Virginia Research Day 2021

Via Research Recognition Day

February 26, 2021

Welcome

Welcome to the sixteenth 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

8:30am

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

8:35-9:00am

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

9:00-10:00am

Keynote Lecture: Rapid (and Precise) COVID-19 Vaccine Development

Barney Graham, MD, PhD Deputy Director, Vaccine Research Center Chief, Viral Pathogenesis Laboratory, NIAID, NIH

10:00-2:00pm

Poster Session and Poster Competition Judging by zoom

2:15pm

Poster Competition Awards Ceremony

2:30pm

Closing Remarks and Adjournment

3

2 0 2 1 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 . ........................................................................................................................34

Medical Resident Research - Educational. ............................................................................................................................82

Faculty Research - Biomedical...............................................................................................................................................86

Student Research - Biomedical. .............................................................................................................................................98

Graduate Student Research - Biomedical............................................................................................................................110

Undergraduate Student Research - Biomedical. .................................................................................................................132

Faculty Research - Clinical....................................................................................................................................................136

Medical Student Research - Clinical.....................................................................................................................................138

Medical Student Case Reports - Clinical..............................................................................................................................166

Student Research - Educational...........................................................................................................................................170

Faculty Research - Educational............................................................................................................................................184

5

2 0 2 1 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

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

Residency Director at Metropolitan Hospital in Grand Rapids, Michigan.

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.

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

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.

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.

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.

7

2 0 2 1 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

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.

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.

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.

8

Program Moderator

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

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.

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

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.

9

2 0 2 1 R e s e a r c h R e c o g n i t i o n D a y

Keynote Speaker

Barney S. Graham, MD, PhD Deputy Director, Vaccine Research Center, NIAID, NIH Chief, Viral Pathogenesis Laboratorye

Dr. Graham is Deputy Director of the NIAID Vaccine Research Center where he directs basic laboratory research and has developed novel vaccines for RSV, influenza, Zika, and coronaviruses including an mRNA COVID-19 vaccine being distributed under Emergency Use Authorization.He has a BA from Rice University, an MD from the University of Kansas School of Medicine, and a PhD in Microbiology & Immunology from Vanderbilt University School of Medicine where he also completed Internal

Medicine residency, chief residencies, and a fellowship in Infectious Diseases. His primary interests are vaccine development for viral diseases, viral pathogenesis, mechanisms of immunity, and pandemic preparedness. He directs basic laboratory research, contributes to the pipeline of new VRC vaccines, and provides oversight of candidate VRC vaccines and antibodies in advanced development including those for HIV, Ebola, and Chikungunya. His laboratory explores the structural basis for

antibody-mediated viral neutralization, investigates basic mechanisms by which T cells affect viral clearance and immunopathology, and has developed novel vaccines for RSV, influenza, Zika, and coronaviruses including the first COVID-19 vaccine and monoclonal antibody to enter clinical testing and that have now achieved Emergency Use Authorization.

10

11

2 0 2 1 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

03 The Effects of Implementing the ABCDEF Protocol in an ICU Within a Level III Trauma Center

Richard Miller, DO; William Cox, DO Corresponding author: richm2711@gmail.com

LewisGale Hospital-Montgomery

Background: The ABCDEF protocol, which stands for Assess, prevent and manage pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of analgesia and sedation, Delirium: assess, prevent and manage, Early mobility and exercise, and Family engagement and empowerment, also known as the ICU Liberation Bundle, is an evidence based model that combines the individual components involved in managing a patient on mechanical ventilation, into one interdisciplinary protocol. The Society of Critical Care Medicine provides resources for facilities to implement the protocol within their own Intensive Care Unit (ICU). It is well established that the longer a patient remains on mechanical ventilation, the more complications arise. Recent studies have demonstrated significant improvement in ICU outcomes, when utilizing the protocol in tertiary care centers, including survival, ICU readmission, next-day mechanical ventilation, delirium and restraint use¬¬¬. However, no studies

Results: LGHM had 32.9% of patients receive mechanical ventilation for less than 24 hours pre- implementation of the intervention, which increased to 47.9% post-intervention. Additionally, 33.3% of patients on mechanical ventilation expired pre- intervention, which was reduced to 21.7% post- intervention. Overall, the odds of mortality decreased by 19% after implementation of the protocol. Conclusion: The ABCDEF protocol effectively decreased mortality and duration of mechanical ventilation for mechanically ventilated patients at LewisGale Hospital Montgomery.

have specifically examined the protocol’s impact on mortality and duration of mechanical ventilation in a small, community hospital. Objective: To determine if mortality and duration of mechanical ventilation were impacted by implementation of the ABCDEF protocol, in a 10 bed ICU within a Level III Trauma Center. Design: Retrospective secondary analysis of 546 ICU patients requiring mechanical ventilation within LewisGale Hospital Montgomery (LGHM) from 2014 to 2019. Intervention: Implementation of the ABCDEF Protocol Measurements: Number of patients in each hospital requiring mechanical ventilation greater than or less than 24 hours, as well as the total number of expired patients.

12

THE EFFECTS OF IMPLEMENTING THE ABCDEF PROTOCOL IN AN ICU WITHIN A LEVEL III TRAUMA CENTER

Richard Miller D.O., William Cox D.O., Brady DeHart Ph.D.

Background

Results

Duration of Mechanical Ventilation

0 20 40 60 80 100

The ABCDEF protocol, which stands for Assess, prevent and manage pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of analgesia and sedation, Delirium: assess, prevent and manage, Early mobility and exercise, and Family engagement and empowerment, also known as the ICU Liberation Bundle, is an evidence-based model that combines the individual components involved in managing a patient on mechanical ventilation, into one interdisciplinary protocol. The Society of Critical Care Medicine provides resources for facilities to implement the protocol within their own Intensive Care Unit (ICU). It is well established that the longer a patient remains on mechanical ventilation, the more complications arise 1 . Recent studies have demonstrated significant improvement in ICU outcomes, when utilizing the protocol in tertiary care centers, including survival, ICU readmission, next-day mechanical ventilation, delirium and restraint use 2,3. However, no studies have specifically examined the protocol’s impact on mortality and duration of mechanical ventilation in a small, community hospital.

Duration of Mechanical Ventilation Year

χ 2 =11.805 · df=1 · φ=0.151 · p<0.001

<24 hours >24 hours

Time 2014 2015 2016 2017 2018 2019 Total <24 hrs 44 34 30 36 36 46 226

* Red Line indicates time of intervention

>24 hrs

83

76

56

39

40

26 320

Total

127 110 86

75

76

72 546

2014 2015 2016 2017 2018 2019

χ 2 =26.357 · df=5 · Cramer’s V=0.220 · p<.0.001

Mortality

Mortality Year

0 20 40 60 80 100

χ 2 =8.708 · df=1 · φ=0.130 · p<0.01

Expired Other

Objective

Time 2014 2015 2016 2017 2018 2019 Total

To determine if mortality and duration of mechanical ventilation were impacted by implementation of the ABCDEF protocol, in a 10 bed ICU within a Level III Trauma Center.

Expired

34 45 20 21

8

18 146

Other

93 65 66 54 68 54 400

* Red Line indicates time of intervention

Total

127 110 86 75 76 72 546

Methods

χ 2 =22.177 · df=5 · Cramer’s V=0.202 · p<0.001

2014 2015 2016 2017 2018 2019

References 1.Hortal J, Giannella M, Pérez MJ, Barrio JM, Desco M, Bouza E, Muñoz P . Incidence and risk factors for ventilator-associated pneumonia after major heart surgery. Intensive Care Med. 2009;35(9):1518. 2.Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital survival and reducing brain dysfunction at seven California community hospitals: implementing pad guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med 2017;45:171 – 8. 10.1097/CCM.0000000000002149 3.Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med. 2019;47:3 – 14. doi: 10.1097/CCM.0000000000003482 LewisGale Hospital Montgomery had 32.9% of patients receive mechanical ventilation for less than 24 hours pre-implementation of the intervention, which increased to 47.9% post-intervention. Additionally, 33.3% of patients on mechanical ventilation expired pre-intervention, which was reduced to 21.7% post-intervention. Overall, the odds of mortality decreased by 19% after implementation of the protocol. Statistical significance values listed on the tables above utilize data from each individual year, whereas those listed on graphs were derived from grouping data as either pre or post implementation.

Population

Intervention

Outcomes

Discussion

The ICU Liberation Bundle, or ABCDEF Protocol, is a non-invasive intervention that has been shown to only improve outcomes in the critical care setting. This study does have significant limitations, including the fact that data was analyzed on a macro-scale without accounting for the variety of variables impacting outcomes in critically ill patients. However, implementation of the protocol poses no risks to the patient, improves communication between members the patient care team, and has now been shown to be beneficial in almost every type of healthcare facility that manages ICU patients. Therefore, a strong argument should be made to universally implement the ABCDEF Protocol as the standard of care for mechanically ventilated patients. Conclusion The ABCDEF protocol effectively decreased mortality and duration of mechanical ventilation for mechanically ventilated patients at LewisGale Hospital Montgomery.

546 patients who required mechanical ventilation at LewisGale Hospital Montgomery, from 2014 to 2019

Implementation of the ABCDEF protocol

1) # of patients on vent greater than 24hrs vs less than 24hrs 2) # of patients who expired

• Protocol implemented in 2016 • Duration of Mechanical Ventilation determined by ICD 10 Codes: • 5A1935Z for <24hours • 5A1945Z and 5A1955Z for >24 hours • Mortality was determined by the discharge disposition description listed as “expired” within the database query

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

13

2 0 2 1 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

04 Retrospective Assessment of Intravenous Drug Use on Southwest Virginia For Relative Risk Reduction of Proposed Needle Exchange Program

Yelena Kiseleva, DO, PGY-2; Jake Norris, DO, PGY-2; Billy Turner, DO, PGY-3; Brady Dehart, PhD; Madiha Kamal, MD Corresponding author: Yelena.kiseleva@hcahealthcare.com

LewisGale Hospital-Montgomery

The social, economic, and health consequences of intravenous drug abuse cannot be understated and methods of reducing that impact are needed. While the majority of treatment revolves around complete cessation, harm reduction methods are gaining in acceptance. Harm reduction refers to a number of approaches aimed at alleviating or curtailing the damages correlated with various behaviors in high- risk groups or individuals. One such method is the availability of community needle exchange programs, aimed at reducing IV drug use related infections from needle sharing. Our project examined the impacts

of IV drug abuse on a regional healthcare system in Southwest Virginia: including associated infections, length of stay, admission costs, and readmission rates. We found that healthcare costs of patients with substance use disorders (SUD) and IV-drug use related infections were much higher than SUD patients without IV-drug use related infections. Our analyses also indicated a significantly higher likelihood of re-admittance in patients with IV-drug use associated infections compared to SUD patients without corresponding infections. Overall, there is significant evidence to support the assertion that

needle sharing and re-use in IV drug users contribute to additional medical costs. Furthermore, this data indicates that Southwest Virginia may benefit both socially and financially from programs aimed at reducing the re-use of contaminated needles such as needle exchange programs with the byproduct of reducing healthcare costs.

14

Retrospective Assessment of Intravenous Drug Use on Southwest Virginia For Relative Risk Reduction of Proposed Needle Exchange Program Jake Norris, DO, Yelena Kiseleva, DO, Billy Turner, DO, Madiha Kamal, MD, William Dehart, PhD

Results Proportion of Re-admissions - 2 = 59.205, p < .002 Re-admitted IVDU Disease

Objective

Results Cont.

Odds of Readmission Within 90 Days Predictors Odds Ratios

Our project examined the impacts of IV drug abuse on a regional healthcare system in Southwest Virginia; including associated infections, length of stay, admission costs, and readmission rates.

CI

Total

No

Yes

Age

1.00*** 0.54*** 1.42***

1.00 – 1.01 0.49 – 0.60 1.22 – 1.65 1.09 – 2.35

5684 93.5 % 54.3 % 4781 89.4 % 45.7 % 10465 91.6 %

398 6.5 % 41.3 % 565 10.6 % 58.7 %

6082 100 % 53.2 % 5346 100 % 46.8 % 11428 100 %

Background

No

Insurance (non-Medicaid)

The social, economic, and health consequences of intravenous drug abuse cannot be understated. Harm reduction refers a number of approaches aimed at alleviating or curtailing the damages correlated definitively with various behaviors in high-risk groups or individuals. Our project examined the impacts of IV drug abuse on a regional healthcare system in Southwest Virginia. Methods and Analyses • Patient electronic health records were analyzed from four hospitals in Southwest Virginia from the following dates: 01/01/2015 through 12/31/2019 • 11,428 patients identified as having a substance use disorder • The data were divided into those without an intravenous drug-use related infection (n=10,465) and those patients with an intravenous drug-use related infection such as Hepatitis C, HIV, osteomyelitis, endocarditis etc. (n=963) • Percentage differences instead of gross amounts were used to report total billed charges due to their proprietary • Regression models were conducted to evaluate the differences in encounter cost (log transformed) and likelihood of re-admittance • Due to the large number of patients with hospital stays <24 hours, a zero-inflated negative binomial model was conducted to analyze length of stay • Lastly, logistic regression model was performed with readmission dichotomously coded as yes or no

IV Disease (Yes)

Yes

IV Disease (Yes) x Race (Black)

1.59*

* p < .05, ** p < .01, *** p < .001 Note – Race comparison group is Caucasian, Sex comparison group is Female

963 8.4 %

Total

Conclusion

Encounter Cost Predictors

This project was specific to our local community (Montgomery County, Virginia and surrounding area), in order to evaluate if there could be a benefit from a needle exchange program. Our findings indicate a higher healthcare cost for patients with IV- drug use related. Also, length of hospital stay is about twice as long (RR = 1.24, p < .001) . Our analyses also found a significantly higher re- admittance rate in patients with IVDU associated infections compared to SUD patients without such corresponding infections. Overall, there is significant evidence to support the assertion that needle sharing and re-use in IV drug users contribute to these findings. Further, this data indicates that our community may benefit from programs aimed at reducing the re-use of contaminated needles with the possible benefit of reducing healthcare costs.

Estimate

CI

Age

0.00*** -0.49*** 0.75***

0.00 - 0.00 -0.55 - -0.43 0.51 – 0.99 -0.02 – 0.07 0.73 – 0.91 -0.71 - -0.29

Insurance (non-Medicaid)

Race (Black) Sex (Male)

0.03

IV Disease (Yes)

0.82*** -0.50***

IV Disease (Yes) x Race (Black)

* p < .05, ** p < .01, *** p < .001 Note – Race comparison group is Caucasian, Sex comparison group is Female

References

• Des Jarlais, D.C. (2017). Harm Reduction in the USA: the research perspective and an archive to David Purchase. Harm Reduction Journal, 14(1), 1-7. https://doi.org/10.1186/s12954-017-0178-6 • Harm reduction: An approach to reducing risky health behaviours in adolescents. (2008). Paediatrics & Child Health, 13(1), 53-56. https://doi.org/10.1093/pch/13.1.53

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

15

2 0 2 1 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

05 Ultrasound Guided Hydrodissection Using 5% Dextrose in Sterile Water and Platelet Releasate To Treat Ulnar Nerve Entrapment Post Ulnar Nerve Translocation in D1 Women’s Basketball Student Athlete

L. Shen DO; A. Kozar DO; E. Cash PhD ATC; G. Beato DO Corresponding author: lshen@vcom.edu

Introduction : Mononeuropathy secondary to nerve compression is a common disorder that causes loss of productivity and decreases in quality of life with activities. In athletes, having a severe mononeuropathy can be debilitating and prevent the athlete from being able to train or compete. Treatment options are limited to medications, physical therapy/rehabilitation, bracing, and ultimately surgical correction. Even after undergoing surgical correct, complete resolution is not guaranteed. Nerve entrapment hydrodissection with 5% Dextrose in sterile water (D5W) has been discovered to be an effective method of decompressing and treating mononeuropathies. Case: 23-yo female, collegiate basketball athlete presented with chronic right medial elbow pain with marked hyperalgesia & allodynia. She has history of ulnar decompression with transposition at the cubital tunnel performed in May 2017. Patient felt improvement for 1- year post surgery but later progressed to having worsening discomfort surrounding her medial epicondyle and forearm. Edward Via College of Osteopathic Medicine – Virginia Campus Virginia Tech

Patient had limited relief with physical therapy and corticosteroid injections. The few months prior to the start of the 2020 season, the patient was unable to practice or use her right arm to any significant function secondary to hyperalgesia and discomfort. EMG showed evidence of demyelinating ulnar mononeuropathy at the elbow, consistent with the clinical diagnosis of cubital tunnel syndrome and elicited responses from motor fibers of the right ulnar nerve in both the ulnar groove and anterior to the medial epicondyle. MRI revealed no significant findings regarding her ulnar nerve. Diagnostic ultrasound revealed significant kinking of the ulnar nerve at the level of the FCU on the distal portion of the humerus. The cross-sectional area of the ulnar nerve was found to be 10-14mm sq in areas of enlargement and was 6mm sq in its greatest area of compression. Significant hyperechoic fascial thickening in both areas of enlargement and entrapment with loss of normal nerve fascial pattern in longitudinal viewing. Patient elected to undergo US guided hydrodissection with D5W. She tolerated the initial procedure well with mild improvement in

overall paresthesia, hyperalgesia, allodynia, focal localization of pain and right upper extremity function. A second US guided hydrodissection with platelet releasate (PRP) was performed after 3 weeks from her initial treatment with D5W. Patient tolerated second procedure well. Results: Over the course of 3 months from initial US guided hydrodissection, patient saw substantial improvement in her ulnar sensitivity, discomfort, and function. Towards the start of the 2020 season, patient was able to practice and play at a competitive level with minimal discomfort and soreness, a vast improvement in from her previous status. Discussion: Hydrodissection of nerve entrapment is a proven method of mechanical decompression of mononeuropathies. The use of US guided hydrodissection can provide patients a non-surgical treatment option to resolve moderate to severe mononeuropathies that is well tolerated. The procedure can be performed with minimal risks from anesthesia and surgical risk/complications.

16

ULTRASOUND GUIDED HYDRODISSECTION USING 5% DEXTROSE IN STERILE WATER AND PLATELET RELEASATE TO TREAT ULNAR NERVE ENTRAPMENT POST ULNAR NERVE TRANSLOCATION IN D1

WOMEN’S BASKETBALL STUDENT ATHLETE L. Shen 1,2 DO, A. Kozar 1 DO, E. Cash 2 PhD ATC, G. Beato 2 DO

Edward Via College of Osteopathic Medicine – Virginia Campus Virginia Polytechnical Institute and State University, Blacksburg, VA

Introduction

Images

Follow Up

Mononeuropathy secondary to nerve compression is a common disorder that causes loss of productivity and decreases in quality of life with activities. In athletes, having a severe mononeuropathy can be debilitating and prevent the athlete from being able to train or compete. Treatment options are limited to medications, physical therapy/rehabilitation, bracing, and ultimately surgical correction. Common mononeuropathies affecting athletes and general population include carpal tunnel syndrome and cubital tunnel syndrome. Ultrasound-guided hydrodissection has been used to treat common mononeuropathies such as carpal tunnel syndrome and often referred to in peer reviewed text as an efficient method of treatment without the side effects of corticosteroids prior to surgical management. 1 Even after undergoing surgical correction, complete resolution is not guaranteed. Nerve entrapment hydrodissection with 5% Dextrose in sterile water (D5W) has been discovered to be an effective method of decompressing and treating mononeuropathies. 23-yo female, collegiate basketball athlete presented with chronic right medial elbow pain with marked hyperalgesia & allodynia. She has history of ulnar decompression with transposition at the cubital tunnel performed in May 2017 . Patient felt improvement for 1 year post surgery but later progressed to having worsening discomfort surrounding her medial epicondyle and forearm. Patient had limited relief with physical therapy and corticosteroid injections. The few months prior to the start of the 2020 season, the patient was unable to practice or use her right arm to any significant function secondary to hyperalgesia and discomfort. EMG showed evidence of demyelinating ulnar mononeuropathy at the elbow, consistent with the clinical diagnosis of cubital tunnel syndrome. MRI revealed no significant findings regarding her ulnar nerve. Diagnostic ultrasound revealed significant kinking of the ulnar nerve at the level of the Flexor Carpi Ulnaris on the distal portion of the humerus. The cross- sectional area of the ulnar nerve was found to be 10-14mm 2 in areas of enlargement and was 6mm 2 in its greatest area of compression, normal diameter being 6.4mm 2 . Significant hyperechoic fascial thickening in both areas of enlargement and entrapment with loss of normal nerve fascial pattern in longitudinal viewing. Patient elected to undergo US guided hydrodissection with D5W. She tolerated the initial procedure well with mild improvement in overall paresthesia, hyperalgesia, allodynia, focal localization of pain and right upper extremity function. A second US guided hydrodissection with platelet releasate (PRP) was performed after 3 weeks from her initial treatment with D5W. Patient tolerated second procedure well. Report

Over the course of 3 months from initial US guided hydrodissection, patient saw substantial improvement in her ulnar sensitivity, discomfort, and function. Towards the start of the 2020 season, patient was able to practice and play at a competitive level with minimal discomfort and soreness, a vast improvement in from her previous status.

Figure 2

Conclusions

Reoccurring mononeuropathies even after multiple modalities of treatment can be a debilitating disease that often causes loss of productivity and function of patients. With US guidance, tissue deformities and structural abnormalities that are not well appreciated in other imaging modalities can be visualized in both static and dynamic testing. D5W has been shown to be well tolerated by patients as a solution to perform nerve decompression without adverse side effects that can be common with steroids including fat atrophy and transient hyperglycemia. 1 Using platelet releasate to enhance the healing process after nerve decompression has been shown to provide additional improvements in symptomatic relief compared to using only D5W. 2 Platelet releasate does require more preparation prior to injection and incurs higher costs to patients. The use of US guided hydrodissection can provide patients a non-surgical treatment option to resolve moderate to severe mononeuropathies that is well tolerated. 3 The procedure can be performed with minimal risks from anesthesia and surgical risk/complications. 4 As reflected from this case, nerve hydrodissection is a beneficial method of treating complex mononeuropathies in high level athletics.

Figure 1

Figure 3

(1) Ulnar nerve near medial epicondyle in transverse view, with signs of enlargement and compression. Hydrodissection under ultrasound guidance above (2) and below (3) the nerve.

References

Figure 4

Figure 5

1. Wu, Y.T., et al., Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Ann Neurol, 2018. 84(4): p. 601-610. 2. Wu, Y.T., et al., Six-month efficacy of platelet-rich plasma for carpal tunnel syndrome: A prospective randomized, single-blind controlled trial. Sci Rep, 2017. 7(1): p. 94. 3. Maniquis-Smigel, L., et al., Analgesic Effect of Caudal 5% Dextrose in Water in Chronic Low Back Pain. A Randomized Controlled Trial of Epidural Injection. . Anesthesiology and Pain Medicine. 2017 Feb; 7(1): e42550. Published online 2016 Dec 6. doi: 10.5812/aapm.42550 4. Lam, S.K.H., et al., Ultrasound-Guided Nerve Hydrodissection for Pain Management: An Updated Review of Anatomy and Techniques. Preprint., 2020. https://www.researchgate.net/publication/338627920_Ultrasound- Guided_Nerve_Hydrodissection_for_Pain_Management_An_Updated_Review_of_Anatomy_and_Techniques. Date accessed 1/18/21

(4) Introduction of needle to site of nerve compression in transverse view. (5) Nerve appears more normal after hydrodissection.

Acknowledgements

Figure 6 Figure 7 (6/7) Needle was introduced along the superficial aspect of the ulnar nerve in longitudinal view and hydrodissected along the length of the nerve freeing points of restriction

Acknowledgement made to the Virginia Tech Sports Medicine and Athletic Department, Women’s Basketball Team and Trainers, and VCOM Sports and Osteopathic Medicine Clinic

17

2 0 2 1 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

06 Can Patient Compliance With Continuous Positive Airway Pressure (CPAP) Be Improved?

Andrew Wyker, DO, Mary Mondul, R.EEG T, RPSGT, Kimberly Bird, MD Corresponding author: michael.moore1@LPTN.net

SOVAH Health Internal Medicine Residency Program

Introduction: Adjusting to use of CPAP for obstructive sleep apnea requires effort and lifestyle changes. It is estimated that 50% of sleep apnea patients prescribed CPAP are non-compliant with prescribed therapy one year later. Multiple strategies have been implemented to improve compliance including smaller and quieter CPAP machines, different mask types and sizes, heated humidification, mobile applications, and flexible expiratory pressures. Through increased compliance, patients benefit from better sleep, improved medical conditions such as hypertension and diabetes, and lower the risk of heart disease, stroke, cancer, and ultimately premature mortality. Methods: A retrospective study was performed which compared CPAP compliance between patients initiating CPAP with standard follow up at an American Academy of Sleep Medicine (AASM) accredited Sleep Center in 2018 versus those initiating a new team management and online cloud-

Conclusions: Data revealed that standard close follow up with an AASM accredited Sleep Center resulted in compliance that was non-inferior to team management with an online cloud-based learning program approach. Previous studies of the cloud- based management approach revealed an overall 24% increase in compliance when utilized by all physicians. Patients treated for sleep apnea by primary care physicians may benefit the most from the cloud-based program as compared to those managed by sleep specialists. A potential factor in the study’s outcome was the lack of successful patient contact during the first week in the cloud-based intervention group. In addition, both groups had patients lost to follow up after initiation of CPAP.

based learning program added to standard follow-up visits at the Center in 2019. Patients were selected at random from lists of patients requiring CPAP from both 2018 and 2019. This new 2019 program utilized CPAP Sleep Coaches and Respiratory Therapists who contacted each patient at days 3, 7, 14, 30, 45, 60, and 90 after starting CPAP to promote patient compliance. Compliance was defined based on requirements implemented by the Center for Medicare Services which include usage of CPAP at least 4 hours a night 70% of the time. Results: There were 86 patients in the 2018 control group and 86 patients in the 2019 interventional group. In the 2018 group, 36 had mild sleep apnea, 26 had moderate, and 24 had severe. In the 2019 group, 25 had mild sleep apnea, 16 had moderate, and 45 had severe. Ninety-day compliance between the 2018 and 2019 groups were 63.9% and 43.0% respectively, p value 0.005929.

18

CAN PATIENT COMPLIANCE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) BE IMPROVED? Andrew Wyker, DO, Mary Mondul, R.EEG T, RPSGT, Kimberly Bird, MD Sovah Internal Medicine Residency Program, Danville, VA

RR-6

Materials and Methods: A retrosp ec� ve s tudy was do n e c omparing CP AP c ompliance bet w een pa �en ts ini� a �ng C P AP with st anda r d f ollow up a t an Ameri c an A cade my of Sleep Medicine (AA SM) accr edi t ed Sleep Ce n ter in 2018 versus thos e a n e w t eam managemen t and o nline c loud -base d learning pr og r am added to st anda rd serial f ollow - up visits . Pa �en ts wer e selec t ed a t r and o m fr om li s ts of p a �en ts r equiring C PAP fr om 2018 and 2019 . The clo ud-base d p r og r am u�li z ed C P AP Sleep Coaches and R espi ratory Ther api sts who co n tact ed p a �en ts a t d ay s 3, 7, 14, 30, 45, 60, and 90 a �er st ar�ng C P AP t o p r omo t e p a �en t c ompliance. Compliance w as d e fined b y the Cen t er f or Me d i car e Se r vices d e fini�on w hich includ e C PAP usa ge a t lea s t 4 ho ur s a nig h t 70% of th e �me.

Introduc�on: Adjus �ng to CP AP f or o bs truc� v e slee p apne a takes e ffort and li fes tyle chang es. It is es �m ated tha t 50% of sleep apnea p a �ents pr escribed C P AP a r e n o n -c ompliant w ith pr escribed the rapy on e y ear l ater . M u l�ple strat egies hav e been used to imp rov e c ompliance including smaller and qui eter CP AP machines, diff ere n t mask t y pes and s i z es, he ated humidifi ca �on, mobile appli ca �ons, and fl e xible e xpi ratory pressures. With inc rease d c ompliance, p a �en ts ben e fit fr om b e �er sleep, imp rov ed medi c al c on d i�ons such a s hypert ensi o n and d iab et es, and lo w er risk of car di ov ascular diso rder s, c ance r , and ul�m at ely mor t alit y.

AASM Traditional Method

Cloud-Based Method

Results: Ther e wer e 86 pa �ents in the 2018 c o n tr ol g roup and 86 pa �en ts in t h e 2019 in terve n�onal g roup . In the 2018 g roup , 36 had mild slee p apnea, 26 had m oderate and 24 had severe. In t h e 2019 g roup , 25 had mild s leep apnea, 16 had mode rat e, and 45 had severe. Nin ety-day c ompliance betw een the 2018 and 2019 g r oups wer e 63.9% and 43 . 0% respe c� v el y , p v alue 0.005929.

Conclusion: Dat a rev ealed th a t st anda r d cl ose f ollow up with an AASM accr edi t ed Sleep Cen ter r esul t ed in c ompliance th a t was nonin f erior to t eam online c loud -base d learning p r og r am app roach. P re viou s s tudies of the cloud -base d management app r oach rev ealed an o ver all 24% inc rease in c ompliance when u�li z ed b y all phy sicians. Pa �en ts treat ed f or sleep apnea b y prim ary care phy sicians m a y ben e fit the mo s t f r om the c loud -base d p r og r am as c ompa r ed t o th o se managed b y sleep speciali sts. A pote n�al fact or in the study’s outc ome was the lack of succes s ful pa �ent co n t act during the fi rs t w eek in the cloud -base d int erve n�on g roup . In ad d i�on, b o th g r oups had p a �ents lo s t t o f ollow up a �er ini� a �on o f C PAP .

19

2 0 2 1 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

07 Retrospective Review of Maternal Morbidity and Obstetrical Interventions Following Intrapartum Osteopathic Manipulative Treatment (OMT)

Introduction: Few studies have demonstrated correlation between osteopathic manipulative treatment (OMT) and its direct impact on parturition. One retrospective study in 2003 revealed that the use of prenatal OMT in pregnant patients significantly decreased the incidence of meconium-stained amniotic fluid, use of forceps during delivery, and likelihood of preterm delivery1. In 2013, OMT during labor was demonstrated to decrease the incidence of vaginal tears and improved both APGAR scores and umbilical pH levels2. Much of the osteopathic literature has focused on improving pregnancy-related concerns solely within the musculoskeletal system, such as back pain or quality of life while intrapartum3. Beyond its structural importance during pregnancy, the musculoskeletal system also provides access to the neuroendocrine and cardiopulmonary systems4. These systems can impact the autonomic nervous system5, venous return, and lymphatic drainage6, which have each demonstrated benefit from OMT in individual studies. It is theorized that treating patients holistically during their pregnancy can affect these systemic variables and influence the need for Edward Via College of Osteopathic Medicine-Virginia Campus VCOM Sports and Osteopathic Medicine Samuel H. Werner, DO; Albert J. Kozar, DO, FAOASM, R-MSK Corresponding author: swerner@vt.vcom.edu

obstetric interventions, ultimately impacting maternal morbidity. Methods: This retrospective study at VCOM Sports and Osteopathic Medicine (VSOM) includes previous patients who received OMT to three or more body regions, within each of four or more visits during a single pregnancy. The VSOM EHR was searched for any office visits from 1/1/2015 to 12/31/2020 which included an ICD-10 pregnancy diagnostic code and then cross-searched for OMT CPT codes. These charts were then searched for both the quantity of OMT visits and of body regions treated, as well as details on their duration of labor and hospital stay, the use of any obstetric interventions, and maternal morbidity. For any charts with absent details, the subjects were contacted to request permission to obtain any missing records from their delivery center. Individuals who had a home birth were excluded from the study, as were non-English speakers. Data gathered from VSOM records regarding parturition outcomes will be compared to the concurrent average rates reported by the corresponding medical

institutions as well as to the national average, as available. Then, the number of OMT sessions and the number of body regions treated at each session will be compared to those outcomes, with correlations drawn as confidence permits. Results: This retrospective study is currently pending IRB approval. It will be completed in time for poster presentation in February 2020. Conclusion: We hope to quantify how intrapartum OMT reduces maternal morbidity and obstetric interventions, by considering patients who were seen iteratively throughout pregnancy thereby allowing the physician to address those chronic and underlying issues which may lead to complications during delivery. Doing so will not only provide impetus for more focused and prospective studies in the future but also provide direction for those seeking a safer and more positive birth experience which requires fewer medical or surgical interventions.

20