Medicine and Health Sciences Commons^™

Pandemic Driven Innovation: Development Of An Alternative Respiratory Pathogen Self-Collection Device, Thang Nguyen

Theses & Dissertations

The SARS-CoV-2 virus outbreak has underscored numerous weak links in our biodefense countermeasures against highly communicable diseases. Many believe it was our lack of an effective testing model that allowed the virus to become a global pandemic within a short period. The gold standard collection method for the SARS-CoV-2 virus involves mechanical debridement of the nasopharyngeal cavity with a stiff swab applicator, which has been known to cause pain and injury to patients, subsequently resulting in low patient acceptance of the procedure. Due to the invasive nature of the nasopharyngeal swab collection method, it may not be conducive to the …

Glycemic Variability In Patients With Stage Ii-Iii Colon Cancer, Natalie Mandolfo

Theses & Dissertations

Patients with cancer experience metabolic changes such as hypoglycemia, hyperglycemia, and glycemic variability; collectively termed malglycemia. Glycemic variability, defined as fluctuations in glucose, is a marker of metabolic instability. Higher glycemic variability is associated with adverse health outcomes in the general population and in those with diabetes. Little is known about glycemic variability in patients with cancer, especially those with solid tumor malignancies. Glycemic variability is associated with increased infection, shorter periods of remission, and higher mortality in patients with hematological cancer. This body of work describes the concept and measurement of glycemic variability to assess glycemic control in patients …

Spare Parts Surgery For Oncologic Reconstruction To Preserve Local Advancement Flap For Decubitus Ulcer Reconstruction: A Case Report, Emily Zurbuchen, Nathan Foje, Sean Figy

Graduate Medical Education Research Journal

A 58-year-old male presented to our institution with synchronous large left thigh sarcoma and sacral decubitus ulcer requiring oncologic resection and reconstruction. Due to extensive tumor involvement, use of local flap for reconstruction was not feasible. Therefore, a spare parts free fillet flap from the disarticulated lower leg was utilized for reconstruction following oncologic resection. The benefits of this spare parts approach include no donor site morbidity, sufficient tissue padding for later use of prosthesis, and preservation of other flaps for future reconstruction of his sacral decubitus ulcer.

Multi-Digit Auto-Amputation In Setting Of Mixed Connective Tissue Disease, Kishan P. Patel, Jennifer L. Medlin, Michelene Hearth-Holmes

Graduate Medical Education Research Journal

Raynaud’s disease is a cutaneous manifestation often present in various connective tissue and vascular diseases. Depending on the age of onset and acuity of symptoms, the phenomenon can provide clinicians with some insight as to the severity of underlying disease, including the distinction between primary and secondary Raynaud’s. However, this diagnostic approach seems to have its limitations regarding efficacy and timing of treatment. Traditionally, treatment of Raynaud’s has focused on reestablishing blood perfusion to affected tissue, which has previously been achieved with vasodilatory medications and site-specific surgical intervention. In lieu of the severe sequelae of Raynaud’s in the setting of …

Nontuberculous Mycobacterium (Ntm) Infection In Aquatic Workers With Purified Protein Derivative (Ppd) And Gold Quantiferon Tests., Lavanya Ravipati, Sarah A. Howard

Graduate Medical Education Research Journal

Background: Nontuberculous mycobacteria (NTM) infections are commonly caused by Mycobacterium marinum and fortuitum with M. marinum more likely to cause skin infections. Aquatic environments are a potential source of contact with M. marinum and fortuitum. Patients with NTM infections may present with positive tuberculin purified protein derivative (PPD) and/or gold QuantiFERON tests. However, PPD cannot differentiate between NTM infection and other tuberculous infections caused by different mycobacterial strains. We present a patient a marine biologist who was asymptomatic and presented for further evaluation as she has a h/o positive PPD and gold QuantiFERON test.

Methods: Patient informed consent was …

Costs Associated With Recurrent Epistaxis In A Patient With A Ventricular Assist Device, Eric T. Rohe, Evan M. Ryan, Jayme R. Dowdall, Dwight T. Jones

Graduate Medical Education Research Journal

Mucosal bleeding is a well-known complication of having a ventricular assist device and commonly presents with epistaxis. Although the frequency of epistaxis as a complication in patients with a ventricular assist device has been documented in the literature, to our knowledge the cost of this complication has not been reported. This case report examines the financial burden of ventricular assist device-associated epistaxis in a single patient from September 2018 to December 2019 using ICD 10 diagnostic codes. The patient was found to have accumulated $138,020 in costs over 38 encounters. This case report not only highlights the recurrent nature and …

A Case Of Carcinoid Heart Disease And Echocardiographic Findings, Brandon Alex, Jeffrey Songster, Helenmari L. Merritt, Rebecca A. Aron

Graduate Medical Education Research Journal

Abstract: Carcinoid heart disease occurs in approximately 50% of patients with carcinoid syndrome. Right heart involvement resulting in tricuspid regurgitation, tricuspid stenosis, pulmonic regurgitation and pulmonic stenosis is most common. We report a case of tricuspid heart disease resulting in tricuspid regurgitation, tricuspid stenosis, pulmonic regurgitation and pulmonic stenosis.

Internet Transparency Of Local Men’S Health Clinics In Nebraska, Jinfeng Jiang, Jordan Stegman, Christopher M. Deibert

Graduate Medical Education Research Journal

An overview of Men’s Health Clinics offering Testosterone Therapy in a Midwest State.

Introduction/ Background – Since 2001, there has been a 300% increase in the use of Testosterone therapy. However, there remains limited published data on the demographics of facilities and providers that advertise this service. This study aims to look at such demographics of advertised Men’s health clinics in Nebraska.

Methods/ Materials – An internet search was conducted with the phrases “Nebraska Male health clinics, Nebraska Low T/testosterone, Nebraska Hormone Replacement Therapy”. All clinics that were found offering Testosterone therapy with Men’s health in their mission statement were …

Customized Blister Packaging For Patients Living With Hiv: Assessment Of Patient Attitudes And Satisfaction, Holly Groteluschen, Harlan Sayles, Rebecca Osborn, Joshua P. Havens, Sara Bares, Jasmine R. Marcelin

Graduate Medical Education Research Journal

Adherence to antiretroviral medication results in reduced HIV transmission and improved health outcomes, yet challenges with medication adherence remain. A Collaborative Care Program was developed with a community pharmacy integrating a multi-dose adherence packaging service. We surveyed program participants to assess their satisfaction with this program and found an overall positive sentiment toward the program, that the program helped with reducing missed doses, and all patients would recommend the program to others.

Reorganizing Emergency Department Information Systems To Reduce Physician Cognitive Load, James C. Mcclay, Jeffery Nielson, Benjamin Slovis

Posters and Presentations: Emergency Medicine

No abstract provided.

Surprisingly Low Levels Of Measles Immunity In Persons With Hiv: A Seroprevalence Survey In A United States Hiv Clinic, Lindsey Rearigh, Jennifer O'Neill, Maureen Kubat, Harlan Sayles, Susan Swindells, Sara Bares

Journal Articles: Infectious Diseases

Background: Measles outbreaks have become increasingly common due to deteriorating vaccination rates, fluctuating herd immunity, and varying antibody decline. Limited knowledge exists regarding prevalence and risk factors associated with measles seronegativity among persons with HIV (PWH).

Methods: This was a cross-sectional study conducted at an academic HIV clinic in Omaha, Nebraska. Participants were screened for the presence of measles IgG antibody. Demographic and clinical information was obtained through electronic medical record review. Simple and multivariable logistic regressions were performed to identify risk factors for measles seronegativity.

Results: Three hundred fifty-one participants were enrolled, with a measles seroprevalence rate of 70.3%. …

Endoscopic Removal Of Fractured 3d-Printed Nasopharyngeal Swabs From The Olfactory Cleft During Covid-19, Matthew Miller, Kristy Carlson, Jayme Dowdall, Christie Barnes, Sam Pate

Graduate Medical Education Research Journal

The severe acute respiratory syndrome SARS-CoV-2 pandemic has posed significant challenges to hospital and public health systems in the United States. In response to a shortage in nasopharyngeal swabs, our institution developed, tested, and deployed 3D-printed swabs to obtain a specimen for testing. A patient was tested in preparation for a scheduled Esophagogastrodeuodenoscopy. During the procedure the swab broke and a portion remained in the superior meatus and olfactory cleft. This case study describes the process of locating and removing the broken sections of the 3D-printed swab. In response to this incident, 3D-printing teams test swabs for sample collection and …

Laryngeal Histoplasmosis In Patients With Crohn’S Disease Undergoing Treatment With Humira (Adalimumab): A Case Series, Jenna Berg, Jonathan Blecha, Chris Bingcang, Justin Oltman, Jayme Dowdall, Subodh M. Lele

Graduate Medical Education Research Journal

The FDA has advocated for increasing awareness of histoplasmosis for patients undergoing TNF blockers as delay in diagnosis can lead to a poor outcome.¹ Laryngeal histoplasmosis is a rare entity that should be part of the differential diagnosis in patients receiving immune suppression for Crohn’s disease. Patients with laryngeal histoplasmosis often report hoarseness, mucosal ulcerations, dysphagia, and odynophagia. We present a series of two cases of laryngeal histoplasmosis in patients with Crohn’s. These cases illustrate the high index of suspicion required to make the diagnosis of laryngeal histoplasmosis, especially in the Midwestern United States. Diagnosis is made quickly and …

The Clinical Relevance Of Cement Volume In Percutaneous Vertebral Augmentation, Ravi G. Mirpuri, Madhuri Are, Virginia Hardie, Michael J. Warden, Robin High

Graduate Medical Education Research Journal

Introduction: Vertebroplasty and Kyphoplasty are two forms of percutaneous vertebral augmentation (PVA), in which polymethylmethacrylate cement is used to stabilize vertebral compression fractures (VCF). This study sought to evaluate the relationship between cement volume and clinical outcomes, including pain reduction, opioid use, and complication rate.

Methods: Retrospective chart review produced 88 patients who received PVA at a tertiary care outpatient pain clinic. Cement volume, type of PVA, gender, level (thoracic vs lumbar) were collected, as well as clinical outcomes of numeric pain score (NPS) reduction, opioid percent change (OPC), and complications. Both pre-procedure and post-procedure (between 2-4 weeks) data were …

Irrigation For Cerumen Removal Causing Meningitis – Case Report, Steven Tenny, Pashayar Lookian, Andre Wakim, Daniel Surdell

Graduate Medical Education Research Journal

Introduction: Cerumen impaction is a common problem seen in primary care clinics. There are a variety of methods to deal with impacted cerumen including water irrigation but meningitis after water irrigation cerumen removal has not been previously reported.

Methods: We describe the case of a 59-year-old female with otitis media who developed meningitis with empyema after water-jet irrigation for impacted cerumen.

Results: Our patient presented 24-hours after water-jet irrigation for impacted cerumen with worsening headaches. Workup included positive CSF cultures and empyema on MRI consistent with meningitis. She also had ear drainage from the treated ear which was positive for …

Ponv Prophylaxis Failure Disproportionately Affects Female Patients, Despite Intraoperative Computerized Decision Support Guidance, Karl A. Krieser, John B. Riley Iii, Jospeh E. Baus, Julie T. Hoffman, James N. Sullivan Md, Robert L. Lobato

Graduate Medical Education Research Journal

Objectives: To compare postoperative nausea and vomiting (PONV) prophylaxis treatment and outcomes based on patients’ sex, using a retrospective cohort. The setting was the operating room and post-anesthesia care unit of a tertiary care university medical center.

Patients: A total of 678 adult male and female patients with American Society of Anesthesiologist (ASA) scores of 1-4 underwent surgery with general anesthesia. All patients received preoperative PONV risk assessment. PONV prophylaxis was administered at the discretion of the anesthesia care team members with guidance from a computerized decision support system.

Measurements: Adequacy of prophylaxis was retrospectively determined based on individual patient …

Role Of Extracellular Vesicles In Substance Abuse And Hiv-Related Neurological Pathologies, Katherine E. Odegaard, Subhash Chand, Sydney Wheeler, Sneham Tiwari, Adrian Flores, Jordan Hernandez, Mason Savine, Austin Gowen, Gurudutt Pendyala, Sowmya V. Yelamanchili

Journal Articles: Anesthesiology

Extracellular vesicles (EVs) are a broad, heterogeneous class of membranous lipid-bilayer vesicles that facilitate intercellular communication throughout the body. As important carriers of various types of cargo, including proteins, lipids, DNA fragments, and a variety of small noncoding RNAs, including miRNAs, mRNAs, and siRNAs, EVs may play an important role in the development of addiction and other neurological pathologies, particularly those related to HIV. In this review, we summarize the findings of EV studies in the context of methamphetamine (METH), cocaine, nicotine, opioid, and alcohol use disorders, highlighting important EV cargoes that may contribute to addiction. Additionally, as HIV and …

Staphylococcus Aureus Atp Synthase Promotes Biofilm Persistence By Influencing Innate Immunity, Megan E. Bosch, Blake P. Bertrand, Cortney E. Heim, Abdulelah A. Alqarzaee, Sujata S. Chaudhari, Amy L. Aldrich, Paul D. Fey, Vinai C. Thomas, Tammy Kielian

Journal Articles: Pathology and Microbiology

No abstract provided.

Effect Of Maternal Retinol Status At Time Of Term Delivery On Retinol Placental Concentration, Intrauterine Transfer Rate, And Newborn Retinol Status, Melissa K. Thoene, Haley Haskett, Jeremy Furtado, Maranda Thompson, Matthew Van Ormer, Corrine K. Hanson, Ann Anderson-Berry

Journal Articles: Pediatrics

Retinol (vitamin A) is essential, so the objective of this Institutional Review Board approved study is to evaluate retinol placental concentration, intrauterine transfer, and neonatal status at time of term delivery between cases of maternal retinol adequacy, insufficiency, and deficiency in a United States population. Birth information and biological samples were collected for mother-infant dyads (n = 260). Maternal and umbilical cord blood retinol concentrations (n = 260) were analyzed by HPLC and categorized: deficient (≤0.7 umol/L), insufficient (>0.7-1.05 umol/L), adequate (>1.05 umol/L). Intrauterine transfer rate was calculated: (umbilical cord blood retinol concentration/maternal retinol concentration) × …

Impact Of Immunotherapy On The Survival Of Pancreatic Adenocarcinoma Patients: An Analysis Of The National Cancer Database, Saber A. Amin

Theses & Dissertations

Pancreatic adenocarcinoma (PDAC) represents 7.2% of all cancer deaths, and by 2030, it will become the second leading cause of death due to cancer. The median overall survival (OS) is 17-23 months in resectable and 4-6 months in metastatic PC [8-9]. The 5-year survival of resectable PC is 22%, and unresectable PC is 8%. A majority of patients treated with standard treatments such as surgery, chemotherapy, and radiation therapy eventually succumb to the disease due to widespread micrometastases at the time of diagnosis. Due to the minimal effect of the current treatments, novel treatment strategies such as immunotherapeutics have been …

Multiquantal Glutamate Release From Rod Photoreceptors, Cassandra L. Hays

Theses & Dissertations

Neurons communicate via Ca²⁺-dependent release of neurotransmitters packaged into vesicles (quanta). Some CNS neurons, especially sensory synapses, can release multiple vesicles at a time, increasing information transmission and overcoming the unreliability of a stochastic process. Ribbon-bearing neurons, including retinal photoreceptors, face the challenge of encoding sensory receptor potentials into an ever-changing train of vesicle release events. We studied release of glutamate using voltage clamp to measure anion currents activated during glutamate reuptake into presynaptic terminals (I_A(glu)) of salamander and mouse rods, finding that each employ distinct mechanisms for multiquantal release. In amphibian rods, we found that …

Leveraging Aqueous Humor Dynamics And Ocular Biometrics For Improving Therapeutic Outcomes In Glaucoma, Vikas Gulati

Theses & Dissertations

Glaucoma laser and incisional surgical treatments are associated with a known risk of complications. The ability to better predict treatment outcomes and individualize treatment recommendations can enhance the benefit to risk ratio of a treatment option. The work presented in this dissertation explores the interplay of biometrics, race and aqueous humor dynamics and their influence on treatment outcomes. In the first chapter, we demonstrate that pre-operative aqueous humor dynamics (higher aqueous flow, lower outflow facility and lower uveoscleral outflow) are predictive of greater intraocular pressure lowering after selective laser trabeculoplasty. The second chapter describes significant race-based differences in aqueous humor …

Urinary Bile Acid Indices As Diagnostic And Prognosic Biomarkers For Liver Diseases, Jawaher Alamoudi

Theses & Dissertations

Hepatobiliary diseases result in the accumulation of toxic bile acids (BA) in the liver, blood, and other tissues which may contribute to an unfavorable prognosis. We compared the urinary BA profile between 300 patients with hepatobiliary diseases vs. 103 healthy controls. Also, we investigated the use of the urinary BA profile to develop survival models to predict the prognosis of hepatobiliary diseases. The urinary BA profile, a set of non-BA parameters, and the adverse events of liver transplant and/or death were monitored in patients with cholestatic liver diseases for up to 7 years. The BA profile was characterized by calculating …

Development Of An Lc-Esi-Ms/Ms Method For Determination Of A Novel Pyrrolomycin (Mp-1) And Application To Pre-Clinical Adme Studies, Wafaa N. Aldhafiri

Theses & Dissertations

A rapid, selective, and sensitive liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) method was developed and validated for quantitation of a novel Pyrrolomycin (MP-1) in mouse plasma. MP-1 was extracted from plasma utilizing a structural analog (PL-3) as the internal standard (IS). Analyte separation was achieved using a Waters Acquity UPLC®BEH C18 column (1.7 µm, 100 x 2.1 mm) protected with Acquity UPLC C18 guard column. Mobile phase consisted of 0.1% acetic acid in water (10%) and methanol (90%) at a total flow rate of 0.25 mL/min. The mass spectrometer was operated at unit resolution in the multiple reaction …

Structural Magnetic Resonance Imaging As A Diagnostic Biomarker Of Hiv-Associated Neurocognitive Disorders (Hand), Mikki Schantell

Capstone Experience

Objective: The goal of this study was to do an exploratory analysis to determine if gray matter brain volumes and cortical thickness measures obtained from structural magnetic resonance imaging (sMRI) can discriminate people with HIV-associated neurocognitive disorders (HAND), neurocognitively unimpaired people with HIV (NU PWH), and HIV-negative controls (HIV- controls) using linear discriminant analyses.

Methods: A total of 231 participants, including 110 PWH and 121 HIV- controls, completed a neuropsychological (NP) battery and an sMRI protocol. The bilateral gray matter volumes and cortical thickness brain regions were analyzed using 18 linear discriminant models to assess the discriminability of gray matter …

Incidental Findings On Brain Mri In People With Hiv Infection, Kevin F. Hanna, Harlan R. Sayles, Jennifer O'Neill, Matthew L. White, Tony W. Wilson, Susan Swindells

Journal Articles: Internal Medicine

BACKGROUND: Incidental findings are a well-known complication of imaging studies done for both diagnostic and research purposes. Little is known about the rates and types of incidental findings found on brain MRI in patients with HIV infection, who may be at risk for HIV-Associated Neurocognitive Disorders (HAND).

METHODS: The parent study included 108 adults with HIV infection and 125 demographically-matched uninfected controls who completed MRI and neuropsychological testing. Incidental findings were classified by the study team as vascular, neoplastic, congenital, other neurologic, or non-neurologic. Categorical measures were compared using Pearson chi-square tests; continuous measures were compared using t-tests.

RESULTS: Among …

Effects Of Acute Intracranial Pressure Changes On Optic Nerve Head Morphology In Humnans And Pig Model, Sachin Kedar

Theses & Dissertations

The optic nerve head (ONH) is located at the interface of intracranial and intraocular compartments. It is comprised of lamina cribrosa (LC), a fenestrated connective tissue tethered to the posterior sclera across the scleral canal. Since LC is exposed to intraocular pressure (IOP) anteriorly and intracranial pressure (ICP) posteriorly, it is an ideal site for noninvasively detecting intracranial pressure (ICP) fluctuation. We hypothesized that the pressure differential between IOP and ICP across LC, will determine LC position and meridional diameter of scleral canal (also called Bruch’s membrane opening- BMOD). We tested our hypothesis in 19 human subjects undergoing medically necessary …

Integrating Geriatric Assessment And Genetic Profiling To Personalize Therapy Selection In Older Adults With Acute Myeloid, Vijaya R. Bhatt

Theses & Dissertations

Integrating geriatric assessment for patient profiling and genetic profiling of leukemic cells represents an innovative approach to personalize therapy selection in older adults with acute myeloid leukemia (AML). We report results of a pre-planned interim analysis of a pragmatic phase II trial that utilized this strategy to personalize therapy. Patients ≥60 years with a new diagnosis of AML underwent geriatric assessment prior to initiation of treatment. Geriatric assessment of physical function, cognitive function and comorbidity burden were used to determine fitness for chemotherapy. Patients with good or intermediate-risk AML received intensive chemotherapy such as anthracycline and cytarabine (7+3) if determined …

Development Of Fluorescent Hyaluronic Acid Nanoparticles For Intraoperative Tumor Detection, Nicholas E. Wojtynek

Theses & Dissertations

Surgical resection remains to be the primary treatment for the majority of solid tumors, including breast cancer. The complete removal of the primary tumor, local metastases, and metastatic lymph nodes dramatically improve a patient’s treatment outcome and prognosis. Nevertheless, surgeons are limited to tactile and visual cues in distinguishing malignant and healthy tissue. This can result in a positive surgical margin (PSM), which occurs when tumor goes undetected and is left behind in the surgical cavity. PSMs decreases a patient’s prognosis and necessitate additional treatment in the form of surgery, radiation, and chemotherapy. An emerging imaging modality, known as fluorescence-guided …

The Evolving Management Of Aortic Valve Disease: Trends In The Utilization And Cost Of Savr, Tavr, And Medical Therapy, Andrew Goldsweig

Theses & Dissertations

Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding usage and cost of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease. From the Nationwide Readmissions Database, we determined utilization and cost trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted 2012-2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. From 2012 through 2016, there was a 48.1% increase in the number of patients hospitalized for aortic valve disease annually. Overall, 19.9%, 6.7%, …