Auburn Research Day 2021

Via Research Recognition Day Fourth A nnua l

Feb. 19, 2021

Welcome

T he Edward Via College of Osteopathic Medicine (VCOM)-Auburn campus is hosting the fourth annual VCOM-Auburn Via Research Recognition Day. Via Research Recognition Day is a significant event for VCOM that supports the mission of the College to provide medical education and research that prepares globally-minded, community-focused physicians and improves the health of those most in need. Started in 2018, this annual event on the VCOM- Auburn campus provides a full day of activities focused on medical research. Via Research Recognition Day offers a forum for health professionals and scientists in academic institutions, teaching hospitals and practice sites to present and benefit from new research innovations and programs intended to improve the health of all humans. By attending the sessions with the speakers, participants have the opportunity to learn cutting edge information in the physiological bases of osteopathic manipulative therapy efficacy, new trends in physician-based research networks and how to develop innovative research projects with high impact for human health. Poster sessions allow participants to learn about the biomedical, clinical and educational research activities at VCOM-Auburn and its partner institutions.

Contents

Agenda �������������������������������������������������������������� 5 Keynote Speaker ���������������������������������������������� 7 Biomedical Research Abstracts 014 ��������������������������������������������������������������������15 027 ������������������������������������������������������������������ 21 028 ������������������������������������������������������������������ 22 030 & 031 �������������������������������������������������������� 24 032 ������������������������������������������������������������������ 25 034 ������������������������������������������������������������������ 26 036 ������������������������������������������������������������������ 27 038 ������������������������������������������������������������������ 28 040 ������������������������������������������������������������������ 29 Clinical Case Report Abstracts 002 �������������������������������������������������������������������� 8 004 & 005 ���������������������������������������������������������� 9 009 �������������������������������������������������������������������12 012 ��������������������������������������������������������������������13 016 ��������������������������������������������������������������������16 019 ��������������������������������������������������������������������17 020 & 021 ���������������������������������������������������������18 022 & 023 ���������������������������������������������������������19 024 ������������������������������������������������������������������ 20 026 ������������������������������������������������������������������ 21 035 ������������������������������������������������������������������ 26

Clinical Research Abstracts 001 �������������������������������������������������������������������� 8 006 �������������������������������������������������������������������10 007 �������������������������������������������������������������������11 010 ��������������������������������������������������������������������12 011 ��������������������������������������������������������������������13 015 ���������������������������������������������������������������������15 017 ��������������������������������������������������������������������16 018 ��������������������������������������������������������������������17 025 ������������������������������������������������������������������ 20 029 ������������������������������������������������������������������ 23 037 ������������������������������������������������������������������ 27 039 ������������������������������������������������������������������ 28 Educational Research Abstracts 003 �������������������������������������������������������������������� 8 008 �������������������������������������������������������������������11 013 ��������������������������������������������������������������������14 033 ������������������������������������������������������������������ 25

Notes ���������������������������������������������������������������� 30

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Via Research Recognition Day Fourth A nnua l

Feb. 19, 2021

Agenda

8:00 – 11:00 a.m.

Student Poster Presentations

11:00 – 12:00 p.m.

Faculty Poster Presentations

12:00 – 12:15 p.m.

The State of Research at the Edward Via College of Osteopathic Medicine Plenary Lecturer – P. Gunnar Brolinson, DO, FAOASM, FAAFP, FACOFP

12:15 – 1:00 p.m.

Osteopathic Research: The Good, The Bad, and The Ugly Keynote Speaker – Kendi Hensel, DO, PhD, FAAO

1:00 p.m.

Poster Competition Awards, Closing Remarks and Adjournment

6

Keynote Speaker

Kendi Hensel, DO, PhD, FAAO Professor and Vice Chair Year 3 OMM Clerkship Director Lake Granbury ONMM Residency Program Director Department of Family Medicine and OMM Texas College of Osteopathic Medicine Immediate Past President, American Academy of Osteopathy

K endi Hensel received her DO from Oklahoma State University College of Osteopathic Medicine. After completing a traditional rotating internship in Oklahoma City, she moved to the University of New England in Biddeford, Maine, and was one of the first graduates from combined Family Practice and Neuromusculoskeletal Medicine residencies. A fter achieving board certification in both specialties, she returned to her native Texas in 2004 to join the faculty of the Texas College of Osteopathic Medicine (TCOM) at the University of North Texas Health Science Center. She has worked as an investigator and treatment provider on many clinical research studies on OMM. In 2006 she became the first DO to receive a K23 Mentored Patient- Oriented Research Career Development Award from the NIH-NCCIH. This project studied the effects of OMM on pregnant women. Dr. Hensel received her PhD in OMM Clinical Research and Education in 2009 from UNTHSC-Graduate School of Biomedical Sciences. She served as the 2019-2020 President of the American Academy of Osteopathy, and served six years as an Associate Editor of the Journal of the American Osteopathic Association. She is currently involved in clinical, educational and research activities at TCOM, and in national efforts to improve the evidence base and utilization of OMT in patient care. She currently represents the osteopathic profession as a member of the NIH-NCCIH Advisory Council. Her research interests center around mechanistic and clinical effectiveness studies of OMM.

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2021 Via Research Recognit ion Day

Cl i n i ca l Resea rch | Med i ca l St udent Longitudinal Seroconversion Analysis of Children Testing Positive for SARS-COV-2 an Observational Study

001

Lynch Major; Austin Clements; Dr. Rian Anglin; Dr. Danielle McCullough Edward Via College of Osteopathic Medicine-Auburn; Brookwood Baptist Health; Children’s Medical Group

SARS-CoV-2 is the novel virus that continues to infect thousands of people of all ages daily. Much research has been conducted in order to better understand the details of this infection, but most of this research pertains to adults with less focus on the pediatric population. Our study was done to further understand how this virus manifests in children and specifically the immune response to the infection. Using the Biohit SARS-CoV-2 IgM/IgG Antibody Test Kit, we assessed the antibody seroconversion results from 12 confirmed positive pediatric patients, with emphasis on the type of antibody (IgM and IgG) positivity over time. The subjects consisted of 12 antigen positive children who were reassessed for antibody seropositivity at one month after diagnosis, and six of the subjects were tested for antibodies again at three months following diagnosis. We found that at one month and three months, 81.8% with one

indeterminate and 66% respectively were positive for both IgM and IgG. Of the 12 patients, only two failed to produce antibodies at one month following illness, and two additional patients who were positive at one month had lost antibody positivity for both IgM and IgG at the three-month interval. In conclusion, the results of this study are consistent with other similar studies, which show seropositivity lasting on average four months after symptom onset, on average. This study had a shorter time frame than the four-month average, but we did find that the majority of our subjects remained seropositive three months post infection. We conclude based on our sample that seropositivity with IgM and IgG will be seen in a majority of pediatric patients at three months following SARS-CoV-2 infection.

Cl i n i ca l Case Repor t | Med i ca l St udent Rapid Progression of Nodular Bronchiectatic Mycobacterium Avium Complex After Pseudomonas Superinfection

002

Background: Nodular bronchiectatic Mycobacterium avium complex (NB-MAC) is a subtype of a rare disease. This disease is known to have an indolent course with old age, low BMI, comorbidities, anemia and cavitary lung disease being known risk factors for progression. This report serves to document the unique disease progression seen after a patient with stable NB-MAC developed an acute Pseudomonas superinfection. Case Presentation: An 81-year-old white female with chronic cough and shortness of breath was diagnosed with nodular bronchiectatic Mycobacterium avium complex in 2016. At the time of diagnosis, the patient’s BMI was 19 and she had a history of Rachel Rice Edward Via College of Osteopathic Medicine-Auburn

anemia, GERD, COPD and fibrocavitary lung disease. In spite of her numerous risk factors for progression and noncompliance with treatment, the next three years of follow up CT scans showed that her disease remained stable. In 2019, she was diagnosed with a Pseudomonas superinfection in her lungs and that was when the NB-MAC was noted to rapidly progress. Conclusions: This case demonstrated an adverse effect a Pseudomonas superinfection had on a patient that showed to be otherwise resistant to well known risk factors for NB-MAC progression.

Educa t i ona l Resea rch | Med i ca l St udent Implications and Significance of Mercury in Rice

003

James R. Palmieri; Tracee Guthrie; Gurleen Kaur; Erin Collins; Brooke Benjamin; Jessica Brunette; McAlister Council-Troche; Meghan L. Wilson; Susan Meacham; Beverly Rzigalinski Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA; Analytical Research Laboratory at the Virginia- Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA; Department of Biology and Biomedical Science, Bluefield College, Bluefield, Virginia, USA

Previous research on rice asserts certain heavy metals, like mercury, in the agricultural soils are incorporated into the rice plant. Mercury is considered to be the most toxic heavy metal. This study aims to investigate mercury levels in rice grown in the United States versus rice imported from Asia. In this study, 29 samples of rice were compared for mercury content (12 from Thailand, six from India, six from China, compared to five control samples from the

USA). Samples ranged from 0.18 to 6.01 ng of element / g. Further research is needed to establish standards for mercury toxicity. These standards are necessary, especially for breastfeeding mothers who are exposing their children to the mercury they might be consuming on a daily basis.

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Cl i n i ca l Case Repor t | Med i ca l St udent Association of COVID-19 with Spontaneous Pneumomediastinum

004

Spontaneous Pneumomediastinum is a rare complication of COVID-19. A study conducted in Guiyang, China concluded that 7.14% of their patients with COVID-19 pneumonia developed a spontaneous pneumomediastinum. In another study with 976 COVID-19 patients, it was found that there were five cases of spontaneous pneumomediastinum and two cases of a spontaneous pneumothorax. This case can help support the development in the understanding of the association between COVID-19 and spontaneous pneumomediastinum. A 55-year-old male with PMHx of T2DM, anxiety, prior DVT was admitted to the hospital for acute hypoxic respiratory failure due to COVID-19 pneumonia. He had tested positive for COVID three days prior to the hospital admission. The patient’s hospital course was complicated by increasing oxygen demands, which was managed with Bi-PAP. His WBC increased overnight and repeat CXR showed worsening of the bilateral lower lobe opacities, indicating worsening of his pneumonia. After ten days Mary Klacik OMS III; Ankit Tzivion, MD; Kashyap Patel, MD LewisGale Medical Center, Salem, VA

in the hospital a CT scan showed a pneumomediastinum. The patient was then taken off BiPAP and placed on high flow nasal cannula and non rebreather mask. His oxygen saturations were labile and the patient was transferred to the ICU and was intubated. Previous studies have suggested that there is an association with SARS- CoV-2 with an air leak as a complication in no relation to intubation or positive pressure ventilation. The CT findings of the patients with a spontaneous pneumomediastinum consisted of diffuse airspace disease with ground glass opacities. This patient’s spontaneous pneumomediastinum can be explained by the association between COVID-19 leading to an acute lung injury and eventually a spontaneous air leak. It is suggested that peribronchiolar abscess formation probably leads to interstitial pulmonary emphysema, which tracks along the bronchovascular sheath and reaches the mediastinum. At that point the chest CT shows a spontaneous pneumomediastinum.

Cl i n i ca l Case Repor t | Med i ca l St udent Bilateral Isolated Choroidal Melanocytosis 005

Lauren Mason, MBA; John O. Mason III, MD University of Alabama-Birmingham, Department of Ophthalmology; Retina Consultants of Alabama

Background: Bilateral Isolated Choroidal Melanocytosis is a rare condition in which the patient presents with patches of melanocytic hyperpigmentation of the choroid but is otherwise asymptomatic. The case described here is particularly unique

because it examines both the youngest patient and only African American seen with bilateral isolated choroidal melanocytosis. We describe the case in further detail, as well as offer implications for management of the condition. *This case report was published in Retina Cases Brief Reports PMID: 26200387 Case Report: A 24-year-old African American female with no prior medical history and no visual complaints was referred for bilateral pigmentation of posterior pole. On examination, visual acuity was 20/30 bilaterally, and the patient had normal intraocular pressures. There was no vitiligo, uveitis, skin or sclera pigmentation, or systemic malignancy, and the anterior segment was normal. The right eye exhibited darkly pigmented lesions that were flat. The hyperpigmentation had feathered margins that measured roughly 8 clock hours. The left eye also exhibited darkly pigmented lesions that were flat. The hyperpigmentation in the left eye also had feathered margins but measured much smaller at just 3.5 clock hours. Wide field color photographs revealed bilateral choroidal pigmentation (Figure 1, Figure 2). The optical coherence tomography (OCT) (Figure 3, Figure 4) was remarkable for increased choroidal thickness with a normal inner and outer retina, while the B-scan ultrasonography was normal. In conclusion, we describe the youngest patient reported with bilateral isolated choroidal melanocytosis, as well as the first African American to have this diagnosis. We recommend longer follow up of our patient and the other four patients described in the literature, which will help elucidate the best term for this rare condition, as well as demonstrate whether these lesions can enlarge or have an increased risk of developing uveal melanoma.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

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2021 Via Research Recognit ion Day

Lauren Mason, MBA; Benjamin Roberts, MD University of Alabama-Birmingham, Department of Ophthalmology; Retina Consultants of Alabama; Tenwek Missions Hospital, Bomet, Kenya Cl i n i ca l Resea rch | Med i ca l St udent Treatment Outcomes and Following Compliance Rates of Kenyan Patients with Diabetic Macular Edema 006

Purpose: To assess the long-term visual outcomes and compliance rates of patients in rural Kenya with diabetic macular edema (DME) following treatment with focal grid laser and bevacizumab intravitreal injections. Methods: One hundred and fifty patient records were reviewed at Tenwek Mission Hospital in Bomet, Kenya having received laser treatment for DME from 2011 to 2016. Only 42/150 patients (55 eyes) returned for a minimum two month follow up care and were entered into the study. Of those 55 eyes, 31 eyes received bevacizumab intravitreal injections in conjunction with the focal laser treatment. Results: In the laser only group, mean pre op BVCA was 20/200, and mean post op BVCA was 20/80. In the laser only group, 12/55 (22%) patients received a second laser. In the combined laser and injection group, mean visual acuity went from pre-op 20/140 to post- op 20/200 over the course of treatment. In the combined laser and bevacizumab group, 20/31 (65%) eyes remained stable or improved over the course of treatment, and 11/31 (35%) eyes had worse vision. In the laser only group, 19/24 (79%) eyes had stable or improved vision over the course of treatment, and 5/24 (21%) eyes had worse vision. Final BVCA was > 20/40 in 7/31 (23%) eyes in the combined laser and injection group, and 15/31 (48%) eyes in the laser only group. Of the 150 patients diagnosed with DME over a period of five years, 67% of patients (100/150) did not return for follow-up care.

Figure 1. Diabetic Macular Edema

Figure 2. Diabetic Macular Edema

Conclusion: The results of our study demonstrate the efficacy of focal laser treatment for populations in rural East Africa suffering from diabetic eye disease.1 We found that mean visual acuity improved in the population of patients who were treated with focal laser only, from 20/200 to 20/80. In the combined laser and injection group, overall mean visual acuity changed from 20/140 to 20/200 over the course of treatment, showing no statistically significant change. The poor compliance with follow-up demonstrates that patients in rural areas, such as East Africa, may not benefit from injection therapy. This evidence of improvement of visual acuity in the majority of patients in the laser only group bolsters the fact that laser is efficacious, laser is long lasting, and that laser is the better choice instead of short acting bevacizumab injections for this population of patients. The results of our study show that 67% of patients (100/150) did not return for follow-up care. Poor compliance rates seen in the literature and in this study verify that focal grid laser treatment upon presentation should be the treatment of choice in this area of the world where healthcare is sparse, many cannot afford treatment, and follow-up visits are poor. In the case of an area such as Kenya, a treatment plan can be modified to control a patient’s DME with a limited number of office visits, the most effective solution that matches this particular population’s socioeconomic status. **Previously accepted and presented as a poster presentation at the American Academy of Ophthalmology annual meeting

Table 1

Focal Laser Group (n=24)

Focal Laser + Bevacizumab Injections Group (n=31)

Mean pre-op VA 20/200

20/140 20/200

Mean post-op VA (one week)

20/80

Final VA ≥ 20/40 15/31 (48%) Final VA ≤ 20/200 5/24 (21%)

7/31 (23%)

11/31 (35%) 11.6 months (range 2-34)

Median follow-up time (months)

11.2 months (range 2-44)

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Cl i n i ca l Resea rch | Med i ca l Facu l t y Promoting Older Adult Fall Prevention Education and Awareness in a Community Setting: A Nurse-Led Intervention

007

Tiffani Chidume, DNP, RN, CCRN-k, CHSE Auburn University, School of Nursing

Background and Objectives: Falls are costly and one of the most expensive medical conditions to treat. The implementation of fall prevention toolkits (FPTs), such as fall risk screenings and fall prevention education (FPE), have become progressively important in reducing fall incidences. Nurses have a greater role and responsibility to care for the aging population. The purpose of this project was to implement a FPT to adults age 65 and older that attended mobile IPE community clinics. Research Design and Methods: This project used quantitative pretest-posttests and an open-ended participant feedback survey. The Missouri Alliance for Home Care 10-question survey and components of the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) FPE were used to assess and educate participants on fall risks and fall prevention. An initial baseline fall assessment and fall education score was obtained at the mobile IPE clinics. Follow-up assessments occurred one month after the initial assessment and compared to the initial fall assessment and fall education scores with an additional open-ended participant survey. Context: With the development of Osteopathic Core Competencies and Core Entrustable Professional Activities (EPAs), there has been a shift towards competency-based curriculum in osteopathic medical education. Descriptions of Competency Based Learning (CBL) and Competency Based Assessment (CBA) were provided to osteopathic medical students at the Edward Via College of Osteopathic Medicine, Auburn campus (VCOM-Auburn), which utilizes the traditional, randomized Osteopathic Manipulative Medicine (OMM) practical testing style, They were surveyed on their preference towards an OMM practical testing modality to determine how receptive students would be to curricular change. Objective: The study evaluated the learning and assessment preferences of first- and second-year osteopathic medical students (OMS I & OMS II) at VCOM-Auburn, regarding which OMM practical testing style was more conducive to learning OMM techniques. Methods: Participants, regardless of sex, age, race, or academic achievement, were recruited using class announcement and emails. A six-question anonymous and voluntary survey of OMS I & OMS II students was conducted via iClicker to evaluate perception and readiness for change in OMM curriculum and assessment formats. Yen-Chung Jonathan Wang; Miho Yoshida Edward Via College of Osteopathic Medicine-Auburn 008

Results: In both fall risk assessment tools, lower scores indicated a lower fall risk; both fall risk assessment tool mean scores decreased over the one-month period. Discussion and Implications: Future FPE implementation projects should consider providing needed resources the participants may need so there is no delay in increasing fall prevention and safety measures. The follow-up time period should also be increased to fortify FPE and keep participants engaged in fall prevention safety. Tables or Figures may be used in this box – but the text must be reduced so that the total abstract fits within this box.

Educa t i ona l Resea rch | Med i ca l St udent Medical Students' Perceptions on Changing Osteopathic Manipulative Medicine Lab Practical Assessment Styles

Results: Out of 308 students, 243 responded to the iClicker survey. Study results found OMS I and OMS II students demonstrated similar preferences in each question and that most students preferred the current traditional OMM practical testing style over competency-based testing. However, there is a significant difference in the proportion of student satisfaction and testing preference between OMS I and OMS II; satisfaction with the current practical setup decreased from 82% among OMS I students to 68% among OMS II students, x2(1)=5.114, p=0.024. Conclusion: Data suggests that OMS I and OMS II students at VCOM-Auburn are satisfied with the current traditional practical assessment with a significant decrease with the increase in seniority. Previous experience in traditional assessment may be a factor for students to favor this method. The willingness to utilize CBL as medical education progresses anticipates that students and residents with increased medical education experience acknowledge the importance of a more interactive and flexible curriculum in addition to the preference towards assessment based on competencies and milestones. Therefore, this shows implications for the upcoming changes with Single Accreditation System for Graduate Medical Education.

11 2021 Via Research Recognit ion Day

1 Raj H. Patel, MBA; 2 Pablo M. Pella, MD; 3 Naeem Haider, MD; 2 Renato Blanco, MD 1 Edward Via College of Osteopathic Medicine, Monroe, LA, USA; 2 Memorial Hospital, Jacksonville, FL, USA; 3 Baptist Medical Center, Jacksonville, FL, USA Cl i n i ca l Case Repor t | Med i ca l St udent Treatment of Severe SARS-COV-2 Infection with Remdesivir in a Patient with End Stage Renal Disease 009

As research regarding coronavirus disease 2019 continues to evolve, there is a paucity of reports describing the management of COVID-19 in patients with acute kidney failure and end-stage renal disease (ESRD). These patients have increased susceptibility to developing severe clinical symptoms from SARS-CoV-2 infection due to their underlying comorbidities. Remdesivir has emerged as a promising antiviral drug against COVID-19. Unfortunately, data regarding the clinical benefits of remdesivir in patients with severe renal impairment is unavailable as they have been excluded from clinical trials due to the risk of sulfobutylether- β -cyclodextrin (SBECD) accumulation. We present the first case of a 47-year-old male with end-stage renal disease who was safely treated with remdesivir during hospitalization for acute respiratory distress syndrome and

respiratory failure arising from COVID-19. The patient’s worsening clinical progress led to the decision to use remdesivir, despite his eGFR being <15 ml/min per 1.73m2. The patient responded favorably to treatment but developed reversible hepatotoxicity after the five- day course of remdesivir was completed. We report the first instance of relatively safe use of remdesivir for COVID-19 treatment in the setting of end stage renal disease which led to a sequalae of severe clinical symptoms including ARDS.

Cl i n i ca l Resea rch | Med i ca l St udent Retrospective Review of Multitarget Stool DNA as a Screening Test for Colorectal Cancer

010

Thomas K. Kleinschmidt, MD; Austin Clements; Mark A. Parker, MD; Steven D. Scarcliff, MD Brookwood Baptist Health; Edward Via College of Osteopathic Medicine-Auburn

Objectives: To review the effectiveness of noninvasive multitarget stool DNA testing as a screening test for colorectal cancer. Methods: We performed a retrospective review of patients referred to two high-volume outpatient procedural centers for colonoscopy for positive Cologuard test. Positive findings for colorectal cancer based on pathologic findings and also advanced adenomas were recorded. Positive predictive value was assessed. Results: Of the 1,585 patients evaluated and referred for colonoscopy from January 1, 2018, to November 1, 2019, for ICD- 10 codes R19.5 (Other Fecal Abnormalities) and K92.1 (Melena), 84 were referred for a positive Cologuard test. Out of the 84, six were excluded based on family history of colon cancer in 1st degree relative or personal history of inflammatory bowel disease. Of the remaining 78 patients, one patient (1.3%) had colorectal cancer and five (6.4%) had advanced adenomas (>1cm size, high grade dysplasia or villous). Positive predictive value (PPV) for colorectal cancer was 1.3% and for precancerous lesions plus colorectal cancer was 7.7%. A total of 53 (68.0%) patients had either totally normal colonoscopy or hyperplastic polyps. Out of the 78 individuals in our study, 70 (89.7%) had normal findings, hyperplastic polyps, or non-advanced adenomas.

Conclusions: Multitarget stool DNA testing carries an unacceptably low positive predictive value to be utilized as a screening test for colorectal cancer. The study fails to detect both adenomas and colon cancer at a higher rate than screening colonoscopy in selected studies. The advantage of being noninvasive has been noted to increase colorectal cancer screening in otherwise non-compliant Medicare patients.

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Cl i n i ca l Resea rch | Med i ca l St udent Intraoperative Pain Management in Spinal Tumor Ablations Improves Postoperative Recovery

011

Caroline G. Pupke; Sara Wallace; Nathan J. Neufeld, DO Edward Via College of Osteopathic Medicine-Auburn; Cancer Treatment Centers of America

Objectives: Postoperative pain is a significant adverse outcome reported by patients following surgical procedures. Multimodal analgesia is currently recommended for effective postoperative pain control and has been shown to decrease the requirement for postoperative analgesics. This study examines the administration of multiple different analgesics intraoperatively during a vertebral augmentation with radiofrequency ablation and how these analgesics affect pain medication consumption postoperatively, as well as length of stay in the postoperative anesthesia care unit (PACU). Design: The study included 28 patients undergoing vertebral augmentation with radiofrequency ablation. Of these patients, 13 patients were administered 8mg of Decadron, 1g of IV Tylenol, 30mg of Toradol, and 1g of Robaxin intraoperatively. The remainder of the patients were not given the complete medication regimen due to various contraindications. Patients who were not given the medication regimen intraoperatively were considered our control group. The patients were monitored postoperatively in the PACU.

Pain medication consumption, as well as length of stay in the PACU were recorded by PACU nurses. Results: 81% of the patients that didn’t need additional pain medication in the PACU were given the full 4-drug medication regimen intraoperatively. 68% of the patients who stayed less than an hour in the PACU were administered all 4 medications intraoperatively. All 13 patients that received the 4-drug medication regimen intraoperatively stayed in the PACU less than an hour and did not need to be administered additional pain medication in the PACU. Conclusions: From this study, we concluded that administering our 4-drug regimen intraoperatively during a vertebral augmentation with radiofrequency ablation reduces consumption of pain medication postoperatively and decreases PACU recovery time. Decreasing the need for additional pain medications postoperatively can decrease the risk of side effects and drug interactions, especially in cancer patients taking multiple classes of drugs.

Cl i n i ca l Case Repor t | Med i ca l St udent Radiofrequency Ablation and Vertebroplasty of Cervical Metastatic Lesion: A Novel Anterior Approach

012

Subtitle: Introduction: The case of a 63-year-old male with lymphoma and an anterior C7 metastatic lesion treated in a novel fashion using the combination of radiofrequency ablation and cement vertebroplasty using an anterior cervical approach is reported. The patient was considered for this treatment after failing narcotics management for pain. The typical approach for bone tumor ablation in the vertebral bodies is done bi-pedicular and posteriorly. However, in the cervical spine the pedicles are very small, and the vertebral artery runs through the transverse processes causing increased risk and difficulty with a posterior approach. Therefore, with the help of neurosurgery we decided to attempt an anterior neck open vertebral access to ablate the tumor. Methods: Computed tomography and positron emission tomography scans of the cervical spine revealed metastasis to the body of the C7 vertebra. Pre-procedural pain was rated as 7/10. The access to the anterior surface of the C7 vertebra was accomplished by making an initial incision of the anterior cervical area and dissecting down through the soft tissue. The platysma muscle was then opened in a superior-to-inferior fashion. The prevertebral soft tissue was then dissected in routine fashion exposing the anterior spinal anatomy. The longus coli muscles were dissected off the vertebral body and a retractor was placed for exposure. The area Nathan J. Neufeld, DO; J. Blair Davis, OMS-III; Said Elshihabi, MD Cancer Treatment Centers of America

of the tumor was approximately 7mm x 5mm in the anterior inferior left corner of the C7 vertebra. After seating of the trocar in the periosteum, a measurement drill was used to prepare a canal for the ablation probe. Radiofrequency ablation was performed using a bipolar single needle with a temperature setting of 80 degrees Celsius for six minutes. A cement vertebroplasty was then performed without complications. Results: After completion of the procedure, the patient’s pain was completely resolved and rated as 0/10. Computed tomography and positron emission tomography scans taken four months after the procedure demonstrated complete resolution of the lesion. Conclusion: For the cervical spine where vertebral metastasis is painful, and anterior open approach for vertebral augmentation with bone tumor ablation can be performed is safe and possible to reduce symptoms and tumor burden locally. However, further study would be advised to purse this technique in all circumstances.

13 2021 Via Research Recognit ion Day

Educa t i ona l Resea rch | Med i ca l St udent

Craving Conqueror Program 013

Saumya L. Karne; Jesse Giles; Annie Kirby, PhD, RD; Ning Chen, MS, PhD; Joshua C. Hollingsworth, PharmD, PhD Edward Via College of Osteopathic Medicine – Auburn Campus

The prevalence of obesity in the United States has increased to 42.4% [CDC Data Briefs No. 360]. In Alabama, the prevalence is 36.2% [Obesity Data Trends, Alabama Dept. of Public Health]. An individual’s eating pattern is directly associated with their risk for obesity [Heerman et. al. 2017, Forslund et. al. 2005]. One modifiable factor that significantly influences many individuals’ eating pattern is the character and frequency of food cravings that they experience. Frequent food cravings for highly processed foods is associated with overweight and obesity [Roefs et. al. 2019]. Food cues, which may be external (e.g., seeing or smelling food) or internal (e.g., thoughts of food or particular emotions) can prompt cravings. A recent meta-analysis found that food-cue reactivity and cravings account for 11% of variance in subsequent eating behavior and weight gain [Boswell and Kober 2016]. Programs are needed that help motivated individuals with strong food cravings to gradually improve their eating patterns and effectively deal with cravings in the process. Our aim is to create such a program, which we are calling the Craving Conqueror, and assess its effectiveness using a quasi-experimental design. It will be a four-week interactive program that is delivered remotely online, via Zoom and email. Up to 50 participants will be recruited on a rolling basis, with 10 participants per class/cohort in the program. Participants will be taught a systematic approach to starting new healthy eating habits, stopping existing unhealthy eating habits and swapping unhealthy for healthy eating habits, using the Fogg Behavior Model and Tiny Habits ® Method [Fogg 2019]. To deal with food cravings, participants will be taught to “surf the urge,” an acceptance-based coping strategy in which the individual mindfully acknowledges the craving without judgement or attachment, recognizing that the feeling will pass on its own [Bowel and Marlatt 2009, Lloyd 2003]. Alabamians 18–35 years of age with strong food

cravings, as measured by the Food Cravings Questionnaire-Trait- Reduced (FCQ-T-R) [Lloyd 2003], will be recruited as participants. Change in FCQ-T-R scores from baseline to program completion will serve as the primary outcome. This will also be assessed three- and six-months after program completion. Change in dietary intake of added sugar, saturated fat and sodium will be assessed at the same time points, using the Automated Self-Administered 24-Hour (ASA24 ® ) Dietary Assessment Tool [Meule et. al. 2014]. The ultimate aim is to develop this program into a scalable and sustainable dietary intervention that is part of VCOM’s efforts to combat the obesity epidemic.

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B i omed i ca l Resea rch | Med i ca l St udent How Well Do Older Women with Mild Cognitive Impairment Comply with Dietary Guidelines? 014

Kristyn Kraus, OMS-II; Jessica Barkhouse, OMS-I; Amal Kaddoumi, PhD; Annie Kirby, PhD, RD Edward Via College of Osteopathic Medicine – Auburn Campus

Cognitive decline is a multifaceted disease process, more often associated with aging, but also influenced by socioeconomic status, environmental factors, genetics and diet. Diet, being a modifiable risk factor, is an important step in preventing neurological disease. The Mediterranean diet has been associated with lower risks of developing degenerative neurologic diseases like Alzheimer’s. This diet is centered around plant-based foods, with moderate amounts of dairy, poultry, eggs and seafood, and little red meat. Implementation of similar whole food diets, or the use of the Dietary Guidelines for Americans (DGA), has been shown to increase cognitive functioning, combating one of the factors in neurological decline. The purpose of this project was to characterize the dietary quality of older females in Alabama with self-diagnosed mild cognitive impairment (MCI) and compare it to the DGA, 2020-2025. We hypothesize that the participant’s dietary pattern would not adhere to the DGA. This was a cross sectional study of female participants (n-17) between ages 55-75 who completed two dietary recalls, on non-consecutive days, using the Automated Self- Administered 24-Hour Dietary Assessment Tool (ASA24). Recalls were averaged, descriptive statistics were generated and one sample t tests were used to compare participant’s food and nutrient pattern to the DGA. All statistics were run in SPSS Statistics 27. Results indicate that participants consumed on average 1850 kcals daily, which falls within the DGA recommendations for daily energy intake of females 51+ years old (p=0.79). Their macronutrient breakdown

revealed that protein accounted for 16% of energy, carbohydrate for 41% of energy and fat for 43% of energy, which is indicative of the Standard American Diet (SAD) and outside of the DGA acceptable macronutrient distribution ratio for carbohydrate (45-65%) and fat (25-35%). Evaluation of macronutrients in grams revealed protein and carbohydrate intake were significantly higher than the recommended dietary allowance (RDA; p<0.001, p=0.002, respectively). Additionally, saturated fat intake was significantly above the DGA recommendation (p=0.01). Fiber intake was significantly lower than the national guidelines (p=0.007), while the essential fatty acids, linoleic acid and alpha-linolenic acid, were significantly higher than the RDA (p=0.004, p=0.002, respectively). Participants met the DGA recommendation to consume <300 mg/d of cholesterol by averaging 227 mg/day (p=0.02). Additionally, participants met the recommendation for grain intake, yet did so by exceeding the recommendation for refined grain (p<0.001) and falling short of the recommendation for whole grain (p<0.001). Participants also did not consume enough vegetables (p=0.006), seafood (p<0.001), or dairy (p<0.001). Conclusively, older females with self-reported MCI from Alabama were not adherent to many of the recommendations in DGA, with overall excessive total fat, saturated fat and refined grain intake, and limited fiber, vegetable, seafood and dairy intake.

Mayra Rodriguez, PhD, MPH; Ning Cheng, PhD; Heidi Kluess, PhD; Ann Lambert, DNP, MSN; David Stephen, DO; Mary Ann Taylor, PhD; Rian Anglin, MD; Theresa McCann, PhD, MPH Edward Via College of Osteopathic Medicine-Auburn, Virginia; Auburn University, School of Kinesiology and School of Nursing Cl i n i ca l Resea rch | Med i ca l Facu l t y Mom Stress and Child Health (Medal) Study: A Mixed-Methods Approach to the Associations Between Maternal Experiences and Child Toxic Stress Response in Black/African-American Families: Study Protocol 015

Persons who experience chronic stress experiences early in life may have significant health inequities across the life course, including increased mortality. The MEDAL Study aims to better understanding of the dynamics between a mother and young child residing in rural counties in Alabama. With the current social climate, our intent is to explore how Black/African-American families are navigating the COVID-19 pandemic and racism/discrimination. The purpose of the study is to promote the understanding of the relationship between environmental stressors and the physiologic impact it has on the mother’s mental health and that of her child. This exploratory mixed-methods study intends to measure the relationship between a mother’s reported experiences and child indicators of stress in

dyads living in rural Alabama. The MEDAL Study will recruit 125 Black/African American mother + child dyads from two pediatric clinics located in Tallapoosa and Coosa counties in Alabama. We expect to find increased stress levels between mother and child from hair cortisol, salivary C reactive protein and blood pressures. We anticipate that children may demonstrate increased levels of stress, perhaps absorbing some of what they experience in their environment. We may also learn more about the strength between mother and child and how it grows during periods of stress. We hope to have a follow up of this cohort in the following year to determine a longitudinal comparison of their stress level scores.

15 2021 Via Research Recognit ion Day

Cl i n i ca l Case Repor t | Med i ca l St udent Transesophageal Echocardiography is a Vital Tool in the Assessment and Management of Valvular Atrial Fibrillation Prior to a Planned Cardioversion Regardless of the CHA2DS2-VASc Score

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Ghassan Dalati; James Healy; Charles Bergdolt; Kimberly Hernandez; Wisam Dalati Medical Center Enterprise, Enterprise, AL

Rheumatic heart disease is the most common cause of mitral stenosis (MS) worldwide. Patients with rheumatic heart disease have a high risk of developing MS and, subsequently, valvular AF. Once the mitral valve begins to stenose, cardiac remodeling begins to take place with elevated left atrial and pulmonary venous pressures and left atrial enlargement being common findings. These anatomical and hemodynamic changes significantly predispose patients to development of AF and subsequent thrombus formation. The prevalence of AF in patients with rheumatic mitral stenosis is 70% which is why close monitoring of these patients with regular scheduled clinic visits is recommended. CHA2DS2-VASc score is an important and a valid tool to determine the risk of embolization in AF patients; however, it should not be the main factor when determining the safety of restoring the normal sinus rhythm via an electrical or

chemical cardioversion. Left atrial thrombi can be best visualized with a transesophageal echocardiography (TEE) especially when a more urgent pre-cardioversion assessment (as opposed to 3-4 weeks of anticoagulation) is warranted. Extremely large intracardiac thrombi pose a risk for fragmentation and systemic embolization with thrombolytic usage and, therefore, require clinical judgement for the appropriate management. Surgery is a viable option for thrombus removal when the risk of fragmentation with thrombolytic administration is considered too high. In this paper, we will be discussing a case report of a 49-year-old Korean gentleman with a history of rheumatic mitral stenosis and new-onset atrial fibrillation who developed several large thrombi in his left atrium which were surgically removed via a median sternotomy approach.

Nikki Lauderback, OMS-II; Ahmad Abukhader, OMS-III; Bari Elfenbein, OMS-III; Zachary Holley, OMS-III; Kaelin Young, PhD; Siraj Abdullah, DO; Danielle Wadsworth, PhD; Joshua Hollingsworth, PharmD, PhD Edward Via College of Osteopathic Medicine - Auburn, AL; Auburn University School of Kinesiology - Auburn, AL Cl i n i ca l Resea rch | Med i ca l St udent Minute Calisthenics: A Randomized Trial with a Delayed-Start Control of a Daily, Habit-Based, Bodyweight Resistance Training Program 017

Background: Resistance-training (RT) provides significant health benefits. However, roughly 3/4 of U.S. adults do not meet current RT guideline recommendations. Studies are needed that assess the effectiveness of RT programs that are time-efficient and simple to perform. Methods: Untrained osteopathic medical students and college/ university “office workers” were recruited and randomized (1:1) to a delayed-start control group or an intervention group. The control group was instructed to refrain from any RT during Phase I (baseline to midpoint), while the intervention group was instructed to perform push-ups, angled-rows, and air squats every weekday. In Phase II (midpoint to final), the control group was instructed to start performing the daily workouts, and the intervention group was instructed to continue performing the workouts. Before the intervention, both groups received equipment and training needed to safely perform the exercises and were taught the Tiny Habits ® Method and received digital coaching via email to promote consistency and habit formation regarding the exercises. The outcome of interest was the change in composite repetitions (push- ups + angled-rows + squats) under a standardized protocol (i.e., the strength assessment) over time (baseline vs. midpoint vs. final) in the intervention group as compared to the control group. Phases I and II were set at 12 weeks (84 days) and other in-person measures (blood pressure, hemoglobin A1c, blood lipids, body composition, muscle thickness) were included, under the original protocol.

Results: A total of 47 participants were recruited. Baseline characteristics did not differ significantly between the control group (n=22; 14 females; 29.5±9.8 years of age) and intervention group (n=25; 17 females; 34.8±12.4 years of age). Due to the COVID-19 pandemic, in-person follow-up could not be completed as planned. In order to collect composite repetitions from as many participants as possible, the decision was made to forgo all in- person measures and to conduct the midpoint and final strength assessments remotely via Zoom. Midpoint strength assessments were performed 243±4.9 days (~35 weeks) after baseline, and final strength assessments were performed 86.3±3.5 days (~12 weeks) after midpoint assessment for 30/47 (64%) participants. Intervention group composite repetitions increased significantly from baseline to final (56±26 vs. 69±28, p=0.03) and from midpoint to final (64±26 vs. 69±28, p=0.03), with no significant difference between baseline and midpoint (56±26 vs. 64±26, p=0.12). Composite repetitions in the control group showed no significant change from baseline to midpoint (56±27 vs. 53±25), before starting the intervention, and increased significantly from midpoint to final (53±25 vs. 65±25, p=0.006) after 12 weeks of the intervention. Discussion: This study suggests that a simple, habit-based RT intervention consisting of brief, but daily, bodyweight exercises can significantly increase physical strength in untrained individuals. Future studies should assess the impact of such an RT program on other clinical health markers (e.g., hemoglobin A1c, blood lipids, blood pressure, body composition, muscle thickness) as was originally planned in this study.

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Zachary Holley, OMS-III; Ahmad Abukhader, OMS-III; Bari Elfenbein, OMS-III; Nikki Lauderback, OMS-II; Kaelin Young, PhD; Siraj Abdullah, DO; Danielle Wadsworth, PhD; Joshua Hollingsworth, PharmD, PhD Edward Via College of Osteopathic Medicine - Auburn, AL; Auburn University School of Kinesiology - Auburn, AL Cl i n i ca l Resea rch | Med i ca l St udent Minute Calisthenics: A Randomized Controlled Trial of a Daily, Habit- Based, Bodyweight Resistance Training Program 018

Background: Resistance-training (RT) provides significant health benefits. However, roughly 3/4 of US adults do not meet current RT guideline recommendations. Studies are needed that assess the effectiveness of RT programs that are time-efficient and simple to perform. Methods: Untrained osteopathic medical students and college/ university “office workers” were recruited and randomized (1:1) to a control group or an intervention group. The control group was instructed to refrain from any RT, while the intervention group was instructed to perform push-ups, angled-rows, and air squats every weekday during the intervention. The intervention group received equipment and training needed to safely perform the exercises. They were also taught the Tiny Habits ® Method (THM) and received digital coaching via email to promote consistency and habit formation regarding the exercises. The primary outcome of interest was the change in composite repetitions (push-ups + angled-rows + squats) under a standardized protocol (i.e., the strength assessment), from baseline to follow-up in the intervention group as compared to the control group. The intervention period was set at 12 weeks (84 days) and other in-person measures (blood pressure, hemoglobin A1c, blood lipids, body composition, muscle thickness) were included, under the original protocol.

Results: A total of 47 participants were recruited. Baseline characteristics did not differ significantly between the control group (n=22; 14 females; 29.5±9.8 years of age) and intervention group (n=25; 17 females; 34.8±12.4 years of age). Due to the COVID-19 pandemic, in-person follow-up could not be completed as planned. In order to collect primary outcome data from as many participants as possible, the decision was made to forgo all in-person measures and to conduct the follow-up strength assessment remotely via Zoom. Strength assessment data were collected 243±4.9 days (~35 weeks) from baseline for 39/47 (83%) participants. A 2x2 (group x time) repeated measures ANOVA was run to determine if there were differences between groups over time in composite repetitions. A significant group x time interaction was detected (p=0.004). After decomposing the model, the intervention group significantly increased composite repetitions (52±23 vs. 63±23 repetitions, p=0.006) over time, whereas the control group experienced no significant change (58±27 vs. 56±27, p=0.265). Discussion: This study indicates that a simple, habit-based RT intervention consisting of brief but daily bodyweight exercises can significantly increase physical strength in untrained individuals. Future studies should assess the impact of such an RT program on other clinical health markers (e.g., hemoglobin A1c, blood lipids, blood pressure, body composition, muscle thickness) as was originally planned in this study.

Cl i n i ca l Case Repor t | Med i ca l St udent Early Screening, Differentiation and Diagnosis of Medullary Thyroid Carcinoma to Prevent Metastasis and Improve Prognosis: A Case report

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Kashan Mahmood, MA, OMSII 1 , Neil Schaffner, MD 1,2 1. Edward Via College of Osteopathic Medicine – Auburn 2. East Alabama Medical Center

Medullary thyroid carcinoma (MTC) is a malignant neuroendocrine tumor that arises from the parafollicular cells of the thyroid. MTC can have variability in terms of cytologic appearance and therefore can be misdiagnosed as other cancers. Persistently elevated levels of calcitonin can indicate MTC. Furthermore, there is a strong association with MTC and patients with Multiple Endocrine Neoplasia (MEN) syndrome, particularly the 2A and 2B variants. Mutations in the rearranged during transfection (RET) proto- oncogene plays a role in the development of MTC. In this case, we report a 63-year-old female with a RET proto-oncogene mutation that presents with persistently elevated levels of calcitonin, despite undergoing thyroidectomy three years prior. The average age of

diagnosis and normal levels of preoperative calcitonin is 34. Since calcitonin levels remained elevated post-thyroidectomy, additional testing was needed. Computerized tomography (CT) confirmed MTC metastasis to the liver. The patient was started on a tyrosine kinase inhibitor (TKI) and is currently under close surveillance while being treated symptomatically. This case serves as an example for early screening, differentiation and diagnosis of medullary thyroid carcinoma to prevent metastasis and improve patient prognosis.

17 2021 Via Research Recognit ion Day