2022 AOA Research Abstracts and Poster Competition

Examining Levels of Catecholamine Neurotransmitter Regulatory Proteins within the Prefrontal Cortex of Rodents Following Traumatic Brain Injury

Eleni Papadopoulos, OMS-III; Christopher P. Knapp; Claire M. Corbett, PhD; Jessica A. Loweth, PhD; Rachel L. Navarra, PhD

Department of Cell Bio and Neuroscience, Rowan University School of Osteopathic Medicine

Statement of Significance: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide causing lasting impairments of cognition that leads to increased risk-taking behavior. Risk/reward related processes are modulated within the prefrontal cortex (PFC). Previous studies have shown increased catecholamine transmitter levels in the PFC immediately following TBI, which is then followed by a decreased state. Currently, the mechanisms of catecholamine imbalances following TBI in the PFC are unknown.

Research Methods: The closed head-controlled cortical impact (CH-CCI) model was used to mimic human mild TBI (mTBI) scenarios in rodents. Separate groups of young adult male and female Long Evans rats (n = 6-8) received either no injury (sham), a single injury (smTBI), or 3 repetitive injuries (rmTBI) with 2-day intervals. One week post-final injury, brain tissue from the medial (mPFC), orbitofrontal (OFC), and anterior cingulate (ACC) sub-regions of the PFC were collected. Standard Western blotting protocols were used to measure protein levels of the packaging enzyme, VMAT2, and degradation enzymes, COMT and MAO, in each region. A one-way analysis of variance (ANOVA) followed by Dunnet’s multiple comparison post-hoc tests were used to compare the percentage of protein levels from smTBI and rmTBI to sham. Our experimental paradigm was designed to create a platform to uncover novel treatment targets aimed to promote quality of life and prevent further progression of underlying pathology following TBI.

Data Analysis: Multiple injury-induced alterations of protein levels were found in the OFC. rmTBI demonstrated a trend to reduce VMAT2 when males and females were combined for analysis (p < 0.1). rmTBI also demonstrated a tendency to reduce COMT in females (p < 0.1) and a significant reduction when males and females were combined (p < 0.05). MAO-A appears to differentially increase in males, but decrease in females following injury, with more pronounced effects dependent on severity (i.e. rmTBI, p < 0.1). No differences in male and female combined analysis indicates that injury-induced regulation of MAO-A was neutralized by opposite sex-dependent effects in males vs females.

Results: Multiple injury-induced alterations of protein levels were found in the OFC. rmTBI demonstrated a trend to reduce VMAT2 when males and females were combined for analysis (p < 0.1). rmTBI also demonstrated a tendency to reduce COMT in females (p < 0.1) and a significant reduction when males and females were combined (p < 0.05). MAO-A appears to differentially increase in males, but decrease in females following injury, with more pronounced effects dependent on severity (i.e. rmTBI, p < 0.1). No differences in male and female combined analysis indicates that injury-induced regulation of MAO-A was neutralized by opposite sex-dependent effects in males vs females.

Conclusion: Decreased VMAT2 levels in the OFC indicate less capacity for packaging, storage, and release of catecholamine transmitters in this region, leading to a hypo-catecholaminergic tone as previously reported (4-13) and hypothesized here. Decreased levels of COMT in the OFC suggest reduced capacity for catecholamine degradation; however, this down regulation may result as a secondary compensatory response to lowered catecholamine levels and decreased need for degradation. Interestingly, the sex-specific decrease of MAO-A in the OFC of females following injury may underlie the sex-specific increased preference in risky choice observed in our previous behavioral data. Based upon these findings, we conclude that alterations in the levels of catecholamine neurotransmitter regulatory proteins may underlie functional catecholamine imbalances in the PFC. The sex-specific decrease of MAO-A in the OFC of rmTBI females may serve as a novel variable to further elucidate differential rmTBI-induced mechanisms of increased risky choice preference. Although this work has been limited to using a rodent TBI model where tissue was collected postmortem, these results still pose clinical relevance as they establish a pre-clinical understanding of the molecular basis of cognitive and behavioral impairments following multiple mild traumatic brain injuries. Additional studies will use pharmacological agents to further probe how sex-specific changes in catecholamine regulatory proteins impact preference for risky choice following repetitive head injury.

References

1. Smith CJ, Xiong G, Elkind JA, et al. Brain Injury Impairs Working Memory and Prefrontal Circuit Function. Front Neurol. 2015;6:240-240. doi:10.3389/fneur.2015.00240

2. Ozga JE, Povroznik JM, Engler-Chiurazzi EB, et al. Executive (dys)function after traumatic brain injury: special considerations for behavioral pharmacology. Behavioural pharmacology. 2018;29(7):617-637. doi: 10.1097/FBP.0000000000000430

3. Clark KL, Noudoost B. The role of prefrontal catecholamines in attention and working memory. Front Neural Circuits. 2014;8:33-33. doi: 10.3389/fncir.2014.00033

4. Kobori N, Clifton GL, Dash PK. Enhanced catecholamine synthesis in the prefrontal cortex after traumatic brain injury: implications for prefrontal dysfunction. J Neurotrauma. 2006;23(7):1094-1102. doi: 10.1089/neu.2006.23.1094

5. Wilson MS, Chen X, Ma X, et al. Synaptosomal dopamine uptake in rat striatum following controlled cortical impact. J Neurosci Res. 2005;80(1):85-91. doi: 10.1002/jnr.20419

6. Yan HQ, Kline AE, Ma X, et al. Tyrosine hydroxylase, but not dopamine beta-hydroxylase, is increased in rat frontal cortex after traumatic brain injury. Neuroreport. 2001;12(11):2323-2327. doi: 10.1097/00001756-200108080-00009

7. Yan HQ, Kline AE, Ma X, et al. Traumatic brain injury reduces dopamine transporter protein expression in the rat frontal cortex. Neuroreport. 2002;13(15):1899-1901. doi: 10.1097/00001756-200210280-00013

8. Huger F, Patrick G. Effect of concussive head injury on central catecholamine levels and synthesis rates in rat brain regions. Journal of neurochemistry. 1979;33(1):89-95. doi: 10.1111/j.1471-4159.1979.tb11710.x

9. Massucci JL, Kline AE, Ma X, et al. Time dependent alterations in dopamine tissue levels and metabolism after experimental traumatic brain injury in rats. Neurosci Lett. 2004;372(1-2):127-131. doi: 10.1016/j.neulet.2004.09.026

10. McIntosh TK, Yu T, Gennarelli TA. Alterations in regional brain catecholamine concentrations after experimental brain injury in the rat. Journal of neurochemistry. 1994;63(4):1426-1433. doi: 10.1046/j.1471-4159.1994.63041426.x

11. Wagner AK, Chen X, Kline AE, et al. Gender and environmental enrichment impact dopamine transporter expression after experimental traumatic brain injury. Exp Neurol. 2005;195(2):475-483. doi: 10.1016/j.expneurol.2005.06.009

12. Laskowski RA, Creed JA, Raghupathi R. Frontiers in Neuroengineering Pathophysiology of Mild TBI: Implications for Altered Signaling Pathways. In Kobeissy FH, (Ed). Brain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects. Boca Raton (FL): CRC Press/Taylor & Francis © 2015 by Taylor & Francis Group, LLC. 2015.

13. Fujinaka T, Kohmura E, Yuguchi T, et al. The morphological and neurochemical effects of diffuse brain injury on rat central noradrenergic system. Neurol Res. 2003;25(1):35-41. doi: 10.1179/016164103101201094

Financial Disclosures: None reported

Support: New Jersey Commission on Brain Injury Research CBIR20PIL004 (Navarra) and Osteopathic Heritage Foundation for Primary Care Research (Navarra).

Ethical Approval: IACUC approval #2020-1194

Informed Consent: N/A

Poster No. *B-2

Abstract No. 14

Category: Basic Science

Research Topic: Impact of OMM & OMT

Levels of Beta-endorphin in Extracellular Vesicles as Efficacy Marker for Osteopathic Manipulative Treatment of Patients with Neuropathic Pain

¹Derek Tai, OMS-IV; ¹David Wang, OMS-IV; ¹Zhiyin Lin, OMS-IV; ¹Jodi Bauson, OMS-III; ¹Gyunghwi Woo, DO; ¹Kevin Huang, DO; ¹Tony Huynh, DO; ²Mark Santos, PhD; ²Germana Rappa, MD/PhD; ¹Eric Toder, DO; ¹Aurelio Lorico, MD/PhD

¹Touro University Nevada College of Osteopathic Medicine; ²Department of Basic Sciences Research, Touro University Nevada College of Osteopathic Medicine

Statement of Significance: Almost 16 million Americans suffer from neuropathic pain. Osteopathic manipulative treatment (OMT) is not widely used in patients with neuropathic pain even though many pharmaceutical interventions have risks of side effects, including addiction. The main point of this proof-of-concept study was to establish an objective measurement of efficacy of OMT on neuropathic pain. Extracellular vesicles (EVs) are present at levels of billions/ml of blood and carry all sorts of biochemical mediators.

Research Methods: 10 patients with neuropathic pain were recruited and given informed consent as approved and dictated by the Touro University Nevada IRB. We analyzed 10 patient plasma samples collected before, immediately after, 24 hours after, and 7 days after OMT. First, we examined whether OMT treatment resulted in changes in blood plasma EV size. The same combination of myofascial release and balance ligamentous tension release techniques were utilized on all 10 patients. We then analyzed 10 patient plasma samples collected pre-OMT, directly after OMT, 24 hours after OMT, and 7 days after OMT. First, we measured changes in blood plasma EV size. The EV size was measured with Particle Metrix ZetaView NTA, calibrated and focus aligned with a 5% PBS solution. Each sample was measured 3 times to ensure accuracy and precision. Second, we used immunoblotting, specifically Western Blot, to measure changes in blood plasma EV beta-endorphin levels via ThermoFisher’s Beta Endorphin Recombinant Rabbit Monoclonal Antibody. When antibody staining was completed, we used iBright FL1000 to image the immunoblot membrane. After, we used iBright Analysis to measure the concentration of beta-endorphin levels within the blood plasma EVs. The mean and standard deviation for each patient plasma sample are presented for pre-OMT, directly after OMT, 24 hours after OMT, and 7 days after OMT. Additionally, Patients took a pain scale survey for pre-OMT, 24-hr post OMT and 1-week post OMT.

Data Analysis: We observed an increase in EV size after OMT with a gradual return to pre-OMT values 7 days later. For 3 patient samples, we observed a pre-OMT EV size of 125nm, 150nm, and 180nm. Post-OMT EV sizes measured 160nm, 155nm, and 220nm before dropping to 150nm, 150nm, and 165nm one week later respectively. Then, we examined by immunoblotting whether OMT treatment resulted in changes in blood plasma EV beta-endorphin levels. Normalized initial beta-endorphin protein band concentration for 3 patient samples were 1.18, 2.08, and 11.9 which increased to 3.3, 2.5, and 26.9 post OMT respectively before dropping back to 1.7, 2.3, and 12.8 respectively 7 days later. In conclusion, OMT caused an increase in blood plasma beta-endorphin levels, associated with an increase in EV size. These observations suggest that OMT reduces physiologic stress and pain on patients through increased production of endorphins. This information provides biochemical evidence of the efficacy of OMT and opportunities to expand its use.

Results: We observed an increase in EV size after OMT with a gradual return to pre-OMT values 7 days later. For 3 patient samples, we observed a pre-OMT EV size of 125nm, 150nm, and 180nm. Post-OMT EV sizes measured 160nm, 155nm, and 220nm before dropping to 150nm, 150nm, and 165nm one week later respectively. Then, we examined by immunoblotting whether OMT treatment resulted in changes in blood plasma EV beta-endorphin levels. Normalized initial beta-endorphin protein band concentration for 3 patient samples were 1.18, 2.08, and 11.9 which increased to 3.3, 2.5, and 26.9 post OMT respectively before dropping back to 1.7, 2.3, and 12.8 respectively 7 days later. In conclusion, OMT caused an increase in blood plasma beta-endorphin levels, associated with an increase in EV size. These observations suggest that OMT reduces physiologic stress and pain on patients through increased production of endorphins. This information provides biochemical evidence of the efficacy of OMT and opportunities to expand its use.

Conclusion: Our results suggest that there is a significant difference in EV size and beta-endorphin values post-OMT compared to pre-OMT values, demonstrating that OMT induces biochemical changes and physiologic reduction in pain in patients. Although we were able to only analyze 10 patient samples, these results provide many more opportunities to investigate the efficacy of OMT not only in neuropathic pain, but in other conditions like edema or vascular restrictions. We hope to recruit more patients in future studies and refine and expand our pain surveys to explore other biochemical changes during OMT and strengthen and validate the efficacy of OMT as an additional treatment option in clinical practice.

References

1. Properzi, F., Logozzi, M., and Fais, S. (2013) Exosomes: the future of biomarkers in medicine. Biomark Med 7, 769-778

2. Gardiner, C., Harrison, P., Belting, M., Boing, A., Campello, E., Carter, B. S., Collier, M. E., Coumans, F., Ettelaie, C., van Es, N., Hochberg, F. H., Mackman, N., Rennert, R. C., Thaler, J., Rak, J., and Nieuwland, R. (2015) Extracellular vesicles, tissue factor, cancer and thrombosis - discussion themes of the ISEV 2014 Educational Day. J Extracell Vesicles 4, 26901

3. Crewe, C., Joffin, N., Rutkowski, J. M., Kim, M., Zhang, F., Towler, D. A., Gordillo, R., and Scherer, P. E. (2018) An Endothelial-to-Adipocyte Extracellular Vesicle Axis Governed by Metabolic State. Cell 175, 695-708 e613

Financial Disclosures: None reported

Support: A $3000 grant provided by Touro College Student Research Fellowship Grant Program. The following materials would be required to successfully collect the proposed data. The majority of our supplies came from Thermo Scientific and its associated branches. We allocated $450 for blood processing supplies such as needles, tubes, and so on for proper specimen collection, $400 for ultracentrifuge tubes to allow us to centrifuge the samples, $350 for ThermoFisher’s Beta Endorphin Recombinant Rabbit Monoclonal Antibody to allow us to identify the endorphins in the sample through Western Blot, $200 for gels and buffers for immunoblotting, and $100 for syringes to allow for proper handling and transfer of the samples. The remaining $1500 was evenly distributed among the contributing authors for living expenses during the duration of the project.

Ethical Approval: This project has been approved by Touro University Nevada’s Institutional Biosafety Committee (protocol reference number: AL-COM-19-002). Additionally, this project involves human subjects and has been approved by Touro University Nevada’s Institutional Review Board (protocol reference number: TUNIRB000077).

Informed Consent: The study was performed on already collected extracellular vesicle purified from patients’ plasma mainly collected to study markers of venous stasis, and therefore did not require additional blood withdrawals or discomfort to the patients. Due to the risks associated with handling human tissue, we treated all specimens, body fluids, and blood as potentially infectious (Hepatitis B, Hepatitis C, HIV) to minimize the likelihood of blood-to-blood exposure. Work with human blood was performed in a BSL-2 certified laboratory. In case of spills, the centrifuge was disinfected immediately with 10% bleach. Moreover, benches and laminar flow hood surfaces where blood has been handled was cleaned and decontaminated at the completion of work.

Poster No. *B-3

Abstract No. 16

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

A DBA/2J Strain Mouse Model of Warfarin-Induced Calcification: A Pilot Study Investigating Ultrasound Physiological Parameters

Julie Brett Ochs, OMS-II; Puneet Dhaliwal; Mohnish Singh; Danyang, MA, OMS-II; Mugdha Padalkar, PhD; Olga V. Savinova, PhD

Department of Biomedical Sciences, New York Institute of Technology

Statement of Significance: Recent publications illustrated a correlation between warfarin, a leading prescribed anticoagulant, and increased vascular calcification [1-3]. Based on literature review, DBA/2J mice are susceptible to vascular calcification and can reproduce vascular side effects of warfarin use [3-6]. Vascular calcification increases aortic stiffness and can lead to left ventricular hypertrophy [3]. Thus, we aim to identify additional physiological parameters in a model of warfarin-induced calcification [6].

Research Methods: Animals: This prospective interventional project utilized DBA/2J mice strains obtained from the Jackson Laboratory (Strain #:000671). Sixteen, two-month-old mice were randomly assigned to two groups (8 animals per group, 50% males). The control group was fed a standard diet with 1.5% Vitamin K supplement and the treatment group received 3.0 mg/g warfarin with a 1.5% Vitamin K supplemented diet [7]. Cages, consisting of four mice, were maintained in a 12-hour light and dark cycle throughout the experiment at the New York Institute of Technology College of Osteopathic Medicine animal facility.

Echocardiography: Echocardiogram imaging consisted of long-axis B-mode, short-axis B-mode, M-mode, and doppler using Vevo 3100 ultrasound system [8,9]. Mice were anesthetized with 3% isoflurane for induction, ranging from 2-3% for maintenance, while heart rate and respiration were monitored on a heated platform at 40-42 degrees Celsius. LV mass was obtained by echocardiography of the left ventricle by isolating the long-axis and then moving the probe 90 degrees to the short-axis. Images were analyzed using Vevo LAB software. The anterior and posterior left ventricular walls were traced excluding papillary muscle to measure LV geometry and contractile function.

Statistics: Power was calculated based on results from Van den Bergh, G., et al 2021 [7]. Analysis was performed using GraphPad Prism software. Pulse wave velocity (PWV), left ventricular mass (LV), body weight (BW), fractioning shortening (FS), left ventricular: ejection fraction (LVEF), systolic diameter (LVIDs), diastolic diameter (LVIDd), heart rate (HR) and cardiac output (CO) were quantitative variables. Two-way ANOVA, unpaired t-tests and multiple linear regression were used. Significance was determined at a p-value < 0.05.

Understanding the physiological parameters for a cardiovascular reversal model is in the spirit with osteopathic philosophy and study of promoting self-healing and vascular function restoration.

Data Analysis: Baseline and 4-week analysis

Pulse wave velocity (m/s) average increased between baseline and 4-weeks from 2.165 m/s to 2.624 m/s (p-value = 0.0005) but was insignificant between warfarin (2.642 m/s) and control (2.607 m/s) diets (p-value = 0.5263). The average body weight at baseline was 21.4 g and increased significantly independent of group assignment to 24.0 g (p-value < 0.0001). There was no significant change in left ventricular mass between control (4.767 mg/g) and warfarin (4.455 mg/g) groups after 4-weeks of treatment (p-value = 0.7452) or from baseline average (4.646 mg/g) to 4-week time point (4.611 mg/g) (p-value = 0.8925). Mean FS increased from 31.10% to 37.74% (p-value = 0.0388) yet, there was no significant change after 4-weeks between control (39.02%) and warfarin (36.45%) groups (p-value = 0.7695). However, mean LVEF did not significantly increase from baseline 59.09% to 67.53% (p-value = 0.0509), and there was no significant change between control (69.15%) and warfarin (65.91%) groups after 4-weeks (p-value = 0.7854). LVIDs/BW decreased from 0.1246 mm/g to 0.1048 mm/g after 4 weeks (p-value = 0.0124). Similarly, LVIDd/BW did decrease between baseline (0.1807 mm/g) and 4-week data collection (0.1686 mm/g) (p-value = 0.0497). HR decreased from 455.9 BPM to 414.5 BPM at 4-weeks (p-value = 0.0200). CO when adjusted for body weight did not change significantly from baseline average (0.7929 mL/min) to 4-week time point average of (0.8363 mL/min) (p-value = 0.5520) or between control (0.7609 mL/min) and warfarin (0.9117 mL/min) treated groups (p-value = 0.2778).

Results: Baseline and 4-week analysis: Pulse wave velocity (m/s) average increased between baseline and 4-weeks from 2.165 m/s to 2.624 m/s (p-value = 0.0005) but was insignificant between warfarin (2.642 m/s) and control (2.607 m/s) diets (p-value = 0.5263). The average body weight at baseline was 21.4 g and increased significantly independent of group assignment to 24.0 g (p-value < 0.0001). There was no significant change in left ventricular mass between control (4.767 mg/g) and warfarin (4.455 mg/g) groups after 4-weeks of treatment (p-value = 0.7452) or from baseline average (4.646 mg/g) to 4-week time point (4.611 mg/g) (p-value = 0.8925). Mean FS increased from 31.10% to 37.74% (p-value = 0.0388) yet, there was no significant change after 4-weeks between control (39.02%) and warfarin (36.45%) groups (p-value = 0.7695). However, mean LVEF did not significantly increase from baseline 59.09% to 67.53% (p-value = 0.0509), and there was no significant change between control (69.15%) and warfarin (65.91%) groups after 4-weeks (p-value = 0.7854). LVIDs/BW decreased from 0.1246 mm/g to 0.1048 mm/g after 4 weeks (p-value = 0.0124). Similarly, LVIDd/BW did decrease between baseline (0.1807 mm/g) and 4-week data collection (0.1686 mm/g) (p-value = 0.0497). HR decreased from 455.9 BPM to 414.5 BPM at 4-weeks (p-value = 0.0200). CO when adjusted for body weight did not change significantly from baseline average (0.7929 mL/min) to 4-week time point average of (0.8363 mL/min) (p-value = 0.5520) or between control (0.7609 mL/min) and warfarin (0.9117 mL/min) treated groups (p-value = 0.2778).

Conclusion: DBA/2J mice after 4-week administration of warfarin at 3mg/g did not demonstrate significant cardiac physiological changes based on echocardiogram. Our results did not demonstrate a PWV trending towards significance at the 4-week time period described in Kruger et al, 2013 [6]. Increased body weight for control and warfarin fed mice indicate 3mg/g did not correlate with growth inhibition at the 4-week time interval. Confounding variables that may also impact cardiac development or physiology include decreased regular exercise because warfarin and control diets were placed directly in cages. Decreased heart rate at the second visit could be due to increased use of anesthesia required for sedation. Furthermore, we aim to continue the experiment through the 12-week time point to follow potential PWV and LV mass trends as understanding hypertrophic response is critical to managing the adverse effects of long-term use of warfarin.

References

1. De Mare A, Opdebeeck B, Neven E, D’Haese PC, Verhulst A. Sclerostin Protects Against Vascular Calcification Development in Mice. J Bone Miner Res. Jan 17 2022;doi:10.1002/jbmr.4503

2. Poterucha TJ, Goldhaber SZ. Warfarin and Vascular Calcification. Am J Med. Jun 2016;129(6):635 e1-4. doi:10.1016/j.amjmed.2015.11.032

3. Mac-Way F, Poulin A, Utescu MS, et al. The impact of warfarin on the rate of progression of aortic stiffness in hemodialysis patients: a longitudinal study. Nephrol Dial Transplant. Nov 2014;29(11):2113-20. doi:10.1093/ndt/gfu224

4. Schurgers LJ, Teunissen KJF, Knapen MHJ, et al. Novel Conformation-Specific Antibodies Against Matrix γ-Carboxyglutamic Acid (Gla) Protein. Arteriosclerosis, Thrombosis, and Vascular Biology. 2005;25(8):1629-1633. doi:10.1161/01.ATV.0000173313.46222.43

5. Elango K, Javaid A, Khetarpal BK, et al. The Effects of Warfarin and Direct Oral Anticoagulants on Systemic Vascular Calcification: A Review. Cells. Mar 31 2021;10(4)doi:10.3390/cells10040773

6. Kruger T, Oelenberg S, Kaesler N, et al. Warfarin induces cardiovascular damage in mice. Arterioscler Thromb Vasc Biol. Nov 2013;33(11):2618-24. doi:10.1161/ATVBAHA.113.302244

7. Van den Bergh G, De Moudt S, Van den Branden A, et al. Endothelial Contribution to Warfarin-Induced Arterial Media Calcification in Mice. Int J Mol Sci. Oct 27 2021;22(21)doi:10.3390/ijms222111615

8. Zhao W, Zhao T, Chen Y, et al. A Murine Hypertrophic Cardiomyopathy Model: The DBA/2J Strain. PLOS ONE. 2015;10(8):e0133132. doi:10.1371/journal.pone.0133132

9. Hart CC, Lee Yi, Hammers DW, Sweeney HL. Evaluation of the DBA/2J mouse as a potential background strain for genetic models of cardiomyopathy. bioRxiv. 2022:2022.05.16.492163. doi:10.1101/2022.05.16.492163

Financial Disclosures: None reported.

Support: New York Institute of Technology College of Osteopathic Medicine Summer Research Program.

Ethical Approval: Procedures and practices were approved and performed according to IACUC regulatory standards: IACUC protocol #2022-OS-01.

Informed Consent: Not Applicable

Poster No. *B-4

Abstract No. 80

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Does Intestinal Fructose Metabolism Occur in Humans?

¹Gagandeep Gill, OMS-II; ¹Sergiu P. Palii, PhD; ¹Angela Arata, BS; ¹Mariel Dologmandin, MS; ¹Sally Chiu, PhD; ²Jean-Marc Schwarz, PhD; ³Grace Marie Jones, PhD

¹Department of Research, Touro University College of Osteopathic Medicine-CA; ²Department of Research and Department of Basic Science, Touro University College of Osteopathic Medicine-CA; ³Department of Basic Science, Touro University College of Osteopathic Medicine-CA

Statement of Significance: Fructose consumption has soared since the introduction of High-Fructose Corn Syrup (HFCS) in the 1970s. Now, an average American consumes 94 grams of added sugars per day, nearly 3-4 times the recommendation¹. Increased fructose intake is correlated with insulin resistance, hyperlipidemia, inflammation, and metabolic syndrome^{1, 2,3}. High dietary fructose is associated with the development of cardiovascular disease, obesity, diabetes,⁴ dementia,⁵ cancer,⁶ and non-alcoholic fatty liver disease.⁷

Research Methods: Healthy adult volunteers were recruited based on specific criteria. Males and females between 18-65 y/o who willingly participated were included. Participants were excluded if: pregnant; nursing; taking hypolipidemic, diabetic, hypertensive or depression meds; or diagnosed with diabetes, liver, kidney, or thyroid disorders. Participants consumed a standardized diet, a commercially prepared tuna sandwich and a one-liter sugar-sweetened beverage (SSB) divided into 9 meals and 17 drinks consumed over the 8 hour study day by each subject. A stable isotope, sodium [1-¹³C] acetate, was combined with the SSB and administered orally. Blood was drawn every 30 minutes. Triglyceride-rich lipoproteins (TRL) were isolated by ultracentrifugation of plasma at 40000 rpm for ≥17 hours. Isolated TRL were applied to immuno-affinity columns to separate postprandial TRL, very low density lipoproteins (VLDL) from chylomicrons (CM). Intestinal DNL was determined from CM and Hepatic DNL from VLDL. Lipids were extracted from VLDL and CM fractions by Folch Solvent Extraction. Triglycerides were then isolated by Thin Layer Chromatography (TLC) and transmethylated by Methanolic HCl to fatty acid methyl esters. Fractional DNL was calculated using mass isotopomer distribution analysis (MIDA). A 2-tailed t-test was performed on area under the curve (AUC) data to determine any significant difference between CM-DNL AUC and VLDL-DNL AUC (t 2–8 hours). This study has Osteopathic significance because Osteopaths go beyond managing conditions by promoting behaviors and lifestyle choices that ensure a patient’s overall wellness. The Osteopathic tenet of self-regulation, self-healing, and health maintenance encourages patients to make healthy nutritional choices to prevent disease states. This study provides the foundation for larger studies that will advance an Osteopath’s ability to practice evidence based medicine and inform patients on how increased fructose consumption might negatively impact health.

Data Analysis: We successfully separated CM from VLDL using an improved immunoaffinity methodology.⁹ Fractional DNL (% of newly synthesized palmitate isolated from CM and VLDL fractions) was measured using gas chromatography/mass spectrometry (GC/MS) and mass isotopomer distribution analysis (MIDA). The first detectable DNL sample in both VLDL and CM fractions came 2 hours after the beginning of the oral tracer study. At that time, fractional DNL was approximately 6% in VLDL and 1.5% in CM. As time progressed, the fractional DNL in the VLDL fraction increased and plateaued at 15% at hour 4 through the end of the study. However, unlike the VLDL fraction, the CM fraction plateaued at hour 2.5 at 3% through the end of the sampling period. In the VLDL fraction, AUC-DNL averaged 53.6 (n = 2, t 2–8 hours) and in the CM fraction, AUC-DNL averaged 15.2 (n = 2, t 2–8 hours). Between the two participants, we found minimal individual differences. In participant A, a 36-year-old female, BMI of 27.4 kg/m2, we observed CM-DNL plateau at 6% (t 5 hours) and VLDL-DNL plateau at 15% (t 5 hours). In participant B, a 29-year-old female, BMI of 21 kg/m2, we observed CM-DNL plateau at 2.5% (t 3 hours) and VLDL-DNL plateau at 16% (t 5 hours). Participant A had a VLDL-DNL AUC of 82.59 and a CM-DNL AUC of 26.94. Participant B had a VLDL-DNL AUC of 101.31 and a CM-DNL AUC of 10.7. We found the difference between CM-DNL AUC and VLDL-DNL AUC to be significantly different (p < 0.03, n = 2).

Results: We successfully separated CM from VLDL using an improved immunoaffinity methodology.⁹ Fractional DNL (% of newly synthesized palmitate isolated from CM and VLDL fractions) was measured using gas chromatography/mass spectrometry (GC/MS) and mass isotopomer distribution analysis (MIDA). The first detectable DNL sample in both VLDL and CM fractions came 2 hours after the beginning of the oral tracer study. At that time, fractional DNL was approximately 6% in VLDL and 1.5% in CM. As time progressed, the fractional DNL in the VLDL fraction increased and plateaued at 15% at hour 4 through the end of the study. However, unlike the VLDL fraction, the CM fraction plateaued at hour 2.5 at 3% through the end of the sampling period. In the VLDL fraction, AUC-DNL averaged 53.6 (n = 2, t 2–8 hours) and in the CM fraction, AUC-DNL averaged 15.2 (n = 2, t 2–8 hours). Between the two participants, we found minimal individual differences. In participant A, a 36-year-old female, BMI of 27.4 kg/m2, we observed CM-DNL plateau at 6% (t 5 hours) and VLDL-DNL plateau at 15% (t 5 hours). In participant B, a 29-year-old female, BMI of 21 kg/m2, we observed CM-DNL plateau at 2.5% (t 3 hours) and VLDL-DNL plateau at 16% (t 5 hours). Participant A had a VLDL-DNL AUC of 82.59 and a CM-DNL AUC of 26.94. Participant B had a VLDL-DNL AUC of 101.31 and a CM-DNL AUC of 10.7. We found the difference between CM-DNL AUC and VLDL-DNL AUC to be significantly different (p < 0.03, n = 2).

Conclusion: Isolation of the CM and VLDL particles allows for the assessment of metabolic activity in the tissues of origin, here DNL. The presence of the [1-¹³C] acetate tracer in newly synthesized palmitate found in the CM fraction strongly suggests the occurrence of DNL in the human small intestine. It has been known that fructose is processed by the liver, in part, by metabolizing fatty acids via DNL and packaging the metabolic end-products into VLDL particles. Using mouse models, Jang et al.⁸ demonstrated that the small intestine metabolized fructose to glucose via gluconeogenesis. In this study, we found that human fructose-derived TRL particles originate from either the liver or the small intestine as VLDL and CM, respectively. Both particles are responsible for lipid transport in circulation and may be responsible for sugar-induced postprandial lipidemia. Jang et al. also hypothesized that intestinal fructose metabolism functions as a mechanism to shield the liver from oral fructose loads, in a saturable manner⁸. The preliminary data here agree as the CM-DNL for both participants plateau and saturate early in the study, (t 3 hours). While further work is required to assess intestinal DNL and intestinal fructose metabolism functioning as a shield to the liver, it may lead to an understanding of how the human body is impacted by and responds to different doses of fructose. Due to the large difference in turnover rates, it will also be important to quantify absolute amounts of VLDL and CM to fully understand the magnitude of the intestine’s involvement in fructose metabolism. The future application of the immunoaffinity method is to further elucidate intestinal fructose metabolism by assessing the impact of different dietary conditions on DNL and TRL metabolism as well as their contributions to increased risk for cardiovascular disease and other aforementioned chronic diseases.

References

1. Bidwell AJ. Chronic Fructose Ingestion as a Major Health Concern: Is a Sedentary Lifestyle Making It Worse? A Review. Nutrients. 2017;9(6):549. Published 2017 May 28. doi:10.3390/nu9060549

2. Miller A, Adeli K. Dietary fructose and the metabolic syndrome. Curr Opin Gastroenterol. 2008;24(2):204-209. doi:10.1097/MOG.0b013e3282f3f4c4

3. Lê KA, Faeh D, Stettler R, et al. A 4-wk high-fructose diet alters lipid metabolism without affecting insulin sensitivity or ectopic lipids in healthy humans. Am J Clin Nutr. 2006;84(6):1374-1379. doi:10.1093/ajcn/84.6.1374

4. Pollock NK, Bundy V, Kanto W, et al. Greater fructose consumption is associated with cardiometabolic risk markers and visceral adiposity in adolescents [published correction appears in J Nutr. 2013 Jan;143(1):123]. J Nutr. 2012;142(2):251-257. doi:10.3945/jn.111.150219

5. Stephan BC, Wells JC, Brayne C, Albanese E, Siervo M. Increased fructose intake as a risk factor for dementia. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2010;65A(8):809-814. doi:10.1093/gerona/glq079

6. Port AM, Ruth MR, Istfan NW. Fructose consumption and cancer: is there a connection?. Curr Opin Endocrinol Diabetes Obes. 2012;19(5):367-374. doi:10.1097/MED.0b013e328357f0cb

7. Abdelmalek MF, Suzuki A, Guy C, et al. Increased fructose consumption is associated with fibrosis severity in patients with nonalcoholic fatty liver disease. Hepatology. 2010;51(6):1961-1971. doi:10.1002/hep.23535

8. Jang C, Hui S, Lu W, et al. The Small Intestine Converts Dietary Fructose into Glucose and Organic Acids. Cell Metab. 2018;27(2):351-361.e3. doi:10.1016/j.cmet.2017.12.016

9. Jones GM, Caccavello R, Palii SP, et al. Separation of postprandial lipoproteins: improved purification of chylomicrons using an ApoB100 immunoaffinity method. J Lipid Res. 2020;61(3):455-463. doi:10.1194/jlr.D119000121

Financial Disclosures: None reported.

Support: Touro University California, NIH R01HL113887

Ethical Approval: IRB# TUC IRB Application #0716

Informed Consent: The informed consent is approved by the Touro University-California Institutional Review Board. The informed consent is a detailed description of the research study and its goals, as well as the risks and benefits of study participation, written in layman terms. Participants were able to read, discuss, and ask questions before, during, and after enrolling in the study. Participants were consented by research staff and given a copy of the entire consent form for their reference.

★ Poster No. *B-5

Abstract No. 79

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Measuring the Oxidation of Varying 2-¹³C Fructose Loads During a 6-hour Feeding Protocol

¹Marc Matossian, OMS-II; ²Mariel Dologmandin, MS; ²Sally Chiu, PhD; ³Nathalie Bergeron; ²Jean-Marc Schwarz, PhD; ⁴Grace Marie Jones, PhD

¹Touro University College of Osteopathic Medicine-CA; ²Department of Research, Touro University College of Osteopathic Medicine-CA; ³Department of Biological and Pharm, Touro University College of Osteopathic Medicine-CA; ⁴Department of Basic Science, Touro University College of Osteopathic Medicine-CA

Statement of Significance: The increased incidence of chronic diseases (diabetes, and fatty liver) has warranted research on the risk factors that influence their occurrence. Lifestyle, namely sugar consumption, is implicated in the increased risk for chronic diseases.¹ Dietary sugars can be used by the body for energy, stored as fat, or other fates.² Fructose intake in particular, has been linked to the chronic diseases mentioned.³ For this reason, elucidating the metabolic fates of fructose is of interest.

Research Methods: Five participants were selected for this study based on the following criteria. They were between 20-55 years, had a BMI between 22 to 35 kg/m2, and were normoinsulinemic with normoglycemia [fasting insulin <12 μIU/mL, fasting glucose <100 mg/dL, HbA1c < 5.7]. An equal number of men and women were recruited. Exclusion criteria included: pregnancy or lactation within the past six months; type 1 or 2 diabetes mellitus (fasting glucose ≥126 mg/dL, HbA1c ≥6.5%); history of liver disease or AST and ALT above the upper limit of normal (ULN); fasting triglyceride or total cholesterol levels above ULN; use of any anti-diabetic medications or hypolipidemic agents in the past six months; self-reported change in body weight greater than 5% in the past six months; history of other conditions known to affect insulin sensitivity and lipid metabolism, known intolerance to components of test meals; or any other condition that would put the participant at risk. Subjects participated in two 6-hour tracer study days in which isocaloric liquid meals containing low-fructose, 18 grams 2-13C-fructose, on one day and high fructose, 48 grams 2-13C-fructose, on another day (the order was randomized). On both study days, expired CO2 was collected over the 6 hour period to measure 13C enrichment by isotope-ratio mass spectrometry. To calculate fructose oxidation, we employed the equation described by Egli et. al, where 13CO2 enrichment in conjunction with VCO2 and the enrichment of fructose load were used to calculate oral fructose oxidation in grams per minute.⁵ A paired t-test was employed to evaluate the difference between the total fructose oxidized during the low-fructose study day versus the high-fructose study day. This study promotes the osteopathic tenet of basing rational treatment on the mind, body, and spirit of the patient, through a better understanding of fructose metabolism and its disease risk.

Data Analysis: Three males and 2 females completed the study. The average amount of fructose oxidized during the low-fructose meals was 6.4 ± 1.1 grams of fructose load, versus 12.9 ± 1.7 grams during the high-fructose meals. The proportion of the fructose load oxidized during the low dose meal was 33.8 ± 6.3% vs. 26.9 ± 3.5% for the high dose meal. A paired t-test showed that the absolute amount of fructose oxidized was higher with the large fructose load (p = 0.0001).However, the fraction of the fructose load oxidized was significantly lower with the higher fructose load (p = 0.004). There were no significant differences in the amount of fructose oxidation (p = 0.7) or the fraction of fructose load oxidized (p = 0.3) between the 3 male and 2 female participants.

Results: Three males and 2 females completed the study. The average amount of fructose oxidized during the low-fructose meals was 6.4 ± 1.1 grams of fructose load, versus 12.9 ± 1.7 grams during the high-fructose meals. The proportion of the fructose load oxidized during the low dose meal was 33.8 ± 6.3% vs. 26.9 ± 3.5% for the high dose meal. A paired t-test showed that the absolute amount of fructose oxidized was higher with the large fructose load (p = 0.0001).However, the fraction of the fructose load oxidized was significantly lower with the higher fructose load (p = 0.004). There were no significant differences in the amount of fructose oxidation (p = 0.7) or the fraction of fructose load oxidized (p = 0.3) between the 3 male and 2 female participants.

Conclusion: These findings suggest that the fraction of fructose sample that is oxidized to carbon dioxide decreases as the load of fructose increases, as shown when comparing oxidation during the 18 gram meals versus the 48 gram meals. As the amount of dietary fructose increases, a threshold is reached, after which the proportion of the fructose load that is oxidized as carbon dioxide decreases. Increasing the fructose load by 2.7 times, from 18 grams to 48 grams, only resulted in a 2-fold increase in total oxidation rates, illustrating this disproportion. This difference suggests that the total amount of fructose that is oxidized is dictated more by the energy demands of the individual, as opposed to the dose of fructose given. This finding relates to fructose oxidation as a whole, in which several avenues of metabolism exist, including oxidation, storage as triglycerides via DNL, glycogen synthesis, etc.⁶ As less fractional oxidation occurs at high fructose loads, we suggest that the fraction of fructose contributing to DNL, and other metabolic fates, may increase. On average, about 30% of the consumed fructose was oxidized as exhaled carbon dioxide. This represents a significant portion of the original load, and enhances our understanding of the regulation of fructose metabolism, and how the crossroads between oxidation, fat storage, glucose conversion and lactate production are affected based on the amount ingested. It would be valuable to further investigate the threshold value of oxidation, in order to better understand the tipping point, and to better inform dietary recommendations.

References

1. Ruiza G Ang B, Yu GF. The role of fructose in type 2 diabetes and other metabolic diseases. Journal of Nutrition & Food Sciences. 2018;08(01). doi:10.4172/2155-9600.1000659

2. Softic S, Stanhope KL, Boucher J, et al. Fructose and hepatic insulin resistance. Critical Reviews in Clinical Laboratory Sciences. 2020;57(5):308-322. doi:10.1080/10408363.2019.1711360

3. Patterson ME, Yee JK, Wahjudi P, Mao CS, Lee W-NP. Acute metabolic responses to high fructose corn syrup ingestion in adolescents with overweight/obesity and diabetes. Journal of Nutrition & Intermediary Metabolism. 2018;14:1-7. doi:10.1016/j.jnim.2018.08.004

4. Sun SZ, Empie MW. Fructose metabolism in humans – what isotopic tracer studies tell us. Nutrition & Metabolism. 2012;9(1):89. doi:10.1186/1743-7075-9-89

5. Egli L, Lecoultre V, Cros J, et al. Exercise performed immediately after fructose ingestion enhances fructose oxidation and suppresses fructose storage1. The American Journal of Clinical Nutrition. 2015;103(2):348-355. doi:10.3945/ajcn.115.116988

6. Stanhope KL, Schwarz JM, Keim NL, et al. Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans. Journal of Clinical Investigation. 2009;119(5):1322-1334. doi:10.1172/jci37385

Financial Disclosures: None reported.

Support: This study is support by NIH Grants: NIH R01DK116033, NIH R01DK132064

Ethical Approval: The study was approved by Touro University-California Institutional Review Board (TUC IRB Application # M-3018)

Informed Consent: The informed consent is approved by the Touro University-California Institutional Review Board. The informed consent is a detailed description of the research study and its goals, as well as the risks and benefits of study participation, written in laymen terms. Participants were able to read, discuss, and ask questions before, during, and after enrolling in the study. Participants were consented by research staff and given a copy of the entire consent form for their reference.

★ Poster No. *B-6

Abstract No. 38

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Hypomethylating Agent Azacitidine in Treating Regular and Brain Metastasized HER2-positive Breast Cancer

¹Kelsey Donoughe, OMS-II; ²Lauren Forchette; ²William Sebastian; ²Christopher Butler; ²Tuoen Liu, MD, PhD

¹West Virginia School of Osteopathic Medicine; ²Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine

Statement of Significance: Breast cancer is the second leading cause of cancer with the highest mortality rate in females in the United States [1]. Late stage breast cancer can metastasize to different locations of the body, and patients with brain metastasis have a poor prognosis and short survival time. HER2-positive breast cancer, composed of ∼15-20% of total cases, is aggressive with unfavorable clinical outcomes. Although HER2-targeted therapies are available, they are mostly ineffective against brain metastasis.

Research Methods: Cells and chemicals: The brain metastasized HER2-positive breast cancer cell line (JIMT-1 Br) and its parental regular breast cancer cell line (JIMT-1) were used in the study. Both cell lines were cultured at 37°C, 5% CO2, in DMEM medium containing 10% FBS, 10 mM L-glutamine, and 1X penicillin/streptomycin. The agent AZA was purchased from Sigma-Aldrich Inc. The cells were treated with AZA and the following methods were used to determine its effectiveness.

Cell counting: BioRad TC20TM automated cell counter was used to count the number of live and dead cells.

MTT assay: Cell viability was measured using the MTT assay kit. The IC50 values of AZA were calculated based on the cell viability measured by three independent MTT assays.

Apoptosis assay: Cell apoptosis was measured using the PE Annexin V apoptosis detection kit. The percentage of apoptotic (Annexin-V positive) cells was detected and analyzed using flow cytometry.

Western blotting assay: The expression of proteins was measured using Western blotting assay. Briefly, cell lysates were prepared in RIPA buffer, and protein samples were loaded on an SDS-polyacrylamide gel, separated by electrophoresis, and subsequently transferred to a PVDF membrane. Membranes were blocked with 5% milk in 1X TBS containing 0.05% (v/v) Tween-20 for 4 hours at room temperature and washed seven times with 1X TBS and 1X TBST alternatively. Membranes were then incubated with primary antibody overnight at 4°C followed by incubation with secondary antibody at room temperature for 1 hour. Pierce supersignal chemiluminescent substrates were used, and images were captured by using the gel doc system.

Statistics: Statistical significance of the data between two groups was analyzed by the Student’s t test (Prism 8), and more than two groups was analyzed by one-way ANOVA with a Tukey posttest (Prism 8). Significance levels were set at p < 0.05 (*), p < 0.01 (**), and p < 0.001 (***).

Data Analysis: Brain metastasized HER2-positive breast cancer (JIMT-1 Br) cells have similar growth rate compared to their parental regular breast cancer (JIMT-1) cells. Equal number of cells were plated in 6-well plates in vitro on day 0 and cell numbers were counted each day for 5 days. The fold change of cell numbers in each day was compared, and the results suggested that both cell lines have similar growth rates.

Regular breast cancer cells are more sensitive to AZA treatment. (1) The IC50 value of AZA in JIMT-1 cells is significantly lower than that in JIMT-1 Br cells (35 ± 14 µM vs. 98 ± 23 µM , p AZA treatment does not significantly change the expression of metastasis protein markers in either cell line. Epithelial-mesenchymal transition is defined by the loss of epithelial and acquisition of mesenchymal characteristics, which promotes cancer cell progression, invasion, and metastasis into surrounding microenvironment. Epithelial markers include cytokeratins (consist of at least 20 members including keratin 18 and 19) and E-cadherin, and mesenchymal markers include N-cadherin and vimentin. We measured the expression of those markers in both cell lines after AZA treatment, and found that the expression of pan-cytokeratins and keratin 18 were equivalent between both cell lines upon AZA treatment. However, the expression of keratin 19, E-cadherin, V-cadherin, and vimentin were not detected in either cell line.

Results: Brain metastasized HER2-positive breast cancer (JIMT-1 Br) cells have similar growth rate compared to their parental regular breast cancer (JIMT-1) cells. Equal number of cells were plated in 6-well plates in vitro on day 0 and cell numbers were counted each day for 5 days. The fold change of cell numbers in each day was compared, and the results suggested that both cell lines have similar growth rates.

Regular breast cancer cells are more sensitive to AZA treatment. (1) The IC50 value of AZA in JIMT-1 cells is significantly lower than that in JIMT-1 Br cells (35 ± 14 µM vs. 98 ± 23 µM , p AZA treatment does not significantly change the expression of metastasis protein markers in either cell line. Epithelial-mesenchymal transition is defined by the loss of epithelial and acquisition of mesenchymal characteristics, which promotes cancer cell progression, invasion, and metastasis into surrounding microenvironment. Epithelial markers include cytokeratins (consist of at least 20 members including keratin 18 and 19) and E-cadherin, and mesenchymal markers include N-cadherin and vimentin. We measured the expression of those markers in both cell lines after AZA treatment and found that the expression of pan-cytokeratins and keratin 18 were equivalent between both cell lines upon AZA treatment. However, the expression of keratin 19, E-cadherin, V-cadherin, and vimentin were not detected in either cell line.

Conclusion: In conclusion, in this study, we tested the in vitro effects of the hypomethylating agent AZA in both regular and brain metastasized HER2-positive breast cancer cells. We found that AZA inhibits cell growth and promotes apoptosis in both cell types, but the regular breast cancer cells are more sensitive to AZA treatment compared to brain metastasized cells, shown by the differences in IC50 values and extents of cell growth inhibition and apoptosis induction.

As current treatment regimens (surgery, radiation, and chemotherapy) for brain metastasis of breast cancer are largely ineffective and associated with significant side effects, seeking new treatment options is necessary. Our study may find a new drug of choice for breast cancer and metastasis treatment. Our study also has high relevance to the principles of the osteopathic philosophy. As a potentially effective drug, AZA could help restore the body to homeostasis following the imbalance caused by cancer, as well as provide patients with a more improved outlook, which is central to the behavioral model of osteopathic care. In addition, with a clear understanding of the mechanism of metastasis and drug treatment in breast cancer, osteopathic physicians could better treat their patients suffering from the disease.

To further study the role of AZA in HER2-positive breast cancer treatment, we will (1) increase the AZA concentration to treat JIMT-1 Br cells; (2) explore other oncologic characteristics including signal transduction pathways, cell cycle, angiogenesis, migration, and metastasis studies; (3) elucidate the potential molecular mechanisms such as the methylation status of target genes, which may cause the different effects of AZA treatment observed in this study; (4) study the synergic effects of hypomethylating agent and HER2-tarageted therapy drug; and (5) compare the effects of AZA between normal breast (MCF 10A) and cancer cell lines.

References

1. Siegel RL, et al., Cancer statistics 2022. CA Cancer J Clin. 2022;72(1):7-33. doi: 10.3322/caac.21708.2.

2. Bulter C, et al., Hypomethylating Agent Azacitidine Is Effective in Treating Brain Metastasis Triple-Negative Breast Cancer Through Regulation of DNA Methylation of Keratin 18 Gene. Transl Oncol. 2020;13(6):100775. doi: 10.1016/j.tranon.2020.100775.

Financial Disclosures: None reported.

Support: This work is supported by West Virginia School of Osteopathic Medicine intramural grant (Dr. Tuoen Liu). We thank Dr. Paul Lockman (West Virginia University) for sharing the JIMT-1 Br cells with us.

Ethical Approval: This study was approved by the WVSOM Biosafety Committee.

Informed Consent: Not applicable.

Poster No. *B-7

Abstract No. 60

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Determining the Effect of Diet on Markers of Lipid Metabolism in a Mouse Model of Hypertension

Claire Saunders, OMS-III; Andrew Hiatt, OMS-III; Jeffery Houghton; Timothy O. Leonard, MD, PhD; Joseph C. Gigliotti, PhD

Liberty University College of Osteopathic Medicine

Statement of Significance: There is an established relationship between dietary quality and disease susceptibility. Through development of a novel “Americanized” diet (AD) that incorporates many nutritional inadequacies reported in America, we found that diet impacts the structure-function relationship in the kidney and liver prior to overt morbidity. Previous reports suggest the pleiotropic hormone angiotensin II contributes to systemic metabolic dysfunction and may impact the physiological sequelae of a poor diet.

Research Methods: Weanling male C57Bl/6 mice (N=24) were purchased from the Jackson Laboratory and given 1-week to acclimate to a pelleted chow diet. Mice were then randomly assigned (n=7-9) to receive a standard rodent chow (Teklad #2018), a commercially available Western Diet (WD), (high-fat and high-sugar, Teklad #TD.88137) or our novel AD ad libitum. After 20 weeks on their assigned diet, all mice underwent a brief surgery to implant (subcutaneous) miniosmotic pumps delivering saline (vehicle control, n=3 for each diet) or AngII (n=5 for each diet) at a dose of 700 ng/kg body weight per minute. Body weight and blood pressure were recorded each week during the infusion period. Mice remained on their assigned diets throughout the 4-week perfusion study and food intake was measured during the last week by housing mice individually in metabolic cages. Mice were then fasted for 5 hours and euthanized and kidney and liver tissues were collected and processed for routine histology (hematoxylin and eosin) and the quantification of total tissue lipid content. Kidney and liver tissues were also processed to quantify the mRNA expression of genes that regulate lipid metabolism and transport. Data were analyzed using General Linear Models procedures in SPSS (IBM) and Tukey’s Post Hoc analysis with statistically significant differences defined as P.

Data Analysis: Histological evaluation revealed pronounced hepatic steatosis in mice fed the WD, with intermediate effects in mice fed AD and minimal fatty liver change in mice fed chow. This was confirmed with liver tissue lipid quantification where mice fed WD had the greatest tissue lipid content (P<0.001) with minimal change observed in mice fed AD and chow (P=0.9). Interestingly, mice fed the AD and WD had similarly elevated renal tissue lipid content as compared to mice fed chow, based on histological and chemical tissue analyses. In the liver samples, 7 genes relating to lipid metabolism and transport were found to be significantly (P<0.05) altered by diet (Hmgcr, Plin2, Ppard, Abcg1, Nr1hs, Nrr1h4, Srebf1), while 2 genes were found to be altered by AngII (Hmgcr and Abcg1). Interestingly, Hmgcr was significantly increased (3-fold) with AngII only in the chow fed mice (P=0.007). In the kidney samples, 4 genes were found to be significantly (P<0.05) altered by diet (Hmgcr, Ppard, Nr1h4, Srebf1), while none of the evaluated genes were found to be altered by AngII.

Results: Histological evaluation revealed pronounced hepatic steatosis in mice fed the WD, with intermediate effects in mice fed AD and minimal fatty liver change in mice fed chow. This was confirmed with liver tissue lipid quantification where mice fed WD had the greatest tissue lipid content (P<0.001) with minimal change observed in mice fed AD and chow (P=0.9). Interestingly, mice fed the AD and WD had similarly elevated renal tissue lipid content as compared to mice fed chow, based on histological and chemical tissue analyses. In the liver samples, 7 genes relating to lipid metabolism and transport were found to be significantly (P<0.05) altered by diet (Hmgcr, Plin2, Ppard, Abcg1, Nr1hs, Nrr1h4, Srebf1), while 2 genes were found to be altered by AngII (Hmgcr and Abcg1). Interestingly, Hmgcr was significantly increased (3-fold) with AngII only in the chow fed mice (P=0.007). In the kidney samples, 4 genes were found to be significantly (P<0.05) altered by diet (Hmgcr, Ppard, Nr1h4, Srebf1), while none of the evaluated genes were found to be altered by AngII.

Conclusion: The findings of the current study highlight the significant effect of diet on lipid metabolism in the liver and kidney. As expected, a high calorie WD resulted in significantly increased lipid accumulation in both kidney and liver tissues. Interestingly, the novel AD resulted in significantly increased lipid accumulation only in kidney tissue. Diet altered expression of various genes related to lipid metabolism and transport in both kidney and liver, indicates a mechanism for the increased lipid deposition in these tissues. The similar increase in expression of HMG-CoA reductase (Hmgcr), farnesoid X-activated receptor (Nr1h4), and sterol regulatory element binding factor 1 (Srebf1) in the kidney and liver suggest these gene are critical in tissue lipid deposition and will be the focus of future studies. The significance of AngII on Hmgcr expression, a key enzyme in the metabolism of cholesterol, will also be further explored. Based on the findings of the current study, verification of increased gene expression by Western Blot and tissue staining is warranted. It is also of interest to verify the class of lipid (triglycerides, cholesterol, phospholipids)that is being deposited Additionally, functional studies with conditional knockout of these genes would further highlight the importance of these genes in hepatic steatosis and kidney lipid vacuolization.

References

1. Yvan-Charvet L, Quignard-Boulange A. Role of adipose tissue renin-angiotensin system in metabolic and inflammatory diseases associated with obesity. Kidney Int. 2011;79(2):162-168. doi:10.1038/ki.2010.391

Financial Disclosures: None Reported

Support: None reported

Ethical Approval: This study was conducted in accordance with a protocol (#13.170421) approved by the Liberty University Institutional Animal Care and Use Committee.

Informed Consent: N/A

Poster No. *B-8

Abstract No. 25

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Role of Noncanonical NF-kB Signaling in the Development of Intestinal Cell Subpopulations

¹Creighton Kellogg, OMS-III; ²Creighton Kellogg, OMS-III; ²Mandy Stallard, OMS-III; ²Stephan Brown, MD PhD; ²Katherine Baumgarner, MS; ³Holly A. Morrison; ³Irving C. Allen, PhD

¹Edward Via College of Osteopathic Medicine-South Carolina; ²Department of Research, Edward Via College of Osteopathic Medicine-South Carolina; ³Department of Research, Edward Via College of Osteopathic Medicine-South Carolina

Statement of Significance: This study was performed to examine the close relationship between ulcerative colitis and colorectal cancer. We looked more closely into the specific NF-kB gene pathway to see how certain genes and proteins are regulated in the development of ulcerative colitis. NF-kB has two pathways: canonical and noncanonical. The canonical pathway has been heavily studied, but the noncanonical pathway has not. Our project hopes to fill in this gap of existing literature regarding the NF-kB pathway.

Research Methods: This project began with receiving microscopic slides of mouse 3D organoid models that are designed to mimic in vivo intestinal crypts of humans and mice. We took these slides and performed immunohistochemistry to identify epithelial cell sub-types. These organoids were isolated from crypts of wild-type and genetically modified mice (in this study, these mice had the NIK protein knocked-out). We stained each slide with antibodies detecting four specific proteins: Glycoprotein 2 (GP2), Mucin 2 (MUC2), Villin, and Chromogranin A. These four proteins were quantitatively analyzed to assess the degree of inflammation and proliferation and potential tumorigenesis of these organ models. The control measures for each microscopic slide to compare the staining of these four proteins involved the use of a nuclear stain (DAPI) and a structural stain (E-cadherin). Once each slide was stained with antibodies and quantitatively measured, the results of the wild-type and NIK knockout mice were compared to assess the importance of the noncanonical NF-kB pathway in the development of ulcerative colitis and the potential development of colorectal cancer. The significance of this study is to look for another potential cause of ulcerative colitis, which can be used to look for more treatment options and further prevention of colorectal cancer.

Data Analysis: The NIK knockout mice have shown to have dysregulated colonic immune system homeostasis. With that being understood, many samples were not viable which speaks to the fragility of the NIK knockout crypts. The dysregulation of the noncanonical pathway creates an inflammatory microenvironment less conducive for crypt development leading to a cytotoxic, aberrant large intestine phenotype with reduced stem cell marker expression. From the viable samples, we see a marked difference in markers of inflammation and dysplasia including MUC2, GP2, Villin, and Chromogranin A between the wild type and knockout crypt populations. For GP2, there was a 19% increase in expression in the knockout mice compared to the wild-type mice, indicating increased inflammation. For MUC2, there was a 55% decrease in expression in the knockout mice compared to the wild-type mice, indicating a loss of the protective mucus barrier in the knockout mice. For villin, there was an erratic, low-intensity staining pattern that was diffuse in the knockout mice. The quantitative data showed a 367% increase in villin in the knockout mice, but this increase was not concentrated in the lumen of the organoid, indicating tumorigenesis. For chromogranin A, there was a 67% decrease in the knockout mice compared to the wild-type mice, indicating that the potential tumor stemming from these mice is not a carcinoid tumor.

Results: The NIK knockout mice have shown to have dysregulated colonic immune system homeostasis. With that being understood, many samples were not viable which speaks to the fragility of the NIK knockout crypts. The dysregulation of the noncanonical pathway creates an inflammatory microenvironment less conducive for crypt development leading to a cytotoxic, aberrant large intestine phenotype with reduced stem cell marker expression. From the viable samples, we see a marked difference in markers of inflammation and dysplasia including MUC2, GP2, Villin, and Chromogranin A between the wild type and knockout crypt populations. For GP2, there was a 19% increase in expression in the knockout mice compared to the wild-type mice, indicating increased inflammation. For MUC2, there was a 55% decrease in expression in the knockout mice compared to the wild-type mice, indicating a loss of the protective mucus barrier in the knockout mice. For villin, there was an erratic, low-intensity staining pattern that was diffuse in the knockout mice. The quantitative data showed a 367% increase in villin in the knockout mice, but this increase was not concentrated in the lumen of the organoid, indicating tumorigenesis. For chromogranin A, there was a 67% decrease in the knockout mice compared to the wild-type mice, indicating that the potential tumor stemming from these mice is not a carcinoid tumor.

Conclusion: The results of our study suggests that the loss of NIK corresponds with increased inflammation and diminished integrity of the colonic mucosa. The increased expression of GP2 along with the decreased expression of Villin, MUC2, and Chromogranin A are associated with dysplastic changes underlying the development of colorectal cancer. The inflammatory microenvironment induced by dysregulation of the non-canonical pathway requires further attention to illuminate components suitable for inhibition to improve the outcomes for patients with non-canonical induced inflammatory bowel disease and Colorectal cancer.

References

1. Morrison, H., Mounzer, C., Eden, K., Baumgarner, K., Brown, S., Holy, E., & Allen, I. C. (2020). Inflammation-Induced Tumorigenesis: Diminished Noncanonical NF-κB Signaling is Associated with Pathogenesis of Colitis-associated Colorectal Cancer. The Journal of Immunology , 204 (1 Supplement).

2. Allen, I. C., Eden, K., Morrison, H., Rothschild, D., Brown, S., & Holl, E. (2019, May 1). Noncanonical NF-κB controls stem cell signatures in the colonic mucosa and affects susceptibility to inflammation-induced carcinogenesis. The Journal of Immunology. https://www.jimmunol.org/content/202/1_Supplement/129.11

3. Bennett, K. M., Parnell, E. A., Sanscartier, C., Parks, S., Chen, G., Nair, M. G., & Lo, D. D. (2016). Induction of Colonic M Cells during Intestinal Inflammation. The American Journal of Pathology, 186(5), 1166–1179. https://doi.org/10.1016/j.ajpath.2015.12.015

4. Hsu, H. P., Lai, M. D., Lee, J. C., Yen, M. C., Weng, T. Y., Chen, W. C., Fang, J. H., & Chen, Y. L. (2017). Mucin 2 silencing promotes colon cancer metastasis through interleukin-6 signaling. Scientific Reports, 7(1). https://doi.org/10.1038/s41598-017-04952-7

5. Arango, D., Al-Obaidi, S., Williams, D. S., Dopeso, H., Mazzolini, R., Corner, G., Byun, D. S., Carr, A. A., Murone, C., Tögel, L., Zeps, N., Aaltonen, L. A., Iacopetta, B., & Mariadason, J. M. (2012). Villin Expression Is Frequently Lost in Poorly Differentiated Colon Cancer. The American Journal of Pathology, 180(4), 1509–1521. https://doi.org/10.1016/j.ajpath.2012.01.006

6. Zhang, X., Zhang, H., Shen, B., & Sun, X. F. (2019). Chromogranin-A Expression as a Novel Biomarker for Early Diagnosis of Colon Cancer Patients. International Journal of Molecular Sciences, 20(12), 2919. https://doi.org/10.3390/ijms20122919

Financial Disclosures: None reported

Support: None reported

Ethical Approval: IRB exempt

Informed Consent: Informed consent was not needed for this project.

Poster No. *B-9

Abstract No. 81

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Cannabinoid Receptor CB1R Regulates Craniofacial Morphogenesis in Xenopus Laevis Embryos

¹Daljit Girn, OMS-I; ¹Afrin Pattani, MSMHS; ²Tamira Elul, PhD

¹Touro University College of Osteopathic Medicine-CA; ²Department of Department of Basic Sciences, Touro University College of Osteopathic Medicine

Statement of Significance: Cannabis legalization is associated with increased cannabis abuse among pregnant women and increased prenatal cannabis exposure may cause morphological birth defects1,2. Cannabinoid 1 receptors are prevalent in neuronal cells in the brain and regulate neurogenesis and neuronal circuit and eye development of vertebrate models including frogs, mice, and zebrafish3,4. However, the effects of CB1R on craniofacial morphogenesis through neural crest cells in Xenopus laevis has not been investigated.

Research Methods: Xenopus laevis frog embryos generated by natural matings were dejellied and cultured in a 10% modified Ringer’s solution (MMR) and staged according to Nieuwkoop and Faber (1956). Early tailbud stage frog (Xenopus laevis) embryos were bathed in 10 uM ACEA(CB1R agonist), AM251(CB1R inverse agonist) or Blebbistatin(Myosin II inhibitor) reagents. Approximately one day later, late tailbud stage control and experimental embryos were fixed in 4% PFA, and then rinsed and stored in vials containing PBS. Images of the later tailbud stage embryos were captured using a Nikon SMZ500 dissecting microscope with fiber optic illumination, and a Nikon color camera (DS-5M) with controller (DS-U1) driven by Nikon Elements Imaging software (Version 3.1) in frontal view, dorsal view, and lateral view. Morphometric parameters were measured from these images using ImageJ software. The Mann Whitney U-Test was used to test for statistical significance of difference between parameters.

Data Analysis: The heads and eyes of the treatment groups of late tailbud stage frog embryos were relatively small, round, and underdeveloped compared to the control group embryos which had large, angular heads. In frontal view images, the distance between the center of the eyes was significantly decreased in Xenopus laevis embryos treated with AM251(37.6 ±0.61 n=23), ACEA (66.9±1.00 n=31), and Blebbistatin (39.12±0.92 n=21) in comparison to control embryos (100.8±3.61 n=27, p < 0.005 for all). The distance between the center of the eyes to the top of the cement gland was also significantly decreased for embryos treated with AM251(49.4±0.71 n=46), ACEA(52.8±1.12 n=40), and Blebbistatin (50.1±0.83 n=38) compared to control embryos (77.4±1.73 n=40; p <.005 for all). In dorsal view images, the head length, width, area, and perimeter all showed a significant decrease in treatment groups compared to the controls (p < 0.05 for all). However, the head length to width ratio for embryos treated with AM251(1.1±0.03 n=23), ACEA(1.1±0.02 n=31), Blebbistatin(1.1±0.02 n=21) was significantly larger than in control embryos (0.924±0.04 n=27; p < 0.005 for all). The head circularity (roundness) for embryos treated with AM251(0.93±0.01 n=23), ACEA(0.93±0.01 n=31), Blebbistatin(0.93±0.01 n=21) was also significantly larger in comparison to control embryos (0.91±0.01 n=27; p < 0.05 for all). In lateral view images, the eye areas for embryos treated with AM251(999.9±12.0 n=46), ACEA(1215.9±21.5 n=62), Blebbistatin(1006.0±42.0 n=54) was significantly smaller in comparison to control embryos (1341.6±28.8 n=54; p <.001 for all). The eye perimeters for embryos treated with AM251(120.2±1.2 n=46), ACEA(129.9±1.3 n=62), Blebbistatin(117.4±2.5 n=54) was significantly smaller in comparison to control embryos (136.9±1.5 n=54 ; p <.001 for all). The percentage of eyes showing underdeveloped phenotype for the embryos were control=5.77% n=52, AM251=50% n=34, ACEA=55.88% n=34, Blebbistatin=64.29% n=42.

Results: The heads and eyes of the treatment groups of late tailbud stage frog embryos were relatively small, round, and underdeveloped compared to the control group embryos which had large, angular heads. In frontal view images, the distance between the center of the eyes was significantly decreased in Xenopus laevis embryos treated with AM251(37.6 ±0.61 n=23), ACEA (66.9±1.00 n=31), and Blebbistatin (39.12±0.92 n=21) in comparison to control embryos (100.8±3.61 n=27, p < 0.005 for all). The distance between the center of the eyes to the top of the cement gland was also significantly decreased for embryos treated with AM251(49.4±0.71 n=46), ACEA(52.8±1.12 n=40), and Blebbistatin (50.1±0.83 n=38) compared to control embryos (77.4±1.73 n=40; p <.005 for all). In dorsal view images, the head length, width, area, and perimeter all showed a significant decrease in treatment groups compared to the controls (p < 0.05 for all). However, the head length to width ratio for embryos treated with AM251(1.1±0.03 n=23), ACEA(1.1±0.02 n=31), Blebbistatin(1.1±0.02 n=21) was significantly larger than in control embryos (0.924±0.04 n=27; p < 0.005 for all). The head circularity (roundness) for embryos treated with AM251(0.93±0.01 n=23), ACEA(0.93±0.01 n=31), Blebbistatin(0.93±0.01 n=21) was also significantly larger in comparison to control embryos (0.91±0.01 n=27; p < 0.05 for all). In lateral view images, the eye areas for embryos treated with AM251(999.9±12.0 n=46), ACEA(1215.9±21.5 n=62), Blebbistatin(1006.0±42.0 n=54) was significantly smaller in comparison to control embryos (1341.6±28.8 n=54; p <.001 for all). The eye perimeters for embryos treated with AM251(120.2±1.2 n=46), ACEA(129.9±1.3 n=62), Blebbistatin(117.4±2.5 n=54) was significantly smaller in comparison to control embryos (136.9±1.5 n=54 ; p <.001 for all). The percentage of eyes showing underdeveloped phenotype for the embryos were control=5.77% n=52, AM251=50% n=34, ACEA=55.88% n=34, Blebbistatin=64.29% n=42.

Conclusion: The results show that both the CB1R agonist (ACEA) and inverse agonist (AM251) induced morphogenetic defects in craniofacial and eye regions in developing frog embryos. These phenotypes are likely underlain partially or completely by a deficit in neural crest cell migration, and molecular factors that influence cell motility such as actin cytoskeletal regulators may be involved. In support of this, Blebbistatin, a Myosin II inhibitor, also impacted craniofacial morphogenesis in frog embryos similar to the CB1R agonist ACEA and inverse agonist AM251. These data suggest that cannabinoid signaling through CB1R regulates craniofacial morphogenesis in vertebrate embryos, likely by modulating migration of neural crest cells. These are the first data in a non-mammalian vertebrate to demonstrate craniofacial defects with manipulation of cannabinoid signaling. In addition, this is the first study to show that both activation and inactivation of cannabinoid signaling impact craniofacial morphogenesis, which suggests that cannabinoid signaling may homeostatically regulate craniofacial development. Given the homeostatic regulation of craniofacial development by cannabinoid signaling we have shown here, one could potentially promote embryonic self-healing of craniofacial defects therapeutically through prenatal manipulation of CB1R signaling pathway as an alternative to postnatal corrective surgeries (5). As the next step, the dose dependent response with regards to the three tested pharmaceutical reagents can be assessed. Additionally, using fluorescence, the exact target location of the reagents can also be analyzed. Furthermore, the actual mechanism of action behind these reagents remains unknown, therefore studies can be developed to understand those pathways. Also, given the bigger picture that neural crest cells possibly develop into the craniofacial structures, the disruption of the migration patterns of neural crest cells can be tracked in vivo and in vitro.

References

1. Page, K., Murray-Krezan, C., Leeman, L. et al. Prevalence of marijuana use in pregnant women with concurrent opioid use disorder or alcohol use in pregnancy. Addict Sci Clin Pract 17, 3 (2022). https://doi.org/10.1186/s13722-021-00285-z

2. Meinhofer A, Hinde JM, Keyes KM, Lugo-Candelas C. Association of Comorbid Behavioral and Medical Conditions With Cannabis Use Disorder in Pregnancy. JAMA Psychiatry. 2022;79(1):50–58. doi:10.1001/jamapsychiatry.2021.3193

3. Elul, T., Lim, J., Hanton, K., Lui, A., Jones, K., Chen, G., Chong, C., Dao, S., & Rawat, R. (2022). Cannabinoid Receptor Type 1 regulates growth cone filopodia and axon dispersion in the optic tract of Xenopus laevis tadpoles. The European journal of neuroscience, 55(4), 989–1001. https://doi.org/10.1111/ejn.15603

4. Langenberg T, Kahana A, Wszalek JA, Halloran MC. The eye organizes neural crest cell migration. Dev Dyn. 2008;237(6):1645-1652. doi:10.1002/dvdy.21577

5. Pinet K, Deolankar M, Leung B, McLaughlin KA. Adaptive correction of craniofacial defects in pre-metamorphic Xenopus laevis tadpoles involves thyroid hormone-independent tissue remodeling. Development. 2019;146(14):dev175893. Published 2019 Jul 22. doi:10.1242/dev.175893

Financial Disclosures: None reported

Support: This work was supported by intramural grants from the College of Osteopathic Medicine at Touro University California.

Ethical Approval: All animal experiments were performed at Touro University California and approved by the Touro University California Institutional Animal Care and Use Committee.

Informed Consent: N/A

Poster No. *B-10

Abstract No. 35

Category: Basic Science

Research Topic: Acute and Chronic Pain Management

Establishing a Mouse Model of Massage-Like Stroking-Induced Analgesia

¹Zachary M.S. Waarala, OMS-II; ²Geoffroy Laumet, PhD

¹Michigan State University College of Osteopathic Medicine; ²Department of Physiology, Michigan State University College of Osteopathic Medicine

Statement of Significance: Massage-like stroking (MLS) induces analgesia in humans but the underlying molecular and cellular mechanisms remain elusive. To decipher these mechanisms it is necessary to establish a rodent model of MLS.

Research Methods: The MLS protocol was chosen on the basis of similarity to soft tissue technique, which involves manipulation of the subcutaneous tissue and fascia. Mice were separated into a massage group, hold-only group, or control group. The massage group underwent the MLS protocol; the hold-only group were held in the handler’s hand for the duration of the massage treatment, but did not receive any MLS; the control group was left untouched for the full 60 minutes. Female and male adult wild-type mice underwent MLS for 60 minutes daily during the light cycle over the course of one week according to a previous protocol [1]. Mice in the massage group received 20 strokes per five-minute interval over the course of the 60-minute treatment at a rate of three centimeters/second in a cephalo-caudal direction along the dorsum using three fingers of the handler’s dominant hand while holding the mouse in the palm of the non-dominant hand. Mice in the hold-only group were held for 20 seconds in the palm of the handler’s hand without MLS per five-minute interval over the 60-minute treatment. Pain response was measured before and after the seven-day treatment cycle via hot plate testing. Latency to react to heat stimuli was measured as the time to either lick hind paw or to jump at 52C. This hot plate method is a well-established preclinical model used to measure analgesia [2]. If there was no response within 60 seconds, mice were removed from the hot plate to prevent tissue injury. Results were analyzed in GraphPad Prism software to obtain a p-value which was considered significant if p<0.05.

Data Analysis: Mice that were subjected to the MLS protocol were found to have an increased latency to heat stimuli (p<0.0001) compared to control which was also increased (p<0.05), which indicates an analgesic effect of MLS. To better illustrate the difference between control and massage groups, percentile change from baseline was calculated. Mice in the massage group had a significantly higher percentile change (p<0.01). The analgesic effect of MLS measured as increase in latency was present in both males (p<0.01) and females (p<0.0001). However, while significant for females (p<0.01), percentile change from baseline for male mice was not significant. To control for the influence of the MLS performer on the post-treatment measurements, mice underwent post-treatment hot plate testing done by a third party, i.e. not the handler who had conducted the MLS protocol. The massage groups still showed a significant increase in latency (p<0.001) compared to control when comparing pre-treatment and post-treatment latency. However, percentile change from baseline in this group was not significant. MLS involves long periods of holding the mice, so to distinguish the effects of simply holding the mice from the effects of the MLS treatment, control groups were added that involved only holding the mice without performing the MLS protocol and comparing with MLS groups. The massage groups in these experiments showed a significant increase in latency (p<0.001) compared to this hold-only control, as well as a significant difference from baseline percentile change (p<0.01).

Results: Mice that were subjected to the MLS protocol were found to have an increased latency to heat stimuli (p<0.0001) compared to control which was also increased (p<0.05), which indicates an analgesic effect of MLS. To better illustrate the difference between control and massage groups, percentile change from baseline was calculated. Mice in the massage group had a significantly higher percentile change (p<0.01). The analgesic effect of MLS measured as increase in latency was present in both males (p<0.01) and females (p<0.0001). However, while significant for females (p<0.01), percentile change from baseline for male mice was not significant. To control for the influence of the MLS performer on the post-treatment measurements, mice underwent post-treatment hot plate testing done by a third party, i.e. not the handler who had conducted the MLS protocol. The massage groups still showed a significant increase in latency (p<0.001) compared to control when comparing pre-treatment and post-treatment latency. However, percentile change from baseline in this group was not significant. MLS involves long periods of holding the mice, so to distinguish the effects of simply holding the mice from the effects of the MLS treatment, control groups were added that involved only holding the mice without performing the MLS protocol and comparing with MLS groups. The massage groups in these experiments showed a significant increase in latency (p<0.001) compared to this hold-only control, as well as a significant difference from baseline percentile change (p<0.01).

Conclusion: This study established a novel preclinical model of MLS-induced analgesia in wild type mice. MLS can be thought of as a simplified version of a variety of manual therapy methods including manipulation of the fascial system [3], massage, and osteopathic manipulative treatments such as myofascial release and soft tissue technique. This model will allow us to decipher the cellular and molecular mechanisms of MLS.

References

1. Major B, Rattazzi L, Brod S, Pilipović I, Leposavić G, D’Acquisto F. MLS boosts the immune system in mice. Sci Rep. 2015;5:10913. Published 2015 Jun 5. doi:10.1038/srep10913

2. Barik A, Thompson JH, Seltzer M, Ghitani N, Chesler AT. A Brainstem-Spinal Circuit Controlling Nocifensive Behavior. Neuron. 2018;100(6):1491-1503.e3. doi:10.1016/j.neuron.2018.10.037

3. França MED, Sinhorim L, Martins DF, et al. Manipulation of the Fascial System Applied During Acute Inflammation of the Connective Tissue of the Thoracolumbar Region Affects Transforming Growth Factor-β1 and Interleukin-4 Levels: Experimental Study in Mice. Front Physiol. 2020;11:587373. Published 2020 Dec 3. doi:10.3389/fphys.2020.58737

Financial Disclosures: None reported.

Support: Laumet: This work was supported by NIH NINDS R01NS121259

Ethical Approval: All animal experiments were approved by IACUC (AUF#201900249) and in accordance with NIH guidelines.

Informed Consent: Not relevant

Poster No. B-11

Abstract No. 29

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Novel Combination of Protein SUMOylation Inhibitor and Enzalutamide Inhibits the Aggressive Phenotypes of Prostate Cancer Cells

¹Dahir Hassan, OMS-III; ²Shams G. Shams, PhD; ³Hala Taha, MD; ⁴Zakaria Y. Abd Elmageed, PhD

¹Edward Via College of Osteopathic Medicine-Louisiana; ²Department of Pharmacology, Edward Via College of Osteopathic Medicine-Louisiana; ³Department of Urology, Edward Via College of Osteopathic Medicine-Louisiana; ⁴Department of Pharmacology; Edward Via College of Osteopathic Medicine-Louisiana

Statement of Significance: Androgen and its receptor (AR) are the main driving force for the development of PCa. The development of castration-resistant prostate cancer (CRPC) is a current major concern in disease management. The first option for CRPC patients’ treatment is antiandrogen enzalutamide. Unfortunately, up to 25% of patients develop de novo resistance to enzalutamide and the rest of the patients who initially responded will develop acquired resistance within a few months.

Research Methods: CRPC PC-3 and CWR-R1ca cells were treated with different concentrations of TAK-981 and enzalutamide, individually and in combination. The half-maximal inhibitory concentration (IC50) for each drug was determined. The effect of 0.1 and 0.5 IC50 of drug combinations on suppressing PCa aggressiveness was assessed in vitro by cell proliferation, migration, and invasion assays.

Data Analysis: The IC50 of TAK-981 for PC-3 and CWR-R1ca cells was 11.3 and 15.7 µM and for enzalutamide was 16.8 and 21.2, respectively. Treatment of CRPC cells with 0.1 and 0.5 IC50 of the two drugs showed a significant decrease (p<0.001) in cell proliferation, colony formation, migration, and invasion by inhibiting epithelial-mesenchymal transition (EMT). The best combination was observed when 0.1 IC50 of TAK-981combined with 0.5 IC50 of enzalutamide.

Results: The IC50 of TAK-981 for PC-3 and CWR-R1ca cells was 11.3 and 15.7 µM and for enzalutamide was 16.8 and 21.2, respectively. Treatment of CRPC cells with 0.1 and 0.5 IC50 of the two drugs showed a significant decrease (p<0.001) in cell proliferation, colony formation, migration, and invasion by inhibiting epithelial-mesenchymal transition (EMT). The best combination was observed when 0.1 IC50 of TAK-981combined with 0.5 IC50 of enzalutamide.

Conclusion: The study constitutes an innovative effort for the treatment of the most aggressive forms of PCa cells through dual targeting of androgen receptor and protein SUMOylation. Interfering with these two pathways inhibited the CRPC cells which can lead to efficient treatment and improve the overall survival of PCa patients. Further studies are warranted to investigate the efficacy of this drug combination using a preclinical model.

Financial Disclosures: None reported.

Support: This work was supported by Delta Collaboration Research Program (ZYA)

Ethical Approval: Not applicable

Informed Consent: Not applicable

Poster No. *B-12

Abstract No. 72

Category: Basic Science

Research Topic: Musculoskeletal Injuries and Prevention

Characterization of Fluid Uptake in 3D Bioprinted β-Tricalcium Phosphate/Alginate Scaffolds Doped with Strontium

¹Shebin Tharakan, OMS-I; ²Sally Lee; ²Serin Ahn; ²Chris Mathew; ²Michael Hadjiargyrou, PhD; ³Azhar Ilyas, PhD

¹New York Institute of Technology; ²Department of Biological and Chemical Sciences, New York Institute of Technology; ³Department of Electrical and Computer Engineering, New York Institute of Technology

Statement of Significance: Fractures are debilitating injuries that drastically limit the activities of daily life for patients. In conjunction with the complications associated with fractures, the healing time is often months. Bio-responsive implantations serve as a modality for rapid regeneration for in vivo models [1,2]. In particular, β-Tricalcium Phosphate (β-TCP) has shown to accelerate bone growth with alginate [3,4]. However, the influence of strontium ions has not been characterized in this biomaterial composite.

Research Methods: The study is designed as an experimental trial between Sr2+ and Ca2+ influence on 3D bioprinted β-TCP/Alginate scaffolds. No IRB approval was required. Scaffolds (n=35) were 3D printed with β-TCP concentrations of 3, 5, 10, and 20 mg and then polymerized with 100mM SrCl2 or 100mM CaCl2 to introduce the ions into the construct. After polymerization, the crosslinking agent was removed with vacuum suction and the scaffolds were dried at room temperature. The scaffolds were weighed to assess the baseline mass. Scaffolds were then immersed in α-MEM (10% FBS, 1% Pen/Strep) for 7-days to assess fluid uptake and changes in the scaffold area. At the termination of the final weight, scaffolds were dried and placed into a Fourier-transformed Raman Spectrometer (FT-Raman) to obtain molecular spectra. Additionally, degradation of the scaffolds was determined over 7, 14, 21, and 28 days. Scaffolds were printed and immersed in PBS. The PBS was changed every 3 days. After each time point, images were taken of the samples and the PBS was discarded. The osteopathic significance of this study ties to the importance of taking advantage of the body’s natural healing process during bone fractures or injuries to reduce patient morbidity and improve daily function. Statistical analysis was conducted in GraphPad Prism 9 using two-way ANOVA with p < 0.05 considered significant.

Data Analysis: CaCl2-doped and SrCl-2-doped scaffolds have similar swelling kinetics over a period of 7 days. CaCl2-doped scaffolds demonstrate a dose-dependent inverse effect with greater β-TCP concentrations resulting in decreased swelling. CaCl2-doped scaffolds with 20 mg of β-TCP have the lowest swelling at 7 days at a 214% increase. 3 mg of β-TCP in these scaffolds yield a 369% swelling increase at 7 days. SrCl-2-doped scaffolds have a dose-dependent effect indicating greater swelling with greater β-TCP concentrations. SrCl-2-doped scaffolds with 20 mg of β-TCP have 328% increased swelling, while 3 mg of β-TCP has 268% increased swelling at 7 days. Variation in the scaffold area was not significant and was determined to be independent of ionic composition and β-TCP concentration. The area of the scaffolds ranged between 350 and 400 mm2. The Raman spectra indicated no difference between all groups. Qualitative analysis of degradation indicated greater β-TCP concentrations preserve structural integrity in both CaCl2-doped and SrCl-2-doped scaffolds. CaCl2-doped scaffolds begin to degrade prior to 14 days, however, SrCl-2-doped scaffolds maintain their structure for at least 21 days.

Results: CaCl2-doped and SrCl-2-doped scaffolds have similar swelling kinetics over a period of 7 days. CaCl2-doped scaffolds demonstrate a dose-dependent inverse effect with greater β-TCP concentrations resulting in decreased swelling. CaCl2-doped scaffolds with 20 mg of β-TCP have the lowest swelling at 7 days at a 214% increase. 3 mg of β-TCP in these scaffolds yield a 369% swelling increase at 7 days. SrCl-2-doped scaffolds have a dose-dependent effect indicating greater swelling with greater β-TCP concentrations. SrCl-2-doped scaffolds with 20 mg of β-TCP have 328% increased swelling, while 3 mg of β-TCP has 268% increased swelling at 7 days. Variation in the scaffold area was not significant and was determined to be independent of ionic composition and β-TCP concentration. The area of the scaffolds ranged between 350 and 400 mm2. The Raman spectra indicated no difference between all groups. Qualitative analysis of degradation indicated greater β-TCP concentrations preserve structural integrity in both CaCl2-doped and SrCl-2-doped scaffolds. CaCl2-doped scaffolds begin to degrade prior to 14 days, however, SrCl-2-doped scaffolds maintain their structure for at least 21 days.

Conclusion: Modulation of the mechanical properties of hydrogels can be studied in vitro to fabricate appropriate bio-responsive implants. Our results demonstrate controlled swelling and degradation of β-TCP/Alginate hydrogels in vitro, however, due to the poor structural stability of degraded scaffolds, we are unable to quantitatively measure the true weight. Differences in β-TCP concentration will allow for the fine-tuning of structural behavior both in vivo and in vitro. Future approaches to evaluating bio-responsive implants involve the use of in vivo models to characterize cellular function in critical-sized defects.

References

1. Neves N, Linhares D, Costa G, Ribeiro CC, Barbosa MA. in vivo and clinical application of strontium-enriched biomaterials for bone regeneration. Bone & Joint Research. 2017;6(6):366-375. doi:10.1302/2046-3758.66.bjr-2016-0311.r1

2. Preethi Soundarya S, Haritha Menon A, Viji Chandran S, Selvamurugan N. Bone Tissue Engineering: Scaffold preparation using chitosan and other biomaterials with different design and fabrication techniques. International Journal of Biological Macromolecules. 2018;119:1228-1239. doi:10.1016/j.ijbiomac.2018.08.056

3. Kalkandelen C, Ulag S, Ozbek B, et al. 3D printing of Gelatine/alginate/β-tricalcium phosphate composite constructs for bone tissue engineering. ChemistrySelect. 2019;4(41):12032-12036. doi:10.1002/slct.201902878

4. Eslaminejad MB, Mirzadeh H, Mohamadi Y, Nickmahzar A. Bone differentiation of marrow-derived mesenchymal stem cells using β-tricalcium phosphate–alginate–gelatin hybrid scaffolds. Journal of Tissue Engineering and Regenerative Medicine. 2007;1(6):417-424. doi:10.1002/term.49

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This study is exempt from IRB and IACUC review processes.

Informed Consent: This study is exempt from requiring informed consent.

Poster No. *B-13

Abstract No. 36

Category: Basic Science

Research Topic: Impact of OMM & OMT

Use of Osteopathic Manipulative Medicine in Treating Migraines

¹Makayla Lund, OMS-III; ²Yan Pan; ²Jared Burns-Martin, OMS-III; ³Regina Fleming, DO; ²Jennifer Xie, PhD

¹New York Institute of Technology College of Osteopathic Medicine at Arkansas State University; ²Department of Basic Sciences, New York Institute of Technology College of Osteopathic Medicine at Arkansas State University; ³Department of Osteopathic Manipulative Medicine, New York Institute of Technology College of Osteopathic Medicine at Arkansas State University; ²Department of Basic Sciences, New York Institute of Technology College of Osteopathic Medicine at Arkansas State University

Statement of Significance: Headache disorders, especially migraines, are among the leading causes of disability worldwide. Many people use medications such as triptans and NSAIDs (non-steroidal anti-inflammatory drugs) to mitigate their pain which are prone to induce medication overuse headaches that promote transition of episodic to chronic migraines. Thus, efficacious non-pharmacological treatments such as Osteopathic Manipulative Treatment (OMT) would be advantageous and highly desirable.

Research Methods: To induce migraines in rats, we utilized a monoterpene ketone known as umbellulone that can elicit migraines in susceptible individuals (migraineurs). Umbellulone was administered via inhalation to induce migraines in rats primed with an inflammatory reagent, CFA (Complete Freund’s Adjuvant). The OMT procedure we created involves soft tissue techniques applied to the paraspinal muscles in the cervical region, and articulatory release techniques to the cervical spine. We used a variety of behavioral tests to determine the effectiveness of our treatment. All tests were performed in female Sprague-Dawley rats which were divided randomly into the following groups: rats induced with migraines with OMT provided, rats induced with migraines with sham treatment, rats given a control reagent without migraine with OMT provided, and rats given a control reagent without migraine with sham treatment. In the first part of our study, we determined the effectiveness of OMT in the prevention of migraines. We first primed the animals with CFA on day 0 and performed OMT on days 1, 3, and 5. On day 6 we induced migraines using umbellulone inhalation and measured the behavioral changes including the cutaneous allodynia and the spontaneous wheel-running activities In the second part of our study, we looked at the effectiveness of OMT in aborting acute migraines. OMT was performed immediately after the administration of the migraine trigger on day 6, and the cutaneous allodynia was assessed. Von-Frey filaments were applied to the periorbital and hindpaw regions to detect cutaneous allodynia using “up-and-down” method. We also allowed the animals to voluntarily run on a wheel that rotates freely to assess the energy output over a 3 hour period. In addition, we measured the change of plasma levels of an important neuropeptide, CGRP (calcitonin gene- related peptide), using ELISA (Enzyme-Linked Immunoassay) kits to gauge the molecular impact of OMT on migraine pathophysiology.

Data Analysis: The results of our von-Frey behavioral testing showed a significant decrease in both periorbital and hind paw withdrawal threshold, i.e., tactile allodynia developed, after umbellulone inhalation only in rats with CFA pre-treatment, suggesting both the priming and trigger are required for the naive rats to develop migraine-like pain. The application of OMT before migraine induction was able to prevent the development of cutaneous allodynia completely. When given after the migraine trigger umbellulone, OMT partially abolished the development of periorbital and hindpaw tactile allodynia. In terms of wheel-running activities, umbellulone reduced the number of rotations in rats with CFA priming. OMT produced a similar trend of efficacy, in which rats treated with OMT tended to have maintained the wheel-running activities over a 3 hour period rather than reduction of this activity seen in the sham-treated animals. We did not find any significant change in CGRP levels among different groups of rats either treated with or without OMT.

Results: The results of our von-Frey behavioral testing showed a significant decrease in both periorbital and hind paw withdrawal threshold, i.e., tactile allodynia developed, after umbellulone inhalation only in rats with CFA pre-treatment, suggesting both the priming and trigger are required for the naive rats to develop migraine-like pain. The application of OMT before migraine induction was able to prevent the development of cutaneous allodynia completely. When given after the migraine trigger umbellulone, OMT partially abolished the development of periorbital and hindpaw tactile allodynia. In terms of wheel-running activities, umbellulone reduced the number of rotations in rats with CFA priming. OMT produced a similar trend of efficacy, in which rats treated with OMT tended to have maintained the wheel-running activities over a 3 hour period rather than reduction of this activity seen in the sham-treated animals. We did not find any significant change in CGRP levels among different groups of rats either treated with or without OMT.

Conclusion: Our study has shown that the use of OMT as a preventative or abortive treatment significantly reduces the tactile hypersensitivity in the periorbital and hindpaw regions induced by CFA and umbellulone, confirming the efficacy of OMT in migraine management. Since this model is not CGRP-dependent, we will further study the potential mechanisms underlying this effect in the trigeminal systems.

References

1. Cerritelli, F., Lacorte, E., Ruffini, N. & Vanacore, N. Osteopathy for primary headache patients: a systematic review. J Pain Res 10, 601-611, doi:10.2147/JPR.S130501 (2017).

2. Tfelt-Hansen, P., Lous, I. & Olesen, J. Prevalence and significance of muscle tenderness during common migraine attacks. Headache 21, 49-54 (1981).

3. Hawkins, J. L., Cornelison, L. E., Blankenship, B. A. & Durham, P. L. Vagus nerve stimulation inhibits trigeminal nociception in a rodent model of episodic migraine. Pain Reports 2(6): e628,(2017).

4. Nassini, R. et al. The ’headache tree’ via umbellulone and TRPA1 activates the trigeminovascular system. Brain 135, 376-390, doi:10.1093/brain/awr272 (2012).

5. Xie, J. Y. et al. Kappa opioid receptor antagonists: A possible new class of therapeutics for migraine prevention. Cephalalgia 37, 780-794, doi:10.1177/0333102417702120 (2017).

6. Ashina, M., Bendtsen, L., Jensen, R., Schifter, S. & Olesen, J. Evidence for increased plasma levels of calcitonin gene-related peptide in migraine outside of attacks. Pain 86, 133-138 (2000).

Financial Disclosures: None Reported

Support: This work is supported by NIH/NCCIH (National Institute of Health/National Center for Complementary and Integrative Health) to JYX, award No. 1R15AT011097-01

Ethical Approval: This research has been approved by the IACUC (Institutional Animal Care and Use Committee) of Arkansas State University.

Informed Consent: Not Applicable

Poster No. *B-14

Abstract No. 75

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

The Effect of Cerebellar Transcranial Electrical Stimulation (tES) on Rat Thalamic Neuron Firing Rates Using an In Vivo Approach

¹Michael Bien, OMS-II; ²Halley S. Fowler, BS; ³Jessica T. Hiscox, OMS II; ³Anum Ul-Haque, OMS II; ²Huo Lu, PhD

¹Philadelphia College of Osteopathic Medicine-Georgia Campus-GA; ²Biomedical Sciences Program, Philadelphia College of Osteopathic Medicine-Georgia Campus-GA; ³Doctor of Osteopathic Medicine Program, Philadelphia College of Osteopathic Medicine-Georgia Campus-GA

Statement of Significance: Osteopathic medicine functions on the belief that structure and function are intimately related. A thorough understanding of neuronal pathways is essential in maximizing therapeutic effects in cerebellar ataxia. Our study explores the mechanisms behind tES, which has been suggested as a potential therapy. By investigating the effects of cerebellar tES on thalamic neuron firing rates, we can better understand the specific mechanisms by which tES may work to treat cerebellar pathology.

Research Methods: Six male Sprague-Dawley rats were used in this experiment. Isoflurane induction of the rats was followed by initial anesthesia using a cocktail. Supplemental injections were administered throughout the experiment to maintain anesthesia based upon vital signs and presence of pedal reflex. Two holes were drilled into the skull after the rats were stabilized using a stereotaxic apparatus in order to gain access to the VL and VM thalamic nuclei. A metal recording electrode was inserted into one of the two holes to isolate a cell at a depth from 5.5 mm to 7.5 mm from the cortical surface. These coordinates for VL and VM were determined using a rat brain atlas (Paxinos, 2007). Recordings were obtained using Clampex 9 software. A direct current of 200 μA was delivered for 20 minutes contralateral to the recording site. LFP and single unit (action potential) activities were recorded in three sets: pre-stimulation (5 min), stimulation (20 min), and post-stimulation (5 min). Data analysis was then performed using MATLAB software. LFPs (1 to 100 Hz) were examined for thalamic neurons in VL and VM. A power spectrum plot was then generated for each recording to depict the dominant frequencies of the LFPs in three conditions. The dominant frequencies were visualized to determine if a change from baseline (pre-stimulation) was observed. For single unit analysis, the recordings were filtered between 0.3 and 10 kHz to display action potential spikes. The average firing rates of the thalamic neurons were then studied from each recording: pre-stimulation, stimulation, and post-stimulation. These average firing frequencies were used to determine if a change from baseline (the pre-stimulation average) was observed. Paired t-test was performed to determine significant changes for both LFP and single unit activities between pre-stimulation and stimulation conditions.

Data Analysis: A total of ten recordings were taken from thalamic cells of the VL nucleus (5.5 mm to 6.5 mm from the cortical surface) and three recordings were obtained from the VM nucleus (6.5 mm to 7.5 mm from the cortical surface). In the LFP studies of the 13 thalamic neurons, 12 cells demonstrated no change in the dominant frequency between baseline and tES stimulation, with one cell demonstrating a decrease in peak frequency from control to post-stimulation. The average peak frequency at baseline occurred at 1.38 ± 0.23 Hz. Statistical analysis showed no significant change in average firing frequencies from pre-stimulation to stimulation conditions (p=0.92). In the single unit studies, the average pre-stimulation firing rate ranged from 0.49-6.15 Hz. The average firing rate across all control recordings was 1.83 ± 1.43 Hz. The highest pre-stimulation frequency observed was 13 Hz. The average firing rate during stimulation ranged from 0.24-6.45 Hz. Of the 13 thalamic neurons isolated, four cells demonstrated an increase from control in firing frequency during tES, with the rest showing a decrease in firing frequency. Nine of the 13 cells had frequency changes of more than 15% from baseline, with three cells demonstrating greater than 50% changes in firing frequency. When comparing stimulation with baseline activity, VL and VM neurons showed no preference for increasing or decreasing frequency. When observing the cumulative data, statistical analysis showed no significant change in average firing frequencies from pre-stimulation to stimulation conditions (p=0.55). However, an isolated comparison of only those cells whose firing rates decreased during stimulation demonstrated a significant change from baseline (p=0.007). Additionally, only three of the 13 cells showed a return towards baseline firing frequency after the stimulation. The other 10 cells showed a sustained or further exaggerated change in firing frequency from baseline.

Results: A total of ten recordings were taken from thalamic cells of the VL nucleus (5.5 mm to 6.5 mm from the cortical surface) and three recordings were obtained from the VM nucleus (6.5 mm to 7.5 mm from the cortical surface). In the LFP studies of the 13 thalamic neurons, 12 cells demonstrated no change in the dominant frequency between baseline and tES stimulation, with one cell demonstrating a decrease in peak frequency from control to post-stimulation. The average peak frequency at baseline occurred at 1.38 ± 0.23 Hz. Statistical analysis showed no significant change in average firing frequencies from pre-stimulation to stimulation conditions (p=0.92). In the single unit studies, the average pre-stimulation firing rate ranged from 0.49-6.15 Hz. The average firing rate across all control recordings was 1.83 ± 1.43 Hz. The highest pre-stimulation frequency observed was 13 Hz. The average firing rate during stimulation ranged from 0.24-6.45 Hz. Of the 13 thalamic neurons isolated, four cells demonstrated an increase from control in firing frequency during tES, with the rest showing a decrease in firing frequency. Nine of the 13 cells had frequency changes of more than 15% from baseline, with three cells demonstrating greater than 50% changes in firing frequency. When comparing stimulation with baseline activity, VL and VM neurons showed no preference for increasing or decreasing frequency. When observing the cumulative data, statistical analysis showed no significant change in average firing frequencies from pre-stimulation to stimulation conditions (p=0.55). However, an isolated comparison of only those cells whose firing rates decreased during stimulation demonstrated a significant change from baseline (p=0.007). Additionally, only three of the 13 cells showed a return towards baseline firing frequency after the stimulation. The other 10 cells showed a sustained or further exaggerated change in firing frequency from baseline.

Conclusion: The LFP study demonstrated that there was no change in dominant frequency after tES indicating no significant activity change in a population of thalamic neurons. Regarding the single unit studies, there was a general decrease in firing frequency observed during cerebellar tES. When only those cells that demonstrated a decrease in firing frequencies were analyzed, a statistically significant change was observed. This finding is consistent with the LFP results, as the average of activity across a large population of neurons negates any significant change in firing frequencies in one direction or another. For the majority of cells, this decrease continued throughout the post-stimulation observation period, implying that the effect of stimulation is less transient than we anticipated. Future experiments will aim at obtaining more recordings from the VM nucleus in order to establish a more complete picture of the effects of cerebellar tES on thalamic activity.

References

1. Bower JM, Beermann DH, Gibson JM, Shambes GM, Welker W (1981) Principles of organization of a cerebro-cerebellar circuit. Micromapping the projections from cerebral (SI) to cerebellar (granule cell layer) tactile areas of rats. Brain Behav Evol 18:1–18.

2. Paxinos, K. B. J. Franklin (2007). The Rat Brain in Stereotaxic Coordinates, Academic Press.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This study was reviewed and approved by the IACUC at PCOM (IACUC #A22-003).

Informed Consent: N/A.

Poster No. *B-15

Abstract No. 91

Category: Basic Science

Research Topic: Acute and Chronic Pain Management

Examination of Alterations in Glial Activation and Cortical Volume in Moderate Pain Model

¹Shirley Chua, OMS-II; ²Mital Joshi, OMS-II; ²Melissa Cummins, OMS-II; ²Joyce Morris-Wiman, PhD

²West Virginia School of Osteopathic Medicine; Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine

Statement of Significance: The Anterior Cingulate Cortex (ACC) is responsible for processing the affective component of nociception. In prior pain studies, the ACC was determined to decrease in size and harbor activated astrocytes and microglia which have been given a role in maintenance of chronic pain. The hippocampal formation is a significant area for neural stem cell (NSC) development and neurogenesis. In chronic pain, neural stem cell activation and proliferation have been shown to decrease in the hippocampus.

Research Methods: Experimental groups: Female CD-1 mice were assigned to groups: Neutral (n=5); Pain (n=5); APETx2 (n=5) and unmanipulated control (n=5). After general anesthesia, the left masseter muscle was injected with either 10μl of acidic saline (pH 4.0; Pain) or neutral saline (pH 7.3; Neutral). 5 days later, animals were anesthetized and again injected with 10 μl of either acidic saline (Pain) or 10μl of neutral saline (Neutral). Animals in the APETx2 group were injected with 10 μl of acidic saline containing APETx2, known to block chronic pain in this model.

Animals were euthanized 7 days post second injections and cerebral hemispheres harvested for immunostaining. Serial 14μm longitudinal cryosections of cerebral hemispheres were placed consecutively on sets of 10 contiguous slides to allow the comparison of Kluver-Barrera staining and GFAP/IBA1 antibody labeling. All animal procedures were approved by the WVSOM IACUC.

Immunofluorescent Analysis: Sections were immunostained for GFAP and IBA1 according to standard protocols. GFAP and IBA1 immunofluorescent intensity was evaluated using Image Pro Plus in the ACC and within the hippocampus. Images were acquired using a Leica Aperio system and thresholded to remove background fluorescence to allow unbiased assessment of immunostaining intensity. Immunopositive staining was expressed as a percentage of the demarcated area.

Klüver-Barrera staining: Digital images of Kluver-Barrera stained section were acquired using a Leica Aperio system. The cortical thickness of the ACC was measured and expressed as the ratio of the thickness of ACC and the adjacent primary motor cortex.

Statistical Analyses: Data were analyzed for statistical differences among groups using the MiniTab software for the variables of percent area covered (GFAP, IBA1) and cortical depth ratios. Differences among groups were assessed using a MANOVA and, if significant, by appropriate post-hoc comparisons. The probability level of significance was set at 0.05.

Data Analysis: Activated astrocytes are enlarged, highly branched and are GFAP- immunopositive. In sections from all groups, very few GFAP-immunopositive cells were detected in the ACC cortex. However, cells immunopositive for GFAP were detected in great numbers in the corpus callosum and cingulum adjacent to the cortex and participating in communication between the ACC and other regions of the pain matrix. In the pain group there was a significant increase in immunostaining for GFAP as compared to the other group (p=0.012, LSD test). In contrast, there was a decrease in GFAP immunostaining within the hippocampal formation. The percentage of immunostaining ranged from 50% in the neutral group, 62% in the acid group, 81% in the APETx group, to 84% in the control group. GFAP-immunopositive cells were more prominent in the dentate and decreased in number towards CA1. In all groups, astrocytes were oriented perpendicular to neurons in the granular layers.

Activated microglia expressing IBA1 are enlarged and range from amoeboid in shape to highly branched. Activated microglia were prominent in the ACC cortex in all groups. No significant differences were detected between groups in the percent area covered by IBA1 in the ACC (p=0.365, ANOVA). IBA1 immunostaining was not prominent in the hippocampus and was not associated with CA1 cell layers but rather were identified in the adjacent non-granular layers. Percent area covered ranged from 2.2% covered for the APETx group, 3% covered for the acid group, 3.6% for the control and 4.1% for the neutral group. Significant differences were detected for IBA1 expression between the acid and APETx groups, and the control and neutral groups (p=0.001, LSD test).

The volume of the ACC expressed as a ratio between the ACC depth and the depth of the primary motor cortex differed significantly between groups (p=0.043, LSD test) with the neutral group having the greatest ratio (91%) and the control group having the least (78%).

Results: Activated astrocytes are enlarged, highly branched and are GFAP- immunopositive. In sections from all groups, very few GFAP-immunopositive cells were detected in the ACC cortex. However, cells immunopositive for GFAP were detected in great numbers in the corpus callosum and cingulum adjacent to the cortex and participating in communication between the ACC and other regions of the pain matrix. In the pain group there was a significant increase in immunostaining for GFAP as compared to the other group (p=0.012, LSD test). In contrast, there was a decrease in GFAP immunostaining within the hippocampal formation. The percentage of immunostaining ranged from 50% in the neutral group, 62% in the acid group, 81% in the APETx group, to 84% in the control group. GFAP-immunopositive cells were more prominent in the dentate and decreased in number towards CA1. In all groups, astrocytes were oriented perpendicular to neurons in the granular layers.

Activated microglia expressing IBA1 are enlarged and range from amoeboid in shape to highly branched. Activated microglia were prominent in the ACC cortex in all groups. No significant differences were detected between groups in the percent area covered by IBA1 in the ACC (p=0.365, ANOVA). IBA1 immunostaining was not prominent in the hippocampus and was not associated with CA1 cell layers but rather were identified in the adjacent non-granular layers. Percent area covered ranged from 2.2% covered for the APETx group, 3% covered for the acid group, 3.6% for the control and 4.1% for the neutral group. Significant differences were detected for IBA1 expression between the acid and APETx groups, and the control and neutral groups (p=0.001, LSD test).

The volume of the ACC expressed as a ratio between the ACC depth and the depth of the primary motor cortex differed significantly between groups (p=0.043, LSD test) with the neutral group having the greatest ratio (91%) and the control group having the least (78%).

Conclusion: The results of this study indicate that there was no statistically significant increase in activation of microglia or astrocytes in the ACC in response to moderate pain. However, there was decreased activation of microglia and astrocytes in the hippocampus. Additionally, no decrease in the volume of the ACC was detected. These are unexpected findings, inconsistent with previous results examining maintenance of chronic pain in more profound pain models. In these models, GFAP and IBA1 markers are upregulated in the ACC in response to chronic pain and this activation of astrocytes and microglia has been proposed to maintain chronic pain. The lack of GFAP activity in the ACC in this study is inconsistent with this mechanism. The overall results of this study are not consistent with patterns identified in more profound chronic pain models and may indicate an alternative mechanism in the maintenance of chronic pain in moderate pain conditions which warrants further investigation. The observation of increased astrocyte activity in the corpus callosum and the cingulum has not been previously reported and may play a role in maintenance of chronic pain. The results of this study could lead to better treatments for chronic pain and could additionally improve patients’ quality of life.

Financial Disclosures: None reported.

Support: Intramural Grant - research supplies WVSOM Student Research Program - work-study stipend

Ethical Approval: Reviewed and approved by IACUC (2015-2).

Informed Consent: NA

Poster No. *B-16

Abstract No. 44

Category: Basic Science

Research Topic: Osteopathic Philosophy

Fryette Mechanics not Appreciated in Radiography of Lumbar Vertebrae Using 3D Symmetry Plane Analysis

Dillon Haughton, OMS-III

Burrell College of Osteopathic Medicine

Statement of Significance: Osteopaths commonly cite Fryette’s Laws of Spinal Mechanics as validation for diagnosis and treatment,[1] therefore it is imperative to seek more evidence of these laws. Open-sourced datasets designed for machine-learning applications such as VerSe,[2,3,4] offer a large reservoir of radiographic data which can be used to test Fryette’s Laws.

Research Methods: 58 CT scans, containing both normal and abnormal spines, were obtained from the VerSe testing data. 3D models of these vertebrae were generated and analyzed within a Slicer-Jupyter notebook,[5,6] coded completely by using python and open-sourced python modules. The natural symmetry within each vertebra was used to generate three planes of symmetry. One plane of symmetry considered the entire vertebra, this plane’s offset from the sagittal plane of the patient represented rotation. The other two symmetry planes considered only the vertebral body without their posterior elements, their offsets from the coronal and transverse planes of the patient represented flexion/extension and side-bending, respectively.[7,8,9] If the symmetry planes could not be calculated accurately due to abnormal symmetry within the vertebra, or insufficient constraints within the code, the vertebra was excluded from analysis. This method was successful for 256 out of 285 lumbar vertebrae with the average flexion/extension being -3.2 +/-10.2 degrees. Vertebrae within this range were categorized as neutral, positives values outside this range were categorized as flexed, and negative values outside this range were categorized as extended. Positive and negative rotation and side-bending values coded right and left directionality respectively. The number of vertebrae fitting Fryette’s laws, classified as being neutral with opposing rotation/side-bending as well as flexed/extended with same side rotation/side-bending, were compared to those that did not satisfy these criteria.

Data Analysis: Out of 256 vertebrae, 45 were classified as flexed with 35 matching Fryette’s criteria (77.7%). 28 were classified as extended with 11 matching Fryette’s criteria (39.3%), though 17 matched Greenman’s description (60.7%).10 183 were classified as neutral with 108 matching Fryette’s criteria (59%). Overall, only 154 vertebrae out of 256 demonstrated Fryette mechanics (60.2%).

Results: Out of 256 vertebrae, 45 were classified as flexed with 35 matching Fryette’s criteria (77.7%). 28 were classified as extended with 11 matching Fryette’s criteria (39.3%), though 17 matched Greenman’s description (60.7%).10 183 were classified as neutral with 108 matching Fryette’s criteria (59%). Overall, only 154 vertebrae out of 256 demonstrated Fryette mechanics (60.2%).

Conclusion: Fryette’s Laws were shown as little more than chance using this project’s methodology. Although it does demonstrate that Greenman’s description of lumbar coupled motion10 is slightly more likely. A possible explanation for the lack of continuity with Fryette’s Laws could be pathologic specimens within the database. Also troublesome is the lack of numerical descriptions of neutral and non-neutral mechanics, making it possible that this study’s numerical estimations of these states are flawed. Future studies on this topic should seek to identify a quantitative description of neutral, and non-neutral mechanics, as well as rule out pathologic specimens.

References

1. Seffinger, Michael A.; Hruby, Ray. Chapter 27: Osteopathic Segmental Examination. Walter C. Ehrenfeuchter, Raymond J. Hruby. Foundations of Osteopathic Medicine: Philosophy, Science, Clinical Applications, and Research. 4e. Wolters Kluwer Health, Inc. Dec 31, 1969

2. Sekuboyina A, Husseini ME, Bayat A, et al. VerSe: A Vertebrae labelling and segmentation benchmark for multi-detector CT images. Med Image Anal. 2021;73:102166. doi:10.1016/j.media.2021.102166

3. Löffler MT, Sekuboyina A, Jacob A, et al. A Vertebral Segmentation Dataset with Fracture Grading. Radiol Artif Intell. 2020;2(4):e190138. Published 2020 Jul 29. doi:10.1148/ryai.2020190138

4. Liebl H, Schinz D, Sekuboyina A, et al. A computed tomography vertebral segmentation dataset with anatomical variations and multi-vendor scanner data. Sci Data. 2021;8(1):284. Published 2021 Oct 28. doi:10.1038/s41597-021-01060-0

5. Steve Pieper, Isomics, Kitware, and the 3D Slicer community. Slicer. 3D Slicer image computing platform. October 7 2009. Updated May 1 2022. https://www.slicer.org

6. Fedorov A, Beichel R, Kalpathy-Cramer J, et al. 3D Slicer as an image computing platform for the Quantitative Imaging Network. Magn Reson Imaging. 2012;30(9):1323-1341. doi:10.1016/j.mri.2012.05.001

7. Vrtovec T, Pernus F, Likar B. A symmetry-based method for the determination of vertebral rotation in 3D. Med Image Comput Comput Assist Interv. 2008;11(Pt 1):942-950. doi:10.1007/978-3-540-85988-8_112

8. Cicconet, M., Hildebrand, D.G., & Elliott, H. Finding Mirror Symmetry via Registration and Optimal Symmetric Pairwise Assignment of Curves. IEEE International Conference on Computer Vision Workshops (ICCVW). 2017. doi:10.1109/ICCVW.2017.207

9. Di Angelo L, Di Stefano P. A new method for the automatic identification of the dimensional features of vertebrae. Comput Methods Programs Biomed. 2015;121(1):36-48. doi:10.1016/j.cmpb.2015.04.003

10. DeStefano, Lisa A. Chapter 5: Greenman’s Principles of Manual Medicine, 5e. Wolters Kluwer Health, Inc. Dec 31, 1969

Financial Disclosures: None reported

Support: None reported

Ethical Approval: deemed exempt.

Informed Consent: Research was performed on an open-source databank of CT scans known as VerSe https://github.com/anjany/verse.

Poster No. *B-17

Abstract No. 42

Category: Basic Science

Research Topic: Acute and Chronic Pain Management

Investigating the Mechanism of Prolotherapy: The Fibroblast Response to Dextrose In Vitro

¹Cailee Dean, OMS-III; ¹Andrew H. van Nispen, OMS-II; ¹Robert L. Repetti, OMS-II; ²Thomas M. Motyka, DO, MHPE; ³Amy N. Hinkelman, ¹Campbell PhD University-Jerry M. Wallace School of Osteopathic Medicine; ²Department of Osteopathic Manipulative Medicine, Campbell University-Jerry M. Wallace School of Osteopathic Medicine; ³Department of Microbiology and Immunology, Campbell University-Jerry M. Wallace School of Osteopathic Medicine

Statement of Significance: Ligament and cartilage avascularity can limit healing from injury causing joint laxity or osteoarthritis (OA). In 1958, Dr. George Hackett demonstrated injections with a proliferative agent strengthened ligaments (1). Dextrose prolotherapy is thought to induce inflammation where injected, resulting in cellular proliferation and clinical outcomes of decreased pain and improved joint stability (2,3). The low cost and reduced side effect profile of prolotherapy make it a promising treatment for OA.

Research Methods: Prolotherapy fits well within the second tenet of Osteopathic Medicine; the body is capable of self-regulation, self-healing, and health maintenance. It’s apt as this study hopes to identify the mechanism of how prolotherapy triggers the body’s own inflammatory response.

The human embryonic lung fibroblast cell line, MRC-5, was purchased from American Type Culture Collection and maintained in Eagles Minimum Essential Media (EMEM) supplemented with 10% fetal bovine serum (FBS), 1% L-Glutamine, and 1% penicillin/streptomycin at 37°C at 5% CO2.

XTT assays were used to assess cell viability under several treatment conditions using 96-well plates. Cells were plated overnight prior to treatments at 2x10^4 cells in 100uL media per well for each time point up to 12 hours or at 1x10^4 cells per well for 24 hr treatments. Treatments tested included the media control and 5% - 25% dextrose at 5% increments. Time points included 0.5, 1, 2, 4, 6, 8, 10, 12, and 24 hrs. Run in duplicate from three independent experiments, significance determined by ANOVA.

A customized, multiplex analysis (R&D Systems) was designed to determine the concentrations of 34 secreted factors including cytokines, chemokines, growth factors, and metalloproteinases. Cell culture supernatant fluid from the media control and treatments of 5%, 15%, and 25% dextrose were collected at 0.5, 1, 2, 4, and 8 hrs of exposure. Run in duplicate from two independent experiments.

Utilizing the same conditions as the multiplex analysis, bone morphogenic protein 12 (BMP-12) and CXCL12 concentrations were determined using ELISA (Novus Biologicals). Run in duplicate from two independent experiments.

Data Analysis: Compared to media alone, 5% dextrose solution has no significant impact on cell viability. However, compared to 5% dextrose at the 0.5, 1, 2, and 4 hr timepoints, 25% dextrose concentration significantly decrease cell viability (p=0.0472, p=0.0032, p<0.0001, and p=0.0047, respectively). This effect of decreased cell viability in response to exposure to 25% dextrose continues at longer timepoints of 6, 8, 10, and 12 hrs (p=0.0198, p=0.0209, p=0.0253, and p=0.0168 respectively). Starting at 6 hrs, viable cells cannot be detected by the XTT assay for treatments of 20% and 25% dextrose.

Data analysis of the multiplex assay is currently underway.

Informed by the XTT assay data, two independent collections of supernatants were performed as described above and analyzed for BMP-12 and CXCL12. Limited concentrations of BMP-12 were detected prior to 4 hrs of treatment, with no protein detected at 2 hrs for any condition. At 4 hrs, all treatment conditions detected at least 48 pg/mL of BMP-12. At 8hrs all treatment conditions detected at least 12 pg/mL with the 25% dextrose condition showing a spike in BMP-12 production of 119 pg/mL. Concentrations of CXCL12 were around 0.2 ng/mL for all conditions prior to 4 hrs of exposure. However, at 4hrs, treatment with 15% dextrose or 25% dextrose decreased production of CXCL12 by fibroblasts compared to media control by about 2-fold. At 8hrs, treatment with 15% dextrose or 25% dextrose decreased production of CXCL12 by fibroblasts compared to media control and 5% dextrose treatment by about 4-fold and 2-fold respectively.

Results: Compared to media alone, 5% dextrose solution has no significant impact on cell viability. However, compared to 5% dextrose at the 0.5, 1, 2, and 4 hr timepoints, 25% dextrose concentration significantly decrease cell viability (p=0.0472, p=0.0032, p<0.0001, and p=0.0047, respectively). This effect of decreased cell viability in response to exposure to 25% dextrose continues at longer timepoints of 6, 8, 10, and 12 hrs (p=0.0198, p=0.0209, p=0.0253, and p=0.0168 respectively). Starting at 6 hrs, viable cells cannot be detected by the XTT assay for treatments of 20% and 25% dextrose.

Data analysis of the multiplex assay is currently underway.

Informed by the XTT assay data, two independent collections of supernatants were performed as described above and analyzed for BMP-12 and CXCL12. Limited concentrations of BMP-12 were detected prior to 4 hrs of treatment, with no protein detected at 2 hrs for any condition. At 4 hrs, all treatment conditions detected at least 48 pg/mL of BMP-12. At 8hrs all treatment conditions detected at least 12 pg/mL with the 25% dextrose condition showing a spike in BMP-12 production of 119 pg/mL. Concentrations of CXCL12 were around 0.2 ng/mL for all conditions prior to 4 hrs of exposure. However, at 4hrs, treatment with 15% dextrose or 25% dextrose decreased production of CXCL12 by fibroblasts compared to media control by about 2-fold. At 8hrs, treatment with 15% dextrose or 25% dextrose decreased production of CXCL12 by fibroblasts compared to media control and 5% dextrose treatment by about 4-fold and 2-fold respectively.

Conclusion: Despite the observed clinical benefits, cell-based studies investigating the mechanism of prolotherapy are limited, and clinical trials have varied greatly in the injection procedure, resulting in varied outcomes (4–9). Therefore, the 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of OA of the Hand, Hip, and Knee conditionally recommends against prolotherapy of the hip and knee, pending more research (10).

This study was undertaken to begin to address this recommendation. The need for mechanistic understanding and how prolotherapy treatment functions within the joint space informed the study design. Therefore, the cell viability of fibroblasts was determined for various therapeutic concentrations of dextrose at stepwise durations of exposure. This allowed identification of dextrose concentrations and timepoints of interest for multiplex and ELISA analysis which can be used to inform future experiments on other cell lines and primary cells. Future experiments will be needed to characterize the functional responses of other cell types to dextrose prolotherapy such as tenocytes, chondrocytes, and synoviocytes.

References

1. Hackett, G.S. Ligament and Tendon Relaxation. 3rd ed. Charles C Thomas; 1958.

2. Rabago D, Kansariwala I, Marshall D, Nourani B, Stiffler-Joachim M, Heiderscheit B. Dextrose Prolotherapy for Symptomatic Knee Osteoarthritis: Feasibility, Acceptability, and Patient-Oriented Outcomes in a Pilot-Level Quality Improvement Project. J Altern Complement Med. 2019;25(4):406-412. doi:10.1089/acm.2018.0361

3. Sit RWS, Reeves KD, Zhong CC, et al. Efficacy of hypertonic dextrose injection (prolotherapy) in temporomandibular joint dysfunction: a systematic review and meta-analysis. Sci Rep. 2021;11:14638. doi:10.1038/s41598-021-94119-2

4. Johnston E, Kou Y, Junge J, et al. Hypertonic Dextrose Stimulates Chondrogenic Cells to Deposit Collagen and Proliferate. CARTILAGE. Published online June 10, 2021:19476035211014572. doi:10.1177/19476035211014572

5. Woo MS, Park J, Ok SH, et al. The proper concentrations of dextrose and lidocaine in regenerative injection therapy: in vitro study. Korean J Pain. 2021;34(1):19-26. doi:10.3344/kjp.2021.34.1.19

6. Ekwueme EC, Mohiuddin M, Yarborough JA, et al. Prolotherapy Induces an Inflammatory Response in Human Tenocytes In Vitro. Clin Orthop Relat Res. 2017;475(8):2117-2127. doi:10.1007/s11999-017-5370-1

7. Güran Ş, Çoban ZD, Karasimav Ö, et al. Dextrose solution used for prolotherapy decreases cell viability and increases gene expressions of angiogenic and apopitotic factors. GULHANE Med J. 2018;60(2):42. doi:10.26657/gulhane.00016

8. Freeman JW, Empson YM, Ekwueme EC, Paynter DM, Brolinson PG. Effect of prolotherapy on cellular proliferation and collagen deposition in MC3T3-E1 and patellar tendon fibroblast populations. Transl Res. 2011;158(3):132-139. doi:10.1016/j.trsl.2011.02.008

9. Reeves KD, Sit RWS, Rabago DP. Dextrose Prolotherapy: A Narrative Review of Basic Science, Clinical Research, and Best Treatment Recommendations. Phys Med Rehabil Clin N Am. 2016;27(4):783-823. doi:10.1016/j.pmr.2016.06.001

10. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;72(2):220-233. doi:10.1002/art.41142

Financial Disclosures: None reported.

Support: Campbell University

Ethical Approval: Not applicable.

Informed Consent: Not applicable.

Poster No. *B-18

Abstract No. 93

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

STK11IP Overexpression in Simian Cell Models to Determine Host Protein Interactions in Rotavirus Infected Cells

¹Preston McClain Allison, OMS-II; ²Michael Battistoni, MS; ²Crystal Boudreaux, PhD

¹West Virginia School of Osteopathic Medicine; ²Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine

Statement of Significance: Rotaviruses are the leading cause of severe, dehydrating gastroenteritis in children under 5 years of age. The AMP-protein kinase signaling pathway (termed AMPK) was previously determined to promote successful rotavirus replication. Understanding the role serine/threonine kinase 11 interacting protein (termed STK11IP) mediates in the regulation of the AMPK pathway is paramount to understanding the host’s proteomic changes under rotavirus challenge.

Research Methods: African Green monkey cells (MA104 cells) were infected with wild-type SA11-4F simian rotavirus strain. Overexpression of STK11IP was performed using N terminally labeled GFP. Knockdown of STK11IP was accomplished using SMART pool siRNA to STK11IP. Four sample populations were established: control, wild-type SA11-4F only, GFP only, and GFP/virus. Mock and infected cell lysates were collected and the protein target, STK11IP, was separated using SDS-PAGE gel electrophoresis. GFP-Trap magnetic agarose pulldown was used to precipitate the target GFP-fusion protein, STK11IP. Western blot analysis probed with an antibody specific for STK11IP was performed. Silver staining protocol was used to assess the total protein concentration in the different cell lysates for standardization purposes.

Data Analysis: ChemiDoc imaging analysis tool was used to examine the western blot results for cellular band expression. Bands of interest were scored based on whether the protein targets appeared at their expected molecular weight. STK11IP was found to have the greatest expression in both the GFP/viral sample compared to the samples that were only infected with the wild-type SA11-4F virus. Further comparison shows that the siRNA STK11IP knockout sample yielded the lowest expression of STK11IP when compared to both GFP/viral and SA11-4F wild-type virus samples. Protein concentrations among the samples were uniform, confirmed by silver stain analysis.

Results: ChemiDoc imaging analysis tool was used to examine the western blot results for cellular band expression. Bands of interest were scored based on whether the protein targets appeared at their expected molecular weight. STK11IP was found to have the greatest expression in both the GFP/viral sample compared to the samples that were only infected with the wild-type SA11-4F virus. Further comparison shows that the siRNA STK11IP knockout sample yielded the lowest expression of STK11IP when compared to both GFP/viral and SA11-4F wild-type virus samples. Protein concentrations among the samples were uniform, confirmed by silver stain analysis.

Conclusion: STK11IP was previously identified as an intriguing candidate based on its downstream signaling targets related to the AMPK pathway, a known mechanism used by rotaviruses for cell cycle replication. The AMP-protein kinase signaling pathway (termed AMPK), is a complex and extensive phosphorylation cascade that senses intracellular adenosine nucleotide levels. Understanding the role STK11IP mediates in the regulation of the AMPK pathway is critical to understanding the host’s proteomic changes under rotavirus infection. Preliminary data suggest that STK11IP is critical for successful rotavirus replication as knockdown experiments show significantly decreased viral titers in simian cell models.

The concentration of STK11IP was measured among mock and infected samples, followed by a comparison between STK11IP siRNA knockout and GFP STK11IP overexpression samples. This allowed for the observation of differential protein expression under the different experimental samples. The results suggest that samples infected with SA11-4F plus GFP, yield the greatest expression of STK11IP compared to SA11-4F wild type alone, suggesting a viral influence on the upregulation of STK11IP. Knowing this will further facilitate the investigation of STK11IP knockout experiments and potential protein purification efforts.

References

1. World Health Organization (WHO). Rotavirus. WHO. 2022; (https://www.who.int/teams/health-product-policy-and-standards/standards-and-specifications/vaccines-quality/rotavirus

2. Mihaylove M, Shaw R. The AMP-activaed kinase (AMPK) signaling pathway coordinates cell growth, autophagy, and metabolism. National Cell Biology. 2011; doi: 10.1038/ncb2329

3. Tate JE, Burton AH, Boschi-Pinto C, Parashar UD. Global, regional, and national estimates of rotavirus mortality in children. World Health Organization– Coordinated Global Rotavirus Surveillance Network. 2016; DOI: 10.1093/cid/civ1013

4. Green VA Pelkmans. A Systems Survey of Progressive Host-Cell Reorganization during Rotavirus Infection Cell Host & Microbe 20, 107–120; doi: 10.1016/j.chom.2016.06.005

Financial Disclosures: None reported

Support: This work is supported by the West Virginia IDeA Network of Biomedical Research Excellence NIH (NIGNS) Grant#P20GM103434Stu

Ethical Approval: Deemed exempt - no human or animal subjects used.

Informed Consent: Not applicable - no human subjects used.

Poster No. *B-19

Abstract No. 94

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

STK11IP and AMPK Cascade Protein Identification in Cells Infected With Recombinant Rotavirus by Subcellular Fractionation

Gregory Brantley Lawson, OMS-II; Michael Battistoni; Crystal Boudreaux, PhD

West Virginia School of Osteopathic Medicine

Statement of Significance: Rotavirus has been identified as the underlying cause of severe gastroenteritis in children, posing a serious health challenge to a vulnerable population. Although vaccinations are available, current treatments are limited because of the way rotavirus exploits human cells for survival is unclear. Utilizing the osteopathic principle that the body is a unit, this project investigates the dependence of rotavirus on native (host) mammalian proteins for perpetuation of its lifecycle.

Research Methods: MA104 cells (simian monkey, kidney) were infected with a SA11-4F recombinant laboratory strain of rotavirus. These infected cells were then lysed and fractionated via ultracentrifugation to allow for separate analysis of infected vs noninfected cells, as well as independent analysis of cytosol proteins (cytosolic fraction) versus a whole cell lysate that was not well fractionated (nuclear fraction). These fractions were confirmed to be cytosol by the presence of an alpha tubulin marker via dot blot, and confirmed to be free of nuclear components by the absence of NUP98 on dot blot. These fractions were normalized by mass on BCA assay and later probed on western blot to determine the relative expression of various proteins theorized to be involved in rotavirus infection. Findings were deemed to be significant if expression levels were altered with the presence of infection, and if expression levels appeared to have a relationship with a specific cellular compartment. All analysis and imaging were performed on BioRad’s image lab program.

Data Analysis: Antibodies were utilized to target host proteins hypothesized to play a role in rotavirus infection. Successful fractionation of cytosol away from other components was confirmed via dot blot. Viral non-structural cytoplasmic inclusion protein. NSP2 was found to express in cytosol fractions, as was STK11IP. This STK11IP was also noted to shift from a more massive dominant isoform to a less massive one when observed in the cytosolic fractions. Thus, both NSP2 and STK11IP were found to increase in expression with infection, while STK11IP also shifted to favor a less massive isoform in both cytosolic and infected conditions. By contrast, mTOR and STK11, (only found in non-cytosol fractions) were found to actually decrease in expression with rotavirus infection. These cytosolic samples will be further evaluated via FPLC to fractionate by size and determine the predominate size of proteins and complexes present. Finally, whole mounted cells were probed by fluorescent antibodies to view the location of these proteins in vivo.

Results: Antibodies were utilized to target host proteins hypothesized to play a role in rotavirus infection. Successful fractionation of cytosol away from other components was confirmed via dot blot. Viral non-structural cytoplasmic inclusion protein. NSP2 was found to express in cytosol fractions, as was STK11IP. This STK11IP was also noted to shift from a more massive dominant isoform to a less massive one when observed in the cytosolic fractions. Thus, both NSP2 and STK11IP were found to increase in expression with infection, while STK11IP also shifted to favor a less massive isoform in both cytosolic and infected conditions. By contrast, mTOR and STK11, (only found in non-cytosol fractions) were found to actually decrease in expression with rotavirus infection. These cytosolic samples will be further evaluated via FPLC to fractionate by size and determine the predominate size of proteins and complexes present. Finally, whole mounted cells were probed by fluorescent antibodies to view the location of these proteins in vivo.

Conclusion: The increased expression of NSP2 is consistent with a strong infection occurring. This is a marker of the cytosolic inclusion, this makes sense to express strongly in infected samples. The presence of this protein in the nucleus seems counterintuitive for a cytosol, RNA based rotavirus, but this is likely due to the imprecise nature of cell fractionation. Thus, the nuclear fraction is in reality a mix of cytosolic and nuclear fractions. This is demonstrated by the nuclear fraction testing positive for both nuclear and cytosolic markers on dot blot, and presents a clear area for improvement in the future. The strong expression of STK11IP concurrent with rotavirus infection has been seen before, and a smaller isoform of STK11IP has been previously observed. The observed shift towards a smaller isoform perhaps indicates a further marker of rotavirus infection. However, it is interesting to note that this smaller isoform appears to only dominate in cytosolic fractions, which is consistent with rotavirus being an RNA virus. However, given the robust expression of STK11IP, it is odd that STK11 and mTor, two downstream targets of STK11IP do not flux in expression with rotavirus infection. Also, pmtor, the activated form of mtor was probed multiple times with different antibodies, and no significant signal was detected. Thus, STK11IP is active, yet STK11, mtor, and pmtor are not. These findings together suggest that although STK11IP is clearly playing a part in rotavirus infection, its physiological downstream targets are not. Therefore, rotavirus may use host protein signaling cascades in ways that appear to be different from their endogenous pathways. In the future, we expect that further fractionation of cytosolic fractions via size exclusion on FPLC may further elucidate what proteins are present in mass in infected samples. This will hopefully enable investigation of protein-protein complexes and interactions occurring during rotavirus infection.

References

1. Rotavirus. www.who.int. https://www.who.int/teams/health-product-policy-and-standards/standards-and-specifications/vaccines-quality/rotavirus

2. Shackelford DB, Shaw RJ. The LKB1-AMPK pathway: metabolism and growth control in tumour suppression. Nat Rev Cancer. 2009 Aug;9(8):563-75. doi: 10.1038/nrc2676. PMID: 19629071; PMCID: PMC2756045.

3. Uniprot. https://www.uniprot.org/uniprotkb/A0A8J1IS57/entry. Accessed July 11, 2022.

4. Viskovska M, Anish R, Hu L, et al. Probing the sites of interactions of Rotaviral proteins involved in replication. Journal of Virology. 2014;88(21):12866-12881. doi:10.1128/jvi.02251-14

Financial Disclosures: none reported

Support: This work is supported by the West Virginia IDeA Network of Biomedical Research Excellence NIH (NIGNS) Grant#P20GM103434

Ethical Approval: Study was exempt from IRB

Informed Consent: We did not work with human cells or subjects so there was no informed consent process.

Poster No. *B-20

Abstract No. 107

Category: Basic Science

Research Topic: Osteopathic Philosophy

Trends in Osteopathic Research: An Evaluation of Presentation Topics at OMED from 2018 Through 2021

¹Dawniel Facque MA, OMS-II; ¹Rakael Brown, OMS-IV; ¹Yoojin Kim, OMS-II; ¹Daniel Girgis, OMS-II; ¹Nicole McCormick, OMS-II; ¹Eliza Skemp, OMS-II; ²Anthony Santarelli, PhD; ²Diana Lalitsasivimol, PhD; ³John Ashurst, DO, MSc

¹Midwestern University Arizona College of Osteopathic Medicine; ²Office of Research, Kingman Regional Medical Center; ³Department of Graduate Medical Education, Kingman Regional Medical Center

Statement of Significance: Osteopathic Medicine was founded on the principles of evidence-based support for the treatment of the entire individual above a singular focus on disease processes. However, over the past decade, allopathic physicians (MDs) have contributed the majority of published medical literature and have received substantially more funding to complete medical research studies. Analysis of recent research trends could be the first step to understanding barriers to funding, research, and publication.

Research Methods: A retrospective review of abstracts published for the AOA Research Abstracts and Poster Competition was conducted. Author demographics (Degree, Sex, Affiliations), main research topics (e.g., academic, disease, or utilization), publication history, and population, intervention, comparison, and outcome (PICO) characteristics were collected. Research topics were further classified into sub-objectives and modifiers to specify research topics.

Data Analysis: A total of 265 abstracts were reviewed from 2018 through 2021. Osteopathic medical students (OMS-I through OMS-IV) made up the largest portion of 1st authors (69.4%, 184/265) followed by individuals holding neither a DO, MD, nor PhD (15.8%; 42/265). The most frequent senior author listed on the abstract held a PhD (41.5%; 110/265) followed by a DO (24.5%; 65/265). Females more frequently contributed to abstracts in the 1st author position (145 Female vs 115 Male) but comprised a smaller number of the last author contributions (125 Female vs 138 Male) than did their male counterparts. The three most explored specialties in the abstracts were primary care (20.8%; 55/265), followed by Internal Medicine (14.3%; 38/265), and Osteopathic Manipulative Medicine (9.1%; 24/265). Most studies presented were conducted with a longitudinal cohort design (17.7%; 47/265) and showed a primary disease-based objective (71.3%; 189/265). A total of 12.1% (32/265) abstracts have been published as a full manuscript.

Results: A total of 265 abstracts were reviewed from 2018 through 2021. Osteopathic medical students (OMS-I through OMS-IV) made up the largest portion of 1st authors (69.4%, 184/265) followed by individuals holding neither a DO, MD, nor PhD (15.8%; 42/265). The most frequent senior author listed on the abstract held a PhD (41.5%; 110/265) followed by a DO (24.5%; 65/265). Females more frequently contributed to abstracts in the 1st author position (145 Female vs 115 Male) but comprised a smaller number of the last author contributions (125 Female vs 138 Male) than did their male counterparts. The three most explored specialties in the abstracts were primary care (20.8%; 55/265), followed by Internal Medicine (14.3%; 38/265), and Osteopathic Manipulative Medicine (9.1%; 24/265). Most studies presented were conducted with a longitudinal cohort design (17.7%; 47/265) and showed a primary disease-based objective (71.3%; 189/265). A total of 12.1% (32/265) abstracts have been published as a full manuscript.

Conclusion: The majority of abstracts presented at OMED are diseased based primary care with a longitudinal cohort design. Only a small percentage of presented abstracts within the study period are published as a full manuscript. Further studies assessing factors that lead to publication are needed to better understand if a correlation exists between presentations and publications.

Financial Disclosures: None reported

Support: None reported

Ethical Approval: IRB number KHI-0279. Exempt.

Informed Consent: Not relevant.

Poster No. *B-21

Abstract No. 67

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Selective Sweep Analysis as a Tool to Detect Mutations that Increase SARS-CoV-2 Virulence

¹Ariana Eugenia G. Faraji, OMS-III; ²Juan Guerra, OMS II; ²Kasia Michalak, MS; ²Nora Rady, OMS II; ²Stephen DiGiuseppe, PhD ²Lin Kang, PhD; ²Pawel Michalak, PhD

¹Edward Via College of Osteopathic Medicine-Louisiana; ²Department of Biomedical Sciences, Edward Via College of Osteopathic Medicine-Louisiana

Statement of Significance: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a profound impact on healthcare worldwide, with our understanding of it constantly evolving throughout these past years. Initially presenting in bats and pangolins, SARS-CoV-2 underwent several selective mutations that allowed the virus to enter the human host. The exact mutations that allowed SARS-CoV-2 to infect humans are not completely elucidated, but recent innovations have provided insight into these mutations.

Research Methods: To create the lentiviral particle, we co-transfected cells with a lentiviral backbone encoding the reporter protein(s), a plasmid expressing Spike, and plasmids encoding the other proteins necessary for virion formation (Tat, Gag-Pol, and Rev).2 We infect 293A-ACE2 cells with these lentiviral particles, and examine them for infectivity, looking specifically at mutations in the viral genome by conducting a selective sweep for signatures of SARS-CoV-2 and correlating these mutations to infection rates. For the selective sweep region detection, a total of 182,792 complete SARS-CoV-2 genomes from the human host were downloaded from the GISAID EpiCov database. Sequences were first aligned to SARS- CoV-2 reference using Minimap2.3 Sequences with aligned lengths less than 20,000 were excluded from the analysis. The 136,114 remaining sequences were then aligned by using MAFFT.4 OmegaPlus and RAiSD were used for sweep region detection, and the SARS-CoV-2 isolate Wuhan-Hu-1 genome was used as an outgroup.5,6 Functional ELISA was performed by Sino Biological using purified RBD from WT, A372T, and N501Y. RBDs were expressed in HEK293 cells and purified using the polyhistidine tag at the C terminus. Viral titers were compared to WT using a two-way ANOVA with Dunnett’s multiple comparisons test; a p-value of less than 0.05 was considered significant. As osteopaths, we must follow and apply the tenets of osteopathic medicine in all aspects of our practice, including our research. The third and fourth tenets read, “structure and function are reciprocally interrelated”, and “rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.”7 Just as we apply these tenets to the human body, we can apply them to our research. We must strive to understand the structure of the SARS-CoV-2 virus to better understand its function within the human cell.

Data Analysis: Our data shows that a total of six sites of significant mutations were identified. Upon review of these sites, a single site (A1114G, genomic position 22,676) was centrally located in one of the sweep regions; this is within the codon position 372 of the S protein. The amino acid threonine in this position of the four Sarbecovirus members was substituted with alanine (Thr372Ala) in human SARS-CoV-2. Through functional ELISA, we compared T372A to wildtype (A372) and N501Y. N501Y has been previously shown to increase binding to human ACE2 (hACE2), and thus was used as our positive control.8 With statistical analysis using one-way ANOVA (P < 0.0001) to compare the three strains, we saw that the mutation T372A was advantageous as it enhanced the virus’s binding affinity to hACE2.

Results: Our data shows that a total of six sites of significant mutations were identified. Upon review of these sites, a single site (A1114G, genomic position 22,676) was centrally located in one of the sweep regions; this is within the codon position 372 of the S protein. The amino acid threonine in this position of the four Sarbecovirus members was substituted with alanine (Thr372Ala) in human SARS-CoV-2. Through functional ELISA, we compared T372A to wildtype (A372) and N501Y. N501Y has been previously shown to increase binding to human ACE2 (hACE2), and thus was used as our positive control.8 With statistical analysis using one-way ANOVA (P < 0.0001) to compare the three strains, we saw that the mutation T372A was advantageous as it enhanced the virus’s binding affinity to hACE2.

Conclusion: Understanding SARS-CoV-2 from an evolutionary standpoint in addition to a clinical one can improve how we approach the prevention of SARS-CoV-2. Our data supply solid evidence that S protein residue 372 is critical for replication in human cells. If we can further verify this mutation in the varying strains of SARS-CoV-2 or identify more advantageous mutations in the SARS-CoV-2 genome, then we may be able to better understand the virulence of this virus. We plan to continue this research to further analyze varying strains of SARS-CoV-2 and key advantageous mutations increasing their virulence.

References

1. Kang L, He G, Sharp AK, Wang X, Brown AM, Michalak P, Weger-Lucarelli J. A Selective Sweep in the Spike Gene has Driven SARS-CoV-2 Human Adaptation. Cell. 2021;184(17):4392-400. https://doi.org/10.1016/j.cell.2021.07.007

2. Crawford KHD, Eguia R, Dingens AS, Loes AN, Malone KD, Wolf CR, Chu HY, Tortorici MA, Veesler D, Murphy M, Pettie D, King NP, Balazs AB, Bloom JD. Protocol and Reagents for Pseudotyping Lentiviral Particles with SARS-CoV-2 Spike Protein for Neutralization Assays. Viruses. 2020; 12(5):513. https://doi.org/10.3390/v12050513

3. Li H, Minimap2: pairwise alignment for nucleotide sequences, Bioinformatics, Volume 34, Issue 18. 2018, Pages 3094–3100. https://doi.org/10.1093/bioinformatics/bty191

4. Kazutaka Katoh, Daron M. Standley, MAFFT Multiple Sequence Alignment Software Version 7: Improvements in Performance and Usability, Molecular Biology and Evolution, Volume 30, Issue 4, 2013; Pages 772–780. https://doi.org/10.1093/molbev/mst010

5. Alachiotis N, Stamatakis A, Pavlidis P. OmegaPlus: a scalable tool for rapid detection of selective sweeps in whole-genome datasets, Bioinformatics, Volume 28, Issue 17. 2012; Pages 2274–2275. https://doi.org/10.1093/bioinformatics/bts419

6. Alachiotis N, Pavlidis P. RAiSD detects positive selection based on multiple signatures of a selective sweep and SNP vectors. Commun Biol 1, 79 2018. https://doi.org/10.1038/s42003-018-0085-8

7. Tenets of osteopathic medicine. American Osteopathic Association. (2019, September 3). Retrieved July 10, 2022, from https://osteopathic.org/about/leadership/aoa-governance-documents/tenets-of-osteopathic-medicine/

8. Collier DA, De Marco A, Ferreira IATM, Meng B, Datir, RP, Walls AC, Kemp SA, Bassi J, Pinto D, Silacci-Fregni C, Bianchi S, Tortorici MA, Bowen J, Culap K, Jaconi S, Cameroni E, Snell G, Pizzuto MS, Pellanda AF, … Gupta RK. Sensitivity of SARS-COV-2 B.1.1.7 to mrna vaccine-elicited antibodies. Nature News. 2021. https://doi.org/10.1038/s41586-021-03412-7

Financial Disclosures: None Reported

Support: None Reported

Ethical Approval: The generation of recombinant SARS-CoV-2 was approved by the Institutional Biosafety Committee at Virginia Tech. All studies with live infectious SARS-CoV-2 or mutant viruses were performed in an approved BSL3 facility following CDC and NIH guidelines. Re- searchers manipulating live virus wore an N95 respirator or Powered Air Purifying Respirators (PAPR) as approved by the IBC.

Informed Consent: Not Applicable

Poster No. *B-22

Abstract No. 52

Category: Basic Science

Research Topic: Acute and Chronic Pain Management

Osteopathic and Podiatric Medical Students’ Attitudes Toward Low Back Pain

Samantha Johnson, OMS-II; Emily Garcia, OMS-II; Chase Bauer, OMS-IV; Kye See-McLaughlin, OMS-II; Sebastien Fuchs, MD, PhD

Western University of Health Sciences College of Osteopathic Medicine of the Pacific

Statement of Significance: Primary care practitioners managing low back pain (LBP) have a range of beliefs from biomedical to biopsychosocial. Previous studies found a positive association between biopsychosocial beliefs about pain and adherence to evidence based guidelines (1,2). Past research has focused on training clinicians on pain science and treatment recommendations to improve patient outcomes, though it’s been shown that LBP beliefs develop early in education and can be resistant to change (3).

Research Methods: The Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS) questionnaire is a 7-point Likert scale, measuring the level of belief that back pain justifies disability and activity limitations on 4 subscales: “functional expectations,” “social expectations,” “need for cure,” and “projected cognition.” The total score ranges from 15 to 105. A higher HC-PAIRS score indicates belief that LBP justifies disability and the limitation of physical activity, bias toward a biomechanical attitude which is associated with lower adherence to guidelines (4). A lower score indicates more biopsychosocial attitudes. This survey was submitted in June 2022 to all osteopathic (DO) and podiatric (DPM) students currently enrolled at Western University of Health Sciences classes of 2022-2025. DO programs located on two campuses, Lebanon, OR and Pomona, CA. DPM programs located only on Pomona campus. Pre-clinical students are students of DO/DPM classes 2024 and 2025 who are enrolled in didactic curriculum before interacting with patients. Clinical students are DO/DPM classes of 2023 and 2022 who are participating in clinical rotations in hospitals and clinical practices. The HC-PAIRS score for each group was averaged and standard deviation calculated. A Mann-Whitney Test was used to analyze statistical significance.

Data Analysis: The survey was sent to 705 preclinical and 685 clinical DO students, as well as 88 preclinical and 61 clinical DPM students. 175 surveys were completed, consisting of 85 (12.1% response rate) preclinical and 66 (9.6% response rate) clinical DO students, as well as 13 (14.8% response rate) preclinical and 11 (18% response rate) clinical DPM students. After analysis, average scores between clinical and preclinical groups were not significantly different using a Mann-Whitney Test. Clinical DO students and preclinical DO students scored an average of 60.8 ±9.4 and 61.7 ±8.1, respectively. Clinical podiatric medicine students and preclinical podiatric students scored an average of 61.3 ±7.7, and 69.7±8.3, respectively.

Results: The survey was sent to 705 preclinical and 685 clinical DO students, as well as 88 preclinical and 61 clinical DPM students. 175 surveys were completed, consisting of 85 (12.1% response rate) preclinical and 66 (9.6% response rate) clinical DO students, as well as 13 (14.8% response rate) preclinical and 11 (18% response rate) clinical DPM students. After analysis, average scores between clinical and preclinical groups were not significantly different using a Mann-Whitney Test. Clinical DO students and preclinical DO students scored an average of 60.8 ±9.4 and 61.7 ±8.1, respectively. Clinical podiatric medicine students and preclinical podiatric students scored an average of 61.3 ±7.7, and 69.7±8.3, respectively.

Conclusion: No significant difference in HC-PAIRS scores were observed in all groups. In particular no difference was found comparing preclinical and clinical cohorts. Compared to other health professional students in previous studies, these students’ scores were more consistent with biomedical attitudes toward LBP (5). This serves to show that medical school didactic and clinical education may not significantly steer student’s attitudes toward biopsychosocial perspectives of low back pain. This may suggest the need for a shift in medical education to include more pain science and pain management content, including content that discusses the psychosocial component of low back pain, leading to more guideline adherent care.

This was a single university study, which may limit results. Additionally, as is often the case with survey-driven studies, the response rate was low. This may have been exacerbated by the COVID-19 pandemic and a mostly online education. There are limited studies evaluating low back pain attitudes in medical students in the United States using the HC-PAIRS questionnaire. Therefore, the validity of the correlation of the survey score with adherence to clinical guidelines should be confirmed in this population as well. Additionally, the COVID-19 pandemic could have some effect on the delivery of educational content. Assessing results at different points in time may show varied outcomes. A future multi-centric study that follows each class longitudinally may be useful in further identifying the impact that didactic and clinical exposure have on DO and DPM attitudes towards LBP and association with adherence to clinical guidelines and patient outcomes.

References

1. Bishop A, Foster NE, Thomas E, Hay EM. How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists. Pain. 2008;135(1-2):187-195. doi:10.1016/j.pain.2007.11.010

2. Houben RMA, Ostelo RWJG, Vlaeyen JWS, Wolters PMJC, Peters M, Berg SGM. Healthcare providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. Euro J Pain. 2005;9(2):173-183. doi:10.1016/j.ejpain.2004.05.002

3. Darlow B, Fullen B, Dean S, Hurley D, Baxter G, and Dowell A. The association between health care professional attitudes and outcomes of patients with low back pain. Euro J Pain. 2012;16:3-17. https://doi.org/10.1016/j.ejpain.2011.06.006Ehrström

4. J, et al. Psychometric Properties and Factor Structure of the Finnish Version of the Health Care Providers’ Pain and Impairment Relationship Scale. Musculoskelet. Sci. Pract. 2022. 57;102471. https://doi.org/10.1016/j.msksp.2021.102471

5. Briggs A, Slater H, Smith A, Parkin-Smith G, Watkins K, and Chua J. Cross-discipline student beliefs and practice behaviours. 2013. Euro J Pain. 17: 766-775. https://doi-org.proxy.westernu.edu/10.1002/j.1532-2149.2012.00246.x

Financial Disclosures: None Reported

Support: None reported

Ethical Approval: PROJECT TITLE: [1923040-1] Development of Attitudes About Low Back Pain in Doctor of Osteopathic Medicine and Doctor of Podiatric Medicine Students REFERENCE #: X21/IRB/092 (1841766-1) Exempt Status

Informed Consent: Consent was obtained by including a statement in the introductory paragraph of the survey and submission of a completed survey was taken as informed consent.

★ Poster No. *B-23

Abstract No. 98

Category: Basic Science

Research Topic: Impact of OMM & OMT

AOA Grant Award: # 19137759

Effect of Occipito-Atlantal Decompression, Transcutaneous Auricular Vagus Nerve Stimulation, and the Splenic Pump on Circulatory Immune Cell Numbers

¹Kathryn Cerami, OMS-II; ²Julia Wong, OMS-II; ²Richard Huynh, OMS-II; ²Felicia Romero, OMS-II; ²Adam Viegas, OMS-II; ²Minyu Chen, OMS-II; ²Harald Stauss, MD; ³Adrienne Kania, DO, FAAO

¹Burrell College of Osteopathic Medicine (BCOM); ²Department of Biomedical Sciences, Burrell College of Osteopathic Medicine; ³Department of Clinical Medicine, Burrell College of Osteopathic Medicine

Statement of Significance: Occipito-atlantal decompression (OA-D) and transcutaneous auricular vagus nerve stimulation (taVNS) may activate the cholinergic anti-inflammatory pathway through parasympathetic activation (1-3) and potentially through a change in immune cell numbers. The splenic pump technique may augment the effect of OA-D or taVNS on immune function, potentially through facilitating an exchange of immune cells between the spleen, other reticular organs, and the blood.

Research Methods: This study was approved by the Institutional Review Board of Burrell COM (IRB# 0054_2019 and IRB# 0089_2021) and registered with ClinicalTrials.gov (NCT04177264). The study participants (n=34) were healthy adults (age > 18 years) of both genders. Exclusion criteria included: pregnancy; any medical condition or medication that interferes with the autonomic nervous system or the immune system; acute or chronic infections, diabetes; and current drug or alcohol abuse. On three consecutive days OA-D or taVNS was performed followed (30 min later) by either the splenic pump or a sham intervention (no splenic pump). A blood sample was drawn at the end of the third day. OA-D was done according to Greenman’s textbook. (4) The fingers of both hands were placed at the junction of the occiput and neck and 5 N of pressure were applied for 10 min. For taVNS a current of 2 mA, 10 Hz frequency and 300 µs pulse width was applied via a bipolar clip electrode attached to the cymba conchae of the left ear for 10 min. The splenic pump technique was performed with 10 min of rhythmic pumping of the left upper abdominal quadrant at a controlled pressure of 2-4 mmHg and rate of 30 compressions per min. For flow cytometry leukocytes were isolated from the blood samples obtained on the third study day and T-helper cells (CD3+, CD4+), cytotoxic T-cells (CD3+, CD8+), B-cells (CD19+), monocytes (CD14+, CD11b+), and natural killer (NK, CD3-, CD56+) cells were detected using the respective fluorescence-labeled antibodies.Flow cytometry data were analyzed using a stepwise multiple linear regression analysis using the R Statistical Platform. (5) The dependent variables were the relative number of immune cells (percent of total cells) and the independent variables were the body mass index (BMI) and whether OA-D, taVNS, or the splenic pump had been performed. Independent parameters detected by the linear regression analysis were considered significant at P<0.05 and considered trends at P<0.15.

Data Analysis: Study participants (11 male, 23 female) were in the overweight range (BMI: 27.9±1.1 kg/m2). A higher BMI was associated with a larger relative number of T-helper cells (effect size: +0.16, P<0.05) and cytotoxic T-cells (effect size: +0.06, P<0.05). When corrected for BMI, taVNS significantly reduced the relative number of T-helper cells (effect size: -1.4, P<0.05) and cytotoxic T-cells (effect size: -0.47, P<0.15). The relative number of B-cells was reduced by taVNS (effect size: -0.32, P<0.05) and the splenic pump (effect size: -0.21, P<0.15). The relative number of monocytes was increased by the splenic pump technique (effect size: +0.51, P<0.15) and decreased by OA-D (effect size: -0.74, P<0.15). The relative number of NK cells significantly decreased by the splenic pump (effect size: -0.71, P<0.05).

Results: Study participants (11 male, 23 female) were in the overweight range (BMI: 27.9±1.1 kg/m2). A higher BMI was associated with a larger relative number of T-helper cells (effect size: +0.16, P<0.05) and cytotoxic T-cells (effect size: +0.06, P<0.05). When corrected for BMI, taVNS significantly reduced the relative number of T-helper cells (effect size: -1.4, P<0.05) and cytotoxic T-cells (effect size: -0.47, P<0.15). The relative number of B-cells was reduced by taVNS (effect size: -0.32, P<0.05) and the splenic pump (effect size: -0.21, P<0.15). The relative number of monocytes was increased by the splenic pump technique (effect size: +0.51, P<0.15) and decreased by OA-D (effect size: -0.74, P<0.15). The relative number of NK cells significantly decreased by the splenic pump (effect size: -0.71, P<0.05).

Conclusion: A higher BMI was associated with elevated numbers of T-helper and cytotoxic T-cells, confirming the chronic inflammatory nature of obesity. taVNS reduced the number of T-helper and cytotoxic T-cells independent of the splenic pump, suggesting taVNS may be beneficial in treating chronic inflammation in obesity or other inflammatory conditions. Both, taVNS and the splenic pump reduced the relative number of circulating B-cells. This gives rise to the intriguing hypothesis that the combination of taVNS with the splenic pump may be beneficial in B-cell-mediated auto-immune disorders or for the prevention of secondary treatment failure (via anti-drug antibodies) of biologic medications for chronic inflammatory diseases. While OA-D tended to decrease the relative number of monocytes, this effect was offset by the splenic pump that tended to increase the monocyte numbers. Considering the spleen contains 10-times more monocytes than the whole blood, it is reasonable to conclude the splenic pump mobilizes monocytes from the spleen that are then translocated into the systemic circulation. The splenic pump caused a marked reduction in NK cells. Presumably the splenic pump translocated NK cells from the blood into reticular organs, such as the spleen. This effect of the splenic pump on NK cells is opposite to that on monocytes. It is possible that immune cells with higher concentrations in the spleen than in the blood (e.g., monocytes) translocate into the blood (6), while immune cells with lower concentrations in the spleen than in the blood (e.g., NK cells) translocate away from the blood. Thus, the splenic pump appears to facilitate an exchange of immune cells between the spleen, other reticular organs, and the blood that depends on the relative abundance of the respective immune cells in these compartments. As a limitation of this study, our experimental protocol does not allow us to determine the specific reticular organs from which cells are being translocated.

References

1. Curi ACC, Maior Alves AS, Silva JG. Cardiac autonomic response after cranial technique of the fourth ventricle (cv4) compression in systemic hypertensive subjects. J Bodyw Mov Ther. Jul 2018;22(3):666-672. doi:10.1016/j.jbmt.2017.11.013

2. Giles PD, Hensel KL, Pacchia CF, Smith ML. Suboccipital decompression enhances heart rate variability indices of cardiac control in healthy subjects. J Altern Complement Med. Feb 2013;19(2):92-6. doi:10.1089/acm.2011.0031

3. Kania AM, Weiler KN, Kurian AP, Opena ML, Orellana JN, Stauss HM. Activation of the cholinergic antiinflammatory reflex by occipitoatlantal decompression and transcutaneous auricular vagus nerve stimulation. J Osteopath Med. Feb 24 2021;121(4):401-415. doi:10.1515/jom-2020-0071

4. DeStefano LA. Greenman’s Principles of Manual Medicine. Lippincott Williams & Wilkins. Baltimore, MD; 2011.

5. R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing. https://www.R-project.org/

6. Swirski FK, Nahrendorf M, Etzrodt M, et al. Identification of splenic reservoir monocytes and their deployment to inflammatory sites. Science. Jul 31 2009;325(5940):612-6. doi:10.1126/science.1175202

Financial Disclosures: None reported.

Support: This study was supported by funding through the Research Office of Burrell College of Osteopathic Medicine, Las Cruces, NM. A follow-up study is being supported by grants from the American Osteopathic Association (Grant No.: 19137759) and the American Academy of Osteopathy (LBORC, 2022).

Ethical Approval: This study was approved by the Institutional Review Board of Burrell COM (IRB# 0054_2019 and IRB# 0089_2021) and registered with ClinicalTrials.gov (NCT04177264).

Informed Consent: All study participants provided written informed consent according to the approved IRB protocols.

Poster No. *B-24

Abstract No. 99

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Loss of Tumor Suppressor Gene Rb1 Affects Osteoblast Specific miRNA Expression and Function

¹Raj Shah, OMS-III; ²Nalini Chandar, PhD; ²Elisha Pendleton

¹Midwestern University Chicago College of Osteopathic Medicine; ²Department of Biochemistry Institution, Midwestern University Chicago College of Osteopathic Medicine

Statement of Significance: Osteosarcomas arise from changes in the homeostasis of bone regulation. Often, they are characterized by inactivation of tumor suppressor genes p53 and Retinoblastomas (Rb1).(1) Our lab wished to see if changes in Rb1 expression would change expression of connexin43, which is a transmembrane protein that mediates cell-cell communication, and microRNAs (miRNA), which are small molecules that are important in regulating gene expression in Osteoblasts.

Research Methods: We stably reduced Rb1 expression in some mouse preosteoblast cell lines and reduced connexin 43 in other mouse preosteoblast cell lines using shRNA technology and assessed changes to several parameters related to osteoblast differentiation compared to control cell lines. Changes in expression of miRNAs were measured using realtime PCR analysis. Changes in expression of connexin 43 were measured at the level of transcripts (Realtime PCR) and protein (by western blotting). Putative miRNA targets were identified using miRbase.(3)Communication was quantitated using a dye transfer method. (4)

Data Analysis: We observed loss of gap junctional intercellular communication in osteoblasts with reduced Rb1 expression. Connexin 43 normally increases with osteoblast differentiation and is an important part of the differentiation process coinciding with expression of several osteoblast specific transcription factors. Connexin 43 expression was present in Rb1 knockout cells but appeared to be haphazard when compared to control cells, where there was a steady increase in expression with differentiation. Immunofluorescence analysis demonstrated the protein to be detectable in the plasma membrane similar to normal osteoblasts. Interestingly, the presence of connexin 43 did not correlate with the ability for gap junctional intercellular communication, which we found to be reduced in Rb1 deficient cells. (2-4 fold changes in control cells vs < 1 in Rb knockdown cells). As miRNAs are important regulators of gene expression, especially in osteoblasts, we explored changes to miRNAs that are seen in cell lines with loss of Rb1 expression. We chose to further analyze miRNAs that have already been established to have osteoblast specific roles (miRNAs 206, 218, 23a, 144, 125b-1, and 125b-2). While expression of most of these miRNAs were decreased with Rb1 loss, miR218 showed a 4-6 fold increase and was further analyzed. miR218was also increased 5-fold in cells that lacked connexin 43 expression. This suggested a role for miR218 in the regulation of connexin 43. To further determine the function of miR-218, bioinformatics analysis was carried out to predict direct targets of this miRNA. These studies revealed that connexin 43 gene contained putative target sites for miR218 in its 3’UTR.

Results: We observed loss of gap junctional intercellular communication in osteoblasts with reduced Rb1 expression. Connexin 43 normally increases with osteoblast differentiation and is an important part of the differentiation process coinciding with expression of several osteoblast specific transcription factors. Connexin 43 expression was present in Rb1 knockout cells but appeared to be haphazard when compared to control cells, where there was a steady increase in expression with differentiation. Immunofluorescence analysis demonstrated the protein to be detectable in the plasma membrane similar to normal osteoblasts. Interestingly, the presence of connexin 43 did not correlate with the ability for gap junctional intercellular communication, which we found to be reduced in Rb1 deficient cells. (2-4 fold changes in control cells vs < 1 in Rb knockdown cells). As miRNAs are important regulators of gene expression, especially in osteoblasts, we explored changes to miRNAs that are seen in cell lines with loss of Rb1 expression. We chose to further analyze miRNAs that have already been established to have osteoblast specific roles (miRNAs 206, 218, 23a, 144, 125b-1, and 125b-2). While expression of most of these miRNAs were decreased with Rb1 loss, miR218 showed a 4-6 fold increase and was further analyzed. miR218was also increased 5-fold in cells that lacked connexin 43 expression. This suggested a role for miR218 in the regulation of connexin 43. To further determine the function of miR-218, bioinformatics analysis was carried out to predict direct targets of this miRNA. These studies revealed that connexin 43 gene contained putative target sites for miR218 in its 3’UTR.

Conclusion: Rb1 is a tumor suppressor gene that plays an important role in controlling cell proliferation and differentiation. However, Rb1 appears to be important for cells to maintain gap junctional communication. A reduction in communication was not associated with reduction in connexin 43 expression. Our studies have found that mouse preosteoblast cell lines that had reduced Rb1 expression also had dramatically increased miR218 expression. Additionally, we have found that mouse cell lines that lack connexin 43 expression, an integral protein in cell-cell communication, also had increased miR218 expression. Further, bioinformatics analyses revealed that the connexin 43 gene had target sites for miR218 in its 3’UTR. Together, these findings suggest that (1) Berman SD, Calo E, Landman AS, et al. Metastatic osteosarcoma induced by inactivation of rb and p53 in the osteoblast lineage. Proceedings of the National Academy of Sciences . 2008;105(33):11851-11856. doi:10.1073/pnas.0805462105; (2) Indovina P, Pentimalli F, Casini N, Vocca I, Giordano A. RB1 dual role in proliferation and apoptosis: Cell fate control and implications for cancer therapy. Oncotarget . 2015;6(20):17873-17890. doi:10.18632/oncotarget.4286; (3) Liu W, Wang X. Prediction of functional microRNA targets by integrative modeling of microRNA binding and target expression data. Genome Biol. 2019;20(1). doi:10.1186/s13059- 019-1629-z; and (4) 3. Warawdekar U. An Assay to Assess Gap Junction Communication in Cell Lines. J Biomol Tech. 2019;30(1):1-6. doi:10.7171/jbt.19-3001-001 miRNAs likely contribute to changes seen with loss of Rb1 function. Future studies are required to investigate this connection and other miRNA connections with the Rb1 gene.

References

1. Berman SD, Calo E, Landman AS, et al. Metastatic osteosarcoma induced by inactivation of rb and p53 in the osteoblast lineage. Proceedings of the National Academy of Sciences . 2008;105(33):11851-11856. doi:10.1073/pnas.0805462105

2. Indovina P, Pentimalli F, Casini N, Vocca I, Giordano A. RB1 dual role in proliferation and apoptosis: Cell fate control and implications for cancer therapy. Oncotarget . 2015;6(20):17873-17890. doi:10.18632/oncotarget.4286

3. Liu W, Wang X. Prediction of functional microRNA targets by integrative modeling of microRNA binding and target expression data. Genome Biol. 2019;20(1). doi:10.1186/s13059- 019-1629-z

4. Warawdekar U. An Assay to Assess Gap Junction Communication in Cell Lines. J Biomol Tech. 2019;30(1):1-6. doi:10.7171/jbt.19-3001-001

Financial Disclosures: None reported

Support: None reported

Ethical Approval: Not applicable

Informed Consent: Not applicable

Poster No. *B-25

Abstract No. 74

Category: Basic Science

Research Topic: Chronic Diseases & Conditions

Mycoplasma Genitalium Detection Using Loop Mediated Isothermal Amplification (LAMP)

¹Love Opoku Afrifa, OMS-II; ²Debra E. Bramblett, PhD

¹Burrell College of Osteopathic Medicine; ²Department of Biomedical Sciences, Burrell College of Osteopathic Medicine

Statement of Significance: Mycoplasma genitalium is a sexually transmitted pathogen, causing 25-35% of nongonococcal urethritis in males and linked to premature rupture of placental membranes in females (1). This pathogen is difficult to culture, requiring an alternative identification method for diagnosis (2). Loop-mediated isothermal amplification (LAMP) is a novel nucleic acid amplification technique that uses a set of 4 to 8 DNA primers, allowing for rapid target amplification and a viable detection method.

Research Methods: Primer sets for the LAMP assay were designed using available pdhD gene sequences of the G37 strain of M. genitalium from GenBank (L43967.2)3. Alignments of the pdhD genes of four M. genitalium types were performed using Clustal Omega (4). LAMP primers (F3, B3, FIP, and BIP) were created using NEB’s LAMP Primer design tool (5). Loop primers (LF, LB) were designed separately to increase the specificity and sensitivity of the LAMP assay using the NEB LAMP Primer design tool (5). The final primer set was chosen based on delta g values. The specificity of all primers was confirmed using BLAST (6).

The G37 strain of M. genitalium DNA was obtained from American Type Culture Collection (Mycoplasma genitalium ATCC 33530). Colorimetric LAMP reactions were performed using the WarmStart® Colorimetric (or Fluorescent) LAMP 2X Master Mix (DNA & RNA) (M1800S) from New England Biolabs (NEB, Ipswich, MA, USA) or the WarmStart® Fluorescent LAMP/RT-LAMP Kit (E1708S) with LAMP Fluorescent Dye (NEB #B1700). Reaction mixes were prepared as described by the manufacturer (NEB). Colorimetric reactions were carried out in an MJ Research PTC-200 Thermal Cycler, incubating the reaction at 65°C for 30 minutes. Fluorescent detection was monitored by the CFX96 Touch Real-Time Thermocycler during the incubation at 65°C with a FAM absorption and emission spectra of 493nm/517nm. Genomic copies were calculated based on the M. genitalium genome size (580,076 base pairs).

Data Analysis: The LAMP reactions performed with the novel-designed primers resulted in the highly specific and sensitive detection of Mycoplasma genitalium. The pdhD Color LAMP reaction allowed target detection of 15.97 genomic copies at a concentration of 1x10-2 pg/μL in 30 minutes. Fluorescent LAMP allowed detection of a much lower target DNA copy amount, 1.6 genomic copies which equate to a concentration of 1x10-7ng/μL, in a shorter amount of time (18 minutes). Controls that contained no target DNA or off-target DNA and did not result in any noticeable amplification. Lateral flow detection of the Mycoplasma genitalium LAMP assay for POC detection is currently under development.

Results: The LAMP reactions performed with the novel-designed primers resulted in the highly specific and sensitive detection of Mycoplasma genitalium. The pdhD Color LAMP reaction allowed target detection of 15.97 genomic copies at a concentration of 1x10-2 pg/μL in 30 minutes. Fluorescent LAMP allowed detection of a much lower target DNA copy amount, 1.6 genomic copies which equate to a concentration of 1x10-7ng/μL, in a shorter amount of time (18 minutes). Controls that contained no target DNA or off-target DNA and did not result in any noticeable amplification. Lateral flow detection of the Mycoplasma genitalium LAMP assay for POC detection is currently under development.

Conclusion: In this study, we developed a Colorimetric and Fluorescent LAMP assay for the detection of the highly conserved pdhD gene of Mycoplasma genitalium. LAMP assays maintain the high sensitivity of normal PCR assays while allowing for a more rapid diagnosis with similar sensitivity, eliminating the need for thermal cycling (2).

This study determined the limit of the Color LAMP and fluorescent LAMP assays for M. genitalium. The pdhD fluorescent LAMP was found to be more sensitive (1.6 genomic copies) than the Colorimetric LAMP assay (15.97 genomic copies). Fluorescent LAMP reactions were monitored for 32 minutes at 65° with the fastest time to detection of 14 minutes containing the highest concentration of the target.

Although LAMP is advantageous in many ways, the assay does have some drawbacks. The requirement of 8 primers rather than two in comparison to PCR makes assay development more challenging. The products of LAMP are not a single identical sequence identical to the original target. LAMP also produces a high amount of amplicon and could pose a significant risk of contamination in post-amplification analysis (7).

This study developed a unique LAMP assay for Mycoplasma genitalium G47 that is a rapid, sensitive, and specific method of detection, but further evaluation using clinical samples is necessary to determine its efficacy as a diagnostic test. We predict that this assay is specific to Mycoplasma genitalium, but further work is needed to determine other mycoplasma species that may also be detected with this primer set. Current work is underway to establish a point of care LAMP assay. With mycoplasmas infections becoming more common, causing a variety of adverse reproductive symptoms, more clinical detection methods like LAMP are important to the future of reproductive health. We project that screening pregnant women for Mycoplasma colonization could potentially be a preventative measure precluding chorioamnionitis and possibly fetal loss.

References

1. Ma C, Du J, Dou Y, et al. The Associations of Genital Mycoplasmas with Female Infertility and Adverse Pregnancy Outcomes: a Systematic Review and Meta-analysis. Reprod Sci. 2021;28(11):3013-3031. doi: 10.1007/s43032-020-00399-w

2. Edwards T, Burke P, Smalley HB, et al. Loop-mediated isothermal amplification (LAMP) for the rapid detection of Mycoplasma genitalium. Diagn Microbiol Infect Dis. 2015;83(1):13-17. doi: 10.1016/j.diagmicrobio.2015.05.010

3. Benson DA, Cavanaugh M, Clark K, et al. GenBank. Nucleic Acids Res. 2013;41(Database issue):D36-42. doi: 10.1093/nar/gks1195

4. Sievers F, Wilm A, Dineen D, et al. Fast, scalable generation of high-quality protein multiple sequence alignments using Clustal Omega. Mol Syst Biol. 2011;7:539. doi: 10.1038/msb.2011.75

5. NEB LAMP Primer Design v1.3.0. Updated June 3, 2022. Accessed May 18, 2022. https://lamp.neb.com/#!/.

6. Altschul SF, Gish W, Miller W, Myers EW, Lipman DJ. Basic local alignment search tool. J Mol Biol. 1990;215(3):403-410. doi: 10.1016/s0022-2836(0580360-2)

7. Dhama K, Karthik K, Chakraborty S, et al. Loop-mediated isothermal amplification of DNA (LAMP): a new diagnostic tool lights the world of diagnosis of animal and human pathogens: a review. Pak J Biol Sci. 2014;17(2):151-166. doi: 10.3923/pjbs.2014.151.166

Financial Disclosures: None Reported.

Support: This project was supported by the Burrell College Summer Research Experience.

Ethical Approval: Not applicable.

Informed Consent: Not applicable.

Poster No. *C-1

Abstract No. 1

Category: Clinical

Research Topic: Impact of OMM & OMT

Osteopathic Manipulative Treatment Efficacy in Mean HIT-6 Score Reduction in Tension-Type Headaches: A Meta-Analysis

¹Elena Tran, OMS-III; ¹Charles Thomas, OMS-III; ¹Tina Zheng, OMS-III; ¹Arun Thalody, OMS-III; ¹Austin Winegar, OMS-III; ¹Vincent Torelli, OMS-III; ²Shan Shan Wu, DO

¹Lake Erie College of Osteopathic Medicine-Erie (LECOM); ²Allergy/Immunology Associates, Inc.

Statement of Significance: Tension type headaches (TTH) are the most diagnosed subgroup of headaches physicians encounter1. This is substantial as physicians attempt to improve quality of life (QOL) in TTH management. Osteopathic manipulative treatment (OMT) is becoming popular in management of TTH in an effort to use alternative treatments to improve QOL. Using the Headache Impact Test-6 (HIT-6), physicians can measure a patient’s general function with a numeric score ranging from 36 to 78, in several social situations2.

Research Methods: A meta-analysis of three randomized controlled trials (RCTs), found via extensive database search, was conducted with the Cochrane RevMan 5 software3 to determine the efficacy and safety of osteopathic manipulative medicine (OMT) in the reduction of mean Headache Impact Test-6 (HIT-6) scores in the management of tension-type headaches (TTH). The criteria for eligible literature were RCTs published after 2014 that assessed the change in mean HIT-6 scores post-treatment in previously diagnosed TTH patients. Exclusion criteria included: (1) TTH with concomitant systemic, structural, or psychological disorders; (2) history of prior head or neck trauma; (3) prior spinal surgery; (4) application of other treatments such as physical and pharmacologic therapies prior to study inclusion; (5) patients less than 18 years old; (6) pregnancy. A total of 361 participants were included. The analysis used both pre- and post-OMT mean HIT-6 scores. A random effect meta-analysis and forest plot were conducted with a p-value of 0.0009 with a confidence interval of 95%.

Data Analysis: The pre-OMT (control) mean HIT-6 scores ranged from 55.67 to 57.2 [SD 4.5 to 8.4] with a total of 156 participants. The post-OMT mean HIT-6 scores ranged from 44 to 57.3 [SD 5.1 to 8.62] with a total of 160 participants. There was a statistically significant decrease in mean HIT-6 scores of 4.40 points, in groups in which OMT techniques were applied compared to control groups.

Results: The pre-OMT (control) mean HIT-6 scores ranged from 55.67 to 57.2 [SD 4.5 to 8.4] with a total of 156 participants. The post-OMT mean HIT-6 scores ranged from 44 to 57.3 [SD 5.1 to 8.62] with a total of 160 participants. There was a statistically significant decrease in mean HIT-6 scores of 4.40 points, in groups in which OMT techniques were applied compared to control groups.

Conclusion: This meta-analysis reviews results from three RCTs and determines that OMT is efficacious in reducing post-treatment mean HIT-6 scores for patients with TTH. The evidence supports the use of OMT to manage TTH as it can improve QOL and measurable outcomes of patients that suffer from either episodic or chronic TTH.

References

1. Chin J, Qiu W, Lomiguen CM, Volokitin M. Osteopathic Manipulative Treatment in Tension Headaches. Cureus. 2020;12(12):e12040. doi:10.7759/cureus.12040

2. Yang M, Rendas-Baum R, Varon S, Kosinski M. Validation of the Headache Impact Test (HIT-6™) across episodic and chronic migraine. Cephalalgia. 2011; 31(3): 357-367. doi: 10.1177/0333102410379890

3. Review Manager (RevMan) [Computer program]. Version 5.4, The Cochrane Collaboration, 2020.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Exempt.

Informed Consent: Not relevant.

Poster No. *C-2

Abstract No. 2

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Sotrovimab Outcomes in Adult Outpatients with COVID-19 at a Community Hospital During an Omicron Surge

¹Stephanie Lourdes Echeverria, MPH, MBS, OMS-II; ¹Tyler Seelye, OMS-II; ²Sarah Schritter, RN; ²Justina Truong, DO; ²Diana Lalitsasivimol, PhD; ²Anthony Santarelli, PhD; ²John Ashurst, DO, MSc

¹Midwestern University Arizona College of Osteopathic Medicine (MWU/AZCOM); ²Kingman Regional Medical Center

Statement of Significance: During 2021, the SARS-CoV-2 B1.1.529 (Omicron) variant emerged as the dominant strain (1). Omicron displayed an increased ability to evade monoclonal antibodies (2). Bamlanivimab/etesevimab and casirivimab/imdevimab were found to be ineffective in neutralizing the virus in those with mild-to-moderate COVID-19. Sotrovimab (VIR-7831), has retained efficacy against all variants, including Omicron, and emerged as the mainstay therapy for outpatients presenting with mild-to-moderate COVID-19 (3, 4).

Research Methods: A convenience sample of consecutive adults given sotrovimab for the treatment of mild-to-moderate COVID-19 due to the presumed omicron subvariant between January 16, 2022 and March 10, 2022 at either an outpatient infusion center or within the emergency department were included in analysis. Per the Emergency Use Authorization (EUA) for sotrovimab, adult patients with positive results of direct SARS-CoV-2 viral testing, and who were at high risk for progression to severe COVID-19, including hospitalization or death, met inclusion criteria for the study. Adult patients hospitalized with COVID-19, patients requiring oxygen therapy and/or respiratory support, or patients who required an increase in baseline oxygen flow rate and/or respiratory support, and all pediatric patients were excluded from the study. Sotrovimab dosing and infusion was given per the EUA and each patient was monitored for one hour post infusion. Patient demographics, authorized use qualifiers from the EUA, baseline vital signs at the time of infusion, representation rates to a healthcare provider within the hospital’s network, and any admissions to the hospital following infusion were collected from the patient’s electronic medical record.

Data Analysis: A total of 126 patients were included in the final analysis with 86 identifying as female and zero patients experiencing an allergic reaction during the monitoring phase. The most prominent risk factors for EUA qualification consisted of 69.0% (87/126) as overweight or obese, followed by 50.8% (64/126) as ≥65 years of age, and 39.7% (50/126) with a history of hypertension. Median time between exposure and treatment was 9.0 days (IQR 6.25-9.75) and median time between symptom onset and treatment was 6.0 days (IQR 4.0-7.0). Of those who received sotrovimab, 4.8% (6/126) had an unscheduled representation to either the urgent care or emergency department within 28 days. In those patients who represented, none were admitted to the hospital at 28 days following infusion and no patients suffered from mortality during the study period. No significant association was found between representation after therapy and a patient’s demographic/medical history.

Results: A total of 126 patients were included in the final analysis with 86 identifying as female and zero patients experiencing an allergic reaction during the monitoring phase. The most prominent risk factors for EUA qualification consisted of 69.0% (87/126) as overweight or obese, followed by 50.8% (64/126) as ≥65 years of age, and 39.7% (50/126) with a history of hypertension. Median time between exposure and treatment was 9.0 days (IQR 6.25-9.75) and median time between symptom onset and treatment was 6.0 days (IQR 4.0-7.0). Of those who received sotrovimab, 4.8% (6/126) had an unscheduled representation to either the urgent care or emergency department within 28 days. In those patients who represented, none were admitted to the hospital at 28 days following infusion and no patients suffered from mortality during the study period. No significant association was found between representation after therapy and a patient’s demographic/medical history.

Conclusion: Sotrovimab treatment of mild-to-moderate outpatient COVID-19 during the omicron surge proved effective at reducing representation and admission rates at a community hospital located in Kingman, AZ.

References

1. Sharma A, Ahmad Farouk I, Lal SK. COVID-19: A Review on the Novel Coronavirus Disease Evolution, Transmission, Detection, Control and Prevention. Viruses. 2021;13(2):202. Published 2021 Jan 29. doi:10.3390/v13020202

2. Hoffmann M, Krüger N, Schulz S, et al. The Omicron variant is highly resistant against antibody-mediated neutralization: Implications for control of the COVID-19 pandemic. Cell. 2022;185(3):447-456.e11. doi:10.1016/j.cell.2021.12.032

3. Gupta A, Gonzalez-Rojas Y, Juarez E, et al. Early Treatment for Covid-19 with SARS-CoV-2 Neutralizing Antibody Sotrovimab. N Engl J Med. 2021;385(21):1941-1950. doi:10.1056/NEJMoa2107934

4. Fact Sheet for Healthcare Providers Emergency Use Authorization (EUA) of Sotrovimab. fda.gov. Updated March 2022. Accessed March 26, 2022. https://www.fda.gov/media/149534/download

Financial Disclosures: None reported.

Support: SLE was supported by funds from the Midwestern University Kenneth A. Suarez Summer Research Fellowship.

Ethical Approval: Kingman Hospital, Inc./Kingman Regional Medical Center (KRMC) has a federally registered IRB and maintains compliance with Federal requirements. Study proposals are reviewed by The Human Rights Administrator and an IRB quorum for approval. This study was reviewed and approved by the IRB prior to study initiation.

Informed Consent: N/A

Poster No. C-3

Abstract No. 9

Category: Clinical

Research Topic: Impact of OMM & OMT

Thoracic Pump as Adjunctive Therapy to Wean Oxygen Supplementation in the Hospitalized COVID 19 Patient

¹Abby Rhoads, DO; ²Zeeshan Baig, DO, PGY2; ²Zachary Sterling, DO, PGY2

¹St. Luke’s University Health Network-Bethlehem Campus; ²Department of Family Medicine, St. Luke’s University Health Network - Anderson

Statement of Significance: Viral pneumonia is the main outcome of COVID 19 infection that results in inflammatory changes to the lung parenchyma. Potential for OMT as an adjuvant therapy for COVID pneumonia has been speculated by individuals studying COVID’s pathophysiology as research supports benefits of OMT in bacterial pneumonia. Literature suggests OMT, improves respiratory function, reduces length of stay and mortality in the hospital, when OMT was used with conventional therapy for treatment of pneumonia.

Research Methods: This study is a retrospective chart review of patients admitted to the hospital with a diagnosis of COVID 19 treated with OMT by a DO attending. We identified four patients in this study that met the inclusion criteria. Inclusion criteria included age greater than 18, admitted to the hospital with the diagnosis of acute COVID 19, on moderate pathway for treatment requiring at least 2 litters of oxygen supplementation, and receiving thoracic pump technique within 48 hours of expected discharge. Exclusion criteria included: treatment for co-infection with bacterial pneumonia, requiring high flow nasal cannula, non-invasive positive pressure or mechanical ventilation. Osteopathic Manipulative Treatment included Thoracic pump with respiratory assist technique to the lower and upper rib cage bilaterally, specifically ribs 2-4 and 7-9 respectively. The technique is performed by physician placing hands on ribs 2-4 or 7-9, and then instructing the patient to inhale and exhale deeply. The Physician provides a compressive force downward onto the chest wall. Then, oscillate the degree of compression to produce a pump motion during exhalation. This is repeated for three breathing cycles. Oxygen saturations were recorded prior to treatment and within five minutes of treatment for post-treatment values and then at the time of discharge. Statistical analysis was conducted in IBM SPSS for Windows Version 26. Due to small sample size, only descriptive statistics were included for median oxygen saturation before OMT, five minutes post-OMT and at time of discharge. The osteopathic significance of this study is to demonstrate OMT as an adjunctive therapy to be considered for hospitalized COVID 19 patients, as previous literature supports efficacy of OMT in hospitalized pneumonia and influenza patients.

Data Analysis: After review of inclusion criteria, four subjects met criteria of admission for COVID 19, on nasal cannula oxygen for acute hypoxic respiratory failure on moderate pathway for treatment of COVID 19 and received two sessions of OMT with thoracic pump within 48 hours of discharge. Ages ranged from 44-96, with a mean age of 67.75 years old. Two subjects were female and two subjects were male. Median oxygen saturation before initiating OMT as adjunctive therapy on hospitalized COVID-19 patients was 91.5%(minimum 90%, maximum 93%). After initiating thoracic pump as adjunctive therapy on hospitalized COVID-19 patients, median oxygen saturation increased to 94.5% (minimum 93% maximum 97%). There was a slight dip in median oxygen saturation when measured at the time of discharge, median 93% (minimum 93% maximum 94%.) Three out of four patients were discharged on oxygen supplementation, one patient was on chronic oxygen supplementation prior to hospitalization and was discharged at their baseline oxygen supplementation.

Results: After review of inclusion criteria, four subjects met criteria of admission for COVID 19, on nasal cannula oxygen for acute hypoxic respiratory failure on moderate pathway for treatment of COVID 19 and received two sessions of OMT with thoracic pump within 48 hours of discharge. Ages ranged from 44-96, with a mean age of 67.75 years old. Two subjects were female and two subjects were male. Median oxygen saturation before initiating OMT as adjunctive therapy on hospitalized COVID-19 patients was 91.5%(minimum 90%, maximum 93%). After initiating thoracic pump as adjunctive therapy on hospitalized COVID-19 patients, median oxygen saturation increased to 94.5% (minimum 93% maximum 97%). There was a slight dip in median oxygen saturation when measured at the time of discharge, median 93% (minimum 93% maximum 94%.) Three out of four patients were discharged on oxygen supplementation, one patient was on chronic oxygen supplementation prior to hospitalization and was discharged at their baseline oxygen supplementation.

Conclusion: In conclusion, despite a limitation in small sample size due to availability of an osteopathic attending physician, post OMT oxygen saturations were within non-hypoxic ranges directly following treatment with five minutes of performing thoracic pump technique. Larger randomized control studies would be needed to demonstrate statistically significant improvement in oxygen saturations with thoracic pump treatment compared to standard of care. However, this chart review demonstrates a change in oxygen saturations post treatment to non-hypoxic levels. Literature suggests that techniques targeting lymphatic flow, including thoracic pump, are advantageous for treatment of pneumonia by improving respiratory function, enhancing antibody response, decreasing hospital length of stay, and increasing the abundance of white blood cells in peripheral blood. Therefore, thoracic pump technique should be considered as an adjunctive therapy for hospitalized COVID 19 patients and should be utilized as early as possible into hospital admission to decrease respiratory complications and need for oxygen supplementation from COVID 19 infection.

References

1. Marin T, Maxel X, Robin A, Stubbe L. Evidence-based assessment of potential therapeutic effects of adjunct osteopathic medicine for multidisciplinary care of acute and convalescent COVID-19 patients. Explore (NY). 2021 Mar-Apr;17(2):141-147. doi: 10.1016/j.explore.2020.09.006. Epub 2020 Sep 25. PMID: 33158784; PMCID: PMC7516474. https://doi.org/10.1016/j.explore.2020.09.006

2. Yao S, Hassani J, Gagne M, George G, Gilliar W. Osteopathic manipulative treatment as a useful adjunctive tool for pneumonia. J Vis Exp. 2014 May 6;(87):50687. doi: 10.3791/50687. PMID: 24836893; PMCID: PMC4173698.

Financial Disclosures: None Reported

Support: None Reported

Ethical Approval: This study was reviewed by the Institutional Review Board at St. Luke’s University health network. It was deemed exempt and approved on July 5, 2022. IRB number: SLIR 2022-78.

Informed Consent: No informed consent is required

★ Poster No. *C-4

Abstract No. 11

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Inappropriate Albumin Utilization at a Community Hospital: A Retrospective Cohort Study

¹Joshua Hicks, OMS-IV; ²John Ashurst, DO, MSc

¹Rocky Vista University College of Osteopathic Medicine (RVUCOM-Southern Utah); ²Emergency Medicine Residency, Kingman Regional Medical Center;

Statement of Significance: The use of albumin for the treatment of numerous diseases has been in practice for nearly eight decades. Improved outcomes have been noted when albumin is used in large volume paracentesis, spontaneous bacterial peritonitis, and hepatorenal syndrome. However, the inappropriate use of albumin has drastically risen over the last decade with a large number of all usage labeled as inappropriate based upon national guidelines.

Research Methods: A retrospective cohort study evaluated all adult (≥18 years) patients administered albumin from April 01, 2021 to August 31, 2021. Appropriate usage of albumin was defined as administration due to large volume paracentesis (> 5 liters), plasmapheresis, spontaneous bacterial peritonitis, or hepatorenal syndrome. Appropriate dosage of albumin was delineated as 1.5g/kg within 6 hours of diagnosis and 1g/kg on day 3 for spontaneous bacterial peritonitis, 1g/kg daily for 2 days (maximum: 100g/day), then 20 to 50g daily until midodrine plus octreotide is discontinued for hepatorenal syndrome, and 5-10g for every liter removed or 50g total for a paracentesis >5L. The patients electronic medical record was reviewed for baseline patient demographics, in-hospital mortality, length of stay, and albumin-related costs for those deemed appropriate and inappropriate.

Data Analysis: A total of 158 patients were given albumin during the study period with 15.8% (25/158) receiving albumin for an indicated use. 12.7% (20/158) of patients received albumin for a large volume paracentesis, 1.3% (2/158) for spontaneous bacterial peritonitis, 1.9% (3/158) for hepatorenal syndrome. 82.9% (133/158) of patients were administered albumin for other medical conditions, including hypoalbuminemia (12.0%; 19/158), ascites (6.3%; 10/158), and hypovolemia (20%; 20/158). Patients were more likely to inappropriately be given albumin if aged over 65 years (91.2% vs 74.6%; p = 0.005) or having a past medical history of diabetes mellitus (93.5% vs 73.8%; p = 0.040), congestive heart failure (91.2% vs 74.6%; p = 0.040), or hypertension (91.3% vs 74.2%; p = 0.004). The median length of stay in the entire cohort was 7.0 (4.0 – 14.0) days. A difference of 6 hospital days was noted between patients who were given albumin appropriately and inappropriately (2.0 vs 8.0; p< 0.001). In total, 14.6% (23/158) patients expired during hospitalization after receiving albumin. In those who expired during hospitalization, 4.3% (1/23) received albumin appropriately and 95.7% (22/23) inappropriately.

Results: A total of 158 patients were given albumin during the study period with 15.8% (25/158) receiving albumin for an indicated use. 12.7% (20/158) of patients received albumin for a large volume paracentesis, 1.3% (2/158) for spontaneous bacterial peritonitis, 1.9% (3/158) for hepatorenal syndrome. 82.9% (133/158) of patients were administered albumin for other medical conditions, including hypoalbuminemia (12.0%; 19/158), ascites (6.3%; 10/158), and hypovolemia (20%; 20/158). Patients were more likely to inappropriately be given albumin if aged over 65 years (91.2% vs 74.6%; p = 0.005) or having a past medical history of diabetes mellitus (93.5% vs 73.8%; p = 0.040), congestive heart failure (91.2% vs 74.6%; p = 0.040), or hypertension (91.3% vs 74.2%; p = 0.004). The median length of stay in the entire cohort was 7.0 (4.0 – 14.0) days. A difference of 6 hospital days was noted between patients who were given albumin appropriately and inappropriately (2.0 vs 8.0; p< 0.001). In total, 14.6% (23/158) patients expired during hospitalization after receiving albumin. In those who expired during hospitalization, 4.3% (1/23) received albumin appropriately and 95.7% (22/23) inappropriately.

Conclusion: The majority of doses of albumin were given inappropriately based upon national guidelines. Future studies are needed to determine ways to decrease the amount of inappropriate albumin use in the community setting.

References

1. Buckley MS, Agarwal SK, Lansburg JM, Kopp BJ, Erstad BL. Clinical Pharmacist-Led Impact on Inappropriate Albumin Utilization and Associated Costs in General Ward Patients. Ann Pharmacother. 2021 Jan;55(1):44-51. doi: 10.1177/1060028020935575. Epub 2020 Jun 24. PMID: 32578446.

2. Buckley MS, Knutson KD, Agarwal SK, Lansburg JM, Wicks LM, Saggar RC, Richards EC, Kopp BJ, Erstad BL. Clinical Pharmacist-Led Impact on Inappropriate Albumin Use and Costs in the Critically Ill. Ann Pharmacother. 2020 Feb;54(2):105-112. doi: 10.1177/1060028019877471. Epub 2019 Sep 22. PMID: 31544470.

3. Castillo AM, Natkowski J, Rubal-Peace G. Assessing adherence to current national guidelines for appropriate albumin use at an academic medical center. Pharm Pract (Granada). 2018 Apr-Jun;16(2):1190. doi: 10.18549/PharmPract.2018.02.1190. Epub 2018 Jun 30. PMID: 30023030; PMCID: PMC6041205.

4. Coyle T, John SM. Evaluation of albumin use in a community hospital setting: A retrospective study looking at appropriate use and prescribing patterns. PLoS One. 2021 Oct 6;16(10):e0257858. doi: 10.1371/journal.pone.0257858. PMID: 34613990; PMCID: PMC8494356.

Financial Disclosures: None reported

Support: None reported

Ethical Approval: The study was reviewed by the Kingman Healthcare Inc IRB and was approved. The IRB number for the project was KHI-0255

Informed Consent: NA

★ Poster No. *C-5

Abstract No. 90

Category: Clinical

Research Topic: Impact of OMM & OMT

Impact of Osteopathic Manipulative Techniques on the Management of Dizziness Caused by Neuro-Otologic Disorders: Systemic Review and Meta-Analysis

¹Barbara Senger, OMS-IV; ²Yasir Rehman; ³Karen T. Snider, DO, FAAO, FNAOME; ³Jonathon Kirsch, DO; ⁴Mary Ying-Fang Wang; ⁵Robert Johnston; ³Jonathan Bingham, OMS-IV; ⁵Hannah Ferguson; ⁶Susan Swogger

¹A.T. Still University Kirksville College of Osteopathic Medicine (ATSU-KCOM); ²Health Research Methodology, MDCL, McMaster University, Hamilton, Ontario; ³Department of Osteopathic Manipulative Medicine, A.T. Still University Kirksville College of Osteopathic Medicine (ATSU-KCOM); ⁴Department of Research Support, A.T. Still University Kirksville College of Osteopathic Medicine (ATSU-KCOM); ⁵Michael G. DeGroote Inst. for Pain Research & Care, McMaster University, Hamilton, Ontario; ⁶University Libraries, University of Vermont

Statement of Significance: Osteopathic manipulative treatment (OMT) has been utilized by osteopathic physicians as a potential primary intervention or adjunctive treatment for dizziness caused by neuro-otologic disorders. Currently, there are no systematic reviews that provide pooled estimates to explore the impact of OMT and/or OMT analogous techniques on the treatment of dizziness caused by neuro-otologic disorders.

Research Methods: We performed a literature search in CINAHL, Embase, MEDLINE, Allied and Complementary Medicine Database (AMED), EMCare, Physiotherapy Evidence Database (PEDro), PubMed, PsycINFO, Osteopathic Medicine Digital Repository (OSTMED.DR), and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to March 2021. Included studies were randomized controlled trials (RCTs) and prospective or retrospective observational studies of adult patients experiencing dizziness from neuro-otological disorders which were written in English. Eligible studies compared the effectiveness of OMT and/or OMT analogous techniques with a comparator intervention, such as sham manipulation, a different manual technique, standard of care, or nonpharmacological intervention like exercise or behavioral therapy. Assessed outcomes included: disability associated with dizziness, dizziness severity, dizziness frequency, risk of fall, improvement in quality of life (QOL), and return to work (RTW). Assessed harm outcomes included: all-cause dropout rates (ACD), dropouts due to inefficacy, and adverse events. The meta-analysis was based on the similarities between the OMT and/or OMT analogous technique and the comparator interventions.

The risk of bias was assessed using a modified version of the Cochrane risk of bias tool for RCTs and the Cochrane Risk of Bias in Non-randomized Studies – of Interventions (ROBINS-I) for observational studies. The quality of evidence was determined using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. All statistical analyses were performed with the R package meta and reported using a random effect model with P<0.05 being significant.

Data Analysis: There were 3,375 studies identified and screened, out of which 12 (11 RCTs1-11, 1 observational study12, n=367 participants) met the inclusion criteria. The median age of participants was 53 years with 60.5% female and 39.5% male.The moderate-quality evidence showed articular OMT was significantly associated with decrease in disability6,8,9 associated with dizziness [n=141; MD (95%CI)= -11.08 (-16.22, -5.94)], dizziness severity6,8,9,11 [n=158; MD (95%CI)= -1.56 (-2.43, -0.68)], and frequency [n=136; MD (95%CI) = -0.64 (-1.06, -0.22)]. In the sensitivity analysis for the disability associated with dizziness4,6-11, any OMT type was associated with a decrease in disability associated with dizziness; however, heterogeneity among studies was high (I2=59%) thus reducing the confidence in the pooled analysis. In the dizziness severity outcomes1,6,8,9,11, any OMT type was also associated with improved outcomes. With the addition of one study1, the heterogeneity was not substantially high.

Low-quality evidence showed articular OMT was not significantly associated with ACD rates6,8,9. For the sensitivity analysis, six studies (n=217) were pooled for any OMT technique;4,6-10 however, heterogeneity was high among the pooled studies (I2=46%).Among the non-pooled outcomes, there was improvement in the mental component summary scores (MCS) but not in the physical component summary score (PCS) for articular OMT6. Variable associations were reported for fall risk, and for other OMT techniques for disability, dizziness severity, and frequency. A single observation study12 showed cranial OMT was significantly associated with a reduced fall risk but no RCT2,6 showed significant association of OMT with falls. Six studies1,2,4,6,7,10 explicitly provided statements about adverse events out of which in three studies adverse events occurred in patients2,4,6.

Results: There were 3,375 studies identified and screened, out of which 12 (11 RCTs1-11, 1 observational study12, n=367 participants) met the inclusion criteria. The median age of participants was 53 years with 60.5% female and 39.5% male.The moderate-quality evidence showed articular OMT was significantly associated with decrease in disability6,8,9 associated with dizziness [n=141; MD (95%CI)= -11.08 (-16.22, -5.94)], dizziness severity6,8,9,11 [n=158; MD (95%CI)= -1.56 (-2.43, -0.68)], and frequency [n=136; MD (95%CI) = -0.64 (-1.06, -0.22)]. In the sensitivity analysis for the disability associated with dizziness4,6-11, any OMT type was associated with a decrease in disability associated with dizziness; however, heterogeneity among studies was high (I2=59%) thus reducing the confidence in the pooled analysis. In the dizziness severity outcomes1,6,8,9,11, any OMT type was also associated with improved outcomes. With the addition of one study1, the heterogeneity was not substantially high.

Low-quality evidence showed articular OMT was not significantly associated with ACD rates6,8,9. For the sensitivity analysis, six studies (n=217) were pooled for any OMT technique;4,6-10 however, heterogeneity was high among the pooled studies (I2=46%).Among the non-pooled outcomes, there was improvement in the mental component summary scores (MCS) but not in the physical component summary score (PCS) for articular OMT6. Variable associations were reported for fall risk, and for other OMT techniques for disability, dizziness severity, and frequency. A single observation study12 showed cranial OMT was significantly associated with a reduced fall risk but no RCT2,6 showed significant association of OMT with falls. Six studies1,2,4,6,7,10 explicitly provided statements about adverse events out of which in three studies adverse events occurred in patients2,4,6.

Conclusion: The current review is the first systematic review and meta-analysis that reports pooled estimates of the impact of OMT and analogous techniques on outcomes for the treatment of dizziness caused by neuro-otologic disorders. We adjudicated the assessed OMT and analogous techniques according to similarities between OMT technique types. As a result of adjudication and data pooling based on similarities between technique types, heterogeneity in our meta-analyses was low. The review showed moderate-quality evidence that articular OMT was significantly associated with a decrease in disability associated with dizziness, dizziness severity, and frequency. The pooled analysis for ACD rates showed a non-significant association with OMT techniques. For safety outcomes, OMT was well tolerated and was not significantly associated with the ACD. A limitation of the study, due to the limited data, was that we were not able to pool for QOL outcomes and no study reported RTW outcomes. As quality of life can be employed as an indirect measure for RTW, OMT was significantly associated with the improvement in the mental component of the SF-36 scale for the QOL outcome. Secondly, the findings should be interpreted cautiously due to the high risk of bias, and small study sample size in the eligible studies. In the future, good quality RCTs with larger sample sizes should be conducted to better delineate the effectiveness of OMT and analogous techniques for the treatment of dizziness.

References

1. Carrasco-Uribarren A, Rodriguez-Sanz J, López-de-Celis C, Pérez-Guillen S, Tricás-Moreno JM, Cabanillas-Barea S. Short-term effects of the traction-manipulation protocol in dizziness intensity and disability in cervicogenic dizziness: a randomized controlled trial [published online ahead of print, 2021 Jan 20].Disabil Rehabil. 2021;1-9. doi:10.1080/09638288.2021.18727192

2. DiFrancisco-Donoghue J, Apoznanski T, de Vries K, Jung MK, Mancini J, Yao S. Osteopathic manipulation as a complementary approach to Parkinson’s disease: A controlled pilot study. NeuroRehabilitation.2017;40(1):145-151. doi:10.3233/NRE-1614003

3. Oliveira OA do N, Mesquita LS de A, Mendes MR, Oliveira LMMC de, Almeida LC. Effects of cranial osteopathic techniques in the symptoms of benign positional paroxistic vertical. Manual Therapy, Posturology & Rehabilitation Journal.2020;18:1-5.doi:10.17784/mtprehabjournal.2020.18.7884

4. Fraix M, Badran S, Graham V, et al. Osteopathic Manipulative Treatment in Individuals With Vertigo and Somatic Dysfunction: a Randomized, Controlled, Comparative Feasibility Study. Journal. Journal of the American Osteopathic Association.2020;121(1):71-83.doi:10.7556/jaoa.2020.1475

5. Heikkila H, Johansson M, Wenngren BI. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Man Ther 2000;5(3):151-157.doi:10.1054/math.2000.03576

6. Kendall JC, French SD, Hartvigsen J, Azari MF. Chiropractic treatment including instrument-assisted manipulation for non-specific dizziness and neck pain in community-dwelling older people: a feasibility randomised sham-controlled trial. Chiropr Man Therap. 2018;26:14.Published 2018 May 10.doi:10.1186/s12998-018-0183-17

7. Papa L, Amodio A, Biffi F, Mandara A. Impact of osteopathic therapy on proprioceptive balance and quality of life in patients with dizziness. J Bodyw Mov Ther.2017;21(4):866-872.doi:10.1016/j.jbmt.2017.03.0018

8. Reid S, Callister R, Snodgrass S, Katekar M, Rivett D. Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Man Ther.2015;20(1):148-156.doi:10.1016/j.math.2014.08.0039

9. Reid SA, Rivett DA, Katekar MG, Callister R. Sustained natural apophyseal glides are an effective treatment for cervicogenic dizziness. Man Ther.2008;13(4):357-366.doi:10.1016/j.math.2007.03.00610

10. Sun YX, Wang Y, Ji X, et al. A Randomized Trial of Chinese Diaoshi Jifa on Treatment of Dizziness in Meniere’s Disease. Evid Based Complement Alternat Med.2014;2014521475.doi:10.1155/2014/521475.11

11. Karlberg M, Magnusson M, Malmström EM, Melander A, Moritz U. Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Arch Phys Med Rehabil.1996;77(9):874-882. doi:10.1016/s0003-9993(9690273-712)

12. Atay F, Bayramlar K, Sarac ET. Effects of Craniosacral Osteopathy in Patients with Peripheral Vestibular Pathology. ORL J Otorhinolaryngol Relat Spec.2021;83(1):7-13.doi:10.1159/000509486

Financial Disclosures: The funding for this work was secured from the A.T. Still University Strategic Research Fund.

Support: None reported

Ethical Approval: Exempt category under Section 45CFR46.104(d)(4)(i)

Informed Consent: N/A

Poster No. *C-6

Abstract No. 12

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Responsiveness of Inhaled Epoprostenol on Patients with Respiratory Failure Due to COVID-19 at a Community Hospital

¹Nathan Wilks, OMS-IV; ¹Lelann Latu, OMS-IV; ²Joshua Macke, DO; ²Elisha Bremmer, DO; ³John Robinson, PharmD; ³Tyson Dietrich, PharmD; ⁴Ordessia Charran, MD; ⁵Diana Lalitsasivimol, PhD; ²Anthony Santarelli, PhD; ²John Ashurst DO, MSc

¹Pacific Northwest University of Health Sciences College of Osteopathic Medicine (PNWU-COM); ²Department of GME, Kingman Regional Medical Center; ³Department of Pharmacy, Kingman Regional Medical Center; ⁴Department of Pulmonology, Kingman Regional Medical Center; ⁵Research and Sponsored Programs, Kingman Regional Medical Center

Statement of Significance: A large number of patients with COVID-19 progress to respiratory failure requiring mechanical ventilation. A subset of these patients will further progress to profound hypoxemia despite treatment and develop COVID acute respiratory distress syndrome (CARDS). Inhaled epoprostenol (iEPO) has been used as a rescue therapy for those with CARDS but conflicting data on its utility has been seen in the literature.

Research Methods: A retrospective cohort of adult patients who received iEPO for CARDS from January 01, 2020 to February 22, 2022 were included in the final analysis. Patients were deemed to be an iEPO responder if a 10% increase was noted in the PaO2/FiO2 ratio between pre and post arterial blood gases. The primary outcome was improved oxygenation based upon the change in PaO2/FiO2 between pre and post iEPO therapy. Secondarily, predicting iEPO responsiveness, hospital length of stay and in-hospital mortality were assessed between iEPO responders and non-responders.

Data Analysis: A total 118 patients were included in final analysis with 51 being considered as an iEPO responder. No differences were noted in baseline patient demographics between responders and non-responders to iEPO. The median PaO2/FiO2 prior to receiving iEPO was 0.65 (0.55 – 0.89) and the improvement in PaO2/FiO2 ratio following iEPO was 1.05 (0.94 – 1.21). Time to mechanical ventilation (B = -0.071; p = 0.040) and lower Pa02/FiO2 when iEPO was initiated (B = -02.824; p = 0.004) predicted a better response in patients with CARDS. iEPO responders had a shorter length of stay within the hospital as compared to non-responders (17 vs 22 days; p=0.05). No difference in in-hospital mortality was noted between those who were responders and non-responders to iEPO therapy (34 vs 48 patients; p=0.91).

Results: A total 118 patients were included in final analysis with 51 being considered as an iEPO responder. No differences were noted in baseline patient demographics between responders and non-responders to iEPO. The median PaO2/FiO2 prior to receiving iEPO was 0.65 (0.55 – 0.89) and the improvement in PaO2/FiO2 ratio following iEPO was 1.05 (0.94 – 1.21). Time to mechanical ventilation (B = -0.071; p = 0.040) and lower Pa02/FiO2 when iEPO was initiated (B = -02.824; p = 0.004) predicted a better response in patients with CARDS. iEPO responders had a shorter length of stay within the hospital as compared to non-responders (17 vs 22 days; p=0.05). No difference in in-hospital mortality was noted between those who were responders and non-responders to iEPO therapy (34 vs 48 patients; p=0.91).

Conclusion: iEPO therapy for CARDS showed an improvement in oxygenation within a subset of patients. A decrease in overall length of stay was noted in those who were deemed to be a responder to iEPO therapy but no change in in-hospital mortality was noted.

References

N/A

Financial Disclosures: None reported

Support: None reported

Ethical Approval: The study was reviewed by the Kingman Healthcare Inc IRB and approved. The IRB number for the project was KHI-0274.

Informed Consent: N/A

Poster No. *C-7

Abstract No. 13

Category: Clinical

Research Topic: Health Disparities-Social Determinants of Health

PrEP Prescribing by Southern U.S. Primary Care Providers

Daryl O’Neal Traylor, MS, MPH, PhD, OMS-I

University of the Incarnate Word School of Osteopathic Medicine

Statement of Significance: Pre-exposure prophylaxis (PrEP) uptake has increased since 2012 but there has not been a substantial decrease in US HIV incidence.1 500,000 African Americans have PrEP indications, yet African Americans lag behind other groups regarding PrEP uptake.2 The Southern U.S. has the highest numbers of African Americans with PrEP indications.1,2 Emerging research shows that primary care providers (PCPs) are missing opportunities to prescribe PrEP.3 The literature is not clear on why this is, however.

Research Methods: PCPs from 10 Southern states were invited, via social media and emailed invitations, to take a survey that was administered via Qualtrics. All data were analyzed using SPSS 26. The study was guided by four research questions:

Research Question 1: What are the relationships between primary care provider personal and practice variables and the TTM stage of adoption, using the TTM, of PrEP prescribing to African Americans?Research Question 2: What primary care provider personal and practice characteristics predict prescribing or not prescribing PrEP to African Americans residing in the Southern U.S.?Research Question 3: What is the relationship between the TTM decisional balance construct and the TTM stages of change for PrEP prescribing?Research Question 4: Does primary care provider’s TTM decisional balance predict prescribing or not prescribing PrEP to African Americans residing in the Southern U.S.?

Descriptive statistics, including means and standard deviations were calculated and Chi-square tests of independence were conducted to determine the TTM stage of change of PrEP prescribing and the actual prescribing of PrEP. To address Research Questions 1 and 3, an ordinal logistic regression was conducted. Multicollinearity was assessed by calculating variance inflation factors (VIFs). To address Research Questions 2 and 4, a binary logistic regression was conducted.

Data Analysis: 965 individuals viewed the online survey instrument, and 330 individuals completed the survey. This yielded a survey response rate of 34.1%. Data cleaning yielded a final sample size of 223. Chi-square tests of independence showed that participants who had more African American patients in their practice were more likely to be in a higher TTM stage of change (p = .002) and were more likely to have written a PrEP prescription (p = .001). Access to PrEP resources (OR = 1.85, p = .001, 95% CI[1.30, 2.62]), streamlined insurance prior authorization processes (OR = 1.52, p = .010, 95% CI[1.11, 2.09]), working with staff who have PrEP knowledge (OR = 1.51, p = .033, 95% CI[1.03, 2.20]), having PrEP training (OR = 40.26, p < .001, 95% CI[12.35, 131.24]) and having patients who are motivated to take PrEP (OR = 2.19, p = .007, 95% CI[1.24, 3.88]) were significant facilitators to PrEP prescribing. Other facilitators of PrEP prescribing included being a non-white provider (OR = 5.86, p<.001, 95% CI[2.29, 14.99]), identifying as gay (OR = 359.51, p =.002, 95% CI [8.16, 15,838.94]), lesbian (OR = 19.24, p = .034, 95% CI[1.24, 298.28]), or bisexual (OR = 62.75, p = .030, 95%CI [1.51, 2,609.31]), and practicing in an urban settings (OR = 11.36, p < .008, 1.87, 68.95]). Significant barriers to PrEP prescribing included a lack of provider PrEP training (OR = 0.43, p = .003, 95% CI [0.24, 0.75]), lack of clinical leadership regarding PrEP (OR = 0.65, p = .018, 95% CI [0.45, 0.93]), lack of insurance (OR = 2.74, p = .002, 95% CI [1.43, 5.24]), and likelihood of low patient adherence to PrEP (OR = 0.53, p = .001, 95% CI[0.36, 0.78]).

Results: 965 individuals viewed the online survey instrument, and 330 individuals completed the survey. This yielded a survey response rate of 34.1%. Data cleaning yielded a final sample size of 223. Chi-square tests of independence showed that participants who had more African American patients in their practice were more likely to be in a higher TTM stage of change (p = .002) and were more likely to have written a PrEP prescription (p = .001). Access to PrEP resources (OR = 1.85, p = .001, 95% CI[1.30, 2.62]), streamlined insurance prior authorization processes (OR = 1.52, p = .010, 95% CI[1.11, 2.09]), working with staff who have PrEP knowledge (OR = 1.51, p = .033, 95% CI[1.03, 2.20]), having PrEP training (OR = 40.26, p < .001, 95% CI[12.35, 131.24]) and having patients who are motivated to take PrEP (OR = 2.19, p = .007, 95% CI[1.24, 3.88]) were significant facilitators to PrEP prescribing. Other facilitators of PrEP prescribing included being a non-white provider (OR = 5.86, p<.001, 95% CI[2.29, 14.99]), identifying as gay (OR = 359.51, p =.002, 95% CI [8.16, 15,838.94]), lesbian (OR = 19.24, p = .034, 95% CI[1.24, 298.28]), or bisexual (OR = 62.75, p = .030, 95%CI [1.51, 2,609.31]), and practicing in an urban settings (OR = 11.36, p < .008, 1.87, 68.95]). Significant barriers to PrEP prescribing included a lack of provider PrEP training (OR = 0.43, p = .003, 95% CI [0.24, 0.75]), lack of clinical leadership regarding PrEP (OR = 0.65, p = .018, 95% CI [0.45, 0.93]), lack of insurance (OR = 2.74, p = .002, 95% CI [1.43, 5.24]), and likelihood of low patient adherence to PrEP (OR = 0.53, p = .001, 95% CI[0.36, 0.78]).

Conclusion: The study had several limitations. First, it was geographically limited to the Southern U.S. and is therefore not generalizable to other areas of the U.S. The study used a convenience sample that was recruited from a variety of social media sites, email listservs, and direct email communication. All answers to the instrument questions were self-reported by participants. Finally, most participants in the study did not see large numbers of African American patients. Findings indicate that this sample of PCPs were more likely to be at a higher TTM stage of change and have written a PrEP prescription if they saw more African American patients in their practice. Further, significant facilitators of PrEP prescribing included access to PrEP resources, streamlined insurance prior authorization processes, working with staff who have PrEP knowledge, having PrEP training, and having patients who are motivated to take PrEP. Significant barriers to PrEP prescribing included a lack of PrEP training, a lack of clinical leadership regarding PrEP, patient lack of insurance, and likelihood of low patient adherence. The results of this study may yield ways to motivate PCP’s to screen for and prescribe PrEP to African American patients.

References

1. Chan SS, Chappel AR, Maddox KEJ, et al. Pre-exposure prophylaxis for preventing acquisition of HIV: A cross-sectional study of patients, prescribers, uptake, and spending in the United States, 2015–2016. Barnabas RV, ed. PLOS Medicine. 2020;17(4):e1003072. doi:10.1371/journal.pmed.1003072

2. ‌Smith D, Van Handel M, Grey J. By race/ethnicity, Blacks have highest number needing PrEP in the United States, 2015. 25th Conference on Retroviruses and Opportunistic Infections. Published 2018. https://www.croiconference.org/abstract/raceethnicity-blacks-have-highestnumber-needing-prep-united-states-2015/

3. Edelman EJ, Moore BA, Calabrese SK, et al. Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers. Preventive Medicine Reports. 2020;17:101012. doi:10.1016/j.pmedr.2019.101012

4. ‌Terndrup C, Streed CG, Tiberio P, et al. A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection. Journal of General Internal Medicine. 2019;34(7):1258-1278. doi:10.1007/s11606-019-04947-2

Financial Disclosures: None reported

Support: None reported

Ethical Approval: This study was reviewed as exempt and approved by the University of Missouri Institutional Review Board (approval #2041004).

Informed Consent: All participants provided electronic informed consent prior to accessing and completing the study instrument. No identifying information was collected.

Poster No. C-8

Abstract No. 17

Category: Clinical

Research Topic: Osteopathic Philosophy

Obstetrics and Gynecology Resident Confidence Performing Urinary Incontinence Slings Prior to Graduation

¹Andrew Bergloff, DO; ²Andrew Bergloff, DO; ²Jared Floch, DO; ²Mark Krupp, DO; ²Jennifer DeAnna, DO; ³Nathan Chance

¹Ascension Genesys; ²Department of Obstetrics and Gynecology, Ascension Genesys; ³A.T. Still University Kirksville College of Osteopathic Medicine

Statement of Significance: Currently there is limited research on resident confidence regarding placement of slings for urinary incontinence. With increasing demand for competent providers to place these, we hope that this survey will shed light on the quality of training in this area within graduate medical education for training OBGYN’s residents.

Research Methods: Perspective respondents will be identified via the American College of Graduate Medical Education which lists the number of Obstetric and Gynecology residency program training sites. From there the program coordinators, which are listed on the American Medical Association with their respective email addresses, will be sent the survey and asked to send it to their respective residents.

To be included in the study, residents had to be a current Obstetric and Gynecology resident physician that is at least 18 years of age. Survey participants were excluded if they were not in a categorical Obstetric and Gynecology residency, had completed or partially completed residency in another specialty prior to entering Obstetrics and Gynecology residency training, or who had completed Obstetrics and Gynecology residency in another country prior to entering OBGYN training in the United States.

In total, all 297 OBGYN resident programs were sent the email for residents to respond to.

Investigators were blinded to all identifiers through the RedCAP anonymous collection service.

All statistical analysis was performed using SPSS (IBM, Inc. New York). Chi-squared and Fisher’s exact test were performed to assess bivariate associations between a respondent’s level of postgraduate training and program type (academic, mixed, community based) and the residents perception of their confidence level performing, counseling on the use of, and performing the workup for urinary incontinence slings. Nonparametric comparisons between groups were performed with the Kruskal Wallace test. Data was reported as the percentage of respondents to each question and p values for chi-squared test.

Data Analysis: Residents were categorized based on their year in residency and type of training program. The largest group of respondents consisted of PGY3 residents (n=36 or 35%). Program type consisted of academic, community or mixed program type (i.e combination of academic and community based program). The largest number of respondents were from the academic-based program. Finally, respondents were asked to define the location of their program from which the largest number came from the Northeast (n=45, 43.3%).

Respondents reported on their confidence in performing various clinical functions related to urogynecology procedures. A majority (64, 56.6%) did not feel confident (disagree and strongly disagree) in performing urinary incontinence slings. However, a large number (50, 44.2%) felt confident in counseling patients on slings (agree and strongly agree) and the comfort level for conducting a patient workup for slings showed a similar proportion across agree, disagree and neutral levels. The most common procedures that respondents were comfortable with performing independently were Anterior colporrhaphy (57, 50.4%) and Posterior colporrhaphy (53, 46.9%).

Overall, education and training was considered to be insufficient. Less than 40% of respondents believed that there was sufficient education on placing slings and twice as many reported not receiving enough training in procedures (48, 42.4%) as those who reported receiving enough (28, 24.8%). This is also supported by the reported number of lectures and training received. Almost half of respondents received either no lectures or just one lecture on slings (48, 42.4%) and a majority reported receiving no simulation training on slings (69, 61.1%). The vast majority of procedures conducted by respondents was performed with OBGYN trained urogynecology (87, 77%) as compared to other provider types.

Results: Residents were categorized based on their year in residency and type of training program. The largest group of respondents consisted of PGY3 residents (n=36 or 35%). Program type consisted of academic, community or mixed program type (i.e combination of academic and community based program). The largest number of respondents were from the academic-based program. Finally, respondents were asked to define the location of their program from which the largest number came from the Northeast (n=45, 43.3%).

Respondents reported on their confidence in performing various clinical functions related to urogynecology procedures. A majority (64, 56.6%) did not feel confident (disagree and strongly disagree) in performing urinary incontinence slings. However, a large number (50, 44.2%) felt confident in counseling patients on slings (agree and strongly agree) and the comfort level for conducting a patient workup for slings showed a similar proportion across agree, disagree and neutral levels. The most common procedures that respondents were comfortable with performing independently were Anterior colporrhaphy (57, 50.4%) and Posterior colporrhaphy (53, 46.9%).

Overall, education and training was considered to be insufficient. Less than 40% of respondents believed that there was sufficient education on placing slings and twice as many reported not receiving enough training in procedures (48, 42.4%) as those who reported receiving enough (28, 24.8%). This is also supported by the reported number of lectures and training received. Almost half of respondents received either no lectures or just one lecture on slings (48, 42.4%) and a majority reported receiving no simulation training on slings (69, 61.1%). The vast majority of procedures conducted by respondents was performed with OBGYN trained urogynecology (87, 77%) as compared to other provider types.

Conclusion: The treatment and surgical management of stress urinary incontinence is likely going to continue to increase as risk factors remain prevalent throughout the United States. With estimates that almost 10 million women over the age of 50 experience some kind of bothersome stress and/or urgency incontinence, the need for treatment from trained providers has never been greater. Gynecologists are at the forefront of women’s healthcare and are often the first providers seen when incontinence complaints present themselves. Currently graduate medical education for Obstetric and Gynecology residents does not require education in the placement of mid-urethral slings for stress urinary incontinence. The landscape of Urogynecological education in OBGYN residency is limited and residents may leave residency with little education or training in this area leaving patients with limited options to receive care when treatment for urinary incontinence is needed.

A total of 297 Obstetric and Gynecology residency programs were sent the survey of whom 113 residents completed it. All residents who completed the survey provided their consent by completing the consent form prior to beginning the survey. Overall, data suggests that education and training was considered to be insufficient. Less than 40% of respondents believed that there was sufficient education on placing slings and twice as many reported not receiving enough training in procedures (48, 42.4%) as those who reported receiving enough.

Overall our study supports the hypothesis that resident medical education for Obstetrics and Gynecology on placement of urinary incontinence slings is inadequate for upcoming graduates to feel confident once in practice. OBGYN resident medical education must improve to better meet the educational standards in this area so physicians can provide these services to patients in need.

References

1. Shah D, Haisch CE, Noland SL. Case Reporting, Competence, and Confidence: A Discrepancy in the Numbers. J Surg Educ. 2018;75(2):304-312. doi:10.1016/j.jsurg.2018.01.007Nathan Chance8:30 PM Jul 6

2. Barnsley L, Lyon PM, Ralston SJ, Hibbert EJ, Cunningham I, Gordon FC, et al. Clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence. Med Educ. 2004;38(4):358–367. doi: 10.1046/j.1365-2923.2004.01773.x.

3. Gude T, Finset A, Anvik T, et al. Do medical students and young physicians assess reliably their self-efficacy regarding communication skills? A prospective study from end of medical school until end of internship. BMC Med Educ. 2017;17(1):107. Published 2017 Jun 30. doi:10.1186/s12909-017-0943-y 4. Mariam Rahmani; Medical Trainees and the Dunning–Kruger Effect: When They Don’t Know What They Don’t Know. J Grad Med Educ 1 October 2020; 12 (5): 532–534. doi: 10.4300/JGME-D-20-00134.1

4. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999;77(6):1121-1134. doi:10.1037//0022-3514.77.6.1121

5. Maxwell B James, Marissa C Theofanides, Wilson Sui, Ifeanyi Onyeji, Gina M Badalato, Doreen E Chung. Sling Procedures for the Treatment of Stress Urinary Incontinence: Comparison of National Practice Patterns between Urologists and Gynecologists. The Journal of Urology. 2017; 198(6):1386-1391. doi: 10.1016/j.juro.2017.06.093.

Financial Disclosures: None reported

Support: Ascension Genesys Research Department

Ethical Approval: Ascension Genesys IRB reviewed and approved: RMI20220007

Informed Consent: Our survey was distributed through RedCAP and respondents were consented before proceeding to the main survey. All information regarding the survey, the anonymous nature of the results, and the use of the respondents information for the project was all discussed in the initial consent form. Respondents who did not wish to continue to the main survey could click yes or no. Those who clicked no were unable to continue to the main survey and were not included in the survey results.

Poster No. *C-9

Abstract No. 20

Category: Clinical

Research Topic: Acute and Chronic Pain Management

Evaluation of Ropivacaine and Liposomal Bupivacaine Pectoral Blocks for Pain Management Following Breast Surgery

¹Rachel O’Connor, OMS-II; ²Chanda Mullen, PhD; ³Andrew Fenton, MD; ³Mary Murray, MD; ³Amanda Mendiola, MD

¹Ohio University Heritage College of Osteopathic Medicine; ²Department of Health Sciences, Cleveland Clinic Akron General; ³Department of Surgical Breast Oncology, Cleveland Clinic Akron General

Statement of Significance: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, patient-centered approach to surgery that optimizes the use of multimodal opioid-sparing analgesia techniques, utilizing a combination of both local and intravenous (IV) analgesics. These techniques have been shown to decrease unwanted surgical side effects. 1–4 Cleveland Clinic Akron General initiated a Breast Recovery After Surgery (BRAS) protocol in February 2017. The protocol includes pectoral I and II blocks.

Research Methods: This was a retrospective, single-center cohort study of patients undergoing breast surgery between 1/1/2016-4/27/2020. Cases included were those undergoing mastectomy with and without reconstruction who received an intraoperative pectoral block with either LB or Ropivacaine. Patients prior to implementation of the BRAS protocol in February 2017 were excluded. Group assignment was based on the type of anesthetic, LB or Ropivacaine. Outcomes measured were median PACU pain scores and median hospital length of stay. Statistical analysis was performed by a biostatistician. Bivariate comparisons were analyzed by chi-squared or fisher’s exact test as appropriate for categorical variables and student’s t-test or non-parametric equivalent dependent on the normality of the data distribution for continuous variables. Generalized linear models were used to assess the effect of the type of pectoral block on PACU pain and hospital length of stay after controlling for malignancy, reconstruction, and laterality.

Data Analysis: A total of 1,031 cases were reviewed, of which 855 were excluded and 176 were included. 101 patients received an LB block, and 75 patients received a Ropivacaine block. All patients included were female, of those, 89% were Caucasian, and the average age was 58. The proportion of patients with malignancy and unilateral surgeries was higher in the ropivacaine group (97% vs 89%, p=0.037 and 81% vs. 44%, p<0.001, respectively). Those receiving LB underwent reconstructive surgery more than those receiving ropivacaine (64% vs 37%, p<0.001). PACU pain was not significantly different between LB and ropivacaine groups (median 6 versus median 6; p=0.226), respectively. The median hospital length of stay was significantly higher in the ropivacaine group (18 hours versus 11 hours; p=0.032). After controlling for malignancy, reconstruction and laterality, the differences in PACU pain and hospital length of stay between groups were not significant.

Results: A total of 1,031 cases were reviewed, of which 855 were excluded and 176 were included. 101 patients received an LB block, and 75 patients received a Ropivacaine block. All patients included were female, of those, 89% were Caucasian, and the average age was 58. The proportion of patients with malignancy and unilateral surgeries was higher in the ropivacaine group (97% vs 89%, p=0.037 and 81% vs. 44%, p<0.001, respectively). Those receiving LB underwent reconstructive surgery more than those receiving ropivacaine (64% vs 37%, p<0.001). PACU pain was not significantly different between LB and ropivacaine groups (median 6 versus median 6; p=0.226), respectively. The median hospital length of stay was significantly higher in the ropivacaine group (18 hours versus 11 hours; p=0.032). After controlling for malignancy, reconstruction and laterality, the differences in PACU pain and hospital length of stay between groups were not significant.

Conclusion: A significant association between analgesic type and PACU pain scores or length of stay was not observed in this study. Future studies with larger populations may aim to further investigate the potential impact of analgesia type on patient outcomes. Additionally, future studies may aim to evaluate pain after discharge, rather than just perioperative, to further investigate the long-acting effects of these drugs on postoperative pain.

References

1. Offodile AC, Gu C, Boukovalas S, et al. Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature. Breast Cancer Res Treat. 2019;173(1):65-77. doi:10.1007/S10549-018-4991-8

2. Kennedy GT, Hill CM, Huang Y, et al. Enhanced recovery after surgery (ERAS) protocol reduces perioperative narcotic requirement and length of stay in patients undergoing mastectomy with implant-based reconstruction. Am J Surg. 2020;220(1):147-152. doi:10.1016/J.AMJSURG.2019.10.007

3. Dumestre DO, Redwood J, Webb CE, Temple-Oberle C. Enhanced Recovery After Surgery (ERAS) Protocol Enables Safe Same-Day Discharge After Alloplastic Breast Reconstruction. Plast Surg (Oakville, Ont). 2017;25(4):249-254. doi:10.1177/2292550317728036

4. Tan P, Martin MS, Shank N, et al. A Comparison of 4 Analgesic Regimens for Acute Postoperative Pain Control in Breast Augmentation Patients. Ann Plast Surg. 2017;78(6S Suppl 5):S299-S304. doi:10.1097/SAP.0000000000001132

5. Zamora FJ, Madduri RP, Philips AA, Miller N, Varghese M. Evaluation of the Efficacy of Liposomal Bupivacaine in Total Joint Arthroplasty. J Pharm Pract. 2021;34(3):403-406. doi:10.1177/0897190019872577

6. Kuthiala G, Chaudhary G. Ropivacaine: A review of its pharmacology and clinical use. Indian J Anaesth. 2011;55(2):104-110. doi:10.4103/0019-5049.79875

7. Nadeau MH, Saraswat A, Vasko A, Elliott JO, Vasko SD. Bupivacaine Versus Liposomal Bupivacaine for Postoperative Pain Control after Augmentation Mammaplasty: A Prospective, Randomized, Double-Blind Trial. Aesthetic Surg J. 2016;36(2):NP47-NP52. doi:10.1093/ASJ/SJV149

Financial Disclosures: None reported

Support: None reported

Ethical Approval: This study was approved by the institutional review board #21022 with a waiver of consent granted.

Informed Consent: N/A

Poster No. *C-10

Abstract No. 23

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Ultrasound Derived Fat Fraction (UDFF) and MRI-PDFF of Adult Liver: A Preliminary Observation

¹Colby Adamson, OMS-III; ²James Dolan, DO; ³Benjamin Wilde, DO; ⁴Jing Gao, MD

¹Rocky Vista University College of Osteopathic Medicine-Southern Utah; ²Department of Research, Rocky Vista University College of Osteopathic Medicine-Southern Utah; ³Department of Clinical Sciences, Rocky Vista University College of Osteopathic Medicine-Southern Utah; ⁴Office of Research and Scholarly Activity, Rocky Vista University College of Osteopathic Medicine -Southern Utah

Statement of Significance: Nonalcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease worldwide [1, 2]. It is clinically important to detect NAFLD in its early stages when fat accumulation in the liver is potentially reversible [3]. Given the clinical value of detection and limitations of current invasive diagnostic testing, development of other non-invasive and efficacious options such as ultrasound derived fat fraction (UDFF) for screening, grading, and monitoring NAFLD is imperative.

Research Methods: We prospectively measured UDFF and MRI-PDFF of the liver in 45 participants (22 men and 23 women, mean age 51y, age range 20-75y) after receiving the Institutional Review Board approval and written informed consent. Based on MRI-PDFF, participants were divided into normal liver group (MRI-PDFF <5%) or steatotic liver group (MRI-PDFF ≥5%). Differences in hepatic UDFF and MRI-PDFF between the two groups were examined by two-tailed t-test. The correlation of liver UDFF to MRI-PDFF was analyzed using linear regression.

Data Analysis: Liver UDFF and MRI-PDFF differed significantly between participants with (n=33) and without (n=12) NAFLD. Liver MRI-PDFF was closely correlated with liver UDFF (R2= 0.798). AUC of UDFF in determining ≥ mild hepatic steatosis was 0.913.

Results: Liver UDFF and MRI-PDFF differed significantly between participants with (n=33) and without (n=12) NAFLD. Liver MRI-PDFF was closely correlated with liver UDFF (R2= 0.798). AUC of UDFF in determining ≥ mild hepatic steatosis was 0.913.

Conclusion: UDFF positively correlates with liver MRI-PDFF in quantifying fat content in the liver. Further investigation may also explore clinical utility of UDFF in analyzing pathologies of other major organs and systems. Limitations of this study include a relatively small sample size, and no histologic sampling of the liver was available to correlate liver fat content with UDFF findings. Instead, we relied on the correlation of UDFF and MRI-PDFF findings with acknowledgement that MRI-PDFF has been shown to be reliable in assessment of liver fat content in past studies [4].

References

1. Carr RM, Oranu A, Khungar V. Nonalcoholic Fatty Liver Disease: Pathophysiology and Management. Gastroenterol Clin North Am. 2016;45(4):639-652. doi:10.1016/j.gtc.2016.07.003

2. Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64(1):73-84. doi:10.1002/hep.28431

3. Vilar-Gomez E, Martinez-Perez Y, Calzadilla-Bertot L, et al. Weight Loss Through Lifestyle Modification Significantly Reduces Features of Nonalcoholic Steatohepatitis. Gastroenterology. 2015;149(2):367-e15. doi:10.1053/j.gastro.2015.04.005

4. Castera L, Friedrich-Rust M, Loomba R. Noninvasive Assessment of Liver Disease in Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology. 2019;156(5):1264-1281.e4. doi:10.1053/j.gastro.2018.12.036

Financial Disclosures: Financial Disclosures: Dr. Jing Gao has no financial relationship to disclose. Dr. Jing Gao was loaned research equipment from Siemens Healthineers to support the study. Colby Adamson, James Dolan, and Benjamin Wilde, have nothing to disclose.

Support: Support and Acknowledgements: Authors thank Siemens Healthineers for providing equipment to support the study.

Ethical Approval: Ethical Approval: Institutional Review Board at Rocky Vista University approved the study (IRB: 2019-0009).

Informed Consent: Informed Consent: All participants provided written informed consent.

Poster No. *C-11

Abstract No. 96

Category: Clinical

Research Topic: Impact of OMM & OMT

The Effects of Upper Trapezius Muscle Energy Technique on Pain, Muscle Tension, and Cervical Range of Motion Using the MyotonPRO

¹Lerone Clark, OMS-III; ²Jai Joshi, OMS-III; ²Aziz-ur-Rahman Khalid, OMS-III; ²Rejath Jose, OMS-III; ²Mariama Furman, OMS-III; ²Faiz Syed, OMS-III; ³Min-Kyung Jung, PhD; ²Sheldon Yao, DO, FAAO; ²Philip Noto, DO, FAAPMR

¹ New York Institute of Technology; ²Department of Osteopathic Manipulative Medicine, New York Institute of Technology; ³Department of Research, New York Institute of Technology

Statement of Significance: Medical students are prone to neck/upper back pain related to computer use and poor posture while studying. Muscle energy technique (MET) is thought to reduce muscle tension and pain. The MyotonPRO measures properties of muscle including tone and stiffness. A previous study showed a reduction of pain scores in upper trapezius tender points after counterstrain treatment, but without reduction in stiffness or tone; this study examined the ability of MET to reduce muscle stiffness, tone, and pain.

Research Methods: Twenty-four medical students (fourteen females and ten males) were evaluated and treated by a board-certified osteopathic physician. Osteopathic medical students (OMS) were recruited using a survey posted on social media platforms (GroupMe, Facebook, etc.). Inclusion criteria included being an OMS with shoulder and/or neck pain or discomfort. Subjective ratings of pain in the upper trapezius (from 1 to 10) and range of motion (ROM) of the neck in both sidebending and rotation were recorded for both the treatment side and control side before and after treatment. A blinded student investigator also measured muscle data using the MyotonPRO bilaterally before and after MET was applied. The participants chose the side to be treated with MET for the upper trapezius muscle regardless of the side with the highest pain rating. Treatment of the upper trapezius with MET consisted of the physician providing resistance to the temporal side of the head and ipsilateral shoulder while the participant tried to side bend their neck towards the ipsilateral side. Changes in the subjective pain scores, Myoton-measured muscle parameters, and sidebending and rotation range of motion measurements before and after treatment were analyzed using paired t-tests in SPSS statistical software.

Data Analysis: After analysis of the collected data, there was a statistically significant (p=0.033) difference of 5.8 newtons per meter (N/m) between pre-treatment and post-treatment measurements for muscle stiffness. There was also a statistically significant (p=0.001) difference of 0.4 hertz (Hz) between pre-treatment and post-treatment measurements for muscle tone. There was no significant difference observed between stiffness (p=0.30) or tone (p=0.15) on the non-treatment (control) side. The analysis also indicated that there was a significant difference in pre-treatment and post-treatment pain scores on both the treatment (p<0.001) and non-treatment (p=0.014) sides. P-values were calculated by running Wilcoxon signed-rank test. Spearman’s rank correlation coefficient was also calculated for the changes in stiffness and pain score for both sides; no significant correlation between pain score change and stiffness change was found for either the treatment (r = -0.24) or non-treatment side (r = 0.31). No subjects were excluded from the final statistical analysis.

Results: After analysis of the collected data, there was a statistically significant (p=0.033) difference of 5.8 newtons per meter (N/m) between pre-treatment and post-treatment measurements for muscle stiffness. There was also a statistically significant (p=0.001) difference of 0.4 hertz (Hz) between pre-treatment and post-treatment measurements for muscle tone. There was no significant difference observed between stiffness (p=0.30) or tone (p=0.15) on the non-treatment (control) side. The analysis also indicated that there was a significant difference in pre-treatment and post-treatment pain scores on both the treatment (p<0.001) and non-treatment (p=0.014) sides. P-values were calculated by running Wilcoxon signed-rank test. Spearman’s rank correlation coefficient was also calculated for the changes in stiffness and pain score for both sides; no significant correlation between pain score change and stiffness change was found for either the treatment (r = -0.24) or non-treatment side (r = 0.31). No subjects were excluded from the final statistical analysis.

Conclusion: This study highlights the complexity of the relationship between muscle tension and pain. The use of MET for the upper trapezius reduced muscle tone and stiffness on the treatment side, but not on the control side. While there was a statistically significant decrease in pain on both sides, it was markedly more reduced on the treatment side. MET engages the golgi tendon organ reflex, but it also engages reciprocal inhibition thus explaining a lesser, though still noteworthy, effect on the contralateral side. Moreover, MET does not guarantee pinpoint accuracy, thus while the position does favor the upper trapezius, there will be spillover to additional cervical muscles. This is likely why we also observed a smaller effect, bilaterally, in increased cervical ROM. The upper trapezius, which bore the focus of the technique, exhibited a decrease in tension, but the overall cervical ROM is likely a composite of all regional muscles. These additional muscles, even if mildly reduced in tension, could collectively sum to an overall increase in ROM. Our previous study on Counterstrain showed decreased pain but no decrease in muscle tension. We postulated, after our Counterstrain study, that MET would more directly inhibit muscle tension because of its mechanism, and our results bore that conclusion out. Our present analysis shows that there was no significant relationship between the changes in these two variables. The control side did not have a significant decrease in muscle tension but did show a significant decrease in pain. The treatment side did achieve significant reductions in muscle tension and pain but failed to show a correlation between them. This study, while demonstrating the efficacy of MET on the upper trapezius for neck and upper back pain, casts doubt on this long-held assumption that pain and muscle tension are related phenomena.

References

1. Du JY, Aichmair A, Schroeder JE, Kiely PD, Nguyen JT, Lebl DR. Neck Pain and Low Back Pain in Medical Students: A Cross-Sectional Study. Int Arch Public Health Community Med. 2017;1:002. Accessed July 11, 2022. https://www.researchgate.net/profile/Jerry-Du/publication/322157626_Neck_Pain_and_Low_Back_Pain_in_Medical_Students_A_Cross-Sectional_Study/links/5f0c3ec1299bf1074452d535/Neck-Pain-and-Low-Back-Pain-in-Medical-Students-A-Cross-Sectional-Study.pdf

2. Feng YN, Li YP, Liu CL et al. Assessing the elastic properties of skeletal muscle and tendon using shearwave ultrasound elastography and MyotonPRO. Sci Rep. 2018; Article no. 17064. https://doi.org/10.1038/s41598-018-34719-7.

3. Liang R, Wong S, Song K, Clark L, Joshi J, Khalid A, Jung M, Yao S, Noto P. The Effect of Counterstrain Technique on Muscle Stiffness and Pain on Trapezius Tender Points in Medical Students. J Osteo Med. 2021;121(12). https://doi.org/10.1515/jom-2021-2000

4. DiGiovanna EL, Amen CJ, Burns DK. Chapter 13: Muscle Energy. In: An Osteopathic Approach to Diagnosis and Treatment. Fourth edition. Wolters Kluwer Health; 2021. Accessed July 11, 2022. https://meded-lwwhealthlibrary-com.arktos.nyit.edu/content.aspx?sectionid=248812205&bookid=2969

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This study was approved by the New York Institute of Technology Institutional Review Board under Protocol #BHS-1561.

Informed Consent: Research subjects were informed of the purpose, description, potential risks, and potential benefits of the research study by a member of the research team. Research subjects then signed an informed consent form after being given adequate time to ask any questions they may have. All health information of research subjects remained confidential and accessed only by members of the research team. Research subjects voluntarily agreed to participate in this study and were given the option to withdraw from the study at any time without penalty or loss of benefits.

Poster No. *C-12

Abstract No. 31

Category: Clinical

Research Topic: Impact of OMM & OMT

Assessing Validity and Reproducibility of Goniometry: Establishing the Use of a Markerless Video Motion Capture System

¹Cailee Dean, OMS-III; ²Thomas M. Motyka, DO, MHPE; ¹Ryan J. Schell, OMS-II; ³Adam D. Foster, PhD

¹Campbell University-Jerry M. Wallace School of Osteopathic Medicine; ²Department of Osteopathic Manipulative Medicine, Campbell University-Jerry M. Wallace School of Osteopathic Medicine; ³Department of Anatomy, Campbell University-Jerry M. Wallace School of Osteopathic Medicine

Statement of Significance: Traditional range of motion (ROM) studies utilize goniometry extensively (1–3). Therefore, goniometry provides a comparison to assess a novel markerless video motion capture system. The Theia3D markerless system allows for quick, objective assessments of multiple subjects. When analyzing gait, this system was found to have comparable results to a marker-based motion capture system (4). This indicates the utility of further investigation of the Theia3D system into joint specific ROM applications.

Research Methods: Potential subjects were recruited via flyers on Campbell University Facebook student pages, and before presentations at CUSOM to reach members of the community, students, faculty and staff who may be interested in participating in the study. Potential subjects contacted the Principle Investigator to be enrolled after completing the screening process. All subjects needed to be over 18 years old, follow verbal instruction in English, and be recreationally fit. Subjects were excluded if they experienced any recent injuries, had a history of chronic pain, rheumatologic condition, spinal surgery, neck or back trauma, herniated disc or lumbar protrusion, vertigo, respiratory, neurologic, or cardiovascular disease, allergies to adhesives/cosmetics, or were pregnant. A preliminary sample of 5 subjects were selected after completing this process and asked to perform a variety of predetermined movements (e.g., flexion and extension) used to assess the Theia3D system. On command, the targeted motion was performed to the end of the subject’s comfortable range of motion and recorded by the Theia3D system. This position was then held to allow simultaneously measurement of joint angles by goniometer and was repeated three times. Measurements for the goniometer and Theia3D system were compared using the coefficient of variation, which measures dispersion about the mean, and is expressed as a percentage. Identifying a more objective measure of ROM changes is essential for demonstrating the efficacy of osteopathic manipulations.

Data Analysis: Preliminary results on a subset of movements at the shoulder demonstrate a smaller coefficient of variation for the Theia3D markerless system [Theia Flexion: 0.06; Theia3D Extension: 20.894; Goniometer Flexion: 7.69; Goniometer Extension: 32.94]. Qualitatively, extremity ROM tests were challenging for subjects to isolate motion to the targeted joint.

Results: Preliminary results on a subset of movements at the shoulder demonstrate a smaller coefficient of variation for the Theia3D markerless system [Theia Flexion: 0.06; Theia3D Extension: 20.894; Goniometer Flexion: 7.69; Goniometer Extension: 32.94]. Qualitatively, extremity ROM tests were challenging for subjects to isolate motion to the targeted joint.

Conclusion: Preliminary data suggests the Theia3D markerless motion capture system offers a more precise measure of joint ROM that accounts for linked correlated movements of adjacent body segments. Use of this system requires more time for analysis. However, with automated workflows, this system offers objective measurement of joint mobility in clinical settings and could broaden the scope of future ROM studies investigating treatments or observing human movement outside the laboratory.

References

1. Greene WB, Heckman JD, American Academy of Orthopaedic Surgeons. The Clinical Measurement of Joint Motion. 1st ed. American Academy of Orthopaedic Surgeons; 1994.

2. Soucie JM, Wang C, Forsyth A, et al. Range of motion measurements: reference values and a database for comparison studies. Haemophilia. 2011;17(3):500-507. doi:10.1111/j.1365-2516.2010.02399.x

3. Youdas JW, Garrett TR, Suman VJ, Bogard CL, Hallman HO, Carey JR. Normal Range of Motion of the Cervical Spine: An Initial Goniometric Study. Phys Ther. 1992;72(11):770-780. doi:10.1093/ptj/72.11.770

4. Kanko RM, Laende EK, Davis EM, Selbie WS, Deluzio KJ. Concurrent assessment of gait kinematics using marker-based and markerless motion capture. J Biomech. 2021;127:110665. doi:10.1016/j.jbiomech.2021.110665

Financial Disclosures: None reported.

Support: Campbell University

Ethical Approval: This study was reviewed and approved by IRB, #728.

Informed Consent: A member of the research team reviewed the purpose, description, and potential risks and benefits of the study with eligible subjects after the completion of the screening process. Research subjects then were given the opportunity to ask any questions and signed the informed consent document with a witness from the research team. All health information and recorded videos of research subjects remained confidential and accessed only by members of the research team. Participation in the study was voluntary. All subjects were given the option to withdraw from the study at any time without penalty or loss of benefits.

Poster No. *C-13

Abstract No. 28

Category: Clinical

Research Topic: Chronic Diseases & Conditions

The Incidence of Respiratory Syncytial Virus (RSV) Bronchiolitis and Concomitant Urinary Tract Infection (UTI) in Young Infants

¹Wesley Gregory, OMS-IV; ¹Luke Saunders, OMS-IV; ¹Samantha Houston, OMS-III; ²Sami E. Rishmawi, MD; ³David Redden, PhD; ²Hanna S. Sahhar, MD

¹Edward Via College of Osteopathic Medicine-South Carolina; ²Department of Pediatrics, Edward Via College of Osteopathic Medicine-South Carolina; ³Departments of Biomedical Affairs and Research, Edward Via College of Osteopathic Medicine-Auburn

Statement of Significance: Respiratory syncytial virus (RSV) is the leading cause of bronchiolitis in young infants1 while adjuvant urinary tract infections (UTI) pose a major risk factor to the morbidity and mortality of pediatric patients2. Previous efforts to determine a direct relationship between RSV and concomitant UTI in infants reveal conflicting data and an inability to provide robust evidence3. In practice, evidenced work-up modalities may lead to early and accurate diagnosis while limiting harmful consequences.

Research Methods: A single-center, retrospective, observational study was conducted by reviewing all pediatric patients admitted with RSV to the general pediatrics unit or Pediatric Intensive Care Unit at Spartanburg Medical Center from October 1, 2016 to December 16, 2021 using EPIC SlicerDicerTM software. Study participants were stratified into three cohorts; positive RSV PCR with no urine culture, positive RSV PCR with negative urine culture, and positive RSV PCR with positive urine culture for bacterial co-infection. Exact Chi Squared and Wilcoxon Rank Sum tests compared the incidence of co-infection and associated risk factors. All statistical analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC).

Data Analysis: A total of 269 patients diagnosed and admitted for bronchiolitis caused by RSV were identified, of which 166 infants younger than 1 year of age were included in the study analysis. Infant demographics consisted of 66 females and 100 males; 19 children were 0-28 days old, 37 were 29 -56 days old, 110 were 57 or more days old; 35 children were African American, 124 White, and 7 others. A total of 3 (2 female, 1 male) of the 166 children tested positive on urinalysis and urine culture for a co-existing UTI. Results of an exact 95% confidence interval estimate that the true percent of children with co-infection may be between 0.37% and 5.19%. Several factors for increased association with UTI were investigated using an exact Chi-Square approach with a Type I error rate of 0.10. An increased Type I error rate was utilized due to the rarity of co-infection. Even with this approach, no statistically significant associations with concomitant UTI for factors such as circumcision (males only p = 1.0), fever (p = 0.605), PICU (p = 0.580), or prematurity (p = 1.0) were observed. However, using a Type I error rate of 0.10, perihilar infiltrates on chest radiography (p = 0.058) were associated with co-infection and non-invasive ventilation approached statistical significance (p = 0.101). Wilcoxon Rank Sum tests compared length of stay (p = 0.325) and days with fever (p = 0.581) between infants with RSV and concomitant UTI versus RSV alone.

Results: A total of 269 patients diagnosed and admitted for bronchiolitis caused by RSV were identified, of which 166 infants younger than 1 year of age were included in the study analysis. Infant demographics consisted of 66 females and 100 males; 19 children were 0-28 days old, 37 were 29 -56 days old, 110 were 57 or more days old; 35 children were African American, 124 White, and 7 others. A total of 3 (2 female, 1 male) of the 166 children tested positive on urinalysis and urine culture for a co-existing UTI. Results of an exact 95% confidence interval estimate that the true percent of children with co-infection may be between 0.37% and 5.19%. Several factors for increased association with UTI were investigated using an exact Chi-Square approach with a Type I error rate of 0.10. An increased Type I error rate was utilized due to the rarity of co-infection. Even with this approach, no statistically significant associations with concomitant UTI for factors such as circumcision (males only p = 1.0), fever (p = 0.605), PICU (p = 0.580), or prematurity (p = 1.0) were observed. However, using a Type I error rate of 0.10, perihilar infiltrates on chest radiography (p = 0.058) were associated with co-infection and non-invasive ventilation approached statistical significance (p = 0.101). Wilcoxon Rank Sum tests compared length of stay (p = 0.325) and days with fever (p = 0.581) between infants with RSV and concomitant UTI versus RSV alone.

Conclusion: Our statistical analysis did not reveal a clinically significant rate of concomitant UTI in infants diagnosed with RSV bronchiolitis. Appreciating a low yield of positive UTI cases, patient factors (i.e. congenital malformation, circumcision status, prematurity, fever) revealed no statistical significance for influencing the incidence of concomitant UTI, with the exception of perihilar infiltrates on chest radiography. This suggests a low predictive value of such factors in a clinical setting. As such, for standardized practice we recommend against routinely obtaining urinalysis and urine culture for all children less than 1 year old diagnosed with RSV. We recommend that the workup for RSV-positive infants remains individualized and UTI diagnosis be pursued when there is a high clinical suspicion for co-infection.

References

1. Hall CB, Weinberg GA, Iwane MK, et al. The burden of respiratory syncytial virus infection in young children. N Engl J Med. 2009;360(6):588-598. doi: 10.1056/NEJMoa0804877Zorc

2. JJ, Levine DA, Platt SL, et al. Multicenter RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics; Clinical and Demographic Factors Associated With Urinary Tract Infection in Young Febrile Infants. Pediatrics 2005;116(3):644–648. doi: 10.1542/peds.2004-1825

3. Hendaus MA. Why Are Children With Bronchiolitis At Risk Of Urinary Tract Infections? Risk Manag Healthc Policy. 2019 Nov 14;12:251-254. doi: 10.2147/RMHP.S222470.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Reviewed and approved by the Spartanburg Regional Healthcare System IRB. IRB reference number 1849618. Based on applicable federal regulations, the submission qualified for expedited review.

Informed Consent: In accordance with 45 CFR 46.116 (c) (2) and 45 CFR 46.116 (d), the IRB approved waiving the requirements to obtain informed consent due to the minimal risk to study participants.

Poster No. *C-14

Abstract No. 33

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Impact of Diabetes Mellitus on Patients with Sepsis at a Community Hospital

¹Rachel Wilks, OMS-IV; ²Carmelita Coca, PharmD; ²Tyson Dietrich, PharmD; ²John Robinson, PharmD; ³Adam Dawson, DO; ⁴Diana Lalitsasivimol, PhD; ³Anthony Santarelli, PhD; ³John Ashurst, DO, MSc

¹Pacific Northwest University of Health Sciences College of Osteopathic Medicine; ²Department of Pharmacy, Kingman Regional Medical Center; ³Department of GME, Kingman Regional Medical Center; ⁴Research & Sponsored Programs, Kingman Regional Medical Center

Statement of Significance: Data has shown that diabetics have an increased risk of infection and the development of sepsis. Despite this increased risk, however, diabetics diagnosed with sepsis are not at an increased risk of mortality but do have an increased risk of the development of acute renal failure. Current literature, however, fails to include those who meet and do not meet the three-hour sepsis bundle.

Research Methods: A single-center, retrospective case-control study was conducted among adult patients who were seen in the emergency department between June 1, 2019 and January 31, 2021. Patients were included in analysis if diagnosed with sepsis and had a past medical history of either type I or type II diabetes. Baseline characteristics, laboratory results, source of infection, sepsis bundle management, in-hospital mortality, and 28-day readmissions were recorded.

Data Analysis: A total of 226 patients were included in the final analysis with 28.3% (64/226) having diabetes, 45.1% (102/226) being female, and 8.4% (19/226) self-reporting as a racial or ethnic minority. In total, 73.5% (166/226) of patients met the three-hour and 68.1% (154/226) met the six-hour sepsis bundle. Patients with diabetes were equally likely to meet both the three-hour (68.8% vs 75.3%; p = 0.314) and six-hour bundles (70.3% vs 67.3%; p = 0.660) when compared to those without diabetes. The most common chief complaints among diabetics with sepsis was shortness of breath/dyspnea (35.9%; 23/64) followed by altered mental status (10.9%; 7/64). The most common reason patients with diabetes failed to meet the three-hour sepsis bundle was due to a lack of antibiotics being administered in the appropriate timeframe (80.0%; 16/20). The median time to antibiotic administration from physician order placement was 860.0 mins (250.0 – 1110.0). No differences in the rates of critical care utilization (25.0% vs 19.1%; p = 0.328), in-hospital mortality (9.4% vs 14.2%; p = 0.329), nor re-admittance within 28-days (9.4% vs 9.9%; p = 0.909) were detected between patients with diabetes and their non-diabetic peers.

Results: A total of 226 patients were included in the final analysis with 28.3% (64/226) having diabetes, 45.1% (102/226) being female, and 8.4% (19/226) self-reporting as a racial or ethnic minority. In total, 73.5% (166/226) of patients met the three-hour and 68.1% (154/226) met the six-hour sepsis bundle. Patients with diabetes were equally likely to meet both the three-hour (68.8% vs 75.3%; p = 0.314) and six-hour bundles (70.3% vs 67.3%; p = 0.660) when compared to those without diabetes. The most common chief complaints among diabetics with sepsis was shortness of breath/dyspnea (35.9%; 23/64) followed by altered mental status (10.9%; 7/64). The most common reason patients with diabetes failed to meet the three-hour sepsis bundle was due to a lack of antibiotics being administered in the appropriate timeframe (80.0%; 16/20). The median time to antibiotic administration from physician order placement was 860.0 mins (250.0 – 1110.0). No differences in the rates of critical care utilization (25.0% vs 19.1%; p = 0.328), in-hospital mortality (9.4% vs 14.2%; p = 0.329), nor re-admittance within 28-days (9.4% vs 9.9%; p = 0.909) were detected between patients with diabetes and their non-diabetic peers.

Conclusion: Diabetics at a community hospital were equally likely to meet the three and six-hour sepsis bundle as compared to non-diabetics. No difference in critical care utilization, in-hospital mortality, and re-admittance rates were noted between diabetics and non-diabetics admitted for sepsis at a community hospital.

References

NA

Financial Disclosures: None

Support: None

Ethical Approval: The study was reviewed by the Kingman Healthcare Inc IRB and approved. The IRB number for the project was KHI-0257

Informed Consent: NA

Poster No. *C-15

Abstract No. 37

Category: Clinical

Research Topic: Osteopathic Philosophy

Barriers to Research Opportunities Among Osteopathic Medical Students

¹Madison George, OMS-II; ²Angela Ho, OMS IV; ³Alyssa Auerbach, DO; ⁴Jantzen J. Faulkner, OMS III; ⁵Satvinder K. Guru, OMS IV; ⁶Amber Lee, OMS III; ²David Manna, PhD; ¹Madison George, OMS II

¹Michigan State University College of Osteopathic Medicine; ²Touro College of Osteopathic Medicine-Middletown (TouroCOM); ³Department of Emergency Medicine, St. John’s Riverside Hospital; ⁴Oklahoma State University Center for Health Sciences; ⁵New York Institute of Technology; ⁶Arkansas College of Osteopathic Medicine

Statement of Significance: Osteopathic medical students (OMS) have significantly fewer research experiences than U.S. allopathic medical students and non-U.S. international medical graduates. However, few studies have addressed this long-standing discrepancy, and none directly have focused on osteopathic medical students to assess their unique needs. The literature would benefit from identifying the barriers osteopathic medical students encounter when participating in research, and understanding the available resources.

Research Methods: A survey was created by the investigators and administered to participants over a three-month period via a GoogleForm. Research participants were surveyed for demographic information, as well as their involvement in research projects in the past, mentor availability, institutional resources, motivation to participate in research, individual barriers to participation, and confidence in their ability to do independent research. 669 responses were collected from 32 U.S. osteopathic medical schools, de-identified, and analyzed using basic statistical techniques.

Data Analysis: After relevant exclusion, 668 responses were included. Of the students surveyed, 85.9% (n=574) indicated they currently and/or in the past were involved in research. More than half of the respondents that are not currently involved in research are interested in pursuing it (51.5%, n=344). The primary barriers students reported facing include lack of time, feeling overwhelmed and unsure how to start, and lack of access to research. 34.7% (n=232) of students stated they either did not have resources from their school or were unsure whether these resources were available. The two most cited motivations to pursue research included boosting their residency application and/or interest in the area of study. Reporting of confidence in research was significantly affected by gender and current involvement in research.

Results: After relevant exclusion, 668 responses were included. Of the students surveyed, 85.9% (n=574) indicated they currently and/or in the past were involved in research. More than half of the respondents that are not currently involved in research are interested in pursuing it (51.5%, n=344). The primary barriers students reported facing include lack of time, feeling overwhelmed and unsure how to start, and lack of access to research. 34.7% (n=232) of students stated they either did not have resources from their school or were unsure whether these resources were available. The two most cited motivations to pursue research included boosting their residency application and/or interest in the area of study. Reporting of confidence in research was significantly affected by gender and current involvement in research.

Conclusion: Findings from this study provide a synopsis of the barriers to research opportunities among osteopathic medical students. To help overcome these barriers, we recommend osteopathic medical schools and national organizations implement comprehensive research education programs and research project databases, as well as making it a priority to allocate funds to financially support this infrastructure, to enable students to develop skills, obtain experience, and remain competitive within the medical research community.

References

N/A

Financial Disclosures: None reported

Support: This study was funded by the Student Osteopathic Medical Association (SOMA) and Arkansas College of Osteopathic Medicine SOMA Chapter.

Ethical Approval: This quantitative cross-sectional study was reviewed and approved by the Touro College HSIRB, who deemed this study exempt (HSIRB# 2142E).

Informed Consent: All survey respondents provided electronic informed consent prior to access of survey.

Poster No. C-16

Abstract No. 39

Category: Clinical

Research Topic: Impact of OMM & OMT

A Feasibility Study to Assess OMT for NAS

Lara Householder, DO; Breanna Glynn, DO; Holly Wadman, DO; Kathryn Hoffmann, DO

Maine Dartmouth Family Medicine Residency

Statement of Significance: Neonatal abstinence syndrome (NAS) occurs when an infant withdraws from substances they were exposed to in utero. Non-pharmacologic interventions to support withdraw tolerance are a focus of current research as they decrease LOS and cost (1, 2, 3). Osteopathic manipulative therapy (OMT) has been theorized to support NAS infants by decreasing somatic dysfunction, balancing sympathetic and parasympathetic nervous drive, and improving feeding, however, no studies have yet been conducted.

Research Methods: We designed a retrospective chart review of 54 NAS infants born at a single community based teaching hospital in central Maine. Data gathered included birth and pregnancy information, substance use history, eat-sleep-console scores and team huddle outcomes, pharmaceutical interventions, length of stay, and time required to complete chart review. We also gathered information on osteopathic consults including the reason for the consult, what day of life the consult occurred, and how many treatment areas were addressed. Chart review was completed by three reviewers after a chart review protocol was created.

Data Analysis: We found that all desired information was accessible in the charts, however, chart review was time consuming. Infants who required pharmaceutical intervention had the greatest LOS and their charts took the longest to review. Of note, all of the osteopathic consults were requested for issues related to feeding. Our study was too small to complete statistical analysis and because of the small size, our groups differed in several factors including gestational age at delivery and weight category at delivery.

Results: We found that all desired information was accessible in the charts, however, chart review was time consuming. Infants who required pharmaceutical intervention had the greatest LOS and their charts took the longest to review. Of note, all of the osteopathic consults were requested for issues related to feeding. Our study was too small to complete statistical analysis and because of the small size, our groups differed in several factors including gestational age at delivery and weight category at delivery.

Conclusion: Although we did find that we were able to access all desired data, we discovered several limitations to consider if we were to progress to a larger study. First, data gathering was time consuming. We could consider gathering fewer data points in a larger study, revising our protocol, and offering more training to reviewers. Next, OMT consults were placed for infants who had difficulty with feeding which could be an indication of withdraw intolerance. This may indicate that a retrospective study could be difficult to interpret as infants who receive OMT may already be having difficulty tolerating withdraw compared to their peers. Lastly, our desired outcome, decreased LOS, is driven by utilization of pharmaceutical intervention and by protocol with all infants with NAS requiring a 5 day minimum. In order to show that OMT is effective at decreasing LOS, we would either have to demonstrate that OMT decreased the need for pharmaceutical intervention or the dosage of medication necessary. This would require a large study size in order to obtain adequate power as only 13% of infants at our facility required pharmaceutical treatment. As a larger retrospective study would be limited by an NAS assessment change at our facility in 2018, a multicenter collaboration would be necessary.

References

1. Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004-2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520

2. MacMillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Volpe Holmes A. Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis. JAMA Pediatr. 2018;172(4):345-351. doi:10.1001/jamapediatrics.2017.5195

3. Pahl A, Young L, Buus-Frank ME, Marcellus L, Soll R. Non-pharmacological care for opioid withdrawal in newborns. Cochrane Database Syst Rev. 2020;12(12):CD013217. Published 2020 Dec 21. doi:10.1002/14651858.CD013217.pub2

Financial Disclosures: None reported

Support: None reported.

Ethical Approval: Initial IRB was approved on 12/7/2018 for the study, “Feasibility of assessing the effect of OMT on outcomes in neonates who do not breastfeed well: A pilot study.” Our modification to include NAS data was approved 9/2021. We have no IRB number or clinical trial number. Study was submitted to Maine General Medical Center IRB and was approved, modified, and undergoes continuing reviewed per MGMC IRB protocol.

Informed Consent: None

Poster No. *C-17

Abstract No. 117

Category: Clinical

Research Topic: Impact of OMM & OMT

Beliefs and Attitudes About Opioid Prescribing in Patients With Low Back Pain: A Survey of Osteopathic Physicians

¹Bryan Pham, OMS-III; ²Abigail Tzau, OMS III; ²Angela S. Lee, MPH; ²Lisa A. DeStefano, DO; ²John. M. Popovich Jr., PhD, DPT

¹Center for Neuromusculoskeletal Clinical Research; ²Department of OMM, Michigan State University College of Osteopathic Medicine

Statement of Significance: The American Osteopathic Association guidelines state that Osteopathic Manipulative Treatment (OMT), effectively reduces pain and improves functional status in patients with chronic nonspecific Low Back Pain (LBP) [1], which is further corroborated by a recent review and meta-analysis [2]. These findings are significant for the health of patients with LBP and warrant further investigation into osteopathic physicians’ perspectives on the use of opiates in their management of patients with LBP.

Research Methods: Osteopathic physicians were recruited to participate in this study. Participants completed an online questionnaire that included: 1) Demographic information, 2) Health Care Providers’ Pain and Impairment Relationship Scale (HC-PAIRS), 3) Pain Attitudes and Beliefs Scale for Physical Therapists (PABS-PT), and 4) Opioid Therapy Provider Survey (OTS). The HC-PAIRS was used to measure physicians’ attitudes and beliefs regarding the relationship between LBP and impairment. The PABS-PT was used to differentiate between biomedical and biopsychosocial treatment orientations for patients with LBP. The OTS is a ten-item survey that was used to assess providers’ practice behaviors and confidence in managing their patients with opioid therapy with each question labeled from OTS1 through OTS10. The responses to the OTS were scored on a 5-point Likert scale where 1 = “Completely Disagree” and 5 = “Completely Agree”. Comparisons between multiple physician groups were conducted using the non-parametric independent samples Kruskal-Wallis test and comparisons between two physician groups were conducted using the non-parametric Mann-Whitney U test. Data are reported as median [range]. Statistical analyses were conducted using SPSS Statistics (Ver. 28.0. Armonk, NY) and statistical significance was set at p≤0.05. This study has osteopathic significance because understanding osteopathic physicians’ beliefs and attitudes on opiate usage in the management of patients with LBP may provide clarity and direction as to why patients treated with OMT have significant reductions in medication and opioid drug use.

Data Analysis: A total of 35 osteopathic physicians (n=10 women, n= 1 unspecified, n= 24 men) with an average of 17.2 ± 10.4 years post/after residency participated in this study and represented the following specialties: ONMM, n=9; PM&R, n=13; Family Medicine, n=12; Pediatrics, n=1. Of the 35 physicians, 32 (91.4%) reported using OMM in their practice for a total of 86% [range 5-100%] of the time. Overall (n=35 physicians), the scores for the HC-PAIRS, PABS-PT-Biomedical, PABS-PT-Biopsychosocial, and OTS were 51 [34-75], 34 [19-43], 34 [24-44], 30 [14-41], respectively. There were no significant differences among the different specialties (Pediatrics was excluded from this comparison due to the small sample size) in any of the aforementioned questionnaire scores (all p>0.05). However, when comparing physicians who almost exclusively use OMM in their practice (defined as greater than 90% of the time, n=13) to physicians who use OMM less often (defined as 90% or less, n=19) there were significant differences in questionnaire responses. Specifically, there were significant differences between physicians who exclusively practice OMM compared to those who use OMM less often in OST1) “I am willing to prescribe opioids with support from a pain clinic” (1[1-4] vs. 3 [1-5], p=0.05), OST5) “I would likely prescribe opioids when other treatments are ineffective” (1[1-5] vs. 2 [1-4], p=0.04), and HC-PAIRS (56 [43-75] vs. 50 [34-67], p=0.02).

Results: A total of 35 osteopathic physicians (n=10 women, n= 1 unspecified, n= 24 men) with an average of 17.2 ± 10.4 years post/after residency participated in this study and represented the following specialties: ONMM, n=9; PM&R, n=13; Family Medicine, n=12; Pediatrics, n=1. Of the 35 physicians, 32 (91.4%) reported using OMM in their practice for a total of 86% [range 5-100%] of the time. Overall (n=35 physicians), the scores for the HC-PAIRS, PABS-PT-Biomedical, PABS-PT-Biopsychosocial, and OTS were 51 [34-75], 34 [19-43], 34 [24-44], 30 [14-41], respectively. There were no significant differences among the different specialties (Pediatrics was excluded from this comparison due to the small sample size) in any of the aforementioned questionnaire scores (all p>0.05). However, when comparing physicians who almost exclusively use OMM in their practice (defined as greater than 90% of the time, n=13) to physicians who use OMM less often (defined as 90% or less, n=19) there were significant differences in questionnaire responses. Specifically, there were significant differences between physicians who exclusively practice OMM compared to those who use OMM less often in OST1) “I am willing to prescribe opioids with support from a pain clinic” (1[1-4] vs. 3 [1-5], p=0.05), OST5) “I would likely prescribe opioids when other treatments are ineffective” (1[1-5] vs. 2 [1-4], p=0.04), and HC-PAIRS (56 [43-75] vs. 50 [34-67], p=0.02).

Conclusion: In conclusion, our hypothesis that osteopathic physicians who use OMM to treat their patients with LBP will have a unique perspective on the use of opioid drugs was supported by our findings in Osteopathic physicians who practice OMM for more than 90% of their practice.

In the HC-PAIRS survey, physicians who practice OMM >90% of their practice scored an average of 56 in comparison to physicians who practice OMM less often of their practice which scored an average of 50. This higher score in physicians who practice OMM >90% of their practice suggest greater adherence with the notion that LBP necessitates the avoidance of activities and justifies disability; however, while this 6-point difference was statistically significant, it may not constitute clinically meaningful differences between groups. [3]

Additionally, the difference in scores for questions OST1 and OST5 between physicians who used OMM in >90% of their practice and physicians whose practice was 90% OMM or less may indicate why patients with chronic LBP who are treated with OMM, by an osteopathic physician, have been shown to utilize less opiates than their non-OMM counterparts [4]. Further investigation is required to fully understand why the practice patterns of physicians who practice OMM result in significantly less opiate drug usage in this patient population.

References

1. American Osteopathic Association Guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. (2016). Journal of Osteopathic Medicine, 116(8), 536–549. https://doi.org/10.7556/jaoa.2016.107

2. Dal Farra, F., Risio, R. G., Vismara, L., & Bergna, A. (2021). Effectiveness of osteopathic interventions in chronic non-specific low back pain: A systematic review and meta-analysis. Complementary Therapies in Medicine, 56, 102616. https://doi.org/10.1016/j.ctim.2020.102616

3. Houben, R. M., Vlaeyen, J. W., Peters, M., Ostelo, R. W., Wolters, P. M., & Stomp-van den Berg, S. G. (2004). Health Care Providers’ attitudes and beliefs towards common low back pain: Factor structure and psychometric properties of the HC-pairs. The Clinical Journal of Pain, 20(1), 37–44. https://doi.org/10.1097/00002508-200401000-00008

4. Licciardone, J. C., & Gatchel, R. J. (2020). Osteopathic medical care with and without osteopathic manipulative treatment in patients with chronic low back pain: A pain registry–based study. Journal of Osteopathic Medicine, 120(2), 64–73. https://doi.org/10.7556/jaoa.2020.016

Financial Disclosures: None reported

Support: None reported

Ethical Approval: This study was reviewed and determine to be exempt by the Michigan State University Institutional Review Board.

IRB #: STUDY00005051

Informed Consent: Osteopathic physicians were contacted via email address that were accessed through online resources. If they were interested, a following online Qualtrics survey was emailed which prompted a consent statement prior to completion of the survey. Consent included a detailed explanation of the study, how participation is voluntary, and how participants may withdraw from the study at any time without consequence. The consent form also included the option as to whether the participant’s information could be used in future studies. Prior to participation all participants agreed to participate and were consented electronically.

Poster No. *C-18

Abstract No. 49

Category: Clinical

Research Topic: Osteopathic Philosophy

Postoperative Urinary Functional Outcomes in Patients’ with Simultaneous Prostatectomy and Mesh Hernia Repair VS Isolated Prostatectomy

¹Natalie Ohlde, OMS-III; ¹Lauryn Orsillo, OMS-III; ¹Kellie Gaura, OMS-IV; ¹Edie Sperling, DPT; ¹Johannie Spaan, PhD; ²Jeffrey Woolsey, MD

¹Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Oregon; ²Oregon Urology Institute

Statement of Significance: Prostatectomy is well researched in its safety and effectiveness for treatment of prostate cancer. Simultaneous prostatectomy and inguinal hernia repair has also been validated as a safe dual procedure. However, there has been little research on the long term urinary functional outcomes for simultaneous prostatectomy and inguinal hernia repair.

Research Methods: Patients treated at Oregon Urology Institute (OUI) completed the Expanded Prostate Index Composite (EPIC) questionnaire post prostatectomy at regular intervals. The survey assessed subjective functional outcomes and patients reported overall satisfaction of treatment outcomes in various domains, however, this study will be analyzing urinary functional outcomes exclusively. Patients were divided into two cohorts, isolated prostatectomy and simultaneous prostatectomy and inguinal hernia repair. Each cohort completed this survey at 6,9, and 12 months postoperatively. Results from each cohort were compared and analyzed using generalized linear model (GLM) with a Poisson distribution for count data and negative binomial distribution for over dispersed count data and a proportional odds logistical regression (POLR) model for ordinal data.

Data Analysis: Overall, there were 390 prostatectomy patients without hernia repair and 32 with hernia repair. However, sample sizes varied by each category due to the number of patient responses. Average age of patients undergoing a prostatectomy were 63.64 years old (range: 43 – 83). Inguinal hernia repair done at the same time as prostatectomy did not worsen postoperative urinary function at 6 months (P = 0.3408), 9 months (P = 0.3800), or 1 year (P = 0.4510), while accounting for age at surgery. Older patients at time of surgery are expected to have decreased urinary function (i.e., 1% for every month older) at either 6, or 12 months postoperative (6 months: P = 0.0379; 12 months: P = 0.0210), but not 9-months (P = 0.2280). Inguinal hernia repair done at the same time as prostatectomy did not worsen postoperative urinary function at 6 months (P = 0.9838), 9 months (P = 0.3319), or 1 year (P = 0.9502), while accounting for age at surgery. Age of patients at time of surgery were not associated with a change in urinary function at 6, 9, or 12 months (6 months P = 0.5024; 9 months P = 0.0855; 12 months P = 0.6648). Inguinal hernia repair done at the same time as prostatectomy did not worsen postoperative urinary function at 6, 9 or 12 months, while accounting for age at surgery (6 months: P = 0.4440; 9 months: P = 0.9060; 12 months: P = 0.5413). Older patients were associated with an approximately 8% higher odds of causing worsening urinary function at 6 months post-surgery (P = 0.0275), but not at 9 and 12 months post-surgery (9 months: P = 0.2109; 12 months: P = 0.9146).There was no significant improvement in prostatectomy patients’ degree of continence at 12 months post-surgery with or without inguinal hernia repair (P = 0.9443).Older patients were associated with an approximately 7% lower odds of improved degree of continence at 12 months post-surgery (P = 0.0145).

Results: Overall, there were 390 prostatectomy patients without hernia repair and 32 with hernia repair. However, sample sizes varied by each category due to the number of patient responses. Average age of patients undergoing a prostatectomy were 63.64 years old (range: 43 – 83). Inguinal hernia repair done at the same time as prostatectomy did not worsen postoperative urinary function at 6 months (P = 0.3408), 9 months (P = 0.3800), or 1 year (P = 0.4510), while accounting for age at surgery. Older patients at time of surgery are expected to have decreased urinary function (i.e., 1% for every month older) at either 6, or 12 months postoperative (6 months: P = 0.0379; 12 months: P = 0.0210), but not 9-months (P = 0.2280). Inguinal hernia repair done at the same time as prostatectomy did not worsen postoperative urinary function at 6 months (P = 0.9838), 9 months (P = 0.3319), or 1 year (P = 0.9502), while accounting for age at surgery. Age of patients at time of surgery were not associated with a change in urinary function at 6, 9, or 12 months (6 months P = 0.5024; 9 months P = 0.0855; 12 months P = 0.6648). Inguinal hernia repair done at the same time as prostatectomy did not worsen postoperative urinary function at 6, 9 or 12 months, while accounting for age at surgery (6 months: P = 0.4440; 9 months: P = 0.9060; 12 months: P = 0.5413). Older patients were associated with an approximately 8% higher odds of causing worsening urinary function at 6 months post-surgery (P = 0.0275), but not at 9 and 12 months post-surgery (9 months: P = 0.2109; 12 months: P = 0.9146).There was no significant improvement in prostatectomy patients’ degree of continence at 12 months post-surgery with or without inguinal hernia repair (P = 0.9443).Older patients were associated with an approximately 7% lower odds of improved degree of continence at 12 months post-surgery (P = 0.0145).

Conclusion: Prostatectomy with simultaneous inguinal hernia repair did not cause decreased urinary functional outcomes in comparison to prostatectomy alone. There was a statistically significant decrease in urinary functional outcomes postoperatively related to increased age.

Financial Disclosures: None reported

Support: None reported

Ethical Approval: Reviewed and Approved. IRB: 1859478-1

Informed Consent: N/A

Poster No. C-19

Abstract No. 15

Category: Clinical

Research Topic: Health Disparities-Social Determinants of Health

The effects of positive preoperative SARS-CoV-2 testing on outpatient procedures at a community hospital

¹Lucas Lloyd, DO; ²Anthony Santarelli, PhD; ²Diana Lalitsasivimol, PhD; ³Rozalyna Gritten, OMS-IV; ⁴Donald Morgan, DO; ⁵John Ashurst, DO

¹Kingman Regional Medical Center; ²Department of Research, Institution: Kingman Regional Medical Center; ³Pacific Northwest University of Health Sciences College of Osteopathic Medicine; ⁴Department of Family Medicine, Kingman Regional Medical Center; ⁵Department of Emergency Medicine, Institution: Kingman Regional Medical Center

Statement of Significance: The screening for clinical and epidemiological risk factors has been a staple of the preoperative process to minimize surgical morbidity and mortality for decades. With the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, healthcare providers had to rapidly change how patients were not only screened in the preoperative period but also triage those in need of surgical procedures to minimize risk to both patient and the healthcare team.

Research Methods: A retrospective cohort of all patients undergoing SARS-CoV-2 testing at Kingman Regional Medical Center between April 01, 2020 and February 31, 2022 was completed. Patients were included in final analysis if the patient underwent SARS-CoV-2 testing as part of an outpatient preoperative process. Excluded patients included those who received SARS-CoV-2 testing prior to an in-patient procedure or prior to being admitted to the obstetrics service for delivery. Abstracted data included: patient demographics, SARS-CoV-2 results, date of SARS-CoV-2 results, surgical procedure cancelled, ordering department, and reschedule date for the same surgical procedure that was cancelled. Continuous data is presented as the median and interquartile range and categorical data is presented as frequencies with percentages of the sample.

Data Analysis: A total of 184 patients had a positive SARS-CoV-2 PCR test prior a procedure during the time period studied. The median age of those with a positive test was 61.0 (38.3 – 69.0) years, with 37.0% (68/184) being female, and 51.6% (95/184) procedures being labeled as diagnostic in nature. In total, 55.8% (53/95) diagnostic procedures and 61.8% (55/89) interventional procedures were delayed while 32.6% (31/95) diagnostic procedures and 14.6% (13/89) interventional procedures were cancelled due to COVID-19 testing. Diagnostic procedures were more likely to be cancelled without rescheduling as compared to interventional procedures (p = 0.004). The delay to completion of diagnostic (35.0 [21.0 – 56.0] days) and interventional (30.0 [21.0 – 51.0] days) procedures which were postponed did not differ (p = 0.968). The most common specialty affected by postponement was gastroenterology (31.5%, 34/108) followed by orthopedics (21.3%, 23/108). The most common specialty affected by cancellations was gastroenterology (56.8%, 25/44) followed by obstetrics and gynecology (11.4%, 5/44).

Results: A total of 184 patients had a positive SARS-CoV-2 PCR test prior a procedure during the time period studied. The median age of those with a positive test was 61.0 (38.3 – 69.0) years, with 37.0% (68/184) being female, and 51.6% (95/184) procedures being labeled as diagnostic in nature. In total, 55.8% (53/95) diagnostic procedures and 61.8% (55/89) interventional procedures were delayed while 32.6% (31/95) diagnostic procedures and 14.6% (13/89) interventional procedures were cancelled due to COVID-19 testing. Diagnostic procedures were more likely to be cancelled without rescheduling as compared to interventional procedures (p = 0.004). The delay to completion of diagnostic (35.0 [21.0 – 56.0] days) and interventional (30.0 [21.0 – 51.0] days) procedures which were postponed did not differ (p = 0.968). The most common specialty affected by postponement was gastroenterology (31.5%, 34/108) followed by orthopedics (21.3%, 23/108). The most common specialty affected by cancellations was gastroenterology (56.8%, 25/44) followed by obstetrics and gynecology (11.4%, 5/44).

Conclusion: Following a positive preoperative SARS-CoV-2 test, the majority of procedures were rescheduled to be completed at a later date. However, a large number of procedures were cancelled and not rescheduled during the time frame studied. This was especially true for procedures labeled as diagnostic in nature.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: The study was reviewed by the Kingman Healthcare Inc IRB and approved. The IRB number for the project was KHI-0273.

Informed Consent: NA

Poster No. *C-20

Abstract No. 46

Category: Clinical

Research Topic: Impact of OMM & OMT

The Use of Osteopathic Manipulative Treatment (OMT) in the Management of Patients With Post-COVID Symptoms

¹Violeta Foss, OMS-III; ²Jashandeep Kaur, OMS-III; ²Georgianna Stoukides, OMS-III; ²Sheldon C. Yao, DO, FAAO

¹New York Institute of Technology (NYITCOM); ²Department of Osteopathic Manipulative Medicine

Statement of Significance: Patients continue to face the reality of chronic multisystem post-COVID symptoms even weeks after the resolution of acute illness (1,2). Since COVID-19 impacts body tissues similarly to other viral illnesses, OMT may be a powerful tool to optimize symptom management (3,4). Identifying the most effective OMT approaches and target areas for treatment through the perspective of osteopathic physicians can help determine the best ways OMT can be utilized in post-COVID care to improve outcomes.

Research Methods: This project was approved by the NYIT IRB on January 25, 2022, BHS-1719. NYITCOM OMM department faculty and adjunct faculty were sent an email invitation with a REDcap survey link. The survey collected information on osteopathic physician demographics and experiences treating patients with post-COVID symptoms in specific organ systems, including the musculoskeletal, pulmonary, cardiovascular, genitourinary, neurological, and gastrointestinal systems. Additionally, there were questions regarding OMT modality used, body regions treated, number of manipulation sessions, and perceived efficacy. Participants were given one week to complete the survey; to follow up, three weekly reminders were sent via email. A participant was considered a non-responder if they did not complete the survey after three email reminders. Those physicians who responded to the survey (N=18) answered the questions based on any and all patients for whom they provided OMT for the management of post-COVID symptoms. Statistical analysis of the data was performed to assess the use of OMT in the management of post-COVID symptoms.

Data Analysis: A total of 18 osteopathic physicians responded to the survey and 77.8% (14/18) reported seeing patients presenting with post-COVID symptoms and providing OMT accordingly. Of the responders who utilized OMT, 92.9% (13/14) addressed pulmonary complaints, predominantly dyspnea and cough; 92.9% (13/14) addressed musculoskeletal complaints, predominantly muscle fatigue and pain; 85.7% (12/14) addressed neurological complaints, predominantly headache, anosmia, and sleep disturbance. 42.9% (6/14) treated cardiovascular complaints, predominantly palpitations and chest wall pain; 14.3% (2/14) addressed gastrointestinal complaints, including diarrhea, acid reflux, nausea, and abdominal pain; 7.14% (1/14) addressed genitourinary complaints, including dysuria and pelvic pain; 21.4% (3/14) treated patients presenting with miscellaneous complaints, including otorhinolaryngological, rheumatological, and psychobehavioral symptoms. Across all systems listed in the survey, the 14 physicians who incorporated OMT into the management of post-COVID patients reported a total of 51 clinical presentations encountered. The most frequently utilized technique was reported to be Balanced ligamentous tension (utilized by providers in 90.2% (46/51) of the various clinical presentations), followed by Osteopathic Cranial Manipulative technique (utilized in 88.2% (45/51) of the presentations). The least frequently reported techniques were Chapman Point Release (utilized in 7.84% (4/51) of the presentations), Still technique (utilized in 11.8% (6/51) of the presentations), Counterstrain (utilized in 19.6% (10/51) of the presentations), and Muscle Energy Technique (utilized in 19.6% (10/51) of the presentations). Furthermore, the application of OMT in post-COVID cases was deemed ‘extremely effective’ in 35.3% (18/51), ‘very effective’ in 43.1% (22/51), and ‘somewhat effective’ in 15.7% (8/51) of the presentations. None of the providers rated OMT as ‘slightly effective’ or ‘not effective at all.’

Results: A total of 18 osteopathic physicians responded to the survey and 77.8% (14/18) reported seeing patients presenting with post-COVID symptoms and providing OMT accordingly. Of the responders who utilized OMT, 92.9% (13/14) addressed pulmonary complaints, predominantly dyspnea and cough; 92.9% (13/14) addressed musculoskeletal complaints, predominantly muscle fatigue and pain; 85.7% (12/14) addressed neurological complaints, predominantly headache, anosmia, and sleep disturbance. 42.9% (6/14) treated cardiovascular complaints, predominantly palpitations and chest wall pain; 14.3% (2/14) addressed gastrointestinal complaints, including diarrhea, acid reflux, nausea, and abdominal pain; 7.14% (1/14) addressed genitourinary complaints, including dysuria and pelvic pain; 21.4% (3/14) treated patients presenting with miscellaneous complaints, including otorhinolaryngological, rheumatological, and psychobehavioral symptoms. Across all systems listed in the survey, the 14 physicians who incorporated OMT into the management of post-COVID patients reported a total of 51 clinical presentations encountered. The most frequently utilized technique was reported to be Balanced ligamentous tension (utilized by providers in 90.2% (46/51) of the various clinical presentations), followed by Osteopathic Cranial Manipulative technique (utilized in 88.2% (45/51) of the presentations). The least frequently reported techniques were Chapman Point Release (utilized in 7.84% (4/51) of the presentations), Still technique (utilized in 11.8% (6/51) of the presentations), Counterstrain (utilized in 19.6% (10/51) of the presentations), and Muscle Energy Technique (utilized in 19.6% (10/51) of the presentations). Furthermore, the application of OMT in post-COVID cases was deemed ‘extremely effective’ in 35.3% (18/51), ‘very effective’ in 43.1% (22/51), and ‘somewhat effective’ in 15.7% (8/51) of the presentations. None of the providers rated OMT as ‘slightly effective’ or ‘not effective at all.’

Conclusion: While post-COVID patients presented with various symptoms, the pulmonary, musculoskeletal, and neurological systems were most commonly involved. Overall, Balanced ligamentous tension and Cranial OMT was reported by respondents to be more beneficial than Chapman Point Release, Still technique, Counterstrain, and Muscle Energy Technique. At least one-third of the osteopathic physicians who utilized OMT were able to effectively address multisystem post-COVID symptoms experienced by their patients. These promising findings can help guide future research and potentially build larger-scale prospective studies concerning the role of OMT in post-COVID management. Some of the limitations of this study include the retrospective data collection, which may lead to recall bias. Other limitations are the small sample size and possible selection bias, as only NYITCOM faculty members and affiliates were surveyed. In order to make more reliable conclusions about the effectiveness of OMT in post-COVID patients, the goal is to distribute the survey to include OMM department faculty of all Osteopathic Medical Schools in the United States. Learning more about COVID-19 and its pathophysiology, osteopathic physicians can utilize diverse training and knowledge to address persistent symptoms. By sharing their experiences of using OMT to treat the sequelae of this novel illness and improve function, providers can help alleviate the burden of disease for their patients.

References

1. Al-Aly Z, Bowe B, Xie Y. Long COVID after breakthrough SARS-CoV-2 infection [published online ahead of print, 2022 May 25]. Nat Med. 2022;10.1038/s41591-022-01840-0. doi:10.1038/s41591-022-01840-0 Long Covid or post-covid conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html. Accessed July 9, 2022.

2. Marin T, Maxel X, Robin A, Stubbe L. Evidence-based assessment of potential therapeutic effects of adjunct osteopathic medicine for multidisciplinary care of acute and convalescent COVID-19 patients. Explore (NY). 2021;17(2):141-147. doi:10.1016/j.explore.2020.09.006

3. Alschuler L, Chiasson AM, Horwitz R, et al. Integrative medicine considerations for convalescence from mild-to-moderate COVID-19 disease. Explore (NY). 2022;18(2):140-148. doi:10.1016/j.explore.2020.12.005

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This study was approved by the New York Institute of Technology InstitutionalReview Board under Protocol BHS-1719.

Informed Consent: Participants have been made aware that participating in the study and completing the survey is completely voluntary. Consent is implied by completion of the survey.

Poster No. *C-21

Abstract No. 45

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Prescribing Patterns for Cystitis in Women with an Allergy to Guideline Recommended Antimicrobials

¹Darcy Alexis Davis, OMS-III; ²Amber Stroupe, DO, FAAP, FACOP, FACP; ³Jaime Foushee, PharmD, BCPS, BCCCP; ⁴Shannon Smith, DO; ²Samantha Rikabi, OMS-III

¹Edward Via College of Osteopathic Medicine -South Carolina; ²Department of Internal Medicine Edward Via College of Osteopathic Medicine-South Carolina; ³Department of Medical Education Edward Via College of Osteopathic Medicine-South Carolina; ⁴Spartanburg Regional Healthcare System

Statement of Significance: Uncomplicated cystitis is a frequent infection seen in women. The 2010 Infectious Disease Society of America (IDSA) guidelines recommending antimicrobials for treatment when not contraindicated due to patient factors such as antimicrobial allergies. The presence of antimicrobial allergies may lead to the use of less preferred agents for treating the infection.

Research Methods: The study was approved by Spartanburg Regional Healthcare System (SRHS) Institutional Review Board (1711429-1). An electronic medical record was used to identify female patients between the ages of 18-50 with the diagnosis of acute uncomplicated cystitis at outpatient visits between December 1, 2017 through December 31, 2021 within SRHS Family Medicine Residency Clinic using ICD-10 codes N30.0 (acute cystitis without hematuria), N39.0 (urinary tract infections), and R30.0 (dysuria). Patients with complicated urinary tract infections or pyelonephritis were excluded. After identification of eligible subjects, a retrospective chart review was used to collect demographic information, known antimicrobial allergies, urinalysis and culture information, and prescribed antimicrobial agent. The primary outcome was receipt of a guideline-recommended antimicrobial. Secondary outcomes included prevalence of antimicrobial allergies, and a priori defined subgroup analyses of patients with allergies to preferred antimicrobial agents. The data was analyzed by a biostatistician using the individual as the unit of observation. Nominal data was analyzed using Chi-Squared or Fisher’s Exact tests. Continuous data was analyzed using t-test, analysis of variance, or Wilcoxon rank-sum tests. This study sought to evaluate prescribing practices for premenopausal women in the treatment of UTI. Prescription medications are included as a health service for patients and reflect quality of care and health outcomes.

Data Analysis: A total of 496 patient encounters were screened for inclusion, with 183 meeting inclusion criteria. Of those, 40 were identified as having a documented antimicrobial allergy. Demographic and clinical characteristics were similar between patients with and without antimicrobial allergies, except for age. Antimicrobial allergies were noted in 40 patients, most frequently to beta-lactams (60%), followed by TMP-SMX (22%), nitrofurantoin (12%), and fluoroquinolones (5%). Patients without an antimicrobial allergy were significantly more likely to receive a guideline-recommended therapy (140 of 143 patients; 98%) compared to those with an allergy (33 of 40 patients; 82%) to a guideline recommended antimicrobial agent (p=0.001). No difference in secondary outcomes was observed.

Results: A total of 496 patient encounters were screened for inclusion, with 183 meeting inclusion criteria. Of those, 40 were identified as having a documented antimicrobial allergy. Demographic and clinical characteristics were similar between patients with and without antimicrobial allergies, except for age. Antimicrobial allergies were noted in 40 patients, most frequently to beta-lactams (60%), followed by TMP-SMX (22%), nitrofurantoin (12%), and fluoroquinolones (5%). Patients without an antimicrobial allergy were significantly more likely to receive a guideline-recommended therapy (140 of 143 patients; 98%) compared to those with an allergy (33 of 40 patients; 82%) to a guideline recommended antimicrobial agent (p=0.001). No difference in secondary outcomes was observed.

Conclusion: Patients with an antimicrobial allergy were less likely to receive guideline recommended antimicrobial for the treatment of acute uncomplicated cystitis. No statistical difference was seen in the secondary outcome analyses, likely due to a small sample size for these subgroup analyses. Study limitations include use of retrospective electronic documentation for data, strict inclusion/exclusion criteria potentially limiting external validity of data, and the inability to capture outside patient factors that may have influenced prescribing other than the presence of antimicrobial allergy. Future implications include the development of a quality improvement project to assess the impact of an educational initiative on antimicrobial prescribing in this population.

References

1. Finn SD. Acute uncomplicated urinary tract infection in women. N Engl J Med. 2003;349:259-66.

2. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Rax R, Schaeffer AJ, Soper DE. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the infectious disease society of America and the European society for microbiology and infectious disease. Clinical Infectious Diseases. 2011;52(5):e103-e120.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Study approved by Spartanburg Regional Healthcare System Institutional Review Board (1711429-1).

Informed Consent: Informed consent will not be obtained from subjects in place of adequate protections to data confidentially. The burden would be intolerable if subjects had to be re-contacted for consent for use of their records.

Poster No. *C-22

Abstract No. 118

Category: Clinical

Research Topic: Health Disparities-Social Determinants of Health

Disparities Between Demographics in Pediatric Prescriptions and Diagnoses in Latin America

¹Dakota Becker-Greene, OMS-II; ¹Alyssa DeMutis, OMS-III; ¹Mandy Stallard, OMS-III; ²Cameron Sumpter; ²Harold R. Garner, PhD; ³Mayra Rodriguez, PhD, MPH

¹Edward Via College of Osteopathic Medicine; ²Department of Research, Edward Via College of Osteopathic Medicine; ³Department of Preventive Medicine, Edward Via College of Osteopathic Medicine-Alabama

Statement of Significance: Short-term medical service trips (MSTs) are ubiquitous among U.S. medical schools, with trips typically ranging from 7-14 days in duration with the goal of addressing the unmet healthcare needs of developing countries. While these programs garner around $250 million in funding annually, little research has been conducted to analyze the types of care provided by MSTs and to examine their overall impact on community health within the pediatric populations of the countries they serve (1).

Research Methods: This study utilized a retrospective chart review approach to study the pediatric population at the Edward Via College of Osteopathic Medicine international outreach sites in the Dominican Republic, El Salvador, and Honduras. All encounters at these sites were documented in the International Classification of Diseases (ICD) Logger, called CREDO (Clinical Rotation Evaluation and Documentation Organizer). Analysis of these encounters was conducted to illuminate the most effective practices for providing patient centered care in underserved, pediatric populations.

A total of 51,788 patient encounters occurring between 01/2019 and 06/2022 were analyzed from the CREDO system of patients younger than 18 years old at the time of visit to one of the five clinics. Main independent variables assessed were gender and age. Groups based on age at the time of encounter were established in conjunction with the International Congress on Harmonization (ICH) E11 to create 4 groups; 11 years old (2,3). Other independent variables collected for each encounter through the CREDO system included patient gender, nationality, date of birth, date of encounter, diagnoses, prescriptions, and clinic country. Dependent variables assessed were diagnoses and prescriptions. All encounters were grouped according to the country of the clinic, including the Dominican Republic, Honduras, or El Salvador.

The encounter data was evaluated using descriptive statistics to determine the mean, median, and standard deviation for all continuous variables. These variables were visualized through histograms to establish normality. For analysis, two-tailed Pearson Correlation, chi-square test, and two-tailed Student’s t-tests were conducted. A p-value of <0.05 was considered significant and all analyses were performed using SPSS IBM software.

Data Analysis: Demographic data showed that 49.8% (n=25,780) of the patients identified as male and 50.2% (n=26,008) as female with Dominican (n=24,884, 48.0%) and Haitian (n=13,673, 26.4%) making up the most frequently reported ethnicities. The average age of patients at time of encounter was 4.69 years old (SD=4.60) with a reported 1.14 average number of diagnoses (SD=0.49) and 1.02 mean number of prescriptions (SD=1.01). Age was weakly inversely correlated with the number of diagnoses (r(51,786)=-0.025, p11 years old (n=6,369, 12.2%). In all groups, there was no significant association between the number of diagnoses and gender. Furthermore, no association was found between gender and the number of prescriptions in 11 years old (M=14.45, SD=2.10), 38.9% reported as male and 61.1% reported as female, t-test analysis showed that there was a significant difference between gender and the number of prescriptions (t(6,367)=6.90, p<0.001).

Finally, all encounters were stratified in accordance with the country of the clinic site: Dominican Republic (n=39,438, 76.1%), Honduras (n=2,770, 5.3%), and El Salvador (n=8,039, 15.5%). The number of diagnoses was found to be independent of gender in all countries. Additionally, the number of prescriptions was independent of gender in the Dominican Republic and Honduras; however, t-test analysis demonstrated a significant association of the number of prescriptions and gender (t(8,037)=5.55, p<0.001) in El Salvador with male patients receiving 1.26 (SD=1.01) prescriptions on average compared to females receiving 1.13 prescriptions (SD=1.00).

Results: Demographic data showed that 49.8% (n=25,780) of the patients identified as male and 50.2% (n=26,008) as female with Dominican (n=24,884, 48.0%) and Haitian (n=13,673, 26.4%) making up the most frequently reported ethnicities. The average age of patients at time of encounter was 4.69 years old (SD=4.60) with a reported 1.14 average number of diagnoses (SD=0.49) and 1.02 mean number of prescriptions (SD=1.01). Age was weakly inversely correlated with the number of diagnoses (r(51,786)=-0.025, p11 years old (n=6,369, 12.2%). In all groups, there was no significant association between the number of diagnoses and gender. Furthermore, no association was found between gender and the number of prescriptions in 11 years old (M=14.45, SD=2.10), 38.9% reported as male and 61.1% reported as female, t-test analysis showed that there was a significant difference between gender and the number of prescriptions (t(6,367)=6.90, p<0.001).

Finally, all encounters were stratified in accordance with the country of the clinic site: Dominican Republic (n=39,438, 76.1%), Honduras (n=2,770, 5.3%), and El Salvador (n=8,039, 15.5%). The number of diagnoses was found to be independent of gender in all countries. Additionally, the number of prescriptions was independent of gender in the Dominican Republic and Honduras; however, t-test analysis demonstrated a significant association of the number of prescriptions and gender (t(8,037)=5.55, p<0.001) in El Salvador with male patients receiving 1.26 (SD=1.01) prescriptions on average compared to females receiving 1.13 prescriptions (SD=1.00).

Conclusion: These results demonstrate that adolescent males were more likely to receive a greater number of prescriptions compared to females, which highlights the gender disparities in the pediatric medical care provided by MSTs. Previous studies have also demonstrated how gender disparities are prevalent in the medical care of pediatric populations. Results from a paper in the American Journal of Psychiatry showed that adolescent males are diagnosed with a greater number of mental health disorders compared to females, leading to higher rates of adult crime (4). Potential limitations of this study include uneven sample size from each country and their respective clinics. Additionally, few studies have been conducted on this topic to date.

Further evaluation is needed to adequately address the underlying cause of these disparities. Data could be further analyzed to determine the type of prescriptions and diagnoses pediatric patients are most likely to receive within each age group, and to determine how these vary by geographic location and/or gender. Disparities may exist due to a lack of cultural awareness and prior expectations held by biomedical professionals traveling internationally. Physicians may have presumptions as to what conditions they will encounter on MSTs, influencing the treatment plans for future patients. Future studies can investigate if patients were receiving adequate care for their diagnoses or if there were confounding variables for treatment, such as lack of resources within rural clinics. Specifically, the inverse correlation between diagnoses and prescriptions should be further investigated. The tenets of osteopathy state that the body is capable of self regulation, yet these results indicate that prescription medications may be over prescribed in pediatric-specific populations, interfering with this capability.

References

1. Maki J, Qualls M, White B, Kleefield S, Crone R. Health impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Serv Res. 2008;8:121. Published 2008 Jun 2. doi:10.1186/1472-6963-8-1212

2. Williams K, Thomson D, Seto I, et al. Standard 6: age groups for pediatric trials. Pediatrics. 2012;129 Suppl 3:S153-S160. doi:10.1542/peds.2012-0055I3

3. Job KM, Gamalo M, Ward RM. Pediatric Age Groups and Approach to Studies. Ther Innov Regul Sci. 2019;53(5):584-589. doi:10.1177/21684790198565724

4. Copeland WE, Miller-Johnson S, Keeler G, Angold A, Costello EJ. Childhood psychiatric disorders and young adult crime: A prospective, population-based study. American Journal of Psychiatry. 2007;164(11):1668-1675. doi:10.1176/appi.ajp.2007.06122026

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Project approved under [1821431-2] Clinical Rotation Evaluation and Documentation Organizer - Electronic Clinical Records (CREDO ECR) through the Edward Via College of Osteopathic Medicine (VCOM) Institutional Review Board (IRB). This IRB was approved on November 8th, 2021 (record number 2021-028) and was deemed exempt under category 4 of the review process and approved with an end date of November 7th, 2023.

Informed Consent: No informed consent was needed as this is a retrospective study utilizing de-identified information.

Poster No. *C-23

Abstract No. 43

Category: Clinical

Research Topic: Chronic Diseases & Conditions

The Analysis of Dietary Recalls for Students Enrolled In An Interdisciplinary Culinary Medicine Elective To Enhance Personal Health, Knowledge, and Confidence With Counseling On Nutrition

¹Christopher Cacciatore, OMS-III; ¹Jessica Barkhouse, BS, OMS III; ¹Kathryn Wirth, BENG, OMS III; ¹Jonathan Bishop, BS, OMS III; ¹Nancy Nguyen, MS, OMS III; ¹Kristyn Kraus, BS, OMS IV; ¹Katie Wolter, MD; ¹Heidi VanderVelde, DO; ¹Gary Mount, PharmD; ²Joy DeBellis, DNP, RN; ²Chih-hsuan Wang, PhD; ³Annie Kirby, PhD, RD

¹Edward Via College of Osteopathic Medicine-Auburn; ²Auburn Univerity College of Nursing; ³Preventive Medicine and Public Health, Edward Via College of Osteopathic Medicine-Auburn

Statement of Significance: Non-communicable diseases (NCD) contribute to the majority of deaths despite being preventable and treatable. Practitioners must provide evidence-based lifestyle recommendations to patients, and apply this knowledge in their own lives. By training practitioners in nutrition counseling, the health outcomes of practitioners and patients may improve. Despite the potential benefits, the nutrition curriculum continues to be underdeveloped. Culinary medicine (CM) aims to bridge this curricular gap.

Research Methods: Nurse practitioner and medical students (n=11) were recruited via email to enroll in a 6-module CM elective/independent study course. For inclusion, students must have been currently enrolled as an OMS1 or OMS2 student or a first year Master of Nursing Family Nurse Practitioner student. They also had to be within good academic standing (minimum GPA of 3.2). Students participated in each module by reviewing material and videos that prepared them to engage in hands-on culinary activities with case-based discussion. Each module related didactic material with nutritional guidance for common NCD in the Appalachian and Delta regions. Students completed two 24-hour dietary recalls (on non-consecutive days) via the Automated Self-Administered 24-hour Assessment Tool (ASA24®) prior to the course and after completing the course to determine changes in personal dietary habits. Primary outcomes included the students’ intake of protein, total fat, carbohydrates, fiber, potassium, sodium, saturated fat, and total calories. Paired t-tests were conducted to determine pre and post changes across outcome measures. All data was analyzed in Microsoft® Excel® for Microsoft 365 MSO.

Data Analysis: When compared to the Dietary Guidelines for Americans, at baseline participants’ carbohydrate, fiber, and potassium intake were below the recommended values. Although across the study, six students increased their carbohydrate intake, three students increased their fiber intake, and four students increased their potassium intake in order to meet the daily requirements. In contrast, the average trans fats, saturated fats, and sodium intake were above the recommended values. Across the study, six students lowered their trans fat intake, seven students lowered their saturated fat intake, and six students lowered their sodium intake to meet the daily requirements. The only variable that met the USDA recommendation was the protein intake which averaged 375 kcals. At follow-up, a decrease in caloric intake from 2344 kcal/day to 1981 kcal/day was observed. Despite these shifts, no statistically significant differences were noted between baseline and follow-up for any variables.

Results: When compared to the Dietary Guidelines for Americans, at baseline participants’ carbohydrate, fiber, and potassium intake were below the recommended values. Although across the study, six students increased their carbohydrate intake, three students increased their fiber intake, and four students increased their potassium intake in order to meet the daily requirements. In contrast, the average trans fats, saturated fats, and sodium intake were above the recommended values. Across the study, six students lowered their trans fat intake, seven students lowered their saturated fat intake, and six students lowered their sodium intake to meet the daily requirements. The only variable that met the USDA recommendation was the protein intake which averaged 375 kcals. At follow-up, a decrease in caloric intake from 2344 kcal/day to 1981 kcal/day was observed. Despite these shifts, no statistically significant differences were noted between baseline and follow-up for any variables.

Conclusion: Results from this pilot project indicate some positive shifts in the intake of sodium, carbohydrates, fat, protein, and calories, which may be attributed to their increased awareness of dietary choices after the conclusion of the course. However, there were also negative shifts in some variables, like fiber. Due to the small sample size of this pilot project, the results, while encouraging, should be taken with caution. Additionally, the time commitment to complete the ASA24® alongside academic and personal schedules may have played a role in these findings. With this knowledge, alternative survey methods can be explored in order to improve data collection in future cohorts. Additionally, as this course continues and the sample size increases, the statistical power will increase and can be used to compare changes against peers who did not participate in the course. The long term aim of this course is that through the self-application of nutritional education, students will become more inclined and equipped to provide high quality nutritional counseling when delivering patient-centered holistic care.

Financial Disclosures: None reported

Support: Research Eureka Accelerator Program; VCOM Seed Grant

Ethical Approval: IRB Approved, IRB #21-396 EX 2108

Informed Consent: N/A

Poster No. *C-24

Abstract No. 83

Category: Clinical

Research Topic: Impact of OMM & OMT

Inter- and Intra-Observer Reproducibility of Student Researchers in Performing Shear Wave Elastography of the Lower Trapezius Muscle

¹Tanner Roberts, OMS-III; ¹Hunter Bell, OMS-III; ¹Jessica Kitsen, OMS-III; ¹Tammy Zamaitis, OMS-III; ¹McKenzie Frye, OMS-III; ²Jing Gao, MD, FAIUM

¹Rocky Vista University College of Osteopathic Medicine-Southern Utah; ²Office of Research and Scholarly Activity, Rocky Vista University College of Osteopathic Medicine-Southern Utah

Statement of Significance: Ultrasound shear wave elastography of muscle has been adopted in quantifying tissue mechanical properties in osteopathic medicine.1,2 The efficacy of Osteopathic Manipulative Treatment (OMT) on muscular somatic dysfunction may be evaluated by quantifying the change in muscle stiffness following OMT.1 Inter- and intra-operator reliability plays an important role in generating reproducible and reliable data for future muscular and osteopathic research using shear wave elastography (SWE).

Research Methods: The Institutional Review Board of Rocky Vista University approved the study (IRB#2019-0088). All participants provided written informed consent at the enrollment. Two student researchers individually measured shear wave velocity of the lower trapezius bilaterally in a convenience sample of 10 participants (5 men and 5 women, mean age 26y, mean BMI 25 kg/cm2) during August 2021. Inclusion criteria for participant enrollment were age > 18 years old, medically stable, ability to sign written informed consent, and able to tolerate the ultrasound scan. Using an Acuson Sequoia ultrasound scanner, muscle SWE for each participant was measured lying prone by placing the linear array (10L4, bandwidth 4-10 MHz, Siemens Healthineers) transducer lateral from T7 spinous vertebrae in the lower trapezius muscle’s longitudinal plane. The scans were performed in B-mode and SWE using the manufacturer-recommended settings for the musculoskeletal exam with the transducer frequency set to 8 MHz. The participants were then instructed to place their ipsilateral arm out at 90 degrees on support to ensure a relaxed muscle, then exhale and hold their breath before the measurement was taken for consistency. SWE images were produced by acoustic radiation force impulse (ARFI) software called Virtual Touch IQ (VTIQ) installed on the Acuson Sequoia machine. Quality maps were also taken using VTIQ to ensure high-quality SWV estimations. Shear wave velocity (SWV, m/s) for each lower trapezius muscle was scanned twice by each student researcher bilaterally. Eight SWV values were measured by circular region of interest (0.3 cm in diameter) using point SWE on each SWE image. The measurements were evaluated for inter- and intra- reliability by using intraclass correlation coefficient (ICC).

Data Analysis: All 10 participants (5 men and 5 women, mean age 26y, mean BMI 25 kg/cm2) who began the study completed the SWE measurements taken by both student researchers. The inter-operator reliability was calculated using the ICC and demonstrated significant agreement (ICC 0.953; 95% CI: 0.881-0.981). The intra-operator reliability value for operator 1 was an ICC of 0.932 (95% CI: 0.829-0.973) and the intra-operator reliability for operator 2 was an ICC of 0.901 (95% CI: 0.751-0.961). These intra-rater reliability values showed excellent consistency of measured and subsequently re-measured values for each individual operator.

Results: All 10 participants (5 men and 5 women, mean age 26y, mean BMI 25 kg/cm2) who began the study completed the SWE measurements taken by both student researchers. The inter-operator reliability was calculated using the ICC and demonstrated significant agreement (ICC 0.953; 95% CI: 0.881-0.981). The intra-operator reliability value for operator 1 was an ICC of 0.932 (95% CI: 0.829-0.973) and the intra-operator reliability for operator 2 was an ICC of 0.901 (95% CI: 0.751-0.961). These intra-rater reliability values showed excellent consistency of measured and subsequently re-measured values for each individual operator.

Conclusion: Students who receive training on the operation of shear wave elastography may effectively collect shear wave velocity data of the lower trapezius for evaluating muscle stiffness. Good inter- and intra-observer reliability in data collection by trained student researchers can contribute to high confidence for conducting future studies involving OMT and ultrasound shear wave elastography.

References

1. Gao J, Caldwell J, McLin K, Zhang M, Park D. Ultrasound Shear Wave Elastography to Assess Osteopathic Manipulative Treatment on the Iliocostalis Lumborum Muscle: A Feasibility Study. J Ultrasound Med. 2020;39(1):157-164. doi:10.1002/jum.15092

2. Dieterich AV, Andrade RJ, Le Sant G, et al. Shear wave elastography reveals different degrees of passive and active stiffness of the neck extensor muscles. Eur J Appl Physiol. 2017;117(1):171-178. doi:10.1007/s00421-016-3509-5

Financial Disclosures: None reported

Support: Dr. Jing Gao received equipment to support this study. The authors thank Siemens Healthineers for loaning an ultrasound scanner to support the study.

Ethical Approval: Prior to any research being performed, a Full Review was performed and approved by Rocky Vista Institutional Review Board. IRB#2019-0088

Informed Consent: Written informed consent was obtained via signature after explaining risks and benefits.

Poster No. *C-25

Abstract No. 95

Category: Clinical

Research Topic: Impact of OMM & OMT

AOA Grant Award: #2005803

Preliminary Results from a Randomized Controlled Trial on the Efficacy of Osteopathic Manipulative Medicine in Recovery from Concussions

¹Austin Blake Benedict, OMS-II; ²Chase Torretta, OMS-II; ²Jacek Cholewicki, PhD; ²Lisa DeStefano, DO; ³Nathan Fitton, DO; ⁴Mathew Saffarian, DO; ²John Popovich Jr., PhD, DPT, ATC; ²Matthew Zatkin, DO; ²Angela Lee, MPH; ⁵Alla Sikorskii, PhD; ⁶Lauren Leslie, DO; ²Zachary Shiver, DO

¹Michigan State University College of Osteopathic Medicine; ²Department of Osteopathic Manipulative Medicine, Michigan State University College of Osteopathic Medicine; ³Department of Orthopedics, Michigan State University College of Osteopathic Medicine; ⁴Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine; ⁵Department of Psychiatry, Michigan State University College of Osteopathic Medicine; ⁶Department of Orthopedics, Ochsner Medical Center

Statement of Significance: Sports-related concussions (SRC) are a significant public health concern in organized sports.[1] Current treatment of athletes that sustain an SRC includes monitoring symptoms using standardized symptom scores, physical and cognitive rest, physical and vestibular rehabilitation, and a gradual return to play plan.[2] Osteopathic manipulative medicine has been proposed as a safe, adjunctive treatment for patients with post-concussion symptoms.[3,4]

Research Methods: A total of 15 athletes with an SRC (10 women, ages 14-25 years old) were randomized to either an experimental (usual care+OMT, n=9) or control (usual care alone, n=6) group. The Sport Concussion Assessment Tool Symptom Evaluation Score (SCAT) (taken at the initial visit and at two weeks post-concussion) and time to return to play (RTP) were measured. The administered SCAT consists of self-reported 22 concussion symptoms on a scale ranging from 0 (none) to 6 (severe), providing 22 possible symptoms with a severity score out of 132.[5] Inclusion criteria include a minimum and maximum age of 14 and 25, respectively, primary diagnosis of sports-related concussion within the last 10 days, and active participation in an organized sport. Exclusion criteria include contraindications for OMT such as skull/cervical fracture, intracranial bleeding, and stroke, surgery within the last 6 month, will not be under the care of healthcare professional, or having any conditions that contraindicates or impedes protocol implementation. For this preliminary analysis, Cohen’s d was used to assess effect size of the differences between the groups, where the magnitude of the effect size can be interpreted as small (d=0.2), medium (d=0.5), and large (d=0.8).[6] Intention-to-treat (ITT) analysis was applied, whereby any SCAT score missing at week 2 follow-up were replaced with the corresponding baseline score (the last observation carried forward).

Data Analysis: The athletes participated in a variety of organized sports including rowing, wrestling, wake surfing, swimming, diving, basketball, and soccer. On average, athletes in the experimental group received 2 OMT sessions during the 2-week period. Groups were similar in terms of age and gender (p>0.05). Based on the ITT analysis, athletes receiving usual care+OMT reduced the number of their symptoms from 12(SD=5) to 5(6) and their symptom severity score from 32(23) to 9(11), whereas the number of symptoms and severity score in the control group reduced from 12(6) to 6(6) and from 23(17) to 11(12), respectively. RTP for athletes in the usual care+OMT group was 2.6 days sooner than athletes in the control group (10.7(5.6) vs. 13.3(8.3) days, respectively), which produced a medium effect size of d=0.40. For 5 athletes (2 from usual care and 3 from usual care+OMT), RTP was not reported.

Results: The athletes participated in a variety of organized sports including rowing, wrestling, wake surfing, swimming, diving, basketball, and soccer. On average, athletes in the experimental group received 2 OMT sessions during the 2-week period. Groups were similar in terms of age and gender (p>0.05). Based on the ITT analysis, athletes receiving usual care+OMT reduced the number of their symptoms from 12(SD=5) to 5(6) and their symptom severity score from 32(23) to 9(11), whereas the number of symptoms and severity score in the control group reduced from 12(6) to 6(6) and from 23(17) to 11(12), respectively. RTP for athletes in the usual care+OMT group was 2.6 days sooner than athletes in the control group (10.7(5.6) vs. 13.3(8.3) days, respectively), which produced a medium effect size of d=0.40. For 5 athletes (2 from usual care and 3 from usual care+OMT), RTP was not reported.

Conclusion: The results from this preliminary analysis suggest that OMT used as complementary to current concussion management helps enhance the recovery process in athletes who sustained an SRC.[7] Further research is needed to determine the specific mechanisms of OMT enhancing the recovery from SRCs.

References

1. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42:495-503.

2. Patel DR, Shivdasani V, Baker RJ. Management of sport-related concussion in young athletes. Sports Med. 2005;35:671-84. doi: 10.2165/00007256-200535080-00002

3. Patel KG, Sabini RC. Safety of Osteopathic Cranial Manipulative Medicine as an Adjunct to Conventional Postconcussion Symptom Management: A Pilot Study. J Am Osteopath Assoc. 2018;118:403-9. doi: 10.7556/jaoa.2018.061

4. Guernsey DT 3rd, Leder A, Yao S. Resolution of Concussion Symptoms After Osteopathic Manipulative Treatment: A Case Report. J Am Osteopath Assoc. 2016;116(3):e13-e17. doi: 10.7556/jaoa.2016.036

5. Petit KM, Savage JL, Bretzin AC, Anderson M, Covassin T. The Sport Concussion Assessment Tool-5 (SCAT5): Baseline Assessments in NCAA Division I Collegiate Student-Athletes. Int J Exerc Sci. 2020;13(3):1143-1155.

6. Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Front Psychol. 2013;4:863. doi: 10.3389/fpsyg.2013.00863

7. Mazzeo S, Silverberg C, Oommen T, Moya D, Angelo N, Zwibel H, Mancini J, Leder A, Yao SC. Effects of Osteopathic Manipulative Treatment on Sleep Quality in Student Athletes After Concussion: A Pilot Study. J Am Osteopath Assoc. 2020;120(9):615-622. doi: 10.7556/jaoa.2020.100

Financial Disclosures: None reported.

Support: AOA grant was provided for this study.

Ethical Approval: Study is reviewed and approved by IRB.

IRB number: STUDY00004542

Clinical trial registry number: NCT04932278

Informed Consent: If the participant is under 18 years old, the parent is being asked to provide parental permission. Researchers are required to provide an assent form/parental permission form to inform both the parent and participant about the research study, to convey that participation is voluntary, to explain risks and benefits of participation, and to empower them to make an informed decision. The participant should feel free to ask the researchers any questions they may have. Both the parent and participant need to agree for the child’s participation in this study.

Poster No. *C-26

Abstract No. 97

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Perioperative and Clinical Outcomes of Transcarotid Artery Revascularization: A Single-Center Experience

¹Yibei Lun, PharmD, OMS-II; ²Zachary T. AbuRhama, DO; ³Elaine Davis, RN, MS, EdD; ³L. Scott Dean, MBA, PhD; ⁴Ali F. AbuRahma, MD; ⁴Adrian Santini, MD; ⁴Matthew Beasley, MD; ⁴Megan Davis, MD; ⁴Andrew Lee, MD; ⁴Christina Veith, MD; ⁴Mazen Roshdy, MD

¹Charleston Area Medical Center; ²Department of Vascular Surgery, Charleston Area Medical Center; ³Charleston Area Medical Center for Health Services and Outcomes Research; ⁴Department of Vascular Surgery, Charleston Area Medical Center

Statement of Significance: Transcarotid Artery Revascularization (TCAR) is a hybrid technique using flow reversal for neuroprotection. This study was intended to assess perioperative and long-term clinical outcome of TCAR and compare the result of our patient outcome to those reported in the ROASTER trials.[1,2] Current literature assessed 30-day perioperative complications of TCAR. Our study thought to build on the previous study of TCAR at our institution by adding additional patients and conducting longer follow-up.

Research Methods: Retrospective analysis of collected data from 155 consecutive patients (6/20/2016-5/26/2022) performed at our single institution. These TCAR procedures were done for high-risk patients for CEA, which included anatomical (previous CEA, radiation induced stenosis, stoma, high cervical lesion, etc.), physiological (COPD patients on oxygen therapy, congestive heart failure, severe coronary artery disease, etc.) or combined physiological/anatomical high risk patients. [3,4] These procedures were all performed by trained vascular surgeons. Variables include demographics, comorbidities, symptomatic status, in hospital complications and findings of post discharge follow-up. Descriptive statistics were used to depict categorical and continuous variables. Kaplan-Meier analysis was used to estimate survival, freedom from stroke/death and freedom from in-stent restenosis (≥50% and ≥80%).

Data Analysis: These TCAR patients included 87% primary and 13% redo (patients who had TCAR or transfemoral carotid artery stenting previously). The mean/median age was 72 years. The mean follow-up time was 10.9 months. Ten percent of the patients developed in-stent restenosis greater or equal to 50%; 3.4% had in-stent restenosis greater or equal to 80%. Ninety-four percent of the patients had pre-stenting dilation and twenty-five percent had post-stenting dilation. Sixty-three percent of the patients were asymptomatic, seventeen percent had stroke, and twenty-one percent had transit ischemic attack. Comorbidities include hypertension (91%), hyperlipidemia (85%), smoking history (68%), coronary artery disease (63%), diabetes (47%), and congestive heart failure (18%). The rate of 30-day post operative stroke was 2.6%, stroke/death rate was 1.9%, stroke/death/MI rate was 3.2%, major bleeding requiring re-exploration was 5.2%, and cranial nerve injury was 1.9%. Freedom from greater or equal to 50% in-stent restenosis at one year was 86.5% and freedom from greater than or equal to 80% in-stent restenosis was 94.2%. Freedom from stroke at one year was 95% and freedom from stroke/death was 94% at one year.

Results: These TCAR patients included 87% primary and 13% redo (patients who had TCAR or transfemoral carotid artery stenting previously). The mean/median age was 72 years. The mean follow-up time was 10.9 months. Ten percent of the patients developed in-stent restenosis greater or equal to 50%; 3.4% had in-stent restenosis greater or equal to 80%. Ninety-four percent of the patients had pre-stenting dilation and twenty-five percent had post-stenting dilation. Sixty-three percent of the patients were asymptomatic, seventeen percent had stroke, and twenty-one percent had transit ischemic attack. Comorbidities include hypertension (91%), hyperlipidemia (85%), smoking history (68%), coronary artery disease (63%), diabetes (47%), and congestive heart failure (18%). The rate of 30-day post operative stroke was 2.6%, stroke/death rate was 1.9%, stroke/death/MI rate was 3.2%, major bleeding requiring re-exploration was 5.2%, and cranial nerve injury was 1.9%. Freedom from greater or equal to 50% in-stent restenosis at one year was 86.5% and freedom from greater than or equal to 80% in-stent restenosis was 94.2%. Freedom from stroke at one year was 95% and freedom from stroke/death was 94% at one year.

Conclusion: The patient population exhibited a high frequency of hypertension, hyperlipidemia and tobacco use. The overall 30-day complications declined with the addition of 53 new patients in the current study. With these additional patients and longer follow-up on the previously reported one hundred and two patients, freedom from in-stent restenosis greater or equal to 50% was 90% and greater or equal 80% was 96.6%. Our study demonstrated acceptable/low rates of perioperative 30-day stroke/death rate (1.94%) and stroke/death/MI rate (3.23%) which are similar to results from ROADSTER (2.8% and 3.5%) and ROADSTER II (2.3% and 3.2%). [1,2] The primary limitations of our study was the retrospective design which inherently leads to reliance on previous documentation within the record. Single-center study, results may not be generalizable. Long term follow-up can be challenging in an elderly population in a rural state, thus, encouraging patients to continue follow-up of their carotid artery diseases may require a more multi-disciplinary and holistic osteopathic approach than we currently have. Encouraging involvement of the primary care provider community in promoting regular follow-up may help detect in-stent restenosis or neurological symptoms as early as possible.

References

1. Kwolek CJ, Jaff MR, Leal JI, et al. Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal. J Vasc Surg. 2015;62(5):1227-1234. doi:10.1016/j.jvs.2015.04.460 2. Kashyap VS, Schneider PA, Foteh M, et al. Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease. Stroke. 2020;51(9):2620-2629. doi:10.1161/STROKEAHA.120.030550

2. Mullen M. Management of symptomatic carotid atherosclerotic disease. In: Post T, ed. UpToDate. UpToDate; 2022. Accessed July 7, 2022. https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease?search=managment%20of%20symptomatic%20carotid%20atheroscloerotic%20disease&source=search_result&selectedTitle=1∼150&usage_type=default&display_rank=14. AbuRahma AF, AbuRahma ZT, Santini A, et al. A single-center experience of 30-day perioperative and one year clinical outcomes of transcarotid artery revascularization in 100 consecutive patients [published online ahead of print, 2022 May 29]. Vascular. 2022;17085381221106330. doi:10.1177/17085381221106330

Financial Disclosures: None reported

Support: CAMC institute academic medicine provides internal funding - summer externship only

Ethical Approval: This study with IRB#17-379 has been reviewed and approved by CAMC-WVU Institutional Review Board on 5/16/2022.

Informed Consent: granted waiver of informed consent

Poster No. *C-27

Abstract No. 101

Category: Clinical

Research Topic: Acute and Chronic Pain Management

Patient Perspectives on the Perceived Effectiveness, Ease of Use, and Satisfaction of Different Pain Rating Scales for People Living with Chronic Pain

¹Rachel Supinda Sinit, OMS-III; ¹Clarice Martinez deCastro, OMS-III; ¹Madeleine Stack, OMS-III; ¹Danielle Weismann, OMS-III; ¹Nicholas Scrivens, OMS-III; ¹Taryn Caroll, OMS-III; ²Rebecca Rdesinski, MPH; ³Edie Sperling, DPT; ⁴Kimberly Mauer, MD

¹Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Oregon; ²Department of Biostatistics, Oregon Health & Science University; ³Medical Anatomical Sciences, Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Oregon; ⁴Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University

Statement of Significance: Chronic pain is the most common driver of adults seeking medical care1 resulting in an annual cost of $560-636 billion each year in medical care, lost productivity, or disability services in the United States.2 According to an analysis of 2016 National Health Interview Survey (NHIS) data, it was estimated that about 20.4% if U.S. adults had chronic pain3. Due to the prevalence and complexity of chronic pain, it is of vital importance to investigate proper methods to diagnose and treat it.

Research Methods: Oregon Health and Science University Comprehensive Pain Center patients aged 18 years or older with any chronic pain diagnosis were recruited for this 19 question survey through a link in their After Visit Summary and through waiting room flyers. Participants were asked questions about the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), Defense and Veterans Pain Rating Scale 2.0 (DVPRS), Brief Pain Inventory (BPI) and Mankoski Pain Scale (MPS). Once consented, they were asked to describe their pain in their own words. Next, each scale was presented followed by questions “This scale helped me effectively describe my pain to my doctor”, “This scale was easy to use and understand”, and “I am satisfied with this pain scale”. They were asked to select yes, somewhat, no, or N/A to each. Finally, the participants were asked to choose the scale that was most effective at describing the quality of their pain, followed by a free response box to detail their reasoning. Of the 100 total responses collected, 99 were included in the analysis due to incomplete responses. Kruskal-Wallis tests were run to assess whether there were differences between pain scales in terms of perceived effectiveness, ease of use, and satisfaction. The free text responses were qualitatively analyzed by identifying key code words and grouping those into themes. The study’s geographical and cultural representation is indicative of the patient population at the clinic, but we did not collect data associated with demographics directly. The survey was open until 100 survey responses were recorded.

As future osteopathic physicians, we recognize that chronic pain impacts the body, mind, and spirit. When we use tools that recognize this concept of body unity, we can better serve our patients by collaborating to plan a rational treatment plan that centers on improving their entire quality of life rather than only reducing physical pain.

Data Analysis: 100 patients completed the survey with mixed results on patient preference. When asked to describe their pain, participants discussed their unique experiences including different types of pain, varying levels of pain throughout the day, and how their pain is often complex, exhausting, and poorly understood with the current pain scales utilized in clinical practice. The Kruskal-Wallis tests for the Effectiveness measure, the Ease measure, and the Satisfaction measure indicate there is a significant difference among the five pain scales (Effectiveness: χ2= 64.304, p < 0.0001, Ease: χ2=30.989, p < 0.0001, Satisfaction: χ2=65.165, p< 0.0001). Forty-nine participants chose the DVPRS as the most effective in describing their pain. Twenty-two people chose the BPI and MPS each. Five people selected the VRS. One participant chose the NRS, though many voiced concerns that ranking their pain with a single number was highly ineffective.

Results: 100 patients completed the survey with mixed results on patient preference. When asked to describe their pain, participants discussed their unique experiences including different types of pain, varying levels of pain throughout the day, and how their pain is often complex, exhausting, and poorly understood with the current pain scales utilized in clinical practice. The Kruskal-Wallis tests for the Effectiveness measure, the Ease measure, and the Satisfaction measure indicate there is a significant difference among the five pain scales (Effectiveness: χ2= 64.304, p < 0.0001, Ease: χ2=30.989, p < 0.0001, Satisfaction: χ2=65.165, p< 0.0001). Forty-nine participants chose the DVPRS as the most effective in describing their pain. Twenty-two people chose the BPI and MPS each. Five people selected the VRS. One participant chose the NRS, though many voiced concerns that ranking their pain with a single number was highly ineffective.

Conclusion: Trends in the data suggest patients prefer a pain scale that does not separate out the physical pain but describes the total experiential aspect of chronic pain that affects the mind and spirit. This may explain why functional pain scales like the DVPRS and BPI were preferred by patients more frequently than less descriptive pain scales (i.e., NRS and VRS). Ensuring the scales utilized to understand patients’ pain appropriately represent the patients’ entire experience is critical to translating it to thoughtful and effective clinical management. Moving forward, we hope to optimize survey accessibility into more diverse clinical settings in order to generalize these findings to the larger population of patients living with chronic pain. In the future, we hope to query physician perspectives on pain scales in hopes of bridging the gaps in patient and clinician communication to improve the quality of patient care.

References

1. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults - United States, 2016.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 Sept. 2019, https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm. Accessed 11 July 2022.

2. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US), 2011. doi: 10.17226/13172.

3. Dahlhamer, James, et al. “Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016.” MMWR. Morbidity and Mortality Weekly Report. 2018; 67(36): 1001–1006. doi:10.15585/mmwr.mm6736a2.

Financial Disclosures: None reported

Support: Western University of Health Sciences Summer Research Grant (2021) for housing expenses during conduction of research in the summer of 2021.

Ethical Approval: IRB Number: STUDY00023017. IRB submission was completed at Oregon Health & Science University (OHSU) as participants were recruited from OHSU’s Comprehensive Pain Center. Study documents including study protocol and informed consent form were submitted and approved for Exempt Category #2 through 6/29/2024. Exemption #2 is defined as,

"Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior unless: i. information obtained is recorded in such a manner that human subjects can be identified, directly or through identifiers linked to the subjects; and ii. any disclosure of the human subjects’ responses outside the research could reasonably place the subject at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, or reputation."

Informed Consent: Since this was an anonymous, minimal-risk survey protocol, which was conducted across Oregon and Southern Washington, an information sheet was used in place of an informed consent document. The information sheet was part of the online survey and participants confirmed that they read and agreed with the information sheet before being directed to the survey.

Poster No. *C-28

Abstract No. 114

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Concurrent Mutation in EGFR Mutant Non-Small Cell Lung Cancer May be Associated with Resistance to First and Second Generation EGFR tyrosine kinase inhibitors, a meta-analysis

Marissa Viola, MS, OMS-IV; ²Jun Wang, MD, PhD; ³Adam Kolatorowicz, PhD

Lincoln Memorial University DeBusk College of Osteopathic Medicine

Statement of Significance: Lung cancer is currently the second most prevalent cancer and most common cause of cancer mortality in the United States. Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have improved both the survival and quality of life for non-small cell lung cancer (NSCLC) patients harboring EGFR mutations.TKI treatment is the first choice for EGFR mutated NSCLC. Although effective, many NSCLC patients have primary or acquired resistance after initial response to EGFR-TKIs.

Research Methods: To delineate the role of concurrent mutation of various genes in TKI resistance, meta-analysis were performed using published observations of EGFR mutant lung cancer patients treated with first or second generation TKIs. Studies that have reported clinical responses to first and second generation TKIs with or without concurrent mutations were collected through PubMed. 32 studies are included after screening for studies with similar methodologies that can be used for meta analysis. Probability of TKI resistance and/or progress free survival (PFS) were compared in patients with or without concurrently mutations.

Data Analysis: An increased probability of TKI resistance is only seen in p53 mutant lung cancers. Interestingly, when resistance is defined as PFS<6 months, there is insignificant increase of resistance in p53 mutant patients (OR=1.93, 95% CI [0.38, 9.85], p=0.43). When resistance is defined as PFS<4 months there is a marked increase in resistance (OR=20.16, 95% CI [2.61, 155.75], p=0.004). In addition, p53 mutation is associated with a significantly shortened progress free survival in these patients (HR=1.57, 95% CI [1.26,1.97], p<0.0001). However, no significant differences were seen in concurrent mutations of other genes, including PIK3CA, ERBB2, MET and CTNNB (p=0.07-0.85).

Results: An increased probability of TKI resistance is only seen in p53 mutant lung cancers. Interestingly, when resistance is defined as PFS<6 months, there is insignificant increase of resistance in p53 mutant patients (OR=1.93, 95% CI [0.38, 9.85], p=0.43). When resistance is defined as PFS<4 months there is a marked increase in resistance (OR=20.16, 95% CI [2.61, 155.75], p=0.004). In addition, p53 mutation is associated with a significantly shortened progress free survival in these patients (HR=1.57, 95% CI [1.26,1.97], p<0.0001). However, no significant differences were seen in concurrent mutations of other genes, including PIK3CA, ERBB2, MET and CTNNB (p=0.07-0.85).

Conclusion: These findings suggest that concurrent mutations may be associated with resistance to TKIs in EGFR mutant lung cancers, but more standardized evaluation appears to be needed for better understanding of the effects of these concurrent mutations.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: IRB #: 1024 V.0. Status: exempt

Informed Consent: N/A

Poster No. *C-29

Abstract No. 115

Category: Clinical

Research Topic: Impact of OMM & OMT

Effects of Osteopathic Manipulative Treatment on Primary Dysmenorrhea

¹Nicole Companion, OMS-III; ¹Erum Ahmed, DO; ²Jordan Keys, DO; ²Reem Abu-Sbaih, DO; ²Sheldon Yao, DO

¹New York Institute of Technology; ²Department of Osteopathic Manipulative Medicine, New York Institute of Technology

Statement of Significance: Primary Dysmenorrhea affects 45-90% of females with varying severity. With increasing severity, daily activities are affected; in one study, 38% of women were not able to perform their regular daily activities. Current treatment options are limited to NSAIDs (non-steroidal anti-inflammatory drugs) and oral contraceptive pills (OCPs). OMT may provide an additional treatment option to reduce menstrual pain and symptoms.

Research Methods: This is a prospective intervention, with A-B-A design, utilizing survey data and muscle measurements. Females over the age of 18 diagnosed with primary dysmenorrhea not attributed to a physiologic cause and not treated with any form of birth control were included. Five female subjects (ages 20-25) suffering from menstrual-related pain participated. Subjects completed a validated survey, Menstrual Distress Questionnaire (MDQ), to gather subjective symptoms during three consecutive menstrual cycles: control, treatment, and follow-up. The MDQ was filled out at three time points of each cycle: premenstrual, menstrual, and postmenstrual. The MDQ is divided into four sub-sections: pain, water retention, autonomics, and negative affect. Each subject’s first complete menstrual cycle acted as a control to gather baseline symptom duration and severity, in which no OMT interventions were made. During the second menstrual cycle, paraspinal muscles at L1 and L3 bilaterally were measured prior to and after each treatment session. The MyotonPRO measured tone, stiffness, decrement, creep, and relaxation of erector spinae muscle. A team of three board-certified osteopathic physicians performed osteopathic structural exams and treated subjects 6-8 times throughout the second menstrual cycle, using a systematic and uniform OMT protocol.The treatment protocol applied principles of OMT to free tissue tension and promote adequate blood and lymphatic flow in order to remove inflammatory mediators, leading to relief in back and suprapubic pain. OMT was done in regions of sympathetic innervation to the Gastrointestinal and Genitourinary systems to relieve diarrhea, nausea, and vomiting. OMT targeting the sacral nerve roots and vagus nerve was done to improve parasympathetic innervation to GI and GU systems. After addressing these regions, OMT could lead to an overall psychological improvement in the subject’s energy level and mood.

Data Analysis: MyotonPRO data was analyzed from 124 unique measurements using paired t-tests with SPSS statistical software.The tone significantly decreased after OMT (13.9242 ± 1.7 Hz) compared to prior to treatment (14.2048 ± 1.6 Hz), p=0.004, with a power=0.898.The stiffness significantly decreased after OMT (235.2581 ± 73.4 N/m) compared to prior to treatment (247.1613 ± 66.5 N/m), p<0.001, with a power=0.961.The decrement (1/elasticity) significantly decreased after OMT (1.0772 ± 0.27) compared to prior to treatment (1.1278 ± 0.29), p=0.001, with power=0.948. However, relaxation and creep did not show statistically significant differences from prior to post-OMT (p= 0.223, p=0.133).Survey data of 45 responses from 5 subjects over 3 cycles was analyzed using repeated measures ANOVA using SPSS statistical software. Raw scores were totaled from each sub-section and converted to standard T-scores to permit comparison within and across cycle phases and between females.The pain score at baseline (64.6 ±17.8) was significantly reduced to 47.67 ± 8.75 during the treatment cycle, as well as the follow-up cycle (52.4 ± 12.25), (F(2,28)=9.543, p<0.001), which was statistically significant.The water retention score at baseline (65 ± 23.15), was improved during the treatment cycle (50.067 ± 16), and follow-up cycle (52.6 ± 20.3). (F(2,28)=4.162, p=0.026), which was statistically significant.The negative affect score at baseline (48.2 ± 13.3), improved during the treatment cycle (40.267 ± 5), as well as during the follow-up cycle (41.13 ± 10.4), (F(2,28)=4.086, p=0.028), which was statistically significant.The autonomics score at baseline (47.867 ± 8.2) trended down to 44 ± 3.3 and 44.73 ± 3.95; however, this change was not statis.tically significant, (F(2,28)=2.359, p=0.113.).

Results: MyotonPRO data was analyzed from 124 unique measurements using paired t-tests with SPSS statistical software.The tone significantly decreased after OMT (13.9242 ± 1.7 Hz) compared to prior to treatment (14.2048 ± 1.6 Hz), p=0.004, with a power=0.898.The stiffness significantly decreased after OMT (235.2581 ± 73.4 N/m) compared to prior to treatment (247.1613 ± 66.5 N/m), p<0.001, with a power=0.961.The decrement (1/elasticity) significantly decreased after OMT (1.0772 ± 0.27) compared to prior to treatment (1.1278 ± 0.29), p=0.001, with power=0.948. However, relaxation and creep did not show statistically significant differences from prior to post-OMT (p= 0.223, p=0.133).Survey data of 45 responses from 5 subjects over 3 cycles was analyzed using repeated measures ANOVA using SPSS statistical software. Raw scores were totaled from each sub-section and converted to standard T-scores to permit comparison within and across cycle phases and between females.The pain score at baseline (64.6 ±17.8) was significantly reduced to 47.67 ± 8.75 during the treatment cycle, as well as the follow-up cycle (52.4 ± 12.25), (F(2,28)=9.543, p<0.001), which was statistically significant.The water retention score at baseline (65 ± 23.15), was improved during the treatment cycle (50.067 ± 16), and follow-up cycle (52.6 ± 20.3). (F(2,28)=4.162, p=0.026), which was statistically significant. The negative affect score at baseline (48.2 ± 13.3), improved during the treatment cycle (40.267 ± 5), as well as during the follow-up cycle (41.13 ± 10.4), (F(2,28)=4.086, p=0.028), which was statistically significant.The autonomics score at baseline (47.867 ± 8.2) trended down to 44 ± 3.3 and 44.73 ± 3.95; however, this change was not statistically significant, (F(2,28)=2.359, p=0.113.).

Conclusion: This study demonstrated that OMT can be used to address primary dysmenorrhea and the debilitating effects that females experience each month. OMT significantly reduced pain, water retention, and negative affect associated symptoms’ duration and intensity. OMT can provide relief to patients, is a non-invasive method, and has minimal to none adverse effects. OMT can also potentially treat those that cannot use NSAIDs or OCPs for medical or financial reasons. In choosing to measure the lumbar paraspinal muscles at L1 and L3, this study showed muscle changes which may correlate with viscerosomatic sympathetic reflex changes associated with the uterus. OMT significantly decreased the stiffness, tone, and decrement of the lumbar erector spinae at these levels. Limitations of this study are a small sample size, variability of treating physicians, as well as variability in cycle lengths and symptoms experienced. This suggests further study in this area is warranted.

References

1. Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014 Mar 1;89(5):341-6. Review. PubMed PMID: 24695505.

2. Schoep ME, Nieboer TE, van der Zanden M, Braat DDM, Nap AW. The impact of menstrual symptoms on everyday life: a survey among 42,879 women. Am J Obstet Gynecol. 2019 Jun;220(6):569.e1-569.e7. doi: 10.1016/j.ajog.2019.02.048. Epub 2019 Mar 15. PMID: 30885768.

3. Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015 Nov- Dec;21(6):762-78. doi: 10.1093/humupd/dmv039. Epub 2015 Sep 7. Review. PubMed PMID: 26346058.

4. Barassi G, Bellomo RG, Porreca A, Di Felice PA, Prosperi L, Saggini R. Somato-Visceral Effects in the Treatment of Dysmenorrhea: Neuromuscular Manual Therapy and Standard Pharmacological Treatment. J Altern Complement Med. 2018 Mar;24(3):291-299. doi: 10.1089/acm.2017.0182. Epub 2017 Nov 14. PMID: 29135277.

Financial Disclosures: None Reported.

Support: None reported.

Ethical Approval: This study was reviewed and approved by the New York Institute of Technology Institutional Review Board under Protocol #BHS-1521.

Informed Consent: Research subjects were informed of the purpose, description, potential risks and potential benefits of the research study by a member of the research team. Research subjects then signed an informed consent form after being given adequate time to ask any questions they may have. All health information of research subjects remained confidential and accessed only by members of the research team. Research subjects voluntarily agreed to participate in this study and were given the option to withdraw from the study at any time without penalty or loss of benefits.

★ Poster No. *C-30

Abstract No. 119

Category: Clinical

Research Topic: Chronic Diseases & Conditions

A Collaborative Modeling Approach to Understand the Perspective of Patients with Low Back Pain Referred for Osteopathic Manipulative Medicine Management

¹Abigail Tzau, OMS-IV; ²John M. Popovich, Jr., PhD, DPT

¹Michigan State University College of Osteopathic Medicine; ²Center for Neuromusculoskeletal Clinical Research, Michigan State University College of Osteopathic Medicine

Statement of Significance: Chronic low back pain (CLBP) is widely accepted as a multifaceted issue with many biopsychosocial factors. Previous research emphasizes biomechanical, psychological, and behavioral/lifestyle factors in patient perspectives of CLBP1,2,3,4. Clinicians are trained to identify such factors, but the relative importance of factors may differ from patients to clinicians. There remains no clear consensus regarding the most prominent factors contributing to the patient populations’ perspective of CLBP5.

Research Methods: The patient population were those seen by a physician for their CLBP and referred to a large Midwestern university’s Osteopathic Manipulative Medicine (OMM) outpatient clinic for treatment, but had not yet been seen there. Participants were recruited based on referrals to the clinic. Prior to participation, each participant underwent an IRB-approved informed consent process. After completing a questionnaire recording demographic and self-reported health information, each participant underwent a semi-structured virtual interview to create a fuzzy cognitive map (FCM) representing their understanding of how numerous factors are related to CLBP6. This process involved nomination of Factors relating to patients’ outcomes (i.e., pain, disability, and quality of life) and assigning weight/strength to connections between these factors. Each FCM’s Factors were then categorized into eight Domains: 1) Behavioral/Lifestyle, 2) Biomechanical, 3) Comorbidities, 4) Individual Factors, 5) Nociceptive detection and processing, 6) Psychological, 7) Social/Work/Contextual Factors, and 8) Tissue injury or pathology. To determine the importance of each factor in each FCM, centrality (Ci) was computed. Ci measures the weighted contribution of each Factor i in each FCM: Ci = (sigma)n sub k=1 |a sub k|. n is a total number of Connections going to and from a Factor and a is the weight of each Connection. Thus, centrality of a factor increases with the number of connections to and from that factor and by the weighting of these connections6. Centrality of each domain (sum of centrality for each factor within the designated domain) was expressed as a percentage of the eight domains. Individual FCMs and metamodels were analyzed with descriptive statistics. This study is in line with the osteopathic tenets, as understanding how patients view their CLBP will enable physicians to treat patients more holistically and take on a whole person/patient-centered approach to managing patients with CLBP.

Data Analysis: 30 patients with CLBP (n=18 female, n=11 male, and n=1 unknown), averaging 13.1±14 years of LBP history with Oswestry Disability Index of 11.0±6.5% and 3.8±2.3 pain intensity rating out of 10, participated in this study. Based on these 30 participants’ interviews, a total of 639 factors were identified, with a total of 88 unique factors. On average, individual FCMs contained 21±4.7 factors and 40.2±27.8 connections. Of the 8 domains, Biomechanical (23.8%), Behavioral/Lifestyle (22.4%), and Psychological (21.9%) were the most prominent in the aggregated model, followed by Social/Work/Contextual Factors (15.7%), Tissue injury or pathology (7.8%), Comorbidities (4.7%), Individual Factors (2.4%), and Nociceptive detection and processing (1.3%). Furthermore, for the domains of Biomechanical, Behavioral/Lifestyle, and Psychological, each shared an equal number of participants (9 participants each) that expressed these domains as being most “central” to their understanding of CLBP.

Results: 30 patients with CLBP (n=18 female, n=11 male, and n=1 unknown), averaging 13.1±14 years of LBP history with Oswestry Disability Index of 11.0±6.5% and 3.8±2.3 pain intensity rating out of 10, participated in this study. Based on these 30 participants’ interviews, a total of 639 factors were identified, with a total of 88 unique factors. On average, individual FCMs contained 21±4.7 factors and 40.2±27.8 connections. Of the 8 domains, Biomechanical (23.8%), Behavioral/Lifestyle (22.4%), and Psychological (21.9%) were the most prominent in the aggregated model, followed by Social/Work/Contextual Factors (15.7%), Tissue injury or pathology (7.8%), Comorbidities (4.7%), Individual Factors (2.4%), and Nociceptive detection and processing (1.3%). Furthermore, for the domains of Biomechanical, Behavioral/Lifestyle, and Psychological, each shared an equal number of participants (9 participants each) that expressed these domains as being most “central” to their understanding of CLBP.

Conclusion: Similar to our previous report of individuals with LBP4, the aggregated model of patients with CLBP referred to the OMM outpatient clinic demonstrated Biomechanical factors as being most central to the perspective of CLBP patients, with Behavioral/Lifestyle and Psychological being the next most prominent factors in the aggregate model. These findings speak to the perceived importance of the numerous factors in patients with CLBP and highlight the unique perceptions in this patient population. The study has osteopathic significance as understanding how patients view their CLBP will enable osteopathic physicians to consider patients more holistically, thereby taking on a whole person/patient-centered approach to managing patients with CLBP, which is in line with the osteopathic tenets. Post-OMM interviews aimed at investigating potential changes in patient perspectives following participant visits to the OMM clinic as well how patient perspectives may diverge or converge with the perspectives of treating osteopathic physicians are currently underway.

References

1. Borkan J, Reis S, Hermoni D, Biderman A. Talking about the pain: a patient-centered study of low back pain in primary care. Soc Sci Med. 1995 Apr;40(7):977-88. doi: 10.1016/0277-9536(9400156-n). PMID: 7792636.

2. Buus N, Jensen LD, Maribo T, Gonge BK, Angel S. Low back pain patients’ beliefs about effective/ineffective constituents of a counseling intervention: a follow-up interview study. Disabil Rehabil. 2015;37(11):936-41. doi: 10.3109/09638288.2014.948135. Epub 2014 Aug 8. PMID: 25104215.

3. Ong BN, Hooper H, Dunn K, Croft P. Establishing Self and Meaning in Low Back Pain Narratives. The Sociological Review. 2004 Nov;52(4):532-549. doi:10.1111/j.1467-954X.2004.00494.x.

4. Hodges PW, Setchell J, Daniel E, Fowler M, Lee AS, Popovich Jr. JM, Cholewicki J. How Individuals With Low Back Pain Conceptualize Their Condition: A Collaborative Modeling Approach. The Journal of Pain. 2022 June; 23(6):1060-1070. doi: 10.1016/j.jpain.2021.12.014.

5. Cholewicki J, Popovich Jr. JM, Aminpour P, Gray SA, Lee AS, Hodges PW. Development of a collaborative model of low back pain: report from the 2017 NASS consensus meeting. The Spine Journal. 2018 Nov; 19(6):1029-1040. doi: 10.1016/j.spinee.2018.11.014.

6. Özesmi, U., & Özesmi, S. L. Ecological models based on people’s knowledge: A multi-step fuzzy cognitive mapping approach. Ecological Modelling. 176(1-2), 43-64. doi:10.1016/j.ecolmodel.2003.10.027.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Study was approved by Michigan State University IRB on 11/09/2020. IRB Number: STUDY00005055

Informed Consent: CLBP patients were contacted prior to their OMM clinic appointment and if they were interested, a consent form was provided, detailing the study, how participation is voluntary, and how they may withdraw from the study at any time and without consequence.

Poster No. *C-31

Abstract No. 57

Category: Clinical

Research Topic: Musculoskeletal Injuries and Prevention

Educational Intervention Promotes Injury Prevention Adherence in Club Collegiate Men’s Lacrosse Athletes

¹Westin Wong, OMS-III; ¹Steven P Gawrys, OMS-III; ¹Lawsen M. Parker, OMS-III; ¹Justin T. Bradshaw, OMS-III; ¹Evan G. Starr, OMS-III; ²Ben Wilde, DO, FAAFP

¹Rocky Vista University College of Osteopathic Medicine-Southern Utah; ²Department of Clinical Sciences, Rocky Vista University College of Osteopathic Medicine-Southern Utah

Statement of Significance: Club sports are student led, intercollegiate athletics. With club sports being mainly student led, many club teams student and coaching leadership do not have professional credentialing.1 Club athletes have an increased rate of injury compared to their NCAA counterparts.2,3 Most injuries that occur in lacrosse are non-contact injuries.4 Education and implementation of stretching and strength training have demonstrated decreased rates of non-contact injuries.5,6,7,8.

Research Methods: Injury prevention education focused on stretching specific muscle groups was given to club athletes. Education focused on the psoas9,10, ankle10, piriformis11 and hamstrings10. A 30-minute lecture was given to athletes detailing anatomy, information on the inverse relationship of stretching and muscle injury, and methods to self-evaluate flexibility was given to athletes at the beginning of the 2022 competitive lacrosse season. Optional surveys were distributed to athletes of the men’s club lacrosse teams of Southern Utah University, Utah Valley University, and Utah State University. Surveys were administered online via Qualtrics immediately after the initial lecture, two weeks post lecture, and at the end of the season to track progress and promote spaced repetition12. Questions were asked regarding range of motion, pain, susceptibility to injury, strength, and balance. Additional questions aimed to quantify number of games or practices missed due to non-contact injury and visits to the trainer. All respondents included in the analysis were 18 years of age or older. Any contact related injuries were excluded from analysis. Unpaired two-tailed t-tests were used to determine statistical significant of changes from survey responses from the beginning of the season compared to the end. The osteopathic significance of this study was to provide education regarding reciprocal inhibition, stretching, and exercise to reduce somatic dysfunction in club athletes.

Data Analysis: After exclusion, survey samples sizes returned with n=75 for the initial survey, n=54 for the second survey (2 weeks post lecture), and n=39 for the final survey at the end of the season. Two-tailed unpaired t-tests demonstrated p-values <0.05 for the following: overall decreased levels of self-reported pain (p<.0001), increased range of motion (p<.0001), increased frequency of stretching the muscle groups psoas, (p<.0001) calves (p=0.0081), and piriformis (p<.0001), decreased pain levels for the hamstring (p= 0.0274), and increased frequency of stretching after practice (p<.0001). The most common reported non-contact injuries reported were hamstring (n=4) and groin strains(n=3). Coach commentary from each team suggested that hamstring and groin injuries were most common among players during the 2022 season. Each team coach requested similar training be given next year.

Results: After exclusion, survey samples sizes returned with n=75 for the initial survey, n=54 for the second survey (2 weeks post lecture), and n=39 for the final survey at the end of the season. Two-tailed unpaired t-tests demonstrated p-values <0.05 for the following: overall decreased levels of self-reported pain (p<.0001), increased range of motion (p<.0001), increased frequency of stretching the muscle groups psoas, (p<.0001) calves (p=0.0081), and piriformis (p<.0001), decreased pain levels for the hamstring (p= 0.0274), and increased frequency of stretching after practice (p<.0001). The most common reported non-contact injuries reported were hamstring (n=4) and groin strains(n=3). Coach commentary from each team suggested that hamstring and groin injuries were most common among players during the 2022 season. Each team coach requested similar training be given next year.

Conclusion: The statistical significance of the increased frequency of stretching the psoas, ankle, piriformis, as well as overall stretching after practice suggests an increased compliance towards injury prevention practices. Decreased self-reported levels of overall pain, and decreased pain in the hamstring shows the positive effect of stretching. Increased levels of range of motion demonstrate an increased capacity to prevent injury in lacrosse club athletes. Educational intervention offers a cost-effective measure to provide club collegiate athletes with resources to reduce injury rates through athlete compliance to targeted stretches. Further studies are warranted to establish a clear statistical effect on injury rates once injury prevention measures are practiced after educational instruction.

References

1. Lifschutz L. Club Sports: Maximizing Positive Outcomes and Minimizing Risks. Recreational Sports Journal. 2012;36(2):104-112. doi:10.1123/rsj.36.2.104

2. Arthur-banning S. An Epidemiology of Sport Injury Rates Among Campus Recreation Sport Programs. Rehabilitation Science. 2018;3:38. doi:10.11648/j.rs.20180302.13

3. Brezinski T, Martin J, Ambegaonkar JP. Prospective Injury Epidemiology in Competitive Collegiate Club Sports, Quidditch, and Ultimate Frisbee. Athletic Training & Sports Health Care. 2021;13(3):111-116. doi:10.3928/19425864-20200107-01

4. Lacrosse Injuries - Sports Medicine Program - UR Medicine, University of Rochester Medical Center - Rochester, NY. Accessed November 10, 2021. https://www.urmc.rochester.edu/orthopaedics/sports-medicine/lacrosse-injuries.cfm

5. Mendonça LDM, Bittencourt NFN, Alves LEM, Resende RA, Serrão FV. Interventions used for Rehabilitation and Prevention of Patellar Tendinopathy in athletes: a survey of Brazilian Sports Physical Therapists. Brazilian Journal of Physical Therapy. 2020;24(1):46-53. doi:10.1016/j.bjpt.2018.12.001

6. Lewis J. A Systematic Literature Review of the Relationship Between Stretching and Athletic Injury Prevention. Orthopaedic Nursing. 2014;33(6):312-320. doi:10.1097/NOR.0000000000000097

7. Landis SE, Baker RT, Seegmiller JG. NON-CONTACT ANTERIOR CRUCIATE LIGAMENT AND LOWER EXTREMITY INJURY RISK PREDICTION USING FUNCTIONAL MOVEMENT SCREEN AND KNEE ABDUCTION MOMENT: AN EPIDEMIOLOGICAL OBSERVATION OF FEMALE INTERCOLLEGIATE ATHLETES. Int J Sports Phys Ther. 2018;13(6):973-984.

8. Padua DA, DiStefano LJ, Hewett TE, et al. National Athletic Trainers’ Association Position Statement: Prevention of Anterior Cruciate Ligament Injury. Journal of Athletic Training. 2018;53(1):5-19. doi:10.4085/1062-6050-99-16

9. Von Rickenbach K, Borg-Stein J, Borgstrom H. Anterior Hip Disorders. In: Mostoufi SA, George TK, Tria Jr. AJ, eds. Clinical Guide to Musculoskeletal Medicine: A Multidisciplinary Approach. Springer International Publishing; 2022:359-370. doi:10.1007/978-3-030-92042-5_38

10. Krivickas LS, Feinberg JH. Lower extremity injuries in college athletes: Relation between ligamentous laxity and lower extremity muscle tightness. Archives of Physical Medicine and Rehabilitation. 1996;77(11):1139-1143. doi:10.1016/S0003-9993(9690137-9)

11. Dolinger J. Review of Effective Injury Preventing and Performance Enhancing Strategies for Runners. Undergraduate Honors Theses. Published online May 1, 2022. https://dc.etsu.edu/honors/673

12. Adler AJ, Martin N, Mariani J, et al. Mobile phone text messaging to improve medication adherence in secondary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews. 2017;(4). doi:10.1002/14651858.CD011851.pub2

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Ethical Approval: Rocky Vista University IRB 2021-174 – reviewed and approved.

Informed Consent: Study participants were asked to read and electronically sign an informed consent document prior to beginning any of the three surveys. Informed consent outlined the purpose of the study, reinforced that participation is entirely voluntary, how survey responses would be de-identified and stored, as well as contact information for the Rocky Vista University IRB Compliance Administrator.

Poster No. *C-32

Abstract No. 71

Category: Clinical

Research Topic: Health Disparities-Social Determinants of Health

Secondary Characteristics of Side Effects Experienced in Pediatric Hematology and Oncology Patients Receiving the COVID-19 Vaccine

¹Whitney Carroll, OMS-III; ²Seethal A. Jacob, MD, MS; ²Jennifer Belsky, DO, MS

¹Marian University College of Osteopathic Medicine; ²Division of Hematology/Oncology, Riley Hospital for Children

Statement of Significance: In healthy adults, lymphadenopathy (LAD) is a common side effect of vaccination. LAD is also a concerning feature in patients with cancer or sickle cell disease (SCD). Post-COVID-19 vaccine LAD may mimic metastasis or cancer recurrence; therefore, it is imperative to start distinguishing features of reactive LAD following COVID-19 vaccination compared to malignancy. No study to date has investigated the incidence of LAD on imaging in children with cancer or SCD following COVID-19 vaccination.

Research Methods: A retrospective chart review was conducted with data from Riley Hospital for Children in Indianapolis, Indiana. Patients were between the ages of 0-30 years with a diagnosis of cancer or sickle cell disease that was made from January 2017 – December 2020. We identified 159 unique patients with cancer or SCD who received any COVID-19 vaccination from December 2020 – January 2022. We investigated patients 1) aged 0 30 years of age, 2) received any COVID-19 vaccination, 3) had an active or previous oncology or SCD diagnosis and/or 4) a new patient referral for lymphadenopathy 8 weeks post-vaccination. Illness prevention is a key component of the osteopathic approach to medicine. The COVID-19 pandemic has reiterated the critical role of vaccines in protecting patients, families, and communities against avoidable illnesses; thus, it is important to explore various components of COVID-19 vaccination, including side effects seen in different patient populations.

Data Analysis: Of the 159 patients in our study, 122 had oncologic diagnoses and 37 had hematologic diagnoses. In the cancer cohort (n=122), the most common oncologic diagnoses were solid tumors (n=33, 27.0%), leukemia (n=25, 20.1%), central nervous system cancer (n=25, 20.1%), and lymphoma (n=22, 18.0%). The median age of this cohort was 18 years (ranging from 12 to 30 years). The majority of the cancer cohort was male (n=68, 55.7%) and Caucasian (n=112, 91.8%). In the SCD cohort (n=37), the most common genotypes were HbSS (n=24, 64.9%) and HbSC (n=12, 32.4%). The median age was 17 (ranging from 13 to 20 years). The majority of this cohort was female (n=22, 59.5%) and African American (n=26, 97.3%). There were 3 unique patients in both the cancer cohort (n=3, 2.5%) and the SCD cohort (n=3, 8.1%) that demonstrated reactions to the COVID-19 vaccine. In the cancer cohort, fever, chills, myalgia, headache, and lymphadenopathy were all equally reported (n=1, 0.82%). In the SCD cohort, only other kinds side effects were seen (n=3, 8.1%). Of the cancer patients who received routine surveillance imaging (n=47, 38.5%), there were instances of symptomatic lymphadenopathy (n=1, 0.82%) detected 4 days after the 1st dose of Pfizer, and incidental lymphadenopathy (n=1, 0.82%) detected 1 day after the 2nd dose of Pfizer. Of SCD patients who received routine imaging (n=11, 29.7%), there were no reported instances of lymphadenopathy.

Results: Of the 159 patients in our study, 122 had oncologic diagnoses and 37 had hematologic diagnoses. In the cancer cohort (n=122), the most common oncologic diagnoses were solid tumors (n=33, 27.0%), leukemia (n=25, 20.1%), central nervous system cancer (n=25, 20.1%), and lymphoma (n=22, 18.0%). The median age of this cohort was 18 years (ranging from 12 to 30 years). The majority of the cancer cohort was male (n=68, 55.7%) and Caucasian (n=112, 91.8%). In the SCD cohort (n=37), the most common genotypes were HbSS (n=24, 64.9%) and HbSC (n=12, 32.4%). The median age was 17 (ranging from 13 to 20 years). The majority of this cohort was female (n=22, 59.5%) and African American (n=26, 97.3%). There were 3 unique patients in both the cancer cohort (n=3, 2.5%) and the SCD cohort (n=3, 8.1%) that demonstrated reactions to the COVID-19 vaccine. In the cancer cohort, fever, chills, myalgia, headache, and lymphadenopathy were all equally reported (n=1, 0.82%). In the SCD cohort, only other kinds side effects were seen (n=3, 8.1%). Of the cancer patients who received routine surveillance imaging (n=47, 38.5%), there were instances of symptomatic lymphadenopathy (n=1, 0.82%) detected 4 days after the 1st dose of Pfizer, and incidental lymphadenopathy (n=1, 0.82%) detected 1 day after the 2nd dose of Pfizer. Of SCD patients who received routine imaging (n=11, 29.7%), there were no reported instances of lymphadenopathy.

Conclusion: The majority of pediatric patients with cancer or sickle cell disease who received the COVID-19 vaccine experienced few side effects, and the occurrence of side effects in these patients were reflective of those seen in the general population. Children with cancer or SCD are prone to severe COVID-19 infections, and getting vaccinated could help protect these patients from potentially life-threatening effects of COVID-19. Pediatric hematologists and oncologists should be aware of the post-vaccine course for patients to appropriately guide patients and families.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Our study was reviewed by the Institutional Review Board and was deemed exempt due to the retrospective nature of the study. The IRB number is Protocol #11780.

Informed Consent: N/A - this was a retrospective chart review.

Poster No. *C-33

Abstract No. 87

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Association between Ehlers-Danlos Syndrome, Mast Cell Diseases, and Syncope/Presyncope at an Osteopathic Medical Center

¹Mohammad Farhan Aktar, OMS-II; ²Joseph Aabye, OMS-II; ²Ian Snyder, OMS-II; ²Rebecca P. Winter, OMS-II; ²Mario L. Silva, OMS-II; ³Bernadette Riley, DO; ⁴Todd Cohen, MD

¹New York Institute of Technology; ²Department of Clinical Specialties, New York Institute of Technology; ³Department of Family Medicine, New York Institute of Technology; ⁴Department of Cardiology, New York Institute of Technology

Statement of Significance: Many patients present with concurrent symptoms of Ehlers-Danlos Syndrome (EDS) and mast cell disorders (MCD). EDS is characterized by hypermobile joints, joint discomfort, and hyperelastic skin. Patients with EDS and MCD often present with symptoms of presyncope and/or syncope resulting from autonomic dysfunction and hypotension, respectively [1,2,3]. Further clinical research may help elucidate the complex relationship between these conditions.

Research Methods: A retrospective de-identified database was developed using the diagnostic code searching feature in the LIHRC electronic medical record system. Data was analyzed in all patients with the diagnosis of EDS between January 2019 through June 2022. These EDS patients were further stratified based on their specific subtype. Patients were classified as having syncope/presyncope if they mentioned symptoms associated with those diagnoses. Patients were diagnosed with MCD if their medical history indicated any form of mast cell-related conditions. Analyses included calculating odds ratios (ORs) and Phi Coefficients to determine the association for binary variables, along with 95% confidence intervals (CI). Statistical analyses were performed using Microsoft Excel Version 16.62.

Data Analysis: Among the sample of 727 patients, 61.3% are female and 38.7% are male, the mean age was 55 (SD +/- 21.5). Out of 73 EDS patients, 71 had hypermobile EDS, 1 had classical-like EDS, and 1 was recessive for vascular EDS. Based on our analyses, patients with EDS were 10.8 times more likely to experience syncope/presyncope than patients without EDS (OR, 10.8; CI, 6.0-19.4, p<0.0001). EDS patients also were 79.6 times more likely to have any form of MCD compared to non-EDS patients (OR, 79.6; CI, 26.6-238.5, p<0.0001). Patients with MCD were 9.3 times more likely to experience syncope/presyncope compared to patients without MCD (OR, 9.3; CI, 3.7-23.4, p>0.0001). We found a moderately positive relationship between EDS and syncope/presyncope (phi=0.35), a strong positive relationship between EDS and MCD (phi=0.50), and a weak positive relationship between MCD and syncope/presyncope (phi=0.21).

Results: Among the sample of 727 patients, 61.3% are female and 38.7% are male, the mean age was 55 (SD +/- 21.5). Out of 73 EDS patients, 71 had hypermobile EDS, 1 had classical-like EDS, and 1 was recessive for vascular EDS. Based on our analyses, patients with EDS were 10.8 times more likely to experience syncope/presyncope than patients without EDS (OR, 10.8; CI, 6.0-19.4, p<0.0001). EDS patients also were 79.6 times more likely to have any form of MCD compared to non-EDS patients (OR, 79.6; CI, 26.6-238.5, p<0.0001). Patients with MCD were 9.3 times more likely to experience syncope/presyncope compared to patients without MCD (OR, 9.3; CI, 3.7-23.4, p>0.0001). We found a moderately positive relationship between EDS and syncope/presyncope (phi=0.35), a strong positive relationship between EDS and MCD (phi=0.50), and a weak positive relationship between MCD and syncope/presyncope (phi=0.21).

Conclusion: EDS patients have a higher likelihood of experiencing symptoms of syncope/presyncope and MCD than those without EDS. Additionally, patients with MCD have an increased incidence of presyncope/syncope symptoms than those without MCD. This study provides additional support for a relationship between the triad of EDS, syncope, and MCD [4]. Limitations include the study’s retrospective design and some patients self-reporting their medical diagnoses. Further research should prospectively evaluate EDS patients and the significance of the EDS, syncope, and MCD triad in a larger cohort.

References

1. Lawrence E. The Clinical Presentation of Ehlers-Danlos Syndrome. Advances in Neonatal Care. 2005;5(6):301-314. doi:10.1016/j.adnc.2005.09.006Giannetti A, Filice E, Caffarelli C, Ricci G, Pession A. Mast Cell Activation Disorders. Medicina (Kaunas). 2021;57(2):124. Published 2021 Jan 30. doi:10.3390/medicina57020124Akin C, Metcalfe DD. Systemic mastocytosis. Annu Rev Med. 2004;55:419-432. doi:10.1146/annurev.med.55.091902.103822

2. Wang E, Ganti T, Vaou E, Hohler A. The relationship between mast cell activation syndrome, postural tachycardia syndrome, and Ehlers-Danlos syndrome. Allergy Asthma Proc. 2021;42(3):243-246. doi:10.2500/aap.2021.42.210022

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Informed consent waived by NYITCOM IRB (BHS-1465).

Informed Consent: Informed consent waived by NYITCOM IRB (BHS-1465).

Poster No. *C-34

Abstract No. 88

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Creative Approaches at Managing Chronic Insomnia

¹Gibrael A Barlaskar, OMS-I; ²Lori Dillard, ¹Michigan DO State University College of Osteopathic Medicine; ²Department of Osteopathic Manipulative Medicine, Michigan State University College of Osteopathic Medicine

Statement of Significance: Sleep is an essential part of our life when our body is able to heal itself. Disruption of the regular, consistent sleep pattern is insomnia. Insomnia is a disorder where people are unable to fall asleep, stay asleep, or wake up earlier than planned, leading to daytime fatigue, ultimately not allowing the body to heal itself. Chronic insomnia leads to cognitive decline and memory impairment, severe psychiatric disorders (1), certain cancers, and cardiac issues (2), lower metabolism (3).

Research Methods: In carrying out this project, a broad literature search was completed targeting over 20 articles regarding chronic insomnia and different treatments. PubMed search engines were used to target articles with keywords “insomnia,” “daytime fatigue,” “trazodone,” “CBT for insomnia,”, and “yoga for insomnia.” This targeted approach to an article search allowed for a concise review of the current literature on the pathology of insomnia along with effective treatments.

Data Analysis: CBT using slow breathing techniques in addition to good sleep hygiene is a better tool in combating insomnia over pharmacotherapy (1). Patients using CBT long term had better sleep latency, efficacy, and total sleep time over patients using pharmacotherapy and a combination of CBT and pharmacotherapy (4). CBT itself was more effective at combating insomnia over using combined CBT and pharmacotherapy and pharmacotherapy by itself, allowing patients to sleep more effectively and gain better quality sleep (5). CBT allowed patients to fall asleep more quickly (67.2 minutes vs 23.4 minutes), awaken less throughout the night (2 vs. .4), sleep more efficiently (77.3 vs 91 %), have better quality falling asleep (3.2 vs 6), have better quality sleep (3.3 vs 5.8), and have better quality morning awakenings (3.2 vs 6) (6). Trazodone combined with CBT increased slow wave sleep duration compared to CBT alone, shortened sleep latency (p=.03), increased sleep efficiency (p=.004), and prolonged sleep time (p=.006) (7). Yoga is also shown to significantly increase quality of sleep for women with major sleeping disorders (8).

Results: CBT using slow breathing techniques in addition to good sleep hygiene is a better tool in combating insomnia over pharmacotherapy (1). Patients using CBT long term had better sleep latency, efficacy, and total sleep time over patients using pharmacotherapy and a combination of CBT and pharmacotherapy (4). CBT itself was more effective at combating insomnia over using combined CBT and pharmacotherapy and pharmacotherapy by itself, allowing patients to sleep more effectively and gain better quality sleep (5). CBT allowed patients to fall asleep more quickly (67.2 minutes vs 23.4 minutes), awaken less throughout the night (2 vs. .4), sleep more efficiently (77.3 vs 91 %), have better quality falling asleep (3.2 vs 6), have better quality sleep (3.3 vs 5.8), and have better quality morning awakenings (3.2 vs 6) (6). Trazodone combined with CBT increased slow wave sleep duration compared to CBT alone, shortened sleep latency (p=.03), increased sleep efficiency (p=.004), and prolonged sleep time (p=.006) (7). Yoga is also shown to significantly increase quality of sleep for women with major sleeping disorders (8).

Conclusion: There is a myriad of ways to treat insomnia, including cognitive behavioral therapy (CBT), benzodiazepines which are drugs used to induce relaxation, and a combination of both CBT and other prescription drugs such as Trazodone. However, benzodiazepines and other prescription drugs can be subject to abuse, have major side effects, and also lead to death in some cases, in addition to being very expensive. cognitive behavioral therapy (CBT) with its broad and holistic approach for patients, is not only the most effective solution for long term chronic insomnia, but is also the least expensive, and has been shown to have sustained long-term for patients with chronic insomnia, ultimately allowing the body to heal itself. CBT with its patient-centered approach should be the first line intervention in treating chronic insomnia. In this way, patients can empower themselves without having to rely on pharmacotherapy which can be expensive, and also lead to dangerous side effects. However, in the event of using pharmacotherapy, Trazodone along with CBT has been shown to improve sleep quality in patients. Through this approach, we hope that patients will more proactively engage in their health to tackle their chronic insomnia, while using medication as a last resort given its cost, potential for abuse, and adverse side effects.

References

1. Jerath R, Beveridge C, Barnes VA. Self-Regulation of Breathing as an Adjunctive Treatment of Insomnia. Front Psychiatry. 2019;9:780. Published 2019 Jan 29. doi:10.3389/fpsyt.2018.00780

2. Nano MM, Fonseca P, Vullings R, Aarts RM. Measures of cardiovascular autonomic activity in insomnia disorder: A systematic review. PLoS One. 2017;12(10):e0186716. Published 2017 Oct 23. doi:10.1371/journal.pone.0186716

3. Gehrman P, Sengupta A, Harders E, Ubeydullah E, Pack AI, Weljie A. Altered diurnal states in insomnia reflect peripheral hyperarousal and metabolic desynchrony: a preliminary study. Sleep. 2018;41(5):zsy043. doi:10.1093/sleep/zsy043

4. Wu R, Bao J, Zhang C, Deng J, Long C. Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. Psychother Psychosom. 2006;75(4):220-228. doi:10.1159/000092892

5. Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004;164(17):1888-1896. doi:10.1001/archinte.164.17.1888

6. Gałuszko-Węgielnik M, Jakuszkowiak-Wojten K, Wiglusz MS, Cubała WJ, Landowski J. The efficacy of Cognitive-Behavioural Therapy (CBT) as related to sleep quality and hyperarousal level in the treatment of primary insomnia. Psychiatr Danub. 2012;24 Suppl 1:S51-S55.

7. Zavesicka L, Brunovsky M, Horacek J, et al. Trazodone improves the results of cognitive behavior therapy of primary insomnia in non-depressed patients. Neuro Endocrinol Lett. 2008;29(6):895-901.

8. Wang WL, Chen KH, Pan YC, Yang SN, Chan YY. The effect of yoga on sleep quality and insomnia in women with sleep problems: a systematic review and meta-analysis. BMC Psychiatry. 2020;20(1):195. Published 2020 May 1. doi:10.1186/s12888-020-02566-4

Financial Disclosures: None Reported

Support: None reported

Ethical Approval: Abstract is a literature review of use of CBT for chronic insomnia and therefore there was no need to obtain an IRB or patient consent.

Informed Consent: Abstract is a literature review of use of CBT for chronic insomnia and therefore there was no need to obtain an IRB or patient consent.

Poster No. *C-35

Abstract No. 106

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Malnutrition Screening and Treatment in Pediatric Oncology: A Systematic Review

¹Jessica Franke, OMS-III; ²Chris Bishop, MLS; ³Daniel V. Runco, MS

¹Marian University College of Osteopathic Medicine; ²Medical Library, Marian University College of Osteopathic Medicine; ³Department of Pediatrics, Indiana University School of Medicine

Statement of Significance: Pediatric cancer is the leading cause of non-accidental childhood death in the United States. Within the pediatric population undergoing cancer treatment, 80% experience malnutrition. Malnutrition and cachexia worsen treatment-related side effects and long-term quality of life. Clinical practice varies widely and lacks a standard diagnosis of malnutrition and nutrition interventions, in addition to lacking a comprehensive definition of pediatric cancer cachexia.

Research Methods: Ovid Medline, CINAHL, and Cochrane Library were searched without temporal limitations. Abstracts from the database search were independently and separately reviewed by two authors. Full manuscript review was performed by two authors for final determination of article inclusion. Included studies contained patients of the pediatric population (less than 20 years old) with cancer undergoing chemotherapy, radiotherapy, and/or immunotherapy treatments with the implementation of either a nutritional intervention or cachexia screening tool. The primary outcomes compared were anthropometric, radiographic, or biochemical measure of malnutrition. Secondary outcomes included use or validation of nutritional assessment and/or malnutrition screening tools. The heterogeneity of reported data precluded any formal statistical analysis. Comparisons were made in a narrative manner to reach conclusions.

Data Analysis: The search yielded 234 articles, and 17 articles were identified from external sources. Of these 251 articles, 9 met inclusion criteria, 6 regarding nutritional interventions and 3 involving nutritional screening tool implementation and validation. The limited number of studies had high variable measures and outcomes reported. Nutrition intervention studies measured outcomes such as laboratory evaluations (albumin, prealbumin, and total protein) and body measurement (weight loss and mid-upper arm circumference). Treatments utilized included appetite stimulants (megestrol or cyproheptadine), nutrition supplementation (ready-to-use, iso- or hypercaloric), and proactive feeding tube placement. All the studies demonstrated improved weight, but no significant difference was seen in isocaloric versus hypercaloric formulas or ready-to-use therapeutic food versus traditional formulas. Similarly, appetite stimulants, regardless of which one used, appear to improve weight. Screening tools validated a nutritional support algorithm and evaluated the effectiveness of nutritional support teams and a nutritional screening tool for childhood cancer (SCAN). The utilization of a nutritional support team and screening algorithms yielded mixed results on preventing weight loss, weight gain, and survival.

Results: The search yielded 234 articles, and 17 articles were identified from external sources. Of these 251 articles, 9 met inclusion criteria, 6 regarding nutritional interventions and 3 involving nutritional screening tool implementation and validation. The limited number of studies had high variable measures and outcomes reported. Nutrition intervention studies measured outcomes such as laboratory evaluations (albumin, prealbumin, and total protein) and body measurement (weight loss and mid-upper arm circumference). Treatments utilized included appetite stimulants (megestrol or cyproheptadine), nutrition supplementation (ready-to-use, iso- or hypercaloric), and proactive feeding tube placement. All the studies demonstrated improved weight, but no significant difference was seen in isocaloric versus hypercaloric formulas or ready-to-use therapeutic food versus traditional formulas. Similarly, appetite stimulants, regardless of which one used, appear to improve weight. Screening tools validated a nutritional support algorithm and evaluated the effectiveness of nutritional support teams and a nutritional screening tool for childhood cancer (SCAN). The utilization of a nutritional support team and screening algorithms yielded mixed results on preventing weight loss, weight gain, and survival.

Conclusion: Our review demonstrated a paucity of primary evidence for malnutrition screening and intervention in pediatric cancer treatment. The following limitations should be acknowledged while reviewing the conclusion of this study: the low frequency of search results is impacted by the drastically lower frequency of cancer amongst the pediatric population compared to the adult population, a vast heterogeneity of variables reported in each study prevented an accurate meta-analysis from being conducted, and appropriate treatments varies due to different developmental needs present between the youngest and oldest patients within this population. While a wide variety of malnutrition diagnostic criteria, nutritional intervention, and screening tools were used, the utilization of any nutritional interventions appear to increase patient weight and decrease complications. Screening tools decreased malnutrition risk and suggest some improvement in weight gain. The variability of patient populations studied and differing definitions, interventions, and outcomes highlight potential age- and disease-specific nutritional benefits and toxicities. This further emphasizes the critical need for standardized malnutrition definitions, screening, and interventions in clinical care for children with cancer as well as the need for future prospective research studies to assist in improving the quality of life amongst this population.

References

1. Zimmermann K, Ammann RA, Kuehni CE, De Geest S, Cignacco E. Malnutrition in pediatric patients with cancer at diagnosis and throughout therapy: A multicenter cohort study. Pediatr Blood Cancer. Apr 2013;60(4):642-649. doi:10.1002/pbc.24409

2. Evans WJ, Lambert CP. Physiological basis of fatigue. Am J Phys Med Rehabil. Jan 2007;86(1 Suppl):S29-46. doi:10.1097/phm.0b013e31802ba53c

3. Brinksma A, Huizinga G, Sulkers E, Kamps W, Roodbol P, Tissing W. Malnutrition in childhood cancer patients: a review on its prevalence and possible causes. Crit Rev Oncol Hematol. Aug 2012;83(2):249-75. doi:10.1016/j.critrevonc.2011.12.003

4. Sala A, Pencharz P, Barr RD. Children, cancer, and nutrition--A dynamic triangle in review. Cancer. Feb 15 2004;100(4):677-87. doi:10.1002/cncr.11833

5. Runco DV, Stanek JR, Yeager ND, Belsky JA. Malnutrition identification and management variability: An administrative database study of children with solid tumors. JPEN Journal of parenteral and enteral nutrition. Jan 17 2022;doi:10.1002/jpen.2329

6. Sadeghi M, Keshavarz-Fathi M, Baracos V, Arends J, Mahmoudi M, Rezaei N. Cancer cachexia: Diagnosis, assessment, and treatment. Crit Rev Oncol Hematol. Jul 2018;127:91-104. doi:10.1016/j.critrevonc.2018.05.006

7. Bouma S. Diagnosing Pediatric Malnutrition: Paradigm Shifts of Etiology-Related Definitions and Appraisal of the Indicators. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. Feb 2017;32(1):52-67. doi:10.1177/0884533616671861

8. Joffe L, Schadler KL, Shen W, Ladas EJ. Body Composition in Pediatric Solid Tumors: State of the Science and Future Directions. J Natl Cancer Inst Monogr. Sep 1 2019;2019(54):144-148. doi:10.1093/jncimonographs/lgz018

9. Runco DV, Yoon L, Grooss SA, Wong CK. Nutrition & Exercise Interventions in Pediatric Patients with Brain Tumors: A Narrative Review. J Natl Cancer Inst Monogr. Sep 1 2019;2019(54):163-168. doi:10.1093/jncimonographs/lgz025

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: N/A

Informed Consent: N/A

Poster No. *C-36

Abstract No. 64

Category: Clinical

Research Topic: Impact of OMM & OMT

AOA Grant Award: #22013852

Augmentation of Immune Response to COVID-19 mRNA Vaccination Through Osteopathic Manipulative Treatment

¹Edward Lee, OMS-III; ¹Andrew Comer, OMS-III; ¹Eric Martinez; ¹Paula Crone, DO; ¹Brian Loveless, DO; ¹Sebastien Fuchs, MD, PhD; ¹Hendrik Szurmant, PhD; ²Joseph Zammuto, DO; ³Robert Hostoffer, DO; ¹Jesus Sanchez, DO

¹Western University of Health Sciences College of Osteopathic Medicine of the Pacific; ²American Osteopathic Foundation Board; ³University Hospitals, Cleveland Medical Center

Statement of Significance: In response to COVID-19, scientists mobilized to produce vaccines and treatments in record time, which have provided relief.(1) However, protection against the virus has since waned as multiple new variants continue to lead to higher levels of vaccine escape, higher transmissibility, and increased virulence.(2) Past research utilizing lymphatic pump techniques has shown an ability to enhance vaccine delivery with improved antibody titers for the Hepatitis B vaccine.(3)

Research Methods: The participants were recruited at the WesternU free vaccination clinic open to the public and community at large in Pomona, California. Each participant was vaccinated with the Pfizer mRNA COVID-19 vaccine (BNT 162b2) following the FDA recommendations (2 injections 3 weeks apart). All subjects had blood drawn on day 0 (1st vaccine), day 7, day 21 (2nd vaccine), day 28, and day 90. Subjects were randomly assigned to either the control group or the OMT intervention arm, who received a session of OMT the day of and the day after each administration of the vaccines. The OMT protocol consisted of myofascial release of the thoracic inlet, pectoral traction, diaphragm release with MFR, splenic pump, and thoracic pump. Each technique was administered over a one-minute time frame. Participants were compensated with a nominal gift card per blood draw.

Descriptive statistics were used to determine if randomization was valid and if the two groups were similar. Blood was drawn, and plasma was biobanked. The Abbott AdviseDx SARS-CoV-2 IgG II assay was used to measure the anti-spike IgG immunoglobulin titer. Some subjects were found to have detectable anti-spike IgG titer (AS IgG) on the initial blood draw, prior to the first vaccine injection, suggesting previous exposure to SARS CoV-2. Therefore, the population was further stratified to account for pre-exposure. Participants were contacted by phone once a week and surveyed for potential side effects and medication use. These data were analyzed using nonparametric Mann-Whitney statistical analyses, and all statistical analysis was done using SPSS (v28). This research study was approved by WesternU IRB committee, protocol # FB21/IRB026.

Data Analysis: 104 participants were recruited and 91 were retained throughout the duration of the study. Demographic data of the participants enrolled shows a diverse population representative of the Pomona, CA community. 41 participants are male (45.1%), and 50 participants are female (54.9%). The participants in the study identified themselves as Hispanic (59.3%), Non-Hispanic White (18.7%), Asian/Pacific Islander (13.1%), Black (5.5%), and American Indian (3.3%). The experimental group age ranges from 19 to 61 years old (median: 30 years old) with 59.1% females and the control group age is 18 to 63 years old (median: 32 years old) with 53.2% females. Reported side effects and medication usage after each of the vaccines have been very similar between the two groups with no significant differences identified for any reported side effects (p>0.1). The population was stratified based upon AS IgG measured in the first blood draw before the 1st vaccination into 2 groups: previously exposed to SARS-CoV-2, and naive to COVID-19. The initial blood draw titer is similar in the OMT or non-OMT arm whether or not you are previously exposed to COVID-19 (852 ± 154 AU/mL OMT, 2132 ± 803 AU/mL non-OMT) or not (undetectable in both groups). In the group naive to COVID-19, the AS IgG rises after the second vaccine injection and peaks one week after the 2nd injection (34804 ± 6622 AU/mL, OMT group, 26144 ± 3986 AU/mL, Non-OMT group). In the group that was previously exposed to COVID-19, the AS IgG rises immediately after the 1st injection and also peaks one week after the 2nd injection (69700 ± 10630 AU/mL OMT group, 54929 ± 9957 AU/mL Non-OMT group). For each time point in all groups, the average AS IgG in patients who received OMT is higher compared to those in the control group. Two-way ANOVA analysis showed statistical significance (p <0.001) when comparing titer 1 week after 2nd injection in the population naive to previous COVID-19 infection.

Results: 104 participants were recruited and 91 were retained throughout the duration of the study. Demographic data of the participants enrolled shows a diverse population representative of the Pomona, CA community. 41 participants are male (45.1%), and 50 participants are female (54.9%). The participants in the study identified themselves as Hispanic (59.3%), Non-Hispanic White (18.7%), Asian/Pacific Islander (13.1%), Black (5.5%), and American Indian (3.3%). The experimental group age ranges from 19 to 61 years old (median: 30 years old) with 59.1% females and the control group age is 18 to 63 years old (median: 32 years old) with 53.2% females. Reported side effects and medication usage after each of the vaccines have been very similar between the two groups with no significant differences identified for any reported side effects (p>0.1). The population was stratified based upon AS IgG measured in the first blood draw before the 1st vaccination into 2 groups: previously exposed to SARS-CoV-2, and naive to COVID-19. The initial blood draw titer is similar in the OMT or non-OMT arm whether or not you are previously exposed to COVID-19 (852 ± 154 AU/mL OMT, 2132 ± 803 AU/mL non-OMT) or not (undetectable in both groups). In the group naive to COVID-19, the AS IgG rises after the second vaccine injection and peaks one week after the 2nd injection (34804 ± 6622 AU/mL, OMT group, 26144 ± 3986 AU/mL, Non-OMT group). In the group that was previously exposed to COVID-19, the AS IgG rises immediately after the 1st injection and also peaks one week after the 2nd injection (69700 ± 10630 AU/mL OMT group, 54929 ± 9957 AU/mL Non-OMT group). For each time point in all groups, the average AS IgG in patients who received OMT is higher compared to those in the control group. Two-way ANOVA analysis showed statistical significance (p <0.001) when comparing titer 1 week after 2nd injection in the population naive to previous COVID-19 infection.

Conclusion: No significant differences were observed between the two groups regarding side effects or adverse events from vaccines or OMT. This indicates that OMT is safe when used adjunctively with COVID-19 mRNA vaccination. We also confirm that lymphatic pump OMT provided a trend that enhanced the vaccine’s efficacy as seen from the higher AS IgG measured in the experimental group compared to the control group over the three months duration of our study whether the participants were naive or not infected with COVID-19 at the time of the vaccination. Our study is underpowered to obtain statistical significance across all time points. A Future investigation should include a larger group of participants and should be confirmed using other immunizations such as Hepatitis B or other vaccinations. Future analysis of the biobank serum will also look at anti-nucleocapsid IgG to confirm previous COVID-19 infections. The inclusion of a true sham treatment arm (i.e. hand contact over the identified regions) could help the identification of a placebo effect. This study is ongoing, and each participant is followed for a period of one year. The experimental protocol has been amended to include the recommended booster and will now measure the effectiveness of OMT in participants who choose to receive it.

References

1. Polack FP, Thomas SJ, Kitchin N, Absalon J, et al. Safety and Efficacy of the BNT162b2mRNA Covid-19 Vaccine. N Engl J Med. 2020 Dec 31;383(27):2603-2615. doi:10.1056/NEJMoa2034577. Epub 2020 Dec 10.

2. Curran J, Dol J, Boulos L, et al. Transmission characteristics of SARS-CoV-2 variants of concern Rapid Scoping Review. medRxiv. Published online January 1, 2021:2021.04.23.21255515. doi:10.1101/2021.04.23.21255515

3. Jackson KM, Steele TF, Dugan EP, Kukulka G, Blue W, Roberts A. Effect of lymphaticand splenic pump techniques on the antibody response to hepatitis B vaccine: a pilotstudy. J Am Osteopath Assoc. 1998;98(3):155.

4. Khoury, D.S., et al. Neutralizing antibody levels are highly predictive of immune protection from symptomatic SARS-CoV-2 infection. Nature Medicine, 2021: p. 1-7.

5. Earle, K.A., et al. Evidence for antibody as a protective correlate for COVID-19 vaccines. Vaccine, 2021. 39(32): p. 4423-4428.

6. Noll DR, Degenhardt BF, Morley TF, et al. Efficacy of osteopathic manipulation as anadjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial. Osteopath Med Prim Care. 2010;4:2. doi:10.1186/1750-4732-4-2

Financial Disclosures: None reported

Support: We have received funding from the American Osteopathic Association (AOA), the American Academy of Osteopathy (AAO), the American Osteopathic Foundation (AOF), the Osteopathic Physicians & Surgeons of CA, the American College of Osteopathic Family Physicians (ACOFP) Education and Research Foundation, Western University of Health Sciences Intramural Funding, and Robert Hostoffer.

Ethical Approval: This study was reviewed by Western University of Health Sciences’ Institutional Review Board under Full Committee Review and received full approval on May 12, 2021. It was approved for again on April 18, 2022 with continuing review approval. IRB Reference #: FB21/IRB026.

Informed Consent: All participants were given informed consent forms to read and review before consenting to the study. All participants were given the chance to ask any questions, given the option to withdraw at any time, and signed the informed consent form before beginning participation in the study.

Poster No. *C-37

Abstract No. 100

Category: Clinical

Research Topic: Chronic Diseases & Conditions

Liver Normalized Local Variance and Liver/Kidney Ratio to Assess NAFLD: A Pictorial Essay

¹Joseph Jenkins, OMS-III; ¹Lauren Hagenstein; ²Jing Gao, MD, FAIUM

¹Rocky Vista University College of Osteopathic Medicine-Southern Utah; ²Departments Ultrasound in Research & Education, Rocky Vista University College of Osteopathic Medicine-Southern Utah

Statement of Significance: Non-alcoholic fatty liver disease (NAFLD) affects approximately 30% of adults in the United States, being even higher in some states nd populations. NAFLD is defined as a change in the tissue texture and function of the liver and is in many ways a manifestation of metabolic syndrome within the liver. With such a prevalent disease, there should be consideration as to what steps can be taken to improve its diagnosis and management. The current standards of diagnosis of NAFLD include biopsy and…

Research Methods: A retrospective analysis was conducted on the scans of 116 patients who underwent ultrasound, MRI-PDFF and labs test within 30 days. Participants were volunteers randomly enrolled in the local community. IRB approval was granted. All participants provided written informed consent at their initial enrollment. Ultrasound images stored in the scanner were analyzed by two student-researchers concurrently. Care was taken to avoid measurements that could result in inconsistency (for example, avoiding the measuring of capsule tissue when assessing the L/K ratio), and both student-researchers were to agree on the correct placement of the ROI for accepting the measurement. Three NLV and three L/K ratio images were analyzed for each patient. For NLV, the circle ROI, with a diameter of 4.0 cm, were at the depths of the capsule, and 6 cm and 10 cm from the surface of the skin. NLV value at depth of 8 cm was from the initial scan. The L/K ratio ROI’s, a circle withdiameter of 1.0 cm, were at depths of 6 cm, 8 cm, and 10 cm from the surface of the skin. The resulting measurements at each depth for the three scans were then averaged, providing us with a mean measurement at each depth. The mean measurement for each patient at each depth was then averaged and a standard deviation calculated, along with one-way analysis of variance (ANOVA). Measurements were then correlated to MRI-PDFF, and a two-tailed test was used to determine significance.

Data Analysis: The mean NLV with depths near the capsule, 6 cm., 8 cm, and 10 cm. were 1.1±0.14, 1.11±0.23, and 1.18±0.33, with standard deviations of 0.30±0.19, 0.34±0.23, and 0.47±0.33 respectively. ANOVA for both mean and standard deviation was <0.001. The mean L/K ratio with depths of 6 cm., 8 cm., and 10 cm. were 3.2±2.18, 1.76±1.06, and 1.09±0.68, with standard deviations of 1.67±1.13, 0.93±0.55, and 0.57±0.35 respectively. Like the analysis of variance of NLV, ANOVA for both the mean and standard deviation for L/K ratio was also <0.001. Where they differed was in the percentage of failure rate. The failure rate did not exceed 5.4% for NLV, which was found at a depth of 10 cm. However, the failure rate of L/K ratio was as high as 54%, found at a depth of 6 cm., and was lowest at 9%, found at 8 cm. Correlations of the mean NLV and MRI-PDFF near the capsule, at 6 cm., and at 10 cm. were -.52 (-.65/-.37), -.58 (-69/-.43), and -.44 (-.58/-.26) respectively. The 2-tailed significance test at each location was <0.001. Correlations of the mean L/K ratio and MRI-PDFF at 6 cm., 8 cm., and 10 cm. were -.19 (-.37/0.01), .31 (.12/.47), and .46 (.30/.60) respectively.

Results: The mean NLV with depths near the capsule, 6 cm., 8 cm, and 10 cm. were 1.1±0.14, 1.11±0.23, and 1.18±0.33, with standard deviations of 0.30±0.19, 0.34±0.23, and 0.47±0.33 respectively. ANOVA for both mean and standard deviation was <0.001. The mean L/K ratio with depths of 6 cm., 8 cm., and 10 cm. were 3.2±2.18, 1.76±1.06, and 1.09±0.68, with standard deviations of 1.67±1.13, 0.93±0.55, and 0.57±0.35 respectively. Like the analysis of variance of NLV, ANOVA for both the mean and standard deviation for L/K ratio was also <0.001. Where they differed was in the percentage of failure rate. The failure rate did not exceed 5.4% for NLV, which was found at a depth of 10 cm. However, the failure rate of L/K ratio was as high as 54%, found at a depth of 6 cm., and was lowest at 9%, found at 8 cm. Correlations of the mean NLV and MRI-PDFF near the capsule, at 6 cm., and at 10 cm. were -.52 (-.65/-.37), -.58 (-69/-.43), and -.44 (-.58/-.26) respectively. The 2-tailed significance test at each location was <0.001. Correlations of the mean L/K ratio and MRI-PDFF at 6 cm., 8 cm., and 10 cm. were -.19 (-.37/0.01), .31 (.12/.47), and .46 (.30/.60) respectively.

Conclusion: When diagnosing or monitoring a patient with NAFLD using ultrasound, there are technical considerations that should be taken into account. One of these considerations is the depth of the ROI when measuring NLV and L/K ratio. For example, despite demonstrating statistically significant ANOVA, L/K ratio had a poor reliability when measured at 6 cm. due to its failure rate of 54%. When compared to MRI-PDFF, the L/K ratio at the same depth also showed the lowest significance, with a 2-tailed test of 0.04. However, the ROI’s at depth of 8 cm. and 10 cm. for L/K ratio were both statistically significant, with more acceptable failure rates (9% and 16% respectively), and statistically significant 2-tailed t tests. Due to low standard deviations, low failure rates, low variance, and strong correlations to MRI-PDFF, NLV measurements can confidently be taken at any of the depths discussed in this study. With such strong correlations to the gold standard for NAFLD diagnosis, medical professionals can more strongly consider using ultrasound measurements like L/K ratio, and especially NLV, in the diagnosis and management of their NAFLD patients. Due to the lower cost and higher availability of ultrasound when compared to MRI-PDFF (among other benefits of US), this could positively affect current health disparities, more quickly identify disease, and improve disease management as objective progress can be monitored and tracked for quality healthcare.

Financial Disclosures: None reported

Support: Canon Medical Systems USA supported the study- Research fund and equipment

Ethical Approval: IRB#2019-0009

Informed Consent: All participants provided written informed consent at their initial enrollment.

Poster No. *C-38

Abstract No. 76

Category: Clinical

Research Topic: Health Disparities-Social Determinants of Health

Why Not Breastfeed? Identifying Barriers to Breastfeeding and the Effectiveness of Antenatal Breastfeeding Education in a Rural Hospital in Southeastern United States

¹Ankita Mishra, OMS-IV; ²Axita Patel, DO, PGY-4; ²Natalia Sopiarz, DO, PGY-4

¹Cape Fear Valley; ²Department of Ob-Gyn Cape Fear Valley Hospital

Statement of Significance: The American Academy of Pediatrics recommends exclusive breastfeeding for six months, as it is the best source of nutrition for infants. Breastfed infants have reduced risk of otitis media, respiratory tract infections, and gastroenteritis. Breastfeeding mothers have decreased postpartum blood loss and are less likely to develop postpartum depression, ovarian cancer, breast cancer, and type 2 diabetes. Despite this, many mothers in America do not breastfeed, especially younger mothers.

Research Methods: An anonymous fourteen item survey was administered to all obstetric patients in a rural Southeastern United States hospital affiliated Obstetrics and Gynecology visit presenting at their initial prenatal visit. The fourteen-item survey included questions regarding demographic information, previous attempts at breastfeeding in prior pregnancies, reasons for early discontinuation of breastfeeding, plans of breastfeeding after her current pregnancy, knowledge of the benefits of breastfeeding to mother and newborn. In addition to this, an educational intervention in the form of a pamphlet was provided that included information regarding the benefits of breastfeeding to mother and baby, barriers that women often face in breastfeeding, and local resources to overcome those barriers. Questions in changes in perception and awareness of breastfeeding benefits were included in the survey to assess change after educational intervention. A total of 136 surveys were administered between March and May of 2022. Staff at the Obstetrics and Gynecology office will be involved with data collection as well as pamphlet and survey distribution. No protected health information will be gathered on survey participants. Patient’s privacy was protected through anonymity of survey. Data will be collected on a secure CFV server with access granted to investigators only. The variables that were studied were history of breastfeeding, knowledge of benefits of breastfeeding, prior success with breastfeeding. Descriptive data analysis was conducted in association with Campbell University School of Osteopathic Medicine’s Department of Biostatistics. The significance of this research is related to the osteopathic tenet regarding the body being a unit and the person a unit of body, mind, and spirit. By understanding the specific barriers that the population we serve face that limit their success in breastfeeding, we can understand our population better to serve their mind, body, and spirit.

Data Analysis: A total of 136 respondents were included in the study. Most respondents were between pregnant females between the ages of 21-30 years old, specifically 75 respondents. Most respondents planned on both breastfeeding and bottle feeding, 38.2%. However, 36.8% of patients planned on breastfeeding exclusively. Furthermore, the majority of respondents, 79 respondents, were bottle fed as infants. Most respondents had attempted breastfeeding after prior pregnancies (52.2%); however, the majority were non-successful (54.9%). When noting reasons why they were not successful at breastfeeding previously, most patients cited issues with lactation (7.4%), effort associated with pumping milk (2.9%), and lack of physical facilities for breastfeeding as the barriers to their success (4.3%). After reading the educational pamphlet provided as prompted after question 9 in the questionnaire, most patients (90.4%) agreed that breastfeeding has numerous health benefits for mother and baby. Furthermore, most respondents reported improved understanding of the resources that are present locally to support them and their newborn (90.6%). 66.9% of respondents were more inclined to breastfeed their newborn after delivery, whereas 28.7% of respondents reported wanting to bottle feed.

Results: A total of 136 respondents were included in the study. Most respondents were between pregnant females between the ages of 21-30 years old, specifically 75 respondents. Most respondents planned on both breastfeeding and bottle feeding, 38.2%. However, 36.8% of patients planned on breastfeeding exclusively. Furthermore, the majority of respondents, 79 respondents, were bottle fed as infants. Most respondents had attempted breastfeeding after prior pregnancies (52.2%); however, the majority were non-successful (54.9%). When noting reasons why they were not successful at breastfeeding previously, most patients cited issues with lactation (7.4%), effort associated with pumping milk (2.9%), and lack of physical facilities for breastfeeding as the barriers to their success (4.3%). After reading the educational pamphlet provided as prompted after question 9 in the questionnaire, most patients (90.4%) agreed that breastfeeding has numerous health benefits for mother and baby. Furthermore, most respondents reported improved understanding of the resources that are present locally to support them and their newborn (90.6%). 66.9% of respondents were more inclined to breastfeed their newborn after delivery, whereas 28.7% of respondents reported wanting to bottle feed.

Conclusion: The purpose of this study was to elucidate that gaps in care that may be evident in supporting women who want to breastfeed. The results indicated that most women were previously unsuccessful in breastfeeding due to issues with lactation and lack of physical facilities for breastfeeding. These findings are concordant with those found on the national level through research conducted by the Centers of Disease Control. The respondents of this study were primarily 2- to 30-year-old pregnant women who were bottle fed as infants. It should be noted that this is the population of women that had the lowest breastfeeding rates nationally. Furthermore, despite being bottle fed, majority of respondents were inclined to breastfeed after their pregnancy. Our educational pamphlet proved beneficial, as questions after administration of this educational intervention revealed increased inclination to breast feed, improved awareness on the benefits of breastfeeding for mother and baby, and the importance of a well-balanced diet while breastfeeding. Our research accomplished the goal of educating the population that was studied while also understanding the barriers they face in successful breastfeeding. Further investigation is warranted on whether mode of delivery impacts a women’s inclination to breastfeed versus bottle-feeding, as cesarean section rates increase as breastfeeding rates decrease in developed countries like the United States of America.

References

1. American Academy of Pediatrics. Section on Breastfeeding. Breastfeeding and the Use of Human Milkexternal icon Pediatrics. 2012;129(3):e827-841. DOI 2011-3552. Accessed August 24, 2021.

2. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. (2021, August 24). Breastfeeding Facts. Centers for Disease Control and Prevention. Retrieved November 25, 2021, from https://www.cdc.gov/breastfeeding/data/facts.html.

3. Beake S, Bick D, Narracott C, Chang YS. Interventions for women who have a caesarean birth to increase uptake and duration of breastfeeding: A systematic review. Matern Child Nutr. 2017;13(4):e12390. doi:10.1111/mcn.12390

4. Li R, Fein SB, Chen J, Grummer-Strawn LM. Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics. 2008;122 Suppl 2:S69-S76. doi:10.1542/peds.2008-1315i

5. Tang K, Gerling K, Chen W, Geurts L. Information and Communication Systems to Tackle Barriers to Breastfeeding: Systematic Search and Review. J Med Internet Res. 2019;21(9):e13947. Published 2019 Sep 27. doi:10.2196/13947

6. Cohen SS, Alexander DD, Krebs NF, et al. Factors Associated with Breastfeeding Initiation and Continuation: A Meta-Analysis. J Pediatr. 2018;203:190-196.e21. doi:10.1016/j.jpeds.2018.08.008

7. Sayres S, Visentin L. Breastfeeding: uncovering barriers and offering solutions. Curr Opin Pediatr. 2018;30(4):591-596. doi:10.1097/MOP.0000000000000647

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: IRB Exempt

Informed Consent: None applicable.

Poster No. C-39

Abstract No. 109

Category: Clinical

Research Topic: Chronic Diseases & Conditions

High Folate Level and Vitamin B12 Deficiency in Neurological Pathologies: Knocking Down the Misdiagnosis Barrier

¹Jenny Song, DO; ²Olivia Wilkins, OMS IV; ²Eric Kwo, DO; ²Tricia Hall, DO; ²Michael Waddington, DO

¹Eastern Connecticut Health Network; ²Neuromuscular Medicine SpecialistsManchester Memorial Hospital

Statement of Significance: Vitamin B12 (cobalamin) deficiency is associated with degradation of the myelin sheath and damage to nerves. Prior studies have found that high serum folate levels during vitamin B12 deficiency can worsen cognitive symptoms associated with the deficiency [1]; and elevated folate levels can mask the anemia associated with vitamin B12 deficiencies, making vitamin B12 deficiencies harder to diagnose [2].

Research Methods: This is a prospective observational study conducted at the Neuromuscular Medicine Specialists Clinic of Manchester Memorial Hospital. No randomization has been utilized in this study. Vitamin B12 supplementation is administered to patients with borderline normal B12 levels in serum or plasma (between ∼200 to 250 pg/mL) and simultaneous elevated folate levels (normal range for adults: 140-628 ng/mL), while presenting with neurological symptoms. This study incorporates the nutritional and neurological models of osteopathic philosophy. Diet is a vital part of health maintenance and metabolism within the body. The recommended dietary allowance (RDA) of vitamin B12 is 2.4 µg/d. Vitamin B12 deficiency in elderly adults ranges from 5 to 20%, usually due to atrophic gastritis (which becomes more prevalent as one ages, as gastric acid production diminishes).[1] Abnormalities in nutritional status can result in physical and neurologic manifestations due to the interconnectivities of the human body. The aim is to recruit about 100 patients in total for the study and perform statistical analyses using Spearman correlation and ANOVA variance analysis (via the IBM SPSS Statistics Software) to delineate the relationship between B12 and folic acid levels before and after B12 supplementation, as well as characterize the role of B12 supplementation on amelioration of neurological symptoms.

Data Analysis: Vitamin B12 (cobalamin) deficiency is associated with multiple neurologic conditions including subacute combined degeneration, dementia, peripheral neuropathy, and paralysis. Multiple causes may lead to the development of vitamin B12 deficiency, including malnutrition, pernicious anemia, gastrointestinal disease, and prior gastrointestinal surgery. Two clinic patients have been recruited to the study to date. They both experienced neurologic symptoms commonly associated with vitamin B12 deficiency including dementia and peripheral neuropathy. The peripheral neuropathy was isolated to the soles of the feet for one patient and to the lower lumbar region and bilateral legs for the second patient. The patients were elderly and suffer from cognitive decline from unspecified dementia, had no other neurologic history, no previous diagnosis of diabetes, and no degenerative spinal disease. The patients reported maintaining western diets including high amounts of processed foods and regularly taking OTC multivitamin supplements. Laboratory testing revealed the vitamin B12 levels to veer toward the lower end of normal (between 200 and 250 pg/ml), accompanied by elevated folate (>630 ng/ml) levels. Additional laboratory testing performed to rule out other comorbidities, such diabetes, iron deficiency anemia, rheumatological diseases, osteogenic disorders, thyro-genic causes, or Lyme disease, that could potentially result in the patients’ peripheral neuropathies, included anti-nuclear antibody, complete blood count, comprehensive metabolic panel, calcium, magnesium, phosphorus, thyroid stimulating hormone, hemoglobin A1C, Lyme disease titer, and venous blood lead levels, all of which were unremarkable. Vitamin B12 supplementation has been prescribed for both patients, and one of the two patients has reported a decrease in the paresthesia of his lower extremities. Continued longitudinal monitoring of both patients as well as recruitment of qualified subjects will ensue.

Results: Vitamin B12 (cobalamin) deficiency is associated with multiple neurologic conditions including subacute combined degeneration, dementia, peripheral neuropathy, and paralysis. Multiple causes may lead to the development of vitamin B12 deficiency, including malnutrition, pernicious anemia, gastrointestinal disease, and prior gastrointestinal surgery. Two clinic patients have been recruited to the study to date. They both experienced neurologic symptoms commonly associated with vitamin B12 deficiency including dementia and peripheral neuropathy. The peripheral neuropathy was isolated to the soles of the feet for one patient and to the lower lumbar region and bilateral legs for the second patient. The patients were elderly and suffer from cognitive decline from unspecified dementia, had no other neurologic history, no previous diagnosis of diabetes, and no degenerative spinal disease. The patients reported maintaining western diets including high amounts of processed foods and regularly taking OTC multivitamin supplements. Laboratory testing revealed the vitamin B12 levels to veer toward the lower end of normal (between 200 and 250 pg/ml), accompanied by elevated folate (>630 ng/ml) levels. Additional laboratory testing performed to rule out other comorbidities, such diabetes, iron deficiency anemia, rheumatological diseases, osteogenic disorders, thyro-genic causes, or Lyme disease, that could potentially result in the patients’ peripheral neuropathies, included anti-nuclear antibody, complete blood count, comprehensive metabolic panel, calcium, magnesium, phosphorus, thyroid stimulating hormone, hemoglobin A1C, Lyme disease titer, and venous blood lead levels, all of which were unremarkable. Vitamin B12 supplementation has been prescribed for both patients, and one of the two patients has reported a decrease in the paresthesia of his lower extremities. Continued longitudinal monitoring of both patients as well as recruitment of qualified subjects will ensue.

Conclusion: Vitamin B12 ensures the adequate functioning of the heart, brain, and nerves, making B12 deficiency a cause of concern for irreversible nerve damage. Studies have also found that a high blood folate level, when coupled to B12 deficiency, also expedites the progression of age-related dementia in elderly patients. This is seen in our recruited subjects and highlights the potential detrimental effect of undetected B12 deficiency in cognitive function [3,4]. While a deficiency of folate can cause similar neurological pathologies, folate elevations in blood has been shown to mask the B12-induced megaloblastic anemia. Although the most common test for B12 deficiency is blood levels, where folate supplementation is used, B12 level should be determined, and deficiency corrected. There exist other tests used to measure B12 level in cases of elevated folate. This includes serum methylmalonic acid (MMA) level-- a B12-associated metabolite, which can preclude misdiagnosis of B12 deficiency due to the masking effect of high folate. MMA levels greater than 0.271 µmol/L indicates B12 deficiency [5]. Total plasma homocysteine level shares an inversely reciprocal relationship to the B12 level. Serum homocysteine levels of >15 µ/L may suggest B12 deficiency [5]. However, both markers are affected by renal function and age. Limitations of our data collection includes the limited sample size and sample bias of the neuromuscular specialty clinic. Our study highlights the correlation between elevated folate levels and the degree of B12 deficiency, and the presence and severity of neurological symptomology, before and after prescribed vitamin B12 supplementation. The goal is to educate the medical community on this commonly misdiagnosed condition; reduce the misdiagnosis of folate-masked vitamin B12 deficiency, ultimately preventing delay in treatment, irreversible nerve damage, and incidences of unnecessary workup and treatments in neuropathologic disorders caused by this etiology.

References

1. Johnson MA. If high folic acid aggravates vitamin B12 deficiency what should be done about it? Nutr Rev. 2007 Oct;65(10):451-8. doi: 10.1111/j.1753-4887.2007.tb00270.x. PMID: 17972439

2. Cuskelly GJ, Mooney KM, Young IS. Folate and vitamin B12: friendly or enemy nutrients for the elderly. Proc Nutr Soc. 2007 Nov;66(4):548-58. doi: 10.1017/S0029665107005873. PMID: 17961276.

3. Bailey, R. L., Jun, S., Murphy, L., Green, R., Gahche, J. J., Dwyer, J. T., Potischman, N., McCabe, G. P., & Miller, J. W. (2020). High folic acid or folate combined with low vitamin B-12 status: Potential but inconsistent association with cognitive function in a nationally representative cross-sectional sample of US older adults participating in the nhanes. The American Journal of Clinical Nutrition, 112(6), 1547–1557. https://doi.org/10.1093/ajcn/nqaa239

4. Moore, E. M., Ames, D., Mander, A. G., Carne, R. P., Brodaty, H., Woodward, M. C., Boundy, K., Ellis, K. A., Bush, A. I., Faux, N. G., Martins, R. N., Masters, C. L., Rowe, C. C., Szoeke, C., & Watters, D. A. (2014). Among vitamin B12 deficient older people, high folate levels are associated with worse cognitive function: Combined Data from three cohorts. Journal of Alzheimer’s Disease, 39(3), 661–668. https://doi.org/10.3233/jad-131265

5. U.S. Department of Health and Human Services. (n.d.). Office of dietary supplements - vitamin B12. NIH Office of Dietary Supplements. Retrieved July 17, 2022, from https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This is a prospective observational study, the data collected for this study does not contain any Health Insurance Portability and Accountability Act of 1996 (HIPAA) identifiers. Based on the Manchester Memorial Hospital’s Institutional Review Committee criteria for human subjects research, this type of research project does not meet criteria to be considered human subjects research. Since this is not considered human subjects research, the project does not require Institutional Review Committee review.

Informed Consent: This is a prospective observational study that does not meet the Manchester Memorial Hospital criteria for human subjects research. As a result, no informed consent process is required for this research project.

★ Poster No. *H-1

Abstract No. 4

Category: Health Services

Research Topic: Osteopathic Philosophy

Utilization and Reimbursement Trends of Osteopathic Manipulative Treatment for Medicare Patients: 2000-2019

¹Evan Starr, OMS-III; ²Jacob F. Smith, MS III; ³Romney B Hanson, OMS III; ⁴Jonathan B Woolstenhulme, OMS III; ⁵Andrew J. Roush, OMS III; ⁵Nathan B Sperry, OMS III; ⁵Benjamin Wilde, DO; ⁵Amanda Brooks, PhD; ⁵Isain Zapata, PhD ¹Rocky Vista University College of Osteopathic Medicine-Colorado; ²Department of Biomedical Sciences, Mayo Clinic Alix School of Medicine; ³Department of Biomedical Sciences, University of Colorado School of Medicine; ⁴Department of Biomedical Sciences, University of Utah School of Medicine; ⁵Department of Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine-Colorado

Statement of Significance: The application of Osteopathic Manipulative Treatment (OMT) is unique to osteopathic physicians as a noninvasive and beneficial treatment modality (1-3). The proportion of osteopathic physicians of total physicians, both allopathic (MD) and osteopathic (DO), has increased from 6.9% of the total workforce to 9.9% from 2010-2020 (4). With increased representation of osteopathic physicians in the physician workforce, we expect that the number of OMT claims would increase proportionally.

Research Methods: OMT utilization data among Medicare patients from the Part B National Summary Data File on Centers for Medicare and Medicaid Services’ website for the years 2000 through 2019 was accessed. The Healthcare Common Procedure Coding System codes 98925-98929 were used to identify OMT procedures. OMT procedures are billed based on the number of body regions treated, ranging from 0-10 regions, with no more than one billed code allowed per day (5). These codes are for 1-2, 3-4, 5-6, 7-8, and 9-10 body regions treated. The data evaluated included “allowed services” or total billing volume in the calendar year, and “allowed charges” which is the payment total disbursed by Medicare in the calendar year.

Average reimbursement per-code-billed was determined by dividing the allowed charges by the allowed services. Reimbursement data was adjusted for inflation using the CPI Inflation Calculator using the buying power for December 31 of each respective year relative to January 1, 2022 (6). Service volume data was adjusted for the total number of Medicare enrollees using data from cms.gov and census.gov (7,8) to obtain the ratio of OMT codes billed per 10,000 Medicare beneficiaries. All data was evaluated descriptively based on their frequencies and proportions.

Data Analysis: From 2000 to 2019, the total usage of OMT claims had a negative trend. Proportional comparisons of 2000 to 2019 demonstrated a -24.46% change. The only increase in utilization was observed in the 5-year interval from 2000-2004 followed by a decrease in utilization in all other intervals. A constant decrease in utilization of 1-2 (-63.8%), 3-4 (-44.0%), and 5-6 (-11.8%) body regions treated was observed. Utilization of 7-8 (+45.0%) and 9-10 (+88.9%) increased.

Reimbursement by Medicare declined for all 5 treatments, with codes representing more body regions showing a smaller decrease compared to codes representing fewer body systems. A decrease in reimbursement was found for treatment of 1-2 (-25.6%), 3-4 (-25.3%), 5-6 (-20.7%), 7-8 (-17.1%), 9-10 (-12.5%) body regions. The adjusted sum reimbursement of all codes showed a decrease of -23.2%, which equates to $11.24 on average.

Results: From 2000 to 2019, the total usage of OMT claims had a negative trend. Proportional comparisons of 2000 to 2019 demonstrated a -24.46% change. The only increase in utilization was observed in the 5-year interval from 2000-2004 followed by a decrease in utilization in all other intervals. A constant decrease in utilization of 1-2 (-63.8%), 3-4 (-44.0%), and 5-6 (-11.8%) body regions treated was observed. Utilization of 7-8 (+45.0%) and 9-10 (+88.9%) increased.

Reimbursement by Medicare declined for all 5 treatments, with codes representing more body regions showing a smaller decrease compared to codes representing fewer body systems. A decrease in reimbursement was found for treatment of 1-2 (-25.6%), 3-4 (-25.3%), 5-6 (-20.7%), 7-8 (-17.1%), 9-10 (-12.5%) body regions. The adjusted sum reimbursement of all codes showed a decrease of -23.2%, which equates to $11.24 on average.

Conclusion: These trends indicate a shift from providing treatment on fewer body regions per visit to providing treatment to a larger number of body regions per session. A potential justification for this trend appears when comparing reimbursements, which revealed a greater decrease for lower numbers of body regions treated. We conjecture that lower remuneration for OMT has disincentivized physicians financially and contributed to the overall decline in OMT utilization among Medicare patients. It is also possible that physicians are increasing the comprehensive usage of OMT treatment of more body regions, thus justifying the use of higher-level codes, and reducing the overall financial impact of OMT reimbursement cuts.

Limitations for this study include Medicare being this study’s sole source of volume and reimbursement data. Medicare is the single largest insurance payer in the United States and its beneficiaries represent an older population. Due to the complexity of their care, physicians may prioritize other exams or treatments over OMT thus decreasing its utilization in this specific population. Clinicians may also be limited by financial constraints when accepting or providing care to Medicare beneficiaries.

This study’s focus on OMT does not reveal whether similar decreases in compensation from Medicare exist in non-osteopathic treatment modalities in similar primary care settings. Future research should examine these trends and be compared to the steady decline in reimbursement for OMT. The proven efficacy of OMT should prompt advocacy for sustainable and fair reimbursement.

References

1. Dal Farra, Fulvio et al. Effectiveness of osteopathic interventions in chronic non-specific low back pain: A systematic review and meta-analysis. Complementary therapies in medicine vol. 56 (2021): 102616. doi:10.1016/j.ctim.2020.102616

2. Cerritelli, Francesco et al. Clinical effectiveness of osteopathic treatment in chronic migraine: 3-Armed randomized controlled trial. Complementary therapies in medicine vol. 23,2 (2015): 149-56. doi:10.1016/j.ctim.2015.01.011

3. Müller, Axel, Franke, Helge, Resch, Karl-Ludwig and Fryer, Gary. Effectiveness of Osteopathic Manipulative Therapy for Managing Symptoms of Irritable Bowel Syndrome: A Systematic Review. Journal of Osteopathic Medicine, vol. 114, no. 6, 2014, pp. 470-479. https://doi.org/10.7556/jaoa.2014.098

4. Young A, Chaudhry H, Pei X, Arnhart K, Dugan M, Simons K. FSMB Census of Licensed Physicians in the United States, 2020. Federation of State Medical Boards. 107(2):57-64. Accessed April 30, 2022. https://www.fsmb.org/siteassets/advocacy/publications/2020-physician-census.pdf

5. James S, Johannes J, Novak C. Demystifying Documentation and Billing for Osteopathic Manipulative Treatment. Family Practice Management. 2021;28(3):18+. Accessed April 20, 2022. https://www.aafp.org/fpm/2021/0500/fpm20210500p18.pdf

6. U.S. Bureau of Labor Statistics. CPI Inflation Calculator. https://www.bls.gov/data/inflation_calculator.htm

7. Centers for Medicare and Medicaid Services. CMS Medicare Total Enrollment 2013-2020. https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/medicare-and-medicaid-reports/medicare-total-enrollment

8. U.S. Census Bureau. Census Medicare Enrollment 1966-2013. https://www.census.gov/history/pdf/medicare1966-2013.pdf

Financial Disclosures: None reported

Support: None reported

Ethical Approval: Due to the public nature of the data, IRB approval was not needed

Informed Consent: None required

Poster No. *H-2

Abstract No. 6

Category: Health Services

Research Topic: Musculoskeletal Injuries and Prevention

Effect of Movement-Based Pelvic Health Intervention on Knowledge Acquisition and Exercise Adherence

¹Anna Dold, OMS-II; ¹Kara La Gorio, OMS IV; ²Alexis Kendrick, PT, DPT, EdD; ²LaVona Traywick, PhD

¹Arkansas College of Osteopathic Medicine; ²Department of Physical Therapy, Arkansas Colleges of Health Education, Arkansas College of Osteopathic Medicine

Statement of Significance: An approach to treating pelvic floor dysfunctions is using movements to target the musculature of the pelvis.[1,2,3] Effective treatment for pelvic floor dysfunctions is dependent on patients’ consistent adherence to the regimen.[1] Online modalities are useful to educate patients remotely and to approach sensitive topics like pelvic health.[2,3] This study examines a virtual movement-based pelvic health educational intervention and its impact on knowledge acquisition and exercise adherence.

Research Methods: This study recruited participants from the western region of Arkansas via social media and newsletters. The study consisted of an online pretest, a live-virtual intervention, an immediate posttest, and a one-month follow-up questionnaire with an optional interview. The one-hour movement-based educational intervention was led three different times by a pelvic health physical therapist who integrated information about pelvic floor health during the demonstration of various movements.

The pre, post and follow-up questionnaires determined participants’ general pelvic health knowledge with overactive/underactive pelvic floor dysfunctions. Data was analyzed using a repeated measures ANOVA. Participants that did not complete all three questionnaires were excluded.

The pretest and follow-up questionnaires included additional questions regarding adherence to pelvic floor exercises. Confidence in performing the exercises was assessed in the posttest and follow-up questionnaires. Adherence and confidence at each time point were compared using a paired t-test.

The first eight volunteers with scheduling availability were individually interviewed (virtually or in-person) by an osteopathic medical student approximately one month post intervention. The open-ended questions regarded overall experience, learning acquisition, and implementation of session information. The audio was recorded, transcribed, and analyzed for themes.

This study analyzed participants’ knowledge acquisition and exercise adherence in response to a movement-based pelvic health educational intervention that can be applied clinically by providers communicating treatment plans for pelvic health dysfunctions. A treatment plan must account for the individual needs of patients to optimize knowledge and adherence. It is within the responsibility of an osteopathic physician to ensure comprehension and adherence to treatment is achievable to implement the basic principles of body unity.

Data Analysis: The 24 female participants were between the ages of 30 and 69 with over 90% being White and highly educated (at least a bachelor’s degree). Twenty-one of the participants completed the posttest and 20 participants completed the follow-up questionnaire one month later. Analysis of the 20 participants that completed all three questionnaires indicated that scores showed a statistically significant increase (p<0.001) from the pretest mean score of 70.2% to the posttest mean of 95.3%. The follow-up questionnaire had an overall mean of 93.7%, also a significant increase (p<0.001) compared to the pretest. No significant difference was indicated between the posttest and follow-up questionnaire. Furthermore, subcategory scores of general pelvic health knowledge, underactive dysfunctions, and overactive dysfunctions increased from the pretest to posttest and from pretest to follow-up questionnaire. No significant difference was found in any subcategory from the posttest to the one-month follow-up.

There was no statistical difference in the overall confidence mean score of participants from posttest (2.9) to the follow-up questionnaire (1.4).

No statistical difference was found in number of pelvic exercises participants were performing preintervention in comparison to one month later, with means of 15.3 and 15.7 respectively.

Participants were interviewed one month following the intervention until saturation was reached. Thematic analysis of the eight transcribed interviews indicated that participants found learning about pelvic health a positive experience regardless of prior apprehensions about the topic. Many participants described having learned new information that built on their previous knowledge or yoga backgrounds. All participants demonstrated knowledge acquisition by stating something they learned and defining normal or abnormal pelvic health functioning. Participants also expressed wanting more information and specific direction for implementation.

Results: The 24 female participants were between the ages of 30 and 69 with over 90% being White and highly educated (at least a bachelor’s degree). Twenty-one of the participants completed the posttest and 20 participants completed the follow-up questionnaire one month later. Analysis of the 20 participants that completed all three questionnaires indicated that scores showed a statistically significant increase (p<0.001) from the pretest mean score of 70.2% to the posttest mean of 95.3%. The follow-up questionnaire had an overall mean of 93.7%, also a significant increase (p<0.001) compared to the pretest. No significant difference was indicated between the posttest and follow-up questionnaire. Furthermore, subcategory scores of general pelvic health knowledge, underactive dysfunctions, and overactive dysfunctions increased from the pretest to posttest and from pretest to follow-up questionnaire. No significant difference was found in any subcategory from the posttest to the one-month follow-up.

There was no statistical difference in the overall confidence mean score of participants from posttest (2.9) to the follow-up questionnaire (1.4).

No statistical difference was found in number of pelvic exercises participants were performing preintervention in comparison to one month later, with means of 15.3 and 15.7 respectively.

Participants were interviewed one month following the intervention until saturation was reached. Thematic analysis of the eight transcribed interviews indicated that participants found learning about pelvic health a positive experience regardless of prior apprehensions about the topic. Many participants described having learned new information that built on their previous knowledge or yoga backgrounds. All participants demonstrated knowledge acquisition by stating something they learned and defining normal or abnormal pelvic health functioning. Participants also expressed wanting more information and specific direction for implementation.

Conclusion: The results of the study support participants having greater knowledge of general pelvic health and pelvic related dysfunctions after the movement-based educational session. Participants reported being confident in their ability to perform the movements after the intervention but did not display a change in adherence to the pelvic exercises. The interviews supported the conclusion that the participants had a greater knowledge of pelvic health after the session that helped them establish normal functioning, but they described a need for more information to further implement exercises into their daily lives.

This study showed alternative means of patient education is effective; however, participants’ knowledge acquisition is not enough for change in behavior. The interview results helped explain the lack of adherence to pelvic floor exercises as participants expressed wanting more information and direction for implementation. This is consistent with the current literature that finds specific treatment plans for exercise have greater adherence. Future studies could include specific instructions for daily implementation to attempt to improve pelvic health exercise adherence.

References

1. Navarro-Brazález B, Vergara-Pérez F, Prieto-Gómez V, Sánchez-Sánchez B, Yuste-Sánchez MJ, Torres-Lacomba M. What Influences Women to Adhere to Pelvic Floor Exercises after Physiotherapy Treatment? A Qualitative Study for Individualized Pelvic Health Care. J Pers Med. 2021;11(12):1368. doi:10.3390/jpm11121368

2. Morrison C, Pereira A, Masuda K, Bargstadt-Wilson K, Peterson J, Snyder K. From the Core to the Floor—Utilizing a Webinar to Provide Pelvic Health Education. J Womens Health Phys Therap. 2022;46(2):95-99. doi:10.1097/JWH.0000000000000225

3. Sjöström M, Umefjord G, Stenlund H, Carlbring P, Andersson G, Samuelsson E. Internet-based treatment of stress urinary incontinence: a randomised controlled study with focus on pelvic floor muscle training. BJU Int. 2013;112(3):362-372. doi:10.1111/j.1464-410x.2012.11713.x

Financial Disclosures: None Reported.

Support: Supported by an ACHE Internal Grant. The eight interviewed participants received a yoga mat as compensation.

Ethical Approval: This study was approved by the Institutional Review Board at Arkansas Colleges of Health Sciences. ID: PT-2021-009 approved on August 26, 2021.

Informed Consent: Participants of this study electronically signed written informed consent.

Poster No. *H-3

Abstract No. 8

Category: Health Services

Research Topic: Health Disparities-Social Determinants of Health

Psychiatric CPT Code Trends in Medicare Patients: 2013-2020

¹Steven Gawrys, Jr., OMS-III; ²Evan G. Starr, OMS-III; ²Lawsen M. Parker, OMS-III; ²Justin T. Bradshaw, OMS-III; ²Westin J. Wong, OMS-III; ³Patrick Tufts, MD; ²Mark Wardle, DO

¹Rocky Vista University College of Osteopathic Medicine-Colorado; ²Department of Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine-Colorado; ³Department of Primary Care Medicine, Rocky Vista University College of Osteopathic Medicine-Colorado

Statement of Significance: An increase in the importance of mental health over the past decade has placed an emphasis on correctly diagnosing and treating patients with mental illness1. In 2019, mental disorders were among the top ten leading causes of health burden worldwide2. Current evidence has shown that the COVID-19 pandemic has spurred a simultaneous psychiatric epidemic3. As mental health and psychiatric conditions become more prevalent, it is necessary to analyze best practices within this field of medicine.

Research Methods: Since 2013, codes 90832, 90834, and 90837 have been used for individual psychotherapy appointments4. Code 90832 identifies individual psychotherapy with a duration of 30 minutes (time range 16-37 minutes). Code 90834 identifies individual psychotherapy with a duration of 45 minutes (time range 38-52 minutes). Code 90837 identifies individual psychotherapy with a duration of 60 minutes (time range 53 minutes or more)4,5.

Data from the CMS database was pulled for Medicare patients from 2000-2020, including total billing volume of the calendar year amongst the enrolled of Part B beneficiaries of Medicare and total dollars Medicare paid for that specific code in that calendar year.6 Average reimbursement per code was calculated by dividing the number of total dollars compensated by number of codes claimed. Claims per 10,000 Medicare beneficiaries were calculated by obtaining the ratio of claims to the total number of beneficiaries and adjusting the ratio to 10,000 beneficiaries7,8. Inflation was accounted for by adjusting reimbursement rates into current dollar value by utilizing USA government inflation calculator coefficients9,10.

When considering the osteopathic philosophy, the wholistic approach of patient care must be considered when analyzing psychiatric evaluation codes.

Data Analysis: From 2013 to 2020, calculated hourly compensation for CPT codes 90832, 90834, and 90837 each increased between 68.41% and 72.47%. From 2013-2020, usage of code 90837 (60 minutes of psychotherapy) per 10,000 beneficiaries has had an 58.26% increase while code usage for 90834 (45 minutes of psychotherapy) per 10,000 beneficiaries has decreased by 38.79%. Usage of code 90832 per 10,000 beneficiaries has decreased by 21.34%. From 2013 to 2020, CPT code claims per 10,000 Medicare beneficiaries overall decreased 9.24%.

From 2013 to 2020, the average reimbursements by code for 90832 was $45.45, 90834 was $59.40, and 90837 was $86.89. From 2013 to 2020, calculated average hourly compensation for code 90832 (30 minutes of psychotherapy) was $97.51, and $93.19 for code 90837 (60 minutes of psychotherapy). Meanwhile, average hourly compensation for code 90834 was $85.49, which was 87.7% and 91.7% of the compensation rates for codes 90832 and 90837, respectively.

Results: From 2013 to 2020, calculated hourly compensation for CPT codes 90832, 90834, and 90837 each increased between 68.41% and 72.47%. From 2013-2020, usage of code 90837 (60 minutes of psychotherapy) per 10,000 beneficiaries has had an 58.26% increase while code usage for 90834 (45 minutes of psychotherapy) per 10,000 beneficiaries has decreased by 38.79%. Usage of code 90832 per 10,000 beneficiaries has decreased by 21.34%. From 2013 to 2020, CPT code claims per 10,000 Medicare beneficiaries overall decreased 9.24%.

From 2013 to 2020, the average reimbursements by code for 90832 was $45.45, 90834 was $59.40, and 90837 was $86.89. From 2013 to 2020, calculated average hourly compensation for code 90832 (30 minutes of psychotherapy) was $97.51, and $93.19 for code 90837 (60 minutes of psychotherapy). Meanwhile, average hourly compensation for code 90834 was $85.49, which was 87.7% and 91.7% of the compensation rates for codes 90832 and 90837, respectively.

Conclusion: From 2013 to 2020, Individual Psychotherapy CPT code claims for Medicare patients demonstrate a shift from 90834, individual psychotherapy for 45 minutes, towards 90837, individual psychotherapy for 60 minutes.

Calculated reimbursement per hour for Individual Psychotherapy CPT codes present differences that could play a role in physician preference when treating patients. We posit that the decreasing value for code 90834 could influence the length of time spent with patients. This shift, juxtaposed with an increased reimbursement per unit time for 90837, draws attention to potential underlying factors such as physician priority or a potential increased need for psychotherapy for Medicare patients.

Potential psychiatric needs for Medicare patients could also explain the increased time spent with each Medicare patient. Further investigation is warranted to help determine the contributing factors to this phenomenon. Significant limitations apply to these results as the data only applies to Medicare patients, and therefore, results may not be extrapolated to infer similar trends in the general population. Lower payment from Medicaid, variable physician participation in Medicaid, and the COVID-19 pandemic are also factors that could limit the scope of the statistical analysis.

References

1. Ferrari AJ, Norman RE, Freedman G, Baxter AJ, Pirkis JE, Harris MG, Page A, Carnahan E, Degenhardt L, Vos T, Whiteford HA. The burden attributable to mental and substance use disorders as risk factors for suicide: findings from the Global Burden of Disease Study 2010. PLoS One. 2014 Apr 2;9(4):e91936. doi: 10.1371/journal.pone.0091936. PMID: 24694747; PMCID: PMC3973668.

2. GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry. 2022 Feb;9(2):137-150. doi: 10.1016/S2215-0366(2100395-3). Epub 2022 Jan 10. PMID: 35026139; PMCID: PMC8776563

3. Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L, McKyer ELJ, Ahmed HU, Ma P. Epidemiology of mental health problems in COVID-19: a review. F1000Res. 2020 Jun 23;9:636. doi: 10.12688/f1000research.24457.1. PMID: 33093946; PMCID: PMC7549174.

4. American Psychiatric Association. Current Procedural Terminology (CPT) Code Changes for 2013 Overview. Psychiatry.org. 2013. Accessed May 1, 2022. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Practice-Management/Coding-Reimbursement-Medicare-Medicaid/Coding-Reimbursement/cpt-overview.pdf

5. University of Rochester Medical Center. Current procedural Terminology (CPT) Codes in Psychiatry. Urmc.rochester.edu. Accessed May 1, 2022. https://www.urmc.rochester.edu/medialibraries/urmcmedia/compliance-office/education-tools/compliance/documents/psychiatrycptcodesupatedfor2013.pdf

6. CPT codes 2000-2020: Centers for Medicare & Medicaid Services. Part B National Summary Data File. Cms.gov. Accessed May 1, 2022. https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Part-B-National-Summary-Data-File/Overview

7. CMS Medicare enrollment data 2013-2020: Centers for Medicare & Medicaid Services. Medicare Total Enrollment. Data.cms.gov. Accessed May 1, 2022. https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/medicare-and-medicaid-reports/medicare-total-enrollment

8. Medicare enrollment 2000-2013: United States Census Bureau. Medicare Enrollment – National trends 1966-2013: Medicare Aged and Disabled Enrollees By Type of Coverage. Census.gov. Accessed May 1, 2022 https://www.census.gov/history/pdf/medicare1966-2013.pdf

9. USA INFLATION 1: U.S Bureau of Labor Statistics. CPI Inflation Calculator. Data.bls.gov. accessed May 1, 2022. https://data.bls.gov/cgi-bin/cpicalc.pl?cost1=1.00&year1=202012&year2=202201

10. USA INFLATION 2: US Inflation Calculator. Current US Inflation Rates: 2000-2022. Usinnflationcalculator.com. Accessed May, 1, 2022. https://www.usinflationcalculator.com/inflation/current-inflation-rates/

Financial Disclosures: None Reported

Support: None Reported

Ethical Approval: Due to the public nature of the data, IRB approval was not needed

Informed Consent: None required

Poster No. *H-4

Abstract No. 24

Category: Health Services

Research Topic: Health Disparities-Social Determinants of Health

Evaluating the Utilization of Telemedicine in Obstetrics and Gynecology: A Survey of the Practitioner Perspective

Sarah E Colando, OMS-IV; Lindsay Saleski, DO; Eleanor Williams, DO

Edward Via College of Osteopathic Medicine-South Carolina

Statement of Significance: The SARS-COV-2 pandemic of 2020 has encouraged a rapid increase in the utilization of telemedicine for most non-emergent and non-procedural complaints within the specialty of obstetrics and gynecology(1).Understanding the perspectives of a variety of providers during this time is important to identify barriers to adoption of telemedicine. Due to lack of widespread utilization prior to the pandemic, there are very few studies that have considered the use of this technology specifically in OB-GYN.

Research Methods: Following approval from the Institutional Review Board, application #2020-020 IRBNet ID 1592251-2 I, a multicenter, cross-sectional, survey-based study assessing obstetric and gynecologic providers’ disposition toward the incorporation of telemedicine during a pandemic and potential future use was prepared. A web-based survey was distributed via email to two hundred twenty-eight OB-GYN practitioners that were clinical medicine preceptors for medical students associated with Edward Via College of Osteopathic Medicine, primarily in the Southeast United States. All participants who returned the survey were included in the study, even partial survey responses. A survey response was excluded from the analysis if the practitioner submitted the survey more than once. In this case, the first submission was kept. Consent was obtained from all participants in the research project when they opened the Qualtrics survey link from their e-mail. The consent statement was reviewed and signed by the research study participant prior to submission of the survey. A survey analysis was conducted with Fisher’s exact test utilizing JMP Pro 16. Results from the Fisher exact test were imported into tables for further interpretation from the study authors. To avoid study bias, the survey language was revised multiple times and reviewed by the principal investigator to ensure equivalent positive, negative, and neutral verbiage. As a token of appreciation, each participant was placed into a randomized raffle for a Visa Gift Card funded by a grant from the Research Eureka Accelerator Program.

Data Analysis: A total of 228 OB Gyn providers affiliated with Edward Via College of Osteopathic Medicine were provided with the survey. Out of the 228 surveys sent, a total of 42 responded and have been included in the survey analysis. Over the span of the COVID 19 pandemic, there has been a 78.5% increase in utilizing telemedicine among survey participants. Most practitioners surveyed felt there is a place and need for telemedicine in the Ob-Gyn community. And when appropriate, they felt telemedicine was a more beneficial use of both the providers and patient’s time. Providers involved in telemedicine prior to the pandemic felt patient outcomes were improved in their telemedicine visits compared to in clinic, p value 0.0437. Improvement in patient care was significantly increased by utilizing telemedicine in practices who were already engaged in virtual visits, p-value 0.0435. Ob Gyn providers encounter a variety of visits daily during their practice. Out of all Ob- Gyn encounters, providers felt well women, non-stress test fetal monitoring and vaginal bleeding are visits types that the respondents disagreed strongly with being completed using telemedicine.

Results: A total of 228 OB Gyn providers affiliated with Edward Via College of Osteopathic Medicine were provided with the survey. Out of the 228 surveys sent, a total of 42 responded and have been included in the survey analysis. Over the span of the COVID 19 pandemic, there has been a 78.5% increase in utilizing telemedicine among survey participants. Most practitioners surveyed felt there is a place and need for telemedicine in the Ob-Gyn community. And when appropriate, they felt telemedicine was a more beneficial use of both the providers and patient’s time. Providers involved in telemedicine prior to the pandemic felt patient outcomes were improved in their telemedicine visits compared to in clinic, p value 0.0437. Improvement in patient care was significantly increased by utilizing telemedicine in practices who were already engaged in virtual visits, p-value 0.0435. Ob Gyn providers encounter a variety of visits daily during their practice. Out of all Ob- Gyn encounters, providers felt well women, non-stress test fetal monitoring and vaginal bleeding are visits types that the respondents disagreed strongly with being completed using telemedicine.

Conclusion: The SARS-COV-2 pandemic created a rapid uprise in the use of telemedicine for many non-emergent and non-procedural complaints in the field of Obstetrics and Gynecology. Understanding the experiences of practitioners during this time is vital to identify barriers to practice in effort to help reduce and overcome them. Most practitioners in this survey felt there is a suitable area to use telemedicine in ob-gyn visits. The majority felt non-emergency visits such as lab results and pre/post operative visits were most proper for telemedicine use. Allowing visits to become virtual could be beneficial to both providers and patients and increase the efficiency of the practice. Further investigation is called for to dive further into the barriers and look at societal and economic differences and their availability and access to telemedicine.

References

1. Feghali M, Binstock A, Henderson J, Simhan H. Pregnancy outcomes with telemedicine management in women with gestational diabetes mellitus. American Journal of Obstetrics and Gynecology. 2019;220(1):S273-S273. doi:10.1016/j.ajog.2018.11.422

Financial Disclosures: None

Support: Funding grant from Research Eureka Accelerator Program for $500

Ethical Approval: Approval from the Institutional Review Board, application #2020-020 IRBNet ID 1592251-2 I

Informed Consent: All participants in this study were provided with written informed consent prior to their participation in the study. The participant must have read the informed consent prior to proceeding with the study.

Poster No. *H-5

Abstract No. 73

Category: Health Services

Research Topic: Chronic Diseases & Conditions

An Analysis of Opioid-Related Overdoses and Deaths in Florida to Assess the Need for Safe Injection Sites

¹Kristina Fritz, OMS-IV; ²Jonathan Rozenberg, MPH, OMS-IV; ²Mary Rachel Nute, OMS-IV; ²Mark Martin, OMS-IV; ²Rushil Nakhre, OMS-IV; ²Farzanna Haffizulla, MD, FACP, FAMWA; ²Alan Bloom, MD; ²Sahar Sarrami Amini, DO; ²Marc Kesselman, DO

¹Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine; ²Department of Internal Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine

Statement of Significance: The number of deaths from opioid overdoses continues to rise in the United States.[1] A safe injection site (SIS) is a harm reduction strategy whereby intravenous drug users can carry out recreational drug use in medically supervised areas and has been shown to decrease drug overdoses, drug overdose deaths (DODs), and all-cause mortality in communities internationally.[2,3] Florida, the third most populous state, was analyzed to determine which counties may benefit most from implementing a SIS.

Research Methods: Secondary, quantitative data from the Florida Department of Health was used to analyze the number of drug and opioid overdose deaths, Naloxone doses administered, and drug-overdose-related EMS calls in each county of Florida from 2015-2019.[4] The Florida Department of Health’s Rural Counties map was used to analyze general associations between the number of drug overdose deaths and county, based upon population density greater than or less than or equal to 100 persons per square mile (urban/rural) according to 2010 US census data using two-tailed t-tests.[5,6] The United States Census’ County Population Totals from 2010-2019 were used to determine the highest populated counties.[6] Odds ratios were calculated to compare drug overdose deaths among counties geographically bordering Miami-Dade county as well as among the 5 most populated counties in Florida, and among the counties with population size closest to that of Miami-Dade. Determining the area that would be most impacted allows for a discussion to be made on an alternative solution and method of educating, treating, and preventing opioid and other drug-related overdoses in the US/Florida; which is significant to the osteopathic profession because it is an alternative that will prevent deaths and better the health of patients/populations suffering from substance use disorder.

Data Analysis: There is a statistically significant difference in the mean number of urban and rural age-adjusted drug overdose deaths in 2019, with a higher mean death rate in urban FL counties (p<0.05). Miami-Dade, Florida’s largest county by population, had the least age-adjusted drug overdose-related deaths every year from 2015-2019 compared to its neighboring counties (Monroe, Collier, and Broward) and counties closest in population density (Broward, Palm Beach, Hillsboro, and Orange County, respectively). The age-adjusted death rate increased in every county from 2015. Collier county had the steepest growth trend with a 14.6% average increase in deaths annually, followed by Broward with 13.4%, and Miami-Dade had the third-highest with an 11.8% increase. Residents of counties with similar population density (Broward, Palm Beach, Hillsboro, Orange) had increased odds of dying from a drug overdose compared to Miami-Dade residents, with Palm Beach residents showing the greatest odds every year for the past 5 years; 3.15x, 3.65x, 4.13x, 3.29x, and 2.94x from 2015-2019, respectively. The Florida county that would benefit most from an SIS installation is Palm Beach County because among the urban counties analyzed the residents of this urban county have the highest odds of dying from a drug overdose when compared to Miami Dade residents.

Results: There is a statistically significant difference in the mean number of urban and rural age-adjusted drug overdose deaths in 2019, with a higher mean death rate in urban FL counties (p<0.05). Miami-Dade, Florida’s largest county by population, had the least age-adjusted drug overdose-related deaths every year from 2015-2019 compared to its neighboring counties (Monroe, Collier, and Broward) and counties closest in population density (Broward, Palm Beach, Hillsboro, and Orange County, respectively). The age-adjusted death rate increased in every county from 2015. Collier county had the steepest growth trend with a 14.6% average increase in deaths annually, followed by Broward with 13.4%, and Miami-Dade had the third-highest with an 11.8% increase. Residents of counties with similar population density (Broward, Palm Beach, Hillsboro, Orange) had increased odds of dying from a drug overdose compared to Miami-Dade residents, with Palm Beach residents showing the greatest odds every year for the past 5 years; 3.15x, 3.65x, 4.13x, 3.29x, and 2.94x from 2015-2019, respectively. The Florida county that would benefit most from an SIS installation is Palm Beach County because among the urban counties analyzed the residents of this urban county have the highest odds of dying from a drug overdose when compared to Miami Dade residents.

Conclusion: The data and analysis show a continued rise in DODs in Florida counties and further efforts are needed to combat the opioid epidemic in Florida, with Florida’s urban counties, particularly Palm Beach, needing the most help with opioid intervention. SISs may be one intervention to reduce morbidity and mortality in these areas. Future research can be done to determine areas in other states or regions of the country that have more need for an SIS or would benefit more than Florida counties. Additionally, future research can be done to determine factors that affect drug overdose in Palm Beach county versus other counties in Florida, as well as measures taken by each county that could describe the disparity in overdose death rate. Limitations of this study include limited data sets, including subclassification into the drugs that caused the overdoses, as well as town-specific instead of county-wide data. Additionally, the scope of this research study was narrowed to Florida, and other states with a higher proportion of deaths caused by drug and opioid overdose could have been considered.

References

1. Overdose Death Rates. National Institute of Health. Updated January 20, 2022. Accessed July 11, 2022. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates

2. Marshall, B. D., Milloy, M.-J., Wood, E., Montaner, J. S., & Kerr, T. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: A retrospective population-based study. The Lancet, 2011; 377(9775), 1429–1437. doi: 0.1016/S0140-6736(1062353-7) https://doi.org/10.1016/S0140-6736(10)62353-7

3. Kennedy, M. C., Hayashi, K., Milloy, M.-J., Wood, E., & Kerr, T. (2019). Supervised injection facility use and all-cause mortality among people who inject drugs in Vancouver, Canada: A cohort study. PLoS Medicine, 16(11), e1002964. doi: 10.1371/journal.pmed.1002964 https://doi.org/10.1371/journal.pmed.1002964

4. Substance Use Dashboard. Florida Department of Health. Updated 2022. Accessed July 11, 2022. https://www.floridahealth.gov/programs-and-services/community-health/rural-health/index.html

5. Rural Counties Map. Florida Health Rural Health Florida. Updated February 1, 2022. Accessed July 11, 2022. https://www.flhealthcharts.gov/ChartsDashboards/rdPage.aspx?rdReport=SubstanceUse.Overview

6. County Population Totals: 2010-2019. United States Census Bureau. Updated October 8, 2021. Accessed July 11, 2022. https://www.census.gov/data/tables/time-series/demo/popest/2010s-counties-total.html

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Study deemed exempt.

Informed Consent: Irrelevant to study.

Poster No. *H-7

Abstract No. 86

Category: Health Services

Research Topic: Osteopathic Philosophy

Evaluation of Impact on Medical Students’ Confidence to Give Patient-centered Nutrition Interventions​ - Pre and Post "Food and Nutrition as Medicine" Course (FANAM)

¹Gabriel Ward, MA, OMS-III; ¹Eli Hopkins, OMS-III; ¹Alyssa DeMutis, OMS-III; ¹Merwan Faraj, OMS-IV; ¹Annie Nguyen, OMS-IV; ²JuliSu DiMucci-Ward, PhD, MPH, RDN, CDE, LD; ²Amber Stroupe, DO

¹Edward Via College of Osteopathic Medicine-South Carolina; ²Department of Clinical Medicine, Edward Via College of Osteopathic Medicine-South Carolina

Statement of Significance: Non-communicable diseases (NCDs) are major health burdens in terms of human suffering and economic consequences due to increased disability and healthcare costs[1-8]. Research indicates that when physicians lack confidence in their ability to address an issue, they may fail to address it at all [9]. The goal of FANAM is to enhance students skills at the patient-clinician interface. Core elements include interviewing, culinary skills, and heritage diet awareness are key to care plan development.

Research Methods: This is a Quality Improvement/Quality Assessment (QI/QA) to address two general end points: Student knowledge of course objectives and confidence implementing evidence-based nutrition recommendations before and after completing the FANAM course. 54 non-randomly selected students were enrolled in the course, 20 students in the first year who worked in 6 small groups and 34 students in the second year who worked in 9 small groups. Students applied to participate in the course and were selected by a committee. Inclusion criteria included a strong interest in utilizing the osteopathic tenets to gain both physical and communication skills to adequately teach patients about personalized nutrition. FANAM was implemented, and the QI/QA survey’s purpose is to evaluate the effectiveness of the student - physician training. The QI/QA surveys rated students’ level of understanding/confidence with a Likert scale from 1 through 5. 1 “minor understanding,” 2 a little bit, 3 “competent,” 4 a foundation, 5 “expert level.” Likert scale items are strongly recommended in literature to capture qualitative concepts including confidence, competency, and satisfaction [10]. In the 2 academic years, the pre- and post-course evaluations were used to assess the overall course by calculating a mean score for all students. An evaluation of each individual module was utilized in both academic years; however, in the first year pre- and post- module surveys were used to develop the curriculum. In the second year, with curriculum developed, only post-module surveys were used to refine individual module objectives in future years. The class mean score was calculated from student responses respective of each category. The same method was used to analyze the collective confidence of the participants pre- and post- FANAM course. The osteopathic significance of an apprenticeship approach to NCDs prevention trains clinicians to begin the education process and to collaborate with community support systems.

Data Analysis: 54 non-randomly selected students (N=54) were enrolled in this course over two years. These students applied to participate in the course and were selected by committee. Qualitative assessments showed that all students believed further education on nutrition beyond what they received from standard curriculum was necessary. Quantitative assessment of the surveys showed that between the two years that the course was offered, student confidence in providing effective nutritional and lifestyle modification counseling increased by 59.3%, demonstrating the value of additional medical nutritional therapy education to the standard medical school curriculum. The response rate of the post-course survey for the second year the course was offered was 61.7%, above the national average of 44.1%[11]. Furthermore, students in the second year reported on average 4% higher satisfaction with each module’s delivery of the set objectives when compared to the first year results, indicating success in fine tuning of each module’s content between the first and second years the course was offered.

Results: 54 non-randomly selected students (N=54) were enrolled in this course over two years. These students applied to participate in the course and were selected by committee. Qualitative assessments showed that all students believed further education on nutrition beyond what they received from standard curriculum was necessary. Quantitative assessment of the surveys showed that between the two years that the course was offered, student confidence in providing effective nutritional and lifestyle modification counseling increased by 59.3%, demonstrating the value of additional medical nutritional therapy education to the standard medical school curriculum. The response rate of the post-course survey for the second year the course was offered was 61.7%, above the national average of 44.1%[11]. Furthermore, students in the second year reported on average 4% higher satisfaction with each module’s delivery of the set objectives when compared to the first year results, indicating success in fine tuning of each module’s content between the first and second years the course was offered.

Conclusion: FANAM’s goal was to bring practical real-life scenarios requiring proficiency in multiple skills including communication, assessing patient readiness, counseling, culinary skills, understanding of food scarcity, and working with community resources. The classes have reported increased confidence in addressing nutrition and lifestyle habits when forming integrative patient care plans. A recurring theme of modules was a concise didactic portion leaving more time to cook and interact with the guest speakers or practice communication exercises. Using that feedback, we plan to expand the hands-on portion of our class and have our guest speakers emphasize real-world scenarios throughout a given module. Future classes will take a pre and post exam covering the core FANAM topic areas: nutrition, mindfulness, lifestyle choices, medicine and patient care plans to obtain an objective measure of knowledge change. A limitation of this study was survey participation rate. We had a 77-100% response rate that would fluctuate per month, as a result of varying academic demands and the fluctuations of the COVID-19 pandemic. On a positive note the survey participation rate we obtained was greater than “the average response rate of 44.1 percent”[11]. A second limitation that needs addressing is selection bias; because the study participants were already interested in nutrition, and more likely to implement nutrition in future patient care. Lastly, recall bias may have occurred with surveys, because participants submitted their post-class survey from the night of the class up to several weeks post class, thus the recollection rating could be altered. To account for these biases, the pre survey could be given to all medical students to gather a baseline and post survey could only be accepted the last night of the course. Long term research needs to determine the amount of knowledge that will be carried into their future practices.

References

1. Crowley J, Ball L, Hiddink GJ. Nutrition in medical education: A systematic review. The Lancet Planetary Health. 2019;3(9):e379-e389.

2. Crowley J, Ball L, Wall C. How does self-perceived nutrition competence change over time during medical training? A prospective longitudinal observational study of new zealand medical students. BMJ nutrition, prevention & health. 2020;3(2):270-276.

3. Aspry KE, Van Horn L, Carson JAS, et al. Medical nutrition education, training, and competencies to advance guideline-based diet counseling by physicians: A science advisory from the american heart association. Circulation. 2018;137(23):e821-e841.

4. Devries S, Freeman AM. Nutrition education for cardiologists: The time has come. Curr Cardiol Rep. 2017;19(9):5/1/21-77.

5. Devries S, Willett W, Bonow RO. Nutrition education in medical school, residency training, and practice. JAMA. 2019;321(14):1351-1352.

6. Magallanes E, Sen A, Siler M, Albin J. Nutrition from the kitchen: Culinary medicine impacts students’ counseling confidence. BMC medical education. 2021;21(1):88-88. 7. CDC N. Health and economic costs of chronic diseases. https://www.cdc.gov/chronicdisease/about/costs/index.htm. Updated 2022. Accessed January 19, 2022.

7. Narayan KMV, Ali MK, Koplan JP. Global noncommunicable diseases: Where worlds meet. N Engl J Med. 2010;363(13):1196-1198.

8. Adimoolam V, Charney P. Identification and management of overweight and obesity by internal medicine residents: Christopher B. ruser, lisa sanders et al. Journal of General Internal Medicine. 2006;21(10):1128-1128.

9. Jr,Sullivan GM FAU - Artino, Anthony R., Artino A,Jr. Analyzing and interpreting data from likert-type scales. Journal of graduate medical education JID - 101521733 PMC - PMC3886444 EDAT- 2014/01/24 06:00 MHDA- 2014/01/24 06:01 CRDT- 2014/01/24 06:00 PHST- 2014/01/24 06:00 entrez] PHST- 2014/01/24 06:00 pubmed] PHST- 2014/01/24 06:01 medline] AID - JGME-(TRUNCATED). 2013;5(4):541-542.

10. Wu M, Zhao K, Fils-Aime F. Response rates of online surveys in published research: A meta-analysis. Computers in Human Behavior Reports. 2022;7:100206.

Financial Disclosures: None reported

Support: None reported

Ethical Approval: Per IRB Administrative Review it was determined to be a QI/QA study.

Informed Consent: Informed consent was not required for this research design.

★ Poster No. *H-8

Abstract No. 65

Category: Health Services

Research Topic: Health Disparities-Social Determinants of Health

The Exploration of Dance Therapy as an Approach to Neurodegenerative Diseases in Rural Appalachian Communities with Limited Access to Care

¹Meaghan E Kuzmich, OMS-III; ¹Cambri L. Fox, OMS-II; ¹Sophia A. Tunny, OMS-III; ²Lori McGrew, PhD

¹Lincoln Memorial University DeBusk College of Osteopathic Medicine; ²Department of Pharmacology, Lincoln Memorial University DeBusk College of Osteopathic Medicine

Statement of Significance: Despite studies of rural Appalachian communities consistently demonstrating poor mortality measures, (1) the existing literature has yet to assess the health literacy regarding neurodegenerative disorders such as Parkinson’s Disease (PD) within these rural areas. The continued growth of the aging population highlights the need to prioritize the exploration of affordable therapies for neurodegenerative diseases such as Dance for Parkinson’s Disease® classes (DfPD®).

Research Methods: This study included a twelve-question voluntary paper survey of individuals that attended a DfPD® class at a senior center in Harrogate, Tennessee. DfPD® is a program that utilizes a variety of dance genres to target skills such as balance, coordination, flexibility, and strength; which has been shown to improve motor impairments, anxiety/depression, and interpersonal relationships in individuals with PD. (2,3) Many of the individuals that attended the class participate in events hosted at the Harrogate and Tazewell Senior Centers on a regular basis. The class was hosted by student organizations from Lincoln Memorial University DeBusk College of Osteopathic Medicine (LMU-DCOM). Prior to the one-hour dance class, LMU-DCOM medical students gave a brief presentation outlining the benefits of DfPD® classes according to the current literature. To be included in the study, subjects must have attended the DfPD® event at the senior center and be at least 50 years of age. Analysis was conducted utilizing the Pearson correlation coefficient (r) to measure linear relationships. Monotonic relationships were also assessed utilizing Spearman’s rank correlation coefficient (⍴).

Data Analysis: Twenty-three subjects (mean age range of 70-79 years) completed the survey with nineteen self-identifying as female and four identifying as male. 76% of subjects considered themselves to be from the Appalachian region (n=16). There was highly positive support for future access to similar programs with 95.5% of subjects indicating they would like more access in the future (n=21). Analysis revealed that subjects who were unaware of the physical benefits of DfPD® classes prior to participating were also likely to be unaware of the emotional or social benefits of DfPD® classes (⍴(19)=0.713, 0.798 respectively; p<0.001). Pearson correlation analysis revealed a strong positive correlation between subjects that indicated a high likelihood of continuing dance exercise on a regular basis and those that indicated a preference for dance exercise over activities such as walking (r(20)=0.788; p<0.001), swimming (r(19)=0.861; p<0.001), and outdoor activities (r(19)=0.729; p<0.001). Subjects viewed the information they had received as generally reliable with an average of 9.4 on a scale of 1 to 10 with 1 being “not reliable” and 10 being “very reliable”. These reliability results were positively correlated with a higher likelihood to continue dance exercise on a regular basis (r(19)=0.621; p=0.003) and have greater preference for dance exercise over walking (r(19)=0.587; p=0.005), swimming (r(20)=0.674; p<0.001), and outdoor activities (r(20)=0.679; p<0.001). No significant correlations were identified according to subjects’ age range or gender.

Results: Twenty-three subjects (mean age range of 70-79 years) completed the survey with nineteen self-identifying as female and four identifying as male. 76% of subjects considered themselves to be from the Appalachian region (n=16). There was highly positive support for future access to similar programs with 95.5% of subjects indicating they would like more access in the future (n=21). Analysis revealed that subjects who were unaware of the physical benefits of DfPD® classes prior to participating were also likely to be unaware of the emotional or social benefits of DfPD® classes (⍴(19)=0.713, 0.798 respectively; p<0.001). Pearson correlation analysis revealed a strong positive correlation between subjects that indicated a high likelihood of continuing dance exercise on a regular basis and those that indicated a preference for dance exercise over activities such as walking (r(20)=0.788; p<0.001), swimming (r(19)=0.861; p<0.001), and outdoor activities (r(19)=0.729; p<0.001). Subjects viewed the information they had received as generally reliable with an average of 9.4 on a scale of 1 to 10 with 1 being “not reliable” and 10 being “very reliable”. These reliability results were positively correlated with a higher likelihood to continue dance exercise on a regular basis (r(19)=0.621; p=0.003) and have greater preference for dance exercise over walking (r(19)=0.587; p=0.005), swimming (r(20)=0.674; p<0.001), and outdoor activities (r(20)=0.679; p<0.001). No significant correlations were identified according to subjects’ age range or gender.

Conclusion: The overwhelmingly positive support for future access to similar programs and preference for dance exercise over other low-impact activities suggests the enthusiasm and willingness of the community to take an active role in improving their health. This warrants further exploration of programs that patients enjoy and look forward to regularly participating in as implementation of these programs may, in turn, lead to better outcomes long term and help improve the overall quality of life for members of the local, rural Appalachian community.

A limitation of this study includes the small sample size, which may have impacted the ability to find correlations based on demographics. Future studies could further elucidate the impact of geographical isolation on health literacy by having additional sites, which would allow for the comparison of rural communities to their metropolitan counterparts. While existing literature supports the benefits of DfPD® classes regardless of geographic location, increasing access to therapies in rural areas that can be facilitated by osteopathic medical students in partnership with programs like DfPD® may uniquely address an intricate, yet prevalent disparity experienced in healthcare.

The field of osteopathic medicine is built on the four tenets of osteopathy and places emphasis on a whole-body approach to patient care. With this in mind, future studies could also take a more integrated approach to determine how closely the DfPD® method aligns with the philosophy of osteopathic medicine. The pre-established level of trust between osteopathic student doctors and their local community presents a noteworthy opportunity for medical students to better serve their often rural communities and help alleviate healthcare disparities within these areas. Looking forward, longitudinal interventional studies that measure patient outcomes and healthcare costs appear feasible and welcomed by the community.

References

1. Marshall J, Thomas L, Lane N, Holmes G, Arcury T, Randolph R, Silberman P, Holding W, Villamil L, Thomas S, Lane M, Latus J, Rodgers J, Ivey K. Health Disparities in Appalachia. Appalachian Regional Commission. August 23, 2017. Accessed April 14, 2022. https://www.arc.gov/report/health-disparities-in-appalachia/

2. Bearss KA, & DeSouza JF. Parkinson’s Disease Motor Symptom Progression Slowed with Multisensory Dance Learning over 3-Years: A Preliminary Longitudinal Investigation. Brain Sciences. 2021;11(7):895. https://doi.org/10.3390/brainsci11070895

3. Kalyani HHN, Sullivan KA, Moyle G, Brauer S, Jeffrey ER, Kerr GK. Impacts of dance on cognition, psychological symptoms and quality of life in Parkinson’s disease. NeuroRehabilitation. 2019;45(2):273–283. https://doi.org/10.3233/nre-192788

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This study was reviewed and approved by the Lincoln Memorial University Institutional Review Board on March 16, 2022. The project was deemed to be minimal risk and reviewed as expedited as described in HHS 45 CFR 46.110(7). IRB number 1089 V.0.

Informed Consent: Informed consent was obtained utilizing a prepared oral script and an informational sheet regarding the details of the voluntary study and any risks associated with participation. No identifying or sensitive information was collected on the survey, and as a result, the completion of the survey indicated the subjects’ consent to participate.

Poster No. *H-9

Abstract No. 53

Category: Health Services

Research Topic: Health Disparities-Social Determinants of Health

Patient Attitudes and Perceived Barriers towards Mental Health Treatment Options in a Rural Clinic

¹Mariah Hydzik, OMS-II; ²Thomas Motyka, DO ¹Campbell University-Jerry M. Wallace School of Osteopathic Medicine; ²Department of Osteopathic Manipulative Medicine, Campbell University-Jerry M. Wallace School of Osteopathic Medicine

Statement of Significance: Improving our understanding of access inequality regarding mental health care is important. Data representative of underserved populations often excludes non-English speaking populations. Previous studies have shown potential benefits of osteopathic manipulative technique on mental health, but is not widely utilized (1,2). Understanding the needs and preferences of the rural underserved population could be useful in planning programs that increase their access to mental health treatment.

Research Methods: All adult patients attending a single outpatient rural clinic over a four-month period in 2022 were screened for participation. This included about 105 patients. Those unable to provide full consent in either English or Spanish were excluded. Both English and Spanish translations of the study were created. The survey consisted of tables of Likert scale graded questions about mental health treatments, access, knowledge, and perceived barriers including questions about osteopathic manipulative techniques (OMT). Frequencies and percentages were generated for categorical variables while summary measures of central tendency and dispersion are generated for continuous variables. Relevant tests were performed for inferential questions involving natural subgroups using parametric methods or their non-parametric equivalents as appropriate. For the inferential analyses, statistical significance was set at P ≤.05.Osteopathic Significance: Mental health treatment is multifactorial and involves a combination of multiple therapeutic options addressing patient symptoms both physiologically and psychologically. OMT is a safe and cost-effective treatment technique. Previous studies have indicated potential positive outcomes from the use of osteopathic techniques as an adjunctive treatment for mental health/affective disorders such as anxiety and depression (1,2). In respect to the osteopathic philosophy of the interconnectivity of systems, OMT may be beneficial in the management of mental health conditions and more research is needed on this topic. The use of OMT as adjunctive care could improve access in rural areas as physicians using OMT are more heavily representative in rural areas. Additionally, OMT as an adjunctive therapy for the somatic symptoms of mental health conditions could address mental health stigma around patient contact which can be perceived as a barrier to holistic care.

Data Analysis: A total of 46 respondents completed the survey out of about 105 administered–response rate of approximately 43.8%. Responses indicate that these patients are very likely to seek mental health care and were open to most forms of interventions. The top preferred treatments are therapy, spiritual guidance, and modifying diet and exercise. 47% of respondents indicated they were likely to see a therapist in any capacity, making that the most likely treatment method to be sought of those listed. 61% of respondents indicated cost of treatment as a logistical barrier to care. 80.5% of respondents did not have a good understanding of OMT and were generally hesitant to accept OMT on that basis.

Results: A total of 46 respondents completed the survey out of about 105 administered–response rate of approximately 43.8%. Responses indicate that these patients are very likely to seek mental health care and were open to most forms of interventions. The top preferred treatments are therapy, spiritual guidance, and modifying diet and exercise. 47% of respondents indicated they were likely to see a therapist in any capacity, making that the most likely treatment method to be sought of those listed. 61% of respondents indicated cost of treatment as a logistical barrier to care. 80.5% of respondents did not have a good understanding of OMT and were generally hesitant to accept OMT on that basis.

Conclusion: The patient population studied is open to mental health treatment. However, the majority of the study participants were more likely to seek hands-off treatment modalities such as spiritual guidance and therapy as opposed to hands-on treatments, i.e., medications or electroconvulsive therapy. Most respondents trusted mental health therapists and noted that they actually care about their patients compared to other providers. The results from this study can inform rural providers about the attitudes, preferences, beliefs, and perceived barriers that underpin choices about mental health treatment in rural, underserved populations. Cost of care is the dominant barrier to seeking mental health services. Future studies should include more Spanish speaking populations especially those who are migrant farm workers in rural communities.

References

1. Wiegand S, Bianchi W, Quinn TA, Best M, Fotopoulos T. Osteopathic manipulative treatment for self-reported fatigue, stress, and depression in first-year osteopathic medical students. J Am Osteopath Assoc. 2015;115(2):84-93. doi:10.7556/jaoa.2015.019

2. Plotkin BJ, Rodos JJ, Kappler R, et al. Adjunctive osteopathic manipulative treatment in women with depression: a pilot study. J Am Osteopath Assoc. 2001;101(9):517-523.

Financial Disclosures: None Reported

Support: None Reported

Ethical Approval: Campbell University Institutional Review Board Approved #717

Informed Consent: All respondents went through an informed consent process, whereas approved IRB personnel provided the respondents with a consent form as well as a verbal description and confirmation of willingness to participate.

★ Poster No. *H-10

Abstract No. 82

Category: Health Services

Research Topic: Impact of OMM & OMT

Reduction in Stress Among Frontline Healthcare Workers Receiving Osteopathic Manipulation

¹Ryan Schnautz, OMS-II; ²Andrew Eilerman, DO, FACOFP; ³Mallory Faherty, PhD, ATC

¹Ohio Health Doctors Hospital; ²Department of Medical Education, OhioHealth Doctors Hospital; ³OhioHealth Research Institute, OhioHealth Riverside Hospital

Statement of Significance: Burnout in the healthcare profession has been an ongoing challenge. In 2020, the American Medical Association surveyed healthcare workers and reported that 43% of respondents suffered from work overload and 49% were suffering from burnout [1]. Osteopathic Manipulative Medicine (OMM) has been shown to help reduce stress among those in the healthcare field [2,4,5], however, more studies are needed to examine the relationship between individualized OMM and stress in frontline healthcare workers.

Research Methods: An OMM service was established in October 2021 in a mid-sized community-based institution in central Ohio with the intent of improving the well-being of its associates. This hospital is one of the largest Osteopathic teaching institutions in the United States, having 158 residents training in programs which have received the status of the Accreditation Council for Graduate Medical Education (ACGME) as being Osteopathically Recognized. Two hours were set aside weekly for associates to voluntarily sign up on a first-come, first-served basis for OMM using QR codes directing them to the Signup Genius® website. Posters advertising the service were displayed in all hospital units. Through this service, associates were provided manipulation in 20-minute sessions after signing a waiver for consent and indicating that they were free from contraindicated conditions that would have excluded them from study participation. Since a complete history and physical were not obtained, associates were not considered patients and no patient-doctor relationship was established. Voluntary manipulation “providers” included osteopathic medical students, residents, fellows, or faculty. Attending faculty were Doctors of Osteopathic Medicine (DOs) who oversaw the manipulation provided. Manipulation was provided to associates based on findings from the structural exam. The associates were then encouraged to complete an anonymous online survey. Data on responses was collected through Redcap, a secure, HIPAA compliant web application for building online surveys and databases, and feedback will be used to modify the service for continuous quality improvement. After 4 weeks of doing OMM and the survey which would be on 7/8/2022, 22 associates have filled out the survey.

Data Analysis: After 4 weeks of doing OMM and the survey which would be on 7/8/2022, 22 associates have filled out the survey. Of the responses, 50% stated they regularly felt stressed in their work; 54.54% of respondents stated that their severity of stress was moderate or significant. The associates were then surveyed about their primary reasons for attending the associate OMM service for which they could select multiple reasons. 93.75% of respondents stated that they attended the service to reduce pain and musculoskeletal issues, and 81.25% of respondents stated that they attended to improve wellness and reduce stress. When asked if the service had accomplished these stated goals, 95.45% of respondents stated that it had. When the associates were surveyed as to what their overall views on the service were, the feedback was overwhelmingly positive. 95.45% of respondents stated that they were extremely satisfied with the service and that they were extremely likely to attend another session.

Results: After 4 weeks of doing OMM and the survey which would be on 7/8/2022, 22 associates have filled out the survey. Of the responses, 50% stated they regularly felt stressed in their work; 54.54% of respondents stated that their severity of stress was moderate or significant. The associates were then surveyed about their primary reasons for attending the associate OMM service for which they could select multiple reasons. 93.75% of respondents stated that they attended the service to reduce pain and musculoskeletal issues, and 81.25% of respondents stated that they attended to improve wellness and reduce stress. When asked if the service had accomplished these stated goals, 95.45% of respondents stated that it had. When the associates were surveyed as to what their overall views on the service were, the feedback was overwhelmingly positive. 95.45% of respondents stated that they were extremely satisfied with the service and that they were extremely likely to attend another session.

Conclusion: Preliminary results from the project suggest that OMM may be a modem to use for the reduction of stress in healthcare workers. This bolsters previous findings regarding OMM and stress reduction [2,4,5]. Many of the staff receiving manipulation at the associate OMM service were experiencing stress at work and many of them stated that the OMM service was helpful at alleviating much of that stress while improving their overall wellness. An overwhelming proportion of associates stated that they would be extremely likely to return to the service in the future to further improve their well-being which demonstrates the extent to which this service is positively viewed. While the preliminary findings have shown that this service has the potential to improve wellness and reduce the potential for burnout in healthcare workers, the project is continuing to gather more data from attendees of the OMM service. This data will be used to further strengthen the study’s conclusions and modify the OMM service for continuous quality improvement such as more broadly marketing the service, streamlining the process, and increasing the availability of the service in order to increase associate participation and further improve the wellness of frontline healthcare workers. The limitations of this study include a lack of a control group due to the individualization of the OMM from associate to associate based on the somatic dysfunctions that they are presenting with, and a small sample size due to a limited number of OMM providers being able to attend each service. Examination of specific OMM techniques and their effect on frontline healthcare worker stress is outside of the scope of this study, however, further research is warranted in order to examine any possible relationships between these two variables.

References

1. Prasada, K, et al. Prevalence and Correlates of Stress and Burnout Among U.S. Healthcare Workers During the COVID-19 Pandemic: A National Cross-Sectional Survey Study. EClinicalMedicine. 2021; 35. doi: 10.1016/j.eclinm.2021.100879

2. Wiegand S, Bianchi W, Quinn TA, Best M, Fotopoulos T. Osteopathic Manipulative Treatment for Self-Reported Fatigue, Stress, and Depression in First-Year Osteopathic Medical Students. J Am Osteopath Assoc. 2015 Feb;115(2): 84-93. doi: 10.7556/jaoa.2015.019

3. Foundations Author of Chapter. Behavioral Medicine. Foundations of Osteopathic Medicine, 4th edition. Seffinger, MA, ed. Wolters Kulwer 2018. P424-430.

4. Dixon, L et al. Effect of Osteopathic Manipulative Therapy on Generalized Anxiety Disorder. JOM. 2020 Mar. 120 (3). 133-142. doi: 10.7556/jaoa.2020.026

5. Abraham, C et al. Osteopathic Manipulative Treatment as an Intervention to Reduce Stress, Anxiety and Depression in First Responders: A Pilot Study. Mo Med. 2021 Sept-Oct. 118 (5): 435-441.

Financial Disclosures: None reported

Support: None reported

Ethical Approval: This project was granted a quality improvement exemption by the Ohio Health Institutional Review Board.

Informed Consent: Participants were informed about the effects of OMM prior to receiving manipulation and consented to participate in the project before they voluntarily filled out their anonymous surveys.

Poster No. *PH-1

Abstract No. 51

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Student Developed Didactic Series Rooted in Osteopathic Philosophy

¹Nicole Newman, OMS-III; ¹Saniya Ahmed, OMS-III; ¹Vivian Shiffler, OMS-III; ¹Isabelle Sinitsa, OMS-III; ¹Zoe Harold, OMS-III; ¹Abeera Naeem, OMS-III; ²Gretchen Lovett, PhD; ²Andrea Nazar, DO

¹West Virginia School of Osteopathic Medicine; ²Department of Clinical Science, West Virginia School of Osteopathic Medicine

Statement of Significance: It is important to recognize that cultural competency is a vital aspect of social determinants of health and by addressing it, one can impact the domains of education and healthcare access and quality. Cultural beliefs can affect many aspects of patients’ lifestyle, self-care factors, and compliance with therapeutic regimens. To promote clinical competency in a variety of diverse situations, a group of students at WVSOM created a series of co-curricular sessions to augment this area of study.

Research Methods: A student developed didactic presentation series was created to enhance diverse clinical education for first- and second-year medical students. This series included presentations on the following groups: Muslim women, LGBTQIA+ individuals, black individuals in a pain crisis, individuals with PTSD related to healthcare settings, and nonverbal individuals. There were 86 students who attended all 4 optional educational events to receive a certificate. There were also faculty and standardized patients that attended each event.

The didactic presentation followed a standard outline. Each presentation involved a short background presentation, a clinical case involving history, physical exam, and osteopathic significance. To assess the validity of this teaching method, before and after event surveys were distributed to participants. Surveys analyzed pre and post knowledge and comfort levels. Results were analyzed using t-tests and correlation analysis.

This presentation series relies on the osteopathic tenet of treating the whole individual. The designers of this series felt strongly that future physicians must better understand cultural backgrounds of patients to be able to better respond to each patient’s unique needs. Therefore, this series allowed for future providers to strengthen their awareness of how the mind, body, and spirit are all interconnected and important when treating a patient.

Data Analysis: Students ranked their average comfort level in treating a patient of a specific population from 1 to 5, 1 being very uncomfortable, 3 being neutral, 5 being very comfortable. Average ratings recorded before the didactic events ranged from 3.07 to 3.93, while after the events, average ratings increased to a range of 4.20 to 4.51. On average, participants rated their comfort levels at 3.41 before the presentation compared to 4.33 after the presentation. There was an overall average increase of 0.98 in comfort ratings across all 5 events. These findings were found to be statistically significant. Students also provided qualitative responses stating what they learned about each population, which was used to assess what knowledge was gained and what participants were taking away as the most important points of each event.

Results: Students ranked their average comfort level in treating a patient of a specific population from 1 to 5, 1 being very uncomfortable, 3 being neutral, 5 being very comfortable. Average ratings recorded before the didactic events ranged from 3.07 to 3.93, while after the events, average ratings increased to a range of 4.20 to 4.51. On average, participants rated their comfort levels at 3.41 before the presentation compared to 4.33 after the presentation. There was an overall average increase of 0.98 in comfort ratings across all 5 events. These findings were found to be statistically significant. Students also provided qualitative responses stating what they learned about each population, which was used to assess what knowledge was gained and what participants were taking away as the most important points of each event.

Conclusion: On analysis of the pre and post surveys, the results demonstrate that the presentations were successful in increasing participant knowledge and comfort within the five sub-groups. To further study the usefulness of long-term knowledge, comfort and application in clinical practice, the group intends to follow up with participants who are students doing their clinical rotations with another survey at the end of the academic year. The success of the series allowed the group to create a new committee, entitled the Committee for Diversity and Cultural Integration, that will continue to work with the Division of Clinical Science as well as work under the head of DEI for the school. Using the teaching method of the group, the new committee will put together a range of interest driven topics from the student population, while also taking on new DEI initiatives. Additionally, the committee will work on increasing student and faculty engagement with other projects throughout the academic year. The work created by the group is being integrated into the academic curriculum, allowing for the message to reach a broader range of participants in order to enhance the education of future clinicians. These diversity presentations will further students’ understanding for better patient compliance, communication, and overall healthcare outcomes.

Financial Disclosures: All project funding was provided by the West Virginia School of Osteopathic Medicine Office of Student Life.

Support: We would like to thank the Division of Clinical Science for their support of all authors involved in this project. We would like to thank Dr. Morrow and Belinda Evans from the Office of Student Affairs for providing us with resources needed to carry out these events.

Ethical Approval: This project was approved by the Office of Student Research and Projects at the West Virginia School of Osteopathic Medicine. After submitting project details, the Office of Student Research and Projects deemed this work as non-research scholarly activity, which exempted us from IRB and IACUC.

Informed Consent: Students were informed prior to submitting the survey that information would be blinded and used for research purposes. Filling out the survey was understood to mean consent.

Poster No. *PH-2

Abstract No. 19

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

The impact of Age, Race, Religion, and Gender on Patients’ Comfort with Medical Physical Examinations

¹Amani Masoud, OMS-IV; ²Tony A. Slieman, PhD; ¹William Hawkins; ¹Ifran Ali; ¹Sabrina Tahseen; ¹Asiya Gosla Radhanpuri

¹New York Institute of Technology College of Osteopathic Medicine at Arkansas State University; ²Department of Basic Sciences, New York Institute of Technology College of Osteopathic Medicine at Arkansas State University

Statement of Significance: Healthcare disparities have been a recurrent problem facing vulnerable populations in the United States. Literature suggests that age, religion, race/ethnicity, and gender affiliation are factors that present as barriers to patients seeking healthcare. Although the literature shows a physician’s lack of understanding of patient demographics can pose hurdles in healthcare, there is a gap if specific demographics impact patient comfort levels in physical and osteopathic structural exams.

Research Methods: We developed a 22-question survey based on the Bates’ Guide to Physical Examination and key components of the osteopathic structural exam. Responses were collected from 88 members of religious centers, 35 college students, and 53 medical students from across the United States collecting a total of 176 responses. The data collected included demographic information such as age, gender, religion, and race/ethnicity. Participants were asked to rank their comfort levels in various types of physical examinations using a 5-point Likert Scale with 1 being the least comfortable and 5 being the most comfortable. Each participant’s response to each question was analyzed based on categories of their age, gender, religion, and ethnicity. Means, standard deviations, frequency distribution, and median were then calculated using excel spreadsheets for each category. We also utilized the Mann-Whitney U test to determine if the difference between two sets of data groups was significant. Our hypothesis was that participants would be more comfortable with less invasive physical exams and less comfortable with more invasive ones.

Data Analysis: The results show that participants, in general, were significantly less likely to be comfortable with exams such as pelvic exams, rectal exams, or tailbone palpation while more comfortable with blood pressure measurements, thyroid exams, or scalp exams. When specifically looking at age as a factor we found that younger participants (11-20 years old) have significantly less comfort than older participants (61-70 years old) in 8 out of the 14 physical exam questions. In regard to gender, the data showed that female participants have less comfort than male participants in 6 out of the 14 exam questions. Additionally, we explored the effect patient gender may have on primary care physician gender preference. While the majority of participants did not have a gender preference a smaller minority (30.7%) expressed a gender preference with 79.2% of females stating yes to having a primary care physician gender preference as compared to males. We wanted to explore religious affiliation and its influence on patient comfort. Due to sampling size, we focused on individuals that identified as Atheist/Agnostic, Muslim, Jewish, or Christian. We found that individuals that identified as Muslim were generally less comfortable than the rest of the other groups in 5 out of the 14 physical exam questions. We also explored the potential effect of race/ethnicity on patients’ comfort. The majority of our participants identified as White, Asian, or Middle Eastern. We found that individuals that identify as Middle Easterners were significantly less comfortable in specifically 3 out of 14 physical exams (thyroid, cardiac and tailbone palpation). Generally, our results suggest that individuals irrespective of their background, age, ethnicity, etc. are less comfortable with invasive examinations such as rectal or pelvic exams. These results align with both our hypotheses as well as the literature regarding how age, gender, religion, and race/ethnicity may affect patients.

Results: The results show that participants, in general, were significantly less likely to be comfortable with exams such as pelvic exams, rectal exams, or tailbone palpation while more comfortable with blood pressure measurements, thyroid exams, or scalp exams. When specifically looking at age as a factor we found that younger participants (11-20 years old) have significantly less comfort than older participants (61-70 years old) in 8 out of the 14 physical exam questions. In regard to gender, the data showed that female participants have less comfort than male participants in 6 out of the 14 exam questions. Additionally, we explored the effect patient gender may have on primary care physician gender preference. While the majority of participants did not have a gender preference a smaller minority (30.7%) expressed a gender preference with 79.2% of females stating yes to having a primary care physician gender preference as compared to males. We wanted to explore religious affiliation and its influence on patient comfort. Due to sampling size, we focused on individuals that identified as Atheist/Agnostic, Muslim, Jewish, or Christian. We found that individuals that identified as Muslim were generally less comfortable than the rest of the other groups in 5 out of the 14 physical exam questions. We also explored the potential effect of race/ethnicity on patients’ comfort. The majority of our participants identified as White, Asian, or Middle Eastern. We found that individuals that identify as Middle Easterners were significantly less comfortable in specifically 3 out of 14 physical exams (thyroid, cardiac and tailbone palpation). Generally, our results suggest that individuals irrespective of their background, age, ethnicity, etc. are less comfortable with invasive examinations such as rectal or pelvic exams. These results align with both our hypotheses as well as the literature regarding how age, gender, religion, and race/ethnicity may affect patients.

Conclusion: This information is essential for healthcare providers so that they can understand how a patient’s religious affiliation, age, gender, ethnicity/race can influence their comfort during medical care and can lead to a more conducive and welcoming environment that promotes privacy, ease, and may help patients to become more open to communicating sensitive health issues which enhance care and improve health outcomes which can be further researched. Limitations of this study may include exploration of additional factors that may also impact patient care such as language and socioeconomic status.

References

1. References: Dykes DC, White AA 3rd. Getting to equal: strategies to understand and eliminate general and orthopaedic healthcare disparities. Clin Orthop Relat Res. 2009;467(10):2598-2605. doi:10.1007/s11999-009-0993-5

2. Simpson JL, Carter K. Muslim women’s experiences with health care providers in a rural area of the United States. J Transcult Nurs. 2008;19(1):16-23. doi:10.1177/1043659607309146

3. Kerssens JJ, Bensing JM, Andela MG. Patient preference for genders of health professionals. Soc Sci Med. 1997;44(10):1531-1540. doi:10.1016/s0277-9536(9600272-9)

4. Alqufly AE, Alharbi BM, Alhatlany KK, Alhajjaj FS. Muslim female gender preference in delaying the medical care at emergency department in Qassim Region, Saudi Arabia. J Family Med Prim Care. 2019;8(5):1658-1663. doi:10.4103/jfmpc.jfmpc_141_1

Financial Disclosures: None Reported

Support: None Reported

Ethical Approval: This project obtained IRB approval through the New York Institute of Technology IRB under Category 2 Exemption, Protocol Number: BHS1470.

Informed Consent: Written informed consent for participation was obtained from each site before surveys were administered. Surveys were conducted through email and on paper. Participants were emailed a hyperlink to the survey additionally consent information was prefaced again prior to the start of the survey questions.

Poster No. *PH-3

Abstract No. 30

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

The Use of Health Policy to Overcome Colorectal Cancer-Related Health Disparities in the African American Community

¹Michael Jacob Farber, BS, OMS-II; ²Sreejan Saha, BA, OMS-II; ²Karthik Madhira, BS, OMS-II; ²Steven W. Tseng, BS, OMS-II; ²Jonathan Kim, BA, BS, OMS-II; ³Arthur A. Klein, MD; ²Joerg R. Leheste, PhD, MS

¹New York Institute of Technology; ²Department of Biomedical Sciences, New York Institute of Technology; ³Department of Clinical Specialties, New York Institute of Technology

Statement of Significance: Colorectal cancer (CRC) is the second leading cause of cancer deaths in the US [1]. Persons with CRC spreading to distant body parts only have a 15% 5-year survival rate. However, when diagnosed at a localized stage, that rate jumps to 91% [2]. CRC also disproportionately affects African Americans largely because of their low screening compliance [3]. Due to COVID-19 pandemic, about 9.4 million cancer screenings have been missed, resulting in an estimated additional 4,500 deaths in the US [4,5].

Research Methods: Currently, Medicare covers colonoscopies for patients on a 10-year basis. Medicare also covers Fecal Immunochemical Tests (FIT) performed every year and Multitarget-Stool DNA (mtSDNA) tests, also known as Cologuard, every 3 years. This health disparity-driven analysis focuses on CRC screening-linked healthcare disparities affecting African Americans, particularly during the COVID-19 pandemic. This work compares and contrasts the financial impact, compliance, and mortality outcomes of four FDA-approved CRC screening methods: colonoscopies every 10 years, Cologuard every 3 years, FIT every year, and the Epi proColon test every year. To explore the financial impact of the 4 reviewed CRC-screening methods, we analyzed CRC-related costs per one thousand 50-year-olds. To explore adherence, we have adopted previously established methodology by D’Andrea and colleagues established for comparison of multiple methods tested via a validated microsimulation model [7]. The same microsimulation model was used to define averted CRC cases and deaths per thousand people, before and after adjusting for adherence to screening. For the comparison of mortality rates, we used the Quality-Adjusted Life-years Gained (QALYG) metric introduced by Peterse and colleagues [6]. Based on these outcomes, we reviewed The Donald Payne Sr. Colorectal Cancer Detection Act of 2021 for stakeholder positions, predicted pertinent outcomes, and ended with a recommendation.

Data Analysis: The total associated cost of colorectal cancer care per one thousand 50-year-olds in the US is $7.286 million excluding CRC screening, $7.751 million with obtaining a colonoscopy every 10 years, $8.887 million with completing Cologuard screening every 3 years, $6.793 million with completing FIT every year, and $8.574 million with taking the Epi proColon test every year [6]. Patient adherence to completing the CRC screenings with the aforementioned methods lies at 38% when obtaining a colonoscopy every 10 years, 42.6% when completing Cologuard screening every 3 years, 42.6% when completing FIT screening every year, and 85% when taking the Epi proColon test every year [7]. When incorporating adherence into mortality data, the number of CRC cases identified (sensitivity) and deaths averted per thousand people expressed as (cases, deaths), are (34, 20) with obtaining a colonoscopy every 10 years, (24, 16) with completing Cologuard screening every 3 years, (21, 14) with completing FIT screening every year, and (37, 23) with taking the Epi proColon test every year [7]. In terms of mortality, the QALYG per one thousand people is 209 years with obtaining a colonoscopy every 10 years, 175 years with completing Cologuard screening every 3 years, 189 years with completing FIT screening every year, and 194 years with taking the Epi proColon test every year [6].

Results: The total associated cost of colorectal cancer care per one thousand 50-year-olds in the US is $7.286 million excluding CRC screening, $7.751 million with obtaining a colonoscopy every 10 years, $8.887 million with completing Cologuard screening every 3 years, $6.793 million with completing FIT every year, and $8.574 million with taking the Epi proColon test every year [6]. Patient adherence to completing the CRC screenings with the aforementioned methods lies at 38% when obtaining a colonoscopy every 10 years, 42.6% when completing Cologuard screening every 3 years, 42.6% when completing FIT screening every year, and 85% when taking the Epi proColon test every year [7]. When incorporating adherence into mortality data, the number of CRC cases identified (sensitivity) and deaths averted per thousand people expressed as (cases, deaths), are (34, 20) with obtaining a colonoscopy every 10 years, (24, 16) with completing Cologuard screening every 3 years, (21, 14) with completing FIT screening every year, and (37, 23) with taking the Epi proColon test every year [7]. In terms of mortality, the QALYG per one thousand people is 209 years with obtaining a colonoscopy every 10 years, 175 years with completing Cologuard screening every 3 years, 189 years with completing FIT screening every year, and 194 years with taking the Epi proColon test every year [6].

Conclusion: While standard colonoscopy, the gold standard in CRC diagnosis, produces the best results with a QALYG of 209 years per 1000 people, the Epi proColon test closely follows with a QALYG of 194. When taking into consideration an exceptional patient adherence with the Epi proColon test (85%) that is 2-3 times above other methods, as well as its superior sensitivity and lives saved (37, 23), Medicare coverage will likely result in the intended effect of saving lives throughout all and particularly the African American community.

Stakeholders other than CRC patient advocacy groups who have an interest in passing this bill are insurance companies involved with the financial burden of cancer therapy, which becomes less costly with an earlier diagnosis [8,9]. Also, hospital systems challenged by staff and equipment shortages during the COVID-19 pandemic would likely support this bill [10]. Stakeholders against this bill could be the ones rallying around the comparatively high cost of Epi proColon ($8.574 million per 1000 50-year-olds), which is only topped by Cologuard ($8.887 million per 1000 50-year-olds).

There are some additional downsides to the Epi proColon test such as the research behind it being mostly based on simulation. Besides being more costly than FIT, for example, it also comes with a higher rate of false positives necessitating additional colonoscopies.

As discussed earlier, CRC is the second leading cause of cancer deaths in the US, in which a majority of these deaths can be prevented with increased screening. However, the compliance of all available screenings today is less than 50%. That is where the strength of the Epi proColon test lies: especially for communities with the lowest compliance rates. African-American communities show the lowest CRC-related compliance and are leading in CRC-related deaths. Approving Medicare coverage for Epi proColon testing would be a major step forward alleviating disparities in healthcare based on socio-economic status.

References

1. Centers for Disease Control and Prevention. An Update on Cancer Deaths in the United States. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, Division of Cancer Prevention and Control; 2022.

2. American Cancer Society. Colorectal Cancer: Statistics. Cancer.Net. https://www.cancer.net/cancer-types/colorectal-cancer/statistics. Published May 31, 2022. Accessed July 9, 2022.

3. Farr DE, Haynes VE, Armstead CA, Brandt HM. Stakeholder Perspectives on Colonoscopy Navigation and Colorectal Cancer Screening Inequities. J Cancer Educ. 2021;36(4):670-676. doi:10.1007/s13187-019-01684-2

4. Nodora JN, Gupta S, Howard N, et al. The COVID-19 Pandemic: Identifying Adaptive Solutions for Colorectal Cancer Screening in Underserved Communities. J Natl Cancer Inst. 2021;113(8):962-968. doi:10.1093/jnci/djaa117

5. NCI Staff. Working to Close the Cancer Screening Gap Caused by COVID. NIH | National Cancer Institute. https://www.cancer.gov/news-events/cancer-currents-blog/2022/covid-increasing-cancer-screening. Published May 17, 2022. Accessed July 9, 2022.

6. Peterse EFP, Meester RGS, de Jonge L, et al. Comparing the Cost-Effectiveness of Innovative Colorectal Cancer Screening Tests [published correction appears in J Natl Cancer Inst. 2022 May 20;:]. J Natl Cancer Inst. 2021;113(2):154-161. doi:10.1093/jnci/djaa103

7. D’Andrea E, Ahnen DJ, Sussman DA, Najafzadeh M. Quantifying the impact of adherence to screening strategies on colorectal cancer incidence and mortality. Cancer Med. 2020;9(2):824-836. doi:10.1002/cam4.2735

8. American Cancer Society. The Affordable Care Act. American Cancer Society. https://www.cancer.org/treatment/finding-and-paying-for-treatment/health-insurance-laws/the-health-care-law.html. Published September 25, 2019. Accessed July 8, 2022.

9. EARLY CANCER DIAGNOSIS SAVES LIVES, CUTS TREATMENT COSTS. Saudi Med J. 2017;38(3):328-329.

10. Cancino RS, Su Z, Mesa R, Tomlinson GE, Wang J. The Impact of COVID-19 on Cancer Screening: Challenges and Opportunities. JMIR Cancer. 2020;6(2):e21697. Published 2020 Oct 29. doi:10.2196/21697

Financial Disclosures: None reported

Support: None reported

Ethical Approval: Exempt

Informed Consent: Not applicable

Poster No. *PH-4

Abstract No. 41

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Supervised Drug Injection Sites to Reduce Intravenous Drug Usage and Prevent Drug Overdose

¹Farhaad Rasool, OMS-II; ²Arthur A. Klein, MD; ³Joerg R. Leheste, PhD, MS ¹New York Institute of Technology; ²Department of Clinical Specialities, New York Institute of Technology; ³Department of Biomedical Sciences, New York Institute of Technology

Statement of Significance: Bill H.R 7029 states that no Federal funds may be allocated to an injection center [1]. This study analyzes H.R 7029 by gathering data on I.V drug use, overdose deaths, and disease rates. Knowledge gaps exist because two New York sites are the first to open in the U.S [2]. Studies have looked at other locations in various countries [3]. The Biden administration proposed that sites can prevent overdose deaths [4]. Site efficacy requires exploration due to potential health benefits for drug users.

Research Methods: This study reviews and analyzes a wide range of literature on injection facilities in an effort to end with a scientific assessment followed by a recommendation. Topics included a focus on the effectiveness of current supervised drug injection sites operating in Canada and Australia, service industry workers’ experience with people who inject drugs (PWID), public drug use, drug treatment services, and blood-borne diseases like Hepatitis C. Data concerning rates of HIV, Hepatitis B and C, and opioid overdose were gathered from the Centers for Disease Control and Prevention (CDC) and analyzed to draw correlations between I.V. drug use, age, race, and transmission of disease. The analysis was conducted through the creation of charts and graphs, and further comparing and contrasting the data across different categories. The study has osteopathic significance in the sense that limiting drug usage ties into the holistic approach that osteopathic physicians embody. The goal of osteopathic physicians is to enable the health of a patient by allowing the body to heal itself.

Data Analysis: The data analyzed sheds light on the severity of the opioid epidemic in America. More than 75% of 91,000 deaths due to drug overdose were directly tied to opioid usage [5]. In 2020, 68,630 deaths involved an opioid overdose - a number that has more than tripled since 2010 [6]. These deaths have predominantly occurred in the White, Non-Hispanic ethnic group, followed by the Black and Hispanic population [7]. Overdose deaths have skyrocketed by 31% since 2019, leaving policymakers with the task of finding solutions to manage the crisis [8]. Research has shown a drastic rise in cases of Hepatitis C predominantly due to injection drug use, specifically in the age groups of 20-29 and 30-39 [9]. The number of reported cases per 100,000 population has more than tripled in the last decade [9]. In addition, while reported cases of Hepatitis B appear low in number, the CDC estimates that the actual number of cases is almost 8x that which is reported; in 2018, 3,322 cases were reported, while 21,600 cases were estimated to exist [10]. Considering the increasing number of blood-borne diseases, opioid overdoses, and drug-related deaths, supervised drug injection sites have assumed a position of alleviating the issue. The data shows that after two months of being open, the two New York City sites were able to reverse a total of 114 overdoses while facilities have been utilized 4,974 times by 585 PWID [2]. Also, both Sydney and Vancouver have run successful drug injection site programs in terms of decreasing public injection, promoting drug detoxification, and providing sterile needles to prevent the spread of disease [3].

Results: The data analyzed sheds light on the severity of the opioid epidemic in America. More than 75% of 91,000 deaths due to drug overdose were directly tied to opioid usage [5]. In 2020, 68,630 deaths involved an opioid overdose - a number that has more than tripled since 2010 [6]. These deaths have predominantly occurred in the White, Non-Hispanic ethnic group, followed by the Black and Hispanic population [7]. Overdose deaths have skyrocketed by 31% since 2019, leaving policymakers with the task of finding solutions to manage the crisis [8]. Research has shown a drastic rise in cases of Hepatitis C predominantly due to injection drug use, specifically in the age groups of 20-29 and 30-39 [9]. The number of reported cases per 100,000 population has more than tripled in the last decade [9]. In addition, while reported cases of Hepatitis B appear low in number, the CDC estimates that the actual number of cases is almost 8x that which is reported; in 2018, 3,322 cases were reported, while 21,600 cases were estimated to exist [10]. Considering the increasing number of blood-borne diseases, opioid overdoses, and drug-related deaths, supervised drug injection sites have assumed a position of alleviating the issue. The data shows that after two months of being open, the two New York City sites were able to reverse a total of 114 overdoses while facilities have been utilized 4,974 times by 585 PWID [2]. Also, both Sydney and Vancouver have run successful drug injection site programs in terms of decreasing public injection, promoting drug detoxification, and providing sterile needles to prevent the spread of disease [3].

Conclusion: The ethics and efficacy surrounding supervised injection sites are controversial topics in today’s society. Evidence proves that the rates of blood-borne diseases, such as HIV, Hepatitis B, and Hepatitis C are increased through drug injection [9,10]. Overdose prevention centers alleviate this concern by providing a sterile and safe environment for PWID to inject themselves without the risk of using contaminated needles. In addition, the opioid crisis in America has become more and more apparent in recent years, with deaths due to opioid overdose reaching an all-time high [6]. These facilities also tackle that issue by having healthcare workers on standby to manage overdoses. Bill H.R 7029, the Stop Injection Sites for Illegal Drugs Act of 2022, seeks to prohibit any kind of federal funding that goes toward drug injection sites [1]. Policymakers, however, may be transitioning to a new approach to treating substance abuse by allowing PWID access to supervised sites. A limitation to the study includes the short duration of time the two New York sites have been open; in the future, more data will be available for a thorough and complete analysis. Despite success in other countries, whether or not these supervised sites will help solve the opioid crisis in the United States is yet to be determined.

References

1. Beutler JH. H.R.7029 - Stop Injection Sites for Illegal Drugs Act of 2022. Congress.gov. https://www.congress.gov/bill/117th-congress/house-bill/7029?q=%7B%22search%22%3A%5B%22hr+7029%22%2C%22hr%22%2C%227029%22%5D%7D&s=1&r=1. Published March 9, 2022. Accessed July 7, 2022.

2. Davick A. Supervised injection sites avert over 100 overdoses, organization says. Spectrum News NY1. https://www.ny1.com/nyc/all-boroughs/news/2022/01/24/supervised-injection-sites-avert-over-100-overdoses--organization-says. Published January 24, 2022. Accessed July 7, 2022.

3. Beletsky L, Davis CS, Anderson E, Burris S. The law (and politics) of safe injection facilities in the United States. American Journal of Public Health. 2008;98(2):231-237. doi:10.2105/ajph.2006.103747

4. The Associated Press. Justice Department signals it may allow safe injection sites. NBCNews.com. https://www.nbcnews.com/politics/justice-department/justice-department-signals-it-may-allow-safe-injection-sites-n1288775. Published February 8, 2022. Accessed July 6, 2022.

5. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. The Drug Overdose Epidemic: Behind the Numbers. Centers for Disease Control and Prevention. https://www.cdc.gov/opioids/data/index.html. Published June 1, 2022. Accessed July 8, 2022.

6. National Institute on Drug Abuse. Overdose death rates. National Institutes of Health. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:∼:text=Opioid%2Dinvolved%20overdose%20deaths%20rose,2020%20to%2068%2C630%20overdose%20deaths. Published June 3, 2022. Accessed July 4, 2022.

7. KFF. Opioid overdose deaths by race/ethnicity. KFF. https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-raceethnicity/?currentTimeframe=4&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D. Published May 9, 2022. Accessed July 7, 2022.

8. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Death Rate Maps & Graphs. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/deaths/index.html. Published June 2, 2022. Accessed July 9, 2022.

9. CDC, National Notifiable Diseases Surveillance System. Hepatitis C surveillance in the United States, 2018. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/statistics/2018surveillance/HepC.htm. Published August 28, 2020. Accessed July 9, 2022.

10. CDC, National Notifiable Diseases Surveillance System. Hepatitis B surveillance in the United States, 2018. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/statistics/2018surveillance/HepB.htm. Published July 27, 2020. Accessed July 9, 2022.

Financial Disclosures: None reported

Support: None reported

Ethical Approval: Exempt

Informed Consent: Not applicable

Poster No. *PH-5

Abstract No. 47

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Investigating SARS-CoV-2 Vaccine Hesitancy among Various Demographic Groups Employed at Long-Term Care Facilities in Southwest Virginia

¹Howard N. Rainey, OMS-III; ¹Seth J. Weir; ²Theresa McCann, PhD

¹Edward Via College of Osteopathic Medicine-Virginia; ²Department of Preventive Medicine, Edward Via College of Osteopathic Medicine-Virginia

Statement of Significance: Expeditious efforts to vaccinate the population against the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is crucial to slowing the pandemic that has been ongoing for over two years. Despite the increase in accessibility of vaccines, approximately 20% of the United States’ population has yet to become fully vaccinated. A population of concern is employees within long term care facilities as the residents of these facilities are at higher risk of poor prognosis from COVID-19.1

Research Methods: We created an anonymous survey with questions regarding demographics, religious background, political ideology, vaccination status, and several Likert scale-style responses to gauge the importance of various common concerns in participants’ vaccination decision. In addition, all research materials were available in Spanish to ensure maximal accessibility. In June of 2021, the survey was sent by email to eighty-four administrators of long-term care facilities throughout southwestern Virginia, identified through the Virginia Health Workforce Development Authority and Virginia Department of Social Services. Follow-up telephone calls were made to each facility, and survey information for posting was also sent by U.S. mail. Despite our efforts, a total of twenty-eight responses were recorded of which twenty-one were usable. Our study results, while limited quantitatively, do qualitatively describe the issues reported in other sources, particularly regarding educational and occupational influences. Data were exported from the Qualtrics data collection survey to Excel and SPSS version 28 for descriptive analyses, and group comparisons.

Data Analysis: In this study, fourteen of the twenty-one responders had a bachelor’s degree or higher education, and all reported that they were vaccinated against COVID-19. Conversely, seven participants reported an education level of less than a four-year degree; five of these participants had not received the vaccine. In addition, our data suggest that individuals with jobs that required higher education and yielded higher income were more willing to receive the vaccine. Thirteen participants were either facility directors, physicians, or registered nurses, and all received the vaccine. The additional eight participants were front desk employees, certified nursing assistants, dining services, housekeeping, licensed practical nurse, and patient care assistants. Among these participants, only half had received the vaccination. Among the individuals that reported vaccine hesitancy, the most common reasons included: fear of adverse effects, history of anaphylaxis, personal views, religious views, and, most substantially, social media influence. Although response rates were less substantial than desired, they are around the national average of 6% that was determined by the Pew Research Center. When studying the impact of low response rate on data quality, Pew Research Center found that response rates are not a reliable metric of data accuracy (Pew Research Center studies were conducted in 1997, 2003, 2012, and 2016).

Results: In this study, fourteen of the twenty-one responders had a bachelor’s degree or higher education, and all reported that they were vaccinated against COVID-19. Conversely, seven participants reported an education level of less than a four-year degree; five of these participants had not received the vaccine. In addition, our data suggest that individuals with jobs that required higher education and yielded higher income were more willing to receive the vaccine. Thirteen participants were either facility directors, physicians, or registered nurses, and all received the vaccine. The additional eight participants were front desk employees, certified nursing assistants, dining services, housekeeping, licensed practical nurse, and patient care assistants. Among these participants, only half had received the vaccination. Among the individuals that reported vaccine hesitancy, the most common reasons included: fear of adverse effects, history of anaphylaxis, personal views, religious views, and, most substantially, social media influence. Although response rates were less substantial than desired, they are around the national average of 6% that was determined by the Pew Research Center. When studying the impact of low response rate on data quality, Pew Research Center found that response rates are not a reliable metric of data accuracy (Pew Research Center studies were conducted in 1997, 2003, 2012, and 2016).

Conclusion: Because this study’s focus was to understand why individuals were facing vaccine hesitancy, we asked questions in our survey about this directly. Our findings are consistent with published literature concerning vaccine hesitancy.2,3 Along with the data on educational levels, occupational data disparities are in agreement with worldwide literature regarding vaccine hesitancy.4 With these findings in mind, it is vital that our focus in vaccine compliance move toward educating individuals who may be misinformed or provide additional pre-requisite information to help them to understand the importance of vaccination for COVID-19. It is essential to address concerns with individuals when discussing the vaccine and to address misinformation spread via social media. We hope that this information will support vaccination recruitment efforts to focus on target populations that are most susceptible to hesitancy within the United States.

References

1. Nguyen K.H., Srivastav A, Razzaghi H, Williams W, Lindley M.C., Jorgensen C, Abad N, Singleton J.A. COVID-19 vaccination intent, perceptions, and reasons for not vaccinating among groups prioritized for early vaccination — United States, September and December 2020. MMWR. Morbidity and Mortality Weekly Report. 2021; 70(6): 217– 222. doi: 10.15585/mmwr.mm7006e3

2. Bertoncello C, Ferro A, Fonzo M, Zanovello S. Socioeconomic determinants in vaccine hesitancy and vaccine refusal in Italy. Vaccines. 2020; 8(2): 276. doi: 10.3390/vaccines8020276

3. Biaso L.R. Vaccine hesitancy and health literacy. Human Vaccines and Immunotherapies. 2016; 13(3): 701-702. doi: 10.1080/21645515.2016.1243633

4. Wagner A, Masters B, Domek G, Mathew J, Sun X. Comparisons of vaccine hesitancy across five low- and middle-income countries. Vaccines. 2019; 7(4): 155. doi: 10.3390/vaccines7040155

Financial Disclosures: None Reported

Support: None Reported

Ethical Approval: This study was reviewed and approved by the Edward Via College of Osteopathic Medicine Institutional Review Board, Blacksburg, VA. IRB Number: 1760585-4. Approved on 08/27/2021.

Informed Consent: Consent was implied by the return of the questionnaire. The questionnaire included the IRBNet template for consent statements.

Poster No. *PH-6

Abstract No. 113

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Online Virtual Reality Simulations to Improve Health Professional Students Empathy and Attitudes Towards Opioid Use Disorder (OUD)

¹Dominique Rehl, OMS-II; ¹Mason Mangapora, OMS-III; ²Elizabeth Beverly, PhD

¹Ohio University Heritage College of Osteopathic Medicine; ²Department of Primary Care, Ohio University Heritage College of Osteopathic Medicine

Statement of Significance: Opioid use disorder (OUD) has a considerable morbidity and mortality burden in the US(1). Most clinicians hold a negative attitude towards substance use disorder(2). Negative attitudes can lead to a lower quality of care. Experience-based education may help improve attitudes and empathy(3,4). Virtual reality(VR) can help students understand abstract ideas based on simulations of real experiences(5). There remains a gap in knowledge regarding the use of VR for non-surgical skills training(6).

Research Methods: We recruited current medical students enrolled at the Ohio University Heritage College of Osteopathic Medicine during the 2021-2022 academic year to participate in the study; there were no other exclusion criteria. Before and after viewing the virtual reality simulations, participants took the Adapted Opening Minds Survey for Health Professional Students and the Jefferson Scale of Empathy Health Care Provider Students Version. The Adapted Opening Minds Survey for Health Professional Students is a 20-item survey that provides information on stigma held by health professional students regarding opioid use disorder; summation of the survey provides a composite stigma score. Participants also completed a brief demographic form. Next, participants viewed 12 simulations that followed a main character and her interactions with a nurse, social worker, family members, and community. The main character, Destiny, was a 23-year-old woman from Ohio who is pregnant and struggling with opioid use disorder. With a lack of support at home, she needs the help of clinicians to assist and empower her through her pregnancy. Finally, we assessed sociodemographic factors using descriptive statistics and presented them as means and standard deviations or sample size and percentages. Next, we performed paired t-tests and Wilcoxon sign-rank tests to examine changes in stigma towards opioid use disorder and empathy scores before and after the virtual reality training program. We defined statistical significance as a p-value less than .05 and conducted analyses in SPSS statistical software version 28.0 (Chicago, IL: SPSS Inc.).

Data Analysis: To date, a total of 24 osteopathic medical students participated, and 21 people completed the post survey. (mean age=24, 87.5% women, 12.5% men, 0% transgender, 0% non-binary, 0% genderqueer or gender nonconforming, 58.3% OMS Year 2, 25.0% OMS Year 3, 12.5% OMS Year 4, 4.2% Senior). Preliminary findings show no statistical improvements in empathy (mean change = -2.24, Z= -9.309, p=.198). We observed a statistical trend in reducing stigma towards opioid use disorder (mean change= 3.00, Z= -1.930, p=.054). We are continuing to collect data.

Results: To date, a total of 24 osteopathic medical students participated, and 21 people completed the post survey. (mean age=24, 87.5% women, 12.5% men, 0% transgender, 0% non-binary, 0% genderqueer or gender nonconforming, 58.3% OMS Year 2, 25.0% OMS Year 3, 12.5% OMS Year 4, 4.2% Senior). Preliminary findings show no statistical improvements in empathy (mean change = -2.24, Z= -9.309, p=.198). We observed a statistical trend in reducing stigma towards opioid use disorder (mean change= 3.00, Z= -1.930, p=.054). We are continuing to collect data.

Conclusion: Preliminary findings support the notion that virtual reality education may be an innovative approach to improve attitudes toward opioid use disorder among osteopathic medical students. Additional research with a larger, more diverse sample is needed to confirm this finding as well as examine the impact on empathy. Further, more research should examine the long-term impact of the virtual reality education on opioid use disorder. The current study is limited by a small sample size taken from a university setting. Additionally, findings may have been influenced by selection bias and social desirability bias. Virtual reality enables medical students to see the whole patient by immersing themselves in their experiences both inside and outside of the clinic. This approach may help osteopathic medical students consider their patient’s lived experiences, and therefore approach patients more holistically.

References

1. Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The Burden of Opioid-Related Mortality in the United States. JAMA Netw Open. 2018;1(2):e180217. doi:10.1001/jamanetworkopen.2018.02172.

2. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug Alcohol Depend. 2013;131(1):23-35. doi:10.1016/j.drugalcdep.2013.02.0183.

3. Ding L, Landon BE, Wilson IB, Wong MD, Shapiro MF, Cleary PD. Predictors and consequences of negative physician attitudes toward HIV-infected injection drug users. Arch Intern Med. 2005;165(6):618-623. doi:10.1001/archinte.165.6.6184.

4. Patel S, Pelletier-Bui A, Smith S, et al. Curricula for empathy and compassion training in medical education: A systematic review. PLoS ONE. 2019;14(8):e0221412. doi:10.1371/journal.pone.02214125.

5. Zare-Bidaki M, Ehteshampour A, Reisaliakbarighomi M, et al. Evaluating the Effects of Experiencing Virtual Reality Simulation of Psychosis on Mental Illness Stigma, Empathy, and Knowledge in Medical Students. Front Psychiatry. 2022;13:880331. doi:10.3389/fpsyt.2022.8803316.

6. Jiang H, Vimalesvaran S, Wang JK, Lim KB, Mogali SR, Car LT. Virtual Reality in Medical Students’ Education: Scoping Review. JMIR Med Educ. 2022;8(1):e34860. doi:10.2196/34860

7. NOTE: The formatting of superscripts is not possible on this submission platform. Therefore the numerical references in the "context" section that correspond to their appropriate citation in the "references" section are in plain, non-superscripted text.

Financial Disclosures: None reported.

Support: Heritage Faculty Endowed Fellowship in Behavioral Diabetes OHF Ralph S. Licklider, D.O., Research Endowment was used to pay study participants via a $25 Amazon gift card. All of the VR technology for this project is developed by the Ohio University’s Game Research and Immersive Design (GRID) Lab. Dr. Elizabeth Beverly provided support as a mentor.

Ethical Approval: IRB 22-X-18 was reviewed and approved on 05/02/2022.

Informed Consent: Those who are interested in taking the survey will be emailed an instruction sheet that contains a Qualtrics link (online questionnaire service) with a screen that introduces the study. Here, participants can read the Informed Consent document. To avoid coercion, the informed consent document will emphasize the voluntary nature of participation and will remind participants that the study is NOT related to their performance or grades in school. No researchers will be present when potential participants decide to participate or decline, and thus they may feel less pressure than in a face-to face consent process. Participants with questions about the study are directed to email or phone Dr. Elizabeth Beverly. To consent, the participants will be asked to click a button indication “Yes, I consent to participate in this study. I may withdraw my participation at any time.” To decline, participants will click a radio button indicating “I decline to participate.”

Poster No. *PH-7

Abstract No. 104

Category: Public Health

Research Topic: Osteopathic Philosophy

Awareness of the Osteopathic Field and Understanding of Osteopathic Philosophy Improve After Participation in a Healthcare Camp for High School Students

¹Ashley Lynn Orr, MS, OMS-III; ¹Mary K. Flanagan, MS; ¹Alexis M. Klink, MS; ¹Kasey M. Kruse, MS; ¹Joseph M Vroegop; ²Erica L. Ausel, PhD; ³Clint Whitson, MS; ¹Brian W. Skinner, PharmD, BCPS; ²Julia M. Hum, PhD;

¹Marian University College of Osteopathic Medicine; ²BMS Program, Marian University College of Osteopathic Medicine; ³Student Affairs, Marian University College of Osteopathic Medicine

Statement of Significance: Diversifying the healthcare workforce may reduce health disparities, combat inequities, and increase access to medical care in underserved populations. Introducing high school students to health professions may enhance their perceptions of healthcare careers and demonstrate that these careers are attainable.

Research Methods: The hypothesis was tested through administration of a pre- and post-camp voluntary, confidential survey. A total of 53 campers attended the camp, of which, 46 completed the surveys. Each participant generated a unique code used to facilitate matched response data analysis and ensure confidentiality. The pre-camp survey collected demographic data, including gender identity, race, ethnicity, grade level, presence of a healthcare worker in their immediate family, and previous participation in a healthcare camp. Campers were asked to list all careers in healthcare they were familiar with, and then rank on a Likert-scale (1-Strongly Disagree, 5-Strongly Agree) their interest in a career in healthcare, how obtainable a career in healthcare felt for them, how comfortable they felt describing what osteopathic medicine is, and whether they could explain the similarities and differences between osteopathic and allopathic medicine/philosophy. Campers rotated through activity stations that highlight unique patient cases using MU-COM’s Simulation Center, Anatomage table, ShareCare virtual reality system, and osteopathic manipulative medicine (OMM) lab. Further onboarding and debriefing sessions were utilized to facilitate discussion and contextualize relative healthcare provider roles related to the patient case of the day. Information was presented to the students on training, salaries, summary of duties, and pathways to achieving a career in healthcare. Current medical students, along with other students in the health professions, served as counselors and activity leaders allowing campers to create connections with in-training members of the medical community. At the conclusion of healthcare camp, participants were asked to again complete the original survey. A Wilcoxan Signed-Rank test was employed to compare participants’ pre- and post-camp responses of listed careers in healthcare, understanding of the osteopathic philosophy, and comfort explaining osteopathic medicine.

Data Analysis: Response rate for both pre- and post-camp surveys was 92.5% with 21.7% of participants identifying as male, 73.9% as female, and 4.4% as prefer not to answer/other. The participants included ten sophomores(21.7%), twenty-one juniors(45.6%), twelve seniors(26.0%), and three incoming college freshmen(6.5%). Further, 19.6% of participants indicated their ethnicity as Hispanic, 6.5% preferred not to answer, the remainder selected Non-Hispanic. Of the campers, 52.2% identified as Caucasian, 21.7% as Black, 10.9% as Asian, and 15.2% preferred not to answer. Prior to the intervention of the camp, participants listed on average 7.2 healthcare professions, which significantly increased to 10.5 careers on the post-camp survey(p< 0.0001). At the conclusion, there was a statistically significant increase in camper’s responses to the Likert-scale question “I feel comfortable explaining what osteopathic medicine is”. Pre-survey average was 2.3(2-Moderately Disagree) and post-survey average was 4.2(4-Moderately Agree). Awareness of the osteopathic profession, as indicated by listing DO, osteopathy, osteopathic, or OMM in the pre- and post-camp surveys, increased from 2.17% to 23.9%. There was a statistically significant(p< 0.0001) increase in camper’s response to the Likert-scale questions, “I feel comfortable explaining the DIFFERENCES between osteopathic(DO) and allopathic(MD) medicine/philosophy” and “I feel comfortable explaining the SIMILARITIES between osteopathic(DO) and allopathic(MD) medicine/philosophy”, with pre- and post-survey averages yielding 2.3, 2.3 and 4.3, 4.1 respectively. There was a slight increase in the perceived attainability of a healthcare career. Pre-survey data yielded an average of 4.3 and post-survey data yielded an average of 4.6. This increase is noted, but not statistically significant. Likely attributed to the camp being marketed to students as a healthcare camp attracting participants who already believe they are headed to a healthcare career.

Results: Response rate for both pre- and post-camp surveys was 92.5% with 21.7% of participants identifying as male, 73.9% as female, and 4.4% as prefer not to answer/other. The participants included ten sophomores(21.7%), twenty-one juniors(45.6%), twelve seniors(26.0%), and three incoming college freshmen(6.5%). Further, 19.6% of participants indicated their ethnicity as Hispanic, 6.5% preferred not to answer, the remainder selected Non-Hispanic. Of the campers, 52.2% identified as Caucasian, 21.7% as Black, 10.9% as Asian, and 15.2% preferred not to answer. Prior to the intervention of the camp, participants listed on average 7.2 healthcare professions, which significantly increased to 10.5 careers on the post-camp survey(p< 0.0001). At the conclusion, there was a statistically significant increase in camper’s responses to the Likert-scale question “I feel comfortable explaining what osteopathic medicine is”. Pre-survey average was 2.3(2-Moderately Disagree) and post-survey average was 4.2(4-Moderately Agree). Awareness of the osteopathic profession, as indicated by listing DO, osteopathy, osteopathic, or OMM in the pre- and post-camp surveys, increased from 2.17% to 23.9%. There was a statistically significant(p< 0.0001) increase in camper’s response to the Likert-scale questions, “I feel comfortable explaining the DIFFERENCES between osteopathic(DO) and allopathic(MD) medicine/philosophy” and “I feel comfortable explaining the SIMILARITIES between osteopathic(DO) and allopathic(MD) medicine/philosophy”, with pre- and post-survey averages yielding 2.3, 2.3 and 4.3, 4.1 respectively. There was a slight increase in the perceived attainability of a healthcare career. Pre-survey data yielded an average of 4.3 and post-survey data yielded an average of 4.6. This increase is noted, but not statistically significant. Likely attributed to the camp being marketed to students as a healthcare camp attracting participants who already believe they are headed to a healthcare career.

Conclusion: The survey results demonstrate that healthcare camps are an effective means to increase awareness of osteopathy and perceptions of healthcare careers amongst high school students. Future studies will include appropriate controls to compare data as well as an extended overnight option to expand the student population past that of central Indiana. To further support students in their pursuit of a healthcare profession, Marian University offers additional scholarships for camp attendees, should they choose to attend the university.

References

1. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med. 2014; 174(2): 289–291. doi: 10.1001/jamainternmed.2013.12756

2. Shen MJ, Peterson EB, Costas-Muñiz R. et al. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. J Racial Ethn Health Disparities. 2018; 5Z(1): 117-140. doi: 10.1007/s40615-017-0350-4

Financial Disclosures: None reported.

Support: Support for the Marian University Healthcare Camp was provided through a generous donation from the Julie and Tom Wood Family Foundation. The survey distribution and completion was not financially supported.

Ethical Approval: This study was submitted to the Marian University Institutional Review Board and received IRB approval (IRB #S22.139).

Informed Consent: Parental consent was obtained for each participant, as well as assent forms for each camper were signed.

Poster No. *PH-8

Abstract No. 70

Category: Public Health

Research Topic: Osteopathic Philosophy

AOA Grant Award: #1907746

Gender Differences in Stress, Anxiety, and Depression Perceived by Osteopathic Medical Students Within the Context of the COVID-19 Pandemic

¹Victoria Herr, OMS-III; ²Jillian Emanuel, OMS-III; ²Atif Farid, OMS-III; ²Alexander Morris, DO; ²Jerry Balentine, DO; ²William Blazey, DO; ²Bhuma Krishnamachari, PhD

¹New York Institute of Technology; ²Department of Research, New York Institute of Technology

Statement of Significance: Females are more likely to experience psychological distress than males,1 with research supporting sociological, cognitive, and biological causes.2 Medical students also have higher levels of stress,3 depression, and anxiety.4 The Coronavirus 2019 (COVID-19) pandemic and the resulting isolation of students are predicted to exacerbate this problem.3 Research is currently lacking on the causal factors behind gender differences in mental health among medical students in the context of COVID-19.

Research Methods: This is a repeated-measures survey study with osteopathic significance. The study population consists of students enrolled at an osteopathic school, specifically the New York Institute of Technology College of Osteopathic Medicine (NYITCOM). All participants were recruited via email and NYITCOM students in their first or second year. Participants received surveys via REDCap during the 2019-2020 (Cohort 1) and 2020-2021 (Cohort 2) academic years. Cohort 1 was surveyed six times over the academic school year. Cohort 2 was surveyed four times over the academic school year. Initially, 206 participants were part of the study. Exclusion criteria included participants whose gender was classified as non-binary and those who did not complete a survey after initial recruitment.

The survey contained questions about demographics and measurements of stress, such as the Perceived Stress Scale 10 (PSS-10), Depression Anxiety Stress Scale 21 (DASS-21), and the Medical Education Hassles Scale-R (MEHS-R) questionnaires. To further investigate the effects of certain stressor types on participants, individual stressors from the MEHS-R questionnaire were grouped based on commonly shared themes. The resulting categories were School, Transportation, Social, Financial, Household Chores/Personal Time Commitments, Health/Appearance, and Environmental stressors. The scores of the individual stressors were combined in each category, and the mean scores were determined to evaluate the effect of each stressor type on individuals.

Jamovi was the statistical software used to analyze our data. To assess the differences in questionnaire scores between genders, a student’s t-test was performed at each interval of Cohort 1 and Cohort 2 combined, with these scores analyzed as continuous variables. The alpha value used was 0.05.

Data Analysis: After 13 were excluded, 193 participants remained, with 52 females and 51 males in Cohort 1 and 55 females and 35 males in Cohort 2. A combined analysis of both cohorts showed females consistently scored higher on the PSS-10 scale than males, and this difference was statistically significant at all four times (p.05).

Results: After 13 were excluded, 193 participants remained, with 52 females and 51 males in Cohort 1 and 55 females and 35 males in Cohort 2. A combined analysis of both cohorts showed females consistently scored higher on the PSS-10 scale than males, and this difference was statistically significant at all four times (p.05).

Conclusion: The results showed that female medical students scored significantly higher than male medical students on almost all mental health screening tools. This indicates that female medical students have higher levels of stress, anxiety, and depression than their male counterparts. In addition, when the specific categories were assessed, females appeared disproportionately affected by social, academic, and environmental stressors and those regarding their personal time commitments and health/appearance. In contrast, males showed relatively higher stress levels relating to transportation and finances. Future research could explore why these stressors affect osteopathic medical students differently depending on their gender.

This study’s results signify that the existing trend of higher psychological stress in females persists in our group of osteopathic medical students, and the Covid-19 pandemic did not alter these gender differences. Because it has been shown that both females and medical students are groups individually more susceptible to adverse mental health outcomes, this study further supports the notion that female medical students are a particularly vulnerable group, suggesting they may need more resources than males perhaps tailored to their gender-specific stressors. Future research on how to mitigate these stressors would be an appropriate next step that could benefit the future cohorts of osteopathic student physicians.

A limitation of this study includes the accuracy of the participants’ responses due to the length of each questionnaire which may have caused participants to experience fatigue when answering the survey. Additionally, the participants’ responses may have been altered due to their particular mood on the day they took the survey resulting in their answers inaccurately reflecting their mental health. There were also fewer males than females in the study group, which may have skewed the data.

References

1. Gao W, Ping S, Liu X. Gender differences in depression, anxiety, and stress among college students: A longitudinal study from China. J Affect Disord. 2020;263:292-300. doi:10.1016/j.jad.2019.11.121

2. Hankin BL, Abramson LY. Development of gender differences in depression: description and possible explanations. Ann Med. 1999;31(6):372-379. doi:10.3109/07853899908998794

3. Menon B, Sannapareddy S, Menon M. Assessment of Severity of Stress Among Medical and Dental Students During the COVID-19 Pandemic. Ann Indian Acad Neurol. 2021;24(5):703-707. doi:10.4103/aian.AIAN_19_21

4. Moutinho IL, Maddalena NC, Roland RK, et al. Depression, stress and anxiety in medical students: A cross-sectional comparison between students from different semesters. Rev Assoc Med Bras (1992). 2017;63(1):21-28. doi:10.1590/1806-9282.63.01.21

Financial Disclosures: None reported.

Support: Funding went to purchasing survey licenses, purchasing a computer, and salary support for Dr. Bhuma Krishnamachari, PhD and Dr. William Blazey, DO.

Ethical Approval: IRB approval was obtained through the NYIT Institutional Review Board (IRB) as the study was conducted at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM). The protocol is #BHS-1491.

Informed Consent: Consent was obtained each survey with a disclaimer at the top stating that no one will see the completed questionnaires except for the Principal Investigator and Research Coordinator. Participants were informed they will not be identified, are free to withdraw consent and to discontinue participating in this study at any time, and that their refusal to participate will not in any way affect their grades. They were told that if they have questions or concerns they can contact the Principal Investigator or the institutional contact person at the address and telephone numbers in IRB details. Participants were then instructed to electronically sign the agreement that reads as follows: “I have read this consent form and I understand the procedure to be used in this study. I freely and voluntarily choose to participate. I understand that I may discontinue my participation at any time without penalty.”

Poster No. *PH-9

Abstract No. 111

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

A Peer-led Program to Increase Diversity in Osteopathic Medical Schools: Three Year Update

¹Jackie Hu, OMS-III; ¹Huxley Smart, OMS-III (co-first author); ²Jan Andrea Garo, DO; ³Omar Rachdi, DO; ¹Mirabelle Fernandes Paul, EdD

¹Western University of Health Sciences College of Osteopathic Medicine of the Pacific-Oregon; ²Internal Medicine. Legacy Emanuel Medical Center; ³Physical Medicine and Rehabilitation, University of Utah Hospital

Statement of Significance: According to the American Medical Student Association (AMSA), diversity among the student body facilitates cultural competence in medical education. A UCLA study found that medical students who attend racially and ethnically diverse medical schools feel that they are better equipped to serve diverse patient populations. In addition, physicians from underrepresented racial/ethnic groups are likely to be able to better identify and empathize with racially/ethnically marginalized patients.

Research Methods: The DREAM (Diversity Recognized Emphasized and Assimilated into Medicine) Program consisted of workshops and talks that were chosen to counter dis-empowering messages while equipping participants with skills and understanding of the medical school application process. The goal was to increase URM representation in osteopathic medical schools to increase diversity in osteopathic medicine and provide holistic patient care. From 2018-2021, there were a total of 111 participants selected into the DREAM program based on a holistic review including URM pre-medical student status. Only participants who took part in the program were invited to complete the survey study voluntarily. Qualtrics was used to distribute the survey and collect data. Participants were surveyed before and after the program to measure the impact the program had on their interest and barriers in pursuing medical school; surveys were also used to gain insight into URM’s perspective on their own healthcare experiences in the U.S. Participants were given a follow-up survey each consecutive year after their participation to determine if they matriculated to medical school. A Mann-Whitney U test and independent samples t-test were used for statistical analyses.

Data Analysis: From 2018-2021, the survey response rate was 76.6% for pre-survey and 72.1% for post-survey. From 2018-2021, 83.5% of respondents felt that physicians of their race/ethnicity are not well-represented in the US and felt a physician of the same race/ethnicity providing their care could be more empathetic towards them than a physician of a different race/ethnicity. Respondents from the 2021 cohort reported 15 out of 18 perceived barriers in the path to medical school were addressed by the program. From 2019-2021, there was a statistically significant increase (all p-values <0.05) when comparing pre- and post-program Likert responses for understanding of the following: medical school application process, what a physician does, difference between an allopathic and osteopathic physician, what being a pre-clinical and clinical medical student entails, and the residency application process.

Results: From 2018-2021, the survey response rate was 76.6% for pre-survey and 72.1% for post-survey. From 2018-2021, 83.5% of respondents felt that physicians of their race/ethnicity are not well-represented in the US and felt a physician of the same race/ethnicity providing their care could be more empathetic towards them than a physician of a different race/ethnicity. Respondents from the 2021 cohort reported 15 out of 18 perceived barriers in the path to medical school were addressed by the program. From 2019-2021, there was a statistically significant increase (all p-values <0.05) when comparing pre- and post-program Likert responses for understanding of the following: medical school application process, what a physician does, difference between an allopathic and osteopathic physician, what being a pre-clinical and clinical medical student entails, and the residency application process.

Conclusion: The DREAM program for URM pre-medical students continues to successfully address perceived barriers in pursuing a medical education as well as an understanding of medical school and a career as a physician. Limitations of the study include potential for response bias due to self-reported nature of survey and accuracy of reported medical school matriculation rate after DREAM program due to lack of follow-up survey response and/or participants are in early stages of pre-medical pathway. Future directions include tracking participants over the next five years on medical school matriculation status to determine the long-term efficacy of the program and continue to expand the DREAM program to include participants in other geographical areas and improve workshops to address all perceived barriers.

References

1. American Medical Student Association. (2017). Enriching medicine through diversity. Retrieved February 09, 2022 from https://www.amsa.org/wp-content/uploads/2015/03/Handout-AMSA-Mission-Priorites.pdf

2. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA. 2008;300(10):1135–1145. doi: 10.1001/jama.300.10.1135

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This study was approved by Western University of Health Sciences Institutional Review Board as an exempt project (IRB #1283154).

Informed Consent: An informed consent page was provided prior to the start of the surveys that included information on invitation to participate, basis for subject selection, overall purpose of study, explanation of survey, potential risks and benefits, confidentiality, injury/special costs, withdrawal, offer to answer questions, consent statement. Participation was voluntary and participants were able to withdraw consent and discontinue participation in the survey at any time with no consequence. Participants were required to acknowledge they have fully read the informed consent prior to starting the surveys.

Poster No. *PH-10

Abstract No. 112

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

The Evolving Role of Private Equity in Healthcare

¹Jeri Ann Ramilo, OMS-II; ²Jeri Ann Ramilo; ²David Oladosu, BS; ²Joshiah Philips, BS; ²Shebin Tharakan, BS; ²Omar Hasan-Hafez, BS; ³Arthur A. Klein, MD; ²Jorge R. Leheste, PhD, MS

¹New York Institute of Technology; ²Department of Biomedical Sciences, New York Institute of Technology; ³Department of Clinical Specialties, New York Institute of Technology

Statement of Significance: The influence of private equity in hospital systems introduces a non-governmental funding source that fuels multi-million dollar deals for technological acquisition, infrastructure, and branding rights. However, a major concern from private management is the quality of care and service affordability for patients while minimizing healthcare costs.

Research Methods: All authors conducted a literature review of articles published between 1995 to 2022 to produce this scoping review. Search terms in Google Scholar and PubMed included but are not limited to queries of “healthcare investment”, “healthcare regulations”, and “hospital funding”. Articles detailing Mergers and Acquisitions (M&A), hospital funding sources, hospital budgeting were included while articles prior to 1995 were excluded. As this article is a scoping review, statistical analysis was not independently performed by the authors. The osteopathic significance of this article is linked to the ever-rising patient costs that may sacrifice holistic treatment for reduction of healthcare costs to increase hospital revenue.

Data Analysis: M&A deals in health services drew over 1,200 deals in 2019 alone. Of these deals, laboratory and MRI services had a 503% growth. However, outpatient services including behavioral care, rehabilitation, and hospice had a 19%, 28%, and 55% decrease in deal value, respectively. This discrepancy in growth can affect patient care in specific settings as they are deemed less profitable. Additionally, while private equity can increase operating margins by 1.78%, it often comes at the risk of downsizing staff leading to decreased quality of care and less full-time providers [1]. Private investments provide distressed hospitals with a safety net, preventing closure and allowing for continued patient care. There is an indicated 4.3% decrease in myocardial infarction mortality after one year along with decreased mortality rates in pneumonia and stroke death [2].

Results: M&A deals in health services drew over 1,200 deals in 2019 alone. Of these deals, laboratory and MRI services had a 503% growth. However, outpatient services including behavioral care, rehabilitation, and hospice had a 19%, 28%, and 55% decrease in deal value, respectively. This discrepancy in growth can affect patient care in specific settings as they are deemed less profitable. Additionally, while private equity can increase operating margins by 1.78%, it often comes at the risk of downsizing staff leading to decreased quality of care and less full-time providers [1]. Private investments provide distressed hospitals with a safety net, preventing closure and allowing for continued patient care. There is an indicated 4.3% decrease in myocardial infarction mortality after one year along with decreased mortality rates in pneumonia and stroke death [2].

Conclusion: While reports of varying benefits of private equity have been observed in healthcare administration, the overarching results indicate that they must be evaluated on a case by case basis. Hospital acquisition by private companies can turn hospital revenue and expenditures into a positive margin to reduce operating costs and increase sustainability, but may sacrifice patient care. However, investments in technology and resources can provide patients with state-of-the-art medical care to reduce mortality. Therefore it is imperative to fully grasp the impact of private lenders and investors as patient care is directly affected through capital means.

References

1. Cerullo M, Lin Y-L, Rauh-Hain JA, Ho V, Offodile II AC. Financial impacts and operational implications of private equity acquisition of US Hospitals. Health Affairs. 2022;41(4):523-530. doi:10.1377/hlthaff.2021.01284

2. Jiang HJ, Fingar KR, Liang L, Henke RM, Gibson TP. Quality of care before and after mergers and acquisitions of Rural Hospitals. JAMA Network Open. 2021;4(9). doi:10.1001/jamanetworkopen.2021.24662

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This study was deemed exempt from IRB approval.

Informed Consent: None Reported.

Poster No. *PH-11

Abstract No. 50

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Investigating Differences in COVID-19 Outcomes in Southwest Virginia

¹Bruce Liberi, OMS-III; ²Theresa McCann, PhD, MPH, CHSE

¹Edward Via College of Osteopathic Medicine-Virginia; ²Preventive Medicine and Public Health, Edward Via College of Osteopathic Medicine-Virginia

Statement of Significance: The SARS-CoV-2 virus (COVID-19) has reportedly exacerbated pre-existing health disparities throughout the United States. Southwest Virginia (SWVA) has historically had worse health care outcomes and a higher burden of chronic disease than the rest of the state. We showed statistically significant differences in reported cases of COVID-19 and deaths from COVID-19 between the eight health districts in SWVA and the rest of Virginia.

Research Methods: We performed a retrospective study investigating potential differences in the outcomes of infection, hospitalization, and death from COVID-19 between SWVA and Virginia through July 7, 2021. These outcomes were accessed from publicly available datasets provided by the Virginia Department of Health’s (VDH) “Virginia Open Data Portal.” Age-adjusted rates were calculated using the 2000 projected U.S. Census Population and grouped into ten-year intervals through 80+ years of age. The age-adjusted rates for each Virginia Health District were then summed and output to SPSS Version 28.

To investigate if self-reported race and ethnicity were associated with differences in COVID-19 outcomes, information including total state and county populations and percent self-reported race and ethnicity data were acquired from the U.S. Census Bureau’s QuickFacts tool for each of the counties in SWVA and the State of Virginia. Percentage data were then multiplied by total population per county and grouped by VDH Health District. Additionally, a dataset with information regarding COVID-19 cases, hospitalizations, and deaths grouped by self-reported race and ethnicity, and Virginia Health District was downloaded from the VDH Open Data Portal. Total numbers for cases, hospitalizations, and deaths were determined. These two datasets were then used to calculate rates for each outcome (per 100,000). Summed rates for Asian or Pacific Islanders, Blacks, Latinos, Native Americans or Native Alaskans, Whites, and Two or More Races in SWVA and Virginia were outputted to SPSS Version 28.

For each dataset, all cases with age or race or ethnicity data were included through July 7, 2021. All rates were assessed using a two-sided univariate t-test for independence (p<0.05) assuming equal variances.

Data Analysis: We found statistically significant differences in the outcomes of cases (p<0.001) and deaths (p=0.014) from COVID-19 between SWVA and Virginia. To investigate if self-reported race and ethnicity were associated with the different rates of outcomes between SWVA and Virginia, we used another dataset acquired from VDH’s Open Data Portal with this data. We found no statistically significant differences between SWVA and the rest of the state using self-reported race and ethnicity for the outcomes of hospitalizations and deaths. We did find a statistically significant difference (p=0.04) for the outcome of cases of COVID-19 for Whites between SWVA and Virginia; however, no other racial or ethnic group showed this association.

Results: We found statistically significant differences in the outcomes of cases (p<0.001) and deaths (p=0.014) from COVID-19 between SWVA and Virginia. To investigate if self-reported race and ethnicity were associated with the different rates of outcomes between SWVA and Virginia, we used another dataset acquired from VDH’s Open Data Portal with this data. We found no statistically significant differences between SWVA and the rest of the state using self-reported race and ethnicity for the outcomes of hospitalizations and deaths. We did find a statistically significant difference (p=0.04) for the outcome of cases of COVID-19 for Whites between SWVA and Virginia; however, no other racial or ethnic group showed this association.

Conclusion: A core tenant of the Osteopathic Philosophy is looking at the whole person, which includes accounting for social determinants of health (SDH) and how they impact disease. Investigating SDH and their impact on COVID-19 outcomes can provide opportunities to improve overall patient care by considering more than just the disease process. Using self-reported race and ethnicity is a blunt tool to investigate for potential health disparities when the true underlying reasons for these differences are more likely due to marginalization, socioeconomic factors, and barriers in access to care. Unfortunately, there are limited data accessible regarding these SDH. The different rates of cases and deaths between SWVA and Virginia may be a result of underlying health disparities; however, the finding that only Whites in SWVA had a higher case rate of COVID-19 indicates that these differences are not associated with race and ethnicity. We suggest the true reasons for the differences in outcomes between SWVA and the rest of the state are more likely due to socioeconomic factors, pre-existing disease, and access to care.

References

1. Mackey K, Ayers CK, Kondo KK, et al. Racial and Ethnic Disparities in COVID-19-Related Infections, Hospitalizations, and Deaths : A Systematic Review. Ann Intern Med. 2021;174(3):362-373. doi:10.7326/M20-6306

2. Sherbuk JE, Knick TK, Canan C, et al. Development of an Interdisciplinary Telehealth Model of Provider Training and Comprehensive Care for Hepatitis C and Opioid Use Disorder in a High-Burden Region. J Infect Dis. 2020;222(Suppl 5):S354-S364. doi:10.1093/infdis/jiaa141

3. U.S. Appalachian Regional Health Commission. Health Disparities in Appalachia. August 2017. Accessed December 8, 2021. https://www.arc.gov/wp-content/uploads/2020/06/Health_Disparities_in_Appalachia_August_2017.pdf

4. Virginia Open Data Portal. Virginia Department of Health. Updated December 9, 2021. Accessed December 9, 2021. https://www.vdh.virginia.gov/data/

5. Klein, R J, and C A Schoenborn. “Age adjustment using the 2000 projected U.S. population.” Healthy People 2010 statistical notes : from the Centers for Disease Control and Prevention/National Center for Health Statistics ,20 (2001): 1-10.

6. U.S. Census Bureau quickfacts: Virginia. U.S. Census QuickFacts. https://www.census.gov/quickfacts/fact/table/VA,US/PST045221. Accessed July 9, 2022.

7. Chowkwanyun M, Reed AL Jr. Racial Health Disparities and Covid-19 - Caution and Context. N Engl J Med. 2020;383(3):201-203. doi:10.1056/NEJMp2012910

Financial Disclosures: None Reported.

Support: None Reported.

Ethical Approval: This study (VCOM IRB RECORD #: 2021-053) was approved by the Edward Via College of Osteopathic Medicine Institutional Review Board (IRB), Blacksburg, VA. The IRB indicated it was exempt since it did not meet the regulatory criteria for human subjects research and no IRB review or approval was needed.

Informed Consent: Not required since publicly available databases without identifiers were used.

Poster No. PH-12

Abstract No. 48

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Use of Neuraxial Anesthesia Administration in Childbirth to Reduce Racial Health Disparities in Maternal Mortality Rates

Crystal Barroca, OMS-II; Miis Akel

Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine (NSU-KPCOM)

Statement of Significance: The purpose of this study was to identify health disparities in receiving appropriate neuraxial intervention among pregnant minority women, which resulted in increased maternal and neonatal morbidities. Along with raising awareness and closing the gap to improve maternal outcomes and overall obstetric quality of care.

Research Methods: A multivariable model was used to assess the quality of obstetric anesthesia care in relation to maternal morbidity among minority women in comparison to white women, with adjustments for maternal age, insurance type, level of education, BMI at delivery, and socioeconomic status

Data Analysis: A clinical data study of over 50,000 women who delivered at 19 obstetric centers in the United States found racial/ethnic disparities in the use of general vs neuraxial anesthesia for women undergoing Caesarean section. In another study, the incidence of severe maternal morbidity was significantly higher among women of all racial and ethnic minority groups compared to non-Hispanic white women. Severe maternal morbidity occurred in 231.1 (95 percent CI 223.6-238.5) and 139.2 (95 percent CI 136.4-142.0) non-Hispanic black and non-Hispanic white women per 10,000 delivery hospitalizations, respectively (P.001). Furthermore, in another cohort study compromising of 50,974 women who underwent Caesarean section, the rates of general anesthesia among racial/ ethnic groups were 5.2% for Caucasians, 11.3% for African Americans, and 5.8% for Hispanics. African Americans had the highest odds of receiving general anesthesia compared with Caucasians (adjusted odds ratio [aOR] = 1.7; 95% confidence interval [CI], 1.5-1.8; P < 0.001).

Results: A clinical data study of over 50,000 women who delivered at 19 obstetric centers in the United States found racial/ethnic disparities in the use of general vs neuraxial anesthesia for women undergoing Caesarean section. In another study, the incidence of severe maternal morbidity was significantly higher among women of all racial and ethnic minority groups compared to non-Hispanic white women. Severe maternal morbidity occurred in 231.1 (95 percent CI 223.6-238.5) and 139.2 (95 percent CI 136.4-142.0) non-Hispanic black and non-Hispanic white women per 10,000 delivery hospitalizations, respectively (P.001). Furthermore, in another cohort study compromising of 50,974 women who underwent Caesarean section, the rates of general anesthesia among racial/ ethnic groups were 5.2% for Caucasians, 11.3% for African Americans, and 5.8% for Hispanics. African Americans had the highest odds of receiving general anesthesia compared with Caucasians (adjusted odds ratio [aOR] = 1.7; 95% confidence interval [CI], 1.5-1.8; P < 0.001).

Conclusion: Data from multiple cohort studies suggest that there is a racial disparity in maternal mortality rates related to the use of neuraxial analgesia delivery. Additional research is required to determine the cause of the existing variations and whether this variation influences maternal or perinatal outcomes. As well as addressing the need for public programs to reduce these disparities. These studies, however, did not include hospital-level data, hospital type, the frequency of neuraxial analgesia at each hospital, or the number of anesthesia providers.

References

1. Butwick AJ, Blumenfeld YJ, Brookfield KF, Nelson LM, Weiniger CF. Racial and Ethnic Disparities in Mode of Anesthesia for Cesarean Delivery. Anesth Analg. 2016;122(2):472-479. doi:10.1213/ANE.0000000000000679

2. Guglielminotti J, Landau R, Daw J, Friedman AM, Chihuri S, Li G. Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity. JAMA Netw Open. 2022;5(2):e220137. Published 2022 Feb 1. doi:10.1001/jamanetworkopen.2022.0137

3. Burton BN, Canales C, Du AL, Martin EI, Cannesson M, Gabriel RA. An Update on Racial and Ethnic Differences in Neuraxial Anesthesia for Cesarean Delivery. Cureus. 2021;13(11):e19729. Published 2021 Nov 18. doi:10.7759/cureus.19729

4. Butwick AJ, Bentley J, Wong CA, Snowden JM, Sun E, Guo N. United States State-Level Variation in the Use of Neuraxial Analgesia During Labor for Pregnant Women. JAMA Netw Open. 2018;1(8):e186567. Published 2018 Dec 7. doi:10.1001/jamanetworkopen.2018.6567

5. Howell EA, Brown H, Brumley J, et al. Reduction of Peripartum Racial and Ethnic Disparities: A Conceptual Framework and Maternal Safety Consensus Bundle [published correction appears in Obstet Gynecol. 2019 Jun;133(6):1288]. Obstet Gynecol. 2018;131(5):770-782.

6. Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012-2015. Obstet Gynecol. 2018;132(5):1158-1166. doi:10.1097/AOG.0000000000002937

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Not Applicable

Informed Consent: Not Relevant.

Poster No. *PH-13

Abstract No. 116

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Motivations and Impact of Restrictive Abortion Laws in the United States

¹Christine Jisoo Lee, OMS-I; ²Arthur A. Klein, MD; ³Joerg R. Leheste, PhD, MS

¹New York Institute of Technology; ²Department of Clinical Specialties, New York Institute of Technology; ³Department of Biomedical Sciences, New York Institute of Technology

Statement of Significance: The current landscape of reproductive policy in the United States on the issue of abortion rights is one of the most polarizing issues facing Americans today [1]. The recent overturning of Roe v. Wade has made the future of abortion access and maternal mortality rates unknown. Understanding the implications of restricting second trimester abortions can shed light towards the consequences of completely restricting abortion procedures as set by the Supreme Court of the United States.

Research Methods: A systematic review was conducted through a literature analysis of articles associated with Google Scholar and PubMed. Articles were chosen based on relevancy, credibility and significance towards the search terms “abortion”, “abortion access”, “restrictive abortion policy” and more. Following this inclusion criteria, we reviewed and assessed the corresponding literature to determine article inclusion or exclusion within the study. Once selected, data was extracted and interpreted to understand the implications of restricting abortion access in the United States. Due to the interpretive nature of this study, no statistical analyses were performed independently from the articles included. The osteopathic significance of this research is interconnected between two patient populations – the birthing individual and their children. The limitations of abortion may limit patient access to holistic care for both parties.

Data Analysis: In 2008, 10.3% of abortions were performed in the second trimester within the United States [2]. Those who are most likely to seek abortion options during this period identify as Black, have less education, use health insurance as their primary payment method, and have experienced three or more disruptive events in the past year [2]. Health disparities and factors associated with the social determinants of health perpetuate maternal mortality in the United States with considerable effects on people of color. Specifically, black birthing individuals “are 3-4 times more likely to die from pregnancy-related complications than white” [3]. These health disparities and mortality rates are especially concerning regarding abortion procedures and are captured by the median rate of unsafe abortions index. In 82 countries with the most restrictive abortion laws the index lies at 23/1,000 women compared to 2/1,000 in nations that allow abortions [2,4]. It has also been established that abortion denial is indicative of long-term economic hardship and insecurities for birthing individuals [5]. Lessons learned from the country of Romania show, that the rates of displaced children and abandonment significantly increased once the abortion ban was enacted thereby overwhelming social institutions [6]. In terms of political and religious views, those who identify with a Republican ideology and those with an Evangelical Christian stance, tend to support more restrictive abortion policies [7]. Even after a decade of increasing numbers, the current 117th Congress comprises only 27% of women [8]. Since female legislators tend to lead in determining prospective reproductive policy legislation in the United States, a gender imbalance can have profound consequences on issues that predominantly affect women [9,10]. In addition, women legislators actively seek to secure committee assignments positioned to block anti-abortion legislation as well [11].

Results: In 2008, 10.3% of abortions were performed in the second trimester within the United States [2]. Those who are most likely to seek abortion options during this period identify as Black, have less education, use health insurance as their primary payment method, and have experienced three or more disruptive events in the past year [2]. Health disparities and factors associated with the social determinants of health perpetuate maternal mortality in the United States with considerable effects on people of color. Specifically, black birthing individuals “are 3-4 times more likely to die from pregnancy-related complications than white” [3]. These health disparities and mortality rates are especially concerning regarding abortion procedures and are captured by the median rate of unsafe abortions index. In 82 countries with the most restrictive abortion laws the index lies at 23/1,000 women compared to 2/1,000 in nations that allow abortions [2,4]. It has also been established that abortion denial is indicative of long-term economic hardship and insecurities for birthing individuals [5]. Lessons learned from the country of Romania show, that the rates of displaced children and abandonment significantly increased once the abortion ban was enacted thereby overwhelming social institutions [6]. In terms of political and religious views, those who identify with a Republican ideology and those with an Evangelical Christian stance, tend to support more restrictive abortion policies [7]. Even after a decade of increasing numbers, the current 117th Congress comprises only 27% of women [8]. Since female legislators tend to lead in determining prospective reproductive policy legislation in the United States, a gender imbalance can have profound consequences on issues that predominantly affect women [9,10]. In addition, women legislators actively seek to secure committee assignments positioned to block anti-abortion legislation as well [11].

Conclusion: The restrictive nature of the current abortion landscape following the United States Supreme Court decision to reinterpret the United States Constitution and overturn Roe v. Wade on June 24, 2022, is predicted to exacerbate maternal health disparities and mortality, specifically for populations of color. As funding for social systems will continue to decrease, health outcomes are destined to decline for birthing individuals and newborns as well. At the same time, abandoned children and their displacement are projected to increase. Political views, religious beliefs and gender identity of elected representatives in the United States Congress are major factors in shaping the legislative landscape for birthing individuals in the United States. This work analyzes historical and current contributors and concludes with a prediction on the future of reproductive rights in the United States.

References

1. Railsback CC. PRO-Life, PRO-Choice: Different Conceptions of Value. Womens Stud Commun. 1982;5(1):16-28. doi:10.1080/07491409.1982.11089638

2. Jones RK, Finer LB. Who has second-trimester abortions in the United States? Contraception. 2012;85(6):544-551. doi:10.1016/j.contraception.2011.10.012

3. [3] Louis JM, Menard MK, Gee RE. Racial and Ethnic Disparities in Maternal Morbidity and Mortality. Obstet Gynecol. 2015;125(3):690-694. doi:10.1097/AOG.0000000000000704

4. Haddad LB, Nour NM. Unsafe abortion: unnecessary maternal mortality. Rev Obstet Gynecol. 2009;2(2):122-126.

5. Foster DG, Biggs MA, Ralph L, Gerdts C, Roberts S, Glymour MM. Socioeconomic Outcomes of Women Who Receive and Women Who Are Denied Wanted Abortions in the United States. Am J Public Health. 2018;108(3):407-413. doi:10.2105/AJPH.2017.304247

6. Mitrut A, Wolff FC. The impact of legalized abortion on child health outcomes and abandonment. Evidence from Romania. J Health Econ. 2011;30(6):1219-1231. doi:10.1016/j.jhealeco.2011.08.004

7. Medoff MH. State Abortion Politics and TRAP Abortion Laws. J Women Polit Policy. 2012;33(3):239-262. doi:10.1080/1554477X.2012.667746

8. Blazina C, Desilver D. A record number of women are serving in the 117th Congress. January 15, 2021. Accessed July 11, 2022. https://www.pewresearch.org/fact-tank/2021/01/15/a-record-number-of-women-are-serving-in-the-117th-congress/

9. Pearson K, Dancey L. Elevating Women’s Voices in Congress: Speech Participation in the House of Representatives. Polit Res Q. 2011;64(4):910-923. doi:10.1177/1065912910388190

10. Swers M. Understanding the Policy Impact of Electing Women: Evidence from Research on Congress and State Legislatures. Polit Sci Polit. 2001;34(02):217-220. doi:10.1017/S1049096501000348

11. Berkman MB, O’Connor RE. Do Women Legislators Matter?: Female Legislators and State Abortion Policy. Am Polit Q. 1993;21(1):102-124. doi:10.1177/1532673X9302100107

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: Exempt.

Informed Consent: Not applicable.

Poster No. *PH-14

Abstract No. 54

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

The Effect of Median Household Income on Annual Osteochondral Cancer Death Rates: A Study of 36 Florida Counties

¹Christopher Rennie, OMS-II; ¹Barbara Prol, OMS-II; ²Kelsey Reindel, DO

¹Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine; ²Department of Family Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine

Statement of Significance: In the American Cancer Society’s 2020 report, there were an estimated 1,720 deaths due to bone and joint cancer1. As these cancer diagnoses make up roughly only 1% of all cancers each year, there is limited literature on the factors associated with treatment and outcomes2. One social determinant of health (SDOH) outlined in Healthy People 2020 was economic stability3. Here we highlight the disparity between osteochondral cancer death rates and economic stability based on median household income.

Research Methods: This study is a cross-sectional database analysis of patient information from 2020 collected and compiled by the Florida Department of Health in the Community Health Assessment Resource Tool Set, or FLHealthCHARTS. Using the FLHealthCHARTS Death Rate Query System, we isolated data pertaining to the 2020 Age-Adjusted Annual Death Rate (AADR) in all Florida counties that recorded deaths due to both bone and articular cartilage cancer using ICD-10 codes C40 and C41. The osteochondral cancer AADR is an age adjusted rate using the US 2000 standard population and is a rate per 100,000 individuals. 2020 Median Household Income data was collected by the United States Census Bureau and compiled by FLHealthCHARTS for all 67 Florida counties. We subsequently limited this dataset to the 36 Florida counties who reported an osteochondral cancer AADR. This data was analyzed via R Studio 2022.02.0 for a p-value < 0.05 (95% CI) and a linear regression model was created. Through this analysis, we established whether a potential health disparity existed between a SDOH such as Median Household Income and osteochondral cancer AADRs.

Data Analysis: 36 Florida counties in total were used in this study based on the inclusion criteria. The median household incomes (MHI) in these counties ranged from $36,978 to $70,297, with an average MHI of $55,102 and a median MHI of $55,665. The bone and articular cartilage cancer AADR in the 36 reporting counties ranged from 0.1 to 4.9, with an average AADR of 0.81 and a median AADR of 0.45. A simple linear regression of the bone and articular cartilage cancer AADR against median household income yielded a statistically significant p-value of 0.00004483 (p<0.05) and a negative correlation between osteochondral AADR and MHI. The R2 for this line of regression was 0.37, primarily due to an AADR outlier of 4.9 in Calhoun County. The F-statistic of 21.88 confirms a 95% likelihood of null hypothesis rejection with the critical value being F(0.05,1,34) = 4.130.

Results: 36 Florida counties in total were used in this study based on the inclusion criteria. The median household incomes (MHI) in these counties ranged from $36,978 to $70,297, with an average MHI of $55,102 and a median MHI of $55,665. The bone and articular cartilage cancer AADR in the 36 reporting counties ranged from 0.1 to 4.9, with an average AADR of 0.81 and a median AADR of 0.45. A simple linear regression of the bone and articular cartilage cancer AADR against median household income yielded a statistically significant p-value of 0.00004483 (p<0.05) and a negative correlation between osteochondral AADR and MHI. The R2 for this line of regression was 0.37, primarily due to an AADR outlier of 4.9 in Calhoun County. The F-statistic of 21.88 confirms a 95% likelihood of null hypothesis rejection with the critical value being F(0.05,1,34) = 4.130.

Conclusion: This study revealed a statistically significant (p=0.00004483) inverse relationship between bone and articular cartilage cancer AADR and median household income, with residents of lower income counties experiencing a proportionally higher death rate compared to their higher income counterparts. Patients from lower income counties may be more likely to experience loss of or inadequate health insurance, employment instability and lack of funds for payment, improper nutrition, and insufficient means of transportation4,5. These are just a few examples of the numerous factors that may play into this strong association that must be highlighted. As these conditions are uncommon, the case data is limited, however, future studies may benefit from the inclusion of states beyond Florida in order to combat the relatively small sample size and help generalize the findings to the US population as a whole. These findings are still of clinical significance, however, as there is limited literature on the socioeconomic health determinants involved in the outcomes of bone and articular cartilage cancer. Albeit rare, these cancers still affect thousands in the US each year, and a greater understanding of these relationships can aid in the improvement of healthcare access and delivery.

References

1. American Cancer Society. Cancer Facts & Figures 2020. Atlanta: American Cancer Society; 2020.Ferguson JL, Turner SP. Bone Cancer: Diagnosis and Treatment Principles. Am Fam Physician. 2018;98(4):205-213.

2. Ochiai E, Blakey C, McGowan A, Lin Y. The Evolution of the Healthy People Initiative: A Look Through the Decades. J Public Health Manag Pract. 2021;27(Suppl 6):S225-S234. doi:10.1097/PHH.0000000000001377

3. Beck P. Social Determinants of Health - Madison County Memorial Hospital. http://www.mcmh.us/wp-content/uploads/2021/04/social-determinants.pdf. Accessed July 6, 2022.

4. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014 Jan-Feb;129 Suppl 2(Suppl 2):19-31. doi: 10.1177/00333549141291S206. PMID: 24385661; PMCID: PMC3863696.

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: The study was deemed exempt.

Informed Consent: N/A

Poster No. *PH-15

Abstract No. 84

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

The Relationship Between Maternal Education Level and Preterm Birth: A Study of All 67 Florida Counties in 2020

¹Barbara Ibeth Prol, OMS-II;¹Christopher Rennie; ²Kelsey Reindel, DO

¹Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine; ²Department of Family Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine

Statement of Significance: About 15 million babies are born prematurely every year globally, accounting for the leading cause of death among children.1 In 2020, the preterm birth rate in the United States was 10.1%, greater than the annual average of 9.3% in similar high-income countries.1 2 While several social factors increase the risk of preterm birth, maternal education is one of the strongest known predictors in public health.3 4 Here, we highlight the relationship between maternal education level and preterm births.

Research Methods: This project is a cross-sectional database analysis of patient information collected by the Florida Department of Health, Bureau of Vital Statistics, and found on the Community Health Assessment Resource Tool Set or Florida Health Charts. Using the Health Indicators tool, we analyzed the rate of preterm births and births to mothers with less than a high school education in all 67 counties of Florida in 2020. Preterm births were defined as a birth with a gestational age of less than 37 weeks and the rate was collected as a percentage of preterm births to “term” births, defined as a gestational age of 37 weeks or greater. Births to Mothers with Less Than a High School Education is described as a mother’s level of education at the time of birth as 8th grade or less or 9th-12th grade without a diploma, where unknown maternal education was excluded from the denominator; this piece of information is based on data from the infant’s birth certificate. This data was analyzed via R Studio 2022.02.0 for a p-value < 0.05 (95% CI) and a linear regression model was created. Through this analysis, we established whether a correlation existed between maternal education level and preterm birth rate throughout Florida counties and recognized it as a potential social determinant of health.

Data Analysis: Data for Percent of Births to Mothers with Less Than a High School Education ranged from 3.1% to 30.7%, with Saint Johns County representing the smallest percentage of Births to Mothers with Less Than a High School Education and DeSoto County representing the largest. The average of all 67 Florida counties was 13.5% while the median was 12.5%. Regarding the percentage of Preterm Births, these values ranged from 6.7% in Gulf County to 17.3% in Hamilton County and Gadsden County. The average percent of preterm births from all 67 Florida counties was 11.3% and the median was 11.1%. After performing a simple linear regression comparing the percent of Births to Mothers With Less Than a High School Education and the percent of Preterm Births among all 67 Florida counties, we revealed a strong positive correlation with a statistically significant p-value of 0.011 (p<0.05). The F-statistic of 6.838 confirms a 95% likelihood of null hypothesis rejection with the critical value being F(0.05,1,65) = 3.989.

Results: Data for Percent of Births to Mothers with Less Than a High School Education ranged from 3.1% to 30.7%, with Saint Johns County representing the smallest percentage of Births to Mothers with Less Than a High School Education and DeSoto County representing the largest. The average of all 67 Florida counties was 13.5% while the median was 12.5%. Regarding the percentage of Preterm Births, these values ranged from 6.7% in Gulf County to 17.3% in Hamilton County and Gadsden County. The average percent of preterm births from all 67 Florida counties was 11.3% and the median was 11.1%. After performing a simple linear regression comparing the percent of Births to Mothers With Less Than a High School Education and the percent of Preterm Births among all 67 Florida counties, we revealed a strong positive correlation with a statistically significant p-value of 0.011 (p<0.05). The F-statistic of 6.838 confirms a 95% likelihood of null hypothesis rejection with the critical value being F(0.05,1,65) = 3.989.

Conclusion: This study yielded a statistically significant p-value of 0.011, indicating that Florida counties with increased rates of mothers having less than a high school education were associated with an increased rate of preterm births (<37 weeks). A combination of pregnancy characteristics can explain this increased rate of preterm births among mothers with less education, including psychosocial well-being, and lifestyle habits.5 There are limitations to our study, as rates may be skewed due to under-reporting and the single-year and single-state focus. Further analyses of more states and longitudinal studies, including data for longer time periods, would help to generalize these findings to the entire US population. There are programs like the Pregnancy Assistance Fund (PAF) that provide services to expectant and parenting teens and their families, however, most interventions focus on helping the parents and infants after the infant is born.6 Programs created by the PAF were found to be especially helpful for parents’ educational progress, use of contraception, and reduction in future unintended pregnancies.7 Despite the aforementioned limitations, this is still a clinically significant investigation, as further research is required on the effectiveness of programs created by the PAF and programs similar to it, and how to best implement them to specifically target populations most at risk for preterm births.

References

1. Walani SR. Global burden of preterm birth. Int J Gynecol Obstet. 2020;150(1):31-33. doi:10.1002/ijgo.13195

2. Preterm Birth | Maternal and Infant Health | Reproductive Health | CDC. Published November 1, 2021. Accessed July 5, 2022. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm

3. Auger N, Leduc L, Naimi AI, Fraser WD. Delivery at Term: Impact of University Education by Week of Gestation. J Obstet Gynaecol Can. 2016;38(2):118-124. doi:10.1016/j.jogc.2015.11.001

4. Prior E, Modi N. Adult outcomes after preterm birth. Postgrad Med J. 2020;96(1140):619-622. doi:10.1136/postgradmedj-2020-137707

5. Jansen PW, Tiemeier H, Jaddoe VWV, et al. Explaining educational inequalities in preterm birth: the generation r study. Arch Dis Child - Fetal Neonatal Ed. 2008;94(1):F28-F34. doi:10.1136/adc.2007.136945

6. Pregnancy Assistance Fund (PAF) | HHS Office of Population Affairs. Accessed July 7, 2022. https://opa.hhs.gov/grant-programs/pregnancy-assistance-fund-paf

7. Harding JF, Zief S, Farb A, Margolis A. Supporting Expectant and Parenting Teens: New Evidence to Inform Future Programming and Research. Matern Child Health J. 2020;24(S2):67-75. doi:10.1007/s10995-020-02996-2

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: The study was deemed exempt.

Informed Consent: N/A

Poster No. *PH-16

Abstract No. 85

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Curricular Changes to Increase Quality of Healthcare for Individuals with Intellectual and Developmental Disabilities: Combating Health Disparities by Increasing Inclusion in Medical Education

¹Lisa Millar, OMS-III; ¹Amreeta Jammu, OMS-IV; ¹Heidi Michael, OMS-III; ¹Jacob Speechley, OMS-III; ¹Shelby Terrell, OMS-III; ¹Ellen Cravens, OMS-III; ²Neal Chamberlain, PhD

¹A.T. Still University Kirksville College of Osteopathic Medicine; ²Department of Microbiology, A.T. Still University Kirksville College of Osteopathic Medicine

Statement of Significance: People with intellectual and developmental disabilities (IDD) face health disparities in areas including social determinants of health, access to care, and a lack of educated healthcare providers. Less than 20 medical schools provide a curriculum about disability health and culture. This study was created to develop and validate a curriculum for medical students to bridge the knowledge gap, which could lead to inclusion of IDD education in more medical schools leading to increased care access.

Research Methods: Thirty-nine osteopathic medical students (sixteen first-years and twenty-three second-years) voluntarily enrolled in the Intellectual and Developmental Disabilities Elective, a two-credit hour course that included: eight lectures, a mentor/mentee partnership with a community member with an IDD, three standardized patient encounters with a patient with an IDD, two Health Fairs in collaboration with Special Olympics, and an End of the Year Symposium, where mentor/mentee pairings present their accomplishments. Over the year, the students served as mentees and assisted their mentors with specific goals created by the mentor to work on throughout the year. The purpose of instilling these roles is to promote self-advocacy for individuals with an IDD and educate students on various aspects of their daily life. This enables students to fulfill the osteopathic philosophy of treating the whole person’s mind, body, and spirit.

Performance metrics were collected from first and second-year medical students utilizing both the National Curriculum Initiative in Developmental Medicine (NCIDM) Attitudes Survey and Knowledge Survey. Students completed the surveys twice, once before taking the IDD Elective and again after completing the course. Student identifying information was blinded, and results were analyzed using the Wilcoxon Signed Ranks Test to determine statistical significance with a p-value of less than 0.05.

For the NCIDM Attitudes Survey, student responses were measured as a level of agreement using a 5-point Likert scale. These responses were from before and after the elective course. The results were then compared.

For the NCIDM Knowledge Survey, student responses were graded as correct and incorrect, and student scores were compared before and after the elective course.

Data Analysis: The National Curriculum Initiative in Developmental Medicine (NCIDM) Attitudes and Knowledge Surveys were utilized as a standard and validated tool to determine the effectiveness of the curriculum on the knowledge and attitudinal changes in students within the elective. Analysis of the NCIDM Attitudes Survey (n=39) indicated that students had a statistically significant (p

* I have received adequate training so that I feel comfortable caring for people with IDD. (p

* I feel competent to care for a person with IDD. (p=0.00128)

* People with IDD should always be accompanied by a caregiver during medical appointments. (p=0.0088)

* Problem behaviors (aggression, self-injury, etc.) exhibited by people with IDD may be caused by physical health problems. (p=0.00424)

Statements 1, 2, and 4 shifted from an average of disagreement to agreement, while statement 3 shifted from agreement to disagreement. The significant shift in attitude for Statements 1, 2, and 4 considers the degree of competency and comfortability our students have developed in treating patients with an IDD. Conversely, statement 3 shifted to a disagreement, which exemplifies how students have grown to see patients with an IDD as capable of self-advocacy and autonomy in a medical setting.

NCIDM Knowledge Survey (n=39) analysis showed a statistically significant (p<0.05) improvement in students’ medical knowledge of the IDD community (p=0.00164) using the Wilcoxon Signed-Rank test.

Results: The National Curriculum Initiative in Developmental Medicine (NCIDM) Attitudes and Knowledge Surveys were utilized as a standard and validated tool to determine the effectiveness of the curriculum on the knowledge and attitudinal changes in students within the elective. Analysis of the NCIDM Attitudes Survey (n=39) indicated that students had a statistically significant (p

* I have received adequate training so that I feel comfortable caring for people with IDD. (p

* I feel competent to care for a person with IDD. (p=0.00128)

* People with IDD should always be accompanied by a caregiver during medical appointments. (p=0.0088)

* Problem behaviors (aggression, self-injury, etc.) exhibited by people with IDD may be caused by physical health problems. (p=0.00424)

Statements 1, 2, and 4 shifted from an average of disagreement to agreement, while statement 3 shifted from agreement to disagreement. The significant shift in attitude for Statements 1, 2, and 4 considers the degree of competency and comfortability our students have developed in treating patients with an IDD. Conversely, statement 3 shifted to a disagreement, which exemplifies how students have grown to see patients with an IDD as capable of self-advocacy and autonomy in a medical setting.

NCIDM Knowledge Survey (n=39) analysis showed a statistically significant (p<0.05) improvement in students’ medical knowledge of the IDD community (p=0.00164) using the Wilcoxon Signed-Rank test.

Conclusion: This study demonstrates that students reported increased competency and comfort when working with the IDD patient population after participating in the curriculum. Additionally, students had a significant increase in medical knowledge of the IDD community and reported higher degrees of competency, ability to work with IDD patients, and understandings of self-advocacy among this patient population. These shifts in attitudes and knowledge empower and enable future physicians preparedness increasing health access and quality of care. The comprehensive curriculum created for this elective can be adapted by other medical schools in order to continue to bridge this disparity in health care.

Given that this curriculum was only implemented at ATSU-KCOM, the study lacks control group sampling in comparison to other schools and has not been reproduced. Other limitations include a small sample size due to mentor recruitment limiting the student participation. Confounding variables to also note are the implementation of this curriculum during COVID-19, which may have affected data due to adjustments safety precautions imposed.

This study also does not include data regarding attitudes and knowledge of the healthcare field for the community members with IDD (mentors). This data point would be valuable in asserting that our curriculum is beneficial to fulfill the full research goal: to educate medical students on the IDD community, as well as provide trust and education to the IDD community on their healthcare needs.

Future research opportunities include:

1. Increasing student sample size to provide more power in our metrics through greater mentor recruitment

2. Expanding the study to a longitudinal cohort study to assess efficacy of the curriculum on long-term knowledge and attitudinal retention

3. Creating metrics to measure Mentor experience and confidence in the healthcare field

4. Expanding partnerships with other medical schools to collaborate and implement this curriculum

References

1. Symons, A. B., McGuigan, D., & Akl, E. A. (2009). A curriculum to teach medical students to care for people with disabilities: development and initial implementation. BMC medical education, 9, 78. https://doi.org/10.1186/1472-6920-9-787.

2. Rogers J.M., Morris M.A., Hook C.C., Havyer R.D. Introduction to disability and health for preclinical medical students: didactic and disability panel discussion. MedEdPORTAL. 2016;12:10429.https://doi.org/10.15766/mep_2374-8265.10429

3. Office of the Surgeon General (US); National Institute of Child Health and Human Development (US); Centers for Disease Control and Prevention (US). (2002). Closing the gap: a national blueprint to improve the health of persons with mental retardation: report of the surgeon general’s conference on health disparities and mental retardation. Washington (DC): US Department of Health and Human Services. Goals and Action Steps. Retrieved January 10, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK44354/

Financial Disclosures: None reported.

Support: Adair County SB40 Board provided grant funding for the project. Grant funds were utilized to fund curricular activities such as guest speakers and standardized patient compensation. National Curriculum Initiative of Developmental Medicine provided surveys used.

Ethical Approval: Study deemed IRB exempt.

Informed Consent: The medical students in this study joined the elective voluntarily and participated in the surveys as part of the course requirements. The Intellectual and Developmental Disability is an elective course, and students receive 2 credit hours for completing course requirements. Students are informed of course requirements and expectations and consent when agreeing to enroll in the course. Community mentors in the mentorship program that the medical students participated in also joined the program voluntarily and with clear expectations of what the mentorship program entailed.

Poster No. *PH-17

Abstract No. 63

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Underlying Pressures that Black Mothers and their Children Face: A Qualitative Assessment on the Effects of Racism/Discrimination and the COVID-19 Pandemic

¹Denisia Nesha Thomas, OMS-IV; ¹Ashley Rizzeri, MPH; ¹Jesse D. Hunt; ¹Crystal Smith, MS; ¹Stephanie Kyeremeh; ¹Leondria Hinds; ¹Brittney Thomas; ¹Jordan Frank; ¹Tori Knapp; ¹Madeleine Schultz; ¹Rian Anglin, MD; ²Heidi Kluess, PhD; ³Theresa McCann, PhD; ¹David Stephen, DO; ⁴Mary Ann Taylor, PhD; ⁵Mayra Rodriguez PhD; ⁵Mayra Rodriguez PhD

¹Edward Via College of Osteopathic Medicine-Auburn; ²School of Kinesiology, Edward Via College of Osteopathic Medicine-Auburn; ³School of Nursing, Edward Via College of Osteopathic Medicine-Auburn; ⁴Department of Psychiatry, Edward Via College of Osteopathic Medicine-Auburn; ⁵Department of Epidemiology, Edward Via College of Osteopathic Medicine-Auburn

Statement of Significance: Witnessing the Black Lives Matter protests and the constant deaths of African Americans due to COVID 19 became the inspiration for this study. Poverty, racism, discrimination, inadequate access to healthcare, and personal, everyday stressors such as parenting lead to poor health outcomes, especially in African american families in the south. This study recruited seven black mothers and their children aged 4-10 years old living in the population of rural and underserved Alexander City, Alabama.

Research Methods: Utilizing the Health Belief model, a survey was constructed affording us to interview 7 black mothers and their children (aged 4-10yo). The families were recruited from a pediatric office in the rural city of Alexander City, Alabama. Interviews took place in an intimate setting and lasted for 1.5-2 hours. Medical students conducted these interviews, recorded, and transcribed each interview. Through both quantitative and qualitative analysis, this topic was assessed in depth. The qualitative measures established an association between the COVID 19 pandemic, personal traumatic events, and racism and discrimination in the every day lives of black mothers and their child. Osteopathic Medicine withholds the principles of treating the patient as a whole. One must take into consideration the effects of the stressors of the world that their patients are faced with daily.

Data Analysis: Through qualitative analysis, the components that were assessed, racism, daily activities, and the COVID 19 pandemic demonstrated to be significant stressors for the mothers. Knowledge, school/work, actions, emotions, and seriousness/susceptibility displayed stressors not only in the mom as one would expect, but in the children as well. Using the resilience model, we assessed each adversity, the mother and the child’s coping strategies, and self efficacy. As one might expect, each situation brought about a different level of anxiety in each family; however the coping strategies varied much more. Some moms took to smoking to cope with it while others chose suppression. The children’s coping ranged from inconsolable crying and using outlets such as phones to cope.

Results: Through qualitative analysis, the components that were assessed, racism, daily activities, and the COVID 19 pandemic demonstrated to be significant stressors for the mothers. Knowledge, school/work, actions, emotions, and seriousness/susceptibility displayed stressors not only in the mom as one would expect, but in the children as well. Using the resilience model, we assessed each adversity, the mother and the child’s coping strategies, and self efficacy. As one might expect, each situation brought about a different level of anxiety in each family; however the coping strategies varied much more. Some moms took to smoking to cope with it while others chose suppression. The children’s coping ranged from inconsolable crying and using outlets such as phones to cope.

Conclusion: Ultimately, our qualitative approach found that there was an association between the pandemic and discrimination. More participants are needed to assess if the same results will apply to a larger population.

References

1. Garner AS. Home visiting and the biology of toxic stress: Opportunities to address early childhood adversity. Pediatrics. 2013;132(Supplement_2). doi:10.1542/peds.2013-1021d

2. Ford CL, Airhihenbuwa CO. Critical race theory, race equity, and Public Health: Toward antiracism praxis. American Journal of Public Health. 2010;100(S1). doi:10.2105/ajph.2009.171058

3. Hertzman C, Boyce T. How experience gets under the skin to create gradients in Developmental Health. Annual Review of Public Health. 2010;31(1):329-347. doi:10.1146/annurev.publhealth.012809.103538

4. Johnson SB, Riley AW, Granger DA, Riis J. The science of early life toxic stress for pediatric practice and Advocacy. Pediatrics. 2013;131(2):319-327. doi:10.1542/peds.2012-0469

5. Lupien SJ, McEwen BS, Gunnar MR, Heim C. Effects of stress throughout the lifespan on the brain, behaviour and cognition. Nature Reviews Neuroscience. 2009;10(6):434-445. doi:10.1038/nrn2639

6. Paradies Y. A systematic review of empirical research on self-reported racism and health. International Journal of Epidemiology. 2006;35(4):888-901. doi:10.1093/ije/dyl056

7. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine. 1998;14(4):245-258. doi:10.1016/s0749-3797(9800017-8)

8. Crouch E, Probst JC, Radcliff E, Bennett KJ, McKinney SH. Prevalence of adverse childhood experiences (ACES) among us children. Child Abuse & Neglect. 2019;92:209-218. doi:10.1016/j.chiabu.2019.04.010

9. Mersky JP, Choi C, Plummer Lee CT, Janczewski CE. Disparities in adverse childhood experiences by race/ethnicity, gender, and economic status: Intersectional Analysis of a nationally representative sample. Child Abuse & Neglect. 2021;117:105066. doi:10.1016/j.chiabu.2021.105066

10. Tirupathi R, Muradova V, Shekhar R, Salim SA, Al-Tawfiq JA, Palabindala V. Covid-19 disparity among racial and ethnic minorities in the US: A Cross-Sectional Analysis. Travel Medicine and Infectious Disease. 2020;38:101904. doi:10.1016/j.tmaid.2020.101904

Financial Disclosures: None reported.

Support: Edward Via College of Osteopathic Medicine Funding.

Ethical Approval: VCOM IRB approved. IRB number is 1604801-11.

Informed Consent: All participants in this study provided written informed consent prior to participation.

Poster No. *PH-18

Abstract No. 77

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Social Needs Assessments in Women of Reproductive Age

¹Anjali Patel, OMS-IV; ¹Destine Settlemyre, OMS-III; ²Maria Crompton DO, DipABLM; ²Didi Ebert DO, MPH, MS, CPPS, FAAFP

¹University of North Texas Health Science Center; ²Department of Family Medicine and OMM, University of North Texas Health Science Center

Statement of Significance: Social determinants of health (SDOH) are factors that influence one’s health and welfare [1]. As research on SDOH and their impact on health has increased, there has been a growing focus on the subpopulation of women of reproductive age. This study aims to highlight the prevalence of social needs among women of reproductive age and identify specific SDOH that are important to address by physician providers during clinical encounters.

Research Methods: This study is a retrospective chart review focused on completed social needs assessments during usual clinic workflow among women of reproductive age (18-45 years old) who visited the Health Science Center Central Family Medicine Clinic in the past 12 months. The current data represents preliminary results from May 2021-May 2022. The PRAPARE (Protocol for Responding to & Assessing Patients’ Assets, Risks, & Experiences) tool, which is a nationally standardized tool created by the National Association of Community Health Centers (NACHC), was used to assess social needs [2]. Social needs assessments were collected for 94 women aged 18-45. After completion of the assessment, specific community resources were provided based on the determined needs of each patient. Descriptive statistical analysis was used to quantify the social needs among the respective study population.

Data Analysis: Demographic data for the participants showed that 66% identified as White, 27% as Black or African American, 2% as Asian, 1% as American Indian, and 4% chose not to answer. Additionally, 16% identified as Hispanic or Latino, 31% as Not Hispanic or Latino, and 53% chose not to answer. Of those who identified a transportation need, 38% stated they have difficulty obtaining transportation for medical needs (attending appointments, picking up prescriptions) and 62% state they have difficulty obtaining transportation for non-medical needs. Of those who provided information, 100% stated they currently have housing; however, 6% reported they are fearful of losing their housing. Additionally, 10% reported being afraid of a partner, 4% reported difficulties in obtaining childcare, 3% with clothing, 7% with food, 10% with medical costs, 2% with phone bills, and 8% with utilities. Information regarding stress level was also collected and showed that 14% of women reported they were not at all stressed, 22% reported a little bit of stress, 28% reported somewhat stress, 20% reported quite a bit of stress, and 16% reported very much stress.

Results: Demographic data for the participants showed that 66% identified as White, 27% as Black or African American, 2% as Asian, 1% as American Indian, and 4% chose not to answer. Additionally, 16% identified as Hispanic or Latino, 31% as Not Hispanic or Latino, and 53% chose not to answer. Of those who identified a transportation need, 38% stated they have difficulty obtaining transportation for medical needs (attending appointments, picking up prescriptions) and 62% state they have difficulty obtaining transportation for non-medical needs. Of those who provided information, 100% stated they currently have housing; however, 6% reported they are fearful of losing their housing. Additionally, 10% reported being afraid of a partner, 4% reported difficulties in obtaining childcare, 3% with clothing, 7% with food, 10% with medical costs, 2% with phone bills, and 8% with utilities. Information regarding stress level was also collected and showed that 14% of women reported they were not at all stressed, 22% reported a little bit of stress, 28% reported somewhat stress, 20% reported quite a bit of stress, and 16% reported very much stress.

Conclusion: The osteopathic philosophy highlights the importance of viewing the whole patient and not simply their symptoms. For women of reproductive age, SDOH play an important role in the ability to access healthcare. This study demonstrates how women face many social issues, including transportation, childcare, food and medical costs. Inability to access both medical and non-medical necessities impact their ability to attend medical appointments and adhere to medical recommendations.A similar study was conducted by Planned Parenthood among women of reproductive age (18-44) who visited their clinics with incomes under 300% of the Federal Poverty Level (FPL). In this study, women reported difficulties obtaining the following social needs: Food (23%), Utilities (17%), Childcare (12), and Housing (8%) [3]. The local population at the Central Family Medicine clinic has similar needs to those seen on a larger scale at Planned Parenthood clinics across the nation. Addressing SDOH is an important part of comprehensive care among all patients, but specifically among women of reproductive age as frequent prenatal, antenatal, and postpartum appointments are crucial to a healthy pregnancy. This study is a preliminary report on social needs among women of reproductive age seen at the Central Family Medicine Clinic in Tarrant County, Texas. Additional data from various clinics across Texas would provide more comprehensive data that could provide the foundation for local and state level policy changes.

References

1. Social determinants of health. Health.gov. Accessed July 12, 2022. https://health.gov/healthypeople/priority-areas/social-determinants-healthPRAPARE. nachc.org. Accessed July 12, 2022.

2. https://www.nachc.org/research-and-data/parpare/Why the Social Determinants of Health (SDOH) is a Women’s Health Issue?. Planned Parenthood. Published January 23, 2020. Accessed July 12, 2022.

3. https://ppfa.medium.com/why-the-social-determinants-of-health-sdoh-is-a-womens-health-issue-14b8d392972a

Financial Disclosures: None reported.

Support: None reported.

Ethical Approval: This study is IRB reviewed and approved as it is a global protocol for retrospective chart review of data collected in usual practice. The IRB number is #2013-102.

Informed Consent: Not reported.

Poster No. *PH-19

Abstract No. 108

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Effect of Covid -19 Pandemic on Domestic Violence Related Complaints Reported in the Clinical Setting using CREDO Recording System

Brittany Rae Davis, OMS-IV; ²Alexis Stoner, PhD, MPH; ³David Redden, PhD

Edward Via College of Osteopathic Medicine-South Carolina

Statement of Significance: Due to the stay-at-home orders and quarantine in place from March 2020 to early 2021 as a result of the Coronavirus-2019 pandemic, we have seen an increase in domestic violence issues. We wish to evaluate the reporting of patients seen with domestic violence related complaints presenting in the clinical setting and documented within the CREDO (Clinical Rotation Evaluation and Documentation Organizer) reporting system by 3rd and 4th year medical students.

Research Methods: Using the CREDO reporting system developed at Edward Via College of Osteopathic Medicine, we analyzed the reported sum of 7 domestic violence related cases by ICD-10 code (International Classification of Disease Code, 10th revision) classified as before March 2020 and after March of 2020. All races, sexes, and ages were included in this study and there were no patient identifiers used in the documentation process. These cases were reported from health care settings, both ambulatory outpatient and inpatient hospital facilities across the east coast by 3rd and 4th year students at all campuses of Edward Via College of Osteopathic Medicine. The sum and percent increase of each ICD-10 Code was calculated using the total amount for all ICD-10 Codes on CREDO before March 2020 and after March 2020. The event rates of domestic violence codes between time periods were then compared using Poisson Regression modeling. From the Poisson Regressions, risk ratios and their 95% confidence intervals were calculated. Type I error rate was set to 0.05. The results of this study rely on student reporting of clinical encounters. This is subject to error and the accidental omission of some encounters or the incorrect ICD-10 codes entered for an encounter, which could lead to a slight overestimation or underestimation of the actual patients seen in the clinic. The osteopathic principles emphasize much more than the presence or absence of diseases and encompass not only physical, but mental and spiritual aspects of well being. In order to integrate these principles into practice, one critical aspect is prevention of disease. By recognizing situations like pandemics in which populations may be at increased risk for certain issues, such as domestic violence, discovering trends may help further the awareness and allow providers to provide better care for their patients.

Data Analysis: Analysis of the 7 ICD-10 codes revealed a 214.7% increase in all cases of domestic violence related ICD-10 codes reported since March of 2020 and the onset of the covid-19 pandemic compared to before March 2020. The ICD-10 codes with the largest number of cases were Child Sexual abuse, confirmed and Personal history of adult physical or sexual abuse. The ICD-10 Codes with the biggest increase in cases reported were ICD-10 code Child Sexual abuse, with a 675.5% jump, from 40 cases to 303 cases and ICD-10 code Sexual abuse, confirmed with an increase from 13 cases to 63 cases, a 384.6% increase. The risk ratios calculated for 5 out of the 7 of the ICD-10 codes were above 1 (4.03, 1.9,6.31, 9.99, and 1.32), showing an increase in incidence of those domestic violence related ICD-10 codes after March of 2020 compared to incidence of the domestic violence related ICD-10 codes before the onset of the covid-19 pandemic in March 2020. All 5 of the ICD-10 codes with risk ratios above 1 showed a statistically significant increase with p-values less than .05 (<.0001, .0005, <.0001, .027 ,0458).

Results: Analysis of the 7 ICD-10 codes revealed a 214.7% increase in all cases of domestic violence related ICD-10 codes reported since March of 2020 and the onset of the covid-19 pandemic compared to before March 2020. The ICD-10 codes with the largest number of cases were Child Sexual abuse, confirmed and Personal history of adult physical or sexual abuse. The ICD-10 Codes with the biggest increase in cases reported were ICD-10 code Child Sexual abuse, with a 675.5% jump, from 40 cases to 303 cases and ICD-10 code Sexual abuse, confirmed with an increase from 13 cases to 63 cases, a 384.6% increase. The risk ratios calculated for 5 out of the 7 of the ICD-10 codes were above 1 (4.03, 1.9,6.31, 9.99, and 1.32), showing an increase in incidence of those domestic violence related ICD-10 codes after March of 2020 compared to incidence of the domestic violence related ICD-10 codes before the onset of the covid-19 pandemic in March 2020. All 5 of the ICD-10 codes with risk ratios above 1 showed a statistically significant increase with p-values less than .05 (<.0001, .0005, <.0001, .027 ,0458).

Conclusion: Overall, there was a statistically significant increase in the rates of many of these domestic violence cases presenting in a variety of health care settings. These cases were present among all age groups and both males and females. This data correlates with other previous studies showing increases in domestic violence related police calls and usage of domestic violence hot lines.

References

1. Smith S, Zhang X, Basile K. et al. National Intimate Partner and Sexual Violence Survey 2015 Data Brief . National Center for injury Prevention and Control / Centers for Disease Control and Prevention. Published November 2018. Accessed April 15, 2022. https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf

2. Sharma, A., Borah, S.B. Covid-19 and Domestic Violence: an Indirect Path to Social and Economic Crisis. J Fam Viol (2020). https://doi.org/10.1007/s10896-020-00188-8

3. Brad Boserup, Mark McKenney, Adel Elkbuli, Alarming trends in US domestic violence during the COVID-19 pandemic, The American Journal of Emergency Medicine, Volume 38, Issue 12, 2020, Pages 2753-2755, ISSN 0735-6757, https://doi.org/10.1016/j.ajem.2020.04.077

4. Wubah AA, Yankson JA, Sumpter C, et al. Evaluation of an ICD logging system to supplement an EMR in a Sub-Saharan country. Journal of Hospital Administration. 2018;7(2):8. doi:10.5430/jha.v7n2p8

5. Rawlins F, Sumpter C, Sutphin D, Garner HR. Quantifying medical student clinical experiences via an ICD code logging app. International Journal of Medical Informatics. 2018;111:51-57. doi:10.1016/j.ijmedinf.2017.12.017

6. Abramson AA. How covid-19 may increase domestic violence and child abuse. American Psychological Association. Published April 8, 2020. Accessed April 17, 2022. https://www.apa.org/topics/covid-19/domestic-violence-child-abuse

7. Piquero A, Jennings W, Jemison E. et al. Domestic Violence During Covid-19, Evidence from a Systematic Review and Meta Analysis. National Commission on COVID-19 and Criminal Justice. Published February 2021. Accessed April 17, 2022. https://build.neoninspire.com/counciloncj/wp-content/uploads/sites/96/2021/07/Domestic-Violence-During-COVID-19-February-2021.pdf.

8. Niolon PH, Dills J, Kearns M. et al Preventing Intimate Partner Violence Across the Lifespan: A Technical Package of Programs, Policies, and Practices. National Center for Injury Prevention and Control, Division of Violence and Prevention . Published 2017. Accessed April 10, 2022. https://www.cdc.gov/violenceprevention/pdf/ipv-technicalpackages.pdf.

Financial Disclosures: None Reported

Support: None reported

Ethical Approval: Exempt. "CREDO (Clinical Rotation Evaluation and Documentation Organizer), our medical student patient encounter database, no longer needs IRB approval due to changes in regulations (45 CFR 46.102) regarding the secondary analysis of de-identified existing data, as determined after a review by the VCOM IRB.In these cases, patient data is de-identified (indeed, patient identity data was never acquired in CREDO), and students making entries are also de-identified”

Informed Consent: No informed consent necessary. CREDO, our medical student patient encounter database, no longer needs IRB approval due to changes in regulations (45 CFR 46.102) regarding the secondary analysis of de-identified existing data, as determined after a review by the VCOM IRB.In these cases, patient data is de-identified (indeed, patient identity data was never acquired in CREDO), and students making entries are also de-identified”.

Poster No. *PH-20

Abstract No. 78

Category: Public Health

Research Topic: Health Disparities-Social Determinants of Health

Impact of the COVID-19 Pandemic on Osteopathic Medical Students in the 2021-2022 NRMP Application Process

¹Danielle Lukish, DO; ²John Lukish, MS; ²Annamarie Lukish, MS; ³Danielle Lukish, DO; ⁴Linda Mintle, ¹Ascension PhD; Saint Joseph Hospital; ²Department of Research, Kansas City University of Medicine and Biosciences College of Osteopathic Medicine; ³Department of Obstetrics and Gynecology, Ascension Saint Joseph Hospital; ⁴Department of Behavioral Health, Liberty University COM

Statement of Significance: The COVID-19 pandemic significantly changed the undergraduate medical education (UME) NRMP application process (NAP). This included virtual interviews, the suspension or elimination of away rotations, elimination of COMLEX 2 PE/USMLE STEP 2 CS licensing exams, and increased online rotations. Previous literature has reported on the impact the pandemic had on the 2020-2021 NAP; however, limited data exists on the impact of the pandemic on this past cycle, from 2021-2022 (1 – 4).

Research Methods: An IRB-approved 20 question survey was developed and distributed after the 2022 match via email and social media. 86 students from the Liberty University College of Osteopathic Medicine and the Kansas City University College of Osteopathic Medicine participated in the study. Likert-scale questions with a range of 1-5 and a comment box were used to assess student experiences related to changes the pandemic had on their match process. Several areas were assessed, e.g., away rotations, virtual interviews, board requirement changes including the suspension of COMLEX Level 2 PE, advising, psychological well-being, etc. Statistical analysis was performed using Qualtrics software.

Data Analysis: 97.59% matched in the 2021-2022 NAP. 94.81% matched in their first-choice specialty. The number of away rotations in matched specialties ranged from 1 to 9 (M=2.36, SD=0.91). Only 39.74% matched at an away rotation site. On a scale of 1 to 10, overall impact felt by the pandemic on the 2021-2022 NAP was M=4.92, SD=1.92. 50.77% of students reported the suspension of the third board exam impacted their application process very highly. Approximately one-third of students rated both stress and anxiety as high impacts. 72.06% of participants sought feedback from students from the 2020-2021 NAP and 48.98% of participants found this feedback to be highly helpful.

Results: 97.59% matched in the 2021-2022 NAP. 94.81% matched in their first-choice specialty. The number of away rotations in matched specialties ranged from 1 to 9 (M=2.36, SD=0.91). Only 39.74% matched at an away rotation site. On a scale of 1 to 10, overall impact felt by the pandemic on the 2021-2022 NAP was M=4.92, SD=1.92. 50.77% of students reported the suspension of the third board exam impacted their application process very highly. Approximately one-third of students rated both stress and anxiety as high impacts. 72.06% of participants sought feedback from students from the 2020-2021 NAP and 48.98% of participants found this feedback to be highly helpful.

Conclusion: Changes in the 2021-2022 NAP due to COVID-19 positively and negatively impacted students. Student comments indicated that virtual interviews opened up more opportunities to interview and save money. Students also commented that due to the strain of the pandemic, they had less time with their attending physicians and that this could have negatively impacted their letters of recommendation. Overall, cancellation of the PE and CS was viewed positively. And many students sought out feedback from applicants of the 2020-2021 NAP to be better prepared to face the challenges of the continued pandemic.

References

1. Akers A, Blough C, Iyer MS. COVID-19 Implications on Clinical Clerkships and the Residency Application Process for Medical Students. Cureus. 2020 Apr 23;12(4):e7800. doi: 10.7759/cureus.7800. PMID: 32461867; PMCID: PMC7243841.

2. Ferrel MN, Ryan JJ. The Impact of COVID-19 on Medical Education. Cureus. 2020 Mar 31;12(3):e7492. doi: 10.7759/cureus.7492. PMID: 32368424; PMCID: PMC7193226.

3. Gardezi M, Moore HG, Socci AR, Grauer JN. Impacts of COVID-19 on orthopaedic surgery residency / spine trainee application trends. N Am Spine Soc J. 2021 Dec;8:100088. doi: 10.1016/j.xnsj.2021.100088. Epub 2021 Oct 30. PMID: 35128498; PMCID: PMC8577833.

4. Venincasa MJ, Steren B, Young BK, Parikh A, Ahmed B, Sridhar J, Kombo N. Ophthalmology Residency Match in the Covid-19 Era: Applicant and Program Director Perceptions of the 2020-2021 Application Cycle. Semin Ophthalmol. 2022 Jan 2;37(1):36-41. doi: 10.1080/08820538.2021.1906917. Epub 2021 Apr 7. PMID: 33825672.

Financial Disclosures: None reported

Support: None reported

Ethical Approval: Liberty University College of Osteopathic Medicine’s (LUCOM) IRB process is the following: complete the necessary CITI training, obtain a permission request letter from the Dean of LUCOM to perform the research, create a recruitment letter that is to be sent to participants via email and/or social media, create an informed consent, create survey, and upload all of these required documents to the Cayuse IRB application portal. This project was reviewed and approved by Liberty University College of Osteopathic Medicine’s IRB. IRB number: IRB-FY21-22-908

Informed Consent: The first page of the survey includes a brief overview of the project and a link to a PDF of the informed consent for participants to review. The potential participant then has the option to select either ‘I consent’ or ‘I do not consent.’ If ‘I consent,’ is not selected, the potential participant cannot move to the second question of the survey and the survey closes.