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Abstracts from John B. Graham Student Research Day

The John B. Graham Student Research Society

45th Annual Student Research Day

January 17, 2013

Basic Sciences – Oral Presentations

Optimizing Timing of Introduction of CTGF for Elastin Production in Tissue Engineered Cartilage

Fahad Chaudhary, Montserrat Caballero, Jonathan Hill, John van Aalst

Department of Plastic Surgery

A current limitation of tissue engineered cartilage implanted in vivo is the rapid development of a hypertrophic phenotype (exhibited by increased collagen X), and cartilage ossification (demonstrated by calcium deposition with abnormal cross linking of elastin), which results in a dense, inflexible mass. In order to maintain flexibility of tissue engineered cartilage, control must be maintained over elastogenesis (the process by which elastin is cross-linked to fibrillin in the extracellular matrix). CTGF has been shown to increase synthesis of elastin and decrease collagen X in mature rabbit auricular chondrocytes in a dose-dependent manner. The aim of this work in immature hUCMSCs undergoing chondrogenesis is to analyze optimal timing of CTGF treatment to increase elastin production.

hUCMSCs were isolated from the umbilical cord (UC) Wharton’s Jelly, grown to passage 3, seeded onto electrospun nanofiber scaffolds and chondroinduced for 21 days. Chondrogenesis in hUCMSCs was induced with TGF-β1 (10 ng/ml) and supplemented on days 0 or 7 with 25 ng/mL of CTGF. Western blot analysis for protein quantification (Elastin) and Verhoff Elastin staining for elastin deposition was performed on days 0, 3, 7, 14, and 21. Statistical analysis was performed on three separate hUCMSC primary cultures.

Analysis shows that CTGF treatment (25 ng/ml) at day 7 increased both elastin mRNA and protein levels when compared to controls where CTGF was added at day 0. Verhoff’s staining confirmed the presence of elastin in the cartilage constructs in each of the conditions.

Chondrogenic differentiation of hUCMSCs in the presence of CTGF demonstrated increased elastin mRNA and protein expression, decreased collagen X mRNA expression, without evidence of matrix calcification. These findings suggest that CTGF may be a powerful adjunct in engineering flexible elastic cartilage.

ECoG Responses to Tones from the Round Window in Human Cochlear Implant Patients: Correlation with Speech Outcomes

Mathieu Forgues, Oliver Adunka, MD, Baishakhi Choudhury, MD, Adam Campbell, MD, Craig Buchman, MD, Doug Fitzpatrick, PhD

Department of Otolaryngology/Head and Neck Surgery

Background: The degree of neural survival is expected to be an important factor contributing to variability in speech performance with cochlear implants. Electrocochleography (ECoG) responses from the round window to acoustic stimuli can characterize the condition of hair cells and auditory nerve fibers in patients receiving cochlear implants. In the ongoing response to tones, the ECoG contains both the cochlear microphonic (CM) and auditory nerve neurophonic (ANN) which are a challenge to separate. Understanding these waveforms along with distortions seen in the recordings could help us evaluate cochlear health and neural survival.

Methods: ECoG potentials in response to tone bursts of varying frequency and intensity were recorded from the round window intraoperatively in pediatric and adult patients undergoing cochlear implantation. Intraoperative measurements of neural and hair cell activity were correlated with 6 month speech perception outcomes (CNC word scores).

Results: Maximum CNC word scores at 1-6 months were positively correlated with the magnitude of ECoG responses. Discrete patterns of distortions in the ECoG waveform were present that had either a hair cell or neural origin. Distortions due to phase locking of nerve fibers (the ANN) were the main cause of distortion at low frequencies and up to moderate intensities. At high intensities distortions were present at all frequencies, suggesting saturation of stereociliary movement in the hair cells that produce the CM.

Conclusions: ECoG recordings in cochlear implant patients can provide important predictive information regarding speech perception outcomes. Within the recorded waveforms, distortions with hair cell or neural origins are present that reflect sensorineural integrity.

Hair Cell and Neural Potentials Recorded at the Round Window in Gerbils

Mathieu Forgues, Heather Koehn, Askia Dunnon, Craig Buchman,MD, Oliver Adunka,MD, Douglas Fitzpatrick, PhD

Department of Otolaryngology/Head and Neck Surgery

Electrocochleography measured at the round window contains both hair cell and neural responses. Responses from the hair cells are the cochlear microphonic (CM) and summating potential (SP). Responses from the auditory nerve are the compound action potential (CAP) and auditory nerve neurophonic (ANN). The CAP and SP are relatively isolated and can be readily identified in the waveform. The CM and ANN are both present in the ongoing part of the response; the CM follows the fine structure of all frequencies and the ANN is the evoked response correlate of phase locking in the auditory nerve. Because these signals are mixed, it is a challenge to separate them.

For this study, we measured ECoG potentials from the round window of Mongolian gerbils to tones of different frequencies and intensities. Forward masking was also used in an attempt to attenuate the neural response. Gerbils were either normal hearing or had a pattern of high frequency noise induced hearing loss (NIHL) similar to many cochlear implant recipients.

In normal hearing gerbils, distortions in the ECoG waveform, likely attributable to phase locking associated with the ANN, were present at low frequencies at low and moderate intensities. At high intensities, distortions were present at all frequencies, suggesting saturation of stereociliary movement. Forward masking with a masker 30 dB louder than the probe reduced the distortions across the frequency range including high frequencies, suggesting that a preference for closed channels in stereocilia persists for a time after the stimulus. In gerbils with NIHL, the ongoing part of the ECoG saturated at relatively low intensities indicating a loss of spread of excitation.

These results show that distortions in the ECoG attributable to phase locking in nerve fibers are restricted to low and moderate intensities and that forward masking is present in hair cells at high intensities.

Designing an Electrode to Monitor Cochlear Implant Surgery

Christopher K. Giardina, Oliver F. Adunka, MD, Craig A. Buchman, MD, Douglas C. Fitzpatrick, PhD

ENT Department

A cochlear implant is a medical device which directly stimulates cochlear neurons in response to auditory stimuli, assisting in voice and sound perception for patients with functional hearing losses due to anatomical or neurological damage of the inner ear. Recently, there is substantial emphasis on preserving hearing by reducing the damage to hair cells during the surgical implantation of the cochlear implant. One approach to detect hair cell damage during insertion is to record the neural output signal of the cochlea. The objective of this study was to design, construct, test, and validate a bioelectrode surgical device which is capable of recording cochlear nerve output from the stapes footplate, far from the round window where the cochlear implant is inserted. A model of the engineering parameters is presented. Three electrode designs are described in this study: a rigid platinum iridium (Pt/Ir) wire electrode, a flexible silver/silver chloride (Ag/AgCl) ball electrode, and a sponge-saline pipette electrode. Each electrode was analyzed quantitatively using impedance and sound-induced cochlear microphonic (CM) recordings in gerbil models over a wide range of tones and dB levels. Electrodes were qualitatively analyzed with feedback from surgeons on usability and biosafety. The Ag/AgCl electrode had the lowest impedance of 3 kOhm. During sound-induced recordings at the round window, the Pt/Ir and Ag/AgCl electrodes showed similarly strong neural recordings, whereas the sponge electrode had a 10x loss in signal power. Because of the low impedance, strong recording characteristics, and flexible nature, ENT surgeons chose the Ag/AgCl device to record CM potentials in human patients.Preliminary results demonstrate that recording a signal from the stapes footplate is both feasible and effective. Long-term goals include correlating signal patterns to hair cell damage instantaneously, giving feedback to the physician during insertion in order to minimize damage and maximize hearing outcomes.

Novel Poly-Lactic Acid Nanofiber-Filled Slurry for Improved Elastic Cartilage Engineering from Human Umbilical Cord Mesenchymal Stem Cells

Alexandra E. Halevi, BS, Montserrat Caballero, PhD, Miles C. Wright, Michael Pharaon, MD, John A. van Aalst, MD, MS, FACS

Department of Plastic and Reconstructive Surgery

Background: Synthetic nanofiber tissue engineered scaffolds are versatile and effective for cell attachment, proliferation, and chondrogenesis; these dynamic, 3-dimensional (3-D) scaffolds need to be easily remodeled by the cells to improve tissue quality. A limitation of current electrospinning techniques is the lack of construct 3-dimensionality and a restriction of cell migration into the scaffold. A novel glycerin-based method for creating a nanofiber-filled slurry (Xanofi) that creates numerous disassociated nanofibers, allows for improved 3-D capacity for cell interaction and scaffold remodeling. In this study, human umbilical cord mesenchymal stem cells (UC MSCs) are utilized to demonstrate cell attachment, proliferation, and chondrogenesis in a poly-lactic acid (PLA) nanofiber-filled slurry.
Methods: hUC MSCs were isolated from Wharton’s Jelly by explant technique, grown to 80% confluence, and seeded at passage 2 (1 x 10^4 cells/scaffold) on 3 material densities (0.05, 0.1, 0.5 gm/well) of PLA nanofiber-filled slurry (1.28% solids) and grown for 7 days in standard medium. Cells were stained with calcein/ethydium bromide, DAPI, and imaged by fluorescent microscopy; DNA was collected on days 1, 3, 5, and 7. Cells were chondroinduced for 14 days with TGF-beta1, TGF-beta3, and IGF. Samples were fixed, sectioned, and stained with Alcian blue for glucosaminoglycan (GAG) content; collagen I, II, X, and elastin mRNA was determined by qRT-PCR at days 3,7, 10, and 14.
Results: Cells were viable throughout the study. DNA quantification demonstrated MSC proliferation for the entire 7 days. The presence of GAG, increased collagen II and elastin mRNA, with no increase in collagen X, was consistent with elastic cartilage formation in the chondroinduced samples.
Conclusions: PLA nanofiber-filled slurry is a novel material that facilitates cell viability, proliferation, and chondrogenesis, and may provide a superior platform for generating engineered elastic cartilage.

Enteric dysbiosis in intestinal injury: Cause or consequence?

Emery Harris, Christopher Packey, R. Balfour Sartor

Midgette Distinguished Professor of Medicine, Microbiology and Immunology

BACKGROUND: Dysbiosis, or imbalance between protective and deleterious microbes, has been found in inflammatory bowel disease patients. We hypothesize that enteric dysbiosis may contribute to the pathogenesis of intestinal injury. Aim: To determine if dysbiosis contributes to the host response in mouse models of radiation intestinal injury and spontaneous, immune-mediated colitis.
METHODS: We analyzed microbiota composition in the lumen/mucosa of the mid-jejunum, distal ileum and cecum of three groups of specific pathogen-free (SPF) wild-type (WT) C57BL/6 (B6) mice (n=5/group): 1) Non-irradiated 2) Exposed to 15 Gy 3) Exposed to 15 Gy and treated with antibiotics. We amplified the 16S rRNA gene from DNA samples with high-throughput 454 pyrosequencing and quantitative real-time PCR (qPCR). Next, cecal contents from group members were pooled and transplanted into recipient germ-free (GF) and (SPF) WT B6 irradiated mice (n=4/group), as well as recipient GF WT and interleukin-10 KO (IL-10 KO) 129 SvEv (129) mice (n=6-7/group).
RESULTS: Radiation decreases intestinal Firmicutes (p<0.0001), and the Lactobacillus genus within this phylum. Intestinal Proteobacteria, and specifically Escherichia coli, are increased by radiation. The antibiotic ciprofloxacin largely prevented these radiation-induced microbiota shifts. In cecal transfer experiments, GF and SPF WT B6 mice receiving a dysbiotic microbiota from irradiated mice experienced accelerated morbidity and mortality compared to GF and SPF mice inoculated with conventional microbiota following equivalent radiation doses (p<0.02). IL-10 KO mice colonized with a conventional or dysbiotic microbiota and WT 129 mice inoculated with a dysbiotic microbiota lost weight, while WT 129 mice inoculated with conventional microbiota gained weight appropriately.
CONCLUSIONS: Intestinal dysbiosis drives radiation intestinal injury and potentially causes injury in non-irradiated hosts. Microbiota constituents may contribute to pathogenesis (E. coli) or confer protection (Lactobacillus spp.). Agents that prevent/correct enteric dysbiosis, including ciprofloxacin, are promising prophylaxis/treatment options for radiation intestinal injury and should be studied in clinical trials.

Large Animal Model for Novel Autologous Treatments of the Alveolar Cleft

Jonathan F Hill BS, Montserrat Caballero PhD, Fahad F Chaudhary BS, T. Brad Wood BS, Omri Emodi MD, John A. van Aalst MD

Department of Plastic Surgery

Congenital malformations of craniofacial bone occur in 1:250 live human births, and include multiple deformities, the most common of which is cleft lip and palate. This study focused on the repair of the alveolar cleft. Early surgery (defined as an operation on a child under a year-of-age) to correct these defects using rib graft is often associated with poor outcomes because the bone grafts cannot keep pace with growth of the child’s craniofacial skeleton. Because of these concerns, surgeries are often delayed to allow further growth of the craniofacial skeleton before intervention, using iliac crest cancellous bone. This study aimed to assess the critical sized defect of the alveolar cleft & determine which repair technique, the historical rib graft repair or the iliac crest cancellous bone repair, showed improved bone growth using the porcine model system. First, to access the critical size defect of the swine alveolar cleft, a 1cm or 2cm defect was surgically created & allowed to repair without treatment for 30 days. Second, to access the treatment conditions of the alvelor cleft, a defect was created and repaired using a rib or iliac crest cancellous bone graft for 30 days. The critical size defect of the porcine alveolar defect was determined to be 2cm. The iliac crest cancellous bone repair demonstrated bridging bone growth and improved healing, while the rib did not within the time frame.

Investigating the role of enteric dysbiosis in the development of intestinal inflammation in the interleukin-10 knockout mouse model of spontaneous, immune-mediated colitis

Hudson P, Manick S, Packey CD, Carroll I, Sartor RB.

Center for Gastrointestinal Biology and Disease, Department of Microbiology and Immunology, University of North Carolina School of Medicine

Background: Inflammatory bowel diseases (IBD) have been associated with a dysbiosis of intestinal bacteria. However, the exact role of dysbiosis in the development of intestinal inflammation is unclear. Methods: We utilized 454 pyrosequencing and quantitative real-time PCR amplification of the 16S rRNA gene to conduct a longitudinal characterization of the intestinal microbial composition of germ-free interleukin-10 knockout (IL-10 KO) mice conventionalized with a specific pathogen-free microbiota compared to that of a cohort of wild-type (WT) mice conventionalized with an identical donor fecal slurry. The aim was to identify any key components of the dysbiosis that may occur before, during or after the onset of inflammation in the IL-10 KO animals. Results: Colonic tissue explant secretion of pro-inflammatory cytokine IL-12p40 was increased in IL-10 KO mice by 2 weeks after conventionalization. 454 pyrosequencing revealed that species richness and species diversity are maintained or increased in both WT and IL-10 KO mice for 2 weeks after conventionalization, but both decrease significantly in the IL-10 KO mice by weeks 3 and 4. The Bacteroidales order and Lachnospiraceae family decreased in abundance by weeks 3 and 4 in IL-10 KO mice. Ruminococcae increased by week 2, then decreased at weeks 3 and 4 in IL-10 KO mice. Verrucomicrobia, Firmicutes and Actinobacteria phyla progressively declined in abundance in IL-10 KO mice, while Tenericutes and Proteobacteria increased. Conclusions: Some changes in the composition of the microbiota are observed at 2 weeks when inflammation is first present, although other components of the dysbiosis are not present until weeks 3 and 4. These data suggest that some components of enteric dysbiosis may be present at the onset of inflammation in IL-10 KO mice, and may impact or even drive the initiation and/or progression of inflammation in this model.

Ciprofloxacin confers protection from radiation intestinal injury through both bacterial-dependent and bacterial-independent mechanisms

Susan Shiyuan Li, Christopher Dennis Packey, Ryan Balfour Sartor

Microbiology and Immunology

Background: Approximately half of the 1.6 million Americans diagnosed with cancer in 2012 will be treated with radiation, which causes acute intestinal symptoms and permanent bowel habit changes in >70% of those afflicted. The RB Sartor lab previously showed the antibiotic ciprofloxacin has intestinal radioprotective effects. Aim: To explore mechanisms of ciprofloxacin’s radioprotection. Methods: We performed 16S rRNA 454 pyrosequencing and quantitative real-time PCR (qPCR) on DNA isolated from mucosa/lumen samples from jejunum, cecum, and distal colon in 3 groups of specific pathogen-free, wild-type C57BL/6 mice (n=5/group): non-irradiated, exposed to 15Gy radiation for 1 hour, and exposed to radiation and treated with ciprofloxacin. Weighted (relative abundance) and un-weighted (presence-absence) UniFrac distances were measured using the QIIME pipeline. In a separate experiment, intestinal tissue from germ-free (GF) mice were harvested 6 hours after treatment with either ciprofloxacin or water, and qPCR was performed on cDNA generated from isolated RNA to assess for anti-microbial peptide (AMP) expression. Results: Principal coordinate analyses/OTU (operational taxonomic unit) networking revealed that radiation induced dysbioses throughout the mucosa/lumen of the small/large intestine (increased alpha-diversity increased in colon; increased beta-diversity in small/large intestine). At the phylum level, radiation decreased intestinal Firmicutes (p<0.0001) and increased Proteobacteria (p=0.05). Reduced Firmicutes OTUs were identified as Lachnospiraceae family (cecum mucosa) and Lactobacillus species (jejunum mucosa). Radiation also increased Porphyromonadaceae family and Bacteroides species (cecum mucosa). Ciprofloxacin prevented many of the radiation-induced microbiota shifts and induced mRNA expression of several AMPs, including α-defensins (Defa5, p<0.03) in the jejunum and other AMPs in the distal ileum (lysozyme, NS; Reg3gamma, NS).These AMPs, produced/secreted by small intestinal Paneth cells, modulate the composition of enteric microbiota. Conclusions: Ciprofloxacin may prevent radiation-induced intestinal dysbioses through bacterial-independent induction of expression of AMPs that modulate the composition of the microbiota. Ciprofloxacin may be an efficacious prophylaxis/treatment for radiation intestinal injury.

Novel use of RAPD PCR to screen selectively colonized gnotobiotic animals for contamination

Manick S, Packey CD, Sartor RB, Carroll IM.

Department of Medicine

Background: Gnotobiotic studies elucidate roles of gastrointestinal (GI) microbes in health and disease. Gnotobiotic isolators are highly susceptible to contamination and meticulous screening is required. 16S rRNA PCR techniques that screen germ-free animals for bacterial contamination cannot detect contamination of selectively colonized gnotobiotic animals. Aim: Develop method to screen selectively colonized animals for contamination utilizing Random Amplification of Polymorphic DNA PCR (RAPD) fingerprinting. Methods: We 1) Used a single random oligonucleotide 3H primer (5′-AAGCTTGATTGCCC-3′) and optimized RAPD conditions to generate fingerprints from cultures of 30 relevant bacterial strains. 2) Conducted RAPD on DNA isolated from cultures of defined intestinal bacterial species as well as fecal samples of mice mono-associated with the same respective bacterial strains. 3) Performed RAPD on fecal DNA from mono-associated mice before and after inoculation with a second bacterium. 4) Tested mixtures of DNA isolated from the 7 members of a simplified humanized microbiota (SIHUMI) consortium using RAPD. Results: 1) RAPD fingerprinting revealed unique, reproducible fingerprints for DNA isolated from pure cultures of strains of Escherichia coli, members of Bacteroides, Lactobacillus, Pseudomonas, Bifidobacterium, Bacillus, and Staphylococcus genera, as well as Enterococcus faecalis, Citrobacter freundii, Streptococcus agalactiae. 2) RAPD fingerprints of DNA isolated from pure cultures of E. coli NC101, E. faecalis OG1RF, E. coli K12, and Bacteroides vulgatus exhibited high degree of similarity to fecal DNA fingerprints from rodents mono-associated with each bacterial strain. 3) Inoculation of E. coli NC101 mono-associated mice with E. faecalis OG1RF (and vice versa) was easily determined using RAPD. 4) 7 bacterial strains belonging to the SIHUMI consortium demonstrated unique fingerprints. Each fingerprint was clearly identifiable when up to at least 4 constituent strains were mixed. Conclusion: We have developed an optimal RAPD protocol that can serve as a highly sensitive, reproducible, cost-effective method to screen selectively colonized gnotobiotic animals for contamination.

Highly Luminescent Tridentate C^N*N and N^C*N Platinum (II) Complexes: Synthesis, Photophysical Characterization, and Biological Application

Deepak Ravindranathan, Dileep A. K. Vezzu, Libero Bartolotti, Paul D. Boyle, Alexander W. Garner, Meredith E. Smith, and Shouquan Huo

Department of Chemistry, East Carolina University.

Phosphorescent platinum-based complexes have recently attracted a great deal of interest because of their potential applications in various areas such as biological labeling, chemical and biological sensing, and photodynamic therapy. Platinum-based complexes are also well known for their anticancer activity. For example, Cisplatin is one of most successful anticancer drugs used in clinic. A key factor in the development of phosphorescent materials is the emission quantum efficiency, a property that holds advantage for biological labeling. The synthesis, structure, and photophysical properties of a series of novel, highly luminescent tridentate platinum complexes with general coordination geometry of (C^N*N)-PtL and (N^C*N)-PtL are reported, where “C^N” or “N^C” denotes a five-membered metallacycle with platinum and “N*N” or “C*N” denotes a six-membered metallacycle with platinum; L is a mono anionic ligand such as halides or acetylides. The structures of these complexes were confirmed by X-ray crystallography and their photophysical properties such as emission and quantum yields were studied. Compared to the known C^N^N platinum (II) complexes that feature a fused five-five membered metallacycle, the platinum coordination in C^N*N complexes is much closer to a square planar geometry. The geometrical change from C^N^N to C^N*N led to a substantial improvement in phosphorescence efficiency of the complexes in solution at room temperature. For example, (C^N*N)-PtL complexes with L = hexylacetylide and phenylacetylide emitted intensely with quantum yields of 47% and 56%, respectively. The N^C*N coordinated platinum complexes also exhibited square planar geometries and were emissive in fluid at room temperature with quantum yields up to 65% compared to N^C^N coordinated platinum complexes. Structural modification of the ligands of N^C*N platinum complexes allowed for emissions ranging from blue to red to be achieved. These complexes show useful potential for various biological applications.

The Role of B Cells in Pemphigus

Chris Stamey, Donna Culton

Department of Dermatology

Pemphigus Vulgaris and Foliaceus are autoimmune blistering diseases caused by antibodies to keratinocyte adhesion proteins desmoglein 1 and 3. Due to the high mortality rate if left untreated, pemphigus has typically been treated with systemic immunosuppressive agents with many undesirable side effects. Recently, rituximab has shown efficacy in these patients and appears to specifically target anti-desmoglein antibodies without affecting the level of circulating antibodies to many other common pathogens. Rituximab is a chimeric monoclonal antibody against B lymphocyte surface protein CD20 that has shown efficacy in other autoimmune diseases such as Rheumatoid Arthritis and Systemic Lupus Erythematosus. It has been thought that the mechanism of action in these diseases is the clearance of a CD20+ plasma cell precursor population known as plasmablasts. This cell population has not been well characterized in pemphigus patients. We hypothesize that this antigen experienced B cell population plays a critical role in the pathogenesis of pemphigus by serving as immediate precursors to autoantibody secreting plasma cells.
We examined the peripheral blood B cell populations in 8 pemphigus vulgaris and 4 foliaceus patients by multicolor flow cytometry.
These patients show an expanded plasmablast population relative to controls. Interestingly the majority of these plasmablasts were CD20-. The circulating memory B cell compartment (CD19+, IgD-, CD38+/-) was also evaluated. While the frequency of memory B cells was similar between pemphigus patients and controls, the percentage of memory B cells lacking CD20 was increased in pemphigus patients.
We believe the plasmablasts in these patients to be a significant component of the autoantibody secretion in pemphigus and would explain their expanded numbers in these patients.. While CD20- plasmablasts have been described, the lack of CD20 expression on memory cells is a novel finding and highly intriguing as these cells would be resistant to rituximab.

Circulating Tumor Cells as an early biomarker of response in patient derived xenograft models of pancreatic cancer

Robert Torphy, Christopher Tignanelli MD, Jen Jen Yeh MD

Department of Surgery

Circulating tumor cells (CTCs) are shed from solid tumors into circulation. Numerous epithelial based cancers release CTCs including pancreatic cancers. These cells offer an easily accessible marker for monitoring treatment effectiveness because they are obtained noninvasively through a routine blood draw. The objective of this study was to evaluate the use of CTCs as a biomarker of response to treatment using an oral PI3K inhibitor, BKM120, in patient derived xenograft (PDX) mouse models of pancreatic cancer.

PDX mice were treated with vehicle or BKM120 by oral gavage for 28 days. CTCs were isolated from 250 µL of blood before treatment and at 28 days using a novel microfluidic chip selecting for EpCAM positive cells. Captured cells were released with trypsin for enumeration using electrical conductivity.

Mean CTC count per mL pretreatment was 41 in the BKM120 group vs 18 in the control group. At day 28, mean CTC count was 20 in the BKM120 group vs 59 in the control group. There was a decrease in CTCs over the treatment interval in the BKM group (% change -51%, 95% CI -48 to -54%). There was a slight increase in the CTCs in the control group (% change 12%, 95% CI 4 to 20%). There was a significant difference in tumor growth with BKM120 treatment (% change 56%, 95% CI 27 to 85%) compared to control (% change 116%, 95% CI 89 to 143%) (t-test p=0.015).

CTCs can be detected in small volumes of blood due to the higher sensitivity of microfluidic platforms and appear to be a promising biomarker of response to BKM120 treatment in PDX models of pancreatic cancer. Longer treatment and increased sample size will be needed to further evaluate the significance of CTCs as a biomarker for response to BKM120 treatment.

Exploring mechanisms by which the antibiotic ciprofloxacin confers protection from radiation intestinal injury

Nida Waheed, Chris Packey

Department of Medicine (Gastroenterology), Microbiology and Immunology

Background: A gastrointestinal (GI) syndrome characterized by gut-derived sepsis is the cause of initial morbidity and mortality after radiation exposure, and there are no FDA-approved therapies. Methods: We compared the effect of several antibiotics on the development of intestinal injury in specific-pathogen free wild-type C57BL/6 mice exposed to 15 Gy x-ray, a dose that universally causes the GI syndrome in mice. We then used 16S rRNA-based 454 pyrosequencing and qPCR to investigate the impact of radiation and antibiotics of interest on the intestinal microbiota. Weighted (relative abundance) and un-weighted (presence-absence) UniFrac distances were measured using QIIME. Results: The antibiotic ciprofloxacin rescued mice from the GI syndrome and prevented radiation-induced small intestinal injury histologically. Several other antibiotics (rifaximin, metronidazole, trimethoprim-sulfamethoxazole, neomycin) conferred no protection. Colitis was prevented by ciprofloxacin, as measured by secretion of pro-inflammatory cytokines by colonic tissue ex-vivo explants (ELISA), tissue weight, and mouse endoscopy. We showed that ciprofloxacin was protective if given: 1) continuously starting one hour after radiation (p<0.003), but not if given continuously starting at 24 hours after radiation 2) for 2 weeks and then stopped before radiation (p<0.0001) and 3) once orally (p<0.003), with untreated cagemates also being protected, surprisingly. 454 pyrosequencing revealed that radiation induced dysbioses in the mucosa and lumen of the small intestine and colon that resemble those seen in human inflammatory bowel diseases. Ciprofloxacin prevented the development of many components of this dysbiosis. Conclusions: Kinetic analysis revealed that prevention of sepsis is not the only mechanism by which ciprofloxacin protects mice from the radiation GI syndrome, and deep sequencing revealed that ciprofloxacin prevents profound enteric dysbioses induced by radiation. Ongoing studies are exploring other bacterial-dependent and bacterial-independent mechanisms by which ciprofloxacin protects against radiation intestinal injury, and these studies will guide much-needed translational and clinical studies.

Computational Modeling of the Effects of Functional Endoscopic Sinus Surgery (FESS) on Nebulized Particle Deposition in the Maxillary Sinus

DO Frank, V Dhandha, M Kibwei, GM Fleischman, CS Ebert, AM Zanation, BA

UNC Otolaryngology/Head and Neck Surgery; Biomedical Engineering

FESS is often used to treat chronic rhinosinusitis (CRS) in patients for whom conservative medical therapy has failed; one goal being improved topical drug delivery to the maxillary sinus (MS). Controversy exists regarding an optimal nebulized particle size for MS deposition in post-surgical patients, and it is unclear how variations in the antrostomy size or position also affect deposition. Drug deposition in the MS is difficult to quantify experimentally, but computational fluid dynamics simulations have been validated as a technique capable of making reliable, quantitative predictions.

Sinonasal airway models were constructed for three patients with refractory CRS who underwent FESS, one bilaterally, from pre-surgery and 12-week post-surgery CT scans using MimicsTM software. For each patient, four virtual surgery (VS) models were also created from the post-FESS scan, representing alternative antrostomy positions and sizes. Nebulized particle transport during laminar, steady-state, resting, inspiratory airflow was simulated using FluentTM for particles within the 1-30µm range found in commercial products. Deposition fraction was analyzed by sinonasal region and particle size.

Peak MS deposition in post-FESS models ranged from 0.4%-6.2% of inhaled particles, and this was consistently greater than preoperatively; only one pre-FESS model had any MS deposition. In all cases, the largest virtual antrostomy resulted in greatest MS deposition (3.4-20.7%), while smaller antrostomies were consistently least (0.4-2.1%). Interestingly, a slight increase from the original post-FESS antrostomy size led to decreased maxillary deposition in 3 of 4 cases. The particle size with peak MS deposition varied across all models from 6.4-15µm.

Generally, increasing antrostomy size increased MS deposition, but more complicated behavior was seen at a mid-size range. Preliminary results from the Post-FESS and VS models indicate that nebulized 6.4-15µm particles improved MS deposition, with possible implications for targeting of this size range by nasal nebulizer devices to increase therapeutic drug delivery in post-FESS patients.

Deep brain stimulation at the internal globus pallidus produces fMRI response in the motor cortex

John Younce, Hsin-Yi Lai, and Yen-Yu Ian Shih

Dept of Neurology and Biomedical Research Imaging Center

Deep brain stimulation (DBS) is currently used to treat several neurological and psychiatric disorders, including Parkinson’s disease (PD), although its mechanism is still incompletely understood. In this study, we aimed to compare fMRI response to DBS of the internal globus pallidus (GPi) with the subthalamic nucleus (STN). We hypothesized that DBS at either location would produce frequency-dependent fMRI-visible responses in the motor cortex. Sprague-Dawley rats were stereotactically implanted with commercial titanium electrodes unilaterally in either the STN or GPi. They were imaged with 3 sec EPI sequences under isoflurane and electrically stimulated at 11 frequencies between 10 and 400 Hz. This study demonstrated fMRI response to DBS. Stimulation at both locations produced a positive BOLD response centered in the ipsilateral motor cortex, but GPi DBS also produced a diffuse negative response in the contralateral hemisphere. BOLD response ipsilateral to stimulation was positive, peaking at 100 Hz, and frequencies between 40 and 220 Hz exhibited a significant positive response in one or both groups. Contralateral BOLD fMRI response was negative, peaking at 40 Hz, with significant negative responses at frequencies up to 160 Hz. The ipsilateral response peaked near the high frequencies (100 Hz) that are therapeutic for DBS, while the contralateral response peaked in the frequency range (40 Hz) known to either exacerbate or be ineffective in treating parkinsonian symptoms, suggesting that the response pattern may be related to the mechanism of DBS in alleviation of PD symptoms. Future use of this technique in hemiparkinsonian animals may permit correlation of fMRI with symptomatology and further insight into the mechanism of DBS.

Clinical Sciences – Oral Presentations

Electronic Medical Records and Imaging Use in U.S. Emergency Departments

D. Levin Brown, Denise Esserman, Chris Shea, Tim Platts-Mills

Department of Emergency Medicine

Electronic medical records (EMR) have been promoted as a mechanism to make health care more cost effective, but the impact of EMR on resource utilization remains unclear. Medical imaging is a major cost component of emergency department (ED) care. EDs are a unique environment for assessing the impact of EMR because ED providers generally have no prior knowledge about their patients, yet have many imaging tools available and limited time to make decisions. Using nationally representative data, we tested the hypothesis that EMR use was associated with lower ED imaging use.

We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for years 2005-2009, which reports both image orders (CT, MRI, Ultrasound, Xray) and hospitals’ self-reported use of EMR (All, Partial, or None). We used multivariable logistic regression to estimate the association between the EMR and imaging use while controlling for both ED setting and patient characteristics.

For all visits, use of an All electronic EMR system was associated with increased odds (OR 1.20) of ultrasound. Partial EMR systems were associated with increased odds of MRI (OR 1.36), as compared to no EMR. For unadmitted patients with shortness of breath, All EMR and Partial EMR was also independently associated with greater odds of CT scan (OR 1.53 and 1.62, respectively).

EMR in US EDs from 2005-2009 was not associated with decreased imaging use. When stratifying analyses to various clincally prevalent patient cohorts, EMR was associated with increased odds of use for CT, MRI, and other imaging resources.

Health Literacy and Numeracy as Predictors of Transition Readiness/Self-management and Depressive Symptoms among Adolescents and Young Adults with Chronic Kidney Disease

Marley Burns, MS2, Kristi Bickford, B.A., Nicole Fenton, M.A., Edward Iglesia, MS4, Maria Ferris, MD, MPH, PhD

UNC Kidney Center

Background: Adolescents and young adults with chronic kidney disease (CKD) have great survival and must either undergo a transition process from pediatric to adult-focused health care or learn how to self-manage their disease effectively to decrease morbidity. We examined the roles of health literacy and numeracy in predicting transition readiness and/or self-management and depressive symptoms.
Methods: We recruited English-speaking patients ages 14-29 with CKD stage ≥ 4 from the UNC Kidney Center pediatric and adult nephrology clinics. Participants completed three provider-administered scales: (1) Rapid Estimates of Adult Literacy in Medicine (REALM) to assess health literacy, (2) Newest Vital Sign, a food label to assess literacy/numeracy, (3) TRxANSITION Scale to assess transition readiness/self-management, and a self-administered web-based scale: (4) CES-D to assess depressive symptoms.
Results: To date, we have enrolled 25 patients with CKD stage ≥ 4 (including 20 transplant patients) with the following characteristics: 60% Female; 50% White, 34% Black, 13% Hispanic; Mean age 21.6 (±4.7); Mean age at diagnosis 9.5 (±8.5). Nine participants were managed by pediatric nephrology and 16 by adult nephrology.

Health literacy – The REALM score was a significant negative predictor of depressive symptoms (β= -.38, p=.09) and a significant positive predictor for overall transition readiness/self-management (β= .64, p=.00).

Health numeracy – The Newest Vital Sign score was a significant negative predictor of depressive symptoms (β= -.41, p= .07) and a significant positive predictor for overall transition readiness/self-management (β= .38, p= .02).

Conclusions: Higher health numeracy and literacy independently predict fewer depressive symptoms and higher overall transition readiness/self-management among youth with CKD. Without adequate health literacy and numeracy skills, adolescents and young adults with chronic health conditions are ill-equipped for disease self-management and have poorer mental health. Enrollment continues underway.

Prospective Study of Head and Neck Quality of Life in a Comprehensive Skull Base Surgical Practice

Emily E. Cohn, BSPH; Stephen A. Wheless, MD; Kibwei A. McKinney, MD; Robert J. Taylor, BS; Adam M. Zanation, MD

Department of Otolaryngology-Head and Neck Surgery

Introduction: Skull base surgery encounters a broad range of pathologies, utilizes various surgical approaches, and spans multiple disciplines. Current comprehensive skull base surgical practice accounts for these categories however few studies have examined the differences in quality of life outcomes across a diverse cohort. This study evaluates the effects of endoscopic and open skull base surgery on quality of life and head and neck symptoms throughout the post-operative period.

Methods: A prospective cohort study was performed with 45 patients undergoing skull base surgery. Quality of life and symptoms were assessed with a Cancer Quality of Life Questionnaire (EORTC QLQ-C30) with modules for Head and Neck (H&N35) and Brain Cancer (BN20). These surveys were administered pre-operatively and at three post-operative time points: post-operative visit 1 (POV1) at <1 month; POV 2 at 1-3 months; and POV 3 at >3-12 months. Mean quality of life (QoL) and symptom-specific scores were compared using Student’s T-Test.

Results: 45 patients were included in this analysis; malignant pathologies were present in 23 cases and advanced benign tumors made up the remainder. 37 of 45 (82%) patients underwent endoscopic endonasal surgery, and 8 (18%) patients underwent open skull base surgery. 15 of 45 (33%) patients underwent adjuvant chemo/radiotherapy. Mean QoL scores were not significantly different between any time point. Compared to the benign group, patients with malignant disease experienced more pain and problems with smell/taste and eating at POV3 (mean symptom score differences: 14.7, (p=0.02); 29.2, (p=0.01); 14.2, (p=0.02) respectively).

Conclusion: Head and Neck quality of life metrics provide insight into how our patients are healing . In the late post-operative period, patients with malignant disease experience worse head and neck symptoms, which are likely related to prolonged healing secondary to adjuvant therapy. In the entire cohort, despite increased symptoms, overall quality of life is not adversely affected.

Differences in White Matter Developmental Trajectories and Acquisition of Fine Motor and Receptive Language Priors in 6 to 24 Month Infants with Autism Spectrum Disorder

Department of Psychiatry

Jeremy Ford, Jason Wolfe, Joseph Piven

Recent research indicates that autism spectrum disorder (ASD) could be related to the aberrant development of neural circuitry early in life. However, the relationship between white matter connectivity in infants who develop ASD and behavioral phenotypes remains an important yet unexplored topic. In the present study, we applied diffusion tensor imaging (DTI) to assess white matter microstructure in the superior thalamic radiation (STR) and the uncinate fasciculus (UF) in 6-24 month high-risk ASD-positive (n = 28), high-risk ASD-negative (n = 64), and typically developing (n = 29) infants. To assess behavior, infants were administered receptive language and fine motor tests from the Mullen Scales of Early Learning at 6 months. Developmental trajectories of white matter replicated prior findings of initially high but blunted growth for the high-risk ASD positive group. Analyses controlling for IQ yielded a significant correlation between fine motor scores at 6 months and left STR connectivity at 12 months (R2 = 0.201) in ASD-negative and typically developing infants. No UF correlations were observed, which could be accounted for by a general under-specialization of infant brain. Remarkably, receptive language scores in ASD-positive subjects at 6 months and right STR connectivity exhibited the strongest relationship (R2 = 0.627), an relationship also seen in the left STR. This suggests that STR may play a differential role in the acquisition of receptive language priors (e.g. social attention) in the developing brain of children who develop ASD compared to typically developing children.

Unconventional imaging strategies in temporal arteritis: the value of gadolinium-enhanced MRI and optical coherence tomography in atypical cases of temporal arteritis

Katy C. Liu and David A. Chesnutt

UNC Department of Ophthalmology

We report two atypical presentations of temporal arteritis with unusual yet revealing findings observed on fat-suppressed gadolinium-enhanced magnetic resonance imaging (MRI) and optical coherence tomography (OCT). In Case 1, an 83 year old woman with headache and blurry vision experienced rapidly deteriorating vision loss, reaching no light perception in both eyes within two weeks despite aggressive steroid treatment. In Case 2, a 68 year old woman with no prior history of eye disease developed sudden, rapidly progressive monocular vision loss with no associated systemic symptoms such as headache or jaw claudication. Within a week, her visual acuity in the affected eye deteriorated to hand motions only and to no light perception upon presentation two weeks later at our institution. In both patients, the erythrocyte sedimentation rate (ESR) values were normal.

Dedicated orbital MRI in both patients showed distinctly perineural retrobulbar enhancement, which confirmed posterior optic nerve involvement, at least in part, in both cases. Temporal artery biopsy confirmed the diagnosis of giant cell arteritis.

Using optical coherence tomography, we show in the second patient that the retinal nerve fiber layer (RNFL) in the affected eye continued to thin several months beyond the initiation of corticosteroid treatment, while the fellow eye remained normal. Thus, OCT may be a useful tool to follow the progression of temporal arteritis.

Temporal arteritis is a dangerous and vision-threatening optic neuropathy. In atypical cases, diagnosis can be delayed, yet vision loss is potentially rapidly progressive and irreversible. In atypical presentations of temporal arteritis, dedicated orbital MRI can be a valuable tool in the patient workup – in addition to ruling out other possible etiologies, orbital MRI can potentially aid in the diagnosis of temporal arteritis.

Combined Local and Systemic Antibiotic Treatment for Implant Infection

Medda, Suman; Casp, Aaron; Del Gaizo, Daniel; Dahners, Laurence

Department of Orthopaedics

Periprosthetic infections are difficult to treat, often recurring despite long-term systemic antibiotics and prosthetic explantation. Because local antibiotics can be administered at high concentrations into the wound cavity without systemic toxicity, we hypothesized that a combination of local tobramycin and systemic ceftriaxone would yield better results against a peri-implant infection than systemic antibiotics alone.

Sprague-Dawley rats had a HDPE, titanium wire and chrome cobalt wire composite implant attached to their lateral femur. The implants were inoculated with 1.0e6 CFU of Staphylococcus aureus. After forty-eight hours, four groups were established including a no treatment control (CTRL) and three once daily antibiotic therapy groups: systemic ceftriaxone only (SYST), local tobramycin only (LOCL), and combination systemic ceftriaxone and local tobramycin (COMB). The rats were sacrificed at seven days. Quantitative culture was performed to determine the most effective treatment.

The mean colony counts of all four treatment groups were significantly different from each other. The mean colony count of the CTRL group was 1.8e7 CFU/mL, which differed from the SYST group (mean: 5.8e5, p = 0.002), LOCL group (mean: 6.8e4, p = 0.001) and the COMB group (mean: 489, p = 0.002). There were no complete eradications of bacteria in any of the groups. The lowest count was 60 CFU/mL in one rat in the COMB group.

As hypothesized, the group receiving both local tobramycin and systemic ceftriaxone yielded the best results. Both the high concentration of local antibiotic and the synergistic effect between aminoglycosides and cephalosporins may have played a role. Although this strategy was not sufficient to produce a cure in this model, the three order of magnitude improvement over

systemic antibiotics suggests that further study of these methodologies are warranted.

Public Health – Oral Presentations

Access to Care among Adults with Previously and Newly Diagnosed Hypertension and Cardiovascular Disease Presenting to the Emergency Department of a Tertiary Referral Hospital in Nairobi, Kenya

Rita Kaur Kuwahara, Kathryn W. Koval, Ian B.K. Martin, Meredith H. Arasaratnam

Department of Emergency Medicine and Internal Medicine, UNC School of Medicine

Background/Objectives: According to the WHO, 326-401 deaths per 100,000 population in Kenya are attributed to cardiovascular disease (CVD) and diabetes, yet no national policies currently exist to address CVD in Kenya (WHO 2011). This study’s primary objective was to further characterize Kenya’s CVD epidemic by assessing the influence of socioeconomics on access to care among patients with CVD presenting to Kenyatta National Hospital’s Emergency Department (ED).

Methods: In this cross-sectional study, clinician-administered questionnaires were used to collect clinical, demographic and healthcare utilization data from 112 CVD patients presenting to Kenyatta National Hospital’s ED in Nairobi, Kenya. Enrolled patients were 18-89 years with newly or previously diagnosed hypertension, heart disease, stroke and/or deep vein thrombosis.

Results: Of the patients interviewed, 27% had new onset CVD with an average age of 48 years. Seventy-three percent had previously diagnosed CVD with an average age of 50.5 years and an average of 7.6 years since diagnosis. Of patients with new onset CVD, 47% had regular sources of medical care and 67% cited barriers to care, particularly cost and transportation. In contrast, 86% of patients with known CVD had regular access to care, with 74% reporting at least one barrier. Thirty-nine percent of patients earned under 2,499 Kenyan Shillings (USD$30) monthly, and 53% lived in rural areas. Fifty-six percent of participants living in rural areas cited at least one barrier to care, in contrast to 44% of participants living in urban/suburban districts. Hypertension (62%), congestive heart failure (23%), and stroke (19%) were the commonest CVD diagnoses, and family history of CVD (34%) and diabetes (25%) were the commonest risk factors.

Conclusion: These results highlight the role of the ED in identifying patients with undiagnosed CVD and emphasize the need to address existing barriers to healthcare when developing novel policies/programs to address Kenya’s emerging CVD epidemic.

Association between maternal birth weight status and birth weight status of offspring: a systematic review and meta-analysis of cohort studies

Andrea Dotson, Lisa Williams, Su Lee, Nan Guo, Ligia Fernandes

Epidemiology, Johns Hopkins Bloomberg School of Public Health


To assess whether women born with low birth weight have a higher risk of giving birth to offspring with low birth weight than women born without low birth weight. An updated systematic review and meta-analysis on Shah ‘Influence of the Maternal Birth Status of offspring: A Systematic Review and Meta-Analysis.”

Systematic review and meta-analysis.

Electronic database search of Pubmed, EMBASE, Scopus, and CINANHL Abstracts. Eligibility criteria were limited to observational cohort studies published between 2009-2011.

Twenty three studies were included in the final review from the initial 1060 abstracts identified through the search strategy. A strong, statistically significant association between low maternal birth weight and low infant birth weight was identified. Meta-analysis calculations included a crude odds ratio of 2.21 (2.12-2.31, I(2) = 32.3%). An adjusted odds ratio was derived from a selection of studies and calculated at 2.82 (2.05-3.88). A subgroup analysis indicated no difference in association between developed and developing countries with crude odds ratios 2.21 (2.11-2.31) and 3.25 (1.96-5.38), respectively.

There is a statistically significant, positive relationship between maternal low birth weight and infant low birth weight. The casuality of this relationship cannot be ascertained from the data presented in this systemic review. Further research should investigate the clinical importance of a mother’s birth weight on the prevention and management of low infant birth weight.

Developing the Palestinian Congenital Anomalies Database

Sonya V. Patel (MD Candidate), Hala Borno (MD Candidate), John van Aalst, MD

Division of Plastic & Reconstructive Surgery, Dept of Surgery at UNC

Background: The Palestinian territories lack research infrastructure. This study is the first to establish a Palestinian congenital anomalies database to determine incidence and prevalence of craniofacial anomalies; to serve as a model for future healthcare databases, and to guide resource allocation.

Methods: A 500-item, validated, IRB-approved, survey was administered after informed consent to mothers of affected children. Interviews were held in Government Hospitals. All data were uploaded to a secure, internet-supported database. Descriptive statistics were generated from database queries, with significance reported as < 0.05.

Results: Data were collected on 97 children: 12 (12.4 %) with cleft lip (CL) only, 47 (48.5 %) with cleft lip and palate (CLP), 30 (30.9 %) with cleft palate only (CP); 8 (8.3 %) with other anomalies. Patients with CL underwent primary repair at 8.55 months. Non-refugees reported a longer time to repair (10 months) than refugees (5.5 months; p=0.69). Patients with CP underwent primary repair at 26 months. Refugees reported a longer time to repair (30 months) than non-refugees (23 months; p=0.39). A majority of parents (59; 61 %) were related, of which 41 (70 %) were first cousins. Higher consanguinity rates were reported among rural residents (63 %, p=0.67), refugees (76 %, p=0.09); those with a positive family cleft history (77 %, p=0.22) and other congenital anomalies (77%, p=0.22). Most mothers (66; 68 %) received prenatal ultrasounds (US); 43 of those undergoing US had diagnoses of CL and CLP. Only 6 of these 43 US (14 %) detected the CL.

Conclusion: This work reports the initial findings of the Palestinian Congenital Anomalies Database. The data suggest that there are delays in CL and CP repair, a majority of parents are related, and US techniques do not detect CL. These data–though limited in scope—will eventually assist in decision-making for resource allocation.

Eating behavior in children’s programming: a potential contributor to childhood obesity

Elise Stephenson, Alice Ammerman

UNC School of Public Health, Department of Nutrition

There is a myriad of research correlating advertising with childhood obesity, but a dearth of studies analyzing the food content of the actual programs themselves. Given previous research on child vulnerability, there is strong reason to believe that the content of children’s programs–that is the food discussed and consumed by on-screen characters–may be contributing to the correlation between screen-time and childhood obesity. After coding the food content of 64 episodes (sixteen hours) of children’s programming on PBS, Nickelodeon, Cartoon Network, and the Disney Channel, I found that all networks were significantly different from two respected sources for dietary recommendations. More specifically, 35-53% of the food presented fell into the category of solid fats and added sugars, compared to a recommendation of less than 4-10% by the American Academy of Pediatrics and United States Department of Agriculture. Further analysis showed significantly low amounts of dairy, fruits, and vegetables on these networks. This evidence suggests that the content of children’s programs may be contributing to childhood obesity, thereby presenting a new area for regulation and reform.

Basic Sciences – Poster Presentations

Evaluation of B-lymphocyte and fibroblast p-ERK/ERK expression in Alzheimer’s by Western blot and FACS

Vincent Arnone, Tapan Khan, Abhik Sen, Thomas Nelson, Daniel Alkon

Blanchette-Rockefeller Neuroscience Institute


Alzheimer’s disease is becoming one of the prevalent and devastating neurologic diseases in the world. It has been predicted that 5% of men and 6% of women will be affected with the disease in their lifetimes. Alzheimer’s disease has been traditionally thought of as principally a neurologic disorder and involved few other tissues or cells of the body, but this thinking has evolved in recent years and previous studies have shown that cell cycle abnormalities in the neurons of Alzheimer’s patients extend to B-lymphocytes and fibroblasts.

Using these recent findings, this study’s goal was to examine Erk and the active form p-Erk in the B-lymphocytes and fibroblasts of Alzheimer’s disease (AD) and age-matched controls (AC) to determine if there was a measurable difference in expression of these cell cycle regulators.

This study employed the use of Western blot and found that the ratio of expression (p-Erk/Erk) in AD patients was higher for B-lymphocytes and fibroblasts versus AC patients. The Western blot findings for the B-lymphocytes were confirmed with FACS for 5 cell lines (2 AD, 3 AC) and found the ratio of p-Erk/Erk expression to be higher in AD. This study also examined p-Erk1 and p-Erk2 separately to determine if there was a difference in expression between these two similar proteins and found p-Erk1/p-Erk2 expression to be higher on average in AD patients vs. AC. Akt was also examined due to its role as a cell cycle regulator and it was found that p-Akt/Akt expression ratio was lower in AD when compared to AC although it was not as large of a difference as p-Erk/Erk expression ratio.

Expanding the Ciliopathy Spectrum: An Analysis of KIF7

CL Bennett, EE Davis, A Putoux, S Thomas, K Coene, N Elkhartoufi, M Winey, P Beales, T Attie-Bitach, N Katsanis

Duke University School of Medicine

KIF7, the human ortholog of Drosophila Costal2, is a key component of the Hedgehog signaling pathway. Here we report mutations in KIF7 in individuals with hydrolethalus and acrocallosal syndromes, two multiple malformation disorders with overlapping features that include polydactyly, brain abnormalities and cleft palate. Consistent with a role of KIF7 in Hedgehog signaling, we show deregulation of most GLI transcription factor targets and impaired GLI3 processing in tissues from individuals with KIF7 mutations. KIF7 is also a likely contributor of alleles across the ciliopathy spectrum, as sequencing of a diverse cohort identified several missense mutations detrimental to protein function. In addition, in vivo genetic interaction studies indicated that knockdown of KIF7 could exacerbate the phenotype induced by knockdown of other ciliopathy transcripts. Our data show the role of KIF7 in human primary cilia, especially in the Hedgehog pathway through the regulation of GLI targets, and expand the clinical spectrum of ciliopathies.

The Osteoinductive Potential of Biomaterials in Subcutaneous sites

Aaron Casp, Suman Medda

Department of Orthopaedics

Expedited healing of fractures and bony defects is valuable clinically for improved outcomes and decreased recovery times. This may be achieved by utilizing certain osteogenic substances in the appropriate combination and timing of release. Bone morphogenetic protein-2 (BMP-2) is one such substance that has found its way into clinical usage, but its full potential has not yet been optimized and it remains prohibitively costly. While the order in which the body releases healing factors in response to bony injury is known, the combination and exact concentration of these factors that maximizes bone growth is yet to be determined. The purpose of this study was to quantify ectopic bone formation stimulated by osteoinductive and angiogenic factors, both separately and in conjunction using a calcium sulfate implant. It also evaluated how the timing of the release of the factors influences bone formation. Using a rat model, the materials were surgically implanted in an ectopic site on the dorsum of the animal. Bone growth evaluations were completed at 6 weeks post-op via plain film X-ray, micro-computed tomography, and ash fraction for bone determination. Initial evaluation of plain film X-rays do not show appreciable bone formation with any consistencies among the test groups. This suggests either a flaw in the preparation of the implants or some sort of anatomic difference among the various subcutaneous spaces.

It was hypothesized that the combination of factors would lead to enhanced bone formation, and that delivering the vascular factor first would yield more osteogenesis than when it is slow-released during the healing process.

Identification of Functional Regulatory Elements in Crohn’s Disease

Timothy AH Dinh, Shehzad Z Sheikh, Jason D Lieb

UNC, Department of Biology

Crohn’s disease is an inflammatory bowel disease that is caused by a combination of environmental, microbial, and genetics factors. Recent genome-wide association studies have revealed loci, including multiple intergenic regions, implicated in the pathogenesis of Crohn’s disease. Our laboratory has developed a technique, formaldehyde-assisted isolation of regulatory elements (FAIRE), that isolates regions of open chromatin in the genome, which correspond to active regulatory elements. Previous work has demonstrated the utility of FAIRE to identify tissue-specific regions of open chromatin in addition to single nucleotide polymorphisms (SNPs) that affect local chromatin structure and regulatory activity. Here, we use FAIRE to identify regions of open chromatin in gut tissue from patients with Crohn’s disease and identify non-coding genomic regions that could influence Crohn’s disease pathogenesis. We found two Crohns’s disease-associated SNPs that lay in open chromatin regions. One of these SNPs was located in an open chromatin region in both healthy and Crohn’s diseased tissue, while the other was located in an open chromatin region specifically in healthy tissue, suggesting a possible causal role in Crohn’s disease for the latter SNP. These results demonstrate a potential biological function for some functionally unnannotated Crohn’s disease-associated SNPs and support a method to identify functional properties of SNPs in additional disease contexts.

Upper Airway Sensitization Causes Lower Airway Disease

Dr. Stephen Tilley, Dr. Xiaoyang Hua, Warren Naselsky (MD candidate), Corey Jania, Kelly Chason

UNC Pulmonology

Background: Asthma, allergic rhinitis, and chronic rhinosinusitis are the most prevalent airway diseases in developed countries. Allergens can cause a surge of IgE into the bloodstream in all three diseases, suggesting that they are mediated by IgE. This has led to the “unified airway theory,” proposing that there is a relationship between the upper and lower airway through a mucosal inflammation that is generalized throughout both.

Objectives: The goal of this study is to compile data derived from examining inflammation in the lower airway of control mice compared to experimental mice. These findings will add to the growing body of research surrounding the unified airway theory.

Methods: Wild-type BALB/c mice were randomly divided into experimental and control groups. The experimental group was challenged with 10 microliters house dust mite allergen (a solution of 25 micrograms Purified House Dust Mite extract in 10 microliters of saline) intranasally, 5 microliters/nostril, 5 days/week for 5 weeks. Mice were euthanized and lung inflammation evaluated by examining cell numbers and differential analysis in BALF, lung histopathology, cytokine assays, and heart puncture and blood collection to examine serum IgE. Airway hyperresponsiveness to methacholine was investigated by measuring airway mechanics after anesthesia and tracheostomy. The results from these mice were compared to results from control mice living under identical circumstance.

Results: HDM-challenged BALB/c mice developed a robust inflammatory response in the lungs with significant increases in eosinophils, lymphocytes, macrophages, and neutrophils in the lung lavage fluid compared to controls. They also had significantly increased airway histopathologic changes and a large number of goblet cells in the respiratory epithelium compared to control mice.

Conclusions: The experimental group had more inflammation than the control group, so this study adds to the growing body of research proposing that the connection between the upper and lower airways is immunological.

The role of microparticle docking in the development of cancer-induced venous thrombosis

Julia E. Geddings, Jianguo Wang, Mauricio Rojas, Todd M. Getz, Wolfgang Bergmeier, Nigel Mackman

Pathology and Laboratory Medicine

Venous thromboembolism (VTE) is a clinical term which refers to the development of deep vein thrombosis and pulmonary embolism. It is a common occurrence in cancer patients with pancreatic cancer having one of the highest rates of VTE. The development of this condition by pancreatic cancer patients has been shown to be associated with many negative patient outcomes including increased mortality. Microparticles (MPs) are small membrane vesicles that are released by many cell types including cancer cells that contribute to the activation of the coagulation cascade due to the PS content of their plasma membrane and their ability to carry tissue factor. Pancreatic tumors in particular have been shown to release procoagulant MPs into the circulation. This study evaluates the role of MP-endothelial cell docking interactions in the development of cancer induced venous thrombosis. For the first part of this study a method was developed to monitor the growth of venous thrombi in vivo in mice that had undergone inferior vena cava (IVC) stenosis or ligation. We successfully utilized ultrasonography for this purpose allowing for multiple timepoints to be analyzed in each mouse during measurement of thrombosis. The docking of CFSE-labeled pancreatic tumor-derived MPs to the laser-activated endothelium of the mouse cremaster microcirculation was also imaged in vivo by intravital microscopy and in vitro to cultured human umbilical vein endothelial cells.

Alterations of the Gut Microbiota in Irgm1-/- Mice Susceptible to Inflammation

Rachel Gooding, Jen Uno PhD, Ian M. Carroll PhD, Gregory Taylor PhD, R. Balfour Sartor MD, Ajay S. Gulati MD

Department of Pediatrics; Center for Gastrointestinal Biology and Disease

Crohn’s Disease (CD) is characterized by inflammation of the gastrointestinal tract, and is thought to result from improper immune responses to commensal enteric bacteria. CD patients are believed to display an intestinal microbial dysbiosis favoring a bacteria profile that leads to increased susceptibility to intestinal inflammation. Furthermore, host genetics also contribute to the onset of CD. The risk allele IRGM has recently been implicated in CD. Therefore, the present study aimed to assess the luminal and mucosally-adherent microbial composition of mice lacking the mouse homologue of IRGM, Irgm1, to determine if the absence of this risk allele could lead to altered enteric bacterial composition. Specifically, we hypothesized that Irgm1-/- mice would possess increased gut pro-inflammatory commensal bacteria and decreased anti-inflammatory commensal bacteria relative to WT mice. To test this, bacterial DNA was isolated from the stool and ileal tissue of Irgm1-/- and wild-type mice, and qPCR was used to determine relative abundances of various pro-inflammatory and anti-inflammatory commensal bacterial groups. Interestingly, Irgm1-/- mice possessed higher relative levels of anti-inflammatory Lactobacillus spp. and F. prausnitzii compared to WT animals, with no significant differences shown in the other studied bacterial groups. Although this increase in anti-inflammatory commensals was unexpected, this result does demonstrate alterations of the gut microbiota in Irgm1-/- mice. These mice do not develop spontaneous intestinal inflammation, but do display increased inflammatory susceptibility to DSS. Future research may focus on measuring the enteric bacterial composition of Irgm1-/- mice treated with DSS to induce an active disease state.

Acute miR-223 inhibition in murine neutrophils in vitro

Lee Hong, John Gomez, PhD, Claire Doerschuk, MD

CF Center, School of Medicine

Bacterial pneumonia is associated with high cost, mortality, and morbidity as the 8th leading cause of death in the US. Neutrophils are one of the first responders to infection. While neutrophils are instrumental in killing and eliminating bacteria, excessive neutrophil infiltration can cause life-threatening inflammation and lung disease. However, the regulatory networks that control neutrophil function and cytokine secretion during bacterial pneumonia are still not fully understood. Our lab is interested in the role of microRNAs (miRNAs, miRs) in regulating the expression of interferon-gamma (IFN-gamma), a pro-inflammatory cytokine. Our objective is to determine whether commercially available miRNA inhibitors can block miRNA function in neutrophils.

Based on a literature review and our data from microarrays for miRNA expression during bacterial pneumonia in neutrophils, we identified miR-223 as 1) a miRNA highly expressed by neutrophils, 2) a key regulator of granulocyte differentiation and 3) the only miRNA for which a knockout mouse has been generated. Neutrophils from miR-223 knockout mice have been shown to have defects in the respiratory burst and in Igf-1r expression. We used a FITC-tagged miR-223 inhibitor and compared the effect of the miR-223 inhibitor with that of genetic knockout using flow cytometry.

We found that 1) 20-35% of bone marrow-derived neutrophils take up the control or miR-223 antagomir, 2) Inhibition of miR-223 causes increased ROS production (1.49 fold change, SE=0.08 compared to 1.22 fold change, SE=0.20 in control), and 3) Expression of cell surface and total Igf-1r increases after miR-223 inhibition, consistent with our hypothesis that miR-223 targets would be upregulated. We concluded that the miR-223 inhibitor of miR-223 causes similar effects as miR-223 genetic knockout, and thus, importantly, inhibitors of miRNAs are likely to be effective in neutrophils when given using this protocol.

The FhaB prodomain is essential for Bordetella virulence

Kurtis Host, Jeff Melvin, Peggy Cotter

Department of Microbiology and Immunology

Respiratory tract infection with the Gram-negative bacterial pathogen Bordetella pertussis results in whooping cough, a condition that is currently rising at alarming rates worldwide. The re-emergence of whooping cough is theorized to be a result of waning immunity of acellular vaccine immunization. Filamentous hemagglutinin (FHA), an adhesive, immunomodulatory protein, is a primary component of the acellular vaccine. FHA is first synthesized as a preproprotein called FhaB that contains a large C-terminal prodomain. The FhaB prodomain, removed during translocation across the outer membrane, plays a pivotal role in FHA maturation. Deletion of a large portion of the C-terminus of the prodomain abolishes Bordetella pathogenesis, although adherence to epithelial cells is unperturbed. To better characterize the role of the prodomain, we created strains producing FhaB lacking either the uncharacterized prodomain (UPD) subdomain, the proline rich region (PRR) or the extreme C-terminus (ECT) subdomain. Preliminary data obtained with a co-integrate strain has shown that the absence of the ECT causes a defect in pathogenesis, resulting in increased bacterial clearance. Also, FHA processing efficiency is increased when the ECT is absent. These findings suggest that rapid maturation of FHA diminishes its ability to contribute to Bordetella virulence, but not adherence to epithelial cells. These results provide the first evidence of an active role for the FHA prodomain during infection. The study of these subdomains will lead to a better understanding of the function of the FHA prodomain and mature FHA during infection.

Transgenerational Effects of Starvation on Development, Reproduction, and Lifespan

Meghan Jobson, Moses Sandrof and Ryan Baugh

Duke University, Biology

Starvation during early human development produces epigenetic effects that are thought to be adaptive if famine persists. Nutritional deprivation in utero has been reported to lead to increased incidence of heart disease and metabolic disorders later in life. We attempted to model the response to early exposure to starvation in C. elegans. When this organism hatches in the absence of food, it responds by reversibly arresting post-embryonic development, entering ‘larval stage 1 (L1) arrest.’ We wondered if C. elegans has a lifelong epigenetic response to early environmental conditions, and we examined a variety of life history traits in well-fed animals following L1 arrest to address this question. We show that development, reproduction and lifespan are all affected after recovery from L1 arrest and, remarkably, that these epigenetic effects persist for multiple generations. Development is delayed, producing smaller adults, and fertility is reduced, but stress resistance and lifespan increase. Egg-laying behavior is also affected, with a high frequency of internal hatching (i.e. ‘bagging’), revealing epigenetic control of reproductive behavior. Starvation causes a striking amount of phenotypic variation among isogenic individuals, and those that develop slowest are least fertile but most stress resistant. These most affected individuals live 50% longer, and they transmit the life span extension phenotype as well as increased starvation resistance to their progeny. Our work shows that environmental conditions and life history have profound transgenerational epigenetic effects on several organismal traits including lifespan. In particular, we demonstrate epigenetic control of a fitness trade-off between reproduction and stress resistance in response to starvation, suggesting anticipation of stress.

miRNA-Regulated Genes in Pancreatic Ductal Adenocarcinoma (PDAC)

Matthew B. Lipner, Jeran K. Stratford, David J. Bentrem, Judy M. Anderson, Cheng Fan, Keith A. Volmar, J. S. Marron, Elizabeth D. Routh, Laura S. Caskey, Jonathan C. Samuel, Channing J. Der, Leigh B. Thorne, Benjamin F. Calvo, Hong Jin Kim, Mark S. Talamonti, Christine A. Iacobuzio-Donahue, Michael A. Hollingswort, Charles M. Perou, Jen Jen Yeh

Departments of Surgery and Pharmacology

Pancreatic cancer is the fourth leading cause of cancer-related death and has the highest mortality rate of all cancers, about 97-98%, with patients dying of metastasis soon after diagnosis. The mechanism by which metastasis occurs remains unclear, and its elucidation is crucial for the development of effective treatments. Recently, we identified a metastasis-associated gene signature that was able to predict survival in patients with localized resectable pancreatic adenocarcinoma (PDAC), and may be used to better stage patients and inform treatment decisions. We hypothesized that the six genes in this metastasis-assoc signature may have a functional relationship through regulation by common microRNAs (miRNAs), small regulatory RNA molecules that repress gene expression by binding to the 3’ untranslated region of mRNA molecules. Using a bioinformatics approach, we identified 9 candidate miRNAs. We further identified 50 genes differentially expressed in patient tumor metastases that were predicted to bind these candidate miRNAs. Several especially interesting candidate genes: FSTL3, ULK1, and ULK4 were identified that have been studied in relation to cancer progression in the past. An initial qRT-PCR run indeed demonstrated that all three were downregulated in most PDAC cell lines compared to a normal immortalized pancreatic epithelial cell line, indicating that these genes may be metastasis suppressors. The roles of these genes in tumorigenesis and metastasis, as well as the specific miRNAs repressing each of the candidate genes remain to be explored.

Design of a Portable Solid State Head CT for Hyperacute Stroke Detection

Mao, Yuxuan; Dr. Lee, Yueh; Dr. Zhou, Otto; Dr. Lu, JianPing; Shan, Jing; Tucker, Andrew

Neuroradiology, Physics and Astronomy

Every year in the United States, nearly 800,000 people are afflicted by strokes, with an associated health care cost of $40 Billion. While strokes can be either ischemic or hemorrhagic, the vast majority (87%) are due to ischemia and can be treated with IV thrombolytic therapy within the first 3-4.5 hrs of symptom onset, leading to improved outcomes. However, only 2-5% of eligible stroke patients receive thrombolytic therapy due to delay in reaching the hospital. Secondly, standard of care dictates early head CT to differentiate between ischemic and hemorrhagic stroke, for thrombolytic therapy is contraindicated in patients with active bleeding. However, only 41% of patients arriving at the ER gets scanned within 25 minutes. This presentation describes the design and prototyping of a portable solid state head CT, which can be mounted on an ambulance to provide hyperacute stroke detection, and thus drastically reduce time to treatment and improve patient outcomes. Since the design uses fixed carbon nanotube X-ray sources and solid state detectors, there are no moving parts or rotating gantries, which lead to improved robustness during transportation in the field. We will also demonstrate superior image quality and radiation dose performance compared to a commercially available portable head CT that is currently used in ICU’s.

Guiding Attention with Shape

Suzanne Michalak, Heida Sigurdardottir, & David Sheinberg

Brown University Department of Neuroscience

Over-learned shapes, such as arrows, have been shown to automatically orient visual attention regardless of viewer intention. Our research investigated whether the shape of randomly generated blobs has an automatic effect on visual orienting. In the first experiment, we generated eighty novel shapes. Participants viewed these shapes and drew a line on the screen to where they thought the shape “pointed.” 69 of the 80 shapes showed a strong consensus in the shape’s “directionality.” We then used the strongest twelve shapes and tested whether participants could learn to associate a novel shape with a target in a location opposite the direction of its empirically measured directionality. While participants could learn to find a target in a location opposite a shape’s inherent directionality, they were significantly faster when the shape of the object predicted the target’s location (F(4,28)=2.007, p=0.035). Our next experiment aligned the forty strongest shapes to the horizontal axis. In each trial, several copies of a shape moved either left or right. Eye movements were recorded with an eye tracker, and participants were told to look in the direction of motion. When a participant looked three degrees in either direction, the trial ended. When the shape moved in a direction congruent with its inherent directionality, participants were significantly more accurate (t(9) = 3.046, p = 0.014). An algorithm was then created that assessed the aerodynamic properties of shapes in order to predict the directionality perceived by humans. This algorithm accurately predicted the directionality for shapes with a strong consensus (r(78) = -.336, p < .005). We concluded that an object’s shape automatically pushes attention away from itself towards locations in space, making people look in a particular direction even when it is counterproductive. This directional bias can be partially explained by an object's aerodynamic properties.

IL-4 primes human mast cells to secrete IL-5, IL-13, and PGD2 in response to LPS stimulation

Warren C. Naselsky, Kelly D. Chason, Xiaoyang Hua, and Stephen L. Tilley

Department of Medicine, Division of Pulmonary and Critical Care Medicine, UNC

Background: Endotoxin (LPS) is ubiquitously distributed in the environment and is present in significant concentrations in household dust. While it has been recognized for many years that acute exposure of asthmatics to LPS can produce airway hyperresponsiveness and airway inflammation, and at high doses elicit bronchoconstriction, the cellular and molecular mechanisms responsible for these effects remain poorly understood. Clinical observations with cromolyn sodium and in vivo studies in mice suggest that mast cells might mediate these effects of LPS in asthmatics. To test the hypothesis that an LPS-mast cell activation pathway is involved in LPS-induced asthma exacerbation, we examined the capacity of LPS to activate human mast cells in vitro in the presence or absence of the Th2 cytokine IL-4.
Methods: Human mast cells were differentiated from umbilical cord blood CD133+ progenitors using IL-6 and stem cell factor. After 10 weeks in culture, mast cells were incubated for 3 days with or without IL-4, and then stimulated with LPS for 20-24 hours. LPS-induced release of IL-5, IL-8, IL-13, and PGD2 was measured by ELISA. mRNA expression of GATA-1, -2, and -3 was measured by qPCR, and selected IL-4R and TLR-4 signaling pathway kinases were inhibited pharmacologically to determine their involvement in this IL-4-induced change in mast cell phenotype.
Results: IL-8 was constitutively produced by human mast cells. LPS augmented IL-8 synthesis in an IL-4-independent fashion. In contrast, IL-5 and IL-13 were not constitutively produced by human mast cells in the presence or absence of IL-4. Levels of both IL-5 and IL-13 were increased in mast cell culture supernatants following stimulation with LPS only when IL-4 was added to the mast cell cultures 72 hours prior to LPS stimulation. In addition, IL-4 pretreatment augmented LPS induced release of PGD2. In contrast to incubation with IL-4, incubation of mast cells with IL-13 for 72 hours failed to result in significant LPS-induced IL-5 synthesis. mRNA expression of GATA-1, -2, and -3 was unaffected by IL-4 incubation. Pharmacological inhibition of p38, but not AKT and ERK, during either IL-4 or LPS incubation resulted in significant inhibition of LPS-induced IL-13 synthesis.
Conclusions: The Th2 cytokine IL-4 renders mast cells capable of synthesizing IL-5, IL-13, and PGD2 in response to LPS. In contrast to T cells, the mechanism for this effect does not appear to occur through IL-4 induced changes in GATA expression, but possibly through the enhancement of GATA activation by IL-4. These findings support the hypothesis that LPS-induced mast cell activation may contribute to LPS-induced exacerbation of asthma.

Assessing EZH2 inhibitors for the treatment of Non-Hodgkin’s lymphoma

Dean Nehama, George P. Souroullas, Norman E. Sharpless

Dept of Genetics, Lineberger Comprehensive Cancer Center

Non-Hodgkin’s lymphoma is the 7th most common cancer, with the majority of adult cases being either germinal center B cell-like diffuse large B-cell lymphoma (GCB DLBCL) or follicular lymphoma (FL). These two specific lymphoma types have a 22% and 7% incidence, respectively, of a neomorphic mutation at Y641 in EZH2, a methyltransferase. This mutation leads to hypersuppression of the tumor suppressor genes p16INK4A and p14ARF and likely contributes to disease progression. This project aims to develop an assay to assess the efficacy and potency of drugs in inhibiting lymphoma cell proliferation through EZH2 inhibition. Two drugs were tested: UNC1215 (known to bind to a methylated lysine-binding protein) and UNC1999 (known to bind EZH2). Different lymphoma cell lines (Karpas 422, RL, OCI-Ly1), of which only RL lacks the Y641 EZH2 mutation, were treated with each of the two drugs. Cell viability was assessed through cell count while p16INK4A and p14ARF gene expression levels were determined by qPCR. The experiment indicated that UNC1215, in fact, promotes lymphoma cell proliferation in all three cell lines. However, UNC1999 showed the opposite effect on all the cell lines, implying that its anti-proliferative effects are independent of the presence of the neomorphic Y641 mutation. P16INK4A and p14ARF gene expression studies on UNC1999-treated Karpas 422 did not indicate any significant differences in expression levels; other cell lines have not been tested yet. The mechanism of action of either drug is not clear yet, but UNC1999’s effects are likely not p16INK4A or p19ARF-dependent. So far, this assay ruled out only UNC1215 as a potential drug for non-Hodgkin’s lymphoma.

Lipopolysaccharide Potentiates Pulmonary Graft-Versus-Host Disease In Murine Bone Marrow Transplantation Across Minor Histocompatibility Antigen Mismatch

J.L. Nugent, T. Martinu, K.M. Gowdy, C.V. Kinnier, H.L. Zhang, F.L. Kelly, W.M. Foster, S.M. Palmer

Pulmonary Division, Duke University Medical Center

Pulmonary graft-versus-host disease (p-GVHD) is a major limitation to successful long-term outcomes after bone marrow transplantation (BMT). The lung is constantly exposed to environmental stimuli, which activates innate immune responses. Therefore, we developed the overall hypothesis that local innate immunity potentiates the development of p-GVHD. Because GVHD develops in human BMT recipients with minor histocompatibility antigen (MiHAg) mismatches, we sought to determine the effects of lipopolysaccharide (LPS) on p-GVHD across four murine MiHAg-mismatched BMTs. Furthermore, chronic transplant-related fibrosis has been replicated with murine models across MiHAg mismatch, so we sought to determine if chronic p-GVHD develops in this setting.

Recipient male C57BL/6J-H2b mice were irradiated and reconstituted with bone marrow and splenocytes from male bm12, C57BL/10J, BALB/b, and female C57BL/6J mice. Male C3HeB/FeJ-H2k and C57BL/6J mice were donors for major mismatch and syngeneic controls, respectively. Mice were exposed to aerosolized LPS (5 or 10 days, 2.5 hours/day) and necropsied 72 hours after the last exposure. P-GVHD was assessed by histopathological lymphocytic inflammation as well as bronchoalveolar lavage (BAL) cellularity and cytokines.

P-GVHD was significantly increased in LPS-exposed mice with MiHAg mismatch compared to non-LPS-exposed and syngeneic controls; the extent of GVHD in MiHAg mismatch mice was comparable to major mismatch mice. We observed increased lung injury in LPS-exposed MiHAg mice as quantified by levels of lactate dehydrogenase and increased inflammatory cytokines KC and RANTES in the BAL. Total cellularity and CD4+ and CD8+ T cell numbers were increased in the BAL of LPS-exposed MiHAg mismatch mice. Despite these changes, there was no histopathological evidence of chronic p-GVHD.

Innate immune activation by inhaled LPS in the setting of MiHAg mismatch is sufficient to promote the development of p-GVHD. Since pulmonary LPS exposures occur clinically, our results represent a potentially important pathway by which lung disease could develop after BMT.

Effects of Enteric Bacterial Proteases on the Permeability of Intestinal Epithelial Cells

Carroll, Ian; Patel, Siten

School of Medicine, Dept. of Microbiology and Immunology

Inflammatory bowel diseases (IBD) classified as Crohn’s disease and ulcerative colitis are highly prevalent in the United States affecting 1.4 million individuals. These diseases are associated with reduced quality of life and considerable direct and indirect medical costs. As compositional changes in the gut microbiota and increased intestinal permeability are associated with IBD, enteric bacterial proteases capable of inducing intestinal permeability via protease-activated receptors (PARs) present a novel therapeutic target for IBD. The goal of this experiment is to elucidate the specific mechanisms by which enteric bacteria induce intestinal permeability. To address this goal we proposed two specific aims. In specific aim 1 we will determine the ability of protease-producing strains to regulate permeability in human epithelial cells. In specific aim 2 we will determine the ability of protease-producing bacterial strains to activate PARs and induce permeability in human epithelial cells. To achieve these aims we used wild-type and mutant Enterococcus faecalis strains that lack gelatinase or serine protease activity. We exposed the tight-junction forming SK-CO-1 and Caco-2 epithelial cell monolayers to parental and mutant E. faecalis strains and measured cell permeability. The results of our experiments showed that wild type E. faecalis significantly induced permeability in Caco-2 cell monolayers. A reduction in E. faecalis-mediated permeability was observed in gelE and sprE mutant strains, suggesting that these proteases contribute significantly to E. faecalis-mediated permeability of cell monolayers. Additionally, the reduction in E. faecalis-mediated permeability of cell monolayers was significantly greater in the sprE mutant strain when compared to the gelE mutant strain. Further, siRNA silencing of PAR gene expression in SK-CO-1 cells provided a strong indication that E. faecalis-mediated permeability of cell monolayers was facilitated via the PAR 1 receptor. Ultimately, this and future studies will help define a precise mechanism by which enteric bacteria alter intestinal permeability and contribute to inflammation.

Contributions of Turgor Pressure, the Contractile Ring, and Septum Assembly to Forces in Cytokinesis in Fission Yeast

Stephen A. Proctor, Nicolas Minc, Arezki Boudaoud, Fred Chang

Microbiology and Immunology Department, Columbia College of P&S

A paradigm of cytokinesis in animal cells is that the actomysosin contractile ring provides the primary force to divide the cell. In the fission yeast Schizosaccharomyces pombe, cytokinesis also involves a conserved cytokinetic ring. However, in contrast to animal cells, cytokinesis in yeast cells also requires the assembly of a cell wall septum, which grows centripetally inward as the ring closes. Fission yeast, like other walled cells, also possess high (MPa) turgor pressure. Here, we show that turgor pressure is an important factor in the mechanics of cytokinesis. Decreasing effective turgor pressure leads to an increase in cleavage rate, suggesting that the inward force generated by the division apparatus opposes turgor pressure. The contractile ring, which is predicted to provide only a tiny fraction of the mechanical stress required to overcome turgor, is largely dispensable for ingression; once septation has started, cleavage can continue in the absence of the contractile ring. Scaling arguments and modeling suggest that the large forces for cytokinesis are not produced by the contractile ring but are driven by the assembly of cell wall polymers in the growing septum.

Understanding the Role of Intestinal Sub-Epithelial Myofibroblasts in Eliciting Small Intestinal Crypt Budding

Denny Scaria and Dr. Susan J. Henning

Gastroenterology / Cell Biology & Physiology

Following damage to the intestinal epithelial lining, during the regenerative phase, an increase in the number of stem cells is observed along with the formation of more crypts by the process of crypt fission. This summer, I investigated whether subepithelial myofibroblasts from Doxorubicin damaged small intestines could initiate budding in crypts in vitro reminiscent of crypt fission in vivo. Crypts isolated from the proximal jejunum were cultured with exogenous growth factors. Myofibroblasts were isolated from proximal jejunum on day 5 post Doxorubicin treatment and co-cultured with crypts. I was able to replicate crypt budding in vitro, but the enteroid formation efficiency was lower than expected. Upon culturing crypts plated at two different densities, the crypts plated at a lower density had higher enteroid formation efficiency. Crypts co-cultured with myofibroblasts isolated from Dox treated mice were unable to initiate budding unless exogenous growth factors were supplemented. When supplemented, the crypts formed balloon like structures which progressed into cyst like structures that were morphologically different from enteroids. Crypt progression in vitro at various densities has not been replicated due to time constraints, but it presents the interesting possibility of density playing a role in the behavior of crypts in vitro. Although it appears as though myofibroblasts from Doxorubicin treated mice cannot initiate budding in vitro it is worthwhile to further investigate the balloon and cyst like structures seen when crypts are co-cultured in the presence of exogenous growth factors with myofibroblasts isolated from Doxorubicin treated mice.

Biomechanical effects of steroid injections used to treat pyogenic flexor tenosynovitis

Blake R Turvey, Paul S Weinhold, Reid W Draeger, Donald K Bynum, Laurence E Dahners

Department of Orthopaedics

A recent study from our laboratory demonstrated an improved range of motion in the toes of broiler chickens afflicted with pyogenic flexor tenosynovitis when treated with local antibiotic and corticosteroid injections, without receiving surgical drainage. However, the use of corticosteroids as an adjunct treatment raised peer concern, as steroids are thought to have deleterious effects on tendon strength. The purpose of this study was to compare the tensile strength of the aforementioned steroid treated tendons, to a group of tendons which received systemic antibiotics, surgical drainage and no corticosteroids — the current standard treatment.

Twenty-three tendons’ structural and material tensile properties were investigated (fifteen receiving the standard treatment, eight receiving the steroid treatment). The tendon sheath of the flexor profundus in the third toe was locally injected with 0.3 mL of gentamicin-sensitive Staphylococcus aureus. Treatment for both groups began twenty-four hours post-inoculation. 5mg/kg of gentamicin was administered as the antibiotic. Surgical drainage was administered to those tendons in the standard treatment group. 0.06 mg/kg of the steroid, dexamethasone, was administered into the tendon sheath of those tendons receiving the experimental steroidal treatment.

The chickens were then monitored for a twenty-eight day recovery period. Once sacrificed, the tendons were dissected and preserved via freezing. Tendons were later thawed and tensile tested, and the data was interpreted via Student’s unpaired t-test and a post-hoc power analysis.

The steroid treated tendons did demonstrate a trend toward decreased mechanical properties (7-15%), when compared to those tendons treated with the current standard regimen, but these results did not prove to be statistically significant.

Treatment of septic tenosynovitis with local corticosteroid and local antibiotic injections resulted in better digital motion, without a significant loss of tendon strength, compared to those treated with the current standard treatment, over a twenty-eight day recovery period.

Rituximab Sensitivity in B-Cell Lymphoma

Sam Wu, Bill Small, Kristy Richards

Department of Genetics

The anti-CD20 antibody rituximab has become an important agent in the treatment of B-cell lymphomas. As such, there is significant interest in elucidating the mechanisms by which lymphomas acquire resistance to rituximab. Centre d’Etude du Polymorphism Humain (CEPH) lymphoblastoid cell lines (LCLs) were grown in rituximab-containing media and their sensitivity to rituximab were compared to their gene expression profiles to determine 13 candidate genes whose expression levels were all negatively correlated with rituximab sensitivity. Three genes (SAMSN1, CXCL12,ABAT) were selected for knockdown experiments in this study to determine if there is in fact a causative relationship between the expression of these genes and rituximab sensitivity. Preliminary results were inconclusive, as most of the cell lines did not exhibit noticeable changes in cell viability (as measured by alamarBlue assay) in rituximab-containing media over rituximab-free media after knockdown of any of the three genes. However, pretreatment of an ABAT knockdown cell lines with GABA-receptor agonist baclofen dramatically reversed its behavior in the previous experiment from one of slight increase in rituximab sensitivity to one of significant increase in rituximab resistance. Given the known role of ABAT in GABA metabolism, these results suggest the possibility of a previously unknown role of neurotransmitters in immunological signaling.

Evaluating the Dose Distribution of Carbon Nanotube Microbeam Radiation Therapy of Normal Mice Brains

Fan Ye, Yueh Z. Lee, Otto Zhou

Department of Radiology

Purpose: Glioblastoma multiforme (GBM) is an aggressive brain tumor usually causing death within 12 to 15 months even with treatment. Microbeam radiation treatment (MRT) is a pre-clinical radiosurgical treatment for brain tumors that uses irradiation with highly collimated x-ray beams arranged in thin parallel arrays. This preliminary study utilizes a novel carbon nanotube (CNT) microbeam radiation system to compare the dose distributions measured physically with dosimetry film to dose distributions measured biologically with histology in normal mice.

Methods: 9 healthy mice split into two groups: single and dual beam treatment, were irradiated with 500-650 micrometer wide microbeams of 100 Gy and 50 Gy respectively with the CNT MRT system. Entrance and exit dosages were measured with Gafchromic EBT2 films. Mice brains were sacrificed histologically at 1 hour, 7 days, and 9 days post-irradiation and stained with DAPI (cell nuclei marker) and p-H2AX (DNA damage marker). Film and histology data were analyzed using custom MATLAB code.

Results: p-H2AX markers appear at 1 hour and 7 days post-irradiation, but not at 9 days. Average microbeam widths measured by entrance film, histological scans, and exit film, were similar between single (560.807 um, 434.575 um, 668.894 um) and dual beam (518.100 um, 448.490 um, 625.905 um) treatments. Peak-to-valley dose ratio for dual beam is 4.32 for entrance film, and 4.09 for exit film.

Conclusion: This study successfully demonstrated that there is a quantifiable relationship in microbeam width between entrance film dose, biological dose, and exit film dose. Histology microbeam widths were less than entrance film microbeam widths showing a minimal dosage at which DNA damage occurs. Exit film microbeam widths were greater than entrance film microbeam widths due to beam divergence. This study also shows that DNA damage occurs in the microbeam path, and normal brain tissue self-repairs. Presence of valley dose suggests spread of radiation.

Clinical Sciences/Public Health Poster Presentations

Providers’ attitudes toward discussing contraception and fertility intentions with HIV-infected women and serodiscordant couples in the U.S.

Lisa Rahangdale, MD, MPH, Amy Richardson, MS, Rachel Adams, BS, Catherine Grodensky, MPH

Obstertrics and Gynecology

Background: Research demonstrating benefit from Pre-Exposure Prophylaxis (PreP) to protect sexual partners of HIV-infected individuals and perinatal administration of antiretrovirals to prevent mother-to-child HIV transmission suggest that pregnancy is a potentially safe and reasonable option for couples with at least one HIV-infected adult. The purpose of this study was to assess knowledge and behaviors of HIV providers regarding family planning options for HIV-infected women and serodiscordant couples.

Methods: We conducted a cross-sectional self-administered survey of health professionals (physicians, nurse practitioners, physician assistants) who provide HIV services to women attending a national HIV continuing education course. To test for significant associations between various responses on the survey, Fisher’s exact test was used; p< 0.05 was statistically significant.

Results: Of 77 providers completing the survey, 47 met inclusion criteria. Fifty-eight percent were physicians; 29% were nurse practitioners; 17% were physician assistants. When presented with techniques to decrease HIV transmission risk among serodiscordant couples attempting pregnancy, most participants reported awareness of sperm-washing (84%) and the following strategies for minimizing risk of transmission during sexual intercourse: maximally suppressed HIV viral load using antiretroviral therapy (95%), STD screening and treatment (84%), and PrEP (84%). Other options included management of chronic medical conditions (73%), use of assisted reproductive technology for conception (63%), timed intercourse (54%), post-exposure prophlyaxis (51%), home intrauterine insemination or “turkey baster” method (47%) and fertility evaluation (35%). 89% of providers said that they “think that it is safe for an HIV+ woman’s health to have a baby.” However, only 57% reported that they always or usually discuss contraception or fertility intentions with their HIV+ female patients. Discussion of these issues was not associated with provider gender, age, experience in caring for HIV-infected patients, previous training in women’s health or provider’s awareness of options listed above.

Conclusion: In this study, HIV providers were knowledgeable of practices that can lead to safer pregnancy conception and prevent HIV transmission among individuals in serodiscordant relationships but did not always convey this information to their patients. Further research is needed to explore optimal methods for encouraging these conversations and evaluate patient understanding of options for safe pregnancy.

Thermodilution and Fick cardiac outputs differ: Impact on pulmonary hypertension evaluation

Wassim H Fares MD, Sarah k Blanchard BS, George A Stouffer MD, Patricia P Chang MD, Wayne D Rosamond MD, Hubert James Ford MD, Robert M Aris MD

Department of Medicine

This study aims to describe the relationship between the Thermodilution (TD) and the indirect Fick methods for determining cardiac output, highlighting potential clinical implications. We retrospectively reviewed the charts of adult patients who had a right heart catheterization(RHC) between 2007 and 2010 and were seen in the Pulmonary Hypertension program of the Pulmonary Division at an academic institution. For validation, we reviewed the charts of patients who had a RHC during the same time period within the Cardiology Division. We included 198 patients that had 213 RHCs done, 79 (40%) of which had pulmonary arterial hypertension. Forty-three percent of patients had > 20% difference between TD and Fick. The average difference (TD–Fick)(+SD) was -0.39+2.03 liters/minute (N=213;p=0.006). In a multi-variable analysis, the TD – Fick difference was greater in older patients (p=0.001). The presence of such discrepancy of at least 20% between TD and Fick in about 36% of patients evaluated for heart failure and/or heart transplant validated our results. After pooling together, RHCs done by pulmonologists (N=213) and those done by cardiologists (N=1,102), 37% of the 1,315 procedures had a difference of 20% or more between TD and Fick. Significant discrepancy exists between TD and the indirect Fick cardiac output methods.

Disease Activity, Health-Related Quality of Life, and Transition/Self-Management in Adolescents with Systemic Lupus Erythematosus

Edward Iglesia, Nicole Fenton, Kristi Bickford, Leonard Stein, Keisha Gibson, Maria Ferris

UNC Kidney Center

Background: SLE has a >95% five-year survival rate among adolescents. Several factors such as disease activity, health-related quality of life (HRQoL), and mood may interact and contribute to successful transition into adult-focused care. We examined the relationships among disease activity, HRQoL, mood, and transition/self-management in adolescents with SLE.

Methods: Youth ages 12-25 years with SLE completed the UNC TRxANSITION Scale™ (health-provider administered, 32 questions) to assess transition/self-management skills, and the PedsQL to assess HRQOL. Disease activity was measured using the SELENA SLEDAI Scale. Relationships were determined using Pearson’s correlation, and comparative analyses were performed between lupus patients with and without nephritis. Significance levels were set at p<.10.

Results: Of 25 patients, 64% were female, 52% were African American, and the mean age at assessment was 16.8±3.1 years old. Mean age at diagnosis was 13.2±3.7 years. Disease activity did not significantly correlate with total UNC TRxANSITION Scale™ scores, but did correlate with domains of Nutrition knowledge (r=.43, p=0.03) and Ongoing support (r=.36, p=0.08). Disease activity was not associated with physical, emotional, social, or cognitive QOL, and was not associated with mood. Patients with SLE nephritis (N=20) had more knowledge about reproductive issues (mean 0.63 vs. 0.25, p=.056) and better mood (mean 4.1 vs. 2.6, p=.09) than those without SLE nephritis.

Conclusions: In this ongoing study, there seems to be a trend that patients with greater disease activity have more skills managing their own disease, particularly regarding nutrition and future disease self-management. Further, patients with SLE nephritis have more knowledge about reproductive issues and report better moods than lupus patients without nephritis.

A descriptive study of the prevalence of virologic failure among patients receiving viral load testing at Lighthouse HIV clinic, Lilongwe, Malawi

William Garneau, Alexandra Werner, Sam Phiri, Debbie Kamwendo, Mina Hosseinipour

UNC School of Medicine – Infectious Disease Department

Background/study objectives
Anti-retroviral therapy (ART) for HIV/AIDS in highly-affected countries like Malawi has decreased mortality however effective and tolerable long-term therapy represents a public health challenge.

Standard of care in Malawi is triple therapy of stavudine (D4t), lamivudine (3tc), and nevirapine (NVP). Lipodystrophy is a side effect of this regimen. According to 2011 guidelines, patients with lipodystrophy will be switched from D4t to tenofovir (TDF). However, a switch to TDF can result in TDF resistance if the patient has virologic failure.

We assessed the prevalence of virologic failure in patients receiving D4t/3tc/NVP. Previous epidemiologic studies indicate a failure rate of 9% for patients on treatment at 12 months and up to 50% for patients with clinical failure after 12 months.

We collected treatment information from the electronic medical record at Lighthouse HIV clinic for patients who received viral load testing from May 1 – June 30, 2012. Indication for testing was collected from viral load order forms (immune failure, clinical failure, lipodystrophy/toxicity, treatment interruption, or other). We defined treatment failure as viral load >400 copies/mL and calculated descriptive statistics.

206 patients (mean age 41.4 years, 57% female) received viral load testing. Overall, 35/206 (17%) had viral load >400 copies/mL. The rate of virologic failure was 20% (13/65) in patients with clinical failure and 9% (9/100) in patients with lipodystrophy. Mean duration of ART treatment was similar for patients not failing treatment (59.1 months) to those failing treatment (58.1 months).

The prevalence of virologic failure was less than previous estimates for patients with clinical failure (20% vs. 50%). The rate for patients with lipodystrophy was similar to previous estimates for patients alive on treatment at 12 months (9%). The empiric switch for patients with lipodystrophy to TDF proposed by 2011 guidelines will only increase resistance to a modest extent.

The Clinical Behavior of CIN 2 and p16 Immunohistochemistry

Brooke Rambally, MD, Alison Halpern, Daniel Duncan, MD, Megan DiFurio, MD

Department of Pathology

Background: The Lower Anogenital Squamous Terminology Standardization Project for HPV-associated Lesions was recently published to provide a uniform terminology system. CIN 2 and 3 are grouped together into HSIL and it is recommended to use the p16 immunohistochemistry (IHC) as a biomarker to confirm a histologically indeterminate lesion as HSIL. Given the low risk of CIN 2+ lesions progressing to carcinoma, especially in young women (21-25 years), qualifying the SIL terminology with the CIN terminology is recommended. This conservative approach is reflected in the current ASCCP management guidelines, although identifying which patients will resolve without therapy has proved difficult. The objective of this study is to evaluate the use of immunohistochemical biomarkers (i.e. p16 and HPV L1 capsid protein) as prognostic indicators for CIN 2; these results are preliminary.

Design: Women, >21 years and HIV negative, at UNC Hospitals with cervical biopsies performed during 2005-2009 showing CIN 2 were identified. Subsequent cervical tissue samples within 2 years were reviewed to determine regression ( CIN1), persistence (CIN2) or progression (CIN3+). P16 IHC was performed on the index biopsies from 2009 and correlated with subsequent specimens. A positive p16 was defined as strong diffuse staining involving at least the lower one half of the epithelium.

Results: Of 243 evaluable women, the median age was 28. 150 (62%) women were found to regress, 53 (22%) were found to persist and 40 (16%) were found to progress. Staining for p16 on 51 index cervical biopsies from 2009 showed positive staining in 44 (86%) and negative staining in 7 (14%). No significant association between p16 positivity and subsequent behavior was identified (Table 1).
Behavior and p16 IHC
Regress (%) Persist (%) Progress (%) Total (%)
p16 + 30 (68) 8 (18) 6 (14) 44 (100)
p16 – 5 (71) 0 2 (29) 7 (100)

Conclusion: Deciding which patients with CIN 2 can be safely followed without invasive therapy is a challenge. We determined that a minority (16%) of CIN 2 diagnoses progress. Identifying biomarkers to predict CIN 2 progression will significantly decrease healthcare cost by preventing unnecessary treatment. Although we found no correlation between p16 staining and progression in this preliminary stage, the addition of markers such as HPV L1 capsid protein may allow for more predictive prognostic information.

Cardiac Transplant Simulation: Implanting a Donor Heart

Samuel Heathcote, Hadley Wilson, Rebekah MacFie, Dr. Richard Feins, MD

Department of Surgery

The heart transplant waiting list is estimated to be 100,000 people, yet only 2,200 heart transplants are performed every year.7,8 While this is clearly a problem for the patients, it is also a problem for the residents, fellows, and attending surgeons that are trying to either learn or teach the procedures. To help augment this lack of procedures, we hypothesized that it would be possible to simulate cardiac transplantation with a high degree of perceived realism, and the eventual hope would be to use the simulator for training purposes. Using a combination of materials found at the local hardware store, such as silicone caulk and plastic tubing, as well as materials found in the operating room, we were able to produce a synthetic pericardium that had both ports and vessel cuffs representing the venae cavae, pulmonary artery, pulmonary veins, and the aorta. To produce realistic organs and vessel cuffs, we obtained and modified porcine organs. Using the synthetic pericardium and the modified porcine organs, we effectively simulated implantation of a donor heart. The first ever simulated cardiac transplantation was performed on our model by an attending cardiothoracic surgeon at the University of North Carolina. This initial model was also evaluated at the National Thoracic Surgical Director Association boot camp by attending cardiothoracic surgeons from all over the country. After compiling the date, our model was rated to have an above average degree of perceived realism and is believed to offer considerable opportunities in the future.

Psoriasis: Age and Severity

Jaclyn Hess and Dr. Aida Lugo-Somolinos

Department of Dermatology

Incidence of severe outcomes in psoriasis is hard to predict and this study has aimed to determine if there are differing outcomes in older patients, over 60 years of age, compared to their more prevalent younger counterparts. The prevalence of those over the age of 60 with psoriasis is expected to increase in years to come so a better understanding of disease progression is needed. A total of 134 patients completed the anonymous survey, 41 (30.6%) of which were over the age of 60. The mean age was 49.6 years old with 61% females and 39% males. Various factors were assessed such age of onset, past medications, specifically systemic treatments, current treatments, and demographics. We found that patients over 60 were less likely to be on current systemic treatment, which we categorized as severe psoriasis. The use of systemic treatments was 47.3% of those under 60 and only 40.5% over 60 were severe. However, this study could not demonstrate statistical significance in the difference at this time. Older patients were more likely to not be on any medication than their younger counterparts. The family history and location of primary outbreak in conjunction with age of onset was found to differ from previous research, with a higher association of head/scalp and arm involvement in the younger onset group and increased leg involvement in the older onset. This study found a positive family history was relatively the same for all groups of onset less than 50 and then decreased in each decade thereafter. This information is relevant to doctors as they try to assess disease progression and indicates the need for more extensive research.

The effect of hypogonadism on PSA, erectile function, and surgical pathology in patients with prostate cancer

Austin Hester, David Johnson, Will Kirby, Jed Ferguson, Matthew Nielsen, Michael Woods, Eric Wallen, Raj Pruthi, Culley Carson, Mathew C. Raynor

Department of Urology

INTRODUCTION: Previous studies have shown a correlation between serum testosterone and PSA levels. We sought to examine the effect of baseline testosterone levels with preoperative PSA and erectile function, as well as surgical pathology in a group of men undergoing surgical treatment of prostate cancer.

METHODS: After obtaining Institutional Review Board approval, a single institution retrospective cohort study was performed examining men undergoing surgical intervention for prostate cancer between 2009 and 2011. All patients underwent preoperative measurement of serum PSA and total testosterone. Erectile function was evaluated using a validated questionnaire (Sexual Health Inventory for Men). Patients were then stratified according to preoperative total testosterone level. Hypogonadal patients were defined as men having a serum testosterone level less than 200 ng/dL. Preoperative PSA, baseline erectile function, and pathologic outcomes were compared between hypogonadal and eugonadal patients.

RESULTS: A total of 135 men were included in the study. Of these men, 22 were considered hypogonadal with a total testosterone of less than 200 ng/dL. Hypogonadal patients had a significantly lower preoperative PSA than patients with normal testosterone levels (p=0.007). Preoperative erectile function did not differ significantly (p=0.34). Margin status and D’Amico risk classification did not differ between the groups. There was a trend toward increased risk of extracapsular extension in hypogonadal patients, however, this did not achieve statistical significance (p=0.08). When the two groups were changed to redefine hypogonadism as a testosterone of less than 300 ng/dL, no differences were noted in pathologic outcomes or preoperative PSA (p=0.14).

CONCLUSIONS: In the present study, hypogonadism was associated with a lower preoperative PSA but no significant differences were found in baseline erectile function or pathologic outcomes.

MRSA Infections of Synthetic Mesh after Open Ventral Hernia Repair: A review of 56 cases

C Hlavacek BE, T Bradley MD, V Tsirline MD, K Williams MD, B Wormer MD, T Heniford MD

Division of Gastrointestinal and Minimally Invasive Surgery at CMC


Synthetic mesh infection (MI) is a dreaded complication after ventral hernia repair and is a cause of major morbidity. MRSA infections in healthcare have been a major public health problem for over a decade. We aim to examine outcomes of MI with MRSA.

Management and outcomes of all MRSA synthetic MI from 2000-2012 were reviewed. Intestinal fistulas were excluded. Demographics, patient history, mesh specifics, and treatments were reviewed. Descriptive statistics are reported as mean with standard deviation (continuous variable) and percentages (categorical variable).

There were 56 consecutive MRSA MI during the study period. Patient information included: age- 53.1±11.3 years, 57% female, BMI- 36.9±7.5 kg/m2, number of comorbidities- 4.5±2.3, smoker- 28%, mean prior abdominal operations- 5.5 (2-18), and hernia repairs- 2.8(1-17). Mean follow up was 35.6±23.8 months. All had attempted non-excisional therapy initially (antibiotics, wound care, and/or drain placement). Only 3 (5%) patients had successful non-excisional therapy; all were non-smokers and had a lightweight, large pore, polypropylene mesh. Partial mesh excision was attempted in 3 patients, but all 3 eventually required complete mesh excision for persistent infection. Of the 53 that underwent mesh excision, 24 (45%) were closed primarily and 9 patients have undergone definitive repair since primary closure. Of those repaired with mesh, 26 (49%) were with biologic mesh, and 3 (6%) were with synthetic. Two of the synthetic repairs were early in the study and were repaired with heavyweight polypropylene and were eventually excised for recurrent MI. The third, and most recent, was repaired with a lightweight, large pore, polypropylene mesh and has not had a recurrence of MI at 14 months of follow up.

MRSA synthetic MI after ventral hernia repair cause significant morbidity. Non-excisional therapy of MRSA infections carries a very low success rate and should only be attempted in lightweight, large pore, polypropylene mesh in non-smokers. Prevention of MRSA infections is a far better investment of resources rather than treatment.

Learning the Basics of Ophthalmology through Self-Portraits of Art Masters

Richard Davis, MD; Kyle Huynh; Joseph Grubbs

Department of Opthalmology

Introduction: Many medical students have a deficit of knowledge in ophthalmology upon graduating from medical school. Little is known about the benefits of incorporating art into medical education. There is a growing body of literature suggesting that learning of science may be complemented by integrating a standard curriculum with the arts. Therefore, our study aims to compare the effectiveness of a new art-based ophthalmology lecture and a standard ophthalmology lecture.
Methods: First and second-year medical students were recruited via email and in-class announcements to enroll in a supplemental course entitled, “A New Perspective: Learning the Basics of Ophthalmology.” The students were randomized to two groups. The intervention group (21 students) received an hour long lecture covering the basics of ophthalmology, where self-portraits of the Masters were used to highlight major ocular pathology as demonstrated in their self-portraits to guide discussion and teaching points. The control group (17 students) received the same lecture but without the self-portraits or any discussion of art. Subjects completed a pre- and post-course 50-question examination to evaluate whether the integration of art into the lectures facilitated the learning of basic ophthalmology concepts.
Results: The pre- and post-course examinations are currently being graded, and results will be presented at Student Research Day.
Discussion: Our study has the potential to evaluate the effectiveness of incorporating art into medical student lectures as a means to improve student comprehension and retention of lecture materials.

Implementation of statewide triage protocols in North Carolina does not alter rates of trauma center utilization or decrease time to definitive care for trauma patients treated at trauma centers

Christopher E. Jensen; Christopher S. Cowden, MPH; Frances S. Shofer, PhD; Matthew Psioda, MS; Chad Lohmeier, MBA; Jane H. Brice, MD, MPH

Department of Emergency Medicine

Background: Inaccurate field triage for trauma patients has been associated with poor outcomes and increased costs of treatment. In January 2010, the NC Office of EMS required each EMS system in the state to submit a formal Trauma Triage and Destination Plan (TTDP) detailing how the system will make triage and transport decisions for critically injured patients. We hypothesize that the implementation of these standardized decision-making protocols will correlate with reductions in EMS scene time and the time-to-definitive care for trauma patients treated at trauma centers.
Aims: This study seeks to determine if the implementation of the TTDPs correlated with changes in (1) EMS response times and scene times, (2) rates of trauma center utilization, and (3) times to definitive care for trauma patients, both those treated at trauma centers and those treated at other facilities.
Methods: A retrospective before-after analysis was conducted using the time stamp information recorded by EMS personnel during 3/1/2009-9/30/2009 and 3/1/2010-9/30/2010. Records were drawn from North Carolina’s PreMIS database.
Results: There was no significant change in EMS response times, rates of trauma center utilization, or time to definitive care for patients who received care at a trauma center. Scene time for ground EMS units and time to definitive care for patients who received non-trauma-center care increased slightly.
Conclusions: There was little overall change in field triage in North Carolina following the implementation of the TTDPs. Further study is required to determine if this overall trend masks changes in different regions of the state.

Retrospective Fusion of 18F-FDG PET/CT and MRI in Brain Pathology: Towards Hybrid PET/MR Brain Imaging

Brice Kessler, Yueh Lee

UNC Radiology Department

BACKGROUND: The diagnosis and management of brain pathology stands to benefit greatly from current trends towards hybrid imaging modalities, specifically the advent of hybrid PET/MR. While MRI remains the gold standard in brain imaging due to its superb anatomical detail, its ability to assess functional aspects of brain pathology may be limited. PET utilizing the radiotracer 18F-fluorodeoxyglucose (18F-FDG) can provide useful information regarding tissue glucose metabolism, but is significantly limited by its low spatial resolution. As such, hybrid PET/MR utilizing the radiotracer FDG may address the limitations of each modality in brain imaging. As hybrid PET/MR is currently in its infancy, the aim of this study is to retrospectively assess various brain pathology characterized separately by PET/CT and MRI to evaluate potential applications of hybrid brain imaging. METHODS: This qualitative retrospective study reviewed existing diagnostic imaging of UNC patients who have undergone PET/CT and brain MRI within two weeks of each other. The images were then fused using standard clinical software and assessed for areas of agreement and disagreement. RESULTS: The brain pathology identified by concurrent PET/CT and MRI included brain metastases from lung cancer and melanoma, CNS lymphoma, cerebral artery infarcts, and crossed cerebellar diaschisis. Fusion of the images revealed areas of significant benefit in hybrid imaging, specifically in the assessment of the metabolic activity of brain lesions. However, evaluation of brain pathology utilizing the radiotracer 18F-FDG may be limited by the high background metabolic activity of the brain. CONCLUSION: Hybrid PET/MR imaging holds great promise in brain imaging, and further work is needed to better characterize its potential in the diagnosis and management of brain pathology.

Fecal Incontinence: What Determines Which Patients Consult Physicians and Which Physicians Screen?

Lalitha Kunduru, Sung Min Kim, William E Whitehead

Functional GI & Motility Disorders

Though fecal incontinence (FI) affects over 15% of people aged 70 and older, studies suggest only 10-30% of this population discuss FI with their physicians. Also, few clinicians screen for FI. Aims are to discover barriers preventing FI patients from consulting with physicians and physicians from screening for FI. Patients were recruited from 3 clinics after reporting FI on a screening questionnaire. They completed the Fecal Incontinence Severity Index and the Fecal Incontinence Quality of Life Scale. Patients’ experiences with physician consultation and physicians’ views regarding screening were elicited with private open-ended interview questions. Of 76 subjects, 67.1% reported FI to a physician. Overall, FI severity was similar in consulters (24.29±10.80, mean±S.D) and non-consulters (25.76±12.54), p=0.347. Awareness of treatment existence was reported by 68% of non-consulters vs. 88% of consulters, p=0.004. Barriers to consulting reported by non-consulters were: believing FI is not a serious enough condition (64%), personal embarrassment (44%), believing FI is normal with aging (40%), and preference for same gender physician (28%). Non-consulter responses to what would make it easier to talk about FI were: having doctors ask patients directly (88%) and having a strong patient-doctor relationship (20%). Of 9 physicians, 6 usually screen for FI. Belief that FI is rare was reported by 100% of non-screeners vs. 17% of screeners. Among non-screeners, 67% identified insufficient time as a barrier to screening, and 100% ranked other health conditions as more important to screen for. Results suggest knowledge deficits as major barriers to patients consulting for FI and to physicians screening for FI. FI severity was not a significant factor in consulting. Embarrassment was mentioned by 44%, and 28% would be more likely to talk to a doctor of the same sex. Most (88%) would find it easier to discuss FI if their doctor asked them directly about it.

Appendicitis and Obesity in the Southeastern US: Radiologic Imaging, Treatment, and Outcomes in Children and Adolescents

Christine L. Schuler, MD MPH, Amy Marzinski RN, Tiffany L. Scott, MD, Eliana M. Perrin MD MPH, Ayesha Lovick BS, Sean McLean, MD

Pediatric Surgery

Obesity is a prevalent public health problem, particularly in the Southeast, and appendicitis is the most common pediatric surgical emergency. We sought to determine if radiologic imaging, treatment, or outcomes differed in non-obese and obese patients with presumed acute appendicitis.

We reviewed records of 185 patients ages 2 to 18 years who underwent appendectomy for presumed acute appendicitis between 2008 and 2010 at a tertiary care center in the Southeast. We used documented height and weight to calculate body mass index and obesity was determined using standard CDC definitions. We used chi-square and Fisher’s exact tests to determine if imaging, treatment, or outcomes differed between non-obese and obese subjects.

14% of the analytic sample was obese. Most subjects (95% overall) underwent ultrasound (US), CT scan, or both, and receipt of any radiography did not vary by weight status. Obese patients were less likely to undergo US compared to non-obese patients (non-obese 68%, obese 62%) but this difference did not reach statistical significance, p=0.5. Similar proportions of non-obese (43%) and obese (42%) patients underwent CT scan. Overall 88% of patients were determined to have acute appendicitis, and 28% were noted to have perforated appendicitis, as determined by positive pathology report or need for interval (delayed) appendectomy, as occurs after perforation with abscess. We found no statistical difference in the proportions of non-obese (88%) and obese (85%) patients determined to have acute appendicitis or evidence of perforation (non-obese 28%, obese 27%). More obese patients underwent interval appendectomy (12%) than non-obese patients (7%) but this difference did not reach statistical significance, p=0.4. A similar proportion of obese (31%) and non-obese (38%) patients had operative times lasting one hour or more and had open surgery (non-obese 6%, obese 4%).

Unlike other studies, we found no major differences in imaging, treatment, or outcomes between obese and non-obese children. However, the overwhelming majority of children underwent imaging during diagnosis of acute appendicitis, and CT scanning was common in both non-obese and obese children, calling into question imaging practices for this common condition.

What Audiotaping Reveals about Pediatric Anticipatory Guidance Priorities

Julie H. Lucas, Dr. Eliana M. Perrin, MD, MPH

UNC SOM Department of Pediatrics

There is a strong body of evidence showing that anticipatory guidance from pediatricians leads to positive behavioral change for children and their families, especially in the area of injury prevention. Although anticipatory guidance has become a staple of clinical pediatrics, it remains unclear how much time pediatricians actually spend on anticipatory guidance topics.

This study assessed the amount of time devoted to counseling and patient-caregiver conversation regarding the key topics of injury prevention and obesity prevention. It also aimed to determine whether the amount of time spent on different anticipatory guidance topics correlated to topic goals set by the caregivers.

The Greenlight project is an NIH funded cluster randomized trial that aims to assess the efficacy of a low-literacy/low-numeracy intervention designed to promote healthy family lifestyles between the ages of 2 months and 24 months, to prevent obesity at 24 months. The study takes place in 4 pediatric residency clinics nationally, two of which were studied here. Vanderbilt is one of 2 intervention sites, and UNC is one of 2 attention control sites, in which residents receive an injury prevention education program and counseling tools (TIPPs). Digital recorded audiotapes of well-child clinical encounters at 12, 15, 18, and 24 months at these 2 university clinics were obtained, transcribed verbatim, and quantitatively and qualitatively analyzed. Parent-reported goals to change obesity-related and injury-related behaviors were also analyzed.

Results & Conclusions
UNC residents spent more time providing anticipatory guidance on injury prevention, while Vanderbilt residents spent more time providing anticipatory guidance on nutrition. Discussion on injury prevention may increase parental goals to change injury-related behavior.

Performance of WHO clinical criteria for diagnosing symptomatic HIV Infection (Presumptive Diagnosis) in Malawian infants when used by Clinical Officers

Rebekah Macfie, Eric D. McCollum, Geoffrey A. Preidis, Mada Maliwichi, Nora Rosenberg, Dan Olson, L. Madeline McCrary, Peter N. Kazembe, Irving Hoffman, Charles van der Horst, Mina Hosseinipour

Department of Pediatrics Division of Pulmonology Johns Hopkins School of Medicine

Objective: To assess the performance of WHO clinical algorithms for the presumptive diagnosis (PD) of HIV infection in HIV-antibody positive infants when used by local Malawian clinical officers we compared the diagnostic sensitivity and specificity of the algorithm when used by by pediatricians and clinical officers to molecular DNA or RNA PCR testing.
Methods: 167 HIV-antibody positive infants <12 months old were evaluated by both a clinical officer and a pediatrician at admission to an urban Malawian government hospital. Both groups used the WHO clinical algorithm to assign a presumptive diagnosis of HIV-positive or negative to the infant. Patients also received DNA or RNA PCR test for HIV.
Results: Using PCR as the gold standard the clinical algorithm applied by clinical officers had a sensitivity of 70.5% (95% CI 57.4-81.5) and a specificity of 49% (95% CI 39.2-59.0)
In contrast, using PCR as the gold standard the clinical algorithm applied by the pediatricians had a sensitivity of 57.5% (95% CI 46.4-68.0) and a specificity of 63.3 (95% CI 55.1-71.0). Agreement between clinical officers and pediatricians was measured by the kappa statistic, kappa=0.35. Pediatricians had an overall accuracy percentage of 61%, while clinical officers had an overall accuracy percentage of 57%.
Conclusions: While clinical algorithims for presumptive diagnosis of HIV in infants have been validated they have not been previously been studied in local healthcare providers, such as Malawian clinical officers. In our study the higher degree of sensitivity and lower specificity in the clinical officers’ PD may suggest that the clinical officers do not adhere as strictly to the WHO algorithm. Furthermore, the low kappa value reflects a low level of agreement between the clinical officer and pediatrician, suggesting that a more uniform approach to PD is needed.

Assessing the Impact of D2 Dopamine Agonist Drugs and Tumor Fibrosis on Endoscopic Endonasal Transphenoidal Pituitary Surgery: A Retrospective Case Series

Jonathan Manhard, Deanna Sasaki-Adams

UNC Department of Neurosurgery

The endoscopic endonasal transphenoidal approach to tumors located in the sella turcica provides excellent access to neoplasms near the pituitary gland while remaining minimally invasive. When appropriate, the tumors are first treated medically using D2 dopamine agonists such as Cabergoline and Bromocriptine to suppress hormonal production and lessen mass effect on local structures. Treatment with one such drug, Bromocriptine, has been shown to induce the development of fibrotic tissue in prolactinomas, whereas Cabergoline has not. Although surgeons report that fibrotic tumors are more difficult to resect, it is uncertain how this relates to complications and outcomes. This study retrospectively reviewed the records of 75 cases performed at UNC hospital from August 2007 to March 2012, assessing outcomes and complications by markers including blood loss, CSF leak occurrence, and recurrence rates. The majority of patients undergoing this procedure had nonfunctional pituitary macroadenomas (36%), followed by functional macroadenomas of uncertain pathology (15%) and growth hormone secreting macroadenomas (13%). Almost all patients had tumors larger than 1 cm (87%), often compressing surrounding tissue. 22 surgeries were performed on 20 patients that had been previously treated with D2 dopamine agonists, and were consequently more likely to require multiple procedures. Patients that were not treated with D2 dopamine agonists were more likely to have higher estimated blood loss and/or CSF leak during surgery. Tumors described as ‘fibrous’ in operative notes showed a 32% increase in average estimated blood loss, and were twice as likely to experience intraoperative spinal fluid leaks.

Handheld Spectral Domain Optical Coherence Tomography as a Tool to Assess Retinopathy of Prematurity Zone and Stage in Premature Infants

Ronald W. Milam and Michelle T. Cabrera MD

Department of Ophthalmology

Retinopathy of prematurity (ROP) is the second highest cause of childhood blindness in the United States. More objective diagnosis of ROP zone and stage is needed to help determine need for treatment as well as treatment response. This study explores an application for the Envisu-R2300-II (Bioptigen, Inc, Morrisville, NC) handheld spectral domain optical coherence tomography (SDOCT) in diagnosing zone and stage of ROP.

Nine premature infants receiving routine ROP screening in the North Carolina Children’s Hospital Neonatal Critical Care Center underwent imaging with the Envisu-R2300-II. Attempts were made to image the border of zone 1 and zone 2. Images were analyzed using Bioptigen’s InViviVue 2.0 software to identify the zone 1-2 border (twice the distance from the optic nerve to the foveal depression). SDOCT results were compared to the clinical ROP examination and RetCam (Clarity Medical Systems, Inc, Pleasanton, CA) images when available.

Nine premature infants were imaged with handheld SDOCT. Of the 13 imaging sessions, four sessions (3 infants, 3 eyes) captured the zone 1-2 border and three sessions (1 infant, 1 eye) captured the ROP ridge, confirmed with RetCam. The ridge consisted of preretinal hyperreflective structures located in zone 1 and measured 0.19×0.30mm and 0.21×0.60mm at the time of the zone 2 stage 3 clinical diagnosis. The infant then received bilateral intravitreal bevacizumab injections. At 1 week post-treatment these structures measured 0.14×0.15mm and 0.16×0.33mm, respectively, and at 2 weeks post-treatment, 0.11×0.10mm and 0.11×0.25mm, respectively.

The Envisu-R2300-II identified ROP zone and stage, contradicted clinical zone diagnosis in one case and demonstrated progressively decreasing size of the neovascular ridge following bevacizumab. This device could enhance objectivity in assessing zone and stage in helping determine need for treatment and treatment response. Larger studies are necessary to evaluate the ability of handheld SDOCT to accurately diagnose ROP severity.

Prognostic Factors and Outcomes After Neoadjuvant Chemotherapy by Breast Cancer Receptor Subtype

Jahan J. Mohiuddin, Allison M. Deal, Lisa A. Carey

Dept. of Hematology and Oncology

Of all human diseases, few command as much public awareness, fear, and resources as breast cancer. It is one of the most visible successes of taxpayer-supported cancer research, as 5-year survival rates have risen over three decades from 75% to 90%. Some women, however, have more grim prognoses. This study aimed to analyze the survival of breast cancer patients treated with neoadjuvant chemotherapy, create 5-year survival statistical models, and develop a web application for physicians and patients to predict the probability of recurrence within 5 years. A protocol-driven database of breast cancer patients at UNC was used to construct and analyze Kaplan-Meier survival curves by immunohistochemistry (IHC)subtypes, menopausal status, race, and hormone-receptor status. Logistic regression was used to analyze the influence of hormone receptors and HER2 on pathologic complete response (pCR). Cox proportional hazards models were then created to predict 5-year recurrence-free and overall survival, and an online application that uses the statistical models to predict the probability of a recurrence within 5 years was developed and is available at Recurrence-free survival differences by hormone receptor status were statistically significant among post-menopausal women (HR 0.27, 95% CI [0.20, 0.37]), while differences by race, menopausal status, and IHC subtype were not. Hormone receptor-negative status and HER2-positive status were both significantly associated with pCR (OR 4.7, 95% CI [2.9, 7.6]; and OR 2.4, 95% CI [1.40, 3.96] respectively). The statistical models had bootstrap-corrected C-index values of 0.72 each. HR status was a significant prognostic factor for post-menopausal women, while both HR status and HER2 status were significant factors for pathologic complete response.

Prevention Counts: Examining Colorectal Cancer Screening Rates in Assisted Living Communities

KL Moore, CL Lewis, S Zimmerman, K Ward, DW Reed, R Rodriguez, CE Kistler

School of Medicine

Background: Most guidelines agree that colorectal cancer (CRC) screening in older adults should be targeted towards those most likely to benefit and away from those with limited life-expectancy. As Assisted Living (AL) communities grow as housing options for older adults, we need to understand current CRC screening rates and associated likelihood of net benefit.
Methods: We conducted a cross-sectional retrospective study of 93 persons aged 50+ residing in 2 AL communities in central North Carolina, including resident interviews and chart review. Exclusion criteria included history of CRC or inflammatory bowel disease. For residents unable to provide consent, their surrogate was interviewed. In addition to demographics, participants were asked their CRC screening history, CRC screening knowledge, and values towards CRC screening. A modified Charlson comorbidity index was used to assess likelihood of benefit and categorize residents into 3 health status groups: good, intermediate, and poor.
Results: Approximately 30% of residents had never received CRC screening. Those with good health status were more likely to be up-to-date with CRC screening than those with intermediate or poor health. However, only 50% of these healthier residents were up-to-date with CRC screening. Additionally, 20% of residents in poor health and unlikely to benefit were receiving CRC screening. Residents were more likely than surrogates to believe that CRC screening would prolong the residents’ life (48% v. 14%, p<0.001), though 49% of residents did not know whether or not screening would prolong their life.
Conclusion: In this pilot study, almost one-third of older adults in AL communities have never had CRC screening. While older adults most likely to benefit from screening were more likely to be up to date with screening than their less healthy peers, work needs to be done to improve these rates. Differences in CRC screening values occurred between AL residents and their surrogates.

The impact of advanced age on outcomes in squamous cell carcinoma of the head and neck.

Virginia Ann Moye, Sindhu Chandramouleeswaran, Ni Zhao, Hyman Muss, Mark C Weissler, Susan M Brossoie, Michele C Hayward, David N. Hayes


Background: Limited data are available regarding outcomes in elderly head and neck cancer patients. This retrospective cohort was designed to characterize head and neck cancer in geriatric patients in the UNC Tumor Registry.

Methods: Of 1598 patients identified from the registry, 1291 patients were <70 years old (young group, YG) and 307 patients were > 70 (elderly group, EG) at diagnosis. Both overall survival (OS), calculated from diagnosis to death or the last follow up, and relapse free survival (RFS) were censored at 60 months. Log rank test was used to compare survival difference. Cox proportional hazard model was used to estimate hazard ratio, adjusting for potential confounders. All tests were performed in R 2.13.1.

Results: EG patients presented at earlier stage. The median RFS for EG and YG were 25 (95% CI: 20-32 months) and 44 (95% CI: 38-52 months) months respectively (p < 0.0001 log rank test). After controlling for confounders, EG patients were 70% more likely to relapse in 5 years compared to YG (HR 1.704, 95% CI 1.449-2.004, p<0.05). The median life expectancy for elderly patients in our study was nearly 5 years for stage I/II and <2 years for stage III/ IV. Considering only patients with stage III/IV disease, EG patients receiving single- rather than multi-modality therapy had substantially poorer survival (p<0.001). Those receiving multi-modality therapy had similar outcomes to YG patients. There was no significant survival difference between single- and multi-modality therapy in YG. Conclusions: Poor RFS in elderly patients compared to younger patients indicates a need for further investigation considering comorbidities and aggressiveness of treatment. Significant survival differences between late stage elderly patients receiving multi- versus single-modality therapy require further research. Considerable life expectancy differences in elderly patients with early versus late disease may help patients and clinicians determine how aggressively to treat.

Most sexual assault survivors with new moderate or severe pain do not receive medical care in the initial six weeks after sexual assault

Collyn T. Murray, Jacob Ulirsch, April C. Soward, Catherine Rossi, Suzanne Rotolo, Rebecca Wheeler, Kelly A. Foley, Jayne Batts, Renee Collette, Debra Holbrook, Elizabeth Goodman, Ethlyn Csontos, Samuel A. McLean

Department of Anesthesiology, UNC- Chapel Hill

One in 5 US women experience sexual assault (SA) during their lifetime. Studies indicate that persistent pain is a common sequela of SA, but little is known about the health care services (HCS) received by these women. In this prospective observational study, we evaluated HCS received after SA by women SA survivors with and without new moderate or severe pain (NMSP). Women presenting to one of ten emergency care centers in four states after SA enrolled. Initial and six week follow-up interviews included an assessment of pain severity (0-10 scale) in each of eight body regions during the week prior to assault and during the past week, respectively. Six week follow-up interviews also included an assessment of treatments and medications received since SA. NMSP was defined as pain ≥ 4 six weeks after SA in a body region in which pain ≤ 3 was reported during the week prior to assault. Eighty-four SA survivors were enrolled, 75/84 (89%) completed six week follow-up interviews, and 33/75 (44%) had NMSP in one or more body regions. Among women without NMSP, 10/42 (24%) saw a primary care physician, 15/42 (36%) saw a mental health professional, and 14/42 (33%) received follow-up testing. Women with NMSP were more likely to see a primary care physician (16/33 (48%), p = .028), but otherwise received care at similar rates as those without NMSP: 15/33 (45%) saw a mental health professional and 14/33 (42%) received follow-up testing. Rates of pain medication use in women with and without NMSP were low and did not differ: opioids (1/33 (3%) vs 2/42 (5%)); non-opioids (3/33 (9%) vs 8/42 (19%)). These results suggest that most SA survivors with NMSP do not receive medical care or pain medication in the initial six weeks after SA. Supported by NCRR UL1RR025747 and NIH STRT 5T35DK00738632.

Patient perception of chronic illness care in a large inflammatory bowel disease cohort

Rachel L. Randell BA, Millie D. Long MD MPH, Christopher F. Martin MSPH, Robert S. Sandler MD MPH, Wenli Chen MS, MA, Kristen Anton MS, and Michael D. Kappelman MD MPH

Department of Pediatrics, Department of Gastroenterology and Hepatology, Center for Gastrointestinal Biology and Disease

Background: Improvements in care for inflammatory bowel diseases (IBD) could utilize the Chronic Care Model (CCM), an evidence-based approach that has improved patient outcomes and reduced costs in other illnesses. Specific aims include: (1) To explore patient perception of chronic illness care in a large IBD cohort, (2) To determine whether demographic factors, medication adherence, quality of life, disease type and activity were associated with perception of chronic illness care.
Methods: We randomly selected 1000 participants from the CCFA Partners internet cohort to receive the validated Patient Assessment of Chronic Illness Care (PACIC) instrument, which measures patient experience with specific aspects of care congruent with the CCM on a scale of 1-5, with 5 being highest perception of care. We used descriptive and bivariate statistics to assess relationships.
Results: 945 participants completed the PACIC [576 Crohn’s disease, 339 ulcerative colitis, 30 indeterminate or other, 74% female, mean age 45 (SD=15.1), mean PACIC 2.4 (SD=0.93)]. Recent gastroenterologist visit, hospitalization, surgery and current pouch/ostomy were all associated with significantly higher PACIC (p<0.05). PACIC correlated positively with quality of life (Pearson correlation=0.12, p=0.003) but not medication adherence or disease activity.
Conclusions: Reports of chronic illness care in this IBD cohort are in the same range as other illnesses. PACIC is positively associated with quality of life, so efforts to align care with the CCM may benefit this population. Subjects who had more sub-specialty interactions reported an increased perception of care, indicating the important role of direct patient contact.

A Biomechanical Comparison of Two-hole Locking Plate Fixation versus Six-hole Non-locking Plate Fixation of the Pubic Symphysis

Michael P. Ransone, Paul S. Weinhold, Laurence E. Dahners

Department of Orthopaedic Surgery

Background: The senior author has proposed that if a two-hole large fragment locking plate (THLP) achieves equivalent fixation to the commonly applied six-hole non-locking plate (SHP) for the symphysis that there may be advantages due to the smaller incision size. Only 2 studies have compared locking and non-locking plates for the repair of the pubic symphysis. One evaluated four-hole and the other six-hole locking and non-locking plates. No significant difference was found.
Aims: The purposes of this study were 1) to develop a new testing method that allowed for side-by-side comparison of symphyseal plating techniques in the same cadaver specimen, 2) to determine if THLPs could offer similar tensile and cantilever fatigue strength properties to small fragment SHPs.
Methods: Synthetic bone and human cadaver pelvises were tested with the THLP and SHP construct to determine the maximum tensile load and the number of cantilever bending cycles withstood.
Results: In the sawbones cantilever bending test, the THLP lasted 13,743 ± 4,358 cycles while the SHP failed at 1,652 ± 3,244 cycles (p=0.005). The results for tensile loading in sawbones for the THLP were 2.024 ± 0.278 kN and were 2.624 ± 0.425 kN for the SHP (p=0.006). There was no statistical difference in the cantilever bending or the tensile test in cadaver bones.
Conclusions: The data from this study suggest that the THLP may be at least equivalent to the SHP for symphyseal fixation. If so, there should be additional surgical recovery benefits associated with the THLP due to the smaller incision and dissection needed during surgery.

Shared Decision Making for the Selection of Analgesics for Older Adults with Acute Musculoskeletal Pain: A Prospective Observational Study

Alison M Rittenberg, BS, Shannon Matthews, BS, Greg Pereira, Lukas Keil, BS Samuel A. McLean, MD, MPH, Timothy F. Platts-Mills, MD

Department of Emergency Medicine

Background: Older adults who present to the emergency department (ED) with acute pain are less likely to receive analgesics than younger patients. Shared decision making (SDM) may improve the treatment of acute pain among older patients by incorporating physician concerns and patient preferences. We assessed the association between SDM regarding outpatient pharmacologic treatment of acute pain in older adults and pain relief during the subsequent week.

Methods: Non-institutionalized patients age 60 years or older who presented to the ED with moderate or severe acute musculoskeletal pain (score of 4 or more on a 0-10 scale) were eligible. SDM in regard to the selection of the outpatient pharmacologic treatment of pain was assessed at the time of discharge or within 24 hours of discharge using the Shared Decision Making Questionnaire-9 (SDM-Q-9; range 0-45, higher scores indicate greater degree of SDM). A follow-up phone interview 6-10 days after ED discharge assessed pain severity (0-10 scale). The primary outcome was the change in pain severity from the patient’s initial pain, assessed at the time of arrival to the ED, to their final pain, defined as the patient’s average pain over the past 24 hours at the one-week interview.

Results: Of 41 patients screened, 11 fulfilled all eligibility criteria, provided informed consent, and completed the initial interview. Follow-up was obtained for all 11 (100%) of these participants. Scores on the SDM-Q-9 spanned the entire range of the score from 0-45. There were no significant differences in mean SDM scores between females and males (26 vs. 25.5) or for those age 60-74 years vs. those 75 and older (28 vs. 21). SDM scores were higher among patients who received a non-opioid than among those who received an opioid (37, 95% CI 28-46 vs. 22, 95% CI 6-39). SDM score was not associated with change in pain score from the time of ED arrival to the one week assessment. A larger sample size is needed to allow for an assessment of the relationship between SDM and pain recovery after adjusting for confounders.

Conclusions: This ongoing prospective observational study examines the relationship between SDM and recovery from acute musculoskeletal pain in older adults.

High Dose Dexmedetomidine for Pediatric Sedation During Noninvasive Procedures and Discharge Readiness

Ali Russell, Dr. Janey Phelps

UNC School of Medicine; Department of Anesthesiology

The University of North Carolina’s Pediatric Sedation Service adopted a noninvasive procedural sedation protocol that uses high dose dexmedetomidine in children. Mason et al has conducted substantial research on dexmedetomidine and concludes that it provides adequate sedation for pediatric imaging studies with low risk of morbidity and fast recovery times.(1,2,3) The UNC protocol was modeled after Mason’s final protocol but differs in that the initial bolus is 2µg•kg-1 over 10 min, as opposed to 3µg•kg-1 over 10 min. Also, the initial infusion rate at UNC was 1µg•kg-1•hr-1 and later increased to 1.5µg•kg-1 •hr-1, as opposed to 2µg•kg-1•hr-1 in Mason’s protocol.

This study aimed to compare dexmedetomidine discharge times observed at UNC with those previously published. Another aim of the study was to assess adverse events, successful completion of studies/procedures, total boluses required, and reasons for subsequent boluses with data previously reported by Mason et al.

METHODS: Pediatric outpatients (6mo-18yo) who had high dose dexmedetomidine sedation for a noninvasive procedure or imaging study from January 1, 2011 through April 20, 2012 were included in a retrospective chart review. A total of 615 patient encounters were evaluated of which 15 were excluded from analysis because adequate sedation was not achieved with this protocol.

RESULTS: Dosing group 1 and group 2 included patients receiving a bolus dose of 2 µg•kg-1 over 10 minutes followed by a 1 mcg•kg-1•hr-1 infusion or a 1.5mcg•kg-1•hr-1 infusion, respectively. No significant group differences were noted for gender, age, weight, ASA status levels, or time to sedation as seen in Table 1. Time to discharge was statistically significant at 78.7 minutes for group 1 and 100.9 minutes for group 2, respectively. Patients were discharged when they had Aldrete scores greater than 8. Additionally, 38.5% of the patients received a 2nd bolus of dexmedetomidine and 9.9% of patients required a 3rd bolus. Only 2% of patients required iv midazolam as a rescue and the incidence of failed sedations was 2.4%.

CONCLUSION: Dexmedetomidine discharge times observed at UNC are considerably longer than those published by Mason et al. Mason et al has reported average recovery times ranging from 21.3- 35.2 min with higher bolus dosages and infusion rates. This is in stark contrast to the average time to discharge at UNC of 91.3 min. UNC has been unable to reproduce Mason’s short recovery times with dexmedetomidine.

1.Mason KP, Zurakowski D, Zgleszewski SE, et al. High dose dexmedetomidine as the sole sedative for pediatric MRI. Paediatr Anaesth 2008; 18: 403-411.
2.Mason KP, Zgleszewski S, Dearden JL et al. Dexmedetomidine for pediatric sedation for computed tomography imaging studies. Anesth Analg 2006; 103: 57-62.
3.Mason KP, Fontaine PJ, Robinson F, Zgleszewski S. Pediatric sedation in a community hospital-based outpatient MRI center. AJR Am J Roentgenol. 2012 Feb;198(2):448-52.

TEanalyzE: A Novel Approach to Evaluate Transesophageal Echocardiography Simulation

Talia M. Schwartz, BS; Andrea H. Worthington, BA; Todd R.Telle, M.D.; Charles Pozner, M.D.; Thomas Edrich, M.D.; J.Daniel Muehlschlegel, M.D., MMSc

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital

Transesophageal echocardiography (TEE) simulation is increasingly utilized in resident and fellow education. We have previously shown that the TEE simulator (CAE Vimedix, Quebec, CA) effectively distinguishes between levels of echocardiography experience using a subjective image scoring system. We created a custom software program called TEanalyzE that objectively analyzes the degree of overlap between proband and expert cut planes. We hypothesize that TEanalyzE will be able to show differences between 2 cut-planes and detect differences in TEE examination performance of residents before and after a dedicated TEE curriculum. Third-year anesthesia residents were asked to acquire 10 images of a normal heart taken from the ASA/SCA guidelines of perioperative TEE exam before and after a 2-week TEE elective. Probe position in X, Y, and Z planes, pitch, roll,TEE angle, scanning angle, and image depth were recorded for every exam and for 10 data acquisitions created by a board-certified echocardiographer. Using these data, TEanalyzE calculates the area of intersection between a proband plane and the expert volume with a thickness of 2 units. A larger area indicates a greater amount of intersection and thus a higher degree of concordance. Area was calculated for each acquisition and a sum score was generated by adding the 10 individual values. Sum scores were analyzed using pairwise correlation (JMP Pro 10). Mean area increased from pre- to post-rotation (n=12, pre 62.1 ± 49.2; post 88.0 ± 85.2). Pairwise correlation coefficient between pre- and post-elective was r=0.725 (95% CI 0.26 – 0.92, p=0.0077). This study demonstrated the ability of TEanalyzE to detect significant improvement in TEE examination performance after a dedicated TEE curriculum. The analysis of intersecting areas to evaluate image quality is a novel approach that makes it possible to objectively evaluate TEE performance, expanding the potential of TEE simulation as a testing and credentialing tool.

Examining Markers of Quality Palliative Care within the Last Week of Life Amongst Children Who Died at the NC Children’s Hospital

Rob Sellers(1), Mary E. Grimley(1), Diane M. Yorke(1), Elisabeth P. Dellon(1), (1)University of North Carolina, School of Medicine, Chapel Hill, NC

Department of Pediatrics

Pediatric Palliative Care (PPC) serves children suffering from life-threatening conditions by working to improve their quality of life and focusing on their emotional, physical, and psychosocial needs. NC Children’s Hospital recently established a PPC consultation team to focus on enhancing quality of life for seriously ill children. In this study, we aimed to identify areas in which the PPC team could improve quality of end of life care for children dying at NC Children’s Hospital. Using the National Consensus Project for Quality Palliative Care as a framework for high quality end of life care, we established a set of variables reflecting aspects care for dying children. We reviewed records of children who died within a 12 month period at NC Children’s Hospital. Our analysis revealed that the majority of children spent extensive time in an ICU during their last week of life, and many were intubated or given CPR during this time frame. Most of the children in our cohort had “do not resuscitate” orders at the time of death, though most of these orders were put in place during their last day of life. The data indicated a continuing need to improve the frequency and documentation of family conferences held with health care providers and to encourage the participation of children who are developmentally and physically able. Finally, distressing physical symptoms were common in dying children, and while medication orders suggested these were promptly treated, there was limited documentation of symptom assessment and management plans for many patients. To achieve their goal of improving quality of life for seriously ill, dying children, the PPC team can focus on many of these issues, including reducing time spent in ICUs, encouraging earlier discussions regarding resuscitation status, and improving documentation of symptoms and their management.

Assessing the Role of Computed Tomography of the Abdomen in the Staging Evaluation of Primary Breast Cancer

Allison Staley, MPH; Al Parker, MD

Department of Radiology, UNCH

Background: The purpose of this study was to determine the utility of routine abdominal CT in the staging evaluation of women with newly diagnosed primary breast cancer, given no detectable disease beyond the ipsilateral axillary nodes on chest CT.

Methods: The chest and abdominal CT scans from 440 patients over a 10-year period were reviewed. The presence of definite or possible metastatic disease in the axillary nodes, chest wall, internal mammary nodes, mediastinal nodes, lungs, liver and adrenals were recorded for each patient. Cross tabulation bivariate analysis as well as a chi-square test were performed to characterize the relationship between detection of disease in the chest and disease in the abdomen.

Results: Of the 440 patients reviewed, the following were found to have detectable metastatic disease by CT scan: axillary nodes 258 of 440 (56.46%), chest wall 40 of 440 (9.10%), internal mammary nodes 8 of 440 (1.82%), mediastinal nodes 29 of 440 (6.59%), lung 25 of 440 (5.68%), liver 12 of 437 (2.73%), and adrenals 8 of 440 (1.82%). In total, 81 patients had disease detectable in the chest beyond the ipsilateral axillary nodes (ie, chest wall, internal mammary nodes, mediastinal nodes, and lung), and only 12 patients had detectable disease spread in the abdomen (ie, liver and adrenals). Of the 359 patients who had a negative chest CT, only 1 patient had detectable or possible metastatic disease spread on abdominal CT, resulting in a 99.70% negative predictive value (p < 0.001). Conclusion: The routine use of abdominal CT in women with newly diagnosed primary breast cancer and no detectable disease beyond the ipsilateral axillary nodes on staging chest CT scan has little value with a 99.70% negative predictive value. Based on this information, we recommend that if a negative CT scan of the patient’s chest yields no detectable disease beyond the axillary nodes, then further CT imaging of the abdomen is of no additional benefit to the patient.

Do Positive Blood Cultures Predict Positive Cerebrospinal Fluid (CSF) Cultures in Hospitalized Infants?

Kristyn Swan, Matthew Laughon, Christoph Hornik, M Cohen-Wolkowiez, RH Clark, DK Benjamin Jr, PB Smith

UNC School of Medicine, Department of Neonatal-Perinatal Medicine

Background: Neonatal meningitis causes substantial morbidity and mortality in hospitalized infants, particularly those with ventriculoperitoneal (VP) shunts. There is no consensus on the ability of a blood culture to predict CSF culture results in hospitalized infants.

Objective: Determine the odds of positive CSF culture after a positive blood culture with the same pathogen.

Methods: We used the Pediatrix Medical Group database of infants discharged from 333 NICUs from 1997–2010. All infants with a positive blood culture and a CSF culture obtained within 3 days of the blood culture were identified. Using multivariable regression, we evaluated the odds of a concordant blood-CSF culture pair, controlling for severity of illness on the day of the blood culture and the presence of a VP shunt. We used the method of generalized estimating equations.

Results: We identified 8960 infants with 9583 positive blood cultures who also had a CSF culture. Group B Streptococcus (GBS), E. coli, and S. aureus were the 3 most common concordant organisms in the blood-CSF culture pairs. The presence of a VP shunt was associated with increased odds of blood-CSF culture pair concordance: odds ratio = 4.73 (95% confidence interval 3.27–6.84). The odds of concordance were not significantly different by organism type (gram positive, gram negative, or fungus).

Conclusion: A positive blood culture in infants with VP shunts is associated with increased odds of a positive CSF culture.

Inter-Institution variability of FDG-PET Scan Interpretations and its on Effects Lung Cancer Staging

Sanjay Venkatesh, Amir Khandani, MD, Nirmal Veeramachaneni, MD

Division of Cardiothoracic Surgery

Introduction: Lung cancer is one of the leading causes of cancer related death in men women in the western world. A now widely used technique to find evidence of and the clinical stage of cancer is FDG-PET-CT imaging. This imaging modality has made huge contributions to the treatment of lung cancer, but studies have shown it to be more subjective in interpretations than other imaging techniques.

Methods: In this study we examined N = 51 patients who received their cancer care at UNC Hospitals but had a previous PET-CT scan performed at an outside institution. These scans were reread by radiologists at UNC and we compared the two interpretations to find differences. Basic demographic, risk factor, cancer specific, and cancer stage data was collected via chart review.

Results: 7 of the 51 (13.7%) patients were found to have completely different overall clinical staging of their cancer based on the PET interpretation. An analysis of the T staging showed a kappa coefficient of .647 indicating only partial agreement between the two data sets. A further sub-analysis was performed comparing described subjective tumor intensity on PET at UNC to max SUVs at outside institutions.

Conclusion: Overall the results of the study show significant variability in PET-CT imaging interpretation. 2 out of the 7 patients with different overall stages had different M or metastasis stage which drastically alters the treatment one receives. Significant variability was also found within the T stage which may or may not have contributed to an alteration in the overall stage. The sub-analysis comparing subjective tumor intensity at UNC to tumor max SUVs at outside institutions showed no correlation between the two variables, further indicating PET-CT interpretation variability.

Initial neuropathic pain symptoms predict musculoskeletal pain severity six weeks after MVC

N Verma, T Platts-Mills, K Hunold, R Swor, D Peak, J Jones, N Rathlev, D Lee, R Domeier, P Hendry, S McLean

Department of Anesthesiology

Neuropathic pain symptoms have been shown to predict persistent postoperative pain, however to date the ability of neuropathic pain symptoms to predict persistent musculoskeletal pain has not been assessed. In this prospective observational study, we assessed the ability of neuropathic pain symptoms to predict musculoskeletal pain severity six weeks after motor vehicle collision (MVC). European Americans ≥18 years of age presenting to one of eight emergency departments (EDs) in four no-fault insurance states within 24 hours of MVC who did not have a fracture or other injury requiring hospital admission were enrolled. Baseline interviews were performed at the time of ED evaluation and included an assessment of overall pain severity (0-10 scale). Neuropathic pain symptoms (DN4 questionnaire) were assessed in individuals reporting pain (ED pain score ≥1). Six week telephone follow-up evaluation included an assessment of overall pain and neck pain intensity during the past week (each assessed using a 0-10 scale). In the ED, 109/115 (95%) patients reported acute pain (score ≥1); 76/109 (70%) of these patients reported experiencing one or more neuropathic pain symptoms. Number of neuropathic pain symptoms and ED pain severity were moderately correlated (r=0.35, p=0.01). 78/115 (68%) patients reported persistent MVC-related pain (score ≥1) six weeks after MVC; 61/78 (78%) of these individuals reported coincident neuropathic pain symptoms. In a model adjusting for patient age and sex, the number of neuropathic pain symptoms reported in the ED predicted overall pain intensity at 6 weeks (Beta=0.49, p<0.01). The individual ED neuropathic pain symptom that most strongly predicted 6 week pain severity was painful cold (Beta=2.31, p<0.05). These results suggest that neuropathic pain symptoms are common in the immediate aftermath of MVC and predict pain severity at six weeks. Supported NIAMS R01AR056328 and NIH T35 Grant 5T35DK007386-32.

Investigating The Relationship Between Breslow Depth and IRAK-M

Kathleen Conway, Sharon Edmiston, Pei-Fen Kuan, Honglin Hao

Department of Dermatology

The National Cancer Institute estimates that in the year 2012, 76,250 individuals will be diagnosed with melanoma and 9,180 of these patients will die as a result. With the ever-increasing incidence of melanoma, there is a critical need for the reliable detection of subclinical disease that must be addressed. Currently, melanoma is a histological diagnosis, though prior studies have shown that there is a high discordance rate among pathologists. The development of a sensitive and specific clinically relevant biomarker, which could be used in conjunction with histological diagnosis, would provide an evidence-based approach to making management decisions. IRAK-M, a member of a family of interleukin-1 receptor associated kinases, has previously been shown to be an endogenous negative regulator of the immune system. Recent studies indicate that IRAK-M may be exploited by tumor cells to evade the host immune response. In this study, DNA promoter methylation of the IRAK-M gene was analyzed in 47 primary melanomas and compared to Breslow depth. Additionally, normal skin, moles and primary melanomas were stained with IRAK-M antibody to evaluate for protein expression. Our research shows that as the Breslow depth of a melanoma increases, the methylation of the IRAK-M gene increases significantly (p-value = 0.000157). We also demonstrate that there is increased staining for IRAK-M antibody in melanomas as compared to normal skin and moles. Our findings suggest that Breslow depth correlates with the DNA promoter methylation of IRAK-M and that the IRAK-M protein is ectopically expressed in melanoma.

A Retrospective Analysis Of Complications Arising From Intraosseous Insertion During Out-of-hospital Cardiopulmonary Resuscitation In Adults.

Andrew B. Wallace, BS, EMT; Brian Lanier, BS, EMT; Jose G. Cabanas, MD; Valerie J. De Maio, MD, MSc; Robert Lee, MS, MA.

Emergency Medicine, Seton Healthcare Family, Austin, TX; Office of the Medical Director, City of Austin/Travis County EMS System.

Background: Intraosseous (IO) access is routinely used during resuscitation from out-of-hospital cardiac arrest (OOHCA), yet there is a lack of data regarding complications in adults.
Objectives: To identify complications from IO insertion in adult patients resuscitated from OOHCA.
Methods: This was a retrospective chart review of patients ≥ 16 years admitted to hospital after successful resuscitation from OOHCA with IO access in an urban/suburban emergency medical services (EMS) system (population 897,000) from 6/1/2005 to 12/31/2009. Trauma cases were excluded. A literature review revealed a list of potential IO complications; including osteomyelitis, periostitis, fracture, extravasation, compartment syndrome, cellulitis, skin abscess, ischemia, deep vein thrombosis (DVT), and pulmonary embolus (PE). Data was abstracted by one observer to the study database from EMS and hospital records; including demographics, medical history, IO insertion information, hospital course, and complications. Follow-up phone calls were made to survivors to screen for complications arising after hospital discharge. Analysis involved descriptive statistics with 95% confidence intervals (CI).
Results: This study included 217 adults age 16 to 98, comprising 273 IO insertions. Phone follow-up was completed for 31 of 76 survivors. For insertions, 14 (5.1%, 95% CI 2.5-7.8%) had a defined complication including: compartment syndrome 1 (0.4%), ischemic injury 1 (0.4%), and extravasation 5 (1.8%). One extravasation was associated with local necrosis. DVT occurred in 5 insertions (1.8%) and PE occurred in 2 insertions (0.7%).
Conclusion: This is one of the first reports on IO complications in adults and complication rates here are comparable to reports from pediatric populations and are favorable to traditional intravenous catheters. Additionally, DVT and PE rates in this study are similar to rates reported for all hospitalized patients. IO appears to be a safe route for rapid vascular access in emergency situations.

Comparing Chemotherapy Treatment Responses of Bleomycin/Vincristine Combination Therapy versus Vincristine Monotherapy for Kaposi’s Sarcoma Among HIV Infected Patients on Antiretroviral Therapy

Albert Mwafongo, Mina Hosseinipour, Nora Rosenberg

Department of Infectious Diseases

Background: Current recommendations dictate that HAART plus chemotherapy in KS patients with T1 disease (presenting with widespread lesions and edema or oral nodular lesions or lesions in organs other than the lymph nodes) is more effective than HAART therapy alone. However, there is a lack of data to show if one chemotherapy regimen is better than another in these severely immunocompromised patients.

Methods: This study compares the regimens of bleomycin/vincristine combination chemotherapy versus vincristine monotherapy. A chart review was conducted of KS patients seen between 1 March 2007 and 9 Jan 2011 whose charts confirmed the presence of T1 disease and included a documented response to treatment. Treatment responses were stratified by 1. complete or partial response versus 2. no response or disease progression.

Results: We reviewed 455 patient records and analyzed data from the 24 patients that fit the criteria and displayed a documented response rate. 11 patients received monotherapy and 13 received combination therapy. Among those patients on monotherapy 7 (64%) had a complete or partial response and 4 (36%) had no response or disease progression. Among the patients receiving combination therapy 9 (69%) had a complete or partial response and 4 (31%) had no response or disease progression.

Conclusion: Preliminary findings from our small sample show no significant difference between outcomes of patients on monotherapy versus combination chemotherapy. Further chart review of additional patients is recommended.

On the Cusp: A Low Cost Radiation Free and Valid Simulator for Training in Transcatheter Aortic Valve Replacement

Hadley Wilson, Samuel Heathcote, Rebeckah Macfie, Richard Feins

Department of Surgery – Cardiothoracic Surgery

Background: The need for physician training opportunities and the demand for quality control necessitate a consequence free training environment that allows physicians to hone their skills before entering the operating room. Our goal was to design a simulator that could be used to train physicians on transcatheter aortic valve replacement.

1. Request IRB review for designing a simulator and conduct research procedures in accordance with the guidelines of the CMSRP.
2. Design and construct an inexpensive, radiation free and valid device that simulates the transthoracic aortic valve replacement procedure.
3. Display the device in simulation based education at the Cardiovascular Surgery Boot Camp July 28, 2012.

Methods: We constructed a model aorta to contain a circulating fluid through which we could pass catheters and stents and inject contrast media. This was all mounted on a white stage and filmed from above with a web camera streaming to a laptop computer. On the computer we combined our live streaming video with a prerecorded chest fluoroscopy to simulate the operator’s movements occurring in a patient undergoing fluoroscopy.

Results: This simulator closely resembles fluoroscopy and is radiation free, consequence free and quite inexpensive.

Conclusions: The simulator is radiation free and inexpensive. More research is needed however to determine its true validity. Now that the device has been constructed it will be easier to test its validity. The cost, safety and versatility of this simulator make it a potentially valuable tool in training the next generation of physicians.

An Evaluation of Possible Prophylactic Therapies for the Prevention of Post-traumatic Joint Stiffness

Shawn Yeazell BS, Ben Keller MS, Aaron Casp BS, Paul Weinhold PhD, Laurence E. Dahners MD

Department of Orthopaedics

Objectives: To evaluate possible prophylactic therapies for prevention of the formation of post-traumatic joint contractures and/or adhesions.
Methods: The soft tissue on the medial and lateral condyles and the cartilage of the trochlea was incised and scraped with a scalpel blade and the knee was immobilized in flexion for two weeks. Treatments of steroid or hyaluronic acid injections (post op days 1, 3, and 7), whole body vibration (5 days a week), or montelukast (every day) were administered. Post sacrifice the legs were disarticulated at the hip and immobilization angles were measured by X-ray with the immobilizing suture intact. All other measurements were made with a 0.015-Nm extension moment applied to the knee. Pictures were taken and angles were measured digitally, comparing the operated leg to the contralateral limb to standardize each result.
Results: We found there to be a prophylactic effect in three of our four treatment groups. Quantitative analysis showed that treatment with steroid injections resulted in a smaller difference between the operated and non-operated legs in both the “suture cut” and “posterior capsule cut” measurements when compared to control, suggesting steroid inhibited both capsular contracture and adhesion formation. Treatment with hyaluronic acid and vibration therapy resulted in smaller differences in the “posterior capsule cut” measurements, suggesting they both inhibited adhesion formation. Significant differences in any of the measurements were not detected in the montelukast group.
Conclusions: Steroid markedly inhibited capsular contracture and adhesion formation while hyaluronic acid and vibration therapy also inhibited stiffness but to a lesser degree. Further research should be undertaken before these techniques are considered in human subjects.

How to reduce hepatitis C treatment costs in the United States: Lessons to be learned from the National Hepatitis C Treatment Program in Egypt

Essraa Bayoumi B.S, Samer El-Kamary M.B.,Ch.B., M.P.H, Mohamed Hashem M.B.B.Ch.

HCV infection affects 150 million people worldwide, with the highest prevalence occurring in Egypt. According to a Demographic Health Survey in 2008, an estimated 10% of the population is chronically infected. This has been attributed to a well-intentioned national parenteral anti-schistosomal therapy (PAT) campaign during the 1960s and 70s to reduce the levels of schistomosmiasis infection, especially in rural areas. To address this serious health burden, the Egyptian government has implemented a nationwide program for the treatment of HCV. Over the summer, I conducted interviews with adult and pediatric hepatologists, public health employees, and researchers from different teaching and research institutions in Cairo. Questions were structured to better understand the eligibility criteria of patients; cost of treatment; research and health education for HCV; and the impact of the program. The Egyptian government receives pegylated interferon and ribavirin at a subsidized cost (20% of market price) from the manufacturers, and provides treatment to any adult Egyptian citizen who tests positive for HCV and meets eligibility criteria. Protease inhibitors such as Boceprevir® have not been proven to treat HCV genotype 4, the predominant genotype in Egypt, and are not included in the treatment regimen. Children are not treated under the national program, but rather through a non-profit non-governmental organization which works with six HCV treatments centers across Egypt. Approximately 190,000 adults and 322 pediatric patients have been treated at an estimated cure rate of about 50-60% for children and 40-50% for adults. Although these programs are not sufficient to eradicate HCV, they illustrate that large scale intervention programs can be both essential and effective in dealing with endemic diseases. Drugs specifically targeting genotype 4, HCV RNA screening in blood banks, and improved infection control measures are three areas that require increased emphasis to result in a greater change. Improvements in medication adherence, more stringent eligibility criteria, and aggressive price reduction negotiations may result in greater success rates at lower cost and are three cost-effective elements within the Egyptian national program that can be implemented in the US.

Does Sunscreen Use Decrease the Incidence of Melanoma: A Systematic Review

Rachel Blasiak MPH, Andrew Moon MPH, Anthony Viera MD/MPH, Russel Harris MD/MPH

Department of Internal Medicine, Public Health Leadership program

To update the 2008 USPSTF recommendations on sunscreen use for primary melanoma prevention MEDLINE, the Cochrane Library, and the U.S. Government Clinical Trials website were searched for articles from 11/01/2008 to 03/08/2012. Two reviewers independently screened 264 abstracts and 75 full-text articles using predetermined inclusion and exclusion criteria. Articles were independently appraised and only good to fair quality studies were included. One fair quality randomized, controlled trial and one fair quality case-control study were included in the final data synthesis. Both found a decreased risk of melanoma associated with regular sunscreen use. The RCT found a borderline significant HR of 0.50 (95% CI: 0.24 – 1.02) for all melanoma and a HR of 0.27 (95% CI: 0.08 – 0.97) for invasive melanoma. The case-control study found an adjusted OR for regular sunscreen use versus never sunscreen use of 0.44 (95% CI: 0.23 – 0.86). All other types of sunscreen use, including use during outdoor activities, thickness, amount, and reapplication were not associated with melanoma risk. Included studies did not assess harms associated with sunscreen use or melanoma associated morbidity and mortality. Overall, we bestowed a grade I recommendation on sunscreen use for the prevention of melanoma due to insufficient evidence.

Faith Healing Among Latino Immigrants in North Carolina

Victoria Burgos, Raul Necochea

Department of Social Medicine at UNC

This paper analyzes interviews with 15 Hispanic immigrants who live in North Carolina and who have sought to be healed of various illnesses by Protestant faith healers. Through these narratives, the recipients of these interventions explain their motivations for seeking faith healing, the processes healers used to effect health changes, the narratives of the illnesses that led sufferers to seek healing, and the aftermath of these interventions. The analysis demonstrates how those faith intervention recipients who considered themselves successfully healed originally interpreted their illnesses as having religious rather than biomedical causes and were more likely to have an underlying distrust of allopathic physicians. As the disease model shared by these recipients attributes illness, at least partially, to spiritual or emotional origins rather than the physical causes allopathic physicians cite, it follows that to truly treat the origin of their illness, they resort to spiritual healers. These narratives provide an important insight into why individuals may choose faith healing as an adjuvant or alternative to therapy provided by allopathic medicine, even when these healings may come at great financial cost.

Public Access AEDs: Utilization and Missed Opportunities

Arthur Johnson, Jared Lowe, William Carter, William Whited, Frances Shofer, Jane H Brice, Jefferson G Williams

Department of Emergency Medicine

Introduction. Automated external defibrillators (AEDs) for public use are becoming increasingly prevalent. There is little data about the utilization of available public AEDs. Objective. To compare the locations of out-of-hospital cardiac arrests (OHCAs) with the locations of publicly available AEDs to determine whether missed opportunities exist in which nearby AEDs were not utilized in OHCAs. Methods. We conducted a retrospective observational cohort study of all OHCAs in which resuscitation was attempted and that occurred between January 1, 2005, and December 31, 2010, in a suburban and rural emergency medical services (EMS) system. The location of each OHCA, and whether or not an AED was utilized prior to first-responder or EMS arrival, was determined using EMS records. The location of each OHCA was plotted on a map using ArcGIS. Businesses and other public buildings and facilities located within a 100-meter radius of each OHCA were surveyed via telephone to determine AED availability. Data were analyzed using standard descriptive statistics. Results. During the study period, 307 OHCAs occurred at 282 locations. Of these arrests, 219 (71%) occurred in private homes, 26 (9%) in nursing or assisted living facilities, and 62 (20%) in public locations. At the time of the survey, an AED location was within 100 meters of an OHCA location in 26 (42%) of the 62 public arrests. Of these 26 OHCAs, 50% (13) had an AED applied to the patient prior to EMS arrival. In the remaining 13 OHCAs in which an AED was not applied prior to EMS, the installation date of nearby AEDs was unknown for or occurred after ten arrests, and for at least three public OHCAs, a public AED was nearby but was not utilized. Conclusion. In at least three cases of public OHCA, there was a missed opportunity to utilize a nearby public AED.

Understanding Indoor Tanning Behavior Among Sorority Members

Seth Noar, PhD; Jessica Myrick; Brenda Morales-Pico; Nancy Thomas, MD

School of Journalism and Mass Communication, Lineberger Comprehensive Cancer Center

Despite the demonstrated health risks of ultraviolet radiation exposure and the increasing prevalence of skin cancers, the popularity of indoor tanning continues to increase, especially among young women. While many factors that contribute to indoor tanning use have been identified, no studies to date have attempted to understand this behavior by employing the constructs of the Social Cognitive Theory, one of the most common and predictive health behavior theories. The aim of this survey research study was to identify factors that predict tanning bed use among young women and to validate measures of outcome expectations and self-efficacy for use in future research. Members of sororities at a large, southeastern university (N=1805) were invited to participate in an online survey. Of the 714 respondents, 45% (N=323)had tanned indoors in their lifetime, and 30% (N=217) had tanned in the past year. The beliefs of both tanners and non-tanners were evaluated using existing scales and scales designed for this study. While most respondents (>83%) recognized the health risks associated with indoor tanning, the majority also endorsed tanning for special events (68%), for achieving a great glow (58%), and for obtaining a base tan (55%), among other motivations. Further analysis is being conducted to determine which group of beliefs predict tanning behavior. The understanding of tanning beliefs gained from this study will ultimately aid in designing effective health communications targeted at preventing this behavior.

Challenges to Cost-Effective Primary Care Management of Complex Elderly Patients:

Mollie Oudenhoven, Philip D Sloane, MD, Ila Broyles

Department of Family Medicine, University of North Carolina at Chapel Hill

Background: With the increasing prevalence of older persons with multiple chronic conditions, new models of care such as Accountable Care Organizations (ACOs) are emerging in an effort to hold providers accountable for cost and quality of care. However, little is known about the specific challenges that providers in these models will face. The Program of All-Inclusive Care for the Elderly (PACE) has acted as a small accountable care organization for decades and can serve as an excellent model for future ACOs. This study aimed to identify the challenges and solutions in cost-effective primary care management of complex elderly patients through the experiences of PACE programs.

Methods: Sixteen randomly selected PACE medical directors were interviewed using a structured open-ended telephone interview protocol. Probes specifically addressed challenges in preventive services, consultations/referrals, laboratory and radiological tests, outpatient medications and therapies, hospital activities, and palliative care. All interviews were audio recorded, transcribed, and analyzed using an open-coding format in Atlas.ti.

Results: Each director identified specific services that present authorization challenges due to a high risk of adverse patient outcomes or significant cost without clear benefit. Services mentioned with the highest frequency included colonoscopies, dentistry, ophthalmology consultations, vascular procedures, and inpatient care. Despite questioning their appropriateness, PACE frequently provided these services to patients due to one or more of the following factors: lack of expertise, morbidity-related risk, patient/family expectations, program resource constraints, and lack of understanding of the PACE model. Solutions cited by interviewees included aggressive case management, relationship-building, and advocating for less costly alternatives.

Conclusion: The perspectives of PACE medical directors can be invaluable to future ACOs based on their experiences struggling with service authorization. Controlling inpatient costs and providing high-quality, cost-effective care to frail older patients will require building strong referral relationships and an emphasis on strong primary care with aggressive case management.

Prevalence of cardiovascular disease (CVD) risk factors and receipt of preventive care among prostate cancer (CaP) survivors in the United States

Kevin A. Pearlstein, Laura H. Hendrix, Ronald C. Chen

Radiation Oncology, UNC

Cardiovascular disease (CVD) is a major cause of mortality in prostate cancer (CaP) survivors. Previous claims-based studies have reported underutilization of preventive care in cancer survivors, but most CVD preventive care items are not available in claims data. We directly examined the prevalence of CVD risk factors and receipt of care in patients with these risk factors in two population-based data sources: National Health and Nutrition Examination Survey (NHANES) and National Health Interview Survey (NHIS) – both commonly used to examine patterns of care in the US.

2,938 (NHANES) and 452 (NHIS) men with CaP diagnosed from 1999 to 2011 were included. Variables pertaining to cardiovascular disease prevention were identified in both datasets. Statistical analysis accounted for sampling weight, and was stratified by Caucasian (CA) vs. non-CA.

CVD risk factors are highly prevalent, and appear more so in non-Caucasian survivors. Further, 32% of survivors reported history of actual CVD (prior stroke, myocardial infarction, angina, or coronary heart disease). Overall, the majority of survivors receive preventive care. 89% of survivors visited a primary care physician in the past 1 year. Blood pressure checks in the past year were reported by >97% of men with CaP. Cholesterol screens in the past year were reported by >70% off all men with CaP and >84% in those with a history of hyperlipidemia. The use of blood pressure and cholesterol medications were commonly reported in those with hypertension or hyperlipidemia (>80%). The rates of lifestyle modifications, including smoking cessation (42%) and moderate exercise (NHIS: 50%, NHANES: 53%), were lower.

CVD and associated risk factors are prevalent in CaP survivors. However, the majority of these survivors visit a primary care physician and receive CVD preventive care.

A Qualitative Study on the Maternal Death Review process in Zambia’s Eastern Province

Kathleen Tompkins, Carla Chibwesha

School of Medicine, Department of OB/GYN

Background: In 2007, Zambia reported a maternal mortality ratio of 591 per 100,000 live births. Many maternal deaths occur outside of health facilities or in rural health centers that lack trained staff and electronic records for recording deaths. As such, accurate data collection on pregnancy outcomes remains elusive and the causes of many maternal deaths are unknown. Currently, health districts meet quarterly and conduct Maternal Death Review (MDR) to identify causes of maternal death. A review of this process can help identify causes of death and gaps in data.
Methods: From May-July of 2012 I worked with The Centre for Infectious Disease Research of Zambia to analyze the MDR process in the Lundazi and Nyimba districts of Zambia. We interviewed district hospital staff and midwives and attended a district-wide maternal death review meeting.
Results: Of the 5 deaths in Lundazi district reviewed in July, 3 occurred at home, 1 at a rural health center, and 1 at the district hospital. 1 of the 5 (20%) had a known cause of death. Three deaths occurred antepartum, 1 during delivery, and 1 postpartum. Three of the 5 deaths (60%) were prima gravid. In interviews, midwives at Lundazi and Nyimba District Hospitals each explained a distinct data collection procedure following a maternal death.
Conclusion: Lack of data on a patient’s clinical course presents the most significant impediment to conducting meaningful MDR. Potential improvements to MDR include revised data collection forms, standardized procedures for data collection and management, and a centralized database to collect district-wide data and track longitudinal trends.

Student Spotlight: Tony Law

Student Spotlight: Tony Law

I recently caught up with Tony Law, a graduating MD-PhD student who will begin his Otolaryngology/Head & Neck Surgery residency at the University of Washington in July. As someone transitioning between a completed career as a medical student researcher and a future career as an Academician, I thought Tony could provide valuable insight into the value and challenges of medical student research.

What kind of research did you do for you PhD?

Cellular signaling is, in large part, organized by the formation of large macromolecular complexes. These complexes are ‘glued’ together by protein-protein interfaces driven small scaffolding which may offer a novel target for future drug therapy. My research focused on understanding the factors that dictate protein-protein binding. Our work shows that not only is protein structure necessary for these protein-protein interaction, but that fast dynamics (or protein wiggles) are essential to understanding how and what proteins bind.

What background did you have in that area before starting? What skills did you have to learn as you got going?

My undergraduate degree was in Physics and I had a Master’s in Biophysics before starting my PhD training. Both of those degrees served as an excellent foundation to be built upon in my graduate career. The PhD, by design, is less focused on regurgitation of information and focused more on the process of developing a sound scientific question and fully answering that question. For me that meant thoroughly knowing the literature in my field (and being able to judge individual papers’ merits), learning advanced Biophysical techniques (like NMR) and being comfortable with a plethora of statistical methods. An unexpected skill that I learned during my graduate career was the ability to communicate better, both in writing and presentation format.

What first got you interested in this type of research?

Coming into graduate school I knew I wanted to study biophysics of some sort. I felt it really had a good blend of the extremely analytical side of physics and relevance to human health that naturally comes with biological studies. The research I ultimately ended up doing sets the foundation for understanding how future drugs might interact with protein targets as well as tells us a great deal about how proteins work in general. It was perfect for an MD-PhD student with a physics background.

What challenges did you face while doing your research?

One of the hardest challenges in research is dealing with negative results and/or failed experiments. After a lot of energy and time has been put into a project it is draining to have poor results. Repeated poor results necessitate some measure of endurance and attention to detail. It’s usually here that sloppiness can creep into science.

How do you plan on incorporating research into your career?

I’m currently pursuing a career in Otolaryngology/Head & Neck (ENT) surgery and research will be an integral aspect of my future career. Specifically, head and neck cancer research offers many opportunities for someone interested in structural biology.

What are your hobbies?

I enjoy playing the piano, basketball with friends and reading when time allows.

Elliott Robinson focuses on understanding how a genetic variant of the mu opioid receptor alters the rewarding properties of alcohol and affects neural pathways involved in positive reinforcement and addiction. Using intracranial self-stimulation (ICSS), Elliott measures the reward-potentiating effects of drugs of abuse in a humanized mouse model of the A118G mu opioid receptor gene (OPRM1) polymorphism. He will also use whole cell patch clamp recording to investigate how this polymorphism alters dopaminergic neurotransmission in brain reward pathways. The goal of this research is to gain a better understanding of the mechanisms through which genetic differences moderate risk for developing alcohol use disorders.

Audrey Verde is currently researching the neurobiology of alcoholism and how alcohol addiction impacts episodic memory circuits. Employing diffusion tensor imaging (DTI), a magnetic resonance imaging technique (MRI) measuring the diffusion of water molecules in tissue, Audrey is capable of mapping axonal degeneration along white matter tracts and identifying possible disconnects in structural connectivity. She will also be using functional MRI records to monitor the blood oxygenation level dependence (BOLD) signal to determine the functional connectivity within the episodic memory network. By better understanding the interaction between alcoholism neurobiology and episodic memory the efficacy of the clinical approach to alcoholism and addiction disorders can be modified to accommodate the degenerative changes of the disease

Doug Ornoff studies pulmonary processes resulting from damage to the alveolus, specifically Alveolar Type 1 cells and their roles in ion transport and alveolar fluid balance. Unfortunately, current technology does not allow for ideal alveolar cell culture models. Doug plans to remedy this by developing and optimizing microwell arrays with an air-liquid interface that would specialize in growing AT1 cells. Cultured AT1 cells will be manipulated with pharmacologic inhibitors targeting Na+ and Cl- ion transport through specific channels while measuring the height of apical surface fluid resulting from free water movement through aquaporin channels. Clinically, this information will help develop treatment plans for serious conditions like Acute Respiratory Distress Syndrome (ARDS) which has a mortality of 50% in certain patient groups and is currently treated with mechanical ventilation and supportive therapy.

Kate Hacker is studying genetic and epigenetic alterations in clear cell Renal Cell Carcinoma (ccRCC). Recent reports by other groups have identified frequent mutations in epigenetic-modifying genes in ccRCC. Kate’s project involves elucidating the downstream effects of these mutations on chromatin architecture, histone modifications, gene expression, and clinical outcome

By Matt Forgues

“Short-coat”: 2013 William Blythe Essay Competition Winner


I slowly scanned the circle of our cardiology team, the ongoing dialogue about second line anti-arrhythmics sailing over my head. Though it was only my first month as a third year student, I understood enough of the hospital’s culture and unspoken rules to feel conspicuous. I had never put much thought into jacket length before, but now my eyes floated from person to person observing the length and material of each white coat.

The intern next to me, his attire was a bit stained and wrinkled, the flimsy cloth obviously not meant to survive much past that first overwhelming year as a resident. Still, the garment hung down to at least mid-thigh. The attending physician wore one of robust white cotton, it had enviable woven buttons, and the hem clipped him at mid-calf. Though bone white and freshly washed, the well-worn cloth had obviously survived many years; it emanated seniority and experience.

My coat was also a pure white, but the fabric was stiff and rough with a creased fresh-out-of-the-box look. It stopped abruptly at my waist, a length which weeks before seemed arbitrary but now embodied my awkward and benign role on the team. Yes, medical students are folded into the clinical flow as best as possible, but during those early months in the hospital, as the entourage of attendings, fellows, residents, and interns file from patient room to patient room, we short-coats often become the trailing caboose, continually peering over others shoulders in an attempt to glimpse patient care.

In the first week of my rotation, of the many patients admitted to our service, one man stood out. He was a strong septuagenarian from the surrounding farmland and the much-loved patriarch of his family. One day he was on a stool changing a light bulb when he slipped, fell, and broke his hip. The injury triggered a heart attack, which later triggered a stroke. When he arrived to the cardiac floor, his state was cadaveric: skin ashen and stretched over a gaunt face, his mouth draped open in a slack “O.” Our communication with him was usually limited to simple phrases and frequently interrupted by lulls in concentration. On bad days he wouldn’t even respond, but just stare beyond us, his consciousness drifting off.

He was in our ward for nearly my entire month with the cardiology service, and though his state waxed and waned, it never made a clear move towards improvement or decline. I grew to know the family well as they essentially lived on the floor during his stay. Their biggest concern was his refusal to eat which, week after week, was evidenced by his increasingly frail frame. Frustrated, they had brought nearly every item of the cafeteria to his room only to be stonewalled. The son had even bought his father’s favorite food, tomatoes, from a local grocery store but the man didn’t take more than a bite or so.

Eventually, we had done what we could for the man’s heart. Thought it was time for him to move off the floor, he couldn’t be discharged in his anorexic state. At the end of the third week, our attending decided to issue an ultimatum: he eats by Monday or we order a gastrointestinal tube. What I felt then, and what I have seen since that time, is that a g-tube is often a one-way street. Though it is intended as a temporary measure, it can be the first step in a slow decline. I sensed, and I think the family sensed, that if there was still a chance for him to recover, he needed to eat.

That Saturday, I was at a friend’s garden which, like all North Carolinian gardens in the summer, was bursting with vegetables – specifically, sumptuous tomatoes of unreal proportions and hue. On a whim, I set a few of the larger, sun-warmed spheres aside and later that day biked to the hospital. I found the family, handed them the plastic grocery bag, and with a sheepish gesture suggested that there might be an off chance a fresh-picked version of his favorite food would help. I felt clandestine with my package, sure that this was crossing a line of professionalism. Perhaps “Thou shalt not give foodstuffs to thy patients” was somewhere in the Hippocratic oath and I had missed the line. I fled from the hospital, unseen and with a vague pang of guilt.

On Monday, the cardiology fellow arrived for rounds. Sipping her coffee, she asked the resident “So, did Mr. Jones* get his PEG tube over the weekend?” The resident looked up and said “No, apparently surgery came in and watched him finish his whole plate of food. They said they aren’t touching him.” The fellow, wide-eyed, sputtered in disbelief, and soon all the team members formed a procession to go see for themselves.

What we found was nothing short of remarkable. The man, who days before had been one shade above dead, was sitting upright in bed, pink-cheeked, conversing with his wife. He invited us in as if we were visiting at his home, cracked jokes with a surprising level of wit, and answered the confounded attending’s questions crisply. I, as the token short-coat, found myself in the back. Though I had to crane my head able to see beyond the wall of more senior team members, I could clearly hear the residents hypothesizing, in hushed voices, the cause of Mr. Jones’s turnaround. “It must have been the threat of the g-tube” suggested one. “For sure” the other replied nodding in agreement “must have been the fear of the tube.”

At that moment the man’s wife leaned over to his ear and said “there is the young man that brought you those tomatoes.” Then his hand, weathered but confident, lifted and stretched out; it moved beyond the surprised attending, the coffee toting cardiac fellow, the whispering upper level, the agreeing intern, to me, the short-coated medical student. His hand wrapped around mine firmly and drew me, through the group, to the bedside. He folded his other hand on top of mine, looked up, and said “That…was the best tomato…of my life.”

*the name of the patient has been changed to protect his identity

By Matthew Wetschler

Faculty Spotlight: Dr. Jim Evans

Dr. Jim Evans: Educator, Clinician, Researcher and Tar Heel

Dr. Jim Evans is a familiar face to UNC-School of Medicine students as we have the pleasure of getting to know him in our very first block of first year, Molecules to Cells. In addition to being a dedicated educator Dr. Evans is a prominent physician researcher and embodies the rigorous scholarly thinking promoted by the Holderness Distinguished Medical Scholars Program.

Dr. Evans first became involved in research as an undergraduate. As a chemistry major at the University of Kansas he hoped to participate in summer research. To find a summer research position he “literally went to the Yellow Pages” to look up chemistry labs, Out of over 30 applications he was accepted to a single lab studying red blood cell membranes. Dr. Evans said that summer “changed my whole career.” Prior to that experience he wasn’t considering a career in medicine. He said his work in that first lab made him realize that there was an appeal to work that was directly relevant to human illness that made medicine very attractive.

While Dr. Evans continued research throughout his undergraduate years and medical school he says that his “best and most important training was at UNC when [he] came here for internship and residency.” During this time Dr. Evans worked in a hematology lab, where he says he “really learned molecular biology.” With regard to his mentors Dr. Evans says that the common characteristic shared by his most valued mentors is that they have been passionate and retained their “child-like enthusiasm for science.” He says that these mentors helped him appreciate both the beauty and power of science, inspiring and stimulating him, making him feel that he was capable of making an impact.

As both his clinical and research careers have progressed Dr. Evans says he has gotten more focused on trying to pursue things that are of tangible benefit. He says “When I was younger just the science seemed good enough as motivation…There’s a satisfaction in trying to contribute to health and peoples benefit that has grown richer as I have gotten older. That has gone along with my research gradually becoming far more clinical.”

Additionally, as his academic career as progressed Dr. Evans has transitioned from mentee to mentor. As a mentor Dr. Evans reminds himself daily to be critical of his own ideas and hypotheses and does the same for those he mentors. He tries to impart on younger researchers that science boils down to “thinking up experiments that are designed to destroy your own hypothesis.” Dr. Evans also reminds future clinical investigators to think creatively and warns against getting caught up in “group think”. As both a clinician and an investigator Dr. Evans urges students pursuing either field to “be hard-nosed about evidence, to not be seduced by your own ideas and always recognize that you could be wrong.”

As a true Tar Heel, Dr. Evans recognizes the unique and special environment at UNC.

“The community here of students and physicians is wonderful and rare.” He says. “It’s one where there is a lot of mutual support and warmth and enthusiasm and I really like that, it’s a wonderful environment here. We’re all lucky, and yet you can’t take for granted the sense of teamwork, enthusiasm and collegiality that exists; it’s just as fragile as it is important and powerful. We we should appreciate it and perpetuate it.”

By Rebecca Macfie