General Medicine

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    Robotic Assisted Heller's Myotomy for Type II Achalasia - A Case Report
    (2020) Nagatomo, Kei; Mai, Steven
    Background: Type II achalasia is a rare disorder effecting 10/100,000 individuals that can lead to dysphagic symptoms impacting overall quality of life. Traditionally preferred treatment options include pneumatic dilation, laparoscopic operation, and peroral endoscopic myotomy. Robotic-assisted surgeries have demonstrated technical advantages over laparoscopic approaches, including improved precision, decreased blood loss and hospital stay, and ultimately, improved patient outcomes. Here we report a favorable robotic approach to the Heller's myotomy. Case Presentation: A 54-year-old Caucasian female presents with a complaint of worsening dysphagia for the past 6 months. The patent had thorough workup including an upper gastrointestinal barium swallow study and manometry study. These respective studies showed a classic "bird beak" appearance and elevated panesophagus pressure, which are suggestive of type II achalasia. The patient underwent esophageal gastroduodenoscopy to rule out a malignant cause. She previously underwent esophageal dilation which provided mild symptom relief but ultimately left dissatisfied and required surgical management. Following her robotic surgery, the patient returned to the medicine floor where she received a post-operative UGI study showing tortuous esophagus without constriction. She was discharged on day two without complication. Two weeks later, she returned to the clinic and she endorsed improvement without complication, and was encouraged to advance her diet slowly. Conclusion: This case demonstrates the robotic-assisted approach to the Heller's myotomy to be a favorable alternative management of patients suffering from Type II achalasia.
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    CPAP compliance in a County-sponsored Program
    (2020) Hayes, Amanda; Al-Farra, Sherif; Kichena, Sanketh
    Purpose: John Peter Smith provides care for uninsured and underinsured patients in Tarrant County through JPS Connection at a cost covered by Tarrant County Hospital District. Therapy for sleep disordered breathing became a covered service for JPS Connection patients in 2018. Information about CPAP compliance is accessible through a patient portal which monitors frequency and duration of use in addition to other CPAP related parameters. This study examines CPAP compliance rates for JPS Connection patients in comparison to national averages. Methods: We selected 227 consecutive patients from the JPS Connection program. We gathered initial CPAP compliance rates (use of machine >4 hours a night at least 70% of nights) at 1 month and 3 months as well as their current use, which has been defined as use in the 30 days leading up to December 1st, 2019. Other clinical measures recorded are the initial Apnea-Hypopnea Index as well as sleep apnea associated comorbidities. Results: The full analysis of the data is pending but current analysis shows that a significant number of patients did not meet compliance standards. Conclusion: Preliminary indications are that compliance rates within this program compare similarly to the national average. The next step in this research would be to look at methods to improve compliance rates in this program. Future studies could examine a possible relationship between compliance and re-admissions as well as a link between compliance and medical comorbidities.
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    The Effect of Interventions on Adherence to Guidelines for Pediatric Mid-Stream Urine Collection in the Urgent Care Center
    (2020) Nguyen, Jacqueline; Yen, Kyle
    Purpose: Urinary tract infections (UTIs) are common bacterial infections in the pediatric population. Because diagnosing a UTI is dependent upon accurate urinalysis and urine culture results, proper mid-stream urine (MSU) collection in the toilet-trained child is paramount. Our purpose was to assess the effects of interventions on adherence to guidelines for pediatric MSU in urgent care clinics (UCC). Methods: During 2017-2019, interventions—including staff education and standardized urine collection packets—were implemented in 5 UCCs. A survey developed in 2017 assessed patients' perceptions of staff instruction, materials provided for specimen collection, and patient's comprehension and adherence to UCC MSU collection guidelines. The survey was repeated in 2018 and 2019. Data from 2017 and 2019 were both compared to 2018 using logistic regression. P< 0.05 was considered statistically significant. Results: 60 patients were interviewed from 2017-2019. In 2018 and 2019, the proportion of patients instructed to use and actually using 3 wipes improved. In 2019 but not in 2018, the proportion of patients given and following gender-specific instructions improved, and the proportion of patients given MSU instructions improved. However, patients reporting to follow MSU collection methods did not significantly differ by year. Most respondents (89%) claimed to understand the instructions and they (92%) would not have done anything differently without them. Conclusions: Interventions like staff education and standardizing collection materials can have a positive effect on pediatric MSU collection in UCC. Continued research is needed to identify other variables that could positively affect MSU collection compliance.
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    Prolonged Bradycardia After Phenylephrine Administration
    (2020) Kindt, Lexy; Reyes, Kassandra
    Background: Phenylephrine is the first line vasopressor for prophylaxis and treatment in cases of hypotension due to spinal anesthesia in obstetrics. Phenylephrine binds to alpha-1 receptors leading to venous and arterial vasoconstriction. Because of its selectivity, reflex bradycardia can result from an increased baroreceptor firing rate. The duration of bradycardia has not been well characterized. Here we present a case of bradycardia persisting for 87.8 hours after the discontinuation of phenylephrine. Case Information: A 29-year-old female was admitted to the hospital for premature rupture of membranes at 27 weeks gestation of twins. After undergoing C-section, she became hypotensive and hypokalemic and was started on septic shock protocol. The patient was transferred to the ICU and was given antibiotics, IV fluids, and potassium repletion. She was started on a phenylephrine drip and was weaned off within 24 hours. The patient's HR was noted to be 49. TSH was within normal limits, and medication list was negative for beta blockers. She was asymptomatic and was monitored without intervention for 87 hours until HR consistently reached 60. Conclusion: Though reflex bradycardia is a well documented effect of phenylephrine administration, the duration of this effect is less clear. This case describes bradycardia persisting for 87.8 hours, which is the longest duration of this effect we have found in literature review. Because phenylephrine is used both prophylactically and for spinal anesthesia induced hypotension in obstetrics, further studies are needed to specifically characterize the duration and mechanism of this prolonged effect.
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    Pancreatic Heart Paralysis
    (2020) Gonzalez, Gabriel; Mathew, Trina
    A 46 year old Caucasian female presents to the ER for evaluation of generalized weakness and mild left lower quadrant abdominal pain. In the ER, she was noted to have a heart rate of 23. She was given atropine with improvement in heart rate to 46. Cardiology was consulted and treatment options were discussed including obtaining an electrophysiologist consult and possible pacemaker insertion for symptomatic bradycardia of unknown origin. With a concerning heart rate prone to progressive bradycardia, she was sent to the MICU for closer evaluation with pacer pads and the crash cart in close proximity. Patient reported mild left lower quadrant abdominal pain which she attributed it to the fatty meal she had the previous day. She described it as an intermittent pain on the left side of her abdomen without radiation to her back. She had taken TUMS prior to admission without relief. She denied diarrhea, hematochezia, nausea, or fever. She denied any significant cardiac history, chest pain or shortness of breath. Lab results revealed a lipase of 3,413. CT of the abdomen revealed stranding in the mesentery surrounding the uncinate process and head of the pancreas consistent with acute pancreatitis. With treatment of her underlying pancreatitis, her bradycardia resolved. This case illustrates a form of viscero-visceral reaction which could lead providers astray in making the initial diagnosis. Although this presentation of pancreatitis is rare, it is not uncommon for autonomic dysfunction to be a presenting sign of an underlying disorder in an otherwise healthy individual.
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    When is LDL Cholesterol Too Low?
    (2020) Bairuty, Dania
    Background: Familial hypobetalipoproteinemia (FHBL) is a rare genetic disorder that causes unusually low levels of LDL-C and apolipoprotein B (apoB). There are higher incidences of FHBL in pediatric patients with fatty liver disease than the general population and they tend to have more severe hepatic steatosis. Case Presentation: A 6-year-old Caucasian male presented with his mother as a referral with an LDL-C of 25 mg/dL, well below the 5th percentile for age and sex. No pertinent past medical history is recorded. Per mother, his maternal grandfather had a history of low LDL-C with no known heart disease. Mother is well without recorded LDL-C. Father's health status in unknown. A lipid panel of the patient revealed: total cholesterol of 82 mg/dL, triglycerides (TG) of 31 mg/dL, HDL-C of 55 mg/dL and a direct LDL-C of 24 mg/dL. The patient's apoB levels was < 30 mg/dL (RR 52-109 mg/dL) and apoA1 was 134 mg/dL (RR 94-136 mg/dL). Additionally, liver function tests (LFTs) were performed: AST of 23 U/L (RR 12-32 U/L) and ALT 24 U/L (RR 8-32 U/L). APOB sequencing revealed a heterozygous mutation (c.10848delT). A lipid panel of the patient's 8-year-old brother showed a total cholesterol of 91 mg/dL, TG of 37 mg/dL, HDL-C of 54 mg/dL, and an LDL-C of 30 mg/dL. Conclusions: Follow-up recommendations for FHBL include laboratory testing of lipids and LFTs every year with clinical evaluation every 6-12 months.
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    Opioid Effect on the Gut; A Rare Case of Narcotic Bowel Syndrome
    (2020) Hapuarachchi , Menalee
    Introduction The increasing use of opioids over the last two decades has brought national attention to the devastating consequences of opioid misuse. Opioids disrupt gut function by decreasing motility and peristalsis leading to constipation and in some cases, ileus. The purpose of this report is to increase awareness within the medical community about narcotic bowel syndrome (NBS), its pathophysiology, diagnosis, and management. Case Report A 64 year old female with a past medical history of chronic narcotic use presented for severe dull like abdominal pain associated with loose stools and chills. On admission the patient was hypertensive and tachycardic. Patient had leukocytosis of 21.9, lactic acid 2.1. Pertinent positive on physical exam include decreased bowel sounds and diffuse tenderness with mild palpation in all quadrants. Imaging studies were unremarkable. Several doses of morphine and dilaudid were given which exacerbated the pain. Patient admitted to using about 200 Norco 5/325 mg tablets a month. Her pain medication regimen was switched to Tramadol and Tylenol with improvement over several days. Discussion Narcotic bowel syndrome is characterized by intermittent or chronic abdominal pain that worsens with continuing use or increased dose of narcotics.1 Initially, the narcotic improves pain but eventually a tolerance develops requiring higher doses. Key to the diagnosis of NBS is worsening abdominal pain with chronic use of narcotics. Lab values are often normal. Treatment is early clinical identification of the syndrome and gradual withdrawal of the narcotics according to a specific withdrawal program.2
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    Sandwich Allograft for Repair of Tibial Nonunion Fracture in Patient with Osteogenesis Imperfecta Secondary to Failure of Alternative Interventions
    (2020) Nail, Courtney
    Background - Osteogenesis Imperfecta (OI) is a group of connective tissue disorders caused by mutations in the type I collagen gene. Type I collagen acts as a mechanical scaffold for various tissues of the body, the most notable being bone. Patients with this disease classically present with fracture of long bones. These fractures are especially difficult to treat, as the bone quality limits the ability to adequately stabilize the site and it takes longer for bone to heal. As a result, nonunion of these fractures is a common phenomenon. Case Information - A 36-year-old female presents with past medical history of OI and known tibial fracture. After failure of conservative management and previous surgical interventions including tibial osteotomy with open reduction internal fixation and subsequent revision surgery for hardware displacement to correct the tibial fracture, the patient elected for surgical correction of the deformity. Repair was performed using a "sandwich allograft" technique, with added cancellous bone chips and Bone Morphologic Protein 2 (BMP2) impregnated collagenous matrix to facilitate bone regeneration. Conclusion - Patients with Osteogenesis Imperfecta frequently suffer from nonunion fractures. As an adult, these fractures are commonly complex and have prolonged healing processes. The "sandwich allograft" technique presents an additional surgical method which can be used for patient with failure of traditional surgical methods. Repair of these fractures results in reduction of deformity, decrease incidence of future complications, restoration of function though the ability to weight bear or ambulate, and ultimately result in better quality of life.
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    A Storm to be Reckoned With: Hemophagocytic Lymphohistiocytosis
    (2020) Henson, Amanda
    Background: Hemophagocytic Lymphohistiocytosis (HLH) is a poorly understood disorder. There are primary (familial hemophagocytic lymphohistiocytosis) and secondary forms (reactive HLH) that are acquired from autoimmune disorders, malignancy, or infection. Although a specific diagnostic criteria exists for children, no such criteria exists for adults and that is why early recognition of clinical and lab signs is essential. Case Information: A 41 year old Vietnamese woman presented with unintentional 12 pound weight loss, odynophagia, anorexia, periumbilical pain, nausea, and dizziness. She also had a rash that spread from her axilla to her torso/extremities. Of note, she had a history of blood transfusions and travel to Vietnam. Labs revealed: pancytopenia, transaminits, elevated antinuclear antibody, Sjogren's A antibody, double stranded DNA antibody, hyperferritinemia, and hypertriglyceridemia. Bone marrow findings were insignificant. She was suspected to have HLH and treatment was promptly started with IV corticosteroids. Unfortunately, on day 5 of admission her condition acutely deteriorated and she expired. Conclusions: HLH is thought to be caused by uncontrolled macrophage and Th-1 lymphocyte activation. Excess production of cytokines such as IFN-γ, soluble IL-2 receptor, TNF-α, IL-1, IL-6, and IL-18 have been reported. This leads to a cytokine storm. Early diagnosis and treatment is very important in this disease since it carries a very high mortality rate of 50% despite appropriate treatment. Treatment consists of IV corticosteroids, IVIG, cyclosporin/anakinra/plasma exchange/etoposide, supportive care, transfusions, and blood pressure control.
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    (2020) Mederos, Gerardo
    Murine Typhus, once thought to have been eradicated throughout the United States, is on the rise in Texas. Humans are accidental hosts that get infected through a flea bite. The disease is often self-limited and presents with non-specific symptoms such as fever, chills, malaise, headache and rash. Here we present a case of a healthy hispanic female with acute cholecystitis and underlying murine typhus. Patient is a 57 year old hispanic female with no past medical history that presented with emesis, headache, fever, chills and myalgias. Llabs showed thrombocytopenia and elevated LFTs. Abdominal ultrasound showed evidence of cholelithiasis. Patient had a cholecystectomy after which she developed persistent fever and hypotension. Patient was started on antibiotics. The following day, she developed a faint red maculopapular rash over her trunk and extremities. The fever persisted for the next 48 hours. Due to her initial thrombocytopenia and new rash, the patient was started on IV doxycycline. Rickettsia titers were elevated confirming a rickettsial infection. Murine typhus is a vector borne zoonosis typically seen in tropical countries. Symptoms are vague and often self limited. Patient history included travel to south Texas with exposure to farm animals but with no recollection of a tick bite. Her initial symptoms of nausea and vomiting led to diagnosis of cholecystitis. Treatment of choice continues to be Doxycycline for at least for 7 days. With the number of cases increasing in Texas it is important that health care providers recognize the vague symptoms of murine typhus.
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    Multi-Institutional Controlled Trial Comparing the Patient-Perceived Empathic Behavior of EM Residents
    (2020) D'Etienne, James; Alanis, Naomi; Kao, Jeremy; Singh, Jatinder; Fernandez, Chloe; Bell, Charles; Sunderji, Aman; Wombwell, Tamsyn; Pettit, Katie; Kline, Jeffrey; Wang, Hao
    Purpose: The ED poses multiple challenges to physician empathy including rapid pace, lack of privacy, frequent interruptions, the absence of pre-existing relationships between patients and providers, and the possibility of patients having a general distrust of providers. The goal of this project is to test the effectiveness of an educational intervention to improve patient perception of resident physician empathy and trust in the emergency department (ED) setting. Methods: Patient-participants were given The Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE) and the Trust in Physicians Scale (TIPS). There were 6 participating institutions; 3 were the intervention institutions and 3 which were control institutions. JPS was one of the control institutions. Results: This study suggests that the intervention provided no effect in terms of patient perceptions of physician empathy assessed using the JSPPPE but had a modest effect on perception of trust based upon TIPS measured 4-6 months later. An educational intervention on clinician empathy showed modest improvement in one of our primary outcomes as assessed by patients (TIPS). Conclusions: Although we were able to find only modestly significant improvements in patients perception of trust, we believe further work in this area will continue to show the benefit of empathy training for our patients and providers.
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    Does general health status differ by current physical activity levels in middle-aged females with cardiovascular disease?
    (2020) May, Amanda; Mianoor, Kiran; Venecia, Bianca
    Purpose: Few studies have focused on how physical activity levels are related to general health in middle-aged females with cardiovascular disease (CVD). The purpose of this study is to assess whether general health status differs by physical activity levels in women ages 45-64 with CVD. Methods: This cross-sectional analysis used data from the 2017 BRFSS for middle-aged women with a history of CVD in Alabama, Arkansas, Kentucky, and Mississippi. This target population was divided into three subsets related to CVD which included 173 participants with a history of heart attack, 239 participants with a history of heart disease, and 228 participants with a history of stroke. Adjusted analysis was conducted to determine the relationship between general health status and physical activity levels while controlling for multiple variables Results: Across subsets, participants with CVD had a moderate prevalence of good or better general health and a moderate prevalence of physically inactivity. Results of adjusted analysis indicated that general health status may not be related to physical activity levels. However, general health status was found to be related to other health conditions across subsets. Conclusions: Overall, general health status was not found to be significantly related to physical activity levels in general, population-based samples of middle-aged women with CVD. Regardless, practitioners should educate patients on ways to improve general health and on the importance on physical activity when appropriate. On the other hand, general health status was significantly related to the presence of other health conditions.
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    Disability and quality of life following long-term opioid therapy in patients with chronic low back pain
    (2020) Licciardone, John C.; Schultz, Matthew
    Purpose: To compare the effects of long-term opioid therapy versus no opioid therapy on self-reported disability and quality of life (QOL) in patients with chronic low back pain (CLBP). Methods: Patients with CLBP enrolled in the PRECISION Pain Research Registry were grouped according to opioid use. Patients reporting opioid use for 12 consecutive months were classified as opioid users; patients reporting no opioid use for 12 consecutive months were classified as opioid non-users. Disability (Roland Morris Disability Questionnaire) and QOL (29-item Patient-Reported Outcomes Measurement Information System) were compared using multiple linear regression. Results: There were 78 opioid users and 134 non-users. Opioid users were significantly older and reported significantly higher measures of depression and pain intensity. Opioid users reported greater disability (17.1 vs 10.84, p< 0.001), sleep disturbance (57.9 vs 54.7, p< 0.001), pain interference with activities (66.1 vs 57.9, P< 0.001), anxiety (54.1 vs 51.0, p=0.04), and fatigue (61.3 vs 55.0, p< 0.001); less participation in social roles (40.9 vs 48.5, p< 0.001); and lower physical function (34.3 vs 40.6, p< 0.001). With the exception of anxiety, these findings did not change after controlling for age, body mass index (BMI), depression, and pain intensity. Conclusions: After controlling for age, BMI, depression, and pain intensity, patients with CLBP receiving long-term opioid therapy reported significantly greater disability and poorer QOL compared to those receiving no opioid therapy. The findings of this study draw into question the utility of long-term opioid therapy for CLBP.
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    Utility of Pharmacogenetics for Children with Autism Spectrum Disorder
    (2020) Cross, Deanna; Openshaw, Foster
    Purpose: The CDC estimates that 1 in 59 children have Autism Spectrum Disorder, and 64% used at least one psychotropic medication, 35% used more than one medication, and 15% used 3 or more medications. The purpose of the research is to determine whether genotyping children with Autism Spectrum Disorder for a panel of pharmacogenes would potentially change drug choice or dosage to increase drug efficacy and decrease adverse events. Methods: Using literature and database searches, a simulated population of 10,000 pediatric patients based on population demographics of Tarrant County was created and assigned between one and three drugs and relevant pharmacogene alleles related to those drugs with a random number generator based on prescribing frequencies for children with ASD and the allele frequencies of their ethnic group. Results: Children prescribed to one or more drugs would have a 45.99% chance of being prescribed a drug that has a pharmacogenetic usage guideline (one drug- 27.30%, two drugs- 59.95%, three drugs- 70.58%). All of the ethnicities evaluated have a high chance of being prescribed a drug that has a pharmacogenetic usage guideline (Black- 52.23%, White- 43.88%, Asian- 48.87%, Hispanic- 44.38%). Antidepressants(68.73%) and antipsychotics(40.10%) seem to have the highest probability of having a pharmacogenetic usage guideline. Risperidone(62.64%), fluoxetine(92.21%), and citalopram(99.85%) are the drugs that are most likely to have a pharmacogenetic usage guideline. Conclusions: It may be beneficial for children with ASD to receive a pharmacogenetic evaluation before being prescribed any psychotropic drug.
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    Pharmacological Priapism Requiring Penile Implant in a 50-Year-Old Man with Erectile Dysfunction
    (2020) Hey, Wayne; Ames, Kyle
    Background: Most men around the world experience erectile dysfunction at some point in their lives. Not only is this condition a physiologic deficit, but it can also lead to depression, anxiety, lack of self-esteem, and lack of confidence which can make the underlying disorder worse. Erectile dysfunction can develop due to various organic, relational, and psychological causes. Case Information: A 50 year-old Caucasian male presents to the emergency department with priapism for a period of over six hours secondary to the use of Trimix, an intracavernosal and intraurethral injectable three-drug medication. After four repeated episodes of the priapism resolving and reappearing after aspiration and phenylephrine injections over the course of 24 hours, the priapism finally resolved. During an outpatient office visit to the urologist a week later, discussion about the patient's past medical history of failure of first-line and second-line medical therapies, including use of Viagra, Cialis, and Trimix, as well as episodes of priapism, resulted in the decision for the patient to undergo an elective inflatable penile implant procedure. Conclusions: While conservative treatment of erectile dysfunction is considered first-line management, medications and lifestyle modifications are not always effective for patients. Patients often resort to using injections, creams, and alternative therapies. Despite the efficacy of injections, high discontinuation rates have been reported and a risk of priapism has long been a concern. When these therapies are ineffective, it may be necessary for patients to undergo penile implantation surgery.
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    Opioid prescribing habits and effectiveness within subgroups of chronic low back pain patients
    (2020) Sridhar,Varsha
    PURPOSE: This study aims to describe prescription opioid usage among chronic low back pain patients and report the percent compliance with Centers for Disease Control and Prevention guidelines. Additionally, this study seeks to correlate the amount of opioid use with pain intensity and the likelihood of experiencing adverse effects in participants of different race and to determine whether admixture, the estimate of an individual's genetic contribution from different ancestral backgrounds, plays a role in determining the effect of opioids on pain-related measures. METHODS: Medication list and pain measures were collected from participants enrolled in Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION). Saliva samples were obtained to determine participants' admixture scores. Opioid usage was characterized based on morphine milligram equivalents (MME) to calculate mean daily MME. Mean MME was also calculated based on race and was correlated to pain scores and adverse events, collected from questionnaires. Admixture analysis was performed to generate k score. RESULTS: Mean MME prescribed to 164 registry participants was 36.14. Results showed that 78% of participants consumed under 50 MME, 15% of participants consumed between 50 and 90 MME, and 7% of participants consumed >90 MME. Admixture analysis showed a correlation between degree of admixture and reported adverse events and pain scores. CONCLUSION: The majority of participants were prescribed opioids in compliance with CDC recommendations. However, 7% of the participants were prescribed high doses outside recommended limits, which is greater than previous estimates. Admixture may play a role in optimizing opioid metabolism.
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    Exploring the Role of Extracellular Matrix Organization in the Progression of Chronic Low Back Pain
    (2020) Ozguc, Fatma
    PURPOSE: Chronic low back pain (CLBP) is the leading disability in the world, and novel approaches for more effective treatment of CLBP are warranted. Individual genetic differences in pain genes may explain the differences in pain perception. It has been recently found that the extracellular matrix organization is the most regulated pathway in inflammatory and neuropathic pain assays in mice. This project explores the role of ECM variability in the incidence and trajectory of CLBP. This project has two aims: 1) to identify low-risk and high-risk genotypes for ECM genes between two groups of participants, CLBP and chronic widespread pain (CWP), through a retrospective case-control study; and 2) to assess if the identified genetic risk factors are associated with longitudinal outcomes in pain intensity and quality of life through a cohort study. METHODS: Using genetic data from the PRECISION Pain Research Registry, single SNP, SNP-set, and epistasis analyses for ECM-related genes were run using PLINK and CASSI. Necessary adjustments for the covariates age, gender, and genetic ancestry were done. RESULTS: Epistasis relevant to chronicity of low back pain were identified in TNFBxPRTN3, VWFxMMP9, TNF xMMP13, and PRTN3xLILRA5 for African Americans. In non-Hispanic Whites, epistasis between VWFxMMP2, SPARCxMMP2, and VWFxELANE were significantly related to chronicity of low back pain. CONCLUSION: This study suggests that race/ethnicity specific interactions between variants in ECM-related genes may play an important role in progression of chronic low back pain and perhaps useful in formulating precision approaches to CLBP therapeutics.
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    Acute Page Kidney and Renal Vein Thrombosis Secondary to Post-Biopsy Subcapsular Hematoma
    (2020) Olivencia-Yurvati, Albert; Mangin, William
    Background: Major complications of percutaneous core needle biopsy are quite rare; however, renal transplant patients, especially those experiencing graft rejection, are high-risk for graft loss as a result. Renal subcapsular hematomas have the potential to compress the renal parenchyma and cause a secondary HTN, a process called acute Page kidney (APK). These hematomas can also compress the renal vascular, causing renal vein thrombosis. Case Presentation: A 63-year-old medically non-compliant African American female was admitted to the hospital for biopsy confirmed AMR. She underwent a deceased donor renal transplantation 3 years prior for ESRD secondary to DM and HTN. On hospital day 8, she developed RLQ abdominal pain over her transplant site. Her Hgb dropped from 7.8 to 7.1, her BP spiked at 183/78, and she ceased making urine. Ultrasound showed a large perinephric hematoma, which was collaborated by CT. Repeat labs revealed further decreased Hgb (6.2) and increased Cr (4.2). During surgery, a small active bleeding site was found on the biopsy side of the kidney after evacuation of the hematoma. Duplex U/S showed reversed arterial flow, minimal parenchymal perfusion, and no renal vein flow. The allograft was deemed non-viable and nephrectomy was performed. Patient was discharged in stable condition on hospital day 14 with follow-up for outpatient HD. Conclusions: This case highlights some rare complications of renal biopsy and serves as a reminder for practitioners to keep a low-threshold of suspicion when dealing with high-risk patients, such as those with AMR.
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    A Rare Case of Esophageal Stenosis in Behcet's Disease
    (2020) Faisal, Annum
    Background: Behcet's Disease (BD) is a multi-organ inflammatory disease characterized by aphthous oral ulcers, ocular manifestations and genital lesions. Various environmental and genetic factors contribute to the pathogenesis of BD, however the specific etiology remains unclear. Case:A 71-year-old female with a history of BD, pharyngeal ulcers, esophageal stenosis and tracheostomy presented to the emergency department with concerns of food being stuck in her throat for 4 days and inability to swallow. She has a history of dysphagia for many years, but was tolerant of thin liquids and soft foods. BD management consists of chronic steroids and previous dilation with balloon tracheoplasty. She is aphonic due to aphthous ulceration of the larynx. Fiberoptic nasal endoscopy and esophagogastroduodenoscopy were attempted with findings included a surgically absent larynx, unidentifiable upper esophageal sphincter and post-surgical scarring. These explorative studies were later aborted due to failure of scope advancement. A neck CT illustrated present trach and medially displaced carotid AA bilaterally without frank masses. Following recommendation of clinical swallow examination, contrast material passed into the pharynx and entered the upper portion of the airway; it appeared to remain in the glottis above the vocal folds. Patient attempted to swallow with minimal hyoid movement, however, a full swallow reflex was never achieved. Nutritional support with PEG tube was recommended and placed with no complications. Patient was subsequently discharged. Conclusion:This case illustrates the unique presentation of esophageal stenosis secondary to BD and warrants further investigation of the pharyngolaryngeal involvement in disease classification and progression.
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    Analyzing the parameters that influence the engagement of patients in their own health
    (2020) Mattevada, Sravan; Devapriya, Priya; Dravenstott, Ron; Nemati, Rojin
    Purpose: Engaging patients in their care is crucial for the management of their health and a successful health system. Despite the importance of this topic, there is no ideal tool to measure patient engagement in order to enable clinicians to better manage their patients. Previous studies have shown that higher levels of patient engagement are associated with improved health outcomes and lower use of costly health care services. Currently the best available method to measure engagement is PAM which requires patients to fill out a 15-item questioner during every encounter. However, having an index and more reliable parameters to measure patient engagement would potentially improve the quality of care by allowing clinicians to tailor their treatment strategies based on each patient's specific needs. Methods: A brainstorming session was held with a selected group of clinicians on campus to gather information about what defines an engaged patient. During this meeting, they were asked to write their ideas of what an engaged and disengaged patient looks and behaves like. These ideas were then analyzed and classified into different categories. Results: The majority believed that being conversational, inquisitive as well as following through and taking the first step were the most significant factors indicating patient engagement respectively. Conclusion: The collective perception of the group showed that patient's attitude and how they interact with the staff and physician during the visit plays a significant role in physicians' assessment of their level of engagement with their health and how they devise treatment plans accordingly.