The Journal of Medical Sciences at Northeast Ohio Medical University (NEOMED) is a student-led, peer-reviewed scholarly journal created to provide a platform for NEOMED students, faculty, consortium hospital trainees and affiliates to publish original research, opinion pieces, editorials, reviews, abstracts and other works.
Giving Tuesday: Alternative Fundraising in the Era of COVID-19
This abstract discusses a virtual alternative to Casino Night: Giving Tuesday. Non-profit community health services, including free clinics, provide many aspects of care to community individuals. These individual needs are amplified as community health services are strained both financially and physically by the COVID-19 pandemic. Community health workers have been shown to provide vital services to communities, including advocating on behalf of patients, transferring and interpreting information, and ensuring patients are connected to care.1 In-person fundraising events for these programs are restricted, leaving free clinics and other services across the country in need of alternatives to fundraising due to restrictions placed by COVID-19. The Student-Run Free Clinic (SRFC) at Northeast Ohio Medical University (NEOMED) has responded to this challenge by establishing a virtual fundraising initiative, which has profited close to double of in-person events. In the past, the SRFC at NEOMED has hosted a one-night in-person fundraising event, Casino Night, which annually generated a profit of over $10,000. Casino Night was attended by 250 community members with earnings coming from both ticket sales and donations. However, due to COVID-19, a large gathering was not possible, rendering the SRFC at NEOMED’s main fundraiser obsolete. In this abstract, we discussed a virtual alternative to Casino Night: Giving Tuesday. This world-wide initiative used social media to reach audiences traditional fundraising methods may neglect.2 We compared the processes of planning and organizing our 2019 in-person fundraiser to the 2020 virtual fundraiser. Costs to host the fundraisers and overall proceeds were also compared. Giving Tuesday was the most successful fundraiser in clinic history with a profit of $21,330.90 and an operating expense of $0 to the SRFC. The NEOMED Foundation provided the SRFC free access to the online donation portal, GiveCampus, a service the university previously paid for. In comparison, the 2019 Casino Night fundraiser generated $22,013 with an operating expense of $11,000. Giving Tuesday achieved this success with 154 gifts across 153 unique donors. Of these donors, 88 were first time donors to the clinic (57.5%) giving $9,630.90 (45.1%). In terms of planning time, Casino Night required a conservatively estimated 800 hours compared to 80 hours for Giving Tuesday. This data shows our virtual 2020 fundraiser yielded close to double the profit of our 2019 event with a largely new group of donors. Additionally, the virtual fundraiser required less planning time and zero upfront costs due to the generous support of the NEOMED foundation. This suggests virtual fundraisers can successfully replace in-person fundraising events during the COVID-19 pandemic. Further research is necessary to identify how public perceptions of the clinic differ between in-person and virtual fundraisers and if this success is reproducible in the post-COVID-19 era.
The Law and Ethics of Non-beneficial Treatment Policies
A non-beneficial treatment is defined as when a physician decides that the patient’s prognosis of a medical illness or injury, cannot be altered by a certain form of treatment.1 No medical therapy can improve the patient’s prognosis or condition. The ethics regarding non-beneficial treatment policies are of great debate due to their lack of consistency between healthcare systems. This paper compares the non-beneficial treatment policies between a hospital that operates under religious values and one that bases their values on community and population health with no religious ties. These policies will be compared to the guidelines put forth by the American Medical Association (AMA) Code of Medical Ethics, American Thoracic Society (ATS), American Association for Critical Care Nurses (ACCN), American College of Chest Physicians (ACCP), European Society for Intensive Care Medicine (ESICM), and Society of Critical Care (SCCM). The purpose of this paper is to highlight how subjective these policies can be and how their inconsistencies between hospital systems can lead to harmful patient outcomes.
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Comparison of the Wellness of a Medical School to General Student Population
When compared to the general population, healthcare students have been shown to have significantly higher rates of burnout, depression, anxiety, and suicidal ideation. However, there is limited data regarding mental health, access to mental health resources, and utilization of mental health resources by healthcare students in comparison to other student populations. This study aims to evaluate a medical university’s mental health and access/utilization of resources when compared to the general student population. Survey results from The Healthy Minds Study (HMS) of Northeast Ohio Medical University (NEOMED) students were compared to a national sampling of graduate and post-graduate student populations. Categories that were assessed included mental health status (previous diagnosis, depression/ anxiety related symptoms experienced recently or within the past 12 months) and access/utilization of resources (support system, use of psychotropic medications). Analysis was completed through individual Chi-squared tests. Compared to the national sample NEOMED students were less likely to talk to a professional clinician (p=0.017), friend (p=0.001), significant other (p=0.009), or family member (p=0.001) about distress and were less likely to be on anti-anxiety medications (p=0.018). NEOMED students were less likely to be unsure of where to go for help (p=0.009) while preferring to deal with issues on their own (p=0.001); NEOMED students were less likely to report a history of depression (p=0.044) or anxiety (p=0.028). NEOMED students were more likely to have no days of the week be impacted by mental difficulties (p=0.005), and NEOMED students were more likely to strongly disagree that they were in need of help for their mental state (p=0.047). Despite the intensity of healthcare training, this survey showed that students at NEOMED were no worse than the general student population in terms of access and utilization of mental health resources and mental functioning. The data suggest that NEOMED students are more reluctant to seek help but may have fewer mental health issues compared to other student populations.
Prescription Drug Donation and the Private Sector—Why Ohio’s Medical Students Should Care
This perspective piece discusses the important role donation of prescription medication from the private sector plays in the financial health of Ohio’s free clinics and the patients they serve. It also discusses recent changes in Ohio’s nursing home industry that have altered this vital pipeline, why medical students should care about them, and a personal anecdote from the author about the impact these changes can have on patients.
A Review of the Predisposition to Child Abuse
This present review focuses on evaluating works investigating potential risk factors for child abuse. Child abuse is a complex issue, which has many contributing risk factors. Child abuse encompasses physical abuse, sexual abuse, emotional abuse, and child neglect. Each component has its own consequence to a child's health and wellbeing. Theories have been developed to explain the causes of and the predisposition to child abuse. Several studies exist which investigate the relationship between child abuse and a variety of risk factors. Risk factors that have been shown to correlate with child abuse include parental problems and difficulties, prior sexual abuse victimization of a child or siblings, social isolation of a child and family, child drug use, poor social skills, parental substance abuse, and neighborhood risk factors. Focusing on these theories and risk factors can lead to a better understanding of the predisposition to child abuse.
Lumateperone in the Treatment of Schizophrenia: A Review
Schizophrenia is a devastating mental illness that afflicts about 1% of the world’s population. This illness distorts a person’s perception of reality and consists of positive symptoms such as hallucinations and delusions, negative symptoms such as inattention and withdrawal, and cognitive deficits. Antipsychotic drugs are primarily used for the pharmacotherapy of schizophrenia. In this article, we provide a succinct review of a recently approved novel antipsychotic, lumateperone. We present an overview and history of schizophrenia, its symptoms, epidemiology, etiology, and pathophysiology. The classification of antipsychotic agents as first and second-generation based on their receptor affinity is discussed. The review focuses on describing the background, development, receptor pharmacology, mechanism of action, pharmacokinetics, clinical trials, adverse effects, therapeutic uses, and future prospects of lumateperone.
Enhancement of Early-Stage Cancer Detection by Liquid Biopsy using Nanoparticle Platforms
Cancer has consistently been a public health burden for many decades, responsible for high mortality and morbidity rates worldwide. Effective cancer diagnostic methods are crucial to improving patients' survival and timely implementation of therapeutic and surgical interventions. Current diagnostic technologies are much more efficient in detecting cancer at late stages (stages 3 and 4) than early stages (stages 1 and 2), typically in solid tumor-based cancers. Meanwhile, cancer metastasis is a prominent feature of late stages, which poses a significant barrier to the effectiveness of therapeutic and surgical interventions. Thus, detecting early-stage cancer is crucial when the disease remains within the primary site. Though liquid biopsy has gained attention for noninvasive and low-cost diagnosis, cancer biomarkers present at early stages are at concentrations too low for conventional methods to detect with specificity. The low concentrations of early-stage cancer biomarkers pose a significant barrier in diagnosing patients with high sensitivity and specificity. This drawback can be addressed through an innovative combination of diagnostic nanoparticle platforms with liquid biopsy procedures. The strategy has been demonstrated to remarkably improve the efficiency of detecting early-stage biomarkers at the lowest concentration possible, i.e., decreasing the limit of detection (LOD). This review will assess the utility of various nanoparticle platforms in developing novel diagnostic techniques for early-stage cancer detection.
The curry spice, turmeric, is used to provide color and flavor to food, as well as for its health benefits. Turmeric contains many polyphenolic compounds known as curcuminoids, with curcumin being the most prominent curcuminoid. In this perspective, the health benefits of turmeric curcuminoids are highlighted. Specifically, this perspective summarizes the source, history, and the general use of turmeric. The pharmacology, especially the antioxidative and anti-inflammatory properties, safety, and the pharmacokinetic profile, as well as the therapeutic potential of curcuminoids in several disease conditions is discussed. The development of semi-synthetic forms and novel formulations for delivery of curcuminoids is mentioned. This article reflects upon the current status of turmeric use and the potential challenges, as well as future steps needed for development of curcuminoids as therapeutic agents in the clinic.
Human Connection Through Wi-Fi: Is it possible?
Due to the COVID-19 pandemic, all medical student assessments at Northeast Ohio Medical University (NEOMED) were redesigned to be performed virtually. This included my final standardized patient encounter. As nerve-wracking as it may feel to perform any aspect of the physical examination, it serves as a rite of passage for medical students transitioning into clinical rotations all around the country. My biggest concern was that my practice sessions and other standardized patient encounters had always occurred in person over the course of my first two years of medical school. Would I be able to successfully examine a patient virtually? Would I be able to connect with my patient to gather the sometimes personal, yet pertinent, details of medical history through a virtual platform? Knowing specific questions to review each organ system was not enough, and I knew I needed to identify more strategies to connect with patients. Empathizing and connecting with my patient through a virtual platform proved to be much harder than I expected. I no longer had the privilege or security of directly facing my patients. Human connection and empathy were the original foundation of my history-taking and physical examination skills. Staring at my laptop screen, I practiced. I practiced using my eyes to gaze with compassion. I practiced keeping my lips sealed to motivate my patient to overcome their hesitations. I practiced using my hands to encourage my patient to open up and trust me with their problems. I practiced nodding my head to aﬃrm my patient’s feelings. Every part of my physical nature served to complement my purpose. This was not so that my encounter would feel scripted. Rather, I did not want my screen to numb my non-verbal communication skills just because I could hide behind it. On test day, I was able to virtually empathize with my patients by making eye contact, listening to their problems, and trying to absorb each part of the conversation and guide it in the direction the patient wanted. In the words of my standardized patient, “I felt you were truly listening and concerned about me as your patient. When you consistently looked at the screen [maintaining eye contact] … I felt very important and that I had your 100% attention throughout the encounter.” During these unprecedented times, this feedback is promising. Although this encounter was different, I am grateful for the unexpected exposure to telemedicine—a service that most medical students are not typically exposed to. This experience has prepared me, as a future physician, to engage with patients via telemedicine as human connection is very much possible with an online platform. For patients who are unable to travel, the elderly, or those whose needs can be met via telemedicine, this is a great opportunity to receive the undivided attention and care of a physician. To start honing my skills during my medical school education has been invaluable as the use of telemedicine will only continue to grow in the field of medicine.
Cardiac Metabolism in the Diseaase of Acute Myocardial Infarction
Overproduced reactive oxygen species (ROS) with decreased oxidative phosphorylation is a hallmark of the post-ischemic heart, which results in reperfusion-induced oxidative injury of the citric acid cycle (CAC). During ischemia, hypoxic conditions slow down the CAC resulting in succinate accumulation. Succinate is then rapidly oxidized during reperfusion, fueling ROS overproduction and contributing to ischemia- reperfusion (I/R) injury. We test the hypotheses that 1) reperfusion re-accelerates the CAC to correct succinate accumulation and 2) a vicious cycle caused by excess ROS can impair and downregulate the CAC plus other metabolic pathways in the post-ischemic heart. Nine–ten-week-old Sprague-Dawley rats (n=15) were subject to coronary ligation for 30-min followed by 24-h reperfusion. This process allowed us to closely mimic acute myocardial infarction (MI) and I/R injury. The non-ischemic and risk-regions of myocardium were excised, and the mitochondria were isolated. Dimethyl labeling was used to illuminate key metabolic pathways. Previous studies showed data that I/R impairs ADP-dependent O2 consumption rate and ATP generation via downregulating CAC and fatty acid β-oxidation. However, a major finding in our study was that I/R dramatically upregulated the Phosphocreatine (PCr)/Creatine (Cr) shuttle (p<0.05) via upregulation of mitochondrial S-type creatine kinase (Ckmt2). The increased PCr formed in the mitochondria is transferred to the cytosol for ATP regeneration in-situ, which therefore increases the bioenergetic support of the post- ischemic myocardium. Therefore, we conclude that upregulating the PCr/Cr shuttle via increased Ckmt2 serves as feedback regulation of I/R, which can be useful for therapeutic intervention by increasing oxygenation and bioenergetics of the ischemic heart.
Enhancing Diversity in Medical Education Representation of Cutaneous Disease: VisualDx Skin-of-Color Atlas
The COVID-19 pandemic has recently brought to light the gross underrepresentation of cutaneous pathology in SoC. In early 2020, dermatologists created an international registry to compile cases of dermatological manifestaions of COVID-19, to gather clues to the disease and aid diagnosis. Out of the 700 submissions to the registry, there were only 34 Hispanic patients and 13 black patients represented (5). Despite the pandemic starting in March, it took until July of 2020 for the first pictures of "Covid toes" in nonwhite patients to be published in the Journal of the American Academy of Dermatology. This prompted Adelekun et al. to launch an investigation on how severely underrepresented SoC truly is. According to their study published in April 2020, only 4.5% of images in general medicine textbooks illustrate dermatologic diseases in dark skin (6). It is clear that the underrepresentation of SoC in medicine is not a new issue, and physicians worldwide are starting to notice the injustice.
Improving Community Health by Encouraging Remote Office Visits
The COVID-19 pandemic has affected patient access to healthcare in the field of dermatology. Due to efforts to minimize in-person healthcare visits, wait times for dermatology visits have increased, negatively affecting patients’ finances and furthering concerns about their skin conditions. This commentary highlights how the pandemic will potentially change the future of dermatology by promoting the use of telemedicine to reduce office wait times during the pandemic and beyond.
Robotic Assisted Laparoscopic Prostatectomy Post-Prostatic Urethral Lift Implants
Prostate cancer is the second most commonly diagnosed form of cancer in men. While there are several treatment options for prostate cancer, robotic assisted laparoscopic prostatectomy is a customary option in the treatment of clinically localized disease. It entails prostate removal using the Intuitive da Vinci surgical system. Another very prominent urologic condition affecting older males is benign prostatic hyperplasia (BPH); BPH has an increased lifetime prevalence reaching 80% of men by the 9th decade of life. It is characterized by lower urinary tract symptoms due to prostatic enlargement. These conditions often develop concomitantly in males given the high prevalence of each. Surgical advancements such as the prostatic urethral lift (PUL) system are becoming more commonly utilized. However, patients with benign prostatic hyperplasia who independently develop clinically significant prostate cancer may necessitate definitive management, namely prostatectomy. In this case report, we discuss a 67-year-old male presenting with Gleason group 2 (3+4=7) prostate cancer with previous PUL implants, who then underwent robotic assisted laparoscopic radical prostatectomy. Prostatectomy following prior PUL implantation has never been fully discussed in the literature, and there are no intraoperative or postoperative complications from prostatectomy to report thus far.
Efficacy of the Glasgow Coma Scale in Determining the Severity of Traumatic Brain Injury
Mr. D, a 52-year-old male, was in an un-helmeted motorcycle collision with a concrete barrier resulting in polytrauma and traumatic brain injury. Mr. D was assessed by emergency services to be unresponsive with a Glasgow Coma Scale (GCS) of 13. He sustained an open skull injury, subdural hematoma, multiple facial fractures, and traumatic vitreous humor hemorrhage with unresponsive, dilated pupils. He received CT and X-ray imaging before undergoing multiple surgeries for repair and debridement of injuries. After being weaned off sedation, he entered a state of post-traumatic amnesia lasting two months. Fifteen days post- accident, he began a regimen of amantadine to stimulate interaction and participation in physical therapy. Mr. D remained for two months until he progressed with physical therapy and was independent with his mobility. He was admitted to an inpatient traumatic brain injury facility because he was mentally unable to care for himself.
Chemical and Histopathologic Effects of COVID-19 on Virchow’s Triad
Although COVID-19 is known primarily as a respiratory disease, infected patients have been known to experience COVID-19-associated coagulopathy from overactivation of immune response resulting in cytokine storm. As a fundamental principle of venous thromboembolism, Virchow’s triad – consisting of stasis, hypercoagulability, and endothelial injury – remains the foundation for increased clotting risk which can often precipitate life-threatening complications, such as pulmonary embolism, if left untreated. We conducted a literature search using PubMed for evidence to explain the increased coagulopathy in COVID- 19 positive patients in relation to the three pillars of Virchow’s triad. Hypercoagulability in COVID-19 patients is increased due to cytokine-induced fibrin clot formation. Infected patients also have decreased ADAMTS13, which leads to endothelial injury. Lastly, the increased blood viscosity combined with patient immobility promotes vascular stasis. These factors put COVID-19 patients at an increased risk of acquiring blood clots. In conclusion, we have defined a plausible mechanism by which COVID-19 may induce venous thrombosis using the three components of Virchow’s triad. Due to the fatal nature of vascular complications, it is important to consider prophylactically treating these patients with a low molecular weight heparin regimen in order to mitigate the effects of hypercoagulability.
Using Ancient Spices to Treat Chronic Diseases: Turmeric’s Potential to Modulate Disease Pathogenesis in Rheumatoid Arthritis and Inflammatory Bowel Disease
This review aims to highlight two major health conditions that could benefit from regular supplementation of turmeric, as well as to discuss the importance of more widespread uses of this natural therapeutic in commonly used multivitamins and multi-drug regimens. There is a wide range of potential benefits patients could gain from this supplement, but we will be focusing only on the effects on inflammation in two of the most prevalent chronic inflammatory diseases, rheumatoid arthritis (RA) and inflammatory bowel disease (IBD). We propose that turmeric supplementation could be more commonly used in a healthcare setting as an adjuvant treatment in these inflammatory conditions. Future studies investigating turmeric’s role for treatment in RA and IBD must aim to further evaluate the effects of curcumin on the human microbiota and how its bioavailability can be increased to provide therapeutic results.
Burnout and Wellness in the College of Medicine at Northeast Ohio Medical University
Burnout is a syndrome of professional distress defined by symptoms of emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment. Previous surveys (Wellness Surveys) at Northeast Ohio Medical University (NEOMED) seemed to have demonstrated low scores in the wellness categories. As such, we sought to investigate further the frequency and factors of medical student burnout symptoms, the quality of medical student wellness, and contributing stressors at NEOMED. Over three weeks, an anonymous 8-question survey was sent out via e-mail to all NEOMED College of Medicine students. This survey included a novel scale created by the authors to measure burnout, wellness, and contributing stressors. The survey was done on Qualtrics SM Survey software and was statistically analyzed by class using Microsoft Excel. The survey was completed by 166 students (participation = 28%). Results demonstrated statistically significant differences in burnout and multiple components of wellness when stratified by class. Burnout and suboptimal wellness were most severe in preclinical (M1-M2) years. Groups rating higher frequencies of burnout also rated lower qualities of wellness. Nearly 50% of all respondents feel the challenge of medical school was more difficult than expected. At NEOMED, peak burnout frequencies and suboptimal wellness ratings are in the preclinical years. Groups that scored higher frequencies of burnout also scored poorer on wellness ratings. A systematic approach dedicated to promoting wellness at NEOMED may lead to lower frequencies of burnout.
Telehealth Access of Geriatric Patients During COVID-19: A Provider Team Survey
The COVID-19 pandemic has prompted the rise in the use of virtual healthcare through Telehealth. The importance of Telehealth is multi-fold, from communicating with patients virtually to providing care when in-person services are unavailable. Although this virtual platform has significant benefits, the geriatric population is underutilizing this resource. Our initial objective was to understand the perceptions of healthcare providers and their assessment of the comfort level and the utility of telehealth software for geriatric patients. We surveyed Geriatric specialists, Social Workers, Registered Nurses, and healthcare management team members regarding their perceptions of the rise and utility of telehealth before and after the pandemic. The survey was conducted in Northeast Ohio, specifically from Summa Health Akron City Hospital and the Direction Home Akron Canton Area Agency on Aging and Disabilities. 72.7% of those invited completed the survey, specifically five (33.3%) were physicians. Additionally, we surveyed participants regarding patient capability and understanding of telehealth software. A large subset of participants using telehealth (69.2%) stated that their patients fell between “somewhat uncomfortable” to “completely uncomfortable” in utilizing telehealth. Regarding their use of blood pressure and glucose monitors, 76.9% felt their patients had a “medium comfort” level. Finally, 92.3% would find a volunteer service to help train patients and caregivers in the use of telehealth software and medical devices “extremely helpful.” These data demonstrate a perception among geriatric providers that patients have difficulties using telehealth. Our goal is to develop a student-led virtual program to better assist patients and providers in the use of telehealth modalities.
A Histological and Qualitative Analysis of Muscle Spindle Density in the Distal Head of M. Extensor Longus Digiti Majoris
Inconspicuous muscles in avian taxa have been previously discussed as vestigial remnants, however, evidence has shown that such muscles may hold a function in flight. Further investigations into inconspicuous muscles, such as M. coracotriceps, have demonstrated a muscle spindle density much greater than surrounding muscles. A higher density of muscle spindles suggests a proprioceptive function during flight. We investigated another diminutive muscle that may bear a similar function, the distal head of M. extensor longus digiti majoris (ED). Studies included a qualitative histological analysis comparing the density of muscle spindles in the ED to the adjacent proximal head of the M. extensor longus digiti majoris (EP) in 15 total samples excised from Columba livia (rock pigeon) and Gallus gallus (jungle fowl). EP is a functional muscle that serves as an osteo-pulley for the major digit, which we analyzed the ED against. Based on our qualitative histological analysis of ED, this muscle does not demonstrate a greater muscle spindle density compared to the EP. Although further research of this muscle in other Avian species may be necessary to discern its function, our research demonstrates no evidence of a proprioceptive function.
Organizing a Student Led Virtual Research Conference Focused on Addressing Disparities in a Rural Community
The purpose of his study was to describe the implementation of a virtual student-led research conference at a medical school in a rural area that focused on addressing disparities in medical education opportunities and ways to address disparities in an underserved medical community. The ability to host virtual conferences in light of an evolving digital presence in medical education is both cost-effective and allows a greater dissemination of research to those that may not have been able to attend an in-person conference. Two virtual research symposiums were hosted on Zoom in 2020 and 2021 with the help of faculty and students. Submissions were allowed from any student and could have any mentor affiliation involved. Abstracts were organized into sessions based on common themes, such as orthopaedics, cardiology, and translational sciences, then analyzed according to various categories such as social determinants of health, mental health, and healthcare for marginalized groups. Those who attended the conferences were asked to complete a digital evaluation form in weeks following the conference and the average ratings of the responses were analyzed. In total, 425 individuals attended both events with the majority being students (64%) from the College of Medicine, Pharmacy, and Graduate Studies. Eighty-four percent of the 211 presenters were from the College of Medicine. Forty three percent of research presentations addressed rural disparities with a 12% rise in presentations focused on these areas (36% to 48%) from 2020 to 2021. Eighty eight percent of all participants who completed an evaluation form were agreeable to attending a virtual event again. Based on these results, the implementation of virtual conferences led by medical students presents an effective solution to increase research opportunities for students located in rural settings. Increased opportunities to present their research at their school encouraged students to identify and address disparities in their local community.
An Updated Review of Bone Mineral Density and Osteoporosis Prevalence in Postmenopausal Hispanic Women
Background: Osteoporosis is characterized by a loss of bone mineral density (BMD) and bone mass, causing an increased risk of fractures associated with greater morbidity and mortality.1-4 Aged women are at an increased risk of osteoporosis due to loss of ovarian estrogen following menopause.5 Older studies suggest that Hispanic women (HW) have a higher BMD on average than non-Hispanic White (NHW) women and are at less risk for osteoporotic fractures.7-10 The purpose of this literature review is to summarize recent studies on BMD in postmenopausal HW in the United States and to promote bone health education and osteoporosis prevention in this understudied population. Methods: PubMed and CINAHL searches were conducted using the search terms “bone mineral density”, “osteoporosis”, “Hispanic”, and “women.” Inclusion criteria for articles were peer-reviewed, published within the last 20 years, evaluated HW at least 40 years-old in the United States, and measured BMD using dual x-ray absorptiometry (DXA). Studies were excluded that did not fit these criteria, included patients with serious health conditions, involved a specific intervention, or did not include BMD or osteoporosis prevalence as the primary outcome. Results: Of the 1,216 total articles found, 13 were included in this review based on our criteria. There is a gap in the literature regarding BMD and risk factors for osteoporosis in postmenopausal HW. Nonetheless, there were minimal differences in total body BMD between HW and NHW women, with some evidence of greater prevalence of osteoporosis and osteopenia among HW than NHW women.11,17,21-23 When assessing BMD with DXA and high-resolution peripheral quantitative CT (HRpQCT), Caribbean HW had significantly lower BMD and poorer microstructural properties at the lumbar spine than NHW women.12,13 Data from the 2005-2010 and 2013-2014 National Health and Nutrition Examination Survey (NHANES) demonstrated that osteoporosis prevalence is highest amongst individuals who are not U.S. citizens, are unemployed, have lower income and less than a high school education.15 Additionally, increased abdominal fat mass was associated with poorer bone health in Puerto Rican older adults.18 Discussion: Bone health in Hispanic populations involves a multifaceted interplay between various factors, including genetics, hormones, socioeconomic conditions, cultural factors, and lifestyle behaviors, many of which are not fully understood.14,19,21-22 Osteoporosis exhibits varying prevalence among different Hispanic ethnic groups, revealing notable disparities in comparison to NHW women. Many studies focused on specific Hispanic groups, such as Mexican Americans and Puerto Ricans,7,9,14,16-19 , but there is a broader category of “Hispanics” as defined by the U.S. Census Bureau with notable cultural differences. Conclusion: This review demonstrated that HW have similar, or in some cases, lower BMD than NHW women in contrast to what older literature may suggest. Future studies that include HW and stratify by cultural subgroups are needed to better assess BMD and risk factors for osteoporosis in this population to prevent a substantial increase in morbidity and mortality associated with osteoporotic fractures in the U.S. Hispanic community.
Qualitative Analysis of Anterior Cruciate Ligament Reconstruction Surgery in the Hispanic Population
Background: The anterior cruciate ligament (ACL) is a supportive structure in the knee that provides resistance to internal tibial rotation and anterior tibial translation.1 ACL injuries are commonly seen in athletics and can lead to joint instability.1,2 The severity of injury determines the most suitable treatment option for patients. Sprains are typically healed through rest and rehabilitation, while tears may require surgical reconstruction to properly recover.2 The purpose of our study is to evaluate the quality of current literature that investigates ACL reconstruction surgery outcomes in Hispanic patients. Methods: We completed a review of literature that includes post-operative statistics on Hispanic patients who have undergone ACL reconstruction surgery through the PubMed database. Twenty-one of the studies found through PubMed fit the inclusion criteria and were included for review (10 systematic reviews, 7 cohorts, 2 narrative reviews, 1 cross-sectional, and 1 meta analysis).3-23 The data gathered focused on the incidence of multiple postoperative complications. Results: Qualitative measures were used to provide a comparison between Hispanic patients and other ethnicities. The most common variables measured were concurrent meniscal injuries (5), revision procedures (5), physical therapy follow-up (4), delay to surgery (3), sports clearance (2), physical strength (2), and range of motion (1). Hispanic patients from all of the studies reporting saw an increased risk for concurrent meniscus injuries, experienced a greater delay to surgery, and attended fewer physical therapy sessions which contributed to decreased strength during post-surgery recovery. The literature showed conflicting evidence about whether ethnic minorities are at an increased risk for revision surgery or failing sports clearance criteria. There was not a significant difference between ethnic groups for range of motion. Conclusion: Hispanic patients are less likely to have a successful recovery after ACL reconstruction surgery compared to White patients. The social determinants of health that greatly influence positive outcomes following surgery include access to care, insurance status, language barriers, distrust of physicians, and workforce representation. Insurance disparity was the most studied parameter and had the highest correlation to postoperative complications. Language barriers and distrust of the medical field led to Hispanic patients having decreased attendance of follow-up appointments and physical therapy sessions. In order to cultivate a more inclusive healthcare environment for all, there must be a focus on increasing workforce representation, reducing barriers in access to care, and promoting cultural competence in practice. Discussion: There are many studies that have been conducted on ethnic disparity in less emergent procedures, namely total knee and hip arthroplasty, but relatively few on ACL reconstruction surgery. It is important to note that of the 21 articles investigated through this research, only eight had a main focus on Hispanic outcomes. More data needs to be published on ACL reconstruction surgeries among all ethnicities. Recommendations for future research include longitudinal studies that survey long-term outcomes in Hispanic and other minority group patients such as subsequent injuries, revision procedures, continuation of pain, and joint stability.
YAP Signaling is Involved in Keratinocyte Proliferation and Tumorigenesis Mediated by RIPK4 Knockdown
Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer of the skin, with approximately 800,000 new cases diagnosed yearly in the US, and its incidence is continuing to increase. Although local cSCC is curable with conventional treatments, cSCC exhibits a significant risk of metastasis and no effective treatment is currently available for patients with the metastatic disease, leading to a survival rate of less than 20% over 10 years. Thus, a better understanding of the molecular mechanisms of cSCC pathogenesis is urgently needed for developing novel effective therapies to combat this disease. Recently, we have found that RIPK4 mRNA levels are significantly lower in human cSCC samples than in normal human keratinocytes. Interestingly, newly genomic studies identified the protein kinase RIPK4 (also known as PKK) as a recurrently mutated gene in aggressive and metastatic cSCCs. We previously demonstrated that knockdown of RIPK4 expression increased the proliferation of human cSCC cells in vitro as well as tumor growth of human cSCC in a mouse xenograft model. In addition, we showed that conditional knockout of RIPK4 in mouse epidermis greatly enhanced the development of mouse cSCC induced by chemical carcinogen treatment, suggesting RIPK4 functions as a tumor suppressor. Although we showed that the NFkB and p63 pathways are involved in the RIPK4-mediated cSCC development, the link of RIPK4 with the Hippo pathway has not been reported. In our current study, we investigated whether YAP1, a transcription regulator downstream of the Hippo pathway, is involved in RIPK4-mediated tumor formation. By using small-hairpin RNA (shRNA) targeting the RIPK4 gene and small interfering RNA targeting the YAP1 gene, we demonstrated that suppression of RIPK4 led to tumor development in keratinocytes via upregulating YAP signaling. More strikingly, silencing YAP1 expression led to a dramatic decrease in the size of colonies formed due to RIPK4 depletion. Our results may provide a novel therapeutic strategy by targeting the YAP signaling pathway in RIPK4-deficient cSCC, potentially improving outcomes for patients with this aggressive and metastatic disease.
The Current State of the Mitochondrial Diseases LHON, MELAS and Leigh Syndrome and Their Treatments: A Review
Metabolic disorders like Leber Hereditary Optic Neuropathy (LHON), Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS), and Leigh Syndrome (LS) are severe, rare mitochondrial diseases causing perturbed mitochondrial function. These disorders present a broad spectrum of clinical manifestations, complicating diagnosis and treatment. Management of LHON, MELAS, and LS remains largely supportive, with no FDA-approved treatments available. However, therapies like Idebenone for LHON, L-arginine for MELAS, and EPI-743 for LS are showing significant therapeutic promise and are presently being evaluated in clinical trials for their efficacy and safety. This review delves into the defining characteristics of LHON, MELAS, and LS, highlights the current state of therapeutic developments, and discusses established disease models.
Key Practice Indicators for Hypothermia Management for Neonates in Rural Nepal
In rural Nepal, neonatal hypothermia is a common complication due to lack of proper infrastructure and resources at birthing centers. The purpose of this research study is to examine the common medical practices incorporated in Nepal for prevention of hypothermia during the neonatal period. The study took place in Nuwakot, Nepal from June 2022 to June 2023, with surveys conducted on auxiliary nurse midwives from various birthing clinics in 5 different communities. Within these 5 communities surveyed, each birthing center (hospital, health post, home) gave a priority ranking of 1 (most important) to 14 (least important) for newborn temperature management procedures. Findings revealed that hospitals and health posts prioritized the same procedures except for procedures ranked 8 and 9, where less than 50% of health posts agreed with the hospitals. Home births presented significant variation in the ranking of each procedure, with exception to procedures ranked 1-3 and 12-13, which were similar in ranking to the hospitals and health posts. All home birth surveys explained the reason for their ranking variation as due to geographical remoteness. Among all birthing centers, procedures ranked 1-7 and 10-14 were prioritized the same for greater than 50% of surveys. However, for procedures ranked 8 and 9, less than 50% agreement was observed overall. When neonates were found to be cold, all clinics utilized kangaroo mother care as treatment. Overall, neonatal temperature management practices in rural Nepal were consistent across hospitals and health posts, with notable variation in home births. Table 1. Summary rank of newborn temperature management procedures at each birthing center. Parentheses denote how many of the 5 surveys agreed on the rank of that procedure. No parentheses mean the majority of surveys at that birthing location agreed on the ranking for that procedure. Birthing centers surveyed within each of the 5 communities Hospital Health Post Homebirth Warm delivery Room free from drafts 1 1 1 Immediate and thorough drying of the infant 2 2 2 Wrapping the infant in a dry towel 3 3 3 Weighing the infant while wrapped in a towel 4 4 4 (2/5) Placing a hat on the infant 5 5 5 (2/5) Covering the baby and mother together (Kangaroo Mother Care) 6 6 6 (2/5) Initiation of breastfeeding within 1 hour 7 7 7 (2/5) Delaying a bath until 6 hours after birth 8 8 (2/5) 8 (0/5) Only using warm water for bathing 9 9 (2/5) 9 (2/5) Temperature check 1 hour after birth 10 10 10 (0/5) Clean warm blankets available for deliver 11 11 11 (1/5) Resuscitation table with radiant heat source 12 12 12 Low-reading infant thermometer 13 13 13 Heated, water filled mattress 14 14 14 (2/5)
ICUS to ICU: A Case of Germline DDX41 Mutation in a Patient with Idiopathic Cytopenia of Undetermined Significance (ICUS)
Genetic testing for both somatic and germline mutations is a crucial component of the modern work up of cytopenia, myeloid neoplasms, and bone marrow failure syndromes. However, the specific genes tested in each clinical scenario are continually evolving, making standards for genetic testing a moving target. Germline mutation of the DDX41 gene is associated with familial acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS), but its role in idiopathic cytopenia of undetermined significance (ICUS) is less clear. We present the case of a 65-year-old male with a history of rheumatoid arthritis (RA) found to have ICUS with a germline DDX41 mutation. The patient’s cytopenia was long standing, present at least 3 years prior to initiation of immunosuppression for his RA. Two months after his initial hematologic evaluation, the patient was admitted to the ICU for neutropenic enterocolitis. The patient was severely neutropenic and required a right hemicolectomy. Subsequent work-up revealed a pathogenic germline DDX41 mutation. Repeat bone marrow biopsy 8 months later was consistent with MDS/AML as defined by 2022 International Consensus Classification Guidelines. This patient, asymptomatic for years, went through an ICU admission and emergent surgery before his germline DDX41 mutation was discovered. Expanded guidelines regarding somatic and germline genetic testing will likely prove helpful in delineating the etiology of ICUS and initiating early management in the future.
idiopathic cytopenia of undetermined significance
Meningitis Following Otologic Surgeries: A Review
Objective The review aimed to examine the incidence, etiology, and time course of meningitis as a postoperative sequela of otologic surgeries. Data Sources PubMed, Cochrane, and Web of Science databases. Review Methods The date range was 1960-2022. MESH terms “meningitis”, “postoperative complications”, and subcategories of otologic surgical procedures identified through PubMed’s MESH terms “auditory brain stem implantation”, “cochlear implantation”, “endolymphatic shunt”, “labyrinth fenestration”, “mastoidectomy”, “middle ear ventilation”, “myringoplasty”, “ossicular replacement”, “stapes surgery”, and “tympanoplasty” were used with “AND”. Additional studies were identified from reference lists. Non-English and non-human studies were excluded. Studies were included if they specified the presence/absence of meningitis irrespective of the primary goal of the study and provided the number of patients. Results 140 studies were reviewed for a total of 57,108 patients. 49.0% were male, and 57.5% were pediatric patients. There were 215 patients with meningitis, most commonly following cochlear implantation at 72.1% of the total cases. Inner ear malformations were noted in 38.3% of patients with meningitis. Streptococcus pneumoniae was the most common causative agent, followed by Pseudomonas aeruginosa, aseptic, and Haemophilus influenzae. The timing of meningitis ranged from 0-180 months post-otologic surgery. Vaccination status was reported in 14.3 to 34.7% of studies. The overall incidence of meningitis following otologic surgeries was 0.38%, from 1951-1999 was 0.35%, and from 2000-2020 was 0.39%. Conclusion Meningitis post-otologic surgery continues to have an impact on pediatric and adult patients. Meningitis can occur immediately or after many years following otologic surgery, necessitating continual vigilance. S. pneumoniae is the leading causative agent for postoperative meningitis. Inner ear malformations increase susceptibility to postoperative meningitis. While pre- and post-operative vaccinations likely have had an impact on decreasing the number of reported cases, the rates of meningitis remained generally stable with minor increases over time.
Erythrodermic psoriasis is a rare, but serious subtype of psoriasis characterized by widespread erythema affecting over 75% of the total body surface area. It is a condition that may be mistaken for pathologies with similar clinical presentation, including seborrheic dermatitis or atopic dermatitis. A missed diagnosis of erythrodermic psoriasis may lead to life-threatening systemic complications including hypothermia, sepsis, and high-output heart failure. In this report, we introduce a case of erythrodermic psoriasis with acute progression after an initial diagnosis of new onset atopic dermatitis.
Establishment of a New Level 4 Hospital Facility in Machakos County, Kenya