Book of Abstracts:
Research Day 2013
Table of Contents:
Preface
Program
Abstracts
2
Preface
April 25, 2013, marks the sixth annual Carilion Clinic Research Day and my first in my role
as Senior Director of Research. I am really excited by the record number of abstract
submissions we had this year and the high quality content within this abstract book. While
we welcomed any research being conducted by, and in partnership with, Carilion Clinic
researchers, nurses, pharmacists, and physicians, we also wanted to highlight translational
research and its important role in medical relevance and patient-centered care. In this
regard, we invited an outstanding group of speakers from Virginia Tech Carilion Research
Institute (VTCRI) and Carilion Clinic and asked each to present on the health outcomes
impact of their work. We’d like to thank Robert G. Gourdie, Ph.D., VTCRI; Michael S.
Kolodney, M.D., Ph.D, Carilion Clinic; and Thomas M. Kerkering, M.D., Carilion Clinic,
each for their effort in putting together engaging and interesting talks for us!
In addition to our excellent speakers, this event would not be possible without the time
and dedication of the Organizing Committee and Abstract Review Committee. In
particular, the tireless efforts of Beth Harber in keeping everyone on track, motivated, and
focused on both the science and logistics of Research Day.
Thank you for attending the Research Day 2013 and we hope to see you again next year.
Sincerely,
Paul Estabrooks, PhD
Senior Director of Research, Carilion Clinic
Research Day 2013 Planning Committee:
Paul Estabrooks, PhD
Beth Harber
Daniel Harrington, MD
Kristin Knight
Kye Kim, MD
3
Research Day 2013 Abstract Review Committee
Timothy Ball, MD
Beverly Brown, MD
Helena Carvalho, PhD
Rebecca Clark, PhD
Francis Dane, PhD
Sonya Echols, PhD
Evelyn Garcia, MD
Jonathan L. Gleason, MD
Amanda Hansen, PharmD
Robert Herbertson
Ali Iranmanesh, MD
Meghan Kamrada, PharmD
Anita Kablinger, MD
Colleen Kraft, MD
Sandra Malakauskas, MD
Stephen Morgan, MD
Andre Muelenaer, MD
Robert Slackman, MD
Bridgette Smigiel, PharmD
Michelle Theus, PhD
Stuart Tousman, PhD
Research Day 2013 Poster Judges:
Adegbenga Bankole, MD
Damon Kuehl, MD
Leslie LaConte, PhD
Richard Seidel, PhD.
4
Program
11:30 am-1:30 pm
Poster Presentations and Judging
1:45-2:00 pm
Welcome
Paul Estabrooks, PhD
Senior Director of Research, Carilion Clinic
Poster Awards
Kye Kim, MD
Physician, Roanoke Psychiatry, Carilion Clinic
2:00-2:50 pm
Novel Wound Healing Drugs
Robert G. Gourdie, PhD
Professor and Commonwealth Research Commercialization Fund
Eminent Scholar, VTCRI
Director of Emergency Medicine Research, Carilion Clinic
2:50-3:40 pm
Discovery and Development of a Drug to Treat Double Chins
Michael S. Kolodney, MD, PhD
Section Chief of Dermatology, Carilion Clinic
Associate Professor of Medicine at VTCSOM
3:40-4:30 pm
An Applied Academic Approach to the Fungal Meningitis Outbreak
at Carilion Roanoke Memorial Hospital
Thomas M. Kerkering, MD
Section Chief of Infectious Diseases, Carilion Clinic
Faculty at VTCSOM
4:30 pm
Adjourn
5
Table of Contents:
Page Author
10
Konstantinidis Agathoklis
Title
11
Anthony Baffoe-Bonnie
The evolution of Acinetobacter baumannii incidence and
resistance profile over a 7 year period in a tertiary care community
hospital in South West Virginia. Does antibiotic use tell the whole
story?
12
Caleb Behrend
Scapular Dyskinesis Following Displaced Fractures of the
Midshaft Clavicle
13
Caleb Behrend
Smoking Cessation and the Aging Spine Patient
14
Soheir Boshra
15
Eric Bradburn
Early Testing and Intervention for Urinary Tract Infection in a
Nursing Facility
Pre-Trauma Functional Independence Measure Scores Predict
Outcome in Geriatric Trauma Victims
16
Justin Brooks
A molecular mechanism regulating the timing of corticogeniculate
innervation.
17
Jonathan Carmouche
Allogenic and Autogenous Bone Graft is Affected by Historical
Donor Environmental Exposure
18
Jonathan Carmouche
Hospital Readmission after Hip Fracture
19
Lily R. Colpitts
Defining the role of RahU protein in pathogenesis of
Pseudomonas aeruginosa in a murine lung infection model
20
Nathaniel DeYoung
Predictors of Successful Completion of Cardiac Rehabilitation
Following a Cardiacvascular Event
21
Courtney Dickerson
Effect of Discharge Medication Reconciliation by Pharmacists on
Prevention of Unintended Medication Discrepancies
22
Megan P Donohue
Neonatal Mortality, Delivery Methods, And Characteristics Of
Surviving Neonates In Rural Ghana
23
Harry C. Dorn
Radiolanthanides Encapsulated in Fullerenes: A New
Radiopharmecutical Platform
24
Mack D. Drake
Dedicated Trauma/Surgical Critical Care Team is associated with
improved outcomes: The Roanoke Story
25
Vince Faridani
Association of Serum Sodium Levels with Mortality in NonDialysis Dependent Chronic Kidney Disease
Use of NSQIP to Reduce Surgical Mortality: Implementation of
Intensive Pre-operative Screening and Intervention
6
26
Jeeshan Ali Faridi
Investigation of airway location as a risk factor for endobronchial
fire with the use of neodymium-doped yttrium aluminum garnet
(ND:YAG) laser photoresection in a swine model
27
Quentin S. Fischer
Stimulation pattern differentially affects synaptic plasticity
outcome in young adult rats with and without mild traumatic brain
injury (mTBI).
28
Olivia M Fitch
Role of experience in formation of heterogeneous plasticity
outcomes in two pathways of mouse V1 in response to a fixed
time delay conditioning protocol
29
Sujuan Guo
A genome-wide RNA interference screen identifies autophagy
mediators with therapeutic implications in chronic myeloid
leukemia
30
Ellen M. Harvey
31
Geoffrey T. Jao
Non-invasive assessment of the left ventricular end-diastolic
pressure using portable ultrasound measurements of the right
internal jugular vein
32
Jose M. Jimenez
Utilizing Statistical Process Control charts and highly-detailed
simulation for biosurveillance in intensive care units to control
healthcare associated infections
33
Djanenkhodja Kalikulov
Ryanodine and IP3 Receptors Shape Intracellular Calcium Signals
Shifting Synaptic Plasticity Outcomes in Visual Cortical
Pyramidal Neurons.
34
Kye Kim
Caregiver and care recipient agency: transitions from cure to care,
and back again
35
Nick LeBlanc
The Acute Care Surgery (ACS) Hybrid Model: A Shared
Dedicated System of General and Trauma Surgeons Improves
Hospital Length of Stay, Hospital Costs, and OR Utilization
36
Matthew B. Levine
Variation in Use of All Types of Computed Tomography by
Emergency Physicians
37
Kaylene J Logan
Turnaround Times in Breast Cancer: From Screening to
Diagnosis to Treatment
38
Lindsay Makara
Shortening the Time to Initial Antibiotic Administration in the AtRisk Newborn at Carilion Roanoke Memorial Hospital (CRMH)
39
Michael Maloney
Effects of debridement of the biceps tendon insertion and the
superior labrum on stability of the shoulder joint in a cadaveric
concavity-compression model.
A Comparison of Traditional and Simulation TeamSTEPPS®
Training Methods on Nurse Performance Related to Failure-toRescue
7
40
Eric Marvin
Unilateral Cervical Facet Fractures Associated with Focal
Kyphotic Deformity: Predicting the Need for Surgical
Intervention.
41
Niraj Niraula
The Impact of Chronic Opioid Therapy on Obstructive Sleep
Apnea Disease Treated with Positive Airway Pressure
42
Melanie K. Prusakowski
Trends in Emergency Department Abscess Care
43
Natalie Rochester
Is There a Seasonal Variation in Breast Cancer Screening in the
Roanoke Valley and if so, why?
44
Thomas Ruscher
An Ultrasonic Airflow Sensor for Improved Apnea Monitoring of
Pediatric Tracheostomy Patients
45
Mitra Sahebazamani
Decreasing use of continuous sedation in the ICU: Identifying
obstacles to adopting a protocol
46
Hemendra S Sarda
Improvement in Medicare Wellness visits at Roanoke Salem
Family Medicine (RSFM) clinic.
47
Kimberlee A. Saunders
Patient Preferences and Characteristics Influence Development of
a Diabetes Prevention Program in Southwest Virginia
48
Jessica L. Schad
Time to target temperature: A comparison of two therapeutic
hypothermia protocols
49
Richard Seidel
Telepsychiatry in the Emergency Department: Improving Access
and Efficiency in the Care of Psychiatric Patients
50
Caroline Preas Siemer
Evaluation of the Use of Stress Ulcer Prophylaxis in a Trauma
Population Across Transitions of Care
51
Robert Slackman
Prevalence of intrauterine abnormalities discovered on
sonohysterogram in an infertility practice
52
Jianmin Su
Contributions of VLDLR and LRP8 in the establishment of
retinogeniculate projections
53
Jessica L Toms
Ultrasound as a modality in detecting elbow effusions: an
assessment of effusion views in combination with a provocative
technique
54
Shari A. Toomey
Implementation of the neotech ram cannula in the pediatric
intensive care unit
55
Amber Warren
Team Based Approach to Hypertension: A Pilot for the Million
Hearts Campaign
56
Phyllis Whitehead
Moral Distress: A Common Phenomenon Among All Clinicians
8
57
Diana Willeman-Buckelew
Relationship between Knowledge, Perceived Risk, and Influenza
Vaccine Uptake in Undergraduate Health Science Students
58
Xin Zhong
Multiplanar Real Time Ultrasound Guided Infraclavicular
Subclavian Vein Catheterization
9
Carilion Research Day 2013 Abstract Form
RF 1
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Title: Use of NSQIP to Reduce Surgical Mortality: Implementation of Intensive Pre-operative Screening
and Intervention
Authors (Include First Author’s e-mail address): Konstantinidis Agathoklis, MD
(athoskonstan@gmail.com), Carilion Clinic; Fogel Sandy MD, Carilion Clinic; Jim Jones RN, BSN,
Carilion Clinic; Gilliam Brenda, RN, Carilion Clinic; Vanlaeken Amanda, MS, Carilion Clinic
* Student’s Mentor: N/A
Purpose: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP)
data at our institution indicated that surgical mortality was significantly higher than expected. The purpose
of this study is to examine the effect of implementation of a strict, intensive pre-operative screening and
intervention process on post-operative mortality at our institution, as measured by NSQIP.
Methods: Carilion Roanoke Memorial Hospital (CRMH) is a 763 bed tertiary care hospital serving a
population of one million people in southwest Virginia. Data was collected for NSQIP at CRMH from
07/2007 to 12/2011. In January 2010 a new pre-operative process was implemented to include risk
assessment and intervention for hypertension, cardiac disease, pulmonary disease, diabetes, renal disease
and obstructive sleep apnea.
Results: Before initiation of our pre-operative program (07/07 to 12/09), odds ratios (OR) for 30-day
mortality in all cases were significantly higher than expected (1.40, 1.43, 1.58 and 1.56 in successive
reporting periods). Beginning with the first report after implementation of the pre-operative screening
program, CRMH showed a progressively decreasing OR for overall 30-day mortality (1.26, 1.19, 1.14, and
.86), with similar reductions in both General (.92) and Vascular (.92) surgery for the last year.
Conclusion: The implementation of an intensive pre-operative screening and intervention process in our
institution was accompanied by a significant decrease in the 30-day mortality for General surgery and
Vascular procedures, as measured by NSQIP.
10
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Title: The evolution of Acinetobacter baumannii incidence and resistance profile over a 7 year period in a
tertiary care community hospital in South West Virginia. Does antibiotic use tell the whole story?
Authors (Include First Author’s e-mail address):
Anthony Baffoe-Bonnie MD1, (awbaffoebonnie@carilionclinic.org), Marissa Grifasi PharmD2, Jayashima
Rao Ph.D1,Thomas Kerkering MD1 and 3
1
Internal Medicine/Section of Infectious Diseases/ Carilion Clinic, Virginia Tech Carilion School of
Medicine, Roanoke, VA, 2Department of Pharmacy, Carilion Clinic, Roanoke, VA and 3Medical Director
Hospital Infection Control, Carilion Clinic, Roanoke, VA.
* Student’s Mentor:
Purpose: The literature on the interplay of changing trends in the “defined daily dosing” of
cephalosporin’s, monobactams, carbapenems, aminoglycosides, quinolones, beta-lactam/beta-lactamase
inhibitor combinations and the incidence of multi-drug resistant-Acinetobacter in the healthcare system is
sparse. This is especially so for the USA. The objective of this study was to evaluate the trends in the use of
candidate antibiotics and the resistance pattern of Acinetobacter baumanii to the same antimicrobials over
the 2006 -2012 time period in an 800 bed hospital in South-West Virginia.
Methods: This retrospective analysis of inpatient clinical culture data (culture obtained for clinical care of
patient) spanned from January, 2006 - August, 2012. Only the first Acinetobacter baumannii isolate
recovered during an admission period per patient was included. Resistance rates to the candidate antibiotics
were calculated for each month during the study period. Measurement of antibiotic use was achieved using
the defined daily dose (DDD) concept. This was further adjusted for patient volume by calculating
DDD/1000 patient-days. Pearson’s correlation was used to assess the statistical significance of changes in a
candidate antibiotic use and subsequent change in resistance of Acinetobacter baumannii to the antibiotic.
Results: A total of 350 clinical isolates were obtained during the study period. There was seasonality to the
occurrence of Acinetobacter infection. There was a rise in resistance to most of the candidate antibiotics
over the study period. In contrast, the use of the same antibiotics either stayed the same or decreased during
this study period with the notable exception of piperacillin-tazobactam, whose use increased as did it’s
resistance
Conclusion: An increasing trend in Acinetobacter baumanii resistance pattern over the study period was
noted particularly after the clonal outbreak of a multi-drug resistance strain in 2009. There could be other
drivers to resistance that merit further investigation using combined molecular and epidemiologic research
tools.
11
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Title: Scapular Dyskinesis Following Displaced Fractures of the Midshaft Clavicle
Authors (Include First Author’s e-mail address): Caleb Behrend,MD+‡
(Caleb_Behrend@URMC.Rochester.edu); JonathanCarmouche, MD‡; Tanya Beiswenger+; Christopher
English+; Edward Shields+; Michael Maloney, MD+; IlyaVoloshin, MD+
+University of Rochester Department of Orthopaedics, Rochester, NY
‡Carilion Clinic Orthopaedics, VTCSOM, Roanoke, VA
* Student’s Mentor:
Purpose: This study evaluated rates of scapular dyskinesis and SICK scapula syndrome in patients
following treatment of displaced midshaft clavicle fractures.
Methods: Scapulothoracic motion was evaluated for 24 patients with displaced, shortened, comminuted
midshaft clavicle fractures with a mean follow up of 24 months. Patients reported outcomes were
documented using the SICK(Scapular malposition, Inferior medial border prominence, Coracoid pain and
malposition, anddyskinesis of scapular movement) Scapula Rating Scale, Simple Shoulder Test, SF36, and
three VAS pain scales . Radiographic and clinical nonunion was documented as well as operative or non
operative treatments provided to each patient. During the physical exam objective measures
included assessment of scapular malposition, shoulder range of motion, and strength measurements using a
hand dynamometer. Statistical analysis was performed using SPSS® Statistics 20 (IBM® Chicago, Illinois)
software for descriptive statistics, and multivariate statistical analysis. Post hoc analysis was performed
when appropriate.
Results: Of the 24 patients, 9 (37.5%) had scapular dyskinesis with the arms at rest. For these patients the
mean SICK Scapula Rating Scale score was 7.1 points compared to 2.2 for those without scapular
dyskinesis (P<0.001). Patients with observed scapular dyskinesis reported increased pain with VAS pain
scales with worst pain of 2.9 compared with 1.1 for patients with no observed dyskinesis (P=0.02). SF36
composite and subscales were decreased for patients with observed scapular dyskinesis (p<.05). These
differences were clinically significant.
Objective measures included decreased strength (P=0.02) and range of motion (P=0.03) on physical exam
for external rotation. Differences in simple shoulder test were observed but did not reach clinical
significance.
Conclusion: Following treatment for displaced midshaft clavicle fractures 37.5% of patients were found to
have scapular dyskinesis at 2 years follow up. These patients reported a clinically meaningful increase in
pain with decreased scores on patient reported outcomes for functional and quality of life measures.
12
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Title: Smoking Cessation and the Aging Spine Patient
Authors (Include First Author’s e-mail address): Caleb J. Behrend, MD+‡,
(Caleb_Behrend@URMC.Rochester.edu); Jonathan Carmouche, MD‡, Lauren M. Ritter+, Ellen Coyne,
MS+, Glenn R. Rechtine II, MD+
+University of Rochester Department of Orthopaedics, Rochester, NY
‡Carilion Clinic Orthopaedics, VTCSOM, Roanoke, VA
* Student’s Mentor:
Purpose: Smoking is a risk factor for back pain. Smoking cessation is associated with improved spinal
fusion rates and improved pain and disability scores. We examined rates of smoking cessation and their
effect on pain and disability. We hypothesized that smoking cessation would be less likely in and less
effective in reducing pain in older patients.
Methods: A prospectively maintained database record for 6,779 patients treatment for painful spinal
disorders was examined with regard to smoking history, age and the patient’s assessment of pain on visual
analog scales during the course of treatment. Confounding factors including secondary gain, BMI and comorbid depression were also examined. The mean duration of care was eight months. Multivariate
statistical analysis was performed with independent variables including smoking status, secondary gain
status, gender, treatment type, depression and age.
Results:
Of patients seeking care in an ambulatory setting for painful spinal disorders 8.9% over the
age of 55 smoked compared with 23.9% of those under 55 years of age. Rates of smoking cessation did not
differ for those older than 55 years of age (25.1%) and younger patients (26.1%). Current smokers in both
age groups reported greater pain than those who had never smoked (P<0.001). Those who quit smoking
during the course of care reported greater improvement in pain than those who continued to smoke (P =
0.009). The mean improvement in VAS pain ratings were clinically significant in patients in all three
groups of non smokers. Those who continued smoking during treatment had no clinically
Conclusion: The present study supports the need for smoking cessation programs given a strong
association between improved patient reported pain and smoking cessation. Older patients are less likely to
smoke and equally likely to quit smoking.
13
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F1
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Title: Early Testing and Intervention for Urinary Tract Infection in a Nursing Facility
Authors (Include First Author’s e-mail address): Soheir Boshra,MD, Carilion Clinic
(ssboshra@carilionclinic.org); Jill Bass, DNP, Carilion Clinic; Laura Collins, BA, Brandon Oaks
* Student’s Mentor:
Purpose: Use of in-house urine dipstick testing at a nursing facility improved patient care by providing
instant assessment of specimen for leukocyte esterase, a hallmark of urinary tract infection (UTI).
Treatment begins 3 days sooner than current practice of sending urine samples to an off-site laboratory and
awaiting results before intervention. Once positive UTI is confirmed via dipstick, the physician orders
treatment. This benefits the patient due to decreased complications such as urosepsis. Delay in initiation of
UTI treatment contributes to high rate of mortality and morbidity. This study is novel because direct benefit
of dipstick use in the elderly vs. laboratory-only testing is compared. All residents exhibiting symptoms of
a urinary tract infection (UTI) June 2011-February 2012 were included.
Methods: Nurses trained on protocols for UTI assessment: 1) health status tool; 2) instruction in collection
of clean-catch urine specimen from catheter with immediate testing by McKesson dipstick followed by
laboratory verification; 3) immediate physician notification - decision to treat or not to treat with narrowspectrum antibiotics; 4) lab follow-up. Negative predictive values: >100,000 microorganisms on dipstick
and lab specimens were compared.
Results: 113 patients with symptoms were evaluated using dipstick; results were compared with laboratory
assessment of same specimens. 108 samples were a direct match with dipstick and lab testing; five samples
(4%) were mismatched. Nine comparison samples indicated a negative dipstick: five with results < 100,000
col/ml and four > 100,000 col/ml. Final evaluation demonstrated sensitivity and specificity.
Conclusion: Generalizable results of 113 patients demonstrated symptoms of UTI with dipstick and
laboratory testing. Immediate testing for leukocytes using dipstick is comparable to “gold standard” of
sending specimens to the laboratory. This study provides sufficient support to introduce dipstick testing as
standard of care in this facility and to expand use of dipstick testing to other area nursing homes.
14
Carilion Research Day 2013 Abstract Form
F2
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Title: Pre-Trauma Functional Independence Measure Scores Predict Outcome in Geriatric Trauma Victims
Authors (Include First Author’s e-mail address): Eric Bradburn, DO (ehbradburn@carilionclinic.org),
VTCSOM; Bryn Collier, DO, VTCSOM; Brian Fletcher, MD, VTCSOM; Katherine Shaver, VTCSOM;
Amanda Vanlaeken, MS, VTCSOM
Purpose: To determine if pre-trauma FIM scores can predict morbidity and mortality in the geriatric
trauma population.
Methods: We retrospectively reviewed 2630 patients, age ≥65, that presented to our institution as trauma
victims over a 6 year period (July 1st, 2006 - July 31st, 2012). The group was randomly divided into two
equal halves and a regression analysis was developed on one sample, leaving the other untouched. From the
sample that underwent regression, 941 observations were used. Through logistic regression, pre-trauma
FIM score (expression) and pre-trauma FIM score (locomotion), were utilized as data points to predict a
binary outcome, that outcome being measured as the primary endpoints of ‘Alive’ or ‘Dead’. The FIM
scores and primary endpoints were then used to calculate the odds of survival (OOS).
Results: There were 1315 observations read and 941 observations used from the sample that underwent
regression. 374 observations were dismissed secondary to missing data. From the 941 observations used,
primary outcome revealed that 854 were‘Alive’ and 87 were‘Dead’. Results revealed that the OOS are
3.532 (2.191-5.718, CI 95%) times greater for every 1 point increase in FIM score (expression) and 1.481
(0.986-2.165, CI 95%) times greater for 1 point increase in FIM score (locomotion).
Conclusion: The results reveal that pre-trauma FIM scores can predict morbidly and mortality in the
geriatric trauma population. The relationship discovered in this study will aid in recognizing those geriatric
patients at greatest risk of complications following trauma. By recognizing those patients at greatest risk,
prompt clinical decisions can be swiftly determined that ultimately has profoundly positive effects from
patient management to cost-effective healthcare. The goal of this study is to utilize the pre-trauma FIM
scores to construct a clinical prediction model directed at recognizing the geriatric trauma victims with the
highest risk of morbidity and mortality.
15
Carilion Research Day 2013 Abstract Form
S1
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Title: A molecular mechanism regulating the timing of corticogeniculate innervation.
Authors (Include First Author’s e-mail address): Justin Brooks, BS (jubrook2@vtc.vt.edu), VCU and
VTCRI; Jianmin Su, PhD., VTCRI; Tania Seabrook, PhD., University of Louisville; William Guido, PhD.,
University of Louisville; Michael Fox, PhD., VTCRI and VT
* Student’s Mentor: Michael Fox, PhD., VTCRI and VT
Purpose: To determine the molecular mechanisms governing the delay of corticogeniculate innervation
until retinogeniculate synapses have formed.
Methods: Brain tissue was analyzed throughout the period of corticogeniculate innervation in both control
mice and mice lacking retinal input. To determine molecules regulating the timing of corticogeniculate
innervation, we employed immunohistochemistry (IHC), microarray analyses, quantitative reverse
transcription polymerase chain reaction (qPCR), and in situ hybridization (ISH). We employed modified
stripe assays with dissociated cortical cultures to test whether corticothalamic axons were directly repelled
by candidate extracellular matrix molecules. In vivo intrathalamic injections of various enzymes were used
to test whether the presence of extracellular molecules contributes to the timing of corticogeniculate
innervation.
Results: We discovered aggrecan, an inhibitory chondroitin sulfate proteoglycan (CSPG), was highly
enriched in the perinatal dorsal lateral geniculate nucleus (dLGN), and aggrecan protein levels dropped
dramatically at ages corresponding to the entry of corticogeniculate axons into dLGN. In vitro assays
demonstrated that aggrecan is sufficient to repel axons from layer VI cortical neurons, and early
degradation of aggrecan, with chondroitinase ABC (chABC), promoted advanced corticogeniculate
innervation in vivo. To understand the mechanisms that control aggrecan distribution, we identified a
family of extracellular enzymes (the a disintegrin and metalloproteinase with thromobospondin motifs
[ADAMTS] family) expressed in postnatal dLGN that are known to contain aggrecan-degrading activity.
Importantly, ADAMTS family members are upregulated in dLGN after retinogeniculate synapses form,
and intrathalamic injection of ADAMTS4 (also known as aggrecanase-1) resulted in premature invasion of
dLGN by corticogeniculate axons.
Conclusion: These results implicate aggrecan and ADAMTSs in the spatial and temporal regulation of
corticogeniculate innervation.
16
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Title: Allogenic and Autogenous Bone Graft is Affected by Historical Donor Environmental Exposure
Authors (Include First Author’s e-mail address): Jonathan Carmouche, MD‡
(jjcarmouche@carilionclinic.org); Caleb J. Behrend, MD+‡, Lauren M. Ritter+; Paul T. Rubery,Jr, MD+; J
Edward Puzas, PhD+,
+University of Rochester Department of Orthopaedics, Rochester, NY
‡Carilion Clinic Orthopaedics, VTCSOM, Roanoke, VA
* Student’s Mentor:
Purpose: Bone graft materials are routinely evaluated for infectious agents; however, data regarding
contamination of bone graft from environmental exposure of the donors to osteotoxic substances is not
routinely available. With a half life of up to 20 years in bone historical exposure to lead is likely to persist
in bone graft materials from donors for several decades. In the present study allograft from commercial
sources and autologous bone graft materials were examined for lead content. Cortical and cancellous bone
graft samples were examined from each specimen.
Methods: Forty-two bone graft specimens; 26 from commercially available bone graft materials and 16
autograft specimens were obtained. Lead levels were determined using an absorption spectrophotometer
equipped with longitudinal Zeeman background correction and a transverse heated graphite furnace.
Results: Commercial bone graft materials had a mean lead level of 2.1 µg/g (0.2µg/g)* and autogenous
bone graft had a mean of 2.0 µg/g (0.5µg/g). There was no statistically significant difference between the
groups (P=0.30) The range for all tested samples varied from <0.1 to 5.0 µg/g. Cortical bone graft
contained 2.2 µg/g (0.3µg/g) and cancellous bone 1.9 µg/g (0.3µg/g), the difference was not significant
(P=0.28). Sixteen of the specimens (38%) had levels between 2-5 µg/g, within the range expected for
individuals with known environmental exposure.
Conclusion: Commercially available bone graft materials tested in the present study had a 50-fold
variation in the concentration of lead. There was no difference between lead levels in autogenous bone graft
and commercial allogenic bone graft materials. A significant percentage (38%) of the specimens had levels
greater than 2 µg/g corresponding to some degree of environmental exposure. Animal studies have
suggested that comparable levels of lead exposure have toxic effects on skeletal tissue. Environmental
exposure to toxic substances is measurably present in bone graft regardless of the source.
17
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Title: Hospital Readmission after Hip Fracture
Authors (Include First Author’s e-mail address): Jonathan Carmouche, MD‡
(jjcarmouche@carilionclinic.org); Stephen L. Kates, MD+; Caleb Behrend, MD, MS+‡; Daniel A.
Mendelson, MS, MD+; Peter Cram, MD+; Susan M. Friedman, MD, MPH+
+University of Rochester Department of Orthopaedics, Rochester, NY
‡Carilion Clinic Orthopaedics, VTCSOM, Roanoke, VA
* Student’s Mentor:
Purpose:
Hospital readmission following hip fracture is a frequent and serious sentinel event that may
be avoidable. Although nearly all patients with hip fracture are admitted to acute care, there is considerable
regional variation in readmission rates. Hip fracture isthe leading orthopaedicdischarge diagnosis
associated with 30 day readmission.Readmission to the hospital following a hip fracture often involves an
adverse event that dramatically impacts patient satisfaction, the course of recovery, and the rate of survival.
The cost of care for patients returning for additional inpatient treatment alsoposes a serious financial strain
on an already overburdened health care system. Nationally, readmission rates following hip fracture have
increased from 2004 to 2009. The present study examines prognostic factors associated with readmission in
patients following treatment for non-pathologic low energy proximal femur fractures.
Methods:
Patients greater than 65 years of age admitted to a university affiliatedlevel 3 trauma center
between 4/30/2005 and 9/30/2010 with a unilateral native, non-pathologic low energy proximal femur
fracture were identified from our geriatric fracture registry.One thousand ninty two records were available
for analysis with 128 records for patients readmitted following initial treatment.. Demographic data,
comorbidities, in-hospital complications and patient functional status were analyzed as predictors of
readmission.
Results: The overall readmission rate was 11.7%. Pulmonary problems (primarily pneumonia)represented
the most common medical reason for readmission at 24.2%(24 patients) followed by musculoskeletal
problems (16%), gastrointestinal problems(15%), genitourinary problems 11% and cardiovascular
complications 11%.
Conclusion: Predictors of readmission were age>85 ( OR=1.52) p=.03, time to surgery >24 hours (1.50)
p=.05, Charlson score ≥ 4 (1.70) p=.04, delirium (1.65) p=.01, Dementia (1.61) p=.01, history of
pacemaker placement(1.75) p=.02, and presence of a pre-op arrhythmia (1.62) p=.02. In review of
records 15.6% (n=20) of the readmissions were preventable.
Patients who were readmitted had high rates of in hospital mortality 14.8%(n=19).
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Carilion Research Day 2013 Abstract Form
S3
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Title: Defining the role of RahU protein in pathogenesis of Pseudomonas aeruginosa in a murine lung infection
model
Authors (Include First Author’s e-mail address): Lily R. Colpitts1 (lrcolpitts@carilionclinic.org), Dorothy C.
Garner, MD2, Thomas M. Kerkering, MD2, Isis Kanevsky-Mullarky, PhD3 and Jayasimha Rao, PhD1
1
Virginia Tech Carilion School of Medicine, Roanoke, VA, 2Internal Medicine/Section of Infectious Diseases/
Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA, and 3Dairy Science Division at Virginia
State Polytechnic University, Blacksburg, VA.
* Student’s Mentors: Jayasimha Rao and Dorothy C. Garner
Purpose: Pseudomonas aeruginosa, the second most common hospital-acquired infection (HAI) nationwide, is a
leading cause of pneumonia in immunocompromised patients. The “colonization” of P. aeruginosa in respiratory
airways serves as a constant inflammatory stimulus that precedes establishment of acute infection. We identified a
protein called “RahU” (PA0122) in P. aeruginosa that appears to modulate the host’s innate immune system. This
study investigated the role of RahU protein in early colonization using a murine lung model.
Methods: Thirty-two patients were enrolled, and 38 P. aeruginosa clinical strains were collected from sputum and
blood samples. Three genetically unrelated clinical strains of RahU expressing phenotypes were selected and
designated as PA#097; high (RahU++), PA#115; low (RahU+) and PA#100-2; none (RahU¯) as determined by
Western blotting. These strains including a laboratory PAO1 strain were used to examine the virulence effect of
RahU protein in Balb/c 6-week-old male mice. Clinical symptoms were monitored daily, and weight and health
scores recorded. Survival curves for two independent experiments were generated.
Results: Expression of the 16 kDa RahU protein was determined during stationary growth in 2 clinical strains and
in 3rd strain was absent. RahU expressing phenotypes showed an impact on mortality rate in the mouse model.
There was a statistically significant decrease in survival of mice infected with strains PAO1 and PA#115 (low
RahU+) as compared to PBS controls (P < 0.05). Furthermore, there was significant decrease in survival of mice
infected with strain PAO1 as compared to strain PA#97 (P < 0.02).
Conclusion: Our data indicate a role of RahU protein in lung pathogenesis in this mouse model. However, we
cannot rule out importance of other virulence proteins during murine infection. In future experiments, we will
delete the rahU gene in these 3 clinical strains and repeat the murine lung model to further define the role of RahU
protein in virulence.
19
Carilion Research Day 2013 Abstract Form
S4
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Title: Predictors of Successful Completion of Cardiac Rehabilitation Following a Cardiacvascular Event
Authors (Include First Author’s e-mail address): Nathaniel DeYoung, M.S.
(Nathaniel.DeYoung@va.gov), Salem Veteran’s Affairs and Purdue University; Elizabeth DeYoung, M.S.;
Franciscan St. Elizabeth Health; & Brian Shenal, Ph.D., VTCSOM and Salem Veteran’s Affairs
* Student’s Mentor: Brian Shenal, PhD
Purpose: Individuals with cardiovascular disease are at an increased risk for anxiety, depression, stress,
and other maladaptive cognitive processes. While participation in cardiac rehabilitation (CR) can lead to
large physical and psychological improvements, a significant percentage of patients fail to complete their
prescribed treatment. The purpose of this study is to determine if depression, anxiety, rumination, and
overall physical health significantly predict CR program completion.
Methods: Over a seven-month period, patients with cardiovascular disease who were enrolled in CR at a
private hospital were tracked over the course of their treatment. Each patient underwent fitness testing prior
to CR participation. Self-reported psychological, health, and fitness data were gathered during the first,
third and eighth week of CR. Logistic regression was used to determine significant predictors of CR
completion.
Results: Fifty-one patients enrolled in the study (35 males, 16 females). Thirty-two (62.7%) of the
patients completed CR. Patients who smoked were significantly more likely to drop out of CR in
comparison to non-smokers (p<0.001). Higher levels of negative affect were also associated with lower
likelihood of CR completion (p=0.004). Patients who considered themselves as generally healthy were also
less likely to complete CR (p=0.011). Finally, rumination was associated with a higher likelihood of CR
completion. Participants who remained in CR for at least 8 weeks reported significant health, fitness, and
psychological improvements.
Conclusion: Smoking, depression and anxiety symptoms negatively impacted CR completion. Patients
who considered themselves as generally healthy were also more likely to drop out since these patients may
not perceive a need for treatment. Patients engaging in rumination may see CR as a way to decrease or
manage their repetitive and intrusive thoughts about their cardiovascular disease, and this may increase
their motivation to complete the recommended treatment. Monitoring these symptoms may help CR
programs improve patient adherence.
20
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RF 7
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Title: Effect of Discharge Medication Reconciliation by Pharmacists on Prevention of Unintended
Medication Discrepancies
Authors (Include First Author’s e-mail address): Courtney Dickerson, PharmD
(cpdickerson1@carilionclinic.org); K. Williams, PharmD, BCPS; C. Blubaugh, RPh, BCPS; Carilion
Roanoke Memorial Hospital, Roanoke, Virginia
Purpose: To determine the number of medication discrepancies that can be identified by pharmacists prior
to discharge that could avoid potential drug related problems and to identify cost savings to patients.
Methods: A prospective pilot project was conducted on patients discharged from a cardiac progressive
care unit from November 1, 2012 to December 7, 2012. Pharmacists reviewed the discharge medication
orders and compared this with prior to admission medications and medication changes made during the
hospitalization to identify potential discrepancies. Data collected included medications involved, number of
discharge medications, number of discrepancies identified, types of discrepancies, severity of discrepancies
(Class 1: No potential to result in discomfort, Class 2: potential to result in mild to moderate discomfort,
Class 3: potential to result in severe discomfort), number of physicians involved in the care of the patient,
amount of time between notification of discharge and resolution of discrepancies, outcome of the
medication reconciliation, and amount of time invested by the pharmacist. Frequency count, mean, standard
deviation, and median were reported for discrepancies and cost savings identified.
Results: Eighty-seven patients were included in the analysis and 115 discrepancies were identified. At
least one discrepancy was identified in 50.6% of patients. Of these discrepancies, 24 were classified as
having the potential to result in severe discomfort or clinical deterioration. Seventy percent of discrepancies
were medications unintentionally added or omitted on discharge. Estimated medication cost savings to
patients totaled $6,324.15 and averaged $54.99 per discrepancy and $72.69 per patient. The actual cost
savings of prevention of readmission are likely much greater but difficult to quantify.
Conclusion: When involved in the discharge process, pharmacists were able to identify at least one
discrepancy in more than half of patients reviewed. These results demonstrate that discharge medication
reconciliation by pharmacists can improve patient safety and reduce healthcare costs.
21
Carilion Research Day 2013 Abstract Form
S5
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Title: Neonatal Mortality, Delivery Methods, And Characteristics Of Surviving Neonates In Rural Ghana
Authors (Include First Author’s e-mail address): Megan P Donohue, MPH1
(mpdonohue@carilionclinic.org); Jessica L Top, MD1, Katherine H Shaver, MS2, Daniel S Cannone, DO1
and Colleen A Kraft, MD1. 1Pediatrics, Carilion Clinic-Virginia Tech Carilion School of Medicine,
2
Biostatistics, Carilion Clinic
* Student’s Mentor: Colleen A Kraft, MD
Purpose: According to the World Health Organization, “Neonatal mortality is increasingly important
because the proportion of under-five deaths that occur during the neonatal period is increasing as under-five
mortality declines.” Little is known about the impact of delivery method on neonatal survival or
characteristics of these neonates. The purpose of this study is to determine the neonatal mortality rate,
impact of delivery method, and characteristics of surviving infants at a global health education site in rural
Ghana.
Methods: Retrospective chart review of maternal and infant delivery records from St. Luke Hospital in
Kasei, Ghana was performed on every birth (n=790) between a period of 10/2011-9/2012. Data included
delivery type (cesarean section vs. vaginal delivery); neonatal survival; infant birth weight and Apgar
scores. Analysis consisted of frequency tables, chi-square, and t-test.
Results: The cesarean section rate was 8.86%. Neonatal mortality of infants delivered by cesarean section
was 17.14% vs. 3.76% for infants born via spontaneous vaginal delivery (p=.001). For SVD and CS
deliveries respectively, birthweight was 2.88 kg vs. 2.92 kg (p=0.579) and gestational age was 38.0 weeks
vs. 37.8 weeks (p=0.656). Apgar scores at 1 minute were 6.7 vs. 5.6 (p=0.001) and at 5 minutes were 7.9
vs. 6.5 (p=0.003) for SVD and CS deliveries respectively. Chart narrative on 25% of infants delivered by
cesarean section who died documented one twin delivered in a village or district hospital, and complication
with the second twin delivery which resulted in intrapartum transfer of the mother.
Conclusion: Method of delivery had a significant influence on neonatal mortality. Cesarean section
delivery was associated with lower mean 1-minute and 5-minute Apgar Scores and higher neonatal
mortality rate. Gestational age and birth weight were similar between surviving and non-surviving
neonates. Further inquiry into the events resulting in cesarean section delivery is warranted given the chart
narrative.
22
Carilion Research Day 2013 Abstract Form
F5
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Title: Radiolanthanides Encapsulated in Fullerenes: A New Radiopharmecutical Platform
Authors (Include First Author’s e-mail address): Harry C. Dorn, hdorn@vt.edu, (VTCRI) Jianyuan
Zhang, (VT) and Cathy S. Cutler (Missouri Nuclear Research Reactor, MURR)
* Student’s Mentor:
Purpose: The lutetium-177 radionuclide has recently emerged as a very favorable radioisotope for cancer
therapy applications, (half-life of 6.61 days). Although this radioisotope has been utilized in clinical trials
in Europe, only recently have the first clinical trials been initiated in North America. A clinical study
employing intra-hepatic artery administration of Lu-177 octreotate in patients who have predominately
liver metastasis from neuroendocrine cancers has been initiated at Baylor College of Medicine. The
purpose of the current study is the preparation of new radiolanthanide (Lu-177) metallofullerenes
containing the appropriate lanthanide isotope encapsulated in a fullerene cage and explore this platform as a
new cancer therapeutic modality.
Methods: In this project, we have synthesized new lanthanide endohedral metallofullerenes, (e.g.,
A3N@C80 A= lanthanide metal) that will be will be neutron activated by our collaborator, Cathy Cutler
(MURR), providing the new high radioactivity radiolanthanide, 177LuxLu(3-x)N@C80. The yield, percent
breakout, and overall in vitro stability will be established. The 177LuxLu(3-x)N@C80 will be conjugated with
a cytokine peptide, interleukin-13, and targeting studies with glioblastoma tumor cell cultures will be
conducted.
Results: In preliminary results we have demonstrated that direct neutron activation of Lu3N@C80 provides
high purity 177LuxLu(3-x)N@C80. This confirms the robust nature of the fullerene cage of radioactive
177
LuxLu(3-x)N@C80 in comparison with other biological samples. The177LuxLu(3-x)N@C80 will be
conjugated with the glioblastoma tumor-targeting cytokine, interleukin-13 (IL-13).
Conclusion: We have found that the direct encapsulation of the radiolanthanide Lu-177 inside the fullerene
cage can be readily achieved. This has several advantages, including shielding of the radionuclide from the
biological environment. Additional studies will establish the feasibility of the radiolanthanide endohedral
metallofullerenes as a next-generation radiopharmaceutical.
23
Carilion Research Day 2013 Abstract Form
RF 8
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Title: Dedicated Trauma/Surgical Critical Care Team is associated with improved outcomes: The Roanoke
Story
Authors (Include First Author’s e-mail address): Mack D. Drake, DO (mddrake@carilionclinic.org);
Mark E. Hamill, MD; Eric H. Bradburn, DO; Dallas A. Taylor, RN; Carol M. Gilbert, MD; Christopher C.
Baker, MD; Bryan R. Collier, DO
Carilion Clinic Roanoke Memorial Hospital
* Student’s Mentor:
Purpose: To determine if a dedicated trauma and surgical critical care faculty is associated with improved
clinical outcomes.
Methods: Using the Carilion Roanoke Memorial Hospital (CRMH) trauma registry database a
retrospective review was performed of data encompassing fiscal years 2010-2012. In 2010, surgical faculty
included a full complement of trauma surgeons. During 2011, seven trauma/surgical critical care faculty
members departed for other institutions. Between September 2011, and January 2012, four full time
trauma/surgical critical care faculty members were recruited. Total number of admissions, Injury Severity
Score with Revised Trauma Score, and clinical outcomes were reported across this time of evolution at our
825-bed Level I trauma center.
Results: 6,633 patients were entered into the trauma registry database between October 2009 and
September 2012. Fiscal year 2011 saw significantly overall poorer outcomes when compared to 2010 and
2012. Higher ventilator days, trauma service census numbers, sepsis rate, DVT/PE rate, unplanned
readmissions to the ICU and mortality were observed. During fiscal year 2012, more patients were treated
with higher injury severity. Fewer patients suffered ventilator-associated pneumonia, sepsis, ARDS, acute
kidney injury, DVT/PE, pressure ulcers, or unplanned readmission to the intensive care unit. Additionally,
a lower mortality rate was observed, yet those who died were more likely to complete organ donation.
Conclusion: Clinical outcomes suffered during a time of greatest faculty attrition. A dedicated trauma and
surgical critical care faculty is associated with improved clinical outcomes. Mortality can be expected to be
lower and a higher rate of organ donation may be realized. Health systems maintaining vital trauma patient
care services should, when presented with trauma and surgical critical care faculty attrition, commit the
necessary resources to expedite the recruitment of dedicated trauma and surgical critical care faculty in
order to sustain expected excellent outcomes.
24
Carilion Research Day 2013 Abstract Form
RF 9
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Title: Association of Serum Sodium Levels with Mortality in Non-Dialysis Dependent Chronic Kidney
Disease
Authors:
Vince Faridani MD1 (VFaridani@carilionclinic.org), Jun L Lu MD2, Kamyar Kalantar-Zadeh MD3, Csaba
P Kovesdy, MD1,4
1
Virginia Tech Carilion School of Medicine, Roanoke, VA, United States
2
Salem Research Institute, Salem, Virginia
3
Harbor-UCLA, Torrance, California
4
Salem VA Medical Center, Salem, VA, United States;
Introduction: Hyponatremia is the most common electrolyte abnormality. It is unclear if similar
associations are present in patients with non-dialysis dependent CKD (NDD-CKD). We examined the
association between serum sodium levels and all-cause mortality in 1,236 male US veterans (age 68 11,
24% Black) with CKD stage 1-5 (estimated glomerular filtration rate [eGFR] 37 17).
Methods: Associations of time-varying outpatient serum sodium with mortality were examined in Cox
models with adjustment for age, race smoking, SBP, DBP, DM, CVD, Charlson comorbidity index,
albumin, calcium, phosphorus, cholesterol, WBC count, percentage of lymphocytes in WBC, Hgb, AST,
ALT, potassium, HgbA1c and SSRI and diuretic use.
Results: Nonlinear associations were explored by using cubic splines. Lower serum sodium was linearly
associated with increased mortality. A 10 mEq/L lower serum sodium was associated with a multivariable
adjusted hazard ratio of all cause mortality (95% CI) of 1.60 (1.11-2.29), p=0.01.
Conclusion: Hyponatremia is associated with increased mortality in patients with moderate and advanced
NDD-CKD. Interventional trials are needed to determine if correction of hyponatremia can result in
improved outcomes in this population.
25
Carilion Research Day 2013 Abstract Form
S6
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Title: Investigation of airway location as a risk factor for endobronchial fire with the use of neodymiumdoped yttrium aluminum garnet (ND:YAG) laser photoresection in a swine model
Authors: Jeeshan Ali Faridi, (jafaridi@carilionclinic.org), VTCSOM; Michael Boyd, MD, Carilion
Clinic; Edmundo Rubio, MD, Carilion Clinic; and Linda Dahlgren, DMV, Virginia Tech School of
Veterinary Medicine
* Student’s Mentor: Michael Boyd, MD, Edmundo Rubio, MD
Purpose: Evaluate the significance of airway location regarding safety and combustion risk at different
power levels [Watts] and oxygen concentration (FiO2) during Nd:YAG laser photoresection (NLPR), in
animals.
Methods: Four anesthetized pigs were orally intubated. A meat section was suspended in the proximal
trachea, distal trachea, right mainstem bronchus and left mainstem bronchus to simulate central airway
lesions (CAL). The NLPR fiber was introduced bronchoscopically 1 cm proximal to lesion. NLPR of CAL
was performed at two power outputs (15W and 30W), pulsed at 0.5 seconds with FiO2 titrated from 30%
up to 80% (10% increments). Firing 40 times at each power and FiO2 level, the process was repeated at
each location, from distal to proximal. FiO2 and wattage at first fire was recorded. Results were analyzed
using the FREQ procedure including Cochran-Mantel-Haenszel statistics and the LOGISTIC procedure
including type 3 analysis of effects and Odds-ratio estimates.
Results: Combustion occurred at all locations. Location ordinal analysis versus FiO2 at first fire yielded a
probability of 0.036 (Cochran-Mantel-Haenszel analysis) indicating association between location and FiO2
as combustion risks. With fire as the primary outcome, FiO2 the dependent variable and location an ordinal
one, a type 3 analysis of effects for location gave a 0.0072 p-value. The odds ratio point estimate for
location was 0.123 with 95% CI 0.027-0.567. Hence, with unchanged FiO2 there is a 12.3% increase in fire
risk moving proximally from location to location. Nominal location versus watts analysis at first fire
yielded a probability of 0.0396 (Cochran-Mantel-Haenszel analysis). The significant “row-means-scoredifference” indicates that increased power is an independent risk for fire, regardless of location.
Conclusion: Location is an independent risk factor for fire, suggesting higher FiO2 may be tolerated when
treating distal airway lesions. Power is an independent risk for fire, regardless of location. Further studies to
identify safety thresholds are encouraged.
26
Carilion Research Day 2013 Abstract Form
F6
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Title: Stimulation pattern differentially affects synaptic plasticity outcome in young adult rats with and
without mild traumatic brain injury (mTBI).
Authors (Include First Author’s e-mail address): Quentin S. Fischer, PhD (fischerq@vt.edu), Virginia
Tech Carilion Research Institute; Michael J. Friedlander, PhD, Virginia Tech Carilion Research Institute.
Purpose: The brain is capable of considerable functional reorganization, often manifest as long-term
potentiation (LTP) or depression (LTD). This plasticity is frequently targeted in neurorehabilitation. Most
protocols for inducing LTP/LTD have relied on regular stimulation patterns (coefficient of variation,
CV=0), but recent studies have used physiologically plausible patterns (e.g. Poisson, CV=1). Here we
evaluate the interaction of stimulus frequency and pattern for most efficiently inducing LTP/LTD in normal
and mTBI cortex.
Methods: Rats were intact (control) or received cortical impact (mTBI). We made whole-cell recordings
from layer 2/3 pyramidal cells in response to stimulation of layer 4 in visual cortex. Conditioning consisted
of a continuous train of 900 pulses with different frequencies (1Hz=900s, 10Hz=90s) and patterns (CV=0,
0.2, or 1). Also, to avoid synaptic fatigue with 10Hz stimulation, in some cases we used discontinuous
patterns (nine 10s trains equally spaced over 900s).
Results: In controls, 1Hz stimulation more efficiently induced LTD as stimulus regularity increased (45%,
50% and 77% of cells for CV=1, 0.2, and 0). In mTBI rats, 1Hz stimulation was most efficient at inducing
LTD for intermediate patterns (100% of cells, CV=0.2) dropping to 60% and 63% of cells for regular
(CV=0) and Poisson (CV=1) stimulation. Continuous 10Hz regular stimulation induced LTP in 30% of
control, but 0% of mTBI cells. Discontinuous 10Hz regular stimulation produced LTP in only 7% of
control but 38% of mTBI cells, while discontinuous 10Hz Poisson stimulation induced LTP in 40% of
control and 25% of mTBI cells. Finally, plasticity induction kinetics differed, with mTBI cells showing
elevated response amplitude during conditioning vs. controls.
Conclusion: Our results suggest mTBI alters the readout of synaptic plasticity inducing conditioning
stimulation, and that selective rebalancing of either the injured pathways themselves in the mTBI brain, or
of neighboring pathways unaffected by the injury, may be an effective approach to neurorehabilitation.
27
Carilion Research Day 2013 Abstract Form
S 16
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Title: Role of experience in formation of heterogeneous plasticity outcomes in two pathways of mouse V1
in response to a fixed time delay conditioning protocol
Authors (Include First Author’s e-mail address): Olivia M Fitch, BA (ofitch@vtc.vt.edu), VTCRI &
Baylor College of Medicine
* Student’s Mentor: Michael J Friedlander, PhD VTCRI
Purpose: To determine if separable sets of synapses onto a common cell have distinct plasticity responses
to a fixed time delay conditioning protocol and the role visual experience in shaping those responses in the
primary visual cortex of mice.
Methods: Synaptic plasticity responses of separable sets of synaptic inputs (isolated by occlusion testing)
onto common postsynaptic neurons in primary visual cortex were evaluated in response to simultaneous
stimulation of distinct sets of afferents (or pathways) in acute brain slices from visually intact or
binocularly-deprived (BD) mice. Alternative activation of each pathway was elicited to evoke a
postsynaptic potential (PSP) every 10 seconds in an interleaved fashion over ten minutes. Then a
conditioning stimulus was applied coupling direct postsynaptic depolarization with simultaneous activation
of both pathways at a 10 milliseconds delay. Plasticity responses were evaluated for an additional 30
minutes. The plasticity response was calculated by dividing the average peak amplitude after conditioning
by the average peak amplitude before conditioning.
Results: Preliminary data from 56 pathways inputs from visually intact mice and 34 pathways in the
binocularly deprived littermates indicate that 1) in the mouse primary visual cortex, heterogeneous
plasticity outcomes are observed, 2) that outcomes onto neurons from binocularly deprived littermates
trend towards more potentiation than visually intact littermates (post/pre ratio of 0.997 and 0.903
respectively, p=0.29, t-test), and 3) that outcomes of the separate pathways onto a common cell are
correlated in binocularly deprived mice but not in visually intact littermates (slope=0.64+/-0.12, R2 = 0.38;
slope=0.18+/-0.07 and R2=0.03 respectively) in response to a fixed time delay conditioning protocol.
Conclusion: Preliminary data suggest binocular deprivation leads to more potentiated synaptic responses
among individual pathways and more correlated plasticity responses between two distinct pathways onto a
common cell in response to a fixed time delay conditioning protocol.
28
Carilion Research Day 2013 Abstract Form
F7
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Title: A genome-wide RNA interference screen identifies autophagy mediators with therapeutic
implications in chronic myeloid leukemia
Authors (Include First Author’s e-mail address): Sujuan Guo1, PhD.(sjguo@vtc.vt.edu), Susan F
Murphy1, PhD., Hanne Varmark2, PhD., Amy Virbasius2, PhD., Michael R Green2, PhD., and Zhi Sheng1
PhD.,
1 Carilion Research Institute, 2 University of Massachusetts Medical School
* Student’s Mentor:
Purpose: little is known about how autophagy is regulated in cancer and how it mediates therapeutic
resistance. Here we use chronic myeloid leukemia (CML) as a cancer model to study autophagy in that it is
driven by a single onco-protein BCR-ABL, whose activity can be selectively blocked by imatinib, a frontline treatment for CML. Moreover, imatinib resistance frequently occurs in CML patients. Thus,
unraveling autophagy regulation in CML and its role in overcoming imatinib resistance have substantial
therapeutic benefits not only for CML but also for other cancers that can be treated by imatinib.
Methods: we performed a genome-wide RNA interference screen in K562 human CML cells using
monodansylcadaverine (MDC) that marks autolysosomes followed by fluorescence-activated cell sorting to
label and isolate autophagic cells. After identified the primary candidates, we used Cyto-IDTM Green dye
that stains autophagosomes and quantitative RT-PCR that measures knocking down efficiency of shRNAs
for further validation. Then we study their role in imatinib resistance by measuring the effect of imatinib in
combination with knocking down of autophagy mediators on the growth of K562 cells.
Results: From primary screen we have identified 336 candidate genes, knockdown of which significantly
increased MDC fluorescence. Our further validation using Cyto-IDTM Green dye staining and quantitative
RT-PCR uncovered a set of genes acting as autophagy mediators in K562 cells. VAMP7, one of these
genes substantially sensitized K562 cells to imatinib. Intriguingly, our further work revealed that depletion
of VAMP7 blocked the activity of key autophagy suppressors AKT and mTOR, suggesting that VAMP7
and perhaps other autophagy mediators regulate imatinib sensitivity through signaling pathways involved
in autophagy inhibition.
Conclusion: In conclusion, a set of genes revealed by a genome-wide RNA interference screen mediates
autophagy in CML cells and, more importantly, some of these genes render CML cells resistance to
imatinib thereby becoming appealing drug targets.
29
Carilion Research Day 2013 Abstract Form
F8
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Title: A Comparison of Traditional and Simulation TeamSTEPPS® Training Methods on Nurse
Performance Related to Failure-to-Rescue
Authors (Include First Author’s e-mail address): Ellen M. Harvey DNP
(emharvey@carilionclinic.org), Carilion Clinic; Sonya Echols PhD, Virginia Tech Carilion School of
Medicine, Jefferson College of Health Sciences; Rebecca Clark PhD, Carilion Clinic; Eunyoung Lee, PhD,
Radford University
* Student’s Mentor:
Purpose: Hospitalized patients are acutely ill and at high risk for clinical decline during their stay. The
registered nurse is the frontline of defense against ‘failure-to-rescue,’ a situation in which unrecognized
changes in patients’ condition lead to mortality and morbidity in hospitalized patients. The purpose of this
study was to compare the impact of in situ simulation-based team training (SBTT) versus a traditional case
study review (TCSR) on nurse knowledge of early warning signs (EWS) of patient decline, teamwork
skills, clinical skills and confidence to act to prevent patient failure-to-rescue, while incorporating
TeamSTEPPS® training.
Methods: This IRB approved quasi-experimental study included pre and post intervention, two-group
comparison of nurses participating in the ‘ACT NOW’ (Alert-Communicate-Treat-Nurses-Observing-forWarnings) educational program, incorporating the TeamSTEPPS ® Rapid Response Team Systems Module
and Society of Critical Care Medicine Ten Signs of Vitality didactic, followed by SBTT or TCSR.
Results: Significant increases in knowledge and overall nontechnical performance were seen in both
groups after education (p < 0.05). Significant increases, in confidence and technical skill performance were
observed in only the SBTT group (p<.05). The SBTT group had a significantly greater improvement in all
teamwork domains (team structure, leadership, situation monitoring, communication and total score) (p<
.05) except for the mutual support domain (p =.08). No significant differences were found between groups
in knowledge, confidence, and clinical skill performance after education.
Conclusion: The findings indicate that nurses educated using the SBTT method show a greater
improvement in confidence and performance of teamwork skills in comparison to nurses receiving the
TCSR method. This study contributes additional evidence to support the use of SBTT to develop nursing
knowledge, skill and confidence in recognition, management and team communication to prevent failureto-rescue in critically ill patients.
30
Carilion Research Day 2013 Abstract Form
RF 10
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Quantitative
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Mixed Methods
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Faculty
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Student*
Title: Non-invasive assessment of the left ventricular end-diastolic pressure using portable ultrasound
measurements of the right internal jugular vein
Authors (Include First Author’s e-mail address): Geoffrey T. Jao MD (gtjao@carilionclinic.org),
Virginia Tech Carilion School of Medicine; Rodney W. Savage MD, Virginia Tech Carilion School of
Medicine; Jie Li PhD, Virginia Tech; Karen Buchanan RN, Carilion Roanoke Memorial Hospital; David C.
Sane MD, Virginia Tech Carilion School of Medicine
Purpose: To determine whether quantitative ultrasound measurements of the right internal jugular vein
(RIJV) correlate with the left ventricular end-diastolic pressure (LVEDP)
Methods: We performed a pilot, prospective, cohort study. Adult patients undergoing non-emergent
diagnostic cardiac catheterization were eligible for inclusion. The following static RIJV parameters were
measured within 2 hours before the scheduled catheterization: diameter and cross-sectional area (CSA) of
the RIJV on inspiration, expiration, and with valsalva. Calculated dynamic parameters include:
expansibility = [(end-expiration – peak inspiration)/peak inspiration], collapsibility = [(valsalva - peak
inspiration) /valsalva], and ∆CSA = [CSA valsalva – peak inspiration]. Analysis of the above parameters
indexed to body surface area (BSA) was also performed. Receiver operator curves and logistic regression
were completed for each of the parameters to determine which best correlated with elevated LVEDP.
Results: Forty-five patients were eligible for inclusion. Four patients did not have LVEDP measured
during cardiac catheterization and were excluded. Mean age was 59 years, 60% were males, 67% had
hypertension, 11% had heart failure, 38% were obese, and 4% had COPD. Of the various static and
dynamic RIJV parameters tested, the ∆CSA/BSA and ∆CSA had the best ROC characteristics and were
similar: area under the curve (AUC) of 0.79 (95% confidence interval 0.64, 0.95), p=0.0002 and AUC of
0.78 (95% CI 0.62, 0.94), p=0.0004, respectively. A ∆CSA/BSA of ≤ -0.05 has a sensitivity of 67%,
specificity of 86%, and moderately correlated (phi coefficient = 0.46) with elevated LVEDP (>18 mmHg).
A ∆CSA of ≤ 0.14 has a sensitivity of 92%, specificity of 62%, and moderately correlated (phi coefficient =
0.49) with elevated LVEDP. None of the RIJV parameters correlated well with normal LVEDP (5-12
mmHg).
Conclusion: The ∆CSA/BSA was the RIJV parameter that best correlated with elevated LVEDP. It slightly
outperformed the ∆CSA although the latter is easier to apply clinically.
31
Carilion Research Day 2013 Abstract Form
S7
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Quantitative
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Faculty
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Student*
Title: Utilizing Statistical Process Control charts and highly-detailed simulation for biosurveillance in
intensive care units to control healthcare associated infections
Authors (Include First Author’s e-mail address): Jose M. Jimenez (jjimenez@vbi.vt.edu), MS, MEM,
PhD/MPH Candidate 1,2,4, Thomas Kerkering, MD3,4, Bryan Lewis, PhD, MPH1, Tina Williamson, RN,
MBA3, Kaja Abbas, PhD, MPH4, Stephen Eubank, PhD 1. (1) Virginia Bioinformatics Institute at Virginia
Tech, Network Dynamics and Simulation Science Laboratory (NDSSL), (2) Virginia Tech, Grado
Department of Industrial and Systems Engineering. (3) Carilion Clinic, Infection Control. (4) Virginia
Tech, Department of Population Health Sciences. jjimenez@vbi.vt.edu
* Student’s Mentor: Thomas Kerkering, MD
Purpose: To determine the effectiveness of combining statistical process control (SPC) charts and
simulation tools to predict and control outbreaks of healthcare-acquired infections in Intensive Care Units
(ICUs).
Methods: Patient and healthcare worker activity data was collected from Carilion Roanoke Memorial
Hospital from electronic medical records and through direct surveillance of healthcare professionals. A
highly-detailed, highly-resolved simulation of the hospital’s ICUs has been modeled as an in-silico
environment for infection control evaluation. Patients and healthcare workers from 7 ICUs were included in
the simulation. Different realistic infection scenarios for Clostridium difficile were used to simulate
outbreaks within the ICUs utilizing a novel simulation algorithm called EpiSimdemics. SPC control charts
were utilized to predict potential outbreaks in the ICUs. The simulated ICU biosurveillance scenarios were
analyzed using SAS JMP Pro 10 to derive useful inferences, which will assist in improving control plans
for HAIs.
Results: The simulation included 100 different runs for each scenario. Nurses and patients in the ICUs
had the highest numbers of contacts in the simulations, followed by therapists. Advanced SPC charts such
as exponentially weighted moving average (EWMA) were able to quickly detect shifts in the infected
population. However, simpler SPC charts like moving range (R) were able to detect abrupt changes in
infection. Advanced SPC charts were more conservative in alerting about possible outbreaks, reducing the
possibility of false positive alarms.
Conclusion: Simulated biosurveillance of HAIs can assist in improving hospital prevention and control
plans, and in planning for optimal allocation of limited healthcare resources to reduce morbidity and
mortality of patients with HAIs.
32
Carilion Research Day 2013 Abstract Form
F9
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Clinical
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: Ryanodine and IP3 Receptors Shape Intracellular Calcium Signals Shifting Synaptic Plasticity
Outcomes in Visual Cortical Pyramidal Neurons.
Authors (Include First Author’s e-mail address): Djanenkhodja Kalikulov , PhD (hodja52@vtc.vt.edu),
Virginia Tech Carilion Research Institute; Michael J. Friedlander , PhD., Virginia Tech Carilion Research
Institute
Purpose: Pairing of presynaptic activity induced by stimulation of afferent fibers in immediate proximity
to basilar dendrites and postsynaptic spiking activity induced by current injection into individual layer 2/3
pyramidal neurons in visual cortex results in variable plasticity outcomes between cells. In order to parse
the underlying mechanisms that give rise to these differential plasticity behaviors, we are investigating the
role of various intracellular calcium sources.
Methods: Somatic recordings were performed in whole-cell current-clamp mode in L2/3 pyramidal
neurons in acute visual cortical slices of guinea pigs. Plasticity was induced by a train of 60 low-frequency
pairings of synaptic stimulation coincident with depolarization of the postsynaptic cell. Cells were loaded
with the fura-4F. Drugs were added to the pipette solution.
Results: Inhibition of release of calcium from intracellular stores by ryanodine, shifted the distribution of
plasticity outcomes from a small net long-term potentiation (LTP) in the control group to a net long-term
depression (LTD) and inhibition of IP3 receptor calcium release with xestospongin C shifted plasticity
outcomes to a greater net LTP. Control neurons had an average peak somatic intracellular calcium transient
= 197.76 ± 20.30 nM, and average somatic calcium transients decay time constant = 995.24 ± 116.17 msec.
Inhibition of ryanodine receptor calcium release reduced the average peak of the somatic calcium transients
to 135.58 ± 7.00 nM, the average somatic decay time constants to 960.01 ± 164.04 msec. Inhibition of
calcium release from IP3 receptors reduced the average peak somatic calcium transients to 140.35 ± 9.18
nM, and increased the average somatic calcium decay time constants to 2264.16 ± 873.49 msec.
Conclusion: Blocking internal ryanodine receptors reduces peak somatic calcium transient amplitudes and
shifts the distribution of plasticity outcomes towards LTD. Blocking internal IP3Rs increases somatic
calcium transient decay time constants and shifts the distribution of plasticity outcomes towards LTP.
33
Carilion Research Day 2013 Abstract Form
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Student*
F 19
Title: Caregiver and care recipient agency: transitions from cure to care, and back again
Authors: Kye Kim, MD, Carilion Clinic (kykim@carilionclinic.org), James Ford, PhD, University of
Georgia at Athens
Purpose: Medical conditions of a family member can pose significant ethical questions. Historically,
health professionals’ best attempts to answer ethical questions were based on a synthesis of Hippocratic
precepts, stoic concepts, and religious traditions. However, these attempts have been seriously complicated
by medical specialization, depersonalization of healthcare, patient autonomy, provider-patient relationships,
managed care, healthcare rationing, etc. Relational ethics appears to offer sound theoretical ground to
assist healthcare professionals with arriving at some practical resolutions. It is generally defined as
perceived fairness of interpersonal give and take, mutually respectful engagement, and responsible actions.
This study explored the impact of relational ethics on the process of resolving ethical caregiving dilemmas
that emerge during healthcare crises and develop a substantive theory of that process.
Methods: This qualitative research examined computerized archives of 15 cases consulted by Ethics
Advisory Committee. This study purposely focused on psychosocial and relational aspects of caregiving
ethics. Those aspects were analyzed from the perspectives of symbolic interaction theory utilizing
grounded theory methodology. It explored caregiving relationships and efforts to resolve ethical dilemmas
at two levels. Part one focuses on psychosocial elements of case documentation describing processes
internal to the institution. Part two focused on psychosocial elements of case documentation describing
interaction between the institution’s staff and patients’ informal caregivers.
Results & Conclusions:
 Lack of emphasis on social documentation is problematic
 Healthcare system has a “default” cure mentality
 Advance directives and DNR orders cannot resolve complex and dynamic ethical healthcare
dilemmas
 Agent is a better operative term than surrogate
 Relational processes and agency grid visuals can help frame and explain case dynamics
 Relational ethics in healthcare can be understood as the dynamic process of clarifying agency
34
Carilion Research Day 2013 Abstract Form
RF 26
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Basic
Clinical
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: The Acute Care Surgery (ACS) Hybrid Model: A Shared Dedicated System of General and Trauma
Surgeons Improves Hospital Length of Stay, Hospital Costs, and OR Utilization
Authors (Include First Author’s e-mail address): Nick LeBlanc MD (ndleblanc@carilionclinic.org),
Sandy Fogel MD, Bryan Collier DO, Charles Paget MD, Christopher Baker MD [All listed affiliated with
Carilion Clinic]
* Student’s Mentor:
Purpose: Before July, 2012 acute care services were provided by trauma and general surgeons under the
paradigm of daily/nightly coverage added to a typical general surgeon elective workload. In July 2012, we
began a hybrid ACS service—dedicated operating room (OR) time, dedicated weekly surgeon, and resident
team seven days/week—of general and trauma surgeons responsible for urgent and emergent general
surgery patients. The purpose was to evaluate pre- and post-ACS effects on hospital length of stay (LOS).
Our hypothesis was a hybrid ACS team would lead to improved outcomes in this patient population.
Methods: This retrospective data review compared pre-ACS (7/1/2011 – 6/30/2012) and post-ACS
(7/1/2012 – 12/31/2012) at a 763 bed Level I trauma and tertiary referral hospital. We analyzed the three
most common acute general surgery DRGs: acute appendicitis (AA), acute cholecystitis (AC), and small
bowel obstruction (SBO). Average time from emergency department (ED) evaluation to OR arrival,
average hospital LOS (aLOS), total hospital costs (HC), and the operating time of day were evaluated.
Comparisons were analyzed using Fisher’s Exact Test.
Results: 582 patients were included. Pre-ACS group totaled 392 patients. Post-ACS group totaled 190
patients. For DRGs, ED to OR remained unchanged, but aLOS was shorter. For AA, aLOS decreased 30.3
hours/patient. For AC, aLOS decreased 3.4 hours/patient. For SBO, aLOS decreased 33.9 hours/patient.
Average decreased LOS across the DRGs was 21.1 hrs, with savings on HC over 6 months ~$300,000. In
addition, the operating cases outside regular operating times decreased. Pre-ACS, 146 (41.2% of total)
cases were performed between 5pm and 7am. Post-ACS, only 54 (29.8% of total) cases during this time
frame were performed (P = 0.01).
Conclusion: A hybrid model for ACS services with a dedicated weekly surgeon and reserved OR time
demonstrates an overall decrease in hospital LOS and a decrease in HC.
35
Carilion Research Day 2013 Abstract Form
S8
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Clinical
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Quantitative
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Faculty
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Student*
Title: Variation in Use of All Types of Computed Tomography by Emergency Physicians
Authors (Include First Author’s e-mail address): Matthew B. Levine1 (mblevine@carilionclinic.org),
Andrew B. Moore1, Damon R. Kuehl MD2, Christopher Franck PhD3, Jie Li PhD3; Virginia Tech Carilion
School of Medicine1, Carilion Clinic2, Virginia Tech3
* Student’s Mentor: Dr. Damon Kuehl MD
Purpose: In light of rising use and costs of medical imaging, we determine emergency physicians’
variability in CT utilization and the provider characteristics that may account for observed differences in an
attempt to delineate appropriateness of use.
Methods: This was a retrospective study of emergency medicine physicians from 2008 to 2012 at an 850
bed tertiary level 1 trauma center with 75,000 annual visits. CT rates were modeled for providers as a
function of patient and encounter characteristics using logistic regression to adjust for population
differences. Variability in provider utilization rates was assessed and correlated with provider experience.
Levene’s test was used to determine if variation in use of different CT types was uniform.
Results: There were 195,801 eligible visits, 44,724 of which involved a CT study (total 57,202). There
were 49 emergency physicians with a mean experience of 10.8 years, averaging 2,494 hours worked, 3,995
patients seen, and 1,167 CTs ordered. The adjusted rate of CT ordering was 23.8% (95%CI 23.4-24.2) of
patient visits, ranging from 11.5% (95%CI 9.2-14.4%) to 32.7% (95%CI 31.0-34.5%). The upper quartile
of providers ordered 78% of the CT studies above the mean. There was large variation in use of all CT
types. CT of the head was the most common subtype ordered (10.7% of visits, range 3.7-16.7%) followed
by abdomen (8.1%, 2.3-12.6%), spine (4.3%, 1.2-8.6%), and chest (3.2%, 0.97-7.9%). Variation was not
uniform across CT types (P<0.0001). CT chest, abdomen, spine, and extremity variation was 1.4 to 2.4
times greater than CT head.
Conclusion: We demonstrate a 3-fold difference in CT utilization among emergency physicians
unexplained by patient population or provider characteristics. Variability in all CT types and large
deviation from the mean by a small group of providers may suggest inappropriate utilization and provide a
target for reducing use.
36
Carilion Research Day 2013 Abstract Form
RF 12
Check research type:
Basic
Clinical
Applied or QA/QI
Check methodology:
Quantitative
Qualitative
Mixed Methods
Check first author listed status:
Faculty
Resident
Student*
Title: Turnaround Times in Breast Cancer: From Screening to Diagnosis to Treatment
Authors (Include First Author’s e-mail address): Kaylene J Logan, MD (kjchlopek@carilionclinic.org),
Carilion Clinic; Patrice M. Weiss, MD, Carilion Clinic; Catherine Hagan-Aylor, MSN, Carilion Clinic;
Bob Herbertson, MS, Carilion Clinic
* Student’s Mentor:
Purpose: Early diagnosis and treatment are associated with improved survival from breast cancer.
Variations in the times from detection to diagnosis, and diagnosis to treatment of breast cancer may be
attributed to the "patient delay" and the "system delay" [1,2]. We conducted a retrospective review of the
turnaround times in 2009 at the Carilion Clinic Breast Care Center (CCBCC), to compare our institution
with national benchmark times, and identify rate-limiting steps in the process. In addition, we sought to
prospectively evaluate patient satisfaction with the turnaround times.
Methods: A retrospective chart review was performed to evaluate the time intervals from abnormal
screening mammogram to diagnostic mammogram, diagnostic mammogram to biopsy, biopsy to MRI, and
MRI to surgery of all patients seen for breast cancer in 2009. A patient survey was mailed out to all
patients (131) managed from abnormal screening to surgery in 2009, assessing their satisfaction with the
turnaround times from screening mammogram to call back, call back to diagnostic mammogram, diagnostic
mammogram to biopsy, biopsy to results call, biopsy result to MRI appointment, MRI appointment to
surgery consult, and surgery consult to surgery; and assessing possible reasons why patients may perceive
the process to be delayed. The MEANS procedure was applied to evaluate the turnaround times, and a Box
and Whisker Plot statistical comparison was made between patient satisfaction and turnaround times.
Results: The mean turnaround time at the CCBCC in 2009 from abnormal screening mammogram to
surgery was 45 days. This falls within the 75th %ile of the National Quality Measures for Breast Centers
(NQMBC), established by the National Consortium of Breast Centers (NCBC) [7]. Of 131 surveys mailed
out, 57 were returned (44%). The patient satisfaction rates for each interval ranged from 96-100%, with an
overall satisfaction rate of 98% for abnormal screening mammogram to surgery.
Conclusion: The CCBCC ranks at the 75%ile in overall turnaround times; however, this turnaround time
included an interval of MRI, not previously measured in NQMBC benchmark [7]. Rate-limiting steps were
identified as the time from screening mammogram to diagnostic mammogram, and biopsy to surgery-specifically, the sub-interval MRI to surgery. Since 2009, the CCBCC has already improved the process
for obtaining insurance approval and preauthorization for MRIs; and has added an additional breast surgeon
to share the burden of benign cases, and a nurse practitioner to see post-op and follow up patients,
improving the accessibility to the primary breast surgeon specialist. Consideration should be given to
future time interval studies that evaluate breast cancer turnaround time including MRI to help establish
benchmarks.
37
Carilion Research Day 2013 Abstract Form
S9
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Basic
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: Shortening the Time to Initial Antibiotic Administration in the At-Risk Newborn at Carilion
Roanoke Memorial Hospital (CRMH)
Authors (Include First Author’s e-mail address): Lindsay Makara, MS3
(lnmakara@carilionclinic.org),Virginia Tech Carilion School of Medicine; James Sherman, MD Carilion
Clinic; Robert Herbertson, Carilion Clinic
* Student’s Mentor: James Sherman, MD, Carilion Clinic
Purpose: Early onset sepsis (EOS) is a serious cause of morbidity and mortality even in term,
asymptomatic newborns. Our project was designed to reduce the time from birth to initial antibiotic
administration in neonates at risk for EOS to 90 minutes or less.
Methods: A new algorithm was created in collaboration with nurses and physicians from the Pediatric and
Obstetric departments at CRMH. The delivering physician was encouraged to make the diagnosis of
chorioamnionitis in mothers with temperatures > 100.4 degrees F, and notify the Pediatric physician and
Birth response team (BRT). The pediatrician would then give verbal orders, and the BRT would expedite
transport to the nursery and antibiotic administration. Data was collected from the electronic medical record
on neonates admitted to the newborn nursery at CRMH who received Ampicillin and Gentamycin in the
first 24 hours of life. Using the two-sided t-test procedure we analyzed the average time from birth to
antibiotic administration in the pre and post algorithm periods.
Results: 44 infants from the pre-algorithm period and 75 infants from the post-algorithm period were
included in the analysis. Children admitted to the NICU after birth were excluded in order to maintain
consistency with the protocol. The mean time from birth to antibiotic administration in the pre-algorithm
period was 314.66 minutes (Std Dev 248.87), and 184.05 minutes (Std Dev 135.58) in the post-algorithm
period. The mean reduction in time from the pre to the post algorithm periods was 130.6 minutes
(p=0.0021).
Conclusion: The new treatment algorithm succeeded in reducing the time from birth to antibiotic
administration by 130 minutes. While there is no optimal “time to treat” suggested in the literature, this
improvement may be important in the “at risk” infant. Further analysis and effort would be necessary to
meet our goal of 90 minutes.
38
Carilion Research Day 2013 Abstract Form
F 10
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Basic
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: Effects of debridement of the biceps tendon insertion and the superior labrum on stability of the
shoulder joint in a cadaveric concavity-compression model.
Authors (Include First Author’s e-mail address): Michael Maloney, MD +
(Mike_Maloney@URMC.Rochester.edu); Caleb Behrend, MD+‡; Jonathan Carmouche, MD‡; Charles
Chan, MD+; IlyaVoloshin, MD+
+University of Rochester Department of Orthopaedics, Rochester, NY
‡Carilion Clinic Orthopaedics, VTCSOM, Roanoke, VA
* Student’s Mentor:
Purpose:
Biceps tenotomy is frequently performed as a primary procedure or in conjunction with other
surgical interventions. The present study examined the effect of debridement of the biceps from the
superior labrum on glenohumeral stability during loading in a concavity-compression model.
Methods:
Eight cadaveric shoulders were tested. The glenoid was mounted horizontally onto a load
cell with the humerus fixed to the loading arm in the hanging arm position. A compressive load of 24N was
applied across the glenohumeral joint. The humerus was then translated superiorly until it subluxated over
the glenoid. This was repeated for 50 cycles. The force resisting superior translation was characterized for
each cycle. For each specimen this test was repeated with an intact labrum and biceps stump as a control,
after debridement of the biceps, with the superior labrum cut/displaced, and after labral repair.
Results:
Debridement of the biceps tendon insertion from the glenoid labrum resulted in an average
decrease in the force required to superiorly subluxate the humeral head by 8.6%(3.2%)* from baseline.
Resection of the entire superior labrum resulted in a decrease of 15.2%(3.1%) from baseline comparable to
previously reported results. Repair of the labrum resulted in restoration of stability with a mean of 101.1%
(5.4%). The majority of the stability was generated from the morphology of the glenoid surface. The
dynamics of the glenohumeral joint were affected by labral repair with earlier upslope on the force
displacement curve and alteration in the total energy required to sublux the humeral head.
Conclusion: The major determinant of glenohumeral stability during axial loading in the hanging-arm
position with concavity-compression was glenoid morphology. Debridement of and resection of the
superior labrum decreased glenohumeral stability. Repair of the labrum restored stability for superior
subluxation and had an effect on the joint dynamics observed during testing.
39
Carilion Research Day 2013 Abstract Form
RF 13
Check research type:
Basic
Clinical
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: Unilateral Cervical Facet Fractures Associated with Focal Kyphotic Deformity: Predicting the Need
for Surgical Intervention.
Authors (Include First Author’s e-mail address): Eric Marvin, DO (eamarvin@carilionclinic.org),
Carilion Clinic; Aaron Danison, DO, Carilion Clinic; Nicholas Qandah, DO, Carilion Clinic; Gary
Simonds, MD, Carilion Clinic
* Student’s Mentor:
Purpose: To define the relationship between traumatic cervical facet fractures with focal kyphotic
deformities, and the predictive nature of treating such injuries with surgical vs. nonsurgical management.
Methods: Retrospective chart review of patients admitted during a 32-month period with cervical fractures
identified via electronic medical record system. Each patient was individually screened to ensure they had
sustained a cervical fractures and facet fracture (if any). Data included admission/treatment dates, surgical
dates (if any), radiological descriptions, amount of facet fracture, types of orthoses, amount of listhesis,
neurological status, SLIC scores, documented reasons for delayed surgery, and amount of
angulation/kyphosis.
Results: 378 patients sustained cervical fracture(s) during this time period, 114 patients with fractures of 1
or more facets. There were 39 total surgeries for which a cervical facet fracture was identified. Of all
patients, kyphotic deformities ranged from 0 to 23 degrees with a median of 6.15 degrees. Average SLIC
scores was 4.82. Listhesis ranged from 0 to 13mm, with an average of 3.4.
In patients requiring delayed surgery (18), 11patients developed progressive listhesis, 4 progressive
pain/radiculopathy, 1 with delayed epidural hematoma. In this group, kyphosis ranged from 0 to 19
degrees; there were 4 patients without kyphosis. Average kyphotic deformity was 6.03 degrees. Average
listhesis in this group was 1.34 (0 to 4mm).
Chi-Square Test found a p-value of 0.000 when testing for significant association between cervical facet
fractures with focal kyphosis and the need for surgical intervention, both immediate and delayed.
Conclusion: Very few studies have identified patients with cervical fractures that are at risk for failing
nonsurgical management. This is the first study, to our knowledge, to identify a subset of patients with
cervical fractures (with kyphotic deformity) that are at an increased risk of requiring surgical stabilization
and/or need for open reduction.
40
Carilion Research Day 2013 Abstract Form
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Quantitative
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Faculty
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Student*
RF 15
Title: The Impact of Chronic Opioid Therapy on Obstructive Sleep Apnea Disease Treated with Positive
Airway Pressure
Authors (Include First Author's e-mail address): Niraj Niraula (nnniraula@carilionclinic.org), Virginia
Tech Carilion School of Medicine; Macrea, M. (Veteran's affairs medical Center, Salem, VA)
Purpose: Obstructive sleep apnea (OSA) is characterized by chronic intermittent hypoxia (CIH) with
reoxygenation, a phenomenon that induces oxidative stress (OS) and reactive oxygen species (ROS)
generation, further triggering cardiovascular comorbidities through various mechanisms, such as
exaggerated endothelial cell damage (hydroxyl radical mediated) or elevated blood pressure (Nox2mediated). As a significant proportion of OSA patients suffer from chronic pain syndrome and require
chronic opiate medications, we aimed to assess if newly diagnosed OSA patients on chronic opiate
medications have more severe nocturnal hypoxemia and therefore higher risk of comorbid consequences
than opiate-naïve patients.
Methods: Patients ages 45-80 without clinically unstable or sleep-induced medical diseases, chronic liver
disease, daily alcohol use, BMI>35, and concomitant use of any sedative or hypnotic medications were
recruited from those already scheduled at the Salem Veterans Medical Center (SVAMC) between January
2009 and June 2011 for overnight polysomnogram. Age, BMI, cardiovascular comorbidities (expressed as
history of CHF, HTN, Afib and Cholesterol) and the degree of nocturnal hypoxia, expressed as lowest
oxygen saturation (LO2sat) or percentage of time spent at an oxygen saturation less than 88% (%O2sat)
were obtained from the Computerized Patient Record System. The unpaired t test was used to assess the
differences in the degree of hypoxemia, cardiovascular comorbidities and sleep characteristics between the
chronic-opiate and opiate-naïve OSA patients.
Results: There was no significant difference in the degree of the nocturnal desaturations (p=0.85 for O2sat
and p=0.58 for %O2sat); cardiovascular comorbidities (p=0.31 for CHF; p=0.57 for HTN; p=0.179 for Afib
and p=0.98 for Cholesterol) and overall PSG parameters (p=0.97 for AHI; p=0.19 for sleep efficiency and
p=0.55 for REM sleep) between chronic-opiate and opiate-naïve OSA patients.
Conclusion: Chronic narcotic medication seem to have no impact on altering the natural history of OSA
disease treated with chronic CPAP therapy.
41
Carilion Research Day 2013 Abstract Form
F 11
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Basic
Clinical
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Quantitative
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Mixed Methods
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Faculty
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Student*
Title: Trends in Emergency Department Abscess Care
Authors (Include First Author’s e-mail address): Melanie K. Prusakowski, MD
(mkprusakowski@carilionclinic.org); Carilion Clinic Department of Emergency Medicine, CRMH,
Virginia Tech Carilion Department of Emergency Medicine; Damon Kuehl, MD Carilion Clinic
Department of Emergency Medicine, CRMH, Virginia Tech Carilion Department of Emergency Medicine
* Student’s Mentor:
Purpose: Abscess is a distinct skin and soft tissue infection (SSTI) requiring incision and drainage (I&D).
Previous surveys combined all SSTI to estimate abscess and evaluate their management by EM providers.
Studies have shown antibiotics may not be needed for care of abscess after I&D but are likely indicated for
other SSTI. It remains unclear how many SSTI require I&D or how providers are using antibiotics. We
examined 4 years of National Hospital Ambulatory Medical Care Survey (NHAMCS) data to estimate the
number of abscesses requiring I&D and determine antibiotic use in their management. We hypothesized
antibiotic rates are declining in response to evidence that antibiotics are unnecessary for most SSTI
requiring I&D.
Methods: NHAMCS is a national probability sample of visits to US Emergency Departments (ED). ED
patients from 2007-2010 with a diagnosis code for cutaneous abscess and SSTI were included. Starting in
2007, NHAMCS included a procedure code for I&D. Patients with SSTI and I&D were determined.
Antibiotics given in the ED or at discharge were obtained for all discharged patients with SSTI and I&D.
Total patients with SSTI, percent receiving I&D, and the percents receiving one or more antibiotics were
determined. Prescribed antibiotics were characterized based on efficacy to MRSA.
Results: ED visits for SSTI increased from 3.55M (95% CI 3.24-3.86) in 2007 to 4.21M (95% CI 3.894.55M) in 2010. Patients receiving I&D rose from 736k (95% CI 602k-869k) to 1.48M (95% CI 1.301.65M). SSTI requiring I&D comprised a mean of 32.2% of SSTI visits over the 4 years. In 2007, 85.1%,
(95 CI 82.6-87.7%) patients were given antibiotics in the ED or at discharge after I&D and the percentage
did not change over 4 years (2010: 85.5%, 95%CI 82.5-88.5). In 2010, 15.5% (95 CI 12.1-18.7%) of
patients received two or more antibiotic prescriptions. The most commonly prescribed antibiotic was
Bactrim (mean 49.1%), followed by Keflex (17.5%) and Clindamycin (15.1%).
Conclusion: ED visits for SSTI continue to rise. Despite evidence against antibiotics in SSTI requiring
I&D, antibiotic use has not declined. Many patients receive multiple antibiotics, including drugs with no
efficacy to MRSA.
42
Carilion Research Day 2013 Abstract Form
RF 19
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Basic
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Quantitative
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Faculty
Resident
Student*
Title: Is There a Seasonal Variation in Breast Cancer Screening in the Roanoke Valley and if so, why?
Authors (Include First Author’s e-mail address): Natalie Rochester, MD nhrochester@carilionclinic.org
Carilion Clinic VTCSOM
* Student’s Mentor:
Purpose: This study investigated if a seasonal variation in breast cancer screening exists and if rates of
screening at certain times of the year are influenced by community awareness programs. We surveyed
those who had undergone mammography in order to determine the motivation behind scheduling and
completing the screen at a particular time. This information may suggest ways to increase awareness and
motivate women to undergo screening as well as to evaluate benefit of current community awareness
activities.
Methods: This quality study was deemed IRB exempt. A two question survey was mailed to all women
who underwent screening mammogram’s at Carilion Clinic breast center from 2007-2011. A total of 3218
surveys were mailed. 908 surveys were returned. Three surveys were incomplete and excluded. Statistical
analysis (Fisher’s Exact Test) was performed on 905 responses.
Results: The most common time frame for screening mammograms was January to March, followed by
April to June. Eight percent of survey responders stated that breast cancer campaign’s motivated them to
undergo screening. This however, did not prove to be statistically significant in terms of seasonal variation.
Four motivational factors were found to be statistically significant: climate changes, insurance premiums,
primary care physician encouragement and turning forty years old.
Conclusions: Patients undergoing screening in the Roanoke Valley at the Carilion Clinic Breast Care
Center under-go screening mammograms in higher frequency in January to June. The most statistically
significant reasons were related to climate changes, travel, insurance premiums, physician encouragement
to complete mammogram, and turning forty years old. While our study did not show a direct link between
awareness campaigns and screening mammograms performed, there may be an indirect relationship
between patient’s knowledge of needing a mammogram at a certain age due to physician recommendation
and awareness related to screening campaigns.
43
Carilion Research Day 2013 Abstract Form
S 12
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Faculty
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Student*
Title: An Ultrasonic Airflow Sensor for Improved Apnea Monitoring of Pediatric Tracheostomy Patients
Authors (Include First Author’s e-mail address): Thomas Ruscher (thrusc@vt.edu), Virginia Tech
Electrical Engineering Graduate Student
* Student’s Mentor: Andre Muelenaer, MD, Carilion Clinic; Alfred Wicks (PhD, VT)
Purpose: Outpatient care of children with a chronic tracheostomy continues to face challenges. Patients are
at high risk for airway obstruction from mucus fouling in the artificial airway. Current monitoring methods
include chest impedance and pulse oximetry, both of which are prone to false positives and frequent false
alarms. Two years ago, we began development of a more reliable apnea sensor that attaches directly to the
tracheostomy tube.
Methods: The sensor we have developed uses ultrasonic time-of-flight (TOF) to measure airflow. This is
a proven technology with a history of use in industrial applications. The FDA recently approved the first
ultrasonic spirometer for pulmonary diagnostics. While our sensor uses the same physics, we faced
different engineering challenges to create a compact form-factor device for clinical monitoring.
Results: Our prototype device has been successfully tested in the laboratory environment. In bench-top
trials with a pediatric ventilator and a test lung, respiration was detected at tidal flows ranging from 2.5mL
to 350mL, corresponding to patient weights from 500g to 35kg. The sensor shows immunity to changes in
air temperature, humidity, and partial mucus buildup in the device.
Conclusion: At this stage, we have a mature prototype sensor intended for respiratory monitoring of
pediatric tracheostomy patients. We are currently in the early stages of applying for an Investigational
Device Exemption (IDE) with the FDA and are planning for animal, then clinical trials.
44
Carilion Research Day 2013 Abstract Form
RF 27
Check research type:
Basic
Clinical
Applied or QA/QI X
Check methodology:
Quantitative
Qualitative
Mixed Methods X
Check first author listed status:
Faculty
Resident (fellow) X Student*
Title: Decreasing use of continuous sedation in the ICU: Identifying obstacles to adopting a protocol
Authors (Include First Author’s e-mail address): Mitra Sahebazamani, MD
(msahebazamani@carilionclinic.org), Carilion Clinic; Donna Bond, RN, Carilion Clinic; Lisha Osborne,
RN, Carilion Clinic; Corey Goodwin, PharmD, Carilion Clinic; Mahtab Foroozesh, MD, Carilion Clinic.
Purpose: To investigate the effects of a patient-targeted sedation protocol in reducing duration of
mechanical ventilation, ICU and hospital stay, as well as identifying the obstacles to adopting the protocol.
Methods: We performed a prospective cohort study of ICU mechanically ventilated patients treated with a
patient-targeted protocol of as needed treatments for pain, agitation, or delirium in a 6-month period and
retrospectively compared them with historical data for similar patients in the same period of the previous
year. After the study period, participating nurses were asked to answer 7 multiple choice and open-ended
questions.
Results: 174 patients met criteria and were started on the sedation protocol. Outcomes were compared
with 180 similar patients from the previous year. The median duration of mechanical ventilation was 3.1
days in the intervention group compared with 3.5 days in the control group (P=0.34). The median ICU and
hospital stays for treatment versus control groups were 5.45 versus 6.0 days (P=0.31), and 10.20 versus
11.20 days (P=0.41), respectively. Ten nurses (67%) felt they were not helping patients by switching from
continuous to as needed sedation. Eighty seven percent were not optimistic about outcomes before
implementing the protocol. This decreased to 50% after completing the project. They identified the lack of
a protocol order-set in our computer system (94%), lack of residents’ education about the protocol (100%),
and differences in attendings’ sedation preferences as major problems during the study.
Conclusion: Trends towards improvement in outcomes were demonstrated in the patients on the protocol
compared with historic controls though not statistically significant. We noted suboptimal nursing and
physician adherence to the protocol throughout the study period. We believe a multidisciplinary approach
to sedation is needed to improve patient outcomes and to reduce barriers to adopting a sedation protocol.
Changing the culture and personal perspectives surrounding pain and sedation management and providing a
thorough education to all involved care providers are necessary in making the protocol a success.
45
Carilion Research Day 2013 Abstract Form
RF 20
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Basic
Clinical
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: Improvement in Medicare Wellness visits at Roanoke Salem Family Medicine (RSFM) clinic.
Authors (Include First Author’s e-mail address): Hemendra S Sarda, MD, (hssarda@carilionclinic.org),
Carilion Clinic Family Medicine Resident; Wayne Brackenrich, DO, Carilion Clinic Family Medicine
Faculty; Kaushal Chaudhari, MD, Carilion Clinic Family Medicine Resident
Purpose: To improve the Medicare Annual Wellness (MAW) and Welcome to Medicare (WTM) visits for
patients at 65 years of age at RSFM Clinic and educating providers to perform these visits.
Methods: All Medicare patients qualify for Annual Wellness visit which is a comprehensive visit mainly
focusing on prevention. This is a great service to the patient and it costs no co-pay to them. A patient list
was prepared consisting of all the patients of Roanoke Salem Family Medicine (RSFM) clinic who are 65
years of age. Chart reviewed to find how many of them had Welcome to Medicare (WTM) or Medicare
Annual Wellness (MAW) visits already. Patients who were due for the visit were contacted by phone
and/or letters. Patients who agreed were scheduled for the visit with their primary care physician (PCP).
Barriers were reviewed. Residents and faculty at the facility are being educated to perform these
comprehensive visits. Data reviewed to see any improvement in the Medicare Wellness visits.
Results: We started with a registry of 67 patients who met the above criteria. 4 of them already had
WTM/MAW visits. 7 of the rest were deceased or under hospice care. 15 patients did not have part B of
Medicare. 22 patients were not reachable by phone and 11 of them had not been seen in RSFM clinic for
more than 2 years. 4 patients refused to schedule for the visit after counseling. 15 patients (79 % of patients
contacted) were scheduled and/or completed the visit, 1 patient was scheduled but did not show up for the
appointment.
Conclusion: Most patients are unaware of the annual preventative visit provided by Medicare. Patient
education results in improvement in patient’s participation in wellness visit with 79 % success in
scheduling visits.
46
Carilion Research Day 2013 Abstract Form
S 13
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Clinical
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Quantitative
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Faculty
Resident
Student*
Title: Patient Preferences and Characteristics Influence Development of a Diabetes Prevention Program in
Southwest Virginia
Authors (Include First Author’s e-mail address): Kimberlee A. Saunders (skim13@vt.edu), Virginia
Tech; Richard W. Seidel, PhD, LCP, Virginia Tech Carilion School of Medicine; Fabio A. Almeida, PhD,
MSW, Virginia Tech; Wen You, PhD, Virginia Tech; Paul A. Estabrooks, PhD, Carilion Clinic Office of
Sponsored Programs
* Student’s Mentor: Paul A. Estabrooks, PhD, Carilion Clinic Office of Sponsored Programs
Purpose: Intensive lifestyle interventions are superior to medication approaches for the prevention and
delay of type-2 diabetes. However, these interventions are difficult to translate into practice because they
do not typically align with the time and resources available to patients—in particular those from lower
socioeconomic groups. The purpose of this pilot project was to determine the acceptability of a technologysupported intervention for diabetes prevention from the patient perspective and to determine if patient
characteristics (e.g., race; economic status) were related to program preferences.
Methods: Participants (n=142; 60% female; 43% African American) at risk for diabetes were identified
through the EMR and completed a survey that included questions about risk factors, including height,
weight, race, ethnicity, family history, and physical activity behaviors, for developing type 2 diabetes.
Participants’ preferences regarding diabetes prevention program approaches were also assessed. Carilion
Clinic IRB approved this study.
Results: Eighty-three percent of the participants were categorized as being at risk for diabetes and 82%
had a household income of less than $20,000. When presented with the preference between a class versus a
technology-based diabetes prevention program, 15% indicated they would not participate in either program,
and of those who indicated a preference between the two options 83% indicated that they would prefer a
technology-based program. The majority of respondents indicated that weekly telephone support for the
first 2 to 3 months of the program followed by every other week between 4 and 6 months, and monthly
through 12 months was the preferred format for follow-up. Respondents (85%) also indicated that call
duration should be less than 10 minutes on average.
Conclusion: Contrary to beliefs that low income audiences may not use technology-based interventions,
lower socioeconomic patients prefer a technology and telephone supported diabetes prevention program
over in-person class based approaches.
47
Carilion Research Day 2013 Abstract Form
RF 21
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Clinical
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Quantitative
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Faculty
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Student*
Title: Time to target temperature: A comparison of two therapeutic hypothermia protocols
Authors (Include First Author’s e-mail address): Jessica L. Schad, PharmD
(jlschad@carilionclinic.org), Carilion Clinic; Michael L. Bentley, PharmD, Carilion Clinic
Purpose: To evaluate if an adjustments made to the pharmacologic management of shivering during
therapeutic hypothermia decreased time to target temperature (32-34°C)
Methods: Patients treated with therapeutic hypothermia following cardiac arrest between July 2010 and
October 2012 were retrospectively evaluated. Since the protocol change occurred in March 2012 patients
were divided into one of two cohorts, prior to March 2012 (cohort 1 representing the retired protocol) or
after March 2012 (cohort 2 representing the updated protocol). Data collection included demographics,
time to target temperature, medications and administered dose, hospital survival, and neurological outcome.
The time required to reach target was the time difference between protocol initiation and the first
temperature reading between 32-34°C. Neurological outcome was assessed using the Cerebral
Performance Categories Scale.
Results: Seventy-six patients were enrolled in the study, 38 in each cohort. The mean age was 61 years in
each group. In the retired protocol group, 67% were male and 60% received early basic life support. For
the updated protocol group, 60% were male and 54% received early basic life support. The average time to
target temperature in the two groups were 171±125 minutes and 145±112 minutes, respectively Patients
treated with the retired protocol received an average of 6 medications to control shivering while those
treated with the updated protocol received an average of 4. Fewer patients in the updated protocol survived
to discharge (36.84% v 44.74%); however, all patients surviving had a favorable neurological outcome.
Conclusion: Patients treated with the updated therapeutic hypothermia protocol reached target temperature
quicker than those treated with the retired protocol and received fewer medications.
48
Carilion Research Day 2013 Abstract Form
F 13
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Basic
Clinical
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: Telepsychiatry in the Emergency Department: Improving Access and Efficiency in the Care of
Psychiatric Patients
Authors (Include First Author’s e-mail address): Richard W Seidel, PhD, Carilion Clinic,
RWSeidel@Carilionclinic.org; Mark D Kilgus, M.D., PhD, Carilion Clinic
* Student’s Mentor:
Purpose: Throughout the United States, inpatient psychiatric beds have declined substantially,
dramatically increasing the number of patients waiting to be evaluated and treated in emergency
departments (ED). Telemedicine represents one method to offer timely assessment to these patients, but
little research has examined emergent patients. This study compared psychiatrists’ evaluations of
Emergency Department psychiatric patients through face-to-face versus telemedicine interviews.
Methods: 73 Patients who presented in the ED between April, 2009, and July, 2012, were enrolled. Only
patients whose disposition regarding need for admission was uncertain were eligible. Each assessment
utilized two psychiatrists who independently completed the instruments. One observed and the other
conducted the interview. Participants were interviewed by a psychiatrist face-to-face in the ED or remotely
through interactive television. The comparisons utilized the Scale for Suicide Ideation, and HCR-20
dangerousness scale. Comparisons were also made for disposition, certainty of disposition decision, and
diagnosis.
Results: For face-to-face, there was 84% agreement, for telemedicine, 86%. Using Cohen’s kappa to
evaluate agreement within groups, there were no differences for disposition recommendation, strength of
recommendation, diagnosis, and the HCR-20 dangerousness scale. Chi-square revealed no differences
between groups. Intraclass correlation coefficients for the suicide scale also showed no differences.
Conclusion: The confidence intervals between conditions overlapped for all variables, indicating no
difference in inter-rater reliability in the remote versus local conditions. Thus this investigation suggests
that the conclusions drawn by psychiatrists interviewing patients in the emergency room are similar for
both face-to-face and telepsychiatry. The reliability statistics were typically in the fair to moderate range,
and the confidence intervals were wide, indicating the utility of replication with a larger sample. These
findings nevertheless offer preliminary evidence supporting using telepsychiatry in emergent situations,
thereby bringing meaningful aid to overtaxed emergency rooms, especially those in areas without readily
available psychiatric services.
49
Carilion Research Day 2013 Abstract Form
RF 22
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Basic
Clinical
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: Evaluation of the Use of Stress Ulcer Prophylaxis in a Trauma Population Across Transitions of
Care
Authors (Include First Author’s e-mail address): Caroline Preas Siemer, PharmD, MSCR
(cpsiemer@carilionclinic.org), Carilion Clinic; Jason A. Hoffman, PharmD, BCPS, Carilion Clinic
Purpose: To determine the current clinical practice of trauma prescribers at Carilion Clinic and evaluate
the appropriate use of stress ulcer prophylaxis (SUP) at admission to the hospital, transfer to a general care
unit, and at discharge.
Methods: A retrospective chart review was conducted in patients greater than or equal to 18 years of age
and admitted under trauma services from April 2012 through June 2012. Patients were evaluated to
determine risk factors and appropriateness of treatment for SUP throughout transitions of care.
Appropriateness of therapy was evaluated based on its compliance with risk factors adapted from the
American Society of Health-System Pharmacists and Eastern Association for the Surgery of Trauma
guidelines. Patients were excluded if previously treated with antisecretory therapy, history of ulcers, upper
gastrointestinal bleed within the past year, or died while in hospital.
Results: One hundred twenty-nine patients were reviewed and 83 patients met inclusion criteria for
analysis. The population was composed of 62 males (75%) and 21 (25%) females, with a mean age of 49
years. Of the 57 (69%) patients receiving SUP, evaluation of the indications for use of therapy found
acceptable indications in 37 (65%) patients. Continuation of therapy during hospitalization was seen in 17
(46%) patients, with 9 patients not demonstrating a compelling risk factor for continuation of therapy at
transition. Forty-nine (86 %) patients had therapy discontinued during their hospitalization stay and 8
patients (14%) received a prescription inappropriately at discharge.
Conclusion: A number of patients inappropriately continued to receive SUP during hospitalization.
Presence of risk factors at admission appear to affect continuation of SUP. By continuing prophylaxis
unnecessarily during hospitalization, patients may have higher risks of being inappropriately discharged on
these agents. A SUP protocol for trauma services is currently being developed to better outline indications
for patient criteria.
50
Carilion Research Day 2013 Abstract Form
F 14
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Clinical
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Quantitative
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Faculty
Resident
Student*
Title: Prevalence of intrauterine abnormalities discovered on sonohysterogram in an infertility practice
Authors (Include First Author’s e-mail address): Robert Slackman, M.D. Carilion Clinic
(RLSlackman@carilionclinic.org); Adrienne Gentry, D.O.
* Student’s Mentor:
Purpose: performed to investigate the prevalence on sonohysterogram of intrauterine abnormalities in a
private practice setting of infertility patients.
Methods: Women presenting for a sonohysterogram to evaluate the uterine cavity as part of their
infertility evaluation were included in this study. Written consent was obtained. Sonohysterograms were
performed after the period had finished but still within the proliferative phase of the cycle. The
sonohysterogram was performed with either an HS catheter or an intrauterine catheter utilizing a Medison
Accuvix V20 ultrasound machine. A transvaginal probe at 6-8 MHZ was employed to visualize the uterus
during the procedure . Five to 10 ml of sterile injectable saline was instilled into the uterine cavity while
transvaginal sonography was performed. Note was made whether or not the uterine cavity was normal. If
an intrauterine defect was detected its size was measured and it was noted whether it had the appearance of
a polyp or a submucosal fibroid. Patient data regarding age, parity, and BMI were also collected. Results:
The prevalence of an abnormal uterine cavity caused by either an intrauterine polyp or submucosal fibroid
in infertility patients undergoing a sonohysterogram was 15%. The data do not reach a level of significance
to suggest an association between a history of full term pregnancy(ies), miscarriage(s), prior abortion(s) or
BMI and the finding of an intrauterine abnormality on sonohysterogram. However, when age was
examined it was found that women less than 40 years of age were more likely to have an abnormal uterine
cavity than women over 40 years of age. (p = 0.0067)
Conclusion: There is a 15% prevalence of intrauterine abnormalities in women undergoing infertility
treatment. Because such an abnormality is known to be associated with infertility, it is important to
identify these abnormalities early in the course of a patient’s evaluation. Younger women, less than 40, are
more likely to be found to have such an abnormality than older women.
51
Carilion Research Day 2013 Abstract Form
F 15
Check research type:
Basic X Clinical
Applied or QA/QI
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Quantitative
Qualitative
Mixed Methods X
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Faculty X Resident
Student*
Title: Contributions of VLDLR and LRP8 in the establishment of retinogeniculate projections
Authors (Include First Author’s e-mail address): Jianmin Su, PhD (sujm@VTC.vt.edu), Virginia Tech
Carilion Research Institute; Anna M. Josephson, Department of Anatomy and Neurobiology, Virginia
Commonwealth University; Michael A. Fox, PhD, Virginia Tech Carilion Research Institute, Department
of Biological Sciences, Virginia Tech (Supervisor)
Purpose: Retinal ganglion cells (RGCs) project to over 20 distinct brain nuclei, including the lateral
geniculate nucleus, a thalamic region comprised of three functionally distinct subnuclei----the dosal LGN
(dLGN), the ventral LGN (vLGN) and the intergeniculate leaflet (IGL). We previously identified reelin, an
extracellular glycoprotein, as a critical factor that directs class-specific targeting of these subnuclei. Reelin
is known to bind to two receptors – Very Low Density Lipoprotein Receptor (VLDLR) and Low-density
lipoprotein Receptor-related Protein 8 (LRP8). Here we examined roles for these canonical reelin receptors
in retinogeniculate targeting.
Methods: To assess the roles of VLDLR and LRP8 in retinogeniculate targeting, we used intraocular
injections of fluorescently conjugated cholera toxin B subunit (CTB) to label all RGC axons in vivo. We
injected 11 wild-type mice, 7 Reln-/- mice, 5 Vldlr-/- mice, 6 lrp8-/- mice, 9 vldlr+/-: lrp8+/- mice, 6 vldlr+/-:
lrp8-/- mice, 7 vldlr-/-:lrp8+/- mice and 9 vldlr-/-:lrp8-/- mice age from P9 to P23. In order to understand the
mechanisms of the ectopic, binocularly innervated region of dorso-medial dLGN in vldlr-/-:lrp8-/- mutants,
we used in situ hybridization and immunohistochemiatry to test several synaptic or neuron markers,
including VGluT2, VGluT1, adamts15 mRNA, SMI32, NPY and NeuN.
Results: We found that defects in vldlr-/-;lrp8-/- double mutant mice were remarkably different than those
observed in mice lacking reelin. First, we failed to observe retinal axons exiting the medial border of the
vLGN and IGL to invade distant regions of non-retino-recipient thalamus. Second, an ectopic region of
binocular innervation was present in the dorsomedial pole of vldlr-/-;lrp8-/- mutant dLGN. Analysis of
retinal projection development, retinal terminal sizes, and LGN cytoarchiecture in vldlr-/-;lrp8-/- mutant
LGN, all indicated that a subset of retinal axons destined for the IGL were misrouted to the dorsomedial
pole of dLGN in the absence of VLDLR and LRP8. Misrouting of retinal axons likely resulted from the
malposition of IGL neurons in the dorsomedial pole of dLGN in vldlr-/-;lrp8-/- mutants.
Conclusion: The development of both the LGN and retinogeniculate projections appeared dramatically
different in mutants lacking reelin or both canonical reelin receptors. These results suggest that there are
reelin-independent functions of VLDLR/LRP8 in LGN development and VLDLR/LRP8-independent
functions of reelin in class-specific axonal targeting.
52
Carilion Research Day 2013 Abstract Form
S 15
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Clinical
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Quantitative
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Mixed Methods
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Faculty
Resident
Student*
Title: Ultrasound as a modality in detecting elbow effusions: an assessment of effusion views in
combination with a provocative technique
Authors (Include First Author’s e-mail address): Jessica L Toms (jltoms10@onejeff.jchs.edu),
Jefferson College of Health Sciences; Natalie Peck, Jefferson College of Health Sciences; Oleg Uryasev,
Virginia Tech Carilion School of Medicine; Oliver Joseph, Virginia Tech Carilion School of Medicine;
John P McNamara, DC, Jefferson College of Health Sciences, Virginia Tech Carilion School of Medicine;
Apostolos Paul Dallas, MD, Virginia Tech Carilion School of Medicine
* Student’s Mentor: John P McNamara, DC
Purpose: To determine the efficacy of ultrasonography and provocative techniques in detecting and
measuring the severity of elbow effusions.
Methods: Bilateral elbow effusions were simulated on 4 unembalmed cadaveric models by injecting
incremental amounts of saline into the synovial cavity from the medial aspects using US guidance. Elbows
received increments of 1mL, 2.5mL, 5mL and 10mL. Each effusion volume was measured at the anterior
and posterior midline and posterior oblique aspects. For each anterior effusion we applied pressure to the
posterior aspect of the elbow joint to illicit a further effusion in the anterior compartment. An identical
technique to provoke posterior effusions was used.
Results: Effusions starting at 2.5mL were visible on anterior and posterior without any provocative
maneuver. With provocative maneuvers applied to the anterior aspect, the effusions increased on average
0.13cm. With provocative maneuvers applied to the posterior aspect, the effusions increased on average
0.22cm. Results were compared using a one tailed t-test. The provocative maneuver was statistically
different on the anterior aspect at 1mL (P<0.05) and 5mL (P<0.10). On the posterior aspect, the
provocative maneuver was statistically different at 5mL (P<0.05) and 2.5mL (P<0.10).
Conclusion: Effusions in synovial joints are visible as hypoechoic spaces next to the bone articulation.
Pressure will reduce the size of the effusion, which requires considerable skill when assessing effusions.
When the provocative technique was used in combination the pressure exerted by the probe was not as
critical in effusion evaluation. The provocative technique increased the ease of joint effusion measurement
by concentrating the fluid in the opposite synovial recess.
53
Carilion Research Day 2013 Abstract Form
F 16
Check research type:
Basic
Clinical
Applied or QA/QI X
Check methodology:
Quantitative
Qualitative
Mixed Methods X
Check first author listed status:
Faculty X Resident
Student*
Title: Implementation of the neotech ram cannula in the pediatric intensive care unit
Authors (Include First Author’s e-mail address): Shari A. Toomey, MBA, RRT – NPS
(satoomey@carilionclinic.org), Carilion Clinic Children’s Hospital
Purpose: Patients with broncholitis, RSV, and apnea require all levels respiratory support, which
can include Non-invasive Ventilation (NIV) or intubation. Current NIV interfaces presently on the
market are uncomfortable, ill fitting, which lead to non-compliance of usage, ineffective ventilation,
and poor outcomes. Intubation leads to complications; airway trauma, infection, and lung damage.
RAM Cannula is a versatile interface for the neonatal and pediatric population. Adopting the
interface for management of patients meeting criteria, goal was to decrease overall intubated days
and length of stay (LOS).
Methods: This prospective study compared a retrospective review of patients in 2010-2011,
looking at ventilator days and LOS of patients meeting criteria. Target population identified:
Patients ≤ 8 months of age, diagnosis of broncholitis, Respiratory Syncytial Virus (RSV) or apnea
requiring NIV or intubation. Per guidelines patients meeting criteria would be placed on RAM
Cannula and receive support based on clinical assessment. Data collection followed the patient till
discharge. Neo/Peds Transport was included in the study and followed the same guidelines.
Results: 2010-7 patients meeting inclusion criteria admitted to PICU – total 10 ventilator days.
2011-16 patients - total of 17 ventilator days. 2012- 31 patients -total 7 ventilator days. LOS in
2010 for included patients was 5.7 days. LOS in 2011 for included patients was 4.6 days. LOS in
2012 for included patients was 4.1 days. In 2010, 14% of patients meeting inclusion criteria were
intubated. In 2011, 25% were intubated. In 2012, 7% were intubated and 35% received NIV via
RAM Cannula.
Conclusion: Implementation of RAM Cannula guidelines decreased ventilator days, rate of
intubation, and LOS. Guidelines allowed standardized care and a comfortable interface. We will
continue to monitor our outcomes as we continue to address the expanded use of RAM Cannula in a
broader patient population.
54
Carilion Research Day 2013 Abstract Form
RF 24
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Basic
Clinical
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Quantitative
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Faculty
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Student*
Title: Team Based Approach to Hypertension: A Pilot for the Million Hearts Campaign
Authors (Include First Author’s e-mail address): Amber Warren, D.O. (arbishop@carilionclinic.org)
Carilion Clinic; Ann Lucktong, PharmD, Carilion Clinic; Beverley Brown, M.D. Carilion Clinic
* Student’s Mentor:
Purpose: To determine if a multidisciplinary approach to hypertension is effective in lowering blood
pressure by utilizing a care team. This is a pilot project inspired by the “Team Up, Pressure Down” Million
Hearts Campaign, which nationally has a goal of preventing one million heart attacks and strokes in five
years.
Methods: Our care team consists of an attending physician, three family medicine residents, two nurses,
one medical office assistant, and clinical pharmacists in the setting of a family medicine residency program.
Sixty eight patients who are assigned to the care team’s patient panel were selected if their systolic blood
pressure was greater than 160 mm Hg and/or diastolic blood pressure was greater than 100 mm Hg. Each
patient was sent a letter explaining the need for tighter blood pressure control and encouraged them to make
an appointment. Subsequent visits were scheduled at 2, 4, and 6 months thereafter wherein the patient was
counseled on lifestyle changes, the need for aspirin was evaluated, cholesterol was discussed, and smoking
cessation was encouraged. At each visit, every patient also met with the pharmacist who did a thorough
review of the patient’s antihypertensive regimen and gave recommendations to the primary care physician.
Nurse blood pressure visits and phone interviews were also utilized.
Results: Out of the 68 who were sent letters, 23 patients responded and were included in the study. To
date, 35% have decreased both systolic and diastolic blood pressures, 52% have decreased either their
systolic or diastolic blood pressures or had no change, and the remaining 13% still require more data. At
the end of six months, average blood pressures pre- and post-intervention were compared.
Conclusion: We found that the team based approach to treating hypertension in the clinical setting
streamlined care and effectively lowered blood pressure.
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Carilion Research Day 2013 Abstract Form
F 17
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Title: Moral Distress: A Common Phenomenon Among All Clinicians
Authors (Include First Author’s e-mail address): Phyllis Whitehead, PhD, APRN
(pbwhitehead@carilionclinic.org) Carilion Clinic and Joan Fisher, MD, PhD, Carilion Clinic
* Student’s Mentor:
Purpose: This research provides an assessment of the prevalence of moral distress of all clinicians using
the Revised Moral Distress Scale (MSD-R).
Methods: A descriptive, comparative design using a web-based survey of demographics, the MDS-R and a
shortened version of Olson’s Hospital Ethical Climate Scale (HECS) was conducted. The MDS-R is a 21
item scale measuring moral distress for nurses, physicians, and other providers. The HECS is a 16-item
scale designed to assess perceptions of the ethical climate in the workplace. In January 2011, surveys were
distributed via Qualtrics to all nurses (n= 1513), physicians (including residents) (n= 875), and other
providers (n=309), totaling 2697 at CRMH.
Results: Moral distress was present with all healthcare providers. 749 of 2697 (a 28% response rate)
clinicians completed the survey. Similarities and differences in moral distress between disciplines were
analyzed revealing that nurses experienced moral distress at higher levels and more frequently than other
clinicians. There was a negative correlation (r=-0.5; p < 0.0001) between moral distress and ethical
workplace climate with all three groups. All healthcare professionals all cited watching patient care suffer
due to lack of continuity and witnessing diminished patient care due to poor team communication as a high
source of moral distress. Providers caring for adults had higher levels of moral distress than clinicians
caring for children (p < 0.0001). Finally the MSD-R was studied to determine its effectiveness in terms of
reliability and validity when studying moral distress in other clinicians such as chaplains and social
workers. The Cronbach alpha for the MDS-R was high with at least 0.85 for all studied disciplines.
Conclusion: Results of this and other recent studies show moral distress is prevalent among all disciplines
and should be anticipated. More effort is needed to develop and study interventions to minimize moral
distress.
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Carilion Research Day 2013 Abstract Form
F 18
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Title: Relationship between Knowledge, Perceived Risk, and Influenza Vaccine Uptake in Undergraduate
Health Science Students
Authors (Include First Author’s e-mail address): Diana Willeman-Buckelew, MSPH
(DLWilleman@jchs.edu), Jefferson College of Health Sciences; Aimee Ferraro, PhD, College of Health
Sciences, Walden University
Purpose: The purpose of this study was to (a) examine what influence perceived risk and knowledge about
influenza and vaccination had on the decision of undergraduate health science students to receive the
vaccine and (b) to identify predictors of vaccine uptake.
Methods: In this cross-sectional study, 863 undergraduate students at Jefferson College of Health Sciences
(JCHS) were recruited via email in the Fall 2012 semester to participate in an internet-based survey that
assessed knowledge, perceived risk, barriers, demographics, and influenza vaccination behaviors. A chisquare test was conducted to determine if there were any associations between vaccinated and unvaccinated
participants. The data was analyzed using an independent sample t test to determine if there were any
significant differences between knowledge, perceived risk, and influenza vaccine uptake. Multivariate
logistic regression was performed to determine which variables were predictors of influenza vaccine
uptake.
Results: The survey was completed by 299 undergraduate students (34.6%) and the self-reported influenza
vaccine uptake was 44.3%. All undergraduate programs of study and academic levels were represented in
the study. A significant association was found between vaccinated and unvaccinated participants (p <
.001). Results indicated that there were significant differences between knowledge (p = .029), perceived
risk (p < .001), and influenza vaccine uptake. Multivariate logistic regression found that perceived risk (p
< .001), patient contact separate from clinical courses (p = .011), and prior vaccination (p < .001) were
predictors of vaccine uptake. Lack of time, inconvenience, and not wanting the vaccine were the most
common barriers reported for not receiving the influenza vaccine.
Conclusion: Influenza vaccine coverage of health science students at JCHS fell below the Healthy People
2020 goal of 90% and did not meet the recommendation of the Centers for Disease Control and Prevention
that all healthcare personnel be vaccinated annually for influenza.
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Carilion Research Day 2013 Abstract Form
RF 25
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Title: Multiplanar Real Time Ultrasound Guided Infraclavicular Subclavian Vein Catheterization
Authors (Include First Author’s e-mail address): Xin Zhong MD (xzhong@carilionclinic.org), Mark
Hamill MD, Bryan Collier DO, Eric Bradburn DO, John Ferrara MD. All affiliated with Carilion Clinic
* Student’s Mentor:
Purpose: Ultrasound guided vascular access has been well-characterized as a safe and effective technique
for internal jugular and femoral vein catheterization. However, there is limited experience with the use of
ultrasound to access the infraclavicular subclavian vein. Multiple ultrasound techniques do exist to
identify the subclavian vein, but real time access to this vessel is limited by vessel identification in a single
planar view. To overcome this shortcoming, we have developed a unique technique of ultrasound guided
infraclavicular subclavian vein central venous catheterization using a real time multiplanar approach. The
initial experience with this approach is described below.
Methods: A single surgeon used combined oblique, transverse, and longitudinal views along with Doppler
color flow images to both define the infraclavicular anatomy and obtain subclavian vein access in 28 adult
patients (12 M/16 F and 15 L/13 R) with a mean body mass index of 29.2 (range = 18.9-46.2). After
successful cannulation, all catheters were inserted using the usual Seldinger technique. A chest x-ray was
obtained afterwards to confirm position and to rule out complications such as pneumothorax.
Results: Using this technique, subclavian vein cannulization was achieved in 100% of subjects.
Subsequent catheterization was successful in 92.8% of patients. The number of sticks required for
cannulation averaged 1.6, ranging from 1 to 5 and decreased after a learning curve. Failure of
catheterization occurred in two patients due to proximal obstruction and aberrant venous anatomy. No
patient developed a pneumothorax, hematoma, line infection, or had a malpositioned line.
Conclusion: Ultrasound guided multiplanar infraclavicular subclavian vein access appears to be a safe and
effective adjunct for central line placement. Further study is needed before promoting wide spread
application.
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