VCOM Research Day Program Book 2023

2023 Via Research Recognition Day

Welcome

Welcome to the eighteenth annual Edward Via College of Osteopathic Medicine Via Research Recognition Day on the VCOM-Virginia Campus. Each year, the 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. The 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 education-simulation research activities at VCOM-Virginia and its partner institutions.

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Agenda 7:30 am

Check In Desk Opens

8:00 - 10:30 am

Poster Viewing

10:30 am

Welcome and Opening Comments – James E. Mahaney, PhD, Associate Dean for Biomedical Affairs and Research, Edward Via College of Osteopathic Medicine – Virginia campus

10:35 -11:00 am

Plenary Lecture: The State of Research at VCOM

P. Gunnar Brolinson, DO, FAOASM, FAAFP, FACOFP Vice Provost for Research Edward Via College of Osteopathic Medicine

11:00-12:00 pm

Keynote Lecture: : “VCOM Research Recognition Day-Things I’ve Learned about Research”

Adrienne Kania, DO, FAAO, NMM/OMM Associate Professor of Clinical Medicine Osteopathic Manipulative Medicine & Division Chief of OMM Burwell College of Osteopathic Medicine

1 2:00 pm

Poster Competition Awards Ceremony

12:30 pm

Closing Remarks and Adjournment

*To go boxed lunches available after the closing remarks for those who registered for the event

ON THE COVER: Bridget Mellon-OMS-II

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RESEARCH

changes the world.

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Contents

Program Moderators. ................................................................................................................................................................6 Speakers Keynote Speaker......................................................................................................................................................................10 Abstracts Medical Resident Research - Clinical.....................................................................................................................................12

Medical Resident Research - Case Reports . ........................................................................................................................17

Medical Resident Research - Educational. ............................................................................................................................51

Faculty Research - Biomedical...............................................................................................................................................53

Student Research - Biomedical. .............................................................................................................................................56

Graduate Student Research - Biomedical..............................................................................................................................89

Undergraduate Student Research - Biomedical. .................................................................................................................105

Medical Student Research - Clinical.....................................................................................................................................112

Medical Student Research- Educational .............................................................................................................................120

Medical Student Research - Case Reports..........................................................................................................................128

Faculty Research - Educational............................................................................................................................................153

Medical Student Research - Public Health...........................................................................................................................154

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Program Moderators

Dixie Tooke-Rawlins, DO, FACOFP President and Provost Edward Via College of Osteopathic Medicine

VCOM International Medical Missions program that provides year round primary care clinics in Honduras, El Salvador and the Dominican Republic. She participates in annual outreach programs in Appalachia including remote community outreach programs by the college and has for many years served the uninsured and medically underserved with time committed to community service. Dr. Tooke-Rawlins is a graduate of Northeast Missouri State (now Truman State University) and the Kirksville College of Osteopathic Medicine with a Doctorate of Osteopathic Medicine degree. She completed her post-graduate work at Grandview Hospital in Dayton, Ohio and entered the field of Emergency Medicine for the first seven years of her early career. She returned to Kirksville where she entered the field of Family Medicine and became board certified in Family Medicine by the American Board of Osteopathic Family Practice.

Residency Director at Metropolitan Hospital in Grand Rapids, Michigan.

Dr. Dixie Tooke-Rawlins has served as the Administrative Officer principal to the founding of the Edward Via Virginia College of Osteopathic Medicine in 2001. As the founding Dean for VCOM, she led the College in the development of the curriculum, clinical site affiliations, budget and long range plan, and assisted in the design of the first educational and research facilities. She currently holds the position of President and Provost as well as the academic title of Professor in the Department of Family Medicine at VCOM. In 2011, Dr. Tooke-Rawlins again served as a founding Dean in the opening of the Carolina campus of VCOM in Spartanburg, South Carolina and again in 2015 in the opening of the Auburn Campus of VCOM in Auburn, Alabama. Prior to this appointment Dr. Tooke-Rawlins held the position of Interim Dean at Kirksville College of Osteopathic Medicine (KCOM) in Kirksville, Missouri. Past appointments include Associate Dean for Academic and Clinical Affairs at KCOM, Director of Osteopathic Medical Education and Program Director of the Osteopathic Family Practice Residency at St. Luke’s Hospital in Allentown, Pennsylvania, and Family Practice

She currently holds several appointments nationally and the state level including President of the Virginia College of Osteopathic Family Physicians, Governor appointee to the Virginia Council on Healthcare Reform and the Virginia Healthcare Workforce Development Authority. Dr. Tooke-Rawlins is a member of the Board of Governors of the American Association of Colleges of Osteopathic Medicine, and has served on the inspection teams for both osteopathic post-graduate training institutes and osteopathic family medical residencies. She is a board member of the American Osteopathic Foundation, and she has been a member of the American Osteopathic Association and the American College of Osteopathic Family Physicians for more than 20 years. Dr. Rawlins has focused her career on the interests of Osteopathic Medicine, Osteopathic Medical Education, Rural Health/Rural Medicine, Health Care Disparities, and Global Health. She was instrumental in the establishment of the

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Jan M. Willcox, DO, FACOFP Dean, Virginia Campus Edward Via College of Osteopathic Medicine

Dr. Willcox received her D.O. degree from the Kirksville College of Osteopathic Medicine in Kirksville, Missouri. She is board certified in Family Medicine and she completed her postgraduate training at the Osteopathic Hospital of Wichita in Wichita, Kansas. She has practiced in solo private practice in Jenks, Oklahoma and large multi-specialty medical practice settings in Phoenix, Arizona in Family Medicine for over 20 years. Dr. Willcox is a Distinguished Fellow of the American College of Osteopathic Family Physicians.

Physicians. She serves on the Board of Deans and as Chair on the International Collaborative Committee of the American Association of Colleges of Osteopathic Medicine (AACOM). She also serves on the Board of Trustees of the Osteopathic International Alliance (OIA), as well as the Board of Directors for the Virginia Osteopathic Medical Association (VOMA) and the Medical Society of Virginia (MSV). She was part of the Osteopathic Clinical Research Committee of the American College of Osteopathic Family Physicians. Dr. Willcox serves on the Bureau of International Osteopathic Medicine of the AOA. She also sits on the Board of Directors for the Southwest Virginia Area Health Education Center. Dr. Willcox was selected to serve the World Health Organization’s Academy in developing the framework for recognition of lifelong learning as well as establishing quality standards and credentialing. Also, as a preceptor, Dr. Willcox has accompanied Appalachian and international outreach experiences for VCOM.

Jan M. Willcox, D.O., is the Dean and Professor of Family Medicine for the Virginia Campus of the Edward Via College of Osteopathic Medicine. She joined VCOM in 2001 as the founding Associate Dean of Clinical Academic and Research Affairs and played an integral role in the development of VCOM’s curriculum and medical education programs. Dr. Willcox has previously served as the Regional Dean for Kirksville College of Osteopathic Medicine (KCOM) in Mesa, Arizona, now A.T. Still University. She also served as the Director of Medical Education for the KCOM Arizona osteopathic postgraduate programs and the Medical Director for the Physician Assistants program. Dr. Willcox has over 20 years of experience in higher education administration and graduate medical education boards. She was recognized as the Guardian of the Profession by the American Osteopathic Association (AOA) and, in 2020, as the Outstanding Female Leader of the American College of Osteopathic Family

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Program Moderator

James E. Mahaney, PhD Associate Dean of Biomedical Affairs & Research Edward Via College of Osteopathic Medicine

In 2008, Dr. Mahaney became the Associate Dean for Biomedical Affairs and Research and shifted his focus to managing the Biomedical Division for VCOM and promoting research for all research active faculty on the Virginia campus. He also works to create opportunities for increased medical student involvement in research and encourages student participation in a wide variety of settings and projects. Dr. Mahaney is an active member of the Biophysical Society and serves on the Cell Transport and Metabolism grant review group for the National American Heart Association. He also serves as a reviewer for the American Osteopathic Association Research Division. In 2004, he received the VCOM Biomedical Educator Award – Peer Choice, and the VCOM Biomedical Educator Award – Student Choice. In 2009 and again in 2014, Dr. Mahaney received the VCOM Golden Apple Award for Excellence in Teaching from the medical students. In 2012, Dr. Mahaney received the VCOM Golden Apple Award for Excellence in Teaching from the Post Baccalaureate class.

Mahaney combined the biophysical techniques of fluorescence spectroscopy and electron paramagnetic resonance spectroscopy with pre steady state and steady state enzyme kinetics methods. The goal was to correlate specific enzyme dynamic transitions with key steps in calcium transport processes related to cardiac muscle relaxation. Dr. Mahaney’s work at West Virginia University was carried out by four graduate students and twelve undergraduate research students, with the help of a full-time technician. His work was funded by an American Heart Association Established Investigator grant and an American Heart Association Grant-in-Aid, and Dr. Mahaney was a co-investigator on two separate NIH R01 awards. In 2003, Dr. Mahaney moved to Blacksburg, VA and served as the founding Discipline Chair for Biochemistry at VCOM. He continued his research work at VCOM with the help of two additional graduate students and eight undergraduate research students from Virginia Tech. He was also funded with new grants from the American Heart Association and an NIH R15 award.

Dr. Jim Mahaney is Professor and Chair of the Biomedical Sciences Department and serves as the Associate Dean for Biomedical Affairs and Research at the Edward Via College of Osteopathic Medicine–Virginia campus. He is also a Research Associate Professor in the Department of Biochemistry at Virginia Tech. Dr. Mahaney received his BS degree in Chemistry from Virginia Tech in 1984, and his PhD in Chemistry/ Biophysical Chemistry from the University of Virginia in 1989. He pursued post-doctoral research training in the Department of Biochemistry at the University of Minnesota Medical School in Minneapolis from 1989-1994. His first faculty appointment was as an Assistant Professor in the Department of Biochemistry at West Virginia University School of Medicine in 1994, and in 2001 he was granted tenure and was promoted to Associate Professor. During this time, Dr. Mahaney established his independent research program designed to elucidate the molecular mechanism of calcium transport regulation in the heart, focusing on age-based and disease-based changes in calcium transport and its regulation. For this work, Dr.

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Program Moderator

P. Gunnar Brolinson, DO, FAOASM, FAAFP, FACOFP Vice Provost for Research Edward Via College of Osteopathic Medicine

the journal Current Sports Medicine Reports. Dr. Brolinson is a frequent speaker at national sports medicine meetings and often teaches didactic laboratory sessions on the use of osteopathic manipulative therapy for athletic injuries. Dr. Brolinson is a contributing author in the latest edition of Foundations for Osteopathic Medicine and he has published several scholarly articles and book chapters in the area of sport and exercise medicine. His research interests have included exercise and immune function, exercise and bone mineral density, mild traumatic brain injury in sports, impact biomechanics, human factors in auto safety, sports performance and manipulation and other health and disease prevention related topics.

Prior to coming to Virginia, he was the co director of the Primary Care Sports Medicine Fellowship training program at The Toledo Hospital in Toledo, Ohio and Team Physician for University of Toledo. He has extensive experience in undergraduate and post-graduate medical education. Dr. Brolinson has served on the boards of the American Osteopathic Academy of Sports Medicine, the American Medical Society for Sports Medicine and the Midwest Chapter of the American College of Sports Medicine. He is a past president of the American Osteopathic Academy of Sports Medicine. Dr. Brolinson is a fellow of the American Osteopathic Academy of Sports Medicine, the American Academy of Family Practice and the American College of Osteopathic Family Practice. In 1997 he was named outstanding young physician in Ohio by the Ohio State Medical Association. He is a former associate editor for the Clinical Journal of Sports Medicine and a former member of the editorial board of the Physician and Sports Medicine. He is former section editor for Competitive Sports and Pain Management in

Dr. Brolinson is Vice Provost for Research, Professor of Family and Sports Medicine at the Edward Via College of Osteopathic Medicine and Team Physician for Virginia Polytechnic Institute and State University. He is an Adjunct Professor in the Department of Mechanical Engineering at Virginia Tech. He is the fellowship director emeritus of the Primary Care Sports Medicine Fellowship at VCOM and Virginia Tech. He is also a volunteer physician for the United States Olympic Committee and a team physician for the United States Ski Team and was head team physician for the Freestyle Ski Team at the 2006 Winter Olympic Games in Torino, Italy. He was also named to the medical staff for the 2010 Winter Olympic Games in Vancouver, BC and was medical director of the USOC performance services center. He obtained his undergraduate training from the University of Missouri at Columbia earning a degree in biology. A 1983 graduate of the Kirksville College of Osteopathic Medicine, Dr. Brolinson is board certified in family practice and holds a subspecialty certification in sports medicine.

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Keynote Speaker

Adrienne Kania, DO, FAAO

Associate Professor of Clinical Medicine, Osteopathic Manipulative Medicine & Division Chief of OMM Burrell College of Osteopathic Medicine

Colorado, and served for several years as a staff physician to military retirees and their families at the Air Force Academy and Peterson Air Force Base in Colorado. She earned her bachelor's degree from Oakland University in Rochester, Michigan, before attending the Michigan State University College of Osteopathic Medicine for her D.O. degree. Dr. Kania completed an internship and an internal medicine residency at Garden City Hospital in Garden City, Michigan, and is board certified in neuromuscular medicine /Osteopathic Manual Medicine. She has a certificate of proficiency in osteopathy in the cranial field from the Osteopathic Cranial Academy and she is a fellow if the American Academy of Osteopathy.

osteopathic research is currently focused on the physiologic response to the manipulative techniques that students learn in the first and second years of osteopathic medical school. In 2022, the faculty at the Burrell College of Osteopathic Medicine honored her with their Excellence in Research Award. In 2002, she was recognized as Physician of the Year by the Colorado Springs Osteopathic Foundation, for her work creating and executing a monthly lesson plan on osteopathic principles and practices for the family medicine residency program affiliated with the foundation. Dr. Kania’s clinical practice is extensive as well. She practiced internal medicine and osteopathic manipulative medicine at her own practice in Colorado Springs, was the medical director and staff physician at Hilltop Community Clinic and Nursing Home in Cripple Creek,

Dr. Adrienne Kania has more than 30 years of experience in the osteopathic profession, including teaching osteopathic manipulative medicine, GME and working as a preceptor for osteopathic medical students. She is currently division chief of OMM at the Burrell College of Osteopathic Medicine in Las Cruces, New Mexico, and teaches Osteopathic Practices, Principles and Techniques at the college. She has mentored many students in research projects through the Summer Medical Student Research program at Burrell, individually for case presentations and as participants of the A. Hollis Wolf Case Presentation Competition at the American Academy of Osteopathy (AAO) Convocation. She is also a regular presenter at the Burrell College of Osteopathic Medicine CME Conference. In addition to her teaching experience, she is also a skilled researcher. Her

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RESEARCH

breaks down barriers.

IN THE PHOTO: Taylor Wynne -OMS-II

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Medical Resident Research Cl inical

01 Ultrasound Assessment of OMT on Diaphragm Motion

Nicholas Snow, DO; Christian DeDi, OMS III; Stephanie Rathjen, OMS III; Albert J Kozar, DO, FAOASM, R-MSK; Luke Robinson, DO, DABMA Corresponding author: Nsnow01@vcom.edu

Edward Via College of Osteopathic Medicine-Virginia Campus; VCOM Sports & Osteopathic Medicine

diaphragm motion assessments were completed using multiple B-mode and M-mode US images. Measurements included static and dynamic grey scale (B-mode) morphologic diaphragm thickness, changes in superior diaphragm elevation distance during both tidal (resting) and maximal inhalation, and M-mode motion variation during both tidal (resting) breath and maximal inhalations. US images were obtained bilaterally and at both the zone of apposition and the dome of the diaphragm. Each subject underwent osteopathic screening exam utilizing the area of greatest restriction (AGR). No more than 3 regions with the greatest restrictions were treated with OMT. Then, an OMT protocol adapted from the Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) trial was used. Total time for OMT was limited to 15 minutes. Statistical analysis included sample mean and standard deviation for continuous measures, proportions to summarize categorical characteristics, and paired t-tests to measure changes in pre- and post-diaphragm measurements. Careful attention was paid to the normality assumption using a normal probability plot and adjusted with Wilcoxon

Rank Sum. Given the pilot nature of this study, we hope to demonstrate the feasibility of the methods and provide variance estimates to inform the statistical power calculation of a larger trial. Results: Data is pending but will be complete and analyzed fully for VCOM Research Day. Discussion/Conclusion: We expect a statistically significant increase in diaphragmatic motion after receipt of OMT. If the results are significant, we plan to extend the project to a prospective, randomized study in subjects with and without chronic pulmonary diseases.

Introduction/Background: Osteopathy has long sought to improve the overall health of an individual. As an essential function of life, thoracic respiratory efficiency is taught to be an important focus of Osteopathic Manual Therapy (OMT). Objective/Hypothesis: This prospective, observational pilot study aims to determine if and how much OMT can affect respiratory efficiency via changes in diaphragm motion based on ultrasound (US) measurements obtained before and after treatment. We hypothesize that OMT will increase diaphragmatic movement significantly, both at rest and with maximal effort. Methods: 10-20 “healthy” male & female volunteers were recruited. Inclusion criteria included subjects age 18-40 with at least 2 regions of somatic dysfunction on screening exam. Exclusion criteria included any chronic pain, neuromuscular, neurological, pulmonary, or sleep disorder; any prior abdominal, chest or spinal surgery; BMI>30; or current active infection. A pre-OMT and post-OMT

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Medical Resident Research Cl inical

03 Has Increased Alcohol Use During the COVID-19 Lockdown Resulted in Greater Incidence of Gastrointestinal Bleeds?

Toni Young, DO; Lauren Sprague, MD; Mufrad Zaman, MD; Samiullah Wagan, MD Corresponding author: Toni.young@hcahealthcare.com

HCA LewisGale Hospital Montgomery, Blacksburg, VA

Safety measures (i.e. social distancing and stay-at home orders) that were enforced to reduce the spread of COVID-19 have altered individuals' routines and social interactions leading to increased use of alcohol. Increased alcohol consumption has been linked to higher risks of gastrointestinal (GI) bleeds. The purpose of this study was to observe the incidence of GI bleeds and alcohol use from 2019 to 2020. The analyses compared the incidence of GI bleeds in all HCA Capital Division facilities between February and August 2020 with concurrent positive alcohol (EtOH) intake in patients 21 years or older to the incidence of GI bleeds between February and August of 2019. A total of 1,306 individuals 21 years of age or older with GI bleeds that had an EtOH test performed during their admission from the specified date ranges were included in the study. GI bleeds were defined as a patient with a diagnosis

of angiodysplasia of the stomach with hemorrhage, acute hemorrhagic gastritis, diverticular disease with hemorrhage, gastritis and duodenitis with hemorrhage, GI hemorrhage, hematemesis, melena/hematochezia, and peptic ulcer with hemorrhage. Unadjusted models demonstrated that the ratio of a positive EtOH test in patients with GI bleeds was significantly increased during 2020 when compared to 2019. The incidence of admissions for GI bleeds with a positive alcohol test was 2.517 times higher in 2020 than in 2019 (P-value < 0.05). The odds of a positive alcohol test in patients with GI bleeds adjusted for demographics (comorbidity, age, sex, BMI, race, NSAID use, steroid use, peptic ulcer disease, and tobacco use) was 2.532 times higher in 2020 than in 2019 (P-value < 0.05). These results suggested a trend of increased alcohol consumption during the COVID-19 lockdown. As GI bleeds can be a dangerous and potentially fatal

sequela of alcohol consumption, education regarding safer coping mechanisms during times of fewer social interactions and the risk of alcohol use should be an important facet of providers’ practice. Additionally, this information can be utilized by public health officials to consider methods for reducing excessive alcohol use if any long-term quarantines are needed in the future.

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Medical Resident Research Cl inical

04 Prevalence of Electric Scooter Injuries in Athletes at an NCAA Division I University: A Retrospective Review

Mohamed Shitia, DO; Annemarie Beran, OMS III; Rachael Larkin, OMS I; Mike Goforth, ATC; Mark Rogers, DO; Per Gunnar Brolinson, DO Corresponding author: mshitia01@vt.vcom.edu

Virginia Tech, Edward Via College of Osteopathic Medicine-Virginia Campus

injury between January 2020 and December 2022. Data gathered included each athlete’s sport, sex, date of injury, type and mechanism of injury, number of days lost from competition, location of injury, and helmet use or non-use. Results: A total of 22 electric scooter injuries were identified between 2020 and 2022, indicating a prevalence of 0.01% during this three-year period. Accident rates of 0.15, 1.35, and 1.82 per 100 athlete years were calculated for 2020, 2021, and 2022, respectively. Of note, there was significant underreporting of injury in 2020 due to a temporary closure of campus caused by the COVID-19 pandemic. Skin abrasion was by far the most common injury type, followed by bone contusion, tooth/lip injury, joint sprain, concussion, finger laceration, upper extremity fracture, and clavicle fracture, respectively. Six of 22 injured athletes (27.3%) lost time from competition due to injury. The average time lost in these six athletes was about 30.3 days, with a median of 20.5 days. Interestingly, 100% of injuries occurred on-campus and without the use of a helmet. Two athletes (9.1%) sustained a repeat electric scooter

injury and four athletes (18.2%) sustained injuries with two people riding a single scooter. Conclusion: Electric scooters continue to be a potential source of high-energy injuries in college athletes. Depending on the severity, injuries may leave athletes vulnerable to missing significant time from competition. As their use continues to grow, the prevalence of injuries will likely increase as well. Future research is necessary to better characterize electric scooter use trends with the goal of addressing rider safety, both in the general and college athletic population.

Introduction: Electric scooters are a rapidly growing means of convenient, short-distance transportation, particularly in metropolitan areas and college campuses. However, this emerging trend brings with it significant safety concerns. Between 2010 and 2019, there was an estimated 230% increase in scooter-related injury incidence. A review of the existing literature yields basic information regarding injury patterns of those in electric scooter accidents, primarily in the general population. However, there is sparse research evaluating scooter use and associated injury prevalence in college athletes, a significant user population of electric scooters. The primary objective of this study is to quantify the prevalence of electric scooter injuries in student athletes at an NCAA Division I university. Additionally, we aim to characterize the frequency of different types of injuries sustained and quantify the average amount of time lost from competition due to injury. Methods: A retrospective chart review utilizing two electronic medical records at an NCAA Division I university was performed with the goal of identifying student athletes who sustained an electric scooter

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Medical Resident Research Cl inical

05 Quantifying Osteopathic Palpatory Motion

Kristopher Schock, DO; Christopher Ciccone, OMS IV; Michael Mitkos, OMS III; David T. Redden, PhD; Hollis H. King, DO, PhD, FAAO, FCA; Albert Kozar, DO, FAOASM, R-MSK Corresponding author:kschock@vcom.edu

Edward Via College of Osteopathic Medicine-Virginia Campus; VCOM Sports and Osteopathic Medicine

6 series of 27 randomized events. The events entailed either a single expansion, contraction, or no motion and each series was within defined range of motion change (50-149, 150-249, 250-349, 350-449, 450 549, 550-649, 650-749, 750-849, 850-949, and 950-1050 micrometers). The randomization of the 27 events is via RAND function in excel of the order of motions or non-motions, with 25% being contractions, 25% expansions, and 50% being non-motions. The subject states a response of motion or no-motion, and if motion, states the motion direction if able (as in or out). The participant starts with the 450-549 micrometer range, and if they correctly determined ≥70% of the 27 events, the subject’s next series was moved down to the next smaller motion range. If <70% are correct, then the participant is given the next larger motion range. This study’s results have been added to the 2018 and 2020 accumulation of the same study information, with the new goal of being able to differentiate between non-trained, students, residents, and experienced practicing physicians. Results: New data is pending but will be complete and analyzed fully for VCOM-VA research day. Our

earlier pilot study noted human motion detection capacity can be in the tens of micrometers but for most people they’re palpatory sensitivity is limited to ~400µm. In the pilot, Osteopathic physicians and students tended to be better at palpating smaller movements than untrained individuals, though this was not statistically significant. Discussion/Conclusion: We have defined the SBMT in groups of non-trained individuals and trained Osteopaths. subject’s SBMT trends toward being inversely proportional to the number of years in training. Limitations to the study were previously sample size, and participant hobbies that could be affecting their maximal palpatory threshold.

Introduction/Background: Palpation is an integral and intuitive examination procedure of physicians and particularly osteopathic physicians in which the kinesthetic and tactile perceptual sensations are utilized. In the fields of manual medicine, the ability to feel small finite motions is necessary to both diagnose and treat somatic dysfunctions (SD). Few studies have evaluated the sensitivity threshold of human palpation for small dimensions of motion, despite the daily utilization of these skills by thousands of manual medicine providers worldwide. Objective/Hypothesis: To determine each subject’s smallest palpable motion threshold (SBMT) to the tens of micrometers, thereby defining the typical human threshold of detectable palpable motion change. We hypothesize that training would decrease an individual subject’s SBMT, thereby improving their palpation sensitivity to even smaller motions. Methods: We conducted a prospective, randomized controlled trial in which the subjects, blinded to visual and auditory stimuli, palpated a device containing a movement actuator that produced

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Medical Resident Research Cl inical

06 Relationship of Leukocytosis and Clostridium Difficile Colitis in Acute Care Setting

Sadia Iqbal; Autumn Jordan; Zachary Birch; Feras Ghosheh Corresponding author: Zachary.birch@hcahealthcare.com

HCA Lewisgale Hospital Montgomery-Blacksburg, VA

Clostridium Difficile is a prominent cause of nosocomial, antibiotic associated diarrhea, and pseudomembranous colitis. Several factors have been studied to potentially indicate a complicated course of Clostridium Difficile Infection. However, no study has linked leukocyte count alone as a predictor of diagnosis of C. difficile colitis. Using retrospective case-control data from HCA database, a total of over

35,000 patients were identified with enterocolitis, diarrhea, and leukocytosis. From these patients, logistic regression was used to predict the diagnosis of Clostridium Difficile infection (CDI) in patients with diarrhea. The mean WBC for case group (those with CDI) was 12.9 x 10 3 , whereas the control had a mean WBC of 9.27 3 . While the total number of patients diagnosed with CDI was low (171 patients), the AUC

value was 0.76 indicating a well-fitting model. Using the data, the optimal cut-off of WBC count of 11.36 x 10 3 was identified. This inference suggest that a person presenting with diarrhea and leukocytosis greater than 11.36 x 10 3 should be screened for CDI to allow for early diagnosis and treatment.

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Medical Resident Research Case Reports

01 A Rare Educational Case of Cutaneous Leukocytoclastic Vasculitis

Leukocytoclastic vasculitis (LCV) is a common form of small vessel vasculitis that involves inflammation of arterioles, capillaries, and postcapillary venules and is characterized on histopathological examination by neutrophilic inflammatory infiltrates, degeneration of neutrophilic nuclear contents (leukocytoclasis), fibrinoid necrosis, and damage to vessel walls. Cutaneous LCV (CLCV), also known as cutaneous small vessel vasculitis, describes LCV that is confined to the skin. CLCV affects males and females equally and can occur in patients of all ages. The hallmark clinical feature of CLCV is bilateral palpable purpura, especially on the lower extremities and buttocks. Most cases of idiopathic CLCV are self-limiting, but further workup needs to be performed if there are constitutional symptoms of fever, weight loss, night sweats, and malaise, which suggest systemic involvement. LCV is idiopathic in approximately half of all cases; infections and drugs are the most common triggers in the other half of cases. Streptococcus Shruthi Vijayalakshmi 1 , Shreyan A Patel 2 , and Admir Syla 1 Corresponding author: shruthi.vijayalakshmi@hcahealthcare.com 1 Internal Medicine, LewisGale Medical Center, Salem, VA 2 Edward Via College of Osteopathic Medicine-Virginia Campus

pyogenes is most commonly the culprit for post infectious LCV, but other infectious etiologies include Mycobacterium, Staphylococcus aureus, Chlamydia, Neisseria, and influenza. Chronic infections, such as hepatitis A/B and HIV, can also cause LCV. There are many drugs that have been associated with LCV including antibiotics, diuretics, allopurinol, NSAIDs, anticonvulsants, and amiodarone among others. Other less common causes of LCV include autoimmune disorders, malignancy, and, more recently, COVID-19 vaccines. Treatment for CLCV includes leg elevation, rest, compression stockings, and antihistamines for mild symptoms and a 4-6 week tapering dose of corticosteroids for moderate to severe symptoms. In rare cases, immunosuppressive agents may be needed. CLCV typically resolves over 3-4 weeks whereas the prognosis for systemic LCV is worse and depends on the severity of the organs involved. The most significant complications of LCV are skin ulcerations and subsequent secondary infections. Therefore,

prompt diagnosis and treatment are key to resolving symptoms and reducing morbidity from CLCV and systemic LCV. Here, we describe the case of a 23-year-old female who presented with palpable, erythematous papules on all her extremities and trunk. An extensive workup for infectious etiologies was performed. Serology testing was positive for HSV-2. A skin punch biopsy of her right lower extremity was performed, which confirmed LCV. However, immunoperoxidase staining of the biopsy sample for HSV was negative. She was started on oral prednisone for her idiopathic exanthem. She was discharged from the hospital two days later after improvement of her symptoms. She was tapered off prednisone over two weeks and did not have recurrence of CLCV.

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Medical Resident Research Case Reports

02 Multiple Myeloma (MM) in a Young Male Adult, a Rare Phenomenon: Single Case Presentation

David M. Johnson, DO, Crystal B. Lafleur, DO, Tanner Bazemore, BS, Heather Brooks, MD Corresponding author: David.johnson14@hcahealthcare.com

LewisGale Hospital Montgomery Internal Medicine Residency Program

stepping into a hole at work. Physical exam revealed mild mid-thoracic tenderness on palpation and was unremarkable for any neurological deficits. CT scans revealed multiple spinal lesions concerning for malignancy. MRI of the cervical and thoracic an infiltrative lesion at T5 with paraspinal soft tissue extension, and additional enhancing lesions at T10, T11, and involving the left fifth. MRI of the lumbar spine showed multiple round enhancing bone marrow lesions in the L4 vertebral body, sacrum, and visualized iliac bones consistent with diffuse osseous metastatic disease. CBC and CMP were within normal limits. Serum and urine protein electrophoresis with immunofixation and serum free light chain analysis was performed. These revealed a serum M-spike of 0.6 (units) and a free kappa/ lambda ratio 2.83 (units). CT-guided biopsy of the T5 bone lesion was performed and revealed plasma cell dyscrasia. Bone marrow biopsy and aspirate revealed plasma cell myeloma, kappa light chain restricted, however, most of the marrow did not show significant plasma cell infiltrate. The plasma cells accounted for about 10% of the overall cellularity. Flow cytometry detected only 0.8% monoclonal plasma

cells. FISH revealed monosomy 17 (along with other cytogenic abnormalities) which is associated with a poor prognosis. The presence of significant skeletal involvement without significant serum involvement suggested that this patient’s disease had characteristics more consistent with macrofocal MM compared to typical MM. Outcomes: Repeat CT scan four days after biopsy showed progressive collapse of the T5 vertebral body. Subsequently, a successful T5 corpectomy with posterior thoracic fixation/fusion from T2 to T8. The biopsy was positive for plasma cell myeloma with kappa light chain restricted. Based on the revised guidelines for staging MM due to the del(17p) deletion, but lack of elevated globulins the patient was classified as stage II. Patient was started on induction treatment with bortezomib, lenalidomide and dexamethasone. After 4 months of treatment, repeat PET/CT showed no evidence of bony lesions. Overall plan included collection of stem cells and proceeding to autologous stem cell transplant, but patient has unfortunately been inconsistent with follow-up.

Introduction: MM is a malignancy involving plasma cell proliferation in the bone marrow which can lead to displacement of other hematopoietic cell lines. Accumulation of proliferated plasma cells in extramedullary or axial skeleton locations can also lead to the development of plasmacytomas. Macrofocal MM is defined by the presence of bone lesions without diffuse bone marrow infiltration. It has been shown that patients diagnosed with MM at a young age are more likely to have a macrofocal MM subtype. The infrequency with which MM is found in patients under the age of 40 leads to intimidating diagnostic and management challenges especially when the patient does not have regular primary care. Early detection is critical to improved overall survival. If caught in an earlier stage overall survival rate at 5-years is 83% for those ≤ 40 years and 53% for those ≥ 40 years old. The 5-year survival rate decreases to 54% if caught in the later stage once the cancer has spread to distant parts of the body. Clinical Findings: A 36-year-old male presented with a five-month history of progressively worsening mid-upper back pain that started after

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Medical Resident Research Case Reports

02 Continued: Multiple Myeloma (MM) in a Young Male Adult, a Rare Phenomenon: Single Case Presentation

Conclusion: This case illustrates a young man presenting with back pain who was ultimately diagnosed with macrofocal MM. Both the low prevalence and absence of serum markers makes macrofocal MM difficult to diagnose early, even with regular follow-up with a primary care physician (PCP). If this patient had an established relationship with a PCP, he may have had diagnostic imaging sooner, which could have led to an earlier diagnosis and management plan. Although MM is a treatable disease, it is not curable. Long term survival is driven by multiple factors including disease characteristics, medical comorbidities, and the patient’s compliance of therapy.

Figure 1. Infiltrative enhancement lesion seen at T5 with paraspinal soft tissue extension.

Additional enhancing lesions at T10 and T11.

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Medical Resident Research Case Reports

03 External Iliac Artery Exercise Induced Vasospasm and Endofibrosis in a Female Athlete

Max Farenwald, DO; Thomas Conlee, MD; Briana Beach, DO Corresponding author: nmfarenwald@carilionclinic.org

Virginia Tech Carilion Clinic

External iliac artery exercise induced vasospasm and endofibrosis is a rare diagnosis with female athletes making up only 7% of all diagnosed cases. Following ABIs with significant changes after exercise, CTA of the external iliac artery is used to depict the anatomical structure of the vessel. Various anatomical anomalies have been described that predispose to claudication symptoms of the anterior thigh: tortuous vessel, arterial stenosis, iliopsoas hypertrophy, atherosclerotic disease, and/or endofibrosis. This case report details further evaluation and treatment following a CTA without obvious endofibrosis. A 40-year-old female triathlete presented with anterior thigh pain at the beginning of her workouts that worsened with uphill activity and was relieved shortly after rest. Patient complained of hip and quadriceps pain with weakness, loss of motion, stiffness, and radiation of pain down the anterior right leg. Initial workup showed a normal lipid profile, CBC, and CMP. MSK ultrasound showed no obvious changes to the quadriceps, IT band, TFL, or greater trochanteric bursa. Hip and lumbar plain films were

non-specific. Intra-articular right hip corticosteroid injection did not provide relief of symptoms. MRI showed no femoral avascular necrosis, fracture, or significant hip osteoarthritis with a right acetabular labral tear. CTA showed no definitive evidence of diffuse myointimal thickening to suggest endofibrosis and no hemodynamically significant stenosis. ABIs following exercise were positive for a significant drop in perfusion on the right. Conventional arteriography and intervention ultrasound was unrevealing to an expected iliac lesion. However, after 200mcg of nitroglycerin, spasm was appreciated in the right external iliac artery. Patient elected to have surgery. The external iliac artery was dissected and noted to have diffuse endofibrosis: 1cm distal to common iliac bifurcation to 1cm proximal to the inguinal ligament. External iliac artery interposition bypass with Dacron graft was performed. Patient has started her return to activity protocol at current time. Being a triathlete was part of our patient’s identity and played a major role in her mind, body, and spirit. Exercise “improved her mentally and physically.”

When the structure of the patient’s external iliac artery had undergone chronic changes and was unable to vasodilate with exercise, this patient’s function suffered, drastically. There have been multiple case reports and a few small case series that illustrate external iliac endofibrosis. Treatment with prosthetic artery replacement is less prevalent in research. Return to activity and long-term outcomes are currently being investigated. This case will provide an additional diagnostic evaluation and treatment approach to the growing research surrounding external iliac artery endofibrosis and vasospasm.

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Medical Resident Research Case Reports

04 Lactococcus Raffinolactis Bacteremia: a Case Study of a Rare Variant

Deborah L. Enns, DO, PhD 1 and William S. Cox, DO 2 Corresponding author: Deborah.enns@hcahealthcare.com

1 Department of Family Medicine and 2 Department of Internal Medicine LewisGale Hospital Montgomery

We present the case of a 71-year-old male who was admitted to hospital with initial complaints of fatigue, weakness, and lack of appetite. Patient had experienced a fall the week prior to admission, but denied hitting his head or any loss of consciousness. Past medical history was significant for prostate cancer, coronary artery disease (status post coronary artery bypass graft), prosthetic heart valve, and pacemaker. In the emergency room, a small pulmonary embolism was found and patient was started on anticoagulation. Patient was also found to have a significant white cell count of 21.9 x 10^9 per liter. Blood cultures revealed bacteremia which was later identified as Lactococcus raffinolactis, a coccoid gram-positive anaerobe. Patient was initially started on vancomycin, which was later switched to ampicillin/sulbactam. Patient underwent extensive workup to determine the source of his bacteremia, including urinalysis, which was

negative, echocardiogram which showed no signs of endocarditis, and CT scans of the chest and abdomen/pelvis, which showed no abnormalities. Throughout admission, patient had complaint of moderate to severe left ankle and lower leg pain that he attributed to his earlier fall. Plain radiographs of the leg and ankle were negative for any acute bony abnormalities. A three-phase bone scan was negative for osteomyelitis. Venous duplex ultrasound showed no signs of DVT. Finally, an infection PET/CT scan was ordered which showed an area of hypermetabolism on the left posterior tibial region. Follow-up CT of the leg revealed a 2.5-cm intramuscular fluid collection along the posterior aspect of the mid-left tibial region most consistent with an intramuscular abscess. Patient had been receiving IV antibiotics throughout admission and had been discharged home with a PICC line to complete a 4-week course of IV ertapenem. Patient returned

to hospital and underwent surgical I&D of the left calf. Unfortunately, no abscess or other source of infection was found during exploration. The patient was continued on IV antibiotics and advised to follow up with an Infectious Disease specialist at completion of treatment. While a definitive source of this patient’s bacteremia was never found, this case nonetheless illustrates a rare and interesting study as very little is currently available in the literature regarding infection by this variant.

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Medical Resident Research Case Reports

05 Thrush in Sjogren Syndrome

Nida Zaheer, MD; Michael Caplan, MD Corresponding author: Nida.zaheer@lpnt.net

SOVAH Health Internal Medicine Residency Program

swallowing and associated loss of appetite. Dry grainy eyes requiring OTC artificial tears. Pertinent Physical Exam: BP 145/95. HR 85. RR 20. T 97.5, O2 saturation 100% on RA. Significant mucosal breakdown and ulcerations of the oral cavity. Multiple whitish patches leaving petechiae upon scraping with a tongue depressor. Pertinent Labs: Low hemoglobin, chronic (Baseline 9-10), ANA +, Anti Ro, and La positive. Imaging: Chest X-ray portable- Chronic interstitial changes with no acute findings. Diagnosis: Severe oropharyngeal thrush and Sjogren syndrome. Treatment: To keep mucosal membranes wet, the patient was initiated on conservative measures with topical lubrication, ice chips, and swish-and-swallow mouthwash. The patient was also recommended to maintain adequate hydration and avoid oral desiccants (e.g., coffee, alcohol, tobacco, and cannabis smoke). After conservative therapy failed, Sialagogues were initiated with pilocarpine 5 mg by mouth, up to four times daily, and cevimeline 30 mg by mouth, up to three times daily, to be taken a half-hour before meals

to allow time for the medication to enhance salivary flow. This medication regimen improved the patient's condition. Comments: Oral Thrush is a common complication seen in patients with Asthma/COPD requiring regular inhaler therapy. Patients with recurrent oral thrush and a history of autoimmune conditions warrant evaluation for Sjogren syndrome. Treatment recommendations should also include avoidance of medications that may worsen oral dryness, especially those with anticholinergic side effects. Over-the-counter cold and sleep remedies may be overlooked as potential contributors. Multiple medications can lead to worsening mouth dryness and contribute to thrush development. Medications for urinary incontinence and depression are strongly associated with this side effect. In our situation, we suspect that the use of inhalers and antidepressants were the likely reasons her Sjogren syndrome was not diagnosed earlier.

Context: Sjögren's syndrome (SS) is a chronic autoimmune inflammatory disorder characterized by diminished lacrimal and salivary gland function with resultant dryness of the eyes and mouth. Sjogren syndrome is also associated with rheumatic diseases such as rheumatoid arthritis or systemic lupus erythematosus and affects 0.5 to 1% of the population. It also may affect other organs of the body, including the kidneys, blood vessels, lungs, liver, pancreas, and brain. Case Report: A 61-year-old female presented to the office with complaints of pain and bleeding in her mouth. Medical History: Rheumatoid arthritis, hypothyroidism, recurrent episodes of oral ulcers and candidiasis (previously attributed to inhaler use for Asthma), hypertension, hyperlipidemia. Family History: Maternal grandmother and sister with a history of “Joint and skin issues.” Social History: Worked part-time as a janitor, independent for all basic ADLs. Pertinent Review of Systems: Bleeding and pain from the mouth with severe difficulty

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