POSTER ABSTRACTS - American Academy of Physician Assistants

POSTER ABSTRACTSTABLE OF CONTENTSCLINICAL AND PROFESSIONAL GALLERYOriginal Research 2Case Studies/Clinical Reports 6Previously Presented 11EDUCATION GALLERYCurricular Innovation 13Educational Research 16Previously Presented 19PROFESSIONAL OUTREACH AND ADVOCACY GALLERYProfessional 22STUDENT GALLERYOutstanding Research 25Original Research 26Case Studies/Clinical Reports 45Previously Presented 56Outreach and Advocacy 56II

21ST ANNUAL CLINICAL AND PROFESSIONAL POSTER SESSIONMake an IMPACT by showcasing your high-quality posters that reflect the diversity of interests andtalents of the physician assistant community.The IMPACT 2012 Clinical and Professional Poster Session marks 21 years highlighting unique research accomplishedby PAs, PA faculty and PA students.Abstracts are listed in four galleries: (1) Clinical and Professional, (2) Education, (3) Professional Outreach andAdvocacy, and (4) Student Research. The categories featured are: original research, case studies/clinical reports,curricular innovations, educational research and posters previously presented at other medical/scientific conferences.Two student abstracts have been selected for outstanding student research; each will receive a $500 travel stipend.All abstracts are listed on the following pages. Nearly 100 posters will be available for viewing in the exhibit hall at theMetro Toronto Convention Centre beginning Sunday, May 27, and continuing through Tuesday, May 29. The authors willbe at their posters to engage in one-on-one discussions in an informal atmosphere on Tuesday, May 29, 2012, fromnoon until 1 p.m.The Poster Session is sponsored by AAPA’s Clinical and Health Affairs Commission.Abstracts are listed alphabetically by title.www.aapa.org/IMPACT 1

POSTER ABSTRACTSin the treatment and prevention of obesity and its secondarycomplications. Consideration of family support is vital whenhealthcare providers recommend healthy changes in diet andexercise within the pediatric population, since changes arevirtually impossible without primary caregiver participation.Such changes can ultimately result in improved health for anentire family. Educational programs that are family-centeredare particularly beneficial for immigrant populations and allowan opportunity to identify and break down some of the barriersthat hinder a healthy lifestyle in the United States.Characteristics of Those with Humeral FragilityFracturesJ. James, E. Pradk, M. Olschansky, D. Sietsema, C. Jones,T. Bacon-Baguley, Grand Valley State University, PhysicianAssistant Studies, Grand Rapids, Mich.Purpose: As the most common bone disease, osteoporosis isestimated to cause fragility fractures in 50 percent of femalesand 25 percent of males 50 years of age or older in the UnitedStates. Although the most common fragility fractures arelocated in the spine, hip and wrist, osteoporosis can affectalmost the entire skeleton. The objective of this study was tocharacterize individuals over age 50 who have sustained ahumeral fragility fracture requiring surgical fixation.Methodology: This study is a retrospective case control studyof patients 50 years of age or older who were surgically treatedfor a humeral fracture from a low-energy fall during the periodof December 2002 through March 2011 at a Level 1 TraumaCenter and treated at a large orthopaedic private practice.Patients were excluded who had known metastatic disease,periprosthetic fractures and incomplete medical records. Twohundred ninety-nine subjects were identified by CPT codesfollowed by a retrospective record review regarding the type offracture, osteoporotic risk factors, and diagnostic and treatmentmodalities.Results: Sixty-eight patients included 21 males (31 percent),mean age of 73 years (range: 55–90), and 47 females (69percent), mean age of 72 years (range: 50–92). The averageBMI was 30.0, with a range of 18.4 to 50.1. Prior to the currentfracture, 18 (27 percent) had a previous fragility fracture, 13 (19percent) were receiving a resorptive therapy for osteoporosis,12 (18 percent) had a prior diagnosis of osteopenia/osteoporosis, 16 (24 percent) were taking calcium and 14 (21percent) were taking vitamin D. Only one of 51 (11 percent)were evaluated for osteoporosis prior to the implementationof an osteoporosis clinic, whereas 12 of 17 (71 percent) wereevaluated. As a result of the fragility fracture, the followingdiagnostic procedure or treatment was prescribed: weightbearingexercise (38, 56 percent), calcium (16, 24 percent),vitamin D (15, 22 percent), bone scan (10, 15 percent),medication (10, 15 percent) and a fall prevention program(three, 4 percent). The most common identified risk factors forosteoporosis included: history of smoking (30, 44 percent),arthritis other than rheumatoid (20, 29 percent), diuretics (20,29 percent), thyroid medication (16, 24 percent), diabetesmellitus (14, 21 percent), history of corticosteroid use (14,21 percent), stroke (14, 21 percent), COPD (11, 16 percent),asthma (nine, 13 percent), dementia (eight, 12 percent),inflammatory bowel disorder (eight, 12 percent) and renaldisease (seven, 10 percent).Conclusions: Humeral fragility fractures occurred despite 19percent having a history of taking a resorptive medication,18 percent having a history of osteopenia/osteoporosis and27 percent having a previous fracture, and nearly all patientshaving identifiable risk factors for osteoporosis. Although themost common fractures due to osteoporosis are located in thespine, hip and wrist, this study identified that fragility fracturesof the humerus should be identified to avoid subsequentfractures. Implementation of an osteoporosis clinic wasimportant to improve screening and follow-up treatment.Hospital Associated Morbidity and Mortalityamong Newton Fire/EMS Patients who ReceivedPre-hospital Rapid Sequence Induction between2002 and 2009R. Muma, G. Berg, S. Metzler, B. Smith, M. Bartlett, A. Bolan,S. Dunn, A. Geist, D. Huff, J. Smith, Wichita State University,Department of Physician Assistant, Wichita, Kan.Background: Rapid sequence induction (RSI) is utilized inpatients with a gag reflex who require sedation and paralyzingof the airway prior to intubation. A measure of success in RSI isdefined as improvements in patient ER and hospital outcomes.Pre-hospital RSI has been shown by several studies to improvemorbidity and mortality, while other studies have shownconflicting results.Purpose: The primary purpose of this exploratory study wasto determine ER and hospital outcomes among EMS patientstransported by a small EMS system (Newton Fire/EMS System[NFEMS] in Newton [Harvey County] Kansas, population 34,684)who received pre-hospital RSI between 2002 and 2009.Methodology: All adult patients who received paramedicadministeredRSI from 2002 to 2009 were identified. Matchedcomparisons were selected from 1997 to 2002. Patient chartswere reviewed for a number of items, including patient age,gender, presenting condition, comorbidities, Glascow Comawww.aapa.org/IMPACT 3

POSTER ABSTRACTSReducing Hispanic Child Obesity Risk: A Look at“Por la Salud de Nuestros Niños”T. Cleveland, S. Walker-Pacheco, D. Piland, Missouri StateUniversity, Department of Physician Assistant Studies,Springfield, Mo.Purpose: Pediatric obesity is a growing epidemic across theUnited States, placing children at risk for adult obesity andchronic health problems. Disparities in rates of pediatricobesity are especially evident with respect to economic status,race and ethnicity. A multidisciplinary approach, focusing onproper nutrition and exercise, are at the cornerstone of obesitytreatment, while also taking into account cultural factorsinfluencing diet. The purpose of this study was to gauge theeffectiveness of our obesity and diabetes prevention programon a group of Hispanic children in Springfield, Mo.Methodology: We conducted a mixed-methods study over thecourse of one-and-a-half years in Springfield, Mo., where weinvestigated a group of 64 at-risk Hispanic children, ages 2 to13 years old. Our multidisciplinary team included a physicianassistant, an anthropologist and a dietician. Quantitative andqualitative data collected included: caregiver and child surveys,24-hour recall nutritional assessments, daily nutritional intakeand physical activity as reported by caregivers, a focus groupand monthly physical measurements (height, weight, bodymass index [BMI], blood pressure and skinfold thickness).Our weekly interactive health program focused on nutritionand exercise education for the children, and handouts wereprepared for caregivers on these topics as well as on therisks of childhood obesity and diabetes. Presented here isa comparison of the first and last set of monthly physicalmeasurements.Results: Data on physical measurements were analyzed for39 participants for whom initial and culminating data wereavailable. A significant difference was found in the beginningand ending BMIs: 35.9 percent had an initial BMI of greaterthan the 85th percentile, while 28.2 percent fell into this highrange at the end of the study. Of these 35.9 percent, 20.5percent fell into the 95th or greater percentile at the beginningof the study, compared with only 15.4 percent in this heaviestcategory at the end of the study. Waist circumference andtriceps skinfold measurements were also reduced by the endof the study: 56 percent of participants had an initial waistcircumference at or above the 75th percentile, reduced to 44percent by the end. Less dramatic changes were observed in thetriceps skinfold measurements, which fell from 58 percent to 55percent at or above the 75th percentile.Conclusions: Overall, physical data measurements improvedover the course of the study for program participants, with BMIexhibiting the greatest change, followed by waist circumference,then triceps skinfold thickness. These findings indicatethat this study was successful in its goal of reducing risk ofchildhood obesity within our study group. Our program utilizeda multidisciplinary approach, which offered a broad basis ofexpertise in nutrition, physical activity, biomedicine and culturalanthropology. Although improvement was observed overall,11 children remained in the overweight and obese categoriesaccording to BMI. Given the fact that much of childhood remainsfor the individuals in our study group, continued support isneeded to prevent adult obesity and chronic health problems.The Role of the Physician Assistant in ImprovingPatient Access to Primary Care within a SpecializedSpinal Cord Injury Patient-Centered Medical HomeR. Boucher, R. Ben-Youssef, J. Cordero, T. DeBord,L. Hermosura, M. Aisen, Y. Szlachcic, Rancho Los AmigosNational Rehabilitation Center, Downey, Calif.Purpose: The ideology of the patient-centered medical home(PCMH) depends on enhanced patient access to healthservices through more efficient and more comprehensive carecoordination. Our goal was to show that assigning managerialroles to physician assistants who have a special focus onadministration and management could be of major benefit tothe success of PCMH programs.The design of the study indicates “no show” patients blockavailable clinic time slots and prevent other patients withreal healthcare needs from accessing our medical services.Likewise, scheduling return visits when not clinically necessaryblocks future appointment options and leads to an increase inthe no show rate (NSR). We developed a task force to improveour clinic’s operations and to improve our patients’ accessto better quality care. This team included a lead SCI-trainedmedical doctor, two internal medicine doctors, two nursepractitioners, six nurses and nurse assistants, and a PA withspecial administrative and managerial skills to whom the role ofPCMH administrator was assigned.Methodology: We implemented three tactical changes;reminder phone calls were conducted to confirm a patient’sappointment. The existing schedule template was changedto incorporate one “same day” slot per hour in each clinicsession; this slot was reserved for patients calling in requestingto be seen in the next 24 to 48 hours. Finally, patient returnvisit intervals were increased or were made as needed whenclinically appropriate, and routine medication refills andprescriptions for supplies were given in larger quantities inorder to reduce return trips to the clinic for just this purpose.www.aapa.org/IMPACT 5

POSTER ABSTRACTSResults: Patients’ improved access to services was measured bythe number of third next available appointments (TNAA) and bythe NSR for one provider over a six-week pilot study period. Theclinic NSR dropped from 28 percent to 0 percent and the TNAAdropped from 75 days to six days over a six-week period.Conclusions: Significant positive changes can be made ina short period and lead to improved patient access to care.PAs with special administrative and managerial skills canplay a major role in the success of PCMH due to their uniquerelationship with the supervising physician and primary caretraining.Seroconversion to HIV Positivity in Follow-Up Testing of Patients with False Positive andIndeterminate Results within the Harris CountyHospital DistrictK. Agura, K. Erdman, T. Giordano, Baylor College of Medicine,Houston, TexasBackground: The gold standard for Human ImmunodeficiencyVirus (HIV) testing consists of a screening test performed withan enzyme immunoassay that can detect both type 1 and 2HIV. Any samples with a positive screening result are thenconfirmed with a Western Blot (WB) analysis. During this testingprocess, a patient may receive a false-positive test, signifyingthe screening test result was positive but the confirmatorytest result was negative. In such cases no additional follow-uptesting is recommended. Alternatively, a patient may receivean indeterminate Western Blot (WBi), signifying that theresult is neither positive nor negative. In this situation, it isrecommended that the patient seek repeat testing in three tosix months. In these populations of patients with false-positiveor WBi test results, the possibility of an increased risk of futureseroconversion has yet to be investigated. Seroconversionconsists of the development of detectable antibodies to HIV inthe blood and it may take up to several weeks from exposure tooccur.Purpose: The purpose of this study was to evaluate follow-upHIV testing in patients who had received a false-positive testresult or a WBi result within a Harris County Hospital District(HCHD) emergency department or clinic. The study focused onidentification of HIV seroconversion identified with subsequentblood draws during follow-up testing.Methodology: Over an 18-month period, patients who receivedblood draws in the HCHD emergency centers were screenedfor HIV through the Routine Universal Screening for HIV (RUSH)program. The charts of patients with a false-positive result or aWBi confirmatory result were reviewed and any additional HIVtest results were extracted for analysis. All HIV test results wereobtained from the HCHD patient electronic medical record.Results: During the designated time period, 66,603 HIV testswere performed in the emergency centers. There were 37 peoplewho received a WBi result. Of those, 24 received follow-uptesting, and six of the 24 seroconverted to WB-positive. Ofall patients tested, there were 77 with a false-positive result.Of those, 33 had follow-up testing, and one seroconverted toWB-positive. Of note, in the false-positive group three peoplewere found to have a detectable HIV viral load either on thesame date or after the index test with a false-positive result.Conclusions: This study showed that there is a significant riskfor seroconverting to HIV-positive in patients with a WBi resultor false-positive result during screening. These patients shouldpotentially be recommended the appropriate additional testingand counseling.Clinical and Professional GalleryCASE STUDIES/CLINICAL REPORTSA 31-Year-Old Man Presenting with Altered MentalStatus and New-Onset SeizuresR. Cassa, J. Navoa, A. Salvatore, A. Rosengart, New York-Presbyterian Hospital/Cornell, New York, N.Y.A 31-year-old right-handed male was referred for bizarrebehavior and distractibility, which quickly developed into frankdelusions, personality changes with anxiety, disorganizedspeech and a series of grand mal seizures. History includedtreated NIDDM and hypertension, recent weight loss andincreasing sleepiness for several weeks. No travels, headachesor seizures; no use of illicit drug or alcohol.His vital signs were HR 106, RR 22, BP 145/87; afebrile, SO2on room air 100 percent. He was awake, opened eyes withsome random fixations but no sustained interactions withthe environment; intermittent perseverations of unintelligiblephrases, persistent hyperkinetic smacking-like, oropharyngealmovements and dystonia of upper extremities; otherwisenonfocal neurological and general examination.CSF 16 lymphocytes, 2000 RBC, protein 3.8 and glucose 99.Negative toxicology, blood and CSF cultures and viral panels;negative for AFB, ANA, rheumatoid factor, ANCA, VDRLT, HIV,EVB, CMV, HSV and West Nile virus. Antibodies to Anti-N-Methyl-D-Aspartate (NMDA) receptors, and anti-HU and MA6

POSTER ABSTRACTSwere positive. Video-EEG identified right frontal lobe slowingwith focal spikes and secondary generalization to tonicclonicseizures. Repeated brain MRI, MR angiography, MRspectroscopy and whole body Positron Emission Tomographywere unremarkable.This patient’s history, clinical examination and initial diagnosticfindings were compatible with imaging-negative, acute,progressive encephalitis. Etiologies such as viral (i.e., West Nile,HIV or HSV) or bacterial infections were excluded by repeatedspinal fluid sampling, and structural or vascular abnormalitieswere ruled out by brain imaging. In this patient, postvaccinationor autoimmune encephalitis was the presumptivediagnosis and he was immediately started on high-dosesteroids. Autoimmune encephalitis entails a wider spectrumof disease ranging from systemic lupus erythromatosus toNMDA receptor encephalitis, viral encephalitis and systemiclupus erythematosus cerebritis. Anti-NMDA receptor antibodieswere positive in this patient. This severe form of autoimmuneencephalitis is associated with antibodies against the NR1- NR2neuronal receptor heteromers and results in a characteristicneuropsychiatric syndrome 1. About 41 percent anti-NMDAreceptor encephalitis patients do not have a clinicallydetectable tumor and, if present, tumor resection is vital toattain recovery or sustain the improvement.The patient was started on a course of IVIG, plasmapheresis anda course of rituximab. His course was complicated by bilateralpulmonary emboli, VRE pneumonia and a left pneumothorax.His seizures were well controlled with oxycarbazepine. Botha testicular ultrasound and a PET scan were unremarkable.At discharge, he was awake, alert and oriented x3 with intactcranial nerves and 4/5 proximal and distal weakness. Thepatient was discharged to a subacute rehabilitation facility andsubsequently made a complete recovery.A Man with Schizoaffective Disorder ParalyzedWithin HoursR. Cassa, C. Jairam, D. Winick, A. Rosengart, New York-Presbyterian Hospital/Cornell, New York, N.Y.We present the case of a 59-year-old male who experienced overthe course of six hours progression of slurred speech, upperairway swelling and ascending weakness of all extremities.This independently living man had a history of schizoaffectivedisorder and hypertension treated with venlafaxine, risperidone,hydroxyzine, aspirin, pravastatin and hydrochlorothiazide. Hewas in his usual state of health until two weeks prior whenhe lost his job as a store attendant and was unable to obtainmedication refills. He presented to the emergency departmentcomplaining of “not feeling right” and a “thick throat.”Examination revealed an alert and fully oriented patient feelingrestless and anxious. Neuropsychiatric and cognitive evaluationdelineated a clear sensorium. Cognitive evaluation was normal.BP 110/60, HR 80, no fever and no skin lesions; hypopnea ofeight breaths/minute, oxygen saturation 91 percent; regularthoracic examination; tympanic and hypoactive abdominalsounds. Neurologically, mild bilateral eye lid drooping, mildbifacial paresis and decreased 4-/5 proximal but normal distalstrength of all extremities.Over the next six hours the patient deteriorated rapidlywith hypotension, bradycardia, respiratory failure requiringintubation and asystolic arrest necessitating resuscitation.Detailed neurological examination after stabilization showedan awake patient with preserved ability to communicate byslight head rotations, bilateral complete ptosis, fixed anddilated pupils, lack of eye and facial movements, absent gagand cough and flaccid tetraplegia with absent reflexes. Head,neck and chest imaging were unrevealing; extensive laboratoryworkup was negative, including normal liver, thyroid, toxin andCSF panels. A clinical diagnosis was established and verified bydiagnostic EMG.The differential diagnosis includes Guillain-Barré syndrome,tick paralysis, brainstem stroke, botulism, intoxications andmotor neuron endplate diseases such as myasthenia gravisand Lambert-Eaton syndrome. However, only pontine ischemia,some intoxications and botulism induces simultaneousparalysis of the pupillary sphincters. Since brain imaging wasunrevealing, EMG was performed identifying incrementalmuscle response to repetitive stimulation at 50 Hz, shortduration but polyphasic motor unit potentials with decreasedamplitude of compound muscle action potentials after nervestimulation. However, motor and sensory conduction velocitieswere all normal. The New York Department of Health and theCenters for Disease Control and Prevention were contactedto report and investigate acute botulism. A diagnostic stoolsample showed botulism type A. Investigation at the patient’sresidence revealed that the temperature of the refrigerator was60°F and a sample of hot sauce was positive for botulism typesA and B.Botulism is a neuroparalytic toxin produced by Clostridiumbotulinum. Five forms of botulism can occur, depending onthe mode of acquisition of the toxin. In our patient, botulismoccurred by ingestion of food containing preformed toxin. About110 cases of botulism are reported each year in the UnitedStates. In an afebrile patient, clinicians should recognize theclassic triad of clear mentation, bulbar palsy and symmetricdescending paralysis.www.aapa.org/IMPACT 7

POSTER ABSTRACTSAn Unusual Cause of Headache and PhotophobiaJ. Van Rhee, Northwestern University, Chicago, Ill.Headache, photophobia, nausea and vomiting are commonpresentations of migraine, post-traumatic injury, neurologicinfections and a variety of systemic disorders. Etiologies ofneurologic infections include bacterial and viral meningitis, viralencephalitis, parasitic and fungal infections.In this case, a 27-year-old Hispanic male who presents withheadache, photophobia, nausea and vomiting is discussed.Presented to the emergency room (ER) with a three-day historyof headache, the patient had been seen in the ER the day priorfor evaluation of the same. On this presentation, the headachehas increased in intensity (pain was a 10 out of 10), new onsetof nausea and vomiting, and photophobia. The patient’s pastmedical history was unremarkable except for a positive PPDone year ago, treated with isoniazid for six months. He hasno known medical allergies. Social history was significant formoving to the United States seven years prior from Guatemala.He was a non-smoker and non-drinker. Review of systems waspositive for weakness, myalgias, chills and low-grade fever.Review of systems was negative for chest pain, shortness ofbreath, cough, abdominal pain or focal neurologic deficit.The patient was afebrile with blood pressure 135/81mm Hg,pulse rate of 80/minute and respiratory rate of 20/minute.Oxygen saturation on room air was 100 percent. The patient wasweak, but in no acute distress. Skin was without rash. HEENTwas unremarkable. Mild tenderness noted with full flexion ofthe neck. Lungs were clear to auscultation and regular heart rateand rhythm without murmur. The abdomen was soft withoutmasses. No hepatosplenomegaly was noted. Extremities werewithout cyanosis or edema. Neurologic exam was normal.Laboratory testing revealed WBC: 12,300/UL, Hgb: 16.0 g/dl, Hematocrit: 48 percent, MCV: 88 percent, platelet count:262,000/UL. Metabolic profile was normal except for sodiumof 132 mEq/L and glucose of 132 mg/dl. Urinalysis, chest x-rayand EKG were normal.A lumbar puncture was performed. The CSF was hazy withoutxanthochromia. Cell count: 30 RBC/UL and WBC 560/UL. CSFdifferential: 15 percent neutrophils, 34 percent lymphocytes,43 percent monocytes and 8 percent eosinophils. CSF glucosewas 57 mg/dl and total protein was 147 mg/dl. The patient wasgiven a dose of IV Solu-Medrol and IV ceftriaxone. The patientwas admitted and a brain CT was performed. CT revealedmultiple punctate calcific densities scattered throughout thebrain. AFB and bacterial cultures of the CSF were negative.Serology studies for Taenia solium were obtained and werepositive. Antibiotics and steroids were discontinued. Finaldiagnosis was neurocysticercosis.Neurocysticercosis is a nervous system infection due to Taeniasolium (pork tapeworm). Presentation of the disease variesfrom asymptomatic to nonspecific neurologic findings, suchas headache, confusion, seizures and psychiatric symptoms,to sudden death. CSF studies may reveal an eosinophilia. CTor MRI of the brain typically presents with cystic structures,enhancing lesions and parenchymal calcifications. Antiparasiticdrugs are available for treatment and in some casessurgery may be needed. In some cases patients do not need tobe treated.Bone Pain in the Elderly Patient: A Diagnosisto ConsiderC. Kelly, Southern Illinois University Physician AssistantProgram, Carbondale, Ill.Multiple myeloma is an important cause of hematologic,malignant disease and is a well-known entity in the medicalliterature. However, multiple myeloma is a disease of insidiousonset and presents in a variety of ways, often misdiagnosedinitially. It is especially important to consider this diagnosiswhen encountering bone pain in the elderly patient.Multiple myeloma results from the malignant proliferation ofplasma cells within the bone marrow, which then causes bothbone marrow and skeletal dysfunction. The first documentedcase of multiple myeloma was reported by Dr. Samuel Sollyin 1844. In 1850 another patient with similar findings wasencountered by Dr. Macintyre and a urine sample was sent tothe well-known pathologist Dr. Bence Jones. The disease wouldearn its name in 1873 by Dr. J. von Rustizky. The understandingand treatment of this disease has come a long way since itsinitial recognition. The link between pathological proteinsynthesis, renal consequences, skeletal destruction and bonepain is complex and often difficult to diagnose.In this case, a previously healthy 83-year-old male with littlemore than a history of osteoarthritis presented to an urgent careclinic to request new medication for complaints of chronic lefthip and knee pain. He had seen his primary care physician fourmonths prior and was placed on celecoxib at that time. Furtherquestioning revealed decreased appetite, fatigue, weight lossand constipation. Differential diagnoses considered includedmusculoskeletal disorders such as osteoarthritis, rheumatoidarthritis and polymyalgia rheumatic, other connective tissuediseases, primary malignancies of the bone or bone marrow,and metastatic disease. Laboratory results revealed white bloodcell count of 9,300, hemoglobin at 7.9 g/dL, serum creatinineof 7.8 mg/dL, calcium at 14.0 mg/dL, total protein of 11.6 g/dL, albumin at 3.3 g/dL, alkaline phosphatase at 55 IU/L, PSAat 2.54 mcg/L and serum protein electrophoresis resulted in a8

POSTER ABSTRACTSbimodal protein peak. Immunofixation exhibited an elevatedresponse to IgA and lambda antisera. Initial radiographs didnot demonstrate lytic lesions, but subsequent total bone surveyrevealed multiple radiolucencies throughout the calvarium,pectoral girdle and femur.The patient’s complex medical picture resulted in the followingdiagnoses: multiple myeloma, renal failure, hypercalcemia,constipation secondary to hypercalcemia, anemia secondaryto bone marrow dysfunction and renal failure. The patient wasadmitted for intensive care and referred for nephrology andoncology consultations.It is important to appropriately attend to complaints of bonepain in the elderly and to consider causes with potentiallycritical consequences, such as multiple myeloma. Bone painaccompanied by constitutional changes such as weight loss andfatigue warrant a thorough workup. This case illustrates theseimportant clinical teaching points that may otherwise be missedin an elderly patient.Coccidioidal Meningoencephalitis: A CommonDisease Presenting in an Uncommon MannerH. Studer, Mayo Clinic Hospital, Phoenix, Ariz.A 70-year-old male with a history of pulmonarycoccidioidomycosis one year ago presented to the emergencydepartment for evaluation of weight loss, gait unsteadiness,progressive lower extremity weakness, and difficulty inconcentration and word-finding abilities.His history was significant for multiple recent admissions forweakness, weight loss and failure to thrive, with previousnegative workups for acute neurological pathology asevidenced by computed tomography (CT) scan. Magneticimaging scan was contraindicated secondary to a pacemaker.He denied symptoms of pain, fever or recent infection andexam was only significant for bilateral lower extremity weaknesswithout meningeal signs. After a repeat CT was negative,lumbar puncture unveiled an inflammatory picture suspiciousfor meningitis. Cerebral spinal fluid revealed antibodies tococcidioidomycosis consistent with acute infection. The patientbegan an extended length treatment with high-dose Diflucan.Coccidioidomycosis is a fungal infection prevalent in theSouthwest United States that commonly presents as apulmonary infection but can rarely manifest as encephalitis ormeningoencephalitis, as in the case of our patient. Practitionersmust maintain a level of suspicion for this disease becauseit can be difficult to diagnose and treat due to presentationwithout a lot of typical meningeal signs or symptoms.Periprocedural Anticoagulation Management inPatients Taking WarfarinL. Kiemele, T. Ransone, Mayo Clinic, Rochester, Minn.The role of warfarin and low-molecular weight heparin(LMWH) is well-established as prophylaxis in preventingthromboembolism (TE). Warfarin is a vitamin K antagonistthat inhibits the production of coagulation factors II,VII, IX, X, protein C and protein S. Warfarin is effective inpreventing arterial and venous thromboembolism (VTE) andis recommended for stroke prevention in patients with atrialfibrillation, valvular heart disease, mechanical heart valveprostheses, deep venous thrombosis (DVT) and pulmonaryembolism (PE).An increasing number of patients with these conditions arereceiving warfarin therapy for preventing thromboemboliccomplications, which often requires temporary interruptionfor an invasive procedure. The data is limited regardingthe incidence of TE and bleeding related to periproceduralanticoagulation management in these patients. Even in patientsnot being anticoagulated, invasive procedures carry a risk ofbleeding up to one week post-procedure.The primary purpose is to illustrate an effective periproceduralanticoagulation regimen for patients being anticoagulated withwarfarin.In a retrospective cohort study, all VTE patients referred tothe Mayo Clinic Thrombophilia Center for periproceduralanticoagulation management between 1997 and 2007 werefollowed for three months post-procedure to investigate theirincidence of TE and bleeding. Warfarin was stopped four to fivedays prior to the procedure and restarted once hemostasis wasachieved. Decisions to provide bridging therapy with LMWHwere individualized and based on their estimated risk of TE andbleeding.Eight hundred sixty-four VTE patients were referred forperiprocedural anticoagulation management. The three-monthincidence of TE and bleeding were low except in those patientswho underwent surgery less than 30 days from the onset oftheir VTE.The incidence of TE and bleeding among VTE patients in whomanticoagulation is temporarily interrupted is low. Our currentpractice is to administer LMWH bridging therapy only for thosepatients at increased risk of TE (such as prior stroke, CHADS2score of four or more in patients with atrial fibrillation) whileconsidering the procedure-associated risk of bleeding. Mostpatients can undergo dental procedures, arthrocentesis,www.aapa.org/IMPACT 9

POSTER ABSTRACTScataract surgery and diagnostic endoscopy without altering theiranticoagulation regimen. In patients at increased risk for VTEwho require temporary cessation of warfarin, a standardizedperiprocedural anticoagulation regimen with LMWH lowers therisk of TE and bleeding complications. Elective surgery shouldbe avoided in the first month after an acute VTE. If a patient isreceiving anticoagulation therapy for less than one month aftera TE event and surgery is needed, a vena cava filter needs to beplaced. Given their propensity for clotting and bleeding, cancerpatients require special care.Switched at Birth: Diagnosis and Treatment ofD-Transposition of the Great ArteriesL. Lang, Sanger Heart & Vascular Institute, Charlotte, N.C.This case is about a three-day-old Caucasian male. He is theproduct of an uncomplicated term pregnancy. APGAR scoresnoted at eight and nine. He fed without complication. On dayone of life, he underwent circumcision. Following the procedurethe infant was noted to be cyanotic, with oxygen saturations inthe 50’s and was transferred to the neonatal intensive care unitwhere he was started on prostaglandin therapy and intubated.Once stable the patient was transferred to Levine Children’sHospital for further workup.A complete transthoracic echo at this time revealsD-transposition of the great arteries with a patent ductusarteriosus and an atrial septal defect. Transposition of thegreat arteries (TGA) accounts for 3 percent of all congenitalheart disease (CHD) and almost 20 percent of all cyanotic CHDdefects. The prevalence in the United States is estimated tobe anywhere from 2.3 to 4.7 per 10,000 live births and has adistinct male predominance.The most common form of TGA is the dextro type or D-TGA, inwhich the pulmonary and systemic circulations exist in parallelinstead of in series. Without surgical intervention this lesion isincompatible with life. TGA is characterized by atrioventricularconcordance and ventriculoarterial discordance; this anatomyresults in nonoxygenated venous blood passing through theright ventricle to the aorta, and oxygenated pulmonary venousblood passing through the left ventricle and back to thepulmonary arterial circulation. Survival is dependent on mixingof oxygenated and deoxygenated blood between a patentforamen ovale, atrial septal defect, ventricular septal defect or apatent ductus arteriosus.Patients with TGA most commonly present during the neonatalperiod, with the most common clinical finding being cyanosis.Once diagnosed, initial management is focused on maintainingsufficient intercirculatory mixing between the two parallelcirculations via prostaglandin E1 infusion to maintain patencyof the PDA and/or balloon atrial septostomy.Once the infant is stabilized, corrective surgery is usuallyperformed in the first weeks of life. The most common practiceis repair of the defect using the arterial switch operation, withmortality rates of less than 5 percent versus 90 percent forunoperated patients. On day two of life, the infant, despitehis prostaglandin infusion, experienced a decline in hisclinical status. An echocardiogram revealed an increasinglyrestrictive atrial septal defect. An emergent bedside balloonatrial septostomy was performed, creating adequate systemicperfusion and oxygen saturations in the mid 80’s. On day six oflife, the infant proceeded to the operating room and underwenthis arterial switch procedure. He remained stable throughoutthe procedure and did well during his postoperative course.Neonatal cyanosis is an alarming clinical finding; efficientevaluation with echocardiography is frequently conclusive inthe diagnosis. Transposition of the great arteries is the numberone cause of neonatal cyanosis. Early surgical intervention,arterial switch operation, has a very low mortality and frequentlyallows children a normal life span with no further intervention.The Mystery of Multiple Thromboemboli: A HighClot Burden in a Patient on Therapeutic LovenoxTreatmentF. McGlothlin, Mayo Clinic Hospital, Phoenix, Ariz.This presentation highlights the case of multiple thrombioccurring in a 77-year-old Caucasian male with stage III nonsmall-celllung cancer while on 1.5mg/kg daily therapeuticLovenox for a previous DVT diagnosis. The patient presentedto the emergency department with complaints of worseningdyspnea for two days, with associated wheezing andhemoptysis. CT angiogram showed bilateral pulmonary emboliwith complete occlusion of the right lower lobe. The patientalso complained of a “lump in his throat” with associatedgeneralized dysphagia. CT of the neck demonstrated bilateralsubclavian vein thrombi, a thrombus in the right internaljugular vein and evidence of new metastatic disease. Bilateralultrasound of the lower extremities showed the presence ofbilateral DVTs. Echocardiogram showed evidence of right heartstrain, and a new RBBB was present on EKG.In addition, the patient also displayed evidence of SVCsyndrome with new collateral vessels appearing on the chestwall. The patient’s platelets were acutely decreased to 41,000,suggestive of a possible DIC or HIT picture. Due to the patient’sthrombocytopenia, heparin treatment was deferred and thepatient was started on argatroban therapy. Vascular medicine10

POSTER ABSTRACTSfelt that the patient was a poor surgical candidate, and athrombectomy was deferred. A factor Xa level was drawn andshown to be within optimal range. A HIT panel was negative,and labs were suggestive of a possible chronic DIC. The patientwas initiated on Lovenox, one mg/kg BID for treatment of hismultiple clots, and discharged home with recommendationto discuss further radiation/chemotherapy with his primaryoncologist.It is very uncommon for an individual to experience such anoverwhelming clot burden while on therapeutic Lovenox. Whilethe case described is rare, it offers many opportunities to learnabout common medical issues.Clinical and Professional GalleryPREVIOUSLY PRESENTEDAdjunctive L-methylfolate in Patients withSSRI-Resistant Depression—Opportunities forPersonalized TherapyI.V. Mackey, G.I. Papakostas, J.M. Zajecka, R. Shelton, A. Clain,L. Baer, M. Pencina, A. Meisner, M. Fava, Psychiatric MedicineAssociates, LLC, Skokie, Ill.Purpose: The purpose of this analysis was to evaluatespecific biomarkers (L-methylfolate serum level, BMI,methylentetrahydrofolate reductase [MTHFR] C677T genotype)on the efficacy and tolerability of adjunctive L-methylfolate 15mg in a double-blind trial of inadequate responders to SSRIs.Methodology: Seventy-five outpatients with SSRI-resistant MDDwere enrolled in a 60-day, multi-center, double-blind, placebocontrolledtrial divided into two 30-day phases. Patientsreceived L-methylfolate 15 mg/day for 60 days, placebo for30 days followed by L-methylfolate 15 mg/day for 30 days, orplacebo for 60 days. The impact of biomarkers on treatmenteffect was evaluated.Results: Adjunctive L-methylfolate 15 mg/day produced asignificant effect ([pooled difference in response rates on theHDRS-17 (17.7 percent, p=0.04)]). Pooled differences in meanchange on HDRS-17 and HDRS-28 were significantly different(p=0.05 and p=0.02, respectively). Treatment effects weresimilar in patients with baseline L-methylfolate levels belowversus above the median. A numerically greater treatment effectwas observed in patients with an allelic variant in the MTHFRC677T genotype (difference in mean change in HDRS-28 of-3.75 for “T” allele [homozygotes and heterozygotes combined]versus -1.99 for “CC” allele). Patients with a BMI ≥30 kg/m2experienced a significantly greater reduction in depressivesymptoms with L-methylfolate (difference in mean change inHDRS-28 of -4.66; p=0.001). In the presence of a combinationof BMI≥30 kg/m2 and C677T “TT” genotype, the treatmenteffect was significantly greater (difference in mean change inHDRS-28 of -9.88; p=0.001).Conclusions: Adjunctive L-methylfolate 15 mg/day mayrepresent an effective and well-tolerated treatment strategy forSSRI partial and non-responders, particularly in patients with aBMI ≥30 kg/m2 and/or the MTHFR C677T “T” allele.BDP HFA Nasal Aerosol 320 µg Once Daily is Safeand Effective in the Treatment of Nasal SymptomsAssociated with Perennial Allergic RhinitisG. Ortiz, E.O. Meltzer, R.L. Jacobs, C.F. LaForce, L. Kelley, S.A.Dunbar, S.K. Tanty, Pediatric Pulmonary Services, El Paso, TexasPurpose: Intranasal corticosteroids, considered one of the mosteffective treatments for allergic rhinitis (AR), are currently onlyapproved as aqueous sprays. Beclomethasone dipropionatehydrofluoroalkane (BDP HFA) has recently been developed asa nonaqueous nasal aerosol for the treatment of AR and hasbeen shown to be safe and effective in subjects with seasonalAR (SAR). The present study evaluated the efficacy, safety andtolerability of BDP HFA nasal aerosol in subjects with perennialAR (PAR).Methodology: A six-week, phase three, randomized, doubleblind,parallel-group, placebo-controlled multicenter study wasconducted in subjects with PAR. Eligible subjects (n=474) 12years of age or older were randomized to receive a once-dailydose (two sprays [80 µg/spray] per nostril) of either BDP HFA320 µg/day or placebo. The primary efficacy endpoint was theaverage AM and PM subject-reported reflective Total NasalSymptom Score (rTNSS) over the six-week treatment period.Safety and tolerability of BDP HFA were also evaluated.Results: The change from baseline in average AM and PMsubject-reported rTNSS was significantly greater with BDP HFA320 µg/day compared with placebo (least squares [LS] meantreatment difference = –0.84 [95 percent CI –1.2, –0.5]; p

POSTER ABSTRACTS(sneezing, runny nose, nasal itching and nasal congestion) withBDP HFA 320 µg/day compared with placebo. BDP HFA 320 µg/day was well tolerated and its safety profile was comparable tothat of placebo.Conclusions: This study demonstrated that treatment withBDP HFA nasal aerosol 320 µg once daily provides significantimprovement in nasal symptoms associated with PAR. Theresults of this study in PAR, in conjunction with the results fromprevious studies in SAR, indicate that BDP HFA nasal aerosolwill be an effective and well-tolerated treatment option for alltypes of patients with AR.“Just a Click Away”: Capturing Tobacco CessationCounseling in Orthopaedic PatientsA.M. Duran-Stanton, A. Johnson, K.L. Kirk, United States Army,Fuquay-Varina, N.C.Background: Tobacco use is a known risk factor for orthopaedicproblems. Studies show that poor wound healing, prolongedrecovery and higher disability are related to tobacco use.Surgeons know tobacco users should be counseled on tobaccocessation. Tobacco cessation counseling provides a “teachablemoment” in behavioral modification. In the military, prevalenceof tobacco use is at 30 to 45 percent. In our institution, oneRVU equates to $38.26. The orthopaedic surgery clinic hasannual RVU goals that reflect workload and productivity.Tobacco cessation counseling for three to 10 minutes equatesto .24 RVUs and >10 minutes equates to 0.50 RVUs. Even if theprivileged provider free texted on the “Assessment and Plan”that they provided the tobacco cessation counseling, it is notcaptured for RVUs if the codes are not selected.Purpose: We wanted to determine if tobacco cessationcounseling are reflected in our outpatient electronic medicalrecords, which equate to workload hours and revenue for theorthopaedic surgery clinic.There were 23,462 new outpatient visits from a total of 195,338visits during the study period.Methodology: A descriptive retrospective design was used toanalyze orthopaedic patient visits at BAMC for coded tobaccouse and tobacco cessation counseling from January 2003 toNovember 2010. Using the Composite Health Care System(CHCS), we determined: (1) how many outpatient orthopaedicsurgery clinic visits there were during the inclusion period ofthe study, (2) how many of those visits were for new patientencounters, (3) how many coded tobacco use (305.1)/historyof tobacco use and (4) how many coded tobacco cessationcounseling (99406/99407). We used $38.26 as one RVU.Results: There was one properly coded tobacco cessationcounseling (99406 – 3–10 minutes). With the calculationsbased on a 25 percent prevalence of the total patient visits weretobacco users, assuming all new patients that were tobaccousers were counseled for >10 minutes, there was a total of$112,207.02 missed revenue. And, for follow-up visits thatwere tobacco users that could potentially have been giventobacco cessation counseling for three to 10 minutes, therewas a total of $416,097.59 missed revenue accounting forthe one 3–10-minute counseling that was properly coded.This totaled $527,812.33. Assuming we did not provide >10minute counseling and only provided 3–10-minute counselingon tobacco users, the missed revenue would have been$448,408.73, which is still a significant amount, especiallywhen it is something that we already provide for our patients.Conclusions: We know that we provide tobacco cessationcounseling to our patients. However, we are underreportingtobacco use and tobacco cessation counseling in ourdocumentation. Future studies should include all the clinicsin the hospital to determine RVUs missed and provide a“teachable moment” to each clinic regarding how theycan improve documentation to capture tobacco cessationcounseling. The solution is literally just a click away to selectthe proper code, which takes less time than free texting.Patient Satisfaction and Ease-of-Use of BDP HFANasal Aerosol Device in Subjects with PerennialAllergic RhinitisG. Ortiz, G.N. Gross, R.A. Settipane, L.B. Ford, L. Kelley, S.A.Dunbar, S.K. Tantry, Pediatric Pulmonary Services, El Paso, TexasPurpose: Intranasal corticosteroids (INCSs) are currentlyavailable only as aqueous formulations. However, somepatients may prefer non-aqueous products to avoid the“wet feeling” and “dripping down the throat” associatedwith aqueous products. Furthermore, none of the availableINCS devices include a dose counter, which may lead manypatients to prematurely discard a device or use the devicebeyond the labeled number of doses. Beclomethasonedipropionate hydrofluoroalkane (BDP HFA) nasal aerosol,a non-aqueous formulation in a device with an integrateddose counter, has been developed and been shown to be aneffective treatment for allergic rhinitis (AR). As part of this nasalaerosol development program, device ease-of-use and subjectsatisfaction with the device were evaluated in a perennial AR(PAR) study and the results are reported here.Methodology: A phase three, randomized, double-blind,parallel-group, placebo-controlled study was conducted insubjects 12 years of age and older with PAR. Eligible subjects12

POSTER ABSTRACTS(n=474) were randomized to receive BDP HFA 320 µg/dayor placebo for six weeks. At the end of the treatment period,device ease-of-use and device satisfaction were self-assessedby subjects using a questionnaire with a 5-point scale(representative scale: Not Easy at All, Not Very Easy, NeitherEasy nor Uneasy, Somewhat Easy, Very Easy; “satisfaction”scale was similar).Results: Nearly all subjects (89.7 percent) assessed the BDPHFA nasal aerosol device with dose counter as “Very Easy”or “Somewhat Easy” to use. The majority of subjects (87.6percent) also indicated that it was “Very Easy” or “SomewhatEasy” to tell when the device was empty, compared with only42.3 percent who were “Very Certain” or “Somewhat Certain” ofbeing able to tell when aqueous nasal spray devices (previouslyused or currently using) were empty. Overall subject satisfactionwith the BDP HFA nasal aerosol device was high: 65.7percent subjects responded that they were “Very Satisfied” or“Somewhat Satisfied”; only 3.6 percent of subjects were “NotSatisfied at All” or “Not Very Satisfied.”Conclusions: Overall, the degree of satisfaction with the BDPHFA nasal aerosol device was high, indicating that this newaerosol device, with an integrated dose counter, effectivelyaddresses the key undesirable attributes associated withcurrently available aqueous INCS formulation devices.Predicting the Need for Calcium and CalcitriolSupplementation after Total Thryoidectomy: Resultsof a Prospective, Randomized StudyA.K. Cayo, T.W.F. Yen, S.M. Misustin, K. Wall, S.D. Wilson, D.B.Evans, T.S. Wang, Milwaukee, Wis.Background: The optimal protocol for the detection andtreatment of postoperative hypoparathyroidism after totalthyroidectomy is unknown.Purpose: We hypothesized that a single PTH level the morningafter surgery would identify patients likely to becomesymptomatic after discharge and sought to determine the idealtreatment of at-risk patients.Methodology: We report a prospective, randomized study ofpatients who underwent total thyroidectomy. Serum calcium(mg/dL) and PTH (pg/mL) levels were obtained on the morningof postoperative day one or earlier if the patient reportedhypocalcemic symptoms. If PTH was ≥10, patients received nosupplementation unless symptomatic; if PTH was

POSTER ABSTRACTSMethodology: A SIM Center course was started in 2010 in orderto better prepare NPs and PAs for care of acutely ill patientsin the hospital, as an adjunct to a robust orientation program.Data was collected over three sessions of the course from May2010 through November 2011 and has included 20 providersfrom the division. Scenario leaders included two hospitalmedicine physicians, an experienced hospital medicine NP andthree experienced PAs in hospital medicine. For each event,one of the learners was “on call” and responsible for beingthe first responder. The cases covered were divided betweenmannequin-based scenarios, those using standardizedpatients and phone calls (to simulate being paged at night).Each scenario was followed by a debriefing and discussion.A 12-question quiz was administered pre- and post-courseparticipation covering the learning objectives of the course. Preandpost-tests were graded by the same individual. Participantswere also surveyed regarding the impact of the course on theirdecision-making and problem-solving skills.Results: Over the three sessions, pre-test scores ranged from4 to 10 (average 7.45). Post-test scores ranged from 7 to 11(average 9.35). Pre-test to post-test performance showed animprovement in each participant ranging from -8.3 to 41.7percent (average 15.8 percent). Consistent feedback fromparticipants is that course participation resulted in improvedcomfort level in handling acute situations in the hospitalizedpatient and a SIM Center course with hands-on learning hadgreater impact than lecture-based learning alone.Conclusions: Use of a SIM Center course as part of anorientation program for NPs and PAs working in hospitalmedicine improved knowledge regarding commonlyencountered scenarios by 15.8 percent on average; andpositively impacted decision-making and problem-solvingskills.Developing a Basic Science Leveling Experience forFirst-Year PA StudentsE.J. Grant, A.L. Brown, Wake Forest Baptist Health, Winston-Salem, N.C.Purpose: Students entering the didactic year of PA programsoften have varying levels of basic science knowledge, providinga challenge to educators when implementing activities thatare focused on group learning. We sought to determine if anintroductory basic science leveling experience, facilitated bymultiple physiology lecturers, could enhance the fundamentalbasic sciences skills of first-year PA students prior to engagingin a problem-based learning medical curriculum.Methodology: In order to assess the knowledge base ofmatriculating students, a pre-test centered on medicalphysiology was administered during the first week of classesbut prior to any course work. Students then entered into athree-and-a-half week experience focused on basic anatomyand physiology concepts, including cellular physiology, energymetabolism, immunology and neuroscience. At the end ofweeks one and two, students were administered quizzes andat the end of the three weeks students took a summativeassessment. In order to evaluate the effectiveness of the basicscience leveling experience, 40 questions from the originalpre-test were included in the post-test. Scores from previouslyadministered questions were compared to newly administeredquestions using a paired t-test.Results: The individual subject areas (“concentrations”) hadvery small numbers of observations, but the data could stillbe compared using a paired t-test. Five of the concentrationshad significant improvements when the pre- and post-testswere compared. When the data is collapsed into the fourmain categories (cellular physiology, energy metabolism,immunology and neuroscience), the improvements weresignificant in three of the four. When new questions werecompared to the old questions in post-test, no significantperformance difference was observed.Conclusions: In summary, following the basic science levelingexperience, students performed similarly when challengedwith new questions versus questions they had seen previously.The non-significant results of the new/old comparisons werepositive, suggesting that the leveling experience improvedbasic science knowledge outside of incidental recall of aprevious question. Future work will determine the usefulness ofthis basic science leveling experience throughout the didacticyear as the students progress into the core problem-basedlearning curriculum.Physician Assistant Students Saving Athletes fromSudden Cardiac DeathJ. Flynn, Missouri State University, Department of PhysicianAssistant Studies, Springfield, Mo.Purpose: The purpose of this educational innovation wasthree-fold: (1) provide screening of Southwest Missourihigh school athletes for risk factors of sudden cardiacdeath and other congenital cardiac abnormalities, (2) addto the body of literature that currently exists regarding theeffectiveness of a thorough history and examination with anelectrocardiogram (ECG) and the addition of an immediatefollow-up echocardiogram for any athletes found to be at risk,and (3) provide didactic year physician assistant (PA) students14

POSTER ABSTRACTSthe opportunity to utilize newly acquired skills of history taking,physical examination and ECG interpretation.Methodology: The Missouri State University (MSU) PA programpartnered with a local high school to provide free athleticphysical examinations at the conclusion of the second semesterof their didactic PA education. The students were supervisedby local physicians while they implemented their new skillsof taking vitals, assessing visual acuity, taking a completehistory and performing a complete physical examination. Thisportion was required of all athletes in order to participatein extracurricular sports. Next, the athletes were given theopportunity to participate in an elective portion, which includeda 12-lead ECG. If the ECG was abnormal or if abnormal heartsounds were detected, a transthoracic echocardiogram wasthen immediately performed on site. MSU received a grantto provide funding for the ECG machines and supplies. MSUpartnered with a local hospital to provide two echocardiogrammachines and two registered technologists to perform the test.Results: There were a total of 152 high school athletes thatparticipated in the event. Of those, 51 athletes elected tohave an ECG as part of their assessment. Thirteen studentshad abnormal ECGs and subsequently had an immediateechocardiogram. Two of those students were found to havesignificant cardiac abnormalities that were referred on forpediatric cardiology consultations. One was found to haveborderline hypertrophic cardiomyopathy, which is a significantrisk factor for sudden cardiac death. The other athlete wasfound to have a congenital bicuspid aortic valve. In addition,the PA student post-activity surveys reflected that this activitywas highly beneficial for their learning outcomes.Conclusions: The three-fold mission of this curricular innovationwas successful. Two high school athletes were found to havepreviously undiagnosed cardiac abnormalities. The data thatwas collected will be submitted for publication. The PA studentsconfirmed that the experience contributed significantly to theirlearning and integrating classroom knowledge into hands-onskills while providing a service (ECG and ecocardiogram) thatwas otherwise not available to this community adolescentpopulation.Promoting Competence in Communication SkillsThrough Review of Prior Standardized PatientEncountersN.M. Hudak, Duke University Medical Center, Physician AssistantProgram, Durham, N.C.Purpose: A novel assignment titled “Communication SkillsAssessment and Planning” was designed and implemented in2011 at the Duke University Physician Assistant (PA) Program aspart of a didactic course that addresses psychosocial aspectsof medical practice. The learning objectives of the assignmentwere to have each student: (1) self-assess their demonstrationof nine verbal and six nonverbal communication skills fromtwo prior audiovisual-recorded standardized patient (SP)encounters; (2) identify strengths in communication skillsfrom each encounter; (3) recognize areas for improvement incommunication skills following each encounter; (4) summarizetheir own development of communication skills over the courseof the didactic year; and (5) develop goals and a plan for furthercommunication skill development on clinical rotations.Interpersonal and communication skills are one of the sixcompetencies for the PA profession and are a required areaof instruction for accredited PA programs. Communicationskills are integral in history taking and patient education,which are common uses for SPs in the training and evaluationof PA students. A majority of accredited PA programs haveincorporated this form of simulation into curricula and the rolesof SPs are likely to expand in the future.Methodology: Following a one-hour lecture that introducedcommunication concepts and skills for healthcare providers,students were allotted time to complete a required assignmentin which they self-assessed communication skills demonstratedin two audiovisual-recorded SP encounters from prior semestersof the didactic year. The self-assessment form for eachencounter involved measuring the frequency of nine verbalcommunication skills and rating the quality of six nonverbalcommunication skills. In addition, the students were askedto list three strengths and three areas for improvement incommunication skills for each encounter. After completing theself-assessments, students were instructed to write a briefreflection on how their communication skills have developedover the course of the didactic year and what communicationskills need to be further developed in the clinical year.The entire class of 75 students successfully completed theassignment based upon review by their faculty advisor andthe course coordinator. To assess the effectiveness of theassignment, students responded to four questions about theirachievement of the assignment learning objectives on therequired course survey.Results: Of the 75 student respondents, 86 percent of studentsagreed that the assignment increased their awareness ofutilizing specific verbal communication skills with patients.Eighty-three percent agreed that the assignment increased theirawareness of utilizing specific nonverbal communication skillswith patients. Eighty-four percent agreed that the assignmenthelped them recognize communication skill development andwww.aapa.org/IMPACT 15

POSTER ABSTRACTSstrengths. And 84 percent agreed that the assignment helpedthem set goals for future communication skill development.Conclusions: Self-assessment and reflection of previouslyaudiovisual-recorded SP encounters may increase PA studentcompetence in communication skills through enhancedawareness of communicative interactions that occur withpatients, identification of communication skill strengthsand recognition of communication skills that need furtherrefinement in the clinical phase of education.Selection for Success: Ensuring the Growth of thePhysician Assistant Profession in CanadaA. Cowan, I. Jones, P. Malik, R. Ives, University of ManitobaPhysician Assistant Education Program, Winnipeg, ManitobaBackground: In 1999 a group of forward-thinking organizationsand individuals seized the opportunity to convince thelegislature to amend the Manitoba Medical Act, thus laying theframework for allowing physician assistants (PAs) to work in theprovince. It was not until 2003, however, that the first licensedPA began to practice in Manitoba. Growth of the professionwas slow, though, and over the next six years only 14 morePAs received licensure to practice. In a province the size of thestate of Texas it became evident that a PA training program wasneeded. In 2008, the University of Manitoba implemented thefirst and only graduate-level PA program in Canada. As a newprofession, class size is constrained to 12 students per year.With eight to 10 applicants per position it is critical that thebest candidates be selected to join the profession.Methodology: Using specific criteria set forth by theDepartment of Graduate Studies at the University of Manitoba,only qualified applicants are presented to the PhysicianAssistant Education Program selection committee for review.Information was collected from all applicant records from 2009to 2011. Applicant age, educational level and degree, gradepoint average, healthcare experience and grades earned inspecific courses were collected and analyzed for commonalityand trends.Results: Students who were selected for entry into the programconsistently displayed characteristics directly in-line with thoseelucidated by the CANMEDS framework.Conclusions: The 23 graduates of the PAEP have proven thebenefit of benchmarking against standards such as CANMEDS.All graduates have successfully passed their nationalcertification exam and are working as PAs in various positionsacross Canada.Education GalleryEDUCATIONAL RESEARCHHigh Fidelity Patient Simulation as a PositiveLearning Experience for Physician AssistantStudents at a Midwestern Problem-Based LearningPhysician Assistant ProgramC. Porter, D. LaBarbera, A. Moll, University of Saint Francis,Department of Physician Assistant Studies, Fort Wayne, Ind.Background: High fidelity patient simulation has been growingin popularity within healthcare education in recent years. Whilethere are several studies that document its positive impact onlearning in nursing students and medical students, physicianassistant (PA) students remain unrepresented in the literature.Purpose: To determine PA student and faculty satisfaction withhigh fidelity patient simulators in the PA curriculum at a private,Midwestern, problem-based learning PA program.Methodology: Two original surveys were used: a student anda faculty survey. The student survey was developed using anonline service (Survey Gizmo) and invitations were sent to94 email addresses for the PA students and graduates of theclasses of 2009, 2010, 2011 and 2012. The survey asked thePA students to rate their satisfaction with the simulation labsoffered in their curriculum and included open-ended questionsfor suggestions on how to best use the simulation lab. Eachclass year experienced a different combination of simulationlabs. The faculty survey was designed to rate faculty perceptionof students’ benefit from the simulation labs and containedopen-ended questions for suggestions.Results: Of the 94 student invitations sent, 60 respondedfor a response rate of 63.8 percent. For the Adult CHF H&Psimulation, 92 percent (n=22) of students answered “VerySatisfied” or “Satisfied”; Pediatric H&P, 82 percent (n=28);Adult COPD H&P, 87 percent (n=34); Infant H&P, 87 percent(n=27); and Code Blue, 95 percent (n=19). Out of the differentskills used during the simulation labs, students reportedimproved confidence, ranging from a low of 55 percent (n=12)in medical documentation to a high of 80 percent (n=16) ininteracting with patients in a clinical setting. Students indicatedinterest in more simulation labs, including procedures such aschest tubes, endotracheal intubation and lumbar punctures,and suggested that the simulation labs correlate with thedidactic curriculum. Of the five faculty members who qualifiedto take the survey, all responded and 100 percent indicated16

POSTER ABSTRACTSthat the students benefit from the simulations. Three of thefive (60 percent) indicated satisfaction with the number ofsimulation experiences. Open-ended questions elicited theneed for more procedures and the addition of interprofessionalscenarios.Conclusions: The PAs indicated that overall, they feel that thesimulation lab has a positive effect on their personal confidencein various areas, including interacting with patients in a clinicalsetting. The faculty members’ perceptions indicated much ofthe same. The PA program should utilize the simulation lab formore than the scenarios it currently uses with the addition ofprocedures.Overcoming Barriers to Obtaining Pre-PhysicianAssistant HoursR.H. Byerly, M.J. Smith, Geisinger Health System, Danville, Pa.Background: More applicants seek training for physicianassistant (PA) careers as workforce growth projections increase.Applicants must present up to 1,000 hours of direct, supervisedclinical observations acquired mainly through shadowing.Regulations (e.g., HIPAA) have led many healthcare institutionsto curtail or prohibit shadowing. We previously developeda successful, innovative summer internship to addressthis barrier. As a result, we have developed a new summerinternship to better help our institution and provide the studentwith a hands-on educational experience.Purpose: To explore new ways for pre-PA students to obtaindirect patient care hours needed as a prerequisite for admissionto PA programs.Methodology: In our initial approach, selected participantsfrom our partner university simultaneously pursued bachelor’sdegrees and experienced five weeks of clinical rotations onour Integrated Health System campus. Practicing PAs provideddirect patient care contact and observational experiences.We surveyed participants pre- and post-program to measureknowledge of core skills, values and qualities of a competentPA. We now collaborate with another local university to train 20pre-PA students in an allied health setting, where they acquire400 hours of direct patient care experience.Results: Participants acquired 120 contact hours during theinitial program. Pre-ratings ranged from one to three (5-pointrating scale), and post-ratings ranged from four to five.Physician Assistant Clinical Scores and TheirCorrelation to Performance on the PA NationalCertification ExaminationE.A. Min, J. Estrin, L. Rau, E. Deuparo, North Chicago, Ill.Purpose: Physician assistant (PA) programs incorporate asignificant clinical-based learning experience, or clinicalrotations, into their curriculum. Since these clinical experiencesgreatly impact a student’s education, maintaining their qualityis vital to the integrity of any PA program. Unfortunately, thereare few studies on the effectiveness of evaluative tools used toassess clinical sites. This study focuses on student evaluationsof clinical sites, which has received minimal attention in PAeducation research and has the potential to be better utilizedas an assessment tool. Using retrospective data from pastRosalind Franklin University PA students, it is hypothesized thata student’s perceived clinical experience scores will positivelycorrelate with their attainment of medical and surgicalknowledge represented by their Physician Assistant NationalCertifying Exam (PANCE) scores.Methodology: This study utilized retrospective, quantitativedata from 113 past Rosalind Franklin University PA students.Pearson correlations were run between each individual’sperceived clinical experience score for each of six core clinicalrotations and their individual PANCE score. An additionalcorrelation was performed between the student’s mean averageperceived clinical experience score for all six core rotations andtheir individual PANCE scores.Results: The results of the Pearson correlation statisticalanalysis are as follows: positive r scores were identified withemergency medicine (0.0676), family medicine (0.0463) andinternal medicine (0.0297) rotations. Negative r scores wereidentified with pediatric medicine (-0.0665), surgery (-0.1386)and women’s health (-0.0014) rotations. The r score for thecorrelation of mean student perception was (-0.0491).Conclusions: None of the r scores were found to be statisticallysignificant, falling into the range of -0.3 to 0.3, which wedeemed to mean “little or no association.” Our hypothesis thata student’s perceived clinical experience scores will positivelycorrelate with their attainment of medical and surgicalknowledge represented by their PANCE scores is thus rejectedand the null hypothesis retained.Conclusions: The prior program did not provide structured,deliberate educational experience. The new program offers theopportunity for 400 contact hours and also provides a viableand relevant learning experience for prospective PA students.www.aapa.org/IMPACT 17

POSTER ABSTRACTSRelationship Between Clinical Rotation Exam Scoresand NationalE.A. Min, A. Leslie, J. Wells, North Chicago, Ill.Purpose: This study was to assess the possible associationbetween scores of physician assistant (PA) students on theirend-of-clinical-rotation subject exams and their nationalcertification board exam. Assessment tools, such as end-ofrotationexams that can predict or contribute to passing scoreson the Physician Assistant National Certification Exam (PANCE),are critical components of a PA curriculum.Methodology: The data used was from the Rosalind FranklinUniversity of Medicine and Science PA graduating classes of2008, 2009 and 2010. The sample size was 165 students.The end-of-rotation subject exams are administered tostudents during their clinical year after the completion of thecorresponding six-week rotation.Results: Correlation analysis was completed using linearregression to determine if there was a correlation betweensubject exam scores and PANCE scores. The mean subjectexam score was compared to the performance on the PANCEand showed a statistically significant relationship (p

POSTER ABSTRACTSEducation GalleryPREVIOUSLY PRESENTEDAdmissions Predictors of Success on the PhysicianAssistant National Certifying ExamM.J. McDaniel, G.B. Russell, R.L. Bushardt, Wake Forest School ofMedicine Physician Assistant Studies, Winston-Salem, N.C.Purpose: This study examined the relationship betweenadmissions factors with the Physician Assistant NationalCertification Exam (PANCE), with models run separately to lookfor values that are associated with success or failure on thePANCE and the raw PANCE score. Prior research of predictorsof PANCE pass rates provided limited results; thus, explorationof PANCE score as a continuous variable was undertaken toprovide further insight into the admissions screening process.Methodology: A retrospective study of admissions recordsand PANCE scores for PA graduates from Wake Forest School ofMedicine (n=286) from 2005 to 2010 was conducted. Analysesexamined the association between students’ performance onthe first attempt PANCE, both categorically and as a continuousvariable, with applicant variables including total GPA, scienceGPA, weighted total GPA, weighted prerequisite GPA, Barron’sindex of prior schools attended, GRE scores, number of patientcontact hours, age, gender and self-reported race. Recursivepartitioning was utilized to assess the independent variableswith an estimate of “cut-off” points. A full model was fit; thismodel allowed for assessment of all variables, with significantlypredictive ones remaining in the model. All statistical analyseswere conducted using analysis of variance (SAS version 9.2,Cary, N.C.) and CART software (Classification and RegressionTrees, version 6, San Diego, Calif.).Results: There were four examined variables that were notsignificantly associated with success on the PANCE as acontinuous variable: patient care hours, gender, analytical GREand analytical writing GRE. Variables that were significantlyassociated with the raw PANCE score included: total GPA(p=0.0001), science GPA (p=0.0001), weighted total andprerequisite GPA (p=0.0001), Barron’s index (p=0.0008),verbal GRE (p=0.0001), quantitative GRE (p=0.0001), age(p=0.0001) and self-reported race (p=0.01). A full modelwith all variables was fit in an iterative fashion, removingnon-significant variables, one at a time, to find a model thathad only significant predictors of PANCE score. The remainingvariables were weighted total GPA, Barron’s index, verbal GRE,quantitative GRE, age and race. Using recursive partitioningto assess PANCE success categorically, the full model wasanalyzed, and the weighted total GPA was the factor found to bemost important in predicting success on the PANCE. A weightedtotal GPA of >3.93 (out of 6.0) was associated with 96.5 percentof students passing the PANCE. For those with GPAs 3.93 (out of 6.0), a second factor was quantitative GRE score;those with >535 had a passing rate of 98.8 percent, with thoseat or below 535 passing at 85.7 percent.Conclusions: Identifying and validating useful predictors ofstudent success are critically important to the admissionsscreening process. The total GPA, in combination with thedegree of difficulty of the institution where that GPA was earned,and the quantitative GRE was found to be a significant factorin predicting PANCE success at our institution. Reproduction ofthis study by other PA programs with subsequent comparisonof results would be helpful in determining predictors widelyshared among programs.Empathy Change During Physician AssistantEducationE.D. Mandel, W. Schweinle, Berkeley Heights, N.J.Purpose: This research investigated trends in PA studentempathy through their PA education. This research partiallyreplicates similar research on empathy among MD and otherhealth professional students. However, until the presentfindings, none exist that are relevant to empathy changesamong PA students. Three hypotheses were tested: (1) Doesempathy decline during PA training similar to other healthprofessions’ students? (2) Are there gender differences inPA student empathy? (3) Is PA student empathy related tostudents’ pre-PA training healthcare experience?Methodology: The Jefferson Scale on Physician Empathy wasadministered to PA students three times: during matriculation,near the end of their didactic training and during their clinicaltraining phase. Data was analyzed using both parametric(ANOVA) and non-parametric (binomial) methods to test thethree hypotheses.Results: The outcome indicates that PA student empathydeclines significantly during the didactic year of PA training andremains stable into their clinical training phase. While womenhave higher initial empathy scores than men, both women andmen show a similar decline in empathy across their didacticPA training. There was no association between empathy scoresand students’ expressed specialty interest (i.e., people versustechnical-orientation). Also, there was no association betweenstudents’ clinical experience prior to entering PA education andtheir empathy scores.www.aapa.org/IMPACT 19

POSTER ABSTRACTSConclusions: These findings illustrate that a decline in empathyappears to accompany PA training and that both gendersexperience decline. This decline is similar to that seen amongmedical students and other health providers’ educations.These findings support the need for further dialogue regardingthe possible role of empathy measurement in prospective PAstudents and consideration for the inclusion and strengtheningof empathy and, in general, humanistic training in PA education.The Presence and Impact of Test Anxiety on ExamPerformance of Physician Assistant Students: ARetrospective StudyL. Lee, M. Silva, S. Massey, S. Steiner, Manchester, N.H.Background: Test anxiety can be debilitating to any student,regardless of the type of program in which they are enrolled.Physician assistant (PA) students often complain of and exhibitthis particular concern for a number of reasons, including thedepth, breadth and volume of material that is presented tothem within a brief period of time and their overall educationalinvestment.Purpose: The purpose of this study is to measure potentiallyexisting relationships between self-reported test anxiety levelsby students enrolled in an accelerated (24-month) PA studiesprogram and their academic performance (exam grades).Methodology: The Brief Symptom Inventory-18 (BSI-18) © ,an 18-question survey instrument that measures anxiety,somatization and depression, was administered, afterIRB approval, to first-year PA students enrolled in theMassachusetts College of Pharmacy and Health Sciences-M/Wprogram immediately prior to two pharmacology exams duringthe spring semester of 2011. Scores obtained on both theanxiety and somatization (anxiety-induced physical symptoms)self-reported levels (the foci of this pilot study) were recordedalong with exam scores received by the student participantsto evaluate any coexisting relationships between self-reportedanxiety and/or somatization levels and exam performances.Results: Through statistical analyses of data collected, it wasnoted that although this study’s participants (first-year PAstudents) were found to have almost three-fold the anxiety andsomatization levels of the community norm levels, there didnot appear to be a statistically significant relationship betweenanxiety/somatization levels and exam performance overall.Somatization scores remained consistent (A=4.08, B=4.85)from exam A to exam B, anxiety levels also remained consistent(A=9.74, B=9.08), but overall grade performance showed aslight improvement (A=mean score 82.3, B=mean score 83.5).However, through a multivariate analyses using ANOVA, nosignificant correlations existed within the dataset (for example:Exam Score Prob>F Ratio= 0.0002).Conclusions: In summary, PA students are faced with manychallenges during their brief educational experience, challengesmostly related to the depth, breadth and volume of materialspresented to them that they must learn in a short period of time.Literature reviews of the existing body of research implicate testanxiety as a potential blockade of students’ academic success.However, this pilot study did not demonstrate a statisticallysignificant correlation between high, test-related anxiety levelsand low exam scores and, in fact, showed slight exam gradeimprovements with time despite the persistently high testanxiety levels. Further research is needed to help differentiatebetween facilitative versus debilitative test anxiety in the PAstudent population.The SIMPLE © Approach—Simulated InterdisciplinaryLearning in Multidisciplinary Progressive LevelEducation: An Effective Means of IntegratingDynamic Multidisciplinary Team-Based LearningH. Jodon, V. Baker, C. Masters, Gannon University, Erie, Pa.Purpose: Understand professional roles to: (1) promoteteamwork; (2) increase student competence and confidence;(3) improve effective communication between and amongdisciplines; and (4) develop a sound understanding of thecontinuum of care from point-of-contact through discharge,including assessment, intervention, implementation,interdisciplinary consultation and patient teaching.Interprofessional collaborative practice is the key to safe, highquality,accessible patient-centered care. Students need tobe prepared to enter the workforce ready to practice effectiveteamwork and team-based care. Current curriculum models donot adequately prepare students to function as effective teammembers. Health professional educators have an obligationto prepare health professionals who are able to participate incollaborative practice. Simulated Interdisciplinary Learning inMultidisciplinary Progressive Level Education (The SIMPLE ©approach) was developed to provide educational experiencesin a patient simulation center for students from multiple healthprofessional programs to collaboratively care for patients acrossthe continuum of care, from point of contact to discharge.Methodology: Students from nursing, physician assistant(PA) and respiratory care completed discipline-specific theoryand static scenarios related to care of a patient with asthmafollowing best practice guidelines. They were instructedin introduction, situation, background, assessment andrecommendation (ISBAR) communication, completed the20

POSTER ABSTRACTSAgency for Healthcare Research and Quality TeamSTEPPStraining, and participated in interprofessional basic physicalassessment skills labs conducted in a patient simulationcenter. Students then progressed to advanced care of asimulated-patient with asthma in their discipline-specificroles. Subsequently, these students from nursing, PA andrespiratory care utilized the multidisciplinary SIMPLE © approachto provide comprehensive, continuous care for a patient withasthma following best practice guidelines. They implementedISBAR communication and TeamSTEPPS, starting from theinitial point of contact and progressing throughout the planof care, including treatment and discharge planning. TheSIMPLE © approach employed sequenced debriefing wherebydiscipline-specific faculty debriefed discipline-specificinterventions as needed and when natural breaks occurredin the scenario. All faculty members participated in guideddebriefing of students on their multidisciplinary collaborativepractice. Students completed pre- and post-evaluations. Facultyassessed students’ performance during the scenario andmultidisciplinary sequenced debriefing.Results: Students utilizing the SIMPLE © approach developedenhanced communication skills within the multidisciplinaryscenario using ISBAR and demonstrated effective patientpresentation and/or reporting skills. Participants gained anunderstanding of each team member’s role throughout theprogressive scenario. They experienced the continuum ofcare, which improved student knowledge in the treatment of apatient with asthma. Participants demonstrated collaborativecomprehensive patient care following best practices from pointof-contactthrough discharge.Conclusions: Students expressed the experience was beneficialfor understanding multidisciplinary team roles and respect forthe importance of each team member’s role throughout theprogressive scenario. They gained confidence in their specificroles as well as their ability to effectively and collaborativelytreat patients across the continuum of care. Faculty valuedthe experience and modeled collaboration. Challengesincluded faculty buy-in and time, student scheduling, andaccommodating differing levels of student education (master’s,bachelor’s and associate degree levels).To Teach or Not To Teach: 2011 National Survey ofPhysician Assistants and Preceptor ExperiencesR. Gonzalez-Colaso, A.M. Johns, J. Sivahop, Yale University,Physician Associate Program, New Haven, Conn.Objective data about PAs’ experiences with and attitudestoward precepting students are limited. Our study aimed todescribe the incentives and the potential barriers to preceptingPA students reported by clinically active PAs.Methodology: We conducted a cross-sectional nationalelectronic and anonymous survey study with all PAs on theNational Commission on Certification of Physician Assistants’database (n=79,676) in March 2011. Clinically active PAswere asked to self identify as current preceptors if theyprecepted PA students for at least two weeks in the currentyear. PAs were also asked to report if they had precepted PAstudents before or not. PA demographics were described withfrequency proportions, and Likert scale response options weredichotomized to analyze the responses about incentives andbarriers to precepting PA students.Results: Most PA respondents (n=11,722; RR: 15.3 percent)were female, older than 40 years, worked full-time and hadgreater than six years of experience in clinical practice. Only 25percent of the full-time, clinically active PAs identified as currentpreceptors. In addition, 41 percent of the respondents reportedthat they had never precepted PA students, and 34 percentreported that they had only precepted PA students in the past.Among current preceptors, decisions to precept were primarilydriven by giving back to the PA profession, the rewards ofteaching and keeping up-to-date in their field. More than 60percent of all respondents identified the opportunity to receivecategory 1 CME credits, counting with the support of theirsupervising physician and the support of the PA program as themost important incentives to precepting PA students. Lack ofsupport from a supervising physician and from administratorswere identified as the most important barriers to preceptingamong all respondents.Conclusions: We identified several incentives and barriersthat reportedly influence the decision to precept PA students.This data will help inform and guide future Physician AssistantEducation Association and PA programs’ policies and initiativesfor the recruitment and retention of clinical preceptors. Futureefforts should not only target clinically active PAs, but also theirsupervising physicians and administrators of clinical sites.Gaining the support of all key members of the physician-PAteam will be important to secure the necessary clinical trainingsites and clinical preceptors for PA programs to meet increasingworkforce demands.Purpose: Shortages of clinical sites and preceptors havebeen identified as critical factors to increasing the number ofphysician assistant (PA) students and thus the PA workforce.www.aapa.org/IMPACT 21

POSTER ABSTRACTSProfessional Outreach and AdvocacyGalleryPROFESSIONALDeveloping the Canadian Physician AssistantProfession: Manitoba’s Example of CollaborationTowards PA PromotionI. Jones, M. Chan, A. Cowan, P. Malik, University of ManitobaPhysician Assistant Education Program, Winnipeg, ManitobaCanada’s healthcare system, like many, is facing an increasingdemand for healthcare reform in primary and specialty care.A collaborative initiative in Manitoba was undertaken to findsolutions to improve access to quality medical care throughthe introduction of an advanced care practitioner who wouldfunction as part of an interdisciplinary team in their approach toproviding patient care.Stakeholders, including the University of Manitoba, the Collegeof Physician and Surgeons of Manitoba, MB Health and otherallied healthcare professionals, worked together to introducethe physician assistant (PA) profession and became the firstprovince to have specific legislation licensing PAs under theMedical Act.The PA workforce and educational programs continue to growand are seen as an example of collaboration between thedifferent professions, their colleges and government branchesto address our province’s healthcare needs.The objectives of this report are to present various experiencesin Manitoba with PAs, including: (1) the PA Manitoba workforce,both clinical and academic; and (2) our dual educationalprograms: (i) our graduate-level Physician Assistant EducationProgram, designed to produce generalist PAs with capabilitiesto enter any healthcare field; and (ii) a collaborative educationalmodel between the Canadian Forces Physician AssistantProgram and the University of Manitoba (along with otherhealthcare centers) to educate military PAs to provide servicearound the globe.These experiences have spanned more than a decade and haveallowed patients and their families, as well as other healthcarestakeholders within the province, to benefit from the addition ofa new and very welcome team member.Enhancing Professional Use of Social Media:Creating a Twitter Tutorial for Physician AssistantsJ.E. Anderson, P. J. Devine, University of Washington, Seattle,Wash.Purpose: A tutorial was produced for use by members ofthe editorial advisory board of the Journal of the AmericanAcademy of Physician Assistants (JAAPA), and was created bya PA member of the editorial board and a medical librarianaffiliate member of AAPA. The project was aimed at introducingparticipants to Twitter in order to promote the PA profession,enhance professional growth, foster networking with PAs,promote interprofessional awareness and increase therecognition of Twitter as a “current-awareness” tool for PAs.The tutorial was a pilot project, with intended future use as aresource for broader PA populations.Description: Interested members of the JAAPA board andstaff were identified as those who were interested in eitherstarting to use Twitter or in enhancing their current Twitteruse. The tutorial leads them through an “asynchronous”Web-based module, starting with setting up a Twitter account,learning how to tweet and exploring tools such as hashtags tomaximize value. Participants move through a “social mediaadoption curve.” This includes a six-phase process: education,observation, broadcasting, participation, relationships andcollaboration. The tutorial is housed on a PBwiki website, wheresupporting module documents are stored and available forusers. Personalized support is available to all users. The tutorialalso includes a contextual segment focusing on professionalissues related to the use of Twitter and other social media andhow to widely utilize these tools for promoting awareness ofboth the journal and the profession.Results: Tutorial users completed the modules within a twomonthperiod, with broadly noted satisfaction. A survey of usersat the conclusion of the tutorial noted enhanced understandingof the value of social media for PAs, and enhancement of thepotential for broadening interprofessional awareness andconnections with the use of Twitter.Conclusions: Results underscore the significant potential ofTwitter to provide value to PAs by increasing their knowledge ofmedical information as well as connecting them with PAs andrelated professions and practitioners and increasing awarenessof the profession. These results indicate this project has valuefor broader PA audiences, including state, regional and nationalPA associations and individual PAs.22

POSTER ABSTRACTSMultidisciplinary Aorta ProgramB. Nuccitelli, Henry Ford Hospital, Detroit, Mich.Purpose: The incidence and prevalence of aortic disease israpidly increasing as our population ages and risk factors,such as high blood pressure, are left undetected or untreated.Unfortunately, aortic disease is often asymptomatic and maynot be detected until a catastrophic event occurs. Thus, itis crucial for patients to be identified in the early stages ofthe disease to eliminate the high morbidity and mortalityassociated with acute presentations. The Multidisciplinary AortaProgram was initiated at Henry Ford Hospital to identify andprovide long-term management to individuals with inheritedand acquired diseases of the aorta.Description: Our multidisciplinary team consists of healthcareprofessionals from cardiovascular medicine, cardiac andvascular surgery, interventional radiology and medicalgenetics. When a patient is referred to our clinic, a physicianassistant (PA) reviews the medical information to determine theurgency of the appointment and whether imaging studies arenecessary. During the patient’s initial visit, a comprehensiveclinical evaluation will be performed by a cardiologist and PA. Ifcorrective surgery is recommended, the case will be discussedwith a surgeon who will see the patient that same day. If aninherited form of disease is suspected, an individual will alsobe seen by a geneticist within a short time frame. All patientsare followed closely for return visits and repeat imaging atappropriate intervals. The patient may be asked to return forheart rate and blood pressure checks at more frequent intervalsif this has proven to be a problem. Medication complianceand appointment attendance are stressed by all healthcareprofessionals involved.Results: As a result of the collaboration between themultidisciplinary team, patients with aortic pathologies arebeing identified at earlier stages of their disease. Our PA hasmade it a priority to ensure urgent cases are seen as soon aspossible and that the appropriate healthcare members areinvolved. By screening our patients in advance, we are able tooptimize our discussion during the visit as well as to ensurethe proper imaging has been obtained. This has reduced theamount of unnecessary duplicate studies and thus limits apatient’s exposure to radiation. By closely monitoring ourpatient’s follow-up intervals, our patients are not simply lostin the health system. Our PA provides support every step ofthe way and counsels our patients on associated risk factorsand use of certain medications. Medication compliance hasincreased as a result of our stricter heart rate and bloodpressure monitoring. Likewise, appointment attendance hasincreased because our patients are contacted more regularly.All of these components have resulted in fewer adverseoutcomes.Conclusions: Since the start of the Multidisciplinary AortaProgram our patients have received treatment based on thecurrent standards and best outcomes. Using this coordinatedapproach, patient compliance, education and overall awarenessof aortic disease have improved.New Offspring on the Block—CPAEA: CanadianPhysician Assistant Education AssociationM. Gottesman, J. Cunnington, D. Hearn, E. Whitmell, M. Chan, D.O’Leary, S. Kanofsky, Acknowledgements to original authors: G.Haley, H. Wagenaar, S. Clarke, D.W. Taylor, University of Toronto,Ontario, CanadaPhysician assistants (PA) are possibly the newest form of alliedhealth profession to enter into higher education in Canada.The recent formation of the first four-year degree programsin Canada has resulted in another new development—PAeducators.In 2009, representatives from the inaugural PA programsestablished the Canadian Physician Assistant EducationAssociation (CPAEA). After initial informal discussions aboutforming an association for PA educators in Canada, advice wassought from various experts, including PA educators from theUnited States, Canadian academics involved in not-for-profitorganizations and the Canadian Association of PhysicianAssistants (CAPA).The initial CPAEA meetings helped to define the intent;subsequent initiatives for the CPAEA have developed. CPAEAMission: To serve as a forum for Canadian PA educators.Vision: To optimize PA education to best serve the healthcareneeds of Canadians. Goals: To encourage communication andcollaboration among PA educators; to foster the professionaldevelopment of PA educators; to advocate for PA educationand educational standards; and to promote professionalism,scholarship and research in PA education.In its evolution and growth, CPAEA serves to represent CanadianPA educators on the local, national and international fronts. Asa grassroots association dedicated to the education of PAs, theCPAEA has evolved from an inspirational thought to an obviousnext step in the path toward the establishment of PAs in thehealthcare system across Canada.www.aapa.org/IMPACT 23

POSTER ABSTRACTSPhysician Assistant Interest in Work in MedicallyUnderserved Areas Abroad or in the United StatesH. Johnson, O. Bockoff, B. Collins, A. Lowe, A. Van Wieren,Physician Assistants for Global Health, Portsmouth, Va.Purpose: A global deficit of healthcare providers exists andphysician assistants (PAs) are in a position to meet theever-growing healthcare needs of the world. This survey wasconducted to document PA interest in work for underservedpopulations and hopes to serve as a needs assessment for thePA governing bodies.Methodology: An online survey of 541 PAs and PA students wasconducted over one year in 2011.Results: A survey of 541 PAs and PA students indicates that91.1 percent of PAs and PA students are interested in workin medically underserved areas; 23.8 percent are currentlyworking or volunteering.For those who are not currently volunteering, 33.5 percentdo not know which non-governmental organizations (NGOs)use PAs or which NGOs use PAs appropriately, 32.5 percentare unable for financial reasons and 77 percent feel thatthere needs to be an organization that helps PAs volunteerin underserved areas. More than two-thirds of PAs wouldlike this organization to offer a database of volunteer or workopportunities and help PAs connect with medical organizations,offer continuing medical education and training, educate NGOsabout PAs and the PA role in healthcare, promote the use ofPAs in medically underserved areas, and provide global healthtraining in PA school and student rotations.Conclusions: This survey confirms that more than 90 percent ofPAs and future PAs are interested in volunteering or working inmedically underserved areas abroad or stateside. It highlightstheir limitations as informed access to organizations that usePAs and financial support. A majority of PAs are also lookingto PA organizations to help them connect with opportunitiesto volunteer, offer education and generally promote the useof PAs in medically underserved areas around the world. Thelarge interest confirmed in this study illuminates one avenue inwhich PA governing bodies, such as the American Academy ofPhysician Assistants, should direct their resources. Many PAsand students expressed in the free writing comment sectionof this survey that they became a PA to participate in this typeof work, and this study serves as a needs assessment to givedirection to future projects of the PA community.Utilization of Physician Assistants to Launch aNewborn Screening Program for Sickle Cell Anemiain Sub-Saharan AfricaE. Hansbury, S.E. Kirk, R.E. Ware, P. McGann, Baylor College ofMedicine, Texas Children’s Hospital, Houston, TexasPurpose: At the request of the Ministry of Health of Angola,Texas Children’s Center for Global Health launched a newbornscreening and treatment program for sickle cell disease. Centralto the design of the program was the utilization of physicianassistants (PAs) as “on-ground” project managers. We sought toexamine the role of PAs in launching this type of program.Description: Diagnosing sickle cell disease at birth providesan opportunity to initiate therapy early in life. Relatively simpleinterventions, such as pneumococcal immunizations, penicillinprophylaxis and insecticide treated malaria nets, are knownto reduce morbidity and mortality. Introduction of a newbornscreening program, followed by administration of the abovetherapeutic interventions, will lead to significant reductionsin under-five child mortality rates in a region of the world withone of the highest. A public-private partnership was createdbetween our institution and the government of Angola, withcorporate sponsorship of Chevron Oil Corporation. The programwas initially launched at two maternity hospitals in Luanda. Allbabies found to have sickle cell disease were contacted andinvited for consultation, confirmatory testing and treatmentinitiation. A clinical team was created consisting of two PAs andone MD. All were experienced in the management and treatmentof sickle cell disease. Each provider served alternating,month-long, on-ground rotations and made real-time programmanagement decisions.Results: More than 5,600 blood specimens were collected andtested in the first six months. One hundred eight babies (1.9percent) were found to have sickle cell disease. Twenty-six (30percent) of 86 babies older than six weeks of age have beensuccessfully located and initiated treatment. Monitoring ofthe affected cohort is ongoing. Evaluation of the mortality rateis expected annually. Lack of a means to communicate withfamilies was the major reason for the low rate of accrual intothe clinical management portion of the program. Numerousmeasurable contributions were made by PAs, including a dailyreport regarding program accomplishments, current obstaclesand upcoming activities. Other specific tasks included:establishment of clinical guidelines; nursing education onblood collection procedure; recruitment and hiring of staff;education of local medical community and affected families;and development of public relations materials. Tasks alsoincluded: procurement of new laboratory equipment, supplies24

POSTER ABSTRACTSand pharmaceuticals; review and aggregation of laboratoryresults; support development of a database; and managementof obstacles to flow of operations.Conclusions: Successful integration of a new strategy intoexisting systems in developing countries requires PAs totravel to the area and work directly in the community. PAscan provide education about disease management andtreatment, which is critical for success since it contributes tothe creation of a sustainable system that can be maintainedby the local community indefinitely. Training and experiencein a team-based working structure poises PAs to serve asproject managers and leads to advancements in global health.A newborn screening and treatment program for sickle celldisease is feasible in Angola but requires access to an adequatecommunication infrastructure. As the infrastructure of this wartorncountry continues to improve, we anticipate improvementin the success rate of the program.Student GalleryOUTSTANDING RESEARCHGoogle It! Comparison of Internet Information aboutConcussionsD. Atterbury, R. Cook, G.M. Berg, M. Mosley, R. Grundmeyer,D. Acuna, Wichita State University, Department of PhysicianAssistant, Wichita, Kan.Purpose: The purpose of this study was to compare informationreadily available to consumers on the World Wide Webregarding the definition, symptoms, treatment and return-toplayafter concussion or mild traumatic brain injury (TBI).Methodology: The top 10 Google-ranked non-media websiteswere identified using the key term “concussion.” Each websitewas evaluated for definition, signs and symptoms, treatment,care-seeking advice, return-to-play recommendations andspecific age-related concussion information. Quality, accuracyand coverage of concussion information were compared withthe Consensus Statement on Concussion in Sport–The 3rdInternational Conference on Concussion in Sport, held in Zurich,Switzerland, in November 2008. The evaluation process of eachwebsite also included search depth within the website to locatethe information.Results: The top 10 websites to be evaluated were chosen fromthe top 11 Google-ranked hits. One media website,CBS Sports.com, was excluded from the evaluation. All 10websites contained similar broad categories, includingdefinition, signs and symptoms, and home treatmentrecommendations. Concussion definitions, although presenton each identified website, varied greatly on specificity. Onewebsite stated that a concussion is a term used to describe aninjury to the brain resulting from an impact to the head, whileanother stated that a concussion is a TBI that may result in abad headache, altered levels of alertness or unconsciousness.Each website evaluated contained a general list of signs andsymptoms. Every website contained a type of home treatmentoption, although not stated directly. Regarding the use ofaspirin or ibuprofen as a home treatment, two websitesrecommended, four websites stated not to use and four didnot make any recommendations. Nine websites containedguidance on when to seek a physician’s care. Eight websitesrecommended athletes not return to play until cleared by ahealthcare professional. Seven websites required informationseeking depth behaviors by the user (clicks within site) toacquire complete concussion information. The average wasapproximately two clicks; however, two websites required fourclicks.Conclusions: Basic information regarding concussion definitionand symptoms is generally present among the top 10 Googlerankedhits for the key term “concussion.” Home treatmentrecommendations varied regarding use of aspirin or ibuprofen;those promoting over-the-counter pharmacotherapy is againstthe recommendation of the consensus statement. Returnto-playrecommendations were not complete enough for theconsumer to make informed decisions without consultingappropriate healthcare professionals. The quality of informationconsumers can find on the Web using Google as a searchengine is generally accurate but varies widely in coverage. Thedescription of symptoms indicating concussion would certainlyhelp the consumer to recognize potential injury; however, thesesymptoms still need healthcare provider evaluation.Physician Assistant Student Assessment andComparison of Readiness for InterprofessionalLearningB.H. Woodward, C.E. Fasser, K. Erdman, Baylor College ofMedicine, Houston, TexasBackground: A 2009 Cochrane review demonstrated thatimproved healthcare outcomes were associated with increasedinterprofessional collaboration. Interprofessional learning,as an activity, is designed and implemented to improvepatient care by increasing collaboration. The Readiness forInterprofessional Learning Scale (RIPLS) was developedto assess healthcare student attitudes concerning otherwww.aapa.org/IMPACT 25

POSTER ABSTRACTSprofessions. RIPLS is a 5-point Likert scale survey composedof 19 questions divided into three basic subscales: effectiveteamwork and professional collaboration, negative and positiveidentity, and roles and responsibilities. Although severalstudies have been performed to understand physician assistant(PA) interprofessional attitudes, there has been no prioranalysis using the RIPLS.Purpose: To assess the interprofessional attitudes of PAstudents at Baylor College of Medicine (BCM) using RIPLS and tocompare the data to prior survey results of medical, pharmacyand nursing students’ interprofessional attitudes.Methodology: The RIPLS was administered to four classes of PAstudents at BCM at different stages throughout their training.The groups’ data were then statistically analyzed with SPSSusing paired and unpaired t-tests, ANOVA, Tukey’s HSD andBonferroni post-hoc test for differences, and then compared toRIPLS results of medical (MD), pharmacy (PhmD) and nursing(RN) students as published by Horsburgh, et al.Results: One hundred thirty-seven of 195 PA studentsresponded to the survey, with most class response ratesranging between 80 to 100 percent, with the exception of theclass of 2012, which had a 27 percent response rate. First-yearPA students reported increased teamwork and collaborationand increased positive identity more than all other Horsburghgroups (p

POSTER ABSTRACTSA Fresh Look at Maternal Mortality: A SystematicReview of Patient Interventions That Have HelpedNations Reduce Their Maternal Mortality RatesL. Allen, A. Torkelson, G. Brown, Wichita State University,Department of Physician Assistant, Wichita, Kan.Purpose: A systematic review to identify specific, practical,patient interventions made in developing countries or regionalareas successful at decreasing the maternal mortality rate(MMR), along with evaluation of which interventions are mosteffective.Methodology: A systematic review of articles collectedfrom EBSCO, Cochrane Library and MEDLINE databases wasconducted.Results: Sixty-three articles were reviewed and 14 were selectedfor evaluation. Calcium supplementation during pregnancyhad a maternal mortality relative risk of 0.80 (95 percent CI0.70-0.91). Women with an interpregnancy interval of 18 to24 months have a significantly lower risk of pre-eclampsia,eclampsia and gestational diabetes. Shorter and longerinterpregnancy intervals were associated with an increase inmaternal adverse outcomes and maternal death (adjusted oddsratio 2.54; 95 percent CI 1.22-5.38). Active management of thethird stage of labor, including uterotonic agents, controlled cordtraction and early cord clamping decreased a woman’s risk ofpostpartum hemorrhage and maternal mortality.Conclusions: We found the use of calcium supplementationreduced gestational hypertension and related disorders.It also decreased maternal mortality and carries a Grade Arecommendation. Educating women to space pregnanciesaccording to lowest risk times (between 18 and 23 months)is given a Grade B recommendation. Using active versusexpectant management of the third stage of labor is given aGrade A recommendation. These simple implementations canpotentially save many lives, especially in remote areas andareas of low-resource, where the most help is needed to reducematernal mortality rates.A Pilot Study to Assess an Online EducationalModule on Blast-Related Mild Traumatic BrainInjury in Physician Assistant EducationK. Dekkinga, K.A. Streitenberger, L. Hyde, T. Bacon-Baguley,Grand Valley State University, Physician Assistant Studies,Grand Rapids, Mich.Purpose: Technological advancements necessitate thereevaluation of educational delivery systems in order to provideoptimal learning strategies. Computer-assisted self-pacedlearning is one method of delivery that has been shown to beeffective in supplementing coursework in higher education.This study addressed the push for technological advancementsin education through the incorporation of an online self-pacededucational module into a graduate course consisting ofphysician assistant (PA) students. The objective of this studywas to evaluate an online educational module by examining itseffectiveness based on a change in knowledge. This study alsoinvestigated the application of the online module by trackingthe location of use, number of times the module was accessed,and days of the week the module was accessed in order toobtain a better understanding of the utilization of onlineeducation, as well as to determine if there was a correlationbetween these variables and a change in knowledge.Methodology: This cohort study utilized a convenience sampleof 30 students enrolled in a graduate PA education course. As arequirement for the neurology module, all students completedan online educational module on traumatic brain injuries thatwas designed by the instructor and made available throughBlackboard Academic Suite (BB). A pre- and post-test wasadministered that included 37 multiple choice questions. Inaddition, demographic information was obtained during thepre-test administration. Tracking the use of the online modulewas done through BB.Results: The average score on the pre-test was 53 percent(range: 35 percent to 76 percent) and the average scoreon the post-test was 90 percent (range: 76 percent to 100percent). Using a paired t-test, there was a significant increasein knowledge when comparing the pre- and post-test scores(p

POSTER ABSTRACTSAccuracy of the Automated Blood Pressure DeviceCompared to Manual Blood Pressure MeasurementWith and Without Irregular Cardiac RhythmsC. Damron, C. Khamis, K. Gingrich-Watson, M. Knoppers,L. Hansen, K.J. Vander Laan, T. Bacon-Baguley, Grand ValleyState University, Physician Assistant Studies, Grand Rapids,Mich.Purpose: There are two major noninvasive methods to obtainblood pressure: manual and automated. Studies of automateddevices have found conflicting results on the accuracy of theautomated devices when compared to manual blood pressurereadings. The purpose of this study is to determine the accuracyof an automated blood pressure device compared to manualblood pressure measurement in patients with and withoutirregular cardiac rhythms.Methodology: A method comparison design was used inthis study. Subjects served as their own controls when bloodpressure readings were obtained with the automated andmanual blood pressure devices. Inclusion criteria were an ageof 18 years or older, arm circumference of 20.5 to 46 cm, anavailable upper extremity for blood pressure measurements,and continuous cardiac monitoring during the time of datacollection. Patients were stratified according to having a normalrhythm or being arrhythmic. The difference between automatedand manual measurements was calculated for systolic anddiastolic blood pressure and graphed using the Bland-Altmanmethod. A clinically significant difference was deemed to bevalues that varied by >5 mmHg.Results: There were a total of 38 patients, with 27 having aregular cardiac rhythm and 11 having an irregular cardiacrhythm. The differences between systolic pressure obtained bythe two methods were analyzed, manually minus automated. Inthe patients with a regular heart rhythm, the mean difference insystolic pressure was 5.93 (range of -24 to 31). In the patientswith an irregular rhythm, the mean difference in systolicpressure between the two methods was 4.45 (range of -2 to16). Normality conditions were met for both groups (regularand irregular rhythm), and a two-sample t-test was used todetermine that there is no statistically significant differencebetween the differences in each group (p=0.593, t=0.540).The differences between diastolic pressures obtained by thetwo methods were analyzed, manually minus automated. Inthe patients with a regular heart rhythm, the mean differencein diastolic measurement was 3.30 (range of -10 to 18). In thepatients with an irregular heart rhythm, the mean difference indiastolic measurement was 1.27 (range of -20 to 9). Normalityconditions were not met in the irregular rhythm group, thereforethe non-parametric test, Mann-Whitney U, was used, whichdetermined that there is no difference between the two groups(z=-0.016, p=0.987). Using a mixed design (Split-Plot) ANOVA,we did find there is statistically significant evidence of aninteraction between the measurement procedure for heart rateand type of heart rhythm (regular and irregular rhythm) withregard to blood pressure (p

POSTER ABSTRACTSan average stay of 0.83 days (±3.03). At the time of review, 47percent of the cohorts were deceased, 77 percent of patientswere readmitted and 51.5 percent of the patients visitedthe emergency department. Patients visited the emergencydepartment an average of 3.3 (±3.43) times and wereadmitted an average of 4.24 (±3.56) times following the indexhospitalization. Tachycardia, left ventricular hypertrophy, rightventricular hypertrophy and ST segment abnormalities wereobserved on baseline EKGs in 4.7, 6.9, 0.86 and 21.6 percentof subjects respectively, and observed at admission in 41.2,5.9, 0.85 and 46.1 percent respectively. Tachycardia and STsegment abnormality occurred significantly more in admissionEKGs (p

POSTER ABSTRACTSdemographics, AO/OTA fracture type, comorbidities, medicationhistory, lifestyle osteoporotic risk factors, and diagnostic andtreatment modalities.Results: Sixty-eight patients met study criteria, of which 27(40 percent) had a previous diagnosis of osteoporosis and/or a fragility fracture. More females were in the osteoporosisgroup (24, 89 percent) compared to the other group (23, 56percent) (x2=0.004). Those in the osteoporosis group had asmaller BMI (27.0, range 18.4-37.8) versus BMI (31.9 range19.9-50.1) in the nondiagnosed group (t=2.544, sig=0.014).Those diagnosed with osteoporosis had a lower rate of pastsmoking (7, 26 percent) compared to those not diagnosed(23, 56 percent) (x2=0.013). Fall prevention strategies wereimplemented more frequently in the previously diagnosedosteoporosis group (three of 27, 11 percent versus zeroof 41, zero percent, x2=0.029). Osteoporosis medicationwas prescribed at a higher rate in the previously diagnosedosteoporosis group (6, 22 percent) versus the nondiagnosedgroup (2, 5 percent) (x2=0.030). No other significantdifferences were found in the AO/OTA fracture classification,age, comorbidities, medication history or osteoporotic lifestylebehavioral factors (p>0.05).Conclusions: As found overall in osteoporosis, more femalesand those with a smaller BMI with humeral fragility fractureshad a previous diagnosis of osteoporosis. Previous smokingoccurred less frequently in the osteoporosis group. Treatmentmodalities were instituted more frequently after a humeralfragility fracture when there was a previous diagnosis ofosteoporosis. Surprisingly, no other differences were found.Astute screening, assessment and treatment are needed toprevent initial and secondary fragility fractures.Assessment of Adult Knowledge Regarding theCurrent Tdap Vaccination RecommendationsJ. Wolkun, N. Bottino, K. Luzzi, M. Mullen, W. Wendt, D. Rizzolo,Seton Hall University Physician Assistant Program, SouthOrange, N.J.Purpose: In the last two decades, the incidence of reportedcases of pertussis in the United States has been increasingsteadily, despite the fact that childhood vaccination is atan all-time high. A possible explanation for this finding isthat immunity wanes around mid-adolescence; therefore,this age group is implicated in the increase in incidence ofrecent outbreaks. The Advisory Committee on ImmunizationPractices now recommends that adults ages 19 through 64years should receive the Tetanus, Diphtheria and Pertussis(Tdap) booster vaccine. In order to achieve higher rates ofimmunization, adolescents and adults must be well educatedon the severity of pertussis, how they can transmit this diseaseto the unprotected population and the new guidelines forimmunization. It is essential to determine the current levelof knowledge in these populations since recent reportsdemonstrate that pertussis booster vaccination rates are low.The purpose of this study is to determine compliance, levelof individual’s knowledge and understanding of the currentrecommendations with regards to the Tdap vaccination.Methodology: Members of a small, private college communityages 19 to 64 years old were asked to voluntarily complete asurvey developed by the authors of the study titled, “Knowledgeof the Updated Pertussis Vaccination Guidelines in Adolescentsand Adults.” The survey collected demographic informationalong with the individual’s understanding of both pertussis andthe Tdap vaccination. The survey was distributed via an emailblast using the Academic Survey System Evaluation. Frequencycounts and descriptive statistics along with chi-square analyseswere used to analyze the data. The Statistical Package for theSocial Sciences (SPSS) software, version 19.0, was used. A pvalue of

POSTER ABSTRACTSPurpose: To investigate associations between fall distance andclinical outcomes of elderly trauma patients after a fall and toevaluate the effectiveness of fall distance in triage criteria at aLevel 1 Trauma Center.Methodology: A retrospective trauma registry review betweenJanuary 1, 2005, and December 31, 2011, was conductedto obtain fall distance (ground level, less than 20 feet andgreater than 20 feet), Injury Severity Score (ISS), Glasgow ComaScale (GCS) score, trauma level activation (1, 2, 3), length ofstay (LOS), mortality rate and discharge disposition of elderly(65 to 79 years of age) and very elderly (80 years and older)trauma patients after a fall. Chi-square analyses and logisticregression were used to determine the association between falldistance and trauma level, ISS, GCS, LOS, mortality rate anddischarge disposition of both elderly and very elderly patients.Significance level was set at p80 years of age. Patients witha more severe ISS and GCS were less likely to survive. In bothage groups, there was no significant association between falldistance and ISS, GCS, LOS, mortality or discharge disposition.A logistic regression analysis using the predictors of ISS andfall distance revealed ISS as the only variable associated withmortality.Conclusions: An overwhelming number of falls in the elderlyare from ground level (standing, slipping, tripping, stumbling)and result in significant injury. Patients who fell from groundlevel had similar outcomes, including LOS and mortality, whencompared to those who fell from a greater distance (higher thanground level). The current triage scheme at this Level 1 TraumaCenter employs fall distance as criteria to determine the levelof trauma team activation. According to this study, fall distancein isolation is not a reliable predictor of injury severity andoverall outcome of elderly fall patients. This study supports therationale to place more emphasis on age and severity of injuryrather than fall distance when triaging elderly patients whosuffer a fall.Correlation of Pre-admission Criteria and PostadmissionDidactic Grade Point Average toPhysician Assistant National Certifying ExamResultsB. Imel, A. Nelson, N. Jansen, G. Brown, Wichita State UniversityDepartment of Physician Assistant, Wichita, Kan.Purpose: The primary purpose of this study is to provideresearch on possible statistically significant correlationsbetween Physician Assistant National Certifying Exam (PANCE)performance and selected pre-admission criteria and postadmissiondidactic grade point average (GPA). Findings couldimprove selection criteria for admission to physician assistant(PA) programs, as well as remediation decisions for currentstudents.Methodology: A retrospective, observational study was doneutilizing three previous graduating classes of the Wichita StateUniversity Physician Assistant Program. One hundred nineteenPA students were divided into the following pre-admissioncategories: majority of core science prerequisites from afour-year university versus two-year community college, andprior healthcare experience with number of hours versus nohealthcare experience. Core science prerequisite GPA as well asoverall PA program pharmacology, anatomy and didactic GPAwere compared to PANCE success. Data was analyzed usingSPSS 17.0 (Chicago, Ill.).Results: PANCE scores, but not pass rate, were stronglyassociated with didactic GPA (r=.665) and programpharmacology GPA (r=.678). A moderate association wasdemonstrated between PANCE scores and program anatomyGPA (r=.414). Institution type (four-year versus two-year) forcore science prerequisites was weakly associated with first-timePANCE pass rate (r=.269). No other correlations regarding preadmissioncriteria were found.Conclusions: As only one weak correlation was found betweenpre-admission criteria and PANCE performance, adviceregarding applicant selection criteria is limited. However, GPAduring the didactic phase of PA school is strongly associatedwith success on the PANCE. Therefore, remediation of studentswith lower GPAs may result in higher PANCE success rates.Current Knowledge and Attitudes of Physicians inKansas Regarding Domestic Minor Sex TraffickingI. Whitacre, A. Reinhard, G. Berg, Wichita State UniversityDepartment of Physician Assistant, Wichita, Kan.Purpose: To determine Kansas physicians’ current level ofdomestic minor sex trafficking (DMST) knowledge, attitudesregarding DMST and self-perceived level of competenceregarding the identification of DMST victims.Methodology: A 20-question survey investigated personalbeliefs about DMST, knowledge about DMST, self-confidencein ability to identify and report victims, and training regardingDMST. The survey was emailed with a link to SurveyMonkey ® towww.aapa.org/IMPACT 31

POSTER ABSTRACTS1,668 physicians registered with the Kansas Board of HealingArts in the specialties of family medicine, pediatrics, obstetrics/gynecology and emergency medicine. Results are reporteddescriptively.Results: There were 69 survey respondents with 17.1 meanyears in practice and almost half in family practice (46 percent).Respondents agreed DMST is a problem in the United States(86 percent) and Kansas (80 percent), but only 12 percentagreed that they are confident in identifying a victim. Up to 48percent admitted to not knowing the answer to factual DMSTquestions. About half (55 percent) underestimated the numberof victims in the United States. More than half (61 percent)reported encountering possible signs of DMST in patients:however, only few suspected DMST. The top two obstacles toreporting were not knowing whether the patient is truly a victimand not knowing how to report. Although most respondents(83 percent) believed that healthcare workers should receivetraining regarding the issue, only a few (6 percent) had receivedtraining on DMST. Only 11 percent screen for DMST victimsin their practice, and only 10 percent take steps to educateyoung female patients. More than half (67 percent) statedthat they would take part in some form of training with thepreferred methods being CME presentations, online tutorials,and seminars/conferences. Five respondents (one emergencydepartment, two private practice and two free clinic) treatedat least one DMST victim, but only two providers reported theincident.Conclusions: Physicians who responded to this surveyappeared to have a pre-existing interest in DMST; literaturesuggests physicians are only likely to respond to surveys ontopics of interest, if at all. The evidence suggests that thereare Kansas physicians who are aware that DMST occurs in theUnited States and even locally. Providers report encounteringvictims of DMST in their own practice, which validates theexistence of DMST in Kansas. It is evident that even physicianswith interest in DMST are lacking in knowledge. In particular,physicians lack the ability to identify signs that indicate aDMST victim. Even if they suspect a victim based on signs, itis rare that they follow through and report the victim. It couldbe extrapolated from the respondents’ self-reported lack oftraining, even though interested in the problem, that training isnecessary in order for Kansas physicians to successfully identifyand report victims of DMST.Got Compliance? Students’ Medical Compliance—No Different From Most PatientsC.M. Eklund, T.L. Cleveland, Missouri State University, PhysicianAssistant Studies, Springfield, Mo.Purpose: In medical therapeutics, compliance is defined asthe extent to which a patient follows advice from a healthprofessional. Issues surrounding noncompliance are a sourceof frustration for both patients and healthcare providers. Thepurpose of this study is aimed to determine: (1) PA students’understanding of compliance issues; (2) if differences existbetween didactic and clinical year students’ concept of patientcompliance; (3) if participation in a mock medication/exerciseregimen changed attitudes about compliance; and (4) thedegree of compliant behavior of participants throughout thestudy.Methodology: Fifty-two didactic and clinical year PA studentparticipants assumed the “patient” role, were prescribed“medications” (jellybeans), and instructed to follow a weeklymoderate-level aerobic exercise regime of 150 minutes perweek combined with strength conditioning over a three-monthperiod. Participants were randomly assigned to three groups:exercise only regimen (Group 1), simple dosing medicationregimen with exercise (Group 2) or complex dosing medicationregimen with exercise (Group 3). Participants were instructedto complete monthly data sheets to record daily medicationand exercise compliance throughout the study. Pre- and poststudysurveys using Likert scales were administered to assessmedication and exercise regimens and attitudes toward patientcompliance issues.Results: Didactic and clinical year PA students had differentattitudes regarding patient compliance, resulting in nine surveyquestions that proved to be statistically significant (p

POSTER ABSTRACTSnovelty of taking five different medications at different timesof day. Didactic year participants were more compliant overallcompared to clinical year participants, which may be attributedto increased daily interaction with the researchers. The“patient” role-playing aspect of the study found that despitebeing knowledgeable about compliance issues, participantsdemonstrated noncompliant behavior throughout the study. Itcan be inferred that even though participants understood theissues surrounding noncompliance, it seemed to have littleimpact on increasing compliant behavior. Ultimately, the studyprovided future medical providers with a personal medicalcompliance experience from a patient’s perspective.Improving Physician Assistant Education withComputer Assisted Learning: An Assessment ofKnowledge Gained in the Area of Traumatic BrainInjuryT. Bacon-Baguley, O. Cain, A. Galdes, R. Bonifas, Grand ValleyState University, Physician Assistant Studies, Grand Rapids,Mich.Purpose: The main purpose of this study was to implementa self-paced computer assisted learning unit in the area oftraumatic brain injury (TBI) and assess the knowledge gained inthe area of pathophysiology, assessment and treatment of TBI.In addition, a qualitative evaluation on the use of the computerassisted learning unit was completed.Methodology: Thirty students enrolled in a physician assistantprogram participated in the self-paced computer assistedlearning. The computer assisted learning unit containedfive Camtasia © units on TBI. Two units were dedicated tothe pathophysiology of TBI and three were dedicated to theassessment and management of TBI. Prior to the units, studentstook a pre-test on the pathophysiology, assessment andmanagement of TBI. Upon completion of the learning units, apost-test was given. In addition, all participants were asked tocomplete an evaluation of the learning units using the onlineIDEA © evaluation program.Results: Twenty-nine students completed the online units,the pre-test and post-test. There was a significant differencebetween the pre-test and post-test scores, with an averageincrease in score of 37 percent (p

POSTER ABSTRACTSMethodology: This retrospective, cohort study was performedusing a database of visits to the ED chest pain unit of a tertiaryreferral center. During a four-year study period, all patientsundergoing therapeutic hypothermia (to a central targettemperature of 33°C, using endovascular cooling) followingcardiac arrest were eligible for the study. Patients less than18 years old, trauma cases, pregnancy and cardiogenic shockcases were excluded. Electronic dispatch, patient care reportsand hospital records were reviewed by three independentreviewers. Our main outcome was the incidence of postrewarmingRH within 48 hours after cooling withdrawal.Analysis of risk factors was performed as follows: 24 potentiallyrelevant risk factors for RH were assessed by univariate analysiswith chi-square test for categorical variables and simplelogistic regression for continuous variables. Collected data alsoincluded the rate of medical complications, severe disability ordeath (modified Rankin Scale 4-6).Results: During the study period, 93 consecutive adult patientswere treated with therapeutic hypothermia following out-ofhospitalcardiac arrest (70 percent male, age 56.8 + 17 years).RH was documented in 23 patients (24.7 percent; 95 percentCI 16.0-33.5) within 48 hours after cooling withdrawal. PostrewarmingRH was associated with an increased risk of death(70 percent versus 41 percent, p

POSTER ABSTRACTSConclusions: In summary, our study shows that from 2000 to2010, urinary E. coli antimicrobial resistance among pediatricoutpatients remained relatively stable. In 2010, higherprevalence of resistance was observed for ampicillin (45.7percent), TMP/SMX (25.1 percent) and cephalothin (15.7percent), and low resistance was observed for cefuroxime (1.8percent) and ceftriaxone (1.0 percent).Is Community Acquired Methicillin-ResistantStaphylococcus Auerus Colonizing Primary CareFacilities?H. Strahl, J. Stein, K. Pierre-Louis, R. Black, L. Herman, New YorkInstitute of Technology, Old Westbury, N.Y.Purpose: Community Acquired Methicillin-ResistantStaphylococcus aureus (ca-MRSA) has become one of the mostprevalent bacteria, causing skin and soft tissue infections inpatients since its emergence in the 1990s. Inspired by growingprevalence of ca-MRSA and limited research in the colonizationof ca-MRSA in various medical settings, including intensivecare units, dialysis centers and emergency departments, theobjective of this study was to test the most frequently touchedsurfaces in outpatient primary care and family practice officesand determine if they are colonized with ca-MRSA.Methodology: Seven busy, geographically disparate primarycare and family practice offices collectively admitting patientsto more than a dozen community and tertiary care hospitalswere swabbed for MRSA in Suffolk County, N.Y. (2,378 squaremiles, population 1,493,350). Seven of the items mostcommonly touched by patients and staff alike were swabbedwithin each office, including: the pen used by patients tosign-in in the reception area, an arm of a chair in the waitingroom, the seat of a chair in the waiting room, an exam table, thereceptionist’s computer keyboard, the pulse oximetry sensorutilized on patients and a well-read magazine located in thewaiting room. The swabs were sent to a reference laboratory(Sunrise Medical Laboratories) for analysis. Samples werecultured utilizing standardized laboratory methods for MRSA.Laboratory methods identified Staphylococcus aureus speciesand, if positive, subsequently allowed differentiation betweenMRSA and MSSA.Results: All 48 samples collected tested negative for MRSA.As such, subsequent testing was unnecessary to distinguish ifcolonization was from MRSA or from MSSA.Conclusions: There has been significant concern that ca-MRSAhas colonized medical facilities, including primary carefamily practice outpatient facilities. The results of this studyconclusively demonstrate that for this relatively small samplesize, ca-MRSA has either not colonized primary care officesin this geographic location or, alternatively, simple cleaningtechniques eradicate ca-MRSA from inanimate objects. The riskof transmission of ca-MRSA was non-existent in this sample.There are few absolutes in medicine and this small studydemonstrates that ca-MRSA has not yet become a serious threatprovided simple precautions are taken. A larger study may benecessary to come to a more definitive conclusion for othergeographic regions.Is Kentucky Prepared for the Patient-CenteredMedical Home?R.N. Eicher, K. Schuer, University of Kentucky, College of HealthSciences Division of Physician Assistant Studies, Lexington, Ky.Purpose: Clinician understanding of both the principles andimplementation strategy of the patient-centered medicalhome (PCMH) model is vital during this transformative timein primary care. The state of Kentucky is not only faced withunique healthcare delivery concerns but also trails behind otherstates in moving toward the medical home model. A descriptiveanalysis was performed to better understand the challengesof adopting the PCMH model among a cohort of primary careproviders in the state of Kentucky.Methodology: Data were collected via personal interviews withprimary care clinicians affiliated with nationally recognizedPCMH’s in Kentucky as well as through a survey instrumenttargeting clinicians associated with the Kentucky AmbulatoryNetwork. Both interview and survey questions were designednot only to assess clinicians’ familiarity of the PCMH model andimplementation process, but also to identify barriers to PCMHdevelopment and whether or not practices are currently meetingspecific criteria required by the National Committee for QualityAssurance (NCQA) for PCMH designation.Results: A total of 263 surveys were faxed to primary careoffices in Kentucky. Data collected demonstrate that 58 percentof responders indicate familiarity with the PCMH model, and ofthese responses 71 percent have started their transformationtoward the medical home model. Barriers to implementationof PCMH were identified from the study as: “lack of funding”(58 percent), “high upfront costs” (67 percent), “lack ofMedicaid support” (75 percent) and “inadequate staff support”(58 percent). Interestingly, “lack of an electronic healthrecord (EHR)” was not indicated as a significant challenge totransformation (83 percent). Criteria being met by more thanhalf of participants required by the NCQA for medical homerecognition include: “24-hour patient access to a healthcareteam member,” “the family/caregiver is considered in patientcare management,” “patient satisfaction survey utilization,”www.aapa.org/IMPACT 35

POSTER ABSTRACTSPPEs. With this information, implications for further educationalpractice and PA curricula may be made clear.Methodology: Using a questionnaire with 38 Likert scaledquestions, data was collected from 39 first-year PA students, 39second-year PA students and 33 third-year PA students enrolledat the BCM PA Program in Houston. The topics assessedincluded: (1) comfort with various aspects of PPEs; (2) attitudesregarding the professionalism, appropriateness and perceivedvalue of PPEs; (3) attitudes toward peer breast, genital andrectal exams; (4) effect of various student characteristics (yearin program, age, gender, marital status, ethnicity, religiousaffiliation, religiosity, prior patient experience, body image,comfort in new situations and perceived confidence in physicalexamination skills) on comfort and perceived appropriatenessand value with PPEs; and (5) effect of faculty mentor gender onstudent comfort with PPEs.Results: Most of the 111 students (82 percent) agreed orstrongly agreed that they were comfortable with practicing PPEson other classmates and undergoing PE of themselves (81.1percent). Most students (87 percent) felt comfortable takingturns examining the chest area with a classmate. In contrast,only 38.7 percent of students felt comfortable taking turnsperforming inguinal examinations. All either agreed or stronglyagreed to the value of PPEs, and nearly all participants (97.3percent) acknowledged the appropriateness of PPEs as aneducational tool. Most felt that it is professional (82 percent) toperform PPEs on future colleagues, and that this does not straintheir relationship (88.3 percent).Conclusions: BCM PA students were comfortable taking turnspracticing PPEs. Most felt PPEs were appropriate and valuableand allowed for more practice time and helpful feedback frompeers. Male students were more comfortable with taking turnswith PPEs. Many students were less comfortable with sensitiveaspects of PPEs. No single independent variables uniquelypredicted perceived appropriateness/value of PPEs. Discomfortwith a peer performing a PPE on the respondent was related tobody image, confidence in PE skills and religiosity. No majoreducational implications need to be considered, but minorchanges to the PhD curriculum should be considered.Physicians vs. Nonphysician Providers: Does Delayin Appointment Scheduling Influence PatientPreference?E. Avvento, N.M. DiMezza, J.L. Vanacore, L. Herman, New YorkInstitute of Technology, Old Westbury, N.Y.Purpose: The incorporation of physician assistants (PAs)and nurse practitioners (NPs) into the healthcare team wasimplemented nearly 50 years ago primarily to improve accessto care in underserved populations. Medical facilities acrossthe country, including primary care practices, have turned tononphysician providers to offer increased and timely access tocare, as well as other reasons, including decreased cost andpotentially enhanced patient satisfaction. However, previousstudies have shown that at least in selected settings, somepatients still prefer to see physicians for part or all of theirhealthcare needs. Despite reports of increased accessibility tocare and increased patient satisfaction, patient willingness tobe seen by a nonphysician provider may remain an issue forsome patients. This study is designed to determine the impactof patient provider preferences given variable temporal accessto providers with varied credentials.Methodology: This study was conducted at three geographicallydisparate and busy primary care offices in Suffolk County, N.Y.(2,378 square miles, population 1,493,350), and performed aconvenience sample surveying more than 650 patients—andthose accompanying patients to appointments—who wereseeing a provider in these three primary care offices. All officesemploy physicians (MDs and DOs), PAs and NPs. Patients werepresented with a paper survey including a multiple-choicedemographic screening tool, and subsequently presentedwith a series of clinical vignettes that describes the signs andsymptoms of an urgent, yet minor, complaint—specifically, asore throat in an environment where close contacts were ill and“strep was going around” the workplace. They were given sixdifferent combinations of available appointments, each withtwo alternative choices of seeing the physician, PA or NP, withsame-day or next-day access to each.Results: This study demonstrates that in the population of morethan 650 surveyed with 3,909 possible choices, the majority ofpatients have no preference as to which type of clinician theysee, provided that they are treated in a timely manner. In theprimary care setting, patients with an urgent yet minor chiefcomplaint prefer to be seen the same day by any practitionerrather than waiting to be seen tomorrow, and this was foundto be a statistically significant finding for all six practitionerscenarios presented. Overall, 92.6 percent (n=3,619 totalresponses to all questions) responded that they would electto see anyone today as opposed to 7.4 percent (n=290 totalresponses to all questions) who responded to see someoneelse tomorrow. Availability to been seen in a prompt time frameis statistically more important to this patient population thanwhat type of clinician they are seen by, whether it was thephysician, PA or NP.Conclusions: This research demonstrates that when facedwith a particular ailment and the consequence of a relativelyminor delay in scheduling an appointment, in this geographicwww.aapa.org/IMPACT 37

POSTER ABSTRACTSof illicit stimulant use between graduate and undergraduatestudents. Seventy percent of graduate students and 83.9percent of freshmen strongly disagreed with taking stimulantsfor nonmedical purposes. Statistically significant differenceswere found in response to specific questions regardingknowledge of stimulant side effects (p

POSTER ABSTRACTSpercent) incidence. Although the correlation between TC andstroke remains unclear, it is important that clinicians appreciatethe potential for concurrent diagnoses. TC is a reversiblecondition that, when treated properly, may not result in longtermconsequences. Additional, larger studies are warrantedto better elucidate the relationship between TC and stroke.The clarification of the relationship is imperative in order toestablish future guidelines for its prevention and treatment.The Emergence and Proliferation of CarbapenemResistant Klebsiella Pneumoniae in the UnitedStatesG. Sanchez, J. Bordon, George Washington University,Washington, D.C.Purpose: Klebsiella pneumoniae is a common cause ofinfection in the respiratory tract, bloodstream and urinary tractof immunocompromised patients, and is frequently isolated inintensive care units in the United States. The trend of increasingantimicrobial resistance, including the proliferation ofcarbapenem-resistant Klebsiella pneumoniae (CRKP), accountsfor significant increases in patient morbidity and mortality,and places additional burdens on healthcare resources. WhenCRKP causes infection, few viable antimicrobial therapeuticoptions remain. This study investigates the prevalence of K.pneumoniae antimicrobial resistance in patients in the UnitedStates using a large national surveillance system.Methodology: We examined K. pneumoniae antimicrobialresistance data collected by The Surveillance Network (TSN)Database-USA (Eurofins Medinet, Chantilly, Va., USA) from1998 through 2010. TSN is a nationally representativedatabase of antimicrobial susceptibility results from morethan 200 community, government and university healthcareinstitutions in the United States, and has been used previouslyto investigate trends and prevalence of antimicrobial resistance.Susceptibility testing of isolates is conducted on site usingFDA-approved testing methods and interpreted using ClinicalLaboratory Standards Institute (CLSI) interpretive breakpointcriteria (CLSI, 2010). Details of quality control in thissurveillance system have been described previously.Results: K. pneumoniae antimicrobial susceptibility results(n=2,149,729) were analyzed from January 1998 throughDecember 2010. During our study time period, there was anincrease of K. pneumoniae antimicrobial resistance to alltested agents. K. pneumoniae resistance to imipenem firstappeared in TSN Database-USA in 2004, and steadily increasedto 4.3 percent in 2010. The greatest increases in antimicrobialresistance from 1998 to 2010 were observed for ceftazadime(5.5 percent to 17.2 percent) and ciprofloxacin (5.5 percentto 16.8 percent). Smaller changes in resistance were shownfor gentamicin (4.9 percent to 9.2 percent) and cefepime (2.1percent to 7.7 percent). In 2010, the agents that showed thelowest resistance rates were imipenem (4.3 percent) andcefepime (7.7 percent).Conclusions: This study provides new insight into antimicrobialsusceptibility patterns of K. pneumoniae from 1998 to 2010.In-vitro K. pneumoniae carbepenem resistance among UnitedStates inpatients during this study is particularly significantsince the emergence of CRKP was first observed around theinception of our data collection period. CRKP isolates are oftenresistant to beta lactams, fluoroquinolones and sulfonamides,and show variable susceptibility to aminoglycosides,polymyxins and tigecycline. Recently, pan-resistant K.pneumoniae has been reported.The consistent, stepwise increase of K. pneumoniae resistanceto imipenem demonstrated from 2004 to 2010 suggeststhe prevalence of CRKP in the United States will continue toincrease into the foreseeable future. Of additional concern,resistance to ceftazadime and ciprofloxacin increasedsubstantially (>10 percent increase), and may be approachinga level at which their efficacy as antimicrobial agents in thetreatment of K. pneumoniae-related infections may be reduced.In summary, this study shows that K. pneumoniae antimicrobialresistance to imipenem in TSN Database-USA began in 2004,and steadily increased to 4.3 percent in 2010. Resistanceto ciprofloxacin and ceftazidime showed substantial (>10percent) increases from 1998 to 2010. Due to the propensityof CRKP to confer resistance to other gram negative pathogens,and increasing prevalence of CRKP in the U.S., this emergingproblem presents a serious threat to public health and warrantsdue diligence in future surveillance efforts.The Impact of Increased Training on PhysicianAssistant Student Competency in AssessingLikelihood of Congestive Heart FailureG. Liaw, E. Love, V. Waters, Baylor College of Medicine, Houston,TexasPurpose: The purpose of this study was to evaluate BaylorCollege of Medicine (BCM) physician assistant (PA) students’abilities to accurately assess the likelihood of clinicalcongestive heart failure (CHF) by applying evidence-basedguidelines and, more specifically, to determine whether theseabilities were improving as the students progressed throughthe program. Additionally evaluated were the students’ abilitiesto order diagnostics based on clinical impression and toaccurately designate CHF classification.www.aapa.org/IMPACT 41

POSTER ABSTRACTSMethodology: Written surveys consisting of clinical casevignettes and follow-up questions were administered to threecohorts of PA students at BCM. Four cases were represented:unequivocal CHF (C2), unlikely CHF (C4) and possible CHF (C1,C3). Each case consisted of seven multiple-choice questionsand answers. This study analyzed a subset of questions in orderto measure PA students’ general knowledge regarding CHFidentification and management. Analyzed questions included:(1) determining presence of CHF based on clinical presentation;(2) selecting diagnostic studies indicated based on assessmentof clinical presentation; and (3) determining classification ofidentified CHF based on New York Heart Association (NYHA)staging criteria. Results were analyzed using SPSS statisticalpackage, version 19. Pearson’s chi-square test of associationwas used to test whether the associations were statisticallysignificant. P values

POSTER ABSTRACTSstudy indicate that the public is not aware of the newest BLSrecommendations; therefore, PAs must take the initiative ineducating the public that performing chest compressions aloneis in itself a life-saving measure.The Use of Airway Pressure Release Ventilation onIntubated Burn PatientsK. Yale, J. Stoehr, K. Foster, M. Pressman, K. Richey, J. Martin,J. Detzel, D. Ashburn, M. Hibbert, Midwestern University,Glendale, Ariz.Purpose: Airway Pressure Release Ventilation (APRV) is a form ofmechanical ventilation being investigated as a safe alternativefor difficult-to-oxygenate patients with acute lung injury(ALI) or acute respiratory distress syndrome (ARDS). Clinicalstudies have shown superiority of APRV over conventionalmethods of ventilation in trauma and surgical intensive careunit patients with ALI/ARDS or at risk for it; however, there is aneed for further research to validate the effectiveness of APRV,specifically in intubated burn patients.Methodology: The charts of all burn patients at MaricopaMedical Center who were ventilated using the APRV model forat least four days between 2005 and 2010 were retrospectivelyreviewed. Data collected included demographic data, burnand inhalation injury data, and outcome data. Outcome dataincluded mortality, ventilator days, ICU days, incidence ofventilator-associated pneumonia (VAP), FIO2, PAO2: FIO2 ratios(P/F ratio), and mean and peak airway pressures. This groupof patients was compared with a historic cohort of 27 patientstreated with high-frequency percussive ventilation. Standardsummary descriptive statistics will be reported for all variables.Descriptive statistics will be calculated including mean, medianand standard deviations. Nominal p-values may be reportedwith a statistical significance defined as

POSTER ABSTRACTSThe time frame for antibiotic administration is as follows:fever to physician notification (n=11), range 0 to 510 minutes,and standard deviation of 175.18; physician notification toantibiotic order (n=62), range 0 to 6,897 minutes, and standarddeviation of 885.76; finally, antibiotic order to antibioticadministration (n=62), range 0 to 1,445 minutes, and standarddeviation of 192.88. Of the sample, 95.2 percent presentedwith severe neutropenia, defined as an ANC, 1,500 microL.Conclusions: The findings of this research indicate that there isno significance between antibiotic timeliness and admissionstatus, blood cultures and oncology certification status. Themost influential time frame (greatest time frame in fever toantibiotic admission) is time between physician notificationand antibiotic order, with a 0 to 6,897 minute range, or almostfive days. Antibiotic administration timeliness for severity ofinfection dependent on ANC levels is not predictable in thisstudy as 95.2 percent have severe neutropenia. Finally, due tothe low return from nurses who cared for these patients (n=7),there is no significance between years of nursing experience,years of oncology experience, nursing education, oncologycertification and timeliness of antibiotic administration.Understanding of the Use of Automated ExternalDefibrillators and When Use Is Appropriate AmongCollege StudentsH. Neidle, C. Schalich, J. Perreault, C. Borders, J. Kalavelil, D.Rizzolo, Seton Hall University Physician Assistant Program,South Orange, N.J.Purpose: Sudden cardiac arrest is a leading cause of deathwithin the United States. Many cases occur in the pre-hospitalsetting, and 95 percent of victims will die before reaching afacility where they can receive advanced care. Prompt use of anautomated external defibrillator (AED) reduces morbidity andmortality in such cases. For this reason, the public placementof AEDs has become increasingly popular. Previous researchsuggests that lay people are capable of using AEDs safely andeffectively, leading to increased survival in out of hospitalcardiac arrests.Purpose: College students’ knowledge of AEDs has not beensufficiently studied; therefore, the purpose of this study is toassess college students’ knowledge of AEDs and whether theywould be willing to use an AED in appropriate situations.Methodology: Full-time students at a small, private universityages 18 and older were asked to fill out a questionnaire titled“Knowledge of AED Use and Willingness to Use,” adapted froma study by Lubin and Schober. The survey consisted of Likertscale questions on demographics, knowledge of AEDs andwillingness to use an AED. The survey was distributed utilizinga broadcast email sent through the Academic Survey Systemand Evaluation Tool. Analysis of the data was done using SPSS19.0. Descriptive statistics and chi-square tests were used toanalyze responses. An alpha value of

POSTER ABSTRACTSMethodology: A thorough review of the literature andnumerous personal interviews were completed initially todetermine the history of the debate over the PA professionaltitle. An anonymous computerized survey was then developedthrough SurveyMonkey® and distributed to 9,697 physicianassistants and physician assistant students across the country.Additionally, it should be noted that a pro-name change blogposted the link to the survey. Microsoft® Excel and IBM’sStatistical Package for the Social Sciences were utilized toanalyze the data.Results: A total of 9,697 surveys were successfully sent byemail; 57 percent (5,523) were sent to physician assistants andphysician assistant students across the nation, excluding NewYork, and 43 percent (4,174) were sent to those from New York.From the survey population, there was participation from 22.6percent (2,192). Students were responsible for the completionof 16.1 percent (353) of the surveys. The remaining 83.9percent (1,839) were completed by practicing and or retiredphysician assistants. When asked “How satisfied are you withthe title physician assistant?,” 47.9 percent (1,050) respondedas either dissatisfied or highly dissatisfied, 34.2 percent(750) responded as satisfied or highly satisfied, and 15.4percent (337) responded as neither satisfied nor dissatisfied.Responding to the question “Do you think the title physicianassistant accurately represents the profession?,” 70.5 percent(1,545) responded no, and 25.0 percent (549) responded yes.In response to asking “Do you think the title physician assistantaffects the way you are perceived as a medical provider?,” 64.6percent (1,417) responded that it negatively affects perception,10.4 percent (228) responded that it positively affectsperception, and 20.5 percent (449) responded that it has noeffect on perception. When asked “Do you feel that a change tothe physician assistant title would be of benefit?,” 57.3 percent(1,254) responded as beneficial, 12.4 percent (271) respondedas not being beneficial, and 25.5 percent (560) responded asundecided.Conclusions: The majority of those who completed the surveyare dissatisfied with the physician assistant title and feel thatthere would be a benefit to changing the title. Many thoughtthat the title “physician assistant” negatively affects theperception of the healthcare that is provided and inaccuratelyrepresents the scope of practice. Based on the findings, themajority of respondents would prefer a title change. The mostcommonly suggested name was “physician associate.”Student GalleryCASE STUDIES/CLINICAL REPORTSA Presentation of Unilateral Ideopathic OrbitalInflammatory SyndromeW.G. Reynolds, U. Shah, A. Marte-Grau, Jefferson College ofHealth Sciences, Roanoke, Va.A 57-year-old male presented to the emergency departmenton two consecutive days with a chief complaint of headaches.On his first presentation, he reported a three-day history ofretro-orbital headaches, with constant 9 out of 10 pain, andassociated symptoms of nausea, vomiting, excessive tearingand blurred vision. Physical examination and vital signs werewithin normal limits. The workup included a complete bloodcount, metabolic panel and liver function tests, which werewithin normal limits, except an ESR of 30. A CT scan of the headwithout contrast demonstrated a normal enhanced brain withsome right sinus congestion. An ophthalmology consult wasobtained, and the patient was diagnosed with mild refractorydisorder.The next day, the patient presented with increased retroorbitalpain and episodes of vomiting. A neurology consultwas obtained, and he was diagnosed with a classical migraineand placed on propranolol and sumatriptan. After two days,he complained of blurred vision and swelling around the lefteye. He was recommended to go to the optometry clinic forfurther evaluation and was directly admitted to the hospitalwith suspected preseptal/orbital cellulitis. During his hospitalcourse, an orbital CT scan with contrast was performed, whichdemonstrated approximately 1.1 cm thickness soft tissueswelling limited to the medical rectus muscle of the left orbit,which was suggestive of an orbital pseudo tumor.After starting intravenous solumedrol, the patient improvedremarkably, with resolution of symptoms within 72 hours. Hewas discharged with corticosteroids. After 10 days, a repeatorbital CT scan with contrast demonstrated 0.5 cm thicknessof the medial rectus muscle; compared with pretreatment, thisdemonstrated a 0.6 cm reduction in thickness of the medicalrectus of the left orbit.An orbital pseudo tumor, also known as Idiopathic OrbitalInflammatory Syndrome, is a rare inflammatory disease thatcauses swelling of the tissues behind the orbit, including theextraocular muscles. It is characterized by a polymorphouslymphoid infiltrate and a varying degree of fibrosis. It caninvolve different parts of the orbit, with different subgroups,www.aapa.org/IMPACT 45

POSTER ABSTRACTSdepending on involvement site. Presentation can be acute,subacute or chronic, with common symptoms of severe pain,changes in vision and proptosis. Diagnosis is based on thesymptoms, radiological findings and response to steroids.Though rare, differentiating an orbital pseudo tumor isimportant because it has an excellent prognosis withcorticosteroid treatment. In the English literature, there havebeen numerous reports of Idiopathic Orbital InflammatorySyndrome that presented itself as an acute, subacute or chronicprogression. Our case is unique because there are no caseswhere Idiopathic Orbital Inflammatory Syndrome has mimickedrefractory disorder of the eye, migraine and preseptal/orbitalcellulitis consecutively. In our case, our patient had no historyof cancer or a connective tissue disorder. Additionally, he hada detailed diagnostic workup which included imaging, serologyand immunological markers, including ANA reflex, which werenormal. His remarkable response to steroids, proven by afollow-up orbital CT scan with contrast, makes the diagnosis ofan orbital pseudo tumor most likely.An Evidence-Based Evaluation of the ClinicalEfficacy of Glucosamine and Chondroitin Sulfate forthe Treatment of OsteoarthritisJ.D. DeGroot, University of Iowa Physician Assistant Program,Iowa City, IowaAs clinicians, it is our responsibility to make appropriaterecommendations regarding controversial therapies ourpatients are introduced to through marketing and the media.The purpose of this study was to identify and critically examinethe best current evidence regarding the clinical efficacy ofglucosamine and chondroitin sulfate for the treatment ofosteoarthritis. The results of those studies were reported andused to formulate answers targeting common clinical inquiries.A literature search was performed in PubMed with the followingkeywords: ‘glucosamine’, ‘chondroitin’ and ‘osteoarthritis.’Results were limited by type: meta-analysis and randomizedcontrol trials, and by species: humans. Ten articles were chosenfor critical review. Based on that appraisal, three randomizedcontrol trials and two meta-analyses were selected forpresentation.The GAIT trial (Glucosamine/Chondroitin Arthritis InterventionTrial) by Clegg et al. in 2006 was an NIH-funded trial designedto meet the demand for a large, unbiased and methodologicallysound trial. Overall, glucosamine and chondroitin sulfate werenot significantly better than placebo in reducing knee pain(66.6 percent combo versus 60.1 percent placebo, p=0.09). Anexploratory analysis of patients with moderate-to-severe painat baseline showed a response that was significantly higherwith therapy than placebo (79.4 percent combo versus 54.3percent placebo, p=0.002). However, an ancillary GAIT report bySawitzke et al. in 2010 demonstrated that the effect did not lastafter two years of treatment (OR of 0.83 [95 percent CI 0.51-1.34]). Another GAIT report by Sawitzke et al. in 2008 lookingat joint space width also reported no significant differencebetween treatment and placebo (0.028 mm difference [95percent CI -0.214, 0.271]). All studies reported that adverseevents were rare and similar between treatment groups. Ameta-analysis by McAlindon et al. in 2000 evaluated 15 trialsand reported that, although a moderate benefit was measuredfor glucosamine (0.44 [95 percent CI 0.24-0.64] and chondroitin(0.78 [95 percent CI 0.60-0.95]), design quality scores werelow. Only one in 15 studies described adequate allocationconcealment, and two in 15 reported an intention-to-treatanalysis. Additionally, most of the studies were supportedby manufacturers; analysis suggested publication bias anddiminished effect sizes were observed in larger, higher qualitytrials. A recent meta-analysis by Wandel et al. in 2010 evaluated10 of the larger, more recent studies and found no difference inpain intensity when treatments were compared to placebo (-0.5cm [-0.9 – 0.0 cm] on 10 cm VAS) or any difference in changesin joint space width. Interestingly, their analysis also reportedthat industry-independent trials reported smaller effects thancommercially funded trials (p=0.02)The highest quality studies demonstrate that there is nosignificant evidence to support that glucosamine andchondroitin sulfate reduce joint pain or delay joint spacenarrowing associated with osteoarthritis. However, manypeople still claim to notice a benefit that researchers generallyattribute to the natural course of osteoarthritis and the placeboeffect. All research has shown that these treatments are safeand have small side effect profiles. By educating patients basedon reliable research, we give them the power to make informeddecisions regarding the costs and benefits of availabletreatments.An Unusual Case of Abdominal Pain Causedby Pacemaker Lead Dislodgement, Proven byFluoroscopyS. Oginsky, U. Sha, A. Marte-Grau, Jefferson College of HealthSciences, Roanoke, Va.An 87-year-old male presents to the emergency departmentwith a chief complaint of new onset of abdominal pain in theright upper quadrant associated with lightheadedness. Theabdominal pain occurred on three separate occasions that day.The original pain lasted for 15 minutes, then again while on the46

POSTER ABSTRACTSway to the hospital for five minutes. The last episode lasted 30minutes while in the hospital.Eight days prior to presentation the patient had a placement ofdual chamber pacemaker for symptomatic bradycardia with noapparent complications. He denied any chest pain, palpations,shortness of breath, abdominal pain, nausea, vomiting orchange in bowel movements.Vital signs, labs and physical examination were all withinnormal limits. The EKG showed a normal sinus rhythm with thepace signal seen without capturing. On the lateral view of thechest X-ray there was inconclusive evidence if the atrial leadwas too high, the ventricular electrode was in good position andshowed no evidence of a pneumothorax.He was admitted under the presumption that there wasatrial dislodgment. An echocardiogram was performed withevidence of left ventricular hypertrophy, an ejection fraction of60 percent, right atrium enlargement and moderate tricuspidregurgitation. A fluoroscopy was then done trying to evaluatethe dual chamber dislodgement and possible ipsilateral phrenicnerve activation to determine the complaint of abdominalpulsations. It demonstrated that the right atrium pacer leadwas indeed displaced in the superior vena cava and that thediaphragmatic pulsations were synchronous with pacing. Thepacer was switched from DDDR mode to VVIR mode so that onlythe ventricles were being paced.Surgery to correct the dislodgement of the pacemaker leadwas performed. The symptoms of abdominal pain andlightheadedness completely resolved after the surgery. In ourcase, the pacemaker lead dislodgement produced phrenicirritation, which caused diaphragmatic stimulation, whichin turn gave abdominal spasms to our patient. This was allproven by fluoroscopic evidence. In our literature review wefound numerous case reports of complications secondary tolead dislodgement, including Twiddler’s Syndrome. Our casewas not secondary to patient induced twisting of the leadsas in Twiddler’s Syndrome. We have not found in the Englishliterature any case report similar to our patient’s where therewas a questionable lead dislodgment with nerve irritation thatwas proven on fluoroscopy.Atypical Genitalia Presentation inNeurofibromatosis Type 1B. Karwaski, C. Rossi, Quinnipiac University Physician AssistantProgram, North Haven, Conn.Neurofibromatosis type 1 is a genetic neurocutaneous disorderthat is characterized by peripheral nerve tumors calledneurofibromas. While neurofibromas can appear anywherethroughout the body, genitalia involvement is rare. Of the onein 2,600 to 3,000 people diagnosed with Neurofibromatosistype 1, there have only been 35 female cases and 15 malecases of genitalia involvement. Of these cases, most presentedas genital enlargement in childhood. Due to so few cases, littleis known about how genitourinary plexiform neurofibromaspresent, which results in the delay of diagnosis.A 40-year-old male with a history of neurofibromatosispresented to the emergency department with acute onset grosshematuria and significant bleeding from his penis beginning at7 a.m. He presented two weeks earlier with a similar episodeof gross hematuria with subsequent discharge of blood clotsfrom his penis. During the patient’s first admission, cystoscopywas performed and a two centimeter lesion was visualized,actively bleeding distal to the urethral sphincter. The lesion wascauterized and the bleeding stopped, at which the patient hadclear urine.One week later, the patient presented for recurrent bleeding.The past medical history is significant for acute spontaneousneurofibroma hemorrhage of the back, requiring emergentsurgical exploration and excision. On physical exam, the patientwas a healthy-appearing 40-year-old male, alert and oriented,and short in stature. His vital signs were within normal limits.There were multiple café au lait spots on the right side of hisabdomen and back (>15 mm). Abdomen was soft, nontenderand nondistended. An 18-French catheter was draining dark redurine with blood clots draining around catheter insertion point.Extremities were warm and well perfused.Assessment of this patient was acute hematuria, likelysecondary to recurrent bleed from urethral lesion that hadrecently been cauterized. The plan was to keep the patient’sFoley catheter in place to tamponade bleeding, bed rest and anMRI of the pelvis. The MRI revealed dilation of the penile urethraof two centimeters, asymmetric thickening and enhancement ofurethral wall, and an intraluminal urethral mass in the proximalurethra measuring 17 mm. These findings are consistentwith a plexiform neurofibroma. The patient underwentangioembolization of the left branch of the pudendal artery.Hemostasis was established with embolization of the pudendalartery and patient was transferred to the intensive care unit forclose monitoring and pain control. There were no immediatesigns of complications relating to angioembolization (i.e. penilecurvature or urethral stricture). The patient was discharged afew days later in stable condition without surgical excision ofhis plexiform neurofibroma due to the complexity of the surgery.Neurofibromas of the external genitalia are extremelyrare, but should be considered in patients with history ofwww.aapa.org/IMPACT 47

POSTER ABSTRACTSneurofibromatosis. Plexiform neurofibromas can present at anyage and may not be evident based solely on a physical exam.The treatment for any neurofibroma is treatment of symptoms.But due to the likelihood of malignancy, the recommendedtreatment for plexiform neurofibromas is surgical removal.Dengue Fever: Etiology of Fever in the ReturningTravelerB. Vogt, C. Rossi, Quinnipiac University Physician AssistantProgram, North Haven, Conn.Dengue fever virus is an arbovirus of the family Flaviviridae andgenus Flavivirus. It is most commonly transmitted via the Aedesaegypti mosquito. Dengue fever causes more than 50 millioninfections each year worldwide and is the second most commoncause of febrile illness in returning travelers. Dengue fever isendemic in regions of the world such as Central and SouthAmerica and Central and Southeast Asia and is a cause of highmorbidity and mortality.A 69-year-old male presented with a two-day history of fever,chills, muscle aches and fatigue. The patient denied nausea,vomiting, diarrhea, rash, headache, genitourinary symptomsor lesions and denied taking anything for symptom alleviation.The patient had returned one week earlier from a two-monthvacation in El Salvador. The patient denied any sexual activitywithin the past year. Past medical history included a syphilisinfection at age 16 and a recently positive RPR (unknown titer)during his vacation in El Salvador. It was unknown whether ornot the patient received treatment for syphilis in El Salvador.The complete physical exam was unremarkable and the patientwas admitted for observation and for further testing. Initialtreatment was supportive pending results of serologic tests forinfectious etiologies, including syphilis and dengue fever. Thepatient developed thrombocytopenia and leukopenia on daythree of the hospital course, however, both resolved withoutintervention by day five. The patient’s fever also resolved withsupportive therapy (IV fluids/acetaminophen) on day five.All serologic tests returned negative except for syphilis RPR,which was positive with a titer of 1:4 (TP-IgG positive). Dengueserology was still pending at time of discharge. The patient wasdischarged following clinical improvement and advised to returnif clinical deterioration occurred.At the time of discharge, the patient was given 2.4 millionunits of penicillin (PCN) IM and advised to follow-up as anoutpatient for two additional doses of PCN for the positive RPR.Syphilis was considered to be a potential cause of his fever,even without characteristic physical findings. Two weeks postdischargethe results of the dengue fever serology returnedpositive with elevated IgM and IgG. At that time, the patient’sfever, leukopenia and thrombocytopenia were deemed to besecondary to dengue fever rather than syphilis. The positiveRPR titer was attributed to a previous infection that was notadequately treated. No additional treatment or follow-upwas needed since the treatment of choice for dengue fever issupportive and the patient had symptomatically improved bythe time of discharge.Travel history in a patient with fever of unknown origin (FUO)is an important historical question because certain infectiousagents are characteristic of particular geographical regions.Dengue fever is a common cause of FUO in the returning travelerand, therefore, must be a diagnostic consideration in a patientwith suggestive signs and symptoms and relevant travel history.Early Clinical Suspicion of Heparin-InducedThrombocytopenia and Thrombosis Can Lead ToLimb SalvageM. Ngugi, Quinnipiac University Physician Assistant Program,Hamden, Conn.Heparin-induced thrombocytopenia (HIT) and thrombosis is acomplex, catastrophic, iatrogenic, yet a very rare complicationof the use of heparin, a common anticoagulant. It is estimatedto cause a mortality rate of about 20 to 30 percent andamputations in 10 to 20 percent of cases. In spite of thesecomplications, HIT is both preventable and treatable. Heparinis an essential anticoagulant with widespread use in medicineand surgery. Therefore, suspecting this rare IgG mediatedimmune complication early is crucial to avoid serious adversecomplications, such as ischemic limb damage and amputation.The complication is a drug adverse effect to heparin that resultsin increased platelet activation, thrombocytopenia and/orthrombotic events (arterial or venous clot formation). This reportconcerns an unfortunate case of late suspicion of HIT leading tolimb loss, highlighting the importance of early clinical suspicionand diagnosis of HIT.This is a case of a 56-year-old male smoker with a past medicalhistory of peripheral artery disease, stroke and past cocaineuse, who developed HIT, thrombosis and skin necrosis 14 daysafter initiation of intravenous therapeutic heparin. On day 14,the patient presented with severe pain, cyanosis and gangreneof his entire right lower leg for the past 24 to 48 hours. Vitalsigns illustrated episodes of hypotension, suggesting an acutesystemic reaction. Laboratory results showed an increase increatinine (suggesting myoglobinuria) and an increase in whitecount. It was determined that the patient suffered an acutearterial occlusion, and it was then necessary to proceed withemergent above-knee amputation. The platelet count fell morethan 50 percent from an initial value of 320 x 109/L to 90 x48

POSTER ABSTRACTS109/L and normalized within 24 hours of heparin cessation,initiating a direct thrombin inhibitor and limb amputation.During the amputation, a white platelet rich clot was found inthe superior femoral artery. No further thrombosis occurredafter treatment.Although the patient lost a limb, the rapid intervention savedhis life. Early clinical suspicion of HIT can lead to limb salvageand the thrombosis that result from irreversible aggregationof platelets known as white clot syndrome. It is important toclosely monitor the patient’s platelet count for a decline ofmore than 50 percent, especially after five days from start ofthe administration of heparin therapy. In the case of suspectedHIT, treatment must be initiated immediately, even beforeconfirmatory test results are available. Early monitoring anda thorough understanding of the unique treatment protocoland prevention of HIT are necessary to prevent the rare risk ofdeveloping complications from heparin use.Endometrial Osseous Metaplasia Presenting asPost-Coital BleedingH. Koning, P. Sandor, Quinnipiac University Physician AssistantProgram, Hamden, Conn.Endometrial osseous metaplasia is the rare transformation ofendometrial tissue into a bony structure; as of 1995, there hadonly been 60 reported cases. Etiology and pathogenesis havenot been definitively defined; however, it is clear that this isnot simply a process of retained fetal bones after a therapeutic(TAB) or spontaneous abortion (SAB). The most consistentfinding in women with this disease process is a past historyof endometrial insult, most commonly through TAB by dilationand curettage. Therefore, the metaplastic change is likely theresult of the endometrial insult. Patients often present duringthe childbearing years with the complaint of abnormal uterinebleeding or secondary infertility. Other common symptoms ofthis disease process include: dysmenorrhea, dyspareunia andpelvic pain. Symptoms resolve after removal of the osseoustissue. This is often achieved via tissue resection duringhysteroscopy, and no further treatment is necessary.A 43-year-old female, gravida two, para two, abortus zero,presents to the office with complaints of post-coital bleeding fortwo months. Her past medical history is significant for abnormaluterine bleeding treated three years prior with endometrialablation, resulting in resolution of symptoms. On physicalexam, the abdomen is soft, nontender, nondistended andwith no palpable masses. On speculum exam, the patient isfound to have a friable cervix with no other pertinent findings.A Papanicolaou smear is performed and is negative fordysplasia and high-risk human papillomavirus DNA. A pelvicultrasound reveals an inhomogenous, vascular mass measuring1.8 cm x 2.5 cm which is given the preliminary diagnosis ofneoplasm until proven otherwise. Hysteroscopy with dilationand curettage is then performed and shows that the ectocervixand endocervical canal are within normal limits; however, theinternal cervical os and lower uterine segment are extremelystenosed with scar tissue, thus rendering it impossibleto visualize the endometrial cavity. Due to the inability toadequately visualize the endometrial cavity, obtain a specimenand rule out neoplasm, a laparoscopic total hysterectomy wasperformed.Pathology revealed a stenotic, denuded endometriumand nodules consistent with osseous metaplastic boneformation. The patient tolerated the surgery well and withoutcomplications. She is currently doing well, and she is withoutcomplaints of post-coital bleeding.Though this patient does not have a history of TAB, SAB ordilation and curettage, she has had an endometrial ablation,a procedure which certainly causes insult to the endometrium.Therefore, it is important to consider this pathology in anywoman with possible insult to the endometrial cavity presentingwith secondary infertility or abnormal uterine bleeding.Treatment often includes resection of the bony tissue duringhysteroscopy; however, laparoscopic total hysterectomy was anoption in this patient because she did not desire to have anymore children. This procedure was also the last available optionbecause the mass could not be assessed via hysteroscopy, andthere is a possibility the mass could have been malignant.Jaundice in a 62-Year-Old MaleW. McCormick, B. Coplan, Midwestern University PhysicianAssistant Program, Glendale, Ariz.The purpose of this case report is to describe the diagnosis of arare malignancy and the subsequent surgical intervention.A 62-year-old male was brought to an emergency department(ED) in Arizona by his family with a chief complaint of pruritisand scleral icterus for the past three weeks. In addition to hispresenting complaints, he admitted to a 17lb. unintentionalweight loss over the past month and complained that for thelast few weeks, each day he felt nauseated and had three to fourloose, light-colored stools. He also admitted to dark-coloredurine for the past two weeks and denied fever, chills or fatigue.Several weeks earlier the patient had seen his primary careprovider in Alaska for evaluation of pruritis. Laboratory workat the time revealed an elevated bilirubin but abdominalultrasound was unremarkable, and the patient did not undergowww.aapa.org/IMPACT 49

POSTER ABSTRACTSany further testing. He was visiting family in Arizona; theynoticed the worsening of his jaundice that prompted his EDvisit. The patient had no past medical history of any majormedical illness. He was not taking any medications and did notsmoke, drink alcohol or use any illicit drugs.On physical exam, icterus of the sclera and oral mucosawas noted. The remainder of the exam was unremarkable.Laboratory studies showed an elevated lipase of 700 units/L,an elevated alkaline phosphatase of 367 units/L, an elevateddirect bilirubin level of 9 mg/dL, an elevated total bilirubin of 12mg/dL and a normocytic anemia.Abdominal CT revealed intra and extrahepatic biliary dilation,pancreatic duct dilation and pancreatic enhancement withoutevidence of inflammation. There was no evidence of gallstonesor gallbladder wall thickening. Subsequent ERCP showedextrahepatic ductal dilatation and mild intrahepatic dilatationwith irregularity. During the procedure, a common bile ductstent was placed to aid the drainage of bile and biopsy of anampullary mass was performed.Biopsy results showed moderately differentiated, invasiveadenocarcinoma of the ampulla of Vater. As a result, the patientunderwent an elective pylorus-sparing Whipple procedure,which includes removal of the head of the pancreas, removalof the duodenum and removal of a portion of the commonbile duct with subsequent anastomoses of the remaining bileduct, pancreatic duct and proximal jejunum to the pylorus. Thepatient tolerated the procedure well.Neoplasms of the ampulla of Vater are rare and typicallyassociated with a better prognosis than neoplasms of thebody or tail of the pancreas, which are usually advanced at thetime of diagnosis. Symptoms of ampulla of Vater carcinoma,including pruritis and jaundice, manifest earlier due to tumorlocation and associated biliary outflow obstruction. Thefive-year survival rate for all stages of pancreatic cancer is sixpercent, whereas cancer of the ampulla of Vater has a five-yearsurvival rate of 40 to 67 percent, and as high as 90 percent ifthe tumor is limited to the duodenal mucosa. Fortunately for thepatient in this case, his symptoms prompted evaluation whichresulted in appropriate surgical management.Malignant Peritoneal Mesothelioma: A Case Reportof 39-Year-Old Male With Persistently High FeverFollowing Hernia RepairM. Hann, C. Rossi, Quinnipiac University Physician AssistantProgram, Hamden, Conn.Malignant peritoneal mesothelioma (MPM) accounts forabout 15 percent of all mesothelioma presentations andapproximately 300 to 400 cases are reported annually in theUnited States. This rare carcinoma, linked to asbestos exposure,develops on the serosal membranes of the abdominal cavity.Due to the aggressiveness of the disease, diagnosis of thecondition must be made promptly and systematically todetermine the prognosis and treatment options for the patient.A 39-year-old Hispanic male, with a past occupational historyof pipe welding, presented with persisting high fever, nausea,vomiting, early satiety, weight loss and significant ascites,as well as severe anemia and thrombocytosis, over a periodof six weeks. A laparoscopic to open inguinal hernia repairwas performed one week prior to occurrence of symptoms.An extensive laboratory workup was performed and included:CT-scan, paracentesis, endoscopy, colonoscopy and omentalbiopsy. CT-scan findings showed omental thickening andmild to moderate ascites. Initial paracentesis of asciticfluid showed poorly differentiated carcinoma. Endoscopydemonstrated Helicobacter pylori infection. Mesotheliomamarkers and laparoscopic omental biopsy was obtained.Pathology described the malignancy as epithelioid typeperitoneal mesothelioma. Liver metastasis was observed duringthe laparoscopy as well as omental caking and small bowelstudding.Systemic chemotherapy (intravenous cisplatin) was initiateddue to liver involvement of malignant peritoneal mesothelioma.No further surgery was performed. Standard treatment wasinstituted for the associated H. pylori infection.Prompt diagnosis of peritoneal mesothelioma presents manychallenges to the practitioner during early workup of the diseasedue to the vague presentation of abdominal symptoms. Thiscase presents a patient with an initial hernia. Research suggestsa hernia as the presenting symptom in 12 percent of peritonealmesothelioma patients. If MPM is suggested in the differentialdiagnosis, an extensive workup is necessary, including serumtumor markers, CT-scan of the chest, abdomen and pelvis, andalso requires laparoscopic biopsy. Biopsy analyzes specificmesothelioma tumor markers and can calculate a prognosis forthe patient. According to the literature, histomorphology andnuclear size are considered major prognostic criteria. Minorpathological criteria also need to be considered to determinepalliative or specific therapy for the patient. Recent researchsuggests that when ascitic fluid is present, ultrasound-guidedomental biopsy is a reliable method of diagnosis. Incidence ofperitoneal mesothelioma is expected to increase over the next20 years worldwide and practitioners must be aware of thediagnostic criteria and early treatment. This case suggests theneed to consider peritoneal mesothelioma in patients with apast history of possible asbestos exposure, since the expectedmean survival of the disease is 25 to 35 months.50

POSTER ABSTRACTSMultiple Endocrine Neoplasia: A Genetic TestingQuandary in a Patient With Hyperthyroidism,Pheochromocytoma and Parathyroid AdenomaR.Grant, L. Ryznyk, Southern Illinois University PhysicianAssistant Program, Carbondale, Ill.Multiple endocrine neoplasias (MEN) include several distinctsyndromes with characteristic patterns. In this case, anelderly female with a four-year history of poorly controlledhyperthyroidism presented with increasing complaintsof anxiety, fatigue and abdominal pain despite medicalmanagement. Palpation of the thyroid gland revealed anenlarged right lobe. The patient’s past medical history wassignificant for hyperparathyroidism with left parathyroidectomyas well as pheochromocytoma with subsequent leftadrenalectomy. Maternal family history was positive forthyroidectomy for “unknown” etiology. Review of the patient’slabs revealed an elevated calcitonin level in addition to asuppressed thyroid stimulating hormone.The student’s self-directed learning resulted in the hypothesisof multiple endocrine neoplasia type 2A (MEN 2A) syndrome.MEN syndromes are hereditary neoplastic disorders ofmultiple endocrine organs divided into MEN type 1 and MENtype 2, with subtypes A and B. Both have an autosomaldominant pattern of inheritance. MEN type 2A is the mostprevalent of these syndromes, with an estimated incidenceof 1 to 3 per 100,000 in the general population. MEN 2A ischaracterized by the occurrence of medullary thyroid carcinoma(MTC), pheochromocytoma and parathyroid hyperplasia oradenoma. Although evidence suggested such syndromesearlier, Sipple first noted the association of thyroid cancer andpheochromocytoma in 1961, with MEN 2A recognized in 1968.MEN 2A is caused by mutations in the RET proto-oncogeneon chromosome 10. These mutations affect the extracellularcysteine-rich domain of RET, leading to an activatingsubstitution of arginine for cysteine. These mutations resultin enhanced cellular proliferation and increased resistance toapoptosis. Potent growth stimulation results in hyperplasia andtumor formation of the parathyroid glands, thyroid gland andadrenal medulla. Testing for the RET oncogene mutations aredone by direct DNA sequence analysis with a sensitivity of 95percent. Nearly all patients with MEN 2A syndrome will developMTC. In patients who present with a suspicious thyroid nodule,histology from a fine-needle aspiration biopsy establishes thediagnosis. The carcinoma commonly metastasizes to the lymphnodes, lung, liver and bones.Thyroidectomy is the treatment of choice. A thorough history,including an in-depth family history, can lead to importanthypothesis generation, genetic testing and proactivemanagement of patients and family members. This patient’srefusal of further testing or surgery and no involvement of familymembers presented a quandary in her care, treatment andfollow-up. The patient subsequently elected to undergo ablationtherapy for symptomatic relief.New-Onset Atrial Fibrillation in the Setting ofSubclinical HyperthyroidismA. Meyer, T. Kodz, Quinnipiac University Physician AssistantProgram, Hamden, Conn.Atrial fibrillation is a cardiac arrhythmia that is well knownfor independently increasing the risk of stroke in affectedpatients. Patients with subclinical hyperthyroidism, definedas having low thyroid stimulating hormone (TSH) levels withnormal free thyroxine (T4) and triiodothyronine (T3) levels,are three times more likely to develop atrial fibrillation thanpatients with normal thyroid stimulating hormone (TSH) levels.However, they often do not present with typical symptomsof hyperthyroidism due to normal T4 and T3 levels. This casedemonstrates the importance of obtaining thyroid laboratorystudies in patients presenting with atrial fibrillation despite alack of expected signs and symptoms of hyperthyroidism andthe special considerations in treating atrial fibrillation due tohyperthyroidism.A 66-year-old Caucasian female with no prior medical historypresented with mild right upper back pain that began theprevious evening. She described the pain as an ache thatradiated across her upper back and anterior chest. Herdiscomfort waxed and waned throughout the day but did notworsen or change upon exertion. She denied lightheadedness,dizziness, shortness of breath, palpitations, nausea ordiaphoresis. She was not on any medications, did notsmoke and rarely drank alcohol. She had no family historyof arrhythmias or cardiac disease but did have a sister withhyperthyroidism.Physical exam was unremarkable except for an irregulartachycardic heart rate. An electrocardiogram indicated that thepatient had atrial fibrillation with a rapid ventricular response.Subsequent thyroid laboratory studies revealed a low thyroidstimulating hormone level of 0.01 mlU/L with normal free T4and low free T3 levels (1 ng/mL and 2.09 pg/mL respectively).Patient was given two doses of diltiazem 25 mg intravenously inthe emergency department for rate control. She failed to convertto normal sinus rhythm in the after being given 600 mg ofpropafenone. However, she successfully converted the followingday without additional treatment. She was discharged on dailywww.aapa.org/IMPACT 51

POSTER ABSTRACTSaspirin and encouraged to follow-up with an endocrinologistand cardiologist. Outpatient radioactive iodine uptake testresults confirmed hyperthyroidism with increased uptake to anenlarged, homogenous right lobe of the thyroid.Hyperthyroidism should be considered in patients presentingwith new-onset atrial fibrillation regardless of the presenceof signs and symptoms of a thyroid disorder. In addition,pharmacologic conversion is unlikely to be effective inpatients with hyperthyroidism. Discovery of thyroid laboratoryabnormalities may represent a reversible cause of atrialfibrillation, yet more research needs to be done to explore theneed for treatment of subclinical hyperthyroidism specifically.Ptosis, Proptosis and Ophthalmoplegia: CavernousSinus Thrombosis Secondary To PansinusitisT. Kramarz, F. Soviero, Quinnipiac University Physician AssistantProgram, North Haven, Conn.Cavernous sinus thrombosis (CST) is an uncommoncomplication of sinusitis in which the cavernous sinus becomesoccluded; however, this complication was not so scarce priorto the advent of antibiotics in the 1960s. Historically, CST wasalso associated with an approximate 80 percent mortality. Sincethe advent of antimicrobial agents there are only a few hundredcases of CST present in the medical literature. Most CSTs wereencountered prior to knowledge of antibiotics. Increased riskof mortality can be avoided with a high index of suspicion andearly treatment.A 60-year-old African-American male with multiplecomorbidities presented with left temporal headache,diplopia and ophthalmalgia for one week with an acuteonset of ipsilateral ptosis, proptosis and ophthalmolplegia.His history was significant for a cough and sinusitis thatwas successfully treated three months prior to presentation.A non-contrast CT scan demonstrated extensive sinusopacification, bulging deformity of the left lamina papyracea,and symmetric prominence of the ophthalmic veins. Based onclinical presentation and correlating CT scan, the patient wasdiagnosed with CST secondary to pansinusitis.The patient was treated with urgent endoscopic sinussurgery and an aggressive antibiotic regimen followed withanticoagulation and steroid therapy. Once stabilized anddischarged, he demonstrated resolution of his headache butlikely permanent ptosis and ophthalmoplegia.Sinusitis, although exceedingly common, is also remarkablytreatable, allowing medical practitioners to avert suchcomplications as CST. Although the incidences of CST arerare in the medical field today, merited by the inventionand improvement in antibiotics, the often permanent anddebilitating neuro-ophthalmic deficits of this condition shallcontinue to push healthcare providers to further exploreimproved methods of diagnosis and treatment. Additionalresearch and continued advancements in medicine may offer asolution to the lasting sequelae of cavernous sinus thrombosis.Schizoaffective Disorder: A Case ReportA.A. Bates, Midwestern University Physician Assistant Program,Glendale, Ariz.Schizoaffective disorder is a psychiatric condition where thepatient presents with symptoms consistent with schizophreniaand mood disorder, but does not meet the criteria for eitherdisorder alone. The schizophrenic traits include hallucinations,delusions, and disorganized thoughts and speech.Depression or mania completes the criteria for mood disorder.Schizoaffective disorder can be classified as “bipolar type” or“depressive type.” Patients can demonstrate mixed episodesof depression and mania, with moods that rapidly alternatebetween depression and mania. It is difficult to differentiatebetween schizoaffective disorder and someone with bothschizophrenia and a mood disorder.The purpose of this report is to demonstrate the clinical declineof a patient with schizoaffective disorder who is noncompliantwith her medication regiment, and to support the recognition ofschizoaffective disorder.A 55-year-old female is brought into the urgent psychiatriccenter (UPC) for suicidal threats. On physical exam, the patientis rocking with her knees to her chest. She will not answerquestions directly and is crying. The patient is alert and orientedbut too disorganized to respond coherently. The patient isdisheveled and malodorous. She responds to internal stimuli.She states the voices are telling her to kill herself and hurtothers. She states “they’re coming to get me,” and to furtherquestions, focuses on one phrase and repeats it continually.The patient has a history of two prior suicide attempts.Medical history is also remarkable for diabetes mellitus andpolysubstance abuse. Medications include citalopram 20 mg,lamotrigine 200 mg, benztropine 1 mg and loxapine 25 mg and50 mg.The patient is admitted to the 23-hour observation unit. Hermedications are not altered. She is reassessed following the23-hour observation period.The patient showed no improvement. Following case review anddiscussion, the patient consented to voluntarily transfer to apsychiatric hospital for further care.52

POSTER ABSTRACTSSchizoaffective disorder is an uncommon psychiatric disorderbecause it presents as both a mood and psychotic disorder. It isimportant to consider the diagnosis in patients with previouslydiagnosed mood or psychotic disorder who continue to decline.Schizoaffective disorder can present with simultaneous mooddisorder symptoms and psychotic features, psychotic featureswithout mood symptoms for a period of time, or psychoticand mood symptoms unrelated to drug use or other medicalissues. Treatment must target both aspects of the disease.If bipolar symptoms are present, patients require a moodstabilizers plus an antipsychotic. If symptoms of depressionexist, patients require antidepressants, preferably SSRIs, plusan antipsychotic. Of special importance, and highlighted in thiscase study, is the critical nature of medication adherence. Thishelps maintain stability in mental and psychological status.Psychotherapy and psychoeducational programs are alsorecommended as an essential part of the patient’s care.The Diagnosis and Management of PolycythemiaVera as a Comorbidity of Spina BifidaM.J. Holtz, M. Freeman, D. Rotenstein, Duquesne UniversityPhysician Assistant Studies, Pittsburgh, Pa.Polycythemia vera is a myeloproliferative disorder thatmanifests as increased red blood cell mass. This state ofhyperviscosity can lead to thrombosis, a potentially significantcomplication in spina bifida patients with severe muscularatrophy and diminished lower extremity innervation. Thesedeficits can encourage venous pooling and undetected deepvein thrombi. We report a case of new onset polycythemia verain an established spina bifida adult patient.A 20-year-old Caucasian male with a history of spina bifida,hydrocephalus and growth hormone deficiency presentedto the endocrine office for a routine visit. He informed theendocrinologist of his recent diagnosis of polycythemia verabased on lab results ordered by his primary care physician.Labs revealed a red blood cell count of 6.33 and platelets of1,175, despite low dose aspirin therapy (81 mg PO daily) andclose monitoring of blood counts by hematology. Upon physicalexamination, the patient’s established diminished sensationand atrophy of the legs bilaterally was confirmed with the use oflight touch. No erythema or edema was noted bilaterally. He wasable to ambulate independently with the support of bilateralleg braces. The rest of the exam was unremarkable. The patientwas encouraged to continue his treatment plan of aspirin 81 mgdaily and lab work every two weeks with phlebotomy as neededin the presence of elevated red blood cell counts.Previously, spina bifida patients were not expected toreach adulthood and disease supervision was a pediatricresponsibility. According to the National Health Service, beforethe 1960s, most children with spina bifida would die duringtheir first year of life. However, due to advancements in themanagement of spina bifida, many of these patients are livinglonger. According to Mary Burke of the Virginia HendersonInternational Nursing Library, 85 percent of children bornwith spina bifida now reach adulthood. Because of this shiftinto the adult population, comorbidities normally seen in anolder population must be recognized and treated followingregimens tailored to the older spina bifida patient. Althoughpolycythemia vera can affect people of all ages, it is consideredto be an adult disease with the average onset being 60 yearsof age. Polycythemia vera can have particularly devastatingeffects in spina bifida patients. Spinal lesions at the level ofinappropriate neural tube development in these patients cancause decreased muscle mass that can encourage venouspooling and diminished innervation to sense pain.An initial treatment regimen that includes aspirin 81 mg dailyis essential to decrease blood viscosity. It is critical to monitorred blood cell counts, hematocrit, hemoglobin and plateletsin these patients in order to identify when to take additionalprecautions to prevent a thrombotic event. Patients shouldbe encouraged to stay as active as possible and to regularlycheck lower extremities for irregular acute masses or erythema.Supervising clinicians must be heedful for suggestive findingson physical exam or lab work. With intensive management,patients with polycythemia vera and spina bifida can beexpected to have a positive prognosis.Treatment Options for Long-Term Non-SteroidalAnti-Inflammatory Drug Use in a Patient with HighGastrointestinal and Cardiovascular RisksS. Tescher, University of Iowa Physician Assistant Program, IowaCity, IowaThe purpose is to provide the clinician with informationregarding the importance of recognizing risk factors in patientsthat could potentially lead to adverse gastrointestinal (GI) and/or cardiovascular (CV) side effects with daily non-steroidal antiinflammatorydrug (NSAID) use and to present an algorithm forthe safest treatment options in the high risk patient in whichlong-term (>4 weeks) NSAID use is a necessity.An established patient, 62-year-old female with chronic historyof rheumatoid arthritis (RA), dyslipidemia, hypertension anda family history positive for CV disease, presented to theclinic with dyspepsia and an increase in frequency of burningepigastric pain. The pain had been relieved by over-the-counterantacids and food, but then recurred within two hours. She hasnot been eating a spicy diet, reports no stress, but does takewww.aapa.org/IMPACT 53

POSTER ABSTRACTSibuprofen 500 mg PO tid for her RA pain and an 81 mg aspirinprophylaxis for CV events. Upper GI endoscopy revealed anulcer in the gastric antrum. The patient now has significant GIrisk that is coupled with her CV risk, yet she needs long-termanti-inflammtory relief for her RA pain. Avoiding NSAID use isnot possible in this patient.Multiple guidelines offer recommendations for moderating theGI risks associated with NSAIDs, but strategies for coexistentmanagement of GI and CV risks are much less understood.Evidence-based literature was assessed, reviewed and criticallyappraised for this patient. The Canadian Consensus Guidelineson Long-Term Non-Steroidal Anti-Inflammatory Drug Therapyand the Need for Gastroprotection: Benefits versus Risks byHunt et al. in 2008 best met the research goal of assessing bothGI and CV risks for this patient.The Canadian Consensus Guidelines were essential in providingevidence-based management recommendations to helpclinicians determine the best treatment options for patients inneed of long-term NSAID therapy. The need for gastroprotection,while assessing the patient for both GI and CV risks, was thebasis of these recommendations. An algorithmic approach wascreated to help simplify the management of patients limited toor with any combination of low or high GI risk, and low or highCV risk.Despite this patient’s NSAID-induced gastric ulcer, and thefact that she qualifies as both a high-risk GI and CV patient,the clinician determined that her overall greatest risk wasCV-related. Therefore, following the algorithm, naproxen wasprescribed for RA pain with omeprazole coverage for theGI toxicity. Continued close monitoring and adjustment ofpharmacotherapy was maintained until the lowest effectivedosage was achieved.Healthcare providers have a responsibility before prescribingNSAIDs to assess each patient’s requirement for antiinflammatorypain relief. Patient risk factors for NSAID use cannotbe strictly limited to GI toxicities. Therefore, it is fundamental thatproviders take into account both the GI and CV risk factors of thepatient. Until newer studies provide better supporting evidence,an effort to follow the established guidelines presented as anevidence-based algorithm is essential to proper long-termNSAID management in the high-risk patient.Upper GI Bleed in 33-Year-Old Female ICU PatientK. Jacobson, B. Coplan, Midwestern University PhysicianAssistant Program, Glendale, Ariz.The purpose of this report is to describe an interesting casethat illustrates the indications for interventional radiology (IR)management with angiography and embolization to treat upperGI bleeding.A 33-year-old female was admitted to the ICU for cardiogenicshock and placed on biventricular assist device (BiVAD), bridgeto transplant. During her hospitalization she suffered multiplecomplications, including septic shock, mild DIC, multi-systemorgan failure and upper GI bleeding. In an attempt to managethe upper GI bleed, she underwent three failed endoscopytreatments, where bleeding was visualized from the lessercurvature of the stomach. Bleeding persisted for three days andshe was ultimately referred to IR for angiography and probableembolization.The patient’s past medical history was significant for nonischemicdilated cardiomyopathy diagnosed at age 24. Shereceived adequate medical therapy and was well compensateduntil becoming pregnant at age 28. She delivered at full-termbut was advised against additional pregnancies. The patientbecame pregnant again at age 32. She had a successfulscheduled C-section but went into heart failure four monthslater. The heart failure resulted in the cardiogenic shock forwhich she was hospitalized. Physical exam performed by the IRservice revealed that the patient was hypotensive, tachycardicand tachypnic. She was sedated, intubated and on BiVAD.Bright red blood was visualized from her OG tube. Her CBCshowed a hemoglobin of 9.8g/dL, hematocrit of 29.0 percent,and a platelet count of 88 k/mm three following 10 units PRBCsand four units of platelets administered in the past 48 hours.Coagulation was acceptable for intervention (INR 1.17 and aPTT34.3 seconds).The patient was taken to the IR suite for intervention. Her leftcommon femoral artery was accessed and angiogram wasperformed. No extravasation was visualized on angiography.Therefore a decision on whether or not to proceed with empiricembolization had to be made. Empiric embolization wasindicated in this patient because the bleeding source wasidentified on endoscopy, she was seriously ill with a highrisk of surgical complications, and because complications ofembolization in the upper GI tract are rare due to extensiveperfusion by collateral vessels. During endoscopy, bleeding wasvisualized from the lesser curvature of the stomach, which isperfused by the left gastric artery (LGA). Therefore the LGA wastargeted for embolization. The patient tolerated the procedurewithout complications. Her upper GI bleeding resolved and heranemia improved the following day.The American College of Radiology describes indications forangiography of nonvariceal upper GI bleeding. Endoscopy isthe best initial diagnostic and therapeutic approach. Followingfailed endoscopic treatment, surgery and IR intervention are54

POSTER ABSTRACTSequally effective. IR intervention is more appropriate in patientsat high risk for surgical complications. IR intervention is lesssuccessful in patients with impaired coagulation. All criteria forIR intervention were met in this patient. In conclusion, patientswith upper GI bleeding and extensive comorbidities can derivesubstantial benefit from IR treatment with angiography andembolization.Use of Botox Injection to Relieve ChronicConstipation in the Mentally RetardedM. Barlow, M. Freeman, A. Fine, Duquesne University,Pittsburgh, Pa.Upon reading this case study, readers will be informed ofthe problem of chronic constipation in the mentally retardedperson, and the extensive treatment methods that are involvedin management of the condition. The similarities betweenour patient’s stool withholding habits and children withHirschsprung’s disease (HD) and internal anal sphincter (IAS)achalasia will be discussed. The reader will learn of the useof Botulinum toxin type A (Botox) as a treatment method inchildren with HD and IAS achalasia, and how it can providethe same beneficial effects for mentally retarded patients witha history of chronic constipation. The beneficial and adverseeffects of Botox injection into the IAS for relief of constipationwill be reviewed.This research report explains the case of a 49-year-old mentallyretarded man with a significant history of chronic constipationand the complications he encountered. The patient lived ina group home, where his caretakers did not have a medicalbackground and had difficulty dealing with his chronicconstipation and would frequently need to bring him to theED for bowel obstructions. The patient was given a regimenof laxatives and enemas for his constipation over the yearsbut would withhold stool, not allowing the laxatives to workefficiently. The patient developed a toxic megacolon secondaryto constipation and underwent a total colectomy and ileostomy.The ileostomy was intended to prevent more bowel obstructionsbut later had to be reversed because of infection and leakage.An injection of 100 units of Botox was injected into the patient’sinternal anal sphincter to relax the muscle and decreasethe patient’s ability to withhold stool. Since the procedurethe patient has been having better output and has not beenbrought to the ED for bowel obstruction.Increased rate of constipation in the mentally retarded doesnot have a specific cause; it is thought to be related to possiblemedication side effects, improper stooling habits fromchildhood, a defect of the central nervous system’s control overperistalsis and other factors. Our patient had a hypertonic IASfrom prolonged stool withholding, similar to the hypertonicIAS of a small percent of the children with HD after correctivesurgery and IAS achalasia.Positive results were seen in our patient’s stooling habits afterBotox injection of his IAS, similar to the positive results seenin children with HD and IAS achalasia that used Botox. Anadverse effect of injecting the IAS with Botox is the possibilityof incontinence. Multiple injections may be needed to maintaingood stooling habits. The use of Botox can prove to bebeneficial in relieving stool retention and chronic constipation.Uterine Didelphys: A Case of ComplicatedContraception Uterine DidelphysP. Lovett, J. Stoehr, Midwestern University Physician AssistantProgram, Glendale, Ariz.This case describes the difficulty encountered when choosinga form of contraception for a patient with an unconventionalreproductive tract. Uterine didelphys is an en uteromalformation due to failed coalescence of the Mullerian ducts.An estimated one in 3,000 women have two uteri, two cervicesand often two vaginas. Renal agenesis frequently coincideswith this condition. These women often present with recurrentmiscarriages, breech presentation at labor and pre-termdelivery.This case describes a 40-year-old, G1 P0 female with a pastmedical history that includes a doubled uterus with unilateralrenal agenesis, an elective abortion at age 20, and cervicaldysplasia at age 25 that was successfully treated with loopelectrical excision procedure (LEEP). At age 14, an emergencyroom visit for severe abdominal pain, secondary to bloodcollection, led to the discovery of uterine didelphys. The patientnow denies having any complications due to her condition.She is currently in a monogamous relationship. She desires anintrauterine device (IUD), despite her known uterine irregularity,in order to prevent pregnancy, yet she expresses concern abouther previously experienced systemic effects of a combined oralcontraceptive (COC).A literature search yielded few cases of IUD alteration toaccommodate the didelphys uterus, with one report of apositive outcome in a 17-year-old G1P1 patient whose antiseizuremedication interfered with COC use. Our patient, uponfurther examination, was found to have scarring on the moreprominent cervix from a LEEP performed 15 years ago. The othercervix has a very small os with a transition zone that overlapsthe other cervix, making it difficult to identify on pelvic exam.The results of the PAPs performed on each of her two cervicesyielded one normal result and atypical squamous cells ofwww.aapa.org/IMPACT 55

POSTER ABSTRACTSundetermined significance, with a positive reflex HPV DNA teston the other cervix. A colposcopy was performed on the affectedcervix and a follow-up PAP was scheduled for six months inorder to evaluate the presence of persistent metaplasia. It wassubsequently determined that this patient was not a suitablecandidate for IUD insertion due to the extensive cellular andanatomical changes in her cervices. She was offered alternativebirth control options and she elected to try a very low doseof Loesterin®. To date, the COC has been well-tolerated andthe patient has denied any noticeable side effects. The lackof previously documented cases of contraceptive optionsfor women with uterine malformations warrants furtherinvestigation in order to provide a greater variety of choices tomeet these patients’ unique birth control needs.Student GalleryPREVIOUSLY PRESENTEDAliphatic Isocyanate Skin Transferability inAutomotive Refinishing WorkersT.T. De Vries, C.A. Redlich, M.H. Stowe, D. Bello, H. Harari, YaleUniversity School of Medicine Physician Associate Program, NewHaven, Conn.Purpose: Skin exposure to isocyanate (NCO), the essentialcross-linking agent to make polyurethane (PU), may contributeto sensitization and the development of isocyanate asthma.Unbound NCO can persist on PU spray-coated car parts andother surfaces, after appearing dry. Whether NCO skin exposurecan result from handling such surfaces, a common workpractice, remains unclear. The study objective was to assessNCO transfer potential to human skin from surfaces recentlysprayed with aliphatic NCO coatings.Methodology: Quantitative surface and skin wipe samplingfor total NCO was performed on test panels sprayed withNCO-containing coatings and on skin samples obtained fromparticipants who had rubbed the recently dried surfaces.Surface and skin samples were prepared following NIOSHmethod 5525 (modified for skin samples) and NCO species,including monomeric hexamethylene diisocyantate, polymerichexamethylene diisocyantate, polymeric isophoronediisocyanate and total NCO were analyzed using highperformanceliquid chromatography with ultraviolet andfluorescence detectors. Eighteen workers in five auto bodyshops participated.Results: Quantifiable unbound NCO species were detected on84.2 percent of all sprayed surfaces sampled when initiallyconsidered dry (n=38 samples). A significant (p < 0.001) decayin free NCO was observed over 24 hours. For all 104 skinsamples obtained after contact with recently dried coatings,only 6.7 percent (7 out of 104) had detectable quantities offree NCO. The seven positive samples were all obtained at theinitial sampling time (t0) and had a geometric mean of 0.016μg NCO cm-2 (range: 0.002-0.88 μg NCO cm-2). Only one ofthe 12 (8.3 percent) skin samples obtained after compoundingwas positive for free NCO. Nevertheless, incongruence betweenquantitative and qualitative samples was noted in pre- andpost-compounding specimen comparisons, potentiallysuggesting the generation of thermal degradation products. Allstudy control (pre-contact) skin samples were negative.Conclusions: Limited transfer of free NCO from surfaces withdetectable NCO levels to the skin of workers handling them wasdocumented. The risk of substantial human NCO skin exposurefrom contact with the dry appearing (yet potentially semicured)NCO coatings evaluated in this study appears to be low,although other products and tasks may pose a more substantialdermal NCO exposure potential.Student GalleryOUTREACH AND ADVOCACYAnalysis and Performance Enhancement Project:Compliance Rates of the 23-Valent PneumococcalPolysaccharide Vaccine for At-Risk Patients atOptimus Health Care’s Park City Primary Care CenterK.S. O’Connor, B. Vogt, R.L. Zuckerman, C.M. Rossi, QuinnipiacUniversity Physician Assistants Program, North Haven, Conn.Purpose: This analysis and performance enhancement studysought to determine if there was a lack of coverage of the23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23) at anurban community health clinic. The project focused on at-riskpatients for invasive pneumococcal disease and attempted toassist the clinic in their mission to improve healthcare to thisunderserved community.Description: This project was undertaken at the Park CityPrimary Care Center in Bridgeport, Conn., as part of aninitiative of the Community Health Center Association ofConnecticut. This organization seeks to help improve the56

POSTER ABSTRACTSquality of healthcare and social services provided to thestate’s underserved populations by bringing students frommedical education programs to these areas. During our timeat Park City, we identified a possible problem with utilizationrates of PPSV23 in adults, especially among racial and ethnicminorities, a population with a high incidence of independentrisk factors for invasive pneumococcal disease. A chart reviewwas performed of a random sample of the clinic’s at-riskgroups, focusing on patients over the age of 65, diabetics,asthmatics and patients with HIV. We analyzed the reasons forfailure to vaccinate with PPSV23 and identified several barriers.These were vaccine availability, cost, clinician time constraints,confusing guidelines and lack of patient education. Strategiesfor improvement were proposed, including an outreachprogram, a payment assistance program, a vaccine clinic anda standing order to be incorporated into the electronic healthrecord system. Educational handouts were developed as well.Lastly, a follow-up study was conducted four months later toevaluate progress.Results: Initial data showed PPSV23 compliance rates of 75percent for patients older than 65 years old, 44 percent fordiabetics, 23 percent for asthmatics, 71 percent for patientswith HIV and an overall compliance rate of 48 percent. Afollow-up study done four months later showed improvementin vaccine administration rates, with more than a 12 percentincrease for patients over 65, more than a 13 percent increasefor diabetics, nearly a 25 percent increase for patients with HIVand no change in the asthmatic population.Conclusions: While there is no statistical information availablefor national PPSV23 compliance rates among patients withdiabetes, asthma or HIV, the clinic’s rate for patients age65 and older far exceeds the national compliance rate of 57percent as reported in Healthy People 2010. Therefore, ParkCity Primary Care is in a good position to meet Healthy People’sgoal of 90 percent for pneumococcal vaccination by 2013. Byraising awareness for the need to vaccinate with PPSV23 andidentifying some of the barriers, this project has furthered ParkCity’s ability to meet their goals.Perceived Health Disparities Among MinorityPopulationsPurpose: The purpose of this study was to examine theperceptions of people from various ethnic backgroundsregarding the quality of medical care they receive from theirproviders.Methodology: Participants were obtained via conveniencesampling at four churches in the Shenandoah Region of Virginiawhose congregations were predominately Caucasian, Korean,Latino or African-American. Participants were asked to completesurvey questions addressing experiences in the healthcaresystem and their perception of the quality of the care that theyreceived. Data were analyzed using SPSS Version 19.Results: A total of 80 usable responses were obtained. Therewere significant differences among the ethnic groups regardinghow often they think the healthcare system treats peopleunfairly based on their race/ethnic background as well asEnglish fluency. Sixty percent of Latino participants reportedtrusting their doctors “almost all the time,” whereas only10 percent of Asians reported the same. More Latinos (33.3percent) felt they were worse off than the average Caucasianperson in terms of getting routine medical care when theyneed it as compared to the African-Americans and Asians,29.6 percent and 16.7 percent respectively. All of the Latinosconfirmed their perception that patients are treated unfairlybased on their race and how well they speak English byexclusively selecting the “somewhat often” or “very often”option on the survey. However, there were no statisticallysignificant racial/ethnic differences in perceptions of raceaffecting whether patients can receive routine medical carewhen they need it.Conclusions: Perceptions of healthcare experiences variedsignificantly among the ethnic groups. It is important to takeinto account that patients might perceive the patient-providerrelationship differently based on their ethnicity, and providersneed to be culturally competent in order to have the strongestrelationship with their patients. Our study showed that manyLatinos, African-Americans and Koreans feel as if they are beingtreated unfairly based on race and/or language barrier, andas a result, do not trust their healthcare providers. Additionalstudies are needed to identify root causes of disparityperceptions.A. Lee, S. Trezza, T. Greer, E. Hunter, N.Hazari, Appleton, Wis.Background: As the demographics of the American landscapecontinue to evolve into a diverse meshwork, it is important thatmedical professionals are aware of the cultural impact patientsbring to the clinical encounter.www.aapa.org/IMPACT 57