Medicine and Health Sciences Commons^™

Symmetrical Drug-Related Intertriginous And Flexural Exanthema Induced By Cellulitis Prophylaxis, Tiffany Truong, Jonathan H. Ryder, Erica Lee, Clayton Mowrer, Ashley Wysong, Jasmine R. Marcelin

Graduate Medical Education Research Journal

Penicillin VK and hydroxyzine are typically well-tolerated antipruritic agents that are indicated in the prophylaxis of cellulitis. We herein report a case of a unique rash occurring during penicillin VK and hydroxyzine treatment in combination with the ingestion of cashews.

A 77-year-old male presented with new onset rash. Eleven days after the administration of penicillin VK and hydroxyzine for cellulitis prophylaxis, he developed a symmetric, erythematous, scaling rash on his buttocks and perineal region with associated pruritus and bleeding without fevers, chills, adenopathy, night sweats, or any other symptoms. He was diagnosed with symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) …

Endotracheal Tube Dislodgment In A High Risk Pulmonary Hypertensive Patient Due To Undiagnosed Tracheomegaly: A Case Report, Andrew Peck, Tammer N. Ghaly, Austin J. Adams, Daniel W. Johnson, Rebecca A. Aron

Graduate Medical Education Research Journal

Introduction

Airway enlargement was first described histologically in 1872, but it was not clinically reported until 1932, when Dr. Mounier-Kuhn published his seminal radiographic studies.¹ Since then, it is estimated that several hundred case reports have been published on congenital Mounier-Kuhn Syndrome (MKS), acquired tracheomegaly, and tracheobronchomegaly (TBM), yet only a few comprehensive literature reviews exist.²

Case

This case report details an elective nasal procedure for a patient with a history of significant pulmonary hypertension ad COPD on 5L home O₂ who had a symptomatic facial trauma. He was considered high risk secondary to his pulmonary disease, …

Preventing Bleeding Complications Of Paracentesis Using Point-Of-Care Ultrasound: An N-Of-1 Case Study, Adam Karevoll, Willie Talbert, Christopher J. Smith

Graduate Medical Education Research Journal

Abdominal paracentesis is a common bedside procedure, and the advent of point-of-care ultrasound has provided an opportunity to reduce the associated risks. Multiple society guidelines now recommend both site and vascular marking to avoid potential complications. This case illustrates the importance of vascular marking specifically to avoid damage to adjacent blood vessels.

Post-Transplant Hepatic Graft Fibrosis In Pediatric Liver-Inclusive Transplant Recipients, Hanh D. Vo

Theses & Dissertations

Hepatic graft fibrosis is a common histologic finding following pediatric liver transplant (LT) that may affect the long-term graft outcome. Hence, it is essential to identify hepatic graft fibrosis at a stage where fibrosis is not yet clinically apparent but has the potential for progression to initiate appropriate intervention and prevent its progression. Liver biopsy is the gold standard for fibrosis staging, but it is invasive, requires general anesthesia in children, and has potential complications. Our long-term goal is to implement non-invasive tests to assess and monitor the progression of hepatic graft fibrosis in liver-inclusive transplant children. The work presented …

Glad To Be Out. I Was Running Out Of Womb: A Study Of Omega-6 And Omega-3 Fatty Acid Metabolites At Delivery And Their Relationship To Infant Growth, Prematurity, And Admission To The Neonatal Intensive Care Unit, Maranda Thompson

Theses & Dissertations

Normal pregnancy relies on inflammation for implantation, placentation, and parturition, but uncontrolled it can lead to poor infant outcomes. Maternal diet is one modifiable factor that can impact inflammation. Omega-3 and omega-6 fatty acids have been shown to be metabolized into bioactive metabolites that effect inflammation. The presence and importance of these metabolites at the time of delivery are not well understood. Therefore, the purpose of this dissertation was to first quantify omega-3 and omega-6 metabolites in maternal plasma, cord plasma, and placental tissue. Then the relationships between metabolites and infant outcomes, including birth weight percentile, length percentile, head circumferences …

The Ecology Of Mental Health And The Impact Of Barriers On Mental Health Service Utilization, Alisha Aggarwal

Theses & Dissertations

Mental health has emerged as a major public health concern in recent times with several disparities and barriers related to adequate health service utilization. Different age groups experience diverse symptoms and face distinct barriers in accessing and utilizing healthcare. Policies like Mental Health Parity and Addiction Equity Act and the Patient Protection and Affordable Care Act were launched to improve insurance coverage and delivery of mental health services. However, a large gap of unmet needs exists for adequate mental health service utilization in the country. This dissertation aims to describe the financial and non-financial barriers to mental health service utilization …

Evaluation Of Stratified Antibiograms For Use In Laboratory And Antimicrobial Stewardship, Linsey Donner

Theses & Dissertations

Antibiograms are critical for choosing empiric antimicrobial therapy. Cumulative antibiograms, which aggregate susceptibility data, can mask differences within specific patient subsets or clinical syndromes. This dissertation was done to determine if antibiotic susceptibilities showed substantial differences when comparing stratified antibiograms to cumulative antibiograms.

Antibiotic susceptibility data was retrospectively obtained from Nebraska Medicine January 1, 2017 – December 31, 2019 for Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus, and Enterococcus faecalis. The University of Nebraska Medical Center’s web antibiogram clinical decision support tool was used to export the data. Bacteria-antibiotic susceptibility rates of stratified antibiograms …

Development Of A Muc16-Targeted Near-Infrared Antibody Probe For Fluorescence-Guided Surgery Of Pancreatic Cancer, Madeline T. Olson

Theses & Dissertations

Pancreatic cancer (PDAC) is an extremely lethal disease with an overall survival rate of 10%. Surgery remains the only potentially curative treatment option, but resections are complicated by infiltrative disease, proximity of critical vasculature, peritumoral inflammation, and dense stroma. Surgeons are limited to tactile and visual cues to differentiate cancerous tissue from normal tissue. Furthermore, translating preoperative images to the intraoperative setting poses additional challenges for tumor detection, and can result in undetected and unresected lesions. Thus, PDAC has high rates of incomplete resections, and subsequently, disease recurrence. Fluorescence-guided surgery (FGS) has emerged as a method to improve intraoperative detection …

The Rotator Cuff Tendon-To-Bone Interface: Maturation, Aging, And 3d Bioprinting For Regeneration, Xiping Jiang

Theses & Dissertations

Rotator cuff tendon injuries often occur at the tendon-to-bone interface (i.e., enthesis) area with a high prevalence for the elderly population. In addition, regeneration of the gradient structure of the enthesis is still a significant clinical challenge. Our studies aim to identify the histological, molecular, and biomechanical alterations of the rotator cuff enthesis with maturation and aging, and develop a novel therapeutic method using three-dimensional (3D) bioprinting technique to regenerate a functional enthesis. Striking variations of the entheses were observed both histologically and biomechanically during the maturation process. The histological features did not show many differences at the insertion site …

Derivation And Validation Of A General Predictive Model For Long Term Risks For Mortality And Invasive Cardiovascular Interventions In Congenital Heart Disease, David A. Danford

Capstone Experience

Introduction. Accurate assessment of prognosis is a key driver of clinical decision making in congenital heart disease (CHD), but is complicated because CHD represents such a diverse collection of conditions. The aim of this investigation is to derive, validate, and calibrate multivariable predictive models for time to surgical or catheter-mediated intervention (INT) in CHD and for time to death in CHD. Methods. 4108 unique subjects were prospectively and consecutively enrolled, and randomized to derivation and validation cohorts. Total follow up was 26,578 patient-years, with 102 deaths and 868 INTs. Accelerated failure time multivariable predictive models for the outcomes, based on …

Evaluating Nebraska Ems Providers' Ability And Willingness To Respond To Bioterrorism Emergencies, Ryan Houser

Capstone Experience

Previous studies have found that public health systems within the United States are inadequately prepared for an act of biological terrorism. This study utilized an Internet-based survey to assess the level of preparedness and willingness to respond to a bioterrorism attack, and identify factors that predict preparedness and willingness among Nebraska Emergency Medical Service providers, who are key to resilience in the face of an attack. The survey was available for one month in 2021 during which 190 EMS providers responded to the survey. The subjects included Registered Nurses, doctors, EMTs, and paramedics. Only 10% of the respondents are both …

Mycobacterium Avium Pulmonary Infection Disguised As A Urinary Tract Infection, Megan Rolfzen, Allison Ashford

Graduate Medical Education Research Journal

In the United States, Mycobacterium avium complex (MAC) has been found to be the most common isolate in non-tuberculous disease, and pulmonary infection is the most frequent presentation. It is ubiquitous in the environment, particularly in soil and manufactured water supply sources. Worldwide, M. avium infections, both pulmonary and disseminated, are steadily increasing. Due to MAC’s ability to cause non-specific symptoms and its pervasiveness within the environment, it is paramount to incorporate this diagnosis in the differential, especially in those most susceptible. We report a case of a Mycobacterium avium complex pulmonary infection in 72-year-old Caucasian male with history of …

Chronic Invasive Fungal Sinusitis Due To Scedosporium Apiospermum Causing Orbital Apex Syndrome, Dallin N. Christensen, Christie Barnes, Matthew Miller

Graduate Medical Education Research Journal

Abstract

Introduction:

Chronic invasive fungal sinusitis (CIFS) is defined as fungal invasion of the sinonasal submucosa for greater than 12 weeks. Common causes are dematiaceous molds followed by Aspergillus species, but can rarely be caused by other pathogens

Case:

A 71-year-old immunocompetent male presented with orbital apex syndrome found to be due to chronic invasive fungal sinusitis caused by Scedosporium apiospermum. After surgical debridement and appropriate systemic antifungal therapy, he made a near full recovery.

Discussion:

Scedosporium apiospermum is an emerging pathogen and a rare cause of chronic invasive fungal sinusitis. The diagnostic and treatment dilemmas involved with …

Thoracoscopic Left Atrial Appendage Ligation Complicated By Persistent Left Superior Vena Cava, Rebecca A. Aron, Maria Decastro, Kristina L. Koch, Kenneth Neff, Tyler Gouvea

Graduate Medical Education Research Journal

We herein report a 64 year-old male who had an incidental finding of a persistent left superior vena cava (SVC) revealed by intraoperative transesophageal echocardiography (TEE) during a Maze procedure with left atrial appendage ligation. During the intraoperative TEE, an incidental dilated coronary sinus > 1.1 cm was noted which prompted further evaluation and aided in our ultimate diagnosis. Consequently, significant additional surgical dissection and manipulation were required to isolate the left upper pulmonary vein. This case report reviews the anatomy and embryology of a persistent left SVC, discusses its clinical implications, and identifies surgical considerations for treatment.

Does Full Transfixion Incision Decrease Tip Projection In Endonasal Septoplasty With Spreader Grafts?, William Wesley Heckman Md, Tyler Bliss Md, Sarah Schmoker Md, Katie Geelan-Hansen Md

Graduate Medical Education Research Journal

The classic teaching is that full transfixion incision decreases nasal tip projection by disrupting the attachment of the medial crura to the caudal septum. A significant decrease in tip projection after endonasal septoplasty with spreader grafts through a full transfixion incision has not been identified at our institution. A retrospective cohort study was performed at our institution. Inclusion criteria consisted of patients undergoing endonasal septoplasty with spreader graft placement and available preoperative and one-year postoperative photos. Patients who had undergone an open approach, cosmetic rhinoplasty, had intercartilaginous incisions, or other procedures to affect tip projection were excluded. A query identified …

The Role Of Photography In Increasing Efficiency Of Dermatologic Inpatient Consulting Service, Ritu Swali, Tyler D. Evans, Dillon Clarey, Corey Georgesen, Ashley Wysong

Graduate Medical Education Research Journal

Abstract

Introduction:

Inpatient dermatology consultations can bring a mixed bag of pathologies. Due to the highly specialized nature of dermatology and the lack of dermatologic training in medical school, the dermatologic team is consulted for matters that range from non-urgent to pressing. Pictures are a critical component of dermatology and greatly aid in the diagnosis of cutaneous diseases. In the inpatient setting, pictures can help streamline diagnosis and prevent unnecessary tests or procedures. The purpose of this study was to evaluate for the presence of pictures in patients’ chart after a dermatology consult had been placed through EPIC at the …

Experience Treating Electrical Storm Using An Ultrasound Guided Stellate Ganglion Blockade, Thomas A. Nicholas Iv, Levi Zehr, Han-Jun Wang, Daniel R. Anderson, Steven J. Lisco

Graduate Medical Education Research Journal

Introduction: Electrical storm is a life-threatening condition in an often medically complex patient population. Pharmacologic ultrasound-guided stellate ganglion blockade is a treatment option in combination with maximized systemic antiarrhythmic medications. There is an emerging body of case reports supporting stellate ganglion block efficacy and safety for this condition.

Methods: Retrospective study on ultrasound-guided stellate ganglion blocks for electrical storm investigating patient clinical characteristics, immediate and long-term outcomes, and procedure related complications.

Results: Four (75% men) critically ill patients maximized on standard antiarrhythmic therapy underwent six bedside ultrasound-guided stellate ganglion block procedures. All blocks were unilateral left-sided, two patients underwent repeat …

The Advantages Of A Rural Resident Rotation In Otolaryngology Training: Comparing Surgical Case Volumes Of A Rural Rotation With A University Rotation, Mark Miller, Paul J. Brosnihan, Christie Barnes, Jayme Dowdall

Graduate Medical Education Research Journal

Objective: Rural residency rotations have played a significant role in encouraging surgical residents to pursue a career in a rural community. This study reviews the resident caseload of an otolaryngology residency rural rotation in comparison with a traditional primary university-based urban location.

Methods: The Accreditation Council for Graduate Medical Education (ACGME) case log system was used to review cases logged by residents during their rural rotations from July 2017 to December 2018. Case log data were compared with a matched resident of similar training experience on the university service during the same time period.

Results: Rural residents reported more cases …

Postoperative Outcomes Of Hip Fracture Surgery In Geriatric Patients On Clopidogrel Or Warfarin At The Time Of Surgery, Josh Locker, Elizabeth Lyden, Justin Siebler

Graduate Medical Education Research Journal

BACKGROUND: The purpose of our study is to evaluate if surgical intervention in the setting of an elevated INR or continued use of clopidogrel lead to elevated post-operative mortality and/or morbidity compared to INR reversal or surgical delay.

METHODS: We retrospectively reviewed 1,007 patients age > 55 undergoing hip fracture fixation at our institution over a 10 year span. We placed patients into four groups based upon their anticoagulation status at the time of surgery. Descriptive statistics were utilized to evaluate for differences in mortality rates, blood loss, time to surgery, and wound complications.

RESULTS: Comorbid conditions occurred at a higher …

Urinary Bile Acid Indices As Prognostic Biomarkers For The Complications Of Liver Diseases, Wenkuan Li

Theses & Dissertations

Hepatobilary diseases cause the accumulation of toxic bile acids (BA) in the liver, blood, and other tissues, which may lead to an unfavorable prognosis. In this study, we compared the urinary BA profile in 257 patients with hepatobilary diseases during a 7-year follow-up period. We investigated the use of the urinary BA profile to develop logistic regression models to predict the prognosis of hepatobiliary diseases in terms of developing disease-related complications, especially for ascites. The urinary BA profile was characterized by calculating BA indices, which quantify the composition, metabolism, hydrophilicity, and toxicity of the BA profile. All patients had high …

Apixaban To Prevent Thrombosis In Adult Patients Treated With Asparaginase, Krishna Gundabolu

Theses & Dissertations

The outcomes of pediatric acute lymphoblastic leukemia (ALL) have improved dramatically after intensification of the multi-agent chemotherapy backbone over a period of time starting from 1960’s, and asparaginase (ASP) is an important part of this success story. Adoption of such strategy in adult ALL and other high grade lymphoid neoplasms had been difficult due to higher anticipated toxicities including thrombosis. Many thrombosis prevention strategies including antithrombin (AT) replacement, Enoxaparin, unfractionated heparin (UFH) was studied but there is no firmly established evidence-based approach yet. We report the safety and efficacy of thrombosis prophylaxis with apixaban 2.5 mg orally twice daily for …

Gene Expression Profiling Of Mapk Pathway Inhibitor Resistance In Cutaneous Melanoma: Can Bioinformatics Be Used To Select Better Melanoma Cell Lines?, Stephen Luebker

Theses & Dissertations

Melanoma is the deadliest form of skin cancer, and incidence has continued to increase. Half of all melanomas have a BRAF V600E mutation and respond to MAPK pathway inhibitors, including BRAF inhibitor therapy or BRAF/MEK inhibitor combination therapy, but nearly all patients develop treatment resistance. Melanoma cell lines produce variable results as models of MAPK pathway inhibitor resistance. To better understand how the genomic similarity of a melanoma cell line to patient-derived tumors affects resistance mechanisms, differences in DNA mutations and copy-number alterations were compared between melanoma cell lines profiled by the Cancer Cell Line Encyclopedia and cutaneous melanoma tumors …

A Collection Of Research In Transplantation Surgery: The Importance Of Assessing Outcomes In A Field Dependent On The Availability Of Limited Resources, Amy J. Hargrove

Theses & Dissertations

This thesis is a collection of three independent projects related to transplantation surgery. In summary, project I involves an assessment of long-term quality of life outcomes of intestinal transplantation in pediatric patients who are now in adulthood, with comparison to other solid organ transplant patients. Health related quality of life surveys were completed in 14 adult patients who underwent intestine, liver, or kidney transplants as children. Project II evaluates pre-surgical characteristics of patients undergoing liver transplant to assess predictive factors for the need of venovenous bypass utilization intraoperatively by assessing trends at the University of Nebraska Medical Center in 95 …

Proof Of Concept: The Use Of Renal Biomarkers In Critically Ill Pediatric Patients For Therapeutic Drug Monitoring, Christopher Lee Shaffer

Theses & Dissertations

Acute kidney injury (AKI) is a serious and common complication in critically ill pediatric patients. The incidence of pediatric AKI continues to increase, especially in patients who undergo surgical correction of congenital heart defects. Serum creatinine and urine output are the most commonly used tools to assess renal function, with international guidelines standardizing AKI-definitions based upon these parameters. However, changes in serum creatinine can occur 24 hours or later after a renal insult event, delaying the diagnosis and potential interventions to reverse injury. It is critical to identify endogenous renal biomarkers within the pediatric population that are both timely and …

Molecular Pathogenesis Of A Novel Subgroup Of Peripheral T-Cell Lymphomas, Jiayu Yu

Theses & Dissertations

Peripheral T-cell Lymphoma (PTCL) consists of numerous distinct disease entities. With the current diagnostic criteria over a third of the cases cannot be further classified and are called "not otherwise specified" (PTCL-NOS). Using gene expression profiling (GEP) of tumors, we identified two novels PTCL-NOS molecular subgroups either characterized by high expression of GATA3 (33%), which is associated with Th2 cell differentiation, or high expression of TBX21 (49%) which regulates Th1 cell maturation. Therefore, stratifying patients for diagnosis and identifying the underlying genetic basis to improve clinical therapy becomes critical to prognosis.

First, we performed DNA copy number analysis by using …

Superoxide And Pulmonary Hypertension, Tammy Wichman

Theses & Dissertations

Pulmonary arterial hypertension (PAH) is a devastating cardiovascular disease, which is progressive and fatal despite advances in therapy. Animal models have shown that oxidative stress may be pathogenic in PAH. We hypothesize that oxidative stress, as measured by increased levels of a specific reactive oxygen species, superoxide (O₂^•-), mayplay a role in PAH in humans. Using a novel application of electron paramagnetic resonance (EPR) spectroscopy, we initially evaluated whether levels of O₂^•- from whole blood collected from the pulmonary artery collected during right heart catheterization (RHC) would correlate with O₂^•- levels in peripheral …

Insights Into Cutaneous Squamous Cell Carcinoma Pathogenesis And Metastasis Using A Bedside-To-Bench Approach, Marissa Lobl

Theses & Dissertations

Cutaneous squamous cell carcinoma (SCC) is the second most common skin cancer, affecting 1,000,000 people in the United States annually and causing approximately 9,000 deaths. SCC and basal cell carcinoma are the most common types of skin cancer arising in the superficial squamous cells or deeper basal cells of the epidermis, respectively. SCC is more likely to invade and metastasize, while basal cell cancer tends to grow locally. While the majority of cases of SCC are cured by surgery alone, approximately 2-5% of SCCs metastasize, at which point outcomes may be poor. Specific patient groups, particularly immunosuppressed patients, have a …

Association Of New And/Or Progressive Multiple Organ Dysfunction Syndrome With Mortality And New Morbidity Among Children Encountering Septic Shock, Rachel L. Waworuntu

Capstone Experience

Despite reductions in sepsis mortality, there remains a substantial morbidity burden among children who survive sepsis. Furthermore, the majority develop multiple organ ‘group has historically been analyzed as a single cohort. Using the Life After Pediatric Sepsis Evaluation (LAPSE) investigation database, we studied the association of new and progressive multiple organ dysfunction syndrome (NPMODS) with morbidity and mortality among children with septic shock. We hypothesized that NPMODS represents a distinct phenotype based on evolving organ dysfunction. There was evidence of an association but it did not reach the 0.05 level of significance. We also hypothesized and confirmed that children with …

Gray Matter Volumes Discriminate Cognitively Impaired And Unimpaired People With Hiv, Mikki Schantell, Brittany K. Taylor, Brandon Lew, Jennifer O'Neill, Pamela E. May, Susan Swindells, Tony W. Wilson

Journal Articles: Infectious Diseases

BACKGROUND: Current diagnostic criteria of HIV-associated neurocognitive disorders (HAND) rely on neuropsychological assessments. The aim of this study was to evaluate if gray matter volumes (GMV) can distinguish people with HAND, neurocognitively unimpaired people with HIV (unimpaired PWH), and uninfected controls using linear discriminant analyses.

METHODS: A total of 231 participants, including 110 PWH and 121 uninfected controls, completed a neuropsychological assessment and an MRI protocol. Among PWH, HAND (n = 48) and unimpaired PWH (n = 62) designations were determined using the widely accepted Frascati criteria. We then assessed the extent to which GMV, corrected for intracranial volume, could …

Prophylactic Corticosteroid Use In Patients Receiving Axicabtagene Ciloleucel For Large B-Cell Lymphoma, Olalekan O. Oluwole, Krimo Bouabdallah, Javier Muñoz, Sophie De Guibert, Julie M. Vose, Nancy L. Bartlett, Yi Lin, Abhinav Deol, Peter A. Mcsweeney, Andre H. Goy, Marie José Kersten, Caron A. Jacobson, Umar Farooq, Monique C. Minnema, Catherine Thieblemont, John M. Timmerman, Patrick Stiff, Irit Avivi, Dimitrios Tzachanis, Jenny J. Kim, Zahid Bashir, Jeff Mcleroy, Yan Zheng, John M. Rossi, Lisa Johnson, Lovely Goyal, Tom Van Meerten

Journal Articles: Internal Medicine

ZUMA-1 (NCT02348216) examined the safety and efficacy of axicabtagene ciloleucel (axi-cel), an autologous CD19-directed chimaeric antigen receptor (CAR)-T cell therapy, in refractory large B-cell lymphoma. To reduce treatment-related toxicity, several exploratory safety management cohorts were added to ZUMA-1. Specifically, cohort 6 investigated management of cytokine release syndrome (CRS) and neurologic events (NEs) with prophylactic corticosteroids and earlier corticosteroid and tocilizumab intervention. CRS and NE incidence and severity were primary end-points. Following leukapheresis, patients could receive optional bridging therapy per investigator discretion. All patients received conditioning chemotherapy (days -5 through -3), 2 × 10⁶ CAR-T cells/kg (day 0) …