Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/32554


Recent Submissions

Now showing 1 - 18 of 18
  • Item
    Biomechanical Markers of Lower Extremity Fatigue: A Literature Review
    (2024-03-21) Malhotra, Garima; Sotelo, Joseph; Ngo, Khang; Do, Khanh; Toledo, David
    Purpose: Lower-extremity (LE) muscular fatigue plays a pivotal role in injury occurrence across various domains, including sports, occupational settings, and daily activities. This is partly because fatigued muscles can absorb less energy before reaching the degree of stretch that causes injury. This review explores the significance of employing measurable biomechanical markers to assess lower extremity fatigue. Some studies have shown significant changes in post-fatigue functional tasks (vertical jump height), acceleration/velocity, postural stability (center of pressure), spatio-temporal gait metrics, and pressure distribution, but few reviews have compared these factors to identify the best predictors of fatigue. With the prevalence of musculoskeletal injuries, understanding the biomechanical changes associated with fatigue becomes imperative for predicting and preventing injury. Methods: PubMed, Google Scholar, and Scopus were searched using 20 distinct queries, which yielded 3,068 articles. The inclusion criteria used were: An experimental pre/post-test design, fatiguing protocol targeting lower extremities, recent studies after 2010, greater than 10 participants, data recorded via force plates or IMU, and a healthy adult population. In total, 44 articles met the inclusion criteria. Results: Of the included studies, CoP changes were dependent on the protocol used. High-intensity fatigue protocols were associated with significant increases in postural instability, measured by CoP displacement, velocity, and variability in both sagittal and coronal planes, but CoP measures were inconclusive in low-moderate intensity fatiguing protocols. When observing Spatio-Temporal gait metrics, the literature showed a strong positive correlation between increased ground contact time and fatigue. Stride length was negatively correlated with fatigue. Step width variability and single stance time were increased following fatigue. In terms of pressure distributions, increasing muscle fatigue was correlated with increases in plantar pressure. Peak pressure and force of metatarsals I - V were inconclusive, attributable to varying rear versus forefoot strike patterns, however, medial and lateral heel peak pressures consistently increased with muscle fatigue. In line with these findings, various studies demonstrated that increasing fatigue correlated with kinetic parameters such as increased stride cadence and, consequently, increased tibial acceleration. Prolonged or repetitive exposure to elevated tibial acceleration levels may be associated with greater impact forces and loading on the lower extremities, potentially contributing to muscle fatigue and elevating the risk of overuse injuries. Functional tests, such as jump height, showed a significant negative relationship with fatigue regardless of protocol intensity. A study comparing different jump height modalities and fatigue showed the highest repeatability and immediate/prolonged fatigue produced changes with CMJ, supported by its widespread use as an indicator for fatigue. Conclusions: We consistently found significant increases in sagittal plane CoP velocity, ground contact time, heel loading, and tibial acceleration with a significant decrease in CMJ height following LE fatigue. Limitations included variability in the fatigue protocols used and limited research that met inclusion criteria. In the future, these results can have implications for the development of wearables to track fatigue in athletes to decrease the incidence of injury.
  • Item
    Evaluation of a bi-modal therapy in a model of cerebral ischemia
    (2024-03-21) Hernandez, Katherine; Jones, Nathan; Ortega, Sterling
    Purpose: Ischemic strokes are a significant contributor to cardiovascular-related deaths in the U.S. Currently, pharmacological interventions are limited to alteplase, an FDA-approved thrombolytic agent, or a surgical procedure known as a thrombectomy. However, their effectiveness is limited by a narrow therapeutic window and incomplete reperfusion rates. Our research explores an alternative strategy centered around PNU-120596 (PNU), a positive allosteric modulator of the alpha7 nicotinic acetylcholine receptor (a7 nAChR), which has shown promise in previous studies in a male rat stroke model. The a7 nAChR is expressed in various central nervous system cells, and studies suggest that PNU directly promotes neuroprotection in these cells. Furthermore, research indicates increased expression of the a7 nAChR in immune cells, specifically in activated inflammatory CD4 T-cells, a cell crucial in stroke studies. We hypothesize that PNU is a bi-modal therapeutic agent, addressing neuronal loss and inflammatory responses, presenting a unique advantage. Methods: This study aims to provide insight into PNU's efficacy and regulatory role in stroke-induced inflammatory CD4 T-cells. The study will assess PNU treatment's efficacy in promoting stroke recovery in transient middle cerebral artery (tMCAO) mice, a murine stroke model, and investigate how PNU modulates stroke-induced inflammatory CD4 T-cells, examining their suppression, neuronal survival, and alleviation of the disease using mixed cortical cultures. Mice that had undergone the tMCAO procedure were administered 20mg/kg of PNU immediately after reperfusion, and brain tissue was collected 24 and 72 hours post-tMCAO for infarct analysis. Spleen and cervical lymph nodes were collected at the same time points for flow cytometry analysis. Results: PNU reduces stroke infarct when administered immediately after tMCAO, and brain tissue is collected 24 hours post-tMCAO. However, protection is lost when the same dose is administered, and brain tissue is collected 72 hours post-tMCAO. No significant changes in levels of CD4 T-cell percentages were seen in the spleen or cervical lymph nodes at both time points. Conclusion: This study suggests that PNU reduces infarct volume immediately 24 hours post-tMCAO, but the protection is lost at 72 hours post-tMCAO. However, subsequent studies are necessary to assess the efficacy of PNU at longer time points with different dosages.
  • Item
    Validation of Smart Insoles’ Fatigue Score, a Case Report
    (2024-03-21) Ngo, Khang; Toledo, David; Do, Khanh; Morcilla, Jericho; Kennedy, Shawn; Patterson, Rita
    Background: Smart insoles give users valuable insights into their gait patterns, aiming to offer a cost-effective, reliable, accurate, and portable alternative to lab-based gait measurement using motion capture and force plates. Recent advancements have allowed IMU and pressure sensors (FSR) to be integrated directly into insoles, facilitating gait measurements outside of a lab environment. One promising application of smart insoles is to detect biomechanical changes in gait patterns and predict lower-extremity (LE) muscular fatigue. Reliable and accurate measurements of fatigue and recovery could play an essential role in injury prevention strategies and optimizing training intensity in various sports. Prior studies have used validated questionnaires such as the Rating of Fatigue (RoF) and Borg’s Rating of Perceived Exertion (RPE), which showed strong correlations with perceived fatigue and exertion ratings. Heart rate (HR) has also been frequently utilized among the objective measurements of fatigue. This case report aims to validate the fatigue score predicted by the smart insoles (LFS) against subjective and objective measures of fatigue such as RoF, RPE, and HR. Case Information: A 24-year-old male without existing gait abnormalities participated in a pre-test/post-test design with a progression-to-fatigue protocol consisting of multiple sets of repeated exercises until fatigue. The baseline (pre-evaluation) assessment included a 20m fast-paced walk and 2 static movement jumps (SMJ), followed by 2 countermovement jumps (CMJ). RoF, RPE, and HR measurements were collected at baseline and after each fatiguing set. Each fatigue set consisted of 6x 10m shuttle sprints followed by 5 vertical jumps consecutively without rest. Following each fatigue set, participants underwent post-evaluations that included the same exercises as the pre-evaluation. This approach enabled the insoles to analyze changes in gait from baseline due to the accumulation of fatigue. A 30-minute recovery session was completed after the participant reached a RoF = 10. The recovery session consisted of the RoF, RPE, HR, and post-evaluation measurements every 2 minutes for the first 10 minutes, then every 5 minutes for the remaining 20 minutes. Conclusion: The participant reached RoF = 10 after 6 repeated fatigue sets. Ground contact time (GCT), measured by the insoles, is one parameter that has been identified to inform the level of fatigue. In the fatiguing session, GCT was very strongly correlated with RoF and RPE (r = 0.971, p=.001); (r=0.986, p<0.001), respectively, but was not strongly correlated with HR (r= 0.543, p = 0.27). In the recovery session, GCT was strongly correlated with both RoF and HR (r =0.689, p=0.04); (r=0.723, p =0.028), respectively. RPE was a poor indicator of fatigue in the recovery session compared to RoF, GCT, and HR.GCT, along with other identified parameters, has the potential to be utilized in the development of the LFS. The LFS score analyzed changes in gait following fatigue and subsequently output a fatigue score for each set. Spearman’s rho and ICC were used to assess correlations and agreement between LFS, RoF, RPE, and HR. Data analysis was done using SPSS v29.0.
  • Item
    Hypoxia and oxidative stress reduce placental efficiency and impair the balance between autophagy and cell death mechanisms in trophoblasts
    (2024-03-21) Gardner, Jennifer; Bradshaw, Jessica L.; de Nazare Oliveria da, Renee; Hula, Nataliia; Mabry, Steve; Wilson, E. Nicole; Cunningham, Rebecca L.; Goulopoulou, Styliani
    Introduction: Hypoxia and oxidative stress can activate autophagy, a lysosomal degradation pathway that maintains cellular homeostasis. Impairments in autophagy mechanisms have been observed in placentas from obstetric complications associated with placental hypoxia and oxidative stress, such as preeclampsia and intrauterine growth restriction. Purpose: The objective of this study was to investigate the effects of hypoxia and oxidative stress on placental autophagy. We hypothesized that exposure to oxidative stress and hypoxia would alter the balance between cytotoxic and cytoprotective mechanisms in human trophoblast cells and rat placentas and would adversely affect placental efficiency. Methods: We used an in vitro model incorporating human trophoblast cells (BeWo cells) exposed to an oxidative stressor, antimycin A (10, 100, 320 μM) or vehicle for 4 hours. Trophoblast cell death and autophagy mechanisms were assessed via flow cytometry and western blotting. Additionally, we used a rodent model of gestational sleep apnea, a pregnancy complication associated with placental hypoxia. Long Evans timed-pregnant dams were exposed to chronic intermittent hypoxia (CIH; n=6-8) or normoxia (NX; n=8-9) during their sleep cycle from gestational day (GD) 15 to 20 (late pregnancy, term=21-23 days). Results: In trophoblast cells (n=5-9 independent experiments), antimycin A increased necrosis and LC3 A/B II/I ratio (autophagy marker) at 100 μM compared to vehicle (p<0.015). Necrosis remained elevated at 320 μM, while BAX (pro-apoptotic marker) and p62 (autophagosomal flux marker) were reduced compared to vehicle (p<0.0001). LC3 A/B II/I ratio returned to vehicle levels at 320 μM (p>0.05 vs. vehicle). Placental weights from CIH exposed dams were greater (NX: 0.51±0.02 g vs. CIH: 0.60±0.03 g, p=0.015) and fetal to placental weight ratios (marker of placental efficiency) were reduced compared to control pregnancies (NX: 5.25±0.13 vs. CIH: 4.43±0.14, p=0.0006) on GD20. Gestational CIH did not affect (p>0.05) fetal weights (NX: 2.76±0.06 g vs. CIH: 2.61±0.06 g), crown to rump length (NX: 3.32±0.03 cm vs. CIH :3.18±0.12 cm), abdominal girth (NX: 3.22±0.06 cm vs. CIH: 3.32±0.12 cm), or litter size (NX: 11.9±0.90 vs. CIH: 10.5±0.82). Conclusion: Oxidative stress alters the balance between cytotoxic and cytoprotective mechanisms in trophoblast cells, promoting cell necrosis. Although assessment of autophagy machinery and cell death in placentas from hypoxic pregnancies is ongoing, our results indicate that maternal CIH during pregnancy adversely affects placental efficiency.
  • Item
    Synchronous bilateral lipoma arborescens of the bicipitoradial bursa
    (2024-03-21) Carpenter, Brayden; Stokes, Cameron; Anderson, Cole; Sederberg, Mark
    Background: Lipoma arborescens (LA) is a rare intra-articular lesion formed by subsynovial villous proliferation in which subsynovial tissue is replaced by mature adipose cells. It is most commonly reported to appear in the knee joint but has also been seen to involve the shoulder, elbow, hip, ankle, and wrist joints. This report adds to the current understanding of lipoma arborescens by providing a rare presentation, and, to our knowledge, the second case reported in literature of bilateral synchronous lipoma arborescens of the elbow joints. Case report: We present a case of bilateral lipoma arborescens in a 36-year-old male with a history of untreated psoriatic arthritis who presented to an outpatient musculoskeletal clinic with a 6-month history of bilateral elbow pain and mass with the left being worse than the right and no history of trauma or injury. He reported morning exacerbation and accompanying stiffness, locking, and noticeable grinding and clicking in the left elbow. Physical examination revealed limited range of motion in flexion in the left elbow, a palpable mobile mass over the area of the distal biceps tendon bilaterally, and tenderness with resisted pronation and elbow flexion in the left elbow. Radiographs of both elbows showed no structural abnormalities, while a diagnostic ultrasound of the elbows revealed cystic anechoic structures adjacent to the biceps tendon with increased vascularity seen on color doppler and several frond-like appendages that entered into the cystic structure. MRI was obtained which showed severe bicipitoradial bursitis with synovitis, frondlike fat projection suggestive of lipoma arborescens within the bursa, mild insertional biceps tendinopathy, and reactive edema in the proximal radius centered at the radial tuberosity. Surgical intervention was recommended. The patient had the left-sided mass resected by a hand orthopedic surgeon. The patient was doing well at his 4-week follow-up and had no pain with range of motion. The pathology report showed a 4.2x1.8x1.8 cm pink-white pigmented soft tissue fragment with mature adipose tissue with marked chronic inflammation and fibrinous exudate which further confirmed the diagnosis of lipoma arborescens. His contralateral mass will be resected if it becomes symptomatic. Conclusion: Lipoma arborescens is a rare, slowly progressive benign lesion that should be on the differential diagnosis of those with a periarticular mass and a chronic inflammatory condition. In this patient, given his untreated psoriatic arthritis, chronic inflammation is likely responsible for its development. Though harmless, it may be resected if it becomes symptomatic due to the mass effect on surrounding tissues.
  • Item
    Artificial Intelligence's Prospects and pitfalls in the field of Diagnostic Radiology
    (2024-03-21) Verdier, Gavin
    Opening: Artificial Intelligence (AI) is a burgeoning field that is integrating into medicine at an accelerating pace. Its capacity for providing quantitative and qualitative image analysis is becoming an increasingly valuable tool for Diagnostic Radiology. Nowadays, a wide array of AI-based solutions are available, employing diverse approaches like Convolutional Neural Networks (CNNs), Reinforcement Learning, and Image and Texual Generation. Support: An area of implementation that is particularly intriguing is in the recent advancements in the interpretation of thoracic imaging. The interpretation of thoracic X-Rays in trauma settings might be delayed due to various hospital processes. Preliminary reads by AI algorithms could identify findings that could lower the workflow burden and allow physicians to focus on more challenging cases (Feng et al.). Additionally, datasets like those collected in these studies have contributed tens of thousands of high-quality, annotated X-Rays in open datasets, which can be used to continually enhance AI tools for the field. The AI technique of reconstruction can fill in the gaps of lower-quality imaging data, which has the potential to lower the amount of time and resources needed for scans such as Knee MRIs. These techniques could help to democratize advanced imaging to more patients and reduce facility operational costs. AI has the potential to provide standardization to the subjective nature of image interpretation, with one example being in evaluating metastatic breast lesions. However, Meta-analyses evaluating the efficacy of using AI in diagnosis and staging still display issues with sensitivity, with reported levels being as high as 20%, a figure unusable in a clinical setting. While approaches such as Deep Learning and Image Reconstruction have a promising future, the truth is that these technologies are still in their infancy. Datasets for Neuroimaging in MRIs might not contain sufficient data to provide the training necessary for certain reconstruction techniques, which could miss crucial artifacts in certain circumstances. There is a genuine concern as well that AI might exacerbate disparities in healthcare because of the inherent difference in how AI and human doctors arrive at decision-making. Concern arises around the interpretation of data and the potential for AI to propagate biases into the diagnostic image interpretation due to suboptimal AI training. Another example is that AI has been shown to deduce a patient's race without the relevant information as perceived by human clinicians being explicitly provided. The relative absence of understanding of the inner workings of AI algorithms can undermine the trustworthiness of many currently available AI systems. This, in turn, reflects the many potential areas in improving the interpretability of these often what regarded as “blackbox” systems. Conclusion: Though AI has many hurdles to overcome, it is likely to gain increasing importance in the Radiologist's toolkit over the coming years. These tools will necessitate the Radiologist to become even more familiar with the technology and data collection. The algorithms that are being developed will undoubtedly benefit from close collaboration between the physician, software developers, and engineers in order to develop effective and clinically relevant software.
  • Item
    Implementation of SERPINA1 Next-generation Sequencing and Bretzi in Alpha-1 Antitrypsin Deficiency
    (2024-03-21) Do, Khanh; Umer, Saad
    Background: Alpha-1 Antitrypsin deficiency (AATD) is a common hereditary disease in families that have autosomal codominant patterns composed of two different variants of alleles, and generally are suspected in young patients (age 25-50) with symptoms of pulmonary emphysema or chronic obstructive pulmonary disease (COPD), with treatment consisting of either augementation therapy with IV purified AAT or symptomatic treatment. It is currently recommended to support initial quantitative serum AAT level measurements with some sort of qualitative testing for comprehensive diagnosis and risk assessment. Case Presentation: We report the case of a caucasian 51-year-old female with no significant history of smoking, occupational chemical exposure, and exposure to birds, who presented to the clinic with complaint of persistent dry frequent coughs with associated shortness of breath (SOB), headache, and difficulty sleeping. At the time of initial presentation the patient reports taking Azelastine HCI, Benzonatate, Albuterol Sulfate, ProAir HFA, Zafirlukast, and Fluticasone Propionate with no improvement of symptoms. Initial workup found significant hyperinflation on Chest X-ray and Pulmonary Functions Tests (PFT) and AAT deficiency testing was initiated based on clinical guidelines. Advanced testing with SERPINA1 next generation sequencing was ordered in conjunction with serum AAT levels to confirm the diagnosis and the patient was started on a month course of Trelegy with minimal improvement of symptoms. A sample of Bretzi was given and on follow-up, patient endorsed resolution of symptoms with improved quality of life and denied any coughing, wheezing, SOB, chest pain, sinus congestion, runny nose, headache, or dizziness. Conclusion: This case illustrates a typical clinical presentation of AATD; we conclude that the addition of SERPINA 1 next generation sequencing (FDA determined no need for clearance) as a confirmatory measure and resolution of symptoms with a course of Bretzi, a 3-in-1 maintenance COPD medication cleared by the FDA in 2020, suggest the efficacy of including these relatively new modalities in the treatment of future AATD patients.
  • Item
    Evaluation of Fat Distribution as a Potential Risk Factor for Infection and Wound Healing Complications in Total Hip Arthroplasty
    (2024-03-21) Hawes, Jaden; Gowen, Lillian; Hernandez, Christian; Wagner, Russel
    Purpose: Surgical site infection (SSI) following joint replacement is a feared complication, as it is associated with worsened outcomes for both the patient and the healthcare system. There is conflicting evidence regarding BMI as a risk, as it does not consider body composition or the distribution of fat relative to the surgical site. This study evaluated the relationship between site-specific fat distribution and SSI following total hip arthroplasty (THA). Methods: Prospective data collection of surgical-site fat depth measured intraoperatively from the skin surface to the center of the greater trochanter. The ratio between fat depth and the size of the lateral trochanter was determined. Chart review of surgeries (n=98) to collect information on patient history, demographics, and various risk factors. Conclusion: Data collected in this study illustrates a statistically significant risk of THA SSI and wound healing complications with higher BMI and a statistical trend with increased localized fat distribution; however, evaluation of a larger patient population will be important to fully characterize the risk factors of THA postoperative complications and the impact of localized fat distribution.
  • Item
    A Missed Case of Synovial Osteochondromatosis
    (2024-03-21) Alkhabbaz, Omar; Bibi, Yasser; Webb, Brian; Milhoan, Madison
    Background: Synovial osteochondromatosis is a benign, uncommon, and interesting disorder that presents challenges in diagnosis and treatment. It is a complication of the synovial membrane of joints, tendon sheath, and bursae that can cause dysfunction most commonly in the knee, hip, or shoulder that has the potential of transforming into chondrosarcoma. While the exact etiology of a primary synovial osteochondromatosis is still in question, hypotheses point toward the metaplasia of the synovial membrane and the detachment of cartilaginous fragments as potential causation. The cause of secondary synovial osteochondromatosis is associated with an underlying joint pathology or condition that triggers development such as osteoarthritis, rheumatoid arthritis, or traumatic joint injuries Patients with this condition usually present with a history of pain in the joint affected, swelling, crepitus, and limited range of motion (ROM).The pain is usually aching in nature and is exacerbated by weight-bearing activities such as prolonged periods of walking or standing. Case Information: A 62-year-old female with a past medical history of hypertension and hypothyroidism presented to the clinic with a chief complaint of bilateral knee pain and effusions, which was diagnosed as osteoarthritis based on clinical exam and past X-rays. The patient had been experiencing moderate relief from bilateral steroid injections that were administered approximately every four to six months. As for diagnostic imaging, she had two MRI scans of her left knee; the first in 2020 and the second in 2023. The differential diagnosis formulated in the clinic after the MRI scan (Fi [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10705034/figure/FIG1/]was pigmented villonodular synovitis (PVNS), rheumatoid arthritis (RA), or synovial chondromatosis. Conclusions: Although synovial osteochondromatosis is generally a benign condition, transformation to chondrosarcoma is still a possibility. Imaging may assist in identifying the loose bodies floating in the joint space, but this becomes much more difficult if the loose bodies are radiotransparent (chondromatosis). Calcified nodules (osteochondromatosis) are relatively less difficult to view on X-ray. T2 weighted MRI imaging can help identify synovial hyperplasia which can help clue clinicians in with other physical exam findings. Although an arthroscopy with histopathology is the gold-standard diagnostic modality, it is important to keep in mind that one or even two different types of imaging modalities may not be sufficient for synovial osteochondromatosis to make the differential. As seen in our case, it took three years after the pain from the onset of chondromatosis for suspicion to arise on MRI. Sometimes patients may not be so fortunate by the time it is noticed and, although uncommon, the formation of chondrosarcoma may already be in progress. If left untreated, patients can also develop severe osteoarthritis. Clinicians must not hesitate to diversify the imaging modalities in which they order, as a diagnosis may become more apparent in one versus the other. Another lesson to take from our case is to stay vigilant in regard to who can present with synovial osteochondromatosis. Although our patient did fit the expected location of the disease (larger joint, the knee in this case), she did not fit the expected gender or age group in which these processes arise.
  • Item
    Transcranial Magnetic Stimulation Efficacy Across Age Groups
    (2024-03-21) Mehdi, Huzair
    Purpose: Transcranial magnetic stimulation is a non-invasive brain stimulation technique that targets treatment-resistant depression and other psychological disorders. TMS involves delivering repetitive magnetic pulses to stimulate electrical activity in the brain, sending a depolarizing current to neurons in the targeted region. For treatment-resistant depression, TMS targets the dorsolateral prefrontal cortex, though for other disorders, the region targeted varies. It is possible that TMS utilizes the neuroplasticity of the brain to cause long-term changes in brain activity. Previous studies have also explored age-related changes in GABA receptors, which could also impact the efficacy of TMS . I hypothesize that younger age groups (18-25 years) would respond better because their brains are still in development. Methods: The Neurostar Magnetic Therapy Machine was used to treat each patient involved in the study. It is FDA approved for the treatment of Major depressive disorder (MDD) and obsessive-compulsive disorder (OCD). Correspondingly, the machine administered varying treatments for each disorder through altering total pulses, seconds of stimulation, and the time span of the break between stimulation. Within each disorder, these variables were kept constant. Treatment for MDD involved a standard total of 3000 pulses with intervals of 4 seconds of stimulation and 11 seconds of rest. Contrastingly, OCD treatment included a standard 2000 total pulses with 2 seconds of stimulation and a 20 second rest break in between. The final metric used for data analysis was the Standard Motor Threshold (SMT), which is a measure of the strength of the patient’s medication and varied between each patient. The PHQ-9 survey was the metric used to measure whether a patient had undergone remission, with a score of 0-4 indicating success. An initial PHQ-9 was completed prior to treatment, and then completed weekly, followed by a final survey post-treatment, yielding roughly 7-9 surveys exhibiting the changes in their respective disorders. For this study, only patients who fully underwent remission were included in the data set. Records of each patient’s PHQ-9 surveys were obtained digitally through the “Trakstar” EMR program, which held every completed survey of each patient. Results: The data supports that patients within the 41-60 age group were the most responsive to TMS. Following that age group in terms of responsiveness was the 18-25 age group, then the 61+ age group, and finally the 26-40 age group was ranked last. It can be posited that the reason for the highest rates of responsiveness in this age group is due to their lower neural plasticity, resulting in the changes caused by TMS to last longer. Conclusion: The results reflected that the 41-60 age group responded best, though all age groups had similar rates of responsiveness close to the 50% mark. Further study is needed to confirm the reasons as to why the 41-60 age group responded higher than the rest. Exploring TMS efficacy on patients with secondary disorders to MDD or experimenting with the idea of placing TMS treatments ahead of rounds of psychiatric medications can support the notion that TMS is a safe and effective psychiatric treatment of the future.
  • Item
    Relationship Between Pain and Total Healthcare Expenditure in Elderly Osteoarthritis Patients: An Interpretable Machine Learning (ML) Investigation with eXtreme Gradient Boosting
    (2024-03-21) Middleton, Claire; Dehghan, Arshama; Park, Chanhyun; Shen, Chan; Sambamoorthi, Usha
    Objective: Osteoarthritis (OA), a painful degenerative joint condition, affects over 32.5 million adults in the United States and one-fourth experience severe joint pain. In 2019, adults with OA had $45.4 billion more annual expenditures relative to those without OA. Although statistical methods have been utilized in studying the additional costs associated with pain among adults with OA, there is still a notable gap in understanding the relationship through the lens of ML methods. The objective of this study is to determine pain as a leading predictor of economic burden among older adults (age > 65 years) with OA using ML methods. Methods: We used data on older adults (age > 65 years) with OA (N = 1,640) from the 2021 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of households in the US. Log-transformed total healthcare expenditures, which included payments by the insurers and the patients, represented the economic burden. We employed eXtreme Gradient Boosting (XGBoost) regression to determine key predictors. Global and local interpretations of associations were performed using a SHapley Additive exPlanation (SHAP), including a Partial Dependence Plot (PDP) for pain. Our predictive model utilized 24 features including biological (sex, age), race and ethnicity, clinical (pain, polypharmacy, physical and mental health status, and chronic conditions), and Social Determinants of Health (SDOH) such as marital status, education, poverty status, census region, insurance coverage, and prescription drug coverage. Chronic conditions included anxiety, depression, thyroid disease, diabetes, hypertension, coronary artery disease, cancer, hyperlipidemia, asthma, and chronic obstructive pulmonary disease. Pain interfering with regular work over the past four weeks was assessed using the Veterans Rand 12-item Health survey (VR-12), employing a Likert scale ranging from 0 (none) to 4 (extreme) to represent pain level. Missing values for pain level were imputed using K-Nearest Neighbors (KNN) Imputation. The model building included 70% training and 30% testing split of the data and 3-fold cross-validations using Python 3.10.12. Model performance was evaluated with R-square, mean absolute error, and Root Mean Square Error (RMSE) using the test dataset. Results: Approximately, one in 4 adults with OA reported moderate to extreme pain. The top 3 predictors of healthcare expenditures were: polypharmacy, physical health, and pain level. Higher pain levels and polypharmacy were associated with higher total expenditures. Excellent physical health was associated with lower total healthcare expenditures. Additionally, the SHAP PDP suggested a linear relationship between pain levels and total expenditures. Model performance was modest with a mean absolute error (1.086), RMSE (1.736), and R-square (0.452) for total expenditures. Conclusion: Higher pain levels predicted higher economic burden in older adults with OA. Effective management of pain may be a pathway to reduce the economic burden of OA. As polypharmacy was a leading predictor of healthcare expenditures, this model underscores the importance of reducing polypharmacy use in older adults with medication utilization review and management.
  • Item
    ANCA positivity in the case of acute bacterial endocarditis
    (2024-03-21) Forsyth, Alyssa; Quresh, Quretul
    Background: The case of ANCA positivity in an individual with bacterial endocarditis demonstrates the importance of thorough testing and labs prior to treatment. This case draws attention to a diagnostic conflict, as starting treatment on immunosuppressants, as would be the standard therapy for ANCA-associated vasculitis (AAV), could exacerbate the bacterial endocarditis and carry severe consequences. In this case of glomerulonephritis and associated endocarditis, the patient presented with several symptoms which mimicked AAV. Thus, it is important for providers to include cultures in routine assessments of ANCA-positive cases to allow for thorough evaluation and appropriate therapy. Case information: A 60-year-old morbidly obese male presented for right knee pain. His medical history includes hypertension, congestive heart failure (CHF), osteoarthritis, atrial fibrillation, and stage IV chronic kidney disease (CKD). The patient denied history of smoking, drugs, or alcohol use. He has no family history of autoimmune disease. Upon evaluation, the patient was found to have a deep vein thrombosis (DVT) with leg pain, as well as paroxysmal atrial fibrillation. He was started on Coumadin for anticoagulation therapy. During his hospital stay, his creatinine levels climbed from 2.0 mg/dL to 6.3 mg/dL and was given a preliminary diagnosis of acute renal failure on top of his preexisting CKD. His renal decline prompted a kidney biopsy, which revealed focal necrotizing and crescentic glomerulonephritis with C3 dominant deposition. Urinalysis showed proteinuria and was positive for active urinary sediment. Bloodwork was remarkable for MPO-ANCA positivity (MPO-ANCA 1:640). Transesophageal echocardiogram (TEE) and blood culture revealed an aortic valve vegetation positive for methicillin-sensitive staphylococcus aureus (MSSA), and the patient was started on broad-spectrum antibiotic therapy. Conclusions: The details of this case prompt reflection on the diagnostic steps taken by providers when presented with an ANCA-positive patient. The standard protocol taken in the treatment of ANCA vasculitis differs tremendously from and could even have devastating consequences in the case of infectious endocarditis. Therefore, careful evaluation for bacterial endocarditis in the case of ANCA positivity should be incorporated into the diagnostic process. Most of the current literature represents cases of c-ANCA positivity in subacute infectious endocarditis (IE), often with Streptococcus viridans responsible. This case is unique in that the patient was positive for MPO-ANCA and not PR3 and the causative organism was MSSA. While several cases of MSSA IE with ANCA positivity have been reported, this combination of MSSA endocarditis and isolated MPO-ANCA positivity has only been represented one other time in the literature to our knowledge.
  • Item
    Effectiveness of AI Use in Qualitative Abstract Coding
    (2024-03-21) Alkhatib, Sarah; Jiwa, Nadiya; Judd, Dallin; Walters, Scott
    Purpose: As the field of qualitative research continues to evolve, the integration of artificial intelligence (AI) methods into data analysis has garnered increasing attention. This research paper presents a comparative analysis that evaluates the effectiveness, advantages, and disadvantages of utilizing AI methods for qualitative analysis of innovation characteristics of grant abstracts from the NIH RePORTER database, compared to traditional manual approaches. By comparing AI results to manual coding results, this project explores the potential transformative impact of AI on qualitative research. Methods: As part of the NIH HEAL initiative, researchers manually coded over 700 HEAL abstracts to examine innovation characteristics of grants funded. Survey questions included the type of study, study innovation, primary goals, and expected outputs. To explore whether these abstracts, when prompted in ChatGPT v4.0 would yield the same results as a human coder, we will input 100 of the 700 coded abstracts into ChatGPT, entering the same instructions given to the human coders. A comparative analysis will then assess and score the output in terms of detail, depth, relevance, and completeness of the responses. Results: We expect there to be no major differences between human and ChatGPT coding. This would suggest that AI can produce valid qualitative coding outcomes, potentially streamlining some research processes that involve abstracting themes from textual data and opening new possibilities for large-scale qualitative analysis. Conclusions: Ultimately, the findings of this study have the potential to shape the direction of qualitative research, offering valuable guidance to researchers and practitioners on the feasibility and reliability of integrating AI methods into their work. This research will contribute to the ongoing discourse on the role of AI in qualitative research and provide a foundation for future investigations in this rapidly evolving field.
  • Item
    Two Presentations of Neuroglial Heterotopias with Cleft Palate
    (2024-03-21) Stucki, Brenton; Marcincuk, Michelle
    Introduction: Neuroglial heterotopias, commonly known as nasal gliomas, are rare masses composed of brain tissue located outside of the cranial vault. These masses are composed of dysplastic glial cells which have lost their intracranial connections and can present as extranasal, intranasal, or mixed masses. They are thought to result from the incomplete closure of the anterior fontanelle between the nasal and frontal bones; this can result in an irregular connection between embryonic ectoderm and neuroectodermal tissue. Although the presentation of a neuroglial heterotopia in a child is uncommon, even more notable is the finding of neuroglial heterotopias visible from a concurrent cleft palate, as this can present additional difficulties in future cleft palate repair and mass excision. Case Presentation: Presented in this report are two cases of a neuroglial heterotopia found simultaneously with cleft palate. Although these lesions are typically considered benign growths, unmanaged neuroglial heterotopias can result in improper craniofacial development resulting in cosmetic complications and airway obstructions. For accurate diagnosis, thorough histological identification of the embryological tissue origins after surgical biopsy should be performed. Although neuroglial heterotopias and other masses of the nasopharynx such as teratomas have similar treatment methods (namely surgical resection), detailed histological evaluation of tissue biopsies allows physicians to properly manage cases such as these post-treatment. Early surgical removal of neuroglial heterotopias are encouraged in order to minimize nasal and craniofacial distortion early in development as well as to slow or prevent further growth of the lesion. Conclusions: Imaging diagnostics, histological evaluation, surgical procedures, and patient management of the two cases are highlighted in the report in an effort to provide more insight into possible differential diagnoses and treatment options to physicians with similar case presentations.
  • Item
    Cannabis Use and Oral Health Behaviors: A Nationally Representative Study of U.S. Adults aged 30-59.
    (2024-03-21) Balasundaram, Rohit Baal; Rossheim, Mathew; Boateng, Sarpong; Akpan, Idara; Nguyen, Uyen-Sa
    Purpose: Given that individuals who use cannabis may exhibit distinct oral health behaviors, including irregular dental visits, reduced adherence to oral hygiene practices such as flossing, and potentially increased tobacco and alcohol use, this research seeks to compare these behaviors with those of non-users. By highlighting these differences and understanding their impact on oral health, the study aims to inform targeted public health interventions, guide healthcare providers in offering tailored advice, and contribute to the development of policies that address the unique oral health challenges faced by cannabis users. This study aimed to explore the association between cannabis use and oral health behaviors among U.S. adults aged 30-59. Methods: We analyzed secondary data using the 2011-2018 National Health and Nutrition Examination Survey (n = 9345). Self-reported cannabis use was categorized as never (reference), experimental (used at least once in their lifetime), or regular (monthly use for more than one year). Outcomes included dental visit reasons (Routine Checkup (ref), Issues & Treatment, Other reasons), flossing frequency (=<3 vs. > 3 times a week), and oral cancer examination in the past year (Yes vs No). Associations between cannabis use and dental health outcomes were examined via multinomial logistic regression for dental visit reasons and binary logistic regression for flossing frequency and oral cancer exam participation. Models were adjusted for age, sex, race, education, income, marital status, diabetes, smoking, and alcohol use. Results: Analysis revealed that individuals who used cannabis experimentally had elevated odds of receiving an oral cancer examination compared to never users (aOR=1.5, 95% CI: 1.1-1.9). Among individuals who used cannabis regularly, there was an observed increase in the odds of flossing more than three times a week (aOR=1.1, 95% CI: 0.9-1.3), although this association was not statistically significant. Furthermore, individuals who used cannabis regularly were more likely to report dental visits for issues and treatment rather than routine check-ups when compared to never users (aOR=1.3, 95% CI: 1.0-1.7) Conclusion: Study findings suggest that cannabis use is associated with certain oral health behaviors. This research highlights the need for targeted investigations to inform public health strategies for improving oral health outcomes among people who use cannabis. Furthermore, these insights underscore the importance of integrating oral health education and preventive measures into cannabis use counseling to improve oral health outcomes and promote overall well-being among cannabis users.
  • Item
    The Association of Multimorbidity with Whole Health-Centric Provider Communication among Older Adults in the US
    (2024-03-21) Shaikh, Shawana; Sambamoorthi, Usha; Pinnamraju, Jahnavi
    The Association of Multimorbidity with Whole Health-centric Provider Communication among Older Adults in the US Shawana Shaikh, OMS II, Jahnavi Pinnamraju PharmD, MS, Usha Sambamoorthi, MA, PhD Background Whole Health is a person-centered approach diverging from the biomedical focus on diseases and emphasizes nutrition, recharging, spiritual, social support, physical well-being, environmental factors, and mental health. Incorporating the central tenant of “what matters to you” is key in whole health-centric patient-provider communication. This starts with inquiring patients about health goals and life quality. Nearly, 38.0 million (73%) of Americans aged > 65 years have multimorbidity. For individuals with multimorbidity, challenges exist to implementing evidence-based practices for each disease. Therefore, it is necessary to focus on the whole person and incorporate individuals' health goals and life quality for optimal management. The purpose of this study is to examine the prevalence of whole health-centered provider communication among community-dwelling older adults aged > 65 years. Methods A cross-sectional study design with data on older adults (age > 65 years) from the publicly available 2020 Medicare Current Beneficiary Survey was used. Whole health variables included how often providers asked about health goals (definitely, somewhat, never) and life quality (never, sometimes, usually, always). Multimorbidity was defined as the presence of two or more chronic conditions. Rao-Scott Chi-square tests and multinomial logistic regression were used to identify the association of multimorbidity with whole health variables while controlling for age, sex, and social determinants of health such as education, poverty, food security, supplemental health insurance, problems paying medical bills, metropolitan area, and marital status. All analyses were conducted with replicate weights using SAS 9.4 survey procedures. Results There were 5,516 older adults in our sample representing ~38.71 million older adults in the US. Overall, 43% reported that their healthcare providers 'definitely' inquired about their health goals while 31.1% reported they were 'not' asked. Additionally, only 17.5% reported being inquired ‘always’ about their life quality, while 46.5% reported 'never'. A higher percentage of those with multimorbidity were ‘definitely’ asked about health goals (69.5% vs 65.7%) compared to those without multimorbidity. However, a lower percentage of those with multimorbidity (16.5% vs. 21.6%) were ‘always’ asked about life quality. In adjusted multinomial logistic regressions, older adults with multimorbidity were more likely to 'definitely' be asked about their health goals (aOR = 1.56, 95% CI 1.26, 1.94, p < 0.001) and less likely to ‘always’ be asked about life quality (aOR = 0.65, 95% CI = 0.53, 0.79 p < 0.001) compared to those without multimorbidity. Conclusion Overall, whole health-centric communication was poor. Older adults with multimorbidity were more likely to be asked about health goals but less likely to be asked about life quality. Our findings suggest missed opportunities by providers to engage in whole health communication with patients including those with multimorbidity. Health encounters with patients can be an opportunity to empower patients to achieve person-centered health. Integrating health goals and quality-of-life questions into visits can assist providers in developing customized management to empower patients in achieving optimal and whole health.
  • Item
    High school wrestler with episode of psychosis and self-harm following loss of consciousness event.
    (2024-03-21) Worley, Josh
    Case History: Patient was a 16-year-old male with a history of depression taking Prozac and ADHD taking Adderall. No previous history of psychosis. Patient presented in February 2023 for evaluation after an episode of LOC following a blow to lateral eye while wrestling. Patient regained consciousness after a few seconds, but reported difficulty with speech, gait, and inability to remember the incident in detail. Patient was taken to the emergency department and CT scan was negative for acute abnormalities. Patient presented 7-days post-incident with dizziness, light sensitivity, and cognitive slowing. At patient visit 1-month post-incident he reported resolution of dizziness and light sensitivity, but persistence of cognitive slowing. Between 1-month and 2-month post incident visits patient experienced episode of psychosis resulting in self-harm. Patient had no recollection of episode. Physical Examination: In office patient was well appearing with no sign of distress. Neck was nontender and supple with full ROM and no bony tenderness. Negative spurling test. No increased work of breathing. Heart sounds normal. No bruits present on auscultation of neck. Alert and oriented with normal mentation and speech. No motor or sensory deficits present. Negative dysmetria, dysdiadochokinesia, pronator drift, Romberg. No evidence of bruising or bony abnormalities to either orbit. Pupils were PERRLA with EOMI. Vertical and horizontal saccades present bilaterally with provocation of symptoms. Normal mood and affect with clear and logical thought processes. Differential Diagnosis #1: Concussion Differential Diagnosis #2: Orthostatic syncope Differential Diagnosis #3: Post traumatic migraine Differential Diagnosis #4: Subdural hematoma Differential Diagnosis: Chronic fatigue syndrome Tests & Results: Testing performed 7-day post-incident; VOMS: saccades horizontal 9 and vertical 9. C3 Logic Data: symptoms severity 15of 27, SAC 20, BESS abnormal with 44 errors, trails A 78.3, trails B 93.3. Testing performed 28-day post-incident; VOMS: saccades horizontal 12 and vertical 11. C3 Logic Data: symptoms severity 17of 27, SAC 26, BESS abnormal with 11 errors, trails A 18.1, trails B 41.6. Final/Working Diagnosis: Psychotic episode with self-harm secondary to concussion. Discussion: Literature suggest mild traumatic brain injuries can trigger initial psychotic episodes in adolescents and adults. This case demonstrates a possible psychotic episode triggered by a TBI due to a concussion. In addition, the risk of trigger may be greater in adolescents with a pre-existing psychiatric diagnosis. Further analysis and research are necessary to evaluate a possible connection between the frequency of psychiatric symptoms following a concussion in adolescents with and without prior psychiatric diagnosis. This information may help identify at risk individuals and help guide prophylactic treatment to prevent psychiatric symptoms from occurring in the post-concussive period. Outcome: Following the psychotic episode patient saw a psychiatrist and medication for MDD was changed from Prozac to Abilify. The patient was stable on this medication regimen at his 2-month follow up visit. At this time patient report 98% improvement from original symptoms and had returned to physical activity and full days at school. He was cleared for full-activity and advised to follow up as needed.
  • Item
    Quality Improvement Study: Adenosine Administration in Pediatric Patients with SVT
    (2024-03-21) Lamichhane, Manav; Patel, Kaelan
    Background: Supraventricular Tachycardia (SVT) is the most prevalent pediatric tachyarrhythmia requiring treatment, with an incidence rate of 1/100 to 1/250 children. Adenosine is the first-line diagnostic and therapeutic intervention for SVT, but its efficacy in pediatric patients varies. The conventional method of administering adenosine involves a 3-way stopcock. Study conducted by Weberding et.al concluded that the adenosine administration with a stopcock delivers less than intended adenosine particularly for patients that are less than 10kg. This quality improvement study aimed to rigorously assess the dose requirements for successful conversion during SVT in distinct pediatric weight groups (0-10kg, 10-20kg, >20kg). We hypothesized that children in the 0-10kg group would exhibit increased dosage needs due to potential medication loss in the 3-way stopcock. Methods: Retrospective data were collected through chart review from Cook Children’s Emergency Department spanning 01/01/2018 to12/07/2023. The study encompassed 85 patients, stratified into three weight groups (0-10kg, 10-20kg, >20kg) with 21, 20, and 40 patients, respectively. Inclusion criteria comprised pediatric patients in SVT who received adenosine with or without symptom resolution. Exclusion criteria were patients receiving additional cardiac medications, cardioversion for SVT treatment, or those later found not to be in SVT initially. Results: The results revealed that there was no association with group and number of doses needed to convert, x2=2.64, p=0.27. Although not significant, the 0-10 group had a higher proportion of patients needing more than 1 dose to convert (18% more than 10-20kg group and 20% more than 20 plus group). Despite statistical non-significance, 72% of patients in the >20 kg group required only a single dose for successful conversion, compared to 52% in the 0-10 kg and 70% in the 10-20 kg groups. These outcomes contradict our hypothesis; however, the limited sample size, especially in the 0-10 kg and 10-20 kg populations, may contribute to this non-significance. Conclusion: Assumption tests revealed no violations for chi-square test. These findings imply that weight group may not exert a significant influence on the required adenosine doses for successful cardioversion in pediatric SVT cases. However, the 0-10 kg group had the highest percentage of patients requiring 2 or more doses. Thus, future studies should prioritize larger sample sizes to bolster statistical power, ensuring more definitive contributions to clinical practice. This study, sponsored by Cook Children’s Medical Center and UNT Health Science Center, was IRB exempt.