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The 2020 St. Luke’s University Health Network Annual Research Symposium: Event highlights and scientific abstracts


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The Annual St. Luke’s University Health Network (SLUHN) Research Symposium was established in 1992 to showcase research and quality improvement projects by residents, fellows, and other trainees. The event is organized by a multi-departmental planning committee, with collaboration and consultation provided by graduate medical education (GME) leadership, medical school leadership, as well as residency and fellowship faculty. Residents, fellows, and students submit an application for podium (8-min) or quick shot (5-min) presentation along with an accompanying abstract describing their project or case report. This year’s event featured the largest number of podium and quick shot presentations in SLUHN’s 28-year Research Symposium history. Before the event, each submitted project was assessed by at least two independent judges for the overall scientific quality (60% of the score). This was followed by a live audience vote for the best presentation (40% of the score). Based on the above methodology, prizes were awarded to top three podium presenters and to the best quick shot presenter. Since 2018, students from the Temple/St. Luke’s Medical School were invited to participate in the Research Symposium, and this year’s event is the first to feature scientific competition prize for the best presentation by a medical student.
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234 © 2020 International Journal of Academic Medicine | Published by Wolters Kluwer - Medknow
The 2020 St. Luke’s University Health Network Annual
Research Symposium: Event highlights and scientic
Anna Ng Pellegrino1, Rachel Birk2, Parampreet Kaur3, Stanislaw P. Stawicki2
1Department of Anesthesiology, St. Luke’s University Health Network, Bethlehem, Pennsylvania USA, 2Department of Research &
Innovaon, St. Luke’s University Health Network, Bethlehem, Pennsylvania, USA, 3Department of Graduate Medical Educaon, Data
Management and Outcomes Assessment, St. Luke’s University Health Network – Richard A. Anderson Campus, Easton, Pennsylvania, USA
The Annual St. Luke’s University Health Network
(SLUHN) Research Symposium was established in
1992 to showcase research and quality improvement
projects by residents, fellows, and other trainees. The
event is organized by a multi‑departmental planning
committee, with collaboration and consultation
provided by graduate medical education (GME)
leadership, medical school leadership, as well as
residency and fellowship faculty. Residents, fellows,
and students submit an application for podium
(8‑min) or quick shot (5‑min) presentation along with
an accompanying abstract describing their project or
case report.
This year’s event featured the largest number of
podium and quick shot presentations in SLUHN’s
28‑year Research Symposium history. Before the
event, each submitted project was assessed by at least
two independent judges for the overall scientific
quality (60% of the score). This was followed by a live
audience vote for the best presentation (40% of the
score). Based on the above methodology, prizes were
awarded to top three podium presenters and to the
best quick shot presenter. Since 2018, students from
the Temple/St. Luke’s Medical School were invited
to participate in the Research Symposium, and this
year’s event is the first to feature scientific competition
prize for the best presentation by a medical student.
The 2020 Research Symposium winners were as
1. Podium presentations
a. First place – Amanda Gifford, MD (General
Surgery Residency), “Disproportionately
affected and underinsured: Trauma and
violence in young African American and
Latino men extend beyond major urban
b. Second place – Farrah Harmouch, MD
(Internal Medicine Residency, Bethlehem),
Association of metabolic syndrome with
diverticulosis and internal hemorrhoids in
geriatric patients ages 75 years and older.”
c. Third place – Kyle Dammann, MD (General
Surgery Residency), “The use of liposomal
bupivacaine in transversus abdominus plane
blocks for postoperative pain control.”
2. Quick shot presentation
a. First place – Meagan Corrigan, DO (Emergency
Medicine Residency, Bethlehem), “Lidocaine
for treatment of acute pain syndromes.”
3. Medical student presentation
a. First place (jointly) – Jessica Fleischer and
Rachel Pallay (Temple/St. Luke’s Medical
School), “Risk factors associated with poor
outcomes in younger COVID‑19 hospitalized
As in the previous 4 years, the 2020 Research
Symposium included Keynote Speakers. This
year’s invitees were Prof. Manish Garg, MD,
Residency Program Director from the Departments
of Emergency Medicine, Weill Cornell Medicine,
Columbia University College of Physicians and
Surgeons, New York, NY; and Dr. Shikha Kapil,
MD, from the Departments of Critical Care and
Emergency Medicine, MedStar Washington Hospital
Center and MedStar Georgetown University Hospital,
Washington, DC. The joint Keynote presentation
discussed the importance of research and evidence‑
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International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 235
based approaches in clinical management of patients
with coronavirus disease 2019 (COVID‑19). Guest
speakers described their institutional experiences with
the ongoing pandemic, provided valuable insights
and perspectives on effective teaching during this
challenging time, and emphasized the importance
of critical thinking when translating evidence‑based
literature into bedside practice. The Keynote Address
concluded the morning session of the Research
The afternoon session of the event included
presentations from various departments that directly
and indirectly support research and scholarly activity
at SLUHN. This highly informative session featured
content from the following areas: Clinical Trials, the
Institutional Review Board, GME Data Management
and Outcomes Assessment, Temple/St. Luke’s Medical
School, Information Technology (IT)/St. Luke’s
Technology Ventures, Knowledge Management,
Nursing/Evidence‑Based Practice, Physical Therapy,
Quality and Safety, Narrative Medicine, and other
specialties, departments, and topics. Furthermore, due
to ongoing COVID‑19 pandemic and associated large
gatherings restrictions, the 2020 Research Symposium
took place entirely online. With the help of the St.
Luke’s IT Media Team, we were able to conduct the
largest, and the most complex, virtual event in the
Network’s history.
Appropriateness and Efficiency of Diagnostic Imaging
Orders Recommended by Physical Therapists
K. G. Patrick1, S. M. Kareha1
1St. Luke’s Orthopaedic Physical Therapy Residency, Allentown, PA,
Introduction: Spine‑related pain is a massive
problem throughout the world, resulting in high
medical expenditures and frequent disability. Physical
therapists are equipped with knowledge and skills to
make appropriate referrals for diagnostic imaging
to reduce cost and improve outcomes by increasing
efficiency in care delivery.
Methods: Consecutive patients who consulted with
a physical therapist first within the Comprehensive
Spine Program at SLUHN were included in this
retrospective analysis. The appropriateness of the
order recommendation by the physical therapist was
determined by chart review and compared to the
gold standard of the American College of Radiology
(ACR) Appropriateness Criteria®. To determine the
efficiency of physical therapist ordering, the number
of physician visits and days between physical therapist
recommendation and physician order placement were
Results: Physical therapists placed imaging order
recommendations in 15 out of 1164 cases. Physical
therapists ordered the appropriate diagnostic
imaging modality 94% of the time. The median
number of physician visits between physical therapist
recommendation and formal ordering was 1 visit
(range 1–3). The median number of days between
physical therapist recommendation and formal
ordering by the physician was 15 days (range 1–104).
Conclusion: The results of this study demonstrate
that given the authority to order diagnostic
imaging, physical therapists do not over‑utilize
diagnostic imaging and order in adherence to the
ACR Appropriateness Criteria®. Furthermore,
the authorization for physical therapists to order
diagnostic imaging would improve the efficiency of
care for those patients who need further diagnostic
Enhancing Providers’ Cultural Competency of the
Lesbian, Gay, Bisexual, Transgender, Queer, or Intersex
Population: A Mixed‑Method Intervention Study
R. H. Markson1, N. Defenbaugh1, P. Kaur1,
A. Rhoads1
1Family Medicine Residency, Richard A. Anderson Campus, Easton,
Introduction: Sexual and gender minorities (SGMs)
experience tremendous social and health inequities
compared to the general population. This topic is
even more relevant and needed given the likely impact
of COVID‑19 on SGM patients.[1‑4] Furthermore,
SGM individuals such as members of the lesbian, gay,
bisexual, transgender, queer, or intersex (LGBTQI)
community are at a disproportionate risk of many
health conditions.[2,3,5‑14] For instance, transgender
individuals are three times as likely to contract HIV.
[6] Many LGBTQI patients avoid seeking medical
care due to the barriers they face in healthcare, such
as issues with insurance, fear of discrimination, and
lack of provider knowledge and cultural competence
about LGBTQI issues.[1,8,9,11] Medical education plays
Conference Abstracts and Reports
236 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
an essential role in ensuring inclusive healthcare;
however, many medical training programs fail
to provide adequate education regarding how to
effectively treat members of the LGBTQI community.
A recent study suggests that the mean time spent
on this topic in medical school is only 5 h.[10]
In this study, we provided a Medical Education
Grand Rounds (MEGR) presentation entitled,
“Foundations of Creating a Safe Space for LGBTQI
in Healthcare” to St. Luke’s healthcare providers. The
aim was to demonstrate through quantitative and
qualitative analysis, the ability of MEGR to enhance
awareness and attitudes, increase knowledge, and
inspire behavioral change to produce more inclusive
healthcare to our LGBTQI community.
Methods: This mixed‑method study used quantitative
and qualitative approaches. The study participants
included St. Luke’s employees who attended the
education session. We included those who attended
the session in person and remotely. Participants were
given pre‑ and post‑surveys reflecting some of the
themes and topics in the presentation [See Tables].
The survey used was a shorter, modified version from
a validated survey of 32 questions.[12] The presurvey
included 12 questions assessing provider’s knowledge
(2 questions), attitudes (4 questions), and practice
behaviors (6 questions) in regard to the LGBTQI
population. The prelecture survey also includes eight
demographic questions. The postlecture survey
includes the same 12 questions as the presurvey with
an additional open‑ended question, “How do you
envision this session will impact your future patient
care?” Surveys were collected in an HIPAA‑protected
data collection software, REDCap (Vanderbilt
University, Nashville, TN). All statistical analyses
were conducted using IBM (Armonk, NY) SPSS for
Windows Version 18. Wilcoxon signed‑rank tests were
performed to determine the effect of the LGBTQI
presentation on the knowledge, attitude, and behaviors
(KAB) of the participants. A P < 0.05 was considered
statistically significant. For the qualitative analysis
of the open‑ended question, we conducted content
analysis. Two of the authors performed a multi‑stage
inductive analysis that included open coding, axial
coding, and rater reliability to consolidate themes.
Using a deductive approach, the final coding scheme
that was applied to the data was based on the KAB
features identified in the Tamargo et al.’s study.[12]
Results: A total of 96 participants completed the
surveys. Missing values were not included in the
analysis. Most participants were medical residents
(72.3%), followed by medical students and fellows.
For gender, 55.3% were female and 44.7% male,
and for sexual orientation, 92.4% were heterosexual
with few as other sexual minorities (e.g., lesbian =
3.16%). There were differences among demographic
groups; however, none were statistically significant.
We saw statistically significant changes in distribution
of answers for both knowledge questions (P < 0.01
for both); two of the four attitudes questions (P =
0.02 for both); and four of the six behavior questions
(P < 0.01 for all four) [Table 1]. Postsession, 94%
felt comfortable treating the LGBTQI population
compared to 86% prior [Table 2]. Among the
participants (n = 44) who responded to the qualitative
question, content analysis revealed that the majority
(n = 38) saw an impact of the presentation on their
Table 1: Impact of LGBTQI MEGR on Participants' knowledge,
attitudes and behaviors
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International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 237
future practice (group labeled “change”). The minority
(n = 8) saw either no impact or no change (group
labeled “unchanged”). The change group revealed
three major themes that reflected the survey question
categories ‑ KAB [Table 3]. Attitudes had four
subthemes and behavior had two subthemes, with
none for knowledge (only 1 comment was made).
The unchanged group was predominantly made up
of surgical specialties, and only two themes emerged:
attitudes and behavior, and one subtheme was revealed
for each [Table 4].
Conclusion: Our study demonstrates that educating
healthcare providers improves cultural competency
by increasing knowledge, awareness, and inspiring
change toward more inclusive practices for treating
our LGBTQI patient population. It has implications
Table 3: Qualitative analysis: Imapact on patient care for
changed group
Table 2: Contd...
Table 2: Frequency and percentages of answer choices in the
likert scale for pre and post-session survers
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238 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
for requiring and integrating LGBTQI education
into medical education curricula, and 84% supported
mandatory education at St. Luke’s. Certain
subspecialties might benefit from a tailored curriculum
as they did not see the same relevance to their practice
as other specialties. Future research should focus on
establishing differences in LGBTQI competency
among medical specialties, and education sessions
should be modified accordingly. Since we have yet to
conduct a 6‑month follow‑up survey, future research
should assess whether endorsed behavioral changes
from survey responses were put into practice and
maintained and the impact on patient care.
1. Ayhan CH, Bilgin H, Uluman OT, Sukut O, Yilmaz S, Buzlu S. A systematic
review of the discrimination against sexual and gender minority in health
care settings. Int J Health Serv 2020;50:44‑61.
2. Blosnich JR, Farmer GW, Lee JG, Silenzio VM, Bowen DJ. Health
inequalities among sexual minority adults: Evidence from ten U.S. States,
2010. Am J Prev Med 2014;46:337‑49.
3. Hu SS, Neff L, Agaku IT, Cox S, Day HR, Holder‑Hayes E, et al. Tobacco
product use among adults ‑ United States, 2013‑2014. MMWR Morb Mortal
Wkly Rep 2016;65:685‑91.
4. COVID‑19: Experts Highlight LGBTI Discrimination, Antisemitism; 17 April,
2020. Available from: [Last
accessed on 2020 May 27].
5. Durso LE, Gates GJ. Serving Our Youth: Findings from a National Survey
of Service Providers Working with Lesbian, Gay, Bisexual, and Transgender
Youth Who Are Homeless or At Risk of Becoming Homeless. Los Angeles,
CA: University of California; 2012.
6. CDC. HIV and Transgender People. Available from:
hiv/group/gender/transgender/index.html. [Last updated on 2019 Nov 09;
Last accessed on 2020 Feb 09].
7. CDC. HIV and Gay and Bisexual Men. Available from:
hiv/group/msm/index.html#. [Last updated on 2019 Nov 12; Last accessed
on 2020 Feb 09].
8. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender
(LGBT) People: Building a Foundation for Better Understanding.
Washington, DC: National Academies Press; 2011.
9. James S, Herman J, Rankin S, Keisling M, Mottet L, Ana MA. Executive
Summary of the Report of the 2015 U.S. Transgender Survey. Washington,
DC: National Center for Transgender Equality; 2016.
10. Obedin‑Maliver J, Goldsmith ES, Stewart L, White W, Tran E, Brenman S, et
al. Lesbian, gay, bisexual, and transgender‑related content in undergraduate
medical education. JAMA 2011;306:971‑7.
11. Safer JD, Coleman E, Feldman J, Garofalo R, Hembree W, Radix A, et al.
Barriers to health care for transgender individuals. Curr Opin Endocrinol
Diabetes Obes 2016;23:168‑71.
12. Tamargo CL, Quinn GP, Sanchez JA, Schabath MB. Cancer and the
LGBTQ population: Quantitative and qualitative results from an oncology
providers’ survey on knowledge, attitude, and practice behaviors. J Clin
Med 2017;6:93.
13. The Lives and Livelihoods of Many in the LGBTQ Community Are
At Risk Amidst COVID‑19 Crisis. Available from: https://assets2.hrc.
ga=2.35731746.341300536.1590630749‑601141570.1588686223. [Last
accessed on 2020 May 27].
14. Valdiserri RO, Holtgrave DR, Poteat TC, Beyrer C. Unraveling health
disparities among sexual and gender minorities: A commentary on the
persistent impact of stigma. J Homosex 2019;66:571‑89.
Blunt Aortic Dissection and Bilateral Internal Carotid
Dissection in the Setting of Polytrauma
A. Shanker1, A. L. Gifford1, C. Bendas1, R. Castillo1
1General Surgery Residency, Temple/St. Luke’s Medical School,
Bethlehem, PA, USA
Introduction: Traumatic mechanisms account for a
relatively small percentage of reported vascular dissections
and are associated with high morbidity and mortality. In
cases of carotid artery dissection, trauma accounts for only
approximately 4% of identifiable causes. Blunt cerebrovascular
artery injuries involving a single internal carotid artery
affect roughly 0.68%–0.86% of all trauma patients. Acute
aortic dissection occursat a frequency of about 3.5–6.0 per
100,000 patient‑years, with only a small fraction attributable
to traumatic causes. This report presents a rare case in which
concomitant type B aortic dissection, bilateral internal carotid
dissection, and multisystem injuries are sustained after blunt
trauma. Treatment of these vascular injuries in the setting of
severe polytrauma requires careful balancing of antiplatelet
and anticoagulation therapy in the setting of solid organ injury
and multi‑disciplinary collaboration.
CARE Statement: The authors of this manuscript
declare that this scientific work complies with
reporting quality, formatting, and reproducibility
guidelines set forth by the EQUATOR Network. The
authors also attest that appropriate patient consent
was obtained prior to the publication of this abstract.
Case Scenario: A 67‑year‑old male was brought to a
level I trauma center as an unrestrained driver involved
Table 4: Qualitative analysis: Impact on patient care for
unchanged group
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 239
in a single‑vehicle collision versus tree. He was intubated
in the field by emergency medical services (EMS) after
extrication due to decreased mental status, for airway
protection. Advanced trauma life support protocol was
followed. After the primary survey, a FAST examination
was positive in the left upper quadrant, and a chest
X‑ray revealed widened mediastinum. The patient was
hemodynamically stable [Table 1] and transported for
computed tomography (CT) of his head, neck, chest,
abdomen, and pelvis [Table 2]. Laboratory results
and imaging revealed that the patient had sustained
significant multisystem trauma with acute blood loss
anemia [Tables 2 and 3]. His vascular injuries included
a partially thrombosed dissection of the aorta at the level
of the left subclavian artery and descending just proximal
to the level of the iliac bifurcation. Hypoenhancement
of the right kidney secondary to dissection was also
noted. Formal CT angiography (CTA) was done on
the hospital day 1. The descending aortic dissection had
an enlarging intramural hematoma with thrombosis of
the false lumen to the inferior mesenteric artery, which
was not flow limiting. A stable known ascending aortic
aneurysm was visualized. Furthermore, a contained
brachiocephalic artery transection, local dissection
of the distal cervical right internal carotid artery, and
dissection of the left internal carotid artery into the
cavernous portion were visualized. A multi‑disciplinary
approach including trauma, cardiothoracic, vascular,
and neurosurgical teams was utilized due to the
extent of injuries. The aortic dissection was managed
conservatively with targeted blood pressure and heart
rate control. Bilateral carotid artery dissection was
managed with the initiation of antiplatelet therapy
once the splenic injury was embolized. However,
repeat imaging on the hospital day 2 demonstrated new
cortical infarcts in the occipital lobe. At this point, full
anticoagulation was started.
Conclusion: The patient went on to have a
lengthy intensive care unit (ICU) course requiring
a pacemaker, tracheostomy, and gastrostomy tube
placement.Repeat CTA of the head, neck, chest,
abdomen, and pelvis on the hospital day 7 was stable.
He was eventually able to be discharged to long‑term
rehabilitation following his ICU stay. He was placed
on warfarin for the treatment of his carotid dissections
and subsequent stroke. In this case, a multi‑disciplinary
approach was essential in formulating a treatment plan
that took into consideration the patient’s stroke risk
versus bleeding risk inherent to polytrauma patients
with vascular injuries.
Role of Intranasal Calcitonin in Charcot
Y. Cha1, J. C. McGovern1, B. Bernstein1
1PodiatryResidency Program, Bethlehem, PA, USA
Introduction: Charcot neuroarthropathy (CNA) is
a complex condition with heterogeneous treatment
options; consequently, there is no definitive treatment
algorithm. The standard of care for this process has
been offloading and decreased or nonweight‑bearing.
In addition to the neurovascular and neurotraumatic
Table 1: Summary of vital signs present on admission
Vital signs Value
Heart rate and rhythm 61/normal sinus rhythm
Blood pressure 93/53 mmHg
Respiratory rate 21/min
Temperature 97.4° Fahrenheit
SpO2 98% (after field intubation)
Table 2: Summary of injuries present on admission
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240 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
theories, increased osteoclastic activity has been
proposed as a contributing factor in the destruction
of bone associated with Charcot. Bisphosphonates
have been shown to have potential positive effect
on bone turnover in patients with CNA; however,
they are contraindicated in patients with kidney
disease and may decrease bone remodeling. Intranasal
salmon calcitonin has been considered for its use in
osteopenia associated with Charcot neuropathy, due
to its potential effect on the receptor activator of
NF‑kB ligand (RANK‑L)/osteoprotegerin pathway.
It has been proposed that there is an unregulated
inflammatory process in patients with Charcot
neuropathy that leads to an increase in RANK‑L.
Methods: A retrospective clinical study was conducted
to evaluate the effect of intranasal salmon calcitonin as an
adjunctive treatment for CNA. All patients were immobilized
and offloaded per standard of care. Patients’ temperature
difference between affected and unaffected lower extremities
was then measured with an infrared thermometer at each
office visit. Our results were then compared to those of Bem et
al.’s study.[1] A total of 13 patients were included in our study
who reached <2°C temperature difference; we compared time
of maximum temperature decrease and overall temperature
decrease rates to those in Bem et al. The sample size required
for the Bem et al.’s study was 32 patients, which gave a power
of 80% to detect a difference of 15% between the intervention
and control groups with a two‑sided α of 0.05.
Results: The average amount of time it took for our
patients to reach <2°C temperature difference in our study
was 103.7 days, as compared to Bem et al.’s study who
reached <2°C temperature difference at 90 days.[1] Thus
far, in our study, subjects had a temperature difference of
1.6°C ± 0.4°C, whereas subjects in Bem et al.’s study had
a temperature difference of 1.5°C ± 0.5°C. Initial skin
temperature difference for our study was 4.1°C ± 1.4°C
and for Bem et al.’s study was 3.6°C ± 0.8°C. Utilizing
the same statistical tools as Bem et al.’s (power of 80% to
detect a difference of 15%), the sample size required for
our study would be 22. Therefore, we are in the process of
gathering more subjects, as we currently have 13 subjects.
Conclusion: Intranasal salmon calcitonin has been
investigated in its use for osteopenia associated with
CNA. Comparing our observations to previously
published data, it was noted that subjects had similar
temperature differences at 90 days (1.6°C ± 0.4°C
vs. 1.5°C ± 0.5°C, our study and Bem et al.’s study,
respectively) although subjects in our study had a greater
starting temperature difference.[1] Intranasal salmon
calcitonin may be an effective adjuvant modality in
preventing progression of the disease, especially in those
with renal disease, although larger clinical trials will be
needed to assess its role with acute Charcot neuropathy.
1. Bem R, Jirkovská A, Fejfarová V, Skibová J, Jude EB. Intranasal calcitonin
in the treatment of acute Charcot neuroosteoarthropathy: a randomized
controlled trial. Diabetes Care 2006:1392‑4.
The Use of Liposomal Bupivacaine in Transversus
Abdominis Plane Blocks for Postoperative Pain Control
K. Dammann1, A. L. Gifford1, R. Fontem1,
A. Ng Pellegrino1
1General Surgery Residency, Bethlehem, PA. USA
Introduction: Standard morphine derivatives used
to treat postoperative pain are associated with delayed
return of bowel function, increased length of stay, and
unneeded economic burden on the healthcare system.
Ultrasound‑guided transversus abdominis plane (TAP)
blocks provide a means for nonnarcotic postoperative
pain control when an epidural is not feasible, or when
complicated laparoscopic procedures are converted to
open surgery in the operating room (OR). Exparel® is
a long‑acting liposomal bupivacaine with a duration up
to 72 h that has been FDA approved for TAP block use.
Here, we examined the effect of Exparel® TAP blocks
on the postoperative pain and outcomes in patients
undergoing abdominal surgery.
Table 3: Summary of laboratory findings present on admission
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International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 241
Methods: This nonrandomized study was institutional review
board (IRB) approved, SLUHN IRB# 2016‑02. Patients
undergoing open abdominal surgery aged >18 years and
with ASA 1–3 were included, and those with allergies to local
anesthesia, advanced liver failure, pregnancy, and dementia were
excluded. Consent was obtained before procedure, and Exparel®
was mixed with 0.25% bupivacaine and normal saline. TAP
block was performed under ultrasound guidance in the OR or
in postanesthesia care unit (PACU) using a Stimuplex® needle (B.
Braun Medical, Allentown, PA) via hydrodissection technique
ensuring 30cc to each side of the TAP block. Pain scores were
collected in the PACU and on the postoperative day (POD)0–5.
Based on alpha = 0.05 and beta = 0.80, we required 20 Exparel®
and 20 non‑Exparel® patients to see 30% change in pain scores.
Results: Fifty‑two patients underwent open abdominal
surgery followed by Exparel® TAP blocks (n = 26) or
standard opioid therapy (n = 26) [Figure 1a]. Fifty‑two
percent were male, and the mean age was 58 ± 17 years.
Exparel® treatment resulted in <50% patients requiring
opioid morphine equivalents (OME) (61–90) for the
treatment of severe postoperative pain [Figure 1b].
Exparel® was also associated with decreased length of stay
(5 ± 2 vs. 9 ± 7 days) [Figure 1c], reduced incidence
of ileus (3% vs. 27%), reduced nausea and vomiting
(8% vs. 42%), readmission (4% vs. 12%), and fewer
postoperative complications (23% vs. 54%) [Figure
1d]. Overall, the effect of Exparel® on OME was most
profound POD2–5; ranging from 41% to 43% decrease
in OME on POD2–3 and 68% to 73% decrease in OME
on POD4–5 [Figure 2]. Exparel® reduced the incidence
of severe postoperative pain scores by 50% or greater
from POD0 to POD4 [Figure 3]. Exparel® reduced pain
scores by 75% on POD2 and 50% on POD3–4 in acute
care surgery patients [Figure 4a] and by 40% on POD2
in colorectal surgery patients [Figure 4b and c].
Conclusion: Exparel® TAP blocks improve
postoperative outcomes by reducing OME and acute
pain scores, resulting in reduced length of stay and
fewer complications at our institution. In the future,
randomized, controlled trials should investigate
whether TAP blocks are similarly effective on large
Effect of Oral Vancomycin Prophylaxis on Clostridioides
difficile Infection Recurrence in Patients Receiving
Antibiotic Therapy
S. Gluhov1, S. C. Depcinski1, A. M. P. Kratz1
1Pharmacy Residency, Bethlehem, PA, USA
Non Exparel Exparel
Number of Patients
Length of stay in days
Non Exparel
Ileus Nausea
vomiting Readmission Complication
Non Exparel 711314
Number of events
0-40 41-6061-90 > 90
Non Exparel 8310 5
Exparel 13 454
Number of Patients
OME Overall
Figure 1: Exparel® improves patient outcomes. (a) Distribution of male and female patients treated with or without Exparel®. (b) Overall opioid
morphine equivalents required throughout the study. X‑axis indicates opioid morphine equivalents to treat mild (0–40), moderate (41–60),
severe (61–90), and chronic (>90) pain. Exparel‑treated patients required fewer opioid morphine equivalents (61–90) range to reduce severe
pain. (c) Exparel® is associated with reduced length of stay in hospital after abdominal surgery. (d) Exparel® is associated with reduced incidence
of ileus, postoperative nausea/vomiting, readmission, and postoperative complications
Conference Abstracts and Reports
242 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
Non Exparel 76 109 258 209 15 00
Exparel 14 69 203 88 600
Laparoscopic Hand Assisted Colectomy
Non Exparel 41 44 72 121 82 57 36
Exparel 561112 76 40 13 5
Laparotomy Bowel Resection
Non exparel 33 84 90 85 46 44 34
Exparel 14 61 1055026149
Non Exparel 24 109 92 80 39 47 35
Exparel 15 28 24
Acute Care Surgery
Exploratory Laparotomy
Figure 2: Effect of Exparel® in surgical specialties. Opioid morphine equivalents required by patients from postanesthesia care unit through postoperative
day 5 in non‑Exparel‑treated (White) (n = 26) and Exparel‑treated (Black) (n = 26) patients. (a) Daily averages through study overall. Trend in
decreased opioid morphine equivalent from postoperative day 2–5. (B) Exparel‑treated acute care surgery patients required fewer opioid morphine
equivalent from postanesthesia care unit through postoperative day 5. Data include exploratory laparotomy procedures including lysis of adhesions,
ileostomy creation and take down, gastric ulcer repair, cholecystectomy, and splenectomy in non‑Exparel® (n = 12) and Exparel® (n = 3) patients.
(c) Exparel® reduces opioid morphine equivalent from postoperative day 2 to 5 in patients undergoing laparotomy, either small or large bowel
resection in non‑Exparel® (n = 5) and Exparel® (n = 7). (d) Exparel® reduces opioid morphine equivalent requirements from the postanesthesia care
unit ‑ postoperative day 2 in patients undergoing laparoscopic hand‑assisted colectomy non‑Exparel (n = 2) and Exparel® (n = 4)
Non exparel 10 810111010
Exparel 9131514146
Number of
Non exparel 12 13 9855
Exparel 15 12 7630
Non exparel
Post operative pain scores
Mild Moderat
(n = 26) (n = 26)
Average pain score
(n = 26) (n = 26)
(n = 25) (n = 25)
(n = 26) (n = 26)
(n = 22) (n = 22)
Average pain score
(n = 19). (n = 18)
(n = 16) (n = 8)
Figure 3: Exparel® reduces severe postoperative pain. (a). Number of patients with mild, moderate, or severe postoperative pain throughout
the entire study. Fewer Exparel‑treated patients report severe postoperative pain on the postoperative day 0–5 in comparison to non‑Exparel®
group. (b) Average postoperative pain scores in postanesthesia care unit through postoperative day 5. Trend in reduction of pain scores on the
postoperative day 2–4 in Exparel® group
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 243
Introduction: Clostridioides difficile infection (CDI)
is one of the most common healthcare‑associated
infections and is plagued with a high rate of recurrence.
National guidelines do not routinely recommend oral
vancomycin prophylaxis (OVP); however, limited
retrospective data demonstrate an inconsistent but
potential benefit with the use of OVP to prevent
recurrent CDI in patients, with a history of such, when
they are started on systemic antibiotics. The objective
of this research is to assess the efficacy of OVP use in
this setting at St. Luke’s University Health Network
Methods: This study retrospectively evaluated
patients admitted to a SLUHN Hospital between
June 1, 2018, and September 30, 2019, with a
medical history of CDI who were initiated on systemic
antibiotics during the admission, with or without
OVP. Patients started on OVP more than 24 h after
initiating systemic antibiotic therapy, transferred
to an outside facility before systemic antibiotic
completion, expired within 48 h of admission, who
were duplicates, or who had their OVP discontinued
before completion of systemic antibiotic therapy were
excluded. The primary objective was to evaluate the
CDI recurrence from initiation of systemic antibiotics
until 30 days after their discontinuation. Categorical
data were analyzed using the Chi‑square or Fisher’s
exact tests; parametric and nonparametric, continuous
data were analyzed using the Student’s t‑test and the
Mann–Whitney U‑test, respectively. A P < 0.05 was
used to determine statistical significance.
Results: A total of 489 patients were screened and 102
were included in the primary analysis. Of these patients,
54 patients were in the OVP group and 48 patients were
in the control group. There was no significant difference
between the two groups with regard to baseline
demographics, level of care, PPI/H2RA = Proton Pump
Inhibitor/ H2 Receptor Blocker or probiotic use in the
hospital, total number of prior CDI episodes, and time
since the last CDI. Type of systemic antibiotic exposure
was similar except for statistically significantly more
patients in the OVP group receiving third‑ and fourth‑
generation cephalosporins (83.3% vs. 47.9%, P < 0.01).
Mean systemic antibiotic duration was statistically, but
not clinically, significantly longer in the OVP group (6.24
vs. 6.12 days, P = 0.036). The primary outcome of CDI
recurrence from the initiation of systemic antibiotics
until 30 days after their completion occurred in only
one patient in the OVP group and none in the control
group (P = 0.34). CDI recurrence at 90 days from the
initiation of systemic antibiotics was also similar between
OVP and control groups (3.7% vs. 0%, P = 0.53). No
differences in the length of stay or 30‑day mortality,
VRE Vancomycin‑resistant enterococcus infection/
colonization, or hospital readmission were seen.
Conclusion: Despite the high‑risk nature of the
patients included, the use of OVP at SLUHN was not
associated with a lower incidence of CDI recurrence
or improved outcomes. This was likely due to higher
rates of third‑ and fourth‑generation cephalosporin
use in the OVP group and the very low baseline level
of recurrent CDI seen at SLUHN compared to other
Figure 4: Exparel® reduces acute pain scores (APS) throughout surgical specialties. (a) Exparel® reduces APS in acute care surgery postoperative
day 2–4. (b and c) Exparel® reduces APS in open and minimally invasive colorectal surgery. (d) Exparel® reduces pain scores following (OBGYN)
Obstetric/Gynecologic surgery from postanesthesia care unit through postoperative day 5. (e) Exparel® reduces postoperative pain in surgical
oncological and urological procedures best seen on the postoperative day 2
Non Exparel 4454442
Exparel 455122
APS following
Acute Care surgery
Non Exparel 5445554
Exparel 4333311
APS following
Open Colorectal Surgery
Non Exparel 735540
Exparel 354322
APS following
Minimally Invasive
Colorectal Surgery
Non Exparel 567600
Exparel 344331
APS following
Non Exparel 6668445
Exparel 6663435
APS following
Surgical Oncology and Urology
Conference Abstracts and Reports
244 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
studies (0% vs. 20%–30%). Given the inconsistency
in results reported across various retrospective and
limited prospective trials, larger prospective studies
are needed to further determine the role of OVP
in reducing the risk of CDI recurrence in patients
receiving systemic antibiotic therapy.
Efficacy of Intravenous Lidocaine Infusion for Renal
Colic versus Nonrenal Colic Pain in the Emergency
T. S. Bartol1, J. T. Binstead1, J. D. Miller1, L. Koons1
1Pharmacy Residency, Bethlehem, PA, USA
Introduction: Studies have shown that intravenous
(IV) lidocaine infusions are an effective analgesic for
renal colic pain. However, its efficacy for other pain
conditions is less conclusive. The objective of this
study is to assess if IV lidocaine can be used as an
effective analgesic in the emergency department (ED)
for nonrenal colic pain.
Methods: A retrospective chart review was completed
that included patients treated at one of the ten hospital
EDs within a community health network who received
IV lidocaine for pain during a 26‑month period.
Pregnant patients and those who received IV lidocaine
for a nonpain condition were excluded. Patients were
classified into two groups: those diagnosed with
renal colic pain and those with nonrenal colic pain.
The primary outcome was need for rescue analgesia
after the IV lidocaine infusion, and the secondary
end points included 30‑day ED revisit for the same
diagnosis, oral morphine equivalents administered,
opioid(s) prescribed at discharge, adverse effects, and
change in pain score. Statistical analyses performed
included the Chi‑square or Fisher’s exact tests for
categorical data, and continuous data were interpreted
using the Student’s t‑test or Mann–Whitney U‑test,
as appropriate.
Results: The study included 61 patients – 21 patients
in the renal colic group and 40 patients in the nonrenal
colic group. Baseline characteristics were similar
between groups. The need for rescue analgesia after
lidocaine infusion did not differ significantly between
the renal colic and nonrenal colic groups (28.6% vs.
40.0%; P = 0.55). The use of opioids as a rescue
analgesia also did not differ significantly between the
groups (9.5% vs. 17.5%; P = 0.48). A change in
pain score of ≥20% (57.1% vs. 45.0%; P = 0.53)
and incidence of adverse events (9.5% vs. 20.0%;
P = 0.47) were not significantly different between
the groups. More patients in the renal colic group
received opioid prescriptions at discharge than the
nonrenal colic group (42.9% vs. 12.5%; P = 0.02).
Conclusion: Previous studies suggest that IV
lidocaine is effective in relieving renal colic pain, with
less conclusive results for nonrenal colic pain. Based on
the results of this study, an IV lidocaine infusion may
be a safe and effective analgesic option for nonrenal
colic pain. Larger, prospective studies are warranted
to find a definitive benefit in nonrenal colic patients.
Impact of Vancomycin with or without Antistaphylococcal
Beta Lactam for Empiric Treatment of Intensive Care
Unit Patients with MSSA Bacteremia
M. Lipski1, S. C. Depcinski1, A. N. Kester1
1Pharmacy Residency, Bethlehem, PA
Introduction: Staphylococcus aureus is the leading
cause of Gram‑positive bacteremia in the United
States and is associated with significant morbidity
and mortality, with critically ill patients at the
highest risk. Patients with a Charlson comorbidity
index score ≥2 and a critical care unit admission
are at even greater risk, with an estimated twofold
increase in mortality. The high incidence of
methicillin‑resistant S. aureus warrants empiric
treatment with vancomycin; however, vancomycin
has been shown to be inferior to antistaphylococcal
beta lactam (ASBL), such as cefazolin or nafcillin,
for the definitive treatment of MSSA bacteremia.
Despite this, it is unknown if ASBL use earlier in
therapy will impact clinical outcomes. The purpose
of this study was to determine if the addition of an
ASBL to empiric vancomycin treatment can improve
clinical outcomes in critically ill adults with MSSA
Methods: This retrospective cohort was submitted
to the St. Luke’s University Health Network
(SLUHN) Institutional Review Board and
approved as exempt. Critically ill adults with
MSSA bacteremia who were admitted to a SLUHN
Hospital between April 2018 and September 2019,
empirically treated with vancomycin alone or
vancomycin plus an ASBL, and definitively treated
with an ASBL were included in this study. Patients
who expired within 48 h of initial MSSA blood
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 245
culture or presence of a polymicrobial bacteremia
were excluded. The primary composite end point
of clinical failure was assessed and defined as 90‑
day all‑cause mortality, persistence of bacteremia
at 3‑7 days, or recurrence of MSSA bacteremia
within 90 days. The following secondary outcomes
were assessed: individual composite end points,
time to blood culture clearance, hospital length of
stay, critical care length of stay, acute kidney injury
within 7 days, and Clostridioides difficile infection
within 30 days. Chi‑square test, Fisher’s exact test,
Student’s t‑test, and Mann–Whitney U‑test were
used to compare the treatment groups (significance
set at a P < 0.05).
Results: A total of 29 patients were included for
analysis (vancomycin plus ASBL combination, n = 19;
vancomycin monotherapy, n = 10). Empiric treatment
with a combination therapy was not associated with
a difference in the rate of clinical failure compared to
monotherapy (57.9% vs. 60.0%, P = 1.00). Ninety‑day
mortality was not significantly lower with combination
therapy compared to monotherapy (36.8% vs. 60.0%,
P = 0.24). The rate of persistent bacteremia was not
significantly higher in the vancomycin plus ASBL
group compared to vancomycin‑alone group (26.7%
vs. 14.3%, P = 0.64). There were no cases of recurrent
MSSA bacteremia in either group.
Conclusion: In critically ill adults with MSSA
bacteremia definitively treated with an ASBL, the early
addition of an ASBL to empiric vancomycin did not
result in significant improvement in the rate of clinical
failure compared to vancomycin alone. However,
due to the limited number of patients evaluated and
multiple differences in baseline characteristics between
the two groups, this topic warrants further research
with large, multicenter cohort studies or randomized
controlled trials.
Prehospital End‑Tidal Carbon Dioxide Measurement
as an Early Marker for Transfusion Requirement in
Trauma Patients
N. Akers1, B. R. Wilson1, R. K. Jeanmonod1
1Emergency Medicine Residency, Bethlehem, PA
Introduction: Below normal end‑tidal carbon dioxide
measurement (ETCO2) is associated with worse
outcomes in sepsis and trauma patients as compared
to patients with normal ETCO2. We sought to
determine if ETCO2 can be used in the prehospital
setting to predict transfusion requirement, operative
hemorrhage control, or mortality in the first 24 h after
admission for trauma.
Methods: This is a retrospective cohort study at a
suburban, academic level 1 trauma center. Patients
were sequentially identified as prehospital trauma
alerts from a single (EMS) Emergency Medical
Services system which requires, per policy, ETCO2 for
all traumas. One‑year prehospital data were collected
and paired with the hospital trauma registry data.
Comparisons were made between ETCO2 values for
patients who required transfusion, with operative
blood loss control, or who died and those who did not.
Results: Two hundred and thirty‑five trauma
patients were transported via the study EMS
system, of which 105 (44.7%) had documented
ETCO2 values. The patients’ mean age was 60
(standard deviation 24) years with 59 (56.2%)
males [Table 1]. Three patients were intubated
prehospital, and seven were intubated in the trauma
bay. The mean prehospital ETCO2 for those who
needed transfusion, surgery, or died (n = 11) was
25.7 (9.1) compared to 30.6 (7.8) for those who
did not (P = 0.049). The optimal cutoff for our
population was ETCO2 ≤27. Characteristics of the
transfused group are shown in Table 2. The receiver
operating characteristic curve is shown in Figure 1.
Conclusion: Below normal ETCO2 values were
associated with increased need for transfusion,
operative intervention, and death. Further study is
warranted to determine if ETCO2 outperforms other
predictors of severe trauma.
Lidocaine for the Treatment of Acute Pain Syndromes
M. Corrigan1, J. T. Binstead1, L. Koons1, K. W. Miller1
1Emergency Medicine Residency, Bethlehem, PA, USA
Introduction: Lidocaine is a medication more
commonly used in cardiology and as a local anesthetic;
however, recent journal articles suggest lidocaine’s
effectiveness in systemic pain relief. Lidocaine is
classified as an amide, local anesthetic and exerts
its effects by inhibiting impulse conduction on
neurons, blocking voltage‑gated sodium channels
peripherally and centrally.[1] Lidocaine also has
potent anti‑inflammatory properties, and infusion
Conference Abstracts and Reports
246 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
of lidocaine is associated with decreased circulating
pro‑inflammatory cytokines.[2] Side effects of
lidocaine toxicity range widely from metallic taste
to central nervous system responses, including
agitation, confusion, and seizure. However, infusion
is generally considered safe at ranges of 0.5–2 mg/kg/h
and patients should be monitored by staff during
infusion.[3] First articles reporting analgesia from
lidocaine were reported for burns, oncological pain,
and postoperative patients.[1,2] More recently, separate
papers have discussed lidocaine as the treatment for
certain complaints in the emergency department,
such as renal colic, migraine, acute limb ischemia, and
chronic pain.[1,2,4] There is support for using lidocaine
in the setting of opiate‑refractory pain including
bowel obstruction and traumatic ankle injury, with a
goal of reducing the use of opiate medications. This
highlights an additional consideration to lidocaine
for systemic pain relief: its use as an opioid‑sparing
pain medication.
Methods: This is a retrospective chart review of
44 patients who received intravenous lidocaine
while in the emergency department for various
painful complaints from July to December 2017. A
specific electronic medical record order set set was
designed and followed before administration of this
medication. This order set included the medication,
dosing options, frequency, time of infusion, route, and
nursing instructions. When selected, recorded weight
is the default for dosing calculations and lidocaine was
dosed at 1.5 mg/kg. Time of infusion and route are not
customizable and set at 30 min intravenously. Nursing
instructions include obtaining vital signs, oxygen
saturation, and pain scores before the administration
of lidocaine, every 15 min during infusion, and before
disposition. Further safety instructions are included
for nursing staff to notify a physician and stop the
infusion at signs of toxicity. Lidocaine toxicity was
classified (from minimal to severe) using a pre‑defined
scale. In addition, if oxygen saturations decrease to
90%, per ordering protocol, nursing staff is to apply
supplemental oxygen at 2 L/min, to hold the lidocaine
infusion, and to notify the physician.
Results: Out of the 44 patients included in the study,
29 did not require treatment with a narcotic agent after
infusion while 15 patients received narcotic analgesia
after lidocaine infusion. There were two patients who
Table 1: Baseline characteristics of study participants
Parameter Total (n=105)
Median age (IQR) 61 (38-82)
Gender (%)
Male 59 (56.2)
Female 46 (43.8)
Mechanism of injury (%)
Motor vehicle crash 22 (21)
Motorcycle/bicycle crash 5 (4.8)
Fall 60 (57.1)
Pedestrian versus vehicle 5 (4.8)
Assault 6 (5.7)
Penetrating trauma 3 (2.9)
Other/not recorded 4 (3.8)
Trauma designation (%)
Level A 22 (21)
Level B 79 (75.2)
Not documented 4 (3.8)
Injury severity score (%)
15 90 (85.7)
>15 12 (11. 4)
Not documented 3 (2.9)
Intubation status
Not intubated 95 (90.5)
Intubated by EMS 3 (2.9)
Intubated in the ED 7 (6.5)
May not sum to 100% due to rounding. IQR=Interquartile range,
EMS=Emergency medical systems, ED=Emergency department
Table 2: Characteristics of patients who required transfusion/
operative hemorrhage control versus those who did not
Median (CI) Requiring
Not requiring
ETCO225.5 (22.5-30.3) 31.9 (29.5-33.5) 0.049*
Hemoglobin, mean (CI) 9.8 (7.4-12.2) 13.1 (12.7-13.5) <0.0002*
Shock index 0.82 (0.56-1.22) 0.61 (0.57-0.66) 0.02*
Respiratory rate 21 (20-26.1) 20 (20-20) 0.21
Heart rate 90 (73.7-125) 90 (84-96) 0.28
Systolic blood pressure 115.5 (89.5-140) 146 (140-151) 0.003*
*Statistical significance. CI=Confidence interval, ETCO2=End-tidal
carbon dioxide measurement
Figure 1: Receiver operating characteristic (ROC) curve of end‑tidal
carbon dioxide measurement as a predictor of need for transfusion,
operative hemorrhage control, or death in trauma patients within 24 h
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 247
experienced brief and transient adverse reactions: one
patient had transient hypotension and one patient had
sensation of pins and needles and fatigue which resolved
without intervention. Most common complaints treated
with lidocaine included flank pain with and without
known stones and acute and chronic back pain. Patient
pain syndromes treated with intravenous lidocaine also
included sickle cell pain crisis, fibromyalgia, migraine,
groin pain, abdominal pain, and constipation.
Conclusion: Most common complaints treated with
lidocaine included flank pain with and without known stones
and back pain. Other patient pain syndromes treated with
intravenous lidocaine also included sickle cell pain crisis,
fibromyalgia, migraine, groin pain, abdominal pain, and
constipation. The administration of intravenous lidocaine
(per protocol) was a safe and effective adjunct to standard
medical therapy in the treatment of acute pain syndromes.
1. Golzari SE, Soleimanpour H, Mahmoodpoor A, Safari S, Ala A. Lidocaine
and pain management in the emergency department: A review article.
Anesth Pain Med 2014;4:e15444.
2. Kandil E, Melikman E, Adinoff B. Lidocaine Infusion: A Promising
Therapeutic Approach for Chronic Pain. J Anesth Clin Res 2017;8:697.
3. Eipe N, Gupta S, Penning J. Intravenous lidocaine for acute pain: An
evidence‑based clinical update. BJA Education 2016;16:292‑8.
4. Farahmand S, Hamrah H, Arbab M, Sedaghat M, Basir Ghafouri H, Bagheri‑
Hariri S. Pain management of acute limb trauma patients with intravenous
lidocaine in emergency department. Am J Emerg Med 2018;36:1231‑5.
A Unique Presentation of Severe Dysautonomia in
Guillain–Barre Syndrome
A. Shaji1, M. A. Ritenuti1, D. Raheja1
1Neurology Residency Program, Richard A. Anderson Campus,
Easton, PA, USA
Introduction: Guillain–Barre syndrome (GBS)
is an acute monophasic illness usually provoked
by a preceding infection. Approximately 70% of
patients present with dysautonomia, which can be
severe in up to 20% of cases. Common symptoms
include tachycardia, urinary retention, hypertension
alternating with hypotension, orthostatic hypotension,
bradycardia, arrhythmias, ileus, and anhydrosis. Here,
we report a unique presentation of GBS with severe
Case Scenario: A 76‑year‑old woman with history
of lumbar degenerative disease (previously treated
with spinal stimulator), diabetes, and hypertension,
presented with acute‑onset, diffuse pain and paresthesias
in all four extremities. She reported recent sinusitis
and current urinary tract infection (UTI). She was
treated for UTI and discharged with the diagnosis of
diabetic neuropathy. She presented 3 days later with
a generalized tonic–clonic seizure in the setting of
accelerated hypertension (243/109 mmHg). Computed
tomography (CT) of the head was unremarkable, and
electroencephalogram revealed diffuse intermixed delta/
theta slowing without epileptiform discharges. One
week later, she presented again with acute‑onset right
gaze preference and right‑sided weakness (NIHSS 22).
Rapid improvement of focal deficits occurred within 20
min with residual encephalopathy, which progressed
over the subsequent day into bizarre behaviors and
delusions with visual ataxia, agnosia, and hallucinations.
CT of the head (CTH) showed a subtle area of decreased
attenuation within the right cerebellum. Repeat
imaging 9 days later demonstrated bilateral occipital
hypodensities. She subsequently developed urinary
retention with obstructive hydroureter. Neurologic
examination revealed weakness, areflexia, ataxia, and
diminished vibration sensation in the distal aspect of
all four extremities. She received 5 days of high‑dose
steroids, with improvement in cognition, but with
persistent extremity symptoms.
Conclusion: Overall, the patient’s clinical course is
consistent with GBS. We suspect that she developed
severe dysautonomia which led to urinary retention,
hyponatremia with SIADH‑like features, accelerated
hypertension, leading to a posterior reversible
encephalopathy syndrome (PRES), manifesting
as encephalopathy/delirium, visual disturbance/
hallucination, and seizures. The high‑dose pulse
intravenous (IV) steroids initially used to empirically
treat presumptive encephalitis unknowingly may have
treated PRES (based on evidence from published
case reports). CTH abnormalities were isolated to
the posterior circulation, consistent with changes
seen in PRES (spinal stimulator precluded magnetic
resonance imaging). Electromyogram confirmed the
diagnosis; she was treated with IV immunoglobulin
with gradual improvement.
Electrosurgical Techniques for Salpingectomies: Is
There Any Difference?
D. Tang1, J. N. Anasti1
1Temple/St. Luke’s Medical School, Bethlehem, PA, USA
Conference Abstracts and Reports
248 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
Introduction: Female or male sterilization is the
most common form of contraception utilized in the
United States. Each year, about 700,000 women
undergo tubal ligation with half being performed at
the time of delivery and half by an interval laparoscopic
procedure. In the past, tubal ligation was accomplished
by simply coagulating or mechanically occluding a small
portion of the tube. Recently, it has been suggested
that the majority of ovarian cancer may begin in the
distal portion of the fallopian tube. This has caused
gynecologic surgeons to rethink the current sterilization
paradigms, moving from simple occlusion to total
removal of the tubes (i.e., bilateral salpingectomy).
The rationale is that the removal of the entire tube
may decrease the incidence of ovarian cancer. There is
limited literature looking at the best way to perform
this now common gynecologic procedure. Our study
design includes retrospective cross‑sectional analysis
to compare the outcomes of various electrosurgical
modalities (Kleppinger™ [KS], LigaSure™ [LS],
and Enseal™ [ES]) that are commonly utilized in
salpingectomies. Opportunistic salpingectomy has been
increasingly utilized as a means of female sterilization
and prevention of ovarian carcinoma. However,
comparisons of different techniques employed in the
salpingectomy have not been well studied. Therefore,
we performed a retrospective chart review of commonly
employed laparoscopic electrosurgical methods to
elucidate any clinical differences.
Methods: Charts of patients who had undergone
laparoscopic bilateral salpingectomy during the
last 4 years were identified with gathering of basic
demographic details (age, body mass index [BMI],
gravidity, parity, and medical and surgical history).
Operative and postoperative notes were reviewed
to discern the instrument used for salpingectomy
as well as operative times and complications.
This particular abstract focuses on differences
in operating times, intra‑ and post‑operative
complications, and differences in patient pain scores
postoperatively. All procedures were performed at a
large teaching hospital. Demographic information,
complications, and operative times were reviewed
from salpingectomies performed employing various
electrosurgical techniques. In addition, the recorded
pain score (0–10 scale) at 30‑min postoperatively and
at discharge was reviewed. Individual techniques were
compared employing one‑way ANOVA with Student–
Newman–Kuels pairwise comparisons as appropriate.
All values were reported as mean ± standard deviation.
Results: We reviewed 50 salpingectomies employing
each of the following techniques; LS, ES, and KS.
The groups did not differ in age, BMI, parity, or prior
procedures. KS had the longest Operating Room
(OR) times (KS 42 ± 12 min, LS 36 ± 11 min, ES
37 ± 10 min, P = 0.04). LS had the lowest 30‑min
postoperative pain score (LS 2.5 ± 2.8, ES 4.0 ± 3.4,
KS 4.6 ± 3.1, P = 0.008). Pain score at discharge did
not differ between procedures.
Conclusion: In salpingectomy surgery, LS was
associated with shorter OR times compared to KS and
less postoperative pain than ES or KS. The clinical/cost
significance of these findings remains to be determined.
Proximal Splenic Artery Embolization for the
Management of a Geriatric Trauma Patient with High‑
Grade Splenic Injury
D. M. Tang1, J. R. Gacke1, C. Bendas1,2
1Temple / St. Luke’s Medical School, Bethlehem, PA, USA; 2Division
of Surgical Crical Care, St. Luke’s Regional Level I Trauma Center,
Bethlehem, PA, USA
Introduction: Splenic artery embolization (SAE)
remains controversial in the management of patients
aged >55 years with high‑grade splenic injury.
Nonsuperiority of the proximal versus distal SAE
techniques further complicates this decision. Careful
selection of patients in this population may be indicated
for SAE as opposed to operative management (OM)
although data supporting this claim are limited to a
retrospective review of few cases and are disputed. We
discuss a case of blunt abdominal trauma secondary
to a fall, treated with proximal SAE. An 84‑year‑old
female hemodynamically stable (HDS) patient with
abdominal pain and inability to ambulate was admitted
with multiple fractures and high‑grade splenic injury.
A nonoperative approach was requested by the patient,
prompting successful treatment via SAE of the main
splenic artery. Current literature dictating the use of
SAE in the elderly patients with high‑grade splenic
injury is insufficient. Careful selection of appropriate
patients for nonoperative management (NOM) in this
demographic may abrogate the risks associated with
OM. The spleen remains the most common injured
intra‑abdominal organ in blunt abdominal trauma,
mandating expeditious management to avoid the
potential of fatal hemorrhage. The decision to pursue
OM versus NOM in the splenic injury is often dictated
by several parameters, including, but not limited to,
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 249
hemodynamic status, medical comorbidities, injury
severity score, and grade of splenic injury.[1] The
latter often favors HDS patients who are younger
with lower‑grade (e.g., I–II) splenic injury [Table 1].
Justifications for nonoperative approaches to the
management include salvage of functional splenic
tissue and avoidance of the risks associated with surgical
intervention, such as infection and postsplenectomy
sepsis. This case report details the management of a
high‑grade splenic injury in a HDS geriatric patient
who did not wish to pursue surgical intervention,
successfully managed by proximal SAE.
CARE Statement: SAE provides an alternative to OM
in patients who have failed observational approaches
to care; however, the indications for embolization
remain controversial in certain demographic groups.
In patients aged >55 years with higher‑grade splenic
injuries (e.g., III–V), current literature demonstrates
varying efficacy of embolization with respect to
splenic salvage and unsuccessful NOM, with failure
rates approaching 30% in patients aged >75 years.
[1] Moreover, the decision as whether to employ
proximal (i.e., main splenic artery) or distal (i.e.,
selective branches of the splenic artery) embolization
poses additional challenges. Current literature does
not demonstrate clear advantages of one method over
the other, although some literature suggests that distal
techniques may result in higher infection rates.
Case Scenario: An 84‑year‑old woman presented to the
emergency department with complaints of generalized
pain in her abdomen, pelvis, neck, and lower back,
following a fall down eight steps the night prior. The
patient returned to bed following the fall and awoke
the next morning unable to ambulate. Of note, the
patient had a history of recurrent mechanical falls and
was recently widowed 1 week before arrival. Additional
medical history was significant for rheumatoid arthritis,
hypothyroidism, osteoporosis, stress/compression
fractures of T8, T9, and L4, and fixation kyphoplasty
of L2–L3. Primary trauma survey revealed an intact
airway, symmetric breath sounds, intact pulses, and a
GCS of 15. Initial hemodynamic parameters showed
a blood pressure of 120/56 mmHg, pulse of 83 bpm,
and respirations of 18 per minute. Secondary survey
revealed tenderness in the chest wall, abdomen, and
lower back and visible ecchymosis over the neck, left
midaxillary region, and lower rib cage. Hemoglobin
level was 12.3 g/dl, with a nadir of 10.3 g/dl before
embolization. No blood transfusions were administered.
Computed tomography (CT) of the chest, abdomen,
and pelvis demonstrated multiple left‑sided rib fractures,
multiple splenic lacerations extending to the splenic
hilum, perisplenic hemoperitoneum tracking to the
lower abdomen, hematoma of the right obturator
internus, and multiple pelvic fractures including the
pubic bone, inferior pubic rami, right sacral wing, and
left ilium [Figure 1]. Multiple branches of the splenic
arteries beyond third‑order branches demonstrated
active extravasation (i.e., blush) on the celiac and splenic
arteriography [Figure 2]. Nonselective embolization of
the main splenic artery was performed in attempt to
minimize the pressure head of the splenic artery and
decrease the risk of subsequent splenic infarct. Following
embolization of the main splenic artery with two 7‑mm
Amplatzer 4 plugs, contrast injection was administered
displaying decreased flow through the plugs [Figure 3].
Conclusion: The HDS geriatric trauma patient with
higher‑grade splenic and associated injury continues to
be a point of controversy among traumatologists. While
plentiful literature exists supporting the efficacy of NOM
in lower‑grade splenic injuries in those aged <60 years,
there is insufficient evidence to support the same level
of success in those aged >60 years with few studies
comparing the efficacy between these two populations.
[1] Further investigation of NOM of the splenic injury in
the geriatric population is warranted to further establish
the criteria for patients who may benefit from such
approaches to care. Despite avoiding potential morbidity
associated with nontherapeutic laparotomy, failure
of NOM may result in delaying surgical exploration,
which itself carries risk of worsening shock and death.
Psychosocial aspects of patient preference should also be
considered when clinically appropriate. Further study is
warranted in this population to optimize patient selection
guidelines when considering OM versus NOM.
Table 1: Splenic injury grading based on anatomic injury
assessed via CT or intraoperatively, derived from the
American Association for the Surgery of Trauma[4]
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250 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
Introduction: Over the past 15 years, opioids have
been overprescribed, which has led to an increase in
the occurrence of opioid addiction. In 2014 alone,
there were a total of 47,055 overdose associated
deaths. Since 2000, the death rate from overdoses
has increased significantly (i.e., >130%). Due to
the rising number of deaths, there is a need to
reduce the amount of prescription opioids that are
dispensed in the United States. Studies have found
that those patients who receive care from a physical
therapist (PT) have a significantly decreased risk of
needing opioid medications. Furthermore, PTs are
trained in pharmacology, and PTs in the military
have been prescribing medications effectively for
Methods: SLUHN has taken steps to reduce
healthcare costs by innovating a comprehensive
spine program, which allows patients with acute
low back pain and neck pain to be triaged to the
appropriate healthcare provider, with PT being
one of the professions of choice. PTs with direct
access licenses have undergone specialized training
to participate in the program. When a patient goes
through the spine program, the data are stored in
the REDCap database. It was explored that during
the direct access treatments, if the PT felt that a
medication was required, a physician was contacted,
and they prescribed a medication.
Results: The comprehensive spine program had 27
recorded patients to whom medication was prescribed.
Of those 27 patients, one was excluded because there
was no medication prescribed throughout the plan
of care, and two others were excluded due to being
chronic pain patients. PTs assisted in prescribing
medication to the remaining 24 patients who met
the criteria of acute spine pain. PTs matched the
physicians’ prescription correctly (58.33%). There
was a 37.5% partial match to what the physician
prescribed. Finally, there was one non‑match (4.17%);
however, it was recognized that the patient required
medication and the PT was able to decrease the time
it took to prescribe the medication.
Conclusion: In conclusion, PTs were able to identify
with high accuracy (i.e., 100%) when a prescription
medication was required. This, in turn, may be
potentially helpful in reducing the consumption of
opioids and therefore prescription‑related deaths in
the U.S.
Figure 2: Pre‑embolization arteriography demonstrating active
extravasation of multiple greater than third‑order vessels
Figure 3: Following nonspecic embolization of main splenic artery
establishing decreased ow through the plugs
Figure 1: Pre‑intervention computed tomography of the chest, abdomen,
and pelvis with contrast demonstrates multiple low‑attenuation areas
extending to the splenic hilum and the subcapsular surface, consistent
with splenic lacerations. Perisplenic hemoperitoneum is also seen
which tracks into the lower abdomen
1. Stawicki SP. Trends in nonoperative management of traumatic injuries–A
synopsis. International journal of critical illness and injury science. 2017
Investigation of the Accuracy and Frequency of
Pharmacological Recommendation of Civilian Physical
K. Barry1, S. M. Kareha1
1Orthopedic Physical Therapy Residency, Bethlehem, PA, USA
Conference Abstracts and Reports
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Disproportionately Affected and Underinsured:
Trauma and Violence in Young African‑American and
Latino Men Extend Beyond Major Urban Centers
A. L. Gifford1, R. Castillo1, N. J. Stewart1, J. Cipolla1,
P. G. Thomas1, B. A. Hoey1, S. P. Stawicki1
1Department of General Surgery
Introduction: Studies from large urban trauma
centers show that African‑American men (AAM) and
Latino men (LM) are disproportionately affected by
the current violence epidemic. The study goal was
to evaluate whether similar disparities exist outside
of densely populated urban areas. Our Level I
Trauma Center’s (L1TC) catchment area consists of
small/medium‑sized cities and surrounding nonurban
areas. We hypothesized that AAM and LM are both
underinsured and disproportionately affected by
penetrating trauma.
Methods: This study was a retrospective analysis
of our L1TC Registry between January 2010 and
December 2016. Variables queried included patient
demographics, all‑cause mortality, length of stay,
discharge destination, injury severity score, trauma
mechanism, and insurance score (number of health
insurance policies per patient on admission). Group
comparisons were performed using Chi‑square test for
categorical data and ANOVA/Kruskal–Wallis testing
for normally and nonnormally distributed continuous
data, respectively. Statistical significance was set at
α < 0.01.
Results: A total of 12,082 patients were analyzed.
Of those, 10,364 were identified as Caucasian, 938
as multiracial, 672 as African‑American, and 108 as
Asian. A total of 1326 (10.98%) were identified as
Hispanic/Latino. Compared to Caucasian men (CM),
AAM and LM were disproportionately affected by
penetrating trauma (P < 0.01). Both AAM and
LM were underinsured when compared to CM
(P < 0.01). Similar but less pronounced trends were
seen for analogous comparisons for female patients
[Table 1].
Conclusion: Our L1TC data show that disparities for
African‑American and Latino trauma patients exist
beyond major urban areas. In addition to ongoing
efforts on ensuring socioeconomic equity, aggressive
community outreach is required to educate young
AAM and LM regarding trauma/injury prevention.
Table 1: Group comparisons for key study outcomes
Age (mean) 50.5 34.5 35.8 63.6 38.4 43.9
Mortality (%) 3.34 2.84 2.07 2.30 1. 21 2.21
ISS (mean) 8.23 7.32 7.24 7.53 5.34 6.67
Penetrating mechanism (%) 4.70 20.6 10.7 1.7 6 4.35 4.47
LOS (days) 4.15 3 .14 3 .17 3.98 3.52 3 . 17
Home discharge (%) 70.0 82.0 81.4 54.1 72.2 76.2
Insurance score 1.33 0.99 1.08 1.55 1.26 1.35
Differences in trauma mechanisms and insurance status are highlighted in
shaded boxes. CF=Caucasian female, AAF=African American Female,
LF=Latina female, ISS=Injury severity score, LOS=Length of stay
Diverse Presentation in Rare Creutzfeldt‑Jakob Disease
– Case Report
A. Mendez1, D. Raheja1, A. C. W. Lasker1
1Neurology Residency Program, Richard A. Anderson Campus,
Easton, PA, USA
Introduction: Creutzfeldt‑Jakob disease (CJD) is a
rare and fatal disorder, with rapid neurodegeneration
that has an estimated yearly incidence of one in
1 million cases worldwide and 350 cases in the
United States. CJD is suspected in cases with rapidly
progressive dementia, especially if accompanied
by myoclonus, ataxia, and/or visual disturbance.
Diagnosis is supported by periodic sharp waves on
electroencephalogram (EEG), positive 14‑3‑3 CSF
assay, hyperintensity in the caudate nucleus/putamen
and/or in at least two cortical regions on DWI or
FLAIR magnetic resonance imaging and RT‑QuIC.
Here, we present two cases of CJD to exemplify varied
presentations and different challenges encountered
during the clinical workup.
CARE Statement: CJD is a rare neurodegenerative
disorder that yearly affects one in 1 million people
worldwide and 350 people in the United States. At
SLUHN we had the opportunity to care for two
patients with this devastating disease. This case report
was written to reflect on the varied presentations of
CJD in patients. Our hope is to bring awareness to
the SLUHN community to rapidly identify these
patients and improve the quality of life for them and
their loved ones.
Case Scenario: First case involves a 62‑year‑old male
who presented initially with 3 months of fatigue,
sleep difficulties, progressive dysarthria, diplopia,
and balance disturbance. Examination showed
mild dysarthria, diplopia with lateral gaze, normal
strength with ataxic finger‑to‑nose and heel‑to‑shin.
Initial workup including MRI, lumbar puncture,
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252 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
electromyogram with repetitive nerve stimulation,
paraneoplastic panel, and lumbar puncture were
inconclusive. Given his oculobulbar symptoms and
negative laboratory studies, seronegative myasthenia
gravis was considered, and he was empirically treated
with plasmapheresis and pyridostigmine, which
mildly improved vision. Progressive symptoms
with hoarseness, visual hallucinations, and truncal/
limb ataxia led to repeat workup. MRI of the brain
then revealed abnormal restricted diffusion and T2
prolongation in the right corpus striatum, minimal
findings on the left caudate and bilateral thalami
with sparing of the internal capsule. EEG showed
diffuse generalized slowing. Positive CSF 14‑3‑3
assay with RT‑QuIC achieves approximately 98%
probability. Second patient is a 66‑year‑old female
who presented to the emergency department with
2 weeks of right hand tremors, weakness, slowing
of speech, and dizziness. Examination revealed high
blood pressure (200 systolic), effortful speech with
apraxia, and tremor of the right upper and lower
extremities, with varying amplitude/frequency
and normal strength/tone. Initial brain MRI was
reported normal. EEG revealed bilateral paracentral
periodic epileptiform discharges with intermittent
bursts of rhythmic activity, as the patient became
more encephalopathic. She was empirically treated
with steroids, plasmapheresis, and AEDs without
improvement. Repeat MRI revealed evidence for CJD,
including the presence of bright cortical ribboning on
DWI and CSF positive for 14‑3‑3.
Conclusion: Similar workups were initially
inconclusive for both patients, who passed away
within months of symptom onset, consistent with
the usual progression of this devastating disease.
These cases highlight the varied clinical presentations,
demonstrating the importance of considering CJD
workup in patients with rapidly progressive cognitive
decline to maximize quality of life.
Efficacy of an Enhanced Recovery after Surgery (ERAS)
Protocol for Orthopedic Spinal fusion Procedures
A. Malige1, G. Sokunbi1
1Orthopaedic Surgery Residency, Bethlehem, PA, USA
Introduction: Spine surgeons often turn to spinal
fusions as a last resort for patients with back and lower
extremity symptoms that are not well controlled by
a combination of physical therapy, a comprehensive
pain regimen, epidural steroid injections, and other
alternative modalities. Regardless of whether patients
have acute or chronic conditions causing these
symptoms, they often rely on opioid medications to
help with their pain control. Narcotic medications are
still the mainstay for postoperative pain regimens, and
patients may endure significant side effects associated
with these medications, including nausea, vomiting,
constipation, and ileus, leading to an increased length
of hospital stay. More recently, enhanced recovery
after surgery (ERAS) protocols have been utilized
across the nation for various surgeries. In 2018, the
orthopedics, anesthesia, perioperative nursing, and
pharmacy departments worked together to construct
and implement an ERAS protocol for orthopedic
spine procedures, with the goal of helping to reduce
opioid use in the postoperative period. This project
highlights our ERAS protocol specifically for
multilevel cervical and lumbar spinal fusions and the
effect it had on changing opioid consumption in the
postoperative period.
Methods: A retrospective chart review was performed
on all patients undergoing spinal surgery in 2016.
All patients older than 18 years of age undergoing
primary spinal fusions were included. Patients were
excluded if they underwent revision surgeries or
spinal surgeries that did not include a fusion. We
reviewed a group of 70 patients in 2016 before
our ERAS protocol was created. Seventy patient
charts were then reviewed in 2019–2020 after our
ERAS protocol for multilevel spine fusion was in
place. Components of the ERAS protocol include
primary utilization of nonnarcotic medications
during the preoperative period (acetaminophen and
gabapentin), the intraoperative period (ketamine
and dexmedetomidine), and in the postoperative
period (acetaminophen, gabapentin, and muscle
relaxants), with the goals of allowing for minimal use
of narcotic medications in the postoperative period.
For each patient, length of stay, re‑admissions, day
out of bed, and the amount of opioid (type of opioid,
dose of opioid, and frequency of use) used in the
immediate recovery period (postanesthesia care unit
stay) until day of discharge were ascertained. Using
an oral morphine equivalent (OME) conversion
chart [Table 1], we were able to calculate a patient’s
daily average OME requirement (i.e., how much
opioid was used in the postoperative period on a
daily basis). The difference in outcomes between
patients having surgery after the ERAS protocol
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International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 253
was implemented and patients before this protocol
was implemented was compared using descriptive
statistics and independent t‑tests. For all analyses, P
< 0.05 denotes statistical significance (IBM SPSS
Version 23 Statistics for Windows, Armonk, NY:
IBM Corp).
Results: Overall, 129 patients were included in our
cohort: 63 from the ERAS group and 66 in the
non‑ERAS group. Fifty patients underwent cervical
procedures (23 ERAS and 27 non‑ERAS), and 79
underwent lumbar procedures (40 ERAS and 39
non‑ERAS). Forty‑seven patients underwent anterior
fusions (21 ERAS and 26 non‑ERAS), and 78
underwent posterior fusions (38 ERAS and 40 non‑
ERAS). The orthopedic spinal fusion ERAS protocol
had a high compliance of the majority, if not all, of
its measures (>90% compliance). The ERAS group
had a higher percentage of patients with low narcotic
usage postoperatively (67% in the 0–40 OME range)
compared to the non‑ERAS group (23% in the 0–40
range). The average OME requirement was significantly
lower in the ERAS group compared to the non‑ERAS
group (41.94 vs. 79.90 OME, P < 0.01). However,
the hospital length of stay (4.10 vs. 3.61 days, P =
0.15), postoperative day out of bed as pain permitted
(0.54 vs. 0.39 days, P = 0.18), and readmission rate
(18.9% vs. 9.1%, P = 0.25) were statistically similar
between the ERAS and non‑ERAS groups. Key study
outcomes are show in Figures 1 and 2.
Conclusion: The ERAS protocol significantly
decreases narcotic usage in patients undergoing spinal
fusions. The effectiveness of this protocol, as well
as the high rates of compliance to this protocol by
patients and providers, shows that not only should this
protocol continue to be used in spine fusion surgeries
but it should also start being implemented in other
orthopedic procedures associated with high levels of
postoperative pain.
YouTubeTM Education Improves Patient Understanding
of Management of Bleeding on Dual‑Antiplatelet
M. Krinock2, M. N. Katz2, K. Shah1, V. Yellapu1,
J. Shirani2
1Internal Medicine Residency and 2Cardiology Fellowship,
University Hospital Campus, Bethlehem, PA
Introduction: Since the advent of percutaneous
coronary intervention (PCI), the mortality rate of
acute myocardial infarction has significantly decreased.
Despite advancements in angioplasty and coronary stent
technology, compliance with dual‑antiplatelet therapy
(DAPT) remains critical. Although physicians routinely
educate patients on the importance of DAPT after PCI,
it is unclear if bedside patient education is retained in the
Table 1: Oral morphine equivalent conversion chart
Narcotic medication Narcotic dose OME conversion
PO dilaudid 1 mg 4 OME
IV fentanyl 100 mcg 30 OME
PO vicodin 5 g 5 OME
PO oxycodone 5 mg 7.5 OME
PO tramadol 50 mg 5 OME
IV morphine 1 mg 3 OME
OME=Oral morphine equivalent
Figure 1: Oral morphine equivalent requirements for enhanced
recovery after surgery patients
Figure 2: Oral morphine equivalent requirements for nonenhanced
recovery after surgery patients
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254 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
long term. Standard print patient education pamphlets
are routinely used upon patient discharge, but their
effectiveness has not been systematically studied. For
certain patients, supplementation of the handouts with
YouTubeTM educational videos may prove beneficial.
We aimed to evaluate the impact of supplemental
contemporary bedside patient education via a YouTubeTM
video on patient understanding of their condition and the
importance of compliance with DAPT after PCI.
Methods: Patients who underwent PCI within the past
24 h were screened via an electronic health record system.
The objectives of the study were explained to the patients,
and informed consent was obtained. A four‑question
preintervention test was administered [Table 1], and
an educational YouTube TM video on an iPad or laptop
computer was provided. Patients then answered the same
four questions as the postintervention test. Inclusion
criteria were patients aged ≥18 years, having undergone
PCI in the last 24 h, and having been prescribed DAPT.
Exclusion criteria were non‑English speaking and inability
to provide informed consent.
Results: A total of 18 patients were enrolled. The
average age of the participants was 63 and seven
were women (38.9%). Two (11.1%) patients had
prior DAPT use, 8 (44.4%) had a medical history
of diabetes, and 10 (55.6%) were former or active
smokers. The average pretest score was 71.75%,
while the average posttest score was 97%. The most
common question answered incorrectly was regarding
nuisance (nonlife‑threatening) bleeds, while on
DAPT. Of those who initially answered this question
incorrectly, all answered it correctly on the follow‑up
postintervention test. Compared to pretest scores, the
average posttest score increased by 25.25%. There
was a statistically significant improvement in the
postintervention test scores measured via two‑tailed
Wilcoxon signed‑rank test (P < 0.05).
Conclusion: Standardized patient education via YouTubeTM
videos is feasible and improves patient understanding of their
overall disease process and understanding of medication
compliance with DAPT after PCI.
Risk Factors for Complications and Return to the
Emergency Department after Interscalene Block using
Exparel® for Shoulder Surgery
A. Malige1, S. T. Yeazell1, G. F. Carolan1
1Orthopaedic Surgery Residency, University Hospital Campus,
Bethlehem, PA
Introduction: Exparel® has recently gained favor for
the use in interscalene regional block for shoulder
surgery. While effective for pain relief, it does have
adverse effects which can lead to postoperative
emergency department (ED) visits. This study aims
to identify any patient risk factors that are associated
with complications, leading to ED return due to
interscalene blocks using Exparel® before shoulder
Methods: A retrospective chart review was performed
for all patients undergoing shoulder surgery with an
Exparel® interscalene block in an 8‑month period. For
each patient, demographic information, comorbidities,
type of block, postoperative complications, ED return
visits, and readmissions were recorded. A five‑factor
modified frailty index and Charles comorbidity
index (CCI) score were calculated. Univariate and
multivariate logistic regressions were conducted to
identify the risk factors associated with increased
complications and return to the ED.
Results: Overall, 352 patients were included,
mostly male, between 51 and 70 years of age, and a
Table 1: Comparison of pre- and post-intervention test scores
showing significant improvement (P<0.05) measured via
two-tailed Wilcoxon signed-rank test
Item Average pretest score Average posttest score
Question 1 77 100
Question 2 83 100
Question 3 33 100
Question 4 94 88
Total 71.75 97.2
P at n0.05 at 18 Figure 1: Minor and major complications based on pulmonary history
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International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 255
body mass index of 25.0–35.0. Fifty‑eight patients
(16.5%) had postoperative complications related
to their Exparel® interscalene block, including
37 (10.5%) minor complications and 21 (6.0%)
major complications that led to return ED visits.
Univariate analysis yielded ASA score (P = 0.03)
as a significant predictor of minor complications.
Multivariate logistic regression analysis yielded ASA
score (P = 0.096, odds ratio = 1.64) as a trending
toward being a significant risk factor for minor
complications. Univariate analysis yielded age (P
= 0.006), ASA score (P = 0.009), and CCI score
(P = 0.002) as the significant predictors of major
complications. Multivariate logistic regression
analysis yielded ASA score (P = 0.049, odds
ratio = 2.25) as the only significant risk factor
for major complications. Key study outcomes are
summarized in Tab les 1‑3 and Figures 1‑3.
Conclusion: Surgeons and anesthesiologists should
strongly consider a patient’s ASA score, in addition
to their pulmonary and cardiac history, when deciding
Table 1: Patients with total, minor, and major complications after Exparel® interscalene block
Complication Total patients (%) Minor complications (%) Major complications (%)
Dyspnea and chest pain 44 (12.5) 28 (8.0) 16 (4.5)
Superficial/skin reaction 6 (1.7) 2 (0.6) 4 (1.1)
Horner’s syndrome 3 (0.9) 3 (0.9) 0 (0.0)
Nausea/vomiting 2 (0.6) 2 (0.6) 0 (0.0)
Multiple/other 3 (0.9) 2 (0.6) 1 (0.3)
Total 58 (16.5) 37 (10.5) 21 (6.0)
Figure 2: Minor and major complications per each ASA score
Figure 3: Minor and major complications based on congestive heart
failure history
whether the patient is an appropriate candidate for
interscalene regional block using Exparel® for shoulder
A Unique Case of Progressive Spasticity and Profound
Brain Atrophy in a Young Female
N. Mufti1, D. Raheja1, C. R. Craven1
1Neurology Residency Program, Richard A. Anderson Campus,
Easton, PA, USA
Introduction: More than 60 types of hereditary spastic
paraplegia (HSP) have been identified. These types can
be classified as pure (mostly spasticity) and complex
(spasticity with neurological features) forms that can be
inherited as autosomal dominant, recessive, or more rarely,
X‑linked disorders. We present a unique case of progressive
spasticity and cortical atrophy in a young woman, who
was eventually diagnosed with spastic paraplegia type
11 (SPG‑11). A 32‑year‑old previously athletic female
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256 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
presented with more than 10‑year history of cognitive
decline and progressive weakness. She was in her usual
state of health up until age 18 when she first presented
with leg pain and difficulty running. Over the next few
years, she continued to decline, was unable to ambulate
without a walker, eventually became wheelchair‑bound.
Similar symptoms started in the upper extremities,
though to a lesser degree, with dysarthria, dysphagia, and
some visual hallucinations. She was noted to have a mild
cognitive impairment, spastic dysarthria, and increased
tone in both lower and upper extremities. Family history
was largely negative for neurocognitive disorders. She was
initially diagnosed with cerebral palsy.
Case Scenario: Laboratory investigations including
CBC, CMP, TSH, B12, ANA, and SPEP were all within
normal range. Arylsulfatase A and long‑chain fatty acids
were unremarkable. Serial brain imaging over the decade
revealed progressive cerebral volume loss, predominantly
in the frontal lobes with normal cerebellar volumes,
thinning of the corpus callosum, and minimal white
matter changes. Electromyogram (EMG) findings were
suggestive of a chronic lower motor neuron involvement.
Due to progressive frontal lobe atrophy and lower motor
neuron findings noted on the EMG, genetic testing
was sent for the ALS‑FTD panel, which showed two
pathogenic mutations in the SPG‑11 gene, known to
cause SPG‑11. SPG‑11 is the most common complex
autosomal recessive disorder of the protein Spastacsin,
on chromosome 15q21.1 which deals with endosomal
trafficking and lysosomal biogenesis.
Conclusion: Defects in this protein resulting in
HSP cause not only spasticity but also parkinsonism,
maculopathy, progressive slow cognitive decline,
and peripheral neuropathy. Hallmark brain magnetic
resonance imaging findings in patients with SPG‑11
gene mutation are thinning of the corpus callosum,
so‑called “ears of the lynx deformity,” as was noted
in our patient and was present on her initial imaging
in 2009. This suggests that imaging markers may
present early in the disease course and may prove
useful in future efforts to develop treatments or early
diagnostics for HSP.
The Efficacy of Liposomal Bupivacaine in Interscalene
Nerve Blocks for Shoulder Arthroplasty
A. Malige1, G. F. Carolan1
1Orthopaedic Surgery Residency Program, University Hospital
Campus, Bethlehem, PA, USA
Introduction: Postoperative pain can have far‑
reaching effects on patient recovery, functional status,
and overall satisfaction. Because of this, surgeons
and anesthesiologists have turned to preoperative
nerve blocks in hopes of providing pain relief and
decreasing opioid usage postoperatively. Interscalene
(IS) nerve blocks have become the standard of care
to provide pain relief following shoulder procedures
due to their effectiveness. Before the introduction of
Exparel®, IS blocks would be administered as a single
shot or a catheter with a continuous pain pump using
the local anesthetic agent of choice. Unfortunately,
these methods were associated with a short period of
pain control associated with significant upkeep, time,
and cost, after which an oral pain regimen centered
Table 2: Statistical analysis for risk factors for minor
complication rate
Parameter Statistical analysis
logistic regression
Age 0.520 N/A
BMI 0.140 N/A
Pulmonary history 0.42 N/A
CHF 0.07 0.191
Smoking history 0.181 N/A
ASA score 0.003 0.096
Exparel® volume 0.660 N/A
Total volume 0.660 N/A
mFI-5 0.510 N/A
CCI 0.530 N/A
Age, BMI, ASA score, Exparel® volume, total volume, mFI-5 score,
and CCI score analyzed using t-test with unequal variance. Pulmonary
history and smoking status analyzed using Chi-squared test. CHF
history analyzed using Fisher’s exact test. All values are reported P.
BMI=Body mass index, CHF=Congestive heart failure, CCI=Charles
comorbidity index, mFI-5=5-factor modified frailty index
Table 3: Statistical analysis for risk factors for return to
emergency department
Parameter Statistical analysis
logistic regression
Age 0.006 0.248
BMI 0.120 N/A
Pulmonary history 0.060 0.182
CHF 0.110 N/A
Smoking history 0.740 N/A
ASA score 0.009 0.049
Exparel® volume 0.660 N/A
Total volume 0.790 N/A
mFI-5 0.460 N/A
CCI 0.002 0.467
Age, BMI, ASA score, Exparel® volume, total volume, mFI-5 score,
and CCI score analyzed using t-test with unequal variance. Pulmonary
history and smoking status analyzed using Chi-squared test. CHF
history analyzed using Fisher’s exact test. All values are reported
P. CHF history analyzed using Fischer’s exact test. All values are
reported P. BMI=Body mass index, CHF=Congestive heart failure,
CCI=Charles comorbidity index, mFI-5=5-factor modified frailty index
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International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 257
around narcotic medication was often needed for
adequate pain control. Recently, the FDA approved
the use of liposomal extended‑release bupivacaine
(Exparel®). This drug has gained popularity as the
anesthetic agent of choice used in IS nerve blocks. The
liposomal formulation allows for an extended delivery
of medication (up to 4–5 days’ time) to specific
targets while decreasing toxicity. This study explores
the effects of IS nerve blocks using Exparel after
shoulder arthroplasty in decreasing postoperative
narcotic consumption, hospital stay, and readmission.
Methods: A retrospective chart review was performed
of patients undergoing shoulder arthroplasty within
our network, either for proximal humerus fracture or
arthritic changes. All patients 18 years of age or older
undergoing primary or secondary arthroplasty with an
ASA of 1–3 were included. Any patients with an ASA
of 4 or did not have adequate documentation in their
chart were excluded. On the day of surgery, patients
were consented for an IS nerve block for postoperative
pain control and general anesthesia was the main
intraoperative anesthetic. The IS block was performed
by an anesthesiologist experienced with regional
anesthesia techniques and procedures. Patients
who received a preoperative ultrasound‑guided IS
block with plain local anesthesia (administered as a
single shot or a catheter with a continuous pump)
were placed into a control group, while patients
who received an ultrasound‑guided IS block with
Exparel® administered as a single shot were placed
into the experimental Exparel® group. All patients
subsequently underwent general anesthesia for the
surgical procedure. For each patient, length of stay,
readmission, and opioid requirements postoperatively
were recorded. The difference in outcomes between
groups was compared using descriptive statistics and
independent t‑tests. For all analyses, P < 0.05 denotes
statistical significance (IBM SPSS Version 23 Statistics
for Windows, Armonk, NY: IBM Corp.).
Results: Overall, 432 patients were included in our
study. There were 181 patients in the Exparel® group
(167 primary surgeries and 14 revision surgeries) and
251 patients in the non‑Exparel® control group (231
primary surgeries and 20 revision surgeries). The
Exparel® group (19.8 opioid morphine equivalent
[OME]) used a significantly lower amount of
average daily OME compared to the non‑Exparel®
(30.0 OME) control group (P < 0.001). There was
no difference in opioid usage between primary and
revision surgery patients in the Exparel® group (19.5
vs. 23.6 OME, P = 0.65) and non‑Exparel® groups
(29.2 vs. 39.8 OME, P = 0.15). Furthermore, more
patients were considered to use a low level of opioids
(0–40 OME) postoperatively in the Exparel group
(86%) compared to the non‑Exparel® group (73%).
Finally, the Exparel® group had a shorter length of stay
(1.67 vs. 2.25, P = 0.016) but similar readmission
rate (3.9% vs. 4.0%, P = 0.951) compared to the
non‑Exparel® group. Key study characteristic and
outcomes are presented in Tables 1‑4 and Figures 1‑2.
Conclusion: The use of Exparel® in the IS nerve blocks
for pain control helps decrease postoperative opioid
requirements and length of stay in patients undergoing
shoulder arthroplasty. Patients and physicians should
strongly consider this adjunct when deciding how best
to effectively treat a patients’ perioperative pain.
Keywords: Arthroplasty, bupivacaine, Exparel,
liposomal, shoulder
Bone Markers in Charcot Neuroarthropathy
K. Patel1, B. Bernstein1, J. C. Stoltzfus1
1Podiatric Medicine and Surgery Residency, University Hospital
Campus, Bethlehem, PA
Introduction: There have been multiple studies
evaluating the effectiveness of pharmaceuticals in the
treatment of acute Charcot neuroarthropathy (CNA).
The effectiveness of most pharmaceuticals historically
has been based on the levels of certain biomarkers of
bone turnover. Previous research has shown that bone
Table 1: Summary of key economic comparisons for
interscalene intervention
Cost of interscalene single shot
block with catheter/pump
Per item cost
USD ($)
Sterile gloves 0.94
Chloroprep 5.96
30 cc syringe 0.20
Stimuplex needle 21 G-2 in 7.46
Ultrasound probe cover 13.33
Naropin 0.5% 30 cc vial 5.93
Total 33.82
Steristrips 0.78
Contiplex Catheter set 40.60
Contiplex nerve tray block 20.60
On-Q pump set 485.00
AMBU pump set 168.80
Mixing medication for On-Q pump
Prepared under sterile hood×60 min (pharmacy tech/pharmacist) more
time and significantly higher cost
If AMBU pump use $230.78+
If OnQ pump use $546.98+
Conference Abstracts and Reports
258 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
acute CNA and decreased in chronic CNA. Hence,
pharmacologic treatment in acute CNA with reference
to levels of such biomarkers potentially could be
beneficial in clinical settings.
Methods: We retrospectively reviewed 41 patients
diagnosed with acute and chronic CNA in our
Charcot clinic. Disease severity was determined
via pedal temperature difference between affected
and unaffected limbs using an OMEGA Surface
Temperature Scanner in conjugation with radiographic
films and clinical presentation. Temperature of 2°C or
greater is considered acute CNA, while temperature
less than 2°C is considered chronic CNA. Urine
and serum blood samples were collected at baseline
to evaluate the levels of BSAP and DPD:CRT via
immunoassays. Statistical analysis was performed via
separate Mann–Whitney rank sum tests to determine
between‑group differences in BSAP and DPD:CRT
in acute versus chronic CNA.
Results: Bone formation marker BSAP (P = 0.46)
and bone resorption marker DPD:CRT (P = 0.92)
were not significantly different in acute versus chronic
CNA. In acute CNA patients (n = 31), the median
BSAP was 11.9 (range 3.8–41.3) versus 15.2 (range
4.4–40.7) in chronic CNA patients. In acute CNA
patients, the median DPD:CRT was 7.8 (range
3.1–38.4) versus 8.8 (range 3.3–18.6) in chronic
CNA patients. Key study outcomes are shown in
Figures 1‑4.
Conclusion: The lack of significant between‑group
differences in BSAP and DPD:CRT calls into question
their reliability in monitoring pharmaceuticals
effectiveness in acute versus chronic CNA.
Table 2: Summary of key economic comparisons for brachial
plexus intervention
Cost of brachial plexus single shot
with Exparel® (pain relief for 2-3 days)
Per item
Sterile gloves 0.94
Chloroprep 5.96
30 cc syringe 0.20
Stimuplex needle 21G- 2 in 7.46
Ultrasound probe cover 13.33
Naropin 0.5% 30 cc vial 5.93
Total 33.82
Exparel 10 cc vial 1.33% $ 170.00
Table 3: Summary of opioid morphine equivalents for study
comparison groups
Daily average
OME range
patients (%)
patients (%)
No block
patients (%)
0-40 120 (70) 60 (79) 3 (75)
41-60 38 (22) 11 (14) 0 (0)
61-90 10 (6) 5 (7) 1 (25)
>90 3 (2) 0 (0) 0 (0)
Total patients 171 76 4
OME=Oral morphine equivalent
Table 4: Oral morphine equivalent conversion chart
Narcotic medication Narcotic dose OME conversion
PO dilaudid 1 mg 4 OME
IV fentanyl 100 mcg 30 OME
PO vicodin 5 g 5 OME
PO oxycodone 5 mg 7.5 OME
PO tramadol 50 mg 5 OME
IV morphine 1 mg 3 OME
OME=Oral morphine equivalent
Figure 2: Exparel® patient average daily opioid morphine equivalent
Figure 1: Non‑Exparel® patients average daily opioid morphine
equivalent usage
turnover markers are increased in the acute phase of
CNA. However, biomarkers’ activity in the chronic
phase of CNA and its utility for monitoring treatment
response remains to be established. In this article,
we evaluated the relationship of such biomarkers to
disease severity. We hypothesized that biomarkers
such as BSAP and DPD:CRT levels will be directly
proportional to disease severity, i.e., increased in
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 259
The Borescope: An Adjunct in Sterile Processing
Department Quality Assurance
K. C. Kelley1, J. J. Lukaszczyk1, T. Bennett1,
R. Castillo1, B. A. Hoey1, S. P. Stawicki1
1General Surgery Residency, University Hospital Campus,
Bethlehem, PA, USA
Introduction: The borescope is a semi‑rigid fiber‑
optic device originally developed as an “inspection
camera” to look down small spaces and cavities. At our
institution, the borescope was introduced as a tool to
inspect surgical instruments after our sterile processing
department (SPD) discovered that internal lumens of
some surgical instruments contained poststerilization
biological residue (e.g., skin, bone, blood, and rust)
and internal damage not otherwise detected. We
hypothesized that the implementation of a borescope‑
based SPD inspection protocol would result in
improved overall process quality and potentially fewer
surgical site infections (SSIs).
Methods: We performed an institutional review
board‑exempt review of our institution’s SPD
Scorecard reports and all‑reported SSIs between
January 2018 and June 2019. After the Healthmark
flexible scope (Fraser, Michigan) was introduced in
our SPD (August 2018), the instrument cleaning
process was modified to include these steps: (a) initial
decontamination of instruments; (b) initial borescope
examination to determine cleaning adequacy; (c)
additional cleaning if required (e.g., brushing/air and
sterile water flushing); and (d) re‑inspection to ensure
complete cleaning before final sterilization. Results are
presented utilizing descriptive statistics, focusing on
comparisons of pre/post‑borescope periods.
Results: Preliminary findings after implementation
of the borescope (August 2018) show a decrease in
the percentage of dirty instrument trays identified by
operating room (OR) staff (0.0003% vs. 0.0002%)
and a decrease in reported SSIs (5.9/month vs. 3.0/
Conclusion: In the 10‑month period since its
implementation, the borescope has shown promise
in reducing the incidence of postprocessing‑soiled
instruments at our institution. Identification of soiled
instruments in the OR leads to greater resource
consumption and potential time delays. Consequently,
we pose that the borescope should be a tool utilized
Figure 2: Chronic Charcot neuroarthropathy: Pedal temperature
versus BSAP (µg/L)
Figure 3: Acute Charcot neuroarthropathy: Pedal temperature versus
DPD:CRT (nmol/mmol)
Figure 1: Chronic Charcot neuroarthropathy: Pedal temperature versus
DPD:CRT (nmol/mmol)
Figure 4: Acute Charcot neuroarthropathy: Pedal temperature versus
BSAP (µg/L)
Conference Abstracts and Reports
260 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
more widely in the SPD and the incidence of refractory
instrument residue should be tracked as an important
quality measure.
Implementation of an Enhanced Recovery after Surgery
Protocol for Video‑Assisted Thoracoscopic Surgery
Lobectomy Decreases Perioperative Opioid Use
Z. A. Frenzel1, R. Fontem1, A. L. Gifford1
1General Surgery Residency, University Hospital Campus,
Bethlehem, PA, USA
Introduction: With the ongoing nationwide opioid
crisis, reduction in opioid remains a priority when
patients are admitted in the hospital. The initiation
of an enhanced recovery after surgery (ERAS)
protocol for thoracic video‑assisted thoracoscopic
surgery (VATS) procedures is one example. Before
initiation of the ERAS protocol, VATS procedures
relied mostly on epidural use or opioid patient‑
controlled analgesia use for pain control, which may
not reduce opioid requirements. ERAS protocols
were introduced in the surgical community in the
late 1990s and implemented to reduce a patient’s
perioperative stress response. Ideally, there would be
improved pain control, reduced rate of complications,
decreased hospital length of stay (LOS), and decreased
readmission rates. Exparel® (liposomal bupivacaine)
was used in intercostal nerve blocks to help reduce
opioid requirements during the perioperative period
in 2016. In 2018, the thoracic surgery, anesthesia,
perioperative nursing, and pharmacy departments
worked together to construct and implement an
ERAS protocol for thoracic procedures. This study
highlights the use of intraoperative Exparel® alone or
in combination with an ERAS protocol in patients
undergoing VATS lobectomies. Primary outcome
measures involve ERAS protocol efficacy in reducing
opioid requirements (calculating daily average oral
morphine equivalent [OME] requirements) [Table 1].
Secondary outcome measures include effect of these
interventions on hospital LOS and 30‑day readmission
Methods: All patients undergoing elective VATS
lobectomy procedures from January 2016 to January
2020 were included. Patients were consented for
Exparel® and ERAS protocol during their final
preoperative visit. Components of the thoracic ERAS
protocol include preoperative patient education,
preoperative nonnarcotic pain medications (Tylenol,
Gabapentin, Celebrex), use of a preoperative
carbohydrate drink to curb fasting, DVT prophylaxis,
maintaining euvolemia and normothermia,
regional anesthesia (via intercostal nerve blocks
with Exparel®, antiemetic use, opioid‑sparing
analgesia (ketamine and magnesium), postoperative
nonnarcotic pain meds (Tylenol, gabapentin, and/or
NSAIDs), early chest drain removal, avoidance of
urinary catheters, and early mobilization after surgery.
ERAS protocol was initiated for patients scheduled
for elective VATS lobectomy procedures and requiring
a hospital admission. ERAS protocol was instituted
upon patient presentation to the hospital, and
Exparel® was administered intraoperatively by the
operating surgeon. Our baseline data group consists
of 20 patients from January 2016 to March 2016,
who did not receive Exparel® intraoperatively and
were not part of an ERAS protocol (NoEx/NoEr).
From this baseline group, we determined opioid
utilization, LOS, and readmission rate. Our study
groups included 142 patients from March 2016 to
September 2018 who received Exparel® but were
not part of an ERAS protocol (Ex/noEr) and 83
patients from October 2018 to January 2020 who
were part of an ERAS protocol and received Exparel®
intraoperatively (Ex/Er). OME requirements, LOS,
and readmission rates were also obtained. Data were
collected by chart review with surgery and anesthesia
staff in EPIC to determine the OME requirements,
LOS, and 30‑day readmission. Daily average opioid
requirements were measured throughout the patient’s
hospital stay. Compliance with individual ERAS
protocol interventions was also investigated.
Results: Two hundred and forty‑five patients
underwent VATS lobectomy during the study period.
Twenty patients underwent VATS lobectomy without
intraoperative Exparel® or use of ERAS protocol
(noEx/noEr), 142 underwent VATS lobectomy with
intraoperative use of Exparel® but without ERAS
protocol (Ex/noEr), and 83 patients underwent VATS
lobectomy with intraoperative use of Exparel and
under ERAS protocol (Ex/Er). Key study results are
listed in Figures 1‑3 and [Tables 1‑3]. Eighty‑four
percent of the patients in the Exparel® /ERAS group
had very low OME requirements (0–40), hence low
opioid use [Table 2] compared to 30% of the patients
who did not receive Exparel® /were not in ERAS
protocol. Exparel use plus ERAS protocol resulted
in decreased LOS 3.92 ± 3.1 days versus 4.12 ± 2.8
days for Exparel® use alone versus 5.09 ± 2.8 days for
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 261
no Exparel, no ERAS [Figure 2]. Exparel® use plus
implementation of the ERAS protocol also resulted in
decreased readmission rates compared to Exparel® use
alone or use of neither intervention with readmission
rates of 2.4%, 5.6%, and 5%, respectively [Figure 3].
However, the average cost per hospital admission was
higher with the use of Exparel® and ERAS protocol
($21,263.27 ± 12,465) versus Exparel® use only
($17,420.27 ± 7561) versus no Exparel®, no ERAS
($18,265 ± 5175) [Figure 4]. While these cost
differences may be fiscally relevant, our analysis did
not reveal a statistical significance. There was >87%
compliance in nine out of the 15 measures of the
ERAS protocol [Table 3].
Conclusion: Exparel® intercostal nerve block in
addition to ERAS protocol results in the improvement
of certain postoperative outcome measures such
as pain control (decreased opioid requirements),
length of hospital stay, and readmission rates. On the
other hand, Exparel®/ERAS use was associated with
increased cost. Randomized controlled studies should
be performed to investigate these findings, especially
given the small sample size in the nonintervention
group. Since the start of the thoracic ERAS protocol
for VATS procedures, other surgical services are
interested in starting their own ERAS protocols:
Colorectal Surgery with Colorectal ERAS Protocol,
Urology Service with Cystectomy ERAS Protocol,
Gynecology Oncology Surgery with Hysterectomy
ERAS Protocol are to name a few.
Abdominopelvic Computed Tomography Utilization
and Age in Emergency Department Patients over Age
65 Presenting with Abdominal Pain
M. L. Grimaldi1, J. M. Shugars1, H. A. Stankewicz1
1Emergency Medicine Residency, University Hospital Campus,
Bethlehem, PA, USA
Introduction: Abdominal pain is one of the
most common chief complaints encountered in
the emergency department (ED), accounting for
approximately 8.8% of all visits in the United States
in 2015. Approximately 3%–4% of all ED visits in
patients over age 65 years are due to abdominal pain.
Multiple studies have demonstrated that the rates of
surgical intervention, morbidity, and mortality are
substantially higher in older patients with abdominal
pain relative to younger patients. Older patients also
tend to present with an atypical history, physical
examination, and laboratory findings, increasing the
value of imaging in the evaluation of these patients. We
aimed to determine whether computed tomographic
(CT) utilization increases with increasing age in a
cohort of ED patients over age 65 years presenting
to an ED within the St. Luke’s University Health
Network (SLUHN) hospital system.
Table 1: Opioid conversion chart
Opioid OME
Dilaudid 1 mg PO 4
Dilaudid 1 mg IV 20
Fentanyl 100 mcg IV 30
Morphine 1 mg IV 3
Vicodin 5 mg PO 5
Oxycodone 5 mg PO 7.5
Tramadol 50 mg PO 5
OME=Oral morphine equivalent
Table 2: Oral morphine equivalent reference ranges
0-40 OME=Low opioid use/consumption postop
41-60 OME=Moderate opioid use
61-90 OME=High opioid use
>91 OME=Excessive opioid use
OME=Oral morphine equivalent
Figure 2: Exparel ®/enhanced recovery after surgery reduces length
of stay
Figure 1: Exparel® and enhanced recovery after surgery improve
opioid morphine equivalent requirements. X‑axis indicates opioid
morphine equivalents used daily: low opioid use (0–40), moderate
use (41–60), chronic opioid dependence (61–90), and excessive
opioid use (>90)
Conference Abstracts and Reports
262 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
Methods: We conducted a multicenter, retrospective review
of patients over age 65 years presenting to an ED within
the SLUHN hospital system with the chief complaint
of abdominal pain from August 1, 2016, to January 10,
2018. Our study was approved by the institutional review
board. The St. Luke’s system has an emergency medicine
residency (EMR) at its Bethlehem, Pennsylvania campus,
but otherwise consists of multiple community hospitals in
Pennsylvania and one in New Jersey. Patient charts were
abstracted from the EMR, Epic (Verona, WI, USA), and
then analyzed for several key variables. These variables
included patient age, sex, and whether abdominopelvic
CT was performed during the patient’s ED course. Patients
who left the ED without being seen were excluded from
the analysis. ED to ED transfers within the St. Luke’s
system generate two separate encounters in the EMR; the
second encounter was excluded from the analysis. Patients
were stratified by age into four categories: 65–69, 70–79,
80–89, and 90 and older. The rate of CT utilization in each
age group was determined. We then assessed for statistically
significant differences in the CT rate between the above
age groups using a Chi‑square test.
Results: We reviewed a total of 1451 patient charts. After
initial review, 10 duplicate encounters resulting from
ED to ED transfers and three patients who left without
being seen were excluded from the analysis. This left 1438
patients who were included in the analysis. The average
patient age was 75.6 years, and 61.8% of the patients
were female. Overall, 82% of the patients underwent
abdominopelvic CT. The rate was 82.1% in patients aged
65–69 years, 82.2% in patients aged 70–79, 83.2% in
patients aged 80–89, and 75% in patients aged over 90.
There was no statistically significant difference in CT
utilization between age groups (P = 0.35).
Conclusion: Two prior studies have examined CT
utilization in older patients presenting to an ED. The CT
rate was 37% for patients over age 60 presenting with
abdominal pain in a 2005 multicenter study conducted in
the United States. Another study conducted in 2007 at a
single center in the United States found a CT rate of 59%
in patients over age 60 presenting with abdominal pain.
CT utilization was higher in our cohort, at 82% overall.
It is likely that the uniformly high CT rate in our cohort
made it less likely that there would be significant variations
by age group. We are presently conducting a review of our
data to evaluate the diagnostic yield of CT and the impact
of CT on patient management in our cohort. As part of
this analysis, we will also determine the most common
pathologies seen on CT, rate surgical intervention, patient
disposition, and in‑hospital mortality in these patients.
Effect of Disposition on Patient Satisfaction in the
Emergency Department
H. J. T. Kleiman1, H. A. Stankewicz1, R. A. Patterson1,
P. Kaur1, S. Koo1
1Emergency Medicine Residency, University Hospital Campus,
Bethlehem, PA, USA
Table 3: Rate of compliance with enhanced recovery after
surgery protocol measures
Compliance of ERAS protocol (n=83)
Ordering carbohydrate drink=96%
Preoperative tylenol=89%
Preoperative gabapentin=87%
Preoperative NSAID=47%
Intraoperative use of ketamine/precedex=59%
Intraoperative antiemetics=100%
Intraoperative fluid restriction=32.5%
Intraoperative phenylephrine drip=71%
Intraoperative albumin=42%
Postoperative tylenol=100%
Postoperative gabapentin=95%
Postoperative NSAID=47%
IV fluids discontinued on POD 1=94%
Diet advanced on POD 0-1=99%
Ambulating POD 1=99%
ERAS=Enhanced recovery after surgery, NSAID=Nonsteroidal
anti-inflammatory drugs, POD=Postoperative day
Figure 3: Exparel® /enhanced recovery after surgery reduces
readmission rates Figure 4: Exparel® /enhanced recovery after surgery results in
increased cost
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 263
Introduction: Patient satisfaction, as measured by
surveys following discharge from the emergency
department (ED), is an important metric for ED
physicians. However, 8%–20% or more of patients
seen in the ED are admitted to the hospital and ED
physicians rarely receive feedback from these patients.
ED physicians often spend more time both at the
bedside and charting for admitted patients, and it is
proposed that the satisfaction ratings of these patients
may be higher than those of discharged patients.
Methods: This single‑center, institutional review
board‑approved study assessed patient satisfaction
in an ED staffed by both resident and attending
physicians. Satisfaction surveys were presented to the
patients directly after disposition was selected and
before leaving the ED. Surveys were presented by
nonbiased research assistants that were uninvolved in
patient care. Patients were asked to rate their level of
satisfaction on a Likert scale from 0 (very dissatisfied)
to 5 (very satisfied) in the following categories:
physician courtesy toward patient, physician listening
to patient, physician keeping patient informed,
physician’s concern for patient comfort, length of
patient wait time, treatment of patient pain, and
overall experience. Patients were asked to complete
separate surveys for the resident and attending
involved in their care.
Results: A total of 267 patients completed a total of
525 surveys. 97 patients (193 surveys) were admitted
and 166 patients (320 surveys) were discharged. The
valid percentage of physicians receiving a rating of
5 for patients who were admitted vs. discharged is
as follows: courtesy (69.1 vs. 63.0), listening (70.5
vs. 60.1), informed (67.7 vs. 60.8), concern for
comfort (61.5 vs. 59.9), length of wait time (48.4 vs.
45.0), treatment of pain (68.1 vs. 52.9), and overall
satisfaction (68.5 vs. 54.9).
Conclusion: Of the patients who participated in
this study, admitted patients more frequently gave
physicians the highest satisfaction rating (5) in all
categories. It can be surmised from these data that
admitted patients are more likely to have a positive
experience in the ED than discharged patients. The
patient satisfaction ratings of both admitted and
discharged patients should therefore be accounted
for when assessing an ED physician’s performance.
This is the first study to show that disposition has a
significant effect on patient satisfaction ratings.
Retrospective Study of Same‑Patient Admissions for
Consecutive Injury Events
: A High‑Volume Level I Trauma Center Experience
R. W. Van De Graaf1, B. A. Hoey1, R. Castollo1,
S. N. DeTurk1, P. G. Thomas1, J. Cipolla1, J. B. Wilson1,
S. Stawicki1
1Department of General Surgery Residency, University Hospital
Campus, Bethlehem, PA, USA
Introduction: Trauma continues to be one of
the leading causes of death across all age groups.
Despite significant amount of research dedicated
to understanding of anatomical and physiological
aspects of injury, there continues to be a paucity
of information regarding patterns of same‑patient,
recurring trauma (SPRT) events over a long period
of time. The aim of our study was to determine the
incidence and temporal characteristics of SPRT at a
busy regional level I trauma center (L1TC).
Methods: A retrospective review of our institution’s
L1TC registry between January 1998 and February
2019. Records of all patients who had more than
one trauma admission during the study period were
abstracted and compared to patients who only had one
trauma encounter. Readmissions related to immediately
preceding injury were excluded. Outcome parameters
included patient demographics, hospital length of stay
(LOS), mechanism of injury (blunt vs. penetrating),
injury severity (ISS), time between admissions, and
number of total SPRT events per patient. Statistical
comparisons were made using appropriate parametric
and nonparametric tests, with statistical significance set
at <0.05.
Results: Approximately 3.8% of trauma admissions
(1281/33,569) were attributed to SPRT events. The
SPRT group had similar proportion of women (40.1%
vs. 38.9%); had lower ISS (8.470.27 vs. 8.8324); was
older (58.70.86 vs. 48.10.76 years); and had slightly
longer LOS (4.060.17 vs. 3.960.13 days). We noted
that the average number of days between consecutive
trauma events decreased for each additional encounter
[Table 1]. Not unexpectedly, the patient age increased
within this longitudinal cohort [Table 1]. Of note, the
patients tended to present with injury mechanisms,
similar to that of the index admission (blunt injury
following blunt injury = 91%; penetrating injury
following penetrating injury = 57%), and did not
appear to have elevated mortality during consecutive
SPRT events (overall mortality, 3%).
Conference Abstracts and Reports
264 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
Conclusion: Our study shows a crescendo pattern
of SPRT episodes within our L1TC long‑term
registry record. Better understanding of risk factors
associated with SPRT will be critical in designing and
implementing long‑term injury prevention programs.
Further research in this important area is warranted.
Emergency Medicine Resident Procedure
Documentation versus Procedure Logs
J. Longenbach1, H. A. Stankewicz1
1Emergency Medicine Residency, University Hospital Campus,
Bethlehem, PA, USA
Introduction: Emergency medicine residents are
required to complete and log a certain amount of
various procedures throughout their residency in order
for each to graduate. Procedural notes are also required
to be completed on all patients who undergo certain
procedures. Oftentimes, the notes are completed to
satisfy the checks that our electronic medical record
(EMR) places on note completion, but the process
of logging the procedure is through a different
medium and is ignored due to time restraints. The
goal of this study is to determine whether or not the
procedure notes completed by the residents or the
log records are a more accurate representation of the
total procedures completed by each resident. There
are 15 core procedures that each resident is required
to be competent in by the time they graduate from
residency. One way to keep track of this is to have
the residents log each procedure they complete on
a third party website called New Innovations: www.
new‑ Logging procedures on this website is
usually of secondary importance to completing your
notes for the day, and often, it gets forgotten. It is
possible to pull the data from our EMR that will show
us how many of each procedure note the residents
have completed in the EMR and then these numbers
can be compared to the residents’ procedure logs on
New Innovations. These data can then potentially be
used to help credential residents in certain procedures
should the EMR numbers be higher.
Methods: This was a retrospective study conducted at
an emergency medicine residency program at a level
1 trauma center. The research assistant compiled data
from the New Innovations website for all 36 residents
in the program from July 1, 2017, to June 30, 2018.
The procedures evaluated were intubations, central
line insertions, chest thoracostomies, procedural
sedations, and lumbar punctures. Data were extracted
from the EMR for the same residents and the same
procedures during the same timeline. These numbers
were then statistically analyzed.
Results: Majority of the residents had more procedures
logged in New Innovations when compared to the
EMR. A negative value (green) indicates that more
procedures were logged into the EMR rather than
New Innovations. A positive value (red) was the
opposite. Out of the 180 data points evaluated, only
15 were negative [Table 1]. Five were a net of zero,
leaving 160 comparisons that showed residents logged
more procedures into new innovations rather than the
EMR. Furthermore, in analyzing the mean, median,
and mode of all the data above, only the central venous
catheter (CVC) procedure offered a positively skewed
frequency distribution [Figure 1]. On the other hand,
intubations showed the opposite trend.
Conclusion: The only data to show a positive skew
came from the CVC results. This suggests that with
more data, a relationship between the logged central
lines and procedure notes could argue more toward
the initial hypothesis. However, the positive skew is
minimal at best. Ultimately, it appears that, at this
time, the third party website is indeed required for
residents to meet their procedure goals by the end
of residency. However, if residents were aware that
pulling data from the EMR would count toward
their graduation requirement, could that be enough
to change the balance? Moreover, if there were a
Table 1: Temporal characteristics of the same-patient, recurring trauma cohort at our Level I trauma center (data shown as
mean standard error)
Parameter Non-SPRT controls
SPRT 1st
SPRT 2nd
episode (n=550)
SPRT 3rd
episode (n=134)
SPRT 4th
episode (n=36)
SPRT 5th
episode (n=11)
Time between episodes (days) N/A N/A 1026 623 607 84
Patient age 48.1 56.7 59.4 62.0 65.4 69.6
Male (%) 59.9 61.1 61.1 49.5 50.0 70.0
Hospital LOS (days) 3.96 4.06 4.06 4.57 3.77 2.67
Blunt injury (%) 95 93 96 92 97 100
ISS 8.83 9.05 8.13 8.00 7.42 6.64
SPRT=Same-patient, recurring trauma, ISS=Injury severity score, N/A=Not available, LOS=Length of stay
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 265
section of the procedure note where a “supervisor”
or “assistant” resident could be captured, that would
solve the primary issue mentioned above. Finally, for
the 15 data points that did agree with the hypothesis,
maybe, these could be added on to the respective
resident to provide a more accurate analysis of their
completed procedures, which could help them in the
future with credentialing.
A Survey of Wellness in Emergency Medicine Residents:
Effects of the COVID‑19 Pandemic
J. Paster1, J. C. Stoltzfus1, H. A. Stankewicz1
1Emergency Medicine Residency, University Hospital Campus,
Bethlehem, PA, USA
Introduction: Physician wellness has long been a
hot topic among attending and resident physicians
alike. Multiple assessments, psychometric testing,
mindfulness exercises, and “wellness guides” have been
developed and implemented by residency programs
throughout the country. Our program was provided a
unique opportunity to compare a wellness questionnaire
given to emergency medicine residents a few months
before and after the onset of the COVID‑19 pandemic.
Methods: This was an institutional review board‑
approved survey study conducted at an emergency
medicine residency program at a level 1 trauma
center in Eastern PA. The initial questionnaire was
provided to each resident during Grand Rounds in
November 2019 and was filled out anonymously to
reduce measurement bias. The survey was partially
derived from a previously validated sleep index, the
Pittsburgh Sleep Quality Index. The questionnaire
was again provided to the same residents on April 15,
2020, via e‑mail by a research assistant.
Results: A total of 34 residents participated. There
were no significant changes in hours spent sleeping,
perceived difficulty in falling asleep at night, sleep
disturbances, or exercise frequency. The question,
“How difficult is it for you to fall asleep during the
day?” demonstrated a decrease in the selection of
“very easy;” from 29.4% to 14.7%. There was also a
noted difference in “level of enthusiasm to get things
done.” Prepandemic surveying showed that 61.8% of
the residents had either “no problem” or “only a very
slight problem,” with 35.3% answering “somewhat
or a problem” or “a very big problem.” Postpandemic
surveying showed 50% and 50%, respectively.
Conclusion: There was a significant decrease in self
assessed measure of productivity and motivation among
emergency medicine residents during the COVID‑19
pandemic, when compared to the same questionnaire
given before the pandemic. There was also an increase
in perceived difficulty to fall asleep during the day. Our
Table 1: Differences (New Innovations versus electronic
medical record)
CVC Intubation Lumbar puncture Sedation Tube thoracostomy
7 4 3 9 1
815 1 5 4
410 510 7
5 45 −1 8 1
11 711 11 4
1 3 3 1 5
−4 3 7 −1 5
616 413 4
0 2 4 5 1
13 32 4 14 8
4 46 4 4 1
613 4 1 4
131 5 9 3
−4 −4 2 −2 1
−3 4 2 4 −2
1 −3 3 2 1
112 5 6 3
7 8 3 2 4
3 35 2 2 5
10 28 2 5 2
2 −2 5 4 1
714 4 0 1
4 6 4 5 4
631 7 5 1
1 2 5 −1 2
5 32 4 10 1
−7 −6 9 0 1
7 36 2 5 5
5 28 5 9 1
6 8 9 0 1
3 9 7 4 4
−1 35 11 7 3
6 7 9 7 6
0 20 7 5 7
831 6 5 2
5 −3 9 8 1
CVC=Central venous catheter
Figure 1: Relation between mean, median, and mode for the ve
studied procedures
Conference Abstracts and Reports
266 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
goal of this study was not to prove that a pandemic is
stressful, but rather to show how stress can manifest
in resident physicians who are already conditioned to
handle an exceedingly stressful environment, albeit early
in their training. This is an unprecedented time to be
an emergency medicine resident, and we hope that this
study contributes to our understanding and prevention
of physician burnout.
Bridging the Gap: The Utilization of Electronic Health
Records to Increase Metformin Prescription
M. Krinock1, T. Chamakkala1, V. Yellapu1,
R. A. Sluder1, M. E. Widawski1, J. T. Hippen1
1Internal Medicine Residency, University Hospital Campus,
Bethlehem, PA, USA
Introduction: Few diseases have had as significant of
an impact on health in the United States as diabetes.
Currently, one in 10 people in the United States are
diagnosed with diabetes which will increase to one
in five by 2025.[1] Diabetes has long been known as a
significant cause for morbidity and mortality, affecting
organs from the cardiovascular system to the eyes.
[1] Beyond this, diabetes also has a tremendous price
tag, with an estimated $245 billion per year in both
healthcare and lost productivity secondary to it.[2] In
recent years, there have been numerous advancements
in the treatment options for diabetes, but unfortunately,
the cost precludes many patients who are most affected
by the disease from receiving them. High costs can
limit patients to only sulfonylureas, pioglitazones, and
metformin.[3] Of these, sulfonylureas and pioglitazones
have significant side effects that limit their use, in
contrast to metformin which has been a long‑term staple
of antidiabetic regimens.[3,4] Despite its effectiveness,
low cost, proven effect on A1C, and favorable side effect
profile, metformin is under‑prescribed, with one study
reporting only 64% of diabetics taking metformin.[5]
This paucity of metformin prescriptions exposes a gap
of care in diabetics, hindering them from lowering
their A1C in the most cost‑effective manner possible.
Due to this deficiency, we set out to perform a quality
improvement project to increase metformin prescription
among residents at an internal medicine clinic.
Methods: This prospective intervention was
conducted at a single internal medicine residency
clinic. After receiving institutional review board
approval, residents were randomly assigned into two
groups (A and B). Group A utilized a clinic visit note
template including a “hard stop,” which required
addressing whether the patient was a diabetic, and if
so, whether they were prescribed metformin. Group
B did not have a “hard stop” in their template. Both
groups received weekly reminders via a secure text
messaging service that included education on the
safety and efficacy of metformin. Other education
topics included contraindications to metformin
prescribing and dose adjustment recommendations
per the society guidelines. Pre‑ and post‑intervention
data were recorded for each group and tracked via Epic
and Tableau™ software using the standard institutional
protocol by nonstudy participating moderators.
Tracked data recorded included the number of
diabetics, the percentage of diabetics prescribed
metformin, as well as the number and percentage
of diabetics poorly controlled (PC) (defined as an
A1C greater than 8%). The data were subsequently
analyzed using SPSS (IBM, Armonk, NY) statistical
software, utilizing two‑tailed paired t‑tests before
intervention implementation and after 4 months to
determine statistical significance.
Results: A total of 476 diabetics were included in
the original cohort, with a total of 508 in the final
analysis. The average percentage of diabetics prescribed
metformin in Group A (“hard stop” + education group)
was 57.85% at baseline while in Group B (education
only) was 68.38%. After 4 months of intervention,
Group A had 63.52% of diabetics prescribed metformin
and Group B had 68.18%. At baseline, 34.1% of the
patients in Group A were defined as PC and 34.39% in
Group B. In follow‑up, Group A had 31.97% PC and
Group B had 39.39% [Tables 1 and 2]. We identified that
there was a statistically significant increase in metformin
prescription over the 4‑month period in the “hard stop”
template Group A (P = 0.02). We did not see the same
increase in metformin utilization in Group B, which
had no “hard stop” intervention. In Group B, we did
see an increase in PC patients over the 4 months (P =
0.011). Additional study outcomes are shown in Table
3 and Figures 1‑2.
Conclusion: As the burden of diabetes increases, the
search for low‑cost ways to lower this burden is of
continual interest.[3] Despite metformin’s minimal
side effect profile, reduction in A1C, and low cost,
a paucity of diabetics receive it, representing a
significant gap in health‑care.[4,5] In our study, we
found that education alone is not enough to bridge
this gap. We demonstrated a significant increase in the
percentage of diabetics prescribed metformin utilizing
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 267
a “hard stop” in resident visit note templates versus
education alone. Notably, the education group’s PC
percentage increased but can be explained due to the
study taking place over the winter when A1Cs are
known to worsen. Through this study, we were able
to demonstrate a promising avenue for the possibility
for the utilization of electronic health records to bridge
the gap and increase metformin prescription.
1. Albright AL, Gregg EW. Preventing type 2 diabetes in communities across
the U.S.: The National Diabetes Prevention Program. Am J Prev Med
2. Tabano DC, Anderson ML, Ritzwoller DP, Beck A, Carroll N, Fishman PA, et
al. Estimating the impact of diabetes mellitus on worker productivity using
self‑report, electronic health record and human resource data. J Occup
Environ Med 2018;60:e569‑74.
3. Vaughan EM, Rueda JJ, Samson SL, Hyman DJ. Reducing the burden of
diabetes treatment: A review of low‑cost oral hypoglycemic medications.
Curr Diabetes Rev 2020;2: DOI: 10.2174/1573399816666200206112318
. [Epub ahead of print]
4. Pawlyk AC, Giacomini KM, McKeon C, Shuldiner AR, Florez JC. Metformin
pharmacogenomics: Current status and future directions. Diabetes
5. Kannan, Arshad, Kumar S. A study on drug utilization of oral hypoglycemic
agents in type‑2 diabetic patients. Asian J Pharm Clin Res 2011;4:60‑4.
A Unique Neurological Presentation of Granulomatosis
with Polyangiitis (Wegener’s Granulomatosis) with
Polyneuropathy, Myopathy, and Small‑Vessel Stroke
A. Shaji1, S. Devarinti1, D. Raheja1, R. Leung1
1Neurology Residency Program, Richard A. Anderson Campus,
Easton, PA, USA
Introduction: Granulomatosis with polyangiitis
(Wegener’s granulomatosis) is a necrotizing,
granulomatous vasculitis of the medium and small
arteries, mainly affecting the respiratory tract and
kidneys; however, it can also affect the central and
peripheral nervous systems. Here, we report a
rare and complicated neurological presentation of
granulomatosis with polyangiitis presenting with
polyneuropathy, polymyalgia rheumatica (PMR), and
small‑vessel stroke.
Case Scenario: A 60‑year‑old woman with a history
of peripheral vascular disease, hypertension, and
osteoarthritis presented with a 4‑month history of
progressive neck and back pain and dysesthesias of all four
extremities. The initial neurological examination revealed
normal motor strength in all muscle groups, acral sensory
loss to all modalities, and decreased reflexes, consistent
with neuropathy. She had an episode of transient
diplopia 6 weeks after presentation, with negative brain
MRI. She was later hospitalized for diplopia, imbalance,
bilateral ptosis, and ophthalmoplegia. The examination
was significant for splinter hemorrhages on several nail
beds and diffuse myofascial tenderness. Neurological
examination showed mild ptosis on the right, right‑sided
internuclear ophthalmoplegia, weakness in the proximal
muscles, acral sensory loss, diffuse hyporeflexia, and
bilateral dysmetria. Blood workup showed elevated (ESR)
Erythrocyte Sedimentation Rate (81), (CRP) C‑Reactive
Protein (61), positive (RF) Rheumatoid Factor, and
(c‑ANCA) Cytoplasmic Antineutrophil Cytoplasmic
Antibodies (1:80), with normal Vitamin B1, B6, mildly
low B12 and D, negative (ANA) Anti‑Nuclear Antibody,
Sjogren’s, (APLA) Anti‑Phospholipid Antibody, (AchR)
Table 1: Comparison of patients on metformin pre- and
post-“hard stop” intervention
Group A: Intervention with “Hard Stop”
Category Before intervention Q1 P
Diabetics (n)223 244
Patients on metformin (%) 129 (57.85) 155 (63.52) 0.023
Poor control patients (%) 76 (34.1) 78 (31.97) 0.795
There is a statistically significant increase in metformin prescription
over one quarter
Table 2: Comparison of patients on metformin pre- and
post-intervention period
Group B: No intervention
Before intervention Q1 P
Diabetics (n)253 264
Patients on metformin (%) 173 (68.38) 180 (68.18) 0.354
Poor control patients (%) 87 (34.39) 104 (39.39) 0.011
This cohort did not have the “hard stop.” There is no statistically
significance in metformin prescription over one quarter. We do however
see a statistically significant increase in poor control patients over time
Table 3: Mean numbers of diabetics per resident prescribed
metformin per month during study
Group November December January February March
A Mean 8.60±6.64 9.07±6.54 9.47±6.71 9.73±6.24 10.33±6.44
B Mean 11.53±8.68 11.80±8.45 11.67±8.46 12.00±8.43 11.20±5.89
Figure 1: Change in metformin prescriptions over time
Conference Abstracts and Reports
268 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
Acetylcholine Receptor antibody, (MuSK) Muscle‑Specific
Kinase, (SPEP) Serum Protein Electrophoresis, and
(UPEP) Urineprotein Electrophoresis. Cerebrospinal fluid
was normal. Electromyogram showed polyneuropathy
with mixed axonal and demyelinating features. MRI
of the brain showed restricted diffusion in the dorsal
median midbrain, in a V‑shaped morphology, as has been
reported in Wernekink commissure syndrome involving
the inferior paramedian mesencephalic arteries. Computed
tomography of the chest showed multiple pulmonary
Conclusion: Overall, our patient’s clinical syndrome
is consistent with a small‑vessel vasculitis, affecting
both central and peripheral nervous systems, resulting
in peripheral neuropathy, PMR versus myopathy, and
small‑vessel stroke. She was treated with high‑dose
intravenous methylprednisolone followed by oral
steroid taper and rituximab with clinical improvement.
Case Report of Delusional Disorder in an Older Adult
Female: Impact of First‑Generation Antipsychotic
K. R. Munzenmaier, F. Sholevar, A. Thomas
Psychiatry Residency, Richard A. Anderson Campus, Easton, PA,
Introduction: Delusional disorder is an uncommon
and treatment‑resistant psychiatric disorder in which an
individual holds one or more delusions, in the absence
of prominent hallucinations or mood symptoms, while
maintaining baseline functioning. Of the many forms
these delusions take on, the persecutory type is most
common. However, rigorous studies examining the
treatment of delusional disorder are lacking, leading
psychiatrists to rely on case reports. These were
reviewed in 2006 and again in 2015, citing a number
of possibly efficacious treatments including typical
and atypical antipsychotics, antidepressants, cognitive
behavioral therapy, and even electroconvulsive therapy.
Further, multiple comprehensive literature reviews
have been unable to identify a best first‑line treatment.
The most recent Cochrane review confirms this,
stating that there is “insufficient evidence to make
recommendations for treatments of any type.” Here,
we present an interesting case of persistent delusional
disorder responsive to monotherapy with a first‑
generation antipsychotic, fluphenazine.
CARE Statement: Delusional disorder is a rare psychiatric
illness, the criteria for which are demonstrated in this
memorable and unusual case. Despite displaying some
criteria of other, more common disorders such as bipolar
disorder or schizophrenia, the patient never met criteria
for these illnesses and maintained her baseline functioning
apart from the ramifications of her delusion. Further, this
case provides insight into possible first‑line treatments.
Generally, patients with this complex illness are managed
with a range of treatments concomitantly, making it
very difficult to elucidate the exact cause of patients’
improvement. However, in this case, the patient improved
dramatically following only one change, the consistent
outpatient use of fluphenazine, suggesting that this
medication should be considered as a first‑line treatment.
Case Scenario: The patient is a single, retired
woman in her mid‑70s with a long psychiatric history
centering around one delusion. For at least 25 years,
she has held the belief that she is being persecuted
by a man she met in the mid‑1960s who has widely
slandered her as a promiscuous and subservient,
broadcasting her behaviors and spreading these false
ideas on the internet. She believes that his actions
have been legitimized by a prestigious law firm to
the point that many people living in the area hold
the same false views of her. She has gone to the
police and written to senators and national women’s
organizations to plead her case and insist on the man’s
arrest, to no avail. She stated that she even moved
across the country and took on an alias in an unfruitful
effort to escape his persecution. Moreover, the patient
maintained this delusion despite evidence that this
man is likely deceased, in addition to multiple attempts
to demonstrate the unlikelihood of her delusion.
Although history is limited by the patient’s memory
and medical record availability, she was involuntarily
hospitalized at least 6 times in a 19‑month period,
with many more reported before that including two
stays in a state hospital. The patient was usually
Figure 2: Change in poorly controlled patients over time
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 269
brought to the emergency room by police who found
her harassing strangers and insisting that what they
have heard about her is untrue. The patient was largely
noncompliant with her medications and psychiatric
follow‑up during that time due to her belief that she
was not mentally ill. She was treated with multiple
antipsychotics while hospitalized and eventually
had some response to fluphenazine. Although she
now continues to maintain that she is being stalked
by the same man, her compliance with outpatient
fluphenazine and psychiatry follow‑up has decreased
the intrusiveness of her delusion such that she does
not fervently bring up the topic as before and has not
been brought into the hospital by police since 2017.
Conclusion: This case of an older adult with
delusional disorder exemplifies the chronic course
of the illness, the pervasiveness of delusions, and the
repercussions that can occur. Despite persistence of her
persecutory delusion, the patient eventually achieved
clinical remission, attributed to consistent use of oral
and intramuscular fluphenazine. This directly opposes
previous literature stating that the exact source of
improvement is impossible to identify because of
the range of treatments employed at once. Previous
reviews have also suggested that antipsychotic
monotherapy is often insufficient and that atypical
antipsychotics may be favored over typicals. However,
the presented case demonstrates the durable efficacy
of fluphenazine monotherapy. This suggests that
typical antipsychotics should be strongly considered
in patients experiencing social and legal ramifications
as a result of their delusion, to decrease the overall
burden of their illness.
Coronary Artery Fistula in Setting of Cardiomyopathy:
To Ligate or Not to Ligate?
K. Shah, I. Taha, M. Krinock, P. Thacker, C. E. Ruggeri
Departments of 1Internal Medicine Residency and 2Cardiology
Introduction: Coronary artery fistulas (CAFs)
are an anomalous connection between a coronary
artery and other cardiovascular structures.[1‑3] CAFs
that connect to right‑sided cardiac structures cause
cardiac shunting from left to right, while left‑sided
connecting fistulas resemble aortic insufficiency
in physiological parameters as well as cardiac
auscultation.[4] CAFs are often clinically benign but
have been reported to cause serious complications,
including heart failure, myocardial infarction (MI),
thrombosis, embolism, rupture, and sudden cardiac
death.[1,2] The gold standard diagnostic test for CAF
is coronary angiography. After diagnosis, the decision
on intervention is controversial but can be aided by
the utilization of the Konna criteria.[5,6] The criteria
include a shunt ratio of left to right >30%, right
ventricular (RV) ischemia/volume overload, presence
of pulmonary hypertension/heart failure, and finally,
the presence or history of infective endocarditis
or aneurysm formation.[5] The 2018 AHA/ACC
guidelines did not specifically give indications for
surgical intervention but did note that there was a high
postoperative MI rate of 11%, adding to the difficulty
of the decision.[6] We present a case of a patient who
had cardiomyopathy of unclear origin and was found
to have a CAF, presenting a clinical decision that must
take into account several different factors, as well as
the patients’ personal decision on whether to proceed
with surgical intervention.
Case Scenario: A 42‑year‑old female presented secondary
to syncope. Her medical history was significant for
hypothyroidism from prior thyroidectomy. Her
presentation was originally consistent with vasovagal
syncope. However, during the workup, the patient was
noted to have a new left bundle branch block. She then
underwent echocardiography which showed an ejection
fraction of 30%, a dilated cardiomyopathy, normal RV
size and function, as well as normal pulmonary artery
size. Laboratories were notable for a TSH 219, T4 0.16,
total CK 2355, and aldolase 14.2. The patient was also
noted to have clinical features consistent with myotonic
dystrophy (MD), as well as a positive family history of
MD in her brother. The genetic test for type 2 MD was
negative and type 1 MD is pending. Cardiac catheterization
showed normal coronary arteries and a possible left
anterior descending (LAD) fistula. A cardiac computed
tomography scan showed a small 2‑mm vascular fistula
extending from LAD to the pulmonary artery [Figure 1].
Conclusion: There has been no association between
MD and CAF noted in the literature. While our patient
did potentially have one of the Konna indications
for surgery in that she did exhibit heart failure, her
fistula was thought to be an incidental finding. She
was managed with guideline‑directed medical therapy
(with angiotensin‑converting enzyme inhibitor, heart
failure approved beta‑blocker), instead of ligation of
the fistula, given the possible concomitant undiagnosed
MD as a most likely cause of her cardiomyopathy as well
as patient not willing to undergo the risk of surgery.
Conference Abstracts and Reports
270 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
The patient has remained clinically stable with thyroid
replacement therapy with mild improvement of ejection
fraction (35%–40%), and she is currently awaiting
genetic test results for her highly suspected MD.
1. Qureshi SA. Coronary arterial stulas. Orphanet J Rare Dis 2006;1:51.
2. Minhas AM, Ul Haq E, Awan AA, Khan AA, Qureshi G, Balakrishna P.
Coronary‑cameral stula connecting the left anterior descending artery and
the rst obtuse marginal artery to the left ventricle: A rare nding. Case Rep
Cardiol 2017;2017:8071281.
3. Alammar AK. Coronary artery stulae discovered during presentation of a
patient having heart failure due to severe aortic stenosis. Case Rep Cardiol
4. Loukas M, Germain AS, Gabriel A, John A, Tubbs RS, Spicer D. Coronary
artery stula: a review. Cardiovasc Pathol 2015;24:141‑8.
5. Takeuchi N, Takada M, Nishibori Y, Maruyama T. A case report of coronary
arteriovenous fistulas with an unruptured coronary artery aneurysm
successfully treated by surgery. Case Rep Cardiol 2012;2012:314685.
6. Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM,
et al. 2018 AHA/ACC guideline for the management of adults with congenital
heart disease: A Report of the American College of Cardiology/American
Heart Association Task Force on Clinical Practice Guidelines. J Am Coll
Cardiol 2019;73:e81‑192.
Effect of Perceptions of Wait Time on Physicians’
Evaluations in the Emergency Department
A. Suri1, H. A. Stankewicz1, H. E. Barnes1
1Emergency Medicine Residency, University Hospital Campus,
Bethlehem, PA, USA
Introduction: With the development of the Emergency
Department (ED) Patient Experience of Care Survey
by the Centers for Medicare and Medicaid Services
(CMS), there has been increasing interest in the
factors influencing patients’ experience of care in
the ED.[1] Differing from patient satisfaction, CMS
defines that patients’ experience has a “focus on
how patients experienced or perceived key aspects of
their care.”[2] Nevertheless, the outcomes of patient
experience surveys rely heavily on patients’ evaluations
of the physicians delivering care. Previous studies have
found that the results of overall satisfaction surveys
are influenced by factors beyond provider–patient
interactions, such as wait time.[3] The relationship
between wait time and patient experience is especially
important in emergency care settings, where wait times
can be lengthy due to ED overcrowding. Moreover,
perceived wait times have been demonstrated to have a
strong impact on overall ratings of ED visits.[4‑6] Studies
found that longer wait times have been associated with
lower overall satisfaction scores.[7] While studies have
shown the effect of perceived wait times on overall ED
experience evaluations, no studies have investigated the
relationship between perceived wait time and patients’
evaluation of providers delivering care.[8] The purpose
of this study is to determine if perceived wait times in
a suburban ED has a significant impact on the postcare
evaluation of emergency care physicians.
Methods: Patients who visited the ED at St.
Luke’s University Health Network in Fountain
Hill, PA, completed patient experience surveys.
Once a disposition was assigned to the patient, a
research assistant showed the patient a picture of
each physician who was caring for them in the ED
and asked them a series of questions. Surveys were
modeled after validated measures developed by Press
Ganey Associates (South Bend, Indiana). Evaluations
of qualities of the physicians included interpersonal
qualities as well as how long the patient waited for the
physician during his or her stay. Physician evaluation
scores followed a Likert‑style rating from 1 through 5,
with 1 indicating “very poor” and 5 indicating “very
good.” The perceived length of time waiting for the
physician followed the same 1 through 5 rating system.
Data were analyzed using the Statistical Package for
Social Sciences (SPSS) software version
(IBM Corporation, Armonk, NY, USA). To develop
a binary outcome variable, the outcome for physician
evaluations was recoded into two categories, with
“very poor,” “poor,” and “fair” responses as “poor”
Figure 1: Computed tomography showing coronary artery stula
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 271
and those with “good” and “very good” responses as
“good.” Similarly, the evaluation of the length of time
waited was categorized into a binary independent
variable of “poor” and “good.” Univariate analyses
provided descriptive statistics for the demographics of
the study population. Chi‑square tests were conducted
to identify significant associations at an alpha of
0.10 between physician evaluations and categorical
predictors. Where applicable, Fisher’s exact test was
used for variables with expected counts of less than
5. An independent sample t‑test was conducted for
continuous variables. Finally, binary logistic regression
was conducted with physician evaluations as the
dichotomous outcome with the length of time until
disposition and perceived length of time as predictors.
This process was repeated separately for attending and
resident physician evaluations.
Results: Table 1 summarizes the characteristics of
survey respondents. In total, 201 and 170 survey
responses were included in the analysis of the residents
and attendings, respectively. Of the individuals who
evaluated resident physicians, the mean age of the
participants was 50 years, and the average length
of time until disposition was 203.9 min. Of the
individuals who evaluated attending physicians, the
mean age of the participants was 50.4 years, and the
average length of time until disposition was 200.9
min. On bivariate analysis, the perceived length of
waiting time was found to be significant for attending
physicians, but not resident physicians (attendings: P
= 0.028; residents: P = 0.303). Length of time until
disposition was not found to be significantly different
between “good” and “poor” attending physician
evaluations (t(4.5) = −0.462, P = 0.665), despite
those reporting higher evaluations having higher mean
wait times (mean [M] = 201.4, standard deviation
[SD] = 128.8), compared to those reporting lower
physician scores (M = 182.4, SD = 89.2). Similarly,
this variable was not significantly different among
“good” (M = 203.9, SD = 124.8) and “poor”
(M = 200.5, SD = 150.6) resident evaluations
(t(1.014) = −0.032, P = 0.979). Table 2a and b
summarizes the results from multivariate analyses of
attending and resident evaluations, respectively. When
accounting for missing variables, 166 surveys were
analyzed for attending physicians whereas 194 surveys
were analyzed for resident physicians.
Conclusion: Results show that attending physicians’
evaluations are strongly influenced by a patients’ perception
of waiting time. Special care should be taken when setting
expectations with regard to waiting times in emergency
care settings. This relationship was not observed with
residents’ evaluations. It is not clear why attendings and
residents differed in factors influencing the evaluations.
It is possible that the length of wait time differed more
among those who rated attendings compared to residents,
but this difference was not significant. It is also possible
that attending physicians were rated differently due to
their advanced training from a patient’s perspective. This
study analyzed data from a single ED in a larger health
network, which limits its generalizability to other settings.
In addition, the majority of evaluations in this analysis fell
into the “good” category. Further studies would benefit
from collecting more responses to increase the likelihood
of capturing a wide array of scores.
1. Weinick RM, Becker K, Parast L, Stucky BD, Elliott MN, Mathews M, et al.
Emergency department patient experience of care survey: Development
and eld test. Rand Health Q 2014;4:5.
2. Centers for Medicare and Medicaid Services. Consumer Assessment of
Healthcare Providers and Systems. 13 November, 2019. Available from:‑Statistics‑Data‑and‑Systems/Research/CAHPS.
[Last accessed September 2, 2020]
3. Aaronson EL, Mort E, Sonis JD, Chang Y, White BA. Overall emergency
department rating: Identifying the factors that matter most to patient
experience. J Healthc Qual 2018;40:367‑76.
4. Davenport PJ, O’Connor SJ, Szychowski JM, Landry AY, Hernandez SR.
The relationship between emergency department wait times and inpatient
satisfaction. Health Mark Q 2017;34:97‑112.
5. Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg
Med J 2004;21:528‑32.
6. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual
waiting time, perceived waiting time, information delivery, and expressive
quality on patient satisfaction in the emergency department. Ann Emerg
Med 1996;28:657‑65.
7. Boudreaux ED, Mandry CV, Wood K. Patient satisfaction data as a
quality indicator: A tale of two emergency departments. Acad Emerg Med
8. Sharp B, Johnson J, Hamedani AG, Hakes EB, Patterson BW. What
are we measuring? Evaluating physician‑specific satisfaction scores
between emergency departments. West J Emerg Med 2019;20:454‑9.
Nonuremic Calciphylaxis
A. Parameswaran, R. Snyder, M. Chalunkal,
R. Garwood1
1Internal Medicine,Richard A. Anderson Campus, Easton, PA, USA
Introduction: Calciphylaxis, known as calcific
uremic arteriolopathy, is classically found in patients
with end‑stage renal disease and advanced chronic
kidney disease. This condition has a high morbidity
and mortality rate; it causes abnormal deposition of
calcium in the vessels, resulting in vascular thrombosis
Conference Abstracts and Reports
272 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
and tissue infarction. “Nonuremic” calciphylaxis is
far less common but also has a high mortality rate. It
is often overlooked as a diagnostic consideration in
patients with normal functioning kidneys. We present
a complex patient with nonuremic calciphylaxis
with significant contributing comorbid illnesses
including antiphospholipid antibody syndrome on
anticoagulation with warfarin.
Case Scenario: A 37‑year‑old Caucasian female
with a medical history of antiphospholipid antibody
syndrome, diabetes mellitus type 2, depression, and
chronic opioid use admitted to pain management for
a recurrent abdominal wound that recently underwent
debridement. The patient underwent a gastrojejunal‑
jejunostomy procedure for a jejunostomy feeding
tube (J‑tube) insertion 6 months prior and had been
combining her tube feeds with oral intake. Shortly after
the procedure, she had been treated for surgical wound
debridement on the abdomen and lower back and pelvis
without penetration into the retroperitoneum. She had
regular follow‑up with wound care, and despite daily
use of opioids for pain management, it was difficult
to control her pain. In addition, the patient noted
considerable weight loss over the past year that was
attributed to malabsorption and gastroparesis which
required J‑tube placement. She had additionally been
placed on warfarin for antiphospholipid syndrome
which was later held for wound debridement and
switched to Lovenox. Before the wound debridement
preceding the admission, a biopsy of the abdominal
wound showed subcutaneous medium‑sized blood
vessels with medial circumferential and near occlusive
calcification and soft tissue calcification consistent with
calciphylaxis. Her serum creatinine was noted to be
slightly elevated at 1.50 from her baseline of 0.9–1.10.
In addition, she was noted to have hyperkalemia and
hyperphosphatemia, while her INR was 1.34. Once
the acute kidney injury and electrolyte disturbances
resolved with tube feeds and fluids, at the suggestion
of nephrology and dermatology, the patient was started
on treatment sodium thiosulfate infusion after port
placement. She was discharged after changing the
wound VAC on her abdomen and was instructed to
follow up with dermatology, nephrology, and wound
care, regularly in addition to palliative care for pain
Conclusion: Among the few observed cases of
nonuremic calciphylaxis, cases cited were primarily
among Caucasian women reporting malignancy,
hyperparathyroidism, protein C and S deficiencies,
mineral abnormalities, and a variety of other
conditions, underscoring a contribution of a multitude
of factors toward the pathogenesis. We have reason
to suspect that antiphospholipid antibody syndrome
could also be implicated as a major contributing factor
to our patient’s presenting complaints. One concern is
that the indicated coumadin treatment increased the
likelihood of warfarin‑induced skin necrosis, leading
to calciphylaxis. While the incidence of nonuremic
Table 1: Descriptive characteristics of survey respondents
separated by populations of resident and attending
Table 2a: Results of multivariate analysis for attending
physiciand (N=166)
Table 2b: Results of multivariate analysis for attending
physiciand (N=194)
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 273
calciphylaxis is low, the high rate of mortality in patients
highlights the necessity for better understanding the
pathophysiology of this rare disorder so that we may
improve our treatment regimen and reduce adverse
effects of this lethal ailment.
Anchoring Bias: In This Patient with Diabetes,
Is Diabetic Gastroparesis Truly the Cause of Her
M. Tawadros1, R. L. N. Hindosh1, A. Brahmbhatt1,
H. B. Liaquat, R. Snyder, J. Sotherland, A. Davis1
1Internal Medicine Residency, Richard A. Anderson Campus,
Easton, PA, USA and Gastroenterology Fellowship, University
Campus, Bethlehem, PA, USA
Introduction: Gastroparesis is characterized by
delayed gastric emptying in the absence of any
mechanical obstruction. Symptoms include nausea,
vomiting, early satiety, and abdominal bloating.
While diabetes is the most common systemic disease
causing gastroparesis, not all gastroparesis in patients
with diabetes is caused by diabetes. It is important to
be aware of potential biases that can affect decision‑
Case Scenario: A 45‑year‑old female with a history of
type 1 diabetes, hypothyroidism, and Stage 3 chronic
kidney disease due to diabetic nephropathy presented
with worsening fatigue, cold intolerance, and
palpitations for 4 weeks. In February, her TSH level
was markedly elevated at 447 mU/L. Prior TSH was
1.1 mU/L in January 2019. She has been on Synthroid
150 mcg daily for years. The patient repeatedly denied
any changes to her medication dosing, formulation,
or method of consumption. She has consistently taken
Synthroid 1 h before her other medications with a
sip of water. On further questioning, she noted that
during those 4 weeks, she had increased abdominal
distention, bloating, and nausea. She denied ever
having these symptoms before. Gastric emptying
study performed at the end of March demonstrated
severely depressed gastric emptying, and she was
prescribed Reglan. The initial assumption was that she
had developed diabetic‑induced gastroparesis. While
Reglan improved her gastrointestinal (GI) symptoms
and she was regularly taking her Synthroid, and her
fatigue persisted. Other laboratory testing done in
March showed AST 98 U/L, ALT 211 U/L, ALP 148
IU/L, total bilirubin 0.5 mg/dL, and Hgb A1C 6.5.
Viral hepatitis and celiac panels were negative. Liver
ultrasound showed normal size, echotexture, and no
splenomegaly. The patient’s abdominal symptoms
improved over the following 3 weeks, and she no
longer required Reglan. Repeat liver function tests
at the beginning of April showed normalization of
liver enzymes. She has not experienced any further
GI symptoms.
Conclusion: The initial assumption was that her GI
symptoms were due to diabetes‑induced gastroparesis.
Given our patient’s prior medical history including
diabetic nephropathy, this would normally be a
reasonable consideration. It was this anchoring bias,
however, that initially attributed her GI symptoms due
to diabetic‑induced gastroparesis. It was the persistent
fatigue that prompted further testing. It was later
concluded that this patient most likely had a viral
illness causing transient gastroparesis and affecting
the absorption of Synthroid. Her symptoms abated
temporally with normalization of her liver function
and likely eradication of her viral illness. She has not
had any further GI complaints. The teaching points
are twofold: we need to be aware of our own decision‑
making biases as it can affect patient management.
Second, it is important to consider viral‑induced
gastroparesis as a potential etiology, especially if the
symptoms are more acute and of a shorter duration.
Natural Options for the Treatment of Chronic Pain
When Chronic Kidney Disease Is Present
A. Parameswaran, R. Snyder1
1Internal Medicine Residency, Richard A. Anderson Campus,
Easton, PA, USA
Introduction: For individuals with chronic pain,
treatment options are often limited, especially if the
patient has chronic kidney disease. Commonly used
medications including nonsteroidal anti‑inflammatory
drugs (NSAIDs) and acetaminophen are not without
risk. The effects of NSAIDs on renal function are well
documented including acute kidney injury, hypertension,
edema, and hyperkalemia. Chronic use of acetaminophen
increases the risk of developing chronic tubular‑interstitial
disease secondary to papillary necrosis. There are other
possible, effective alternatives with minimal side effects
and no reported adverse effect on kidney function. They
should be considered in patients with both coexisting
chronic pain and chronic kidney disease. We report two
patients with chronic kidney disease and chronic pain
in which the use of natural, safe alternatives improved
Conference Abstracts and Reports
274 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
pain and level of functioning with no damaging effects
on kidney function.
Case Scenario: We present a 72‑year‑old male with a
history of stage 3 chronic kidney disease and significant
osteoarthritis of his left knee. He is able to ambulate
without assistance but has chronic pain in that area.
Other medical history includes nephrolithiasis and
hypertension. His baseline creatinine is approximately
1.6 mg/dL. He was started on turmeric 500 mg
daily as well as a topical homeopathic product Arnica
Montana 30X which was applied to his left knee twice
daily. He reported an improvement in his pain levels
and noted being able to walk better within 3 weeks of
initiating this regimen. A 90‑year‑old male with repeat of
hypertension and gout had been maintained on losartan
and allopurinol dose based on renal function for several
years. His baseline creatinine was 1.5 mg/dL. Despite
being on these two medications, he still would experience
intermittent gout flares. The patient was started on tart
cherry extract twice daily the capsule form and he has
not had a gout flare over the last couple of years.
Conclusion: There are alternative options for
people with chronic pain and chronic kidney disease
which deserves further study. Turmeric has been
found to be noninferior to NSAIDs with regard
to pain control however does not cause the renal
dysfunction associated with NSAIDs. It also may
have other beneficial aspects including cardiac‑ and
neuro‑protective properties. Arnica Montana is a
homeopathic supplement that has been demonstrated
to be an effective pain option for patients with both
knee and hand osteoarthritis in peer‑reviewed study.
Tart cherry extract has been demonstrated to reduce
the frequency of gout flare‑ups as well as chronic pain
induced by the gout. Their pain control and level of
functioning have improved without detrimental effects
on renal function. We need to consider incorporation
of these alternative agents in our armamentarium for
pain control in patients both with and without chronic
kidney disease. Further research is needed regarding
optimal dosing and duration.
Varicella Zoster Vasculopathy Causing Multifocal
Cerebral Infarcts
A. S. Elshaikh1, I. Taha1, C. E. Ruggeri1
1Internal Medicine Residency, University Hospital Campus,
Bethlehem, PA, USA
Introduction: Multifocal cerebral infarcts are most
commonly attributed to cardioembolic phenomena
and are seldom seen as a result of varicella zoster
vasculopathy (VZV). In this report, we describe a rare
cause of multiple cerebral infarcts secondary to VZV.
Case Scenario: A 63‑year‑old male was brought to the
hospital after recurrent falls felt to be due to alcohol abuse.
He was recently discharged from physical rehabilitation
and the past workup was unrevealing for cardiac or
metabolic etiologies. Physical examination revealed
a confused malnourished patient, with generalized
skin abrasions at multiple stages of healing and healed
vesicular scabbed lesions on the buttocks. Cardiovascular
examination revealed normal heart sounds with no
murmurs or gallop, lungs clear to auscultation bilaterally.
Neurological examination revealed new left facial droop
otherwise intact cranial nerves, positive left‑sided upper
and lower limb spastic hemiparesis, and brisk reflexes.
Computed tomography (CT) of the head demonstrated
profound cerebral and cerebellar atrophy. Magnetic
resonance imaging of the brain showed three distinct foci
of diffusion restriction in three separate vascular territories
including both middle cerebral artery territories and the left
posterior cerebral artery territory, indicative of multifocal
infarctions [Figure 1]. TPA was not given as the patient
was outside the window. EKG and echocardiogram
excluded atrial fibrillation and vegetations/thrombus,
respectively, as etiology. Lumbar puncture was negative for
pleocytosis or protein. However, it revealed positive VZV
DNA PCR. This prompted CT angiography of the head
and neck which showed no overt inflammation or vascular
beading consistent with central nervous system vasculitis.
The patient was treated for VZV with a 14‑day course
of acyclovir and prednisone and was later discharged to a
rehabilitation facility. Outpatient follow‑up demonstrated
improvement in his neurological examination.
Conclusion: Although multifocal infarcts are usually
attributed to cardioembolic sources, we learned from
our case not to overlook other uncommon causes such
as VZV vasculitis. VZV vasculitis responds well to
antiviral and steroid therapy.
Delayed‑Onset Seizures Following Self‑Inflicted Nail
Gun Injury to the Head: Case Report and Review of
the Literature
T. Xia1, B. A. Hoey1
1 General Surgery Residency, University Hospital Campus,
Bethlehem, PA, USA
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 275
Introduction: Nail gun use has increased since its
introduction in 1959. Not surprisingly, the incidence
of nail gun injuries has increased with approximately
40,000 patients injured per year. A vast majority of
these injuries involve the extremities; however, there
is a subset of patients who suffer intracranial trauma.
There are multiple reports that suggest such an injury
can lead to permanent neurologic impairment or
death. A 2012 review of 41 nail gun head trauma cases
suggested that further study is needed to develop a
proper diagnostic and treatment algorithm for these
individuals with nail gun‑related head trauma. This
case details late‑onset posttraumatic seizures in a
patient who suffered 28 self‑inflicted penetrating
head wounds from a nail gun while distraught
after accidently amputating his hand. In addition,
we present an updated comprehensive review of
relevant literature to discuss proper diagnosis and
management of intracranial nail gun injuries.
CARE Statement: This case details late‑onset
posttraumatic seizures in a patient who suffered multiple
self‑inflicted penetrating head wounds from a nail gun.
He had no neurological deficits and ultimately was treated
conservatively. The patient suffered delayed posttraumatic
seizures requiring life‑long seizure prophylaxis. A
literature search was conducted on PubMed using the
phrases nail gun and penetrating head trauma; this is
the 65th reported case. All articles were reviewed with
attention to patient condition at presentation, treatment
strategies, and outcomes. Based on this review, we present
the first diagnostic and treatment algorithms for patient
with nail gun injuries to the head.
Case Scenario: A 25‑year‑old male construction
worker suffered an accidental amputation of his left
hand while using a circular saw and subsequently
fired a nail gun 28 times into his head in an attempt
to “dull the pain.” He presented to the trauma center
with left arm pain and a headache with numerous
nails protruding from his scalp. His GCS was 15.
Plastic surgery and neurosurgery were consulted for
evaluation. Computed tomographic (CT) scan of
his head revealed 24 nails perforating the skull, with
subarachnoid blood bilaterally [Figure 1, CT scout
image] One nail emerged in the interhemispheric
fissure and several entered the cerebral cortex. There
was no obvious pneumocephalus or intracerebral
hematomas. An arteriogram revealed no major vessel
injury. He was then taken to the operating room
for scalp debridement and hand reimplantation. All
extracranial nails were removed; however, no attempt
was made to remove the embedded nails due to the
risk of intracerebral bleeding and the patient’s intact
examination. On the postoperative day 1, the decision
was made to re‑amputate the patient’s hand due to
ischemic changes. The rest of his hospital course was
uneventful as he completed a 7‑day course of broad‑
spectrum antibiotics and daily seizure prophylaxis.
Fifteen months later, the patient presented to an
emergency department following a seizure. Physical
and neurological examination was unremarkable.
The patient denied previous seizures but admitted
to recently stopping his anticonvulsant. A CT scan
showed no new lesions and an electroencephalogram
revealed bihemispheric cortical abnormalities
without any focal epileptiform activity. The hospital
course was otherwise unremarkable, and the patient
was discharged home back on prophylaxis. He has
since returned to work and is living independently
with no apparent long‑term complications.
Conclusion: We report a case of nail gun injury that
involved 28 self‑inflicted penetrating head wounds.
The patient had no neurological deficits and was
treated conservatively suffering a delayed outpatient
seizure, after stopping his recommended prophylactic
antiseizure medication. Diagnostic and treatment
algorithms for this unique injury are presented based
on this case and a review of the literature.
Risk Factors Associated with Poor Outcomes in
Younger COVID‑19‑Hospitalized Patients
J. G. Fleischer1, R. A. Pallay1, C. Oshea1,
R. Unterborn1, D. Corwin1
1Temple/St. Luke’s Medical School, Bethlehem, PA, USA
Figure 1: Magnetic resonance imaging of the brain (current case)
Conference Abstracts and Reports
276 International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020
Introduction: Over 1,000 patients admitted
to the St. Luke’s University Health Network
(SLUHN) have been afflicted with the COVID‑19
virus during the past several months. With
about 2 million cases of the novel coronavirus
in the United States, the current pandemic has
become the focus of immense research efforts and
innumerable scientific publications. However,
much of the published content is focused on
constantly‑evolving treatment algorithms and
descriptive characteristics of patient cohorts
and clinical experiences. The goal of this project
is to better understand the types of patients
impacted and to identify the influence of common
comorbidities (body mass index [BMI], smoking
status, hypertension, diabetes, coronary artery
disease [CAD], congestive heart failure [CHF],
chronic obstructive pulmonary disease [COPD],
asthma, immunosuppression, and chronic kidney
disease [CKD]) particularly on the younger
patient population (<50 years old) based on
the collective SLUHN experience. The goal of
this project is to identify risk factors for poor
outcomes in our patient cohort and thereby
facilitate improved clinical management of more
severe COVID‑19 cases.
Methods / Study Population: The
retrospective study cohort included 692
COVID‑19‑positive patients admitted to
SLUHN hospital campuses in Pennsylvania
and New Jersey between February 1, 2020
and May 31, 2020. Mean age of the study
population was 64.0 years (±16.7). A majority
of the patients were male (54.1%) while
45.9% were female. 57.9% of the patients were
Caucasian, 17.3% African‑American, 1.7%
Asian, less than< 1% Native‑American, and
19.2% reported their race as “Other.” Within
the study cohort, 30.2% of the patients were
as Hispanic or Latino, 66.0% Not Hispanic
or Latino, with the remaining 3.8% were
reported as Other [Table 1]. The average
BMI of the participants was 31.6 (±7.8),
where 53.9% of patients had a BMI of 30.0
or higher, 26.2% had a BMI between 25 and
29.9, 18.5% had a BMI between 18.6 and
24.9, and 1.4% had a BMI <18.5. 62.7% of
the patients never smoked tobacco, whereas
32.7% report quitting tobacco use, 4.2% are
active tobacco users, and 4.5% declined to
answer. Data were extracted from patients’
electronic medical records both during their
admission and after discharge. Analyses were
carried out using SPSS (IBM, Armonk, NY)
Software 18, with statistical significance set
at P < 0.05. Chi‑square test of independence
was performed to examine the relationship
between known COVID‑19 risk factors among
COVID‑19‑infected patients younger than
50 years (n = 148) versus those 50 years and
older (n = 544).
Results: Risk factors showing statistically
significant difference between the two study
groups (e.g., <50 years versus >50 years) BMI,
smoking exposure, diabetes, hypertension, heart
failure, COPD, and malignancy. There was no
difference in asthma and immunosuppression
between the two groups. Of note, 93.2% of
patients in the younger group were overweight/
obese (BMI >25) compared to 76.5% of patients
>50 years (P < 0.0001). In addition, 27.7%
of younger COVID‑19 patients had smoking
exposure compared to 40.3% of older patients
[Table 2]. 29.7% of younger patients had diabetes
compared to 44.7% of older patients (P =
0.00107). Hypertension was identified in 31.4%
of the <50 years group compared to 66.2% of
older patients (P < 0.00001). 95.9% of younger
patients did not have heart failure compared to
83.8% of older patients (P = 0.00014). Moreover,
97.3% of younger patients did not have CAD
compared to 80.3% among those >50 years of
age (P < 0.00001). 2.3% of younger patients
had COPD compared to 10.9% of older patients
Figure 1: Radiographic depiction of multiple nail gun injuries sustained
by the patient
Conference Abstracts and Reports
International Journal of Academic Medicine | Volume 6 | Issue 3 | July-September 2020 277
(P = 0.00087). 2.7% of younger patients had
malignancy compared to 11.6% of older patients
(P = 0.00120). Finally, 4.7% of younger patients
had CKD compared to 23.5% of older patients
(P < 0.00001).
Conclusion: The results of this study provide
insight into key risk factors that contribute to
severe COVID‑19 infection in young (<50 years)
patients compared to older (50+ years) patients.
Hospitalized COVID‑19 patients of all ages were
more likely to have BMI >25 and hypertension.
However, patients under 50 years of age were
more likely to be overweight/obese compared to
patients 50 years and older. On the other hand,
older patients were more likely to have a history
of smoking exposure, diabetes, hypertension, heart
failure, CAD, COPD, malignancy, and CKD.
Overall, this study suggests that BMI is a major
risk factor for more severe disease in patients under
50 years of age. In comparison, smoking exposure,
diabetes, hypertension, heart failure, CAD, COPD,
malignancy, and CKD are risk factors for more
severe disease in older patients. These results are
important in establishing age‑specific clinical
prognostic criteria.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
All research projects presented during the St. Luke’s
University Health Network Annual Research Symposium
were verified to have either appropriate Institutional
Review Board approvals or exemptions. For case reports,
proof of patient consent documentation was required.
In all instances, applicable EQUATOR guidelines (see guidelines/)
for scientific reporting were followed.
Table 1: Demographic data
Table 2: Risk factors and chi square analysis
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Background The vast majority of individuals diagnosed with diabetes are low/middle income and may have access to only three of the 11 oral hypoglycemic medications (OHMs) due to cost: metformin intermediate release (IR) or extended release (ER), sulfonylureas (glimepiride, glipizide, glyburide), and pioglitazone. Sulfonylureas and pioglitazone have had significant controversy related to potential adverse events, but it remains unclear whether these negative outcomes are class-, drug-, or dose-related. Objective We conducted a narrative review of low-cost OHMs. Results We found that the MAX was often greater than the EFF: metformin IR/ER (MAX: 2,550/2,000 mg, EFF: 1,500–2,000/1,500–2,000 mg), glipizide IR/ER (MAX: 40/20 mg, EFF: 20/5 mg), glyburide (MAX: 20 mg, EFF: 2.5–5.0 mg), pioglitazone (MAX: 45 mg, EFF: 45 mg). Time-to-peak change in HbA1c levels occurred at weeks 12–20 (sulfonylureas), 25–39 (metformin), and 25 (pioglitazone). Glimepiride was not associated with weight gain, hypoglycemia, or negative cardiovascular events relative to other sulfonylureas. Cardiovascular event rates did not increase with lower glyburide doses (p<0.05). Glimepiride and pioglitazone have been successfully used in renal impairment. Conclusions Metformin, glimepiride, and pioglitazone are safe and efficacious OHMs. Prescribing at the EFF rather than the MAX may avoid negative dose-related outcomes. OHMs should be evaluated as individual drugs, not generalized as a class, due to different dosing and adverse-event profiles; Glimepiride is the preferred sulfonylurea since it is not associated with the adverse events of others in its class.