2013 utgsm resident & fellow research day

RESIDENT & FELLOW RESIDENT & FELLOW RESEARCH DAYRESEARCH DAY

2013 Abstracts2013 Abstracts

The University of Tennessee The University of Tennessee Graduate School of Medicine Graduate School of Medicine

andand

Academy of Scholars CommitteeAcademy of Scholars Committee

Healing Education Discovery

The Academy of Scholars Committee

Department

Pages

Anesthesiology 2 - 3 Cytopathology 5 Family Medicine 7 General Surgery 9 - 11 Internal Medicine 13 - 15 Obstetrics / Gynecology 17 - 20 Oral & Maxillofacial Surgery 22 Oral Head & Neck Surgery 24 Pathology 26 - 29 Pulmonary Disease 31 Radiology 33 - 34 Urology 36 Vascular Surgery 38

Anesthesiology

2013 Annual Research DayUniversity of Tennessee Graduate School of Medicine

Academy of Scholars

Title: INCIDENCE OF HYPOTENSION BETWEEN EPIDURAL ADMINISTERED

LIDOCAINE AND CHLOROPROCAINE FOR CESAREAN SECTION

Program: Anesthesiology Author: Brian Adams, MD Co-Authors: Patrick McConville IRB Number: 3264 Original Research Objective: Compare the hemodynamic effects of chloroprocaine versus lidocaine by analyzing the

frequency of hypotension episodes.

Methods: A retrospective database search identified 118 parturients who underwent epiduralanesthesia for cesarean section with lidocaine or chloroprocaine. The number ofhypotension episodes were recorded with an episode defined as a systolic bloodpressure <90 mmHg or a =20% decrease from pre-operative baseline. Variablesincluding age, pre-operative blood pressure, hypertensive disease, estimated bloodloss, ephedrine use (mg), phenylephrine use (mg), and total intravenous fluidadministration (mL) were collected.

Results: Patients receiving chloroprocaine were 4.66 times (95% CI 1.31-16.6) more likely toexperience an episode of hypotension compared to those receiving lidocaine. Nodifference existed between groups using the =20% decrease from baseline criteria(p=0.16) but a difference existed for systolic <90 mmHg (p= 0.049). The mean numberof hypotension episodes in chloroprocaine versus lidocaine patients was 12.57 to 7.82.10% of chloroprocaine patients experienced no episodes of hypotension compared to34.1% of lidocaine patients. No significant differences existed between age, estimatedblood loss, phenylephrine use, pre-operative blood pressure, or total intravenous fluids.Those receiving chloroprocaine did receive significantly more ephedrine.

Conclusion: Chloroprocaine patients experienced more hypotension episodes more frequently.Despite this finding, no significant difference existed for phenylephrine use, totalintravenous fluids, or blood loss as one might expect. Attempting to isolate thehemodynamic effects of the two drugs is not easy and further studies may clarify anyvariation. Our study was limited by chloroprocaine patient size and the need foraccurate variable charting.

2


Academy of Scholars

Title: PREOPERATIVE PREDICTORS FOR INTRAOPERATIVE DOUBLE LOW

AND TRIPLE LOW

Program: Anesthesiology Author: Ron Benton Pitkanen, MD Co-Authors: Robert M. Craft, MD; Roger C. Carroll, PhD; Justin Barnes, MS IRB Number: 3611 Original Research Objective: The combination of low mean alveolar concentration (MAC) requirements, low mean

arterial pressure (MAP), and/or low bispectral index (BIS) are phenomena known as“triple low” and “double low” respectively. Triple low is associated with 30-day mortality.Using this as a surrogate for mortality, we investigated whether preoperative co-morbidities predicted an increased incidence of double/triple low intraoperatively.

Methods: Mean intraoperative MAC, MAP, and BIS were defined for 18,256 patients from 18--99years old undergoing non-emergent, non-cardiac surgery via general inhalationalanesthetic, who had a preoperative evaluation within 30 days. Means and standarddeviations were established for MAC, MAP and BIS intraoperatively. Categories fordouble/triple low as assessed by both case-based and time-based methods werecorrelated with the preoperative evaluation. Multiple regression analysis with stepwiseelimination was utilized to determine independent predictors of double/triple low.

Results: Values that exceeded one standard deviation below the mean for MAC (<0.8), MAP(<75) , and BIS (<40) correlated well with those of Sessler, et al. Age, ASAclassification, tobacco use, low BMI, renal failure, CHF, and CVA were all independentpredictors of intraoperative double low. Advanced age, low BMI, and renal failure wereindependent predictors of triple low.

Conclusion: Advanced age, low BMI, and renal failure were predictors of triple low.Anesthesiologists usually correlate higher BMI with worsened outcomes, but our datasuggests otherwise for this specific occurrence. Renal failure has been associated withnegative outcomes, thus the association with triple low may be more expected. Furtherinvestigations into these relationships with respect to causality are still needed.

3

Cytopathology


Academy of Scholars

Title: CELL BLOCK PREPARATION FOR TRANSBRONCHIAL FINE NEEDLE

ASPIRATION CASES GENERATES ADEQUATE TISSUE FORANCILLARY TESTING

Program: Cytopathology Author: George M. Sneed, D.O. Co-Authors: Lisa D. Duncan, M.D.; Matthew J. Curzon, M.D.; Paul Branca, M.D. IRB Number: 3571 Original Research Objective: Transbronchial fine needle aspiration (TBNA) is routinely performed to diagnose lung

and mediastinal lesions and establish carcinoma nodal stage. TBNA is less invasivethan radiographic-guided core biopsy and mediastinoscopy. No tissue forimmunohistochemistry (IHC) and molecular testing is a procedure limitation. This studydescribes the utility of an optimized cell block (CB) preparation technique.

Methods: 47 patients had TBNA of mediastinal or lung lesions, resulting in 80 cell blocks. Needlerinse from TBNA material was collected in Saccomanno's then subjected tocentrifugation. CB adequacy and diagnoses were compared with aspirate smears.Ancillary testing performed from CB was documented.

Results: 67 (84%) CB were from lymph nodes and 13 (16%) from lung lesions. 41 CB (51%) hadcompanion aspirate smears. Aspirate smears from 2 patients (4.3%) were malignantwith a non-diagnostic companion CB. 18 CB (38% of patients) were malignant (4squamous cell carcinoma, 5 small cell carcinoma, 5 adenocarcinoma, 2 non-small cellcarcinoma, 1 carcinoid, 1 favor Hodgkins lymphoma). 2 CB (2 patients) had sarcoid and1 had Histoplasmosis. 14 malignant CB had successful IHC. Epithelial growth factorreceptor mutation was negative in 2 cases (2 patients). Anaplastic lymphoma kinasemutation was successfully performed on 2 of 3 CB (3 patients).

Conclusion: Our CB preparation method for TBNA is effective in accurately diagnosing lung andmediastinal lesions, providing material for IHC and molecular testing. Patient care isimproved by providing a less invasive procedure which can successfully procurediagnostic tissue suitable for molecular testing needed to guide patient therapy.

5

Family Medicine


Academy of Scholars

Title: THE PSYCHOLOGICAL IMPACT OF CARDIOVASCULAR SCREENING:

THE ATHLETE’S PERSPECTIVE

Program: Family Medicine Author: Jonathan B. Laymance, MD, Irfan M. Asif, MD Co-Authors: Serena Johnson, Jason Schmeig, Brett Toresdahl, MD, Hank Pelto, MD,

Tiffany Smith, Jeffrey Fairbrother PhD, Rebecca Zakrajsek, PhD, LesleeFisher, PhD, Kimberly G. Harmon, MD, and Jonathan A. Drezner, MD

IRB Number: 3316 Original Research Objective: To determine the psychological implications of cardiovascular screening in athletes.

Methods: Prospective, non-randomized controlled trial. High school athletes received astandardized history and physical exam (control group) or a history and physical + ECG(ECG group). Pre- and post-screen validated assessments for health attitudes, anxiety,and impact of screening on sport were conducted using a 5-point Likert scale (-2 to 2).T-tests and ANOVA measured differences between groups.

Results: 955 student-athletes participated in the study (control=153; ECG= 802); 49.7% female,mean age 15.5 years. In the ECG group, 576 had negative screens, 220 had anabnormal screen (by history 19.7%, physical 6.7%, or ECG 1.8%) but normal work-up(false-positive), and 6 were identified with a serious cardiac condition (true-positive,0.75%). Those who received an ECG were more likely to: 1) be satisfied (p<0.001), 2)feel safer during competition (p<0.003), 3) support that all athletes should receivecardiac screening (p<0.001), and 4) state the ECG positively impacted their training(p<0.001). Individuals requiring additional testing did not report anxiety (mean score= -0.25). Compared to control subjects, individuals with false-positive results had similarpositive psychological benefits as above.

Conclusion: ECG screening does not cause undue anxiety in athletes and there are a number ofpositive psychological benefits. Significance: The American Heart Associationsupposition that ECG screening causes excessive anxiety in athletes is unproven.Psychological distress should not be used as a rationale against ECG screening.

7

General Surgery


Academy of Scholars

Title: IN VIVO TESTOSTERONE SUPPLEMENTATION DECREASES

CIRCULATING INTERLEUKIN FAMILY ISOFORMS ANDDIFFERENTIALLY REGULATES MMPS

Program: General Surgery Author: Brian Freeman, MD Co-Authors: Mountain D.J.H., Brock T.C., Chapman J., Kirkpatrick S.S., Stevens S.L.,

Goldman M.H., Klein F.A., Freeman M.B., Grandas O.H.

IRB Number: 3622 Original Research Objective: Androgen deficiency (AD) is associated with increased risk of vascular disease, yet the

molecular mechanisms remain unclear. Our group has previously demonstrated femalesex hormones influence hyperplasia development via inflammatory-modulated matrixmetalloproteinase (MMP) regulation. Here we investigated the effect of testosterone oncirculating MMPs and inflammatory cytokines. We hypothesize that AD is acting as apro-inflammatory modulator contributing to dysfunctional vascular remodeling.

Methods: Aged orchiectomized rats were implanted with testosterone pellets (TST; 0.5-150mg).Serum was collected 0-28d.

Results: TST levels in young, aged intact (AI), and placebo controls were 2.72±0.35, 2.31±0.66,and 0.15±0.07ng/ml per ELISA. Sub-physiological, physiological, and supra-physiological levels were achieved at 14d with 0.5, 2.5, and 35mg pellets (0.37±0.09,2.89±0.44, 13.45±0.65ng/ml). Inflammatory cytokine arrays indicated interleukin familyisoforms IL-1a, IL-2, IL-6, IL-10, and IL-1R6 were elevated in the absence of TST,while TST supplementation decreased interleukins in a dose-dependent manner,approaching basal young and AI levels. MMP inhibitor TIMP-1 was decreased in AI andplacebo vs. young, while TST increased TIMP-1 in a dose-dependent manner. ELISAindicated MMP-9 was significantly decreased in AI vs. young (25.2±2.4, 53.1±8.6ng/ml).Placebo, sub-physiological, and physiological TST had no significant effect, whilesupra-physiological levels significantly elevated MMP-9 (72.0±17.9ng/ml) compared toall aged groups.

Conclusion: Testosterone downregulates interleukins and differentially affects circulating MMPisoforms in vivo. Future studies will examine the role of AD in inflammatory cytokine andMMP-modulated hyperplasia development in animal models of vascular disease. ADcould be playing a role in vascular disease via the regulation of inflammatory signalingcascades.

9


Academy of Scholars

Title: IMPROVED OUTCOMES FOR PERMANENT HEMODIALYSIS ACCESS Program: General Surgery Author: Sagar S. Gandhi, MD Co-Authors: Juan Gallegos MD, Rebecca Jarvis RN, Patrick B. Barlow, R. Eric Heidel

PhD, Mitchell H. Goldman MD, Oscar Grandas MD

IRB Number: 3416 Original Research Objective: To examine our patency rates, compare them to national averages and draw

conclusions to improve outcomes. The secondary goal of our study was to examinepatient factors that may contribute to failure of HD accesses.

Methods: A retrospective review of the UTMCK Vascular Access Database was performed whichconsisted of approximately 1200 patients from 2008-2012.

Results: Five hundred sixteen first permanent accesses were performed. Our Fistula First ratewas 89.5%. Our primary patency rate, assisted primary rate, secondary patency rate forAVF was 77%, 76% and 63% respectively (n = 340) and for AVG was 84%, 85 %, and73% respectively (n = 41). Cumulative patency rates were 86%, 82%, 77%, 69% at 3,6, 12, and 24 months respectively. Mean follow up was 17 months. When reviewingpatient comorbidities, only CHF was found to be statistically significant for patency(p =0.03).

Conclusion: A Fistula First rate above the national average can be obtained. Furthermore, ourpatency rates are higher than rates quoted in the literature. Increased patency ratescan be achieved with a protocol in which all patients have preoperative venousmapping, vascular surgeons who are committed to the Fistula First initiative and whoare aggressive in early interventions. Furthermore, a vascular access center can assistin improving primary patency rates by providing a single channel for feedback, closesurveillance, and education of HD centers. It can also reduce costs by triaging patientsso that same day interventions can be performed, which can decrease the number ofadmissions and reduce ED visits.

10


Academy of Scholars

Title: REMOTE CUTANEOUS PHOTOGRAPHY FOR PUBLIC DERMAL

SCREENINGS

Program: General Surgery Author: Valerie Sams, MD Co-Authors: Georgette Samaras, BS, David Shupp, MD, Matthew Hanngi, MD,

Lindsey Fish, MD, Matthew Jones, MD, John Bell, MD, Keith Gray MD,James Lewis, MD

IRB Number: 3048 Original Research Objective: There are no randomized studies that demonstrate an overall survival benefit from

public cutaneous screenings; however, there may be a substantial benefit to screeningtargeted individuals. We hypothesized that a cutaneous screening program usingphotography would direct individuals with photographically suspicious lesions towardintervention.

Methods: Institutional IRB for the study was obtained. Participants were offered the opportunity toparticipate in photographic dermal screening and attended community screeningvenues between September 2010 and May 2011. After obtaining informed consent andpersonal history, targeted lesions were digitally photographed, stored on a securedatabase, and graded by a physician. A grading system was created to describe thedegree of suspicion that a lesion was malignant and the quality of the photograph itself.Lesions were given a score designated “skin-rads” (SR) score of 0-3. SR0 meant thephoto could not be evaluated, SR1 was visually benign, SR2 needed clinical evaluationand SR3 recommended biopsy. Participants with SR2/3 lesions were referred toclinicians and contacted for results of the biopsy.

Results: Of the 297 lesions photographed, 165 (55.6%) were SR1, 88 (29.6%) SR2, 27 (9.1%)SR3, and 18 (5.6%) SR0. Seventy-seven participants had SR2 or SR3 lesions of whichwe were able to contact 41(53%). Eighteen (44%) sought medical attention and 11(26.8%) underwent biopsy. Biopsy results included 4 non-melanoma carcinomas, 2melanomas, 3 benign lesions and 4 with unknown results.

Conclusion: Public Photographic Dermal Screening (PPDS) can identify patients with suspiciouslesions who need further evaluation. This process continues to be refined and studiedat our institution.

11

Internal Medicine


Academy of Scholars

Title: FUNCTIONAL NEUROIMAGING IN ATHLETES WITH CONCUSSION Program: Internal Medicine Author: Maxwell Rajan, MD Co-Authors: Wen Ching Liu, PhD; Dzung Dinh, MD MBA, University of Illinois IRB Number: 177732 Original Research Objective: Concussion is a common, yet complex entity. Incidence is estimated at 6/1000 within

the general population, more within participants of contact sports. However, little isknown about the actual patterns of damage or their evolution. Diffusion tensor imaging(DTI) is a novel imaging modality for identifying changes in neural tract function; usingwater as the MR contrast, DTI can identify change in axon diffusion pattern and axonwater flux.

Methods: A prospective, controlled study to identify neural tracts damaged by concussion duringsubacute and resolving injury was done. Subjects were gathered from a universitysoccer and high school football team. Soccer subjects were pre-scanned using DTI andfMRI (0- and 2-back protocols) and observed over the season for evidence of head-trauma. High school football players were directly admitted to the study via emergencydepartment without baseline scans. Scans were administered at 24-48 hours and twoweeks post-injury. Scans were pooled and processed using exhaustive, two-sample t-test with family-wise error rate correction and threshold-free cluster enhancement.

Results: Significant disruption in diffusion patterns were found in major anterior-posterior runningtracts and in the limbic system (p<0.05), while significant increases in flux were foundupstream of damage (p<0.05). Superimposed fMRI data identified gray matter regionswith high probability of housing the cell bodies of high flux axons. .

Conclusion: Given that increased flux is occurring upstream of white matter with altered diffusionproperties, neural up-regulation is likely within the setting of concussion.

13


Academy of Scholars

Title: AN ASSESSMENT OF COLIFORM BACTERIA IN WATER SOURCES

NEAR APPALACHIAN TRAIL SHELTERS WITHIN THE GREAT SMOKYMOUNTAINS NATIONAL PARK

Program: Internal Medicine Author: Brian C. Reed, MD Co-Authors: Mark Rasnake, MD IRB Number: 3610 Original Research Objective: It has long been held that water obtained from wilderness sources should be treated

prior to drinking. Compliance with this practice among hikers is variable. This projectfocuses on coliform bacteria in water samples taken near popular Appalachian Trailshelters during two seasons.

Methods: Water was collected from designated water access points near 10 high elevation trailshelters within the Great Smoky Mountains National Park (GSMNP) during summer andfall months. These samples were inoculated on a commercial coliform detection kit forquantitative determination of total coliform counts and Escherichia coli counts.

Results: During summer, 7 out of 10 samples were positive for coliform bacteria and 6 for E. coli.The MPN of CFU for coliform bacteria ranged from 0 to 489 CFU/100mL, with the MPNfor E. coli varying from 0 to 123 CFU/100mL. A total of three sites were negative forcoliform bacteria. These data differed from the fall collection, revealing 4 out of 7samples positive for coliform bacteria and 1 for E. coli. The MPN of CFU for coliformbacteria varied from 0 to 119 CFU/100mL and 0 to 5 to CFU/100mL for E. coli.

Conclusion: EPA drinking water standards require 0 CFU/ 100mL to be considered safe. After apreliminary analysis of 10 water sources along Appalachian Trail, the majority of wateraccess points require treatment during the summer season. Coliform burden was not asworrisome through the fall months, though was still a concern for some sites. This datawill illuminate infectious disease risks for wilderness travelers.

14


Academy of Scholars

Title: A NOVEL APPROACH WITH A NOVEL PRODUCT: AEROSOLIZING

PHYTOBACTERIA FOR DISINFECTION

Program: Internal Medicine Author: Matthew D Stone, MD Co-Authors: David Bemis, PhD; Mark Rasnake, MD FACP IRB Number: 3331 Original Research Objective: Evaluate an aerosolized formula of bactalave as a possible solution to cleaning a

hospital room.

Methods: A study was performed with metal discs inoculated with a known concentration ofmethicillin-resistant Staphlycoccus aureus (MRSA), vancomycin-resistant enterococci(VRE), Acinetobacter baumanii, and Klebsiella pneumoniae. Discs with organismburdems of 103, 104, 105, and 106 colony forming units were prepared then placed ina simulated patient room with groups of discs in covered and open areas. A prototypemachine was used to aerosolize a solution of phytobacteria based disinfectant. Theroom was fogged for a variable amount of time and then allowed to settle for 15minutes. Discs were collected and cultured in broth to evaluate for any growth afterexposure to the disinfectant. A control set of discs were not exposed to disinfectants.

Results: Uncovered bacteria with direct exposure showed no growth of any pathogens atinoculations of 104 or less. Higher organism burdens of MRSA and VRE were moreresistant to inactivation. Uncovered disc with indirect exposure had no growth up to10x-3 colony units for MRSA, 10x-4 colony units for VRE, 10x-5 colony units for K.pneumoniae, and all concentrations for A. baumanii. The covered bacteria had post-exposure growth at all concentrations except in the K. pneumoniae and A. baumaniigroups which both had no growth up to 10x-5 colony units. All control discs had growthat all concentrations.

Conclusion: This study demonstrates the effectiveness of a phytobacteria based disinfectant indecontaminating hospital equipment. Initial results indicate the importance directcontact with the disinfectant.

15

Obstetrics Gynecology


Academy of Scholars

Title: COSTS OF CONTRACEPTIVES VARY BY INCOME Program: Obstetrics and Gynecology Author: Audrey Barry, MD Co-Authors: Nikki B Zite, MD; Lorraine S Wallace, PhD IRB Number: 3634 Original Research Objective: For many patients, cost is a leading barrier to obtaining contraceptives. As a result,

cost-associated lack of access has been hypothesized as one of the major factorsassociated with high unintended pregnancy rates. A previous study showed widediscrepancies in the cost of prescription medication as a function of geographiclocation; the goal of this study was to determine whether this disparity exists forprescription contraceptives (PCs).

Methods: Prices for seven commonly used PCs (oral and transvaginal) were obtained from theMyFloridarx.com website for pharmacies throughout the state. Median householdincome data were obtained for all Florida zip codes from the 2010 census. Medianhousehold incomes were then divided into quintiles with prices of the 7 PCs comparedacross zip code income groups across the state.

Results: Nearly every PC was more expensive to obtain for those residing in low-income zipcodes. A combination of ANOVA and Kruskal-Wallis tests were used to determinestatistical significance of the price variations, which showed a significant main effect forincome group in two PC prices. Post hoc analyses demonstrated that the highestincome group reported significantly lower prices than other income zip codes for twoPCs ( p=.003, .001, .007, & .000).

Conclusion: Prescription contraceptives remain an important option for contraceptive use. This studyshows several contraceptive options are more expensive in lower income areas.Ensuring that costs of contraceptives are equivalent among socioeconomic groupscould foster improved access for all women.

17


Academy of Scholars

Title: HIGH GRADE PRIMITIVE NEUROECTODERMAL TUMOR OF THE

UTERUS: A CASE REPORT

Program: Obstetrics and Gynecology Author: A. Mitch Dizon, MD Co-Authors: Larry C. Kilgore, MD, Kristopher J. Kimball, MD IRB Number: 3501 Case Presentation Objective: Primitive neuroectodermal tumors (PNETs) are small round cell tumors from cells

similar to embryonic ectoderm. PNETs are usually in the central axis, soft tissues, orbones. PNETs of the uterus are extremely rare. Early diagnosis is essential as localizeddisease responds relatively well to intense multi-modality treatment.

Methods: A 50yo female with history of treatment for breast cancer presented withabdominopelvic pain. CT scan revealed an enlarged uterus with ill-defined masscontiguous with the uterine fundus suggestive of sarcoma. CA-125 was 407.

Results: The patient was referred to Gynecologic Oncology, undergoing diagnostic laparoscopy,exploratory laparotomy, radical hysterectomy, bilateral salpingo-oophorectomy,omentectomy, optimal debulking, and extensive lysis of adhesions. A 15 cm, necroticmass arose from the uterine fundus. Immunohistochemical stains were positive for CD99, FLI-1, and Vimentin. Pathology revealed high-grade PNET. The patient receivedadjuvant Carboplatin and Etoposide. Recent CT scan identified no evidence of disease.

Conclusion: PNETs are usually in the central nervous system, soft tissues, or bones. The ovary isthe most common site in the female genital tract; the uterus is rare, reported in lessthan 50 cases. Risk factors include adolescent or postmenopausal age, and Caucasianor Hispanic race. The most common symptom is abnormal vaginal bleeding. Thedifferential diagnosis includes tumors exhibiting neuroectodermal elements. Diagnosisis based on microscopic evaluation and immunohistochemical stains. The standardchemotherapy regimen of Vincristine, Doxorubicin, Cyclophosphamide, and Etoposidehas yielded good results; Carboplatin with Etoposide shows similar survival with lesstoxicity. Due to PNET’s rarity and aggressiveness, mortality is high despite combinationtherapy.

18


Academy of Scholars

Title: CHRONIC OPIATE USE IN PREGNANCY AND NEWBORN HEAD

CIRCUMFERENCE

Program: Obstetrics and Gynecology Author: Kevin Visconti, MD Co-Authors: Kerry Hennessy, Craig Towers, Bobby Howard IRB Number: 3548 Original Research Objective: To evaluate whether opiate abuse/usage in pregnancy affects newborn head

circumference. Maternal opiate use has significantly increased in our location and largedosages of prescription oral agents are the primary drugs ingested.

Methods: All newborns admitted to the NICU for treatment of neonatal abstinence syndrome wereprospectively collected. The birth and perinatal ultrasound information wereretrospectively obtained and analyzed. Data included the gestational age (GA) atdelivery, gender, birth weight, head circumference (HC) at birth, opiate type, and theperinatal ultrasound assessment of growth parameters prior to delivery.

Results: From January 1, 2010 to May 30, 2012, 332 neonates were admitted for the treatmentof NAS. A total of 96 (29.5%) had a HC <10th percentile for GA (p<0.01). Of these 96,25 (7.7%) were <3rd percentile and 71 (21.8%) were >3rd<10th percentile; however,62.5% were AGA in birth weight at delivery. Of the 332 total cases, 196 had at least oneultrasound evaluation prior to delivery and of these, 141 were within 10 days of birth.Based on the ultrasound parameters, a HC<5th percentile was found in 38.3% of casesof which 74% were consistent with the post-delivery findings. Of interest, the femurlength measurements were <5th percentile in 36.2% of fetuses in these 141 ultrasoundevaluations; however, 70.5% of those with a small femur length were AGA in weight atdelivery.

Conclusion: Opiate abuse/usage in pregnancy in the form of oxycodone, oxymorphone, andbuprenorphine appears to increase the risk for a head circumference <10th and <3rdpercentile when compared to controls.

19


Academy of Scholars

Title: BLOOD CONTAMINATED AMNIOTIC FLUID AND THE LAMELLAR BODY

COUNT FETAL LUNG MATURITY TEST

Program: Obstetrics and Gynecology Author: Kevin Visconti, MD Co-Authors: Craig Towers, Mark Hennessy, Bobby Howard, Stephanie Porter, Beth

Weitz

IRB Number: 3369 Original Research Objective: To determine if blood contamination falsely elevates the Lamellar Body Count (LBC)

fetal lung maturity test. Because the TDx-FLM test is no longer available, manylaboratories are converting to LBC. Lamellar bodies are the size of platelets and arecounted by hematology cell counters. Previous studies are limited by small numbers;used stored pooled amniotic fluid specimens; and added non-pregnant heparinized orEDTA blood, none of which occur in clinical practice. The concern with bloodcontaminated amniotic fluid obtained by amniocentesis is the platelets in the bloodcould falsely elevate the LBC.

Methods: Mothers undergoing amniocentesis for fetal lung maturity were prospectively consentedto participate. Approximately 8cc’s of clear amniotic fluid were obtained with 6cc’s forpatient evaluation and 2cc’s for study assessment. 1-2 drops of the patient’s blood wasadded to the 2cc sample creating a specimen that was grossly blood contaminated at alevel previously determined to be consistent with those found in clinical practice. Testswere run in tandem using the non-contaminated sample for clinical purposes.

Results: Of the 50 study patients, the LBC decreased by > 3000 in 33 samples (66%) andremained unchanged in 16 specimens (32%). In only 1 case (2%) did the valueincrease – the actual result of 37,000 increased to 44,000 (both of which exceeded themature level in our institution).

Conclusion: Maternal blood contamination of amniotic fluid obtained for fetal lung maturity testingdoes not falsely increase the LBC in 98% of cases. Therefore, a mature bloodcontaminated LBC test result is reliable.

20

Oral and Maxillofacial

Surgery


Academy of Scholars

Title: A FIVE YEAR RETROSPECTIVE REVIEW OF PRIMARY PALATOPLASTY

CASES UTILIZING AN ACELLULAR COLLAGEN INTERPOSITIONALGRAFT

Program: Oral and Maxillofacial Surgery Author: David O Pickett DMD, MS Co-Authors: JW Hudson DDS IRB Number: 3376 Case Presentation Objective: Herein we report a series of primary palatoplasties reconstructed with acellular collagen

membrane that aided in maintaining closure between the oral and nasal cavity withoutthe development of an oronasal fistula, and did not interfere during speech habilitation.

Methods: Six patients were identified and followed for one year. Patient #1: 10 month old male,patient #2: 12 month old female, patient #3: 12 month old female, patient #4: 6 year oldmale, patient #5: 12 month old female and patient #6: 18 month old female; all withprimary cleft palatoplasty. An acellular collagen membrane was placed between themuscular layer and the oral mucosa during primary palatoplasty procedure. Tisseel wasutilized to stabilize the acellular collagen graft and to provide a further seal between thenasal and oral cavities. Pictures, and post follow up speech evaluations were utilized tofollow progress.

Results: At the one year follow up, no oronasal fistulae had developed where the acellularcollagen membrane augmentation was used. Speech form and function werepreserved. Patients are continuing near (normal) growth development, as would beanticipated.

Conclusion: 1. The use of an acellular collagen graft to aid in the 3 layer of closure of primarypalatoplasty surgery is a very effective strategy both in primary and secondary healingand in preventing oronasal fistulation. 2. To perform a second surgery for oronasalfistula closure increases the risk of an unfavorable outcome. 3. The risk associated withutilization of acellular collagen membranes appears nonexistent.

22

Oral Head & Neck surgery


Academy of Scholars

Title: SECONDARY FINDINGS OF POSITRON EMISSION

TOMOGRAPHY/COMPUTED TOMOGRAPHY (PET/CT) SCANS IN HEADAND NECK CANCER PATIENTS

Program: Oral/Head and Neck Surgery Author: Andrew WC Lee, MSc, DDS, MD Co-Authors: Robert E Heidel, PhD; Eric R Carlson, DMD, MD, FACS IRB Number: 3613 Original Research Objective: Positron emission tomography/computed tomography (PET/CT) scanning has become

a useful imaging modality in staging of many human malignancies. Studies of varioushuman cancers have demonstrated the ability of PET/CT to identify serendipitousfindings. The objective of this study was to evaluate the incidence of secondary findingsin head and neck cancer patients subjected to staging PET/CT studies.

Methods: Four hundred one 18F-FDG PET/CT scans were retrospectively analyzed in 310 headand neck cancer patients from 2002 to 2012. There were 149 females and 161 malesbetween the ages of 18 to 95 years (mean = 63). Secondary, serendipitous diagnoseswere divided into organ systems, which were then subcategorized into specific clinicalfindings. Patients with incidental findings were followed longitudinally and thoserequiring subsequent surgical procedures were recorded.

Results: A total of 929 secondary findings were noted in 275 of 310 patients (88.7%). Pulmonarynodules accounted for 27.2% of the findings; followed by 12.2% perihilarlymphadenopathy; 9.9% hepatobiliary disease; 6.5% renal lesions; 5.3% thyroiddiseases; and 4.7% colon lesions. Fourteen patients (5.0%) underwent surgicalprocedures to address their secondary diagnoses. Nine secondary malignancies werenoted amongst these serendipitous findings (2.9%). This study identified that thenumber needed to treat was 20 to preserve or improve the quality of life of patients inthis study cohort.

Conclusion: PET/CT is valuable in staging patients with head and neck cancer. It can providestructural and functional imaging of many serendipitous secondary findings. Althoughmost incidental findings were benign, secondary malignancies were identified, therebypermitting expedient treatment.

24

Pathology


Academy of Scholars

Title: INTRATHYROIDAL BRANCHIAL CLEFT-LIKE EPIDERMOID CYST

ASSOCIATED WITH NODULAR HASHIMOTO’S THYROIDITIS: A RAREPATHOLOGIC FINDING IN A COMMON PATHOLOGIC ENTITY

Program: Pathology Author: Matthew J. Curzon, M.D. Co-Authors: Sarah Carroll, M.D.; Laurentia Nodit, M.D.; Amila Orucevic, M.D., PhD IRB Number: 3630 Case Presentation Objective: Intrathyroidal lymphoepithelial/epidermoid cysts are identified rarely, with only a handful

of cases described in the literature. We report a case of intrathyroidal branchial cleft-likeepidermoid cyst arising in the background of Hashimoto’s thyroiditis.

Methods: A 71 year old female with history of hypothyroidism treated with levothyroxyn had a“gurgling type” of feeling and neck symptoms for some time. On ultrasound of thethyroid, a 1.3 cm cystic and solid nodule was identified in the right upper pole. Fineneedle aspiration of the lesion showed numerous benign squamous cells with noassociated follicular cells. Differential diagnosis included epidermal inclusion cyst,thyroglossal duct cyst, and squamous metaplasia. The patient underwent a right thyroidlobectomy.

Results: On gross examination, a 1.0 cm cyst filled with brown creamy fluid was seen in thebackground of brown slightly nodular thyroid parenchyma. On microscopic examination,the cyst was lined with squamous epithelium and showed keratinous material within thelumen. Thin fibrotic cyst wall was only very focally associated with lymphoid tissue, andsurrounding thyroid gland showed lymphocytic thyroiditis. A diagnosis of intrathyroidalbranchial cleft-like epidermoid cyst arising in the background of nodular Hashimoto’sthyroiditis was issued.

Conclusion: Proposed etiologies in rare published case reports of intrathyroidallymphoepithelial/epidermoid cysts included development from embryological remnantsof branchial pouches, a metaplastic process of follicular epithelium, teratomatous origin,and an immunological mechanism secondary to inflammation-induced squamousmetaplasia with subsequent cystic degeneration and enlargement. Intrathyroidalbranchial cleft-like epidermoid cyst in our patient is most likely caused by immunologicmechanisms induced by Hashimoto’s thyroiditis.

26


Academy of Scholars

Title: INCIDENCE AND DESCRIPTION OF NEVUS CELL RESTS AND THEIR

DISTINCTION FROM ISOLATED TUMOR CELLS IN SENTINEL LYMPHNODES REMOVED FOR MELANOMA STAGING

Program: Pathology Author: Karyn L. DeSouza, MD Co-Authors: Lisa D. Duncan MD, James Lewis MD IRB Number: 3252 Original Research Objective: Sentinel lymph node excision is integral to melanoma surgical staging. Individual

immunohistochemical (IHC) positive cells are challenging, requiring distinction betweenisolated tumor cells and benign nevus cell rests (NCR), as even isolated tumor cellsrepresent N1 disease. In this study, the incidence and growth pattern of nevus cell restsare described to form a basis of comparison for isolated IHC positive cells in sentinellymph nodes removed for melanoma.

Methods: Melanoma triple stain was performed on nodes from the axilla, inguinal area, cervicalarea, and intraparotid area removed for non-melanoma related conditions, simulatingregions typically sampled during melanoma sentinel node procedures. Location, size,and histomorphology of nevus cell rests were recorded.

Results: Triple stain positive NCR were identified in 4.5% inguinal nodes, 0.5% cervical nodes,(0.9%) axillary nodes, and 0% intraparotid nodes. NCR in these cases wereintracapsular, demonstrate spindle cell morphology, and were not perceptible on routinestains. NCR in 13 additional cases had 16 total NCR with a combined epithelioid andspindle morphology, the majority of which were intracapsular.

Conclusion: Incidence of NCR is higher in the inguinal location relative to other anatomic locationsstudied. NCR identified only by immunohistochemistry are predominantly intracapsularand have a spindled fibroblastic morphology. This finding in sentinel nodes can creatediagnostic confusion with metastasis, emphasizing recognition of this pattern in NCR.Isolated cell pattern was not observed in any of our study cases. Our results suggestthat an isolated cell pattern identified in melanoma-specific IHC stains should beinterpreted as metastatic melanoma.

27


Academy of Scholars

Title: LOWER UTERINE SEGMENT CELLS IN A THINPREP PAP SMEAR: A

DETAILED CYTOLOGIC DESCRIPTION OF A DIAGNOSTICALLYCHALLENGING BENIGN FINDING

Program: Pathology Author: N. Lynn Ferguson, MD Co-Authors: Lucy E. DeFanti, DO; Angela Yates, MD; Lisa D. Duncan, MD IRB Number: 3580 Original Research Objective: Lower uterine segment (LUS) cells are occasionally identified in ThinPrep Pap smears

and can cause diagnostic confusion, mimicking endometrial, endocerivcal, andectocervical neoplasms. Cytology literature is deplete of comprehensive descriptions ofLUS cells, complicating appropriate classification. Our objective was to selectivelycollect and describe LUS cells then compile a photomicrograph database to facilitateeducation of cytotechnologists and pathologists in this diagnostically challengingfinding.

Methods: This study includes 21 consecutive benign hysterectomy specimens. The lower uterinesegment of the bisected uterus was identified by standard accepted criteria. This areawas selectively swabbed with a ThinPrep pap collection spatula and endocervical brush.The specimen was suspended in PreservCyt solution and processed by thestandardized ThinPrep method. LUS cells were described and a photomicrographdatabase was created.

Results: 16 specimens yielded lower uterine segment cells for microscopic examination. 5 caseswere excluded due to low cellularity, and 2 were excluded due to a post-surgicaldiagnosis of at least low grade squamous intraepithelial lesion. The remaining 14 caseswere reviewed and a photomicrograph database was created. LUS cells had largehyperchromatic nuclei, prominent nucleoli, nuclear overlap, and large finger like cellulararrangements.

Conclusion: LUS cells are poorly characterized in ThinPrep Pap smears and are difficult to classifydue to similarities with dysplastic/malignant entities. Our study describes LUS cells andprovides a photomicrograph database to be utilized as an educational tool forcytotechnologists and pathologists who must be able to recognize this cell type toprevent misdiagnosis.

28


Academy of Scholars

Title: PROGNOSTIC VALUE OF YOUNG AGE, BREAST CARCINOMA

RECEPTOR SUBTYPES AND PATHOLOGIC TUMOR CHARACTERISTICSON OVERALL SURVIVAL OF CAUCASIAN WOMEN WITH BREASTCANCER

Program: Pathology Author: Solomon Lee, DO Co-Authors: N. Lynn Ferguson, E. Robert Heidel, John Bell and Amila Orucevic IRB Number: 3156 Original Research Objective: Triple negative breast carcinoma (TNBC) subtype (ER-/PR-/HER2-) has been

associated with worse overall prognosis in comparison to other carcinoma subtypes instudies involving young and ethnic minorities. Our published institutional study of 593Caucasian women with breast cancer diagnosed from 2000-2004 questioned whetherTNBC subtype may carry the same prognostic value in Caucasians. We have nowevaluated the same cohort for the prognostic value of young age on breast canceroverall survival (OS), when controlled for ER/PR/HER2 subtype and pathologic tumorcharacteristics.

Methods: Study of 593 invasive breast cancer cases identified 42 young women age<40. Aftergrouping patients into <40 or >40 y/o, ER/PR/HER2 status and its effect on OS wereanalyzed using a Kaplan-Meier curve, along with effect of tumor grade and tumor-nodestatus using a multivariate Cox regression. Same analyses were performed on groupsdivided by age: <40, 41-50, 51-60, 61-70 and >70.

Results: TNBC patients showed shorter OS than ER+/PR+/HER2-, regardless of age (p=.003-.03). TNBC subtype divided into five age groups showed statistically significant effect ofage on OS. This significance disappeared when the >40 age groups were combined.Overall, patients >70 showed 2.6x higher mortality rates, and patients 41-50 and 51-60showed 0.4x and 0.5x relative mortality rates compared to <40, respectively. Patients<40 and 61-70 had similar OS.

Conclusion: Our data suggest that TNBC subtype, young age and old age may carry worse overallprognosis in Caucasian females compared to other carcinoma subtypes and middleage. However, additional studies are required for validation.

29

Pulmonary Disease


Academy of Scholars

Title: ROLE OF DIASTOLIC HEART DYSFUNCTION ON CLINICAL COURSE OF

PATIENTS WITH ACUTE COPD EXACERBATION WITH POSITIVEPRESSURE VENTILATION REQUIREMENTS.

Program: Pulmonary Disease Author: Arseniy V. Tsapenko, MD, DO Co-Authors: Patrick B. Barlow, Michael T. McCormack, MD, FCCP IRB Number: 3539 Original Research Objective: Positive pressure ventilation (PPV) is being used as a standard rescue modality of lung

ventilation in patients with respiratory failure secondary to COPD with acuteexacerbation (COPDAE).We suspected that those patients with diastolic heart failure(DHF) in the settings of COPDAE with requirements to be on PPV have morecomplicated respiratory failure recovery course rather than those patients with no DHF.The purpose of this study was to evaluate if patients with DHF have longerhospitalization course compare to similar patient with no DHF .

Methods: Patients, who were participated in this study, were selected as per study design criteria.All of these patients were admitted with COPDAE and required PPV were distributed intwo groups with and without evidence of DHF on transthoracic ECHO. Descriptivestatistic of study sample between DHF and no-DHF patient groups was performed,analyzed and compared.

Results: 43 patients admitted with COPDAE who were on PPV were included in this study. 15patients were in no-DHF group and 28 patients were in DHF group. Descriptivestatistics of no-DHF and DHF groups were following: Female n(%)/Male n(%) : 8(58%)/7(42%) and 16(57%)/13(43%) respectively, age mean(SD) : 59.00( 7.98) and63.39(8.05) respectively, days on PPV mean( SD) : 3.60 (2.20) and 4.65 (3.92)respectively.

Conclusion: Patients admitted for COPDAE with DHF with PPV requirement will spend longer timeon PPV before their respiratory status improves compare to patients admitted forCOPDAE with no-DHF.

31

Radiology


Academy of Scholars

Title: 18F-FDG PET/CT PROVIDES ACCURATE GROSS TUMOR VOLUME

DEFINITION FOR 90Y RADIOEMBOLIZATION

Program: Radiology Author: Ted T. Chang, MD Co-Authors: Yong C. Bradley MD, Alexander S. Pasciak PhD* IRB Number: 3502 Original Research Objective: Yttrium-90 (90Y) radioembolization is an innovative treatment for primary and

metastatic liver cancer. 90Y treatment dosage calculations commonly use the SIRTexBody Surface Area (BSA) method which requires measurement of tumor and normalliver volumes from a pre-treatment hepatic protocol CT. These patients, however, oftenreceive concomitant 18F-FDG PET/CT studies to evaluate disease burden. This studycompares the biologic tumor volume (BTV) obtained by fused PET/CT and gross tumorvolume (GTV) obtained with contrast enhanced CT and the subsequent differences inthe prescribed treatment dosage.

Methods: A retrospective review of patients undergoing off-label radioembolization with 90Ymicrospheres from 1/1/2011 – 1/1/2013 was conducted. Per our institutional protocol,these patients received pretreatment hepatic protocol CT and 18F FDG PET/CT within2 weeks prior to treatment. Both the GTV and BTV were measured by two radiologistson an Siemens XD3 workstation. These volumes were then used in the SIRTex BSAmodel to determine differences in Y90 treatment activity.

Results: Tumor volume determination by both PET/CT and CT showed only minimal differences,averaging 2.9% between GTV and BTV. The subsequent BSA dosage calculations forthe administered 90Y activity were similar between both groups with an averagepercent difference of less than 1%.

Conclusion: Differences in tumor volume determined from contrast enhanced CT and thosedetermined from FDG PET/CT do not affect 90Y radioembolization treatment dosagewhen the manufacturer recommended calculation model is used. These findings mayallow for additional flexibility in pretreatment imaging with no resultant affect ontreatment outcome.

33


Academy of Scholars

Title: RESULTS OF THE FIRST INTRA-PROCEDURAL Y90 PET/CT

PERFORMED TO OPTIMIZE TREATMENT EFFICACY OFRADIOEMBOLIZATION FOR HEPATIC MALIGNANCY

Program: Radiology Author: Ted T. Chang, MD Co-Authors: Austin C. Bourgeois MD, John J. Snidow MD, Alexander S. Pasciak

PhD*

IRB Number: 3502 Case Presentation Objective: Radioembolization using yttrium-90 (90Y) microspheres is a popular treatment for

hepatic malignancies. However, the efficacy of this treatment can depend significantlyon patient-specific anatomical variations which can affect the uptake of microspheres inthe tumor. Using standard imaging methods, anatomical variations cannot be assessedprior to treatment, leaving no opportunity for modification of the treatment dosage toimprove efficacy. We present the results from the first published intra-proceduralquantitative 90Y PET/CT performed with the goal of ensuring maximum treatmentefficacy.

Methods: A patient with biopsy-proven hepatocellular carcinoma was referred for 90Yradioembolization. The manufacturer-recommended dosage of 90Y microspheres,which is not patient-specific, was infused in the first part of a two-step treatment.Immediately after the infusion, a 90Y PET/CT was performed which indicated that asub-tumoricidal dose was delivered. An additional infusion of 90Y microspheres wasdelivered on the same day to ensure a tomoricidal therapy, based on the informationobtained from the 90Y PET/CT.

Results: Following the two-part therapy, the average absorbed dose to the tumor was 115.2 Gy.This level of dose is comparable to published tumoricidal thresholds and is significantlyhigher than it would have been if the manufacturer recommended treatment protocolwas used. Follow-up contrast-enhanced CT has shown a significant reduction in tumorburden with expected positive long-term outcome.

Conclusion: 90Y PET/CT has the capability to determine the patient-specific absorbed dosefollowing 90Y microsphere radioembolization. A two-step treatment utilizing this novelimaging method can be effectively used to ensure tumoricidal dose delivery andtreatment efficacy.

34

Urology


Academy of Scholars

Title: PREDICTIVE VALUE OF CURRENT IMAGING MODALITIES FOR THE

DETECTION OF UROLITHIASIS DURING PREGNANCY: A MULTI-CENTER, LONGITUDINAL STUDY

Program: Urology Author: John Beddies MD Co-Authors: Elizabeth Johnson MD, Nikki Zite MD, Amy Krambeck MD, Elias Hyams

MD, Tracy Marien MD, Ojas Shah MD, Brian Matlaga MD, Vernon Pais,Jr. MD and Wesley White MD

IRB Number: 3386 Original Research Objective: To determine the optimal imaging study by which to diagnose and subsequently treat

pregnant patients with suspected urolithiasis.

Methods: A retrospective, multi-center study was performed to determine the comparativeaccuracy of imaging modalities employed prior to surgical management of suspectedurolithiasis in pregnant patients. Patients with clinical suspicion of urolithiasis wereevaluated with directed imaging, including renal ultrasound (RUS) alone, RUS and low-dose computed tomography (LDCT), or RUS and magnetic resonance urography(MRU). The rate of negative ureteroscopy was determined and the positive predictivevalues (PPV) of the aforementioned imaging modalities were calculated.

Results: A total of 51 pregnant patients underwent ureteroscopy. Twenty-four women (47%)underwent RUS and LDCT, 22 women (43%) underwent ultrasound alone, and 5women (10%) underwent RUS and MRU. Negative ureteroscopy, occurred in 7 of the51 patients (14%). Patients who had a CT scan had the lowest rate of negativeureteroscopy at 4.2% (1/24 patients). Patients with ultrasound alone had the highestincidence of negative ureteroscopy at 23% (5/22 patients), and patients with MRU hada 20% incidence of negative ureteroscopy (1/5 patients). Positive predictive values ofCT, MR, and ultrasound were 95.8%, 80%, and 77% respectively.

Conclusion: Among pregnant women undergoing intervention in our series, the rate of negativeureteroscopy was 14%. In the group taken to surgery after imaging with ultrasoundalone, 23% had no ureteral stone, giving it the lowest PPV of the utilized modalities.Alternative advanced imaging techniques, particularly LDCT, offer improved diagnosticinformation that can optimize subsequent management and largely obviateunnecessary intervention.

36

Vascular Surgery


Academy of Scholars

Title: HORMONAL REGULATION OF LYSYL OXIDASE IN VASCULAR

REMODELING

Program: Vascular Surgery Author: Jason R Chapman, MD Co-Authors: Deidra JH Mountain PhD; Stacy S Kirkpatrick BS; Scott L Stevens MD;

Josh D Arnold MD; Mitchell H Goldman MD; Michael B Freeman MD;Oscar H Grandas MD

IRB Number: 3621 Original Research Objective: Lysyl oxidase (LOX) initiates the covalent cross-linking of elastin and collagen in wound

healing and has been shown to increase in vascular lesions post-intervention. We havepreviously demonstrated dysfunctional matrix metalloproteinase regulation in hormonereplacement therapy (HRT)-modulated intimal hyperplasia (IH). Likewise, wehypothesize that HRT plays a role in LOX-mediated IH. Here we investigated the effectof estrogen and progesterone on LOX expression in vitro and in vivo.

Methods: Human vascular smooth muscle cells (VSMCs) were treated with estrogen (Est; 0-500nM) for 24h. LOX expression was measured by qPCR normalized to 18S. Agedovariectomized (OVX) female rats were implanted with slow-release Est (0.72mg),progesterone (Prog; 200mg), combination (EP), or placebo (Plac) pellets and 6 weekslater underwent carotid artery balloon angioplasty. Vessels were stained 14 days post-injury with Trichrome-elastin and LOX-specific antibodies. Intima:Media (I:M) ratios areused to quantify degree of hyperplasia. Data is reported as mean±SEM, n=4-7.

Results: I:M decreased in OVX rats receiving Plac (0.925±0.046, P<0.05) vs. non-OVX controls(1.345±0.074). I:M slightly increased in OVX animals receiving Est (1.022±0.077) andEP (1.066±0.104) vs. Plac. While neither Est or Prog alone had an effect on LOXexpression in vitro or in vivo, EP combination therapy significantly increased LOXexpression in vivo (% intima area stained: non-OVX control, 42.25±6.83; OVX – EP,78.20±6.05; P<0.05)

Conclusion: HRT increased I:M ratios, though significance was not reached with the doses given.While LOX expression may be playing a role in EP-mediated IH, other mechanismsshould be investigated to delineate the role of HRT in IH development.

38

2013 utgsm resident & fellow research day

Documents

astriple low

scholars title

original research objective

categories fordoubletriple

low meanarterial pressure

anesthesiology author

mac cytopathology

general surgery