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ASSOCIATION BETWEEN PLANTAR TEMPERATURE INCREASE AND PLANTAR SHEAR STRESSES IN HEALTHY SUBJECTS
(2014-03) Brem, Ryan; Bawa, Binky; Master, Hiral; Flyzik, Michael; Yavuz, Metin
Unnoticed repetitive plantar stresses are believed to cause diabetic foot ulcers. In severe cases, the development of these foot ulcers can lead to lower extremity amputations. The measurement of vertical plantar pressure has previously been used to predict where ulcers may develop, but was eventually determined to be a poor predictor of these occurrences. Shear is an additional element of plantar stresses that has not been thoroughly investigated due to the lack of available stress platforms with the capability of measuring the horizontal component stresses. Previous investigations have implemented the use of plantar temperature profiles in an attempt to develop an alternative method for determining plantar loading. Increases in temperature were seen and may have been a result of friction from plantar shear forces according to these reports. However, the potential relationship between temperature and shear has not been investigated thoroughly. If significant associations can be determined between the location and magnitude of both peak shear and temperature, researchers and clinicians may develop a better understanding of diabetic foot ulcer formation which could potentially lead to improvements in therapeutic footwear. Purpose (a): Sites of increased plantar temperature have been suggested to indicate plantar loading in previous investigations. However, this idea has not been successfully validated. The purpose of this study was to determine if a linear relationship existed between walking-induced increases in plantar temperature and measured plantar stresses. Significant relationships between the two variables would suggest thermographs to be an effective tool used to assess plantar tri-axial and/or shear loading, potentially leading to significant advancements in the study of biomechanical factors related to the diabetic amputations. Methods (b): Thirteen healthy participants were recruited, and informed consent was obtained prior to the study. Pre-exercise baseline plantar temperature profiles were measured with the use of an infrared thermal camera. Participants were then asked to walk on a custom-built platform that was used to measure tri-axial plantar stress distributions. Subjects then walked barefoot on a treadmill for 10 minutes. Post-exercise temperature distribution was measured and recorded. After all data were collected, sites of increased peak temperature and peak stress for each foot were documented. The frequency in which the two different sites matched was determined. In addition, increased peak temperature values were correlated against plantar stress magnitudes. Results (c): Peak temperature increase site matched the location of peak shear in 23% of participants. Peak temperature increase site also occurred at the peak resultant stress site in 39% of participants. A significant correlation was found between the magnitudes of temperature increase and peak shear (R = 0.78, p = 0.02). Conclusions (d): A moderate linear relationship was established between peak plantar temperature increase and the horizontal component of plantar stresses. It may be useful to explore a potential non-linear association between these two variables. If a non-linear relationship can be modeled, predicting plantar shear may be possible. The ability to predict plantar shear could allow for assistance in assessing the risk of ulcer development in the diabetic foot and subsequent amputation. Thermographs are still not a reliable source for the prediction of shear, but our initial results warrant further investigation.
DOES RESEARCH TOPIC OF INTEREST DIFFER BY GENDER AND RACE/ETHNICITY? RESULTS FROM THE NORTEX REGISTRY PROJECT.
(2014-03) Shabu, Tanjina; Fulda, Kimberly; Espionza, Anna; Roberto Cardarelli
This study is being conducted to assess the difference in research interest between race and gender. Ultimately this will help the NorTex researchers to conduct research in the areas of interest to the community. Purpose (a): NorTex is a collaboration of over 110 clinics that conduct research important to primary care, public health, and the community. The purpose of the NorTex Registry Project (NRP) is to develop and maintain a database of individuals who may be contacted for future NorTex studies. The current study examined gender and racial/ethnic differences in research topics of interest for diabetes, cardiovascular disease, cancer, and mental health among NRP participants. Methods (b): Patients 18 years or older at participating clinics may complete a 4X6 index card (English or Spanish) giving permission to be contacted for NorTex studies. Index cards include contact information, demographic information, medical problems, and topics on which the participant would like more research conducted. Chi-square analysis was performed to determine differences in cardiovascular disease, diabetes, cancer, and mental health research interest by gender and race/ethnicity. Results (c): The NRP includes a total of 1285 participants. Of these, 901(70.1%) are female, 470(36.6%) are Caucasian, 409(31.8%) African American, 297(23.1%) Hispanic, and 109(8.5%) other. 265(76.6%) males and 612(68.3%) females (p=0.004) are interested in cardiovascular disease (CVD) research. 189(54.6%) males and 417(46.5%) females are interested in diabetes research (p=0.011). Racial/ethnic differences exist for interest in diabetes (p<0.001) and mental health (p=0.001) research. No other differences were observed. Conclusions (d): There is a significant difference in research interest between races/ethnicities for diabetes and mental health. Gender differences exist for interest in cardiovascular disease and diabetes. These findings will allow NorTex to conduct research in areas of interest to the community.
FUNCTIONAL ASSESSMENT OF BALANCE AND GAIT IN TRANSTIBIAL AMPUTEES USING K2 VS. K3 PROSTHETIC FEET
(2014-03) Hidrogo, Joe III; Stevens, Gordon; Patterson, Rita M.; Bugnariu, Nicoleta
Purpose (a): The K-Level classification of prosthetic feet is used in conjunction with a similar classification of functional level of amputees to determine which prosthetic feet will be prescribed and reimbursed. Individuals classified as ambulatory level 2, receive a K2 prosthetic foot and not the higher functioning K3 prosthetic. This provides less technology to the patients who need it most, limiting them in their current and potential abilities. We aimed to evaluate gait and balance in transtibial amputees ambulating with either a lower cost K2 prosthetic foot or the more functional dynamic response K3 prosthesis. We hypothesized that K3 prosthesis will show immediate improvements in gait and balance, and a 2- week trial with a K3 would increase functional level and quality of life. Methods (b): Research participants with transtibial amputations secondary to diabetes or vascular disease were fitted by a certified Prostestist-Orthotist with either a K2 or K3 prosthesis. On the initial study visit the quality of life baseline established using standardized questionnaires for reintegration after amputation. Also, the V-gait CAREN (Computer Assisted Rehabilitation Environment Network) system was used to establish baseline balance and gait measures and immediate effects of switching type of prosthesis. The participants were then randomized into groups for a 2-week trial period of wearing a prosthetic foot (K2 or K3) that was either at, above or below the current functional level of the amputee. Post-trial measurements of balance, gait, and quality of life were reassessed. Results (c): To date two subjects have been enrolled in the study. Both subjects expressed limitations and changes in quality of life due to amputation. Balance was compromised in conditions of dual tasks and subjects had significant difficulties walking up and down ramps illustrated by changes in lower limb kinematics. When tested with a K2 prosthetic, one subject was unable to maintain baseline gait velocity even on level ground. Conclusions (d): Preliminary results confirm that K3 prosthetic foot provides additional benefits for balance and gait function compared to K2. Providing higher level prosthetic feet to patients who are classified at lower functional level could improve their balance, prevent serious costly injuries caused by trips and falls, and facilitate transition to higher functional status. Therefore, it is pertinent that the proper K level prosthetic be prescribed.
FRACTURE OF THE FAR CORTEX DURING LARGE FRAGMENT SCREW INSERTION: A POORLY DESCRIBED MEANS OF SQUANDERING SCREW HOLES AND PLACING PLATE FIXATION AT RISK
(2014-03) Ming, Bryan; Collinge, Cory
Purpose (a): Design: Retrospective study of patient records and plain radiographs to determine the incidence and characteristics of iatrogenic fracture caused by screws themselves while using large fragment screw fixation Methods (b): Setting: Level II regional trauma center and tertiary referral center. Patients: Single surgeon cohort of patients treated surgically for acute fractures or fracture nonunions using large fragment plate and screw fixation. Methods: Retrospective cohort retrieved from an experienced fellowship-trained orthopedic traumatologist’s billing database. Demographics, injury, and treatment details were obtained from patient’s medical and radiographic records. Results (c): Seven instances of iatrogenic unicortical fracture of the distant cortex while using large fragment screw fixation was found in 246 cases, representing 3% incidence. Five were recognized and treatment altered by redrilling and applying a screw in a different trajectory (4), and in one case a plate was revised to a longer plate. In the two other cases, the fracture may have been unrecognized as the screw was left in situ. Conclusions (d): Unicortical fracture of the distant cortex around the pilot hole during screw insertion is poorly described iatrogenic complication, occurring in 3% of our cases where large fragment plate fixation was utilized. This circumstance suggests a few potential problem scenarios. First, some of these cases were unrecognized and the risk of treatment failure may be increased by loss of a screw’s purchase or by creation of a significant stress riser. Second, when the cases were recognized, measures were taken to improve stability, which included simply changing a screw’s axis, but also by revision by extending a plate in one case. Vigilant analysis of radiographs (both intraoperative and postoperative), focus on proper technique with placement of large fragment screws, and awareness of treatment options in the face of this uncommon complication can help minimize the impact of far cortical fracture.
RESULTS OF PROXIMAL FEMORAL LOCKING PLATES FOR PROXIMAL FEMORAL NON-UNIONS
(2014-03) Ming, Bryan; Collinge, Cory
Purpose (a): Objective: Review clinical reports from multiple centers that have used Proximal Femoral Locking Compression Plates (PFLCPs) for non-unions of the proximal femur to elicit reasons for failure in an effort to prevent similar failures in the future. Methods (b): Retrospective chart review of 21 adult patients at 3 separate regional Level I and Level II institutions who underwent open treatment of non9nionos of the proximal femur with PFLCPs. Outcomes measured was mechanical failure defined by hardware failure and secondary outcomes including patient and construct variables that may act as predictors for mechanical failure. These included time to failure, bony union, nonunion, time to union, need for additional procedures, type of additional procedures, BMI. Results (c): At 22 months follow up, 5 hardware failures occurred (24%) and 1 persistent nonunion (5%)occurred requiring hardware removal and conversion to total hip arthroplasty. There was no statistically significant association between hardware failure and patient BMI, quality of reduction, plating technique, or bone graft use. A significant difference between cases with and without failure was medial column stability; only 40% of those with hardware failure achieved medial column stability versus 94% of those without hardware failure. Conclusions (d): Proximal Femoral Locking Compression Plates have a high rate of mechanical failure with use for non-union of the proximal femur. Our experience shows a similar rate of mechanical failure compared to previously reported experiences with the use of PFLCPs in acute fractures. Medial column instability was the only significant association of failure with the use of PFLCPs in nonunion surgery.
THE EFFECT OF PREOPERATIVE TRANSTHORACIC ECHOCARDIOGRAM ON MORTALITY AND SURGICAL TIMING IN ELDERLY HIP FRACTURE PATIENTS
(2014-03) Luttrell, Kevin; Nana, Arvind
Echocardiograms are a noninvasive way to assess heart function in elderly patients prior to surgical treatment of hip fractures. Unfortunately testing delays surgical treatment, and intervention for heart disease is rarely performed based on echocardiogram findings. Our patient review demonstrated no benefit to mortality in patients tested with echocardiogram prior to surgical treatment of hip fractures with significant delay in surgical timing and subsequent increased length of hospital stay. Purpose (a): Heart disease is the most common cause of postoperative mortality in elderly hip fracture patients, and transthoracic echocardiogram (TTE) is often used to assess cardiac function prior to surgery. The purpose of our study was to evaluate the effect of preoperative TTE on mortality, postoperative complications, surgical timing, and length of stay in surgically treated hip fracture patients. Methods (b): A retrospective chart review was performed on 694 consecutive hip fracture patients >60 years of age treated surgically at two local hospitals. Patients were identified by billing codes over a 30 month time period from July 1st 2009 to December 31st 2011. Hospital records were reviewed for age, sex, timing of admission, medical clearance, operation and discharge, admitting service, fracture and treatment type, medical comorbidities, American Society of Anesthesiologists (ASA) score, preoperative testing ordered (TTE), preoperative cardiac intervention, complications, and mortality. The social security death index was used for thirty day and one year mortality data when not available in the hospital records. Our primary outcome measure was in-hospital, thirty day, and one year mortality following hip fracture surgery in patients that receive preoperative TTE. Secondary outcome measures included complications (particularly cardiovascular) and time required for medical clearance and operative treatment. Results (c): Preoperative echocardiogram was performed on 131 patients (18.9%). Patients admitted by the medicine service were 1.76 times more likely to receive preoperative TTE (p < .01). Patients were 2.28 times more likely to receive TTE if they had a history of coronary artery disease (p < .001), and 2.12 times more likely if they had a history of arrhythmia (p < .001). Five patients in the TTE group and one patient in the control group underwent cardiac catheterization prior to surgery, but none of these patients required angioplasty or stent placement. There was no difference in mortality between the TTE group and the control group in hospital (3.8% versus 1.8%, p = .176), at 30 days (6.9% versus 6.6%, p = .90), or at one year (20.6% versus 20.1%, p = .89) respectively. There was no significant difference in major cardiac complications between groups. Average time from admission to operative treatment was 66.5 hours in the TTE group and 34.8 hours in the control group (p < .001). Average time from admission to medical clearance was 43.2 hours in the TTE group and 12.4 hours in the control group (p < .001). There was no difference in the time between medical clearance and operative treatment between the two groups (23.3 hours versus 22.4 hours, p = .639). The TTE group also had a significantly longer length of stay at 8.68 days compared to 6.44 days in the control group (p < .001). Conclusions (d): Preoperative TTE does not help reduce mortality rates in elderly hip fracture patients in either short or long term postoperative periods. In addition TTE delayed surgical treatment, resulted in no cardiac intervention, and increased length of stay. The American Heart Association (AHA) and the American College of Cardiology (ACC) have developed guidelines for perioperative assessment of patients in case of non-cardiac surgery. TTE should not be used as a screening tool in hip fracture patients, but instead used to further evaluate active cardiac conditions.
CLINICAL VALUE OF TEMPERATURE IN ASSESSING FOOT LOADING IN DIABETIC PATIENTS WITH AND WITHOUT NEUROPATHY
(2014-03) Master, Hiral; Brem, Ryan; Bawa, Binky; Flyzik, Michael; Yavuz, Metin
Unnoticed repetitive plantar stresses are believed to cause diabetic foot ulcers. In severe cases, the development of these foot ulcers can lead to lower extremity amputations. The measurement of vertical plantar pressure has previously been used to predict where ulcers may develop, but was eventually determined to be a poor predictor of these occurrences. Shear is an additional element of plantar stresses that has not been thoroughly investigated due to the lack of available stress platforms with the capability of measuring the horizontal component stresses. In a limited number of studies higher shear stresses have been found in diabetic patients. Previous investigations have implemented the use of plantar temperature profiles in an attempt to develop an alternative method for determining plantar loading. Increases in temperature were seen and may have been a result of friction from plantar shear forces according to these reports. However, the potential relationship between temperature and shear has not been investigated thoroughly. If significant associations can be determined between the location and magnitude of both peak shear and temperature, researchers and clinicians may develop a better understanding of diabetic foot ulcer formation which could potentially lead to improvements in therapeutic footwear. Purpose (a): Diabetic ulcers lead to an estimated 100,000 amputations every year in the United States. Ulcers are known to have a biomechanical etiology that relates to three dimensional ground reaction forces/stresses. Among these stresses, horizontal shear stress cannot be easily quantified. It was hypothesized that plantar temperatures can estimate shear loading of the foot. The purpose of this study was to explore a site-wise association between peak plantar temperature and peak pressure and shear stresses obtained from diabetic patients using a thermal camera and custom-built pressure-shear plate. If confirmed, thermographs can assist clinicians/researchers in preventing diabetic ulcer related amputations. Methods (b): Two groups, each consisting of 14 diabetic patients with neuropathy (DN) or without neuropathy (DC), were recruited for the study after informed consent was obtained. Resting foot sole temperatures were recorded using an infrared thermal camera. Subjects walked on a 12 ft. walkway that accommodated the stress plate. Stress variables such as peak pressure (PP), peak shear (PS), peak pressure integral time (PTI) and peak shear-time integral (STI) were recorded from five regions of the foot (i.e., hallux, lesser toes, first metatarsal head (1st MTH), central forefoot (2nd and 3rd MTH) and lateral forefoot (4th and 5th MTH)). Results (c): Pearson correlation analysis between each stress variable against temperature were statistically significant (p<0.05) in both groups. The r values ranged between .405 and .511. Despite significant correlation results, peak temperatures could not successfully identify peak stress locations in group DN (14-57%). Success rates were higher for the DC group (50-86%). Conclusions (d): The potential association between plantar stresses and temperature is thought to have a complicated and non-linear relationship. Appropriate modeling schemes can be implemented to explore such relationships. Thus our results warrant further investigation on this topic.
ANTIBODY ENCAPSULATION WITHIN POLYMERIC NANOPARTICLES
(2014-03) Gdowski, Andrew; Ranjan, Amalendu; Mukerjee, Anindita; Vishwanatha, Jamboor
Antibodies represent a large class of drugs that have a number of different therapeutic uses. However, side effects can persist due to off target toxicity that may result when the antibody affects a tissue other than where it is intended to act. The use of targeted nanoparticles is one potential way to deliver an antibody to a specific organ where the antibody can be released in a controlled manner and limit side effects. Purpose (a): The purpose of this study is to characterize a human monoclonal antibody encapsulated within a poly(lactic-co-glycolytic) acid (PLGA) nanoparticle. We hypothesized that encapsulation of an antibody within PLGA nanoparticles is feasible and will release in a favorable manner. Methods (b): AnnexinA2 (AnxA2) IgG antibody was encapsulated within PLGA nanoparticles. Encapsulation efficiency and release kinetics were determined using polyacrylamide gel electrophoresis and coomassie brilliant blue staining. Dynamic light scattering (DLS) from Malvern Zetasizer was used to determine hydrodynamic size and zetapotential. Western blot was accomplished with cell lysates from known AnxA2 expressing cell lines to determine functionality of antibody once released from PLGA nanoparticles. Results (c): Our results show acceptable encapsulation efficiency of AnxA2 within the PLGA nanoparticle. Nanoparticles were formed in a favorable monodisperse manner. Release experiments demonstrate that AnxA2 is released in a controlled manner over a period of 15 days. In addition after release the antibody maintained functionality as evidenced through Western Blot analysis. Conclusions (d): We conclude that encapsulation of IgG monoclonal antibodies is feasible, exhibits sustained release kinetics, and maintains functionality upon release. Further, this encapsulation technique may be used as a method to load antibodies in targeted nanoparticles for release in a tissue specific manner.
HEALTH PROFESSIONALS’ ATTITUDES TOWARDS THE HOMELESS
(2014-03) Burdex, Ashley; Nejtek, Vicki; Talari, Deepika; Koehl, Steven
Purpose (a): About 50% of Tarrant County homeless (n=2,123) have co-occurring medical disorders, receive inconsistent medical care, are at high risk for repeated crisis care hospitalization, and are often discharged prior to full stabilization.1,2 Whether or not medical crisis recidivism is influenced by clinical attitudes towards treating the homeless is uncertain. Here, we examined medical student, resident, and physician attitudes about the homeless condition and treating homeless patients. We hypothesize that medical students MS 1-4, residents, and physicians significantly differ in their attitudes in treating homeless patients. Methods (b): A prospective, cross-sectional between-group comparison of the attitudes towards treating homeless patients among medical school students, residents, and physicians (n=238) was conducted. Data were analyzed using analysis of variance (ANOVA) and Chi-square procedures. Statistical significance was determined using a 95% confidence interval and a probability alpha of 0.05. Results (c): The MS 1-2, residents, and physicians showed more empathy and had a higher interest in treating homeless patients than MS 3-4 (p=0.004). In contrast to other groups, MS 3-4 regard homeless people as lazy (p=0.001) and rude (p=0.028). Compared to medical students, physicians and residents believe that health dollars should be directed toward serving the poor and homeless (p=0.001). In comparison to physicians, MS 3-4 do not perceive homelessness as a health issue (p=0.002), and all medical students judged that government should not waste money on homelessness (p=0.001). Further, compared to other groups (especially physicians), MS 3-4 reported that alcoholism is a personal weakness (p=0.003) rather than a medical illness and think that clinicians should only address physical and not social problems (p=0.014). Conclusions (d): Overall, MS 3-4 are significantly more cynical and judgmental about the homeless condition and treating homeless patients than any other group. The lack of biological insight about the medical needs of the poor and homeless expressed by MS 3-4 is truly concerning. These data indicate a critical need for specialized education that will better inform medical students about socioeconomic conditions that significantly influence medical disease onset, etiology and prognostic outcomes in this vulnerable, complex, and difficult-to-treat patient population.
PROGRESSIVE CEREBRAL ARTERIAL DISEASE DESPITE A SUCCESSFUL HEMATOPOIETIC STEM CELL TRANSPLANT FOR SICKLE CELL ANEMIA
(2014-03) Sweezer, Tonya M.; Bowman, W. Paul; Johnson, Clarissa
Sickle Cell disease often results in cerebral arterial disease including stroke and moyamoya syndrome. Hematopeoietic stem cell transpant (HSCT) is the definitive cure for sickle cell disease, and often slows or stops the progression of the related cerebral arterial disease. A case is presented of a patient whose cerebral arterial disease progressed despite successful stem cell transplant. This project will describe this patient’s clinical course and briefly explore outcome expectations post HSCT in patients with existing moyamoya syndrome. Methods Medical records chart review of one case. Results A 9 year old female experienced cerebral arterial complications of sickle cell disease resulting in stroke. She was then started on monthly transfusions to prevent further strokes. During workup for hematopoietic stem cell transplant (HSCT), she was found to have progressive cerebral arteriopathy (Moyamoya syndrome). She then underwent successful transplant using unrelated cord blood. Shortly following HSCT, she experienced relatively common complications including chronic graft versus host disease, thrombocytopenia, anemia, Epstein-Barr disease reactivation, and several bacterial and fungal infections. These conditions resolved with treatment. HSCT was successful in completely resolving the sickle cell disease. Despite this, she experienced seizures, progression of moyamoya syndrome and a new cerebral infarct. Revascularization surgery has been recommended. Conclusions In some cases, cerebral arterial disease may progress despite successful hematopoietic stem cell transplantation. These cases may suggest a need for further research into the outcomes of sickle cell patients with existing moyamoya syndrome prior to HSCT. Purpose (a): Sickle Cell disease often results in cerebral arterial disease including stroke and moyamoya syndrome. Hematopeoietic stem cell transpant (HSCT) is the definitive cure for sickle cell disease, and often slows or stops the progression of the related cerebral arterial disease. A case is presented of a patient whose cerebral arterial disease progressed despite successful stem cell transplant. This project will describe this patient’s clinical couse and briefly explore outcome expectations post HSCT in patients with existing moyamoya syndrome. Methods (b): A medical chart review of one case was conducted. Results (c): A 9 year old female experienced cerebral arterial complications of sickle cell disease resulting in stroke. She was then started on monthly transfusions to prevent further strokes. During workup for hematopoietic stem cell transplant (HSCT), she was found to have progressive cerebral arteriopathy (Moyamoya syndrome). She then underwent successful transplant using unrelated cord blood. Shortly following HSCT, she experienced relatively common complications including chronic graft versus host disease, thrombocytopenia, anemia, Epstein-Barr disease reactivation, and several bacterial and fungal infections. These conditions resolved with treatment. HSCT was successful in completely resolving the sickle cell disease. Despite this, she experienced seizures, progression of moyamoya syndrome and a new cerebral infarct. Revascularization surgery has been recommended. Conclusions (d): In some cases, cerebral arterial disease may progress despite successful hematopoietic stem cell transplantation. These cases may suggest a need for further research into the outcomes of sickle cell patients with existing moyamoya syndrome prior to HSCT.
CAN PERFUSION MRI PERFORMED IN THE EARLY STAGES OF LEGG-CALVE-PERTHES DISEASE PREDICT LATERAL PILLAR INVOLVEMENT?
(2014-03) Wiesman, Kathryn; Kim, Harry; Kulkarni, Vedant; Burgess, Jamie
Purpose (a): Radiographic prognosticators of outcome for Legg-Calvé-Perthes disease (LCPD), e.g. lateral pillar classification, cannot be applied at the early stages, which is suboptimal since significant deformity of the femoral head can occur. The purpose of this study was to determine if perfusion MRI measurements of the femoral epiphysis obtained at the early stages of LCPD can predict the radiographic lateral pillar involvement at the maximum fragmentation stage. Methods (b): Twenty-nine patients were prospectively enrolled and had gadolinium-enhanced perfusion MRI in the early stages and were radiographically followed. Observers measured percent perfusion of the femoral head using MRI analysis software. Percent perfusion of the lateral third of the epiphysis was measured. Radiographs obtained at maximum fragmentation stage were used for the lateral pillar classification. Intraclass correlation coefficient and logistic regression were used for statistical analysis. Results (c): Mean age was 7.7±1.7 years (range 5.3-11.3 years). The mean time between MRI and the xray at maximum fragmentation was 8.2±5.5 months. Intraclass correlation of MRI measurements was 0.90 (95% CI of 0.83-0.95). In the hips that developed the lateral pillar A, B, or C, the mean percent perfusion of the lateral third of the epiphysis was 92±2%, 68±18%, and 46±12%, respectively (p=0.001). At the perfusion level of 90% and above in the lateral third of the epiphysis, the odds ratio of developing lateral pillar A vs. B or C was 72.0. At the perfusion level of 55% and below in the lateral third of the epiphysis head, the odds ratio of developing lateral pillar C vs A or B was 33.3. Conclusions (d): The lateral third epiphyseal perfusion measurements obtained at the early stages of LCPD using perfusion MRI were predictive of lateral pillar involvement at the maximum fragmentation stage. Significance: Perfusion MRI obtained early in LCPD may yield prognostic information to guide treatment decisions.
CASE STUDY OF AN ANATOMICAL VARIATION OF THE BICEPS BRACHII MUSCLE
(2014-03) Jones, Michelle; Kalathil, Josin
During a dissection for anatomical understanding, we discovered an extra head to the biceps brachii muscle on one arm of our cadaver. Purpose (a): As part of a dissection aiming to increase anatomical understanding of the muscles and movements of the upper arm, a unilateral anatomical variation of the biceps brachii muscle was detected. A case study of the variant is presented. Methods (b): The dissection was performed on both embalmed arms of a 77 year old Caucasian female cadaver donated through the Willed Body Program at the University of North Texas Health Science Center. The epithelium and fascia were removed, and the pectoralis muscles, teres minor, and the deltoid were reflected in order to clearly view the underlying muscles along with their blood supplies and innervations. Results (c): Of the two arms observed, one was found to have an accessory muscle in the anterior arm. This muscle was located deep to the long head of the biceps brachii and distal to the attachment of the coracobrachialis. A branch of the musculocutaneous nerve provided innervation to this muscle, while blood was supplied by a branch from the brachial artery. Upon inspection, the origin appeared to be medial on the mid-shaft of the humerus. The muscle then merged and inserted into the radial tuberosity by a common tendon with the biceps brachii. Conclusions (d): This anatomic variant, known as supernumerary head of the biceps brachii, has been well documented in medical literature. Studies of the biceps brachii note that variation usually occurs with the origin of the supernumerary head and that it maintains a common insertion. The origin of the anomaly discovered and the fact that it is unilateral makes it one of the more commonly seen variations of the biceps brachii muscle.
TOPAZ RADIOFREQUENCY COBLATION FOR LATERAL EPICONDYLITIS: A RETROSPECTIVE STUDY
(2014-03) Sumko, Dan; Wagner, Russell; Sumko, Michael H.
This is a retrospective study involving patients with chronic lateral epicondylitis of the elbow. From 1996 through 2012, 108 elbows in 87 patients underwent TOPAZ (radiofrequency ablation) applied to the lateral epicondyle. Patients were contacted by phone and data collected which showed 86% excellent results with follow-up ranging from 2-18 years. This minimally invasive procedure proved to be an effective modality, with no significant complications, for the treatment of chronic tennis elbow. Purpose (a): To evaluate outcomes of TOPAZ radiofreqency coblation for recalcitrant lateral epicondylitis. Methods (b): The pool of subjects ranged in age from 41 to 72 and had a history of at least 3 months of conservative treatment to include NSAIDs, activity modification, bracing, night splints, and at least 3 steroid injections. All of these had failed to give any long term relief. Subjects were prepared for surgery by marking out the tender area on the skin in a usual rectangular shape. After adequate anesthesia, varying from local with sedation to general, a longitudinal incision was made in the mid-area of the pre-op delineated rectangular area. Most were done without the aid of a tourniquet. The radio-frequency (TOPAZ) tip was touched to the surface of the tendon every 3-4 mm, and every third touch penetrated the tendon surface to a depth of 3-4 mm. When the area of the tendon corresponding to the rectangular skin markings was treated, (making a checkerboard pattern) the wound was closed with subcuticular 3'0 monocryl suture and steri-stripped. A dressing of a simple fluff was held in place with a curlex roll and coban. The patient was instructed to keep the dressing dry until the first post op visit at day 7-10, with no excessive lifting (greater than one pound for 1 week and then no greater than 8 pounds for an additional 2 weeks). Return to normal activities was permitted at week 6 weeks. 87 patients who had undergone TOPAZ radiofrequency coblation therapy for lateral epicondylitis by the same surgeon during a period from 1996-2012 were contacted via telephone. In addition to eliciting the Numeric Pain Scale for the operative elbow, the patients were also asked a series of additional questions pertaining to their satisfaction and results of the procedure seen below. "Was the procedure performed on your right or left elbow? Or Bilaterally?* How would you rate the overall results of your procedure on a scale of 0-10, 10 being a perfect outcome? Does your elbow have a negative impact on your daily activities? Never, Occasionally, Always? How would you rate the appearance of the scar from the procedure, on a scale of 0-10, 10 being a perfect scar that is hardly noticeable? How would you rate your pain since the procedure, on a scale of 0-10, 10 being excrucitating? Postoperatively, do you experience a decreased range of motion? Postoperatively, do you experience any weakness on that side? 8. How would you rate your overall relief of previous pain: Total, Partial, or None? *If both elbows were operated on, questions 2, 4, & 5 were asked for both sides separately." Results (c): Of the 87 patients surveyed, 21 had received TOPAZ bilaterally accounting for 108 total elbows. Male 45% Female 55%. Age - Mean: 56 years old (s=7.85) Years Since Procedure Mean: 9.2 years (s=3.39). Left Elbow 43% Right Elbow 57%. Bilateral TOPAZ 24% Overall Satisfaction out of 10 Mean: 8.6 (s=2.17) Negative impact on ADLs? No: 86% Yes:8% Partially: 7% Appearance of Scar out of 10 Mean: 7.50 (s=2.31) Pain Since Surgery (Numeric Pain Scale) Mean: 1.70 (s=2.81). Experience decreased ROM? None: 98% Partial: 2% Complete: 0% Experience weakness? Never: 87% Sometimes: 11% Always: 2% Relief of symptoms - Total: 86% Partial: 10% None: 4% Conclusions (d): TOPAZ has been shown to be an effective, minimally invasive modality for treatment of recalcitrant lateral epicondylitis.
DOSE-RESPONSE PATTERN OF REWARD OF THREE SUBSTITUTED CATHINONES
(2014-03) Dolan, Sean B.; Gatch, Michael B.
Synthetic cathinones, sold online and in head shops as “bath salts,” have seen a tremendous increase in popularity since 2007. Consequently, the number of cathinone-related hospitalizations has increased, hitting a peak in 2011. Unfortunately, there has been very little research done regarding the behavioral effects of these drugs. The current study aimed to examine the rewarding effect of three cathinones: MDAI, flephedrone (4-FMC), and butylone. The rewarding effects were measured in a conditioned place preference test. In conditioned place preference, mice, animals regularly used as models for human behavior, are placed in one environment while under the influence of a drug, and in another while not. Before being exposed to the drug, animals are given free access to both environments, the time spent in either environment is recorded, and the environment in which less time is spent is designated the drug-paired environment. After multiple drug/nondrug environment pairings, the mice are, once again, given access to both environments and the time spent in the drug-paired environment is measured. If the time in the drug environment increases after drug exposure, the drug is said to have rewarding effects. Each of the cathinones tested produced an increase in time spent in the drug-paired environment. MDAI produced a plateau effect. Butylone produced a dose-dependent increase in time spent on the drug-paired floor. Flephedrone produced an inverted-U dose-response curve These results suggest that MDAI, flephedrone, and butylone produce rewarding effects. Given earlier findings that these compounds produced cocaine- and methamphetamine-like discriminative stimulus effects, they have a strong potential to be abused. Purpose (a): Synthetic cathinones, sold online and in head shops as “bath salts,” have seen a tremendous increase in popularity since 2007. Consequently, the number of cathinone-related hospitalizations has increased, hitting a peak in 2011. Although cathinone usage and hospitalization has decreased since the Synthetic Drug Prevention Act was passed in 2012, the drugs remain popular amongst young people and dance club frequenters. While the literature on synthetic cathinones has been steadily accumulating, behavioral data still remains sparse, especially in regards to abuse liability. The current study examined the dose-dependent rewarding effects of three substituted cathinones: MDAI (0.1, 0.3, 1, 3, 10 mg/kg), flephedrone (4-FMC, 3, 10, 30 mg/kg), and butylone (1, 3, 10 mg/kg). Methods (b): A biased conditioned place preference model of drug reward was utilized. For each drug, doses between 0.1-30 mg/kg were administered to generate a dose-response curve. Results (c): MDAI resulted in increased time on the drug-paired floor from 0.3-10 mg/kg, with 3 mg/kg yielding the largest increase. Flephedrone produced an inverted U-shaped dose-response curve with 10 mg/kg resulting in an increase in drug-paired floor time, but not 3 or 30 mg/kg. Butylone produced a dose-dependent increase in drug-paired floor time from 1 to 10 mg/kg. Conclusions (d): These results suggest that MDAI, flephedrone, and butylone produce rewarding effects. Given earlier findings that these compounds produced cocaine- and methamphetamine-like discriminative stimulus effects, they have a strong potential to be abused. Potency, efficacy, and dose-response pattern differed among the three drugs, with MDAI being the most potent, followed by butylone, then flephedrone.
THE CURRENT USE OF VIRTUAL ENVIRONMENTS FOR ASSESSMENT AND TREATMENT OF AUTISM SPECTRUM DISORDER
(2014-03) Krishnan, Meena M.; Miller, Haylie L.; Bugnariu, Nicoleta L.
Virtual environments (VEs) are an emerging technology used to assess and treat people with Autism Spectrum Disorders (ASD). VEs can be presented on a traditional computer monitor or in a more immersive setting on a large screen or in a room. This review investigates large screen VEs, which include interactive and non-interactive interfaces. Individuals can engage in varying levels of interaction with the VE by using a computer mouse, using a touch screen monitor, or moving their body in space to control virtual representations of themselves. People with ASD have differing levels of deficits in social skills, movement awareness/coordination, and behavioral regulation. In order to accurately draw conclusions about real-world functioning, researchers must produce naturalistic but repeatable experiences, where key variables can be controlled and systematically manipulated. The use of VEs may enable researchers and clinicians to achieve this balance in the assessment and treatment of ASD. Purpose (a): We aim to provide a comprehensive review of immersive large screen Virtual Environments (VEs), and to determine whether immersive VEs are effective for assessing and treating behavioral, social and motor symptoms of Autism Spectrum Disorder (ASD). Understanding applications of VEs will facilitate better understanding of the benefits of controlling naturalistic experiences balanced with the ability to repeat experiences the same way every time. This will assist researchers and clinicians in their ability to diagnose and treat symptoms of ASD related to social skills, movement awareness/coordination, and behavioral regulation. Methods (b): Six search engines were used: PubMed, Scopus, Ebsco via Medline, CINHAL, PsycINFO, and PsycARTICLES. Search dates were July–October 2013. Keywords used were: Autism, Autism Spectrum Disorder, ASD, Asperger, Pervasive Developmental Disorder, PDD, virtual reality, VR, virtual environment, and augmented reality. 71 articles were found. Articles were sorted according to level of immersion. 7 articles met the final criteria for immersive VEs with large screen presentation. Results (c): The majority of studies involving VEs used a traditional computer monitor display, rather than an immersive setting. Studies using large screen presentation of VEs focused primarily on gross motor movements (Cai et al., 2013; Cook et al., 2013; Cheng et al., 2012; Greffou et al., 2012) or a combination of motor and social skills (Jung et al., 2006). Two studies focused on social skills and engagement with the VE (Mineo et al., 2009; Wallace et al., 2010). In 6 of the 7 studies reviewed, participants with ASD were successfully either treated or assessed using VE technology. However, there is a clear need for more research evaluating cognitive and behavioral abilities in ASD using immersive VEs. Conclusions (d): Immersive VE is a promising tool for use in studies of children and adults with ASD. The use of immersive VEs for assessment/treatment of ASD is still new, and therefore not well-understood. However, several studies have demonstrated that both interactive and non-interactive VEs are an effective and engaging tool for assessing motor and social skills in ASD across a broad age range, and may be effective for delivering interventions. This technology also has potential for use as an assessment tool in non-verbal ASD populations (Cai et al., 2013). This growing body of work highlights the potential utility of VEs for assessment and treatment of ASD.
PSOAS AND SACROSPINALIS MUSCLE SIZE AND DENSITY: AN INDICATOR OF FALL RISK IN THE GERIATRIC POPULATION
(2014-03) Icenogle, Kurt; Nana, Arvind
Purpose (a): The sequlae of fragility fractures continue to be a major source of morbidity and mortality, as well as a contributing factor in the rising cost of healthcare. The risks of fragility fracture are multifactorial with the current screening paradigm focused on detecting and treating decreased bone mineral density. Physiologic aging is associated with sarcopenia, and decreasing muscle mass has also been described as an independent risk factor for fragility fracture. This study hypothesized that the observed cross sectional area of the psoas and sacrospinalis muscles would be smaller in patients who developed fragility fractures. Methods (b): To test this hypothesis we performed a retrospective chart review comparing the cross sectional area of Illiopsoas and Sacrospinalis muscles in 145 patients over 50 years of age with fragility fractures compared with 55 controls (patients over age 50 undergoing CT scan for cholelithiasis). Results (c): We found that the population of patients admitted with femoral neck fractures had significantly smaller illiopsoas and sacrospinalis cross sectional areas than controls (P < 0.05). Conclusions (d): The study identifies a quantifiable independent risk factor for fragility fracture that is not currently included in standard screening protocols. Future prospective work will seek to verify if psoas and sacrospinalis muscle morphology is predictive of fracture risk. Ultimately a more predictive multifactorial model of fragility factor risk may be developed that includes screening for both osteoporosis and sarcopenia.
PHYSICIANS PRACTICES AND END OF LIFE
(2014-03) Najafi, Sina; Lieto, Janet; Johnson, Leigh A.
Purpose: The numbers of people who spend their last months of their life in nursing homes and hospices are increasing rapidly. The percentage of older people who received hospice care in the last 30 days of life increased from 19 percent in 1999 to 43 percent in 2009. The percentage of older Americans who died in hospitals dropped from 49 percent in 1999 to 32 percent in 2009. The percentage that died at home increased from 15 percent in 1999 to 24 percent in 2009. This increase in hospice care requires more consideration of palliative care and end of life (EOL) decisions. Physicians often play a role in EOL of their patients in the nursing home setting, and are integral in discussing EOL decision related to care. Thus more research is needed to understand the clinician’s perceptions of spirituality and what constitutes a good death. The goal of this study was to assess healthcare providers' practices that influence end of life care in the nursing home and identify those factors that are associated with what practitioners deem to be a "good death." Methods: A group of 57 healthcare providers working in nursing homes in the United States completed surveys on the end of life experiences of 259 patients. A brief anonymous survey including both open- and closed-ended questions assessed the provider’s practices and perceptions of end of life practices of up to 10 of their patients that had just died. The survey included the demographics of healthcare providers, patients, and institutions. There were also questions regarding the availability of services (e.g., hospice care) within the nursing home and practice patterns of providers and institutions. Lastly, respondents were asked if they felt their patient(s) experienced a "good death." Results: The majority of the surveys were completed by Physicians (90%), and the rest were completed by Physicians Assistants or Nurse Practitioners. Most facilities (35%) surveyed contained between 100-150 patient beds, and over 85% of the patients died in the nursing home facility, with only 10% dying at the hospitals. The provider felt that over 49% of the patients spiritual needs were met, 10% did not feel needs were met, 20% responded NA, and the rest felt they were unsure due to advanced dementia of the patient. Lastly, 77% of providers felt the patient experienced a “good death”, and 13% (34) did not feel the patient had a good death. The most common attributes associated with a good death were pain free, family present, and sudden or peaceful death. Severe pain or patients uncomfortable were most commonly reported for a “bad death.” Conclusion: With continuing advances in medical technology, pharmaceuticals, and aging research, the elderly population of the United States is growing. To that end, it is important for providers to be prepared to address issues related to EOL decisions. A provider’s personal practices, perception and help in transitioning patients at the end of life are important factors to understand so that more patients can experience a good death.
FACTORS ASSOCIATED WITH THE DEVELOPMENT OF SYMPTOMATIC INTERLOCKING SCREWS WITH INTRAMEDULLARY NAIL STABILIZATION OF TIBIA FRACTURES
(2014-03) Elliott, Michael P.; Nana, Arvind
Treatment of tibia fractures with intramedullary nail stabilization is a commonly performed orthopedic procedure. The incidence of complications after undergoing intramedullary nail stabilization of tibia fractures is relatively low, however, a small percentage of patients develop symptomatic pain at the site of their interlocking screws, necessitating removal. The primary goal of our project was to identify reasons for removal of interlocking screws, and secondary goal to assess factors associated with the development of symptomatic interlocking screws to better identify those at risk and reduce the occurrence of this complication. This would be beneficial in reducing the need for repeat surgery to remove symptomatic interlocking screws. Purpose (a): The primary purpose of this study is to identify reasons for removal of interlocking screws after treatment of tibial shaft fractures with intramedullary nail stabilization. The secondary goal is to assess factors associated with development of symptomatic interlocking screws. Methods (b): A retrospective chart review was performed to identify a consecutive series of patients who underwent stabilization of a tibial shaft fracture with intramedullary nail from July 1st, 2005 to July 1st, 2011. We then identified those who underwent removal of interlocking screws at a later date (Group 1). These patients were then compared with a control-matched group (Group 2) who did not require removal of interlocking screws. Patients with pain identified at the interlocking screw sites either proximally or distally were considered to be symptomatic. Patients’ charts were reviewed to obtain demographic, radiographic, and clinical data. Statistical analysis was then performed comparing certain factors between the two groups. Results (c): 20 patients (Group 1) were identified who underwent removal of interlocking screws, 16 (80%) for symptomatic screws and 4 (20%) for dynamization due to non-union. 30 patients (Group 2) were identified who did not require screw removal. Of the patients undergoing screw removal for symptomatic screws, 15 (93%) had complete resolution of symptoms after screw removal. All patients undergoing screw removal for dynamization/non-union purposes went on to fracture union. Group 1 had a higher percentage of males vs. females compared to group 2 (p = 0.019). Average time to fracture union for Group 1 was 32.7 weeks vs. 15.5 weeks for Group 2 (p = 0.014). 14/20 (70%) patients were smokers in Group 1 vs. 13/30 (43%) in Group 2 (p = 0.003). Average Injury Severity Scores (ISS) and Mangled Extremity Scores (MES) for Group 1 were 16.1 and 3.3 respectively, and 6.6 and 3.2 respectively for Group 2 (p = 0.007/0.66). Group 1 had a higher percentage of open fractures (60%) vs. Group 2 (20%). Group 1 had a higher percentage of shaft fractures (40%) vs. Group 2 (27%) (p = 0.007). Group 1 had a higher likelihood and number of associated injuries vs. Group 2 (0.025). The groups did not differ significantly with respect to age, BMI, mechanism of injury, time to surgery, or associated fibula fracture. Conclusions (d): The most common reason for removal of tibial intramedullary nail interlocking screws was not for dynamization, but for pain. Removal of interlocking screws resulted in resolution of pain in 93% of patients. Patients who develop symptomatic interlocking screws were more likely to be male,have delayed fracture union, smoke, have higher ISS scores, open fractures, and higher number of associated injuries. By identifying those that are at higher risk for development of symptomatic interlocking screws after intramedullary nail stabilization of tibia fractures (smokers, males, open shaft fractures, delayed union, higher ISS scores, and presence/greater number of associated injuries) we may have a better ability to counsel patient's about their expected outcome and possible development of complications.
A PROPOSED MODEL FOR POST-APPROVAL MONITORING (PAM) OF INSTITUTIONAL BIOSAFETY PROTOCOL IN AN ACADEMIC ENVIRONMENT
(2014-03) Uche, Uloma I.; Nair, Maya
The main goal of this project is to develop inspection program over research work involving biological agents and to ensure compliance with National Institute of Health guidelines. Purpose (a): Hypothesis: I hypothesize that a well-defined model for post-approval monitoring will enhance the efficiency of biosafety program. Purpose: To ensure that approved protocols are appropriately executed and any changes are reported for approval. Methods (b): Materials: Approved protocols/IBC application. Forms to conduct the post approval monitoring. A program out line or Post approval monitoring. An evaluation process or tool to validate the efficiency of the proposed model. Methods: Prior to PAM, a project protocol has to be approved by the Institutional Biosafety Committee (IBC) and the principal Investigator proceeds with the research. With the current Biosfaty program at UNTHSC, the institutional biosafety officer will conduct an annual inspection of each of these laboratories with containment level BSL2 and BSL2+. We are proposing to develop a model for PAM of Biosafety protocols. The process involve the following steps. Critically examined the existing biosafety auditing program. Research on existing biosafety auditing program in other academic institutions in Texas. Development of the proposed model for Post Approval monitoring program. Timeline and major steps involved in the proposed model are: Inspection of the laboratory and laboratory procedures of the on-going research for compliance must be done by the Biosafety officer within 2-3 weeks after the protocol approval. The crucial component of this inspection will be an on the spot education about any deficiencies identified during the inspection. After the first year of approval, a thorough review of the protocol and laboratory procedures should be conducted by an assigned member of the institutional biosafety committee. Post-visit communication to the principal investigator about any deficiency or compliance found should be recorded and communicated with the principal investigator. Any training requirement should be communicated effectively. Finally towards the end of the research, another lab procedure evaluation should be conducted. Results (c): Results: From the post-approval monitoring, there will be compliance with IBC policies/NIH guidelines and the facility and laboratory workers will be protected from hazardous materials. Conclusions (d): Conclusion: Institutional Biosafety protocol guides and ensures safety and compliance with policies. An efficient post-approval monitoring would be a tool to assist the IBC with its obligations and facilitate a successful program oversight.
DISCOVERY AND DEVELOPMENT OF A BIO-INSPIRED SURGICAL ADHESIVE
(2014-03) Hoffman, Jason T.; Carter, Brian; Kosmopoulos, Victor; Schetz, John A.
Our main focus is to develop a bio-inspired adhesive to be used within a surgical environment to facilitate accelerated healing. This would be beneficial for securing bone fragments, in conjunction with a plate or screw, or anchoring other tissues. Purpose (a): Our goal is to develop an adhesive for securing bone to bone, metal to bone, and tissue to bone. As the aging population increases, the number of fractures due to falls and loss of bone density will increase. The incidence of bone fractures in elderly women, ages 50-79, exceeds the combined incidents for all types of cardiovascular disease and breast cancer. Although there are bone “fillers” (e.g., putties, cements and fillers), there are currently no true adhesives for bone. Drawbacks of current filler-type products complicating their use include the need to completely dry bone prior to application and high curing temperatures which can damage surrounding tissue. Methods (b): In light of naturally-occurring glues from aquatic mussels being able to harden underwater, we adapted the same type of chemistries for our approach. Specifically, we utilized catechol-like chemistries to strengthen protein-based adhesives. A bone surrogate model consisting of hydroxyapatite was employed to measure the tensile strength. Results (c): In previous proof of concept stages, we were able to secure bone to bone but were able to achieve only a small fraction of our target adhesive strength. Using new protein-based approaches we have improved our technology to obtain thousand-fold higher tensile strengths. Conclusions (d): We envision future applications of this adhesive medical device technology to include bone reconstruction, securing screws and metal plates to bone, and cartilage or ligaments to bone. Having a bone adhesive with sufficient strength to serve as a stabilizing force for immediate weight bearing would promote bone regrowth and accelerated healing.

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