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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. 98 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. 99 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. 101 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