Virginia Research Day 2022

Via Research Recognition Day

February 25, 2022

Welcome

Welcome to the seventeenth 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.

2

Agenda

7:30am

Registration Opens

8:00-10:00am

Poster Viewing

10:20am

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

10:35am

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

11:00am

Keynote Lecture: The Importance of Clinical Research to the Practicing Physician Olutayo Sogunro, DO, MS, FACOS, FACS Assistant Professor of Surgery, Netter School of Medicine at Quinnipiac University Member, Quality Initiatives Committee of the American College of Osteopathic Surgeons

12:00pm

Poster Competition Awards Ceremony

12:30pm

Closing Remarks and Adjournment

3

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

4

Contents

Program Moderators. ................................................................................................................................................................6

Speakers Keynote Speaker......................................................................................................................................................................10

Abstracts Medical Resident Research - Clinical.....................................................................................................................................12

Medical Resident Research - Case Reports . ........................................................................................................................14

Faculty Research - Biomedical...............................................................................................................................................29

Medical Student Research - Biomedical................................................................................................................................33

Graduate Student Research - Biomedical..............................................................................................................................50

Undergraduate Student Research - Biomedical. ...................................................................................................................62

Faculty Research - Clinical......................................................................................................................................................66

Medical Student Research - Clinical.......................................................................................................................................67

Faculty Research - Educational..............................................................................................................................................84

Medical Student - Educational................................................................................................................................................87

5

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

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

6

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

She 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 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. She serves on the Board of Deans and as Chair on the International Collaborative Steering 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 on the Board of Directors for the Medical Society of Virginia (MSV). As a preceptor, Dr. Willcox accompanies Appalachian and international outreach experiences for VCOM. Dr. Willcox is the Vice-Chair and AACOM Representative on the Bureau of International Osteopathic Medicine of the American Osteopathic Association. She also serves as a member of the Board of Directors for the Southwest Virginia Area Health Education Center.

Dr. Willcox 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 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. 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 was recognized as the Guardian of the Profession by the American Osteopathic Association.

7

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

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.

8

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. Dr. Brolinson was honored by The American Osteopathic Foundation as the 2021 AOF Educator of the Year.

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.

9

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

Keynote Speaker

Olutayo Sogunro, DO, MS, FACOS, FACS Assistant Professor of Surgery, Netter School of Medicine at Quinnipiac University Quality Initiatives Committee of the American College of Osteopathic Surgeons

community general surgeon and as an acute care and trauma surgeon, she was involved in various hospital-based quality improvement projects. She sits on the Quality Initiatives Committee of the American College of Osteopathic Surgeons. Her research interests include triple negative breast cancer, male breast cancer, genetics, surgical quality, and health disparities.

Osteopathic Medicine (VCOM-Virginia) in Blacksburg, VA. She completed her general surgery training at Mercy St. Vincent Medical Center in Toledo, OH. She was recently practicing acute care surgery and trauma surgery in Bridgeport, CT and decided to transition her career into breast surgical oncology. She is currently completing a breast surgical oncology fellowship at Georgetown University Hospital in Washington, DC. During her previous years of clinical practice as both a

Olutayo Sogunro, DO, MS, FACOS, FACS is a board-certified general surgeon and an assistant professor of surgery at the Netter School of Medicine at Quinnipiac University in North Haven, CT. She graduated from Central Connecticut State University in New Britain, CT with her bachelor's degree in Biology and obtained her master’s in biology from Southern Connecticut State University in New Haven, CT. She earned her medical degree from the Edward Via College of

10

11

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

Medical Resident Research Cl inical

01 Variations In Average Cranial Rhythmic Impulse Rates

Tiffany Crider, DO, MPH, PGY-5; Jared Grim, OMS III, Al Kozar, DO, FAOASM, R-MSK; Hope Tobey, DO Corresponding author: tcrider@vcom.vt.edu

VCOM Sports and Osteopathic Medicine

Introduction: Few studies have been done on cranial rhythmic impulse (CRI) over the years. Even fewer studies have been completed to see if there are any cause in variations of the CRI among specific groups. This study will attempt to identify any variables which cause a deviation from the average CRI. The purpose of the study will be to determine if the average CRI in the VCOM Sports and Osteopathic Medicine (VSOM) Clinic is different based on variables such as age, sex, height, weight, BMI, heart rate, before treatment rate compared to after treatment rate, diagnoses, mood, appearance of patient such as awake, sleeping, crying, calm, and treated somatic dysfunction areas. Methods: A retrospective chart review for the last 3 months will be performed to evaluate documented CRI rates in comparison to the

area can help current and future osteopathic physicians to unlock more information about diagnosing and treating cranial dysfunction. It could also tell researchers and physicians more about possible changes in CRI as patients age and if there should be change as they progress in disease state or during treatment. Performing studies, such as this one can help further determine the role CRI plays in the patient’s overall health, any variations in the average rate based on variables like age, and how to best utilize this information when caring for a patient.

other variables available in the patient’s chart at that time. Initial query of the electronic health record results in about 400 possible patient charts to be reviewed. The quantitative data will be analyzed using descriptive statistics including mean, median, mode, range, standard deviation, and skewness. preliminary review, it is expected that there will be different average CRI rates based on age, especially pediatric patients compared to adult patients. It is also expected that the average CRI rate may vary depending on the medical or somatic dysfunction diagnoses. There is still a lot that is unknown about the CRI. Early osteopaths felt that assessing the CRI could tell osteopathic physicians about the “vitality” of the patient. Further studies in this Conclusion and Discussion: Data collection is still in process. Based on

12

Medical Resident Research Cl inical

02 Select Nutritional Deficiencies Among Patients With Diabetes In Southwestern Virginia

Katherine Mustafa, DO; Andrew Behnke, MD, FACE; Jarrod Uhrig, DO, Katherine Jones, Rd, CDCES Corresponding author: kemustafa@carilionclinic.org

Virginia Tech Carilion; Carilion Clinic

Introduction: The prevalence of diabetes is high in the southeastern and Appalachian regions of the country, including Virginia. In Roanoke County, an estimated 11.6 % of the population is diagnosed with the disease compared to the national average of 9.1%. Medical nutrition therapy (MNT) has shown to reduce HgbA1c levels in persons with diabetes up to 2% and is more effective than most medications. Despite the known importance of MNT, the macro and micronutrient distribution of diets is not well established in those with diabetes. Although patients and providers are overall focused on carbohydrate intake for glycemic control, other nutrients such as magnesium and fiber may also impact diabetes. Previous studies have shown that magnesium deficiency is associated with development of type 2 diabetes and is common in those with poor glycemic control. Increased dietary fiber intake has also been long implicated in improved glycemic control. Despite this data, intake of both fiber and magnesium among

Results: The dietary nutritional content of our participants with diabetes did not meet RDA guidelines with no significant age or sex differences between groups. Total calories were 2314 for men and 1862 for women. Carbohydrate intake exceeded the ADA recommended amount in 83 % of men (218 g/d) and 67 % of women (196 g/d) (p<0.01). In addition, 83% of men and 76% of women did not meet recommended magnesium intake, averaging 314 mg/d for men (p<0.05) and 264 mg/d for women (p<0.01). Finally, 100% of men and 90% of women did not meet reference fiber intake, averaging 19 g/d for men (p<0.01) and 14 g/d for women. (p<0.01). Conclusion: Patients with diabetes in southwest Virginia had excess carbohydrate and inadequate fiber and magnesium intake based on self-reported intake compared to RDA guidelines. Results help highlight dietary needs for patients. Future investigations could focus on dietary interventions to prevent diabetes or improve glycemic control.

people with diabetes within the United States remains inadequate. Our study provides data on the dietary intake of several macro and micronutrients including carbohydrates, magnesium, and fiber among adults with diabetes within southwestern Virginia. Methods: 33 adult volunteers (21 women, 12 men) with diabetes living within southwestern Virginia electronically recorded their food intake over 24 hours via access to the Automated Self-Administered 24-hour (ASA24®) dietary assessment tool. A $25 gift card was provided upon completion of the survey. Macro and micronutrient intakes were calculated with reference intakes provided by Recommended Dietary Allowance (RDA) guidelines and divided by sex and age group. The lowest reference intake was used to calculate pooled comparison for all ages by gender. P-values were calculated using one-sample t tests comparing sample averages with reference values. Logistic Regressions were used to evaluate the effect of age and sex on outcome.

13

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

Medical Resident Research Case Reports

01 Recurrent Hypoglycemia After Diagnosis And Treatment Of Insulin-Derived Amyloidosis

Aaron Estep, DO; Jarrod Uhrig, DO; Curtis Bower, MD; Robert Jarrett, MD Corresponding author adestep@carilionclinic.org

Department of Family Medicine, Carilion Clinic Virginia Tech Carilion Family Medicine Residency

frequent hypoglycemia likely due to improved insulin absorption and action in unaffected tissue. This case demonstrates the importance of recognizing this rare complication from subcutaneous insulin, counseling patients using insulin about frequent rotation of injection sites, and the potential risk of hypoglycemia after patients rotate injection locations.

cessation of injections in the affected areas and can lead to more disruption of insulin absorption. We present a case of a 57-year-old female who developed a firm abdominal mass in the region of repeated insulin injections over at least 15 years. Imaging was inconclusive and she eventually had surgical excision of the mass with pathologic evidence of amyloid deposition in the tissue consistent with insulin-derived amyloidosis. After the surgery, she required multiple reductions in insulin dose due to

Insulin-derived amyloidosis is a rare complication from long-term subcutaneous insulin delivery. Although it is not well- represented in literature, it is typically described as a firm mass in areas of repeated insulin injections over years. The mass can grow over time and limit absorption and action of insulin. Because of this, rotating injection sites away from this area or removing the mass can lead to profound hypoglycemia. Although there is overlap between lipohypertrophy and insulin-derived amyloidosis, insulin-derived amyloidosis will typically not regress with

14

Medical Resident Research Case Reports

02 Late Onset Acromegaly Presenting With Insulin Resistant Diabetes Mellitus

Nam Phan; Andres Tabares; Autumn Jordan Corresponding Author: andy1512005@gmail.com

LewisGale Hospital-Montgomery

Introduction: Acromegaly is a rare acquired disease that usually affects adults between the ages of 30 and 40 but due to the insidious nature of the disease, diagnosis is often delayed years after its onset. Acromegaly results in the persistent hypersecretion of growth hormone (GH) leading to hepatic secretion of insulin-like growth factor-1 (IGF- 1) which ultimately leads to insulin resistant diabetes mellitus. The hypersecretion of GH leads to lipolysis and impaired glucose uptake in adipose tissue leading to features of reduced body fat in the setting of insulin resistant diabetes. These features can clinically mask the diagnosis of diabetes which is clinically relevant as this negatively impacts patient care as diabetes increases the risk of cardiovascular morbidity and mortality. The goal of our case study is to illustrate the presenting complaints of insulin resistant diabetes as a clinical marker for late onset acromegaly.

Case Presentation: We present the case of a 51-year-old male who initially presents for evaluation and management of type 2 diabetes which has been uncontrolled for the past 10 years with an HA1c of 10.5 while on four different hypoglycemic agents. On initial presentation, patient presented as a well- built male with an active lifestyle and history of body building. The decision was made to check IGF-1 levels as the patient had clinically significant features of large hands and feet as well as crowned teeth which in the past was attributed to history of GH injections during his body building career. Further workup revealed elevated IGF-1 levels and negative GH suppression test following oral glucose load suggesting the presence of acromegaly. Subsequent MRI imaging revealed a 3 mm focus of relative decreased enhancement in the pituitary suspicious for a microadenoma. Patient was evaluated by neurosurgery and

underwent successful transsphenoidal resection of the pituitary microadenoma. Following resection of patient’s microadenoma, his HA1c drastically improved to 6.5 with noted improvement in quality of life. Conclusion: In conclusion, this highlights insulin resistant diabetes as an important marker for initial diagnosis of acromegaly. Early and prompt transsphenoidal surgical resection remains the first-line of treatment which leads to near resolution of glucose metabolism abnormalities and as a result can reduce a patient’s dependence on hypoglycemic medications which ultimately reduces unwanted side effects of these medications. Drastic improvement in patient’s hyperglycemia can also result in reduction in long-term complications of uncontrolled diabetes including cardiovascular events, neuropathy and chronic kidney disease.

15

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

Medical Resident Research Case Reports

03 Psychiatric Disorder Following COVID-19 Infection

Zonaira Shabbir, DO; Amber Stephens, DO Corresponding author: Zonaira.Shabbir@LPNT.net

SOVAH Health Family Medicine Residency

Context: The COVID-19 pandemic not only affects physical health but also mental health. The current pandemic is changing priorities for the general population and has been challenging the agenda of health professionals. Case Report: A 55-year-old African American female presented as a hospital follow-up for hypertension management. She had been admitted for hypertensive urgency and COVID-19 infection. Initially, management focused on controlling hypertension with close follow-up. At subsequent office visits she reported ongoing panic attacks and was started on anti-anxiety medications with close follow up with the physician and behavioral therapist. She was also referred to a psychiatrist. There was no improvement in her anxiety after multiple medication adjustments. Her mood quickly escalated, developed emotional liability and eventual flat affect. Family note that before the diagnosis and treatment of COVID -19, the patient was able to care for herself without assistance, had good mood, no history of depression, or anxiety. Due to the recent pause in working, her family had reported increased

stress at home due to financial-related issues. Medical Hx: Hypertension. Surgical Hx: Hysterectomy. Family Hx: Hypertension, Diabetes. Social Hx: Divorced, Lives at home with her son, and is independent. Works at a manufacturing factory. Smokes 5 cigarettes per day. No alcohol or illicit drug use. Pertinent Review of systems: Panic attack, anxiety/worry, depression, headaches, nausea, blurry vision, dyspnea. Pertinent Physical Examination: Well- dressed African American female. BP 203/112, HR 65, RR 20, temp 97.3, Sat 100% RA, alert and oriented x3, anxious, hyperventilating, worried, depressed, poor eye contact, tearful and complete flat affect. Diagnosis: New onset uncontrolled hypertension concomitant COVID-19 infection further complicated by new-onset panic

attacks, anxiety, and depression. Treatment: Initiated citalopram with

hydroxyzine as needed for panic attacks with close follow up with behavioral therapist and PCP. Medication changed to venlafaxine with hydroxyzine as needed, and behavioral therapy. Eventual referral to Psychiatry and Neurology due to a sudden worsening in mental status. Comment: There has been an increase in cases of anxiety and depression associated with COVID-19. Many patients with no history of anxiety or depression have experienced low mood and anxiety with the rise of COVID-19 infection and have been initiated on medication/cognitive behavioral therapy. This patient had abrupt onset of panic attacks and anxiety with a quick turnover to severe depression and flat affect. The patient’s mood fluctuated abruptly throughout the course. This leaves health care providers at a crossroad of appropriately managing patient mental health during a global pandemic.

16

Medical Resident Research Case Reports

04 Intractable, Recurrent Episodes Of Abdominal Pain, Nausea And Weight Loss Secondary To Rare GI Tumor (GIST)

Salma Khan, DO; Amber Stephens, DO Corresponding author: Salma.Khan@LPNT.net

SOVAH Health Family Medicine Residency

Context: Intractable recurrent abdominal pain, nausea, and weight loss secondary to rare GI tumor (GIST). Case report: A 70-year-old African American male presented for intractable abdominal pain with associated nausea and weight loss of 30 lb. He was admitted a few months ago secondary to significant DKA. Since then, has lost significant amount of weight. Patient has difficulty with nausea and significant abdominal pain and feeling full. Primary care physician has recently started him on iron due to anemia. He was referred to gastroenterology and a CT scan of the abdomen demonstrated a large abdominal mass originating from the stomach. Patient was set up for EGD and colonoscopy as an outpatient, however, his pain worsened significantly with the accompanying nausea and vomiting. Underwent a repeat CT scan which again demonstrated a large abdominal mass with numerous liver lesions. Past Medical History: HTN, HLD, DM Type 2, CAD s/p PCI 2005, DVT. Family History: Brother has colon cancer

Social History: Denies smoking, alcohol, or illicit drug use. Pertinent ROS: Weight loss, early satiety, left lower abdominal pain. Pertinent PE: Tenderness to palpation on left middle and left lower quadrant of abdomen with mild distension. Large palpable firm mask on left abdomen. Hyperactive bowel sounds. Vital signs: BP 121/66, HR 80, RR 22, Temp 98.7, Pulse ox 98 %RA. Pertinent diagnostic studies: Hemoglobin 8.4, CT abd/pelv with IV contrast multiseptated mass along the greater curvature of the stomach with areas of irregular soft tissue thickening. Multiple lesions throughout the liver. Fine needle liver biopsy showed GIST. Diagnosis: Large symptomatic metastatic GIST tumor. Treatment: Patient is presented in tumor board and discussion was held about palliative debulking of tumor was recommended. Patient

underwent exploratory laparotomy, partial gastrectomy with en bloc resection of tumor and distal pancreatectomy with splenectomy. Patient was referred to hematology-oncology along with radiation oncology. Patient received Hib, meningococcus, and influenza vaccine. Advised to get Pneumovax at PCPs office. Comment: Four types of standard treatments are used after diagnosis of GIST. Surgery, Targeted therapy, watchful waiting, and supportive care. Targeted therapy with Tyrosine Kinase Inhibitors (TKIs) are the drugs that block signals needed for tumor to grow. If a GIST gets worse during treatment or side effects occur, supportive care plays a role. Radiation therapy is sometimes given to relieve pain in patients with large tumors.

17

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

Medical Resident Research Case Reports

05 Preventing Neurologic Complications Of Syphilis In Elderly Patients With Multiple Comorbidities

Bushra Ferdous, DO; Amber Stephens, DO Corresponding author: Bushra.Ferdous@LPNT.net

SOVAH Health Family Medicine Residency

Context: Elderly Patients with history of undiagnosed syphilis may suffer from serious complications like neurosyphilis as they fail to get initial treatments with antibiotics. Currently, many facilities are not reporting the diagnosis of syphilis in elderly population. Case Report: A 61-year-old African American female who previously had an intracranial hemorrhage in 2020, and TIA, admitted to the hospital for respiratory distress secondary to COVID-19 infection and confusion. Medical History: Intracranial hemorrhage 2020, TIA, IDDM type 2, seizure disorder, essential hypertension, hyperlipidemia, ESRD dialysis on Tuesday, Thursday, Saturday, cervical disc bulging, chronic bronchitis, recurrent C diff, ambulatory dysfunction, wheelchair bound. Family History (Hx): Mother: Deceased, ovarian cancer, diabetes, hypertension. Father: Deceased, diabetes, heart disease, hypertension, hyperlipidemia.

Social Hx: Former smoker, quit approximately 5 years ago.

of nonspecific ascites, mild bilateral lower lobe lung opacities edema versus infection, bladder wall thickening with gas in the bladder, cardiomegaly, arterial and aortic atherosclerotic calcifications. Head CT did not show any acute abnormality, atrophy, positive for chronic microvascular disease. Diagnosis: Acute metabolic encephalopathy secondary to neurosyphilis. Treatment: RPR 1:1 titer and tPA-PA was reactive. Infectious Disease recommended to place patient on penicillin G for 14 days. Patient was continued on penicillin G 4,000,000 units IV every 4 hours for 14 days. Patient was advised to follow up every 6 months for repeat RPR for 2 consecutive years per CDC guidelines. Comment: Studies have shown that the diagnosis of syphilis in elderly patients is significantly delayed due to their multiple underlying comorbidities. A thorough evaluation should be complicated for altered mental status in elderly patients despite their past medical history to ensure that every patient receive treatment in a timely manner.

Pertinent Review of Systems: Positive for some diarrhea, but no vomiting, shortness of breath at times, confusion. Pertinent Physical Exam: Temp 98.1, Blood pressure 210/95, pulse 77, respiratory rate 22, required 93% on room air frail, chronically ill-appearing, alert, verbal, and cooperative, in no acute distress. Normal respiratory effort on 2 L nasal cannula. Alert and oriented to person only, slow speech, could follow simple commands and move all extremities without any trouble. Pertinent Lab: WBC 3.1, hemoglobin 12, hematocrit 41. Sodium 142, potassium 4.5, chloride 100, bicarb 20, BUN 78, creatinine 11, glucose 106. ECG: Normal sinus rhythm, prolonged QTC, nonspecific T-wave abnormalities without any significant ST elevation or depression. CT abdomen and pelvis showed small amount

18

Medical Resident Research Case Reports

06 Severe Facial Edema Secondary To Extensive Subcutaneous Emphysema

Elizabeth Smith, DO; Paulette Bayne-Gaul, DO Corresponding author: Elizabeth.Smith2@LPNT.net

SOVAH Health Family Medicine Residency

Context: While subcutaneous emphysema is not rare, the extension of swelling into the face including perioral and periorbital regions can cause concern for alternative etiology such as angioedema or allergic reaction. Resolution of this edema however will only come with identifying pneumothorax and resolving persistent air leak. Case Report: A 58-year-old caucausian male with history of COPD presented to the emergency department reporting continuously worsening cough for 3 weeks and now with shortness of breath. Medical Hx: COPD, emphysema, sleep apnea on CPAP, hypertension, hyperlipidemia, psychosis, hypothyroidism, depression. History of urethral surgery post gonococcal infection. Family Hx: None reported. Social Hx: Inmate. Former smoker, no illicit drug or alcohol use. Pertinent Review of Symptoms : Shortness of breath. Otherwise negative.

Pertinent Physical Exam: Mild respiratory distress. Diffuse mild wheezing with decreased breath sounds to the left lung. Regular rate and rhythm without murmur. Temp 98.1, BP 102/67, P 88, RR 20, SPO2 90% room air, 97% on 2L. Pertinent Labs: WBC 12.44, pCO2 34, pO2 147, HCO3 19. Diagnosis: Spontaneous left pneumothorax with persistent air leak resulting in extensive subcutaneous emphysema into head and neck. Treatment: Following arrival and identification of pneumothorax, left sided chest tube was placed resulting in improvement in lung expansion and symptoms. Surgery was consulted and monitored progress. Air leak persisted requiring tube repositioning day 5 and VATS with pleurodesis day 6. Day 8 nursing called for rapid evaluation due to severe facial swelling. Due to periorbital and perioral swelling causing distress, prednisone, famotidine, and benedryl were given for possible allergic reaction or angioedema. Imaging however showed extensive subcutaneous emphysema.

Chest tube readjustments resulted in mild improvement but air leak persisted by day 18. CT showed linear subcutaneous emphysema extending to left hemithorax suggesting bronchopulmonary fistula. This was the likely cause of air leak with severe subcutaneous emphysema. This finding required patient transfer for evaluation by cardiothoracic surgeon. Comment: While most pneumothoraces resolve with chest tube placement, this patient, likely due to chronic lung disease, had persistent air leak. Due to this he suffered neck and facial edema which caused concern due to severity and patient distress. While his condition appeared critical he had no oropharygeal edema or worsening dyspnea. Identification of subcutaneous emphysema and treatment of likely bronchopulmonary fistula is the only definitive resolution for this source of facial edema.

19

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

Medical Resident Research Case Reports

07 Rapid Evalution And Treatment Of Wrist Pain In A Division I College Football Athlete

Stephen Despins, DO; Mark Rogers, DO; Micah Jones, DO, Brett Brodsky, OMS IV; Grayson Daffron, OMS II, Brett Griesemer, LAT, ATC; Miguel Silva, LAT, ATC Corresponding author: sdespins@vcom.vt.edu

Virginia Polytechnic Institute and State University VCOM Virginia

History: A student athlete (SA) presented to the sports clinic with left wrist pain after a football scrimmage. He reported falling backwards onto his outstretched hand followed by immediate wrist pain. He went over to the athletic training staff, on the sideline, for evaluation. When attempting to remove his glove, on the sideline, the SA reported feeling a "pop" and immediately felt better. After a few more plays, he started to feel the same type of wrist pain. He started to pull on his wrist and again felt a big "pop" with some relief. After the scrimmage, his wrist still bothered him, so he reported to the sports clinic for further evaluation. Wrist pain was on the medial, dorsal, and volar side of his left wrist. Pain was dull and achy. Pain did not radiate. Pain was worse with any type of wrist movement, including gripping. He denied numbness or tingling in the hand, wrist, or forearm. Physical Examination: Some swelling to the wrist but no erythema or obvious wrist deformities. There was tenderness at the anatomic snuffbox as well as along the dorsal part of the wrist. There was mild tenderness at the distal ulnar styloid and triangular fibrocartilage complex (TFFC). In addition, he

had tenderness to palpation of the mid-carpal and lunate areas. He was able to fully pronate but had limited supination with a loss about 10 degrees. Wrist extension and flexion were severely limited secondary to pain. He had a positive piano key sign. He was neurovascular intact. Tests & Results: Radiographic images demonstrated a volar displaced lunate on lateral view. An MRA would be taken two days later, post-reduction, which demonstrated a significant amount of contrast in the dorsal extensor compartment, no obvious full thickness rupture of the scapholunate ligament, a TFCC tear in the central articular disc, degenerative changes in the lunotriquetral ligament, minimal tendinopathy in the extensor carpo-ulnaris tendon and abnormal non- contrast fluid in the volar flexor compartment. Final Diagnosis: Volar lunate dislocation with concurrent injuries to the triangular fibrocartilage complex and peri-lunate ligaments. Outcome: Noting the volarly displaced lunate on radiographic imaging, the team physician reduced the lunate bone at bedside. Post-

radiographic images confirmed reduction of the carpal bone. Discussion: This was an interesting case of a perilunate dislocation in a division I football athlete. This case demonstrates the importance of combining both radiographic imaging and physical exam to accurately diagnose and treat a dislocation quickly and effectively. Perilunate dislocations are often underdiagnosed and can lead to poor outcomes when missed, including complete loss of wrist function. By initially evaluating the SA on the field and quickly transitioning to the sports clinic, the sports medicine staff were able to quickly develop a plan for the division I athlete without him losing any playtime. Return to Activity and Follow-Up: The SA received weekly radiographs of his left wrist to monitor for worsening instability and avascular necrosis. His left wrist was casted daily for practice and for games. He received reconstructive surgery at the end of the football season by a hand surgeon.

20

Medical Resident Research Case Reports

08 Peg Tube Induced Gastric Volvulus

Janice Chuang, DO; Ryan O’Connell, DO; and Tara Mancl, MD Corresponding author: Janice.chuang@lpnt.net

SOVAH Health Internal Medicine Residency Program

Context: Gastric volvulus is a rare condition resulting from the rotation of the stomach or part of the stomach by more than 180˚, creating a closed-loop obstruction. Gastric volvulus is a life-threatening condition, with high morbidity and mortality, secondary to gastric ischemia, perforation, and necrosis. Borchardt reported gastric volvulus triad as acute stomach distention or pain, inability to pass nasogastric tube, and non-productive attempts at vomiting. Case Report: A 26-year-old female that presented to the ED with complaints of acute nausea and vomiting, abdominal pain. Medical History: Cerebral palsy, non-verbal and PEG tube dependent at baseline, severe developmental disability, Ogilvie syndrome s/p decompression in 2017 and 2018, and seizure disorder Family History: Maternal Grandmother with hx of “GI issues”, family was unclear. Social History: Non-verbal and completely dependent for all basic ADL’s. Pertinent Review of Systems: Unable to obtain.

Pertinent Physical Exam: BP 145/95. HR 125. RR 20. T 97.5. 100% on RA. Distended and tight abdomen, no bowel sounds. Pertinent Labs: Lactic acid of 4.8, mild leukocytosis of 13.9, and lipase of 949. Imaging: CT abdomen and pelvis with contrast showed severely dilated air and fluid- filled viscous thought to represent the stomach. Patulous fluid-filled esophagus. Diagnosis: Intractable Nausea and Vomiting secondary to abdominal distention in the setting of recurrent Ogilvie Syndrome. Treatment: Patient was initiated on conservative measures with NG tube, fluids and PRN pain scale. General surgery and GI were consulted for recurrent Ogilvie and the need for EGD/colonic decompression. GI recommended contrast-enhanced abdominal x-ray secondary to no NG tube output despite multiple attempts at repositioning the tube. This study revealed no evidence of contrast drainage into the stomach, concerning for gastric volvulus. The patient was taken for emergency surgical intervention and found to have acute gastric volvulus wrapped 2-3 times around the PEG tube. The patient underwent total gastrectomy

with Roux-en-Y esophagojejunostomy, appendectomy and feeding jejunostomy placement. The patient was then transferred to the ICU. Post-op discussion with family revealed that the patient's PEG tube had been dislodged multiple times recently and re- inserted in the ER. The patient had a prolonged stay in the ICU and eventually was discharged to a group home after patient was tolerating feeds through J-tube. Comments: While PEG tubes are broadly accepted as safe for a more permanent enteral access there are many complications and risk with the procedure. Common complications of PEG tube include leakage, tube occlusion or dislodgement. There have also been increased concerns and reports about small bowel and gastric volvulus after laparoscopic procedures. This is thought to be due to bowel mobilization and manipulation, set inclination of the operating table, and stasis and pneumoperitoneum. Most cases are typically reported after a recent laparoscopic procedure. In our situation, we suspect that the replacement of the PEG tube was the inciting factor that led to the gastric volvulus.

21

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y

Medical Resident Research Case Reports

09 It’s Not Just A Tumor: It’s A GIST Tumor

Faryal Mirza, MD; Akintunde Akinleye, MD; and Tara Mancl, MD Corresponding author: Faryal.mirza@lpnt.net

SOVAH Health Internal Medicine Residency Program

Introduction: Gastrointestinal stromal tumors (GIST) are rare (<1%) mesenchymal neoplasms of the gastrointestinal tract. Most GISTs are related to mutations in either tyrosine kinase receptor or platelet-derived growth factor receptor alpha. Case Report: 70-year-old man with hypertension, coronary artery disease, Insulin dependent diabetes mellitus type 2, Benign Prostatic Hypertrophy, and previous venous thromboembolism presented with 6 months history of diffuse abdominal pain, and a 30lbs weight loss with no other GI symptoms. Family History: Non-contributory. Social History: No alcohol, tobacco, or illicit drug use. Allergies: ciprofloxacin and morphine caused hives. Review of System: Negative except abdominal pain and weight loss. Pertinent Physical Exam: BP 121/66, pulse 80, respirations 22, temp 98.7, oxygen saturation 98% on room air, taut abdomen with

particularly the role of c-KIT, cellular receptor for tyrosine kinase, which is also known as the stem factor receptor (CD117). Historically, 70-80% of GISTs were thought to be benign. However, all GIST tumors are now considered to have malignant potential and are no longer classified as benign. Tumors <5cm are usually low risk while those >5cm are often malignant. Larger GISTs (>10 cm) occurring anywhere, tend to be malignant. Mutations in c-KIT exon 11 mutations are more common in larger tumors with a worse prognosis than other mutations. Surgical resection (48-65% five- year survival) of the local disease is the gold standard therapy. GISTs are soft and fragile therefore, tumor rupture must be avoided when being removed to avoid potential surgical site spread. Conclusion: Gastrointestinal stromal tumors, while rare, are often malignant, and present with few specific symptoms till advanced. Early recognition and diagnosis are essential for optimal outcomes.

mild distension and moderate tenderness on palpation. Pertinent Initial Lab: White blood cells 11.4, hemoglobin 6.7, hematocrit 23.4, MCV 70.5, creatinine 1.2 with normal electrolytes. Patient received one unit of packed red blood cells in the ED. Abdomen/pelvic CT scan demonstrating multiple liver masses and large abdominal mass measuring 17 x 19 cm in size. He was admitted and had upper GI endoscopy revealing a greater curvature gastric mass. Biopsies of the stomach mass and liver lesions demonstrated GIST. He underwent partial gastrectomy, distal pancreatectomy, and splenectomy. Hospital course was complicated by pneumonia. Resected tumor mutation analysis revealed c-KIT exon 11 mutation. He began an outpatient course of Imatinib as palliative therapy. Restaging CT- chest/ abdominal/pelvis 1 month later demonstrated stable disease. Imatinib was continued. He was stable at last clinic visit. Discussion: GISTs are unique since they can range from benign to malignant in nature. Much of present understanding of GIST biology stems from identification of its molecular basis,

22