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Item A Systems Approach to Postpartum Depression: Opportunities for Prevention and Treatment(2019-03-05) Thompson, Erika; Adhikari, SujitaA Systems Approach to Postpartum Depression: Opportunities for Prevention and Treatment Sujita Adhikari MPH Candidate, Erika L. Thompson, PhD, MPH, CPH Dept. of Health Behavior and Health Systems, UNT Health Science Center, Fort Worth TX,76107 Background Postpartum Depression (PPD) is a common mental health issue that occurs in women after childbirth. The depressive symptoms in affected mother are often manifested as a feeling of extreme sadness, guilt, helplessness, insomnia, excessive crying, extreme concern about child, fatigue and suicidal thoughts. Biological factors (e.g. hormonal changes) and psychological factors (e.g. stress, lack of social support, low socio-economic status, abusive relationships, greater work pressure, the occurrence of adverse life events, previous history of depression) are risk factors for PPD. In 2018, 14.7% of women in Texas who gave live birth experienced postpartum depression. Due to the complexity of this health issue, systems thinking is necessary to identify organizations aligned with addressing PPD, which can then help design effective interventions to minimize the potentially harmful effects of PPD. Objective The main objective is to identify organizations in the Fort Worth region that are involved in postpartum depression prevention or treatment and map organization connections. Methodology A web search was conducted in November 2018 to identify organizations and government bodies who address postpartum depression. Interconnection was established amongst these organizations to analyze using a system thinking approach. Results Three national-level organizations (e.g. Medicaid), four state-level organizations (e.g. Texas Department of Health and Human Services) and three local level organizations (e.g. MHMR of Tarrant County) were identified in the Fort Worth region. These organizations when analyzed were found connected with each other forming a system which operated to address PPD in this region. Conclusion These major ten organizations that are dedicated to working on postpartum depression are interconnected. The organizations operate at different levels to form a complex system. While organizations are making a positive impact on this issue, it is still necessary to dive deeper and understand the underlying factors for this problem. By understanding the complex system for PPD prevention and opportunities for integration, better mental health outcomes can be achieved.Item Coordinated Movement of Diaphragm and Pelvic Floor Muscles in Relation to Respiratory Function(2019-03-05) Lu, Crystal; Beasley, Stephanie; Nichols, Charles; Liu, Howe; Coleman, AudreyBackground: It is known that the diaphragm affects pulmonary function, trunk stabilization, and other systems found in the thoracic and abdominal cavities. The pelvic floor muscles (PFM) aid in function and stabilization of the urinary, excretory, and reproductive organs. The purpose of this literature review is to determine the connection between the function of the diaphragm and PFM and the role that the PFM may play in common thoracic and abdominal diagnoses. Methods: The review was conducted using databases and specific keywords from peer-review articles between 2008 and 2018. Many of the studies used real time magnetic resonance imaging (MRI) and electromyography (EMG) to determine activation and function of the diaphragm and PFM during different activities. Results: The diaphragm and pelvic floor muscles (PFM) have been shown to work together in many aspects of respiration and postural control and move in parallel during quiet breathing. It was noted that stronger PFM resulted in faster respiratory rates due to increased muscle recruitment and strength of respiratory muscles. In a different study, EMG results showed that the anterior diaphragm contributes more to respiratory function, while the middle and posterior diaphragm assist with trunk stabilization. Subjects with larger and stronger diaphragms had better postural stability and experienced less low back pain. The diaphragm and PFM also contribute to intra-abdominal pressure (IAP). When the diaphragm and PFM move cranially during expiration, abdominal muscles contract and thicken causing an increase in IAP. Discussion: The results showed that the diaphragm and PFM are vital in respiration, organ support, bladder and bowel control, and postural support. The diaphragm and PFM move synchronously in healthy individuals but can become dysfunctional with many pathologies. These two muscle groups, along with abdominal muscles, form a bridge and work synergistically, which could explain the association of symptoms between the three. Clinical Implications: It is important during diagnosis and treatment of the thoracic and abdominal cavity that the diaphragm and pelvic floor muscles should be assessed. Use of real time MRI and EMG can help increase strength and decrease irregular contractions in the bridge of the abdominal muscles, the diaphragm, and PFM. Focusing on all three muscles as a group instead of isolating one can increase postural stability in patients.Item Platelet-derived Extracellular Vesicles as an Alternative Therapy for Trauma-Induced Hemorrhagic Shock(2019-03-05) Srivastava, Amit; Burchfield, John; Wang, Yao-Wei; Cardenas, Jessica; Wade, Charles; Lopez, ErnestoIntroduction: Traumatic injuries remain a major cause of death worldwide, with mass bleeding present in most cases. Fluid resuscitation with blood products to achieve hemostasis represents common treatment, with platelet transfusion linked to improved survival in trauma patients. But, limitations on platelet longevity, approximately 5-day shelf life, pose a therapeutic hurdle. Platelet-derived Extracellular Vesicles (PEVs) are vesicles (under 1 µm in size) released from platelets upon activation and/or mechanical stimulation, and PEV mediated response may be linked to platelet attributed benefits. We hypothesized that human PEVs transfusion would promote hemostasis, reduce blood loss, and attenuate progression to hemorrhagic shock. Methods: Platelet units from 4 donors were centrifuged, separating platelets and PEVs. The pellets were washed to obtain plasma-free platelets, and supernatants were subjected to tangential flow filtration for isolation and purification of PEVs. We utilized Nanoparticle Tracking Analysis (NTA) to assess total count and particle size distribution of PEVs, and flow cytometry to characterize for cells of origin and expression of EV specific-surface markers. A rat model was used to compare the therapeutic effects of 8.7 x108 fresh platelets (FPLT group, n=8), 7.8 x109PEVs (PEV group, n=8) or Vehicle (Control, n=16) following severe trauma. Under anesthesia and analgesia, rats were prepared to cannulate the femoral artery and jugular vein, and monitored for continuous mean arterial pressure (MAP). Uncontrolled hemorrhage was induced via approximate 1.1 gram middle hepatic lobe excision. Baseline and 60 minute post injury arterial samples were analyzed via blood gas analyzer and thromboelastography. Results: The obtained pool of PEVs had a mean size of 101±47nm and expressed the platelet-specific surface marker CD41 and the EV specific-surface markers CD9 and CD61. In vivo, a demonstrated 24% reduction in abdominal blood loss following liver trauma in PEVs group compared to Control group (9.9 vs. 7.5mL). PEVs vs. Control also exhibited improved outcomes in blood pressure, lactate level, base excess, and plasma protein concentration. FPLT failed to improve these endpoints vs. Control. Conclusion: Human PEVs offer a novel hemostatic effect following mass bleeding. PEVs also improve the outcome following severe trauma by maintaining hemodynamic stability, and mitigating the development of ischemia, base deficit, and cardiovascular shock.Item Current research status on the treatment of veisalgia using Silybum marianum(2019-03-05) Powell, Jake; Nguyen, Thuy; Tran, ApolloBackground. There is abundant anecdotal evidence for products claiming to reduce veisalgia after alcohol consumption. Among these products is milk thistle (Silybum marianum), a plant that has been widely touted for its hepatoprotective properties against toxins such as alcohol, venom and plant poisons. Companies commonly promote the use of milk thistle proactively and/or actively as a treatment to attenuate symptoms of veisalgia. However, none of these claims are substantiated by research. Purpose. The purpose of this study is to evaluate the current state of the literature concerning the use of milk thistle for treating veisalgia. The supplement is commercially promoted as a cure for hangovers and we aim to assess the validity of these claims. Methods. We completed a literature search on milk thistle and veisalgia using Medline, Scopus, and Excerpta Medica Database (EMBASE). Because there are currently no studies directly linking milk thistle with hangovers, we identified the main pathophysiological pathways implicated with veisalgia to cross examine the validity of using milk thistle for treatment. Results. No studies directly examined the treatment of veisalgia with milk thistle. However, several studies demonstrated milk thistle to have antioxidant and antitoxin effects in the liver, small intestine, and stomach. Animal studies have found that milk thistle may contribute to hepatocyte regeneration and reduce inflammatory processes. Multiple clinical trials using milk thistle as treatment for a variety of liver diseases suggest that milk thistle may be a viable and biologically active supplement. However, most clinical trials assessed milk thistle’s effects on liver related diseases such as hepatitis. Conclusions. Veisalgia is a multifactorial pathological state that has been implicated with liver damage and inflammation. Milk thistle has been found to provide benefits for a variety of liver diseases, which share several pathophysiological processes that cause veisalgia. Based on this evidence it is possible that milk thistle could be effective in alleviating veisalgia symptoms in common with liver disease. However, there is not enough evidence in the current literature to definitively indicate milk thistle for the treatment of veisalgia.Item Opportunities for Tuberculosis Prevention in Private Sector Healthcare: Health Insurance and Usual Sources of Healthcare in Foreign-Born Persons with Latent Tuberculosis Infection(2019-03-05) Stockbridge, Erica L.; Miller, Thaddeus; Mun, Eun-Young; Annan, EstherOpportunities for Tuberculosis Prevention in Private Sector Healthcare: Health Insurance and Usual Sources of Healthcare in Foreign-Born Persons with Latent Tuberculosis Infection E. Annan 1, E. L. Stockbridge 2, T. L. Miller 2, E.Y. Mun2 1Department of Biostatistics & Epidemiology, University of North Texas Health Science Center, Fort Worth, TX, United States. 2 Department of Health Behavior & Health Systems, University of North Texas Health Science Center, Fort Worth, TX, United States. Abstract Background: Preventing TB in the foreign-born US population is a priority, as over two-thirds of active TB cases in the US occur among foreign-born persons. With 90% of incident active TB cases among foreign-born persons stemming from reactivation of latent TB infections (LTBI), there is a need to increase targeted LTBI testing and treatment in foreign-born persons. It may be feasible to conduct these activities within the US private healthcare sector, but LTBI-positive foreign-born persons' use of healthcare and ability to pay for care will facilitate or impede such a strategy. These characteristics are not well-described in current literature. Aims: (1) Estimate LTBI prevalence among foreign-born individuals by health insurance status and usual source of healthcare (USHC); and (2) examine patterns of insurance coverage and USHC among foreign-born persons with LTBI. Methods: We analyzed 2011-12 National Health and Nutrition Examination Survey (NHANES) self-reported health insurance and USHC data for foreign-born individuals in combination with markers for LTBI. The sample was restricted to civilian, noninstitutionalized, foreign-born persons ages 6 years or older with interferon gamma release assay (IGRA) results and self-reported insurance and USHC data (N=1,793). We used Stata /SE 15.1 to conduct analyses and adjust for complex sampling design. Results: Overall, 15.9% of our sample were LTBI-positive. Of LTBI-positive persons, 37.0% had some form of insurance and 76.9% had a USHC. LTBI prevalence was highest in persons who used a clinic or health center as a USHC (17.3%), but 44.6% of persons with LTBI use a physician’s office or HMO as a USHC. Insured persons had a slightly higher prevalence of LTBI than uninsured persons (16.2% and 15.3%, respectively). While LTBI prevalence was highest in persons with Medicare, persons with LTBI were most likely to be uninsured (37.0%) or have private insurance (33.1%). In total, 56.7% of persons with LTBI had both health insurance and a USHC, while 20.2% had neither insurance nor a USHC. Conclusion: Both health insurance and USHC were common within foreign-born individuals with LTBI residing in the US. Although different strategies are needed to address LTBI within the vulnerable population of foreign-born persons without health insurance or USHC, our results suggest that targeted LTBI testing and treatment within the US private healthcare sector could reach the majority of foreign-born individuals with LTBI.Item An ERP study on attention bias in experimental pain individuals under different cognitive loads.(2019-03-05) Liu, Howe; Salem, Yasser; Wu, Wen; wang, kanglingPurpose: The aim of the present study was to investigate the behavioral and electrophysiological differences between experimental pain persons and healthy controls when conducting attention bias task under different cognitive load conditions. Methods: 30 healthy subjects were recruited from the Southern medical university of China, into which equally divided the experimental pain group and healthy control group (7 female/15 and 8 female /15; mean age ± SD: 22.53±2.35 and 21.69±3.25 respectively; mean years of education ± SD:16.30 ±3.58 and 15.78 ±3.65 respectively). All subjects underwent ERP examination when completing an attention bias task. The experimental pain subjects simulated pain by spraying capsaicin on the inner side of the upper arm with an average pain score of 6.08±2.33. Healthy control group reported no pain. Results: Behavioral results showed that the main effect of load was significant, with a longer respond time and lower correct rate under high cognitive load compared with low one, suggesting that the task we used could well distinguish different loads. Further ERP results revealed that the main effect of wave peaks (N1 and P2) between groups was significant. Experimental pain subjects responded to all word interferences with a smaller amplitude than that of the normal group. A significantly synergistic effect of interference word * load, with a significantly smaller amplitude induced by pain words and negative words of early components P2 and N3 under the condition of high cognitive load, and interference word*group, with a smaller amplitude of N1 and N3 elicited by various interference words, were found. Conclusion: Experimental pain subjects’ response to the words of external stimulus was weakened as a result of the disturbance of pain. We believed that cognitive load mainly affected and regulated the early components of attention, that the processing mode of interference words (especially pain words and negative words) was different under high cognitive load compared with low one, which could provid electrophysiological evidence for cognitive load theory.Item Reverse Kretchman Microscope(2019-03-05) Fudala, Rafal; Gryczynski, Ignacy; Borejdo, JulianReverse Kretchmann Microscope J. Borejdo1,2, R. Fudala1,2, 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 Purpose. The purpose of this research was to construct the instrument to supplement Total Internal Reflection Microscopy (TIRF) to mage 10-20 nm thick layer of cells such as membrane lipids, membrane receptors and other structures proximal to basal membranes. Methods. 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. Results. With little effort, we were able to image 100 nm fluorescent nanospheres. Conclusions. Reverse Kretchmann Microscope 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 surfaceItem Efficacy of Sympathetic Nerve Blocks in Pediatric Outpatients with Central Sensitization of Pain(2019-03-05) Blackham, Sterling; Gandhi, Artee; Brooks, Meredith; Hamby, Tyler; Romney, ColePurpose: Central sensitization (CS) is distinguished by an increased sensitivity to painful stimuli, due to a lower pain threshold or an altered response to pain. Clinically, CS frequently presents as enhanced sensitivity to a painful stimulus, triggering of pain by nonpainful events, and expansion of the receptive field. There is currently no standardized treatment for CS. Therapy is normally attempted through medications, lifestyle modifications, stress management, cognitive-behavioral therapy, physical therapy, interventional pain procedures, and occasionally surgery but evidence supporting specific treatments is lacking. Interventional nerve blocks are relatively common for the relief of chronic pain in adults but not in pediatric patients. To the best of our knowledge, this is the largest report examining the use of sympathetic nerve blocks for the relief of chronic pain in children. Methods: This study was a retrospective, chart review of pediatric patients treated between January 2009 and March 2018 for conditions that cause CS at Cook Children’s Medical Center. Patients included were between ages 0-21 years at the time of the procedure. Demographics, diagnoses, pain scores (FACES, VAS, NAS, FLACC; each measured on 10-point Likert scales), patient report of complications, activities of daily living and improvements in limb function were reviewed for each patient. Though each patient had 1-5 procedures, study analysis was limited to the first procedure. Results: There were 69 distinct patients (56 female; 63 white; median age 14.68 years, range 3.54-19.27). Common diagnoses treated include complex regional pain syndrome (45 patients) and abdominal pain (15 patients). Most patients demonstrated improvements in leg functionality (77%), hand functionality (76%), and overall functionality (71%). Pain scores improved after intervention for 74% of patients, and on average, patients reported a statistically significant improvement in the pain score from before (Mean=5.39; SD=3.02) to after (Mean=1.38; SD=2.08) intervention, P Conclusions: Sympathetic nerve blocks are both effective and safe for the short-term treatment of CS in children. Additional research should be done to determine long-term effectiveness and safety in this population.Item Effects of Strength Training on Bone Mineral Density in Adult Women: A Systematic Review(2019-03-05) Rokayak, Natalee; Yasser, Salem; Liu, Howe; Paez, GeneTitle: Effects of Strength Training on Bone Mineral in Adult Women – A Systematic Review In the recent years, exercise has been proposed as a treatment strategy for obtaining an optimal peak bone mass. Moreover, several studies have shown that participating in exercise program can prevent osteoporosis and decrease the risk of fracture. High load exercises such as weight lifting, and strength training provide loading exercises that may improve bone mineral density. To our knowledge, there is no study that have compiled the evidence for the role of strengthening exercises in the prevention and treatment of osteoporosis. Purpose The purpose of this systematic review is to evaluate the effectiveness of strengthening exercises on bone mineral density in adult women. Subjects: This systematic review of literature included 17 published studies that met our inclusion criteria. In total, 1210 adult women participated in those articles and were studied in our final included studies. Methods Electronic databases used were PubMed, Physiotherapy Evidence Database (PEDro), CINAHL, Web of Science Search and Scopus. Key words included osteoporosis, bone mineral density, and strength. Our inclusion criteria included population (adult women 18 years and older), and intervention (strength training is the main exercise program). The initial search yielded 1073 potential articles. These studies were then screened for duplications and selection criteria. Of those 1073 studies, 17 studies were considered to meet all of the required inclusion criteria. Data Analysis This is a systematic review study. Quality of the included studies was rated using the Centre of Evidence-Based Medicine: Levels of Evidence and the PEDro scale. Results In total, 17 research studies were examined and met our inclusion criteria. All of the included studies were randomized controlled trials. Across all 17 studies, 1210 adult women were participants. Sample size for each study ranged between 20 and 226 adult women. The age range of the participants was between 18 and 70 years old. All studies showed beneficial effects of strength training in bone mineral density in adult women. No adverse effects were reported in those studies. Dosing of intervention varied in terms of frequency (ranged 2 to 5 sessions per week), duration (ranged from 15 to 75 minutes), length of the exercise program (ranged from 6 weeks to 2 years) and mode/type of strength training used. Conclusion The results of this study showed that strength training programs are safe and effective to improve bone mineral density in adult women and can be used as a treatment strategy to prevent Osteopenia and Osteoporosis in postmenopausal women. Further studies are needed to determine the appropriate mode and dosage of the exercise program. Relevance: The findings of this study suggest that strength training has beneficial effects on bone mineral density in adult women and can be used as a strategy to prevent and minimize osteoporosis in postmenopausal women.Item Biomechanic Evaluation of AC Joint Reconstruction Techniques: A Systematic Review(2019-03-05) Mong, Joy; Wagner, Lianne; Schultz, Matthew; Hoelscher, Skyler MD; Webb, Brian MD; Tran, ApolloBackground. Acromioclavicular (AC) joint disruption comprises 3.2% of all shoulder injuries, yet there is still broad debate on the optimal surgical approach. Over 150 surgical variations have been proposed, however the lack of common terminology and experimental standards make it challenging to draw any conclusions. For such predicaments, systematic reviews that provide a methodical approach for navigating the literature and have proven useful for identifying areas for improvement, standardizing protocols, and providing direction for a comprehensive analysis. Objective. The purpose of this review is to: 1) systematically evaluate the current state of the literature concerning the biomechanical testing of AC reconstruction; 2) to summarize the surgical techniques and testing procedures; and 3) to identify biomechanical areas that are not well represented in the existing literature. Methods. We completed a literature search to identify biomechanical studies on AC joint fixation using Medline, Scopus, and Excerpta Medica Database (EMBASE) following the 2009 PRISMA statement. Articles were independently reviewed by two investigators and any disagreements were reconciled by consensus in consultation with a third investigator. Investigators independently abstracted data from each study, focusing on surgical techniques and characteristics of the testing protocol. Results. The most popular techniques were the Modified Weaver Dunn and suture button techniques with a tunnel through or looping under the coracoid. To assess construct performance, 28 out of 39 studies included a load to failure protocol to evaluate strength and stiffness of the construct. 18 studies measured vertical plane translation, 16 studies measured horizontal motion, and 5 studies measured rotation. Conclusion. Overall, the most common techniques involved graft with suture augmentation. Techniques looping under the coracoid decreased the likelihood of fracture whereas techniques going through the coracoid improved stability and better maintained reduction. Free graft and hookplates have been found to be biomechanically or clinically inferior. Elastic stiffness serves as a reliable indicator for quantifying early construct stability while strength and translation better represent long-term functional stability. While general conclusions can be made from current biomechanic literature, a more objective verdict requires better standardization of terminology and testing procedures.Item A Novel Mutation of APOB in Two Siblings with Hypercholesterolemia(2019-03-05) Hamilton, Luke; Hamby, Tyler; Wilson, Don; Sprunger, AbigailA Novel Mutation of APOB in Two Siblings with Hypercholesterolemia 1 Abigail Sprunger, BS; 2L. Hamilton, MS; 3T. Hamby, PhD; and 2D. P. Wilson, MD, FNLA 1University of North Texas Health Science Center, Ft Worth, TX, and the Departments of 2Pediatric Endocrinology and Diabetes and 3Research Administration, Cook Children’s Medical Center, Ft Worth, TX, USA. Abstract Background: Familial hypercholesterolemia (FH) is a common genetic disorder cause of premature atherosclerosis due to chronically elevated low-density lipoprotein cholesterol (LDL-C) levels from birth. Individuals with FH experience an increased risk of premature cardiovascular disease (CVD), and lack of early identification and treatment increases the risk of CVD-related coronary events later in life. We report two siblings with FH caused by a novel mutation in APOB. Methods: Electronic medical records were reviewed for two patients with FH. Case Information: Two biologically related siblings (male age 9, female age 11) were found to have LDL-C levels [greater than] 95th centile for respective age and gender. Neither sibling had preexisting medical conditions nor a history of chronic medications. Both siblings were found to have the same missense variant in the APOB gene, a novel mutation causing hypercholesterolemia. Because of parental concerns regarding use of statins, both were treated with a cholesterol absorption inhibitor. Conclusions: Despite the benefits of early identification of those at moderate-to-severe risk, several knowledge gaps impede successful cholesterol screening of children: misunderstanding goals of screening, the best screening method, and ideal age for screening and for intervention. Current guidelines recommend universal cholesterol screening and selective screening starting at 10 and 2 years of age, respectively. Although not routinely preformed, identification of a genetic mutation helps to 1) confirm the diagnosis of FH; and 2) serves as an additional risk factor for CVD, aids risk stratification and clinical-decision making, and helps determine the timing and intensity of treatment that would provide the best long-term health benefits. In addition to lipid-lowering medications, treatment should include global reduction of all CVD risk factors through health education, and adoption of life-long, heart-healthy living with a goal to reduce LDL-C levels toItem Single-stage bilateral distal femur replacement for traumatic distal femur fractures(2019-03-05) Sambhariya, Varun MD; Tran, Apollo; Rahman, Shawn; Dean, Thad DO; Wagner, Russell MD; Sanchez, Hugo MD, PhD; Neal, David MDBackground. Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures remains a difficult challenge for orthopedic surgeons. Previous case series have shown distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and provide stability. However, bilateral injury treated with single stage DFR is rarely encountered and to our knowledge, there are no case reports in the literature. We present a patient with traumatic open left Su III/Rorabeck III periprosthetic distal femur fracture and closed right comminuted intraarticular distal femur fracture with end-stage arthrosis treated with bilateral DFR. We suggest that in elderly patients with similar injuries bilateral DFR can be a viable treatment option. Case Information. An 80-year-old female with past surgical history of left TKA in 2005 presented to our hospital after being involved in a motor vehicle collision resulting in open left periprosthetic distal femur fracture and a closed comminuted right intraarticular distal femur fracture with end-stage arthrosis. She also had a history of anemia and end-stage right knee arthritis for which she was planning a TKA in 2017. She was admitted by our geriatric trauma service for medical optimization prior to surgery. The on-call operative team planned open reduction internal fixation of the open left periprosthetic distal femur fracture after obtaining XR and CT. After making a lateral approach to the femur her fracture was found to be more comminuted than anticipated and the bone-prosthesis interface was not intact. An intraoperative decision was made to place an external fixator with referral to the arthroplasty service for evaluation for possible DFR. For the right distal femur fracture, closed reduction was performed with placement of a knee immobilizer. The patient was taken to the operating room on the 7th day post-admission for bilateral DFR. Postoperatively the patient was made weight bearing as tolerated to both lower extremities and worked with physical therapy daily. She is driving, maintaining her home, and living independently. On exam, her surgical incisions are well healed without evidence of infection. Knee range of motion is from 0-110 degrees bilaterally. One-year postoperative radiographs were obtained demonstrating unchanged alignment of her previously placed prostheses with no signs of loosening Conclusion. Bilateral DFR is a viable treatment option for Su III periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis. We suggest that in elderly patients with similar injuries, bilateral DFR can effectively compensate for bone loss, relieve knee pain, provide stability, and allow for earlier mobilization resulting in satisfactory patient outcomes.Item A comparison of Social Responsiveness Scores in patients aged 0-24 with Autism Spectrum Disorder or schizophrenia.(2019-03-05) Miller, Haylie; Shahub, Nur-AlhudaPurpose: Autism Spectrum Disorder (ASD) and schizophrenia share common features; past research demonstrates that these features include pathophysiology, social-cognitive impairments, possible genetic underpinnings, and risk factors. In both disorders, social cognition presents a key barrier to quality of life. One measure of social cognition designed for use in ASD, the Social Responsiveness Score (SRS), is also commonly used to assess social cognition and plan interventions in schizophrenia. We aimed to determine whether people with ASD and schizophrenia differ in the mean and range of their SRS scores. Methods: We identified an age-matched sample of fifteen individuals with Autism Spectrum Disorder (Male = 13, Female = 2; MAge= 22.71, SDAge= 3.24) from the National Database of Autism Research and thirteen individuals with schizophrenia (Male = 10, Female = 3; MAge= 22.07, SDAge= 2.99) from the SchizConnect database. All individuals were between the ages of 0 and 24 years. Data were analyzed using Microsoft Excel and the Statistical Package for Social Sciences software. SRS T-scores Results: Mean SRS scores did not differ between the ASD (M = 80.50, SD = 14.32) and the schizophrenia (M = 89.78, SD = 39.37) groups (p = 0.22). Although the group means were not significantly different, the schizophrenia group had a notably wider range of SRS scores than the ASD group. Conclusions: Although our groups did not differ in their mean SRS scores, there was wide variability in the schizophrenia group. The SRS was designed for ASD, and may not be an adequate measure of social dysfunction in other populations. At minimum, this wide variability suggests that when using the SRS as a tool for assessing social-communication skills in schizophrenia, the influence of other factors (such as age, behavior, or language) must also be considered. Further study is required to fully assess the clinical utility of this tool for non-ASD populations.Item Avascular Necrosis of the Femoral Head in a Healthy, Young, Adult Male(2019-03-05) Neelakantan, Suguna MD; Burghul, SunaBackground: Avascular necrosis (AVN) of the femoral head can be caused by a variety of factors including tobacco use, traumatic injury, or hypercoagulability. Hypercoagulability in the body can lead to the formation of thrombi in the microcirculation, resulting in many possible complications. This report will discuss a case of a healthy, young male who developed avascular necrosis of the femoral head as a result of Factor V Leiden. Case Information: A 30-year-old previously healthy male presented to the outpatient family medicine clinic with a chief complaint of severe pain in his right hip. The pain had been present for eight months and was progressively getting worse. The patient’s only past medical history was hyperlipidemia. He was not taking any medications, he exercised regularly, he worked as a sales representative, and he did not have any family history of clotting disorders. He had no history of trauma, tobacco use, alcohol consumption, or steroid use. On physical exam, he had extreme pain upon flexion of the right hip. An X-ray of the right hip showed equivocal broadening of the superolateral femoral head-neck junction suggesting mechanical impingement. He then presented two weeks later with more intense pain in his hip and was unable to walk. He was referred to orthopedic surgery, where an MRI was performed and showed Stage 3 avascular necrosis of the femoral head. He then saw hematology and testing revealed that he was heterozygous for a mutation in the r506q gene responsible for factor V, confirming his diagnosis to be Factor V Leiden. The patient had a right total hip arthroplasty and is doing well. Conclusions: AVN of the femoral head is a debilitating condition. When left untreated, it is estimated that between 70-80% of patients will progress to bilateral AVN, making diagnosing the underlying cause vital. Hypercoagulability is believed to be a major and common cause of AVN; thus, systemic anticoagulation therapy should be considered to prevent further complications, especially when a patient is homozygous for the mutation on Factor V. While other treatment options for AVN of the femoral head are available, when the necrotic lesion has become too large or the femoral head has collapsed, total hip arthroplasty remains the best option. Although many patients discover that they have Factor V Leiden due to family history, this patient was unusual in that he presented with an irreversible complication of the disease.Item Sporotrichoid Lymphocutaneous Spread of Metastatic Cutaneous Squamous Cell Carcinoma(2019-03-05) Weis, Stephen; Al-Dossari, RannaBackground: Sporotrichoid lymphocutaneous spread is a dermatologic pattern characterized by superficial cutaneous lesions that follow subcutaneous lymphatics. Typically, this is observed when an infection starts at a site of distal inoculation and leads to the development of ascending nodules. The most common causes are fungal and mycobacterial infections. Metastatic cutaneous squamous cell carcinoma (CSCC) typically presents with regional lymphadenopathy. Primary lesions of the external ear and lip have the highest risk of metastasis, followed by the temple, scalp, hands, and feet. Risk factors for metastasis of CSCC include immunosuppression, tumor recurrence, tumor thickness [greater than] 4mm, and perineural or vascular invasion. However, metastasis of CSCC is rarely seen to follow a sporotrichoid lymphocutaneous morphology. Case Information: A 64-year-old female with a past medical history of severe COPD requiring repeated courses of prednisone and continuous oxygen, presented for a rapid growing lesion on her left hand after trauma in the shower at a nursing home. Due to her poor medical condition, she declined recommended biopsy with follow-up surgery. Patient underwent electrodessication and curettage surgery (EDC) followed by imiqumod treatment as she desired the least aggressive treatment. She also complained of a growth on her forearm at the initial visit. She reported after starting imiquimod, the lesion on her left hand has bled, drained and deepened in appearance. She also reported that the previous growth on her left forearm has grown in size and new lesions appeared on her upper arm and armpit. On exam, she had no healing at EDC site. She had developed an ulcer that exceeded the size of the original EDC. She had multiple erythematous, tender nodules of varying sizes on her left arm in a sporotrichoid lymphocutaneous pattern. She had left axillary lymphadenopathy. A biopsy performed of one of the nodules showed CSCC with intravascular and perineural invasion. Tissue cultures were negative for acid-fast bacilli, aerobic bacteria, mycobacteria and fungus. Chest X-ray did not show evidence of metastatic CSCC. Conclusion: This case highlights a rare presentation of sporotrichoid lymphocutaneous spread secondary to CSCC. The differential diagnosis included infectious causes and metastatic CSCC. Surgical excision is the treatment of choice for high-risk CSCC. She presented with signs of metastasis at initial presentation but these were not recognized. At follow up, she rapidly developed signs of metastasis in an unusual pattern. As malignancy is a rare cause of sporotrichoid lymphocutaneous spread, it is important to raise awareness to physicians who may see sporotrichoid pattern to consider the possibility of malignancy in their differential diagnosis, especially when there is a history of malignancy or there is a concomitant visible mass present.Item Perceived Fatigue May Be an Overlooked Barrier to Successful Therapeutic Lifestyle Change(2019-03-05) Hamby, Tyler; Jarvis, Todd; Wilson, Don; Hamilton, Luke; Bopp, BenPurpose Children and adolescents at-risk of developing premature cardiovascular disease (CVD) due to genetic disorders and acquired conditions, such as obesity and insulin resistance, are often referred to a pediatric lipid clinic. While adoption of a lifelong, heart-hearty lifestyle is encouraged, those with genetic disorders may benefit from lipid-lowering medications. Recommendations for therapeutic lifestyle change in those who are obese, especially the need for less sedentary time and 30-60 min/d of moderate-to-vigorous physical activity, may be hindered by a perception of fatigue. An increased perception of fatigue in obese youth vs healthy controls has previously been reported in those referred to an obesity clinic. The purpose of this study was to examine perceived fatigue in a sample of obese youth (age; BMI ³95th percentile) with acquired CVD risk factors, who were referred to a pediatric lipid clinic. METHODS This study was a retrospective chart review of 237 youth referred to the Risk Evaluation to Achieve Cardiovascular Health (REACH) clinic at Cook Children’s Medical Center between January 1, 2014 and August 31, 2018. During the initial clinic visit, each subject and the child’s parent independently completed the PedsQL Multidimensional Fatigue Scale, a validated survey with 18 items divided into 3 subscales – General, Sleep/Rest, and Cognitive – each containing 6 questions. A total score was computed, the range of possible scores ranging from 0 to 100 for each subscale. Higher scores indicate less perception of fatigue. A t-test was used to compare study subjects to previously reported obese youth (N=43) referred to an obesity clinic and normal weight, healthy controls (N=157). A p-value RESULTS The study population consisted of 200 subjects, 50.5% of whom were morbidly obese (³99th percentile). Study subjects had statistically significantly more perception of fatigue for each sub- and total scale for both self- and parent-reported scales (p CONCLUSION Obese youth with and without reported acquired CVD risk-factors experience greater perceived fatigue than healthy controls. It is important to consider barriers to implementation, such as perception of fatigue, when recommending lifestyle modification.Item Predictors of Mortality Following Traumatic Cardiopulmonary Resuscitation in Pediatric Patients(2019-03-05) Hamner, Chad MD; Hamza, AyahBackground: Pediatric trauma patients developing pre-hospital cardiac arrest have a dismal prognosis; few survive, often with severe neurologic deficits. Withholding or terminating cardiopulmonary resuscitation (CPR) for an injured child can be very difficult. Therefore, injured children may be subjected to protracted, futile CPR attempts which may consume vital resources beneficial to other patients with survivable injuries. This study was conducted to better define mortality in pediatric trauma patients receiving CPR and identify predictors of mortality that may guide decisions to withhold or terminate CPR in injured children. Methods: Pediatric (≤18 years) trauma patients who presented to Cook Children’s Medical Center from Jan. 2006 – Dec. 2017 and received CPR in the pre-hospital or emergency room setting were included: 88 patients met these criteria. Variables studied included the total time of CPR performance (≥15 vs. minutes), type of underlying cardiac rhythm (possibly perfusing vs. non-perfusing), the best recorded Glascow Coma Score (GCS; =3 vs [greater than] 3), and pupil reactivity (reactive vs. not reactive) present during the course of CPR. Fisher’s exact test was used to determine whether these variables were associated with survival. A p-value Results: Mortality in the 88 patients was 92%. Six of the 7 survivors had moderate (n=4) to severe (n=2) disability. Median total CPR time in the survivors was 5 minutes; only 2 surviving patients had CPR ≥15 minutes. The only survivor with no neurologic sequelae suffered a drowning event and had pre-hospital CPR for 5 minutes. Mortality following CPR performed only in the pre-hospital setting was associated with non-perfusing rhythm (p=0.001), GCS=3 (p=0.034), and CPR ≥15 minutes (p=0.022); pupil reactivity was not statistically associated with mortality. When CPR was performed in either the prehospital or emergency department setting, nonreactive pupils also were associated with mortality (p=0.003). There were no survivors who had CPR ≥15 minutes and a non-perfusing rhythm during the entire period of CPR. Conclusion: The results support withholding or terminating resuscitation in pediatric trauma patients who have received longer than 15 minutes of CPR during which time they had a non-perfusing rhythm, either PEA or asystole, and no evidence of neurologic function (GCS=3).Item Three-Dimensional Comparison of Fibular Motion After Syndesmosis Fixation Using Combined Suture-Button and Internal Brace Constructs(2019-03-05) Wood, Addison; Seyed, Arshad; Stewart, Donald; kim, hannahPurpose The purpose of this study was to evaluate the ability of an internal brace to add sagittal plane translational and transverse plane rotational constraint to suture-button constructs with syndesmosis injuries. Methods 11 Fresh frozen cadaver ankles were stressed in external rotation using a custom-made ankle rig. Each ankle had simultaneous recording of ultrasound video, 6 DOF kinematics of fibula and tibia, and torque as the ankle was stressed by an examiner. The ankles were tested in 6 different states: 1. Native uninjured 2. Injured with IOL and AITFL sectioned 3. 1x Suture-button 4. 2x Suture-buttons, divergent 5. 1x Internal Brace with 2x Suture-buttons, divergent 6. 1x Internal Brace with 1x Suture-buttons Results Only the internal brace + 2x suture-buttons and internal brace + 1x suture-button constructs were found to be significantly different than the injured state (P=.0003, P=.002) with mean external rotation of the fibula. Conclusion Overall, the most important finding of this study was the addition of an internal brace to suture-button constructs provided a mechanism to increase external rotational constraint of the fibula. This study provides a mechanistic understanding of how the combined suture-button and internal brace construct provides an anatomically similar reconstruction of constraints found in the native ankle. However, none of the constructs examined in this study were able to fully restore physiologic motion.Item A Case of Symptomatic Angiomyolipoma(2019-03-05) Young, Todd; Eskildsen, DaneBackground: Renal angiomyolipoma (AML) are benign soft tissue neoplasms classically composed of blood vessels, smooth muscle cells and adipocytes. These masses are found in .3 to 2.1% of the population and can be strongly associated with genetic syndromes such as the Tuberous Sclerosis Complex. While most of these masses are found incidentally, they can, in rare cases, become symptomatic. Patients with symptomatic AML most commonly present with hematuria, flank pain and renal hemorrhage. Case Presentations: A.H. is a 51-year-old obese female who presented 7 months ago to the emergency department with sudden onset left upper quadrant pain, nausea and emesis. On admission, her hemoglobin was found to be 9.1. Due to continued anemia she was transfused with 2 units of blood. CT scan of the abdomen and pelvis showed massive hemorrhage in the retroperitoneum surrounding the left kidney and a focus of fatty tissue likely representing a large AML. After Urological consult, left renal pole artery embolization was performed by interventional radiology. Over the next several months, after resolution of the hemorrhage, subsequent scans found that the symptomatic mass measured 4 cm and another 1.2 cm AML was found in the ipsilateral kidney. 6 months’ post presentation it was determined that, due to size and history of hemorrhage that the patient would undergo a radical left nephrectomy. Upon surgical exploration of the abdomen the tissue around the kidney was found to still be incredibly inflamed and thick. Despite this, the surgery proceeded without complications. Conclusion: Classic AML are the only benign renal masses that can confidently be diagnosed using imaging. As such, confirmed asymptomatic AML are often left untreated and actively observed over time. The consensus in literature indicates a size 4 cm as the cutoff for when AML are suspicious for symptomatic manifestation. Indeed, the risk of significant symptoms directly increases with size of the mass. This same 4cm size cutoff is used as a guideline for when treatment is warranted. Modern first line treatment includes embolization, with partial or radical nephrectomy coming into play when embolization fails to control symptoms or with excessively large masses. In this case, although embolization initially controlled the bleeding, patient comorbidities and tumor size warranted definitive removal of the mass.Item Social Media Use by Medical Students: A Review(2019-03-05) Lu, Vinh; Patel, Vishal; Mire, Emily; Browne, TheodoraPurpose: Online social media platforms have become ubiquitous communication tools that allow for the nearly instantaneous distribution of information to a massive, broad audience. Within the general population of US millennials (individuals born between 1981-2000), 89.8% accessed social networking services in 2018. Notably, the proportion of medical students who accessed social media has been reported to be above 93%, even as early as 2011. This study aimed to determine whether potential risks or benefits have been identified within the literature regarding the use of social media by medical students. Methods: A PubMed search was conducted using the following search terms: “medical students,” “social media,” and “social networking.” One hundred and sixty-nine full-text articles in English were initially identified for further review. The articles were then grouped into three categories: professionalism, education, or mental health. Articles were excluded if the topic did not address one of the three aforementioned categories. Results: Out of the 169 originally identified articles, 106 articles were included for further review. The oldest study identified was from 2007 and the majority of examined works were published in 2015 or later. Articles pertaining to the described categories were then quantified as follows to show the proportional distribution of research dedicated to each domain: professionalism (n=46, 43.4%), education (n=48, 45.3%), and mental health (n=12,11.3%). Discussion: The lack of research regarding this subject reflects the need for further study to better learn how current online engagement might impact medical students and their lives as future medical professionals. In addition, upward trends of increasing use of social media among this demographic are predicted to continue in future years. As the usage of social of media has increased significantly since its inception, so too have the number of articles pertaining to professionalism and education. However, the growth of studies examining potential implications of social media on students’ mental health has been relatively stunted. This study was limited by the fact that articles were excluded from the review if the full-text version could not be accessed through the UNTHSC library, thus a broadened review is warranted. Future study should address whether this discrepancy is significant and therefore a potentially neglected target for research.