General Medicine

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    Preconception Care and Reproductive Life Planning: Engaging Primary Care Providers
    (2016-03-23) Fulda, Kimberly; Raines-Milenkov, Amy DrPH; Lee, Michelle; Wilder, Misty; Zhang, Julia; Salyer-Caldwell, Ann; Espinoza, Anna
    Purpose: In the United States, about 51% of pregnancies are unplanned (Guttmacher Institute, 2015). Preconception care (PCC) provides patients with the resources and knowledge to prepare for pregnancy and improve birth outcomes. By utilizing PCC, physicians can advise patients on numerous behavioral and lifestyle changes to help prevent complications from occurring. The usage of preconception care is a strong candidate to decrease the amount of unplanned pregnancies for women in their child bearing years. The objective of this project is to identify primary care providers educational and behavioral needs in preconception care screening practice. Materials and Methods: Participants were recruited from NorTex members “by-invitation only” recruitment. The preconception care surveys were administered on-line via email to clinicians, including primary care providers, pediatricians, OB-GYNs, nurse practitioners, and physician assistants to assess the essential role of clinicians in reproductive life planning. The survey contains approximately 12 questions and takes approximately 10 minutes to complete. The on-line responses were exported in a database and analyzed using Excel. Results: Of the 500 expected surveys, 149 have been completed of by family practice physicians (28%), OB/GYNs (10%), pediatricians (2%), physician assistants (5%), nurse practitioners (22%), and nurses (33%). Survey results revealed providers’ obstacles to providing reproductive life planning in their practice included factors such as lack of time with patients (37%) and inadequate/ insufficient information (brochures, posters, flyers, etc.) to provide to the patient (31%). Additionally, providers indicated the need of educational materials on Reproductive Life Planning (57%) and believed inclusion of Reproductive Life Planning questions into the EMR (47%) would help implement Reproductive Life Planning in their practice. Of the participating providers, 83% were unaware of the Texas Department of State Health Services “Someday Starts Now” public awareness campaign. Conclusions: Integrating preconception health into routine primary care encounters with patients of reproductive age should be a significant driver in the reduction of infant mortality rates and increase in healthy families. Future studies should investigate PCC’s integration into providers’ care with the most effect tool, educational material or inclusion of Reproductive Life Planning questions into the EMR.
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    Clinicopathological correlation of pediatric gonadectomies for neoplastic and non-neoplastic conditions, a 13 year experience at a single institution
    (2016-03-23) Tully, Briana; Ford, Michael; Salganik, Joseph; Batliwala, Shehzad; Bowman, Paul; Sanchez, Irene; Wilson, Jacob
    The purpose of this study is to evaluate patient characteristics, outcomes, and provide a detailed analysis of all gonadectomies performed at Cook Children’s Medical Center between January 2001 and March 2014 Researchers conducted a retrospective chart review of all gonadectomies that have been performed within the past 13 years at CCMC. The patient population included 470 patients with a minimum age of 0, maximum age of 21 years old, and a mean equal to 8.24 years. The population includes 38.7% female, 61.3% male. The population included 49.4% left laterality, 45.7% right laterality, and 4.9% bilateral. This data showed the most common presenting diagnosis indicating gonadectomies, age group, as well as correlations with co-morbidities within the pediatric population.
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    Health Behaviors of Medical Students During the First Year of Medical School
    (2016-03-23) Castillo, Marisa; Sori, Ermias; Stone, Chelsea; Trammell, Randall; Posey, Rachel; Jouett, Noah; Karpel, Lisa; Fulda, Kimberly; Smith, Michael; Kalra, Kyle
    Background: Entering medical students begin their journey into medicine with the desire of being a healthcare professional whose healthy habits serve as a model for their patients. However, the high stress of the academic environment of medical training makes students vulnerable to poor health behaviors. Research has shown that there is an association between high stress environments and poor health behaviors, thus this study is a follow-up on our previous studies to study this relation further. Hypothesis: We hypothesized that the number of days per week spent exercising decreases, and that consumption of alcoholic drinks and energy drinks increases early in medical school and remain changed during the first year of medical school. Methods: This study was approved by the UNTHSC IRB. The study involved the administration of a health behavior survey via Qualtrics to medical students on three different occasions during the first year of medical school. The survey was administered the week before beginning of medical school (n=191), during the 3rd week of classes (n=104) and during the last 2 weeks of the semester (n=99). Data analyses of the three surveys only included the students who completed all three surveys (n=90). Repeated measures ANOVA was used to compare number days per week of exercise, number of alcoholic drinks consumed per week, and the number of 8oz servings of energy drinks consumed per day. An alpha level of less than .05 was considered significant. Results: Results: Of the participants, 46.7% of the students were male and 53.3% were females ranging from ages 21-38. There was a significant increase in the number of alcohol drinks consumed/week (p0.05). Conclusion: Consistent with the proposed hypotheses, we found that within the first 3 weeks of medical school, students significantly decreased their participation in exercise activities and increased their alcohol consumption. There was also a modest increase in the number of energy drinks consumed per day. In order to decrease these behaviors in first medical students, we must build awareness. The healthier the future doctors of America are, the better role models they become for their patients.
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    Internet Accessibility and Perceptions for Possible Online Interventions
    (2016-03-23) Fulda, Kimberly; Franks, Susan; Cung, Tam
    Internet Accessibility and Perceptions for Possible Online Interventions Tam Cung, DO1; Kimberly Fulda, DRPH1,2; Susan Franks, PHD1,2 1Plaza Medical Center; 2Department of Family Medicine, University of North Texas Health Science Center Fort Worth, TX 76107 BACKGROUND: Healthcare costs are a serious escalating burden, especially within Medicare/Medicaid populations. The Internet and social media have made the flow of information cheaper and more efficient. Previous studies have shown increasing internet penetration into lower social economic households creating a potential opportunity to improve health outcomes. HYPOTHESIS: The primary aim was to evaluate internet accessibility of patients of an urban clinic with large Medicare/Medicaid populations. The secondary aim was to evaluate racial/ethnic differences in preferences for using various formats with healthcare information. METHODS: Patients in a family medicine clinic completed a 25-item survey. Logistic regression was performed to assess the association between race/ethnicity (Caucasian, Hispanic, African American, and Other) and likeliness to use selected formats for healthcare information (very unlikely/unlikely, likely/very likely) while controlling for gender, age, and income. A regression model was run for the following formats: online video, 3-4 page handout, and online chat/forum. Odds ratios and 95% confidence intervals were calculated. RESULTS: A total 107 participants with the mean age of 45 (SD=16) completed the survey. Approximately 67% were females, 85% had internet access, 61% were on Medicare/Medicaid. Racial/ethnic distributions were 32% Hispanic, 33% Caucasian, 25% African-American, and 10% Other. All racial/ethnic groups connected to the internet using a phone more than a laptop, desktop, or tablet. Caucasians (70.0%) and Hispanics (59.3%) selected online video more often than other formats. African-Americans (57.1%) and Others (66.7%) were more likely to select handout than other formats. Adjusted analyses showed racial/ethnic differences in the likelihood of using selected formats to receive healthcare information. African-Americans were less likely than Caucasians to select online video (OR=0.18: 95% CI:0.05-0.69). Hispanics were less likely than Caucasians to select handout (OR=0.15: 95% CI:0.04-0.56) and online chat/forum (OR=0.14; 95% CI:0.03-0.61). CONCLUSIONS: Medicaid/Medicare patients are interested in online interventions, but it is best individualized towards each patient in consideration of culturally related preferences. Future studies should further explore sociocultural differences in format preference given equal accessibility, and compare online interventions directly to traditional resources. ACKNOWLEDGEMENTS: Material cost of the survey was funded by UNTHSC. This study was approved by the IRB at UNTHSC. IRB # 2015-125
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    Executive Cognitive Dysfunction Associated with Total Serum Protein and Bilirubin in Severe Obesity
    (2016-03-23) Franks, Susan; Bell, Stephen
    Background: Obesity confers increased risk for several major chronic medical conditions. Studies also have suggested that obesity may carryincreased riskfor future dementia. Recent research has pointed toward obesity’s role in acceleratingage-related cognitive dysfunction; however the underlying process has not been elucidated. The purpose of this study was to explore psychological and biological parameters that may be associated with cognitive dysfunction in severe obesity. Hypothesis: Obese subjects (OB) will have greater deficits in executive cognitive function (EXE) than normal weight controls (NW). Common psychological and biological markers that may predict EXE were explored. Methods: Secondary data analysis of a one-year prospective study in a communitybariatricsurgical setting. OB (n=71) (Mean age=44.6 years, Mean BMI=43 kg/m2) underwent pre- and post-surgical assessments. NW matched for age and gender (n=30) were assessed for comparison.Self-report surveyassessed indicators of psychological dysfunction. Fasting blood samples were taken to analyze common clinical indicators. TheStrooptest was used to determine EXE.Independent t-testwas used to analyze EXE between OB and NW. Relationships between EXE with biological and psychological indicators were explored using Pearson correlation.Significantlycorrelated variables were used in logistic regression to ascertain their ability to predict high or low EXE. Repeated measure t-tests were used to compare changes for OB in EXE at one-year post-surgery. Results: OB hadsignificantly lower EXEthan NW at baseline (t=-2.491, p=.017). EXE was significantly correlated with Total Protein (r=-.279, p=.015) and Total Bilirubin (r=.327, p=.004). Logistic regression for Protein and Bilirubin was significant in predicting cognitive status (X2=8.117, p=.017). Individually each approached significance (Protein p=.060, Bilirubin p=.059). EXE was improved for OB at one year post-surgery EXE (t=-3.216, p=.004). Conclusion: Increases in Total Protein and decreases in Total Bilirubin may be earlybiomarkersof executive dysfunction in severe obesity. These associations may represent distal markers of higher inflammation and lower antioxidant status and are consistent with other work on possible mechanisms for neuropsychiatric sequelae of obesity. Weight loss may ameliorate cognitive risk.
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    Emergency Room Patient Presenting with Severe Hematuria
    (2016-03-23) D'Agostino, Darrin; Wilson, Damalia; Subramaniam, Smita; Saifi, Faraz
    Abstract: Purpose: The purpose of this case study is to describe a patient who presented with hematuria and significant anemia secondary to a renal mass and stone complicated with hydronephrosis. In addition to highlighting the clinical features and medical management for this patient, our aim is to stress the importance of exploring and managing multiple causes for hematuria. Methods: History and physical information were obtained by medical staff on a 64 year old Hispanic male with a history of HTN, BPH, HLD, & prior bladder surgery (1985) who presented with sudden onset of gross hematuria, dysuria, and decreased urine output with red heavy clots for one day. The patient had similar episodes 6 months prior however the incident was milder and resolved on its own. PT also noted 10 lbs weight loss. PT is a retired police officer, fireman, and denied smoking, alcohol, or illicit drugs. Positive findings on physical included a reducible mid-epigastric hernia. There was a urinary catheter in place with gross blood in the foley bag. Results: The patient's lab results indicated severe anemia with a hemoglobin/hematocrit as low as 7.9/26.7g/dL. Urine analysis showed large amounts of blood and few bacteria. BUN and creatinine were elevated. A non-contrast CT scan of the ABD/Pelvis showed right sided hydronephrosis secondary to obstructing mid ureteral stone, abnormal right perinephric stranding, abnormal 10 cm heterogeneous exophytic mass of the inferior right kidney, and gallstones. Work up for pre-op required MRV and Head CT to rule out IVC thrombus and metastasis. PT underwent stent placement for the stone prior to the radical nephrectomy. PT was also consented to have a prophylactic cholecystectomy for the gallstones. During the surgical removal, a lesion was identified on the pancreas suspicious for metastasis or inflammation and was later ruled out with EUS. Conclusion: Although most cases of hematuria are due to a urinary tract infection or urethral stone, it is important to do a thorough evaluation to rule out other significant life threatening causes of hematuria. A biopsy of the kidney done later identified the mass as stage T3 Clear Cell Renal Cell Carcinoma (CCRCC) extending to the renal sinus and major vein. Biopsy also showed glomerulosclerosis, urinary calculus, and chronic interstitial nephritis. This case illustrates and stresses the importance of thorough evaluation of the multiple causes of a patient presenting with hematuria.
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    Natural Product Drug Discovery Through Crowd-Sourcing and Crowd-Funding
    (2016-03-23) Patel, Rinkal; Liu, Xiangyang; Cheng, Yi-Qiang; Mancilla, Viviana J.
    Natural products continue to be a major source of human medicines. We hypothesize that the diverse geographic features and soil types of Texas harbor diverse microorganisms (bacteria and fungi), from which potent natural products may be discovered for the development of new drugs to treat cancer, infectious diseases, parasites or other medical conditions. We designed a crowd-sourcing and crowd-funding project to test this hypothesis. We have conducted a Phase I Feasibility Study using 5 soil samples collected by us within the Tarrant County and the preliminary results are encouraging. For a Phase II Pilot Study, we are reaching out to a high school in each of the carefully selected 11 counties in Texas. We request interested high school science teachers and students to collect 4 to 5 distinctive soil samples within the boundary of their respective counties and send the samples to UNTHSC for processing. In the future Phase III Comprehensive Study, we hope to cover all 254 counties in Texas. Thousands of distinctive microbial isolates will be obtained from those soil samples and will be fermented in different media to produce natural product crude extracts. Those crude extracts will be fractionated through flash chromatography. Tens of thousands of natural product fractions will be arranged systematically in 96-deep well plates to constitute a natural product fraction library. Subsequent screening of this library is predicted to generate dozens of natural product drug leads that possess activities against cancer cells, pathogenic bacteria or fungi, parasites or other medical conditions. An interactive website will be created to provide an effective communication platform between citizen scientists and campus researchers and to solicit donations to support this innovative research project.
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    Clinical Predictors of recurrent stenosis and the need for re-intervention in the cephalic arch in patients with brachio-cephalic AV fistulas
    (2016-03-23) Balamuthusamy, Saravanan; Nguyen, Peter; Vallurupalli, Avinash; Afolabi, Oladapo; Bireddy, Suman; Raghunath, Raju
    1. Introduction: Cephalic arch stenosis is one of the most common reasons for repeated endovascular intervention and eventual abandonment of access in hemodialysis patients with an upper arm brachio-cephalic AV fistula. It would be relevant to identify the clinical predictors of recurrent cephalic arch stenosis and develop a mathematical model to predict BC fistulas that may require repeated endovascular interventions. 2. Methods: Single center retrospective analysis of 143 patients with a BC fistula with cephalic arch stenosis who underwent angioplasty and were subsequently referred to the vascular clinic for access dysfunction were included for the analysis. Twenty patients were excluded due to unavailability of data. The data was analyzed for 12 months post index angioplasty. Clinical parameters were analyzed using parametric, non-parametric and multiple regression models using SPSS software. 3. Results: The mean age of the study population was 62.5 years. The mean need for re-intervention was 2.46/ year. There was a statistically significant correlation for the need for re-intervention with the severity of stenosis at index visit (0.873), access flow (0.863), vessel wall diameter proximal to the stenosis (0.822), average venous pressure [greater than] 50% of Qb (0.746) and prolonged bleeding for [greater than] 30 minutes as a reason for referral (0.528). Step-wise multiple regression analysis reveals significant risk for re-intervention with all the 4 variables above. Three equations have been derived for calculating the need for re-intervention based on the diameter of the vessel wall proximal to the stenosis. 4. Conclusion: Risk stratification of BC fistulas utilizing the above parameters would enable us to identify accesses that are at risk for multiple re-interventions. Early appropriate intervention can be planned for accesses that are at high risk for repeated re-interventions at the cephalic arch which may prolong access survival and reduce the cost involved with repeated interventions. However the risk prediction equations need to be validated in a well powered prospective randomized study.
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    Does Alcohol Misuse Differ by Gender & Veteran Status in Adults Age 25+?
    (2016-03-23) Hartos, Jessica PhD; Decenzo, Megan; George, Benjamin; Hill, James; Neighbor, Amanda; Diver, Thomas MPAS, PA-C
    Introduction: Alcohol misuse has been reported as one of the most common and persistent mental health problems in veterans; however, female veterans may be at less risk than male veterans. Therefore, the purpose of this study was to determine whether alcohol misuse differs by gender and veteran status in a representative sample of adults 25 years and older. Methods: This cross-sectional analysis used 2013 BRFSS data for adults 25 and older from the states of California, Florida, Texas, Virginia, and Washington. The relationship among gender, veteran status, and alcohol misuse (any drinking, binge drinking, and heavy drinking) was assessed using multiple logistic regression while controlling for demographic and psychosocial variables. Results: About 54-58% of female and male veterans reported any drinking, 10-12% reported binge drinking, and 6-7% reported heavy drinking. In adjusted analyses, gender and veteran status were significantly related to alcohol misuse, but differently by type of drinking. Conclusions: This study found that gender and veteran status are related to alcohol misuse, and female veterans may be at similar risk for heavy drinking as male veterans. Providers should continue to monitor male and femala veterans for alcohol misuse.
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    Does Chewing Tobacco Impact the Number of Chronic Health Problems in Adult Males Under Age 45 Years?
    (2016-03-23) Bachman, Melissa; Bailey, Adrianne; Banks, Haley; Hartos, Jessica PhD; Kane, John; Hernandez, Shanda
    Introduction: Chewing tobacco has been suggested as a safer alternative to smoking cigarettes; however, controversy exists over the long-term health effects associated with it. This study assessed the relationship between tobacco use (none, chew only, smoke only, both) and number of chronic health problems in a representative sample of males age 18-44 from states with high rates of chewing tobacco use. Methods: This cross sectional analysis used data from the 2013 BRFSS for nonsmoking males age 18-44 in Mississippi, Montana, North Dakota, South Dakota, and West Virginia. Adjusted logistic regression analyses were conducted to determine the relationship between tobacco use (none, chew only, smoke only, both) and chronic health conditions while controlling for demographic and psychosocial factors. Results: Across states, 36-51% participants reported one or more chronic health problems. In adjusted analyses, having one or more chronic health problems was 1.49 times more likely for those who used chewing tobacco only, 1.34 times more likely for those who smoked, only and 1.95 times more likely for those who used both. Conclusion: Overall, use of chewing tobacco was related to chronic health problems in a representative sample of 18-44 year old males from states with high chewing tobacco rates. Although chewing tobacco use may not be as prevalent in the general population in other states, clinicians should be aware of the risks associated with chewing tobacco use
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    Mechanism of Supination External Rotation Short Oblique Ankle Fractures Revisited: A Cadaveric Study
    (2016-03-23) Wood, Addison; Fisher, Cara; Nana, Arvind; Payne, Joshua; Le, David
    PURPOSE: The Lauge-Hansen classification system for ankle fractures has been the most commonly used system because it explained mechanism of injury of several common fracture patterns. However, there are limitations to the original Lauge-Hansen experiments and we have chosen to focus our central objective of this study on the biomechanical mechanisms behind stage 1 & 2 supination-external rotation (SER) ankle fractures in a cadaveric model. METHODS: 5 Fresh frozen cadaveric specimens were mounted into a custom made ankle rig with the tibia held rigid using half pins while allowing free movement of the fibula. The foot was secured to a wheel with a torque sensor attached to record examiner external rotational stress application. An electromagnetic tracking system was used to track the motion of the specimen with 6 degrees of freedom at each segment. A control arm was used to hold the foot in dorsiflexion while all other rotations were held in neutral. An ultrasound probe was used to monitor tibiofibular space as the examiner applied a controlled 100N maximal external rotational torque. Specimens were first tested with all ligaments intact prior to incremental resection of the anterior inferior tibiofibular ligament (AITFL) with repeat stress examination after each change. RESULTS: All specimens withstood the normal state testing of up to 100N of external rotational force without any injury. However, 4 out of 5 specimens received short oblique fracture patterns to the distal fibula after partial (75%) or full AITFL resection. Comparison of pre and post radiographs, visual observation via dissection, and live ultrasound video confirmed these results. 3D kinematics were recorded and analyzed as well to determine bone movement and fracture timing and compared to ultrasound video of the tibiofibular space. CONCLUSION: Prior studies have used unmeasured forces, non-physiological ligament strain rates, and poor alignment techniques. We sought to exclude the ligament strain rate and other design issues from our study by performing incremental resection of the AITFL as a synthetic mechanism for stage 1 SER ankle injuries and focusing on the reproducibility of the stage 2 fibula fracture in an SER injury. Our study demonstrated: 1. A 100N external rotational force did not result in an AITFL injury 2. Partial sectioning of the AITFL alongside a 100N external rotational force led to a reproducible oblique distal fibula fracture in a cadaveric ankle model.
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    Anxiety in Obese Individuals is Associated With Leptin Concentration
    (2016-03-23) Franks, Susan; Sarker, Marjana; Breuer, Gillian
    Background: Obese individuals suffer from increased incidence of depression and anxiety. Recently research has suggested that appetite regulating hormones may modulate emotions. Although contradictory thus far, some studies suggest that leptin may play a role in mediating anxiety. Obese individuals have higher leptin concentrations primarily due to augmentation of adipose tissue. In addition to leptin’s role in regulating appetite, leptin receptors are also present in non-hypothalamic regions such as the amygdala and hippocampus that modulate emotional function. Obesity is well-known to confer leptin resistance, bringing into question its potential to contribute to emotional dysregulation. Hypothesis: The following hypotheses were examined: (1) Obese subjects (OB) will have higher anxiety than normal weight controls (NW); (2) Leptin will be positively associated with anxiety independent of obesity status. Methods: Bariatric candidates (OB) (n=71) (Mean age = 44.6 years and Mean BMI = 43 kg/m2 ) underwent pre-surgical assessment. Normal weight controls (NW) (n=30) were assessed for comparison. State anxiety was measured using the State-Trait Anxiety Inventory. Fasting blood samples were taken to analyze serum leptin. Difference in anxiety between OB and NW was analyzed using ANOVA. Logistic regressions were performed to ascertain the effects of leptin with and without obesity status on the likelihood that subjects would have high anxiety. Results: There was a significant correlation between anxiety and leptin (r=.202, p=.004). Anxiety was higher for OB compared to NW (F=7.446, p=.008). Logistic regression for fasting leptin was statistically significant (X2=8.600, p=.003); explaining 12% of the variance in anxiety and correctly classifying 65.3% of the cases. Increasing leptin was significantly associated with increasing likelihood of anxiety. The model for leptin and obesity status was statistically significant (X2=9.566, p=.008). When leptin was adjusted for, the association between the anxiety and obesity was no longer significant. This shows that the relationship between obesity, leptin and anxiety was present in the obese, bariatric candidate sample but not in the NM control group. Conclusion: Bariatric candidates have higher anxiety compared to NW counterparts. The association between leptin and anxiety is not independent of obesity status as it was observed in the obese, bariatric candidate group only. While the cause of anxiety is likely multifactorial further, the association between anxiety and leptin should be further explored. Acknowledgements: This study was supported by NIH grants H75/CCH224064, HL04297 and HL64913 and approved by the IRB at the University of North Texas Health Science Center.