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Clinical and Scientific Affairs Council's
16th Annual Clinical and Professional Poster Session
AAPA's 35th Annual PA Conference
Philadelphia, PA
The 16th Annual Clinical and Professional Poster Session, coordinated by the AAPA Clinical and Scientific Affairs Council, features abstracts in three categories: original research, case studies/clinical reports, and posters previously presented at medical/scientific conferences. The Poster Session consists of three galleries: one depicting posters presented by fellow members, another displaying posters created by PA students, and the third focused on PA education.
The poster session highlights the unique research that PAs, PA faculty, and PA students have accomplished during the year and provides an excellent venue for extended informal discussion with meeting attendees.
All the posters, along with their assigned numbers, are listed below. They are available for viewing inside Grand Hall of the Pennsylvania Convention Center beginning Sunday, May 27, through Wednesday, May 30. The authors will be present at their posters for discussion on Tuesday, May 29, from noon to 1:00 p.m. Light refreshments will be provided for those attending this session.
Three student abstracts have been selected for outstanding student research; each will receive a $500 student travel stipend.
The written abstracts for the poster presentations on display during the annual conference can be found on the following pages, listed in order by poster assignments.
CLINICAL AND PROFESSIONAL GALLERY
Original Research
No. Title and Authors
1 Does the Proximity of an Amputation, Length of Time Between Foot Ulcer Development and Amputation, or Glycemic Control at the Time of Amputation Affect the Mortality Rate of People with Diabetes Who Undergo an Amputation?
R. Jones and W. Marshall2 Empowerment and Educational Goals: A Study on the Outcomes of a Mentoring Program.
A. Kulon, K. Snell, S. Grow, and T. Bacon-Bagulely3 Evaluation of an Educational Protocol for the Use of Nesiritide in Acute Decompensated Heart Failure.
R. Kirkhart4 Hepatitis C, All Genotypes and Sustained Virological Remission in Pegylated Interferon 2b/Ribavirin Treated Patients who also Took Nutritional Supplementation.
S. Bahrych, W. Brown, A. Keniston, and N. Toribara5 Investigating the Need for Age-specific Approaches to Intimate Partner Violence.
V. Breitbart, L. Davidson, V. Rickert, J. Tanenhaus, and L. Rottenberg6 Patient Perception of Optimal Weight Goals in the Overweight Population.
C. Innus and J. Patterson7 Physician Assistants' Attitudes, Knowledge, and Skills about Patient Safety and Medical Errors.
L. Mustone Alexander, J. Delaney, M. Doll, K. Korber, R. McNellis, and J. Taft8 Predictors of PSA Recurrence after Robot-assisted Radical Prostatectomy.
M. Mathe, S. Capello, H. Patel, and J. Joseph9 Prevalence of Sleep Apnea in Subjects with Atrial Fibrillation at a Specialty Cardiology Office.
A. Murray, J. Gietzen, and B. Halperin10 Rheumatology Physician Assistant Role Delineation Study.
R. Hooker, J. Seignon, and B. Rangan11 The Effects of Early Patient Education on Immunization Rates of Infants in Galveston County.
T. Bigler and K. Stephenson12 Type II Odontoid Fractures in the Elderly Treated with Cervical Orthosis.
D. Orndorff, I. Marks, R. Whitehill, D. Chun, and V. ArletCase Studies/Clinical Reports
No. Title and Authors
13 An Atypical Presentation of Venous Stasis Ulcers in a Patient with AIDS.
K. Breaux and M. Rodriguez14 An Unusual Case of Cirrhosis in a 56-year-old Male.
J. Van Rhee15 Pneumatosis Intestinalis and Portal Venous Gas Associated with Placement of a Balloon Foley Jejunostomy Feeding Tube.
J. Moore16 Sacral Chordoma.
I. Marks and F. Shen17 Streamlining Kidney Transplant Hospital Stay.
E. Simmons, E. Tichy, S. Kulkarni, N. Edgington, and M. St. George18 The Use of Vacuum-assisted Closure for Staged Skin Grafting of Plantar Foot Defects Following Oncologic Resection.
S. Oates, L. Heller, and J. SchattePreviously Presented
No. Title and Authors
19 Seroma Development Following Body Contouring Surgery for Massive Weight Loss: Patient Risk Factors and Treatment Strategies.
M. Shermak, L. Rotellini-Coltvet, and D. Chang20 An Unusual Reaction to Intracorporeal Injection of Phenylephrine in a Patient with SCD and Stuttering Priapism.
L. Daitch and A. Kutlar21 Relapsing Malaria Infection in an Adolescent Following Travel to Mozambique.
A. Summer, C. Oswald, and P. FischerEDUCATION GALLERY
Original Research
No. Title and Authors
22 Academic-induced Lifestyle Changes in Student Physician Assistants.
J. Rasmussen, E. Frazier, and J. Gietzen23 Analysis of Grade Point Average and First-time PANCE Performance Among Graduate/Undergraduate and Full-time/Part-time status Students of the Drexel University Physician Assistant Program: 2004-2006.
C. Stream and J. Krolokowski24 Complementary and Alternative Medicine in U.S. Physician Assistant Education.
L. Freels-Lloyd, B. Simon, L. Dunn-Ryznky, and F. Isberner25 Diagnostic Reasoning Skills at Entry into a Non-traditional Physician Assistant Program - Registered Nurses Versus Other Allied Health Professions.
S. Kuntz, A. Larson, and M. Laxen26 Faculty Development Essentials in Allied Health Clinical Preceptors.
J. Rogers, L. Dunn-Ryznyk, and C. Lautar27 Imposter Phenomenon in Physician Assistant Education.
J. Prata and J. Gietzen28 Interdisciplinary Coursework: Pathophysiology with PA, NP, and PT Students.
H. Stoll, K. Wick, M. Guthrie, and P. Zimmer29 Using a Game Format to Advance Professionalism in the Second-year Physician Assistant Curriculum.
A. BrennemanPreviously Presented
No. Title and Authors
30 Comparison of Faculty Expectations to Student Performance on a Clinical Skills Performance Instrument.
J. Melson, J. Maring, E. Costello, and M. Plack31 Health Care Teams: Leadership Style, Performance, and Patient Outcome.
D. Bridges, J. Carlson, and E. Min32 Student Attendance Utilizing a Classroom Management System.
E. Lembke, V. McCleary, M. Laxen, and C. Hosford33 Trends in Religious and Spiritual Indicators in Physician Assistant Student Application Essays.
C. Robohm34 What Do PA Students Know about Tuberculosis: Results of a Survey of the Confidence and Knowledge of PA Students Regarding Tuberculosis.
M. Davison and D. Brown35 When do Applicants Learn about the Physician Assistant Program? One Program's Nine-year Experience.
C. Robohm and J. BowserSTUDENT GALLERY
Outstanding Student Research
No. Title and Authors
36 Are Self-reported Patient Encounter Data Accurate?
L. Williams and D. Day37 Breaching Patient Confidentiality: A Pilot Study of Physician Assistants' Awareness and Attitudes.
K. Slabic and A. McGuire38 HIV Seroprevalence Among Patients Admitted to Mulago National Hospital in Kampala, Uganda.
G. Kayingo and M. WarnerOriginal Research
No. Title and Authors
39 A Retrospective Study on the Importance of Salary in the First Job Choice of a Physician Assistant.
K. Postreich, K. Chapman, J. Campell, and W. Carpenter40 A Study of Tanning Operators in the State of Kansas: Their Attitudes and Stated Practices Regarding Minors and Tanning.
M. Apollo and R. Muma41 An Analysis of Stress-related Lifestyle Changes of Physician Assistant Students Across Several PA Training Programs.
A. Hawn, D. LaBarbera, and M. Schomogyi42 An Assessment of Community Awareness and Perceptions of a Mental Health, Drug and Alcohol, and Mental Retardation Agency and Barriers to Treatment.
L. Ulrich, L. Reiner, N. Brown, T. Thompson, and B. Biearman43 Analyzing Pharmacists' Knowledge of Physician Assistant Prescribing Rights.
M. Hill, A. Leighow, A. Uziel, and B. Biearman44 Antibiotic Prescribing Patterns for Acute Otitis Media in One Urban Pediatric Clinic.
K. Sinclair, Y. LeGoff, C. Barra, and E. Mandel45 Breast Cancer Awareness and Genetic Testing Among Students at Seton Hall University.
L. Roenigk, C. Carpenter, and M. Stansfield46 Comparison of Cardiovascular Risks in Paid Versus Volunteer Firefighters.
B. Pherson, R. Ruth, C. Schmidt, and B. Biearman47 Diagnosis and Clinical Management of Potential Statin Myopathy in Polypharmacy.
L. Palmer, W. Insull, and E. Love48 Does a Correlation Exist Between the Number and Type of Clinical Encounters and NCCPA PANCE Scores?
E. Min, H. Comstock, and B. Dickey49 Effect of Educational Materials on Patients' Ability to Recall Medication Regimens and Compliance.
A. Frakes and A. Brenneman50 Emergency Medicine Physicians' Opinions Regarding the Use of Physician Assistants in the Emergency Department Setting in Texas.
E. Elliott, K. Erdman, V. Waters, and D. Holcomb 51 Evaluation of International Adoptive Collaborative Training. C. Haller, T. Mai Houston, B. Prince, A. Vo, and B. Biearman52 Factors Influencing a Woman's Decision to Breastfeed.
K. Pauze, M. Kourtz, J. Streich, K. Wai, and B. Biearman53 How Physician Assistants Use Evidenced-based Medicine in their Clinical Practice.
M. Behr, C. Jordan, J. Olsen, and K. Seelman54 Perceptions of Medical Research Education in Physician Assistant Programs.
K. Angelo, M. Ressler, T. Weber, J. Wackowski, and B. Biearman55 Physical and Physiological Changes Observed Following the Lap-band Surgical Procedure.
M. Nye, R. Simper, O. Chen, and L. Hill56 Physician Assistant Knowledge and Adherence to Cardiovascular Disease Prevention Guidelines: A Pilot Study.
L. Blair, W. Insull, and C. Fasser57 Practicing Physician Assistant Awareness of ATP III Cholesterol Guidelines.
K. Malone, K. Beck, J. Blakeslee, and L. Martin58 The Bird Flu: How Aware Are You?
K. Czekanski, B. Brancazio, W. Stein, and B. Biearman59 The Relationship Between Asthma and Obesity.
J. Oliveira, S. Shapiro, and N. Hadi-Nahavandi60 Weeble Wobble Study: Infant Weight Gain Patterns in a Private Pediatric Setting.
J. Buckweitz, H. Holloway, B. Kanani, and E. Mandel61 Weight Loss and Perceived Improvement in Comorbidities and Psychological Well Being in Lap-band Recipients.
S. Melville, L. Gonzales, O. Chen, and L. Hill62 What are Young Adults' Attitudes, Intentions, and Behaviors Regarding Skin Cancer? A Survey Among Southern Californians.
S. Barnes, G. Mitchell, C. Nagel, E. Park, N. Riotto, D. Lopez, N. Daher, and K. BourneCase Studies/Clinical Reports
No. Title and Authors
63 A Case of Congenital Isolated Hemihypertrophy in a Seven-year-old Male.
J. Palermo and A. Essary64 A Case of Esophageal Herpes Simplex Virus Type 1 in an Immunocompetent 21-year-old Male.
S. Bolander, L. Ritter-Baker, and B. Coplan65 A Case of Hyperbilirubinemia: A Search for the Less Obvious.
M. Miller and M. Statler66 Acanthosis Nigricans in a Female Patient.
C. Shelburne and K. Lohenry67 Acute Exacerbation of Chiari I Symptoms after Chiropractic Intervention.
E. Zink, K. Lohenry, and J. Williams68 An Uncommon Reaction to Prochlorperazine.
M. Matey and J. Spiegel69 An Unexpected Finding in a Two-year-old with a Burn Injury to the Hand.
N. Farrar and T. Moreau70 Congenital Liver Malformation: A Case Report.
S. Adams71 Isolated Thrombolysis Catheter for the Treatment of Upper Extremity Deep Vein Thrombosis: A Case Study.
T. Lavor and J. Spiegel72 Lipoma versus Liposarcoma in a 26-year-old Male.
F. Altuve and K. Lohenry73 Mental Illness in a Pregnant Female: A Case Report.
A. Packham, J. Stoehr, and A. EssaryPreviously Presented
No. Title and Authors
74 How Knowledge of Medication Regimens Influences Adherence in Ambulatory Geriatric Patients Taking Multiple Medications.
B. McBryde, O. Chen, and L. Reed75 Prevalence of Nutritional Deficiency in Elderly Patients Undergoing Mohs Micrographic Surgery.
D. Marquez, H. Lemke, and O. Chen
CLINICAL AND PROFESSIONAL GALLERY
Original Research
1. Does the Proximity of an Amputation, Length of Time Between Foot Ulcer Development and Amputation, or Glycemic Control at the Time of Amputation Affect the Mortality Rate of People with Diabetes who Undergo an Amputation?
R. Jones and W. Marshall, Illiana Veterans Health Care System, Danville, IllinoisObjective: The purpose of our research was to evaluate the three- and five-year mortality rate comparing toe and foot amputations, below the knee amputations, and above the knee amputations. This study also addresses the length of time from ulcer formation and the proximity of an amputation, and its effect on mortality. We also set out to determine whether glycemic control at the time of amputation affects mortality in diabetics. Method and Design: The subjects were all inpatients at our facility with a diagnosis of diabetes, diabetic neuropathy, peripheral vascular disease, and a diabetic foot ulcer that resulted in an amputation. Our sample size was 80 patients, divided evenly between toe and foot amputations, below-the-knee amputations, and above-the-knee amputations. The mean age of all the subjects in all the groups was 68.5 years +/- 7.2 years. We used the Hemoglobin A1C (Hgba1c) level to assess glycemic control. We also examined the time between onset of ulcer formation and amputation and compared proximity of amputation and compared the proximity of amputation and mortality rate. Statistics: We used several chi squares to examine the three-year and five-year mortality rate comparing the amputation groups. An HgbA1c level of 8.0% or less defined good control and an hgba1c level of above 8% defined poor control. A chi square was used again to compare glycemic control, the level of amputation, and the mortality rate. For the length of time from ulcer formation to amputation, determining level of amputation and mortality rate also required a chi square. All statistics were done using SPSS 10.0 student version. Conclusion: Our research revealed a statistically significant difference in mortality at three and five years with the most proximal amputation. There was no statistically significant difference on mortality regarding glycemic control after an amputation. A statistically significant difference was found in the length of time that an ulcer was present prior to amputation.
2. Empowerment and Educational Goals: A Study on the Outcomes of a Mentoring Program.
A. Kulon, K. Snell, S. Grow, and T. Bacon-Baguley, Grand Valley State University, Grand Rapids, MichiganPurpose: The Mazizi Maji Mentoring Program is nestled in a neighborhood populated by families and individuals struggling to meet the challenges of everyday life. Both crime and drug use have put a strain on the neighborhood and the hope of the people who live there. The goal of the mentoring program is to provide individuals (ages 8-17) from underprivileged neighborhoods with a greater understanding of empowerment and academic success. In 2004, Grand Valley State University (GVSU) Physician Assistant Studies (PAS) Program and the Mazizi Maji Mentoring Program united to provide mentorship for the Mazizi Maji participants and to provide assistance in evaluating the goals of the program. Additional mentors of the program include adult volunteers from the community. Methods: Student volunteers from the GVSU PAS Program attended a mentorship orientation and were subsequently assigned a participant of the Mazizi Maji program to mentor. The mentorship program consisted of weekly/biweekly meetings in which one hour was spent in academic tutoring followed by two hours of activities. Activities include guest speakers, informational sessions on job interviewing, and field trips. The effectiveness of the mentoring program was assessed utilizing a previously validated survey, Self Description Questionnaire (SDQ I and SDQ II). This survey was designed to assess the scholastic achievement and empowerment of participants of a mentoring program. The survey was administered to the Mazizi Maji participants every three months. The initial survey completed by a participant was compared to subsequently administered surveys and the difference in scores determined using the Wilcoxon Signed Rank test. The alpha was set at 0.10. Results: There were a total of 20 participants who completed a minimum of two surveys. The group of participants, ages 8 to 12, had a significant improvement in parent relations (p= 0.018), mathematical reasoning (p=0.10), and total non-academic perspectives (p=0.063). In this age group, there was no significant difference in perceptions of physical ability (p=0.225), physical appearance (p=0.308), peer relations (p=0.674), reading ability (p=0.833), general self-difference (p=0.345), and total academic difference (p=0.398). The group of participants ages 13 to 17 had a significant difference in the scores relating to physical appearance (p= 0.018), verbal skills (p= 0.10), mathematical reasoning (p=0.092), general school perception (0.008), and perception of self in general (p= 0.027). Among the older ages, there were no significant differences in perception of physical ability (p= 0.529), peer relations (p=0.275), parent relations (p=0.806), and honesty (p=0.456). Conclusions: As assessed by the SDQ I and II, the participants in the Mazizi Maji Mentoring Program did have significant improvement in some of the attributes related to empowerment and academic success. There were age-associated differences in the changes of empowerment and academics, which may be attributed to stages of development. Although every domain of empowerment and academic success did not show a significant difference, the program has shown anecdotal evidence of the achievement of these goals. PAS students continue to provide mentoring to the participants and a qualitative assessment of the goals is currently in process.
3. Evaluation of an Educational Protocol for the Use of Nesiritide in Acute Decompensated Heart Failure.
R. Kirkhart, University of Findlay Physician Assistant Program, Columbus, OhioPurpose: The purpose of this research was to utilize evidence-based medicine to develop a usage protocol to educate physicians on the proper utilization of nesiritide in the treatment of acute decompensated heart failure. This research was triggered by recently published safety data regarding nesiritide administration. This research studied the prescribing practices as well as the incidence of adverse side effects related to nesiritide administration before and after the implementation of a nesiritide usage protocol. Methods: Data was collected via a medication use evaluation utilizing a retrospective chart review. Data collected from the review process included appropriate indication, presence of exclusion criteria, medications used prior to nesiritide, monitoring parameters, specialty of prescribing physician, length of hospital stay, and incidence of adverse effects. Appropriate indications include patients presenting with acute decompensated heart failure, presence of fluid overload, or poor symptomatic response to diuretic therapy. Patients were not considered to be candidates for nesiritide if they had cardiogenic shock, systolic blood pressure <90mmHg, or presence of a low cardiac output state (mental status changes, oliguria, SBP <90mmHg). The data collected was utilized to educate physicians regarding the safe utilization of nesiritide. A total of 50 charts were reviewed before the protocol was developed and 50 charts were reviewed post-protocol implementation. Results: Data collection showed that the incidence of all side effects decreased post-protocol implementation. Data analysis illustrated that 26% of patients in the pre-protocol group experienced hypotension while 16% did in the post-protocol group (p=0.326). A statistically significant decrease was seen post-protocol implementation compared to the pre group in the number of patients who experienced renal failure while on nesiritide. An increase in serum creatinine (>0.5mg/dL) was observed in 18% of pre-protocol patients and 2% post-protocol (p=0.016). The incidence of worsening renal failure among the pre group was similar to that reported in recent meta-analyses, while the post protocol group had a statistically significantly lower incidence of renal failure when compared to the meta-analysis results. A total of 20% of patients in the pre-protocol group possessed a contraindication to receiving nesiritide, while no patients were reported to have contraindications in the post-protocol group. A loop diuretic was tried initially in 88% of the pre-protocol patients compared to 96% post-protocol implementation. Conclusion: The study concluded that physicians followed the nesiritide usage protocol and, by doing so, the incidence of side effects decreased. Implementation of a nesiritide protocol reduced the incidence of adverse effects, thus promoting the safe use of nesiritide within the hospital system.
4. Hepatitis C, All Genotypes and Sustained Virological Remission in Pegylated Interferon 2b/Ribavirin Treated Patients Who Also Took Nutritional Supplementation.
S. Bahrych, W. Brown, A. Keniston, and N. Toribara, Denver Health Medical Center, Denver, ColoradoBackground: Currently accepted front-line therapy for patients with chronic hepatitis C includes a pegylated alpha interferon/ribavirin. Overall, the U.S. sustained virological remission rates (SVR) for patients who complete their treatment program is 49%. For patients with genotype 1 (which is the most prominent genotype consisting of 70% of U.S. patients), the SVRs are lower: 37-41%. Objective: Our purpose was to analyze our historical cohort of 169 patients who completed their treatment program using pegylated interferon-2b with weight-based ribavirin (WBR). Analysis was done to determine whether the nutritional supplements the patients took (omega 3: 540 mg EPA and 360 mg DHA, 800 units of Vitamin E, and one multivitamin with iron) had any effect on their SVRs. Additionally, we looked to see if SVR varied by sex, baseline viral load, and the effect nutritional supplementation had on steatosis and relapse rates. Methods: Computer searches from 2001 through 2006 were done for patients within the Denver Health System who had an ICD-9 code of 070.54 (chronic hepatitis C). An excel list was compiled with these patients' names, medical records, and pretreatment data (viral load, genotype, liver biopsy). Medical records were then surveyed as to whether the patients initiated and completed their hepatitis C therapy. It was also notated as to whether they achieved a SVR and what their individual parameters were (steatosis, baseline viral loads, liver biopsy stage, ethnicity, sex, and patient's weight). Fourteen percent were African Americans. We had a total of 169 patients who were analyzed from our historical cohort. Unadjusted chi squares were used to assess the SVR rates and correlate these to the patients' individual characteristics. Results: Of the 169 analyzable patients, 110 of them were genotype 1s. Of these genotype 1s, 69 elected to take the nutritional supplementation along with their pegylated interferon 2b/WBR; their SVR was 67% (vs. 41% national average). Of the remaining 59 patients (genotypes 2 and 3), 13 chose not to take the nutritional supplementation, with their pegylated interferon-2b/WBR, and 46 patients did. Of those 46, 27/30 genotype 2 patients cleared their virus (SVR 90% vs. national average of 82%), and 9/10 genotype 3 patients cleared their virus (SVR 90% vs. national average of 66%). Patients on nutritional supplementation had a relapse rate of 7% (vs. 18% for pegIFN/ribavirin and 30% for pegasys). Patients' SVR rates were not affected by the presence of steatosis of 66% or less, as well as the presence of a high viral load (>600K). In our patient population, males cleared their virus (54%) as well as females (56%) (p value=.81). Conclusion: Nutritional supplementation increased the patients' SVR rates, decreased the relapse rates, and negated the bad prognostic factors of high viral load, steatotis, and sex in our patient population. This data, although collected from a historical cohort, shows that a double blind randomized clinical trial needs to be done to prove or disprove the effects of nutritional supplementation in patients on therapy for chronic hepatitis C.
5. Investigating the Need for Age-specific Approaches to Intimate Partner Violence.
V. Breitbart, L. Davidson, V. Rickert, J. Tanenhaus, and L. Rottenberg, Planned Parenthood of New York City, New York, New YorkIn the last decade, there has been increased attention on adult women's experience with intimate partner violence (IPV). Much less is known about younger women's experience with IPV. There are indications in a few studies that the prevalence of adolescent relationship violence is substantially higher than that of older women. Aim: How can health care providers respond appropriately to adolescent and younger adult women experiencing intimate partner violence? Objectives: Investigate the need for age-specific approaches to IPV screening in younger women. Solicit the views of younger women regarding screening for IPV. Inform the development of more effective and appropriate screening tools and provider training needs. Method: This study gave an ethnically diverse group of young women, ages 15 to 23, in a New York City family planning center the opportunity to share their personal experiences and views about being screened for IPV. The study took place in a Planned Parenthood family planning center. Focus group data informed the development of a 175-item anonymous audio computer-assisted survey that was completed in a semi-private area in the center by 645 women ages 15 to 24 years. Participation was anonymous and unlinked to their health records. Results: Of the group who completed the survey, almost all (93%) reported some verbal/emotional dating violence. In addition, 60% reported physical and 29% sexual IPV. Many more young women (184) said that they had been "raped or forced into sex" by a partner than responded affirmatively to the questions about being "sexually abused." They also reported that physical and sexual violence had an impact on their use of condoms. A small group (11.5%) had disclosed their experiences to a provider. Most women in the study (90%) felt that screening by health care providers is a good idea; however, only (46%) reported that they had been asked about IPV, and only 37.9% reported that they had ever been asked about forced sex. The majority of young women in the study (95%) identified health care providers as the most acceptable person to ask them about violence. Discussion: There is a high prevalence of IPV among these young women, and it had an impact on their reproductive behavior. They responded favorably to being asked about IPV, but we need to find new language for screening. Based on the information gained from the survey responses, training was designed and delivered to health care providers at the center. Additional research is needed to test different screening approaches to determine more effective ways to screen this population for IPV.
6. Patient Perception of Optimal Weight Goals in the Overweight Population.
C. Innus and J. Patterson, Daemen College, Amherst, New YorkPurpose: The purpose of this research study is to identify if weight management education needs to be modified. Clinical data has shown a correlation between Body Mass Index (BMI) and illness, including hypertension, diabetes, hyperlipidemia, metabolic syndrome, vascular disease, and cancer. Clinicians spend a great deal of time educating patients on optimal weight goals, but it is unclear if our efforts have impacted our patients. Methods: Participants from family medicine and cardiology practices were asked what they think they should weigh for optimal health. The patients' age, sex, race, height, weight, and perceived optimal weight were recorded confidentially prior to being seen for a routine appointment. Patient consent was obtained at the time the patient was weighed. Information obtained was used at the time of the visit to reinforce individual weight goals. The data collected was analyzed to identify groups of patients in need of intensive weight management education. Chi square testing and analysis was used to analyze various subtypes of patients within this population. P values were determined using one degree of freedom. Results: The population surveyed consisted of 100 individuals with a BMI of greater than 25. Twenty-four individuals (24% of the population) had an accurate perception of their ideal healthy body weight with a target weight that would place their BMI at a value of less than 24.9. The Centers for Disease Control and Prevention has set this parameter as the upper limit of a healthy body weight for both men and women. Data was analyzed for men (58) versus women (42). The women had a more accurate perception of weight goals with a p value of less than 0.005. Patients who were defined as overweight, with a BMI of 25-29.9, were compared to patients defined as obese, with a BMI of greater than 30. There was a significant difference between the overweight (65) and obese (35) populations' perceptions of ideal weight, with the overweight patients being more likely to accurately assess weight goals with a p value of less than 0.025. African-American (27) and Caucasian (73) populations were also compared, with the result of more Caucasians assessing weight goals correctly with a p value of less than 0.025. Half of the population studied was from a primary care setting (50) and half were from a cardiology practice (50), and when comparing these groups' weight goals, there was no appreciable difference with a p value less than 0.9. Younger and older patients were also compared using an age cut off of 55 years. Patients under the age of 55 (46) had no significant difference in weight estimate when compared to patients over the age of 55 (54). X2 equaled zero in this case. Conclusions: The majority of patients surveyed did not have weight goals conducive for optimal health, most significantly males, obese individuals, and African Americans. The results have shown that there is a need for more aggressive weight management education in order to decrease weight-related preventable causes of morbidity and mortality.
7. Physician Assistants' Attitudes, Knowledge, and Skills about Patient Safety and Medical Errors.
L. Mustone Alexander, J. Delaney, M. Doll, K. Korber, R. McNellis, and J. Taft, American Academy of Physician Assistants, Alexandria, VirginiaPurpose: The challenges of preventing medical errors and improving patient safety have received substantial attention during the past 10 years. Physician assistants are an important audience for patient safety advocates and are important leaders in advocating for patient safety and in helping to change the institutional culture for safety. However, no information has been published as to the attitudes, knowledge, and skills of physician assistants about patient safety. The purpose of this survey was to begin to characterize how PAs see their role in patient safety. Methods: The authors adapted a 20-question survey administered to medical students at the University of Colorado. The questions asked PAs to rate their agreement or comfort with the statements on a five-point Likert scale. The survey was administered to a convenience sample of PAs at AAPA's 2006 House of Delegates Meeting. The survey was distributed to more than 250 persons, made up of delegates, attendees, and leaders on the last day of the meeting. One hundred ninety-five completed surveys were received, representing more than a 70% response rate. Results: PAs strongly agreed that professional time should be spent on improving patient care and learning how to prevent errors. PAs also agreed that making errors in medicine is inevitable. PAs were neutral, on average, about whether they routinely report medical errors or whether they routinely share information about errors and their causes. PAs strongly disagreed that only errors that harm patients need to be addressed and that only incompetent PAs make errors. When asked about their comfort level with an error prevention activity, PAs were comfortable with supporting and advising a peer on how to respond to an error and with analyzing a case to find the cause of an error. PAs were less comfortable with entering a Patient Safety Net report and with disclosing an error to a patient. Conclusions: This survey provides a useful glimpse into the knowledge, attitudes, and skills of PAs on patient safety and medical errors. The results show a high level of knowledge with patient safety issues and comfort with basic error prevention activities. However, several responses indicate that even at the highest leadership levels of AAPA and its constituent organizations, there are some misperceptions and organizational culture issues present. No demographic data was collected on the respondents, but it is unlikely that this sample is reflective of the general PA population. It is more likely that the respondents, as leaders of state chapters, specialty organizations, and the profession in general, have higher levels of knowledge about patient safety than most PAs. However, the responses are consistent with many of the demonstrated weaknesses of the health care system in addressing medical errors and improving patient safety. But it also reflects a group of PAs who understand the importance of patient safety efforts and reinforces the important role that PAs play in helping to reduce medical errors, improve patient safety, and deliver the highest quality care.
8. Predictors of PSA Recurrence after Robot-assisted Radical Prostatectomy.
M. Mathe, S. Capello, H. Patel, and J. Joseph, University of Rochester, Rochester, New YorkIntroduction: Cancer control and the prevention of PSA recurrence is the primary goal of robot-assisted radical prostatectomy (RARP). The purpose of this study is to evaluate the role of Gleason score, pathologic stage, and positive margin status in PSA recurrence after RARP. Methods: All patients undergoing robot-assisted radical prostatectomy were evaluated with respect to preoperative (age, preoperative PSA, and clinical stage) and postoperative (pathologic data and PSA) parameters. PSA recurrence was defined as a PSA of >=0.1 ng/dL, with at least six months of follow-up data available. A Student's t-test was used, and statistical significance was determined if the p-value was <0.05. Results: A total of 434 patients underwent robot-assisted radical prostatectomy from July 2003 to October 2006 and had at least six months of PSA follow-up data available to evaluate for PSA recurrence. There were 25 PSA recurrences in this population (5.8%), with a mean time to recurrence of 7.3 months (range 3-21). Patients with PSA recurrence had significantly higher preoperative PSA and Gleason Sum than those without recurrence. Pathologic Gleason score and stage were also higher in patients with recurrence. Positive margins were less than 5% higher in those with PSA recurrence than those without. Conclusions: Pathologic stage and grade appear to be much more important in determining PSA progression than the margin status.
9. Prevalence of Sleep Apnea in Subjects with Atrial Fibrillation at a Specialty Cardiology Office.
A. Murray, J. Gietzen, and B. Halperin, Pacific University, Hillsboro, OregonBackground: Atrial Fibrillation (AF), the most common sustained cardiac arrhythmia, is a growing health concern. Currently, atrial fibrillation affects more than 2 million Americans, and it is estimated that up to 5% of the general population remains undiagnosed. Atrial fibrillation is associated with significant morbidity and mortality, as well as resulting in severe health consequences if left untreated. Studies have shown that there may be a unique connection between AF and obstructive sleep apnea (OSA), thought to be caused by the effects of hypoxemia on the body. The authors are interested in ascertaining the prevalence of sleep apnea in subjects who have been evaluated by Heart Rhythm Consultants PC, with documented atrial fibrillation. Objective: This study tests the hypothesis that the incidence of obstructive sleep apnea will be more prevalent among patients with diagnosed AF than the general population. Design: Questionnaire on sleep habits and up-to-date heart rhythm information filled out by patients with diagnosed AF who have undergone ablation therapy. Age, Body Mass Index (BMI), gender, history of hypertension (HTN), and other variables will also be evaluated to determine if there are any correlations between those events and OSA. Setting: This study was completed gathering data from the clinic of Heart Rhythm Consultants PC, Portland Oregon. Subjects: All patients of Heart Rhythm Consultants over the age of 18 years who have sought treatment for atrial fibrillation and have undergone elective ablation therapy between January 1, 2004, and June 1, 2006. (N=207). Results: This study found that the prevalence of AF subjects with a high risk for OSA was between 57-66%, 19% of which already had a previous diagnosis of OSA. When comparing the results of low-risk subjects vs. high risk subjects for OSA, a statistical significance between the populations was found for BMI (p= 0.0076), HTN (p=0.000), Diagnosed OSA (p=0.0005), and perceived cure rates (p=0.0282). The findings of this study not only support the concept that the associated conditions of OSA, such as HTN and obesity, may lead to AF, but also that there may be a link between the mechanisms of OSA and AF. Conclusions: As the number of patients with AF continues to grow nationwide, it is of utmost importance to find predisposing factors. With obesity and HTN being a risk factor for both AF and OSA, it is of clinical importance to look at the possible connection between these two disorders. With the evidence that successful treatments of OSA result in lowering rates of HTN and recurrence of AF, the presence of OSA should be considered in all patients with AF and warranted for those with AF who also have a history of HTN or obesity.
10. Rheumatology Physician Assistant Role Delineation Study.
R. Hooker, J. Seignon, and B. Rangan, Department of Veterans Affairs, Dallas, TexasIntroduction: Little is known about rheumatology physician assistants (PAs) other than the fact that they have been employed in the rheumatology discipline for more than 30 years and that they represent a small but significant number throughout the United States. A 2003 survey of rheumatologists, conducted by the American College of Rheumatology, revealed that more than one-fifth of respondents employed a PA or NP in their practice. The survey found that there were only 4,500 practicing rheumatologists in the U.S., of which at least 10 percent were in basic science or administrative roles. The annual attrition rate from retirement was approximately 200, in comparison to 145 newly trained rheumatologists who entered the workforce. This has translated into a specialty workforce shortage at a time when the U.S. population is growing, aging, and living longer. To better understand the role of PAs at a time of rheumatology workforce shortages, the authors examined this small, largely hidden workforce. Methods: This study used a combination of telephone interviews and Web-based survey to obtain a picture of the role, relationship, and scope of practice of a study population of 112 rheumatology PAs. Each individual in the study population was invited to participate in a two-phase study, with the first phase involving a 30-minute phone interview. At the conclusion of the telephone interview, the participant was asked to participate in the second phase, an anonymous Web-based survey that probed for more sensitive information. Results: A total of 84 individuals were contacted, and 78 met the criteria for active rheumatology PA. Of those employed, 31.8% were in solo practice, 22.7% in group practice, 20.4% in partnership, and 18.1% in medical school/university. They reported spending, for the most part, 80% to 100% of their time caring for patients, with the remainder in administrative roles. Most of the respondents did not experience any reimbursement insurance difficulty, while a very few of them did. They provided initial consultation for new patients. A total of 54.5% of them were randomly assigned to see patients; 27.2% doctor-assigned. The remaining percentage was either patient-selected or nurse-assigned. They initiated all forms of anti-rheumatic medications without restrictions. Almost all provided joint injections with various medications. More than half the PAs participated in research, such as clinical trials/drug studies, type II and type III phase study, joint assessment, pain management, and biological study. A total of 90% of the respondents reports acquiring their skills through on-the-job training and CME, while only 9.1% participated in a fellowship. Conclusion: These results indicate that PAs employed in rheumatology function at a unique capacity in helping to overcome the shortage of rheumatology specialists in their time of crisis. The result of the intended survey reveals that their versatility is well noted in whatever setting they are employed, as they continue to provide multifaceted support while participating in various research activities. This study was underwritten by AAPA and the PAEA Research Institute.
11. The Effects of Early Patient Education on Immunization Rates of Infants in Galveston County.
T. Bigler and K. Stephenson, University of Texas Medical Branch, Galveston, TexasPurpose: A longitudinal prospective cohort study at a university hospital to evaluate the efficacy of postpartum parental education to improve immunization compliance in Galveston County. In 1999, The Texas Retrospective Immunization Survey (TRIS) reviewed immunization records of 5-year-olds in Galveston County and found an immunization rate of 56.2% when they were 2 years of age. Methods: Physician assistant students on rotation in the newborn nursery performed the intervention, consisting of patient education regarding childhood vaccinations. Specific points included reviewing the immunization schedule, the importance of receiving immunizations at the recommended times, and the availability of reduced cost vaccination clinics. Subjects enrolled in the study received immunization reminders in the mail when their child was 2, 4, and 6 months old; those living in Galveston County received a list of community shot clinics. Using the statewide immunization registry, the child's records were reviewed to establish whether the child obtained the recommended vaccines, and a Pearson's chi square statistic was used to compare the rates of immunization between groups. Results: January 2007. 1,600 subjects enrolled; 414 (25.9%) resided in Galveston County at the time of birth, 838 (52.4%) of the parents prefer to speak Spanish, 825 (51.6%) are male. Of the 1,211 infants at least 12 months of age, 30% have incomplete immunization data in the registry. At 12 months of age, there was no difference in immunization rates between the cohort's intervention (33.4%; n=424) and the control group (34.8%; n=423; x2 [df =1]=.150, p=.699). Of the factors used to predict immunization status (county of residence at birth, gender of the infant, parent's preferred language, and immunization status at 2, 4, and 6 months of age), meeting immunization requirements at 4 and 6 months of age predicted immunization status at 12 months of age (F [4, 841]=61.787; R2 =.227, p=.0001). Beta weights significant at p=0.001 and 0.001, respectively. For Galveston County infants enrolled in the study (n=294) at 12 months of age, the immunization rate is 34.7%. There is no difference in the immunization rates between the control (34.6%) and intervention (34.8%) groups (x2 [df =1]=.001, p=.0.979). Meeting immunization requirements by 6 months of age and Spanish language preference predicted being up to date at 12 months (p=0.003 and 0.013, respectively). Conclusion: Patient education supporting the importance of immunizations prior to hospital discharge has yet to preferentially improve immunization compliance at 12 months of age in the intervention group. Meeting immunization requirements by six months of age predicted being up to date at 12 months for the entire cohort, validating that the reminders at 2, 4, and 6 months are reinforcing the need to complete the immunization series. The cohort will be followed until 36 months of age; continuation of this research will help determine the factors that make a significant difference in immunization rates at 2, 4, 6, 12, and 35 months of age. Additional studies are needed to establish the accuracy of the immunization registry. Funding for this project has been provided by a grant from the PA Foundation.
12. Type II Odontoid Fractures in the Elderly Treated with Cervical Orthosis.
D. Orndorff, I. Marks, F. Shen, R. Whitehill, D. Chun, and V. Arlet, University of Virginia, Charlottesville, VirginiaIntroduction: Type II odontoid fractures are common in the elderly population who sustain simple ground-level falls. In many of these patients, halo immobilization and surgical stabilization have an increased risk of complications and mortality. Minimally displaced type II odontoid fractures in the elderly with the absence of neurologic sequalae can be reasonably treated and have better tolerance with cervical orthosis compared to halo. We performed a retrospective study of all type II odontoid fractures with displacement less than 5mm in the elderly treated with cervical orthosis. Methods: Charts and radiographs of all consecutive patients with C2 fractures from four fellowship-trained spine surgeons were reviewed. We treated a series of minimally displaced (< 5 mm) low-energy injury type II odontoid fractures in the elderly (55-89 years of age) without any neurologic sequalae that were treated with cervical orthosis and close clinical and radiographic follow-up. We discussed the risks of nonoperative and operative treatment. Demographic, mechanism of injury, and clinical and radiographic evaluations were recorded. Results: Fourteen patients were included: 10 women and four men with an average age of 76.0 (range, 55-89). Mechanism of injury was a ground-level fall in all 14 cases. Average fracture displacement was 5 mm (range, 0-8mm). At average six months follow-up, none of the 14 patients developed neurologic sequalae and went on to either a solid union or asymptomatic fibrous nonunion. All 14 patients were treated with a cervical orthosis and none required any additional procedures. Discussion: This study demonstrates that type II odontoid fractures in the elderly can be managed nonoperatively in a cervical orthosis. Halo application has been shown to have an increased mortality in the elderly. If the patient is asymptomatic and would not tolerate surgical stabilization, nonoperative management in a cervical orthosis is a reasonable treatment with successful results. Such information is important for clinicians in treating this common fracture in the elderly.
Case Studies/Clinical Reports
13. An Atypical Presentation of Venous Stasis Ulcers in a Patient with AIDS.
K. Breaux and M. Rodriguez, Michael E. DeBakey VA Medical Center, Houston, TexasA 62-year-old white male with Acquired Immunodeficiency Syndrome (AIDS) since 1993 presented with cellulitis of his right shin in June 2005. Physical exam (PE) revealed warmth, edema, and an erythematous macule on the right shin with normal peripheral pulses. Laboratory data included a non-detectable HIV viral load since 1997, CD4 count of 223 cells/mm3, and a WBC of 5.2 (normal differential). His current highly active antiretroviral therapy (HAART) consisted of nevirapine, tenofovir, and lamivudine. One month later, the cellulitis had failed to respond to courses of keflex and clindamycin. Stasis changes in the lower extremities were noted. X-ray of the right tibia and fibula revealed no bony lesions and cultures were obtained. KOH stain was positive for hyphae in August 2005 and a 42-day course of terbinafine (250 mg daily) was started for presumed Majocchi's granuloma. PE now revealed a 17 x 9 centimeter erythematous patch with scaling and purulent drainage. Routine and fungal cultures were obtained. In September 2005, multiple nodular lesions were draining serosanguineaous fluid, and the terbinafine was increased to 500 mg qd. Lesions were recultured in October 2005, and a punch biopsy revealed necrosis with ill-defined granulomas. Cultures grew E. Coli and Corynebacterium, and a 10-day course of ciprofloxacin was initiated. The patient continued to develop more draining sinus tracts, eroded blisters, and new blisters. Path slides from his original biopsy were reviewed, and a few acid fast bacilli were noted; so despite negative cultures, he was treated empirically with clarithromycin, rifabutin, and gatifloxacin. Repeat biopsy in December 2005 revealed "dermal vascular proliferation suggestive of stasis bullous dermatitis." By February 2006, the patient had no response to AFB therapy and thalidomide was started. PE revealed 11 open ulcers with serous weeping and two intact bullae. In March 2006, this patient's course was completely reviewed. With no response to antimycobacterials, other antibiotics, and thalidomide, it was determined that the etiology was not infectious. Though the lesions were not in the typical location for venous stasis lesions, the patient was referred to the Wound Care Clinic. Within a month of combination treatment with carraklenz, iodosorb, lyofoam, and four-layer compression dressings, only two open lesions remained. These completely resolved by July 2006. The patient was advised to wear compression stockings and, as of December 2006, had no new lesions. This case illustrates the protracted course of an atypical presentation of venous stasis lesions in a patient with AIDS. The patient's only risks for stasis were older age and obesity (body mass index 42). His obesity was felt to be secondary to HAART associated lipodystrophy syndrome. His lesions lacked the typical features of location over the medial and lateral malleoli, irregular borders, pruritis, and no varicosities were present; he had no history of prior injury, deep vein thrombosis, or superficial thrombophlebitis in the affected leg. Though stasis changes were noted in the lengthy course, these findings were overlooked in the pursuit of an infectious etiology by both experienced dermatologists and infectious disease specialists.
14. An Unusual Case of Cirrhosis in a 56-year-old Male.
J. Van Rhee, Wake Forest University, Winston-Salem, North CarolinaIntroduction: Cirrhosis is a common disorder and a major cause of mortality worldwide. Major causes of cirrhosis include viral hepatitis, alcohol or drug-induced, biliary disorders, and metabolic diseases. In this case, a 56-year-old male with jaundice and abdominal pain is discussed. History: A 56-year-old male presented to the ER with a one-year history of epigastric abdominal pain and two-day history of jaundice, weakness, and confusion. The patient had a long-standing history of hypertension, anxiety, and depression, and was on xanax and lisinopril/hydrochlorothiazide. The patient had a 25 pack-a-year smoking history and a past history of heavy alcohol usage. His family history was significant for CAD and esophageal cancer. Review of systems was positive for confusion, decreased appetite, and weight loss. Physical Examination: Vitals were normal, except for a pulse of 61/min and blood pressure of 91/45 mm Hg. The patient was confused but in no acute distress. Skin and sclera were icteric and oral mucosa dry. Decreased bibasilar breath sounds were noted. The abdomen was distended and a positive fluid wave was noted. Laboratory testing revealed a WBC: 8,600/UL, Hgb: 7.7 g/dl, Hct: 21%, MCV: 127%, and platelet count: 99,000/UL. Metabolic profile revealed sodium of 110 mEq/L, chloride 78 mEq/L, albumin 1.9 g/dl, total bilirubin 13.7 mg/dl, AST 129 IU/L, ALT 50 IU/L, alkaline phosphatase 101 IU/L, and ammonia 32 µmol/L. Chest x-ray revealed a large right pleural effusion and cardiomegaly. CT of the abdomen revealed a moderate to large amount of ascites and cirrhotic liver. Treatment and Follow-up: The patient underwent a successful paracentesis; culture and cytology were negative. Other test results included an elevated coagulation studies, negative acute hepatitis panel and ANA, normal alpha-fetoprotein, negative anti-mitochondrial antibody, and normal sedimentation rate. It was felt that the patient had a metabolic cause of their cirrhosis. Further evaluation included a normal ceruloplasmin and alpha-1-antitrypsin levels. Iron studies included a ferritin 1469 ng/ml, serum iron 119 µg/dl, TIBC 129 µg/dl, and % iron saturation 92%. With the diagnosis of probable hemochromatosis, genetic testing was completed and was negative for C282Y and S65C mutations, but positive for homozygous H63D mutation. Discussion: Hereditary hemochromatosis is an autosomal recessive disorder that is due to iron overload. The underlying mechanism is low hepcidin levels. Hepcidin, induced by iron, inhibits iron transport, resulting in decreased iron absorption and increased retention of iron in the tissues. Low levels of hepcidin leads to increased iron retention in the tissue. Clinically, patients are asymptomatic until the fourth or fifth decade of life. Characteristic signs and symptoms include abdominal pain, weight loss, fatigue, joint pain, depression, and hepatomegaly. Laboratory testing reveals elevated liver transaminases and serum bilirubin. Diagnosis is made by noting elevated ferritin, serum iron, and percentage iron saturation. Genetic testing should be completed on patients with possible hemochromatosis. C282Y and H63D mutations are most common. Treatment of hemochromatosis includes removal of excess iron via phlebotomy. In this case, due to the patient's poor prognosis, supportive management only was provided per the patient's request. The patient expired five weeks later.
15. Pneumatosis Intestinalis and Portal Venous Gas Associated with Placement of a Balloon Foley Jejunostomy Feeding Tube. J. Moore, Bassett Healthcare, Cooperstown, New York Purpose: Our purpose is to present an unusual case of pneumatosis intestinalis, venous portal gas, and small bowel obstruction secondary to the placement of a balloon foley catheter to be used as a jejunostomy feeding tube. Background: Percutaneous feeding jejunostomy with a foley catheter is a well-established technique for providing long-term nutritional support. Mechanical complications of these procedures are well recognized and are often related to problems with the catheter balloon. Pneumatosis intestinalis and venous portal gas are unusual but potentially serious complications. The differential diagnosis includes life-threatening conditions, such as intestinal necrosis, that may require immediate surgical intervention. Problem: A 37-year-old male with severe cerebral palsy, spastic quadraplegia, and a percutaneous jejunostomy feeding tube, was admitted through the emergency department for tachycardia, vomiting, and abdominal pain. On several occasions during the previous month, the patient had been seen in the ED for clogging and dislodgment of his jejunostomy tube. During his most recent visit, four days prior to this admission, the jejunostomy tube was removed and replaced with a balloon-inflated foley catheter. The patient subsequently developed symptoms and was brought to the ED for evaluation. Findings: On examination, the patient was non-verbal but appeared to be in discomfort. His heart rate was 140 bpm and his abdomen was distended and firm. Labwork revealed a white blood cell count of 24,200 with an associated 6% bandemia. Contrast study through the feeding channel revealed proper placement with no extravasation. Contrast enhanced CT of the abdomen and pelvis revealed small bowel obstruction, pneumatosis intestinalis, and venous portal gas. Outcome: The catheter balloon was deflated, and the tube was stitched in place. The patient was treated conservatively with intravenous fluids, and his symptoms resolved over the course of the next three days. Repeat contrast CT showed resolution of pneumatosis intestinalis, absence of portal venous gas, and resolution of bowel obstruction. The cause of the patient's problem was attributed to mechanical obstruction by the catheter balloon, and a successful outcome is reported after conservative management. Conclusion: If a patient with a ballooned feeding tube develops intestinal symptoms, balloon complications should be considered. As the use of enteral feeding through catheter jejunostomies continues to be utilized, this cause of pneumatosis intestinalis and bowel obstruction must be recognized. Contrast study through the feeding channel as well as contrast enhanced CT imaging are useful in diagnosing tube-related complications. The threshold for imaging should be low, particularly in patients who are difficult to assess clinically.
16. Sacral Chordoma. I. Marks and F. Shen, University of Virginia, Charlottesville, Virginia Introduction: Chordoma is an uncommon primary tumor of bone restricted to the axial skeleton. It more commonly occurs in men (66%) over the age of 40, is locally invasive, and most commonly occurs in the sacrum (>50%). At the time of diagnosis, it has often invaded local tissue and, in the case of sacral lesions, has spread into the anterior pelvis, typically displacing but not invading the rectum. Because neoadjuvant and adjuvant therapies have had little impact in the treatment outcomes of these lesions, management often requires an extensive surgical resection. Case presentation: LK, a 67-year-old WM with a six-year history of a mass over his tailbone. Initially diagnosed as a nodular cyst, the lesion was not biopsied until several years after initially being evaluated. At the time of our initial evaluation, the lesion was estimated to be 12 x 10 x 6 cm in size. The lesion was severely affecting his ability to sit and was becoming painful. Following advanced imaging and biopsy, the lesion was diagnosed as a sacral chordoma, and the patient was scheduled for resection. A 13.3 x 10.9 x 6.3 cm mass was removed and plastic surgery performed a rotational flap to close the extensive cavity created by the removal of the lesion. Wide margins required by the need to remove as much tumor as possible necessitated the creation of such a large defect. Postoperatively, the patient had loss of bladder continence but regained some bowel control. This is common due to the need to sacrifice sacral nerves during the resection. With six months follow-up, the patient continues to improve and has had a significant improvement in his ability to sit and walk. His wound is completely healed and no signs of recurrence on repeat imaging have occurred. Discussion: Early diagnosis and resection are critical to long-term outcome with these cases. Because of the common delay in diagnosis, poor outcomes are the norm. If the lesion involves the S1 body, the lumbopelvic region will require reconstruction. Currently, the literature most supports the use of en bloc resection and, if needed, subsequent reconstruction. Intralesional resection has proven a poor treatment due to the high rate of recurrence. In the past, high rates of failure of instrumentation have occurred in these reconstructions, but with the use of custom cages and 4 rod constructs, long-term stability has been demonstrated. Further investigation into the use of radiation and chemotherapeutic techniques need to be developed to decrease the attendant recurrence and possibly as a primary treatment instead of surgery, thereby decreasing the common bowel and bladder dysfunction.
17. Streamlining Kidney Transplant Hospital Stay. E. Simmons, E. Tichy, S. Kulkarni, N. Edgington, and M. St. George, Yale-New Haven Hospital, New Haven Connecticut Objective: In an effort to improve the efficiency of hospital course after live and deceased donor kidney transplantation, the inpatient kidney transplant team evaluated opportunities to streamline postoperative patient care. By clarifying caregiver roles and improving communication between members of the service, the expected result was a reduction in length of hospital stay for patients after live and deceased donor kidney transplantation. Methods: We organized a group of key members of the inpatient kidney transplant service. Our team included the social worker, care coordinator, pharmacist, physician assistant, nutritionist, and surgeons. We were able to identify key milestones that needed to be achieved during the admission to appropriately prepare the patient for discharge. These events included: coordination of discharge prescriptions, coordination of home care needs, adequate patient education, return of bowel function, and completion of discharge summary. In an effort to clarify roles, improve communication, and streamline the discharge process: (1) a checklist of key milestones and interim steps identifying responsible caregivers was created and maintained in the chart during the admission; (2) standardized CCSS order sets were developed; (3) a discharge medication process was organized with a mail-order pharmacy; and (4) a quick pocket reference was developed for the surgical house staff. Results: The average postoperative length of stay for DGR 302 (live and deceased donor kidney transplantation) decreased by 1.7 days after program implementation in FY 2006 fourth quarter. Average length of stay for FY 2006 Q1, 2, and 3 was 7.92 days (N=44) and for the study period, FY 2006 Q4 and FY 2007 Q1, 6.18 days (N=39), for a 21% reduction in length of hospitalization (P=0.04). Student t-test was performed to demonstrate statistical significance. There was no statistical difference in the number of live or deceased donor transplants between the study (38%) and control group (33%; P=1). Discussion: The overall length of hospital stay for live and deceased donor kidney transplantation decreased substantially over the study period and is in line with national benchmarks. This improvement occurred with the use of a combination of interventions that helped streamline post-transplant patient care, facilitating this process improvement (PI) initiative. While physical tools such as a checklist were implemented, the process and associated dialog was enhanced among team members about discharge criteria and contributed to the clinical outcome as well as team member job satisfaction. Our project highlights an important lesson that can be applied to other procedure-specific services in the health system, in that PI techniques can be applied to streamline care and shorten length of hospital stay without compromising patient care.
18. The Use of Vacuum-assisted Closure for Staged Skin Grafting of Plantar Foot Defects Following Oncologic Resection. S. Oates, L. Heller, and J. Schatte, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas Background: Reconstruction of plantar foot defects remains a challenge. Traditionally, skin grafts have been used for non-weight-bearing areas, and flaps, either local or free, have been used for weight-bearing areas. Primary grafting is problematic because of the lack of a well-vascularized wound bed, circulatory compromise, and the dependent nature of the foot. Multiple daily dressing changes for weeks to months may be necessary for secondary healing. Purpose: Our purpose was to evaluate staged skin grafting utilizing a vacuum-assisted closure (VAC) system for plantar defects of the foot following oncologic resection. Method: Following resection of plantar melanoma, wound maturation was accelerated using VAC, and skin grafting was performed after achievement of adequate granulation tissue. Results: Fifteen patients who underwent resections for plantar melanoma were treated with a staged split thickness skin graft to weight-bearing and non-weight-bearing defects. The average patient age was 65 years (range 36-85), and the defects averaged 41 square centimeters. The patients averaged 31 days from resection to grafting with VAC changes three times weekly. Twelve patients had VAC dressing as a bolster following grafting, with discontinuation of VAC with initial dressing change at five days. All grafts had 90% or greater take with minimal dressing care needs after two weeks. No patients required regrafting. Average follow-up was 1.5 years. To date, no patients have experienced any graft breakdown or significant problems at the graft site, even on weight-bearing surfaces. All patients returned to their preoperative ambulatory status per Enneking Scoring. Conclusion: Use of staged skin grafting using VAC to accelerate wound maturation allowed for improved graft take and less postoperative wound care than primary grafting. Long-term durability with split thickness skin grafting over weight-bearing areas is an acceptable option in selected patients.
Previously Presented
19. Seroma Development Following Body Contouring Surgery for Massive Weight Loss: Patient Risk Factors and Treatment Strategies. M. Shermak, L. Rotellini-Coltvet, and D. Chang, The Johns Hopkins Hospital, Baltimore, Maryland Introduction: The most common complications following body contouring surgery for massive weight loss (MWL) patients include delayed wound healing and seroma. Seroma development can delay healing and result in the need for further treatment. Limited data exist with regard to seroma management in the MWL population. We investigated significant risk factors for seroma in this patient population and describe treatment strategies. Method: A retrospective review of 222 patients who underwent body-contouring surgery for MWL from March 1997 to December 2005 was performed. Potential risk factors assessed included age, gender, comorbid medical conditions, tobacco use, BMI, weight of skin excised, and surgery performed. Treatment of the seromas included aspiration, drain placement, sclerosis, and/or surgery. Results: Within this group, there were 187 women and 35 men, with a mean age of 42 years. Weight loss was achieved by open (n=168) or laparoscopic (33) gastric bypass surgery or diet and exercise (20). Average BMI at contouring was 33, ranging from 20 to 69. Existing medical conditions included osteoarthritis (n=62), hypertension (51), reflux disease (47), hypothyroidism (24), asthma (24), diabetes (20), cardiac disease (13), sleep apnea (13), immunodeficiency (5), and thromboembolism (5). There were 24 active smokers. Surgical areas addressed either alone or in combination included the abdomen (n=205), thigh (71), arm (69), back (59), and chest (57). Average weight of skin excised at surgery was 9.6 lbs, ranging up to 49 lbs. Seroma occurred in 33 patients, placing risk at 15% in this series. The seromas occurred in the abdomen (n=20), hip or back (n=9), or thigh (n=3). Seroma risk in abdominal panniculectomy was therefore 14%; in circumferential belt lipectomy, 15%; and in thighlift, 4.2%. On multivariate statistical analysis, the major risk factor for seroma formation was weight of skin excised at the time of surgery, with seroma risk increasing 10% for each additional pound of skin excised. When they occur, seromas are aggressively treated and are treated closed. If the seroma develops after drain removal, needle aspiration is performed several times. A seroma catheter is placed in the outpatient clinic if the seroma does not resolve with aspiration. Once this drain is in place for several weeks, or if the original drain has been in place for four weeks, Doxycycline sclerosis is performed, up to two times. If the Doxycycline sclerosis does not work, the Bleomycin sclerosis is performed. In most cases, seroma treatment resolves with Doxycycline therapy. If the sclerosis fails, then patients go to surgery for treatment. This has only occurred on rare occasion. Conclusion: The most important risk factor for seroma is weight of skin excised at the time of surgery. Treatment strategies we will discuss include aspiration, drain placement, sclerosis, and surgery.
20. An Unusual Reaction to Intracorporeal Injection of Phenylephrine in a Patient with SCD and Stuttering Priapism. L. Daitch and A. Kutlar, Medical College of Georgia, Augusta, Georgia Priapism is a common vaso-occlusive complication of sickle cell disease (SCD) affecting 30% to 50% of males with sickle cell disease and may come in two patterns. Stuttering priapism presents with episodes that occur repeatedly, last for brief periods of time, and resolve spontaneously. Prolonged priapism is an acute event lasting for many hours. Priapism poses a risk of irreversible ischemic injury to the penis with resultant erectile dysfunction and impotence. We report the case of a 33-year-old African-American male with SCD (homozygous SS) and a history of stuttering priapism. His first episode occurred at 14 years of age with multiple monthly occurrences that have increased with age. At different times, the patient's priapism was treated with the following medications: Hydralazine 10 mg BID with intermittent effectiveness; Trental 400 mg TID and Verapamil SR 180 mg QD, both with a good initial response but not sustained long-term relief; and pseudoephedrine 30 and 60 mg that shortened the duration of the episodes. Lupron injections were administered for the maximum allotted time of six months with successful prevention of his priapism episodes. Once Lupron was stopped, the episodes returned, so the patient was started on a trial of intracorporeal phenylephrine administered through self-injections. The patient was trained to self-inject. On the patient's drive home from this training at the Urology Clinic at the Medical College of Georgia, the patient experienced another episode of priapism and carried through with the phenylephrine injection. Within 15 minutes of injection, the patient began to experience a burning sensation and pain in his pelvis/hips that quickly intensified. He was admitted for crisis management. Four days later, the patient self-injected again during another priapism episode with the same reaction within 15 minutes. The patient was treated in the clinic for pain crisis and was able to return home. Due to the patient's severe reaction to the phenylephrine, medication was discontinued. Alpha-adrenergic agents, including intracorporeal injections of phenylephrine, have been used with some success in the management of priapism in SCD. To date, there have not been any reports of adverse outcomes with the use of these agents. The occurrence of a vaso-occlusive episode shortly after self-injection of phenylephrine in our patient, on two different occasions, is noteworthy. The precise mechanism for the precipitation of a painful episode in our patient is unknown; it may be speculated that systemic vaso-constriction effects of phenylephrine may have played a triggering role. This observation suggests that caution should be exercised in the use of a-adrenergic agents for the management of priapism in SCD.
21. Relapsing Malaria Infection in an Adolescent Following Travel to Mozambique.
A. Summer, C. Oswald, and P. Fischer, Medical University of South Carolina, Division of Infectious Diseases, Charleston, South CarolinaInfection with Plasmodium ovale is uncommon in travelers. We describe a case of ovale malaria in a traveler to Mozambique who initially presented several weeks after completion of his trip. Species identification was ultimately achieved with a PCR-based diagnostic method. Introduction: Travelers who present with malaria after returning from East Africa typically are infected with Plasmodium (P.) falciparum and often present within the first month after completion of travel. Malaria caused by P. ovale is rare in cases of imported malaria, historically comprising less than 5% of the total malaria cases reported in the United States. Although the majority of P. ovale cases have been reported from countries in West Africa, a small number of P. ovale cases have been reported from East Africa, specifically Malawi, Kenya, and Uganda. We report a case of relapsing malaria in an adolescent traveler to Mozambique who initially presented two months after his trip. Case Report: A 16-year-old male presented with a 10-day history of fever to 39.4o C, rigors, malaise, and diarrhea 60 days after returning from a two-week church mission trip to Mozambique. He reported complete adherence with his malaria chemoprophylaxis, which consisted of mefloquine 250mg weekly, beginning two weeks pre- and ending four weeks post-trip. His primary care physician treated him with atovaquone 250/proguanil HCL100 mg, two tablets BID for three days after a positive blood smear. Species identification was not possible at that time. After completing the course of atovaquone/proguanil, the patient's symptoms resolved. He then presented 45 days later with a two-week history of fatigue and one day of fever, chills, nausea, and vomiting. He was hospitalized for concern of recurrent P. falciparum malaria and given quinine sulfate 650MG TID for seven days and doxycycline 100MG BID for seven days. His blood smear was positive for Plasmodium, suspect ovale. The patient was discharged three days after admission, afebrile and clinically improved. His specimen was later confirmed as P. ovale species by PCR (Centers for Disease Control and Prevention). A G6PD screen was ordered and was normal. He was treated with primaquine (52.6 mg salt) daily for 14 days without further recurrence of symptoms. Discussion: A returning traveler with malaria typically presents within one month of infection, but cases may occur weeks to months after exposure, as occurred with our traveler who presented 60 days after returning from Mozambique. The patient reported full adherence with chemoprophylaxis with mefloquine 250mg weekly, but even in patients who have received appropriate chemoprophylaxis, malaria must be considered in those who present with fever during the months after exposure. At initial presentation, failed chemoprophylaxis was suspected and infection with P. falciparum malaria was presumed given his travel history. The patient was consequently treated with atovaquone/proguanil and responded well. Since P. falciparum is the predominant species in East Africa, no terminal prophylaxis was given. Malaria caused by P. ovale is the least common malaria reported in the U.S., accounting for only 2.6% of 1,268 confirmed imported cases in 2003. In one report, a total of 167 patients contracted malaria after taking a recommended agent for malaria chemoprophylaxis. Of these, 58 (38.7%) reported compliance with the regimen. Approximately 2% were P. ovale infections in patients adherent to recommended chemoprophylaxis, and most of these cases presented >45 days after arrival back in the United States. These cases were consistent with relapsing infections and did not indicate failures with primary prophylaxis. Although rare in travelers to East Africa, infection with P. ovale has been described in travelers to Malawi, Kenya, and Uganda. Of note, no cases of P. ovale species in travelers to Mozambique were reported. P. ovale has been reported in residents of Mozambique, but it usually occurs in the context of mixed species infections. Since species identification was not done before the first treatment course in our patient, it is not possible to say whether there was initially a mixed, multi-species infection or not. As mentioned, species identification was initially indeterminate in our patient. Upon second presentation, blood smears were again obtained and were suspicious for P. ovale. This suspicion was later confirmed by a PCR-based method. Molecular methods are generally more sensitive and specific and surpass microscopy in diagnostic accuracy, and are now available in some commercial laboratories. As these methods become more accessible, they may routinely complement or replace examination of Giemsa-stained blood smears. To our knowledge, this is the first reported case of P. ovale malaria in a traveler to Mozambique. This report serves to remind us of the importance of species identification when caring for returned travelers, and it points out the potential utility of PCR-based diagnostic testing.
EDUCATION GALLERY
Original Research
22. Academic-induced Lifestyle Changes in Student Physician Assistants.
J. Rasmussen, E. Frazier, and J. Gietzen, Pacific University, Hillsboro, OregonPurpose: Anecdotal reports of physician assistant graduate students suggested the stress from their graduate-level educational experience changed how they participated in life. However, a search of the literature revealed a dearth of research on this topic that would verify or refute whether the anecdotal feelings were based in fact. The emotional, physical, and intellectual stressors that accompany successful completion of an intensive educational program, such as a master's degree program in physician assistant studies, can have significant impact on students' quality of life. Graduate students have observed that these stressors appear to impact on their ability to participate in meaningful life events. There is little research that specifically addresses the issue of intensive education programs and student quality life that would provide evidence refuting or supporting the experiences reported by PA students. Hypothesis: Physician assistant students will experience a decline in the full engagement in activities requiring mental, emotional, physical, and social participation during their training. Methods: A nationwide, electronically based survey was developed and solicited among accredited PA schools, which asked questions about the students' demographics, social experiences, and physical and mental well being. Results: 675 students participated in the survey, with 296 representing students at the beginning portion of the training, 277 from the midway part of their training, and 102 nearing the end of their training. Noteworthy lifestyle changes seen include the following: A temporary decline in the perceptions of one's health was noted in the students at the "midway" portion of the training. PA students reported a decrease in the amount of participation in exercise that appears to correlate with the students' perception of their health. Students consumed more coffee early in their studies and at the midway point, but this declined as they neared graduation. An increase in the percentage of "rocky" relationships in the "midway" students as compared to early and later in the training was concerning. Students who were in the midway part of their training tended to be most negatively affected by the academic-induced stress as they reported having the most noteworthy change in depression, difficulties concentrating, loss of interest in one or more aspects of their life, negative feelings, and feelings of low energy. Discussion: This study is the first of its kind to document lifestyle changes in PA students. The results suggest that PA students do have a negative deflection in their lifestyle at the 'midway' point of their training. This seems to rally near the end of their training. It is important to identify this so PA program faculty can properly advise their students. Increasing the awareness of the academic-induced stress experienced by PA students as well as applying stress-coping tactics may be beneficial to both current and future PA students. Conclusions: It is recommended that PA schools consider adopting strategies to effectively coach their students prior to and during the time when the students typically experience a decline in their lifestyle.
23. Analysis of Grade Point Average and First-time PANCE Performance Among Graduate/Undergraduate and Full-time/Part-time Status Students of the Drexel University Physician Assistant Program: 2004-2006.
C. Stream and J. Krolokowski, Drexel University Physician Assistant Program, Philadelphia, PennsylvaniaPurpose: The purpose of the study was to evaluate if a difference exists in first-attempt Physician Assistant National Certifying Exam (f-PANCE) performance and final grade point average (GPA) between both degree completion (master of health science/bachelor of science) and time status (full-time/part-time) of students in the Drexel University Physician Assistant Program. Methods: Final grade point averages and f-PANCE scores were compared with degree completion and time status for students graduating from the classes of 2004, 2005, and 2006 at the Drexel University Physician Assistant Program. The study population included a total of 178 students. One-hundred forty-three (80%) completed with a master of health science degree (MHS), 35 (20%) completed with a bachelor of science degree (BS); of these students, 137 (77%) were full-time and 41 (23%) were part-time. Independent-samples t-test analysis was performed using the SPSS statistical package. Results: Both MHS and full-time students attained a significantly higher GPA and f-PANCE score compared to BS and part-time students. The mean difference in GPA and f-PANCE scores between MHS and BS students was 0.48 (95% CI, 0.38-0.58) (p= 0.00) and 52.3 (95%CI, 17.9-86.8) (p=0.00) respectively. The mean difference in GPA and f-PANCE scores between full-time and part-time students was 0.21 (95% CI, 0.10-0.31) (p=0.00) and 57.7 (95% CI 25.4-89.9) (p=0.00) respectively. Discussion: The difference in curriculum between the MHS and BS students in this institution is that graduate students must achieve at least a 3.0 grade point average in graduate courses and complete graduate projects I and II. BS students must maintain a grade point average of at least a 2.0 in each course and do not participate in graduate projects I and II. This study suggests that possibly the higher academic requirements of a graduate student may have a positive influence on f-PANCE performance and GPA. Full-time students in this cohort performed better in GPA and f-PANCE compared to part-time students. Further analysis is needed to identify variables that would influence academic success and f-PANCE performance such as personal, social, and academic dynamics.
24. Complementary and Alternative Medicine in United States Physician Assistant Education.
L. Freels-Lloyd, B. Simon, L. Dunn-Ryznky, and F. Isberner, Southern Illinois University Carbondale, Carbondale, IllinoisPurpose: This study was designed to more clearly identify the content, methods, purpose, and orientation to complementary and alternative (CAM) education within the PA curriculum. Methods: An on-line survey of all accredited PA programs in the U.S. Survey items included questions about CAM content, teaching methods, instructor qualifications, and core competencies. Results: Sixty-eight percent of the 133 PA programs responded; response bias did not appear to be an issue. Seventy-seven percent of programs included CAM in their curriculum, and 93% of these indicated that CAM education was required. Most of the time (88%), CAM education was included as part of one or more existing courses, and students spent little to no time with an actual CAM provider. The number of CAM therapies included in the curriculum varied from one to 31 with a median number of 10. The most often-cited reason for including CAM in the curriculum was increased use by patients (79%), followed by CAM in the medical literature (66%), and faculty interest or request (63). Conclusions: For the majority of PA programs, CAM is taught as a part of existing courses by traditional lecture and written exams. Responses suggest that the approach to CAM education is predominantly cautious to neutral. That is, the objectives of CAM education appear to be less about teaching the benefits of CAM therapies and more about avoiding complications and adverse interactions while respecting patients' health beliefs and choices.
25. Diagnostic Reasoning Skills at Entry into a Non-traditional Physician Assistant Program - Registered Nurses Versus Other Allied Health Professions.
S. Kuntz, A. Larson, and M. Laxen, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North DakotaBackground: The physician assistant program at the University of North Dakota (UND) has previously only admitted registered nurses with a minimum of three years experience. Beginning in fall 2006, the program began a three-year pilot program to allow individuals with other allied health profession backgrounds to enter the program. The university program is planning intensive evaluation of how the new candidates are prepared to enter and perform during this unique program that has previously been designed around nursing professionals' background and experiences. The initial set of data was collected during the fall orientation program and consisted of the completion of the Diagnostic Thinking Inventory (Bordage, Grant, & Marsden, 1990). This is a pre-test of the students' diagnostic reasoning and will be compared to a post-test of the same inventory at the end of the program. Purpose: Identify potential differences between student group scores (nursing versus non-nursing professionals) on the subcategories of the Diagnostic Thinking Inventory: (1) flexibility in thinking, (2) evidence for structure in memory, as well as their overall combined score. Methods: The participants are the 32 students enrolled in the 2006-2008 university PA program, of which 18 are registered nurses and 14 come from other allied health professions. Data from the flexibility in thinking, evidence for structure in memory, and overall combined scored will be analyzed using t-tests assuming equal variances. The <.10 level of sensitivity will be utilized due to low power (.490), resulting from the low number of participants. Additionally, the data will be analyzed for between-subjects effects using the independent variables of marital status, gender, age, and years in a health profession. Results: T-tests did indicate significantly higher differences in the nursing subgroup of students with the evidence for structure in memory (t-test=2.000, df=30, p=.055) and overall combined score (t-test=1.936, df=30, p=.062), but no significant difference between the groups on the flexibility in thinking score (t-test=1.187, df=30, p=.245). There were no significant differences between subject effects for marital status (F=.519, df=30, p=.477), gender (F=.093, df=30, p=.762), age (F=.022, df=30, p=.884), and years in allied health profession (F=2.737, df=30, p=.109). Conclusions: The registered nurses appear to have a slight advantage with the structure of their learning in their memory, but it is only a slight difference. This may be biased due to the low number of students enrolled in the trial program. Both groups appear to be equally flexible in their diagnostic thought. It is recommended that these results be compared to standardized clinical performance data, objective testing results, and diagnostic post-testing to see if the two student groups are comparable at the completion of the program. The data will allow UND to modify curriculum as necessary to meet the needs of the new allied health professional program participants.
26. Faculty Development Essentials in Allied Health Clinical Preceptors.
J. Rogers, L. Dunn-Ryznyk, and C. Lautar, Southern Illinois University Carbondale, Carbondale, IllinoisPurpose: This study examined the professional development needs of clinical instructors/preceptors for a rural state university as they relate to being educators. Methods: A survey was mailed to 520 clinical instructors/preceptors from an allied health program in a rural state university in Illinois. The survey addressed the clinical instructors'/preceptors' confidence levels in their teaching skills and their interest in attending training on teaching strategies. Results: Findings revealed that clinical instructors/preceptors in rural areas are less confident in their clinical teaching skills but more confident in their ability to practice evidence-based care and to work with their community than their urban and suburban counterparts. In general, respondents were interested in a workshop or have access to a Web site on effective clinical teaching strategies. Conclusions: Clinical supervisors/preceptors have need and interest in improving their teaching skills. Improving confidence in clinical teaching skills could be addressed by providing a continuing education workshop and/or developing an academic Web site on effective clinical teaching strategies.
27. Imposter Phenomenon in Physician Assistant Education.
J. Prata and J. Gietzen, Pacific University, Hillsboro, OregonPurpose: Certain goal-oriented and highly achieving individuals have often been found to have feelings of depression and anxiety related to thoughts that their success can be attributed to luck and reasons not linked to their intelligence or competence. These views have been attributed to The Imposter Phenomenon. The Clance scale includes "fear of evaluation, fear of not being able to repeat success, and fear of being less capable than others." The scale consists of 20 items with a 5-point Likert scale answer range. The Clance Imposter scale has shown proven efficacy in its ability to discriminate imposters from non-imposters. The Clance Imposter Scale has been used in studies ranging from family medicine residents to university professors and has been cited in occupations ranging from teachers to marketing managers to actors. Medical students have high rates of IP that decline as they become more experienced. The IP has not been studied in the physician assistant population. This study set out to quantify the percentage of Pacific University School of Physician Assistant students from the graduating years of 2001 to 2006 who could be classified as having IP. Methods: A Clance Imposter survey was e-mailed to all graduates and students from the years 2001 through 2006. All responses were anonymous; 83 students and past graduates (56 females and 27 males) responded. Results: 46.4% of females and 22.2% of males scored in the accepted range for Imposter Phenomenon for a total of 38.5% of the sample being classified as "imposters." The IP appears to decline the longer a person has practiced as a PA, with a significant drop in IP after one to two years of practicing as a PA (p <0.005). Males appeared to have IP at rates significantly lower than females (p=0.028). IP scores were noticeably lower in individuals ages 36 or older; however, we were unable to demonstrate if this was age-independent or was a factor of increased clinical experience. Conclusions: This information is important to determine the percentage of incoming physician assistant students who may be inclined to attribute their scholarly success to luck or some skill rather than intelligence and ability. Physician assistant programs can utilize the study results to ascertain the percentage of students that may be experiencing this phenomenon. This study concluded that over one-third of students and graduates struggle with feelings associated with Imposter Phenomenon, such as feeling less capable than their peers/colleagues. PA programs should consider the amount of prerequisite clinical experience of a candidate as a strong indicator of whether the candidate will develop IP. Armed with this information, PA programs can provide these students with special services, such as counseling to provide reassurance that these feelings are a normal part of the transition from student to physician assistant.
28. Interdisciplinary Coursework: Pathophysiology with PA, NP, and PT Students.
H. Stoll, K. Wick, M. Guthrie, and P. Zimmer, MEDEX Northwest Division of Physician Assistant Studies, Seattle, WashingtonPurpose: Pathophysiology for Primary Care is a six-credit (one quarter) basic pathophysiology course for physician assistant students at our physician assistant program. The Family Nurse Practitioner (FNP) and the Doctor of Physical Therapy (DPT) programs at our institution requested - 10 and four years ago respectively - that their students be allowed to join our course. Both programs viewed our coursework as more clinically applicable than their previous courses. This poster will describe efforts to integrate students from other professional programs into this course while attempting to meet the needs of each profession. Methods: The course is structured primarily in three-hour lecture blocks taught by both core PA faculty members and specialty guest lecturers. PA and NP students generally have clinical experience and program-specific coursework prior to taking this course. PT students take this course within the first quarter of their program and generally have less clinical experience than the PA and FNP students. Evaluation of all students is conducted via three multiple-choice examinations, with additional writing assignments for PA students only. In 2006, the program instituted immediate post-test reviews of all major exams. This activity divides the class into small groups of seven or eight, each of which includes all three student types. Each group receives copies of the exam as well as a single answer sheet that must be completed by the group as a whole for grading. An end-of-course survey evaluation was administered to all students. The results of this evaluation were reviewed via parametric and non-parametric measures to elucidate differences among the PA, FNP, and DPT student responses. Results: Until the post-exam review was introduced this year, interaction among student groups was limited to break-time conversation. Verbal feedback and course evaluations indicated strong approval of both the post-test review and the interprofessional interaction that resulted from it. Although the course received good evaluations overall, analysis of student responses indicates that DPT students were less satisfied with specific aspects of the course than other students. Rating differences among the three groups were noted for the overall course, appropriateness of material, level of content, understandability of material, and non-class student study time (all P <.001 via Kruskal-Wallis). Additional evaluation variations were significant at P <.05. NP and PA students were more congruent in their ratings. Conclusions: PA and FNP students are highly positive and describe potential future clinical applications of the material. DPT students found the workload heavier and the content more difficult than anticipated. In the first three years with DPT students, the passing standard was adjusted and the grading changed to pass/fail for DPT students to reflect the less essential role of this course in their curriculum. These and other adjustments have lessened anxiety among the DPT students. No other specific efforts have been made to adapt course structure or content to the three different groups. Efforts to integrate the three professional groups are hindered by the largely lecture-driven, passive learning nature of the course. For the future, instructions to speakers to consider the varying backgrounds of the audience might serve to address some perceived imbalances.
29. Using a Game Format to Advance Professionalism in the Second-year Physician Assistant Curriculum.
A. Brenneman, University of Iowa Physician Assistant Program, Iowa City, IowaPurpose: Identify strategies to incorporate professionalism (one of the core competencies of NCCPA/ARC-PA) into the educational model irrespective of institution. Method: More than 200 articles and meta-analysis were reviewed concerning professionalism, its use in education, formats, teaching strategies, and benefits. This information was distilled into three approaches that can be used in any program, regardless of teaching approaches in PA education. The initial workshop was presented at the PA Education Association Annual Meeting in November 2006. One component was then introduced into the second-year PA program curriculum with feedback given on its use in developing professionalism and in the curriculum in general. Twenty-eight students were presented with a 90-minute interactive presentation on professionalism using a technique labeled "Game Format." The first 15 minutes was a presentation on the need for increased attention to professionalism, while the remainder of the period was used to describe the activity and employing the activity. Case scenarios were provided which generated discussion in small groups of three students each. The students were asked to rank the scenario based on what areas of professionalism were being upheld or crossed. The students were then asked to rank them using a color scale that helped them determine likely outcomes for the situation. The small groups reunited for general class discussion and consensus building. Results: Feedback was obtained using a 5-point Likert scale addressing the quality of the presentation, effectiveness of the activity, and amount of time allotted to the activity. Space to write in additional comments was provided. 5/18 or 28% felt the activity was effective and the quality of the presentation was excellent. 9/18 or 50% felt the activity was good and the quality of the presentation was good, while 4/18 or 22% felt the activity was average as well as the quality of the presentation. No students rated the activity below average or poor. However, two students commented they didn't get much out of the presentation or that it didn't expand their knowledge, despite the ranking on the Likert scale. A small majority felt that the time allotted was about right at 58%, but 42% felt that too much time was allotted for the activity. 2/18 or 11% felt that the material covered was too basic for them. These two subjects also commented on not getting much out of the presentation. Conclusions: Professionalism is increasingly an area of concern in the medical professions. New methods and ways of instilling professionalism, as well as ways to measure professionalism, are being developed and employed. Case scenarios are one way to develop awareness of professionalism in the classroom. Following this instructional exercise, the students indicated that their awareness of the issue was expanded. The amount of time allotted for this activity may be shortened when instituted or used in the next round based on current feedback, although the findings are very preliminary in their institution. Additional areas of study and techniques will continue to expand awareness and guide students in their expanding roles as health care providers.
Previously Presented
30. Comparison of Faculty Expectations to Student Performance on a Clinical Skills Performance Instrument.
J. Melson, J. Maring, E. Costello, and M. Plack, George Washington University Physician Assistant Program, Washington, DCPurpose: Mastery of clinical skills is critical to the development of a physician assistant. The purpose of this study was to compare faculty expectations to student performance utilizing a recently developed Clinical Skills Performance Inventory (CSPI) that tracks the developmental performance of PA students across the curriculum. Methods: The CSPI was developed to assess mastery of clinical skills by the PA student. Academic and educational literature, PA program curriculum goals, PA professional educational standards, and faculty expertise were consulted in construction of a 27-variable clinical skills acquisition tracking instrument. The instrument was piloted for ease of use and clarity and revised. To assess the validity of CSPI "mastery"-level performance criteria, senior student performance was assessed using the CSPI during the final OSCE of 47 students in the PA program. Faculty expectations were obtained from nine PA faculty members who ranked expectations of skill acquisition levels for graduates on the CSPI. The mean number of skill areas ranked at "mastery" level was computed for faculty expectations as well as for actual student performance. A t-test was used to determine if a significant difference existed between the mean expectation of faculty versus mean student performance in skill mastery. Results: A significant difference existed between faculty expectations and actual student performance in the final semester of the program (t=2.38; p=0.043). Faculty expectations were considerably higher than student performance as measured on the CSPI. Conclusions: Disparities between expectations and performance may be attributable to (1) failure of the CSPI performance level criteria to accurately define clinical skill levels, (2) unrealistic faculty expectations, or (3) curricular inadequacies. Further research is indicated.
31. Health Care Teams: Leadership Style, Performance, and Patient Outcome.
D. Bridges, J. Carlson, and E. Min, Rosalind Franklin University of Medicine and Science Physician Assistant Program, North Chicago, IllinoisPurpose: The purpose of this study was to identify whether certain leadership styles and/or team behaviors correlate with clinical competence during a high-fidelity patient simulation. Recent studies have shown that several leadership styles may predict subsequent clinical performance. However, no global assessment or teaching tool has been widely adopted to define critical leadership and team behaviors in health care teams. In this study, leadership style and team behavior were evaluated through the use of taped encounters where teams of students interacted with a high fidelity simulator. Methods: Ninety medical students, working in groups of two or three, were evaluated by three independent reviewers from interprofessional disciplines (physician assistant and nursing/health care management) and scored based on an evaluation tool comprised of leadership style and team behaviors. Dominant leadership style was assigned as 1=Transactional, 2=Flexible/Dynamic Team Leadership, or 3=Neither. Team behaviors were assessed using a Likert scale (0-4) and were comprised of workload management, communication, prioritizing, and reassign priorities and vigilance. An independent reviewer with a second clinical competency evaluation tool measured technical criteria identified as important for appropriate management of the simulated case and positive patient outcome. Results: Intrarater reliability was found to be .8711, indicating an almost perfect level of agreement. Twelve of 44 teams (27%) were identified as having transactional leadership, 28 (64%) were identified as dynamic/flexible, and 4 (9%) were identified as "neither." Therefore, 40 of the 44 teams could be categorized as demonstrating either transactional or dynamic leadership characteristics. Teams with transactional leadership had an average global competence score of 2.4 (marginal to standard), teams with dynamic leadership had a global competence score of 2.4 (marginal to standard), and teams determined to have neither had an average score of 1.3 (poor to marginal). The relationship between team behaviors and performance was evaluated using Spearman's Rank Order Coefficient, which found a statistically significant (<.0001) correlation for each of the behaviors. Conclusion: Leadership style did not appear to have an impact on team technical knowledge/medical management in this scenario. Despite the fact that leadership style did not appear to predict performance on the technical knowledge scale (possibly a predictor of patient outcome), teams that demonstrated a strong score on the team behavior items tended to also score well on technical competence. Thus it appears that all four of these behaviors are linked to the successful use of technical knowledge and patient management in this scenario. Thus, better use of team skills roughly translated into improved delivery of care to the simulated patient.
32. Student Attendance Utilizing a Classroom Management System.
E. Lembke, V. McCleary, M. Laxen and C. Hosford, University of North Dakota Physician Assistant Program, Family and Community Medicine, School of Medicine and Health Sciences, Grand Forks, North DakotaThe purpose of this study was to determine if the use of a course management system improved attendance. This study compared attendance during the 2005 and 2006 academic years, prior to and after installation of a course management system. During the 2005 and 2006 academic years, similar unannounced quizzes were given and the number of students present during each lecture was obtained from documented quiz points earned. The total number of students enrolled in the course at the time of the quiz was determined from registrar's records. During the 2005 academic year, students submitted handwritten quizzes that were graded and recorded by the instructor. During the 2006 academic year, students submitted quiz answers using the infrared response pad, which automatically recorded their grades. Two chi square tests of independence were conducted to determine whether there were significant differences in rate of class room attendance. Results indicated a significant increase in attendance (<0.01) during the semesters when the course management system was used.
33. Trends in Religious and Spiritual Indicators in Physician Assistant Student Application Essays.
C. Robohm, University of Colorado at Denver and Health Science Center, Aurora, ColoradoIntroduction: Spiritual and religious values and beliefs continue to receive a great amount of deliberation within popular culture. The U.S. remains a very religious society, with 60% of Americans considering religion "important" in their daily lives. A large study of college students found that, in general, college students show a high level of spirituality and religious involvement. In addition, with two-thirds of medical schools implementing educational curriculum addressing spirituality and faith in relation to medicine, the spirituality and religious values of physician assistant students deserve attention. Purpose: The purpose of this qualitative study is to identify and evaluate spiritual and religious statements within admissions essays of physician assistant students for one program. Methods: As part of the admissions application, applicants to one physician assistant program were required to submit an autobiographical statement and essay describing the applicant's most stressful experience and its outcome. Qualitative review of essays of program matriculants from the 1994-1995, 1999-2000, and 2004-2005 admissions cycles identified statements of spiritual conviction, religious conviction, and religious involvement. Statements were further categorized as reflective of spiritual quest, religious engagement, and religious commitment. Definitions were derived from a previous large, quantitative study. Individual statements were evaluated for statements reflecting life change, declarations of faith, and activities of evangelism. The three admission cycles were evaluated for a change in the quantity and quality of statements over time. Results: Over a 10-year period, there was an increase in the percentage of applicants writing statements of spiritual or religious nature, and a difference of quality was noted in the most recent essays. Examples of statements and results tables will be provided. Discussion: Many applicants self-identify and set life goals as a result of spirituality and religion with a change in quality over 10 years. Further study of religion and spirituality and the effect upon PA students in learning, discrimination, and quality and delivery of care is needed.
34. What Do PA Students Know About Tuberculosis: Results of a Survey of the Confidence and Knowledge of PA Students Regarding Tuberculosis.
M. Davison and D. Brown, University of Oklahoma, College of Medicine, Tulsa, OklahomaRationale: Tuberculosis (TB) continues to be a leading cause of infectious mortality globally. More than 50% of all TB cases in the United States are in foreign-born patients. In 2003, the National Tuberculosis Curriculum Consortium (NTCC) was established through the NIH National Heart, Lung, and Blood Institute (N01-HR-36157). The NTCC aims to improve knowledge, skills, and attitudes in the management and control of active and latent TB among health professions students by standardizing TB education and by providing educational materials to be used by health educators. Methods: This multidisciplinary project administered a survey to senior PA students to learn how much they know and how comfortable these soon-to-be-graduates are in their knowledge of TB. We surveyed students in five programs in NTCC schools (University of Nebraska, University of Southern California, Midwestern University, AZ, Midwestern University, IL, and New York Institute of Technology) during 2005-2006. A 42-item survey was developed by a panel of TB physicians and PA educators in the NTCC. After IRB approval at each school,
