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. Marshall
2 Empowerment and Educational Goals: A Study on the Outcomes of a Mentoring Program.
A. Kulon, K. Snell, S. Grow, and T. Bacon-Bagulely
3 Evaluation of an Educational Protocol for the Use of Nesiritide in Acute Decompensated Heart Failure.
R. Kirkhart
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
5 Investigating the Need for Age-specific Approaches to Intimate Partner Violence.
V. Breitbart, L. Davidson, V. Rickert, J. Tanenhaus, and L. Rottenberg
6 Patient Perception of Optimal Weight Goals in the Overweight Population.
C. Innus and J. Patterson
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
8 Predictors of PSA Recurrence after Robot-assisted Radical Prostatectomy.
M. Mathe, S. Capello, H. Patel, and J. Joseph
9 Prevalence of Sleep Apnea in Subjects with Atrial Fibrillation at a Specialty Cardiology Office.
A. Murray, J. Gietzen, and B. Halperin
10 Rheumatology Physician Assistant Role Delineation Study.
R. Hooker, J. Seignon, and B. Rangan
11 The Effects of Early Patient Education on Immunization Rates of Infants in Galveston County.
T. Bigler and K. Stephenson
12 Type II Odontoid Fractures in the Elderly Treated with Cervical Orthosis.
D. Orndorff, I. Marks, R. Whitehill, D. Chun, and V. Arlet
Case Studies/Clinical Reports
No. Title and Authors
13 An Atypical Presentation of Venous Stasis Ulcers in a Patient with AIDS.
K. Breaux and M. Rodriguez
14 An Unusual Case of Cirrhosis in a 56-year-old Male.
J. Van Rhee
15 Pneumatosis Intestinalis and Portal Venous Gas Associated with Placement of a Balloon Foley Jejunostomy Feeding Tube.
J. Moore
16 Sacral Chordoma.
I. Marks and F. Shen
17 Streamlining Kidney Transplant Hospital Stay.
E. Simmons, E. Tichy, S. Kulkarni, N. Edgington, and M. St. George
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
Previously 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. Chang
20 An Unusual Reaction to Intracorporeal Injection of Phenylephrine in a Patient with SCD and Stuttering Priapism.
L. Daitch and A. Kutlar
21 Relapsing Malaria Infection in an Adolescent Following Travel to Mozambique.
A. Summer, C. Oswald, and P. Fischer
EDUCATION GALLERY
Original Research
No. Title and Authors
22 Academic-induced Lifestyle Changes in Student Physician Assistants.
J. Rasmussen, E. Frazier, and J. Gietzen
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
24 Complementary and Alternative Medicine in U.S. Physician Assistant Education.
L. Freels-Lloyd, B. Simon, L. Dunn-Ryznky, and F. Isberner
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
26 Faculty Development Essentials in Allied Health Clinical Preceptors.
J. Rogers, L. Dunn-Ryznyk, and C. Lautar
27 Imposter Phenomenon in Physician Assistant Education.
J. Prata and J. Gietzen
28 Interdisciplinary Coursework: Pathophysiology with PA, NP, and PT Students.
H. Stoll, K. Wick, M. Guthrie, and P. Zimmer
29 Using a Game Format to Advance Professionalism in the Second-year Physician Assistant Curriculum.
A. Brenneman
Previously 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. Plack
31 Health Care Teams: Leadership Style, Performance, and Patient Outcome.
D. Bridges, J. Carlson, and E. Min
32 Student Attendance Utilizing a Classroom Management System.
E. Lembke, V. McCleary, M. Laxen, and C. Hosford
33 Trends in Religious and Spiritual Indicators in Physician Assistant Student Application Essays.
C. Robohm
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
35 When do Applicants Learn about the Physician Assistant Program? One Program's Nine-year Experience.
C. Robohm and J. Bowser
STUDENT GALLERY
Outstanding Student Research
No. Title and Authors
36 Are Self-reported Patient Encounter Data Accurate?
L. Williams and D. Day
37 Breaching Patient Confidentiality: A Pilot Study of Physician Assistants' Awareness and Attitudes.
K. Slabic and A. McGuire
38 HIV Seroprevalence Among Patients Admitted to Mulago National Hospital in Kampala, Uganda.
G. Kayingo and M. Warner
Original 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. Carpenter
40 A Study of Tanning Operators in the State of Kansas: Their Attitudes and Stated Practices Regarding Minors and Tanning.
M. Apollo and R. Muma
41 An Analysis of Stress-related Lifestyle Changes of Physician Assistant Students Across Several PA Training Programs.
A. Hawn, D. LaBarbera, and M. Schomogyi
42 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. Biearman
43 Analyzing Pharmacists' Knowledge of Physician Assistant Prescribing Rights.
M. Hill, A. Leighow, A. Uziel, and B. Biearman
44 Antibiotic Prescribing Patterns for Acute Otitis Media in One Urban Pediatric Clinic.
K. Sinclair, Y. LeGoff, C. Barra, and E. Mandel
45 Breast Cancer Awareness and Genetic Testing Among Students at Seton Hall University.
L. Roenigk, C. Carpenter, and M. Stansfield
46 Comparison of Cardiovascular Risks in Paid Versus Volunteer Firefighters.
B. Pherson, R. Ruth, C. Schmidt, and B. Biearman
47 Diagnosis and Clinical Management of Potential Statin Myopathy in Polypharmacy.
L. Palmer, W. Insull, and E. Love
48 Does a Correlation Exist Between the Number and Type of Clinical Encounters and NCCPA PANCE Scores?
E. Min, H. Comstock, and B. Dickey
49 Effect of Educational Materials on Patients' Ability to Recall Medication Regimens and Compliance.
A. Frakes and A. Brenneman
50 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. Biearman
52 Factors Influencing a Woman's Decision to Breastfeed.
K. Pauze, M. Kourtz, J. Streich, K. Wai, and B. Biearman
53 How Physician Assistants Use Evidenced-based Medicine in their Clinical Practice.
M. Behr, C. Jordan, J. Olsen, and K. Seelman
54 Perceptions of Medical Research Education in Physician Assistant Programs.
K. Angelo, M. Ressler, T. Weber, J. Wackowski, and B. Biearman
55 Physical and Physiological Changes Observed Following the Lap-band Surgical Procedure.
M. Nye, R. Simper, O. Chen, and L. Hill
56 Physician Assistant Knowledge and Adherence to Cardiovascular Disease Prevention Guidelines: A Pilot Study.
L. Blair, W. Insull, and C. Fasser
57 Practicing Physician Assistant Awareness of ATP III Cholesterol Guidelines.
K. Malone, K. Beck, J. Blakeslee, and L. Martin
58 The Bird Flu: How Aware Are You?
K. Czekanski, B. Brancazio, W. Stein, and B. Biearman
59 The Relationship Between Asthma and Obesity.
J. Oliveira, S. Shapiro, and N. Hadi-Nahavandi
60 Weeble Wobble Study: Infant Weight Gain Patterns in a Private Pediatric Setting.
J. Buckweitz, H. Holloway, B. Kanani, and E. Mandel
61 Weight Loss and Perceived Improvement in Comorbidities and Psychological Well Being in Lap-band Recipients.
S. Melville, L. Gonzales, O. Chen, and L. Hill
62 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. Bourne
Case Studies/Clinical Reports
No. Title and Authors
63 A Case of Congenital Isolated Hemihypertrophy in a Seven-year-old Male.
J. Palermo and A. Essary
64 A Case of Esophageal Herpes Simplex Virus Type 1 in an Immunocompetent 21-year-old Male.
S. Bolander, L. Ritter-Baker, and B. Coplan
65 A Case of Hyperbilirubinemia: A Search for the Less Obvious.
M. Miller and M. Statler
66 Acanthosis Nigricans in a Female Patient.
C. Shelburne and K. Lohenry
67 Acute Exacerbation of Chiari I Symptoms after Chiropractic Intervention.
E. Zink, K. Lohenry, and J. Williams
68 An Uncommon Reaction to Prochlorperazine.
M. Matey and J. Spiegel
69 An Unexpected Finding in a Two-year-old with a Burn Injury to the Hand.
N. Farrar and T. Moreau
70 Congenital Liver Malformation: A Case Report.
S. Adams
71 Isolated Thrombolysis Catheter for the Treatment of Upper Extremity Deep Vein Thrombosis: A Case Study.
T. Lavor and J. Spiegel
72 Lipoma versus Liposarcoma in a 26-year-old Male.
F. Altuve and K. Lohenry
73 Mental Illness in a Pregnant Female: A Case Report.
A. Packham, J. Stoehr, and A. Essary
Previously 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. Reed
75 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, Illinois
Objective: 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, Michigan
Purpose: 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, Ohio
Purpose: 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, Colorado
Background: 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 York
In 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 York
Purpose: 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, Virginia
Purpose: 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 York
Introduction: 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, Oregon
Background: 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, Texas
Introduction: 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, Texas
Purpose: 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, Virginia
Introduction: 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, Texas
A 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 Carolina
Introduction: 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 Carolina
Infection 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, Oregon
Purpose: 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, Pennsylvania
Purpose: 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, Illinois
Purpose: 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 Dakota
Background: 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, Illinois
Purpose: 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, Oregon
Purpose: 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, Washington
Purpose: 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, Iowa
Purpose: 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, DC
Purpose: 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, Illinois
Purpose: 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 Dakota
The 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, Colorado
Introduction: 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, Oklahoma
Rationale: 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, students voluntarily completed the survey. Results: Results were analyzed by the NTCC and reported in aggregate form for the 285 students who responded. Students indicate that they consider TB education to be important in their academic program, with 98% reporting that they have attended at least one lecture on TB. Slightly more than half the students have been involved in the care of patients with either active or latent TB. The majority of the students report that they feel at least somewhat confident in interpreting results of diagnostic tests for TB, in formulating a treatment plan for patients with active or latent TB, and in communicating effectively with patients with TB and their families. Conclusions: There is still much room for improvement in knowledge, attitudes, and confidence about TB by PA students who responded to this survey. By knowing what students think and how confident they are in their knowledge, PA educators can address issues that may improve knowledge of TB in their students. The NTCC-developed teaching modalities may improve student performance that will be assessed with future surveys.
35. When Do Applicants Learn about the Physician Assistant Program: One Program's Nine-Year Experience.
C. Robohm and J. Bowser, University of Colorado at Denver and Health Science Center, Aurora, Colorado
Introduction: As a profession, the importance of planning and implementing recruitment strategies to address the needs of the physician assistant profession in the context of providing care to all populations is paramount. The roots of career choice and post-secondary career planning start as early as eighth grade, making early career education an important task. To date, little data is available on recruitment methods to evaluate the success of current strategies in an effort to continue or develop new strategies. Purpose: The purpose of this study is to evaluate when applicants first learn about the PA profession. Methods: At this physician assistant program, data has been collected on various aspects of applicant knowledge of the PA profession. Short-term recruitment variables were collected as part of the application during cycles from 1997-1998 to 2005-2006. Data were evaluated to determine when applicants first learn about the PA profession and if applicants are learning about the PA profession earlier in their academic careers. Results: Applicants to this program in 2005-2006 cycle learned about the PA program significantly earlier in their academic careers than those in the 1997-1998 cycle (p=0.001). During the 1997-1998 cycle (n=246), 27.2% learned about the profession after college, 58.5% during college, 12.2% during high school, and 2.0% during grades 1-8. In the 2005-2006 cycle (n=157), 18.5% learned about the profession after college, 53.5% during college, 26.1% during high school, and 1.9% during grades 1-8. With descriptive analysis, there is a trend toward younger ages throughout the nine years. Discussion: From this small sample, it appears that recent applicants are learning of the PA profession earlier than those nine years ago. In the earlier application cycles of 1997-1998 and 1998-1999, the majority learned about the profession in or after college. The trend has now shifted to high school and college. Further research is required to determine reasons applicants may be learning about the profession earlier. This may be due to increased recruitment efforts aimed at high school populations or exposure to the profession through health care delivery.
STUDENT GALLERY
Outstanding Student Research
36. Are Self-reported Patient Encounter Data Accurate?
L. Williams and D. Day, Wichita State University, Department of Physician Assistant, Wichita, Kansas
Introduction: Medical education programs are using Personal Digital Assistants (PDAs) to facilitate the recording of encounters between students and patients during clinical rotations. Wichita State University Physician Assistant Program (WSU-PA) uses PDAs to track clinical patient encounters during its clinical year. The WSU-PA clinical rotation at Pratt Regional Medical Center Emergency Department (PRMC-ED) provided an opportunity for a comparison of medical records and PDA entries made by students who spent four to six weeks at that site. Purpose: The purpose of this study was to verify the self-reported data submitted by students with the actual documentation on the medical record and identify any significant inconsistencies. Methods: Student submitted data of all patient encounters by WSU-PA students at PRMC-ED were compared to data obtained through review of medical records for patients seen by the student. The age and sex of the patient as well as the diagnosis of each visit were compared for consistency using HandEchart® Software and Microsoft Excel® Spreadsheets. Results: 32.16% of reported diagnosis matched the medical records, 24.69% of patient age matched the medical records, and 31.18% of patient sex matched the medical records. Conclusion: Data revealed an inconsistency between medical charts and PDA entries of patient encounters during clinical rotations at PRMC. The data that represented the age, sex, and diagnosis of patients encountered in clinical rotations by second-year PA students was consistent 1/3 of the time.
37. Breaching Patient Confidentiality: A Pilot Study of Physician Assistants' Awareness and Attitudes.
K. Slabic and A. McGuire, Baylor College of Medicine, Center for Medical Ethics and Health Policy, Houston, Texas
Introduction: Patient confidentiality, a cornerstone of the physician assistant profession, is essential to the ethical practice of medicine and should be protected. However, it is not absolute and legal exceptions to confidentiality do exist. Therefore, PAs must be aware of what their legal and ethical obligations are with regard to patient confidentiality in order to guide decision making about how to resolve conflicts that may arise. Purpose: To describe and interpret Texas statutes pertaining to patient confidentiality, to identify PAs' awareness of the circumstances under which one is or is not legally permitted to breach patient confidentiality for the protection or benefit of a third party according to Texas law, and to ascertain whether there is a consensus among PAs practicing in the state of Texas about when it is or is not ethically appropriate to do so. Methods: A 20-item survey featuring six case vignettes was developed. Surveys were mailed to 535 licensed Texas PAs, which resulted in the return of 154 completed surveys and eight undeliverable surveys. A repeat mailing sent to 373 non-responders resulted in the return of 78 completed surveys. In total, 232 completed surveys were received, yielding a response rate of 43.36%. The data from the returned surveys was entered into Microsoft Excel and then transferred into the Statistical Package for the Social Sciences (SPSS) software for analysis of the results. Results: The results of the research showed that most physician assistants realize that patient confidentiality is not absolute by the fact that only a few respondents selected "nobody" when asked to identify to whom one is legally permitted to breach patient confidentiality. Therefore, there was an understanding that patient confidentiality may be breached under certain circumstances. However, under what circumstances and to whom one is permitted to breach patient confidentiality yielded variable results. Most respondents knew when it is legally required to breach patient confidentiality, as is the case with reporting a communicable disease such as HIV or syphilis or reporting child abuse. However, in cases when one is not required but is permitted to breach patient confidentiality, there was less consistent knowledge of the law and more variation among answers. Additionally, there was not a majority consensus among PAs as to what constitutes an ethically permissible breach of patient confidentiality. While in PA school, most of the respondents took a medical ethics course (64.7%); however, only 25.9% took a medical jurisprudence course. Conclusion: A successful relationship between PAs and their patients depends on an understanding of the legal and ethical implications of breaching patient confidentiality. Such knowledge can be gained through providing medical ethics and medical jurisprudence courses in PA school in addition to offering continuing medical education to practicing PAs.
38. HIV Seroprevalence Among Patients Admitted to Mulago National Hospital in Kampala, Uganda.
G. Kayingo and M. Warner, Yale University, New Haven, Connecticut
Purpose: Uganda is one of the few countries in the world that reported an early and compelling decline in HIV/AIDS prevalence among the general adult population, from 30% in the early 1990s to less than 10% in 2006. Controversy surrounds the accuracy and generalizability of these estimates as most of the data was obtained solely from women visiting antenatal clinics. Official reports of HIV seroprevalence rates among high-risk patients are reported to be 23%. The primary objective of this study is to examine the seroprevalence of HIV infection in adult patients admitted to Mulago National Hospital in Uganda. Secondary study aims include reporting the demographics of and comorbidities in HIV-positive patients who died during hospitalization. Methods: Using a descriptive cross-sectional study design, we reviewed patients' charts, nursing records, and floor admissions records from a general medicine floor at Mulago National Hospital between September 6 and October 6, 2006. We collected data related to the known HIV-positive status prior to admission, rates of those who were found to be positive during hospitalization as determined by ELISA and Western blot. We also collected data on how many patients died, causes of death, and demographic information for those who died during the study period. Methods, protocols, and testing and data handling followed international guidelines on HIV/AIDS research. Results: A total of 339 patients were admitted to the floor during the study period. The HIV serologic status was positive for 175 (51%), negative for 150 (44%), and unknown for 15 (5%) patients. A total of 53 patients died during this period. Fifty two of the 53 patients who died during the study period were HIV-positive. Review of demographics characteristics reveal that 15 (28%) were male and 37 (72%) were female; 53% of those who died were under the age of 40. Tuberculosis was the most frequent comorbidity, followed by HIV encephalitis. Two patients (4%) died of the emerging condition of lactic acidosis resulting from the antiretroviral regimen. Conclusions: The HIV seroprevalence in patients admitted to Mulago Hospital in Uganda was found to be twice that of the most recent official reports. As recognized in previous estimates, younger adults and women are most likely to die from this disease and devastating consequences of their deaths can not be predicted. Clearly, the results of this study suggest that further large-scale surveillance is warranted to guide policies on HIV prevention and care in Uganda.
Original Research
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. Carpenter, Chatham College, Pittsburgh, Pennsylvania
Purpose: The purpose of this retrospective study is to determine what variables were important to newly graduated physician assistants when they were applying for, interviewing for, and selecting their first job as a PA. The goal of the original PA training was to provide health care to the medically underserved; thus, primary care became the focus of the PA education. In accordance with this original mission, our program focuses on primary care medicine when preparing students; however, the majority of PA students choose to specialize in a field other than primary care upon graduation. It is hypothesized that salary is the most important factor for the PA-C in choosing his or her first job when compared to personal gain or humanitarian factors. Method: The research subjects will be comprised of all college physician assistant program alumni from 1997 to 2005, without preference to sex, age, or race. To be included, the research subjects must be PAs who have graduated from our PA program, certified by passing the PANCE exam, and held at least one job as a PA. A 25-question, close-ended survey was mailed to each subject asking questions about factors influencing career decisions. Each survey question was assigned a category of either personal gain or humanitarian and will be compared across gender, age, and race. Importance of salary will also be compared within the personal gain category to rank its importance in the PA's first job. All data will be analyzed by chi square with SPSS software. Results: Currently, the results of this study are pending due to ongoing data collection and analysis. Preliminary results indicate that the majority of PAs chose their first job based on salary and other personal gain incentives such as compensation. Thus far, humanitarian factors appear to be ranked lower in consideration than salary. Conclusions: It is likely that the general trend of data will indicate that physician assistants are choosing their first jobs as PA-Cs based on personal gain factors. Newly graduated and certified PA-Cs are excited about the prospect of being a professional after their years of hard work and studying. Salary is the most important factor to consider due to debt most students experience after completing their program of study Unfortunately, there appears to be more incentive to choose a higher paid position over a lesser paying one more likely seen in medically underserved populations. Thus, the original mission of the PA program seems to be overlooked when choosing the first professional position.
40. A Study of Tanning Operators in the State of Kansas: Their Attitudes and Stated Practices Regarding Minors and Tanning.
M. Apollo and R. Muma, Wichita State University, Wichita, Kansas
Introduction: It is estimated that 30 million Americans will tan this year and about 2 million of them will be teens. Exposure to UV rays seems to be the most important environmental factor in developing skin cancer. About 23 states have passed some type of legislation on youth access to tanning. Kansas has no regulations on youth access to tanning. Few studies have been done regarding whether tanning operators support or oppose youth access restrictions. Methods: The purpose of this study was to evaluate the basic demographics, attitudes, and stated practices regarding youth access to tanning among Kansas tanning operators. A survey was mailed to Kansas tanning facilities regarding these questions and results were analyzed using descriptive statistics. Results: The survey response rate was 28% (total n=651). The majority of the respondents felt that there were "none to a little risk" with indoor tanning (60%). Most felt that someone could be too young to tan, yet only 65% had ever discouraged one from tanning because of their age. Ninety-two percent of tanning operators supported written parental consent for youth tanning. Conclusion: The majority of operators believed that written parental consent and age regulations for indoor tanning should be required, yet they were not enforcing such consent. This is the first Kansas study documenting perceptions of tanning operators regarding youth access to tanning and stated practices. This information may be helpful to Kansas lawmakers as legislation is considered on this topic.
41. An Analysis of Stress-related Lifestyle Changes of Physician Assistant Students Across Several PA Training Programs.
A. Hawn, D. LaBarbera, and M. Schomogyi, University of Saint Francis Physician Assistant Program, Fort Wayne, Indiana
Background: Students in health professional graduate programs such as medical school, physician assistant school, and nursing school are subjected to rigorous educational programs. While these programs differ in length and intensity, they are similar in the stressful environments that they create for the students. PA education lacks the comparable breaks of medical student training. Studies on stress-related lifestyle changes of medical students report increased caffeine use, weight gain, decrease in activity level, changes in eating patterns, and higher rates of depression and anxiety than in the general public. One study demonstrated that smoking habits persisted throughout medical and nursing education. There are no definitive studies on stress-related lifestyle changes of PA students. An understanding of these changes is important for the health and well being of PA students and may support the need for establishing or improving PA student wellness initiatives. Purpose of the Study: To investigate the lifestyle changes of physician assistant students across different PA training programs. Methodology: Subject Selection and Survey Distribution: A convenience sample of approximately 450 PA students (classes of 2007 and 2008) from several universities were asked to complete an anonymous original survey that was mailed to their program and distributed to and collected from individual PA students by one of their faculty. Original Survey: An original survey was developed, piloted, and modified according to input by PA program faculty and a focus group of 25 PA students. The survey queried into PA students' changes in caffeine intake, exercise habits, dietary habits, weight change, church participation, routine wellness checks, alcohol consumption, tobacco use, sleeping habits, relationships, prescription medications, and overall mood. Data Processing: Demographics and frequencies of responses will be reported. Comparisons between programs and between first- and second-year PA students will be made with non-parametric analysis (e.g., chi square) (significance level of 0.05) as appropriate. Results: TBD Discussion and Conclusions: TBD
42. 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. Biearman, Chatham College, Pittsburgh, Pennsylvania
Purpose: According to the National Institute of Mental Health, an estimated 26.2 percent of Americans ages 18 and older, about 57.7 million people, suffer from a diagnosable mental disorder in a given year. However, fewer than 8 million of those affected seek medical treatment. Studies have shown that there are numerous barriers that prevent people from receiving adequate care for mental illness, addiction, and mental retardation. Some of these include poor collaboration between the medical and mental health team, lack of transportation, inadequate training of mental health needs, and the stigma of receiving mental health services. A proposed mechanism to help solve this problem is the use of organizations that provide self-help services. Studies have shown that organizations that offer structured services and peer-supported groups were associated with greater satisfaction with professional mental health services by the user. This study aims to evaluate the awareness, effectiveness, and the identification of barriers to treatment for one organization, Turtle Creek Valley (TCV) Mental Health/Mental Retardation, Inc., with the help of the Communities That Care (CTC) program. Methods: The population to be studied consists of key leaders and community members in the Braddock, North Braddock, and Rankin areas. The participants receive a survey with two sections. The first section contains general questions such as age, gender, and area of occupancy. The second section contains questions based on Likert, phrase completion, and rating scales, and asks about knowledge of the organization, its effectiveness, and identification of barriers to treatment. Analysis will be conducted with non-parametric tests, including the Mann-Whitney test and Wilcoxon signed-rank test. The level of significance will be set at P<0.05. Results: The results of this study are pending, as survey collection and analysis of data are ongoing. Preliminary results indicate that the level of awareness of the TCV services is relatively low. Also, several factors that are barriers to treatment have been identified for the organization and this study will pinpoint specific areas of needing improvement to increase community penetration. Conclusion: There are several studies that show barriers to seeking mental health, addiction, and mental retardation treatment. Identification of the specific barriers in the studied communities will allow for the development of tactics to overcome these barriers, such as advertisements that target the barrier and offer a solution to it. Identification and solution of barriers will result in a larger population seeking care through the offered services. There are organizations in place in communities that offer self-help services to overcome these barriers. It is important for these organizations to constantly evaluate the penetration, efficacy, and barriers to their services. The findings concluded from this study will be used to improve the accessibility and awareness of Turtle Creek Valley Mental Health/Mental Retardation, Inc.
43. Analyzing Pharmacists' Knowledge of Physician Assistant Prescribing Rights.
M. Hill, A. Leighow, A. Uziel, and B. Biearman, Chatham College, Pittsburgh, Pennsylvania
Purpose: In modern health care, pharmacists and physician assistants work closely with medications and must be knowledgeable in their use and the laws regarding use. Physician assistants have specific laws that they must abide by, depending on the state in which they practice. Pharmacists also must know the laws that physician assistants must follow before dispensing medication prescribed by a physician assistant. With both professions working closely together and knowing state regulations and laws, both parties can work as a check and balance system to avoid prescription errors and subsequent medical misadventures. It is hypothesized that pharmacists may not be knowledgeable in the prescriptive rights of physician assistants in their state and may be unknowingly dispensing medications that the law prohibits being dispensed by a physician assistant. Methods: The sample for the study will consist of employed pharmacists of community pharmacies randomly chosen in our state. All participants will receive a survey querying gender, years of working as a pharmacist, level of education, area of practice, and a list of medications. The pharmacist will have to identify which medications physician assistants are allowed to prescribe by answering yes, no, or I don't know as to whether physician assistants are allowed to prescribe the specific medication. Data from the surveys will be analyzed using chi square tests and t-tests. The survey will reflect the new regulations that were established after commencement of our research project. Results: Currently, the results of this study are pending, as survey collection and analysis are ongoing. Anticipated results are that pharmacists will not be able to correctly identify that PAs cannot prescribe non-controlled substances such as albuterol, Duratuss G, Nolvadex, Nardil, Coumadin, and Plavix in our state. It is anticipated that pharmacists are deficient in the knowledge of PA prescriptive rights and did not receive adequate training of these laws during their education or in practice. It is also hypothesized that pharmacists are not aware of new regulations governing physician assistant prescriptive rights that will be effective January 1, 2007. Conclusions: It is suspected that there is inadequate training in pharmacy school and by the state board regarding physician assistant prescriptive rights. Inadequate training of the physician assistant in knowing their prescriptive powers in the state in which they work can lead to misuse of prescribing rights and loss of licensure if discovered. Since medication errors account for more than 1 million unintentional injuries per annum, pharmacists and physician assistants must be cognizant of the limitations of physician assistant prescriptive practices to prevent patient injury.
44. Antibiotic Prescribing Patterns for Acute Otitis Media in One Urban Pediatric Clinic.
K. Sinclair, Y. LeGoff, C. Barra, and E. Mandel, Seton Hall University, South Orange, New Jersey
Purpose: The purpose of this study was to identify the antibiotic most commonly prescribed for the treatment of uncomplicated acute otitis media (AOM), as compared to the recommendations of the American Academy of Pediatrics (AAP), which state that amoxicillin is the first line of treatment. This study was conducted in one urban pediatric clinic. Methods: A retrospective review of 88 total charts was performed, including patients ages two months to 12 years who were diagnosed with uncomplicated AOM over a period of 18 months. The chi square method was used to analyze the frequency of prescription of the various antibiotics. Other factors explored included age, gender, ethnicity, insurance type, recent antibiotics prescribed within the previous 30 days, and number of days of the current antibiotic prescription. The cost of the prescribed treatment regimen was calculated, based on local pharmacy pricing. Anticipated Results: We anticipate that our study will demonstrate that despite the AAP's recommendation that amoxicillin is the antibiotic of choice for uncomplicated AOM, azithromycin will be the most commonly prescribed antibiotic by pediatricians in this urban pediatric clinic. This finding will be independent of patient age, gender, ethnicity, insurance type, and recent antibiotic use. Conclusions: According to our study, azithromycin is the antibiotic most commonly prescribed for the treatment of uncomplicated AOM. The American Academy of Pediatrics recommendations state that amoxicillin is the standard of care for uncomplicated AOM, but practitioners have their preferences in selecting treatment regimens for their patients. Contributing factors for antibiotic selection may include years of practice, lack of familiarity with current AAP recommendations, perceived or actual community drug resistance, ease of prescribing, convenience of dosing, cost, or patient preference. The clinical implications for this study are significant in that prescription choices for the treatment of uncomplicated AOM undeniably impact the quality and cost of patient care.
45. Breast Cancer Awareness and Genetic Testing Among Students at Seton Hall University.
L. Roenigk, C. Carpenter, and M. Stansfield, Seton Hall University, South Orange, New Jersey
Purpose: The purpose of this study is to review multiple demographic data (education level of students enrolled in Seton Hall University, age, personal or familial history with breast cancer) to describe any trends in knowledge of breast cancer and attitudes toward screening. Methods: A convenience sample will be drawn from the population of female students currently enrolled in Seton Hall University who will be asked to complete an on-line survey distributed via e-mail with questions pertaining to general knowledge of breast cancer, risks of developing cancer, and willingness to undergo any potential screening/testing procedures. The independent variables will be the demographic data collected and examined using non-parametric tests and chi square. The dependent variables will be gathered using the following process: The Likert values from all statements which assess general knowledge will be tallied together and assigned an appropriate categorical level of awareness. The same will be done for all statements pertaining to the participant's desire to undergo screening/testing procedures. These values will be used as the dependent variables. A chi square analysis will be performed to determine if there is a relationship between the categorical variables. Analysis will be performed using SPSS 14.0. Results: It is expected that the results from this study will show certain relationships between each dependent variable and independent variables. Higher levels of education as well as older age are projected to correlate with a higher categorical level of knowledge. It is also anticipated that a positive personal or familial history of breast cancer will be associated with a higher level of knowledge of breast cancer. It is likely that similar relationships will be seen with each of the independent variables and the desire to undergo screening/testing procedures. Conclusions: The previously stated relationships between independent and dependent variables will be seen; therefore, it can be concluded that there is a correlation between general awareness of breast cancer and desire to undergo screening/testing procedures. This demonstrates the importance of breast cancer awareness among women of college age, which may be extrapolated to the importance of awareness in the general population. A greater awareness of the risks of breast cancer will encourage women to utilize the health care system more appropriately, particularly when pertaining to women's health. This will aid physician assistants in properly detecting and treating this disease.
46. Comparison of Cardiovascular Risks in Paid Versus Volunteer Firefighters.
B. Pherson, R. Ruth, C. Schmidt, and B. Biearman, Chatham College, Pittsburgh, Pennsylvania
Purpose: Every year, numerous firefighters die in the line of duty as a result of cardiovascular events. In 2004 and 2005, 194 firefighter deaths were reported to the United States Fire Administration. Fifty-four percent (n=105) of these deaths were attributed to myocardial infarction or cerebral vascular accident. Seventy-six of these deaths were volunteer firefighters, with 29 deaths occurring in career firefighters. The purpose of the proposed research is to identify cardiovascular risk factors in paid versus volunteer firefighters in small community fire services surrounding Pittsburgh, Pennsylvania. Methods: The subject population consists of 40 firefighters from paid and volunteer fire departments in the boroughs of an urban area. Subjects were recruited on a volunteer basis. Each subject completed a short survey on tobacco and alcohol use, exercise, medical problems, and first-degree relative medical problems. Measurements of BP, heart rate, waist circumference, and BMI were obtained by the researchers using standard methods. The study also examined the physical requirements set forth for membership and/or employment and the total call volume of each fire department. On-site exercise facilities and departmental health promotion at each fire station was evaluated. Firefighter deaths while in the line of duty were also examined. Results: Currently, the results of this study are pending due to ongoing data collection and analysis. We propose that paid firefighters will be more physically fit and have less cardiovascular risk factors than volunteer firefighters. This may be attributed to paid fire fighters having a higher call volume, being more active, and performing more physically challenging tasks. In addition, we believe paid firefighters are more likely to have stricter physical requirements, making them more physically fit and reducing their cardiovascular risks. Conclusions: Firefighting is considered to be a physically demanding occupation that requires maintaining adequate cardiovascular fitness. Promoting good cardiovascular health means ensuring that firefighters remain physically fit and routinely pass physical examinations. However, most fire departments have not promoted health maintenance or provided firefighters access to fitness facilities. Often volunteer fire departments do not routinely screen firefighters for cardiovascular risks or follow-up on yearly physical examinations. This often leads to increased morbidity and death among this group. To reduce cardiovascular risks, fire departments should consider mandating annual fitness and medical examinations for both volunteer and paid firefighters. Examining cardiovascular risks among volunteer versus paid firefighters will hopefully implement health maintenance and fitness promotion programs.
47. Diagnosis and Clinical Management of Potential Statin Myopathy in Polypharmacy.
L. Palmer, W. Insull, and E. Love, Baylor College of Medicine, Houston, Texas
Introduction: Statin myopathy remains a challenge and worry to physicians and patients due to the progressively lower LDL goals requiring increased statin doses or multiple drug regimens. Such factors are known to increase the risk of statin myopathy. The variation among muscle symptoms secondary to statin use remains a clinical challenge. Clear guidelines for diagnosis and management of statin myopathy have not yet been developed. The safety profile of statins is based largely on clinical trial data, case reports, and the FDA adverse event reporting (AER) system. Clinical trials provide reliable safety information, but they are limited to a select population that may not be truly representative of the general public. Case reports represent a small sample group and the FDA reporting system is unreliable due to the dependence on the voluntary submission of reports by physicians, completeness of reports, and uncertainties for size of population at risk. Current ambiguous criteria present a challenge for practitioners to correctly identify and manage myopathy. If accurately diagnosed, no generally accepted, clear, stepwise treatment plan exists for the management of muscle symptoms due to statin use. Objective: The purposes of this report were to: (1) review published descriptions of myopathy to clearly define the range of statin-induced muscle symptoms to facilitate identification and treatment of statin myopathy, (2) prepare from these reports educational tools and a pocket guide to aid the clinician in the diagnosis and treatment of statin myopathy, and (3) evaluate the clinical use of these tools and guide. Methods: A comprehensive review of statin myopathy literature published from 2000 to 2006, including clinical trials, case studies, review articles, and the FDA AER system, was performed. The educational tools and pocket guide were critically reviewed by 27 physician assistant graduate candidates and four clinically experienced PA faculty. Results: The three educational tools prepared in the study included: (1) a risk assessment table, (2) a chart of concomitant medications, and (3) a decision tree diagram. The risk assessment table proposed categories to assist clinicians in more accurately identifying patients at high risk of developing myopathy. The chart of concomitant medications was modified from previous publications of CYP inducer/inhibitor charts for increased clarity. The decision tree was constructed from multiple sources to provide management recommendations for statin myopathy. The pocket guide was devised to provide an easily accessible, efficient plan to diagnose and treat statin myopathy. The overall usefulness of the tool on a Likert scale was rated as a 6.9/10 by the PA graduate candidates and 9/10 by the faculty. Discussion: No prior study has suggested a stepwise tool for the management of statin myopathy. Conclusion: Historically, statins have proved to be efficacious and safe in monotherapy, but concern about the risk of myopathy and its management continues to challenge physicians. This study produced educational materials and a pocket guide to provide clinicians with simple, clinically useful tools to better diagnose and treat statin myopathy.
48. Does a Correlation Exist Between the Number and Type of Clinical Encounters and NCCPA PANCE Scores?
E. Min, H. Comstock and B. Dickey, Rosalind Franklin University of Medicine and Science, Physician Assistant Program, North Chicago, Illinois
Purpose: The purpose of this study is to investigate whether the number and type of clinical encounters a second-year physician assistant student has during his or her clinical year will affect board examination scores. Background: Little research has been performed on a possible correlation between the number of clinical encounters and Physician Assistant National Certification Examination (PANCE) scores, though other comparisons have been studied to determine PANCE performance. Written and computer-based objective tests have been created in similar form to PANCE, thereby allowing for predictive PANCE performance. Students who excel on the written examination after their didactic year were likely to do so on the end-of-rotation examinations throughout their clinical year. PANCE results have been shown to strongly correlate with the end-of-rotation examination scores. Because programs track clinical encounter information, it is beneficial to see how these loggings may be linked to PANCE performance. Methods: Clinical encounters will be totaled per student for the six required rotation sites. The encounters are divided up in to several specific categories that parallel the NCCPA breakdown of PANCE performance. This data will be entered into an Excel spreadsheet along with their corresponding PANCE scores. Statistical analysis will compare group means by analysis of variance for repeated measures. P values less than 0.05 will be considered significant. Results: The hypothesized results are that there is a positive correlation between numbers of clinical rotation encounters to higher PANCE scores. Conclusions: Determining whether a significant correlation exists between the number of clinical encounters and performance on PANCE would be of great benefit to physician assistant programs and students. It would enable programs to designate a rotation schedule that would most predict success on the board examination.
49. Effect of Educational Materials on Patients' Ability to Recall Medication Regimens and Compliance.
A. Frakes and A. Brenneman, University of Iowa Physician Assistant Program, University of Iowa Carver College of Medicine, Iowa City, Iowa
Purpose: To investigate the effect of educational material on patients' ability to recall their medication regimens and compliance. Methods: Patients were given a survey asking them to recall their medication regimens and how often they forget to take their medications. The patients were randomly placed into the control or experimental group. The experimental group was given cards containing information regarding the names of their medications, dose, schedule, and indication for use. A follow-up survey was given six weeks later. Results: Twenty surveys were given initially, with four patients choosing not to take the follow-up survey. The average age of the patients was 68 (range 41-86), with 10 females and 10 males participating. They were taking an average of five medications. At baseline, the patients correctly recalled 70% of the medication names, 28% of the doses, 78% of the schedules, and 88% of the indications. The control group correctly named 75% of their medications at baseline and 85% in follow-up. The experimental group recalled 66% of their medications correctly at baseline and 68% at follow-up. Data was also collected for each group at baseline and in follow-up regarding dose, schedule, and indication for use. Patients' answers did not change from baseline to follow-up regarding how often they forget to take their medications. Females correctly recalled 92% of their medications at baseline versus 49% for the males. Conclusions: Medication cards do not seem to improve patients' ability to recall their medication regimens or compliance. Some of the results may be due to the randomization of the patients, which did not assign patients into groups based on sex, age, or previous knowledge of their regimens. This study demonstrated that women were better able to recall their medications than men. The results of the study may have been affected by this because the control group had seven women and three men, while the experimental group had three men and seven women. It was also difficult to assess compliance because the results were based on patients' being truthful and not an objective measurement.
50. 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, Baylor College of Medicine, Houston, Texas
Introduction: Physician assistants are increasingly involved in the provision of health care in the United States. The early mission of the PA profession was to expand primary care services, especially in underserved areas. Today, that role has expanded to involve most specialties and subspecialties in medicine. As a relatively young profession, expansion into the surgical disciplines has been fairly recent, as has the utilization of PAs in emergency medicine (EM). Efforts to understand the attitudes and opinions of physicians about PAs have, for the most part, focused on understanding the perceptions of physicians in primary care settings. Earlier surveys suggest that physicians view PAs as playing important roles in health care delivery. They reduce the workload and patient waiting time while providing cost-effective care. In relationship to the delegation of emergency procedures to PAs, primary care physicians and surgeons indicated being somewhat uncomfortable doing so. The extent to which EM physicians view the PA's ability to function in the emergency department (ED) setting is not known. With some 10% of all PAs in active clinical practice providing health care services in the ED setting, it is paramount to understand the attitudes and beliefs of EM physicians about PAs in the ED setting. Purpose: The purpose of this study was to determine EM physician knowledge of PA education and professional issues and to examine the opinions of EM physicians regarding the PA skills, duties, utility, cost-effectiveness, and capability in the ED setting. In addition, we hoped to demonstrate that EM physicians' confidence in a PA's skills, abilities, and utility increases as the number of years in practice supervising a PA in the ED setting increases. Methods: A 19-question survey was mailed to 960 EM physicians in Texas, with a 29% return rate (N=280). Statistical analysis was done on the survey responses to gain an overall understanding of EM physician opinion of the use of PAs in the ED setting. Results: The majority of EM physicians had experience working with PAs in the ED setting, but reported having poor understanding of PA education and professional issues. EM physicians believe PAs are useful, cost-effective, and capable in the ED setting. EM physicians' confidence in PA's skills, abilities, cost-effectiveness, utility, and capability increased the longer they worked with PAs and the more knowledge they had regarding PA education, training, and professional issues. Conclusions: While most EM physicians in Texas have worked with and supervised a PA in the ED setting, their knowledge regarding PA education, training, and professional issues was surprisingly low. EM physicians reported confidence in the PAs' abilities and skills and believed that PAs were useful, cost-effective, and capable in the ED setting. These results underscore the need for increased efforts to educate physicians about PA education, training, and professional issues.
51. Evaluation of International Adoptive Collaborative Training.
C. Haller, T. Mai Houston, B. Prince, A. Vo, and B. Biearman, Chatham College, Pittsburgh, Pennsylvania
Purpose: International adoption is fraught with issues surrounding appropriate child development, unusual medical events, and attachment disorders. International adoption agencies have multiple training programs for parents before they adopt a child; however, there is no true standardized format or style of training. The purpose of this study is to evaluate the efficacy of an international adoptive collaborative training (IACT) program developed to educate adoptive parents about these concerns. Methods: Interested potential adoptive parents were invited to participate in an education program designed by a pediatrician who specializes in international adoption and four second-year physician assistant students. The IACT programs addressed the topics of unusual medical events, attachment disorders, and development issues. Knowledge and perceptions will be evaluated by survey at the beginning and end of each session. Each session will have two classes, one in the fall and one in the spring. The pre and post scores will be compared by t-test to determine the efficacy of the IACT program. Results: Although the program is ongoing and data collection is continuing, we anticipate that the participants' scores will improve significantly after the training session. We anticipate that the majority of the participants will be satisfied with the training and be more cognizant of their adopted child's needs. Conclusion: Through our evaluation of the IACT, it is likely that parents will benefit significantly with the educational sessions by improving their knowledge concerning medical, attachment, and developmental issues in international adoptions.
52. Factors Influencing a Woman's Decision to Breastfeed.
K.Pauze, M. Kourtz, J. Streich, K. Wai, and B. Biearman, Chatham College, Pittsburgh, Pennsylvania
Purpose: The number of women who breastfeed has increased dramatically in the United States over the past 30 years. Research has allowed for documented benefits of breastfeeding, such as fewer episodes of infant illness, improved cognitive development in low birth weight infants, and reduced risk of eczema and asthma. In addition, breastfeeding is connected with decreased uterine blood loss and a strengthened bond between infants and mothers. Still, factors such as resources and various medical conditions may inhibit certain groups from choosing to breastfeed. The purpose of this study is to fully understand the factors that determine whether a woman will breastfeed or not breastfeed, and whether or not those factors differ among various races, socioeconomic groups, and education levels. Methods: The population for this study consisted of pregnant women at multiple obstetrics and gynecology offices. The participants were given a survey querying race, income level, and education level. Participants were asked to rank the factors that have played a role in their decision to breastfeed using a 1 to 5 scale, one being least influential and 5 being most influential, as well as a not applicable choice. The level of importance was compared for each factor. Data analysis will be performed by chi square and t-tests to determine what factors are important in which groups. Results: The following are anticipated results as data collection is ongoing. The factors that have the most influence on a woman's choice to breastfeed are expected to be the health benefits for the child, the cost of formula, and prior experiences with breastfeeding. It is expected that fewer women of minority groups will choose to breastfeed than Caucasian women. It is expected that women of lower socioeconomic classes are less likely to breastfeed than those of higher socioeconomic classes. Conclusions: This study is important because it will provide further insight as to why women choose breastfeeding versus bottle feeding. While certain trends have been studied regarding the frequency of breastfeeding among various races and socioeconomic groups, little has been reported regarding why women choose breastfeeding. The results of this study can be used in the development of patient education programs as well as to provide a better level of understanding between health care provider and patient.
53. How Physician Assistants Use Evidenced-based Medicine in their Clinical Practice.
M. Behr, C. Jordan, J. Olsen, and K. Seelman, Chatham College, Pittsburgh, Pennsylvania
Purpose: The purpose of this study was to evaluate how physician assistants use evidenced-based medicine (EBM) in their clinical practice. EBM was created based upon the idea that more information is needed to solve a clinical problem. It is the practice of searching for additional up-to-date information to be utilized in problem solving. EBM is a process. It begins with utilizing primary resources for a particular clinical problem. Once the research has been accomplished, the practitioner must then ascertain whether it is applicable to their specific patient and problem for optimal patient care. Methods: The population studied consisted of physician assistants at a 2006 state physician assistant society. The subjects volunteered to complete a 25-question survey inquiring about their use of EBM in clinical practice. The questions focused on the association between males versus females and their respective use of EBM, how years of clinical experience correlate with EBM use, which specialty uses EBM the most, how physician assistants' knowledge of EBM correlates with the use of evidenced-based medicine, and what barriers physician assistants find when integrating EBM into patient care. While data collection is complete, analysis is ongoing at this time. Chi square, Fisher Exact test, and frequency distribution will be used to evaluate changes within and between groups. Results: Results for this study are currently pending. It is anticipated that females will utilize EBM more, that new graduates will be more likely to use EBM rather than physician assistants who have been practicing for greater than 10 years, that specialties that involve surgery will be more likely to use EBM, and that physician assistants that use EBM do not necessarily know the correct EBM terminology. In addition, barriers that physician assistants find when integrating EBM into patient care will be evaluated. Conclusions: There have been no studies conducted on how physician assistants use EBM in their clinical practice. However, research has shown that health care professionals in several specialties are utilizing EBM. It is often used as a teaching method for medical students. EBM can be obtained from various sources such as medical journals, the Internet, conferences, and through independent research. It should be implemented in the diagnosis and treatment of patients resulting in better and more efficient patient care.
54. Perceptions of Medical Research Education in Physician Assistant Programs.
K. Angelo, M. Ressler, T. Weber, J. Wackowski, and B. Biearman, Chatham College, Pittsburgh, Pennsylvania
Purpose: When in clinical practice, it is of utmost importance to stay abreast of current medical literature. It is necessary for the savvy clinician to be able to critique and evaluate the applicability of the large number of studies inundating health care. Unfortunately, the skill of critical reading does not always come naturally and must be taught and practiced. Research shows that only 20% of medical residents will complete a formal hypothesis-driven research project. Additionally, 44% stated that lack of research education in their curriculum was proving to be a barrier to completion of their research projects. Therefore, since physician assistant programs are modeled similarly to medical school education, we decided to assess the perceived effectiveness of research education in physician assistant programs throughout the state. Methods: A survey was distributed at an annual state physician assistant conference by four second-year physician assistant students. Subjects were queried as to whether or not research education was part of their PA program, was a research project completed, current/past participation in clinical research, and what methods are utilized to remain knowledgeable of current medical research. Chi square analysis will be used to evaluate differences between and among groups. Results: The results of this research are pending due to ongoing data analysis. Preliminary findings indicate that the presence of research education in the curriculum as well as completion of an actual research project are strong predictors of those who will be involved in future research. Barriers to participation in job-related research projects are currently being analyzed, but we suspect lack of time as well as funding will be among the most common. Conclusions: It is expected that the data will continue to demonstrate that research education in PA programs is a significant factor that will determines a practicing PA's likelihood of involvement in future medical research. It is also expected that those with formal research education will take on more pivotal roles in the research process itself. If barriers can be identified and addressed, it is likely that physician assistants will become more active participants in the clinical research process. Formal medical research education is a valuable tool that not only teaches future PAs to critically assess the current medical literature, but may also lead to increased involvement in medical research.
55. Physical and Physiological Changes Observed Following the Lap-band Surgical Procedure.
M. Nye, R. Simper, O. Chen, and L. Hill, University of Texas Health Science Center, Fort Worth, Texas
Purpose: This study described specific physical and physiological changes found following the lap-band procedure. The changes evaluated were: blood glucose (BG), triglycerides (TG), high density lipoprotein (HDL), low density lipoprotein (LDL), body mass index (BMI), and blood pressure (BP). Discontinuations or decreased dosages in any anti-hypertensive, anti-lipidemic, or diabetic medications were also observed. Method: The study was conducted as a retrospective chart review. The charts reviewed were taken from two surgery clinics in Fort Worth, Texas. Approximately 30 percent of the charts were randomly selected. The final group of 51 was based on those meeting the inclusion criteria: at least one year postop, over 18 years of age, and the variables must have been completed during the peri-surgical appointment as well as the six-month and/or one-year post-surgery. ANOVA was used to analyze the recorded data. Results: The majority of the patients were middle-aged Caucasian females. Data showed that there were significant differences in BG, BMI, and HDL. BG and BMI had reduced and HDL had increased. Data also showed that TG and SBP had decreased and that LDL and DBP had increased, but these variables did not show significant differences. The study also revealed reductions and discontinuations of anti-lipidemic, hypertensive, and diabetic medications. Data showed a 22% reduction or discontinuation in lipid lowering prescriptions, a 50% reduction or discontinuation in hypertensive prescriptions, and a 62% reduction or discontinuation in diabetic medications. Conclusion: This project provides clinical and literary evidence that supports the lap-banding procedure for assistance in the management of the obese patient with comorbidities such as diabetes, hypertension, and hyperlipidemia. The results of this study showed that there were significant improvements in the levels of HDL, BG, and BMI, and that there were minimal changes in TG, LDL, and BP levels. However, it is important to recognize that reductions in medications will alter lab values masking or lessening the actual effect that the surgery had on these variables. The benefits of this procedure extend beyond one year. A future study could extend the data collection over a longer time span, perhaps two or more years.
56. Physician Assistant Knowledge and Adherence to Cardiovascular Disease Prevention Guidelines: A Pilot Study.
L. Blair, W. Insull, and C. Fasser, Baylor College of Medicine, Houston, Texas
Introduction: Cardiovascular disease (CVD) is the leading cause of death in the United States. Many studies conducted on CVD have found that women receive suboptimal CVD preventive care compared to men. A recent study of physician adherence to CVD prevention guidelines showed physicians had modest use of guidelines. The study concluded that educational interventions for physicians were needed to improve the quality of CVD preventive care. Purpose: As physician extenders, physician assistants can perform CVD diagnosis, treatment, management, and prevention. Therefore, the current role of the PA in CVD preventive care needs to be evaluated. Objectives: The primary objective was to determine PAs' knowledge and adherence to CVD prevention guidelines. The secondary objective was to evaluate two potential sources of PAs' bias in their application of these guidelines: patient gender and PA specialty bias. Methods: A stratified random sample of 52 PAs in the areas of general/family medicine, internal medicine, cardiology, and obstetrics/gynecology were administered an on-line survey. The survey included 10 patient cases and questions regarding the relationship between the PA and his or her supervising physician. Descriptive statistics analysis was made using SAS software. Results: PAs reported being exceptionally aware of the guidelines (86.54%-94.23%). Of the 52 respondents, 55.77% correctly classified >7 of the 10 patient cases. PAs in cardiology appeared more likely to classify the patient cases correctly (OR=2.13) and PAs in ob/gyn appeared less likely to classify the patient cases correctly (OR=0.57) than PAs in PCP. A non-statistically significant trend was seen in which 71.15% of the PAs classified the male intermediate risk cases correctly and 57.69% classified the female intermediate risk cases correctly (p=0.15). Of the low and intermediate risk cases, patients were treated more aggressively if the patient was classified incorrectly. Less than one-fourth of the respondents correctly identified the optimal HbA1c level as <7% and approximately one-third identified the optimal fasting plasma glucose (FPG) as <100 mg/dL. When asked on a 10-point Likert Scale, PAs did not strongly agree that more women than men die each year of CVD (mean 6.19). According to the respondents, 78% stated that the PA alone performs the majority of patient education and 67% reported that the PA, compared to the physician, utilizes the guidelines more regularly. Conclusion: PAs were not accurate in their classification of CVD risk. This misclassification of risk appeared to lead to more aggressive therapy for patients than recommended. PAs used the appropriate CVD prevention medications but had difficulty identifying optimal glycemic goals. The PA perception was that PAs were primarily responsible for the patient education in their practice and utilized the guidelines more regularly. A gender-specific barrier to CVD prevention may also exist. These indicate that improved PA education is needed at both the PA program level and postgraduate level. This pilot study should be replicated to determine which trends are statistically significant and generally applicable to PAs nationally.
57. Practicing Physician Assistant Awareness of ATP III Cholesterol Guidelines.
K. Malone, K. Beck, J. Blakeslee, and L. Martin, Chatham College, Pittsburgh, Pennsylvania
Purpose: In developed countries, atherosclerosis is the major cause of death and premature disability. Abnormal plasma lipoproteins are one of the most firmly established and best described risk factors for atherosclerosis. The current guidelines regarding cholesterol screening, risk factors, and treatment are set forth by the National Cholesterol Education Project (NCEP) Adult Treatment Panel III (ATP III), which is associated with the National Institutes of Health. Thus, it is essential that clinicians be familiar with these guidelines in order to provide optimal patient care. Physician assistants play a direct role in patient care and often manage routine visits where cholesterol screening and discussion of risk factors take place. Therefore, it is essential that PAs are informed of the newest guidelines for high cholesterol detection and treatment so that patients at risk for coronary heart disease can be identified and managed in a timely and appropriate manner. This study aims to determine practicing PAs' awareness of the ATP III guidelines. Methods: The population of this study consisted of certified, practicing PA volunteers from the classes of 1997 through 2006 of one PA program, as well as certified, practicing PA volunteers from the 2006 state physician assistant conference. Participants were requested to fill out a multiple choice 20-question survey. The survey consisted of various questions pursuant to demographics, as well as questions to test basic knowledge of the ATP III Guidelines. The survey was designed to test the participants' knowledge of current guidelines pursuant to risk factors, screening, and management recommendations for hypercholesterolemia. Analysis of survey data will include frequencies of survey answers and cross-tabulations involving the chi square test to determine a significant relationship between two variables (or survey questions). Relationships will be summarized by presenting response percentages for questions on the survey. In addition, general familiarity with the subject of cholesterol guidelines will be assessed by determining the number of participants scoring a 64% on the knowledge testing portion of the survey. Results: Currently, the results of this study are pending as survey collection and analysis are ongoing. Preliminary results indicate that practicing PAs are generally not knowledgeable regarding the current cholesterol guidelines as set forth by the ATP III. In addition, we plan to examine determinants of knowledge such as gender, race, age, years in practice, geographic area of practice, and practice specialty. Conclusions: There have been no studies conducted to determine the knowledge base of practicing PAs pursuant to the ATP III cholesterol screening guidelines. When PAs are informed concerning the newest guidelines for high cholesterol detection, evaluation, and treatment, they can then identify patients at risk for coronary heart disease and provide more efficient instruction concerning treatment and cholesterol goals. Awareness and early intervention are the keys to changing the epidemic of high cholesterol in this society; for this reason, knowledge of the ATP III guidelines is imperative.
58. The Bird Flu: How Aware Are You?
K. Czekanski, B. Brancazio, W. Stein, and B. Biearman, Chatham College, Pittsburgh, Pennsylvania
Purpose: Avian influenza is becoming an increasing threat worldwide due to its virulence and transmission between migratory birds, between birds and certain mammals, and between birds and humans. As of November 13, 2006, there were 258 known human cases of avian influenza. There is great fear that the influenza A viral strain H5N1 may become pathogenic and that human-to-human transmission may occur. The World Health Organization desires to vaccinate approximately six billion people worldwide for prevention of the next possible influenza pandemic caused by avian influenza. Therefore, this study serves to determine the knowledge base of the general population in a metropolitan area regarding avian influenza. Methods: The population for the study consisted of any individual age 18 years or older in a metropolitan area of any educational level who were willing to complete the survey. The populations not included were those individuals currently or previously employed in any health care profession or those currently studying to obtain a degree in the medical field, including M.D., PA, or RN. The first section of the survey included questions regarding the participants' age, gender, race, highest level of education completed, current and previous work in a health care profession, and current studies to obtain a medical degree. The subsequent section included questions concerning avian influenza with seven questions related to epidemiology/transmission of avian influenza; three related to demographics associated with avian influenza outbreak; two related to signs/symptoms of avian influenza; one related to treatment of avian influenza; six related to vaccine/prevention of the avian influenza; and one question related to preparation for avian influenza outbreak. All study participants were given an educational brochure, comprised of current facts regarding avian influenza, including the correct answers to questions asked on the survey. Chi square and paired t-tests will be utilized to evaluate differences in subgroups. Results: The results of the study are currently pending, as the distribution, collection, and analysis of data is ongoing. It is anticipated that the general community is not aware of basic information regarding the avian influenza or may be misinformed, and thus unprepared, in the event of an avian influenza pandemic. Conclusions: There have been no studies in the literature that determine the knowledge base of the general population regarding avian influenza. There is worldwide concern and fear of the possibility of an avian flu pandemic. This concern has resulted in the World Health Organization's desire to vaccinate billions of people worldwide and prevent such a pandemic. Therefore, it is important to determine whether the general population will be prepared to minimize transmission and complications in the event of an avian influenza outbreak.
59. The Relationship between Asthma and Obesity.
J. Oliveira, S. Shapiro, and N. Hadi-Nahavandi, Seton Hall University, South Orange, New Jersey
Purpose: The purpose of this study is to determine if there is a relationship between Body Mass Index (BMI) and diagnosis of asthma in children ages 4-12. Methods: This study is a retrospective chart review analysis comparing Body Mass Index (BMI) in asthmatic and non-asthmatic children. Two hundred charts will be collected of both male and female children ages 4-12. The charts will be divided into two groups. Group one will consist of 100 charts with a diagnosis of asthma within the last two years. Group two will be the control group and include 100 charts of healthy non-asthmatic children. Asthma is defined as recurrent episodes of airway obstruction characterized by wheezing and inflammation of the airway that resolves spontaneously or as a result of treatment. Body Mass Index (BMI) will be calculated using the following formula: BMI=weight (in pounds) multiplied by 703, divided by height squared (in inches). Children with BMI of 29 or more will be considered obese and children with BMI of 28 or less will be considered non obese. Using two by two contingency tables, children with and without asthma will be cross-tabulated with BMI. Chi square analysis will be performed to determine if an association between asthma and BMI exists. Analysis will be performed using Statistical Package for the Social Sciences. Results: A positive correlation between increased BMI and a diagnosis of asthma is expected. Conclusions: Current literature suggests there is a positive association between obesity and the diagnosis of asthma. Analyzed data from the Tucson Epidemiologic Study of Airway Obstructive Disease and found that pre-obese and obese women (BMI < 28) are at increased risk of acquiring asthma. A large prospective study of women concluded a high BMI is significantly related to the risk of asthma incidence and that an increase in body silhouette between menarche and adulthood is related to the incidence of asthma later in life. The fact that the relation between BMI and asthma prevalence and incidence is restricted to women and persists after adjustment for potentially confounding factors, such as physical activity and dietary intake, suggests that other factors may play a role in the causal pathway, such as female hormones. Excess body fat is a major health problem affecting millions of people worldwide, especially in the United States. The American Obesity Association reports about 15.5 percent of adolescents (ages 12 to 19) and 15.3 percent of children (ages 6 to 11) are obese. Asthma is another common chronic disorder currently affecting an estimated 6.2 million children under 18 years of age, as reported by the American Lung Association. The National Health and Nutrition Examination Survey III estimated the prevalence of obesity increased from 18% to 23% (1988-1994) to an estimated 27% (1999); and asthma prevalence has increased from 31 to 55 per 1,000 between 1980 and 1994. An increasing body of evidence suggests that obesity is an important determinant of asthma. If results of the study reveal a positive correlation between asthma and obesity, preventive measures can be taken to decrease weight in obese and overweight children, thereby preventing or decreasing the incidence of asthma.
60. Weeble Wobble Study: Infant Weight Gain Patterns in a Private Pediatric Setting.
J. Buckweitz, H. Holloway, B. Kanani, and E. Mandel, Seton Hall University, South Orange, New Jersey
Objective: The goal of this study is to evaluate infant weights between birth and one year of age, as measured in a private urban pediatric clinic, and compare these weight patterns to the previously held expectations (as per established pediatric references) that infants should double their birth weight in five to six months and triple in a year. Methods: We will conduct a retrospective chart review examining infant weight gain relative to age. We will include healthy infants with recorded weights for birth, four months, six months, and one year of age. We will then compare these weights for age to the projected guidelines using SPSS 14.0. Anticipated Results: We anticipate that infant birth weights will not be consistent with the published weight gain guidelines. We predict this population of infants will double and triple their birth weights significantly earlier than the five- to six-month and one-year references. Conclusions: Obesity is at record high levels in adults and children and the infant population should also be scrutinized for excessive weight gain. If babies are doubling and tripling their birth weights at an earlier age, further research should be conducted to look at issues regarding changes in the weight trends as well as the possible long-term effects on child and adult weights. Some areas of possible influence include ethnicity, socioeconomic status, home care versus daycare setting, sources of nutritional intake, feeding patterns, and habits. Addressing infant weight gain and normative values with parents may help fend off a lifetime of being overweight or obese and poor eating habits.
61. Weight Loss and Perceived Improvement in Comorbidities and Psychological Well Being in Lap-band Recipients.
S. Melville, L. Gonzales, O. Chen, and L. Hill, University of Texas Physician Assistant Studies Program, Fort Worth, Texas
Purpose: The purpose of this study was to investigate outcomes of Lap-band surgery focusing on recipients' weight loss, their perceived improvement of five comorbid conditions, and psychosocial well being. Comorbid conditions included: high blood pressure, diabetes, high cholesterol, osteoarthritis, and gastroesophageal reflux disease. Psychosocial well being was measured using statements that gauged perceived improvements in self image, societal acceptance, and overall happiness. Method: A cross-sectional survey design was used in this study. Lap-band recipients from the University of North Texas Surgery clinic, who were 18 years at the time of surgery and had their surgery between January 2002 and March 2005, were eligible to be included in this study. A total of 254 Lap-band recipients met the inclusion criteria and were invited to participate in the study. A 10-question survey was developed by the researchers and pilot tested before mailing. The survey was sent a second time only to those potential respondents who had not yet replied. SPSS (12.0) was used to perform statistical analyses. Results: A total of 102 surveys were completed and returned (43.8% response rate). Most of the respondents were: Caucasian (90%), female (78%), between 36 and 55 (69%), and college-educated (50%). Respondents, on average, lost 54.21% of their excess weight after lap-band surgery and reported significant improvement in high blood pressure (x2=149.35, p<.001), diabetes (x2=90.35, p<.001), high cholesterol (x2=134.18, p<.001), osteoarthritis (x2=75.92, p<.001), gastroesophageal reflux disease (x2=114.88, p<.001), as well as improvement in psychosocial well being (x2=69.18, p<.001) when compared to their status prior to lap-band surgery. Respondents also reported improvement in additional health conditions after having lap-band surgery, including: muscle/joint pain (96.88%), sleep dysfunction (90%), psychosocial impairment (85.71%), fatigue (100%), respiratory dysfunction (100%), and mobility impairment (100%). Results showed that correlations between weight loss and perceived high blood pressure improvement (r=.347, p <.005), between weight loss and high cholesterol improvement (r=.382, p<.002), as well as between weight loss and perceived improvement in psychosocial well being (r=.341, p<.001) had reached statistical significance. Correlations between perceived improvement in psychosocial well being and two comorbidities: high blood pressure (r=.279, p<.027) and high cholesterol (r=.316, p <.010) also had reached significance; however, correlations between diabetes, osteoarthritis, and gastroesophageal reflux disease with weight loss or psychosocial well being did not reach statistical significance. Conclusion: The results of this study showed that the extent of weight loss following lap-band surgery is predictive of patient's perceived improvement. The more weight respondents lost, the greater improvement in blood pressure, cholesterol, and psychosocial well being they reported. Routine evaluation and dialogue with clinicians, as well as a reduction or discontinuation of certain medications, were events that likely contributed to the respondents' perception of improvement in their comorbidities. The evaluation of medical charts is recommended for future studies in an effort to render more objective data.
62. 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. Bourne, Loma Linda University, Loma Linda, California
Purpose: The objectives of our study were (1) to examine young adults' attitudes, intentions, and behaviors regarding skin cancer, and (2) to determine the motivating factors that play a role in reducing skin cancer incidence in high-risk young adults in southern California. Methods: Fifty-one subjects, ages 19-30 years and literate in English, were included in the study. The instrument used in this study was a survey. Results: There was a significant relationship between educational level and tanned skin appeal (p=<.01). Thirty-eight percent of the respondents with high school or less education had a high appeal for tanned skin compared to 5.7% of the respondents with more than high school education. Regarding sun protective behavior, 66% of females reported using sunscreen compared to 37% of males (p=.04). Conclusion: Our research suggests the need to educate young adults that skin cancer can be a fatal disease and that it is caused by cumulative exposure to the sun before the age of 30. Providers should promote the importance of skin mapping and skin self-exams on a regular basis.
Case Studies/Clinical Reports
63. A Case of Congenital Iisolated Hemihypertrophy in a Seven-year-old Male.
J. Palermo and A. Essary, Midwestern University of Physician Assistant Program, Glendale, Arizona
Purpose: This describes a case of congenital isolated hemihypertrophy (IHH), a rare condition of unknown etiology manifested by unilateral localized or generalized asymmetry of the body. Patients are at increased risk for certain cancers and require monitoring by a multidisciplinary team. Methods: A seven-year-old white male presents with his maternal grandmother for an ultrasound of the abdomen and a referral to a pediatric orthopedist for congenital isolated hemihypertrophy. He was diagnosed with hemihypertrophy with leg length discrepancy as an infant. His right calf, arm, and the right side of his tongue are greater in size compared to his left side. The patient had previously seen an orthopedist for follow-up care and abdominal ultrasounds every six months to evaluate for tumors. The patient has been without health insurance for three years, and has not received follow-up care. His grandmother reports no pathology on prior ultrasounds. Past medical history is remarkable for a history of pertussis and recurrent ear infections. The pregnancy was complicated by blood transfusions and hyperemesis. He was born at approximately 39 weeks gestation, weighing 4 pounds, 7 ounces. He had low blood sugar and difficulty feeding and was in the NICU for 7-10 days. His immunizations are current. On physical examination, the right side of his tongue is slightly larger than the left. Hemihypertrophy is noted on extremity exam with the following measurements: Right calf, 10 in. Left calf, 9 in. Right ankle, 8 in. Left ankle, 7 in. Right wrist, 7 in. Left wrist, 6 in. Measurement of right hip to ankle is 24 in. and left hip to ankle is 24 in. No motor weakness noted. Abdominal examination reveals a soft, non-tender abdomen with normal bowel sounds and no masses or hepatosplenomegaly. Abdominal ultrasound reveals that the right kidney is slightly enlarged (10.5 cm in length) vs. the left kidney (8.7 cm in length). A mild splenic prominence of unknown significance is also noted. Results: The pediatrician recommends multiple specialty referrals, including a nephrologist, a geneticist, and a pediatric orthopedist. Conclusion: Hemihypertrophy may be associated with Beckwith-Wiedemann syndrome, Klippel-Tranaunay-Weber syndrome, neurofibromatosis-1, or Proteus syndrome. Less commonly, hemihypertrophy can be a remote finding (isolated hemihypertrophy). Due to a lack of diagnostic criteria, the incidence of IHH ranges from 1 in 13,000 to 1 in 86,000. The cause of IHH is relatively unknown but thought to be attributed to chromosomal abnormalities or over-expression of insulin-like growth factor-2. With IHH, patients have an increased risk (6%) of abdominal cancers, most commonly a Wilms tumor. Thus, it may be prudent to periodically screen for abdominal carcinomas via abdominal ultrasound. Additionally, some reports recommend periodic screening for hepatoblastoma with alpha fetoprotein (AFP). Involving a multidisciplinary team, including an orthopedist and a geneticist, is crucial in the evaluation and management of the patient with IHH.
64. A Case of Esophageal Herpes Simplex Virus Type 1 in an Immunocompetent 21-year-old Male.
S. Bolander, L. Ritter-Baker, and B. Coplan, Midwestern University of Physician Assistant Program, Glendale, Arizona
Introduction: Herpes simplex virus (HSV) is a common infection; however, esophageal HSV is rare in the immunocompetent patient and, therefore, may be difficult to identify. This case illustrates a typical presentation of primary esophageal HSV in an immunocompetent patient and discusses the testing required to confirm the diagnosis. Case Report: The patient was a 21-year-old male who presented to the emergency room with a two-day history of fever, malaise, and epigastric pain. The patient had recently returned from Argentina and was concerned that he may have contracted an illness. He described the epigastric pain as a constant ache that radiated to the chest and was exacerbated by eating. He denied shortness of breath, nausea, vomiting, diarrhea, melena, or hematochezia. The patient was taking acetaminophen and ibuprofen for his presenting symptoms. He admitted to smoking a half pack of cigarettes a day and to drinking multiple alcoholic beverages three to four times a week. Previously, the patient had been in good health, and his past medical history was non-contributory. On physical examination, the patient's temperature was slightly elevated at 99.4 degrees. He appeared uncomfortable but in no acute distress. Palpation of the abdomen revealed generalized epigastric tenderness and some voluntary guarding. The exam was otherwise unremarkable. Diagnostic testing in the emergency room included a chest x-ray, abdominal ultrasound, and a routine complete blood count and comprehensive metabolic panel. The ultrasound revealed slight hepatomegaly. The chest x-ray and laboratory studies were normal. The emergency room physician made a presumptive diagnosis of Helicobacter pylori infection or gastroenteritis, which may have been exacerbated by alcohol consumption and cigarette smoking. She prescribed famotidine and advised the patient to take aluminum hydroxide/magnesium hydroxide/simethicone (Maalox) liquid as needed. She also instructed him to follow-up with his primary care provider the following day. Subsequently, the patient developed severe odynophagia. The pain radiating from the distal esophageal region to the epigastrium persisted, while his fever and malaise resolved. One day after the emergency room visit, the primary care provider obtained an immediate referral to a gastroenterologist. Based on the history, the gastroenterologist assigned a presumptive diagnosis of esophageal ulcer secondary to HSV or pill injury. She performed an esophagogastroduodenoscopy (EGD) with biopsies on the same day that the patient was evaluated. The EGD revealed esophagitis with multiple discrete coalesced ulcerations consistent with HSV. The gastroenterologist prescribed famciclovir, a "GI cocktail" and narcotic pain medication, to treat the patient. He recovered without complications.
65. A Case of Hyperbilirubinemia: A Search for the Less Obvious.
M. Miller and M. Statler, Midwestern University Physician Assistant Program, Glendale, Arizona
When a patient presents with jaundice, abdominal pain, and hyperbilirubinemia, the most common etiology is secondary to biliary obstruction. When no obvious source is found during the diagnostic work-up, less obvious sources must be explored with diligent pursuit of the medical history. A 36-year-old, non-obese Caucasian male inmate is admitted with a seven-day history of generalized abdominal pain and five days of nausea and vomiting. At the time of admission, the patient is jaundiced; sclera are anicteric initially, but become icteric by day three. The patient denies any fever, chills, shortness of breath, or chest pain. The initial physical exam is unremarkable except for tenderness to palpation in the RUQ and epigastric region along with an equivocal Murphy's sign. There is no rebound or guarding present. The patient reports no prior episodes. The patient's current medications include promethazine, albuterol, flunisolide, loratidine, and QVAR. His past medical history is significant for asthma and tobacco abuse. Patient quit smoking one month ago. HIV, Hepatitis B, and C tests, all done one month ago, were negative. The following admission labs revealed: total bilirubin 10, alkaline phosphatase 278, AST 86, ALT 257, lipase 224, and Tylenol level <2. The UA was positive for the presence of bilirubin. The initial work-up included a normal EKG, a negative portable chest x-ray, RUQ ultrasound showed a contracted gallbladder with no evidence of cholelithiasis. A HIDA scan suggested a common bile duct obstruction or acute hepatitis. Subsequent MRCP, ERCP, EGD, and follow-up ultrasounds and CT scans were negative. CBC, coagulation panel, and ANA was normal; hepatitis serology was negative as well. A liver biopsy showed evidence of cholestasis but no necrosis or hepatitis. These results cast serious doubt on a biliary or hepatic source of the hyperbilirubinemia. The patient's total bilirubin continued to climb until it peaked on day 25 at 23.4 mg/dL. The only causes that were not completely ruled out at this point were metabolic, such as Gilbert's syndrome. No testing was done to determine if there was a metabolic cause as his bilirubin levels began to decline. During the evaluation, the patient developed three MRSA-positive abscesses on his buttocks, which were surgically drained and packed. While being treated for the abscesses, the patient seemed to exaggerate his pain symptoms and demonstrated an excessive need for pain medications. With further questioning, the patient disclosed a prior history of abusing prescription narcotics, taking "60 Vicodin" a day for an undisclosed amount of time. He also admitted to taking about 13 325mg Tylenol tablets a day for several weeks at the prison prior to his admission. Acetaminophen is considered hepatotoxic when taking 10-15 grams/day. If this patient consistently took the above amounts of medication, he would have taken the equivalent of 30 grams of acetaminophen, double the toxic amount. Over time, this abuse of medications would account for the damage to his liver and be a probable cause of his hyperbilirubinemia.
66. Acanthosis Nigricans in a Female Patient.
C. Shelburne and K. Lohenry, Midwestern University Physician Assistant Program, Glendale, Arizona
Purpose: The diagnosis of acanthosis nigricans is often overlooked in the Caucasian population. The exact incidence of acanthosis nigricans is unknown; however, it is more common in people with darker skin pigmentation. Presentation: A 13-year-old Caucasian female presented with neck pain. Patient denies any trauma, injury, and hirsutism. Patient is a well-appearing, moderately obese female in no apparent distress. Patient has a past medical history significant for irregular menstrual periods and a family history positive for diabetes. Examination: Physical exam revealed the presence of a symmetrical, hyperpigmented velvety plaque on her posterior neck, while the rest of the exam was unremarkable. Diagnostics: The diagnostic work-up included fasting serum glucose and serum insulin. The serum glucose and insulin were reviewed, revealing an impaired fasting glucose of 126 mg/dL (50-96 mg/dL) and elevated serum insulin of 43.2 uIU/mL (0.0 - 29.1 uIU/mL). Assessment: The final diagnoses of metabolic syndrome and acanthosis nigricans were made. Plan: The patient was started on 500 mg of Metformin therapy twice a day and a nutritionist consult was ordered. Conclusion: This case reinforces the need for clinicians to perform a thorough history and physical exam. This patient could simply have been discharged with the diagnosis of neck pain, but instead a prediabetic state was discovered and possible chronic complications prevented. Even though acanthosis nigricans is more prevalent in patients with darker skin pigmentation, clinicians must not overlook this phenomenon in the Caucasian population. The prevalence in the Caucasian population is less than 1%. The prevalence in African Americans is 13.3%, and in Hispanics, 5.5%. Insulin resistance is the most common association of acanthosis nigricans in the younger age population. Clinicians must also keep in mind the diagnosis of polycystic ovarian syndrome (PCOS) in young women with acanthosis nigricans, hyperinsulinemia, and hyperandrogenemia. Hyperandrogenemia is usually discovered when a patient complains of increased hair growth. High plasma testosterone levels are also common in PCOS.
67. Acute Exacerbation of Chiari I Symptoms After Chiropractic Intervention.
E. Zink, K. Lohenry, and J. Williams, Midwestern University Physician Assistant Program, Glendale, Arizona
Purpose: This case demonstrates the difficult nature of clinically diagnosing Chiari 1 malformation, as well as the potential for serious exacerbation of symptoms after undergoing chiropractic intervention. Methods: Resources utilized for writing this case report after obtaining appropriate patient consent included the following: review of the patient's medical records from primary care provider, imaging studies, neurosurgical consult, postop evaluation, and patient interview. Results: Case description: A Chiari I malformation is the elongation of the cerebellar vermis with caudal herniation through the foramen magnum greater then 5mm. Although the degree of tonsillar herniation is often related to symptoms, it does not correlate directly with the severity of symptoms. We present a case involving a 48-year-old female with a seven-year history of symptoms related to Chiari I, beginning in 1999, who experienced an acute and unrelenting exacerbation of symptoms after undergoing chiropractic intervention against medical advice in 2006. The patient experienced intermittent or migratory symptoms, including: weakness of the whole body (especially upper extremities), fatigue, headache, disequilibrium, generalized sinus pressure, neuralgia of both arms/shoulders, and slurred speech. Over the course of the seven-year history, the patient was treated medically for these symptoms with muscle relaxers, NSAIDs, pain medication, and home stretching and strengthening exercises, with variable but incomplete success. During this time, diagnosis was complicated with compounding factors like traumatic muscle strains to the neck and back. An MRI of the cervical spine was conducted on 8/17/06, which did not find any significant pathology. A dedicated MRI of the brain was conducted on 9/16/06, which demonstrated a cerebellar tonsillar herniation of 8-10mm below the foramen magnum, meeting the criteria of Chiari 1. Shortly after, she underwent chiropractic manipulation of the neck and shoulders after "forgetting" that her primary care physician had specifically warned against this. At this time, symptoms became markedly worse. The patient received neurosurgical consultation on 10/25/06 and surgical intervention was approved. She received posterior fossa decompression without dura enlargement on 1/4/07. By postop day four, the patient self-reported that she was symptom-free with the exception of a mild headache. Conclusions: Chiari 1 malformation is difficult to diagnose clinically as the patient's symptoms may vary in etiology, location, duration, and severity. Chiropractic manipulative techniques carry the potential for serious exacerbation of Chiari 1 symptoms and should therefore be absolutely contraindicated. Posterior fossa decompression was a successful technique for alleviating symptoms of Chiari 1 in our patient.
68. An Uncommon Reaction to Prochlorperazine.
M. Matey and J. Spiegel, Midwestern University Physician Assistant Program, Glendale, Arizona
Case Report: An 18-year-old female diagnosed with presumably viral gastroenteritis was prescribed prochlorperazine 10mg every 8 hours as needed for nausea or vomiting. After three doses of prochlorperazine over a 24-hour period, the patient was taken to the emergency department. She had developed muscle spasms in her neck, forced jaw opening, tongue protrusion, difficulty speaking, intermittent eye diversion, and increased anxiety. The patient reported no fevers, nausea, vomiting, or diarrhea in the previous 24 hours. She was afebrile, blood pressure 141/94, pulse 88, respiratory rate 20, and oxygen saturation 99% on room air. Physical exam revealed periodic eye deviation superiorly and to the right. Patient exhibited intermittent facial and right-sided neck muscle tightening. No angioedema or dermatologic abnormalities were noted, lung sounds were clear, and the remainder of the exam was unremarkable. It was determined that this patient was having a dystonic reaction, most likely attributed to prochlorperazine. She was given diphenhydramine 50mg intravenously and had complete symptomatic resolution within 20 minutes. Discharge treatment plan included a tapering dose of diphenhydramine over the next 48 hours. Patient was informed to discontinue prochlorperazine. Subsequent follow-up visit revealed continued resolution of symptoms without sequelae. Discussion: Drug-induced acute dystonic reactions have an incidence ranging from 0.5% to 1.0% in patients given antiemetics, particularly dopamine antagonists. Half of these reactions will occur within 48 hours of medication ingestion, and 90% will occur within five days. Children and males have a greater predisposition for dyskinesias. Patients with a history of recent cocaine or alcohol ingestion are also at an increased risk. While dystonic reactions are typically not life-threatening, the nature of the muscle contractions is often quite frightening for patients. Manifestations include oculogyric crisis, torticollis, opisthotonus, macroglossia, buccolingual crisis, spasticity, and rarely, laryngospasm. Pathophysiologically, it is understood that antiemetics in the phenothiazine class act by antagonizing dopamine D2 receptors. This action disrupts the dopaminergic-cholinergic balance in the nigrostriatum and can thereby lead to extrapyramidal symptoms. Optimal adult treatment options include benztropine 1-2mg IV/IM or diphenhydramine 50-100mg IV/IM. Other treatment options include promethazine 25-50mg IV/IM or diazepam 5-10mg IV. Most patients respond to IV treatment within 10 minutes or IM treatment within 30 minutes. Multiple treatments may be necessary for complete symptomatic resolution. If a patient does not respond after the second dose of one of the above medications, an alternative diagnosis should be considered. Once symptoms have resolved, the patient should be continued on outpatient anticholinergic or benzodiazepine therapy for 48-72 hours to avoid relapse. Patient should be counseled to avoid exposure to the precipitating drug and that they are at a higher risk for reoccurrence if another phenothiazine is prescribed. Conclusion: While many clinicians are aware of dyskinesias secondary to neuroleptics, it is important to remember that antiemetics can also precipitate this reaction. Clinicians may consider prescribing a selective serotonin antagonist in place of a dopamine antagonist to lower the incidence of dyskinesias. If a dopamine antagonist is the preferred antiemetic, concurrent prescription of an anticholinergic agent is recommended.
69. An Unexpected Finding in a Two-year-old with a Burn Injury to the Hand.
N. Farrar and T. Moreau, Midwestern University Physician Assistant Program, Glendale, Arizona
Case Report: A two-year-old female presented to the emergency department of a regional burn center with a full thickness burn to her right hand. Her mother and an ex-boyfriend, who had been caring for the girl at the time of the injury, reported that the girl pulled a cup of hot coffee onto her hand, spilling it over the dorsal aspect. The burn however was circumferential and in a glove pattern. In addition, the depth of the burn suggested a more prolonged exposure to hot liquid and was lacking splash marks. Due to the burn thickness and circumferential involvement of the hand and fingers, the child was admitted to the burn unit for pain management and probable surgical debridement. The patient required escharotomies to the dorsal aspect of the hand due to concern for compartment syndrome as well as later surgical debridement and skin grafting. The patient's mother revealed to nursing staff that the child had been injured twice before under this man's care, which prompted a call to Child Protective Services and a non-accidental injury work-up. Full skeletal series and a bone scan showed an old fracture of the T7 vertebral body, consistent with the child being forcefully sat down. The male caregiver subsequently acknowledged having done such a maneuver to the child. Discussion: Non-accidental injuries account for up to 25% of pediatric burns. The mean age of non-accidental burned children is two to four years, and boys are more likely to be affected than girls. This is considered to be a very serious form of child abuse, considering the pain, anxiety, and possible morbidity and mortality associated with burns. The patterns of the burn injury that raise clinical suspicion of non-accidental causes include scald burns with the absence of splash marks, uniformity of burn depth, burn symmetry, and skin sparing in areas such as joint flexion surfaces. The circumstances surrounding the injury can also provide clues that a burn may be non-accidental. Often there is a lack of witnesses and a mechanism of injury incompatible with the presentation. This case demonstrates the necessity to properly investigate suspicious injuries to deem whether abuse was involved, as well as the importance of looking for signs of additional abuse. There is not sufficient data to show the incidence of other forms of abuse found in pediatric burn patients with non-accidental injuries. Additionally, data regarding the incidence of thoracic spine injuries is similarly lacking, not only specific to burned children, but with respect to child abuse in general. Clinicians must adopt a systematic approach when evaluating a child's injuries. Identification of non-accidental injuries is not only important in treating the current injury, it may prevent further and possibly more serious injuries.
70. Congenital Liver Malformation: A Case Report.
S. Adams, Quinnipiac University Physician Assistant Program, Hamden, Connecticut
Introduction: Congenital liver malformations are a rare occurrence. Most commonly, these are lobe and segmental anomalies that present as agenesis or fusion. The most common abnormalities, according to Aktan, Savas, Pinar, et al., as determined through autopsy (n = 54) and CT imaging (n = 383), were fusion of the left and quadrate lobe (14.841%) and absence of the left liver lobe (2.87%). Most liver anatomy abnormalities are incidental findings as a result of intrabdominal pathology leading to surgery or autopsy. Almost all malformations are asymptomatic which contribute to their benign presentation secondary to additional processes. This case report focuses on the incidental finding of a bifid liver during the medical and surgical treatment of gallstone pancreatitis. Case Report: A 74-year-old white male seen and admitted through the emergency department with a several-week history of left-sided abdominal and epigastric pain increasing in severity over the last two days. Laboratory investigation demonstrated a markedly elevated amylase and lipase with liver function tests initially normal prior to a subsequent rise in bilirubin during hospitalization. The gall bladder could not be visualized on ultrasound. CT scan revealed atypical position of the gall bladder, anterior and superior to the right liver lobe, abutting the right hemidiaphragm. The gall bladder contained multiple calculi and demonstrated no biliary dilatation. The liver demonstrated atypical configuration with attenuation of the right liver lobe and prominent left and caudate lobes. Portions of redundant transverse colon were found between the left and right liver lobes, as well as adjacent to the gall bladder and right hemidiaphragm. There was smudging of the peri-pancreatic fat with no focal mass present. The patient was treated for gallstone pancreatitis and planned for cholecystectomy once his lab values normalized. Open cholecystectomy was performed via right subcostal incision. The liver was visualized with near total division of the right and left lobes left only attached by a thin bridge of tissue containing vessels. The transverse colon was located superiorly under the right hemidiaphragm along with the gall bladder. After tedious dissection, the cystic duct was identified, clipped, and cut, and intraoperative cholangiogram revealed normal biliary anatomy and free flow into the duodenum without any filling defects. The incision was closed and the patient extubated and brought to recovery in stable condition. The postoperative course was essentially unremarkable from the surgical standpoint and the patient was discharged home seven days later. Conclusion: Congenital anomalies of the liver are a rare occurrence and most often an incidental finding during surgery or autopsy. Specifically, a bifid liver, also known as a bipartite liver, is very rare and only noted in literature by two previous case reports. All reports of this condition conclude it is asymptomatic posing only the risk for a development of a right-sided diaphragmatic hernia. No increased risk of gallstone pancreatitis has been noted in the literature. From a surgical standpoint, being aware of the possible hepatic anatomical variants is important in the planning and execution of biliary surgery.
71. Isolated Thrombolysis Catheter for the Treatment of Upper Extremity Deep Vein Thrombosis: A Case Study.
T. Lavor and J. Spiegel, Midwestern University Physician Assistant Program, Glendale, Arizona
Purpose: To report on an innovative and minimally invasive technique in the isolation, lysis, and removal of upper extremity (UE) deep vein thromboses (DVT). Background: Current guidelines for the treatment of DVT support initiation of systemic anticoagulation to prevent pulmonary embolism and recurrent thrombosis; however, anticoagulation alone does not promote clot dissolution, nor the re-establishment of proper blood flow and restoration of valve function. As a result, chronic and extensive clots may cause manifestations of post-thrombotic syndrome secondary to obstruction and venous reflux. Systemic thrombolytic agents may be administered in conjunction with anticoagulants to prevent these sequelae. Unfortunately, systemic thrombolytic agents are absolutely contraindicated in many patients, and they only act on the surface of clots, rendering them unsuccessful in penetrating and lysing large DVTs. A proposed alternative treatment method is clot dissolution through isolated thrombolysis catheters. Methods: The patient is a 71-year-old male who presented to the emergency department with severe left UE edema and skin changes. Venous Doppler studies revealed a thrombosed brachial vein. Initially anticoagulation, upper extremity wrapping, and elevation techniques were employed to treat the DVT. However, after symptoms persisted and worsened, the decision to proceed to surgical removal was made. In the operating room, the patient was placed under conscious sedation, and an incision was made in the lower portion of the brachial vein. Intraoperative venography revealed extensive clots in the brachial and subclavian veins. A catheter known as the Trellis 8 Peripheral Infusion isolated thrombolysis catheter was inserted into the subclavian vein. Balloons were inflated at the proximal and distal ends of the thrombus to isolate the treatment area. High-concentration Tissue Plasminogen Activator, or TPA, along with mechanical therapy were employed to dissolve the clot. The resulting material was aspirated and found to be purely liquid. This process was repeated in the brachial vein. Results: A repeat intraoperative venogram showed no residual clot in either vein as well as normal blood flow through the previously thrombosed veins. Postoperatively, the patient noticed rapid improvement in his symptoms. Upper extremity edema and preoperative pain were reduced dramatically. Skin discoloration remained secondary to longstanding venous stasis. No postoperative complications were reported, and the patient was discharged home the next day. Conclusions: Isolated thrombolysis of UE DVTs using a dual catheter system decreases the incidence of postphlebetic syndrome. Local application of high concentration thrombolytic agents in the presence of mechanical disruption allows a significant amount of the thrombus to be aspirated. Removal of the clot prevents structural damage to the vein and valves and prevents long-term venous insufficiency, edema, pain, and the possibility of venous stasis ulceration. This technique has little to no systemic effects, making it a safe and feasible option for patients with absolute or relative contraindications to systemic thrombolytic agents. It is also far less invasive than open thrombectomy procedures and may be completed under conscious sedation, therefore eliminating the risks associated with general anesthesia.
72. Lipoma Versus Liposarcoma in a 26-year-old Male.
F. Altuve and K. Lohenry, Midwestern University Physician Assistant Program, Glendale, Arizona
Introduction: Lipomas consists of a growth of fat cells within a thin fibrous capsule, usually found just below the skin. Liposarcoma is a malignancy of fat cells and is the most common form of soft tissue sarcoma in adults. This case illustrates the complex presentation of a lower extremity mass in a 26-year-old male patient. The diagnosis of a lipoma remains contentious; thus close follow-up, consultation, and review is required. Case Report: A 26-year-old male presents with a six-month history of swelling and pain in his left leg. He also complains of numbness and weakness that radiates to his left lower extremity. He had similar symptoms as a child, but states the current symptoms are more severe. He denies any history of recent weight loss or infections. Past medical history includes a mass in the left thigh that was excised approximately 15 years ago. He admits a six-pack-a-year history of smoking and occasional alcohol use. Physical examination shows swelling of the left thigh and pelvis. Radiograph of the left hip reveals an enchondroma versus infarct of the left ischial ramus. CT and MRI reveal a 16 cm x 15 cm x 5-7 cm. mass, suspicious for a lipomatous tumor of left pelvis and left thigh versus a liposarcoma. Appearance of the mass during biopsy suggests a liposarcoma, but the pathology specimen reveals mature adipose tissue consistent with lipoma. Given the size of the lesion, its symptomatology, and the patient's history, the recommended treatment for the mass was excision. The mass extends through the perineum to the acetabulum and to the sacrum. The mass is "shelled out" while the sciatic nerve is preserved. Given the benign nature of the tissue, the portions of the tumor that are peripherally densely adherent and involve the sciatic nerve are left behind. Following several weeks of specimen evaluation, the pathologists state that the mass is a lipoma, which contradicts the clinical appearance noted during surgery. This patient was advised to follow-up within one month for a repeat MRI to re-evaluate the mass, as the diagnosis remains in question. Conclusion: The differences between lipoma and liposarcoma can be subtle. Given the morbidity and mortality associated with malignant disease, consultation of a musculoskeletal-oncology specialist may also be prudent.
73. Mental Illness in a Pregnant Female: A Case Report.
A. Packham, J. Stoehr, and A. Essary, Midwestern University Physician Assistant Program, Glendale, Arizona
Purpose: This case provides a unique view of a pregnant patient with decompensated psychiatric illness and illustrates key concepts in psychiatric pharmacotherapeutics. Methods: A 24-year-old G1P0 Hispanic female at 24 weeks gestation was admitted to the psychiatric hospital after complaints of "hearing voices" and threatening to overdose on clozapine and fluoxetine. She was previously well controlled on clozapine and fluoxetine until she discovered she was pregnant, at which point she discontinued all medications due to concern about the effects the medications would have on her unborn child. It is unknown how long she has been off her psychiatric medications. She did not complete any psychiatric evaluation or follow-up to re-evaluate her medication management. Her past medical history included a hospitalization for schizoaffective disorder at 16 years old and a history of multiple suicide attempts. She was hospitalized for attempted overdose on fluoxetine two weeks prior to the current admission. She did not complete psychiatric follow-up. On admission, the patient demonstrated psychomotor agitation, emotional labiality, and limited responses to questions. Her mental status exam was incomplete due to poor participation. She denied that she was pregnant. The difficult and complex inpatient evaluation ultimately yielded a diagnosis of schizoaffective disorder-depressed type. The patient was initially stabilized with haloperidol and lorazepam. She also began routine prenatal care. Two weeks into her hospital admission, she was started on fluoxetine for depression. However, five weeks into her hospital stay, the patient decompensated. She became verbally and physically disruptive, expressed suicidal intentions, and demonstrated harmful behavior to the fetus. Following a medication and chart review, her behavior was attributed to an increase in her dose of haloperidol. Results: Since the patient had previously shown improvement on clozapine, the medication was reintroduced and titrated to therapeutic doses. The haloperidol and fluoxetine were tapered and discontinued. By week nine, the patient exhibited marked improvement in her symptoms. Conclusion: Approximately 8% of the 70 million women of childbearing age in the United States suffer from different forms of severe mental illness. Approximately half of these women take psychotropic medications, which are not recommended in pregnancy due to teratogenic side effects. Females who become pregnant while on psychotropic medications risk harm to the fetus, and females who discontinue the medication too abruptly may suffer adverse effects on their mental health. This case report reinforces the need for aggressive patient education, family planning, and prenatal care in female patients on psychiatric medications. It also illustrates principal concepts in psychiatric pharmacotherapeutics - the importance of closely monitoring patients in the inpatient setting and completing a thorough medication history to determine which medications have previously been effective.
Previously Presented
74. How Knowledge of Medication Regimens Influences Adherence in Ambulatory Geriatric Patients Taking Multiple Medications.
B. McBryde, O. Chen, and L. Reed, University of North Texas Health Science Center, Fort Worth, Texas
Purpose: The purpose of this study was to investigate geriatric patients' knowledge about their medications and how their knowledge correlated with adherence. Method: This is a cross-sectional research study. The researchers used a survey, Mini-Cog, and chart review to collect the data. The Medication Knowledge and Compliance Survey was an 18-item survey developed by the researchers. The survey was pilot-tested on five participants at a local senior center. A convenience sample of 61 geriatric participants took part in this study. The level of participants' knowledge was measured by evaluating the consistency between participants' responses regarding their prescription medications and their chart data. Six areas of consistency were evaluated: (1) The medicines on the chart matched the participant's response or the participant knew the medication, (2) The participant was able to give the correct reason for taking the medicine, (3) The participant was able to give the correct dosage or the participant knew the dose, (4) A medicine was listed in the chart but not mentioned by the participant, (5) A medicine was mentioned by the participant, but was not listed in chart, and (6) The participant offered the correct reason for taking the medication. Participants' knowledge scores ranged from 0 to 6. The higher the consistency, the higher the knowledge score gained. T-test and chi square statistical analysis were performed using SPSS (11.5). Results: A total of 50 participants met the study inclusion criteria. The mean participant age was 73.6 years, and 64% were female. On average, participants had 8.2 prescription medications. The mean knowledge score for participants was 4.8 (SD=0.86). However, the knowledge scores of those participants who reported never missing medications (M=4.79) and those who reported sometimes missing some of their medications (M=4.84) did not reach a statistically significant difference (t=-0.201, p>0.05). Likewise, the knowledge scores of those who reported having never stopped any medications (M=4.80) and those who reported having stopped taking a medication (M=5.10) did not reach statistical significance (t=-1.138, p>0.05). Other interesting findings were: There were 32.1% of the total medications that the participants either did not know or the medicine mentioned in the interview did not match a medication in the chart; incorrect dosage information was given by the patients for 31.2% of the total medications. Conclusion: This study did not find a statistically significant correlation between the geriatric patients' medication knowledge and their adherence. Knowledge may or may not play a role in the way elderly individuals comply with their medication regimens. Other possible influential factors, such as patients' beliefs regarding the disease and its treatment, patient barriers to treatment, and social factors need to be further explored. Health care providers need to assess geriatric medicine-taking behavior needs and tailor specific patient-centered plans toward those individuals.
75. Prevalence of Nutritional Deficiency in Elderly Patients Undergoing Mohs Micrographic Surgery.
D. Marquez, H. Lemke, and O. Chen, University of North Texas Health Science Center, Fort Worth, Texas
Purpose: This study was conducted to (1) determine the prevalence of nutritional deficiency in elderly patients undergoing Mohs Micrographic Surgery, and (2) evaluate the efficiency of the Mini Nutritional Assessment (MNA) tool in the dermatologic surgical/clinical setting. Method: This was cross-sectional research. After obtaining IRB approval, the researchers used the MNA, which was developed and validated by Nestle®, to initiate screening for risk of and further assess for nutritional deficiency. The MNA included anthropometric measurements, global assessment, dietary questionnaire, and subjective assessment. A total of 102 elderly patients of DermSurgery Associates in Houston, Texas, were solicited to participate in the study. Participants also were asked to rate the understandability of the MNA. The time required to complete each assessment was recorded. Descriptive statistical analysis was performed using the SPSS (12.0). Results: A total of 100 patients participated in the study. Most participants were Caucasian (99%), male (64%), between the age of 61 and 80 (64%), and 79% had some level of college education. The prevalence of nutritional deficiency in this sample group was zero percent with a risk of being malnourished of 7%. The MNA was easy to use, as determined by 100% of the study participants. Time required to complete the assessment averaged less than three minutes per encounter. Conclusion: Previous studies have shown that malnutrition can lead to problems or delays in wound healing. Correcting these deficiencies promises to enhance wound healing. If malnutrition is suspected in an elderly patient about to undergo surgery, nutritional status should be assessed and can efficiently be done with the MNA. This study did not find the expected prevalence of nutritional deficiency in the elderly patient as predicted by Nestle® when using the MNA. This may be due to the inadequate survey size and unique demographic characteristics of the study population. Other studies found that elderly, black, immigrant, or persons who have a lower education level or socioeconomic status are at higher risk for malnutrition, whereas the study population was mostly an affluent Caucasian subset of the general elderly. The results of this study were limited due to short duration of data collection and a lack of homogeneity in comparison to the United States' elderly population at large. Recommendations for future research are to allow for adequate sample size and diversity of the clinic sites.
