultrasound (US), Tc-99m sestamibi scintigraphy, and computed tomography (CT) scan, preoperative localization of intrathyroid parathyroid adenomas (IPA) may be difficult. Surgeons may occasionally be required to make an intraoperative diagnosis and perform an unplanned hemithyroidectomy. Case description: A 34yo Hispanic female was referred due to complaints of multiple episodes of nephrolithiasis, recent onset of arthritis in her hands and wrists, bilateral hearing loss, and fatigue. Her labs showed 130 pg/mL PTH, 11.0 mg/dL Ca, and 6.1 mg/dL ionized Ca. Further workup with US imaging and sestamibi scintigraphy revealed a single left parathyroid adenoma. The patient subsequently underwent a selective parathyroidectomy. Intraoperatively, the posterior aspect of the gland was looked over carefully to locate the parathyroid adenoma as previously seen on US. However, no adenoma was visualized on the superior or inferior poles. A decision was made to resect the left thyroid lobe. The resected specimen was then sent to pathology for an intraoperative frozen section examination, which confirmed the presence of the IPA. Conclusion: A definitive preoperative diagnosis of IPA may be limited with current imaging modalities. Our case report suggests that an IPA can be diagnosed intraoperatively using frozen section following a careful exploration.
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    Histopathologic Characterization of Lichen Planopilaris, Frontal Fibrosing Alopecia, and Central Centrifugal Cicatricial Alopecia
    (2022) Lim, Henry; Kim, Suhhyun; Dhaliwal, Parneet; Cockerell, Clay
    Intro Lichen Planopilaris (LPP), Frontal Fibrosing Alopecia (FFA) and Central Centrifugal Cicatrical Alopecia (CCCA) are a lymphocytic group of primary cicatricial alopecias (PCA) that are often histologically and immunophenotypically indistinguishable. When left untreated, they result in irreversible hair loss that often results in mental anguish and disturbed self-perception. Clinical overlap of symptoms such as scalp pain or pruritus, follicular hyperkeratosis and perifollicular erythema often require the involvement of characteristic sites and scalp biopsy to make a more definitive diagnosis. Overlap in histopathologic features limits current diagnostic evaluation but also alludes to a common pathomechanism with potential clinical implications. Due to the lack of any controlled study regarding the treatment of these PCAs, current treatment is guided by available case reports and expert opinion. These options with varying efficacy include the use of steroids, calcineurin inhibitors, 5α-reductase inhibitors, Janus Kinsase (JAK) inhibitors, hypoglycemic drugs, and over the counter products. The purpose of this study was to characterize histopathologic similarities between LPP, FFA, and CCCA in order to better define these entities and guide therapeutic targets. Methods A minimum of 25 histologically confirmed cases of LPP, FFA, and CCCA H&E slides were re-examined by a trained dermatopathologist to investigate the common histological findings. Results All across LPP, FFA, and CCCA, there were features of lymphocytic infiltrate particularly around the mantle zone area along with perifollicular fibrosis. The inflammatory infiltrates predominantly consisted of lymphocytes, and the only presence of neutrophils was secondary to rupture of follicles. Conclusion To our knowledge this is the largest case series comparing histological features of LPP, FFA, and CCCA. As these three alopecia exhibit similar pathological changes, it may suggest that they are clinical variants of the same disease process. Current data in the literature has yet to demonstrate a consensus on content of lymphocytic infiltrate and trigger for lymphocytic migration. Future direction of treatment innovations should thus focus on early detection, prevention of scalp trauma, and therapies that target early lymphocytic changes.
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    Designing a study to examine acute cross-over effects of lower limb muscle fatigue during upright standing
    (2022) Agana, Anton; Chen, Kuanting; King, Adam
    Research Question: Are there acute cross-over effects of lower limb muscle fatigue on movement strategies of young adults during upright standing? Background: Our study will make use of three major concepts: the cross-education phenomenon, muscle fatigue, and postural control. The cross-education phenomenon is a theory that dates as far back as 1898 in which it was first coined by Walter Davis in his work and it pertains to the effects of training one side of the body to the untrained contralateral or opposite side. Cross-education experiments have since been expanding in various other aspects of physiology, such as its effects in strength training, muscle size preservation, hip flexor stretching, speed of voluntary effort, and flexibility to name a few. Looking at these various research studies, we can see evidence of cross-education phenomenon in various physiological aspects regardless if it's upper extremity or lower extremity. This leads us to ask if cross-education can be seen in movement strategies and postural control as well. Muscle fatigue, our second concept, is the decrease in maximal force as a response to contractile activity. It can be described in various ways, such as central vs peripheral or global vs local. Finally, Postural control is the ability to control one's body position in space for stability and orientation. Simply put, it is the ability to be able to maintain upright standing. Looking at these three components-the cross-education phenomenon, muscle fatigue, and postural control-that have been studied over the last century, we have developed a research idea that uses the influence these three have on each other. Our research will generate a quantitative analysis of the cross-educational phenomenon on postural control by observing contralateral muscle fatigue. Materials and Methods: Twenty individuals are expected to enroll in the study. Participants will be healthy young (18-35 years old) adults, with no known balance disorder, neuromuscular disorder/impairment, or lower extremity injuries. Postural control data will be collected with a force plate. Participants will perform pre- and post-fatigue balance tasks on a force plate that includes single-legged standing with variations of the right and left foot and stable and unstable surface types. Following initial balance assessment a fatigue task of single leg standing calf raises will be performed until exhaustion. Data from pre-fatigue balance tasks and post-fatigue balance tasks will be analyzed and compared. Anticipated Results, Conclusions, and Impact: We anticipate that acute fatiguability on one of the lower limbs in our subjects will influence contralateral postural stability and control during upright standing. We expect this to be supported objectively by measurements of the muscle activity from the force plate device. As for impact, we want to increase our understanding on postural control training through cross-education and be able to provide evidence via objective data. We also hope this study can provide new insight for various applications, such as physical rehabilitation or performance training.
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    Coronavirus Disease 2019 Pandemic Associated with Depression among Non-Hispanic Whites with Chronic Conditions in the United States
    (2022) Paul, Jenny; Wang, Hao; Ye, Ivana
    Purpose: During the coronavirus 2019 (COVID-19) pandemic, increased depression was reported, with mixed findings among individuals of different races and ethnicities. This study examines whether depression increased during the COVID-19 pandemic compared to the pre-COVD-19 period among different racial and ethnic groups in the United States. Methods: A cross-sectional analysis of secondary data from the National Cancer Institute's Health Information National Trend Surveys 5 (HINTS 5) Cycle 4 was conducted. Survey responses were separated into two groups based on date of response; a pre-COVID-19 cohort (before March 11, 2020, weighted N = 77,501,549) and a COVID-19 cohort (on and after March 11, 2020, weighted N = 37,222,019). The Patient Health Questionnaire (PHQ) was used to measure depression and results were further compared before and during COVID-19. Separate multivariable logistic regression analyses were used to determine the association of the COVID-19 pandemic depression after adjusting for age, sex, insurance, income, and education. Results: A higher percentage of Non-Hispanic Whites (NHW) with chronic conditions reported depression (20.7% vs. 9.3%, p=0.0034) during COVID-19 than pre-COVID-19. The adjusted odds ratio (AOR) of depression for NHWs with chronic conditions during the COVID-19 pandemic was 2.33 (1.17-4.65, p=0.018) compared to NHWs who participated in the survey before the COVID-19. Conclusions: The COVID-19 pandemic was associated with an increased prevalence of depression among NHW adults with chronic conditions, but not among people of color.
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    A Case Report of Situs Invertus Totalis and Polycystic Kidney Disease in a Newborn
    (2022) McCullough, Jason
    Background: Situs Inversus Totalis is a rare disorder in which the internal organs are reflected laterally. The prevalence of Situs Inversus Totalis is 1 in 10,000 live births. Children born with Situs Inversus Totalis can go on to live normal lives if no other conditions are present. Polycystic Kidney Disease (PKD) has multiple patterns of inheritance. PKD has been reported to follow autosomal dominant, autosomal recessive, and X-linked patterns of inheritance. Autosomal Recessive Polycystic Kidney Disease (ARPKD), which used to be called infantile PKD, has a prevalence of 1 in 20,000 individuals. ARPKD has a low life expectancy with 1 in 3 infants dying within the first month of life due to breathing problems, and 9 out of 10 infants who make it past the first month will die before the age of five. Situs Inversus Totalis and ARPKD are not directly linked, but both been associated to primary ciliary dyskinesia which could lead to both disorders occurring in the same infant. Case Information: A newborn child was diagnosed with Situs Inversus Totalis and ARPKD soon after being delivered. The mother was informed during the pregnancy that there was a risk of some abnormalities during prenatal screenings. Family history was not fully obtained due to the father of the child being a sperm donor. The newborn did not experience any symptoms from the Situs Inversus Totalis, but experienced problems associated with ARPKD, such as underdeveloped lungs. The newborn was monitored in the NICU to ensure symptoms could be treated appropriately. After symptoms had resolved, the mother and child were both discharged and returned home and told to follow routine newborn visits. There are currently no cures for ARKPD, but if the child becomes eligible, a kidney transplant could provide an improvement to the child's condition. Conclusion: Situs Inversus Totalis and ARPKD have been associated with primary ciliary dyskinesia but have not been shown to be directly linked together, but this association could provide insight into the condition of this patient. ARPKD is also linked to mutations in the PHKD1 gene but requires inheritance from both parents to be present. Since ARPKD is found in the infant, it can be inferred that both parents would be carriers if this was the cause, instead of the primary ciliary dyskinesia. As previously mentioned, the father's medical history was not obtained. However, in other families, genetic testing can be conducted to determine risk of certain hereditary diseases such as ARPKD. In cases where genetic testing was not conducted, prenatal screenings can be used to determine if any abnormalities are present. Parents should be aware if certain disorders run in their family and should talk to their physician to see if genetic testing or prenatal screenings are necessary. Treatment options for ARPKD are still being explored but further research can develop solutions to increase life expectancy of newborns diagnosed with ARPKD. Cases like this are rare but could provide more information on causes of ARPKD and Situs Inversus Totalis leading to these new solutions.
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    Current Practices and Outcomes of Patella Fracture Fixation
    (2022) Quiring, Mark; Wood, Addison
    Purpose Patella fractures account for approximately 1% of all fractures. Standard treatment includes nonoperative management, screw fixation, anterior tension band wiring, partial patellectomy, and plate osteosynthesis. The choice of surgical treatment is dependent on a multitude of factors, including fracture type, degree of displacement, age and expected activity, and more. Treatment of patella fractures with hardware can result in undesirable outcomes, including residual knee pain, stiffness, re-displacement or re-injury, and even hardware failure. Anterior plating of patellar fractures is a newer, promising treatment modality, reserved primarily for multifragmentation and severe displacement. This review aims to provide insight into outcomes and best practices regarding currently utilized surgical techniques for patella fractures. Methods A systematic search for articles was conducted in the PubMed database. Article types included were prospective cohort studies, retrospective reviews, and biomechanical studies, all from peer-reviewed journals. Studies conducted within the past decade (2012-2022) that analyzed fixation of various patella fracture patterns were included. Treatments of focus included standard screw fixation, tension band wiring, tension band wiring with augmentation, and various plating techniques. Fracture patterns ranged from simple transverse to complex comminuted patella fractures. Results Twenty-three studies (11 biomechanical, 8 prospective, and 4 retrospective) were included in the review, investigating a combined 394 individual patella fractures. The transverse patellar fracture was the most common fracture pattern treated and analyzed (10 articles) included in the review. Common outcomes analyzed included knee range of motion, activities of daily living, knee pain, and various standardized knee and patella scoring systems, such as the Modified Cincinnati knee rating system or the Kujala score. Conclusions Tension band wiring continues to remain a safe and proven technique for various fracture types of the patella. Plating constructs, as a newer modality, show promising results when compared to other standard methods in patella fracture fixation, including superior clinical outcomes, lower non-union rates, and fewer complications. Limitations of some plating techniques include lack of long-term data, especially the newer models, and increased associated costs. Biomechanical comparison between various anterior plates is limited and warrants further investigation.
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    The Incidence of Arterial Injury on CT Imaging in Cervical and Skull Base Fractures
    (2022) Stuebe, Caren; Al-Adli, Nadeem; Oh, Michael
    Introduction: Blunt trauma to the head and cervical spine can result in vascular injury, particularly to the carotid and vertebral arteries. Computed tomography (CT) angiography is replacing conventional cerebrovascular angiography in the screening of trauma patients with suspected arterial injury. We were interested in investigating the incidence of CT-identified vascular injuries in skull base and/or cervical fracture patients. Methods: To assess the incidence of CT-identified arterial injury, a retrospective review was conducted of traumatic cervical and skull base fracture patients at a level I trauma center from January 2015 to September 2021. Results: 726 total patients were identified. 50 patients were excluded for insufficient imaging data. 17 patients (6 with skull base fractures, 10 with cervical fractures, and 1 with both cervical and skull base fractures) received a non-CT imaging modality and were excluded. None had arterial injuries. 659 total patients received CT imaging, 422 with CT-imaged cervical fractures, 213 with CT-imaged skull base fractures, and 24 with CT-imaged cervical and skull base fractures. Of the 422 CT-imaged cervical fractures, 2 had carotid artery injuries, 20 had vertebral artery injuries, and 4 had both carotid artery and vertebral artery injuries. Of the 213 CT-imaged skull base fractures, 2 had carotid artery injuries and 2 had vertebral artery injuries. One of the 24 CT-imaged patients with both cervical and skull base fractures had vertebral artery injury. Conclusion: The incidence of CT-identified arterial injury was 6.16% in cervical fracture patients, 1.88% in skull base fracture patients, and 4.17% in patients with both cervical and skull base fractures. While CT-identified arterial injuries were noted, the incidence was low overall, although it appears higher in the setting of cervical, as compared to skull base, fractures. Future studies will assess the characteristics, screening, and outcomes of cervical and skull base fracture patients with arterial injuries.
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    A Case Report of Selective Skip Laminectomies and Subsequent Catheter Irrigation of a Holospinal Epidural Abscess
    (2022) Doederlein, Alexander R.; Beeton, George; Loeffelholz, Zachary; Sandu, Cezar
    Background: Holospinal epidural abscesses (HEAs) are exceedingly rare, with less than 25 case reports of the condition found in the literature. Broad-spectrum antibiotics are virtually always indicated in its treatment upon its diagnosis, which is typically made via magnetic resonance imaging (MRI). Furthermore, if fulminant neurological deterioration presents, surgical debridement of the infection can help reduce the infectious burden and improve long-term outcomes. Access to the epidural space is attained via laminectomies; however, extensive laminectomies can destabilize the spine. Various case reports noted that selective laminectomies at particular vertebrae can avoid this destabilization, while still allowing catheter access to the length of the spinal cord. Case Information: Our patient was a 60-year-old male who presented with altered mental status, neck pain, and fever. He was diagnosed with methicillin-resistant Staphylococcus aureus meningitis and bacteremia. An MRI revealed an epidural abscess running from the cervical spine through the lumbar spine with concomitant compression of the spinal cord, as well as numerous paraspinal musculature abscesses and a retropharyngeal/prevertebral abscess. The patient was started on broad-spectrum IV antibiotics; however, his condition continued to deteriorate. The decision was made to perform a surgical debridement. Laminectomies were performed at vertebrae T4 and T10, and catheters were then run cranially and caudally through these points to access the length of the spinal canal. The purulent material was aspirated, and an antibiotic solution was then used to irrigate the epidural space; meanwhile, the patient was cycled between Trendelenburg and Reverse Trendelenburg positions to facilitate drainage of the purulent material. Following the procedure, the patient's neurological status started to improve. He was kept on vancomycin postoperatively until his elevated inflammatory markers resolved. The patient recovered fully, and at three months follow-up had no neurological deficits. Conclusions: This surgical technique is an effective way to identify the inciting organism in a HEA, reduce the infectious burden, decompress the spinal cord, minimize surgical time and blood loss, and maintain stability of the spine without the use of instrumentation.
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    Sacroiliac Joint Fusion Using the iFuse Titanium Triangular Implant System: Longitudinal Outcomes Study
    (2022) Al-Adli, Nadeem; Richards, Alexandra E.; Smith, Gregory
    Introduction: Sacroiliac (SI) joint dysfunction causes severe, debilitating lower back pain that often interferes with activities of daily living. It is considered a significant contributor to low back pain in the general population and is amenable to treatment with minimally invasive techniques. This study aimed to characterize the patients who underwent elective SI joint fusion and evaluate the associated long-term outcomes. Methods: From October 2012 to October 2019, 230 eligible cases were identified. Demographic and medical history was collected retrospectively via chart review, while patient-reported measures were collected prospectively via electronic survey. The Oswestry Disability Index (ODI), 5-level EuroQol-5D (EQ-5DL), visual analog scale (VAS) for health, and Likert scales for satisfaction and repeat likelihood were utilized to evaluate long-term outcomes. Patient-reported medications were utilized to calculate opioid oral morphine milligram equivalents (OMME). Results: Twenty-nine patients (M=9; F=20) with a mean age of 61.07 years (SD 12.23, range 31-79) and outcome data, on average, 5.06 years (1.91, 2.66 - 8.38) from surgery were included. Prior to surgery, 12% of patients had pain for less than 1 year, 35% for 1-2 years, 15% for 2-3 years, 19% for 3-5 years, and 19% for more than 5 years. 50% of patients were very satisfied with their surgery, 27% were satisfied, 15% were neutral, only 8% were dissatisfied, and no patients were very dissatisfied. Overall, 38% of patients were very likely to repeat the surgery for the same diagnosis, while only 19% were very unlikely to do so. Mean total ODI score was 16.52 (10.65, 0-72), EQ-5DL mobility was 2.21 (1.14, 1-5), EQ-5DL self-care was 1.42 (0.65, 1-3), EQ-5DL usual activities was 2.38 (1.13, 1-5), EQ-5DL pain discomfort was 2.50 (1.10, 1-4), EQ-5DL anxiety and depression was 2.00 (1.10, 1-5), and VAS health score was 65.08 (17.97, 29-90). ODI total percentage was strongly correlated with VAS health scores (r = -0.6059, p=0.0017). The mean OMME was 5.65 (13.25, 0-50), which was correlated with ODI pain intensity (r=0.2159, p=0.0065), ODI total percentage (r=0.4478, p=0.0248), and VAS health scores (r=-0.4920, p=0.0148). Lastly, pre-operative duration of pain was not significantly associated with ODI scores or VAS health scores. Conclusion: Our data suggest that patients who electively undergo SI joint fusion using the iFuse implant system are mostly satisfied with the operation and likely to repeat it for the same diagnosis. Furthermore, the operation is associated with long-term benefits demonstrated by the mean time since surgery for the entire cohort and their associated ODI, VAS health, and EQ-5DL scores. Lastly, pre-operative pain duration did not significantly affect the patient-reported outcomes, indicating that patients can expect positive outcomes, regardless of the chronicity of their pain prior to the operation. Future studies should focus on predictive factors of these longitudinal measures of patient quality of life, disability, pain features, and return to activity following SI joint fusion.