Download 2016 Research Day Abstract Book

April 5, 2016
Carilion Roanoke Memorial Hospital
Book of Abstracts:
Research Day 2016
Preface
Program
Table of Contents
Abstracts
Preface
April 5, 2016, marks the 9th annual Carilion Clinic Research Day. Research and Development
is excited about the program this year. It just seems to get better and better, especially with the
inclusion of CC Nursing, Virginia Tech Carilion School of Medicine, and Jefferson College of
Health Sciences. Our new title for the event going forward is Carilion Clinic, Virginia Tech
Carilion School of Medicine, and Jefferson College of Health Sciences Research Day.
We had our highest number of abstract submissions (130) this year and the quality was
outstanding.
To reprise our successful format from last year, we will continue with Faculty/Professional,
Resident/Fellow, and Student Rapid Communication Presentations (RCPs), and, once again,
promote three (3) poster sessions. The poster sessions this year will be a mix of
Faculty/Professional, Resident/Fellow, and Students and the online abstract book will be your
guide. In lieu of a hard copy of the Abstract Book, this year we have made it available online.
If you did not receive instructions on how to view the book prior to the event, our staff
assistants will have the URL/website available to you upon sign-in to the event; therefore, you
can view the book on your smart phone.
Of course some things will be the same. We again host Research Day at Memorial Hospital to
make it easier for our busy clinical practitioners, nurses, educators, and staff to attend. We’ll
also have Meritorious Faculty/Professional, Resident/Fellows, and Student research awards
for the top-rated abstracts. Finally, we have an outstanding keynote speaker— Phyllis
Whitehead, Ph.D., A.P.R.N., A.C.H.P.N. Dr. Whitehead is a clinical nurse specialist with
Palliative Care Service/Pain Management Team and Assistant Professor at the Virginia Tech
Carilion School of Medicine; she is one of our top researchers. Her talk is titled "Research: A
Team Endeavor?"
As usual, I want to thank everyone involved in research at Carilion Clinic, VTCSOM, and
Jefferson College, and acknowledge that Research Day would not be possible without the time
and dedication of the Planning Committee and Abstract Review Committee (whose job is
getting harder each year).Also, if you see Beth Harber at the meeting (and you will!), please
thank her for keeping everyone on track, motivated, and focused on both the science and
logistics of Research Day.
Thank you for attending Research Day 2016, and we hope to see you again next year.
Sincerely,
Frank Dane, Ph.D., Assistant Director of Research & Development
Research Day 2016 Planning Committee:
Kimberly "Kim" Carter, PhD
Francis C. "Frank" Dane, PhD
Amanda Ellinger, MRA
Beth Harber
Daniel Harrington, MD
Glenn Kent, PhD
Leslie LaConte, PhD
Richard Seidel, PhD
Kristin Knight, MS
Research Day 2016 Abstract Review Committee
*Adkins, Farrell, MD
*Kamrada, Meghan, PharmD
*Allison-Jones, Lisa, PhD, MSN, RN
*Kees, Donald, MD
*Bankole, Adegbenga, MD
*Kent, Glenn, PhD
*Bankole, Azziza, MD
*Knight, Kristin, MS
*Barrett, Sarah, DVM, PhD
*Kuehl, Damon, MD
*Bond, Donna, DNP
*Laconte, Leslie, PhD
*Borloz, Matthew, MD
*Lilley, Larry, RN, RRT
*Boshra, Soheir, MD
*Link, Laura, MS
*Bower, Curtis, MD
*Muelenaer, Andre, MD
*Bradburn, Eric, MD
*Muelenaer, Penelope, MD
* Brown, Beverly, MD
*Murray, Rhoda,PhD, FNP-C
* Carter, Kimberly, PhD
*Musick, David, PhD
*Dane, Francis (Frank), PhD
*Porter, Ava, DNP, MSN, RN
*Davis, Benjamin, MD
*Reese, Robert, PhD
*Doherty, Emily, MD
*Sane, David, MD
*Ellinger, Amanda, MRA
*Seidel, Richard (Rick), PhD
*Garber, Jeannie, PhD
*Sorrentino, Dario, MD
*Glaser, Gretchen, MD
*Tenzer, Mattie, MS
*Gleason, Jonathan, MD
*Vari, Patty, PhD
*Iglesias, David, MD
*Whiter, Kim, MS, MLS(ASCP)
*Jennings, Cathy, DNP
*Willeman-Buckelew, Diana, PhD
*Kablinger, Anita, MD
Program
9:00 a.m.
Welcome
Frank Dane, PhD
Assistant Director, Carilion Clinic Research & Development
(6th floor auditorium)
9:15 a.m.
First Poster Session
Faculty/Professional, Residents/Fellows, Students
Medical Education classrooms 1, 2, 3
10:30 a.m.
Rapid Communication Presentations
Six Faculty/Professional presentations
11:45 a.m.
Second Poster Session and Refreshments
Faculty/Professional, Residents/Fellows, Students
Medical Education classrooms 1, 2, 3
1:00 pm
"Research: A Team Endeavor?"
Phyllis Whitehead, Ph.D., A.P.R.N., A.C.H.P.N.
2:30 p.m.
Third Poster Session
Faculty/Professional, Residents/Fellows, Students
Medical Education classrooms 1, 2, 3
3:45 p.m.
Rapid Communication Presentations
Four Resident/Fellow presentations and four Student presentations
4:45 p.m.
Awards – Auditorium
Rapid Communication Presentations
12 Meritorious Abstract Citations
Faculty/Professional, Residents/Fellows, Students
5:00 p.m.
Adjourn
Table of Contents
Page Author
Title
Order
Faculty/Professional Meritorious Rapid Communication Presentations - 10:30 - 11:30 a.m.
1
CLEMENTS, John
2
SEIDEL, Laurie
3
4
KEES, Don
MUELENAER, Andre
Cross-sectional Area Measurement of the
Central Tarsometatarsal Articulations
Nurses Transforming Health Care One
Mindful Breath at a Time
A New Training Protocol for Ultrasooundguided Central Line Insertion
An Acoustic Method For Detecting Air Flow
In Artificial Airways
RAO, Jayasimha
Simulation to Support Family Presence
during Resuscitation
Comparative transcriptome analysis in RahU
protein-expressing Pseudomonas
aeruginosa clinical isolates
7
GAZO, Josh
Fecal Lactoferrin and Colonic Disease
Extent in Inflammatory Bowel Disease
8
NGUYEN, Vu
10
ILONZE, Onyedika
5
6
BOND, Donna
1
2
3
4
5
6
Resident/Fellow Meritorious Rapid Communication Presentations - 3:45 - 4:15 p.m.
9
GREEN, Sarah
Diagnostic Delay In Inflammatory Bowel
Disease
Colistin Versus High-Dose Polymyxin B:
Impact on Nephrotoxicity
Rates of Mechanical Valve Thrombosis with
Reversal of Anticoagulant Therapy
1
2
3
4
Student Meritorious Rapid Communication Presentations - 4:15 - 4:45 p.m.
11
YANOFF, Matthew
13
O'NEILL, Conor
12
14
DHIMAN, Nitasha
WALTERSCHEID, Zakk
Arrhythmogenic Intercalated Disk
Microdomain Identified in Human Cardiac
Tissue
Survival after Discharge: Hospital Acquired
Infections Increase Post Discharge Mortality
Local Vertebral Autograft in ACDF:
Technique Description and Cases
Anterior Cervical Discectomy With Fusion
Using Vertebral Autograft: Biomechanical
Analysis
1
2
3
4
Faculty/Professional Abstract for Poster Presentation Alphabetical Order
Pg
Author
Title
15
BAFFOE-BONNIE,
Anthony
EDUCAiTE: Effectiveness in Decreasing Urinary
Catheter Associated Infections Through Education
3
2
16
BATH, Jennifer
Implementing a Patient Call Back Program in the
Trauma Population
1
3
1
2
BOOTH, Kathryn
Preventing Post-operative Pneumonia-Effect of
Toothbrushing and Chlorhexidine
PROGRESSIVE MOBILITY PROTOCOL REDUCES VTE
RATE IN NEUROTRAUMA PATIENTS
1
3
Occupational Therapists Addressing Sleep with
Pediatric Clients
2
3
3
1
3
3
1
1
1
2
2
3
2
3
2
2
1
1
2
1
3
3
2
1
2
2
3
2
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
BOND, Donna
BROWNING, Jason
BROWNING, Jason
CARLISS, Richard
COLEMAN, Keel
FARRELL, Francis
JOHNSON, Sallie
Beth
KIDD, Amanda
MUELENAER,
Penelope
MUSICK, David
MUSICK, David
NEWBOLD,
Temple
SORRENTINO,
Dario
VANCE, J. Eric
WHICKER, Shari
WHITEHEAD,
Phyllis
OT Students' Perceptions of the Entry-Level OT Clinical
Doctorate
Evaluation of Differential Shortening of Telomere
Length in Osteogenesis Imperfecta
MERITORIOUS POSTER AWARD
CT Cervical Spine Decisions in the NEXUS Negative
Patient
Increased Adenosine Signaling Promotes a Profibrotic
Phenotype in Renal Fibroblasts
Pragmatic trials to improve healthcare employee weight
loss program
A Patient Focus Clears the Vision to Excellent Employee
Engagement
Understanding and Improving Water Sanitation
Practices in Malawi, Africa
MERITORIOUS POSTER AWARD
Training New Residents on Patient Handoff
Procedures: A Pilot Study
MERITORIOUS POSTER AWARD
Defining the Medical School Learning Environment: An
Exploratory Survey
Pyxis Supply Waste Reduction and Donation
WILL NOT BE PRESENTING A POSTER
Microbiome profiling in Crohn's Disease patients and
first degree relatives
MERITORIOUS POSTER AWARD
Training to disseminate trauma-focused cognitive
behavioral therapy (TFCBT) into practice
Building an Interprofessional Teaching Academy for
Learner-Centered Excellence
Nurse Practitioners' Perspectives on Patient
Preferences About Serious Illness Instrument
Session
Room
Resident/Fellow Abstracts for Poster Presentation Alphabetical Order
Pg
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
Author
Title
BEAUZILE,
Patricia
BEAVERS, Josh
Uterine Sparing Treatment of Placenta Accreta: Case
Report /Literature Review
Outcomes of Staphylococcus aureus bacteremia with
and without ID consultation.
2
1
1
2
3
3
CARRINGTON,
Anne
CARTER, Mary
Phytonadione utilization and prescribing patterns at
Carilion Roanoke Memorial Hospital
Moving Forward: Progressive Mobility in Medical
Intensive Care Units
2
3
1
2
2
2
1
3
Treatment Experience with Voriconazole During the
2012 Fungal Meningitis Outbreak
Novel Clinical Manifestation of Variant SCN5A Gene
3
2
2
3
3
1
Systemic Embolization from an Unusual Left Ventricular
Intracardiac Mass
2
3
1
1
Evaluation of First Metatarsophalangeal Arthrodesis
Weight Bearing Protocols
Evaluation of First Tarsometatarsal Arthrodesis Weight
Bearing Protocols
1
2
3
2
1
1
Case Conference Preparatory Curriculum: A Six Step
Approach
Novel Multi-Disciplinary Approach to a Challenging
Coronary Sinus Lead Extraction
3
3
3
2
2
2
Appropriate Treatment of Pneumonia in Pediatric
Patients at CRMH
1
2
2
2
CARRINGTON ,
Anne
CARTER, Mary
DINDIAL, Lorne
GREEN, Sarah
LADYZHENSKIY,
Edward
LARSEN, Timothy
LARSEN, Timothy
LARSEN, Timothy
MARTIN, Scott
MARTIN, Scott
MAZLOOM, Sean
MCKENZIE, Ralph
MEMON, Sehrish
MEMON, Sehrish
MILLER, Bethany
MILLER, Bethany
Evaluation of pharmacist-directed versus physicianmanaged warfarin therapy in hospitalized patients
MERITORIOUS POSTER AWARD
Increased Venothromboembolism Risk in H1N1 Patients
This Liver Abscess Seems Fishy
Predictors of Adverse Outcomes after High Voltage
Cardiac Device Procedures
Permanent His Bundle Pacing for Isolated Congenital
Complete Atrioventricular Block
Basal Cell Carcinoma with Vascular Invasion Treated
with Postoperative Radiotherapy
Underestimation of Bioprosthetic Mitral Valves with 2D
Echocardiography:Indication for 3DTEE
Appropriate Health Care-Associated Pneumonia
Management in the Emergency Department
Session
Room
54
55
56
MORTON,
Caroline
Kratom: Old Plant, New Problem
3
3
3
1
NEPAL, Santosh
Systemic inflammation in severe COPD with isolated
nocturnal dyspnea.
2
2
3
2
2
1
1
1
1
3
2
1
Next Day Transfermoral TAVR Discharge: Are We There
Yet?
3
3
1
3
Relationship of Resiliency Factors to Characteristics of
Adolescent Psychiatric Inpatients
3
1
2
2
1
3
3
1
1
1
1
3
MURPHY-RYAN,
Maureen
57
NEPAL, Santosh
58
ORTOLANI, John
59
PATEL, Brijesh
60
PELLEG, Tomer
61
PELLEG, Tomer
62
RATHORE,
Sulaiman
63
64
65
66
67
68
69
RYAN, Scott
SHEBAK, Shady
SIDDIQUI, Faisal
STEFANADIS, Gus
WARREN, Rachel
WHITNEY,
Margaret
YIN, Jun
Differential diagnosis of adult-onset seizures and
psychosis: A missing mechanism.
MERITORIOUS POSTER AWARD
Endobronchial leiomyoma successfully treated with
flexible bronchoscopic cryotherapy
MERITORIOUS POSTER AWARD
Can Surgery Residents Meet Quality Benchmarks for
ADR in Colonoscopy?
Triple Whammy! Intercostal Herniation of Lung, Liver
and Colon
Nonmedical Silicone Injections and
Autoimmune/Inflammatory Syndrome Induced by
Adjuvants (ASIA)
Outcomes of Intensivist Staffing and Admission Times in
Medical ICUs
Emergent and Elective Colo-rectal Surgery Patients
Benefit from Enhanced Recovery
Impact of sepsis alert process in improving clinical
outcomes
Evaluation of the Adult Diabetic Ketoacidosis Protocol
Vancomycin Dosing Calculator: A new tool for optimal
patient care
MERITORIOUS POSTER AWARD
Omentectomy without gross intraperitoneal metastasis
in uterine papillary serous cancer
The Effect of Menstrual Cycle Phase on Adolescent
Psychiatric Hospitalization
Student Abstracts for Poster Presentation - Alphabetical Order
Pg
Author
Title
70
ABRAHAM,
Anand
Modulation of Cardiac Conduction Across Myocytes
by Extracellular Ionic Concentration
2
1
71
ACHEAMPONG,
Joycelynn
Computer Vision Assisted Water Quality Testing
1
2
Association of Clerkship's Order and Cumulative
Experience With Examination Scores
Failure of Chlorhexidine to Prevent Postoperative
Pneumonia: NSQIP Regression Modeling
1
1
1
2
The Orthopaedic Osteoporosis Care Gap: A Survey of
Providers
Perceptions of Certified Driver Rehabilitation
Specialists on video feedback interventions
1
2
3
2
Distributed Thermistor for Temperature Monitoring of
Malnourished Infants
1
3
Are Incisional Hernias Safe To Repair in The Elderly?
3
1
Use of NSQIP to Reduce Re-intubation Rate Among
Surgical Patients
Affordable Automated Technology using Ziehl-Neelsen
Stained Sputum for Tuberculosis Screening
1
1
2
2
2
3
Prenatal Diagnosis of Congenital Heart Disease in
Southwest Virginia
Indications for Direct Laryngoscopic Examination Prior
to Anterior Cervical Surgery
2
1
1
3
3
2
Thermal Infrared Imaging to Measure Breathing During
Sleep
Development of Biological Assays for Assessing aCT-1
Function
1
1
1
2
2
1
3
1
2
3
72
73
74
75
ATHAMNEH, Liqa
BANSAL, Jash
BARTON, David
BROWN, Molly
76
CASHMAN, Lauren
77
CHANG, Yu-Wei
78
CHEN, Jing
79
CLAYBON, Swazoo
80
CONNOR, Brian
81
GAMBALE,
Catherine
GOWD, Anirudh
82
83
84
85
86
87
88
GOWD, Anirudh
GROSSMAN, Peter
HANCOCK,
Kendall
JOHNSON, Nathan
KANABUR, Pratik
KENNEDY, Lauren
MERITORIOUS POSTER AWARD
DRAMATIZATION OF STARLING FORCES: AN
INTERACTIVE LEARNING APPROACH
MERITORIOUS POSTER AWARD
Medial Collateral Ligament Injuries in NCAA Division 1
Football Athletes
MERITORIOUS POSTER AWARD
Financial Impact of an Enhanced Recovery Protocol in
Colo-rectal Surgery
Using ACT1, a Connexin 43 Blocker, Against
Glioblastoma Stem Cells
Specifying parameters for real-time cognitive feedback
Session
Room
89
90
91
92
93
94
95
96
97
98
99
KIM, Eric
LEE PARK, Juniper
LI, Andrew
LIU, Aiwen
MCGURK, Kevin
MENSAH-BINEY,
Kevin
MYERS, Genevra
NAZEMI, Alireza
NAZEMI, Alireza
NG, Seaton
O'BOYLE, Sean
100 OWUSUBOATENG,
Kwabena
101 REED, Christopher
102 ROSS, Julia
103 SCHUMER, Grace
104 SINGLETON,
Rachel
105 SOOD, Nikki
106 TENZER, Mark
3
3
3
3
2
2
3
3
2
3
Transfer Distance and Time in Emergency General
Surgery Outcomes
Using resilience to predict patient outcomes in a
psychiatric population
Addressing Delirium in Elderly Patients Following
Elective Spinal Surgery
2
3
2
3
2
2
Unilateral S2 Iliac Screws for Spinopelvic Fixation
1
1
Relationship Between Sleep Hygiene and Behavior in
Children with ASD
3
2
Lymph Nodes in Laparoscopic and Open Resections for
Colorectal Cancer
3
1
Lilliputian hallucinations and alcohol withdrawal
2
2
Ulcerative Colitis and Crohn's Disease in the Same
Patient
3
1
Narcotics Dependence in Patients Undergoing Colorectal Surgery
3
3
Effect of Exparel on Pain Management in Total Knee
Arthroplasty
1
3
Examining Patient Satisfaction as Reliable Outcome
Measure in Occupational Therapy
1
3
An Algorithm Based Protocol for Treating
Atherosclerotic RAS
3
2
Development of Machine Learning Algorithm as
Diagnostic Tool for EoE
2
1
Incident Heart Failure Prediction in Adults within 1year
Addressing Challenges in using fMRI in Children with
Cerebral Palsy
Clinical Simulation: Engaging Medical Students in
Problem-Based Learning
Risks of Discharging Emergency Department Patients
with Abnormal Vital Signs
Transfusion Setting and Venous Thromboembolism
Risk: A Retrospective Analysis
MERITORIOUS POSTER AWARD
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F3
Key Word(s): Measurement, Orthopedics, Orthopedics Surgery, Radiology
Title: Cross-sectional Area Measurement of the Central Tarsometatarsal Articulations
Authors: John Clements, DPM, Carilion Clinic, [email protected]; Kelley Whitmer, MD, Carilion
Clinic; Hoa Nguyen, BS, VTCSOM; Matthew Rich, MS, VTCSOM
Purpose: We postulated the damage to articular surface by transarticular fixation of primary ligamentous
Lisfranc injuries would predispose to later arthrosis. There is controversy as to whether open reduction internal
fixation or primary arthrodesis is most appropriate in these injuries. This prompted us to investigate the articular
surface areas of the 1st-3rd tarso-metatarsal joints. We evaluated the surface area of the joints to determine how
much articular surface is damaged by screw placement.
Methods: This is a retrospective review of CT scans (n=30) including foot length and undamaged TMT joints.
Calculations included articular surface area averages as compared to the surface area of the fixation screws.
CT images were reconstructed at each joint. Cuneiform and metatarsal articular surface areas were measured.
Percentage of articular surface occupied by the fixation screws was calculated with equation below:
%=
100*(screw area*#screws in joint*2/articular surface area) The screw area was calculated with the standard
4mm diameter screw used for Lisfranc surgeries.
Results: Surface area damaged averaged 4.87%, 4.79%, and 4.86% for the 1st, 2nd, and 3rd TMT joints
respectively with a standard deviation of less than 1% for all joints.
Conclusion: To our knowledge, a quantitative evaluation of the amount of articular surface occupied by screw
placement has not been performed. Results from this investigation shows the amount of articular damage
created by ORIF screw placement is approximately 5%.
1
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F17
Key Word(s): Behavioral Science, Nursing, Education, Health Promotion/Wellness
Title: Nurses Transforming Health Care One Mindful Breath at a Time
Authors: Laurie W. Seidel, MSN, RN, Carilion Clinic, [email protected]; Kimberly F. Carter, PhD,
RN, Carilion Clinic; Andrea C. Wright, MSN, CEN, Carilion Clinic; Francis Dane, PhD, JCHS
Purpose: Unique approaches are needed to improve nurse's resilience in order to reduce stress, minimize
burnout, and enhance nursing practice, including compassionate care. This IRB approved study measured the
effect of a brief mindfulness training, developed specifically for healthcare professionals,on well-being,
burnout, and mindful awareness.
Methods: This pilot study used a one group pre-post design, using a convenience sampling methodology.
Participants completed a set of self-report instruments, the Mindfulness Attention Awareness Scale (MAAS),
the WHO Quality of Life-BREF (WHOQOL-BREF), the Maslach Burnout Inventory (MBI-GS), prior to the
first class, at the end of the fourth (last) session, and 6 months post-intervention. The course included didactic
and experiential components, brief home practice, and incorporated mindfulness practices specifically for the
work environment, "mindfulness in action". The limitations of this study included no control group and a selfselected sample.
Results: Twenty seven nursing employees enrolled and twenty five completed the course. Immediately after
the training, overall quality of life was significantly improved, as were physical, social, and environmental
quality of life. Burnout results neared significance through reduced emotional exhaustion and increased
personal accomplishment. Compared to baseline, six-month follow-up showed statistically significant
improvement in mindful awareness, and in overall, physical, psychological, and environmental quality of life,
and decreased emotional exhaustion (a key indicator of burnout).
Conclusion: The findings support the possible usefulness of this brief mindfulness training/education for
addressing nursing employee stress and quality of life; however, the results do not establish a causal
relationship. This pilot study was also not a randomized trial, but provided support for a subsequent study which
is underway employing a controlled experimental design with a broader sample of healthcare professionals to
determine whether the effects can be replicated and extended.
2
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F13
Key Word(s): Quality Improvement/Quality Assurance, Process Improvement, Education
Title: A NEW TRAINING PROTOCOL FOR ULTRASOUND-GUIDED CENTRAL LINE INSERTION
Authors: Don W. Kees, MD, Carilion Clinic, [email protected]; Claudia Kroker-Bode, MD, Carilion
Clinic; David W. Musick, PhD, Carilion Clinic; Charles Paget, MD, Carilion Clinic; Damon Kuehl, MD,
Carilion Clinic; Timothy Fortuna, DO, Carilion Clinic; Mahtab Foroozesh, MD, Carilion Clinic; Tamela
Morgan, RN, Carilion Clinic
Purpose: The potential for adverse events associated with central venous catheterization (CVC) procedures is
well-established. A multidisciplinary committee established a protocol outlining educational and supervisory
requirements for all postgraduate medical trainees involved in CVC placement.
Methods: Reading materials and online modules were assigned to residents in designated programs (N=235).
Postgraduate Year one (PGY-1) residents and new fellows were assigned to simulation-based training
workshops where they received instruction on CVC insertion and performance feedback. A competency-based
assessment system designated three levels of proficiency, with each level accompanied by specific requirements
for supervision and skill assessment. A reporting mechanism inside our electronic medical record was
developed for tracking central line placements.
Results: Ninety-five percent (95%) of residents assigned the Duke Infection Control Outreach Network
(DICON) training modules completed them. Eighty-five percent (85%) of PGY-1 residents and new fellows
completed the initial simulation-based training workshop. The new reporting system includes data about CVC
placements at the program and individual resident level, which "closes the training loop" and provides valuable
information for program directors. Four months of reporting data indicated that residents as a group are placing
132 central lines per month, with 27% of those placements performed by PGY1 residents. By specialty, total
number of placements were 38% Emergency Medicine, 24% Internal Medicine, 21% Surgery and 16%
Pulmonary/Critical Care Medicine. Ninety-four percent (94%) of all lines were placed successfully. Additional
types of data are also provided for program director review (e.g., patient consent, complications, level of
supervision).
Conclusion: A standardized training process for ultrasound guided CVC insertion, including a competencybased assessment system, has been well-received and could be replicated by other programs. This approach
may also impact clinical outcomes (e.g., patient length of stay) and be associated with reduced financial burdens
from complications of these procedures.
3
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Translational
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F28
Key Word(s): Chronic Care, Respiratory Therapy, Pediatrics
Title: An Acoustic Method For Detecting Air Flow In Artificial Airways
Authors: Andre A. Muelenaer, MD, MS, VTCSoM/Carilion Clinic, [email protected];
Katherine Yang, 2nd Year Student, University of Virginia; Alfred L. Wicks, PhD, Virginia Tech
Purpose: Bench test acoustic flow sensor at air flows, volumes, and respiratory rates consistent with pediatric
patients, ranging from newborn to adolescent, with artificial airways.
Methods: A ventilator was set up with appropriate test lungs. Measurements taken with RR of 15, Vt of 10-300
mL. Inspiration was represented by trials without humidity, while expired breaths were represented by 100%
relative humidified air. At each tidal volume, 10 waveform amplitudes were measured. Comparisons were by
paired t-test. (p < 0.05) A separate experiment introduced sterile lubricant gel.
Results: Tidal volumes as low as 10 mL are readily detected. As tidal volume increases, so does the effect of
humidity on wave amplitude. Humidity attenuates the signal, but does not interfere with detection. Tidal
volumes < 15 mL were unaffected by humidity. Volumes <20 mL (except at 80) were significantly affected.
The lubricant gel was detected as total occlusion of the airway.
Conclusion: The sensor is capable of detecting flows mimicked in tracheostomy tubes of infants and children.
Variability is noted in acoustic signal strength with changes in flow, humidity, and obstructions. This presents
the opportunity for setting threshold values to alert a caregiver of partial blockage. Commercialization of this
technology should result in reduced morbidity and mortality in pediatric patients.
4
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F32
Key Word(s): Critical Care, Nursing, Education
Title: Simulation to Support Family Presence during Resuscitation
Authors: Donna C. Bond, DNP, RN, CCNS, AE-C, CTTS, Carilion Roanoke Memorial Hospital,
[email protected]; Carla Hazelwood, ADN, RN, CRMH; Julie Morris, PhD, CRMH; Sara Kagarise,
AD, RTR/CT, CRMH; Evelyn Rubongoya, MSN, RN, PCCN, CRMH; Susan Bllankenship, BSN, RN, MS,
CRMH; Jeanne Abbott, ADN, RN, CRMH; Cecile Dietrich, BSN, RN, CRMH; Cindy Gillespie, MSN, RN,
CRMH
Purpose: To compare two educational approaches to determine if the inclusion of simulation in education
improves reported self-confidence in having family present during resuscitation events for ICU and PCU staff.
Methods: IRB-determined Quality Assurance/ Improvement Project using pretest post test comparison design.
Twilbell's Family Presence Risk Benefit Scale and Family Presence Self-Confidence Scale 7 were administered
to professional staff in Medical Intensive Care Unit (ICU) and Vascular Progressive Care Unit (PCU). Staff
were then randomized to 2 education groups (Power-Point (TM) education only versus Power-Point(TM)
education and Simulation lab). Surveys were then re-administered after education.
Results: The ICU and PCU staff were similar in gender and race. The PCU staff were older with 41% of the
staff having 11-20 years of nursing experience compared to 54% of the ICU staff having between 1-5 years.
The ICU staff were younger, but with 79% of the staff having too many code experiences to count as opposed
to the PCU staff where 35% had too many code experiences to count. Both units report low experience in
having family presence during resuscitation efforts.
Paired T-tests were calculated with preset alpha =0.05.
PCU nurses who attended the Simulation lab experience statistically significant improvement in risk benefit of
family presence during resuscitation. No statistical significant change in ICU nurses attending the Simulation
lab was found. Although both ICU and PCU showed improved scores following both types of education, only
PCU scores were statistically significant.
Conclusion: Family presence Power-Point (TM) education improved the ICU and PCU Nurses' self
confidence and identification of risk versus benefit. Use of the Simulation lab combined with Power-Point (TM)
education should be considered for nurses with less code experience.
5
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Translational
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F33
Key Word(s): Basic Sciences, Infectious Diseases, Microbiology, Bacteriology
Title: Comparative transcriptome analysis in RahU protein-expressing Pseudomonas aeruginosa clinical
isolates
Authors: JAYASIMHA RAO, PHD, Carilion Clinic/JCHS/VTCSOM, [email protected]; Lily R. Colpitts, MD,
VTCSOM; James M. Gray , Senior student , JCHS; Alyson Prorock, MS, UVA; John Goad, MD, Carilinon Clinic;
Roderick V. Jensen, PHD, VT; Yongde Bao, PHD, UVA; Dorothy C. Garner, MD, Carilion Clinic/VTCSOM; Thomas M.
Kerkering, MD, FACP, FIDSA, Carilion Clinic/VTCSOM/JCHS
Purpose: RsmA is a posttranscriptional regulatory protein in Pseudomonas aeruginosa which regulates
expression of several virulence-related proteins, including RahU protein. It is important to determine genomewide transcriptome expression for other virulence genes, which in 2 clinical isolates of RahU-expressing
phenotypes of P. aeruginosa may provide tools for understanding pathogenesis under clinical conditions.
Methods: In this IRB-approved prospective study, we screened 38 clinical isolates of P. aeruginosa to
determine RahU protein production by Western blotting. We selected 2 clinical RahU-expressing phenotypes of
P. aeruginosa: PA097-RahU+++ and PA115-RahU+. Transcriptome analysis was carried out by measuring
mRNA levels with duplicate Affymetrix P. aeruginosa GeneChip arrays. Quantitative real-time polymerase
chain reaction (qRT-PCR) validated and confirmed the microarray results.
Results: A volcano plot represented the relationship between statistical analysis (P values) and fold changes observed in
microarray analysis. Transcriptome analyses revealed 280 transcripts in PA115 and 263 transcripts in PA097 (10.11%)
differentially regulated 2.0-fold in 5,570 genes at 5 hours. Seventy-three transcripts in PA097 and 68 transcripts in PA115
were 4.0-fold upregulated. Many transcripts involved glucose transporters, metabolic enzymes, heme biosynthesis,
pyochelin, type 3 secretory systems, quorum-sensing or antibiotic-resistance efflux pumps, flagella, type 4 pili, type 6
secretory systems, phenazine 2, bacteriophage and pyoverdin-synthesis locus. Interestingly, expressions of rahU and rsmA
levels in microarray data showed no changes in both isolates. The qRT-PCR validation analysis corroborated microarray
results of 11 selected genes. Transcript levels of an additional 16 genes were determined at 6-hour and 8-hour points by
qRT-PCR. Data reveal that expression of rahU was upregulated in PA097 then PA115. Interestingly, expression of rsmA
was not found differentially expressed in either isolates, but GacS/A regulatory genes such as gacS, gacA, rsmY, rsmZ,
and rsmN were upregulated in PA115.
Conclusion: This study provides additional information toward identification of other differentially expressed
genes involved with pathogenesis under clinical conditions.
6
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R16
Key Word(s): Patient Monitoring, Gastroenterology, Screenings
Title: Fecal Lactoferrin and Colonic Disease Extent in Inflammatory Bowel Disease
Authors: Josh Gazo, MD, Internal Medicine Residency, Virginia Tech Carilion, [email protected];
Marrieth Rubio, MD, Gastroenterology and Hepatology, Virginia Tech Carilion; James H. Boone, MS, Techlab,
Blacksburg, VA; Vu Nguyen, MD, Gastroenterology and Hepatology, Virginia Tech Carilion; Dario Sorrentino,
MD, Gastroenterology and Hepatology, Virginia Tech Carilion; Kristin Knight, MS, Carilion Research and
Development
Purpose: Endoscopy is an established means of identifying disease activity in inflammatory bowel disease
(IBD). However, endoscopy is both expensive and invasive. Previous studies demonstrated the potential of fecal
biomarkers - including fecal lactoferrin - to identify inflammation in IBD. It remains unclear whether the
magnitude of elevation correlates with disease extent. This study evaluates potential correlation between
lactoferrin concentrations and colonic disease extent as determined by endoscopy in IBD.
Methods: A retrospective study was performed in IBD patients at a tertiary referral center examining colonic disease
extent by endoscopy. Patients with evidence of small bowel involvement were excluded. Lactoferrin levels were collected
within 30 days of endoscopy. A colonic disease extent score was developed: no disease (0), Ileocecal valve only (1), 1-5
segments involved (2-6 respectively), and pancolitis (7). Segments were defined as: cecum, ascending, transverse,
descending, sigmoid colon, and rectum. Quantitative lactoferrin was determined by enzyme-linked immunoassay and
reported as ug/g. Spearman's correlation coefficient was applied to assess correlation between lactoferrin levels and
colonic disease extent.
Results: 82 IBD patients were identified; 38(46%) with Crohns Disease (CD) and 44(54%) with Ulcerative
Colitis (UC). Lactoferrin levels for colonic extent groupings were Group 0-1 (N=14) median 7.1 interquartile
range 25%-75% (IQR) [0 - 152.3], Group 2-3 (N=29) median 92.7 IQR [24.9 - 1133.7], Group 4-5 (N=14)
median 589.0 IQR [144.7 - 2269.5], Group 6-7 (N=25) median 2168.1 IQR [482.2 - 3662.8]. Lactoferrin
demonstrated a good correlation with colonic disease extent (R=0.577, p<0.01). Similar correlation was
observed across patients with CD (R=0.556, p<0.01) or UC (R=0.562, p<0.01).
Conclusion: These findings suggest clinical utility of lactoferrin to evaluate inflammation in IBD. Higher
lactoferrin levels were predictive of greater colonic disease extent in both CD and UC patients. Therefore,
changes in lactoferrin concentrations may bear clinical significance as a non-invasive means of monitoring
disease burden over time.
7
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R37
Key Word(s): Family Medicine, Patient Experience, Ambulatory, Chronic Care, Internal Medicine, Preventive
Medicine, Gastroenterology, Process Improvement
Title: Diagnostic Delay In Inflammatory Bowel Disease
Authors: Vu Nguyen, M.D., IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of
Medicine, [email protected]; Dario Sorrentino, M.D., IBD Center, Division of Gastroenterology,
Virginia Tech Carilion School of Medicine; Kristin Knight, M.S., Virginia Tech Carilion School of Medicine;
Jessica Mays, B.S., Virginia Tech Carilion School of Medicine; Yingxing Wu, B.S., Virginia Tech Carilion
School of Medicine; Rachel White, R.N., IBD Center, Division of Gastroenterology, Virginia Tech Carilion
School of Medicine; Joshua Dodge, B.S., Virginia Tech University; Marissa Lang, B.S., Virginia Tech
University
Purpose: European studies suggested that there is considerable delay in diagnosing inflammatory bowel disease
[IBD] (ulcerative colitis [UC] and Crohn's disease [CD]) - an important issue as early and effective therapy can
alter disease course. However, this has not been studied in the U.S. The aim of this study is to examine time
from onset of symptoms to IBD diagnosis at Carilion Clinic.
Methods: 76 IBD patients were identified from 2008 to 2013. Patient demographics, disease phenotype,
complications, healthcare utilization, and time to diagnosis were collected. Disease complications included
intestinal strictures, fistula, abscess, and perforation. Primary outcome was time from symptom onset to
diagnosis. Median times to diagnosis were compared using Mann-Whitney U test.
Results: 50% of patients had CD and 50% UC. Prior to diagnosis, 43% had at least one hospital visit due to
IBD-related symptoms. 21% of CD patients had complicated disease at diagnosis. While the median time from
symptom onset to initial physician visit was short and similar in both groups (2 vs. 3 weeks,p=0.865), median
time from symptom onset to evaluation by a gastroenterologist (32 vs. 13 weeks,p=0.050) and IBD diagnosis
(44 vs. 16 weeks,p=0.010) were significantly longer in CD compared to UC. 75% of UC patients were
diagnosed within 53 weeks of symptom onset; the equivalent interval for CD patients was twice as long at 112
weeks.
Conclusion: CD patients experienced significantly longer time to diagnosis compared to UC patients.
Importantly, median time to diagnosis was >10 months for CD. Major delay occurred during the time from
initial physician visit to evaluation by a specialist and diagnosis. At diagnosis, a large proportion of CD patients
already developed complications. These findings emphasize the importance of raising awareness of IBD among
primary care providers and expedite specialist referral.
8
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R38
Key Word(s): Pharmacology, Infectious Diseases, Nephrology
Title: Colistin Versus High-Dose Polymyxin B: Impact on Nephrotoxicity
Authors: Sarah B. Green, PharmD, BCPS, Carilion Clinic, [email protected]; Marissa G. Williams,
PharmD, BCPS (AQ-ID), Carilion Clinic; Nathan A. Everson, PharmD, Carilion Clinic
Purpose: Although structurally very similar, the polymyxins are not clinically interchangeable. Colistin is
administered as an inactive prodrug, and recent studies have demonstrated that less than 20­-25% of the dose
will be converted to active drug outside of the urinary tract. Weight-based polymyxin B dosing, however,
produces a predictable relationship between dose and serum levels. As a result, utilization of high-dose
polymyxin B replaced colistin for infections outside of the urinary tract. The purpose of this study was to
evaluate whether there has been a change in associated nephrotoxicity rates since adopting aggressive
polymyxin B dosing instead of traditional, weight-based colistin for treatment of infections by multidrugresistant organisms (MDROs).
Methods: This was a retrospective, single­-center cohort study. Forty-four adult patients who received
intravenous colistin or polymyxin B at Carilion Clinic from 2010 through 2015 were identified for inclusion in
the study. Baseline demographic data were collected and the presence of other risk factors for nephrotoxicity
(i.e. concomitant nephrotoxins, Modified Acute Physiology Score, hypertension, and diabetes) were assessed.
Nephrotoxicity was defined as meeting RIFLE Criteria for acute kidney injury or failure. Polymyxin regimens
and renal function were tracked throughout the treatment course.
Results: Twenty-one patients received intravenous colistin and 23 received intravenous polymyxin B during
the 5-year study period. There were no significant differences in study patients at baseline, including risk factors
for nephrotoxicity. The majority of infections were caused by Pseudomonas spp. (39%) with the respiratory
tract (57%) most commonly identified as the infection source. There were no statistically significant differences
between the polymyxin B and colistin groups in the rates of nephrotoxicity (29.4% vs. 35.0%), neurotoxicity
(13.0% vs. 9.5%), or mortality (34.8% vs. 38.1%) observed in this study.
Conclusion: Aggressive, weight-based polymyxin B dosing for MDRO infections will continue to be utilized
as no differences in nephrotoxicity or neurotoxicity were demonstrated.
9
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R50
Key Word(s): Hematology, Cardiology, Cardiac/Cardiovascular Surgery, Critical Care
Title: Rates of Mechanical Valve Thrombosis with Reversal of Anticoagulant Therapy
Authors: Onyedika J. Ilonze, MD, MPH, Carilion Clinic Virginia Tech Cardiology,
[email protected]; Timothy Ball, MD, PhD, Carilion Clinic Virginia Tech Cardiology ; Pratik
Kanabur, BS, Virginia Tech Carilion School of Medicine
Purpose: To determine the rates of ischemic cerebral thromboembolic events in patients with mechanical heart
valves on warfarin anticoagulation admitted with major bleeding necessitating stopping warfarin and reversing
anticoagulation.
Methods: A retrospective review between January 2009 - June 2015 of all patients greater than 18 years of age
with a mechanical heart valve admitted with significant bleeding during which anticoagulation was reversed
and/or warfarin was stopped was performed. The type of bleed and duration the patient was off anticoagulation
was determined. The primary outcome was the rate of clinical stroke and mortality within 30 days of stoppage
of anticoagulation.
Results: A total of 48 patients were identified met the inclusion criteria. The average age of patients was 61.6
with 27 males and 21 females. The average number of days off warfarin was 5.96 days and warfarin was
restarted within 3 days in most patients. The most common reasons for discontinuation of anticoagulation was
intracranial hemorrhage (subdural and subarachnoid hemorrhage) (12) and gastrointestinal bleeding (11). Of
these only, only 1 had a clinical ischemic stroke within 30 days.
Conclusion: Despite, reluctance to stop warfarin and reverse anticoagulation in patients with mechanical heart
valves with bleeding, our results suggests that a temporary discontinuation and reversal of anticoagulation
maybe safe for patients with life threatening bleeding.
10
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S10
Key Word(s): Internal Medicine, Cardiology, Cardiac/Cardiovascular Surgery, Basic Sciences,
Histology/Histopathology
Title: Arrhythmogenic Intercalated Disk Microdomain Identified in Human Cardiac Tissue
Authors: Matthew S. Yanoff, BS, Virginia Tech Carilion School of Medicine, [email protected];
Tristan B. Raisch, BS, Virginia Tech Carilion Research Institute; Steven Poelzing, PhD, Virginia Tech Carilion
Research Institute; William S. Arnold, MD, Virginia Tech Carilion School of Medicine; Soufian T.
AlMahameed, MD, Virginia Tech Carilion School of Medicine; Lisa J. Wilkerson, CCRP, Carilion Clinic;
Joseph W. Baker, MD, Virginia Tech Carilion School of Medicine; Mohammed A. Farooqui, MD, Virginia
Tech Carilion School of Medicine; Timothy R. Larsen, DO, Virginia Tech Carilion School of Medicine
* Student’s Mentor: Steven Poelzing, PhD, Virginia Tech Carilion Research Institute
Purpose: Atrial Fibrillation (AF) is the most common cardiac arrhythmia effecting 2.7-6.1 million people in the
US and is responsible for 15-20% of ischemic strokes. An intercalated disk microdomain, the perinexus, has
been shown to be a site of gap junction independent intercellular coupling. Expansion of the perinexus has been
shown to slow conduction velocity and increase the incidence of arrhythmia in animal models. It is not known
if the perinexus exists outside of animal models. The purpose of this study is to determine if the perinexus is a
conserved structure from animal to human cardiac tissue and if so, to characterize it. This is the first step to
understanding a potential novel factor influencing human arrhythmia.
Methods: Patients ages 18-75 undergoing non-emergent cardiac surgery at Carilion Roanoke Memorial
Hospital were enrolled in the study. Cardiac tissue from the right atrial appendage (RAA) or left atrial
appendage (LAA) was collected intraoperatively and fixed in 2.5% glutaraldehyde in phosphate buffered saline.
The perinexus was identified and photographed on TEM at 150,000x magnification. The width of the perinexus
was then measured at distances of 5-150nm from the gap junction. Mean width of the perinexus (Wp) of the
RAA and LAA was averaged over all samples.
Results: Atrial samples were collected and imaged. The perinexus has been identified in all samples. Wp in
RAA was 13.57±1.67 (n=20). Wp in LAA was 16.16±2.27 (n=10).
Conclusion: The identification of the perinexus in all samples confirms that this structure is conserved in human atrial
cardiac tissue. Whether the human atrial perinexus has a mechanistic role in AF is still unknown. Further studies are
needed to test if this newly discovered human intercalated disk microdomain correlates with arrhythmogenic versus nonarrythmogenic atrial myocardium.
11
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S18
Key Word(s): Patient Monitoring, Hospital Acquired Conditions, Trauma
Title: Survival after Discharge: Hospital Acquired Infections Increase Post Discharge Mortality
Authors: Nitasha Dhiman, Medical Student, Virginia Tech Carilion School of Medicine ,
[email protected]; Daniel Lollar, MD, Virginia Tech Carilion School of Medicine / Carilion Roanoke
Memorial Hospital; Ram Rimal, MS, Carilion Roanoke Memorial Hospital; Mark Hamill, MD, Virginia Tech
Carilion School of Medicine / Carilion Roanoke Memorial Hospital; Eric Bradburn, DO, Virginia Tech Carilion
School of Medicine / Carilion Roanoke Memorial Hospital
* Student’s Mentor: Bryan Collier, DO, Virginia Tech Carilion School of Medicine / Carilion Roanoke
Memorial Hospital
Purpose: Hospital acquired infections (HAI) in trauma patients are associated with increased inpatient
morbidity and mortality. The impact of a hospital infection on post discharge mortality is not well understood.
We hypothesized that trauma patients with HAI (pneumonia and UTI) are at higher risk for post discharge
mortality.
Methods: A retrospective trauma registry analysis of patients admitted to CRMH between 7/1/200812/31/2012 was performed. Patients included survived to discharge and were 18 years or older. Age, gender,
injury severity score (ISS), ventilator use, history of COPD, and HAI were reviewed. Name, SSN and date of
birth matched with National Death Index data from 2008-2013 identified outcomes of mortality after discharge,
and time/cause of death. Unadjusted logistic regression and adjusted multiple logistic regression were
performed.
Results: A total of 8275 patients met inclusion criteria, 65.4% were male and the median age was 47. Mean
ISS was 11±8.9. There were 917 patients (11.1%) that died after discharge. Approximately 4.8% of patients had
hospital acquired pneumonia (HAP), and 4.2% had a UTI; 83 patients (1.0%) had both complications.
Unadjusted odds ratio (OR) of mortality after discharge in patients with pneumonia and UTI were 1.77 [1.35,
2.31], p<0.001 and 2.44 [1.87, 3.17], p<0.001, respectively. After adjusting for patient age, gender, ISS,
ventilator use, and history of COPD (pneumonia patients only), odds for mortality after discharge for
pneumonia were (OR=1.57 [1.09, 2.23], p=0.013) and (OR=1.25 [0.93, 1.68], p=0.147) for UTI. Leading causes
of death after discharge in HAP patients were COPD (11.4%) and falls (7.1%).
Conclusion: Trauma patients with HAP are more likely to die after being discharged alive. Prevention
strategies including pulmonary toilet, early mobility, pain control and early extubation, must be a priority.
Unfortunately, patients who develop HAP may represent a state of debilitation that cannot be reversed. Further
HAI characterization and subsequent treatment strategies are needed.
12
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S46
Key Word(s): Alternative/Complementary Approaches, Orthopedics, Orthopedics Surgery, Neurosurgery
Title: Local Vertebral Autograft in ACDF: Technique Description and Cases
Authors: Conor N. O'Neill, BS, Virginia Tech Carilion School of Medicine, [email protected];
Caleb J. Behrend, MD, Carilion Clinic Orthopedics - Musculoskeletal Education and Research Center; Zakk J.
Walterscheid, BS, Virginia Tech Carilion School of Medicine
* Student’s Mentor: Jonathan J. Carmouche, MD, Carilion Clinic Orthopedics - Musculoskeletal Education
and Research Center
Purpose: To outline a novel technique for Anterior Cervical Discectomy with Fusion (ACDF) in which
autograft is procured from an adjacent cervical vertebrae, and to present a series of cases of patients who
successfully underwent this technique. This project served as a pilot for a prospective randomly designed trial
currently in progress with Carilion Clinic Orthopedics looking to compare three techniques for ACDF (gold
standard iliac crest bone graft, allograft, and novel technique).
Methods: Twelve consecutive patients with cervical radiculopathy or myelopathy underwent single-level or
double level ACDF using a core of autograft obtained from the inferior vertebral body adjacent to the operative
disk. This continuous column of graft was packed into a polyetheretherketone (PEEK) inter-body device and
supplemented with demineralized bone matrix (DBX) and fixed with an anterior plate. Patients were assessed
using Neck Disability Index (NDI) and Visual Analog Scale (VAS) pre- and post-operatively for neck and arm
pain, as well as function. Fusion was determined using CT when radiographs were inconclusive.
Results: The technique was successfully performed in each case and found to be safe and effective. There were
no complications. Specifically we observed no infection, no fracture and no implant subsidence. There were no
revision operations. There were no pseudoarthroses noted at clinical and radiographic follow-up. All patients
experienced significant reduction of radicular symptoms in both the arm (p=0.0038) and neck (p=0.0099) using
VAS scores, with corresponding radiographic evidence of fusion.
Conclusion: We demonstrate the safety and efficacy of this novel technique, which avoids the morbidity
associated with iliac crest graft procurement, while still maintaining similarly high fusion rate. We found no
cases of pseudoarthrosis. The fusion rate in this study compares favorably to published literature rates of fusion
using the gold standard iliac crest bone graft.
13
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S37
Key Word(s): Orthopedics, Orthopedics Surgery, Basic Sciences, Neurosurgery
Title: Anterior Cervical Discectomy With Fusion Using Vertebral Autograft: Biomechanical Analysis
Authors: Zakk J. Walterscheid, BS, Virginia Tech Carilion School of Medicine ,
[email protected]; Raffaella De Vita, PhD, Virginia Tech; Alex Ochs, Undergraduate, Virginia
Tech ; Christopher Drew, Undergraduate, Virginia Tech; Grace Ma, Undergraduate, Virginia Tech; Adrian
D'Averso, Undergraduate, Virginia Tech; Conor N. O'Neill, BS, Virginia Tech Carilion School of Medicine
* Student’s Mentor: Jonathan J. Carmouche, MD
Purpose: Our investigation analyzed the biomechanical implications of a novel anterior cervical discectomy
with fusion technique that uses autograft taken from the adjacent vertebral body by applying uniaxial
compression in order to compare yield strengths of surgically altered and unaltered specimens.
Methods: Biomechanical grade rigid polyurethane foam was cut into 12x17x20mm blocks. Cores in the shapes
of rectangular prisms (4x4x6mm) and cylinders (r=2mm, h=8mm) were removed from 20 blocks per group.
Twenty samples were left intact as a control. Anterior plate crews were set in the models and a standard PEEK
interbody spacer was placed on top. Samples underwent uniaxial compression at 0.1mm/s to the point of
mechanical failure. Yield points were determined using a 0.1% offset and were compared to determine the
reductions in compressive strength.
Results: The mean yield point for intact samples was 450.6N. Average yields for rectangular prisms and
cylindrical cores removed were 383.2N and 398.9N respectively. Removal of a rectangular prismatic core of the
necessary volume facilitated a 15.0% reduction in compressive strength while removal of a cylindrical core of
comparable volume facilitated a reduction of 11.5%.
Conclusion: Autograft from adjacent vertebrae reduces morbidity associated with a second surgical site while
minimally reducing the compressive strength of the donor vertebra. Our study helps validate the biomechanical
efficacy of the proposed ACDF technique. Future studies evaluating antero-posterior and lateral bending will
help further evaluate the procedure's biomechanical effects.
14
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F16
Key Word(s): Alternative/Complementary Approaches, Education, Interactive Patient Care, Hospital Acquired
Conditions, Infectious Diseases, Health Promotion/Wellness
Title: EDUCAiTE: Effectiveness in Decreasing Urinary Catheter Associated Infections Through Education
Authors: Anthony W. Baffoe-Bonnie, MD, Carilion Clinic, [email protected]; Zachary
Widner, GWN, Carilion Clinic; Danielle Nightingale, BSN, RN, Carilion Clinic; Jim Wong, MD, Carilion
Clinic
Purpose: Catheter associated urinary tract infections (CAUTIs) account for greater than 30% of hospital
acquired infections (HAIs) reported in the United States. Annually 13,000 deaths are attributable to this HAI.
Efforts at decreasing CAUTIs have not focused on engaging the patient. We hypothesize that supplementing
standard of care (SOC) patient education with a video through Get Well Network (GWN) will lead to increased
patient engagement, reduction in urinary catheter (UC) utilization and decreased CAUTI rates.
Methods: A 12 month baseline UC utilization and CAUTI rates will be obtained at the unit level from the
CRMH infection control database. Video education on the UC will then be introduced to a pre-selected number
of non-critical care units. A matching group of units will have video education withheld during the same period.
After six months a comparison of UC utilization and CAUTI rates will be made between units that had video
education to those that did not have video education. Each unit will also be compared to itself using pre and
post intervention data. Also sixty consecutively picked patients from intervention arm will be compared to
sixty matched patients from non-intervention arm and the mean duration of catheter use will be compared
between the two groups using Student t-test or Mann-Whitney U test and Poisson regression where applicable.
Results: (Study is ongoing). A 12 month pre-intervention UC utilization and CAUTI rates for the participating
non-critical care units will be available. At the time of the conference, a preliminary 3 month intervention
period data will also be available for initial comparison. Intervention period started from February 1, 2016.
Clinical characteristics of patients who utilize the UC video will also be available.
Conclusion: There is no published literature on patient video education in CAUTI prevention. This study fills
this knowledge gap.
15
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F9
Key Word(s): Process Improvement, Patient Experience, Trauma Surgery
Title: Implementing a Patient Call Back Program in the Trauma Population
Authors: Jennifer Bath, MSN, RN, AGCNS-BC, CEN, TCRN, Carilion Clinic Roanoke Memorial Hospital,
[email protected];
Purpose: The Trauma Call Back Program was created to improve patient outcomes post discharge. The
Trauma Clinical Nurse Specialist (CNS) was tasked with developing a program to insure patients understood
their discharge instructions. The literature supports that patient call backs directly affect patient satisfaction and
clinical outcomes; however, little is known about the impact of call backs in the trauma patient population.
Methods: Follow up phone calls are made by the Trauma CNS72-96 hours after discharge to home. The call
focuses on the patient's knowledge and compliance with discharge medications, follow up appointments, and
any other questions or concerns the patient may have. Patients are identified by date of birth and mechanism of
injury. Any trauma patient that is discharged to home from the inpatient setting is included.
Results: From June 2013 to August 2015 1337 calls were made, of which 56% were reached. A coded spread
sheet was kept of every call. Areas addressed the most were medication clarification and compliance (11.87%),
concussion education (6.87%), and clarification of follow up appointments (7.85%). Of the 55.6% of patients
reached, 44% required some form of action, and 12.5% had already been seen in clinic, the ED, or had been
readmitted.
Conclusion: Findings support that trauma patients discharged to home have the greatest risks related to
confusion regarding medication clarification, concussion-related symptom management, and timing of follow
up appointments. Improved patient understanding of discharge medications was shown by improvement in
Hospital Consumer Assessment of Healthcare Providers and Systems score for discharge information as
evidenced by achieving benchmark in 6/10 quarters and the 75% percentile for 1/10 quarters. The
overwhelming response from the patients called and the number of issues found during the calls has shown that
this project needs to continue.
16
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F30
Key Word(s): Readmissions, Pulmonology, Hospital Acquired Conditions, Nursing, General Surgery
Title: Preventing Post-operative Pneumonia-Effect of Toothbrushing and Chlorhexidine
Authors: Donna C. Bond, DNP, RN, CCNS, AE-C, CTTS, CRMH, [email protected]; Cindy W.
Hodges, BSHS, RN-BC, FCN, CRMH; Linda Brown, BSN, RN, CNOR, CRMH; Patricia Shorner, BSN, RN,
CRMH; Miaria Hirsch, MSN, RN, CRNA, CRMH; Donna Goyer, BS, RN, CPAN, CAPA, CRMH; Debbie
Copening, MSN, RN, CNOR, CRMH; Sandy Fogel, MD, CRMH
Purpose: The purpose of this project was to describe the effect of tooth-brushing and one dose of chlorhexidine
given in the immediate pre-operative area on post-operative pneumonia readmission rates. This was an IRB
determined performance improvement project. Pneumonia following surgery is estimated to occur in up to
eighteen percent of patients undergoing surgery and is associated with substantial mortality and morbidity. The
majority of pneumonia is bacterial in origin and develops from aspiration of bacteria from the oro-pharynex.
Chlorhexidine has been studied in the prevention of ventilator associated pneumonia. Three studies in the
cardiac surgery population have shown that routine oral care with chlorhexidine may decrease or eliminate
lower respiratory tract infection.
Methods: Starting September 20, 2013 patients in the Pre-anesthesia area (PAPA) brushed their teeth with
standard toothpaste and toothbrush followed with 30 second swish and spit of chlorhexidine. Patients were
monitored for admission for pneumonia for 30 days after the procedure.
Results: There were 48,187 surgeries during the study period with eight percent readmitted. One hundred and
thirty patients were identified as having pneumonia. Of the patients identified as having pneumonia, 51%
received chlorhexidine. Comparing the populations with a contingency table the statistical analysis showed
statistical significance with a p=0.007 that there was a decrease in admission for post-operative pneumonia by
using chlorhexidine prior to surgery.
Conclusion: These findings support expanding the use of tooth-brushing and chlorhexidine to prevent postoperative pneumonia.
17
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F15
Key Word(s): Physical Therapy, Critical Care, Trauma, Nursing, Respiratory Therapy, Exercise/Physical Activity
Title: PROGRESSIVE MOBILITY PROTOCOL REDUCES VTE RATE IN NEUROTRAUMA PATIENTS
Authors: Kathryn L. Booth, BSN, RN, CCRN, Carilion Clinic, [email protected]; Mark Hamill, MD,
Carilion Clinic; Douglas Hundley, RRT, Carilion Clinic; Ellen Harvey, DNP, RN, CCRN, Carilion Clinic;
Sandy Hubbard, BSN, RN, Carilion Clinic; Katie Holland, RRT, Carilion Clinic; Bryan Collier, MD, Carilion
Clinic; Flici Richelle, PT, Carilion Clinic; Joshua Rivet, MD, Carilion Clinic
Purpose: To determine the effects of a progressive mobility program in the Neuro Trauma Intensive Care Unit
(NTICU) as demonstrated in recent publications.
Methods: Utilizing the Define-Measure-Analyze-Improve-Control model for quality improvement, unit culture
transformed from " bedrest" to "move-it" for stable patients. Strategies used include identification and
elimination of barriers to mobility, implementation of a mobility algorithm, and patient/ family/staff mobility
education.
Results: In the pre-intervention cohort, physical therapy consults were placed 53% of the time. This rose to
>90% during the post-intervention period. Physical therapy consults seen within 24hrs rose from a baseline 23%
pre to 74-94% in the two highest compliance post-intervention months. On average 40% of patients were daily
determined to be too unstable for mobility per protocol guidelines- most often owing to elevated intracranial
pressures. There were no significant differences in clinical outcomes between the two cohorts regarding hospital
length of stay, intensive care length of stay, average ventilator days, mortality, falls, respiratory failure or
pneumonia overall or within ventilated patients specifically. There was a difference in the incidence of deep
vein thrombosis/ pulmonary embolism.
Conclusion: Progressive mobility is safe and effective for NTICU patients. While this protocol did not produce
the same results seen in other patient populations, there was statistical significant decrease for venous
thromboembolism rates.
18
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Qualitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F10
Key Word(s): Occupational Therapy, Health Promotion/Wellness, Pediatrics
Title: Occupational Therapists Addressing Sleep with Pediatric Clients
Authors: Jason Browning, MS, OTR/L, Jefferson College of Health Sciences - Occupational Therapy
Department , [email protected]; Ashley Mooney, OTS, Jefferson College of Health Sciences ; Renee
McLean , OTS, Jefferson College of Health Sciences; Nicolas Overby, OTS, Jefferson College of Health
Sciences
Purpose: The purpose of this research is to determine if occupational therapists (OTs) address the occupation of
sleep with their pediatric clients, and if so, which assessments and interventions are being utilized.
Methods: This study will be a descriptive, survey-based study consisting of 12 questions. The sample will
include OTs who are members of the American Occupational Therapy Association (AOTA) and who participate
in the AOTA Specific Interest Sections (SIS). Data from the survey will be analyzed using SPSS and Survey
Gold. The researchers will use the Maximum Likelihood-Chi-square test to analyze if there is a relationship
between OTs addressing sleep and categorical variables such as: region of practice, professional definition of
sleep, years, of practice as an OT, age of population treated, and level of education of the OT. The researchers
will be using logistic regression to analyze if years or region of practice are predictor qualities for addressing
sleep.
Results: Result Pending. The results of this study will be obtained by an online survey. There is anticipation of
10-200 surveys to be completed by OTs working with the pediatric population. The researchers expect to find a
small number of OTs who are addressing the occupation of sleep with their pediatric clients. In regards to which
assessments and interventions the OTs are using, the researchers expect to find a wide range of usage, with no
universal measure.
Conclusion: We anticipate that a small subset of pediatric OTs are addressing sleep in children, but we also
hypothesize that this is only a small set of the overall pediatric OT population.
19
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Qualitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F10
Key Word(s): Occupational Therapy, Health Promotion/Wellness, Pediatrics
Title: Occupational Therapists Addressing Sleep with Pediatric Clients
Authors: Jason Browning, MS, OTR/L, Jefferson College of Health Sciences - Occupational Therapy
Department , [email protected]; Ashley Mooney, OTS, Jefferson College of Health Sciences ; Renee
McLean , OTS, Jefferson College of Health Sciences; Nicolas Overby, OTS, Jefferson College of Health
Sciences
Purpose: The purpose of this research is to determine if occupational therapists (OTs) address the occupation of
sleep with their pediatric clients, and if so, which assessments and interventions are being utilized.
Methods: This study will be a descriptive, survey-based study consisting of 12 questions. The sample will
include OTs who are members of the American Occupational Therapy Association (AOTA) and who participate
in the AOTA Specific Interest Sections (SIS). Data from the survey will be analyzed using SPSS and Survey
Gold. The researchers will use the Maximum Likelihood-Chi-square test to analyze if there is a relationship
between OTs addressing sleep and categorical variables such as: region of practice, professional definition of
sleep, years, of practice as an OT, age of population treated, and level of education of the OT. The researchers
will be using logistic regression to analyze if years or region of practice are predictor qualities for addressing
sleep.
Results: Result Pending. The results of this study will be obtained by an online survey. There is anticipation of
10-200 surveys to be completed by OTs working with the pediatric population. The researchers expect to find a
small number of OTs who are addressing the occupation of sleep with their pediatric clients. In regards to which
assessments and interventions the OTs are using, the researchers expect to find a wide range of usage, with no
universal measure.
Conclusion: We anticipate that a small subset of pediatric OTs are addressing sleep in children, but we also
hypothesize that this is only a small set of the overall pediatric OT population.
20
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F31
Key Word(s): Basic Sciences, Biochemistry, Biology
Title: Evaluation of Differential Shortening of Telomere Length in Osteogenesis Imperfecta
Authors: Rick D. Carliss, Assistant Professor/Ph.D., Jefferson College of Health Sciences, [email protected];
Purpose: To assess whether a unique DNA regulatory pathway may be involved in determining the length of
chromosomal telomeres in Types I, II and IV Osteogenesis Imperfecta (OI).
Methods: DNA was extracted from fibroblast cells obtained from normal and OI individuals. DNA
concentrations were measured using a Picogreen assay. Quantitative polymerase chain reaction (PCR) was used
to measure telomere length (TL) in genomic DNA. DNA in fibroblasts from either Type I (mild) Type II
(perinatal lethal) or Type IV (mild to severe symptoms) individuals, was compared to DNA from normal
fibroblasts. Telomerase, an enzyme necessary for the replacement of telomere sequences, was examined using
the telomeric repeat amplification protocol (TRAP) assay. Finally, PCR was used to amplify the promoter and
transcription region of the telomerase RNA component (TERC) sequence, with the resulting products
sequenced and compared to NCBI reference standards.
Results: The most severe OI condition is the lethal Type II where the COL1A1 and COL1A2genes for collagen
are severely mutated. Our initial results with Type II OI indicates that TL is markedly shortened in Type II as
compared to normal, Type I and Type IV telomeres, and thereby could be associated with mutations of the
collagen genes. Telomerase was found to be functional by TRAP and no mutations were found in the TERC
transcriptome. Taken together, these results suggest a unique gene signaling pathway /novel regulatory
mechanism, intersecting telomeres and the collagen genes.
Conclusion: If telomeres and the collagen genes interact in development as these results suggest, then
telomeres may have a more complex role in cellular functions than to simply protect chromosome ends.
Rather, under certain pathological conditions, a functional gene-biochemical pathway may become established,
to mediate chromatin loops between telomeres and certain genes that would affect both gene expression and
telomere length.
21
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F36
Key Word(s): Health Psychology, Emergency Medicine, Radiology
Title: CT Cervical Spine Decisions in the NEXUS Negative Patient
Authors: Keel E. Coleman, D.O., VTCSOM, [email protected];
Purpose: The presence of spinal immobilization as an independent variable in the decision to employ computed
tomography has not been substantially investigated. This is an analysis of a retrospective cohort of patients
presenting with trauma of low-severity mechanism. These patients further met criteria for being clinically
cleared by the National Emergency X-Radiography Utilization Study (NEXUS) protocol. The study is designed
to test if the presence of spinal immobilization with cervical collar/back board is an independent indicator of
cervical spine imaging with CT.
Methods: The main outcome measure was the number of CT scans performed on those patients meeting
NEXUS criteria and what factors potentially impacted the decision to obtain a CT. The information collected
included age, a brief description of the mechanism of injury. Data were analyzed using linear regression
analysis to include age, gender, mechanism as well as the main outcome criteria of cervical spine CT imaging.
Results: 404 visits were analyzed with 107 cervical spine CTs performed. Spinal immobilization was present
in 61 (Table 1). Of immobilized patients, 80.3% had CT imaging, while 16.9% of the non-immobilized group
underwent CT. Controlling for age and gender, the presence of immobilization and mechanism of injury
significantly predicted (p < 0.05) whether a cervical spine CT was obtained. Immobilized patients were 18.6
times more likely to receive a cervical spine CT than those who were not immobilized, and patients in a motor
vehicle crash were 2.3 times more likely to receive a cervical spine CT compared to those who had sustained a
fall.
Chi square analysis was performed demonstrating a significant relationship between cervical spine
immobilization and the decision to obtain CT. =105.9778, p<.0001
Conclusion: In this study, patients with cervical spine immobilization were eighteen times more likely to
receive CT imaging than those not immobilized.
22
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F24
Key Word(s): Basic Sciences, Biochemistry, Diabetes, Nephrology
Title: Increased Adenosine Signaling Promotes a Profibrotic Phenotype in Renal Fibroblasts
Authors: Francis X. Farrell, PhD, Jefferson College of Health Sciences, [email protected]; Patrick Wilkinson,
MS, University of the Sciences in Philadelphia
Purpose: Renal fibrosis is a pathological manifestation of patients diagnosed with diabetic nephropathy (DN)
and chronic kidney disease (CKD). Adenosine is a key regulatory molecule involved in normal kidney
homeostasis. Chronically elevated levels of adenosine are associated with fibrosis of the skin, lung, liver and
kidney. In this study, we sought to determine if adenosine promotes fibrosis in the kidney by increasing
proinflammatory and profibrotic gene expression in an in vitro renal cell model.
Methods: The renal fibroblast cell line, NRK-49F was evaluated for the presence of the four G-protein-coupled
receptors for adenosine: A1, A2A, A2B and A3. Secondly, the functionality of the receptors was assessed by
pharmacological agonism/antagonism and the resultant modulation of the second messenger, cyclic AMP
(cAMP). Lastly, the transcript levels of several profibrotic and proinflammatory genes including alpha-smooth
muscle actin (aSMA) and connective tissue growth factor (CTGF) were measured by qRT/PCR.
Results: NRK-49F cells were shown to only express the A1 and A2B receptors as assessed by qRT/PCR.
When the A1 and A2B receptors were activated with receptor specific agonists, increased cAMP was observed
for A2B only. Subsequently, A2B agonism increased gene expression levels of aSMA, CTGF, IL-6, TGF-B
and fibronectin.
Conclusion: Both the A1 and A2B adenosine receptors were expressed and shown to be functional by
pharmacological investigation; however, only A2B receptor agonism lead to increased cAMP levels and
increased profibrotic gene expression. These studies suggest that therapeutic strategies directed toward
adenosine signaling may hold promise for CKD.
23
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F35
Key Word(s): Obesity, Implementation Science, Behavioral Science, Health Promotion/Wellness, Quality
Improvement/Quality Assurance
Title: Pragmatic trials to improve healthcare employee weight loss program
Authors: Sallie Beth Johnson, MPH, MCHES, Carilion Clinic, VT, JCHS, [email protected];
Fabio Almeida, PhD, University of Nebraska Medical Center; Paul Estabrooks, PhD, Carilion Clinic, University
of Nebraska Medical Center; Jenna Bartlett, MS, Carilion Clinic; Wayne Grey, BS, Carilion Clinic; Mark H.
Greenawald, MD, Carilion Clinic, VTCSOM; Xiaolu Hou, BS, VT; Don Mankie, RD, Carilion Clinic; Patrick
Dunham, MS, Carilion Clinic; Michele Hamilton, MS, Carilion Clinic; Nikki Kumar, BS, VTCSOM
Purpose: Obesity among healthcare employees threatens the patient experience, costs, and population health goals. Health
systems offer employee weight loss programs, but impact is questionable. This presentation reports on a series of
pragmatic trials to improve the effectiveness of a healthcare employee weight loss program (FITRx90). Integrating
evidence-based strategies was expected to increase clinically meaningful weight loss (3-5 percent initial body weight), but
feasibility and costs were unknown.
Methods: An integrated research-practice partnership involving obesity researchers, system administrators, and
inter-professional program delivery staff conducted four trials, 2013-2015. Healthcare employees with a BMI
greater or equal to 30 and physician referral were eligible. FITRx90-1.0 involved a randomized controlled trial
testing Standard vs. Choice of support strategies in a weight loss maintenance phase. FITRx90-2.0 involved a
quasi-experimental trial testing Standard vs. Plus behavioral strategies. FITRxCUSTOM was a feasibility trial
using financial incentives to engage a high-risk department, and FITRx90-3.0 was a validation trial testing the
intensity and suitability of a mobile exercise app. Trials were conducted under real-world conditions using
existing staff. The RE-AIM framework guided a mixed-methods evaluation. Percent initial body weight loss at
3-months was compared across iterations using intent to treat and present at follow-up analyses.
Results: During initial FITRx90 delivery, employees (90% female; mean age=46.4+/-9.8; mean BMI=38.4+/4.7; n=50) lost, on average, 2.9+/-3.3 percent of initial body weight. With subsequent trials, employees (n=143)
lost on average a significantly higher percentage of initial body weight (4.6+/-3.6 percent, p<.05). Retention
varied between 44-81%. Costs ranged from $119-319 per participant. The exercise app facilitated increasing
levels of intensity, but safety is a concern. Staff capacity and employee engagement are challenges.
Conclusion: A series of pragmatic trials using the integrated research-practice partnership approach is a valuable
mechanism for rapid quality improvement and real-world testing of evidence-based weight loss strategies.
24
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Mixed Methods
Abstract Type: Case Study
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F6
Key Word(s): Nursing, Patient Experience, Critical Care
Title: A Patient Focus Clears the Vision to Excellent Employee Engagement
Authors: Amanda L. Kidd, MSN,RN,CCRN,ACNPC-AG, Carilion Roanoke Memorial Hospital,
[email protected];
Purpose: To implement patient centered leadership methodology that will impact employee engagement. If
employee engagement scores are lower, staffs are less likely to be engaged in organizational initiatives capable
of positively impacting our community's health. A patient centered leadership approach can transform
engagement of frontline providers. Employee engagement has a direct relationship with quality outcomes and
patient satisfaction
Methods: Unit Director rounding was instituted, with a patient centered leadership methodology; the elements
of personal qualities, setting direction and delivering the service-attributes of this model, were implemented to
shift culture within a 12 bed Coronary Care Unit (CCU). In response to employee engagement ratings (19th
percentile), purposeful conversations occurred with staff to focus the unit culture on the patient. This
innovative approach to leadership promotes an engaging atmosphere through thoughtful conversations. The
Agency for Healthcare Research and Quality (AHRQ) employee engagement survey when comparing 2014 and
2015 demonstrated significant improvement.
Results: Engagement scores were in the 19th percentile for 2014, prior to implementation with the goal to
increase employee engagement scores. The director empowered her leadership team, in collaboration with the
department medical director to provide a patient focused approach, transforming unit culture and increasing
overall employee engagement to the 84th percentile. The 12 month improvement in employee engagement
scores is impressive, with statistically significant increases in supervisor/manager expectations and actions
promoting patient safety, communication openness, feedback and communication about errors, and frequency
of events reported. Concurrently, patient experience scores improved significantly across 5 of 8 domains. The
translation of these improvements financially to the organization was significant and will be presented.
Conclusion: This leadership model engages staff and maintains high patient satisfaction. This process is being
replicated by other unit leaders within the organization to impact outcomes.
25
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F29
Key Word(s): Infectious Diseases, Preventive Medicine, Health Promotion/Wellness
Title: Understanding and Improving Water Sanitation Practices in Malawi, Africa
Authors: Penelope A. Muelenaer, MD, MPH, Virginia Tech Carilion School of Medicine,
[email protected]; Susan W. Marmagas, MPH, Virginia Tech; Kerry J. Redican, MSPH, MPH,
PhD, Virginia Tech; Rochelle D. Holm, PhD, Mzuzu University, Malawi
Purpose: 1) Understand baseline practices and knowledge related to water supply, safety of drinking water, and
hygiene/sanitation. 2) Compare the efficacy and acceptance of three different point-of-use water purification
interventions.
Methods: A field study of 30 households was conducted in a periurban neighborhood of Mzuzu, Malawi.
Households were randomly assigned to one of three water purification interventions: boiling, chlorine solution,
or ceramic filter. Total coliform and E. coli counts were analyzed in 30 baseline and 30 follow up samples
taken from a drinking water storage container in each household. An initial structured questionnaire addressed
water sources, sanitation, health, consumption patterns, and socioeconomics of each household. Follow up
questionnaires, conducted after one and two weeks of the intervention, focused on use and acceptance of the
assigned treatment modality. Based upon WHO health risk standards, drinking water quality was correlated
with questionnaire responses. Data analysis utilized the Fisher's Exact Test.
Results: Of the households completing the study, 8/9 of filter (89%), 4/10 of chlorination (40%), and 5/9
assigned to boil (56%) achieved the no risk WHO standard. The remaining households in each of the filter
(11%) and chlorination (60%) groups met, while 1/9 of those that boiled (11%) water met the low risk standard.
Three/10 of the households that boiled water (30%) met criteria for high or very high risk. No statistical
differences were noted between the treatment methods (P=0.081), but there was a trend toward significance for
the ceramic filter. Questionnaire responses indicate that drinking water contamination may be related to
sanitation/hygiene practices. In order of acceptability by the study participants, filter>chlorination>boiling in
terms of treatment methods.
Conclusion: The results of this study can be used to develop educational programs that promote household
drinking water treatment, improved hygiene and sanitation practices.
26
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F18
Key Word(s): Quality Improvement/Quality Assurance, Education, Process Improvement
Title: TRAINING NEW RESIDENTS ON PATIENT HANDOFF PROCEDURES: A PILOT STUDY
Authors: David W. Musick, PhD, Carilion Clinic and VTC School of Medicine, [email protected];
Damon Kuehl, MD, Carilion Clinic; Robert Schopf, DPM, Carilion Clinic; Melanie Prusakowski, MD, Carilion
Clinic; Donald W. Kees, MD, Carilion Clinic; Tamela Morgan, RN, Carilion Clinic
Purpose: A sound process of transferring care between members of a healthcare team contributes to safer
patient care. We instituted a workshop on patient handoffs for all incoming first-year residents and new fellows
at Carilion Clinic. The purpose of the study was 1) to gain residents' feedback on workshop effectiveness; and
2) to determine whether residents' confidence level in transferring care was impacted over the course of the
internship year.
Methods: Incoming residents and fellows (N=88) participated in a three hour workshop consisting of didactic
lecture, video presentations, case-based exercises featuring the I-PASS system, and large group "report back" on
lessons learned. On the day of training, residents completed two surveys: a twelve-item pre-workshop survey
concerning knowledge and confidence regarding patient transfer protocols; and a seven-item feedback survey
about training effectiveness. The twelve-item survey was subsequently administered to residents twice during
the internship year to assess retention of training. Item means were compared based on pre-workshop and
follow up surveys using T-test procedures (p=.05).
Results: Fifty percent of residents reported receiving prior training on handoffs. Ninety-eight percent of
residents agreed/strongly agreed that training was useful. Useable pre-workshop surveys were completed by 73
of 88 residents (83%); post-workshop surveys by 28 of 73 residents (35%). Item means were significantly
higher at time of follow up surveys for ten of twelve survey items. The I-PASS mnemonic was attached to all
residents' identification badges as a reminder of the standardized handoff protocol.
Conclusion: The workshop is now a permanent part of our resident orientation each year. Improving the
handoff process has been incorporated as a metric on our teaching hospital scorecard system for nursing,
resident physicians and medical staff. These efforts may be easily duplicated at other GME sponsoring
institutions.
27
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F19
Key Word(s): Quality Improvement/Quality Assurance, Process Improvement, Education
Title: DEFINING THE MEDICAL SCHOOL LEARNING ENVIRONMENT: AN EXPLORATORY
SURVEY
Authors: David W. Musick, PhD, Carilion Clinic and VTC School of Medicine, [email protected];
Aubrey L. Knight, MD, Carilion Clinic and VTC School of Medicine; Richard C. Vari, PhD, VTC School of
Medicine; Daniel P. Harrington, MD, Carilion Clinic and VTC School of Medicine; Tracey M. Criss, MD,
Carilion Clinic and VTC School of Medicine; Felicity A. Adams-Vanke, MD, Carilion Clinic; Cheryl
Valentine, MBA, VTC School of Medicine
Purpose: A learning environment (LE) can be defined as the physical, social, and psychological context for
learning. To help address LCME expectations a 33-item survey assessed the perceptions of stakeholders of the
Virginia Tech Carilion School of Medicine regarding the current state of the LE at a new medical school.
Methods: The survey instrument was developed by a group of individuals from the administrative staff and
leadership team. Medical students, faculty, administrative staff, residents and nurses participated in the survey
over two consecutive academic years. Respondents were asked to rate aspects of the LE using a six-point scale
frequency scale (never, rarely, sometimes, often, very often, unable to rate/NA). Several yes/no questions were
included in the survey to measure participants' awareness of policies and procedures related to mistreatment,
harassment and disciplinary action. An open comment box was also included.
Results: Response rates differed by group surveyed, and ranged from 88% (medical students) to 38% (faculty).
Medical students and residents reported a high awareness of mistreatment policies and rated the professionalism
of faculty positively, but gave lower ratings for receiving feedback, education on cultural biases and
interprofessional experiences. Faculty, residents and nurses rated students negatively regarding seeking
feedback and were concerned about negative team dynamics in the clinical setting. Prominent themes across all
respondents related to work/life balance, competition between groups and health disparities. Comments were
rich in support of the themes identified.
Conclusion: Assessment of a variety of stakeholder groups concerning the LE yielded important group
differences and valuable results. Further work via focus groups is planned to explore these issues in-depth. It is
important to supplement other data sources on the LE (e.g., AAMC graduation questionnaire) with local
surveys, in order to understand nuances regarding perceptions of the LE by various groups.
28
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F34
Key Word(s): Quality Improvement/Quality Assurance, Measurement, Nursing, Process Improvement, Health
Economics, Education
Title: Pyxis Supply Waste Reduction and Donation
Authors: Temple M. Newbold, MSN, RN, Carilion Clinic, [email protected]; Sara E. Wohlford,
MPH, RN, Carilion Clinic
Purpose: To reduce waste of unused, sealed Pyxis supplies caused by chronic overstocking and current room
cleaning process at patient discharge/transfer; and to evaluate a collection and measurement procedure for longterm waste reduction.
Methods: A two-month pilot study was conducted on four nursing units (10 South Palliative, 5 West, 7 East,
and NICU). Unused, sealed Pyxis supplies that are normally thrown away at patient discharge/transfer were
collected in bins by nursing staff, later inventoried and cost analyzed. The data was used to estimate the annual
weight and cost of unused, sealed Pyxis supplies that are currently in the waste stream at Roanoke Memorial
Hospital.
Results: For one month the four units collected 123.1 pounds of unused, sealed Pyxis supplies from patient
rooms after discharge/transfer. Our preliminary results estimate that the annual weight of the wasted supplies is
14,447 pounds (Over 7 tons). The estimated annual cost of these supplies is $196,000. During the pilot project
there was also noted a decrease over time in the waste collected in the bins. This suggests that increasing
awareness about Pyxis supply waste can stimulate process changes to reduce overstocking.
Conclusion: There is a measurable and significant value to furthering this cost-containment project. There is
also evidence to suggest that education and awareness can influence reduction in the amount of wasted supplies.
29
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Translational
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F11
Key Word(s): Microbiology, Gastroenterology, Immunology
Title: Microbiome profiling in Crohn's Disease patients and first degree relatives
Authors: Dario R. Sorrentino, MD, IBD Center, Division of Gastroenterology, Virginia Tech Carilion School
of Medicine, Roanoke VA, [email protected]; Anna Kuballa, PhD, Inflammation Research
Cluster, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast - Queensland,
Australia
Purpose: Differences in flora composition have been reported in Crohn's Disease [CD] patients and first degree
relatives [FDR] compared to healthy controls [HC]. It is unclear whether these findings represent causes or
consequences of CD. We have recently shown that asymptomatic FDR include normal individuals (~60%)
frank CD (~ 10%) and minimal inflammation (~30%) - a non-evolving phenotype intermediate between that of
normal and affected FDR (Inflamm Bowel Dis. 2014;20:1049). However, in microbiome studies FDR have
always been treated as a homogenous population.
Methods: For microbiome analysis we used next generation sequencing 16S using DNA from intestinal
biopsies of HC (n=18), CD patients (n=24) and asymptomatic FDR (n=19; normal: n=10; intermediate: n=5;
frank CD-FDR: n=4). Data were analysed using Illumina CASAVA pipeline v.1.8.2.
Results: A decreased proportion of Rothia mucilaginosa, Bifidobacterium, Parabacteroides, Rikenellaceae,
Gemellaceae, Streptococcus, Haemophilus parainfluenzae, and Akkermansia muciniphila was observed from
HC to FDR to CD patients. Conversely, an increased proportion of Bacteroides fragilis, Clostridium,
Ruminococcus and Alphaproteobacteria was observed across the same groups. Further analysis of the FDR
showed a decrease of Parabacteroides sp and members of the order Clostridiales from normal to intermediate to
frank CD-FDR phenotypes. Additionally, specific bacteria - Bacteroidales members, Turicibacter sp, Dialister
sp, Phascolarctobacterium sp, Bilophila sp, Desulfovibrio sp, and Enterobacteriaceae - were found in normal
FDR but not in the intermediate or frank CD-FDR phenotype. There were no differences between CD patients
and CD-FDR.
Conclusion: Microbial profiling differs among HC, FDR and CD patients. Within FDR each phenotype bears
different species abundance and specific bacterial species. Hence, treating the FDR as a homogenous
population overlooks distinctive signature profiles. Characterization of the intermediate, non-evolving FDR
might answer the question whether the microbiome plays a role in CD development.
30
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Translational
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F20
Key Word(s): Education, Psychology, Psychiatry, Alternative/Complementary Approaches, Implementation Science,
Trauma
Title: Training to disseminate trauma-focused cognitive behavioral therapy (TFCBT) into practice
Authors: J. Eric Vance, M.D., Associate Professor in Psychiatry, Carilion Clinic, VTCSOM,
[email protected]; Joseph Iskandar, D.O., Carilion Clinic Child and Adolescent Fellowship
Purpose: To examine the efficacy of training approaches to integrate TFCBT techniques into the psychotherapy
practice of clinicians treating traumatized youths in the community.
Methods: A group of community-based psychotherapists were trained in TFCBT using a live training, a
training DVD, monthly clinical supervision (MCS), and/or on-line training from the National Child Traumatic
Stress Network. Two years later, an email survey was sent to all trainee-clinicians to ascertain whether, and how
completely, they had integrated TFCBT techniques into their clinical practice as a result of the training.
Outcomes of interest included: the clinician's perceived effect of the TFCBT training on their practice; their
confidence in their ability to use TFCBT techniques; their completion of cases using TFCBT; their use of
specific TFCBT techniques in conducting psychotherapy; and the relationship of the outcomes of interest to the
number and types of training completed. Data analysis involved the collection of qualitative information from
the surveys, generation of frequencies, and the creation of a scatterplot of positive outcomes versus number of
training types completed.
Results: Sixty-one clinicians were surveyed, 21 responded, 18 of these had conducted psychotherapy with
traumatized children since the trainings, 72% reported significant influence of TFCBT training on their therapy
approach, and 28% felt "very confident" in their abilities. Partial cases of TFCBT had been completed by 67%,
and 33% had completed full TFCBT cases. Only 2 trainees regularly used the trauma narrative technique, and
over half frequently used conjoint therapy in their practice of TFCBT. A scatterplot of respondents suggested a
positive association between positive outcomes and number of training types completed.
Conclusion: Dissemination of TFCBT as an evidence-based form of psychotherapy for traumatized youths is
difficult, and seems to require engaging trainee-clinicians in multiple types of training and supervision in order
to achieve full integration into their clinical practice.
31
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Qualitative
Abstract Type: Work in Progress
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?No
Abstract: F14
Key Word(s): Education, Process Improvement, Quality Improvement/Quality Assurance
Title: Building an Interprofessional Teaching Academy for Learner-Centered Excellence
Authors: Shari A. Whicker, EdD, MEd, Carilion Clinic, Virginia Tech Carilion School of Medicine,
[email protected]; Sandra Dehart, ., Carilion Clinic; David W. Musick, PhD, Carilion Clinic,
Virginia Tech Carilion School of Medicine; Elizabeth Pline, LCSW, Carilion Clinic, Virginia Tech Carilion
School of Medicine
Purpose: As is true in most higher education fields, the future success of academic medicine relies heavily on
the recruitment, development, and retention of faculty.1,4 However, faculty often do not feel supported in their
roles as teachers.2,3 While clinicians may be comfortable within their clinical specialty "homes" (e.g. surgery,
pediatrics, nursing, physician assisting) and participate in faculty development activities related to their given
specialty, many lack similar home bases to foster their development related to teaching. It is clear that the
clinical contexts throughout health professions education will vary. However, health professions faculty share
the common need to educate future professionals and the pedagogical practices are consistent.
Methods: At Carilion Clinic, Virginia Tech Carilion School of Medicine, and Jefferson College of Health
Sciences, we have developed a "for the faculty, by the faculty" academy focused on learner-centered teaching
excellence via the development of our faculty's skills as teachers, learners, and education researchers. TEACH
(Teaching Excellence Academy for Collaborative Healthcare) is administratively led by a Director and
administrative staff. However, the development of the Academy is facilitated through an active faculty steering
committee comprised of representatives throughout each profession and their primary related disciplines.
Results: TEACH offers 3 levels of membership, with increased benefits and responsibilities at levels 2 and 3.
Academy benefits are developed and fostered within subcommittees focused on specific topics related to our
mission. Each steering committee member also leads and/or participates on at least one of TEACH's
subcommittees which include: Education Research, Faculty Development, Journal Club, Membership,
Mentoring, Recognition, Teaching Observations, and Technology&Innovation. Each subcommittee actively
works toward fulfilling TEACH's mission on a continuous basis.
Conclusion: TEACH model brings together a community of faculty from different professions and disciplines
to develop and support one another in their roles as teachers in a variety of ways.
32
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Faculty/Professional
Consider for Rapid Communication Presentation?Yes
Abstract: F4
Key Word(s): Nursing, Behavioral Science, Palliative Medicine/Hospice
Title: Nurse Practitioners' Perspectives on Patient Preferences About Serious Illness Instrument
Authors: Phyllis Whitehead, PhD, APRN, ACHPN, RN-BC, Carilion Clinic, [email protected];
Samantha Harden, PhD, Virgnia Tech; Katie Katz, DNP, RN, FNP, Radford University; Kimberly Carter, PhD,
RN, Carilion Clinic; Nithya Ramalingam, BS, Virginia Tech
Purpose: The purpose of this mixed-methods study was to understand nurse practitioners' (NPs) perspectives
on available training and tools for engaging in end-of-life (EOL) conversations as well as their opinions on the
Patient Preferences About Serious Illness (PASI ) instrument.
Methods: Through a sequential exploratory design nurse practitioners (NPs) registered for an annual
conference were invited to participate in an online survey to explore their readiness to engage in EOL
conversations with their patients. Survey respondents were invited to elaborate on the same line of questions via
a focus group. Focus groups included open-ended questions and prompts to encourage participants to discuss
their experiences with EOL care: 1. current practices regarding EOL conversations and 2. perceptions of the
PASI Tool.
Results: Forty-seven NPs completed the online survey, and 13 NPs participated in one of the two focus groups.
The focus group participants rated their health status as very good (62%). They reported higher rates of having a
personal advance directive (62%) and having EOL conversations with their seriously ill patients (92%). The
focus groups participants reported a 23% level of comfort with having dialogues with seriously ill, adult
patients about their EOL preferences. Participants reported a lack of sufficient training to conduct EOL
conversations and found PASI to be useful.
Conclusion: The lack of formal EOL education and conversation barriers experienced by NPs in this study
support the potential contribution for the use of PASI for this group of providers. More study with other care
providers is important to build on the understanding of serious illness conversations. The PASI is a promising
tool that can assist in normalizing EOL conversations and eliciting patients' preferences. More research is
needed to determine its usefulness and feasibility in multiple settings and patient populations.
33
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R30
Key Word(s): Gynecology, Endocrinology, Fertility, Obstetrics, Genitourinary
Title: Uterine Sparing Treatment of Placenta Accreta: Case Report /Literature Review.
Authors: Patricia Beauzile, MD, VTC SOM OBGYN Residency , [email protected]; Emily EvansHoeker, MD, Infertility & Reproductive Endocrinology; Tiffany Tonismae, MD, VTC SOM OBGYN
Residency
Purpose: The purpose of this case report is to present a patient with delayed postpartum diagnosis of placenta
accreta referred to reproductive endocrinology given her desire for future fertility. Placenta accreta is a
condition that is typically diagnosed in the antepartum period and is frequently treated by a planned cesarean
section followed immediately by a hysterectomy. In this case, the patient was treated via hysteroscopic
resection of the intra-cavitary portion of the placenta accreta, with the intramural portion left in-situ. Her
bleeding resolved after the procedure and she resumed normal periods approximately 5 weeks postoperatively.
This case report and literature review presents an alternative treatment for patients who desire future fertility
after diagnosis of an accreta.
Methods: Case report and Literature review
Results: The patient treated via hysteroscopic resection of the intracavitary portion of the placenta accreta, with
the intramural portion left in-situ. The patients bleeding resolved after the procedure and she resumed normal
periods approximately 5 weeks postoperatively.
Conclusion: Our experience suggests that hysteroscopic resection may provide a satisfactory outcome in
women with abnormal placentation desiring uterine sparing treatment.
34
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R49
Key Word(s): Microbiology, Infectious Diseases, Quality Improvement/Quality Assurance
Title: Outcomes of Staphylococcus aureus bacteremia with and without ID consultation.
Authors: Josh Beavers, Pharm D, Carilion Clinic, [email protected]; Nathan Everson, PharmD,
Carilion Clinic; Cody Swindall, PharmD, Carilion Clinic; Marissa G. Williams, Pharm D, BCPS, Carilion
Clinic
Purpose: Staphylococcus aureus bacteremia (SAB) is a leading cause of mortality in the United States and is
associated with increased LOS, higher total treatment cost compared to other bacterial pathogens. The purpose
of this study is to describe the differences in treatment, mortality and adherence to quality measures of between
patients who have received and Infectious Disease (ID) consult to those who did not.
Methods: Data was collected for inpatients at CRMH with one or more positive blood cultures for
Staphylococcus aureus between 2009 and 2014 and randomly selected. Patients were excluded if less than 18
years of age, had polymicrobial blood cultures or if they died, transferred, left against medical advice or were
deemed palliative/comfort care within two days of blood culture collection. Data collected included patient
demographics, comorbidities, APACHE II score, vitals, culture data including MIC data for vancomycin,
antimicrobial data, planned treatment duration, mortality, labs, ID consultation, and adverse drug reactions.
Data will be analyzed to compare patients who received an infectious disease consult to those who did not. In
order achieve 80% power to detect a 15% difference in 60 day mortality between patients who received and ID
consult and those that did not data from 134 patients in each group will be need to be collected.
Results: The primary outcome of the study is mortality at 60 days from first positive culture in patients
receiving an ID consult compared to patients not receiving an ID consult. Secondary outcomes include percent
of patients receiving optimal therapy according to current guidelines, proportion of patients experiencing
adverse drug events, prevalence of complications from SAB and determine differences in quality measures
between patients receiving or not receiving ID consult and time to ID consultation.
Conclusion: Conclusions will be presented at Carilion Research Day after data analysis is completed.
35
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R36
Key Word(s): Internal Medicine, Cardiology, Cardiac/Cardiovascular Surgery, Quality Improvement/Quality Assurance,
Process Improvement
Title: Evaluation of pharmacist-directed versus physician-managed warfarin therapy in hospitalized patients
Authors: Anne Carrington , PharmD, Carilion Roanoke Memorial Hospital, [email protected]; Hannah
Troester, PharmD, BCPS, Carilion Roanoke Memorial Hospital; Charlene Blubaugh, PharmD, BCPS, Carilion Roanoke
Memorial Hospital; Jennifer Wright, PharmD, BCPS, Carilion Roanoke Memorial Hospital
Purpose: To examine the effectiveness of an inpatient, pharmacist-driven Warfarin Dosing and Monitoring Protocol
Methods: A single-center, retrospective, matched cohort study was conducted in patients initiated on warfarin
therapy during hospitalization at Carilion Roanoke Memorial Hospital (CRMH). One physician-managed
warfarin patient (control group) was matched to one patient receiving pharmacist-directed therapy (intervention
group) based on the international normalized ratio (INR) goal. Patients were included if they were at least 18
years old, admitted to CRMH between August 2012 and August 2015, and received more than one dose of
warfarin to achieve a therapeutic INR prior to hospital discharge. Patients who refused any dose of warfarin
during admission or who were on warfarin in the previous 30 days prior to admission were excluded. The
primary endpoint was the time to sustained therapeutic INR (INR within target range for >/= 48 hours) between
a pharmacist-driven warfarin protocol and physician-guided warfarin dosing. Secondary endpoints included
INR on the day of discharge, number of days with a sub- or supratherapeutic INR, and the percentage of time at
therapeutic INR between the two groups. This study also assessed major drug-drug interactions, VTE-3
guideline compliance and incidence of adverse drug events. Assuming that the minimum amount of time to
reach a therapeutic INR is 48 hours and the maximum amount of time is 288 hours, a total of 140 patients (70 in
each group) is needed to achieve a standard deviation of 50 hours. The primary endpoint will be evaluated using
a student's t-test with a p-value of less than 0.05 to be deemed significant.
Results: Data collection is in process and analysis is expected to be completed before Research Day.
Conclusion: To be determined.
36
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R27
Key Word(s): Process Improvement, Internal Medicine, Quality Improvement/Quality Assurance
Title: Phytonadione utilization and prescribing patterns at Carilion Roanoke Memorial Hospital
Authors: Anne Carrington, PharmD, Carilion Roanoke Memorial Hospital, [email protected];
Rachel Warren, PharmD, Carilion Roanoke Memorial Hospital; Meghan Kamrada, PharmD, BCPS, Carilion
Roanoke Memorial Hospital
Purpose: To improve appropriate use of phytonadione at Carilion Roanoke Memorial Hospital (CRMH)
Methods: This medication use evaluation was a retrospective analysis of adult patients who had an inpatient
order from July 2014 to July 2015 for phytonadione. Patient baseline characteristics, medical complications and
clinical outcomes were evaluated. Specific clinical assessments included indication for phytonadione use, route
of administration, number of administrations and cumulative dose, administration to patients with
contraindications, death prior to discharge, need for re-bridging, time to therapeutic INR if anticoagulation was
resumed, and indication for warfarin therapy. Determination of appropriate was based on criteria from current
literature and FDA-approved indications. Descriptive statistics were used to analyze the cohort of patients.
Results: 200 patient charts were evaluated with 111 (55.5%) males and 89 (44.5%) females. The average age
was 67.7 years and the average INR at time of administration of phytonadione was 3.3.The majority of patients
(61%) were on an anticoagulant with 110 (55%) taking warfarin. Phytonadione was used appropriately in 129
(64.5%) patients. Of the 71 patients where phytonadione use was deemed inappropriate, the leading indication
was an elevated INR without bleeding (38%). Another major deviation involved the use of phytonadione in 34
out of 71 patients (48%) who had no documented coagulopathies and were not on any anticoagulant. Warfarin
was restarted in 31% of patients and 32% of those restarted were discharged before reaching therapeutic INR
values.
Conclusion: Phytonadione was utilized appropriately for the majority of patients evaluated. Phytonadione
orders that deviated from guideline recommendations were mostly when the INR was elevated but less than 10
with no signs of bleeding. Based on our results, recommendations were made to the CRMH Pharmacy and
Therapeutics Committee to include order instructions with the PCC order set and all phytonadione orders
indicating when phytonadione should be used.
37
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R19
Key Word(s): Health Economics, Critical Care, Physical Therapy
Title: Moving Forward: Progressive Mobility in Medical Intensive Care Units
Authors: Mary Carter, MD, Carilion Virginia Tech School of Medicine, Pulmonary Critical Care Fellowship,
[email protected]; Mahtab Foroozesh, MD, Carilion Virginia Tech School of Medicine
Purpose: Immobility and bed rest in critically ill patients have been associated with worse outcomes including
decreased functional status, increased mortality, an increase in ventilator and intensive care unit (ICU) days, and
lengthier hospitalizations. Research has shown that physical therapy (PT) can be safely provided in the ICU.
Benefits include shorter delirium duration and overall decreased health care costs. However, progressive
mobility in the ICU is not routinely performed. Barriers for its implementation include human and material
resources. We performed a Quality Improvement study, implementing a multidisciplinary approach that
included getting a dedicated physical therapist assigned to our 12 bed ICU for 4 hours daily, providing
education to staff, implementing a mobility algorithm, and daily assessments of patients for early mobilization.
Methods: We performed a pre/post comparative design study, where data was collected 30 days pre and postintervention. The intervention was staff education and implementation of PT eligibility screening program
daily. Data collected included hospital length of stay, ICU length of stay, ventilator days, and days seen by
physical therapist.
Results: There were 20 patients in the pre-intervention group and 24 patients in the post-intervention group.
There were significantly more days working with physical therapy in the post-intervention group (2.8 vs 0.6
days, p= 0.013). There was no significant change in intensive care length of stay or ventilator free days. There
was a decrease in duration of hospitalization in the post-intervention group (36.8 vs 20.3 days), though this was
not statistically significant (p=0.07).
Conclusion: Our study does show that progressive mobility initiative can be associated with better outcomes,
such as decreased hospital length of stay and endeavors towards earlier mobilization of critically ill patients
without compromising safety. The lack of statistical significance is probably secondary to our small patient
population, but warrants further investigation.
38
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R17
Key Word(s): Critical Care, Hematology, Infectious Diseases
Title: Increased Venothromboembolism Risk in H1N1 Patients
Authors: Mary C. Carter, MD, Virginia Tech Carilion School of Medicine, [email protected];
Mahtab Foroozesh, MD, Virginia Tech Carilion School of Medicine; Umar Sofi, MD, Virginia Tech Carilion
School of Medicine
Purpose: In 2009 the world saw the first influenza A pandemic since 1918. Both of these outbreaks were
secondary to the virus subtype H1N1. Following the 2009 pandemic, multiple case reports and retrospective
studies suggested that H1N1 infection was associated with a hypercoaguable state and increased incidence of
pulmonary thromboemboli. It was apparent in our institution during the fall and winter of 2013 that there was
an association between H1N1 infection and VTE. To our knowledge, there is no study looking at H1N1
infection and the incidence of VTE in the years following the pandemic of 2009. This retrospective study was
designed to determine the incidence and associated risk factors for VTE among patients admitted to the hospital
with H1N1 from October 2009 to February 2014.
Methods: A retrospective chart review was performed of 138 patients admitted to the hospital between October
2009 and February 2014 with H1N1 infection. Their diagnosis was confirmed by H1N1 polymerase chain
reaction. We collected data including patient demographics, hospital length of stay, and mortality to see if there
were any characteristic that were associated with an increase chance of VTE.
Results: Of the 138 patients with H1N1 a total of 18 (13%) had evidence of VTE, confirmed with
ultrasonography or chest computerized tomography (CT) angiography. The length of hospital stay was
significantly higher in patients with VTE (10.04 days vs 33.6 days, p< 0.001).
Conclusion: Our retrospective study demonstrated increased incidence of VTE (13%), when compared to the
rates previously described in critically ill patients (5-10%). Longer hospital course is associated with higher
chance of VTE in H1N1 patients. The role for therapeutic anticoagulation and additional risk factors needs to be
investigated with further prospective studies to examine the relationship between H1N1 and hypercoaguable
states.
39
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Mixed Methods
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R32
Key Word(s): Radiology, Gastroenterology, Infectious Diseases
Title: This Liver Abscess Seems Fishy
Authors: Lorne Dindial, MD, Carilion Clinic Internal Medicine Residency, [email protected];
Kasra Adham, MD, Carilion Clinic; Alan Brijbassie, MD, Carilion Clinic; Vishal M. Patel, MD, Carilion
Clinic; Celeste Pizza, MD, Carilion
Purpose: Ingestion of foreign bodies can have serious and lingering consequences that can include an atypical
presentation of a pyogenic liver abscess. We present the case of a pyogenic liver abscess secondary to an
ingested fish bone.
Methods: A 77-year-old female presents with a one week history of subjective fevers, confusion, and
abdominal pain. Laboratory tests revealed leukocytosis of 16.6 K/µL as well as elevated liver enzymes (AST151 IU/L, ALT-111 IU/L, Alkaline Phosphatase-137 IU/L, and Total bilirubin-2.2 mg/dL). Cross-sectional
imaging demonstrates a 7.2 cm x 6.4 cm complex cystic lesion located within the inferior medial segment of the
left liver lobe. She was initially commenced on empiric broad spectrum antibiotic therapy and underwent IR
guided pigtail drain placement. Cytology as well as Echinococcus and Entamoeba histolytica studies were
unremarkable. Interval cross-sectional imaging demonstrates worsening of the size of the abscess with blood
cultures being positive for Streptococcus anginosus; open surgical drainage was then effected for definite
management.
Results: Imaging obtained 2 months after her clinical presentation defines a 3 cm long needle-shaped radioopacity consistent with a fish bone extending from the prior hepatic abscess site into the wall of the gastric
antrum with retrospective review of prior imaging demonstrating similar findings (Figure 1).
Conclusion: This case illustrates the potential for infection after ingestion of penetrating foreign bodies such as
fish bones. Penetration from the gastric antrum into the liver is a rare occurrence with earlier recognition on
imaging with endoscopic and/or surgical removal potentially thwarting a lengthy hospitalization and prolonged
antibiotic course.
40
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R39
Key Word(s): Pharmacology, Measurement, Infectious Diseases
Title: Treatment Experience with Voriconazole During the 2012 Fungal Meningitis Outbreak
Authors: Sarah B. Green, PharmD, BCPS, Carilion Clinic, [email protected]; Nathan A. Everson,
PharmD, Carilion Clinic; Marissa G. Williams, PharmD, BCPS (AQ-ID), Carilion Clinic
Purpose: To examine the relationship between high-dose voriconazole pharmacokinetics and clinical outcomes
specific to the 2012 fungal infection outbreak population treated at Carilion Clinic.
Methods: This was a retrospective, single­center cohort study. All 35 patients with previous exposure to at
least 1 contaminated steroid injection who received treatment at Carilion Clinic were included in this study.
Variables such as type of infection, presence of complications (e.g. hardware, Cauda-Equina Syndrome),
Charlson Comorbidity Index (CCI) score, age, and body mass index (BMI) were incorporated into the analysis
to examine multicollinearity and interactions. Scattergraphs were used to illustrate the relationship between
voriconazole dose changes and corresponding change in voriconazole levels, as well as the relationship between
serum and CSF voriconazole concentrations. Adverse events were described using time-to-event data.
Results: The study population was comprised primarily of Caucasian females (54.3%) with a mean age of 64
years. Patients in this study had an extremely low rate of comorbidities as assessed by CCI score (mean 0.16 ±
0.05). On average, patient length of stay was 23.5 days during which time they received an average of 11 days
of intravenous voriconazole treatment. Overall, patients were treated for 102.5 +/- 11.1 days and 71.0% (n=22)
of patients met criteria for complete treatment response on voriconazole. The most common side effects
observed in this study were CNS toxicity (e.g. hallucinations or confusion), hepatotoxicity, alopecia, vision
changes, and rash. The average time to each adverse event was 16.2, 18.6, 68.8, 27.4, and 31.8 days,
respectively. The average voriconazole trough associated with an adverse event was 5.79 +/- 0.72 mcg/mL.
Conclusion: High dose voriconazole was efficacious in the treatment of fungal meningitis but high-therapeutic
troughs were associated with significant adverse events throughout prolonged treatment courses.
41
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R3
Key Word(s): Preventive Medicine, Cardiology, Cardiac/Cardiovascular Surgery, Genetics
Title: Novel Clinical Manifestation of Variant SCN5A Gene
Authors: Edward Ladyzhenskiy, PGY2 IM Resident, Carilion Clinic , [email protected];
Mohammed Farooqui , PGY3 Cardiology Fellow, Carilion Clinic; Soufian Almahameed, Electrophysiologist,
Carilion Clinic Cardiology EP Service
Purpose: Brugada syndrome is an autosomal dominant disease caused by loss of function mutation of sodium
channel gene (SCN5A). It is classically described as typical repolarization changes on resting electrocardiogram
(EKG) and poses an increased risk of sudden cardiac death (SCD) especially during sleep and syncope.
Exercise induced Brugada pattern EKG changes has been recently described. We describe a rare case of
exercise induced recurrent syncope secondary to Brugada syndrome.
Methods: An 18 year old male is evaluated on multiple hospital and office visits. He has history of recurrent
exertional syncopal episodes since age 14 and an insignificant prior medical history and family history of
syncope of unknown origin. Baseline EKG was obtained with suspicious Brugada pattern (type 2). Cardiac
imaging was also obtained with a negative result for structural heart disease and extended EKG monitoring was
unremarkable. To further evaluate for Brugada syndrome, he underwent an electrophysiology study with a
procainamide challenge. An exercise stress test was also obtained for assessment of possible arrhythmia.
Results: The repolarization findings on procainamide challenge were consistent with Type 1 Brugada pattern.
Exercise stress test induced sustained monomorphic ventricular tachycardia. Patient underwent single chamber
ICD placement for secondary prevention. Genetic testing was pursued which confirmed Brugada genotype and
revealed heterozygous variant of Brugada causing SCN5A gene (p.Arg282Cys(R282C). Multiple other family
members were also tested positive. Patient started on metoprolol and has no logged ventricular arrhythmias on
his ICD so far.
Conclusion: This case describes a novel manifestation of Brugada syndrome with exercise induced Brugada
EKG changes with exertional syncope and ventricular tachycardia. Genetic testing can be helpful to identify
Brugada syndrome in a suspected patient. Such testing can help guide decision of ICD placement for SCD
prevention.
42
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R4
Key Word(s): Cardiology, Cardiac/Cardiovascular Surgery, Patient Experience, Internal Medicine
Title: Predictors of Adverse Outcomes after High Voltage Cardiac Device Procedures
Authors: Timothy R. Larsen, DO, Virginia Tech Carilion School of Medicine, [email protected]; Carl W.
Musser, MD, Virginia Tech Carilion School of Medicine
Purpose: Implantable cardioverter-defibrillators (ICDs) are implanted for prevention of sudden cardiac death.
Cardiac resynchronization therapy (CRT) reduces mortality and hospitalizations in patients with systolic heart
failure and prolonged QRS duration (e.g. LBBB). We sought to identify characteristics that impact early death
and rehospitalization in patients undergoing ICD/CRT procedures.
Methods: We studied 356 consecutive patients presenting for ICD or CRT procedure. Patients were followed
for 30 days using the electronic record serving our 6 hospital system. Odds ratios for the composite of
hospitalization and death were calculated using univariate modeling.
Results: Adverse events occurred in 31 (8.7%) patients. There were 29 (8.1%) readmissions including 14
(3.9%) cardiac admissions and 6 (1.7%) deaths. General anesthesia was associated with increased risk of
readmission or death (HR 2.48 95% CI 1.17-5.26 p 0.017), inpatient procedure + general anesthesia had higher
risk (HR 5.49 95% CI 1.77-17.00 p 0.0031). Inpatient procedure alone showed a trend toward increased risk
(HR 2.45 95% CI 0.93-6.46 p 0.07).
Conclusion: Patients undergoing ICD/CRT procedures are at increased risk of 30 day death or
rehospitalization when performed as an inpatient particularly if general anesthesia is employed. Outcomes may
be improved if inpatients can be optimized, allowed time to recover and thereby return as outpatients for
ICD/CRT implant.
43
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R5
Key Word(s): Infectious Diseases, Internal Medicine, Cardiology, Cardiac/Cardiovascular Surgery
Title: Systemic Embolization from an Unusual Left Ventricular Intracardiac Mass
Authors: Timothy R. Larsen, DO, Virginia Tech Carilion School of Medicine, [email protected];
Purpose: A 33 year old female developed painful blisters on her right hand associated with generalized malaise,
nausea, vomiting, and fevers for two weeks. History was significant for intravenous heroin use, and
staphylococcus aureus left knee arthritis five months ago. Initial vital signs were blood pressure 144/71 mmHg,
pulse 107 beats/minute, respirations 20 breaths/min, temperature 98.1 Fahrenheit. Physical exam revealed
petechiae and blisters on the right hand, and tender nodules on the right forearm and right thigh. There was a 2/6
diastolic murmur at the left sternal boarder. Transthoracic echocardiogram showed normal LV size and
function, normal appearing aortic valve with moderate aortic regurgitation, there were no valvular vegetations
identified.
Methods: Transesophageal echocardiogram (TEE) confirmed moderate aortic regurgitation yet normal
appearing aortic valve. An 8 mm x 6 mm fixed mass with a 6 mm by 5 mm mobile component was identified
attached to the interventricular septum in the left ventricular outflow tract (LVOT).
Results: TEE confirmed aortic valve pathology and identified the source of systemic embolism which required
surgery to prevent further embolization. Surgery revealed a chronic well healed perforation of the noncoronary
cusp of the aortic valve. There was a mobile fleshy vegetation attached to the muscular portion of the
interventricular septum. Her aortic valve was replaced and the vegetation was excised by focal septal
myomectomy.
Conclusion: Presumably our patient had infective endocarditis with s. aureus 5 months prior when she was
treated for septic arthritis. This led to leaflet perforation. The regurgitant jet was directed toward the
interventricular septum causing endothelial damage, which served as a nidus for infection and allowed for
growth of a vegetation in the LVOT. The high flow rates in the LVOT put our patient at high risk for further
systemic embolization which prompted urgent surgical intervention.
44
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R11
Key Word(s): Cardiology, Cardiac/Cardiovascular Surgery, Biology, Internal Medicine
Title: Permanent His Bundle Pacing for Isolated Congenital Complete Atrioventricular Block
Authors: Timothy R. Larsen, DO, Virginia Tech Carilion School of Medicine, Department of Internal
Medicine, Section of Cardiology, [email protected]; Carl W. Musser, MD, Virginia Tech Carilion School
of Medicine, Department of Internal Medicine, Section of Cardiology; Terrence P. May, MD, Virginia Tech
Carilion School of Medicine, Department of Internal Medicine, Section of Cardiology; Alexander Vigh, DO,
Virginia Tech Carilion School of Medicine, Department of Internal Medicine, Section of Cardiology; Soufian
T. AlMahameed, MD, Virginia Tech Carilion School of Medicine, Department of Internal Medicine, Section of
Cardiology
Purpose: Permanent cardiac pacemaker is recommended for patients with congenital complete heart block who
are symptomatic. His Bundle pacing may prevent pacing induced cardiomyopathy. It is unknown whether
patients with congenital complete heart block have a bundle of His and whether it is functionally intact when
present
Methods: We attempted to electronically map the His bundle in a patient with isolated congenital complete
heart block. After demonstrating the presence of a functional His bundle we implanted a pacemaker lead and
successfully demonstrated the feasibility of His bundling pacing in congenital complete heart block.
Results: Our patient is a 35 year old male who presented with history of isolated congenital complete heart
block and syncope. Echocardiogram showed mildly dilated left ventricle with normal systolic function. We
performed an EP study and confirmed the presence of the bundle of His. Parahisian pacing using hexapolar
CRD-2 catheter was performed successfully. We concluded the His bundle was functionally intact and
proceeded with device implant for permanent HBP. A persistent left superior vena cava necessitated right sided
implant. After establishing vascular access, His Bundle mapping was accomplished with a 3830 Medtronic lead
and preformed His bundle sheath. His bundle recordings were obtained, pacing demonstrated parahisian
capture. The lead was fixed in place with adequate pacing and sensing parameters.
Conclusion: This is the first report to show the feasibility of permanent His bundle pacing in patients with
isolated complete congenital heart block. Such patients can have functionally normal His bundle and permanent
His Bundle pacing is feasible. Attempts for His Bundle pacing in this population may be warranted.
45
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R12
Key Word(s): Exercise/Physical Activity, Orthopedics, Orthopedics Surgery, Process Improvement
Title: Evaluation of First Metatarsophalangeal Arthrodesis Weight Bearing Protocols
Authors: Scott M. Martin, DPM, Carilion Clinic Podiatry Residency, [email protected]; Randy
Clements, DPM, Carilion Clinic
Purpose: To determine if early weight bearing protocol following a First Metatarsophalangeal (MTPJ)
Arthordesis results in decreased fusion rates when compared to fusion rates of conservative weight bearing
protocols in the literature
Methods: Fusion rates were compared between a single surgeon following first MTPJ arthrodesis between
07/2012 and 02/2015. The surgical technique was the same for all patients. The patients followed an early
weight bearing protocol postoperatively that consisted of immediate heel weight bearing in a wooden soled
postoperative shoe. Fusion rates, as well as time to fusion, were determined and compared to typical
postoperative results reported in the literature.
Results: A total of 14 patients underwent a 1st MTPJ arthrodesis with immediate weight bearing in a surgical
shoe postoperatively. All patients (14/14) went on to successful union however on patient did have a delayed
union with fusion at 26 weeks. The mean time to fusion was 8.2 weeks ranging from 4 weeks to 26 weeks.
There was one patient who had a surgical site infection that was resolved with oral antibiotics. No other
postoperative complications occurred.
Conclusion: All patients following an immediate weight bearing protocol when on to successful fusion with a
single delayed union. This study shows that allowing patient to weight bear in a surgical shoe postoperatively
does not affect union rates. Historically, 1st MTPJ Arthrodesis is known to have a nonunion rate around 6%.
Allowing patients to weight bearing postoperatively does not compromise surgical outcome, while avoiding the
risks and burdens of non-weight bearing restrictions on patients.
46
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R13
Key Word(s): Exercise/Physical Activity, Orthopedics, Orthopedics Surgery, Process Improvement
Title: Evaluation of First Tarsometatarsal Arthrodesis Weight Bearing Protocols
Authors: Scott M. Martin, DPM, Carilion Clinic Podiatry Residency, [email protected]; Jason V.
Naldo, DPM, Carilion Clinic; Randy Clements, DPM, Carilion Clinic
Purpose: To determine if early weight bearing protocol following a First Tarsometatarsal (TMT) Arthordesis
results in decreased fusion rates compared to conservative weight bearing protocols
Methods: Fusion rates were compared between two surgeons following first TMT arthrodesis between 07/2012
and 02/2015. The surgical technique for both surgeons is the same. Group A pateints followed a conservative
postoperative weight bearing protocol consisting of 6 weeks non-weight bearing immobilization followed by 4
weeks of protected weight bearing before returning to regular shoes. Group B patients followed a early weight
bearing protocol consisting of non-weight bearing immobilization for 2 weeks followed by protected heel
weight bearing with immobilization for 4 weeks followed by 4 weeks of full protected weight bearing before
returning to a regular shoe. The fusion rates, as well as time to fusion and postoperative complications were
recorded and compared between surgeons.
Results: A total number of patient is 24 underwent a 1st TMT Arthrodesis with 10 patients in Group A and 13
patients in Group B. Group A had 90% union rate with one nonunion that was successfully treated with a bone
stimulator. Group B had a 100% union rate with no delayed/non-unions. The average time to fusion was 9.6
weeks in Group A and 7 weeks in Group B. Group A had zero wound complications. Group B had 28.5%
wound complications consisting of dehiscence or infection.
Conclusion: The union rate for Group A was consistent with historical data that reports approximately 10-12%
nonunion rate. Group B had great results with a union rate of 100%. When compared to more conservative
weight bearing protocols, early weight bearing does not appear to compromise the osseous fusion rates.
47
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R51
Key Word(s): Cancer, Dermatology, Pathology/Lab Medicine
Title: Basal Cell Carcinoma with Vascular Invasion Treated with Postoperative Radiotherapy
Authors: Sean Mazloom, M.D., Virginia Tech-Carilion School of Medicine, Department of Dermatology,
[email protected]; Mariana Phillips, M.D., Carilion Clinic - Virginia Tech Carilion School of Medicine,
Department of Dermatology; Rahul Chavan, M.D., PhD, Carilion Clinic - Virginia Tech Carilion School of
Medicine, Department of Dermatology; Douglas Grider, M.D., Department of Pathology and
Dermatopathology, Virginia Tech-Carilion School of Medicine
Purpose: Although exceedingly rare, non-melanoma skin cancer can invade vascular structures, presenting
multiple challenges to Mohs surgeons. A case of intravascular basal cell carcinoma (IVBCC) was encountered
and reported to increase awareness.
Methods: A 61 year-old male was referred for Mohs excision of an infiltrative basal cell carcinoma on the
scalp vertex. Initial excision was aborted by the referring surgeon due to persisting positive margins. Preoperative examination revealed a 4.0 cm linear scar and no palpable lymphadenopathy. Frozen sections
revealed a BCC in the lumen of a medium sized artery and perineural invasion of BCC surrounding a medium
sized nerve. Excision required four Mohs stages, resulting in an 8.2 x 6.2cm defect. Post-operatively the
patient received 50 Gy of radiotherapy. One year post-operatively, no evidence of metastatic disease was
found on PET-CT.
Results: Few Mohs surgeons have encountered IVBCC in frozen sections and may be unsure how to manage
these patients. We report a patient with BCC showing extensive perineural and intravascular involvement.
Adjuvant radiotherapy was performed given tumor size and perineural and vascular invasion. Long term
follow-up is needed since the median time to distant metastasis can approach 9 years.
Conclusion: Intravascular BCC is rarely emphasized in the literature and likely under reported. One
publication reported five cases of metastatic BCC, two with intravascular invasion. Metastasis to lungs and
lymph nodes occurred in both cases approximately ten years after initial treatment. Another report details a
case of recurrent BCC with intra-arteriolar invasion that metastasized to the lungs and lymph nodes five years
postoperatively. Until further cases detailing clinical outcomes of patients with IVBCC are described, it may
be prudent for Mohs surgeons to consider close clinical follow up, serial imaging, and radiotherapy when
IVBCC is encountered.
48
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R15
Key Word(s): Quality Improvement/Quality Assurance, Psychiatry, Education
Title: Case Conference Preparatory Curriculum: A Six Step Approach
Authors: Ralph R. McKenzie, D.O., M.S., Carilion Clinic, [email protected]; Caleb Pagliasotti,
M.D., MPH, Carilion Clinic; Mahamaya Bhattacharyya, M.D., M.S., Carilion Clinic; Tahnee Wong-Okafor,
M.D., M.H., MBA, Carilion Clinic; Neetu Sakkari, M.D., Carilion Clinic; Julian Lagoy, M.D., Carilion Clinic;
Shady Shebak, M.D., Carilion Clinic; Anita S. Kablinger, M.D., CPI, Carilion Clinic
Purpose: This curriculum was designed in order to prepare PGY-1 residents at the Carlion Clinic Virginia
Tech Carilion School of Medicine-Psychiatry Residency Program to present effective case conferences during
their PGY-2 year. The final outcome of this curriculum should be to achieve a level of understanding of
psychiatry and a confidence that is essential in presenting cases to the department during PGY-2 year. This
curriculum was designed by the PGY-1 psychiatry class with the help of the junior education chief. We used the
six step approach of curriculum development, which includes problem identification and general needs
assessment, targeted needs assessment, goals and objectives, educational methods, implementation, and
evaluation of the curriculum.
Methods: As part of the targeted needs assessment, we developed two surveys. One was given to the PGY-1
residents to assess overall competence, relevance, and overall preparedness with regards to case conferences
and subsequent presentations. Another survey was given to faculty to gauge their impression of the current case
conference series.
Results: Following survey data collection, analysis, resident surveys revealed implemented curriculum
improved the approach, preparation, relevance, information, communication, and relevance of presented data.
Faculty responses revealed improvement in support, professionalism, discipline, accountability, preparation,
and diligence.
Conclusion: Curricular evaluation will continue to be ongoing, with assessment of PGY-1, faculty data during
the implementation of the case conference curriculum. To date, curriculum feedback by resident, faculty favor
the implementation, benefit of described curriculum, aiding in presentation of upcoming case conferences in
subsequent resident years.
49
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R21
Key Word(s): Education, Quality Improvement/Quality Assurance, Cardiology, Cardiac/Cardiovascular Surgery
Title: Novel Multi-Disciplinary Approach to a Challenging Coronary Sinus Lead Extraction
Authors: Sehrish Memon, MD, VTCSOM-Carilion Roanoke Memorial Hospital, [email protected];
Timothy Ball, MD. phD, VTC-SOM Carilion Roanoke Memorial Hospital; Carl Musser, MD, VTC-SOM
Carilion Roanoke Memorial Hospital
Purpose: Extraction of coronary sinus(CS) lead in cardiac resynchronization therapy-defibrillator(CRT-D)
devices can be challenging from distal lead adhesions and tortuous CS anatomy. We present a case CS lead
extraction despite elongation of conductor coil within the insulation using a multidisciplinary approach.
Methods: 60 y.o Male with ischemic cardiomyopathy EF 10-15% underwent CRT-D Implantation 15 months
prior, presented with erythema and pre-erosion of his device. Urgent pocket exploration under guidance of
electrophysiologist and cardiothoracic surgeon via left subclavian approach yielded purulent drainage and
therefore complete device explant was indicated. Right atrial(RA) and ventricular leads were extracted without
difficulty. CS lead extraction was complicated by inability to advance stylet to distal tip. Significant traction
was applied, but friction along superior vena cava, RA, roof of CS and lead tip adhesions resulted in elongation
of conductor coil within the insulation without any movement of the tip leading to a sprung CS lead.
Results: With the help of an interventionalist, femoral vein was accessed with intention of pulling inferiorly
along CS axis, thus reducing friction. A pigtail catheter was rotated, winding around lead, but slipped with
inferior force. Next, a Cordis Bipal7 forcep was advanced but due to limited steeribility was unable to grasp
onto lead. Finally, 6F St. Jude Medical LiveWire EP catheter was advanced and rotated numerous times
coupling to CS lead. Catheter was withdrawn with significant downward force, freeing lead tip from CS. The
entire lead was then withdrawn from subclavian vein. A 3x3mm fibrous adhesion was noted at the lead tip. The
patient did well and there were no post-procedural complications.
Conclusion: This case demonstrates a successful novel multidisciplinary approach to a complex CS lead
extraction from a fibrous adhesion.
50
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R22
Key Word(s): Education, Process Improvement, Cardiology, Cardiac/Cardiovascular Surgery
Title: Underestimation of Bioprosthetic Mitral Valves with 2D Echocardiography:Indication for 3DTEE
Authors: Sehrish Memon, MD, VTCSOM-Carilion Roanoke Memorial Hospital, [email protected];
Jason Foerst, MD, VTC-SOM Carilion Roanoke Memorial Hospital; Sulaiman Rathore, MD, VTC-SOM
Carilion Roanoke Memorial Hospital
Purpose: 3D Real time-echocardiography provides superior mitral valve (MV) assessment with less variability
than 2D and Doppler modalities. 2D echo and Doppler gradients may underestimate MV stenosis and this can
be overcome by use of 3D echocardiography.
Methods: An 81 year old female with bioprosthetic mitral valve (BMV) presented with crescendo dyspnea.
Transthoracic echocardiogram showed normal ejection fraction and moderate to severe BMV stenosis with
mean gradient (MG) of 10 mm Hg. Subsequently, a transesophageal echocardiogram (TEE) showed MG of 913 mmHg, mitral valve area (MVA) of 1.65 cm2 by pressure half-time and restricted posterior leaflet
suggesting moderate BMV stenosis.
Results: Given discrepancy in BMV stenosis assessment with 2D, we decided to do 3D evaluation by TEE. 3D
TEE provided an en-face view of BMV revealing immobile leaflets and MVA of 1cm2 by 3D QLAB
confirming severe stenosis. Due to high surgical risk she underwent transcatheter Sapien XT TM valve in valve
replacement with post-procedure MG of 1mmHg.
Conclusion: 3D TEE is superior to 2D modalities in assessing BMV dysfunction. This case demonstrates how
the severity of BMV stenosis was underestimated with 2D echocardiography and how utilization of 3D TEE
allowed accurate assessment and appropriate management.
51
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R14
Key Word(s): Quality Improvement/Quality Assurance, Infectious Diseases, Pediatrics
Title: Appropriate Treatment of Pneumonia in Pediatric Patients at CRMH
Authors: Bethany A. Miller, PharmD, Carilion Roanoke Memorial Hospital Pharmacy,
[email protected]; Mimi Liu, PharmD, MBA/HSA, Carilion Roanoke Memorial Hospital
Pharmacy; Julie Hughes, PharmD, Carilion Roanoke Memorial Hospital Pharmacy; Gus Stefanadis, PharmD,
MS, Carilion Roanoke Memorial Hospital Pharmacy
Purpose: Community acquired pnuemonia (CAP) is the leading cause of death in children worldwide, and still
remains poorly treated. Medication use evaluation (MUE) is to access appropriateness of empiric antibiotic
selection for pediatric CAP at CRMH. Empiric antibiotic regimen was evaluated to determine hospital
adherence to Infectious Disease Society of America's (IDSA) guidelines for the management of pediatric CAP.
Pediatric inpatient and outpatient pneumonia order-set are currently in place to aid providers.
Methods: Retrospective chart-review of pediatric CAP patients (9-2012 to 7-2014). Data generated via EPIC
Database to include pediatric CAP patients < 18 years of age. Comparisons were made between recommended
treatment, and actual practice at CRMH.
Results: A total of 55 pediatric patients met the study criteria (10 months - 15 years). Forty-six (84%) patients
were treated appropriately per IDSA guidelines. Nine (16%) patients were treated with outpatient regimens that
covered common CAP microorganisms but not recommended per IDSA guideline as inpatient CAP empiric
antibiotics. The inpatient pediatric pneumonia order-set was rarely used (2/55 patient orders). ED pediatric
pneumonia order set was not used. Orders via order set were appropriate. Lack of awareness and complicated
organization of existing order sets contributed to lack of usage.
Conclusion: CRMH providers generally prescribe the correct empiric antibiotic regimen for pediatric CAP. To
enhance guideline compliance, we recommend: 1) Revise and streamline the current pediatric inpatient
pneumonia order-set to model off the new 2015 ED adult pneumonia order set based on location (outpatient,
inpatient) of the patient and diagnosis of CAP. 2) Explore epic reference link and redirect opportunities to
enhance utilization of these order sets.
52
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R26
Key Word(s): Internal Medicine, Emergency Medicine, Hospital Acquired Conditions
Title: Appropriate Health Care-Associated Pneumonia Management in the Emergency Department
Authors: Bethany Miller, PharmD, Carilion Roanoke Memorial Hospital Pharmacy,
[email protected]; Jessica Schad, PharmD, BCPS, Carilion Roanoke Memorial Hospital Pharmacy;
Melissa Hobbins, PharmD, BCPS, Carilion Roanoke Memorial Hospital Pharmacy; Kelly McAllister, PharmD,
MBA, BCPS, Carilion Roanoke Memorial Hospital Pharmacy
Purpose: To evaluate the appropriateness of health care-associated pneumonia (HCAP) diagnosis and treatment
in the Emergency Department (ED) at Carilion Roanoke Memorial Hospital (CRMH). Due to the broad
definition of HCAP throughout the literature, providers may not recognize risk factors for HCAP and instead
prescribe antibiotics to cover common community acquired organisms. Conversely, the unclear definition may
lead to inappropriate use of empiric antibiotics leading to over prescribing and complications such as antibiotic
resistance and Clostridium difficile infection.
Methods: This is a retrospective cohort study that reviewed medical charts of adult patients presenting to the
ED at CRMH. Patients included were at least 18 years old and received antibiotic treatment for pneumonia.
Patients were excluded if their medical record was incomplete or if a sepsis alert was called while in the ED.
The study analyzed data from July 2012-January 2016. The primary objective is to compare the accuracy of
HCAP diagnosis and treatment in the ED among three patient groups: those treated from the old pneumonia
order set, those treated from the newly released order set, and those who were treated not using an order set.
The secondary objectives are to evaluate therapy modifications upon admission to an inpatient unit as well as
antibiotic treatment failure and duration of therapy. Data will be analyzed by regression analysis with 50
patients per arm. If 50 patients per arm is not attained, a Chi Square analysis with descriptive statistics will be
performed.
Results: The results are in process.
Conclusion: It is anticipated this project will provide information on HCAP management both inpatient and in
the ED at CRMH. By optimizing the pneumonia order set to align with the latest treatment guidelines,
appropriate antibiotic selection for patients with HCAP should improve.
53
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R18
Key Word(s): Internal Medicine, Pharmacology, Neurology
Title: Kratom: Old Plant, New Problem
Authors: Caroline M. Morton, MD, Carilion clinic IM resident, [email protected]; Chad Demott,
MD, IM APD; Audrey A. Sova, DO, IM resident
Purpose: Kratom, Mitragyna speciosa, is a leaf from Southeast Asia with many uses, including sedation, pain
control, stimulant, and for opioid withdrawal. It is readily used and abused in the USA, and the side-effect
profile is largely unknown.
Methods: Case Presentation: Thirty-three year old female with bipolar disorder, anxiety, and depression
presented to the ED with a generalized seizure. She reported one seizure in the past attributed to tramadol
overdose. Her father noticed word-slurring and later found her lying on the ground shaking, despite no
prodromal features. She endorsed chronic diarrhea, smoking cigarettes, and using Kratom several times weekly,
including two days prior. She denied head trauma, medications linked to seizure, and family history of seizures.
The patient was post-ictal upon arrival to the ED but returned to baseline within two hours. A CT Head, EEG,
vital signs, CBC, and BMP were all unremarkable. The patient was discharged and counseled about Kratom
abstinence.
Results: Discussion: Kratom, an FDA "drug of concern", is available on the internet and is being purchased
by hundreds of thousands of people. It can be chewed, smoked, or made into tea. Its primary active ingredient,
mitragynine, acts on multiple CNS receptors: opioid, serotonin, and adrenergic receptors. Given the mu-opioid
activity, it is used for pain management and opioid withdrawal. There have not been any case reports of
respiratory depression with this drug alone, and initial studies on rats further support this. Although there is no
mechanism of action known at this time causing seizure activity, there have been multiple cases of seizures
reported, especially when mixing with other medications such as modafinil and tramadol.
Conclusion: Kratom is an up-and-coming drug in the American market. Its abuse potential is high and due to
the grave side effects, including seizures, physicians need to have a greater awareness about the potential for
harm.
54
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R41
Key Word(s): Neurology, Endocrinology, Immunology, Psychiatry
Title: Differential diagnosis of adult-onset seizures and psychosis: A missing mechanism
Authors: Maureen O. Murphy-Ryan, MD, Virginia Tech- Carilion Department of Psychiatry, PGY2,
[email protected]; Mason Ayobello, MD, Virginia Tech- Carilion Department of Psychiatry;
Anita Kablinger, MD, Virginia Tech-Carilion Department of Psychiatry; Bush Kavuru, MD, Virginia TechCarilion Department of Psychiatry
Purpose: Diagnosis of new onset seizures and psychotic symptoms in an adult involves a complicated
differential of relatively rare diagnoses, many of which have poor prognoses. Evaluation includes stabilization,
laboratory testing, EEG monitoring, head CT/MRI, and further specialized investigations. We present a case of
adult-onset seizures and psychosis to demonstrate diagnostic methods and explore a poorly understood
diagnosis through a comprehensive literature review and updated synthesis of known cases.
Methods: Direct care for the patient, review of the electronic medical record, review of the medical literature
via PubMed for articles on diagnosing new onset seizures and psychosis, and for all case reports of our patient's
final diagnosis. We created a comprehensive chart of current clinical data on cases of the final diagnosis to
guide future study and treatment.
Results: Case: 67-year old Caucasian male with hypothyroidism, no prior psychiatric or neurologic history
who had been living independently. Mutism, unilateral blindness, ataxia developed over months. He was
hospitalized for non-convulsive status epilepticus. LP showed high CSF protein. After resolution of seizures he
was disoriented, delusional, hypersexual, hypertalkative, not sleeping with new right-sided weakness and
neglect, dysphagia, and bilateral blindness. Labs/Imaging were negative except high CSF protein and highly
elevated anti-thyroglobulin antibody and anti-TPO antibody. Methylprednisolone was started, and one week
later cognition and sensorium had improved, speech was less pressured and he was oriented to recent events,
year.
Conclusion: Hashimoto's encephalopathy was supported by highly elevated Anti-Tg and Anti-TPO antibodies,
elevated CSF protein, recurrent stroke-like symptoms, and improvement with high-dose steroids. HE's precise
mechanism remains unknown. Anti-thyroid antibody levels do not correlate with disease severity. Other
common features include insidious onset, cognitive impairment, seizures, psychosis, mood symptoms,
insomnia, unremarkable CT/MRI. Most patients are euthyroid. Treatment is with high-dose steroids; symptoms
improve or resolve over months to years.
55
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R6
Key Word(s): Interactive Patient Care, Pulmonology, Screenings, Patient Monitoring
Title: Systemic inflammation in severe COPD with isolated nocturnal dyspnea.
Authors: Santosh k. Nepal, MD, VT Carilion School Of Medicine, Pulmonary and Critical Care Fellowship.,
[email protected]; Martin Thomas, MD, VA Salem Medical Center; Macrea Madalina, MD, VA
Salem Medical Center; Ronnie Mantilla, MD, VT Carilion School Of Medicine, Pulmonary and Critical Care
Fellowship
Purpose: Up to 40% of patients with COPD without evidence of hypoxia while awake has substantial
desaturation at night, particularly during REM sleep. The benefit of long-term nocturnal supplemental oxygen
therapy (NOT) on patient with isolated nocturnal dyspnea has not been proven although nocturnal hypoxia is
likely one of the factors that increase systemic inflammation in COPD. We hypothesized that severe COPD
patients with solated ND have higher serum hs-CRP than COPD patients.
Methods: Cross-sectional study of patients diagnosed with severe COPD ( i.e. FEV1< 50% with FEV1/FVC
<70) referred to the Pulmonary Function Test Lab at the Salem VAMC over a 2 year period .All patients free of
acute illness, known sleep disorders, oral glucocorticoid and home oxygen therapy underwent nocturnal
oximetry on room air. Demographic and nocturnal oximetry data, FEV1 and comorbidities, including Charlson
Comorbidity Index (CCI) were extracted from the Electronic Medical Records. Fasting serum hs-CRP and lipid
profile were measured the morning after nocturnal oximetry in 37 patients with severe COPD (out of which 16
were ND) and 8 healthy controls. Normality of continuous variables was evaluated by the Shapiro-Wilk test.
Comparison of hs-CRP between groups was tested by Wilcoxon rank test. Correlations between serum hs-CRP
and FEV1 and CCI were analyzed using Spearman correlation. A two-sided p value of <0.05 was considered
statistical significant results.
Results: The serum hs-CRP (IQR, mg/dl) was highest in severe COPD patients who were ND and qualified for
NOT (6.58 (3.3-19.3)) as compared with severe COPD patients who did not qualify for NOT (2.48 (1.2-4.6))
and healthy controls (0.46 (0.23-1.07)) (p=0.05).
Conclusion: Serum hs-CRP was highest in severe COPD patients with ND who qualified for NOT which
suggests that these patients could be at higher risk of CVD as indicated by serum hs-CRP and likely benefit
from supplemental NOT
56
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R10
Key Word(s): Alternative/Complementary Approaches, Process Improvement, Pulmonology
Title: Endobronchial leiomyoma successfully treated with flexible bronchoscopic cryotherapy.
Authors: Santosh k. Nepal, MD, VT Carilion School Of Medicine, Pulmonary and Critical Care Program,
[email protected]; Edmundo Rubio, MD, VT Carilion School Of Medicine, Pulmonary and Critical
Care Program; Maria Cirino, MD, VT Carilion School Of Medicine, Pulmonary and Critical Care Program
Purpose: Bronchial leiomyoma is a rare benign tumor with just over 100 cases reported. The mainstay of
management has been surgical resection with a few reports of successful endoscopic therapy with laser
applications. We report the first case of complete resection of bronchial leiomyoma with endo bronchial
cryotherapy.
Methods: We present a 53 year old Caucasian woman presented with episodic wheezing and recurrent
pneumonia for over 10 years. Chest CT showed a lesion obstructing the bronchus intermedius. Flexible
bronchoscopy confirmed an almost completely obstructed bronchus by a white, smooth, pedunculated tumor
(Fig A). A flexible 2.4 mm cryoprobe (ERBE,Marietta, Georgia, USA ) with nitric oxide as a cryoagent, was
subsequently used to remove the tumor. The probe was attached to middle of the lesion (to avoid damage to the
surrounding airway mucosa) and then pushed towards it center. The probe was then frozen until there was a rim
of icing of around s 2-3 mm around the probe. Then, the bronchoscope was removed en-block with the tumor
attached to the probe Blood loss was <2 ml. Histopathology confirmed the diagnosis of Leiomyomoma.
Results: The procedure resulted in a complete resection without recurrence as confirmed by bronchoscopy
repeated 3 months later. Certain tumor characteristics of leiomyoma are favorable for cryotherapy excision
including less vascularity and absence of deeper extension, known as iceberg phenomenon, as seen with other
being tumors . Cryotherapy, traditionally, required repeated interventions allowing the frozen tissue to necrose
and solugh off. With the recent introduction of larger probes, the penetration and effective freezing can be
achieved resulting in a complete resection in a single setting as in our case.
Conclusion: To our knowledge, there are no reports using cryotherapy for complete resection of bronchial
leiomyomoma. This modality , with its good safety profile, should be considered as first line therapy.
57
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R35
Key Word(s): Simulation, Quality Improvement/Quality Assurance, General Surgery
Title: Can Surgery Residents Meet Quality Benchmarks for ADR in Colonoscopy?
Authors: John B. Ortolani, MD, Carilion Clinic, Department of Surgery, [email protected]; John J.
Ferrara, MD, Carilion Clinic, Department of Surgery; Charles J. Paget, MD, Carilion Clinic, Department of
Surgery; Daniel R. Tershak, MD , Carilion Clinic, Department of Surgery
Purpose: The American Society for Gastrointestinal Endoscopy (ASGE)/ American College of
Gastroenterology (ACG) Task Force on Quality in Endoscopy recently released updated quality benchmarks for
colonoscopy. Our initial study concluded that surgery residents could perform safe and competent screening
colonoscopy within a structured endoscopy curriculum. In this follow up prospective study, we sought to
determine whether surgery residents could achieve the increased adenoma detection rate (ADR) benchmarks
endorsed by the ASGE/ACG Task Force.
Methods: An IRB-approved prospective analysis of colonoscopies performed by five PGY-2/PGY-3 surgery
residents from 2013-2015 was completed. All colonoscopies were performed under the direct supervision of
surgical endoscopists after each resident passed a structured endoscopy simulation curriculum. The following
ASGE/ACG quality metrics were recorded: bowel prep quality; cecal intubation rate; polyp and adenoma
detection rates; and, complications. Power analysis determined that 108 procedures were required for an 80%
probability of data analysis accuracy.
Results: 135 screening and diagnostic colonoscopies were performed. Bowel prep was considered "adequate"
in 90% of cases. The cecum was reached independently in 95% of cases. Polyp(s) were visualized and removed
in 39% of patients. The overall ADR was 31.8% (>25%). Male ADR was 38.7% (>30%). Female ADR was
26% (>20%). Average polyp size was 8.7 mm (range: 1-22 mm). One patient was readmitted for postpolypectomy syndrome, and successfully managed non-operatively.
Conclusion: Using our structured endoscopy curriculum, surgery residents achieved ADRs fully consistent
with the updated benchmark values endorsed by the ASGE/ACG Task Force.
58
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R42
Key Word(s): Radiology, Pulmonology, Critical Care
Title: Triple Whammy! Intercostal Herniation of Lung, Liver and Colon
Authors: Brijesh B. Patel, MD, Carilion Clinic/Virginia Tech Carilion School of Medicine, Roanoke, VA,
United States, [email protected]; Umar Sofi, MD, Carilion Clinic/Virginia Tech Carilion School of
Medicine, Roanoke, VA, United States
Purpose: To present a complex case of lung, liver and colon herniation through the same intercostal space.
Methods: A 47 year-old man with a history of COPD, presented after a fall with dyspnea and chest wall pain.
Physical exam showed large ecchymosis over the right flank. Thoracic-CT demonstrated herniation of the lung
and a portion of the liver through the 8th rib-space. Cardiothoracic surgery (CTS) recommended elective repair
of the defect after optimization of pulmonary status. He was subsequently discharged home. A week later, he
was readmitted with worsening dyspnea and a soft, reducible mass over the right posterior chest wall that
decreased and increased in size with inspiration and expiration respectively. Thoracic-CT revealed pleural
effusion contiguous to the herniated lung with new airspace disease. Thoracentesis yielded a large amount of
serosanguinous fluid. He was treated for HCAP and discharged home. Two weeks later, he presented to the ER
with severe abdominal pain. CT-scan revealed interval enlargement of the above hernia, Transdiaphragmatic
Intercostal Herniation(TIH) of mesenteric fat and ascending colon with evidence of incarceration. He was
emergently taken to the OR and underwent successful reduction and repair of the incarcerated hernia. He is
awaiting evaluation for the intercostal defect repair.
Results: Fewer than 300 cases and 40 cases of lung herniation and TIH have been reported in literature
respectively. The majority of cases are acquired and occur after a blunt trauma. While diaphragmatic injury
should be suspected in all cases of intercostal herniation, prompt and precise diagnosis can be made by CTscan. Although, small hernias seldom regress spontaneously, management can be complex. Definitive treatment
can be achieved through surgical repair.
Conclusion: Intercostal lung herniation is rare and even rarer in conjunction with TIH of abdominal contents.
We present an intricate case with unexpected complications of pneumonia, pleural effusion and incarceration
with the management challange of this rare entity.
59
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R20
Key Word(s): Rheumatology, Critical Care, Internal Medicine
Title: Nonmedical Silicone Injections and Autoimmune/Inflammatory Syndrome Induced by Adjuvants
(ASIA)
Authors: Tomer Pelleg, DO, Carilion Clinic, [email protected]; Mahtab Foroozesh, MD, Carilion
Clinic; Edmundo Rubio, MD, Carilion Clinic; Susanti Ie, MD, Carilion Clinic; Faisal Siddiqui, MD, Carilion
Clinic
Purpose: Autoimmune/Inflammatory Syndrome Induced by Adjuvants (ASIA) is a rare disorder recently
introduced in the literature. Autoimmune phenomena associated with adjuvant exposure has only recently been
recognized as an inflammatory syndrome, rarely leading to multi-organ failure.
Methods: A 50 year old male to female transgender patient who participated in silicone "parties" where liquid
silicone was injected into her cheeks and hips experienced myalgias, arthralgias and insomnia for months prior
to developing acute dyspnea and a petechial rash. The clinical course was complicated by respiratory failure,
myocardial infarction, acute encephalopathy and acute renal failure requiring supportive care. Laboratory
investigations revealed low complement levels, cryoglobulinemia and an elevated rheumatoid factor as well as
the presence of HLA-DRB1/DQB1. Skin biopsy demonstrated leukocytoclastic vasculitis; renal biopsy showed
acute vasculitic glomerulonephritis. Brain imaging revealed small vessel vasculitis. Pulse-dose steroids were
administered without improvement. The patient subsequently underwent plasma exchange followed by
Rituximab, resulting in rapid improvement of renal, pulmonary and neurologic symptoms.
Results: Silicone in nature, commonly found as silicone dioxide (silica), is the pathogenic agent implicated in
several occupational lung diseases such as silicosis and asbestosis. In vitro, silica and its derivatives are potent
macrophage activators resulting in a massive production of IL-17 leading to an influx of activated neutrophils.
Within regional lymph nodes, silica's immune adjuvant effect stimulates the production of IgE and IgG,
ultimately leading to chronic T-cell activation. There is convincing evidence implicating the injection of liquid
silicone in the development of severe autoimmune disease. In 2010, Shoenfeld et. al. proposed the criteria for
the diagnosis of ASIA in effect consolidating multiple clinical symptoms associated with various adjuvants. The
patient met 3 major and 2 minor criteria.
Conclusion: ASIA represents a rare cause of inflammatory disease. In patients with chronic adjuvant exposure,
clinical suspicion should be maintained to diagnose this potentially life threatening condition.
60
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R34
Key Word(s): Internal Medicine, Critical Care, Infectious Diseases
Title: Outcomes of Intensivist Staffing and Admission Times in Medical ICUs
Authors: Tomer Pelleg, DO, Carilion Clinic, [email protected]; Susanti Ie, MD, Carilion Clinic;
Edmundo Rubio, MD, Carilion Clinic; Faisal Siddiqui, MD, Carilion Clinic
Purpose: To determine the effects of closed critical care staffing models in Intensive Care Units (ICUs) and
off-shift admission status on patient outcomes.
Methods: Patients admitted to two medical ICUs at Roanoke Memorial Hospital from May 1, 2009 through
May 30, 2014 were retrospectively evaluated. The "Closed ICU" was staffed by a Pulmonary/Critical Care
physicians and the "Open ICU" was open to all services for admission, with critical care consultation as
requested. Patients were case matched based on Acute Physiology Score (APS) quintile, discharge diagnosis
and birth decade. Patients with insufficient documentation were excluded. Mortality rates, length of stay
(LOS), ventilator time and blood product utilization were stratified by ICU type and On- vs Off-Shift status
(5pm to 7am or on weekends). Data was analyzed utilizing ANOVA, Student-T, Z- and F- tests.
Results: We evaluated 7,786 patients and 3,755 were included for analysis. Only 230 patients from each ICU
could be matched; 137 patients were admitted off-shift in the open ICU and 144 in the closed ICU. Hospital
LOS, ICU-LOS, and ventilator time revealed a non-statistically significant trend favoring the closed ICU.
Mortality rates and blood product utilization were not different. There was no difference in On- vs Off-shift
status in the Closed ICU however, there was a statistically significant difference in ventilator time and ICULOS favoring on-shift status in the open ICU.
Conclusion: A non-statistically significant trend favored hospital LOS, ICU-LOS and ventilator time in the
closed ICU; the subgroup analysis demonstrated a significant difference in ICU-LOS and ventilator time in the
open ICU model when factoring time of admission. Different staffing model reinforcing the value of closed
ICU models may be explanatory. Further larger studies are needed to better define this and to identify how the
staffing model may impact these findings.
61
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R9
Key Word(s): Internal Medicine, Cardiology, Cardiac/Cardiovascular Surgery, Readmissions
Title: Next Day Transfermoral TAVR Discharge: Are We There Yet?
Authors: Sulaiman Rathore, MD, Carilion Clinic, [email protected]; Jason Foerst, MD, Carilion
Clinic; Joseph Rowe, MD, Carilion Clinic; Yevgeniy Latyshev, MD, Carilion Clinic; Carl Musser, MD,
Carilion Clinic; Crystal Emore, NP, Carilion Clinic
Purpose: We have minimized the approach to transfemoral transcatheter aortic valve replacement (TF- TAVR)
by avoiding general anesthesia, foley and central lines. Safety for discharge is based on lack of complications,
early ambulation and family support. We aimed to evaluate the impact of a minimalist approach for elective TFTAVR on the safety of next day discharge
Methods: We retrospectively studied 96 patients who underwent elective TF-TAVR in last two years at our
institution. Patients were classified into next day discharge (NDD, N= 21) and later discharge (LD, N = 75).
Baseline characteristics, frailty markers, complications and 30-day readmission rates were compared between
the two groups.
Results: There was no age difference betwen the groups (NDD 81.7±7.7 years and LD 80.1±8.8 years,
p=0.44). Mean length of stay was 3.4 days in LD group. In LD group 36 patients (36.5%) were discharged
between 24 and 48 hours. Demographic differences between the two group were higher use of monitored
anesthesia care (90 vs 36%, p=0.001), less fluoroscopy time (16.2 vs 22.5 min, p=0.008), balloon expandable
valve (90 vs 56%, p=0.003), higher delta hemoglobin (1.1 vs 1.6, p=0.012) and more baseline pacemakers (33
vs 10%, p=0.04). There were no differences between groups in stroke, vascular complication, 30-day
readmission and mortality. In regression analysis monitored anesthesia care (p=0.002) was strongly associated
with NDD.
Conclusion: Next day discharge after TF-TAVR is safe in selected patients. Prospective studies are required to
develop prediction models for safe next day discharge.
62
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R23
Key Word(s): Statistics, General Surgery, Gastroenterology
Title: Emergent and Elective Colo-rectal Surgery Patients Benefit from Enhanced Recovery
Authors: Scott J. Ryan, MD, Virginia Tech Carilion - Carilion Clinic, [email protected]; Sandy
Fogel, MD, Virgina Tech Carilion - Carilion Clinic; Nathan Johnson, Medical Student, Virginia Tech Carilion;
William H. Woodall, PhD, Virgina Tech Dept of Statistics
Purpose: Background: Enhanced Recovery Protocols (ERPs) expand as studies demonstrate effectiveness in
reducing length of stay (LOS) and complications. LOS is a key variable because it is a surrogate for discharge
criteria, such as return of bowl function and activity, tolerance of diet, and control of pain, as well as the sum
total of complications.
Methods: Methods: The Carilion Clinic's ERP was implemented in June of 2014. Prospective data was
collected on all patients who underwent colo-rectal operations. ERP participants were compared to historical
controls obtained from NSQIP data and to contemporary controls who did not participate in the ERP.. Both
emergent and elective patients were included in the protocol. Data were analyzed using logistic regression to
control for co-morbidities.
Results: Results Reduction in LOS was seen for all patients who participated in ERPs. A subgroup analysis
of patients undergoing emergent operation showed reduction in LOS from 9.22 to 5.67 days. (P-value 0.018),
suggesting that the patients who stand to benefit the most from enhanced recovery protocols are those who
present with acute surgical illness.
In a regression analysis of any complication for all patients, ERP
participation was demonstrated to be statistically significant in reducing the likelihood of any complication (coefficient -0.55, P-value 0.05).
Conclusion: Conclusion: Our enhanced recovery protocol resulted in reduced LOS and a lower complication
rate for patients undergoing colo-rectal surgery. The patients who benefited most were those requiring
emergent operation. ERP participation was the only statistically significant variable shown to reduce the rate of
complications.
63
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R45
Key Word(s): Psychology, Psychiatry, Measurement
Title: Relationship of Resiliency Factors to Characteristics of Adolescent Psychiatric Inpatients
Authors: Shady S. Shebak, MD, Carilion Clinic Virginia Tech Carilion School of Medicine Psychiatry Department ,
[email protected]; Tenzing Yangchen , MD, Carilion Clinic Virginia Tech Carilion School of Medicine
Psychiatry Department ; Osman A. Chowdhry, MS, Carilion Clinic Virginia Tech Carilion School of Medicine
Psychiatry Department ; Eric J. Vance, MD, Carilion Clinic Virginia Tech Carilion School of Medicine Psychiatry
Department ; Jackson Bradley, BS, VCOM; Mohammad Ashfaque, MD, Carilion Clinic Virginia Tech Carilion School of
Medicine Psychiatry Department ; Katherine Shaver, MS, Virginia Tech
Purpose: To explore the relationship of self-reported resiliency (protective) factors on severity of psychiatric
characteristics of adolescents hospitalized with psychiatric illness.
Methods: Study population included 106 randomly selected youth between ages of 12-17 admitted to the
Carilion Child and Adolescent Psychiatric inpatient unit between the years 2013-2015. The patients were asked
to complete the Youth Resiliency Checklist (YRC) upon admission as a routine clinical assessment. Youths
who were unable to read, comprehend, or autonomously complete the YRC were excluded. YRC data was deidentified and recorded, and we separately conducted a blinded chart review of psychiatric features of the
subjects in EPIC-EMR. Data was analyzed using one way ANOVA, and correlational tests as appropriate.
Results: A significant relationship was found on one way ANOVA between the outlooks subscale of the YRC,
and length of hospital stay (LOS), (p=0.0067). Those with LOS 11 or more days (N=18) had a significantly
lower mean outlooks score than those whose LOS was 1 to 5 days (N=27; means 13.39 versus 19.19). Also, a
significant relationship (p=0.0393) was found between the social skills subscale, and those with 2 versus 3 or
more hospitalizations ( means 13.92 versus 11.13) . Finally, post-hoc Tukey test also revealed significance at
the 0.05 level comparing social support subscale means for patients with LOS 1-5 days (14.78) compared to
those with LOS 6-10 (12.18). No other significant relationships were found between other YRC scores and
suicidal behavior, internalizing or externalizing symptoms, number of psychotropic medications, number of
substances used, or body mass index.
Conclusion: There are significant relationships between LOS and YRC-rated outlooks and social support, and between
number of hospitalizations and YRC-rated social skills. This may suggest a moderating effect of these
resiliency/protective factors and hospital utilization among adolescent psychiatric patients, and provide potential
psychosocial targets for intervention to reduce burden of hospitalizations.
64
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R47
Key Word(s): Internal Medicine, Critical Care, Emergency Medicine
Title: Impact of sepsis alert process in improving clinical outcomes.
Authors: Faisal M. Siddiqui, MD MSc MCEM, Carilion Clinic, [email protected]; Susanti Ie,
MD, Carilion Clinic; Eric Bradburn, DO MS FACS, Carilion Clinic; Tomer Pelleg, DO, Carilion Clinic; Amy
Lucas, MSN RN, Carilion Clinic
Purpose: Sepsis alert process was recently introduced in the emergency department (ED) at our tertiary care
hospital. In this prospective cohort study we analyzed the impact of this process in improving clinical outcomes
including mortality and length of stay (LOS).
Methods: Adult patients who were admitted with sepsis via ED between August 2014 and July 2015 were
included for this study. Several outcome metrics were evaluated for a 4 month period directly preceding
implementation of the "Sepsis Alert" system and compared to the 2 months following this implementation.
Results: A total of 1671 patients admitted via ED were included for this study. In the pre-alert period, 960
patients; in the post-alert period j698 patients met the inclusion criteria. Only 161 patients actually underwent
"sepsis alert" process. The mean age of patients in the pre-alert phase was 63 (SEM±0.60) compared to 63.2
(SEM±1.10) in the "alerted" and 62.6 (SEM±0.70) in the "non-alerted" group. Patients who were admitted via
the sepsis alert process had a higher lactic acid (3.7 mmol/L SEM±0.24) and a lower mean arterial blood
pressure (82.2 mm Hg with SEM±1.63). The average time to first antibiotic and average LOS in the ED was
considerably lower in patients who were admitted via the alert process (p<0.00001). However no statistically
significant difference in mortality was found in these patients (p=0.7795).
Conclusion: Although sepsis alert system failed to show a mortality benefit, there was a statistically significant
decrease in time to first antibiotic as well as a shorter ED LOS when this alert system was employed. Physicians
tend to use the alert process for critically ill patients and in our opinion this selection bias masked the mortality
benefit of this process.
65
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R33
Key Word(s): Emergency Medicine, Diabetes, Quality Improvement/Quality Assurance
Title: Evaluation of the Adult Diabetic Ketoacidosis Protocol
Authors: Gus Stefanadis, Pharm.D., MS, Carilion Roanoke Memorial Hospital,
[email protected]; Bridgette Smigiel, Pharm.D., Carilion Roanoke Memorial Hospital; Jessica
Schad, Pharm.D., BCPS, Carilion Roanoke Memorial Hospital; Kelly McAllister, Pharm.D., MBA, BCPS,
Carilion Roanoke Memorial Hospital
Purpose: This study will assess the appropriateness and effectiveness of the Carilion Roanoke Memorial
Hospital (CRMH) adult diabetic ketoacidosis (DKA) treatment protocol. The adult DKA protocol is not patientspecific and is suspected to correct glucose levels too rapidly without achieving DKA resolution, which may be
harmful to select patients. Additionally, providers utilizing the current protocol may order inappropriate
intravenous fluids (IVF) containing electrolytes in the setting of hyperkalemia or hypernatremia.
Methods: Adult DKA patients who were treated with the CRMH DKA protocol between August 2014 and
August 2015 were included in this retrospective chart review. Patients were identified if either the inpatient or
outpatient DKA order sets were utilized during treatment. Those who also had orders for Endotool were
excluded. Primary objectives are time to DKA resolution and the impact of body weight on time to DKA
resolution. Secondary objectives include the incidence of insulin infusion discontinuation with an anion gap,
appropriate transition to subcutaneous insulin, length of hospital stay, impact of endocrine consult on time to
DKA resolution, and a composite of inappropriate IVF administration. Safety endpoints will evaluate a
composite of electrolyte values outside the normal range and incidence of cerebral edema. Descriptive statistics
will be used to evaluate the effectiveness of the DKA protocol. T-tests and Chi square tests will be used to
analyze two group samples and nominal data, respectively.
Results: Results are in progress.
Conclusion: The CRMH adult DKA protocol may not be appropriate for all patients. The information collected
will be used to determine effectiveness of the current DKA protocol and potentially identify areas for
improvement.
66
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?Yes
Abstract: R40
Key Word(s): Quality Improvement/Quality Assurance, Mathematical Modeling, Infectious Diseases, Process
Improvement
Title: Vancomycin Dosing Calculator: A new tool for optimal patient care
Authors: Rachel L. Warren, PharmD, Carilion Roanoke Memorial Hospital, [email protected];
Nathan Everson, PharmD, Carilion Roanoke Memorial Hospital; Marissa Williams, PharmD, BCPS-AQ ID,
Carilion Roanoke Memorial Hospital; Tiffany Yoon, PharmD, Carilion Roanoke Memorial Hospital; Mina
Antonius, PharmD Candidate, VCU School of Pharmacy
Purpose: Pharmacists dose vancomycin based on patient specific pharmacokinetic calculations, which can be
time consuming. The purpose of this study is to validate a vancomycin calculator, introduce it into practice, and
compare the use of the calculator to current pharmacist dosing methods.
Methods: This investigation is a pre-post intervention, non-inferiority evaluation of a vancomycin dosing aid
instituted by the Carilion Roanoke Memorial Hospital Pharmacy Department. Adult patients receiving
intravenous (IV) vancomycin between January 1, 2015 and September 30, 2015 were evaluated preintervention. The dosing calculator was introduced to the pharmacy department on October 1, 2015, and postintervention charts were reviewed from implementation to present. Adult patients were included if they received
at least one dose of IV vancomycin and had at least one steady-state trough level result. Patients were excluded
if they required renal replacement therapy or had pre-existing AKI. A non-inferiority test of two proportions
will be performed with a non-inferiority margin of 15%. A total of 264 patients will need to be analyzed to
reach 80% power.
Results: 132 patients were included in the pre-intervention group (78 males, 54 females). The major objective
to be analyzed between this and the post-intervention group is the percentage of initial troughs within goal
range. Additionally, rate of acute kidney injury (AKI), time to onset of AKI if applicable, all-cause mortality,
and infectious mortality will be compared between the two groups. Among the pre-intervention group, 43
(32.6%) patients had initial troughs within goal range. 14 (10.6%) patients developed AKI while receiving
vancomycin and 9 (6.8%) patients died before discharge, 2 (1.5%) of them from presumed infectious causes.
Data collection is in process for the post-intervention group, and full results are expected to be analyzed before
Carilion Research Day.
Conclusion: Conclusions will be drawn when all data is available for analysis.
67
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Qualitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R31
Key Word(s): Cancer, Oncology, Gynecology
Title: Omentectomy without gross intraperitoneal metastasis in uterine papillary serous cancer
Authors: Margaret Whitney, M.D., Virginia Tech Carilion , [email protected]; Whitham Megan,
M.D., Baylor College of Medicine; Janet Osborne, M.D., Virginia Tech Carilion
Purpose: To determine whether routine omentectomy alters staging and treatment of uterine papillary serous
carcinoma (UPSC) in the absence of gross intraperitoneal metastasis at the time of surgery
Methods: Patients with a diagnosis of pure or mixed UPSC between 2003-2013 who underwent
comprehensive surgical stating (CSS) by laparotomy or minimally invasive approach were identified by query
of the electronic medical record. We retrospectively reviewed cases in which no intraperitoneal disease was
found intraoperatively and omental sampling was performed. Patients with gross intraperitoneal metastasis or
those who did not have omental sampling performed were excluded.
Results: A total of 43 patients were diagnosed with UPSC at our institution from 2003-2013. Of these 43
patients, 26 patients (60.5%) had omental sampling at the time of CSS. Eighteen of these cases had no gross
intraperitioneal disease noted at the time of CSS and met inclusion criteria. The remaining 8 cases noted gross
intraperitoneal metastasis. Of the 18 patients who met inclusion criteria, there were 9 patients (50%) with stage
IA, 1 patient (6%) with stage IB, 2 patients (11%) with each stage II, stage IIIC1, stage IIIC2 and stage IVA,
respectively. None of the 18 cases that met inclusion criteria had disease present in the omentum.
Conclusion: Patients without intraperitoneal disease present at the time CSS for UPSC did not have
microscopic or macroscopic disease found in the omentum in this single-institution study. These findings
suggest that routine omental sampling may not be necessary in the absence of gross intraperitoneal metastasis at
the time of CSS for patients with UPSC. This study suggests a potential opportunity for cost-reduction without
impacting stage or post-operative management of patients with UPSC.
68
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Resident/Fellow
Consider for Rapid Communication Presentation?No
Abstract: R48
Key Word(s): Pediatrics, Health Promotion/Wellness, Psychiatry
Title: The Effect of Menstrual Cycle Phase on Adolescent Psychiatric Hospitalization.
Authors: Jun Yin, MD, PhD, Carilion Clinic-Virginia Tech Carilion, [email protected];
Purpose: To determine whether adolescent girls have greater risk for psychiatric admission during different
menstrual phases.
Methods: We conducted a retrospective chart review of 274 hospitalized female psychiatric patients aged 14 to
17 years. Patients were admitted to Carilion Child and Adolescent Psychiatric Inpatient Unit from 2013 to
2014. Exclusion criteria included the current use of oral contraceptives, charts in which no LMP was recorded
within three days of admission, and charts with LMP documented more than 45 days before the admission.
Data collected included age, date of admission, date of the onset of last menstrual period (LMP), primary
diagnoses, suicidality on admission, history of self-injury and previous psychiatric admissions. For analysis, a
28-day cycle was used and divided into four seven day periods of time. The null hypothesis of this study was
that the proportion of hospitalized female psychiatric patients who were menstruating at admission would be
25%. The menstrual phase was defined as days 1-7 of the cycle with day one representing the onset of menses.
The binomial test and two-tailed t test were used to test the hypothesis and compare sub-groups of patients
admitted during the menstrual phase versus those admitted during the three other phases of the menstrual cycle.
Results: A disproportionate percentage (33.58%) of adolescent females were admitted during their menstrual
phase (days 1- 7) (p = 0.0005, binominal test). Most patients were admitted for Mood Disorders (88.69%). The
mean age was 15.24 years. Of the total group, 45.26% had a previous psychiatric admission, and 61.31% had
history of self-injury. Similar patterns of demographic data were observed between girls admitted in all phases
of the menstrual cycle.
Conclusion: There is an increased risk of psychiatric admission during the menstrual phase for adolescent
females.
69
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Translational
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S16
Key Word(s): Critical Care, Internal Medicine, Cardiology, Cardiac/Cardiovascular Surgery, Basic Sciences,
Anesthesiology
Title: Modulation of Cardiac Conduction across Myocytes by Extracellular Ionic Concentration
Authors: Anand M. Abraham, Medical Student, Virginia Tech Carilion School Of Medicine,
[email protected];
* Student’s Mentor: Steven Poelzing, PhD, Virginia Tech Carilion Research Institute
Purpose: To determine the relationship between gap junctional coupling, conduction velocity, and action
potential rise time (RT).
Methods: Heterozygous mouse hearts (HZ) with 50% reduced Cx43 and Wild Type (WT) littermates were
Langendorff perfused. Extracellular sodium was changed from 155.2 (nominal) to 147.5 mM, potassium was
changed from 4 (nominal) to 6.1mM, and calcium was changed from 1.8(nominal) to 3.4 mM. Hearts were
optically mapped with di-4-ANEPPS to measure CV and RT in the transverse and longitudinal directions of
propagation.
Results: In WT hearts, increasing potassium from 4 to 6.1 mM slowed CV by 16% without significantly
changing RT in the transverse and longitudinal directions, regardless of change in sodium. Interestingly, in HZ
hearts, CV decreased by 22% and RT increased by 18% (transverse) when potassium was increased and sodium
was decreased. When sodium was held constant in HZ hearts at 147.5 mM and potassium was increased, CV
decreased by 15% and RT increased by 31% (transverse). When sodium was held constant at 155.2 mM and
potassium was increased in HZ hearts, CV decreased by 20% but rise time did not change. There were
decreases in rise time in both WT and HZ groups in both directions as calcium was increased from 1.8mM to
3.4mM, ranging from 21-24% between groups.
Conclusion: Cellular excitability as measured by action potential rise time(RT) is more sensitive to changes in
extracellular sodium, potassium, and calcium than changes in gap junctional coupling. Changes in extracellular
sodium and potassium are more pronounced when gap junction functional expression is reduced. The data
suggest that tissue excitability can be maintained even when conduction is slow, providing further evidence for
the concept of slow but safe conduction that is dependent more on a mechanism of cell-to-cell electrical
coupling that may be independent of gap junctions.
70
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Translational
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S39
Key Word(s): Process Improvement, Microbiology, Laboratory Science
Title: Computer Vision Assisted Water Quality Testing
Authors: Joycelynn Acheampong, Third Year Undergraduate, Virginia Polytechnic Institute and State
University , [email protected]; Andre Muelenaer, M.D. - M.S., VTC, PMDI ; John Bird, Ph.D., Virginia
Polytechnic Institute and State University; Swazoo Claybon, B.A. - 1st year Master's Student , Virginia
Polytechnic Institute and State University
* Student’s Mentor: Penny Muelenaer, M.D. - MPH, Virginia Tech Carilion School of Medicine
Purpose: Water quality testing by counting cultured coliform colonies is time intensive and vulnerable to
variability. Furthermore, low resource populations have limited access to humans who can be tasked to
laboratory work. In countries like Malawi, it is also important to recognize the absence of advanced laboratory
technologies. Our goal is to establish a program and accompanying system that will photograph and count
colonies based on color staining to decrease time and resources needed to analyze water coliforms.
Methods: We test using colonies that were grown and stained using the m-Coliblue24 broth medium. E. coli
colonies stain blue and all other coliform colonies stain red. We cross correlate counting results against manual
counts, computer program based counts, and computer vision based counts. The system includes a PVC and
wood enclosure, the Raspberry Pi and Raspberry Pi camera, an LCD screen, and a power source. Using the
Raspberry Pi as the hardware for the device, a computer vision program was developed in Python to automate
counting after the image is taken using the Raspberry Pi camera. The method includes a hough transform to
eliminate unnecessary information, an Hue Saturation Value (HSV) conversion for more accurate color
thresholding, and connected component analysis for variability robustness between image colonies.
Results: Based on the count data, the computer works just as well as a human counter with an Root Mean
Square (RMS) error within the range of intra-human error. There is a high correlation between pixel locations of
coliform colonies in the computer vision output when compared to the manual computer-based colony counter.
Conclusion: An affordable colony counting device is made possible with use of a Raspberry Pi and computer
vision analysis. This provides a great platform to determine and test its efficiency within a low resource
laboratory.
71
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S41
Key Word(s): Process Improvement, Implementation Science, Education
Title: Association of Clerkship's Order and Cumulative Experience With Examination Scores
Authors: Liqa Athamneh, MS., Virginia Tech, [email protected]; Heidi A. Lane, EdD, Virginia Tech Carilion
Research Institute and School of Medicine, Roanoke, Virginia, USA
* Student’s Mentor: Sarah Parker, PhD, Virginia Tech Carilion Research Institute and School of Medicine
Purpose: To answer the following questions: at Virginia Tech Carilion School of Medicine (VTCSoM): 1)
Does previous clinical clerkship experience have an impact on subsequent clinical clerkship's overall skills and
scores (regardless of clerkship)? 2) Does order of clerkship affect performance on end-of-clerkship clinical
evaluations for that specific clerkship? 3) Do end-of-clerkship score for different clerkships and/or its order
throughout the year predict the end-of-year Objective Structured Clinical Exam (OSCE) performance?
Methods: Analysis for 123 third year medical students at VTCSOM was performed. A repeated measures
mixed model and a linear combination of estimators were used to investigate the impact of order on end-ofclerkship scores throughout the year. A bivariate linear regression was used to examine the impact of clerkships
and their order on end-of-year OSCE performance. All variables with p<0.05 in the unadjusted analysis were
included in the final multivariate linear regression model to determine predictors of end of year performance.
All the statistical analyses were conducted using Stata 13.1 at a significance level of 0.05.
Results: Clinical performance improved significantly after the first two rotations, regardless of track (coef
0.656, p 0.001). Significant higher end-of-clerkship scores were found in family medicine (coef. 0.77 CI (95%):
0.18 - 1.35) and OBGYN (coef. 1.40 CI (95%): 0.60 - 2.20) for students who took them later in the year
compared to those who took them earlier. Students with higher surgery, internal, or family medicine scores
performed better on the end-of-year exam.
Conclusion: Time of year has a significant impact on end-of-clerkship performance in general and on family
medicine and OBGYN scores specifically with better performance with time. Surgery, internal, or family
medicine's end-of-clerkship scores are significant predictors for the end-of-year OSCE performance. Sharing
those findings with the VTCSoM students may help them better plan their clerkships and improve their
performance.
72
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S8
Key Word(s): General Surgery, Mathematical Modeling, Quality Improvement/Quality Assurance, Hospital Acquired
Conditions
Title: Failure of Chlorhexidine to Prevent Postoperative Pneumonia: NSQIP Regression Modeling
Authors: Jash Bansal, MPH, Virginia Tech Carilion School of Medicine, [email protected]; William
Woodall, PhD, Virginia Tech; Jim Jones, BSN, Carilion Clinic
* Student’s Mentor: Sandy Fogel, MD, Virginia Tech Carilion School of Medicine
Purpose: The purpose of this study was to evaluate the efficacy of chlorhexidine oral rinses in preventing
postoperative pneumonia.
Methods: The National Surgical Quality Improvement Program (NSQIP) database was employed to track
postoperative pneumonia incidence in a population for 6 months prior to the oral CHX rinse implementation
and then for 6 months afterwards. A step-wise regression analysis was used to stratify the populations and
assess their risk for postoperative pneumonia based on other factors so that the two groups could be compared.
Results: A higher incidence of pneumonia was present in the CHX group prior to risk stratification. The stepwise regression model confirms that the criteria were in fact different between the control and CHX groups and
when applied, shows that CHX did have a positive correlation with prevention of pneumonia, but did not reach
levels of statistical significance (p>0.7).
Conclusion: This was a very well powered study, involving 3,294 patients who met criteria for inclusion
within the specified timeframes and had validated data based on its incorporation into the NSQIP database.
Chlorhexidine's lack of efficacy in pneumonia prevention can be explained by its low concentration, at which it
is a poor, gram-specific disinfectant. In conclusion, chlorhexidine failed to reduce postoperative pneumonia
incidence.
73
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Qualitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S48
Key Word(s): Implementation Science, Quality Improvement/Quality Assurance, Orthopedics, Orthopedics Surgery,
Health Services
Title: The Orthopaedic Osteoporosis Care Gap: A Survey of Providers
Authors: David W. Barton, BS, VTC School of Medicine, [email protected]; Caleb Behrend, MD,
Carilion Clinic, Department of Orthopaedic Surgery
* Student’s Mentor: Jonathan Carmouche, MD, Carilion Clinic, Department of Orthopaedic Surgery
Purpose: In 2004, the U.S. Surgeon General called for better recognition and management of osteoporosis.
Since then, numerous organizations have sought to improve osteoporosis management through educational and
quality improvement initiatives. While such programs have achieved local success, 65% of elderly women
presenting with fragility fractures are still not assessed for osteoporosis. The present study investigates barriers
to orthopaedic initiation of osteoporosis care.
Methods: A survey was sent to 50 physicians and physician's assistants in the Department of Orthopaedic
Surgery at a busy level 1 trauma center to evaluate their awareness of, interest in, and expertise in management
of osteoporosis in their fracture patients.
Results: Thirty-six survey recipients (72%) responded. Thirty-two (89%) believed that osteoporosis care was
"very important," while the remaining 11% believed it was "moderately important." Thirty respondents (83%)
said they, were "moderately" or "very" responsible for initiating osteoporosis treatment. Less than 3% of
respondents believed primary care management is "completely adequate," while 33% believed it "inadequate."
Similarly, less than 3% believed that orthopaedists provide completely adequate care, while 61% believed
current orthopaedic management is inadequate. Uncertainty about the correct clinical approach (47%) and lack
of familiarity with relevant medications (68%) were commonly cited as leading reasons for failure to provide
adequate care. Twenty-one respondents (60%) expressed a willingness to initiate osteoporosis management if a
suitable protocol was provided. An additional ten (29%) reserved judgment. Only four providers (11%) said
they were unlikely to follow such a protocol.
Conclusion: This study demonstrates that orthopaedists recognize the under treatment of patients with
osteoporosis who have experienced fragility fractures and wish to provide better care. They are likely to do so if
provided with supporting protocols. Such protocols, therefore, remain critical to closing the care gap in
secondary prevention of osteoporotic fractures.
74
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S15
Key Word(s): Occupational/Rehabilitative/Physiatry, Occupational Therapy, Health Promotion/Wellness
Title: Perceptions of Certified Driver Rehabilitation Specialists on video feedback interventions
Authors: Molly Brown, OTS, Jefferson College of Health Sciences, MSOT Program, [email protected];
Janet Stohler, OTR/L, CDRS, Driver Side Rehab LLC; Stuart Tousman, PhD, Jefferson College of Health
Sciences; Meredith Evans, OTS, Jefferson College of Health Sciences, MSOT Program; AnneLeigh Gibbs,
OTS, Jefferson College of Health Sciences, MSOT Program; Stephanie DeLuca, PhD, VTCRI
* Student’s Mentor: Stephanie DeLuca, PhD, Virginia Tech Carillon Research Institute; Jefferson College of
Health Sciences; Virginia Tech Carilion School of Medicine
Purpose: An individual's ability to drive has a profound impact on their level of independence. If driving
abilities are impaired an individual's capacity to be mobile is extremely limited in most communities (Stav,
Weidley, & Love, 2011). In recent years, the demand for driver rehabilitation services has increased (ADED,
2015). Simultaneously, technology has allowed for the advancement of many intervention tools focused on
better driving outcomes. Video feedback as a tool has demonstrated therapeutic advantages across many
rehabilitation contexts (Schmidt et al., 2011), but has not been established as a consistent intervention method
within driving programs. This study explores the perceptions of current Certified Driver Rehabilitation
Specialists (CDRSs) on the use of video feedback as a tool in driver rehabilitation programs.
Methods: CDRSs (n = 74) from a national registry will be informed about an online survey. Data will be
collected across a three-month period between January 2016 and March 2016.
Results: Data will be analyzed for descriptive frequencies to determine if CDRSs are currently using videofeedback within their driver rehabilitation programs. Further, potential benefits and barriers to implementation
will be explored.
Conclusion: We hypothesize that video feedback is not being widely used as a tool in driver rehabilitation
programs. Barriers to its use may include time associated with implementation, cost factors and operation of
new technology. Secondly, we hypothesize that CDRSs will see the potential benefits to its use and will be
willing to implement this technology in the future.
75
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S45
Key Word(s): Informatics, Patient Monitoring, Pediatrics
Title: Distributed Thermistor for Temperature Monitoring of Malnourished Infants
Authors: Lauren E. Cashman, VT Senior, Virginia Tech College of Engineering, [email protected];
* Student’s Mentor: Andre A. Muelenaer, M.D., M.S., VTCSOM
Purpose: To design a low-cost and easily maintained system for monitoring infant temperature in low-staff
health environments.
Methods: We have developed a low-cost system of multiple distributed temperature sensors that can wirelessly
transmit data to a single device utilizing Bluetooth technology. The system is designed for use in low-resource
health environments to continually monitor the axillary temperature of infants and to report temperatures
wirelessly to a user's device and signal an alarm if any infant's temperature falls outside a preset temperature
range. The device uses an armband to secure a thermistor in the axilla to monitor temperature and Bluetooth to
transmit regular temperature updates to an Android portable device. The device will be equipped with an app
interface that can report which sensor is reporting out-of-range temperature readings.
Results: A test was conducted using four groups of plastic bottles filled with water heated to 40 degrees
Celsius. The thermistor-equipped printed circuit boards were taped to the bottles and the temperatures of the
bottle surfaces were collected in Microsoft Excel. The circuit boards were labeled A, B, C, or D. The bottles
monitored by thermistors A, B, and C were insulated to slow temperature decline. The bottle monitored by
thermistor D was not. The data collected showed a significant difference between the rate of temperature
decrease in group D when compared to groups A, B, and C, with D reaching 25 degrees Celsius after an hour
and groups A, B, and C ending the hour at 30 degrees Celsius. Additionally, the data reported subtle differences
in temperature decrease among the three insulated groups, A, B, and C, reflecting their varying levels of
insulation.
Conclusion: Wireless thermistors can be used to simultaneously monitor the temperatures of multiple infants
as well as to identify infants whose temperature drops below an acceptable temperature range.
76
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S5
Key Word(s): Statistics, General Surgery, Geriatrics
Title: Are Incisional Hernias Safe To Repair in The Elderly?
Authors: Yu-Wei W. Chang, MS, Virginia Tech Carilion School of Medicine, [email protected];
* Student’s Mentor: Sandy L. Fogel, MD, FACS
Purpose: Incisional hernias are common problems in the United States, accounting for the majority of the
380,000 ventral hernias repaired annually. While some hernias can be asymptomatic, repair is generally
indicated, especially if they affect the patient's quality of life or present as emergencies. Currently, limited
information is available regarding the outcome of incisional hernia repairs among elderly patients. This group is
susceptible to complications considering their increased operative risk from comorbidities, increased frailty, and
increased recovery times.
Methods: We designed a retrospective cohort study of patients (>=18 years old) who underwent incisional
hernia repair at Carilion Roanoke Memorial Hospital between 1/1/2008-12/31/2012. We excluded patients with
diastasis rectus and those with hernias repaired with biologic mesh. Our elderly population was defined as
individuals aged 65 years and older at the time of their operation. Complications were defined as the following:
mortality, bowel injury, post-op infection within 30 days, or hernia recurrence within 2 years.
Results: We enrolled 567 patients: 137 (24%) were older than 65. Our study population was predominantly
white (90%) and female (68%). There was an overall complication rate of 11.5% and mortality rate of 0%.
Compared to the younger population, the older patients had a lower average BMI (30 vs 34, p<0.001), required
less narcotics postoperatively (6.1 vs 7.3 orders, p=0.06) and had longer hospital stays (1 vs 0.8 day, p<0.001).
Although the older population had a higher proportion of severe systemic disease defined as ASA score >=3
(48% vs 35%, p=0.02), unadjusted complication rates were comparable between groups (11.4% vs 11.7%,
p=0.99). A logistical regression performed found no significant difference in odds of complications between the
younger and older population (p=0.5).
Conclusion: Our data supports the decision to repair incisional hernias among the elderly population, with no
significant differences in outcomes compared to younger patients.
77
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S7
Key Word(s): Statistics, Quality Improvement/Quality Assurance, General Surgery
Title: Use of NSQIP to Reduce Re-intubation Rate Among Surgical Patients.
Authors: Jing Chen, PhD, Virginia Tech Carilion School of Medicine and Research Institute (VTCSOM),
[email protected];
* Student’s Mentor: Sandy Fogel, MD, Carilion Roanoke Memorial Hospital (CRMH)
Purpose: The goal is to identify modifiable variables that are associated with re-intubation in adult surgical
patients at Carilion Roanoke Memorial Hospital (CRMH). A third of re-intubations are anesthesia-related. We
hypothesize that the non-anesthesia-related re-intubations are associated with post-operative pulmonary
complications.
Methods: This study is a retrospective chart review of patients who underwent surgery at CRMH during our
study period (from 04/01/2012 to 03/31/2014) and were selected for inclusion in National Surgical Quality
Improvement Program (NSQIP). The data include patient demographics, comorbidities, operative factors, and
30-day post-surgical outcomes. Bivariate test was performed to screen variables of interest. The final model was
built by multivariate analysis using variables selected by forward stepwise selection logistic regression.
Results: Among 5585 eligible patients, 77 (1.4%) underwent re-intubation after surgery. Multivariate analysis
showed that three variables were associated with increased risk of re-intubation: post-op pneumonia [odds ratio
(OR) = 12.1; 95% confidence interval (CI) = 5.1-27.5], post-op ventilation > 48 hours (OR = 53.4; 95% CI =
26.2-108.0), and post-op cardiac arrest requiring CPR (OR = 33.5; 95% CI = 12.5-84.1). Other variables, such
as COPD, pulmonary embolus, sepsis, etc., were not significantly associated with re-intubation.
Conclusion: Post-op pneumonia, ventilation > 48 hours, and cardiac arrest requiring CPR are associated with
re-intubation among adult surgical patients at CRMH. Of these, post-operative pneumonia is likely the most
modifiable risk factor. The findings may be helpful for future interventions to reduce the re-intubation rate by
targeting modifiable risk factors such as post-op pneumonia.
78
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Translational
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S42
Key Word(s): Laboratory Science, Infectious Diseases, Screenings
Title: Affordable Automated Technology using Ziehl-Neelsen Stained Sputum for Tuberculosis Screening
Authors: Swazoo Claybon, B.S. - 1st year masters student, Virginia Polytechnic Institute, [email protected];
Sahal A. Thahir, B.S. - 1st year medical student, Virginia Polytechnic Institute; Andre Muelenaer, M.D. - M.S.,
Associate Professor of Pediatrics Chief, Section of Pediatric Pulmonology/Allergy Virginia Tech Carilion
School of Medicine; President/Chief Medical Officer, Pediatric Medical Device Institute; John Bird, Ph.D.,
Associate Professor and Research Scientist at Virginia Polytechnic Institute
* Student’s Mentor: Penny Muelenaer, M.D. - MPH, Assistant Professor, Department of pediatric, Virginia
Tech Carilion School of Medicine
Purpose: Sputum smear microscopy is essential for tuberculosis screening in high-prevalence countries. We
aim to develop an appropriate, affordable medical device for the automated identification of Mycobacterium
tuberculosis on slides of Ziehl-Neelsen stained sputum smears using a bright-field microscope and computer
vision. Ideally, this method may be used as a step in the automation of tuberculosis screening in order to reduce
technician involvement in the process.
Methods: Our device consists of a bright-field microscope, a Raspberry Pi single-board computer, and a linux
integrable, 5 megapixel camera module with a 3.60 mm focal length designed by the Raspberry Pi Foundation.
Ziehl-Neelson stained slides under the microscope will be rapidly imaged and analyzed by the device for the
technician. The algorithm will utilize several image cues such as color contrast, multi-scale saliency, and
superpixel analysis combined in a naive Bayesian classifier to differentiate acid-fast bacilli from peripheral
artifacts.
Results: We aim to conduct a comparative analysis of our test algorithms. We will compare a baseline of hand
annotated tuberculosis colonies with the computer vision based cropped outputs and record the score using
mean precision and mean recall of intersection over union. Furthermore, we plan to compare our device and the
current methods utilized by high-prevalence underdeveloped countries to determine the specificity and
sensitivity of the device in analyzing the ZN-stained sputum smears for acid fast bacilli.
Conclusion: Our goal is to increase the financial efficiency and timeliness of tuberculosis screening in highprevalence, developing countries.
79
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S40
Key Word(s): Cardiology, Cardiac/Cardiovascular Surgery, Biology, Education
Title: DRAMATIZATION OF STARLING FORCES: AN INTERACTIVE LEARNING APPROACH
Authors: Brian W. Connor, Medical Student, Virginia Tech Carilion School of Medicine,
[email protected];
* Student’s Mentor: Helena Carvalho, PhD, Virginia Tech Carilion School of Medicine
Purpose: Virginia Tech Carilion School of Medicine is a modern hybrid medical school where student learning
is facilitated outside of the classroom setting. One hands-on approach is called PBL (Problem-Based Learning),
where students learn with and from a small group of peers. To help first-year medical students better understand
the key players for filtration and reabsorption at the level of the capillary, an interactive exercise, fostering
understanding as well as slight competition, was created to illustrate the concept of Starling Forces.
Methods: Four stacks of cards marked with various numerical values were used to represent Starling Forcescapillary hydrostatic pressure, capillary oncotic pressure, hydrostatic pressure of interstitial fluid, and oncotic
pressure of interstitial fluid. Within the PBL group of first-year medical students, four students randomly drew a
card inscribed with a numeric value for one of the four starling forces. Two other students represented fluid and
competed to move faster than their peer from circulation to the interstitium or vice versa. Upon simultaneous
evaluation of the forces at play, students, behaving as fluid, decided (via movement into or out of the space
designated as "capillary,") whether they were going to be reabsorbed by the capillary or filtered into the
interstitium. The fluid molecule (student) who did not respond as fast "stagnated," and thus remained to
compete in the next round.
Results: In an anonymous survey with scale of 1 (least) to 5 (most) they reported 4 ± 0.7 for effectiveness of
the activity and 4 ± 0.5 (means ± SD) for their confidence level on the acquired knowledge.
Conclusion: Integrating interactive approaches to teaching in the context of graduate-level education can be
helpful in demonstrating challenging yet important concepts, such as filtration.
80
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S28
Key Word(s): Pediatrics, Cardiology, Cardiac/Cardiovascular Surgery, Quality Improvement/Quality Assurance
Title: Prenatal diagnosis of congenital heart disease in Southwest Virginia
Authors: Catherine Gambale, BS, Virginia Tech Carilion School of Medicine, [email protected];
Allison Durica, MD, Virginia Tech Carilion School of Medicine, Carilion Clinic
* Student’s Mentor: Joelle Miller, MD, Virginia Tech Carilion School of Medicine, Carilion Clinic
Purpose: To assess the prenatal detection rate (PDR) of congenital heart disease (CHD) in Roanoke, VA and
surrounding areas over the past 8 years, and to determine if the PDR improved after the Carilion Clinic
Maternal Fetal Medicine (MFM) clinic established a dedicated fetal sonography team with enhanced fetal heart
imaging protocols. We anticipated an improvement in PDR following these changes.
Methods: Retrospective review of all newborns and non-surviving fetuses with a confirmed diagnosis of CHD
in the Carilion Clinic Pediatric Cardiology practice during 1/2007-1/2015 (n=170). Two time periods were
compared; 2007-2011 and 2012-2015. The 2nd period followed protocol changes made in MFM. PDR was
correlated with ductal dependency (DD), need for early surgery (ES) and prior evaluation by MFM or fetal
echocardiogram (FE) and compared between the time periods as well as compared by lesion type for the entire
cohort.
Results: The PDR for fetuses referred to MFM clinic improved during the second time period (66.7%, 85.7%,
p<0.05); however, no differences in PDR were found for the entire cohorts, DD lesions, or ES lesions. Single
ventricle (SV) (73.7% 45.4%, P<0.02) and endocardial cushion defects (ECD) (66.7%, 45.4%, p<0.04), were
detected more frequently while coarctation of the aorta (CoA) (19.4%, 45.45, P<0.001) had a lower PDR.
Conclusion: Despite an improved PDR for fetuses evaluated by MFM during the 2nd time period, referral rates
to MFM and FE remained unchanged with no improvement of the overall PDR. Educating primary care
providers to include cardiac outflow tract imaging on routine fetal screening may improve recognition and
referral of fetuses with CHD in our community. CoA accounted for a large percentage of missed critical CHD.
Establishing imaging protocols in our FE laboratory to better recognize CoA is an opportunity for improvement.
81
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S31
Key Word(s): Statistics, Otolaryngology, Orthopedics, Orthopedics Surgery
Title: Indications for Direct Laryngoscopic Examination Prior to Anterior Cervical Surgery
Authors: Anirudh K. Gowd, B.S., Virginia Tech Carilion School of Medicine, [email protected]; Alireza
K. Nazemi, M.S., Virginia Tech Carilion School of Medicine; Jonathan J. Carmouche, M.D., Carilion Clinic
Orthopedics; Todd J. Albert, M.D., Hospital for Special Surgery; Caleb J. Behrend, M.D., Carilion Clinic
Orthopedics
* Student’s Mentor: Caleb J. Behrend, M.D., Carilion Clinic Department of Orthopedics
Purpose: The present study is a systematic review on etiology and incidence of recurrent laryngeal nerve palsy
summarized with a probability based protocol for direct laryngoscopic examination. Recurrent laryngeal nerve
palsy (RLNP) is the most common complication in both thyroid surgeries and anterior approaches to the
cervical spine. Most bilateral paresis, with subsequent devastating impact on patients, are due to failure to
recognize unilateral RLNP and are often preventable with appropriate history and screening. Manifestations of a
unilateral lesion are varied and may be asymptomatic. This study presents a systematic review of the literature
defining key causes of RLNP with a probability based protocol to indicate pre-operative direct laryngoscopy.
Methods: A systematic review of literature was performed using the Web of Science and PubMed databases.
Twenty-one publications of prospective and retrospective studies were included for analysis. Statistical analysis
of weighted average was created for each etiology and incidence of RLNP. Odd's ratios with respect to RLNP
from intubation were calculated for major etiologies.
Results: 1,283 cases of unilateral RLNP were collected with varied etiologies. Iatrogenic post-surgical injury
accounted for 36.90% of cases, malignancy accounted for 29.74% of cases, and 20.90% of cases were of
idiopathic origin. 472 cases of bilateral RLNP were collected with similar etiologies. Post-surgical
complications accounted for 35.64%, malignancy accounted for 28.59%, and 8.98% of cases were of idiopathic
origin. RLNP is 13.046 and 13.90 times more likely in anterior spine and thyroid surgery, respectively, in
comparison to intubation.
Conclusion: Diagnosis of unilateral RLNP is the critical factor in preventing the occurrence of bilateral RLNP.
Patients with history of prior thyroidectomy, anterior cervical surgery, or history of esophageal or thyroid
malignancy are at highest risk. The importance of patient history should be emphasized, as it is the basis for
indications of pre-operative laryngoscopy.
82
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S32
Key Word(s): Exercise/Physical Activity, Sports Medicine, Orthopedics, Orthopedics Surgery
Title: Medial Collateral Ligament Injuries In NCAA Division I Football Athletes
Authors: Anirudh K. Gowd, B.S., Virginia Tech Carilion School of Medicine, [email protected]; Ali
Mutamedi, M.D., Memorial Hermann Health Systems; Caleb J. Behrend, M.D., Carilion Clinic Orthopedics;
Alireza K. Nazemi, M.S., Virginia Tech Carilion School of Medicine; Jonathan J. Carmouche, M.D., Carilion
Clinic Orthopedics
* Student’s Mentor: Caleb J. Behrend, M.D., Carilion Clinic Department of Orthopedics
Purpose: In this study, we will aim to describe the incidence, magnitude of injury, distribution of injury by
position, and cost of injury in terms of practice and games for medial collateral injuries in NCAA Division 1
football players. Injury to the MCL is the most common ligamentous knee injury. In collegiate football players,
their incidence, magnitude of injury, distribution by position, and missed time has not yet been described in a
consecutive series.
Methods: The knee injuries sustained in 163 consecutive NCAA Division 1 collegiate football players at our
institution were evaluated over the span of six years. Patient chart review was conducted to evaluate the
incidence of MCL injuries amongst other knee injuries. Within the MCL injury group, the extent of injury,
distribution by position, and lost time to practice and games were studied and compared.
Results: The incidence of MCL injuries among our collegiate football players with any knee injury was 28%
(47 of 163 knee injuries). Of the 47 MCL injuries, 34% occurred in defensive linemen and 26% in offensive
linemen. The average days missed by linemen were 14.65 compared to 4.5 by non-linemen (p = 0.07). The
MCL injuries in linemen were more severe than in non-linemen (0.018).
Conclusion: MCL injuries are the most common ligamentous knee injuries in collegiate football players. They
occur most commonly in linemen in whom the magnitude is also more significant than non-linemen. Linemen
miss more days than non-linemen to MCL injury.
83
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S29
Key Word(s): Patient Monitoring, Internal Medicine, Pulmonology
Title: Thermal Infrared Imaging to Measure Breathing During Sleep
Authors: Peter Grossman, MS4, Virginia Tech Carilion SOM, [email protected];
* Student’s Mentor: Andre Muelenaer, M.D., M.S., FAAP, FCCP, Chief, Section of Pediatric
Pulmonology/Allergy; Virgnia Tech Carilion SOM
Purpose: Airflow measurement during polysomnography currently relies on intrusive instrumentation in the
form of cannulas and oro-nasal thermistors that are subject to erroneous data collection through disruption of
baseline sleep architecture among other factors. Thermal infrared imaging (TIRI) is a non-contact modality
preliminarily shown to have the capability to monitor breathing under limited conditions, but has never been
tested in the dynamic setting of a full eight hour diagnostic polysomnogram. We hypothesize TIRI can
successfully monitor respiration throughout diagnostic polysomnography and effectively detect respiratory
disturbances compared to the gold standards.
Methods: Six subjects with a BMI >30kg/m2 underwent an eight hour overnight diagnostic polysomnogram
with standard recording techniques including nasal cannula and oro-nasal thermistor for respiratory event
detection. Thermal infrared imaging was used to simultaneously monitor respiration. Random periods of
breathing captured by TIRI were assessed for signal quality, morphology and responses to flow limitation. All
respiratory signals were scored with standard respiratory event scoring with the recording method blind to the
scoring technician.
Results: Thermal infrared imaging was able to consistently produce a reliable airflow signal with adequate
respiratory deflections and timing responses to flow limitation. The ability of TIRI to consistently detect sleep
disordered breathing was unable to be assessed at this time due to major losses in signal throughout the first six
studies.
Conclusion: Thermal infrared imaging is a feasible contact method for monitoring respiration during an
overnight polysomonogram, although major hardware and connection issues have limited the ability to monitor
breathing for a full eight hours. Due to this, adequate comparison in detecting sleep disordered breathing events
between TIRI and the gold standards has been unsuccessful. Further studies will be required to determine if
hardware and connection issues can be resolved.
84
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S26
Key Word(s): Microbiology, Basic Sciences, Biology
Title: Development of Biological Assays for Assessing aCT-1 Function
Authors: Kendall Hancock, MS3, Virginia Tech Carilion School of Medicine, [email protected];
Jane Jourdan, Lab manager, Virginia Tech Carilion Research Institute
* Student’s Mentor: Robert Gourdie, PhD, Virginia Tech Carilion School of Medicine and Research Institute
Purpose: This study seeks to develop a reliable biological assay based on the dose-dependent effect of aCT-1
on Cx43 gap junction intercellular communication. This objective may be of translational/industrial benefit in
providing an assay of aCT-1 drug activity.
Methods: To study the role of aCT-1 in Cx43 gap junction-mediated coupling, fluorescence recovery after
photobleaching (FRAP) was employed over doses of ¿CT-1 ranging between 1 and 180 uM. Additionally, the
"parachute assay" of intercellular communication in combination with flow cytometry was utilized to develop a
novel and sensitive assay of intercellular communication.
Results: FRAP assays of C6Cx43 unexpectedly revealed that increasing aCT-1 concentrations reduced the gap
junction coupling. However, at higher aCT-1 concentrations, the response of cells to aCT-1 appeared to
segregate into two groups. To further investigate this a "parachute"/flow cytometry assay was used, first
determining that overall intercellular communication in C6Cx43 cells increased with increasing [aCT-1].
However, with increasing aCT-1 concentration, an emergence of two populations of responding cells was noted,
each demonstrating distinct levels of communication. Further analysis determined that the high communication
population rose with increasing aCT-1 dose, though decreased at the highest does tested. Meanwhile the low
communication population increased with increasing aCT-1 dosage. This novel finding of the emergence of two
cell-to-cell communication populations in a dose-dependent manner could provide the basis for a new and
sensitive biological assay of aCT-1 function.
Conclusion: The results of the parachute assay support the existence of a dose-dependent relationship between
aCT-1 peptide concentration and intercellular communication. The results further indicate that with increasing
concentration of aCT-1 peptide, there is an emergence of a second cell communication population and an
increase in cell-to-cell coupling.
85
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S21
Key Word(s): Readmissions, General Surgery, Quality Improvement/Quality Assurance
Title: Financial Impact of an Enhanced Recovery Protocol in Colo-rectal Surgery
Authors: Nathan M. Johnson, MS3, Virginia Tech Carilion School of Medicine,
[email protected]; Scott J. Ryan, MD, Carilion Clinic/Virginia Tech Carilion School of Medicine
* Student’s Mentor: Sandy L. Fogel, MD, Carilion Clinic/Virginia Tech Carilion School of Medicine
Purpose: To assess the financial impact of implementing an Enhanced Recovery Protocol (ERP) in colo-rectal
surgical care. Background: Enhanced Recovery Protocols (ERPs) have been shown in many different settings
to lead to quicker recovery for most patients, with a significantly reduced average length of post-operative stay
(LOS). A less studied impact of ERPs has been their effect on hospital profitability. While these protocols are
resource-intensive and expensive to implement, we argue that they can lead to significantly improved margins.
This can be attributed
Methods: Carilion Clinic's enhanced recovery protocol was implemented in June of 2014. The protocol was
initially used only for colo-rectal cases, both elective and emergent. It contained over 20 pre-, intra-, and postoperative elements of surgical care. The input cost per patient was approximately $500. One year of length of
stay (LOS) data from the ERP cases was compared to contemporaneous controls that did not participate in the
ERP. Financial data was obtained from the hospital cost accountant. Average LOS and transfer data was
obtained from the EHR.
Results: Patients who underwent colo-rectal procedures and participated in the ERP had an average length of
stay (LOS) of 5.60 days, while the controls who did not participate in the protocol stayed for an average of 8.51
days. Financial analysis determined that a full year of compliance with ERAS protocols added over 2 million
dollars to the margin for a return on investment of over 10 to 1, mainly by increasing hospital capacity and
allowing more admissions.
Conclusion: The results demonstrate that ERPs significantly reduce LOS, increasing hospital patient capacity.
The higher patient load more than recoups ERP costs. Further collection and analysis of data aims to determine
the effect on complications, which also have cost saving potential.
86
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S22
Key Word(s): Basic Sciences, Cancer, Neurosurgery, Pharmacology, Oncology
Title: Using ACT1, a Connexin 43 Blocker, Against Glioblastoma Stem Cells
Authors: Pratik Kanabur, B.S., Virginia Tech Carilion School of Medicine, [email protected];
* Student’s Mentor: Zhi Sheng, Ph.D., Virginia Tech Carilion School of Medicine
Purpose: The prognosis for patients with glioblastoma (GBM) is dismal, with a median survival time of 14.6
months following aggressive treatment. Recent evidence suggests that the cells driving GBM malignancy and
recurrence are small populations of glioma stem cells (GSCs) which have been shown to be resistant to
therapeutics that target the entire tumor. Here we establish a method to isolate GSCs from surgically resected
tumor, determine capability of self-renewal and expression of stem cell markers, and gauge the therapeutic
response to temozolamide and ACT1, an inhibitor of connexin43.
Methods: Surgically resected tumor was digested and individual tumor cells were isolated and incubated in
serum-free stem cell media. Spheres were subject to the following assays for assessing their stem cell identity:
(1) Serial dilution assay to assess self-renewal; (2) Western blot of stem cell markers (NESTIN, NOTCH1, and
CD133) and the astrocyte marker GFAP. Verified glioblastoma stem cells were tested for their responsiveness
to ACT1 and/or temozolomide using the sphere formation assay.
Results: Some glioblastoma stem cells had strong capability to form spheres (as low as 4 cells). Glioblastoma
stem cells expressed a high level of NESTIN and NOTCH1, while levels of GFAP were low. Two stem cell
lines VTC 036 and VTC 064 were selected for drug treatment. The sphere formation capability of these stem
cells was significantly inhibited by ACT1 and temozolomide, but not each treatment alone.
Conclusion: Sphere formation is an effective way to isolate and enrich glioblastoma stem cells. The
combinational treatment of ACT1 and temozolomide inhibits glioblastoma stem cell sphere formation.
87
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S9
Key Word(s): General Surgery, Trauma Surgery, Basic Sciences
Title: Specifying parameters for real-time cognitive feedback during acute stress
Authors: Lauren R. Kennedy, Graduate student, Virginia Tech, [email protected];
* Student’s Mentor: Sarah Parker, PhD, VTCRI, VTCSoM, Carilion Clinic, Virginia Tech
Purpose: To inform the presentation timing of coping strategies, to be integrated into a visual real-time
biofeedback display for stress management. Findings will contribute to a device to be used during simulated
training scenarios for surgical fellows and residents.
Methods: We will enroll 20 participants at Roanoke College to play low and high stress versions of a firstperson shooter video game, Counter-Strike: Global Offensive.
We will gather skin temperature,
electrocardiography, and electroencephalography data, and present cognitive feedback in response to
physiological indicators of heightened stress in real-time. The experimental design involves a 4 (Fixed Time,
Fixed Physiology, Random, Control) x 2 (High Stress, Low Stress) within-subjects design. Cognitive
instructions will be displayed either at fixed time intervals during the game, triggered by a significant increase
in heart rate (3 standard deviations above baseline), on a variable time schedule, or not at all, respectively.
Stress measures immediately subsequent to the presentation of feedback will be compared to those at the time
of presentation.
Results: Data from Roanoke College students and alumni will be analyzed to determine that timing scheme of
cognitive feedback presentation most effective in reducing stress. Expected outcomes include a significant
physiological difference between Low and High Stress conditions, regardless of presentation timing, and a
significant difference in stress recovery following feedback presentation depending on the timing scheme.
Conclusion: Implications are broad, in that enhancing a feedback display to the skills and capabilities of
physicians could ensure better surgical performance under stress, and thereby improved patient outcomes.
Determining optimal parameters for information presentation in a tightly controlled setting prior to entering into
the applied setting of healthcare will allow for more reliable and accurate results. The ubiquity of biofeedback
today will continue to expand, making the need for systematic evaluation of design components critical.
88
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S6
Key Word(s): Informatics, Internal Medicine, Cardiology, Cardiac/Cardiovascular Surgery
Title: Incident Heart Failure Prediction in Adults within 1-year
Authors: Eric C. Kim, MS, Virginia Tech Carilion School of Medicine, [email protected]; Stephen
Morgan, MD, Carilion Clinic; Tim Larsen, DO, Carilion Clinic; Ram Rimal, MS, Carilion Health Analytics
* Student’s Mentor: David Sane, MD, Carilion Clinic - Chief of Cardiology
Purpose: Quantifying the risk of developing new onset heart failure (HF) has been difficult because of its
complex pathophysiology. A predictive model is warranted due to HF's high morbidity, mortality, and
economic burden. IBM's predictive model incorporated natural language processing to extract "unstructured
data" within patient encounter notes to identify those at risk of developing incident HF within 1-year.
Methods: IBM's SPSS program analyzed 227 inputs and over 20 million encounter notes to develop a Chi
Squared Automatic Interaction Detection Decision Tree Model. The model identified patients within Carilion
Clinic's electronic records with a significant risk score. A prospective cohort study was completed to identify
incidence of incident HF between 10/2013 through 10/2014.
Results: The predictive model identified 299,432 patients. 2,042 patients (1%) developed incident HF and
299,432 (99%) did not. The cohort was stratified by risk score into quintiles: 0-20%, 21-40%, 41-60%, 61-80%,
and 81-100%. The highest risk strata, 2nd and 3rd next highest risk strata had 1,560 out of 25,724 (6%),
4,323/190,494 (2%), and 112/83,214 (<1%) respectively with an outcome of incident HF or death.
We
measured parameters such as number of ED visits, echocardiograms, electrocardiograms, blood pressure,
A1C%, and others. Our study seeks to identify predictive and protective factors for incident disease.
Conclusion: These results underline the importance of early identification of at-risk persons of developing
incident HF. An interpretable and highly predictive model utilizing NLP implemented into electronic health
records can aid clinical decision-making and better stratify risk for intervention in lifestyle or risk factor
modification.
89
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S11
Key Word(s): Pediatrics, Implementation Science, Measurement, Radiology, Alternative/Complementary Approaches,
Process Improvement, Physical Therapy, Interactive Patient Care, Basic Sciences, Neurology
Title: Addressing Challenges in using fMRI in Children with Cerebral Palsy
Authors: Juniper J. Lee Park, B.S., M.T., Current M.D. Candidate, Virginia Tech Carilion School of Medicine,
[email protected]; Sharon L. Ramey, Ph. D. , Virginia Tech Carilion School of Medicine and
Research Institute; Jonathan M. Lisinski, M.S., Virginia Tech Carilion School of Medicine and Research
Institute; Stephen M. LaConte, Ph. D., Virginia Tech Carilion School of Medicine and Research Institute;
Harshawardhan U. Deshpande, M.S. Current Ph.D. Candidate, Virginia Tech Carilion School of Medicine and
Research Institute
* Student’s Mentor: Stephanie C. DeLuca , Ph. D., Virginia Tech Carilion School of Medicine and Research
Institute
Purpose: Creating functional magnetic resonance imaging (fMRI) methodologies that increase reliability and
validity of data has many advantages, particularly for researchers studying children with pathologies involving
brain lesions such as with Cerebral Palsy (CP). This project used a scanning protocol that included real-time
motion feedback to help children minimize head motion, and novel analysis procedures to compensate for
excessive head motion.
Methods: This descriptive study utilized 10 fMRI scans from adults without known pathology, 2 from
typically developing children (age range: 7-10 y.o.), and 3 from children (age: 7-10 y.o.) with cerebral palsy.
The scanning protocol involved a structural scan (5 min), a functional scan with real-time motion feedback (5
min), a resting-state scan (5 min), and a hand-motion motor-task scan (6 min). During the data analysis,
spherical regions of interest (ROI) was identified and drawn on the structural data for the adult fMRIs, based on
the precentral "handknob", typically associated with hand motion. To verify the accuracy of this ROI, we then
compared them with motor task activity for each subject.
Results: All subjects responded to the real-time feedback with improved head motion control secondary to
feedback. The ROI consistently demonstrated a high overlap with the motor-task activity across both
hemispheres: left hemisphere µ=74.28% (s.d. 29.45%); right hemisphere µ=74.83% (s.d. 22.22%).
Conclusion: Utilizing the identified ROI we were able to accurately capture the task-specific brain activity
without reliance on a functional localizer task.
90
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Applied or QA/QI
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S38
Key Word(s): Education, Simulation, Group Dynamics
Title: Clinical Simulation: Engaging Medical Students in Problem-Based Learning
Authors: Andrew Li, B.S., Virginia Tech Carilion School of Medicine, [email protected];
* Student’s Mentor: Helena Carvalho, Ph.D., Virginia Tech Carilion School of Medicine
Purpose: Problem-Based Learning (PBL) curricula allow medical students to approach preclinical material in
the context of clinical cases through group-facilitated learning. Student presentations on learning objectives is a
major determinant of curricula success with tutors who cannot "teach" being a key disadvantage of PBL. This
study seeks to improve PBL student teaching, learning, and retention through incorporation of interactive
elements into a simulated clinical environment.
Methods: We designed a 30 minute PBL presentation to six M2 students and one facilitator. Chest Pain
Differentials covered six clinical vignettes on various etiologies of chest pain with student patient/physician
scenarios followed by debrief. "Patient" student simulated the vignette containing HPI and key buzzwords.
"Physician" student proposed differentials of chest pain based on the patient interview. Cardiac Rehabilitation is
a simulation of a cardiac rehabilitation orientation with students as incoming admissions. Survey was conducted
four weeks later on effectiveness to learning and retention (scale of 1-5 with 1 being ineffective and 5 being
most effective) and pros/cons for both presentations.
Results: Survey results showed Chest Pain Differentials having 4.17 +- 0.75 (mean +-SD) and Cardiac
Rehabilitation: 3.83 +- 0.98 (mean +-SD). All six students in the group responded to the survey. No scores of 1
or 2 were reported. The two presentations differed by the same two students who rated 4 for Chest Pain
Differentials and 3 for Cardiac Rehabilitation. The remaining four students rated both presentations equal in
effectiveness.
Conclusion: Feedback was generally positive for both presentations. Chest Pain Differentials, which included
student interaction, scored higher than Cardiac Rehabilitation, which was presenter-driven. Students favored the
engaging component of both presentations, which helped with their learning and retention. Limitations include
the limited presentation time preventing further discussion and potential bias of peer-rating. Future directions
include expanding differential scope, giving clearer directions, and recruiting a larger student pool.
91
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S13
Key Word(s): Emergency Medicine, Patient Monitoring, Process Improvement, Informatics
Title: Risks of Discharging Emergency Department Patients with Abnormal Vital Signs
Authors: Aiwen W. Liu, BS, VTCSOM, [email protected];
* Student’s Mentor: Melanie K. Prusakowski, MD, Carilion Clinic, VTCSOM
Purpose: Abnormal vital signs are a common theme in cases of medical malpractice and unexpected death after
ED discharge. Our primary objective was to evaluate the risks of discharging patients from the ED with
abnormal vital signs. We hypothesized that patients discharged with abnormal vitals will have a higher rate of
return within 72 hours.
Methods: We examined a retrospective cohort of all CRMH ED discharges from January 2010 to August 2014.
Parameters for normal respiratory rate, heart rate, blood pressure, temperature, and oxygen saturation were
gathered from literature and stratified by age and gender. Primary outcome was 72-hour-return rate. Secondary
outcomes included percentage of patients with a full set of vital signs at discharge, percentage with at least one
abnormal vital sign at discharge, and disposition of returning patients.
Results: There were 331,216 total visits with 15,563 return visits from 11,166 patients (9464 adults, 1702
children). For adults with abnormal vitals, the return rate was 5.71% versus 5.68% (RR 1.0, 95%CI 0.89-1.14).
For children, 6.09% with abnormal vitals returned, compared to 3.53% in the normal group (RR 1.7, 95%CI
1.53-1.95). Most (96.73% adult, 60.96% pediatric) patients were discharged with a full set of vital signs. Adults
were more likely than children to be discharged with at least one abnormal vital sign (97.69% vs. 8.97%). The
most frequently abnormal vital sign was blood pressure for adults and temperature for children. Among patients
who returned, 17.72% of adults and 13.75% of children were admitted.
Conclusion: Abnormal vital signs at ED discharge are associated with a greater likelihood of 72-hour return in
the pediatric population. No difference was found in the adult population, despite a higher rate of discharge
with at least one abnormal vital sign. Future study to stratify which vitals are most associated with undesired
outcomes and their degree of abnormality is underway.
92
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S30
Key Word(s): Hematology, Orthopedics, Orthopedics Surgery, Trauma Surgery, Trauma
Title: Transfusion Setting and Venous Thromboembolism Risk: A retrospective Analysis
Authors: Kevin McGurk, BA, VTC School of Medicine, [email protected]; Eric Bradburn, DO,
Carilion Clinic- department of surgery; Mark Hamill, MD, Carilion Clinic- department of surgery
* Student’s Mentor: Mark Hamill, MD, Carilion Clinic- department of surgery
Purpose: Venous thromboembolism (VTE) represents a major clinical risk for patients who sustain traumatic
injuries and that risk has been shown to increase with the transfusion of packed red blood cells (pRBCs.) The
effect of transfusion timing on adverse outcomes has not been extensively examined. This study seeks to
determine whether there is an association between the setting of pRBC transfusion and the incidence of VTE.
Methods: The institution's trauma registry was queried for patients admitted between January 1, 2008 and
December 31, 2013 with isolated orthopedic injuries requiring operative fixation and transfusion. Variables
considered included age, gender, obesity, injury severity score (ISS), DVT chemoprophylaxis, transfusion
quantity, and documented VTE. Chart review was performed to determine the setting in which patients were
transfused (i.e. pre-, post-, or intraoperative). Pearson's chi-square test and Student's unpaired t-test were used to
analyze clinical and demographic data and logistic regression was used to measure the independent effect of
each variable on VTE formation.
Results: During the study period a total of 51 patients with isolated orthopedic injuries requiring surgical
intervention were transfused between one and four units of pRBCs. Twelve patients were transfused intraoperatively with 1 documented VTE (8.3%) and 39 were transfused pre- or post-operatively with 11 episodes of
VTE (28.2%) for an effect likelihood ratio of 4.19 (p =0.041). Logistic regression showed intraoperative
transfusion, female gender and BMI less than 30 to be independently associated with decreased VTE incidence.
Age, ISS and number of pRBC units transfused did not represent statistically significant VTE risk factors in the
study population.
Conclusion: Intraoperative transfusion is associated with a decreased incidence of VTE when compared to
patients transfused peri-operatively. Prospective study and further investigation into potential causal
mechanisms merit consideration and additional research to establish reproducibility and extend findings to other
patient populations is warranted.
93
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S34
Key Word(s): Emergency Medicine, Readmissions, Measurement, Statistics, General Surgery
Title: Transfer Distance and Time in Emergency General Surgery Outcomes
Authors: Kevin Mensah-Biney, Medical Student, VTCSOM, [email protected];
* Student’s Mentor: Sandy Fogel, MD, Carilion Clinic
Purpose: To determine the effect that distance and time has on the outcomes of patients transferred for
emergency general surgery.
Methods: Subjects were chosen retrospectively from emergency general and vascular surgery patients from
October 2012 to September 2014 who were transferred emergently to Carilion Roanoke Memorial Hospital
(CRMH). Data about demographics and surgical outcomes were available through data collected by the
National Surgical Quality Improvement Program (NSQIP). Surgical outcomes for our study include unplanned
intubation, unplanned readmission; death within 30 days, and post-operation complications. The transfer time of
subjects was determined by calculating the difference in minutes from the time CRMH was requested to accept
a transfer to the time of actual arrival. Determining the site of origin and using Geographic Information Systems
to calculate the linear distance to CRMH we determined the transfer distance. Time and distance variables will
be plotted separately with each complication. Our hypothesis is that longer transfer times and longer distances
would result in more surgical complications.
Results: The results detailing the relationship between complications and transfer time and distance are
pending. From the initial data collection, our study group has an average age of 63 and contains 47 subjects
with 24 females. Among the study group there were 11 deaths within 30 days, 5 unplanned readmissions, 11
septic shocks, 10 unplanned intubations, and 9 pneumonia cases. Among the group, the average transfer time
was 212 minutes and the average transfer distance was 35 miles.
Conclusion: The relationship between time and distance on patients transferred for emergency general surgery
has not been previously examined in the literature and this study was conducted to determine if any relationship
exists.
94
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S35
Key Word(s): Psychiatry, Behavioral Science, Health Economics, Readmissions, Chronic Care
Title: Using resilience to predict patient outcomes in a psychiatric population
Authors: Genevra Myers, BS, Virginia Tech Carilion School of Medicine, Class of 2017,
[email protected]; J. Eric Vance, MD, Department of Psychiatry and Behavioral Medicine, Carilion
Clinic-Virginia Tech Carilion School of Medicine
* Student’s Mentor: Anita Kablinger, MD, Department of Psychiatry and Behavioral Medicine, Carilion
Clinic-Virginia Tech Carilion School of Medicine
Purpose: To determine whether psychological resilience as measured by the Connor-Davidson Resilience Scale
(CD-RISC) can be used to predict medical care in the mid-term future.
Methods: Patients were recruited from the adult inpatient psychiatric unit of Carilion Roanoke Memorial
Hospital. A randomized version of the CD-RISC was administered to consented participants. After a subject's
discharge, their length of stay, number of medications, and number of diagnoses were determined from the
medical record. After a follow-up period of six months, the number of outpatient encounters, ED or urgent care
visits, hospital admissions, and days spent inpatient were determined. Using average medical costs for the US,
estimated healthcare cost for that six-month period was calculated for each subject. Linear regressions were
performed comparing CD-RISC score to all outcome measures individually.
Results: One hundred subjects were recruited, 58 female and 42 male. All eligible patients were approached
during their hospitalization. Exclusion criteria included involuntary admissions, inability to do a self-report
survey, and inability to give informed consent. CD-RISC scores ranged from 8 to 93, with a median of 58.
Linear regressions of immediate outcome data versus CD-RISC show a maximum R-squared value of 0.013.
Regressions of the follow up data show a maximum R-squared of 0.0208. Two of the subjects died between
discharge and gathering of the 6-month data, although time or cause of death is unknown.
Conclusion: No conclusions on the relationship between CD-RISC score and any of the outcome measures can
be drawn from the preliminary analysis. There appear to be several significant outliers in the follow-up data,
and removing these may uncover a trend in the remaining data. In addition, resilience may have predictive
power for subpopulations, so stratifying subjects by different demographics may lead to significant results.
95
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S23
Key Word(s): Process Improvement, Orthopedics, Orthopedics Surgery, Preventive Medicine, Interprofessionalism
Title: Addressing Delirium in Elderly Patients Following Elective Spinal Surgery
Authors: Alireza K. Nazemi, MS, Virginia Tech Carilion School of Medicine, [email protected]; Todd J.
Albert, MD, Hospital for Special Surgery; Jonathan J. Carmouche, MD, Carilion Clinic - Orthopedics; Anirudh K. Gowd,
BS, Virginia Tech Carilion School of Medicine
* Student’s Mentor: Caleb J. Behrend, MD, Carilion Clinic - Orthopedics
Purpose: Delirium is associated with lengthened hospital admission following elective surgery, as well as increased cost
and risk of readmission and accounts for $6.9 billion per year in medical costs. Early diagnosis and treatment of delirium
can reduce length of stay (LOS), in-hospital morbidity, hospital readmission, and patient care costs. Postoperative
delirium following spine surgery increases average LOS by >20 days and has a prevalence of 12.5- 24.3%. Currently,
studies for management of postoperative delirium following elective spinal procedures are not available. In the present
study, meta-analysis of treatment for postoperative delirium following elective spinal surgery was conducted and an
evidence-based algorithm for prevention, diagnosis, and treatment was developed based on current literature.
Methods: A literature review was performed using PubMed for observational studies, RCTs, and systematic reviews
between 1990-2015.
Results: Risk factors for development of delirium following elective spinal surgery include age, functional impairment,
preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, blood
loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively,
decreasing use of methylprednisolone and promoting movement with appropriate orthosis reduce delirium incidence
(p=0.0091). The Delirium Observation Screening (DOS) scale diagnoses and monitors delirium and is rated by nurses as
easier to use than the NEECHAM Confusion Scale (p<0.003). Haloperidol as needed is used widely in the treatment of
postoperative delirium. RCTs have shown that adding quetiapine results in resolution of delirium an average of 3.5 days
faster than haloperidol alone, along with decreasing agitation and LOS.
Conclusion: An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can
be used clinically for elderly patients undergoing elective spine surgery. Prevention and diagnosis involves a combination
of efforts from the anesthesiologist and postoperative clinical care team. Treatment of postoperative delirium may include
a therapeutic regimen of low-dose neuroleptic medications as needed.
96
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S24
Key Word(s): Orthopedics, Orthopedics Surgery, Measurement, Statistics
Title: Unilateral S2 Iliac Screws for Spinopelvic Fixation
Authors: Alireza K. Nazemi, MS, Virginia Tech Carilion School of Medicine, [email protected];
Jonathan J. Carmouche, MD, Carilion Clinic - Orthopedics; Anirudh K. Gowd, BS, Virginia Tech Carilion
School of Medicine
* Student’s Mentor: Caleb J. Behrend, MD, Carilion Clinic - Orthopedics
Purpose: The purpose of this study was to compare clinical and radiographic complications in the use of
unilateral S2 screws versus published literature on unilateral traditional iliac bolt fixation.
Methods: A series of ten patients with unilateral S2 screws placed for sacropelvic fixation were followed with
regards to maintenance of deformity correction, complication rates, and patient outcomes. Charts were reviewed
for the following complications: reoperation, L5-S1 pseudarthrosis, sacral insufficiency fracture, hardware
prominence, iliac screw loosening, and infection. The t-test, Pearson chi-square test, and Fisher exact test were
used to determine statistical significance compared to published rates of complications for unilateral iliac bolts.
Results: All patients were treated for de novo scoliosis and underwent unilateral S2 sacropelvic fixation. The
mean patient age was 67 (59-76). No early reoperations were observed for failure of fusion compared to 41%
rate of reoperation for unilateral iliac bolts. Early failure at the L5/S1 junction was not observed. There were no
sacral insufficiency fractures. One patient required admission for delirium. No infections were observed.
Deformity correction was maintained in coronal and sagittal plane. One patient noted complaints of hardware
prominence at the proximal junction. No hardware related complaints were reported at the lumbosacral junction.
Conclusion: Unilateral S2 screws demonstrated comparable rates of reoperation, iliac screw removal, and
postoperative infection to a unilateral iliac bolt. No pseudarthrosis and sacral insufficiency fractures were
observed. For spinopelvic fixation, unilateral S2 was associated with positive patient satisfaction and
comparably low complication rates.
97
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S36
Key Word(s): Behavioral Science, Pediatrics, Occupational Therapy, Health Promotion/Wellness, Psychiatry, Health
Psychology, Pharmacology, Neurology
Title: Relationship Between Sleep Hygiene and Behavior in Children with ASD
Authors: Seaton Ng, OTS, Jefferson College of Health Sciences, [email protected]; Tiffany A. Kuyper, MSOT,
Carilion Clinic; Glenn P. Kent, PhD, Jefferson College of Health Sciences; Khadija A. Randall, OTS, Jefferson
College of Health Sciences; Lauren R. Pittard, OTS, Jefferson College of Health Sciences; John P. McNamara,
DC, Jefferson College of Health Sciences and Virginia Tech Carilion School of Medicine; Stuart Tousman,
PhD, Jefferson College of Health Sciences
* Student’s Mentor: Glenn P. Kent, PhD, Jefferson College of Health Sciences
Purpose: The prevalence of autism spectrum disorder (ASD) is increasing. Although not a diagnostic criteria,
sleep problems are commonly associated with ASD. There are few records of research on the topics of
occupational therapy (OT), ASD, and sleep. Weaver (2015) conducted a systematic review that did not find any
articles that address OT practice regarding sleep interventions for children with ASD. More research is needed
for OT practitioners to develop effective treatments in the area of sleep. We aim to better understand the
relationship between sleep hygiene and daytime behavior in the ASD population. We predict better sleep
hygiene will positively correlate with better daytime behavior.
Methods: A descriptive and correlational research design will be implemented for this study in order to
describe the patterns and relationship of sleep participation and daytime behaviors in children with ASD. The
researchers will virtually distribute the surveys to caregivers of children ages 4-10 with ASD via SurveyGold®.
Quantitative data includes correlations between the two surveys. The Family Inventory of Sleep Habit (FISH)
assesses the child's sleep hygiene. The Strengths and Difficulties Questionnaire (SDQ) evaluates daytime
behavior. Qualitative data includes open-ended questions about the child's other diagnoses/medical conditions,
the child's medications, and the parent's perceived quality of sleep.
Results: Pearson correlations will be used between the overall scores of the FISH and the SDQ. To understand
the relationship between sleep hygiene and specific daytime behaviors, correlations will be used between the
overall score of the FISH and each of the five subscales of the SDQ. We predict the scores of the two surveys
will be negatively correlated.
Conclusion: In this study, we want to develop understanding of the factors that influence the relationship
between sleep hygiene and daytime behavior. Understanding this relationship will help enhance treatment by
identifying common difficulties leading up to sleep.
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Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S47
Key Word(s): General Surgery, Cancer, Histology/Histopathology, Oncology
Title: Lymph Nodes in Laparoscopic and Open Resections for Colorectal Cancer
Authors: Sean T. O'Boyle, medical student, VTCSOM, [email protected];
* Student’s Mentor: Keith R. Stephenson, MD, Carilion Clinic
Purpose: Since staging accuracy, and hence the need for adjuvant therapy is strongly predicated on the number
of mesenteric lymph nodes resected in colorectal cancer, survival is potentially impacted by the adequacy of
nodal resection. We sought to compare number of lymph nodes removed, mean tumor staging, and survival
time to determine if any differences existed between resection groups.
Methods: A retrospective chart review of patients at two community hospitals who underwent open or
laparoscopic resection for colorectal cancer between January 2008 and September 2013 was performed. Data
extracted included information such as age, clinical staging, surgical approach, number of lymph nodes
removed, and date and cause of death.
Results: Three hundred seventy-one (371) patients had open (mean age 67.9 years), and one hundred ten (110)
had laproscopic resections (mean age 64.3 years). There was no difference in the number of lymph nodes
resected between open (mean 17.85) and laparoscopic (mean 18.91) approaches (p=0.1711); however, patients
were found to have a higher mean tumor stage in the open (mean 2.41) as compared to the laproscopic (mean
2.17) groups (p=0.0189). There was no difference in late survival between the open and laparoscopic groups
overall (HR 1.52, p=0.208), but patients who had more lymph nodes removed tended to live longer (p=0.052).
Conclusion: No survival advantage was found between resection groups, but patients with more lymph nodes
removed tended to live longer, regardless of surgical approach. This is possibly due to more accurate staging,
but may be an independent effect.
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Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Case Study
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S25
Key Word(s): Psychiatry, Behavioral Science, Education
Title: Lilliputian hallucinations and alcohol withdrawal
Authors: Kwabena B. Owusu-Boateng, Medical Student, VCOM, [email protected]; Arvin
Bhandari, MD, Department of Psychiatry, Department of Veteran Affairs
* Student’s Mentor: Maureen Murphy-Ryan, MD, VTC
Purpose: To explore the differential diagnosis of psychosis in patients with chronic alcohol use through a
review of the literature and presentation of a case.
In the present case study, a 63 year old Caucasian male
with a reported history of heavy drinking presented with a second account of well-formed visual hallucinations
of small blue dismorphic people whose faces were twisted into hideous grimaces. He denied having any
auditory hallucinations or other delusions.
Methods: We searched the medical literature through PubMed and Medscape using terms including "alcoholic
hallucinosis", "alcohol AND psychosis" and "Lilliputian" for articles pertaining to the diagnosis and treatment
of isolated hallucination in alcohol withdrawal. We reviewed the complete medical record relating to a recent
consult for hallucinations in a person withdrawing from alcohol.
Results: The patient was treated with risperidone 0.5mg PO BID and lorazepam (dosage, method of
administration, and duration). One day following the initiation of withdrawal treatment, the patient stopped
exhibiting symptoms of Lilliputian syndrome.
Conclusion: Lilliputian hallucinations are a rare phenomenon that may occur as a result of excessive alcohol
consumption and is usually associated with both visual and audio miniaturized hallucinations. In the current
case, it took the form of only visual hallucinations during alcohol withdrawal and treatment with low dose
atypical antipsychotic and benzodiazepine resulted in the rapid termination of symptoms.
100
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Qualitative
Abstract Type: Case Study
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S33
Key Word(s): Genetics, Histology/Histopathology, Gastroenterology, General Surgery
Title: Ulcerative Colitis and Crohn's Disease in the Same Patient
Authors: Christopher R. Reed, B.S., Virginia Tech Carilion School of Medicine, [email protected];
Douglas J. Grider, M.D., Virginia Tech Carilion School of Medicine
* Student’s Mentor: Sandy L. Fogel, M.D., Virginia Tech Carilion School of Medicine
Purpose: To describe a very rare case of pathologically-proven ulcerative colitis with metachronous
development of Crohn's disease nearly 30 years later, and to highlight its place among relevant recent genetics
literature suggesting that inflammatory bowel diseases are primarily genetically-driven manifestations along a
phenotypic spectrum rather than discrete disease states.
Methods: This 27 year-old white female was referred to surgeon SLF for therapeutic total proctocolectomy
with J-pouch reconstruction in 1985. She subsequently had a small bowel enterectomy in 2014 for obstruction
from strictures and was diagnosed with active Crohn's disease based on pathologic and clinical findings at that
time. Of note, the same surgeon (SLF) performed both procedures and provided much of her care throughout
her course.
Results: Pathologic reports and glass slides from the patient's 1985 proctocolectomy were obtained. In these
reports, gross specimens and histopathology were consistent with the findings of typical active ulcerative colitis,
including mucosal inflammation without evidence of strictures, fistulae, involvement of submucosa, or
transmural inflammation. Independent review of these slides by a fellowship-trained gastrointestinal pathologist
(DJG) similarly found convincing histology for ulcerative colitis. The same pathologist also noted that her 2014
gross and histopathologic specimens were unequivocally characteristic of markedly active CD. Of note, the
disease was not in the J-pouch, which is a separate and more common phenomenon.
Conclusion: Patients with well-documented ulcerative colitis and Crohn's disease are rare, and we believe that
our patient's case contributes to the developing evidence for ulcerative colitis and Crohn's disease as
pathological correlates of primarily genetically-determined disease states.
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Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S44
Key Word(s): General Surgery, Quality Improvement/Quality Assurance, Readmissions
Title: Narcotics Dependence in Patients Undergoing Colo-rectal Surgery
Authors: Julia M. Ross, BA, VTCSOM, [email protected];
* Student’s Mentor: Sandy Fogel, MD, Carilion Clinic
Purpose: Carilion Clinic's patient population is heavily burdened by chronic narcotics use. Southwest Virginia
has endemic levels of chronic narcotics use, and narcotic-related mortalities have been found to be twice the
state average in Roanoke city. It is even higher in surrounding southwest counties. The National Surgical
Quality Improvement Project (NSQIP) systematically collects data regarding surgical outcomes for the purpose
of risk adjustment, but does not currently collect data regarding the impact of pre-operative narcotics
dependence. The purpose of this study is to determine if preoperative narcotics dependence is associated with
negative post-surgical outcomes among colo-rectal surgical patients.
Methods: Approximately 350 patients who underwent colo-rectal surgery at Carilion Clinic within a 15-month
period of 2014 - 2015 have been retrospectively identified for inclusion in this case-control study. Patients have
been evaluated for preoperative narcotics use that extends for at least 30 days prior to their surgical date. Postoperative outcomes established by NSQIP will be assessed, including, but not limited to, length of hospital stay
and need for re-admission or re-operation within thirty days.
Results: Analysis will examine the difference in post-operative adverse events between the narcotics-exposed
and narcotics-naïve group, using the previously defined NSQIP variables. Based on related research in the field,
we anticipate that statistical analyses will demonstrate that patients who have been using narcotics for at least
30 days prior to colo-rectal surgery may exhibit significantly worse surgical outcomes than a demographically
similar control group.
Conclusion: This work-in-progress project will expand the quantification of how chronic narcotics use broadly
affects surgical outcomes. The anticipated demonstration that narcotics use adversely affects surgical outcomes
could be submitted to NSQIP in an attempt to hone national current risk assessment standards.
102
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S20
Key Word(s): Orthopedics, Orthopedics Surgery, Pharmacology, Quality Improvement/Quality Assurance
Title: Effect of Exparel on Pain Management in Total Knee Arthroplasty
Authors: Grace B. Schumer, BS, Virginia Tech Carilion School of Medicine, [email protected];
Matthew Stover, DO, Carilion Clinic; John Sloboda, MD, Carilion Clinic; Michael Wolfe, MD, Carilion Clinic;
Gina Woods, LPN, Carilion Clinic; Carol Cdebaca, PA, Carilion Clinic
* Student’s Mentor: John W. Mann, MD, Carilion Clinic
Purpose: Our study aims to show utilizing wound infiltration with long acting liposomal bupivacaine during
total knee replacement will shorten length of stay compared to patients treated with standard bupivacaine with
or without spinal narcotic. We will evaluate postoperative pain, narcotic usage, and complications.
Methods: The first 100 patients are reported on looking at the use of liposomal bupivacaine in total knee
arthroplasty. Patients were randomized into 3 groups: bupivacaine and a spinal anesthetic with narcotic,
liposomal bupivacaine and spinal anesthesia without narcotic, and bupivacaine and a spinal anesthetic without
narcotic. Patients are then monitored six weeks postoperatively for pain, physical function, and complications.
Results: A trend towards a decreased length of stay (LOS) in the liposomal bupivacaine with a mean LOS of
1.57 compared to bupivacaine with spinal narcotic LOS of 1.70 and without spinal narcotic LOS of 1.65, not
statistically significant p = 0.734. Reported pain scores were no different among groups. The amount of
narcotic used during by each group was highest in the liposomal bupivacaine group although not statistically
significant ( p = 0.375). Nausea/vomiting was most common in Group 1. Itching was most common in Group
1. There were 4 transient peroneal nerve palsies, 3 cases of urinary retention, one ileus and one deep vein
thrombosis noted.
Conclusion: Liposomal bupivacaine showed a trend towards decreased LOS, but was not statistically
significant. No difference in pain scores was reported and the liposomal bupivacaine group showed the highest
narcotic usage despite reports of a longer duration of action of liposomal bupivacaine leading to less
perioperative pain. Advocates of spinal anesthesia with narcotic have cited less perioperative pain but this was
not demonstrated. Currently we cannot justify the extra cost of liposomal bupivacaine as an adjunct for
perioperative pain management in TKA
103
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Basic
Methodology: Mixed Methods
Abstract Type: Work in Progress
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S17
Key Word(s): Occupational/Rehabilitative/Physiatry, Statistics, Quality Improvement/Quality Assurance, Occupational
Therapy
Title: Examining Patient Satisfaction as Reliable Outcome Measure in Occupational Therapy
Authors: Rachel Singleton, OTS, Jefferson College of Health Sciences, [email protected]; Casey L.
Bradshaw, OTS, Jefferson College of Health Sciences; Courtney B. Driver, OTS, Jefferson College of Health
Sciences
* Student’s Mentor: David A. Haynes, D.H.Sc. OTR/L, Jefferson College of Health Sciences
Purpose: To examine the psychometric properties of a survey used to measure patient satisfaction with
Occupational Therapy (OT) services received in the outpatient setting. The psychometric properties of this
survey have been previously researched and the tool was found to be reliable for measuring patient satisfaction
with OT services in skilled nursing facilities, acute care, and inpatient rehab settings.
Methods: Participants were recruited through a community flyer and an online version of the flyer was posted
to Facebook. Any individual who had received outpatient OT services within the last 12 months was invited to
complete the online survey. The survey was accessible through a direct link online, a scanable QR code on the
flyer, or a tear-off tab with the URL. Participation was completely voluntary and ended upon submitting the
survey.
Results: Previous research studies examining the reliability of this survey have used Cronbach's alpha as a
measure of internal consistency. The data collected will be analyzed using Cronbach's alpha as the statistical
measure to determine the reliability of this survey in measuring patient satisfaction with OT services in the
outpatient setting. Cronbach's alpha is considered a measure of scale reliability.
Conclusion: We anticipate that the data will allow us to draw the conclusion that the survey is a reliable tool
for measuring patient satisfaction with OT services in the outpatient setting. From this conclusion we can
further clarify past research on the reliability of this survey tool as a measure of patient satisfaction for OT
services across a variety of settings.
104
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?Yes
Abstract: S12
Key Word(s): Health Economics, Health Promotion/Wellness, Cardiology, Cardiac/Cardiovascular Surgery
Title: An Algorithm Based Protocol for Treating Atherosclerotic RAS
Authors: Nikki Sood, BA, Virginia Tech Carilion School of Medicine , [email protected];
* Student’s Mentor: Timothy C. Ball, MD, Ph D, Carilion Clinic Cardiology
Purpose: Treatment recommendations for patients with asymptomatic critical atherosclerotic renal artery
stenosis(ARAS) are controversial. In 2010, Carilion Clinic Vascular Medicine Clinic(CCVMC) implemented an
algorithm-based treatment protocol that emphasizes maximal medical management for critical ARAS with
percutaneous renal revascularization(PRR) reserved for: ages 18 to 90 with duplex doppler peak systolic
velocity >400 cm/s or diastolic velocity >100cm/s and/or resistant hypertension [persistent systolic blood
pressure(BP) >160mm Hg on maximum dose of 3 or more medications] or acute renal failure or hypertensive
emergency with end organ damage. This study aims to compare the outcomes of patients treated utilizing
CCVMC's algorithm with patients treated by the standard of care (SOC).
Methods: Carilion Clinic EMR was queried for patients who underwent PRR from 2010-2015. Patients treated
by the SOC and the algorithm-based protocol were compared and a detailed chart review was conducted.
Information on demographics, intervention and patient outcomes post PRR were collected and analyzed.
Results: Th algorithm group experienced a 45 +/- 7.5 mm Hg decrease in systolic BP and a 13.8 +/- 7.0 mm
Hg decrease in diastolic BP that persisted for 4 months of follow-up, an average 10.3 +/- 3.3 ml/min/1.73m2
increase in GFR and no hospitalization for hypertensive emergency over the same time period. The SOC group
experienced a decrease in the systolic BP of 13.1 +/- 8.9 mm Hg, the diastolic BP of 7.1 +/- 4.0 mm Hg, and a
decrease in GFR of 3.4 +/- 3.4 ml/min/1.73m2.
Conclusion: The algorithm utilized in CCVMC is effective and results in a marked reduction in systolic and
diastolic BP, preserves renal function and decreases re-hospitalizations when compared to SOC PRR. SOC
intervention shows an insignificant decline in BP and evidence of worsened renal function. This study provides
clinicians with a formula to help optimize outcomes in patients with critical ARAS.
105
Carilion Research Day 2016 Abstract Form
For Internal Use
Research type: Clinical
Methodology: Quantitative
Abstract Type: Completed Project
First author listed status: Student*
Consider for Rapid Communication Presentation?No
Abstract: S19
Key Word(s): Statistics, Informatics, Gastroenterology, Alternative/Complementary Approaches, Allergy
Title: Development of Machine Learning Algorithm as Diagnostic Tool for EoE
Authors: Mark L. Tenzer, student, Roanoke Valley Governor's School, [email protected]; Kristin Knight,
MS, Carilion Clinic, Manager, Basic Science Research Laboratory
* Student’s Mentor: Michael Hart, MD, Chair, Carilion Clinic Pediatric Gastroenterology
Purpose: To develop a novel diagnostic methodology, using only non-invasive data and support vector
machines (SVM) machine learning, for eosinophilic esophagitis (EoE), an allergic inflammatory disease whose
diagnosis currently requires expensive, repeated, and invasive esophagogastroduodenoscopies (EGDs) and
esophageal biopsies.
Methods: Patients presenting to Carilion's pediatric gastroenterology clinic with suspected EoE and planned
EGDs and biopsies were prospectively enrolled. Diagnoses and survey symptomology, standard-of-care
complete blood count (CBC), allergen-specific immunoglobulin E (IgE), and esophageal biopsy data were
collected. ELISAs determined eotaxin-3 and eosinophil-derived neurotoxin levels in patients' serum. SVM was
"trained" with some patients to "learn" to diagnose EoE, as defined by the biopsy results, and "tested" with
others to assess whether the model was correct. Accuracy, sensitivity, and specificity were calculated using
leave-one-out cross-validation (LOOCV): with n patients, an SVM model was trained with n-1 patients and
tested with one patient "left out." This procedure was repeated for each patient, and the results were averaged.
To select training features for the model, all features were initially included, and subsequently, combinations of
features were temporarily removed from the model, which was re-trained. The combinations whose removal
most improved the model were excluded.
Results: Twenty-three patients were enrolled (7 EoE and 16 control). The final model incorporated eotaxin-3
and EDN ELISAs, 18 survey questions, IgE averaged across all allergens, 15 CBC results, and 8 symptoms.
The final model had LOOCV accuracy, sensitivity, and specificity equal to 1: all patients were correctly
classified. Statistical significance was assessed with an approximate permutation test (N=10,000). For accuracy,
sensitivity, and specificity respectively, the approximated p-values were 0.0000, 0.0005, and 0.0011, much
lower than alpha=0.05.
Conclusion: These results suggest that algorithms utilizing non-invasively obtained data successfully diagnose
EoE, with the potential to substantially alleviate the diagnostic burden of EoE on patients and cost of care.
106