Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/21663


Recent Submissions

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    Health Status, Healthy Lifestyle Practices, and Attitudes toward Lifestyle Counseling among Medical Students at the Osteopathic Medical School and Allopathic Medical School in DFW: A Cross-Sectional Analysis
    (2018-03-14) Lee, Jenny; Mason, David; Seals, Ryan; Jetpuri, Zaiba; Bridges, Katie; Crenshaw, Aubrey
    Purpose: By 2020, the World Health Organization predicts that 63% of all worldwide diseases and deaths will be associated with poor lifestyle choices which individuals, families, or groups make every day. It is imperative that health care providers adopt and demonstrate evidence-based and patient-centered competent approaches to improving patients’ lifestyle habits for health promotion, disease prevention, and therapeutic effects. Since medical students are the future of medicine, it is important to investigate their health status, health habits practice, and readiness to engage in lifestyle counseling. Further, it is interesting to investigate if any difference exists between osteopathic and allopathic medical students. Methods: A survey is the key instrument in this cross-sectional study to assess the health status, health habits practice, and attitudes towards engagement in lifestyle counseling among medical students. The survey contains questionnaires, which are in the multiple choice and closed-ended formats. The survey will be sent out via email separately to each TCOM class and each UT Southwestern (UTSW) class. The survey being sent out to TCOM is through Qualtrics and the survey for UTSW is through REDCap. Data: Data is in the process of being collected through Qualtrics for TCOM and REDCap for UTSW. All data at UTSW will be sent to the researcher at TCOM and analyzed. The analysis will be conducted using Statistical Analysis System version 9.4. Hypotheses: The primary hypothesis is that there will be a relationship between health status, health lifestyle practice, and attitude to engage in lifestyle counseling and years spent in medical education. The secondary hypothesis is that there will be a difference in health status, healthy lifestyle practice, and attitude to engage in lifestyle counseling among medical students in different levels of medical education. The tertiary hypothesis is that there will be a difference in health status, healthy lifestyle practice, and attitude to engage in lifestyle counseling among osteopathic medical students and allopathic medical students.
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    Surface Plasmon Assisted Microscope (SPAM)
    (2018-03-14) Gryczynski, Zygmunt; Fudala, Rafal; Joshi, Chaitanya; Borgmann, Kathleen; Ghorpade, Anuja; Gryczynski, Ignacy; Borejdo, Julian
    Surface Plasmon Assisted Microscope (SPAM) J. Borejdo1,2, Z. Gryczynski3, R. Fudala1,2, C. Joshi1, K. Borgmann1, A. Ghorpade1 and I. Gryczynski1,2 1 Dept of Microbiology, Immunology and Genetics, University of North Texas, Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX 76107 2Center for Commercialization of Fluorescence Technologies, University of North Texas, Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX 76107 3 Dept of Physics and Astronomy, Texas Christian University, 2800 S. University Dr., Fort Worth, Texas 76129 The purpose of this research was to construct the instrument to image 10-20 nm thick layer of cells such as membrane lipids, membrane receptors and other structures proximal to basal membranes. Until now this task was best achieved by Total Internal Reflection Microscopy (TIRF). Here we demonstrate an alternative method which has number of advantages over TIRF. The materials required for constructing such an instrument include inverted microscope, a high refractive index coverslip covered with 50 nm thick layer of gold and an optical fiber coupled laser. A sample is placed on a high refractive index coverslip coated with a metal instead of glass and is illuminated by the laser from the top (through aqueous medium). Fluorophores that are close to the metal surface induce surface plasmons in the metal film. Fluorescence from fluorophores near the metal surface couple with surface plasmons allowing them to penetrate the metal surface and emerge at a Surface Plasmon Coupled Emission (SPCE) angle. Fluorescence is collected by a high NA objective and imaged by EMCCD or converted to a signal by avalanche photodiode fed by a single mode optical fiber inserted in the conjugate image plane of the objective. We compared images of cell monolayer of astrocytes transfected with GFP obtained by SPAM with image obtained by TIRF. We think that SPAM image was clearer than TIRF image because: 1. Thickness of the detection layer was reduced in comparison with TIRF because metal quenched fluorophores at a close proximity (below 10 nm) to a surface; 2. The system avoided complications of through-the-objective TIRF associated with shared excitation and emission light path; 3. The microscope had excellent background rejection because all far-field radiation is reflected by the mirror-like metal layer.
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    Contamination Rates in Urine Collection at Cook Children’s Pediatric Urgent Care Centers
    (2018-03-14) Fulton, Audra; Hamby, Tyler; Akkad, Rana; Coplin, Bradley; Martin, Parul; Henson, Robin
    Background: Over $180 million in health care costs are spent annually on pediatric urinary tract infections (UTIs). Pediatric UTI symptoms are often non-specific causing physicians to rely on the results of a urine dip stick to assess appropriate follow up and treatment. Improper urine collections can result in bacterial contaminations and can mask true urinary tract infections. This would lead to inaccurate diagnosis, unnecessary treatment, and/or obtaining additional specimens, all adding to the burden of increased costs and patient/parental anxiety. Hypothesis: Cook Children’s Urgent Care Clinics (UCCs) have significant contamination rates from patients who gave mid-stream urine. Methods: Data collection consisted of a six-week retrospective chart review on patients with suspected UTI at each UCC location. Included in this study were patients five years and older and able to collect a mid-stream urine. Data was placed into Red Cap database. Contamination was defined as culture results= 12 yrs) on the assumption that adult supervision was needed in the former group. Contamination rates were then calculated for age, gender, and UCC location. Results: Of the 258 charts reviewed, 202 met the criteria for this study. The sample size was significantly smaller for males (13%) than females (87%). Total contamination rate was 30% (p=). Based on age, contamination rates showed 54% for 5-11 yrs and 46% for 12 yrs and older (p=0.0069). Females were more likely than males to have contamination, 33% vs 11.5%, respectively (p=0.026). There was no significant relationship between UCC location and contamination (p=0.52). Small, moderate, and large amounts of leukocyte esterase were associated with infection (p= 0.0006), however, trace results were not. Conclusions: The results from this preliminary study reinforce significant urine collection contamination rates. Chart reviews will be completed to provide a more robust sample size, but steps need to be taken to determine what is causing this high rate. To elucidate these variable(s), surveys (patient/family and provider) will be obtained to assess collection methods: how the urine is collected (parent/patient perspective), how it is thought to be collected in the clinic (provider perspective), and financial burdens to the family and institution (administrative perspective).
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    (2018-03-14) Baker, Austin; Marcincuk, Michelle; Torres, Marcela; Homewood, Tyler
    Background: Factor XIII, also known as fibrin stabilizing factor, strengthens the final stages of hemostasis. It plays a pivotal role in angiogenesis, maintenance of pregnancy, wound healing, bone metabolism and cardio protection. A deficiency in this factor is inherited in an autosomal recessive fashion or an antibody against the factor can be developed. Noonan syndrome is a common genetic abnormality that is characterized by webbed neck, short stature, characteristic facies, congenital heart defects, and developmental delay. It is inherited in an autosomal dominant fashion. Commonly, patients with this disease present with a proclivity for bleeding diathesis due to platelet and coagulation factor abnormalities. Case Information: We present a 13-year old boy with known Noonan syndrome who experienced profuse bleeding from the left ear and a large hematoma formation after an otologic procedure. Although Noonan patients are known to experience bleeding complications, our patient had undergone various surgical procedures without prior hemorrhagic events. Due to retained ear tubes and chronic suppurative otitis media, the patient developed conductive hearing loss and was recommended to receive surgical intervention. The patient presented the following day to the emergency department with bleeding from the left ear and hematoma of the left side of his face and neck. He was discharged after bleeding was stopped; but once home, the bleeding started again, and he was re-admitted for an exploratory exam under general anesthesia. Diffuse oozing was discovered, and a platelet transfusion was provided to stop the bleeding. A bleeding disorder workup was sent including a factor XIII activity assay. Preliminary coagulation tests proved normal, however factor XIII deficiency was confirmed. Conclusions: This is the first described case of factor XIII deficiency presenting in a patient with Noonan syndrome. Noonan patients have a proclivity for bleeding diathesis, but much more commonly due to other factor and platelet abnormalities. Noonan syndrome is common enough that many clinicians and surgeons will see these patients in their practice. It is important to be aware of the common bleeding disorders associated with Noonan syndrome, but also to be aware that they can have other rare bleeding disorders despite normal basic coagulation tests.
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    Subcutaneous Depth in Kidney Transplantation: Indication for Negative Pressure Wound Vacuum Therapy?
    (2018-03-14) Ruiz, Richard; Cox, Thomas
    Purpose: Wound complications after kidney transplant (KTx) consume valuable resources, including prolonged hospital stays and increased costs. Risk factors include immunosuppression exposure, diabetes, and obesity as indexed by body mass index (BMI). However, BMI is not an accurate surrogate of body habitus. In this study, we sought to determine the effect of subcutaneous depth (SQD) on KTx outcomes, specifically wound complications. Methods: We measured SQD in 97 KTx only (79 cadaveric;18 living donor) only over 18 months. The mean age of the recipients (56M:41F) was 48 years, with an average BMI 27.8. SQD was measured from the midpoint of the lateral portion of the incision and measured the distance from the fascia to the skin edge, to the closest 0.5cm.. Data analyzed included presence of diabetes, hypertension, PRA, pretransplant dialysis, prior transplant, and induction therapy. Post transplant complications analyzed included wound infection, dehiscence, lymphocele, renal artery thrombosis/stenosis, urine leak, ureteral stenosis and need for vacuum assisted closure therapy. Results: The average SQD of our recipients was 2.9cm. Patients with a SQD > 2.5cm were more likely to require wound vac therapy (average length of therapy, 46.6 days) compared to those with a SQD25, SQD > 2.5cm was still associated with a higher likelihood of requiring a wound vac (odds ratio 3.4). Conclusions: In summary, SQD > 2.5cm is an independent risk factor for requiring negative pressure vacuum therapy. This is a simple intraoperative identifier which should stratify those at risk for later intervention.
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    Effect of Nicotine Consumption in Auto-Brewery Syndrome
    (2018-03-14) DeMoss, Dustin; Khan, Samir; Hogan, Sean; AlFarra, Tariq
    Purpose: Auto-Brewery Syndrome (ABS) is a rare condition defined by a proliferation of yeast species in the gut, where they enter the bloodstream. Patients typically show signs of intoxication upon carbohydrate ingestion as a result of yeast fermentation. A literature review reveals several cases of patients with diagnosed ABS who were admitted to the hospital for psychosis and agitation. In addition to ABS, patients often present with several comorbidities, including Chronic Traumatic Encephalopathy (CTE) and a history of e-cigarette or tobacco consumption. Given the temporal relationship between nicotine consumption and the onset of psychotic episodes in these patients, there may be a link between nicotine consumption and worsening psychosis in patients with CTE and ABS. Question/hypothesis: Could nicotine consumption exacerbate Auto-Brewery Syndrome to induce psychotic episodes in the setting of Chronic Traumatic Encephalopathy? Methods: An English literature review of case reports involving patients who are smokers with concurrent ABS and CTE and an English literature review on the effects of nicotine in the body Results: The literature suggests a connection between nicotine consumption and increased catecholamine levels, which can increase glucose production and blood glucose levels. The proposed mechanism involves activation of the nicotinic acetylcholine receptors in the adrenal medulla, which increase the production and release of catecholamines, namely epinephrine. Epinephrine then binds B2 receptors on the liver and skeletal muscles, upregulating glucose production and release. The glucose may then be fermented by yeast in the bloodstream, resulting in alcohol toxicity and/or psychotic episodes. Conclusion: Our review shows that patients experienced an increase in psychotic episodes while staying at a psychiatric hospital where they were provided with cigarettes and produced elevated BAC measurements during these events. The mechanism by which nicotine increases glucose production in the body led us to believe that these patients were experiencing ABS exacerbations secondary to nicotine consumption, inducing psychotic events in the CTE setting.
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    The Potential Role of E-Cigarettes In Diffuse Alveolar Damage
    (2018-03-14) Khan, Samir; Bakre, Sulaimon; Al-Farra, Sherif; AlFarra, Tariq
    Purpose: The prevalence of e-cigarette usage has increased in non-smokers and those planning to quit smoking. Although the potential long term adverse effects have not been studied in humans, studies have shown that certain components of e-cigarette fluid may lead to the release of cytotoxic components implicated in the pathogenesis of diffuse alveolar damage (DAD), a histopathological diagnosis that is commonly associated with acute respiratory distress syndrome (ARDS). This literature review describes the potential association between e-cigarettes and diffuse alveolar damage while making reference to relevant associated studies. Methods: An English literature review of studies that examine the potential cytotoxic effects of E-cigarette fluid components in relation to the pathophysiology of diffuse alveolar damage. Results: To date, no longitudinal studies have been performed on humans to show the toxicity of e-cigarette vapor on the human lung. However, studies have shown different mechanisms by which the compounds in e-cigarette vapor lead to the destruction of alveolar epithelial cells in-vitro. The major component of e-cigarette vapor, propylene glycol, has been shown by in-vitro studies to be cytotoxic to alveolar type II epithelial cells. Glycerol, another component of e-cigarettes, was also found to be cytotoxic in a dose-dependent pattern. Moreover, lactate dehydrogenase, a common byproduct of cell death, was found elevated in alveolar cells exposed to e-cigarette vapor when compared to alveolar cell controls exposed to clean air, suggestive of cell death. Interleukin-6 (IL-6), a proinflammatory cytokine, was found to be elevated in a dose dependent pattern after young healthy non-smokers hTBE cells (human tracheobronchial epithelial cells) were exposed to e-cigarette fluid. Furthermore, there was an increase in fibroblast growth factor (FGF) in alveolar cells, which is also part of the pathogenesis of DAD. Conclusion: Diffuse alveolar damage is a life-threatening condition with a high mortality rate. The evidence of adverse effects demonstrated by the in-vitro studies described above suggests an association between e-cigarette use and diffuse alveolar damage. Just as studies were able to reveal the harmful effects of tobacco products in the past, this literature review introduces a new avenue of investigation to assess the long-term effects of e-cigarettes on humans.
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    Major Mental Illness: Resources in Tarrant County
    (2018-03-14) Hmaidan, Sarah; Samal, Akanksha; Jiwani, Sonia; Abrams, Stephanie; Petrus-Jones, Michael
    Purpose: Our project sought to present patient resources in Fort Worth and Tarrant County that focus on major mental illness, which affects 1 in 5 adults yearly in the United States. This includes, but is not limited to: major depressive disorder, bipolar disorder, post-traumatic stress disorder, schizophrenia, eating disorders, and substance abuse disorders. There is a higher prevalence of major mental illness among homeless, prisoner, and veteran populations, and in Tarrant County high poverty and uninsured rates contribute to prevalence rates higher than the national averages. Additionally, there are shortages of mental health care providers in Tarrant County and Texas overall. Methods & Results: A thorough investigation and review of resources in Tarrant County was conducted. Among the resources found in Tarrant County, several are branches of larger state or national organizations that provide extensive support and advocacy for, and education about mental illness. In addition to providing information on Tarrant County resources, we included information on resources for medical and health professions students on the UNT Health Science Center campus who may be living with one of these illnesses. High prevalence of physician burnout and maximal stress contributes to mental instability and increased mental illness prevalence among physicians and providers. Conclusions: Based on what we found in our search for resources, we concluded that there needs to be an increase in the number of mental health providers, an increased focus on advocacy and awareness about mental illness and health care, and an open dialogue about the real consequences of untreated mental illness in all populations.
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    Incorporation of pharmacy personnel into medical mission trips: Benefits of an interprofessional team
    (2018-03-14) White, Annesha; Cobern, Brianna
    There is a multitude of literature discussing the benefits of having pharmacy services incorporated into the medical mission team, however very few articles discuss in detail how pharmacists provide those services. The UNTHSC Christian Medical Association organizes an annual trip to various countries in Central America and has recently started incorporating pharmacists. The objective of this research was to review the literature within the last decade on the contribution of a pharmacist on the medical mission team. A secondary aim was to identify specific areas for consideration, such as medication acquisition, formulary development and pediatric dosing. A review of the literature was conducted identifying articles by searching PubMed, Scopus and Academic Search Complete, using the keywords ‘pharmacy’, ‘mission trips’, ‘medical missions’, ‘formulary’, and ‘religious missions.’ Articles that were published between 2007 and 2017 were included in the analysis. A summary was provided based on eight subtopics: acquiring medications; formulary development; work flow; transportation; packaging, labeling and medication setup; medication data collection; counseling; and pediatrics. A template was developed reflecting medical mission trip workflow. The search yielded a total of 10 articles for review. Findings revealed that medication acquisition and formulary development are key pre-trip roles for pharmacists. If medication is being brought outside the country where the trip is taking place, pharmacists should research the foreign country’s policies beforehand to ensure there are no issues with customs during travel. Counseling and work flow were the most common roles in terms of impact. Packaging and labeling improved efficiency for patients when customized to their language preference. Few studies thoroughly examined pediatric dosing, and none of the studies highlighted the pharmacist’s role in pediatric dosing. Previous literature has shown that pharmacy services are beneficial, but developing more standardized methods of how to utilize pharmacy services will help increase pharmacist contributions on mission trips. Since pharmacist involvement is a newer idea, there are a lack of empirical studies to measure the success of pharmacist involvement. More research using randomized control trials or specific outcome measures would benefit the existing body of literature. An opportunity exists for pharmacists to effectively contribute on an interprofessional team.
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    How bamboo has shaped the anatomy and physiology of Hapalemur
    (2018-03-14) Muchlinski, Magdalena; Hemingway, Holden
    Purpose Hapalemur spps. and Prolemur simus (bamboo lemurs) stand out among the relatively homogeneous lemurids because they are bamboo feeders and vertical clingers and leapers. This unique diet presents equally unique challenges, like its verticality, toughness, and toxicity. The bamboo lemurs share the generalized anatomy of the other lemurids, but also display some well-documented adaptations in their limb proportions to overcome the problems presented by bamboo. Soft tissue adaptations, however, remain largely unexplored. Here we begin to explore possible soft tissue adaptations in Hapalemur griseus. Based on the available anatomical and physiological data obtained from other Hapalemur and Prolemur species, we predict that H. griseus will have differences in hindlimb morphology when compared to other lemurids. We further predict that H. griseus will have more hindlimb muscle mass and will amplify muscle mass differences with increased type II muscle fibers. Methods We compared regional muscle mass, relative to total muscle mass, in mainland African, Malagasy, and Asian prosimians and a tree shrew (n = 11). Raw regional muscle mass values (e.g., hindlimb and sural) were divided by total muscle mass for a particular species to compare relative muscle mass. We then used immunohistochemistry to evaluate the fiber profile (the relative amount of type I/type II fibers) of muscles of significance, based on the results of the comparison of muscle masses. Results Relative hindlimb muscle mass in H. griseus is no different than other lemurids (p = 0.26). However, relative sural muscle mass is significantly heavier (p H. griseus than other lemurids. When the fiber profiles of primary foot plantar flexors were evaluated, the soleus muscle of H. griseus displayed a higher amount of type II (fast) fibers than any other species. Conclusions These findings indicate that although H. griseus shares some generalized lemurid morphology, its diet of bamboo has pushed this generalized lemurid to an anatomical extreme. We suspect that based on the diameter of the bamboo stalk and the bamboo lemurs body size, bamboo lemurs may be leaping in a unique fashion that does not easily fit with small-bodied “foot-powered” leapers or large-bodied “hip-powered” leapers. Although the results are preliminary, we suspect additional bamboo-specific adaptations in their anatomy and physiology will be uncovered with further examination into the anatomy of the bamboo lemurs.
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    Are Activity Limitations Related to Mental Health in Veterans Aged 25 and Older?
    (2018-03-14) McElroy, Juliana; Hartos, Jessica; Knickerbocker, Jennifer
    Purpose: Many veterans face difficulties such as physical limitations and mental health disorders, but little is known about how these are related within the veteran population. This study will examine the association between activity limitations and mental health in veterans aged 25 and older. Methods: This cross-sectional analysis used 2015 BRFSS data for veterans aged 25 and older from Oklahoma, Virginia, and Washington. Multiple logistic regression analysis was used to assess the relationship between mental health and activity limitations after controlling for psychosocial and demographic variables. Results: About one-fourth of veterans aged 25 and older reported having less than 30 days of good mental health in the past month (19-23%), and similar amounts reported having serious difficulty walking or climbing stairs (17-28%). After controlling for lifestyle and demographic factors, mental health was inversely related to activity limitations and to chronic health conditions in all three states with moderate to high effect sizes. Conclusion: These findings indicate there is a significant relationship between activity limitations, chronic health conditions, and mental health among veterans 25 years and older. Limitations of this study include the low prevalence of female veterans which made it difficult to assess gender differences. Due to the significant relationship, it is recommended that primary care practitioners screen for activity limitations, chronic health conditions, and poor mental health if a veteran presents with any of these, and then educate and provide referral services as necessary.
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    Severe Hypercholesterolemia in Two Children
    (2018-03-14) Hamilton, Luke; Wilson, Don; Hamby, Tyler; Horner, Susanna
    Background: Extreme elevations of low-density lipoprotein cholesterol (LDL-C) levels are generally consistent with genetic mutations affecting lipid or lipoprotein metabolism, as seen in familial hypercholesterolemia (FH). A detailed family history, medical history, and routine labs are key in determining the underlying cause to support appropriate clinical decision-making. We report two children with severe hypercholesterolemia and discuss evaluation and treatment. Case 1: A 2-yr-old Hispanic female presented for possible FH after routine lab test reported a severely elevated LDL-C of 370 mg/dL. The medical and family histories were unremarkable. Additional tests were ordered to rule out 2nd causes of hypercholesterolemia; her free T4 was low and her TSH elevated. Upon further questioning, the mother stated that the child was diagnosed with congenital hypothyroidism at birth and was started on thyroid hormone, but had been without it for 5 mos. Within 6 weeks of resuming levothyroxine, LDL-C was normal (78 mg/dL). Case 2: A 16-yr-old male was referred for evaluation after a cholesterol-screening test, performed by his PCP, reported an LDL-C of 213 mg/dL. His past medical history was unremarkable and he denied the use of medications. Both parents denied any significant family history. Additional studies revealed a low free T4 and an elevated TSH. He was found to have thyroid antibodies, consistent with the clinical impression of Hashimoto’s disease. Upon treatment with levothyroxine, thyroid function studies and LDL-C were normal (106 mg/dL). Summary: FH is a common genetic mutation that is frequently encountered in primary care. Although severe elevations in LDL-C are generally consistent with genetic mutations in lipid or lipoprotein metabolism, secondary causes must be considered. Both patients presented for evaluation of FH but were diagnosed with hypothyroidism. The dramatic decline of their LDL-C values within 6 weeks of treatment with levothyroxine emphasizes the importance of ruling out secondary causes of hypercholesterolemia. Thyroid dysfunction can lead to alteration of lipid metabolism due to the effects of low thyroid hormone on HMG-CoA reductase, LDL receptor expression, and high-density lipoprotein. Conclusions: While severe elevations of LDL-C can be caused by genetic mutations affecting lipid and lipoprotein metabolism, secondary causes of hypercholesterolemia should be excluded prior to counseling, genetic testing, and implementation of lipid-lowering therapy.
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    The Development of a Framework on Approaches to Adherence Best Practices for Health Plans: A Systematic Review
    (2018-03-14) White, PharmD, MS, PhD, Annesha; Shaw, Nicole
    Background: Roughly 50% of all patients do not adhere to their medication regimens. Root causes for nonadherence are complex and usually involve a variety of factors. A one size fits all approach to intervention programs would likely only yield suboptimal outcomes. Tailoring interventions according to patient characteristics can increase the likelihood of adherence intervention effectiveness. Purpose: The objective of this study was to review the literature within the past decade to develop a framework for best practices in health plan use of medication adherence interventions, with respect to patient perceptions, cultural competence, patient characteristics, and timing and frequency. Methods: This systematic review was conducted using PubMed, SCOPUS, Cinahl Complete, and Global Health databases to obtain articles published in the US from 2007 to 2017. Search terms used included: “medication adherence”, “interventions”, “program evaluation”, “text”, “phone”, “mail”, “visits”, “in person, “acceptability”, “patient preference”, “cultural competency”, “health literacy, “patient perceptions”, “smartphone”, “electronic mail”, “support groups”, “drug”, “medication” and “efficacy”. Abstracts were screened according to broad inclusion and exclusion criteria. Articles were read in detail and graded by Oxford Evidence-Based Grading System. Selected articles were categorized by adherence intervention: telephone outreach, provider-centric, and face-to-face visits. Results: Preliminary findings based on 79 articles retrieved thus far show that studies assessing patient perceptions of telephone interventions in the form of text messaging and mobile apps, prove high acceptability. Face-to-face visits in the form of behavioral-based family counseling have high acceptability among adolescent populations while provider-centric interventions appear to be highly dependent on the patient-provider relationship. Studies assessing cultural competence primarily show usefulness in provider-centric interventions and face-to-face visits as compared to telephone, and trend toward better efficacy in immigrant and low health literacy populations. Conclusion: Next steps in the conduct of this research will include an examination of the impact of patient characteristics (race, age, gender, marital status, SES and disease severity) on the effectiveness of adherence interventions.
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    Age and sex differences in childhood and adulthood obesity association with phthalates: Analyses of NHANES 2011–2014
    (2018-03-14) Moore, Jonathan; Huang, Yuhan; Aryal, Subhash; Uche, Uloma I.
    Purpose: To examine the relationship between urinary phthalates and obesity in children/adolescents and in adults using data from NHANES 2011-2014. Methods: Using the National Health and Nutrition Examination Surveys (NHANES) 2011-2014, data files on ten urinary phthalates and obesity in children/adolescents (aged 6-19 years old) and in adults (20 years and older) were retrieved. Urinary phthalates were grouped as low molecular weight (LMW) phthalates, High Molecular Weight (HMW) phthalates, Di-2-ethylhexyl phthalates (DEHP) and categorized using weighted quartiles. Children/adolescents were classified as underweight/normal, overweight and obese using the BMI z-score. Adults were classified similarly using BMI measures of29.9, respectively. A multinomial logistic regression was conducted to determine the association of urinary phthalates and obesity while controlling for covariates. Participants with missing covariates, pregnant women and breastfeeding women were excluded. Results: Using multinomial logistic regression, the 3rd quartile for LMW and the 4th quartile for DEHP had statistically significant associations with being overweight in children/adolescents. The 3rd quartile for LMW was associated with being overweight in female children/adolescents and the 4th quartile for DEHP was associated with being overweight in male children/adolescents. The 4th quartile of individual phthalate MECPP was found to result in increased odds of being overweight in the female group and in children overall. The highest quartile for MEHHP was also significantly associated with obesity for children overall and for males. There were no statistically significant associations between urinary LMW, HMW and DEHP concentrations and obesity in adults, even when stratified by gender. Analyses of the individual phthalate components of LMW indicated an association between the 4th quartile of MnBP and overweight among female adults. No association was found in other individual phthalates and prevalence of obesity in adults. Conclusion: Urinary concentrations of LMW and DEHP are associated with increased rates of overweight in children/adolescents and there is a sex difference in this association. There is no apparent association between urinary phthalates and obesity in adults.
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    Treating Mood Symptoms: Is the Therapeutic Response in Veterans At-Risk for mTBI Similar to Veterans with No-Risk for mTBI?
    (2018-03-14) James, Rachael; Nejtek, Vicki; Vicenzi, Scott
    Purpose: Active theater combat veterans serving in Iraq and Afghanistan wars encounter more blasts and explosions than any previous war which increases their risk for mild traumatic brain injury (mTBI). Returning veterans often seek behavioral health services to help them overcome traumatic wartime experiences associated with depression and anxiety. Cognitive behavioral therapy (CBT) is a ‘gold standard’ treatment strategy for returning veterans. However, there are few studies comparing the response-to-treatment of CBT for depression and anxiety between veterans at-risk for mTBI versus those with no-risk. We hypothesize that active theater veterans at-risk for mTBI will have a more severe posttraumatic stress disorder (PTSD), more depression and anxiety and will have a slower response-to-treatment time than veterans with no-risk. Methods: In this hypothesis-generating pilot study, we examined the clinical characteristics of veterans at-risk for mTBI compared to veterans with no-risk and evaluated the longitudinal effectiveness of 12-weeks of CBT and the response-to-treatment using secondary data analyses. Data from male veterans (24-57-years old) serving in Iraq and Afghanistan of all race/ethnicities receiving CBT were analyzed as no women in this sample served in active theatre. The PTSD checklist, Beck Depression Inventory, and Beck Anxiety Inventory were used to examine response-to-treatment. Chi-square, ANOVA, and repeated measures ANOVA were used to evaluate between-group differences. Results: Veterans at-risk for mTBI (n=136) had more severe PTSD, higher depression and anxiety scores than no-risk veterans (n=38). Almost 61% of veterans at-risk for mTBI had PTSD compared to 26% of veterans at no-risk. All veterans experienced reduced depression and anxiety symptoms with 12-weeks of therapy [Wilk's Lambda=.59, F(4,76)=13.27, p=0.0005, n2=.41]. However, mood scores for veterans at-risk for mTBI were almost 50% higher at baseline, 6- and 12-week time points than veterans at no-risk. Conclusions: These results inform clinical practice about the psychological consequences of serving in active theater and the long-term treatment needs of veterans with mTBI and PTSD. Clinicians who treat returning veterans should inquire about active theater exposures to blasts and explosions which predisposes them to risks for mTBI and severe PTSD. Clinicians should expect longer and slower responses to CBT in active theater veterans compared to non-combat.
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    Program Review for UNTHSC Clinical Trials - Guidelines for Human Gene Transfer Trials Research Involving Recombinant and Synthetic DNA
    (2018-03-14) Moncus, Matthew; Nair, Dr. Maya; Nessa, Lutfor
    Purpose: Human Gene Transfer (HGT) clinical trials are a rapidly progressing field that involves the introduction of a genetic sequence into a human subject for research or diagnostic purposes. Clinical HGT are regulated by the U.S. Food and Drug Administration (FDA) at the federal level and to oversight by institutional review boards (IRBs) and institutional biosafety committees (IBCs) at the local level before human subjects can be enrolled. In addition, at present, all researchers and institutions funded by the National Institutes of Health (NIH) are required by NIH guidelines to submit human gene transfer protocols for advisory review by the NIH Recombinant DNA Advisory Committee (RAC). NIH guidelines are the definitive reference for Recombinant and Synthetic DNA research in the United States and should have adopted by UNTHSC. The purpose of this research is to review the clinical trials program at UNTHSC and incorporate recent revised NIH guidelines on clinical trials involving Recombinant and Synthetic DNA. Methods: NIH Guidelines for Research Involving Recombinant and Synthetic Nucleic Acid Molecules, UNTHSC IBCs Biosafety Manual, UNTHSC IRBs Guidance for Human Subject Investigators, have been used as core materials to review. Results: UNTHSC IBC webpage was updated with additional information from the review. Existing clinical trial protocols will be reviewed and validated with the department of clinical trials to confirm that at current active clinical trials at UNTHSC does not involve any HGT trials. Conclusions: For future clinical trials, the material developed based on the review will be shared with investigators, clinical trials department, IRB and IBC webpage.
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    Analysis of the UNTHSC Teen Clinic
    (2018-03-14) Bui, Priya; Moses, Michelle
    Background: The UNTHSC Teen Clinic was established in June 2015 by Dr. Priya Bui as a result of her experiences working with teens in the UNTHSC pediatric clinic. The clinic is run ½ day per week by Dr. Bui and PA Lauren Dobbs. Typical visits include taking a thorough history and physical, screening for psychiatric problems, running special labs (for STIs, lipids, etc.) when indicated, and conducting an in-depth confidential interview to explore the teen’s environment and any risky or dangerous behavior or thoughts. The aim of this project is to analyze the first year of teen clinic so as to show others who may be interested in starting a clinic of this kind what exactly it may entail. Specifically, the research objectives were to create a raw database of information from the first year of UNTHSC’s Teen Clinic (stripped of identifiers); discover the population served; and analyze the depression and risky sexual behavior populations and the interventions used for them. Methods: Retrospective data collection and analysis. Created a raw database of all cases seen in teen clinic from 06/04/15 to 06/24/16. Collected and placed the following coded information into a protected Excel file: Age, Sex/gender, Referral Source, Chief Complaint (CC), History of Present Illness (HPI), Assessment, Medical Intervention, Psychiatric Intervention, Outcomes, Provider, and any Miscellaneous Information. Total of 196 encounters and 116 patients were included in the present study with no exclusion criteria. Analyzed chief complaint (CC), history of present illness (HPI), and assessment. Separately analyzed CC, HPI, assessments, and interventions of the Depression/Adjustment Disorder and Hypersexual Behavior populations. Preliminary Results: The top four CC, HPI, and assessments seen were determined. CC: Well child check (80), follow up (44), establish teen clinic (27), and depression (17); HPI: depressive symptoms (56), family instability (45), acute symptoms (31), well child check (29); Assessment: well child check within normal limits (72), depression (49), asthma/allergies (22), obesity (21). Populations with depression/adjustment disorder and hypersexual behavior were analyzed. In the small hypersexual group, there was successful intervention in 44% of females seen (i.e. Nexplanon placement). We found that in the depressive group 54.8% followed up. Conclusions: In its first year alone, Teen Clinic addressed a variety of unique issues not often explored in a typical pediatrician’s visit- most importantly (indicated by the frequency seen) symptoms of depression and adjustment disorder. Additionally, many teens were recommended for follow up, and many actually came back, successfully establishing a medical home. There are many possibilities for future studies, including, but not limited to: correlational analysis between family issues and risk taking behavior; analysis of patient compliance (by tracking follow up visits); analysis of outcomes from various interventions; and continuing the analysis of interventions in the hypersexual and depressed groups.
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    The Radiographic Prepatellar Fat Thickness Ratio Correlates with Infection Risk following Total Knee Arthroplasty
    (2018-03-14) Hogan, Sean; Burge, Ross; Sanchez, Hugo; Wagner, Russell; Bates, Christopher
    1. Purpose Obesity has been associated with complications following a total knee arthroplasty (TKA). Surgical Site Infection (SSI) following TKA is one of the feared complications as it increases revision rates, costs, and stress to the patient. There is conflicting evidence in the literature regarding BMI and risk of infection after TKA and some studies have suggested that site-specific fat distribution may be a better metric for determining risk of postoperative infections. Here we investigate the correlation of soft tissue distribution about the knee to surgical site infection following TKA. 2. Methods We retrospectively review 572 patients who underwent primary TKA at a single institution from 2006 to 2010. We introduce the Prepatellar Fat Thickness Ratio (PFTR) as a radiographic means to quantitatively assess fat distribution about the knee and evaluate this measurement’s ability to assess the risk of developing a SSI following TKA. 3. Results The PFTR was shown to be a better predictor of SSI than BMI in both the univariate (p=0.05) and multivariate (p=0.01) analyses. 4. Conclusions While BMI cannot fully account for variations in adipose distribution, the PFTR may account for this variability and may be a helpful tool for assessing a patient’s preoperative risk of SSI after TKA.
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    Bleeding diathesis in a patient with a novel mutation in SERPINF2: A case study of alpha-2 antiplasmin deficiency
    (2018-03-14) Drummond-Borg, Margaret; Adcock, Dorothy; Dunlap, Elissa; Torres, Marcela
    Background: Alpha-2 antiplasmin is a serine protease inhibitor that inactivates plasmin and prevents premature breakdown of fibrin clots. Deficiency of this enzyme can lead to spontaneous bleeding and hemophilia-like symptoms, despite normal coagulation and platelet function studies. We present a case of congenital alpha-2 antiplasmin deficiency to emphasize the importance of recognizing a patient with bleeding symptoms despite normal coagulation assays and to report a novel SERPINF2 gene mutation as a cause of this disorder. Case Information: A 7-month-old patient presented with a hemarthrosis of the right knee that was assumed to be septic arthritis, despite negative cultures of the bloody synovial fluid. She experienced significant bruising and spontaneous hematomas, necessitating a hematologic consultation. Complete blood count (CBC), Von Willebrand Factor (VWF) activity and antigen, prothrombin time (PT), partial thromboplastin time (PTT), thrombin time, platelet function analysis, and fibrinogen levels were all normal. At 3 years of age, she had a second suspected hemarthrosis of the right knee, prompting the following tests: plasminogen activator inhibitor-1 levels, euglobulin lysis time, factor XIII activity and platelet aggregation studies. All tests showed normal results. In addition, she had two episodes of hemorrhage after a tooth extraction, both instances required red blood cell and fresh frozen plasma transfusions. Whole exome sequencing revealed a novel homozygous mutation in the SERPINF2 gene. Alpha-2 antiplasmin activity was then measured atA), has not been previously reported in patients with alpha-2 antiplasmin deficiency. Family history was positive for consanguinity. These findings suggest that this mutation has likely been present in several generations of this patient’s family and follows the pattern of an autosomal recessive disorder. Conclusions: This case highlights the difficulties in diagnosing bleeding disorders that involve the fibrinolytic pathway. The previously unreported pathogenic mutation of the SERPINF2 gene may provide valuable insight into the molecular mechanisms of alpha-2 antiplasmin deficiency.
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    (2018-03-14) Oderberg, Jane; Severance, Jennifer; Agena, Valerie; Ross, Sarah
    PURPOSE Skilled nursing facilities (SNF) have an increasingly frailer and more dependent patient population with a high risk of re-hospitalization from preventable adverse events. Developing a culture of safety is a core component to clinician and staff behaviors that affect safety, quality, and patient outcomes, although little is known about improving patient safety in long term care settings. With a goal of improving the safety culture and quality of care provided in SNF settings, UNTHSC Center for Geriatrics developed and implemented the evidence-based interprofessional Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) to address falls risk reduction at skilled nursing facilities in Fort Worth, Texas. METHODS We administered the Agency for Healthcare Research and Quality (AHRQ) Nursing Home Survey on Patient Safety Culture Brookdale Broadway Plaza (n=36), the Stayton (n=26) between August and October 2017. Survey results across twelve composites of patient safety culture were used to inform the development and delivery of a TeamSTEPPS Long Term Care 2.0 training series focused on falls risk reduction. The first training session delivered in October 2017 for direct care staff (n=47) provided an overview of the TeamSTEPPS model and communication tools, and an introduction to falls risk reduction in long term care settings. A second session for direct care staff (n=37) delivered in December and January provided additional training in TeamSTEPPS strategies and development of a communication tool to aid in fall risk reduction. Initial evaluation of knowledge and skills of trainees included a Likert scale survey. RESULTS Survey analysis identified that most staff believed their residents were safe in their facility (89% Brookdale,91% Stayton,82%Trinity) and they would recommend their facility to others (76% Brookdale; 80% Stayton). The lack of communication regarding residents (Brookdale 60%; Stayton 48%) was prevalent in both facilities and most direct care staff felt they were not considered members of the care team (61% Brookdale; 50% Stayton). Initial evaluation of TeamSTEPPS training showed that a majority (92-100%) were highly confident they could describe objectives related to the TeamSTEPPS program and falls awareness and prevention. As a result of the training, an action plan and communication tool was developed with input from the trainees to ensure continuity of care, improve communication, and decrease falls. Using a Plan-Do-Study-Act continuous improvement cycle, this checklist will be implemented by designated facility personnel. A post evaluation using the patient safety culture survey will be administered. CONCLUSIONS The implementation of TeamSTEPPS at SNF facilities demonstrated benefits to staff in improving their quality of care and ability to work collaboratively for the good of the patients. We anticipate that SNF will utilize TeamSTEPPS principles to develop, implement and sustain effective patient safety interventions.