Postgraduate Day - Summa Health

Summa Heal th Sy s t emSumma Akron Ci t y and St . Thomas Ho sp i ta l s

Eighteenth Annual

Postgraduate DayJune 7, 2010

Joseph Zarconi, M.D., System Vice President, Medical Education and Chief Academic Officer

Postgraduate Day is a day with a storied history here at Summa Health System, and is a day of celebration.Today we celebrate the commencement of our departing residents into their specialty careers or intofurther specialty or subspecialty training. This commencing marks innumerable accomplishments in serviceto our patients and community, and serves as testimony to our institution’s commitment to graduatemedical education. Summa continues to believe that it cannot fulfill its mission to provide the highestquality, compassionate care to the citizens of our region without a commitment to train the next generationof physicians, and to attract a medical staff committed to excellence in patient care. This year’s residencygraduates demonstrate that these commitments bear fruit. We celebrate today in congratulating all of ourgraduating residents on their achievements. They will always be part of the Summa family, and we lookforward to hearing of their continued successes in the future.

Summa Health System • Summa Akron City and St. Thomas Hospitals • Eighteenth Annual Postgraduate Day

Summa Akron City and St. Thomas Hospital s

Postgraduate Day 2010

FOREWORD

POSTGRADUATE DAY 2010POSTER PRESENTATIONS

June 4, 2010

Ann and David Brennan Critical Care Center LobbySumma Akron City Hospital Campus

TIME EVENT4:00 p.m. Welcome and Opening Remarks

Ann and David Brennan Critical Care Center Lobby

POSTER PRESENTATIONS:

BASIC SCIENCE CATEGORY

Poster Title/Presenting Author(s) PageNumber

P1 Interaction of Bovine Chondrocytes with Electrospun Polycaprolactone (PCL) Polymer:A Step Towards Articular Cartilage RestorationMatthew Dilisio, M.D., Orthopaedic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

P2 New Biomaterial as a Promising Alternative to Silicone Breast ImplantsCherie R. Hart-Spicer, M.D., Pathology and Laboratory Medicine . . . . . . . . . . . . . . . . . . . . . . . 11

CLINICAL SCIENCE CATEGORY

P3 Agenda Setting Improves Patient Satisfaction and Office EfficiencyMariquita Belen, M.D., Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

P4 Detecting Variability in Testing, Imaging, and Disposition in Patients Diagnosed withGallbladder Disease in the Emergency Department: A Retrospective AnalysisTimothy W. Dake, M.D., Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

P5 Role of Palliative Care in Severe Renal Impairment: Overview of Referral Patterns andOutcomes in a Community HospitalChizor Eruchalu, M.D., Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

P6 Prevalence of Strangulation in Victims of Sexual Assault versus Intimate Partner ViolenceGwendolyn E. Fletcher, M.D., Emergency Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

P7 Screening for Low Bone DensityKerwyn Flowers, D.O., Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

P8 Endocrinologist Supported Diabetes Quality Improvement Initiative in anInternal Medicine Residency Continuity ClinicSana Hasan, D.O., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

P9 The Need for aWarfarin Reversal Protocol in Traumatic Head Injured PatientsPatrick D. Huck, M.D., General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1Summa Health System • Summa Akron City and St. Thomas Hospitals • Eighteenth Annual Postgraduate Day

P10 The Effect of Antioxidant Intake on Pulmonary Function in Chronic Lung Diseaseis Moderated by GenderM. Salman Khan, D.O., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

P11 Revision of a Method of Creating and Quantitatively Analyzing Pelvic AdhesionsPaul M. Kidder, D.O., Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

P12 Patient Perspectives of Flu Vaccination and H1N1 Vaccination in PregnancyShruti Malik, M.D., Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

P13 Opt-Out Influenza Immunization 2010: H1N1, Public Perception, and SupplyManasi Revankar, D.O., Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

P14 Suppression of Subconjunctival Fibrotic Response by TGF-Beta Inhibitor afterGlaucoma Filtration SurgeryScott Steiner, M.D., Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

P15 Interovserver Variability in Spectral Domain Optical Coherence Tomographyfor Macular ThicknessMatthew C. Willett, M.D., Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

MEDICAL EDUCATION CATEGORY

P16 In-hospital Mortality in Patients over 60 with Very Low Albumin LevelsJodi L. Hannan, M.D., Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

P17 Effective (and Free) Web-Based Asynchronous Learning Tools and MethodsChristopher Taggart, M.D., Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

CASE REPORTS

P18 A Case of Fatal, Acute Disseminated Encephalomyelitis (ADEM)Randy Allison, M.D., Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

P19 DiagnosingWhat is Not TherePreeti Betkerur, M.D., Geriatric Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

P20 Latissimus Dorsi Rupture in a Shot-PutterAndrew Bries, M.D., Orthopaedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

P21 The Needle and the Damage Done:An Uncommon Re-Presentation of a Heroin OverdoseBrian Cady, D.O., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

P22 Diagnostic Dilemma: Elevated Troponin I in a Patient with LeukocytosisCarrie Lee Caruso, M.D., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

P23 Pegasys Induced RetinopathyMeagan Celmer, M.D., Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

P24 Lethal Invasion of Basal Cell CarcinomaMoriah L. Conner, M.D., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22


P25 Plasmapheresis-Refractory TTP: Successful Treatment with CombinationImmunosuppressive TherapyMichael Dentler, M.D., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

P26 Interbody Fusion Through a Direct Lateral, Mini-Open Transpsoas Approach CanProvide Excellent Indirect Decompression and Reduction of a Degenerative,Unstable Lumbar Spondylolisthesis: A Case ReportMatthew Dilisio, M.D., Orthopaedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

P27 Stent Fracture: A Case in Two PartsJennifer Dy, D.O., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

P28 Unilateral Live Twin Ectopic Pregnancy in a Patient with Limited Risk FactorsBrad Gable, M.D., Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

P29 Atypical Peters’ Plus Syndrome with New AssociationsNancy Hanna, M.D., Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

P31 Plasmablastic Lymphoma in an HIV-Negative Patient Presenting as a Post-TransplantLymphoproliferative DisorderSudy Jahangiri, M.D., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

P32 Fourteen Year Old with Proximal Tibial and Distal Femoral LesionsElizabeth Knazek, M.D., Orthopaedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

P33 Muscular Dystrophy: More than a Pediatric ProblemMorgan Koepke, M.D., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

P34 A Dramatic Presentation of Infective EndocarditisJill Miracle, M.D., Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

P35 Colo-anal Intussusception: A Case ReportLisa Mohrman, M.D., General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

P36 A Case Report: Metastatic Osteosarcoma Presenting 28 Years LaterOlaronke Oshilaja, M.D., Pathology and Laboratory Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . 28

P30 Latisse Induced Periocular Skin HyperpigmentationJoshua Chaim Priluck, M.D., Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

P37 Chronic Mesenteric Ischemia:A Curable Cause of Failure to ThriveSara Snyder, D.O., Geriatric Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

6:00 p.m. Conclusion


POSTGRADUATE DAY 2010ORAL PRESENTATIONS

June 7, 2010Professional Center South • Raymond C. Firestone Auditorium

Summa Akron City Hospital Campus

TIME EVENT8:00 a.m. Welcome and Opening Remarks

Master of Ceremonies, Joseph Zarconi, M.D., System Vice President, Medical Education and Chief Academic OfficerRobert D. Harrigan, President, Summa Health System HospitalsSteven P. Schmidt, Ph.D., Vice President, Clinical Research & Innovation

ORAL PRESENTATIONS:

BASIC SCIENCE CATEGORY

Event Title/Presenting Author(s) PageTime

8:15 a.m. The Effect of Endometriosis on the DNA Integrity of Different Stages of Embryos’ Developmentand the Role of L-Carnitine in Preventing Damage to Early StagesGihan Mansour, M.D., Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

8:27 a.m. TMPRSS2-ERG Gene Fusion is Present in a Subset of Transition Zone Prostatic TumorsMaria Navas, M.D., Pathology and Laboratory Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

8:39 a.m. The Effects of Hypothyroidism on the Proximal Femoral Physis in Miniature SwineJason Tank, M.D., Orthopaedic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31


8:51 a.m. Hallway Versus Bed Emergency Department Patient Satisfaction StudyNathan Billings, M.D., Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

9:03 a.m. Pelvic Floor Tension Myalgia Measurement in Chronic Pelvic PainClara Chae, M.D., Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

9:15 a.m. Sleep Duration or Quality and Obesity in Primary CareAndrew Chema, M.D., Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

9:27 a.m. Use of RFID Technology to Establish EMS ED Turnaround TimesMatthew Frey, M.D., Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

9:39: a.m. INTERMISSION

9:54 a.m. Ability of Prehospital Electrocardiogram Computer Interpretation to Accurately IdentifyPatients with ST Elevation Myocardial InfarctionAmber Gist, M.D., Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

10:06 a.m. Urine Drug Testing for Long Term Opioid TherapyLeslie McKinley, D.O., Family Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34


10:18 a.m. Endoscopic Ultrasound-Guided Fine Needle Aspiration:Clinicopathologic Findings at Akron City HospitalMark Nelson, D.O., Pathology and Laboratory Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

10:30 a.m. Quality of Life in Chronic Pelvic Pain PatientsThida Nunthirapakorn, M.D., Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

10:42 a.m. Three-Dimensional Computer Image Analysis in Foot and Ankle Surgery: Computer Modelingin the Determination of At-Risk Structures for Calcaneal OsteotomiesErin Prewitt, M.D., Orthopaedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

10:54 a.m. Effectiveness of an Advanced Directives Communication Protocol during Hospital TransfersSara Snyder, D.O., Geriatric Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

11:06 a.m. Multiple Chronic Pelvic Pain Diagnoses in a General Gynecology SettingEileen Witten, M.D., Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36


11:18 a.m. The Utility of Web-Based Education in a Community-Based Residency ProgramShruti Malik, M.D., Obstetrics and Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

11:30 a.m. CONCLUSION



CYTOPATHOLOGY FELLOWSHIPCheri Hart-Spicer, M.D. V

DENTAL - GENERAL PRACTICE RESIDENCYCroston, Matthew, D.D.S. IDo, Leslie, D.D.S. IMcKee, Stephen, D.D.S. ISusai, Pamela, D.D.S. I

EMERGENCY MEDICINEBillings, Nathan, M.D. IIIDake, Timothy, M.D. IIIFletcher, Gwendolyn, M.D. IIIFrey, Matthew, M.D. IIIGlueckert, Michael, M.D. IIIJames, Laurie, D.O. IIINiertit, Amy, M.D. IIIRoskos, Erin, M.D. IIIShundry, Nicholas, M.D. IIIDussel, Christopher, M.D IIFinley, Allison, M.D. IIGamez, Jason, M.D IIGist, Mikki, M.D. IIPuppala, Neha, M.D. IIStevens, Aaron, D.O. IIWalters, Michelle, M.D. IIWilliams, Amanda, M.D. IIAllison, Randy, M.D. ICelik, Daniel, M.D. IDixon, Gage, D.O. IFridrich, Christopher, M.D. IGable, Brad, M.D. IJaved, Asad, M.D. IKearney IV, Joseph, M.D. IMaiers, Jarrad, M.D. IOndrejka, Jason, D.O. ISmedley, Jerry, D.O. I

FAMILY MEDICINEBelen, Mariquita, M.D. IIIChema, Andrew, M.D. IIIFlowers, Kerwyn, D.O. IIIMcKinley, Leslie, D.O. IIIRevankar, Manasi, D.O. IIITaggart, Christopher, M.D. IIIAdams, Sarah M.D. IIAgomaa, Albert, M.D. IIBortell, Melanie, D.O. IIBullock, Trevor, D.O. IIDuncan, Rebecca, M.D. IIEmberton, Mihal, M.D. IILookabaugh, Britni, M.D. IIMoreno, Michelle, D.O. IISadler, Amy, M.D. IIAhmed, Arif, M.D. ICheich, Emily, D.O. IDrolshagen, Colin, M.D. IGarrison, Jordan, D.O. IGodlewski, Emily, M.D. IReforma, Janjan, M.D. ITeagarden, Rebecca, D.O. I

GENERAL SURGERYKumar, Raman, M.D. VValente, Stephanie, D.O. VValente, Michael, D.O. VBowman, Dirk, M.D. IVHuck, Patrick, M.D. IVTurney, Eric, M.D. IVLaipply, Erica, M.D. IIIMohrman, Lisa, M.D. IIISudimak, Vincent, M.D. IIIRosenbaum, Amy, M.D. IIShedron, Christin, M.D. IIWydo, Salina, M.D. IIClanton, Jesse, M.D. IReigstad, Katherine, M.D. ISchulz, Steven, M.D. I

GERIATRIC MEDICINE FELLOWSBetkerur, Preeti, M.D. IVSnyder, Sara, D.O. IV

S u m m a H e a l t h S y s t e m

S u m m a A k r o n C i t y a n d S t . T h o m a s H o s p i t a l s

HOUSE STAFF 2009–2010 ACADEMIC YEARTHIS LIST IS ACCURATE AS OF JUNE 1


HOSPICE and PALLIATIVE CARE FELLOWSEruchalu, Chizor, M.D. IVHannan, Jodi, M.D. IVNemeth, Shorin, D.O. IV

INTERNAL MEDICINEArredondo, Mark, M.D. IIICaldwell, Michelle, D.O. IIICaruso, Carrie, M.D. IIIConner, Ronald, M.D. IIIHaynes, Aaron, M.D. IIIHlivko, Jonathan, M.D. IIILigon, Kathy, M.D. IIIMcKinley, Marc, D.O. IIIMuir, Garth, M.D. IIIPeters, Christina, D.O. IIIQua, Debbie, M.D. IIIShaw, Christopher, M.D. IIIShon, Alyssa, M.D. IIIStovsky, Erica, M.D. IIITorregosa, Hope, M.D. IIITrimble, George, M.D. IIIWilliams, Nicole, M.D. IIICady, Brian, D.O. IIChohan, Jameel, M.D. IIChua, Daniel, M.D. IIConner, Moriah, M.D. IIDentler, Michael, M.D. IIDy, Jennifer, D.O. IIFeitl, Julius, M.D. IIHasan, Sana, D.O. IIIlodi, George, D.O. IIJahangiri, Sudy, M.D. IIJames, Nicholas, D.O. IIKoepke, Morgan, M.D. IIMiracle, Jill, M.D. IIMuoh, Ogechi, D.O. IIRichards, Yoleetah, M.D. IIBertalan, George, M.D. ICampbell, Timothy, M.D. IDetore, Nicholas, M.D. IDrost, Jennifer, D.O., MPH IHealy, Amber, D.O. IKiraly, Franciska, M.D. IKohama, Mitsuyo, M.D. ILin, Lin, M.D. IMathur, Vivek, M.D. IMedina, Larissa, M.D. IMills, Ryan, D.O. ISobhanie, Mohammad, M.D. IWard, Sarah, M.D. I

OBSTETRICS and GYNECOLOGYChae, Clara, M.D. IVCrane, Andrea, M.D. IVKidder, P. Michael, D.O. IVNunthirapakorn, Thida, M.D. IVWitten, Eileen, M.D. IVDo, Jean-Anthony, M.D. IIIHojat, Rod, M.D. IIIMalik, Shruti, M.D. IIIMansour, Gihan, M.D. IIITabet, Muriel, M.D. IIIVande Velde, Jennifer, D.O. IIIWilber, Amy , D.O. IIIHensley, Autumn, M.D. IIKermode, Timothy, D.O. IIMelrose, Erica, D.O. IIMiller, Jacqualin, D.O. IIThomson, Emily, D.O. IIBarton, Thomesha, M.D. IClark, Gretchen, M.D. IEvans, Nathaniel, D.O. IGoldschmidt, Melanie, D.O. ITamirisa, Anita, D.O. I

OPHTHALMOLOGYSteiner, Scott, M.D. IVWillett, Matthew, M.D. IVHanna, Nancy, M.D. IIIPriluck, Joshua, M.D. IIICelmer, Meagan, M.D. IICho, Michelle, M.D. II

ORTHOPAEDIC SURGERYBries, Andrew, M.D. VKnazek, Elizabeth, M.D. VNelman, Kyle, M.D. VLaskovski, Jovan, M.D. IVMyer, Daniel, M.D. IVSchrickel, Tyson, M.D. IVJohnson, Jeffrey, M.D. IIIKemppainen, John, M.D. IIIPrewitt, Erin, M.D. IIIDilisio, Matthew, M.D. IIRiley Jr., Patrick, M.D. IITank, Jason, M.D. IIMyer, Christopher, M.D. IWidmer, Steven, M.D. IYi, Seung, M.D. I


PATHOLOGYNelson, Mark, D.O. IVClapper, Marc, D.O. IIIOshilaja, Olaronke, M.D. IIIYoung, Allison, M.D. IIINavas, Maria, M.D. IIBarrett, Heather, M.D. IDrolshagen, Katherine, M.D. IGonzaga, Niki, M.D. I

PLASTIC SURGERYBurke, Mark, M.D. VIIPatel, Nima, M.D. VIIHemphill, Amani, M.D. VIMaalouf, Majed, M.D. VI

PRELIMINARY MEDICINEBaraga, Anthony, M.D. IKhan, Mohammad, D.O. IKimbrough, Dale, M.D. IMontgomery, Jennifer, M.D./Ph.D. IUnger, Ryan, M.D. I

PSYCHIATRYBeklemisheva, Anastasia, M.D. IVOros, Michael, M.D. IVStephenson, Camille, M.D. IVGergis, Sherri, M.D. IIIMisja, Charles, M.D. IIISpivey, Jason, MD IIIAgrawal, Shravan, M.D. IIBaishnab, Raman, D.O. IIBeck, Michael, M.D. IIKassem, Sophia, D.O. IIBrown, Charles, D.O. IDanszczak, David, M.D. ILewis, Heather, D.O. IPacko, Kristine, M.D. I

TRANSITIONAL YEARFuller, Molly, M.D./Ph.D. IGoodman Cyle, M.D. IKudithipudi, Venu, M.D. ILagouros, Evan, M.D. ILe, Tony, D.O. IMahoney, Andrew, M.D. IMyers, Emily, M.D. IOsman, Umar, M.D. IShaikh, Marwan, M.D. ITumu, Anil, M.D. I

UROLOGYCerone, Jeffrey, M.D. VMulligan, Daniel, M.D. VMassanyi, Eric, M.D. IVShie, Scott, M.D. IVChaudry, Nasir, M.D. IIIRusilko, Paul, D.O. IIIGangel, Michael, M.D. IINething, Joshua, M.D. IIAkunne, Odinaka, M.D. ILohr, Christopher, M.D. I




ABSTRACTS


POSTER PRESENTATIONSBASIC SCIENCE CATEGORY

P1. Interaction of Bovine Chondrocyteswith Electrospun Polycaprolactone(PCL) Polymer: A Step TowardsArticular Cartilage RestorationMatthew Dilisio, M.D.1, Walter Horton, Jr., Ph.D.2,Denise McBurney, B.S.2, Scott Weiner, M.D.1,Shing-ChungWong, Ph.D.31Orthopaedic Surgery, SummaHealth System,2NEOUCOM, 3University of Akron

PURPOSE:Human articular cartilage has a limited healing capacity; damage oftenleads to the development of premature joint degeneration. Currentsurgical treatment strategies include abrasion arthroplasty,microfracturetechnique, perichondrium/periosteum implantation, autologouschondrocyte transplantation, and osteochondral autograft/allografttransplantation. These techniques have shown limited long term results.Our goal is to engineer mature hyaline cartilage from surgicallyharvested chondrocytes for implantation into chondral defects that canmore effectively restore articular cartilage structure and function thancurrent treatment strategies. In a previous study, our lab hasdemonstrated the 3-dimensional formation of hyaline cartilage fromhuman and bovine chondrocytes in a collagen-I based hydrogel.However, the response of human chondrocytes is less than optimal.While the cells remain viable and display limited evidence of adifferentiated phenotype, there is no significant extracellular matrixformation or 3-dimensional formation of cartilage tissue. We proposethat embedding the chondrocyte-rich hydrogel into an electrospunpolycaprolactone (PCL) polymer scaffold will enhance the capacity ofchondrocytes to form 3-dimensional cartilage. The purpose of thisstudy is to test the hypothesis that a PCL polymermat embedded withthe chondrocyte/hydrogel construct will support formation of3-dimensional hyaline cartilage.

METHODS:Bovine articular cartilage was dissected from 1 to 3-week-old holsteincalf knees. Chondrocytes were then isolated overnight from thematurecartilage by enzymatic digestion in 4% collagenase. The cells were thensuspended in a collegen I hydrogel and embedded in an electrospunPCL mat through vacuum assisted suction. The polymer/cellconstructs were then cultured for 7 days and then divided forhistological analysis.

RESULTS:Viable bovine chondrocytes were found embedded throughout thePCLmat. The cells generatedmetachromatic territorial and interstitialmatrix consistent with extracellular proteoglycan production bychondrocytes found in articular cartilage.

DISCUSSION:The bovine chondrocytes effectively integrated into the PCL mats.They remained viable and retained the ability to synthesize extracellularmatrix. The production of 3-dimensional hyaline cartilage was notinhibited by integration into the PCL mat. Further investigation isneeded to determine if a PCL polymer scaffold will enhance the abilityof human chondrocytes to form 3-dimensional cartilage.

P2. New Biomaterial as a PromisingAlternative to Silicone Breast ImplantsCherie R. Hart-Spicer, M.D.1, Lisa R. Mohrman,M.D.2, Stephanie A. Valente, D.O.2, Goy Teck Lim,Ph.D.3, Michelle Evancho-Chapman, B.S.2,Judit E. Puskas, Ph.D.3, Steven P. Schmidt, Ph.D.21Pathology and Laboratory Medicine, SummaHealth System,2General Surgery, SummaHealth System, 3University of Akron

PURPOSE/OBJECTIVE:One in eight American women develops breast cancer. Of the patientsrequiring mastectomy, 75% elect some form of breast reconstruction.Since 2006, only silicone breast implants have been approved for useby the FDA. Unfortunately, 34% of women with these implantsexperience complications, including capsular contracture, calcification,hematoma and necrosis. The linear triblock poly (styrene-b-isobutylene-b-styrene) is a self-assembling nanostructuredthermoplastic rubber. The third generation of this material with abranched core (TPE1) shows promising structural potential, and isbeing developed as an alternative to silicone. The purpose of thispre-clinical research was to evaluate tissue/TPE1material interactionsin a rabbit implantation model.

METHODS:A 12-week implantation experiment was performed in a double-blinded manner using three New Zealand white rabbits. The TPE1used in this study was compression molded into 1-mm dumbbellsheets. Medical grade silicone rubber was used as control. Theimplants were placed under sterile conditions into the subcutaneousplane of the rabbits’ lateral thoracic wall. After explantation, tissuesamples underwent histological examination.

RESULTS:The histological examination found that there was a statisticallysignificant increase in chronic inflammatory cells adjacent to thesilicone implants when compared to the TPE1 material. There wereno significant differences between TPE1 and silicone in acuteinflammation, fibrous capsule formation, foreign body giant cellreaction, granulation tissue formation, and evidence of infection.

CONCLUSION:Our data suggests that TPE1 provokes less of a chronic inflammatoryreaction than silicone when implanted. Since inflammation isassociated with eventual capsular contracture, we conclude that TPE1used as a breast implant material may decrease this complication.



P3. Agenda Setting Improves PatientSatisfaction and Office EfficiencyMariquita Belen, M.D., John DiSabato, M.D.,Christopher Taggart, M.D., Everett Logue, Ph.D.,William Smucker, M.D., Patricia Dudley, B.A.Family Medicine, SummaHealth System

PURPOSE:Family physicians face the challenge of maximizing patientsatisfaction while increasing productivity and improving officeefficiency. Elements of patient satisfaction include both attention tothe patient’s agenda and sensitivity to the patient’s time constraints.Agenda setting is one way that allows patients and providers to focusthe visit for a higher quality encounter.

METHODS:All FamilyMedicine Center of Akron providers (30 physicians, 1 NP)began the clinical encounter by discussing the issue that was ‘mostimportant’ for the patient (i.e., patient agenda). After the visit, bothpatients and physicians completed questionnaires.

RESULTS:Patients completed 312 surveys, and providers completed 165 surveysduring a 2 week Plan-Do-Study-Act Quality Improvement cycleperiod. Patients reported that the doctor paid attention to the concernof greatest importance to them (89% Strongly Agree), and showedrespect for their time (86% Strongly Agree). Ninety percent ofproviders recorded an agenda. Providers felt that patients ‘respondedpositively to setting the agenda’ (57% Strongly Agree, 41% Agree),and ‘responded positively to having their agenda item addressed’ (52%Strongly Agree, 42% Agree). Most providers reported that setting theagenda helped control the length of the visit (46% Strongly Agree,36 % Agree).

CONCLUSION:Discussing and recording the issue of greatest importance to thepatient is feasible and can positively impact not only patient andphysician satisfaction with the visit, but also may control visit length.Future studies will address the effect on formal (e.g. Press-Ganey)patient satisfaction scores.

P4. Detecting Variability in Testing,Imaging, and Disposition in PatientsDiagnosed with Gallbladder Diseasein the Emergency Department:A Retrospective AnalysisTimothy W. Dake, M.D., Jason Gamez, M.D.Emergency Medicine, SummaHealth System

PURPOSE/OBJECTIVE:Variability in practice exists. No studies have addressed if a standardizedapproach to cholelithiasis would affect the efficiency of an emergencydepartment (ED) to change patient care. We reviewed patients withcholelithiasis to detect if variability exists in the clinical approach byemergency medicine. We hypothesized that little variability exists.

METHODS:A retrospective chart review was performed on patients presenting toAkron City Hospital with the diagnosis of cholelithiasis from January1, 2009 to June 30, 2009. Data collected included: demographics,insurance, laboratory tests, imaging, disposition, additional testingordered by consults, and recidivism. Data was abstracted by tworesident physicians from the electronic medical record and enteredinto a database. Main outcomes included variability in the initialevaluation in the emergency department. Secondary outcomesinvolved detecting additional testing ordered by consults, incidentalfindings of cholelithiasis on imaging, and recidivism.

RESULTS:Of the 179 patients identified with cholelithiasis, most patientsreceived a BMP (88%, 95% Confidence Interval (CI): 0.83-0.93),CBC (89%, 95% CI: 0.83-0.93), LFT (86%, 95% CI: 0.80-0.90), andlipase (84%, 95% CI: 0.78-0.89) as part of the initial ED evaluation.Additionally, 43% of patients had a surgical consult in ED and 30% ofthese had additional blood tests ordered. The most commonadditional test was a serum amylase 87% (20/23). Initial evaluation forimaging included: ultrasound (68%, 95% CI: 0.61-0.75), CTscan (25%, 95% CI: 0.19-0.32), and abdominal x-ray (3%, 95%CI: 0.009-0.06). During admission or consult, additional imagingincluded an ultrasound (8%, 95% CI: 0.03-0.15), CT scan (2%, 95%CI: 0.002-0.08), HIDA scan (3%, 95% CI: 0.007-0.10), or anothertype of imaging (18%, 95% CI: 0.1-0.27). Of 179 patients, 20% hadcholelithiasis incidentally found on imaging. For disposition, 33% (95%CI: 0.25-0.39) were admitted to surgery with a surgical consult in theED, 8% (95% CI: 0.004-0.03) were admitted to medicine without asurgical consult in the ED, 9% (95% CI: 0.05-0.13) were dischargedafter a surgical consult, and 50% (95%CI: 0.42-0.57) were dischargedwithout a surgical consult in the ED. Follow up was referred to thePCP in 40% of patients and to a surgeon in 56% of patients. Recidivismwas present in 11% (95% CI: 0.07-0.17) of patients.

CONCLUSION:Little variability in lab and imaging assessment occurs in patients withcholelithiasis. Variability existed in the approach to discharged patients.Creating a standardized approach for the disposition and follow upmay assist in caring for patients with cholelithiasis.

POSTER PRESENTATIONS


P5. Role of Palliative Care in SevereRenal Impairment: Overview ofReferral Patterns and Outcomes in aCommunity HospitalChizor Eruchalu, M.D.1, Charina Gayomali, M.D.2,Steven Radwany, M.D.2, Hallie Mason, CNP2,Teresa Albanese, Ph.D.2, Steve Clark, M.D. Ph.D.31Palliative Care, SummaHealth System,2Internal Medicine, SummaHealth System,3SummaHealth System

PURPOSE/OBJECTIVE:Initiation of dialysis as a means of managing end stage renaldisease (ESRD) is life prolonging but not curative and does notalways translate to improved quality of life (QoL). Dialysispatients typically suffer withmultiple co-morbidities, a shortenedlife expectancy and high symptom burden compared with ageand gender-matched individuals in the general population.

In 2002, an in-patient Palliative Consult Service (PCCS) wasestablished in a 645 bed tertiary hospital, followed by a 12 bedAcute Palliative Care Unit (APCU) in 2006. The aims of thestudy were to identify the patterns of Palliative Care ConsultService requests and outcomes for patients with renal failure.

METHODS:The sample consists of 214 patients with a diagnosis of ESRD,Acute or Chronic Kidney Disease for whom a Palliative CareConsult (PCC) was requested. Data were collected from thehospital administrative and PCC database. The variables werepatient demographics, dialysis status, type of dialysis, location ofinitiation of dialysis, hospital LOS, specialty requesting consult,length of survival following discontinuation of dialysis anddischarge outcomes.

RESULTS:Dialysis patients (N = 116) were on average 70 years old witha LOS of 17 days; 50% with ICU days the majority (73%)received hemodialysis (HD). A PCC consult was requested onaverage the 11th day of hospitalization. Forty-two percent ofPCCs were initiated by Intensivists, 23% by Internists and3% by Nephrologists. In-hospital initiation of hemodialysisoccurred in 22% of patients.

Patients who did not require dialysis (N = 98) were on average77 years old. This sub-group had a shorter hospital LOS(7 days), earlier PCC request (4th day of hospitalization) andfewer patients (24%) had ICUdays.Most PCCs were requestedby Internists(30%), Intensivists (18%) andNephrologists (2%).Mortality was high in both the dialysis (48%) and non-dialysis(56%) groups. Mortality was much higher among patientswith in-hospital initiation of dialysis (72%). Average survivalfollowing discontinuation of dialysis was 3 days. Hospicereferral was higher in non-dialysis patients (25% vs 10%)

CONCLUSION:Results suggest that increased knowledge of palliative careoptions for patients with advanced renal disease will improvecare and support for patients and their families.

P6. Prevalence of Strangulation inVictims of Sexual Assault versusIntimate Partner ViolenceGwendolyn E. Fletcher, M.D., Sheila Steer, M.D.,Valorie Prulhiere, BSN,RN, SANE-A,Michelle FaklerEmergency Medicine, SummaHealth System

PURPOSE/OBJECTIVE:Both sexual assault victims (SA) and intimate partner violencevictims (IPV) are at risk of strangulation injury. However, theprevalence of strangulation and lethality risk factors have notbeen well described in either population. Our goal was toidentify the prevalence of strangulation in SA and IPV,determine lethality risk factors, and determine if there was adifference in strangulation between SA and IPV.

METHODS:We performed a retrospective observational study.We includedall patients who were evaluated by our sexual assault nurseexaminers and domestic violence nurse examiners over 5 yearsfrom 2004-2008. We excluded subjects who were victims ofnon-intimate partner violence who were not sexually assaulted.Chartswere by 1of 2 reviewers for physical signs of strangulation,or a history stating the patient was strangled by her perpetrator.Stata Software was used to analyze the data. We report data asmeans and proportions with 95% confidence intervals (CI),comparisons used CIs for the difference between proportions(exclusion of zero is significant).

RESULTS:We reviewed 1542 charts, 54 patients were excluded. Fortypercent of our patients were victims of IPV, with 60% victimsof sexual assault. The mean age was 30.0 +/-12.1 sd years and97% of subjects were female.We had 353 patients that reportedthey were strangled or had injuries to their neck that wereconsistent with strangulation. The prevalence of strangulationwas 40% in IPV and 15% in SA, a 25% difference (95% CI21-30%). Sixty-nine percent of patients were Caucasian,29% African American, and 2% other. Lethality risk factorsincluding pregnancy, a firearm in the household, and threats ofhomicide or suicide by the perpetrator were also identified inthese two populations.

CONCLUSION:IPV patients are more likely than SA patients to have beenstrangled. There was no significant difference in rate ofstrangulation in patients that were pregnant compared topatients that were not pregnant. Though there were morepregnant patients in the IPV group then there were in thesexual assault group.



P7. Screening for Low Bone DensityKerwyn Flowers, D.O., Patricia Dudley, B.A.,Everett Logue, Ph.D., William Smucker, M.D.Family Medicine, SummaHealth System

INTRODUCTION:Screening is an important aspect of secondary prevention inprimary care. We are starting a process of examining thefrequency of screening activities and whether they cluster withone another. Of particular interest is the number of womenover age 40 who received both mammograms and dexa bonescans in 2009.

METHODS:Family Medicine Center patients who received mammogramsand dexa bone density scans in 2009 were identified by usingthe SAS® toMySQL® interface to the electronic medical record.We then looked at indications for testing: demographic riskfactors, diagnoses, and relevant medications.

RESULTS:In 2009, 388 people receivedmammograms. Of these patients,52 (13%) also had dexa bone scans performed. Overall,136 dexa bone scans were ordered in 2009; of these, 60 (44%)were actually completed. Dexa scan reports revealed that 57%of the tested patients had osteopenia, 18% had osteoporosis;and 25% were normal or negative for notable degeneration.The review of diagnoses among the patients with completedscans revealed 3% with costochondritis, 50% with diagnoses ofosteopenia; and 13%with osteoporosis. Twenty-five percent ofthe tested patients were taking bone density medication, andfractures were risk factors for 28% of the patients. The mostfrequently cited patient risk factor was estrogen deficiency(73%) and the most common indication for testing wasestrogen deficient woman at clinical risk for osteoporosis (55%).

CONCLUSIONS:More work is needed to reach evidence-based screeningbenchmarks for deceased bone density among at risk patients.

P8. Endocrinologist Supported DiabetesQuality Improvement Initiative inan Internal Medicine ResidencyContinuity ClinicSana Hasan, D.O., James Salem, M.D.,Ronald Jones, M.D., David Sweet, M.D.,Lynn Clough, Ph.D.Internal Medicine, SummaHealth System

OBJECTIVE:To assess interdisciplinary team skills in learners and improvement indiabetes outcomes following implementation of an endocrinologist-supported quality improvement initiative in an internal medicineresidency continuity clinic.

METHOD:With the support and leadership of an endocrinologist, servicedelivery in the clinic was incrementally redesigned for diabeticpatients to incorporate monthly endocrinologist-facilitated teammeetings, team-based care visits (2008) and enhanced decisionsupport with point-of-care (POC) A1c testing (2009). Theresidency curriculum was also redesigned to include reviews ofpractice patterns and use of an interdisciplinary team. Changes inoutcomes were tracked through a two year longitudinal study ofall diabetic patients in the clinic who had at least 2 visits each yearfollowing implementation (n=560). Educational outcomes wereassessed for all residents in the program through multi-sourceevaluations based on direct observations. Descriptive statistics wereused to report change in the process of care and achievement ofresident competencies. Paired t-tests were used tomeasure changein A1c levels. Since the method of A1c measurement changes in2009 with the addition of POC testing, change in A1c levels wasonly assessed in 2008.

RESULTS:The percent of visits with current A1c results increased from 62%in 2008 to 77% in 2009 after the introduction of POC testing.Treatment intensification for patients occurred at a higher rate(65%) during visits with a completed POC test than during thosewithout a completed POC test (49%).Mean A1c levels for patientsnot at goal at baseline significantly improved during 2008(9.6-9.0%, difference-0.6; 95% Cl .29 to .81) (p<0.001).Currently, 39% of the patients have A1c levels <7.0 at their mostrecent visits. During 2008-2009, the percentage of residentsachieving “Competent” or “Superior” ratings in interdisciplinaryteam related Competencies of Professionalism, System-BasedPractice, and Interpersonal and Communication Skills were 77%,77% and 81% respectively.

DISCUSSION/CONCLUSION:Use of team-based services and enhanced decision support at visitssignificantly improves the quality of care provided by residentsduring training and also improves clinical outcomes for theirpatients with diabetes. This model for collaboration betweenendocrinologists and primary care physicians was shown to bean effective quality improvement strategy in a residency continuityclinic. The elements of the redesign are not specific to one institutionand could be transferred to others to improve patients care.



P9. The Need for a Warfarin ReversalProtocol in Traumatic Head InjuredPatientsPatrick D. Huck, M.D., Michael Cullado, M.D.,Gerald Drocton, B.S.General Surgery, SummaHealth System

PURPOSE/OBJECTIVE:Warfarin coagulopathy increases the mortality of traumaticintracranial hemorrhage to 48% from 10% in non-anticoagulated patients. Previous research has shown thatimproving time to initiation of treatment to internationalnormalized ratio (INR) reversal to less than 1.5 improvesmortality to the baseline 10%.1 This study describes the time totreatment for Summa Health System patients with traumaticintracranial hemorrhage and documented coagulopathy.

METHODS:The Trauma Registry was queried for patients from 2006-2007to review charts that met the criteria of intracranial hemorrhageand coagulopathy. Twenty-nine charts were reviewed for aprimary endpoint of inpatient mortality. Additional variablesincluded age, injury severity score, weight, response level, timefrom presentation to INR, FFP, and normalization of INR to<1.5.

RESULTS:The mean age for these patients was 75 years, a weight of92.4 kg, with a mean injury severity score of 19. Of these29 patients, 15 presented with an INR of greater than 1.5. Themortality in these patients was 46%. Amean of 5.5 units of FFPwere transfused. The mean time from presentation to an INRlab result was 52minutes, to FFP transfusion was 605minutes,and to normalization if INR was 1144 minutes.

CONCLUSION:Mortality is similar to an untreated patient in previous studies.The time from a known coagulopathy to infusion of FFP wasnearly nine hours, and normalization was nearly 20 hours. Thesystemmay benefit from a protocol to rapidly reverseWarfarin.

P10. The Effect of Antioxidant Intake onPulmonary Function in Chronic LungDisease is Moderated by GenderM. Salman Khan, D.O.1, Rachel Pohle-Krauza,Ph.D.2, Michelle McCarroll, Ph.D.2,Matthew Krauza, M.D.11Internal Medicine, SummaHealth System,2Youngstown State University

BACKGROUND:ChronicObstructive PulmonaryDisease (COPD) is a progressivelung disease characterized by air flow limitation. Previous datahave shown that a poor dietary intake of nutrients andmalnutrition are frequent in persons with COPD, and it may bethat poor antioxidant intake exacerbates the dysregulatedsystemic inflammatory response that occurs in this disease. Theobjective of this study was to assess habitual dietary intake ofantioxidants in a sample of patients with COPD. A secondaryaim was to examine the relationship between these dietaryvariables and pulmonary function (as measured by Forced VitalCapacity, FVC).

METHODS:Twenty participants (13 female, 7 male) completed a take-home, self-administered, food frequency questionnaire (FFQ)in order to assess habitual dietary intake of Vitamins A, C, D,E and selenium (i.e. usual intakes within the past 12 months).Nutrient data were compared to nationally-recognizedguidelines (Dietary Reference Intakes [DRIs]). Participants alsounderwent assessment of pulmonary function. Data wereanalyzed using SAS 9.1. Descriptive statistics were used to showthe mean and range for micronutrient intakes, and frequencieswere used to compare nutrient intake data to previously-established normative values. The general linear model wasused to test for effects of nutrient intake as a categoricalcovariate (i.e. over or under the DRI value for each nutrient;Deficient, DE or Not Deficient, NDE), gender (male orfemale) and all interactions of these variables, with a primaryendpoint of FVC.

RESULTS:Results of the analysis showed 45%, 33%, 83%, 55%, and 70% ofparticipants had deficient intakes of Selenium, Vitamin C,Vitamin E, Vitamin A andVitaminD, respectively.Main effectsof deficiency status and gender were found for selenium whereFVC was decreased in those participants who were DE(compared to NDE) or who were female (compared to male).Two-way interactions of deficiency status and genderwere foundfor Vitamins A, C, and D, where FVC was lower in the DEcompared toNDE groups in male, but not female, participants.

CONCLUSION:The contribution of antioxidant deficiency to decreased lungfunction in COPD patients appears to be more pronounced inmen compared to women. Further studies examining the effectof antioxidant intake and gender on lung function in COPDare warranted.



P11. Revision of a Method of Creatingand Quantitatively Analyzing PelvicAdhesionsPaul M. Kidder, D.O.1, Maureen Cheung, B.S.2,Bradford Fenton,M.D., Ph.D.1, Vivian vonGreunigen,M.D.1, Michelle Evancho-Chapman, B.S.11Obstetrics and Gynecology, SummaHealth System,2University of Akron

PURPOSE/OBJECTIVE:Pelvic adhesions are common after pelvic surgery and can resultin significant patient morbidity. Prior studies in this series havebeen performed to create a swine model for inducing pelvicadhesions and quantitatively analyzing the adhesions in orderto better evaluate the impact of novel barriers on adhesionformation. Techniques that were targeted for improvementincluded those that would produce a straighter, less variableadhesion of the uterine horn to the sidewall.

METHODS:Changes in the technique designed to improve the linearity ofthe adhesion included decreasing the length of the catheterplaced in the uterine horn from 7cm to 5cm, and decreasingthe length of the suture used to anchor the uterine horn to thepelvic sidewall. Changes intended to decrease the variabilityof the adhesions included the development of a template forthe pelvic side wall that defined a given area that was tobe cauterized, and elimination of the irrigation withcephazolin/normal saline at the end of the procedure.

RESULTS:Decreasing the length of the catheter in the uterine hornproduced adhesions with obviously improved geometriccharacteristics, visibly more straight than previous methods.Close apposition of the uterine horn and pelvic sidewall usingshorter sutures provided less mobility of the adhesion. Theuse of the cautery template produced an area of injury withconsistent dimensions, which is much more controlled thanprevious freehand sidewall cauterization. No infectiouscomplications were noted in this limited series after omission ofthe antibiotic rinse step.

DISCUSSION:The current changes were investigated due to the increasingtechnical demands of the adhesion model: adhesions must befirm enough to provide a clear level of force in the untreatedstate, yet must be thin enough that conventional andexperimental adhesion barriers can produce significantdecreases in adhesion strength. The current modificationsappear to assist in reaching these objectives.

P12. Patient Perspectives of FluVaccination and H1N1 Vaccinationin PregnancyShruti Malik, M.D., Anita Tamirisa, M.D.,Bradford Fenton, M.D., Amy M. Burkett, M.D.Obstetrics and Gynecology, SummaHealth System

OBJECTIVE:To assess the opinions of postpartum women regardingseasonal flu andH1N1 vaccination during pregnancy.With theadvent of the H1N1 flu and its corresponding vaccine, thegeneral public is becoming more aware of the importance ofvaccination, especially in young adults and pregnant women.The primary objective of this study is to assess the proportionof postpartum women that received the seasonal flu vaccineand H1N1 vaccine this year in comparison to the seasonal fluvaccine last year. Secondary objectives were to evaluate patientrationale for choosingwhether or not toget vaccinated, perceptionof vaccine safety and perception on passive fetal immunity.

METHODS:This is a prospective non-randomized cross-sectional study. Astandardized survey was distributed to postpartum women ata community hospital over a six-week period. All women age13-50 years of age with a recent delivery were eligible. Womenwho were not able to understand English were excluded fromthe study. There were no exclusions for race, ethnicity or ageotherwise. A total of 179 surveys were collected.

RESULTS:Sixty-one percent of the participants stated that they havereceived the seasonal flu vaccine this year, up from 47%the previous year (p=0.007). The most common reasonpatients chose to receive the vaccine was physician or nurserecommendation (66%) and themost common reasons womenchose not to receive it was due to other reasons (41%) concernover side effects (22%) and feeling the vaccine was unsafe (18%).Of the patients who did not receive the vaccine last year, 46%opted to receive it this year; the majority (67%) stating it wasdue to physician or nurse recommendation. Most women feltthe vaccine was safe in pregnancy (83%) and that a protectiveeffect was conveyed to the fetus (65%). Sixty-four percentof the women stated that they received the H1N1 vaccine,the majority (63%) doing so due to physician or nurserecommendation. This was also a significant increase from lastyear’s flu vaccinations (p=0.001). The most common reasonswomen chose not to receive the H1N1 vaccination were dueto feeling the vaccine was unsafe (31%) and concern over sideeffects (29%). Most women felt the vaccine was safe inpregnancy (67%) and that some protective immunity waspassed to the fetus (63%).

CONCLUSIONS:The majority of postpartum women in a community hospitalchose to receive the seasonal flu and H1N1 flu vaccines thisyear, significantly more so than in the past year, and mostlydue to physician or nurse recommendation. Most women inthis population feel that the vaccines are safe in pregnancy andprotective immunity is passed to the fetus.



P13. Opt-Out Influenza Immunization2010: H1N1, Public Perception,and SupplyManasi Revankar, D.O., William Smucker, M.D.,Everett Logue, Ph.D., Patricia Dudley, B.A.,Jan Stapin, RN.Family Medicine, SummaHealth System

PURPOSE/OBJECTIVE:Amultidisciplinary FamilyMedicine Center of Akron Flu TaskForce redesigned practice to overcome barriers to influenzaimmunization encountered in 2009.

METHODS:The Flu Task Force increased the number of personnel able togive the flu shot, streamlined vaccine distribution andmethodsfor documenting administration, secured funding for patientswithout insurance, and created outreach strategies for high riskpatients. An opt-out immunization policy authorized FMCpersonnel to vaccinate all patients who consented and had nocontraindications.

RESULTS:In the first 4 weeks of influenza immunization season,1114 immunizations were given, 45% of the total number ofvaccines given in 26 weeks in 2008-2009. A dramatic drop offin vaccination soon followed.

CONCLUSION:Multiple reasons affected vaccination rates including; vaccinesupply, distribution of vaccine within the system, and publicperceptions of risks and benefits of influenza immunization forboth seasonal and H1N1 influenza.

P14. Suppression of SubconjunctivalFibrotic Response by TGF-BetaInhibitor after Glaucoma FiltrationSurgeryScott Steiner, M.D., Hiroshi Nakamura, M.D., Ph.D.Ophthalmology, SummaHealth System

PURPOSE:In glaucoma filtration surgery (GFS), which is performed toreduce intraocular pressure (IOP) in glaucoma patients, post-operative scarring often interferes with the IOP reduction.Antimetabolites, such as mitomycin C (MMC), have beenconjugated with GFS to suppress post-operative scarring.Antimetabolites, however, sometimes cause severe post-operative complications, which potentially include blindness,and other anti-scarring approaches are required. Thetransforming growth factor beta (TGF-β) signaling pathwayhas been reported to be involved in fibrotic events, and effectof a TGF-β inhibitor in GFS was investigated in this study.

METHODS:Rabbit in vivo GFS model was employed using New ZealandWhite rabbits, and A-83-01 was used as a TGF-β inhibitor.During GFS, either A-83-01 (10 µM, n=4) or vehicle (n=2)was injected at surgical site subconjunctivally. Two out offour rabbits which received intra-operative A-83-01 wereadministered a second injection of the inhibitor 3 days afterGFS. After euthanization 5 days after GFS, conjunctiva andsubconjunctival tissue at the surgical sites were collected toinvestigate expression of downstream protein of TGF-β. ELISAfor alpha smooth muscle actin (α-SMA) was examined, andstudent’s t-test was used for statistical analysis.

RESULTS:Levels of α-SMA after GFS were reduced in the A-83-01treated eyes compared with control to a statistically significantlevel. Optical density at 450 nm was 0.483 +/- 0.023 forcontrol compared with 0.272 +/- 0.099 for one injection(p=0.050) and 0.381 +/- 0.008 for two injections (p=0.014)of 10 µM inhibitor (n=2 for each group).

CONCLUSION:The effect of A-83-01 in reducing scarring after GFS wasshown to be statistically significant in this study. However, thestudy is limited by the small sample size. Additional assays forother downstream products would be beneficial.



P15. Interobserver Variability inSpectral Domain Optical CoherenceTomography for Macular ThicknessMatthew C. Willett, M.D.Ophthalmology, SummaHealth System

OBJECTIVE:Optical coherence tomography (OCT) is a non-invasive andnon-contact method to measure retinal thickness. It useslow-coherence interferometry to produce cross-sectionaltomograms. Previous studies have been performed to show thereproducibility and variation of retinal thickness measurementsusing the time-domain OCT. To date, no study has been doneto show interobserver variability using the new generationspectral-domain OCT. The purpose of our study is todetermine this variability, and thus set a threshold wherechanges may reflect real changes in the pathology beingstudied. The implications of this may change treatment plansincluding the necessity of intravitreal injections of variousmedications.

METHODS:This was a prospective observational study consisting of twoarms; one arm of healthy volunteers without known macularpathology, and one of patients with diabetes mellitius andclinically significant macular edema (CSME). Subjects ageranged from 18 to 70 years old. Inclusion criteria for normalsubjects consisted of eyes without current or past knownmacular disease. Exclusion criteria included pupil dilation lessthan 5mm, visual acuity less than 20/100 ormature cataract ofsignificant density to prohibit adequate signal density. Inclusioncriteria for the diabetic group were patients with type I or typeII diabetes mellitus with current CSME. Exclusion criteriaincluded other knownmacular diseases, poor pupillary dilationor cataract of significant density to prohibit adequate signaldensity. All OCT scans were performed in the SummaOphthalmology clinic. Foveal zone thickness and total macularvolume were measured using the RTVue-100 (Optovue, Inc,Fremont, CA) spectral domain OCT were performed by twodifferent observers in both groups (n=20 eyes of 10 subjectsper group. The data obtained will then be analyzed by statisticalmethods including Bland-Altman coefficient of repeatability,coefficient of variability and intraclass correlation coefficient.

RESULTS AND CONCLUSIONS:At the time of submission of this abstract, statisticians wereevaluating the data, although, a cursory review of the scansshowed good concordance between machine operators. Finalanalysis has not been performed and therefore no conclusionsmay be drawn at this time, however results are expected withina month.


P16. In-hospital Mortality in Patientsover 60 with Very Low Albumin LevelsJodi L. Hannan, M.D., Teresa Albanese, Ph.D.,Steven Radwany, M.D.Palliative Care, SummaHealth System

PURPOSE/OBJECTIVE:Low albumin levels have been associated with increasedmortality, but few studies have looked at the mortality rates ofpatients with very low albumin levels. This study will determinethe in-hospital mortality rates for patients 60 years of age andolder with albumin levels < 2.0 g/dL.

METHODS:All patients ≥ 60 years old who were discharged from SummaAkron City Hospital between July and November 2008 andhad an albumin level < 2.0 g/dL during their hospital stay areincluded in the study. For patients who had more than onealbumin level < 2.0 g/dL, the lowest level will be used. Asample size of 450 will give an estimated statistical power ofgreater than or equal to .80. Data collected include patientalbumin level, date albumin level was drawn, primary diagnosis,discharge status, unit at discharge, age, length of stay, presenceor absence of cancer and End Stage Renal Disease diagnoses,and the presence or absence of dialysis and total parenteralnutrition. Data will be entered into an SPSS© database. Bivariateand multivariate analyses will be conducted to determine theassociation between albumin level and mortality.

RESULTS:Approximately 550 patients are included in the study. Resultspresented will include overall mortality for this group ofpatients with very low albumin levels as well as analysis based onthe lowest measured albumin level.

CONCLUSION:Results will demonstrate whether mortality rates for patients> 60 years of age with albumin levels <2.0 g/dL differ fromthe overall in-hospital mortality for all patients > 60 years oldduring the same time period. Further analysis will also determinewhether other easily obtained patient data help to predictmortality when combined with such very low albumin levels.



P17. Effective (and Free) Web-BasedAsynchronous Learning Tools andMethodsChristopher Taggart, M.D., Justin Catlett, M.D.,William Smucker, M.D.Family Medicine, SummaHealth System

PURPOSE/OBJECTIVE:Summa Health System’s Family Medicine Residency hastraditionally required resident attendance at monthly CoreCurriculum didactic sessions. Work hour restrictions or clinicalrotation schedules may preclude attendance. Competingdemands for residents’ time require flexible options to delivereducational content. This pilot project compared testperformance with didactic and asynchronous learning andmeasured resident attitudes about asynchronous learning.

METHODS:PowerPoint presentations and handouts are posted on the webusing Google Documents, to allow viewing by those unableto attend the session. Residents took a pre-test before, andpost-test after either the didactic or the asynchronous session.

RESULTS:All residents whomissed a didactic session successfully accessedthe web based Core Curriculummaterial. They spent less timeviewing/reading the material than the typical didactic session.All of the residents enjoyed the flexibility and convenience ofweb-based learning. The residents who used the asynchronouscurriculum scored at the same level or better than the residentswho attended the traditional didactic sessions.

CONCLUSION:Web-based delivery of certain Core Curriculum topics iseffective, flexible and a time efficient way to adapt to residentphysicians’ complex schedules.

CASE REPORTS

P18. A Case of Fatal, AcuteDisseminated Encephalomyelitis(ADEM)Randy Allison, M.D., Jerry Smedley, D.O.Emergency Medicine, SummaHealth System

INTRODUCTION:Acute Disseminated Encephalomyelitis (ADEM) is an acutedemyelinating disorder affecting the CNS. While morecommonly diagnosed in children, ADEMhas been reported inadults. CNS autoimmune inflammation is triggered by a varietyof viral and/or bacterial etiologies as well as vaccinations. Earlysymptoms include a viral-like prodrome. The diagnosis ofADEM relies heavily on clinical suspicion and the detectionof white matter lesions on brain MRI. Laboratory findingssuggestive of ADEM include lymphocytic pleocytosis, elevatedalbumin, and variable oligoclonal bands. Long-termoutcomes of ADEM are favorable if the acute illness is treatedaggressively.

CASE STUDY:A 40-year-old male patient presented with the chief complaintof weakness and decreased coordination on the left. His PMHwas significant for a recent flu-like upper respiratory illness2-3 weeks prior. He was being treated for community acquiredpneumonia, and had recently returned from a vacation toMexico one week earlier. Physical exam showed stable,afebrile vital signs withmultiple left sided neurological findings.Initial laboratory studies were normal and a noncontrast headCT showed right cerebral edema. The clinical course includedconfusion and change in mental status with subsequentadmission to the ICU. A MRI showed large areas ofdemyelination with surrounding edema and midline shift. Thepatient was treated with high dose IV steroids, mannitol,an ICP-device, and plasma exchange. Pertinent lab andimmunologic studies include elevated CSF protein and albuminwith negative oligoclonal bands. Further blood tests werepositive for Mycoplasm IgG, and IgM PCR.

A repeat MRI brain continued to show large areas of edema,demyelination, and midline shift. Despite aggressive medicaltreatment the patient had increased cerebral edema withsubsequent herniation. The patient was terminally extubatedand quickly expired.

CONCLUSION:ADEM is a rare disease that if recognized early and treatedaggressively usually results in a favorable outcome. Althoughthe disease is primarily diagnosed in children following viralillness and vaccination, it may present in adults. ADEM doescarry with it a highmortality rate with the possibility of residualmotor and neurologic effects; however, aggressive treatmentwith IV steroids, IVIG, and plasma exchange often are curative.These therapies continue to be investigated in practice as wellas current randomized clinical trials.



P19. Diagnosing What is Not TherePreeti Betkerur, M.D., Elizabeth Baum, M.D.,Susan Fosnight, Pharm. D.Geriatric Medicine, SummaHealth System

INTRODUCTION:Serotonin reuptake inhibitors (SSRI) and serotoninnorepinephrine reuptake inhibitors (SNRIs) are considered tobe among the safest antidepressant categories to use in elderlypatients.During hospitalization thesemedications are sometimesheld either intentionally or unintentionally. SSRI/SNRIdiscontinuation syndrome can occur in up to 25% of patients.

CASE STUDY:An 89-year-old female with a history of HTN, CAD, A.fib,CVA, and depression was admitted for syncope. On admissionshe was slightly confused, but cooperative and at baseline.Ambulation was good and she was independent in ADLs. Onday 2 she became agitated and a validated Nursing DeliriumAssessment Screen went from 0 on admission to 7 (NuDesc>2 suggests delirium). She received a 3.5 mg total haloperidolload with no improvement. On day 3, medication reviewindicated she took citalopram at home and this was resumed.On day 4, the patient returned to baseline, NUDESC to 0 andshe was discharged.

A 69-year-old female was admitted for subdural hematomafollowing a witnessed mechanical fall. She was independentin all her ADLs and IADLs before admission. On day 5 ofhospitalization, the patient was still complaining of severeheadache, nausea, dizziness, flu like symptoms, anxiety andtremor.Her home citalopram,whichhadbeenheld on admission,was resumed and her symptoms resolved within 24 hours.

DISCUSSION:SSRI/SNRI discontinuation syndrome consists ofneuropsychiatric (dizziness, gait instability, tremor, paresthesias,shock like sensations), emotional (insomnia, irritability,nightmares, agitation), and physical (nausea, fatigue, myalgias,headache) symptoms. It is associated with longer durationof treatment and short acting agents like paroxetine andvenlafaxine. It occurs within 2 to 5 days of discontinuation ofthe drug and resolves within 2 to 3 weeks. Our cases occurredwith the discontinuation of citalopram. Although there wereother potential contributing factors to our patients’ conditions,multiple interventions were made with little improvement insymptoms. There was a temporal relation between resumingthe drug and resolution of symptoms. Given the vague natureof symptoms this syndrome may often be overlooked.

CONCLUSION:Physicians should be aware of SSRI/SNRI discontinuationsyndrome. It may contribute to various symptoms whichmay not be life threatening, but could cause patient distress andprolong hospitalization.

P20. Latissimus Dorsi Rupture in aShot-PutterAndrew Bries, M.D.1, Robert Wetzel, M.D.2,Raymond Acus, M.D.11Orthopaedic Surgery, SummaHealth System,2Northwestern University

INTRODUCTION:Most reported cases of latissimus dorsi (LD) muscle rupturesinvolve athletes in sports which have a high stress demand,generate a large amount of force, and require rapid directionalchanges of the arm. Successful operative and non-operativetreatments have been reported; however, due to a limitednumber of documented cases, comparative efficacy of bothtreatments has yet to be identified. We present a case ofefficacious conservative treatment for the rupture of thelatissimus dorsi muscle belly.

CASE STUDY:An 18-year-old, right hand dominant, male shot-putterpresented with gradual onset of pain and deformity in his rightaxilla. His past medical history was negative for medicalabnormalities. On exam he had tenderness and echymosis overhis right axilla, mild/moderate pain with resisted extension andadduction, and an asymmetric bulge and echymosis just distalto his right axillary crease. An MRI of his affected shouldershowed increased signal and loss of continuity of the muscularportion of the latissimus dorsi. Due to the late nature of his di-agnosis and, with a purely muscular tear, the treatment planwas to pursue a non-operative course. On follow-up the patientcontinued to improve clinically and obtained throwingdistances equal to and slightly better than pre-injury andadvanced to his regional meet. He currently denies anyfunctional deficit and hopes to compete at the collegiate level.

DISCUSSION:To the best of our knowledge, there are a total of ten previouslyreported tendinous or myotendinous junction tears. However,this is the only reported case of an isolated nontraumatic slowrupture of the latissimus dorsi muscle belly. The decision by thepatient and orthopaedic surgery to proceed with non-operativecare was based on the delayed diagnosis, the lack of noticeabledisability after pain resolved, and the purely intramuscularlocation of the rupture. At last follow-up the patient hadresumed pre-injury athletic activity with no pain or functionallimitations.



P21. The Needle and the Damage Done:An Uncommon Re-Presentation of aHeroin OverdoseBrian Cady, D.O., Michael Rich, M.D.,Heather Holmes, MLIS.Internal Medicine, SummaHealth System

INTRODUCTION:Overdose from illicit opioid use has increased over the past fewdecades. Opioids represent themost lethal illicit drug, resultingin 33,662 potential life years lost, and 42 years of life lost perdeath. Delayed movement disorders, mainly akinetic ordystonic syndromes, have been described following hypoxic ortoxic brain injuries involving the basal ganglia. These symptomsappear following an asymptomatic interval lasting from days tomonths after the initial injury.

CASE STUDY:Here we describe a case report of a 22-year-old male thatdeveloped a delayed movement disorder sixteen days afterbeing hospitalized for going into cardiac arrest following aheroin overdose. The patient’s first hospital stay was uneventfuland he was discharged on hospital day number four withno neurologic deficits. Computed tomography and magneticresonance imaging done within twenty-four hours of his initialpresentation were both normal. Sixteen days after the patient’sfirst hospitalization he re-presented to the emergency roomwith hyper-reflexia, choreiformmovements, dysdiadochocinesia,and dystonia. Bilateral lesions to the globus pallidi were foundon repeat magnetic resonance imaging.

DISCUSSION:Multiple neuropathologic changes have been described inheroin abusers. It has been reported that between five and tenpercent of narcotic addicts may have lesions of the globuspallidi. Lesions to the globus pallidis have also been describedfollowing strangling or hanging, anesthesia, barbiturateoverdose, and carbon monoxide poisoning. Multiple theorieshave been proposed to account for these findings, however, theprocess remains poorly understood. Outcomes are generallypoor, secondary to the patient’s addiction, and lack of proventreatments. The rarity of delayed movement disorders despitethe common occurrence of severe hypoxia remainsunexplained.

P22. Diagnostic Dilemma: ElevatedTroponin I in a Patient withLeukocytosisCarrie Lee Caruso, M.D., MT(ASCP),Brian J. Donelan, M.D., FACC.Internal Medicine, SummaHealth System

INTRODUCTION:The TIMI risk score estimates risk in patients with unstableangina or non-ST-elevation myocardial infarction. Each ofseven prognostic variables, including the presence of elevatedcardiac biomarkers, carries similar prognostic weight. TheTIMI risk score helps identify patients who may benefitfrom early therapy with low-molecular weight heparins orglycoprotein IIb/IIIa inhibitors and who should undergo earlycoronary angiography, rather than noninvasive stress testing.

CASE STUDY:A 59-year-old white male presented to ER with chiefcomplaints of chest pain, shortness of breath, fever, chills and aproductive cough for one week. Past medical history includedhypertension, hyperlipidemia, tobacco and alcohol use, andgout. Family history was significant for coronary artery diseaseand hypertension. Patient was hypotensive and afebrile. Workup in ER included a chest radiograph which demonstrateda large left lower lobe infiltrate, an EKG with no ST segmentdeviations, a troponin I level of 0.28 ng/ml and a CBC with awhite count of 28,000/ml. Patient was admitted to the generalmedical floor and was treated with IV antibiotics, aerosols andoxygen. A repeat troponin I level six hours later was reportedas 6.16 ng/ml. A repeat EKGwas unchanged. Cardiology wasconsulted and the patient was urgently transferred to the CCU.Cardiac catheterization was planned for the following day.Morning lab work included a troponin I level of 1.17 ng/ml.

After re-centrifugation of the three heparinized samples, repeattroponin I analysis was performed, along with measurement oftotal creatine kinase levels. Re-analysis of troponin I levels werereported as 0.14 ng/ml or less. Creatine kinase levels werereported as less than 40 IU/ml. After reviewing laboratoryprocedures, it was postulated that sample leukocyte alkalinephosphatase from the elevated WBC count (i.e. large ‘buffycoat') caused the falsely elevated troponin I levels. Our patientwas transferred to the general medical floor, where his recoveryfrom community acquired Streptococcus pneumoniaepneumonia was uneventful. Noninvasive cardiac stress testingwas planned for a later date.

CONCLUSION:This case illustrates the use of the Troponin I assay, a keyrisk factor in the TIMI risk score, in the risk stratification ofpatients who present with unstable angina or non-ST-elevationmyocardial infarction. Recognition of falsely elevatedtroponin I levels is critical to correctly diagnose unstableangina/NSTEMI and to help prevent unnecessary emergentinvasive cardiac interventions.



P23. Pegasys Induced RetinopathyMeagan Celmer, M.D.Ophthalmology, SummaHealth System

INTRODUCTION:Pegasys is a commonly prescribed medication for Hepatitis Cinfection. In this case presentation I will present an uncommoncomplication of retinopathy induced by Pegasys use.

CASE STUDY:A 45-year-old African American woman complained of blurryvision in both eyes for the past 5 months, with worsening overthe past 3 months. The patient had a past medical history ofHepatitis C, anemia, and hypertension. On exam, visual acuitywas 20/25 in the right eye, and 20/30 in the left. Anteriorexam was within normal limits, however posterior examrevealed some significant findings including retinalhemorrhages, cotton wool spots, and venous engorgement inboth eyes.

The decision to stop Pegasys therapy was discussed withthe patient’s primary care doctor (IMC), and was seen forfollow-up 3 weeks later. Symptoms were improved. Vision was20/25 in both the right and left eye. Retinal findings weresignificantly improved.

DISCUSSION:The side effects of Pegasys include decreased or loss of vision,macular edema, retinal thrombosis and/or hemorrhages, opticneuritis and papilledema. A literature search returned few casepresentations regarding pegylated interferon and it’s associatedretinopathy. There are minimal studies demonstrating thefrequency of ophthalmologic side effects and/or guidelines formanagement of these patients and possible complications fromthis medication.

P24. Lethal Invasion ofBasal Cell CarcinomaMoriah L. Conner, M.D., Michael Rich, M.D.Internal Medicine, SummaHealth System

INTRODUCTION:Basal cell carcinoma (BCC) is the most common malignantcutaneous neoplasm in Caucasians. It occurs predominantly onsun-exposed areas such as face, ears and scalp. BCC is locallyinvasive and destructive. Only a few cases of BCC of the scalpwith radiological documentation of bone erosion have beenreported. Cerebral invasion is very rare. We present a caseof deeply invasive and destructive BCC of the scalp with directintracranial extension.

CASE STUDY:A 75-year-old man with a history of CHF, HTN, CAD,anemia, and skin cancer presented with lightheadedness anddark stools. He had two pre-syncopal episodes resulting in falls.He had been having melena for the past week and wasscheduled for a colonoscopy. Per the patient’s family, he hadbeen experiencing a significant functional decline over the lastmonth. He became dependent on his wife for most of hisADLs. He stopped driving approximately two weeks beforeadmission. On initial evaluation, he was afebrile, blood pressurewas 112/71 mmHg with a pulse of 58 beats/min. He wasdrowsy, alert and oriented, MMSE 25/30 and a bandagecovered a 2 X 4cm ulcerative lesion on his forehead. Hisneurological exam was unremarkable. Initial laboratory workshowed hemoglobin 11.1 g/dl, but was otherwisenoncontributory. CT of the head revealed a lesion involvingthe subcutaneous soft tissues in the frontal region with bonyerosion and destruction of the frontal bone. There werehypodense lesions in the right frontal lobe and frontoparietallobemeasuring 2.5cm and 3.6cmwith significant surroundingvasogenic edema resulting in compression and leftward shift ofthe lateral ventricles. The patient declined further treatmentand enrolled in home Hospice. He died two weeks later.

DISCUSSION:BCC generally has an indolent growth pattern; however, largeand locally invasive tumors can develop over years because ofneglect by the patient, as demonstrated in this case. Our patientwas informed that he had presumed BCC on his forehead yearsearlier, but refused to seek treatment. The risk of metastasis orinvasion of vital structures by BCCs is extremely low. The BCCin this case invaded the frontal bone and directly extended intothe frontal and frontoparietal lobes. Except for a noticeabledecline in the patient’s mentation, he did not exhibit neurologicdeficits. It is presumed that the patient expired from cerebraledema and brainstem herniation given the extensive vasogenicedema and midline shift seen on CT scan. Given the highprevalence of BCCs in the general population, awareness of thepotential complications that may ensue from years of neglect bythe patient is imperative.



P25. Plasmapheresis-Refractory TTP:Successful Treatment withCombination ImmunosuppressiveTherapyMichael Dentler, M.D.Internal Medicine, SummaHealth System

INTRODUCTION:Thrombotic thrombocytopenic purpura (TTP)may be familial,medication-related, or infection-related. Most cases, however,are idiopathic in origin and result from a deficiencyof ADAMTS-13 activity. ADAMTS-13 is a metalloproteinaseresponsible for cleaving ultra-large vWFmultimers into normalsized molecules. An overabundance of these ultra-large vWFmultimers leads to platelet clumping, subsequentmicrothrombiformation, and intravascular hemolysis. More than 90% ofpatients with TTP are successfully treated with plasmapheresis.This report details the case history of a patient withplasmapheresis-refractory TTP who responded to treatmentwith multiple immunosuppressive agents.

CASE STUDY:We describe a 56-year-old woman who presented to thehospital with confusion, a platelet count of 30,000/mm3, anda peripheral blood smear with changes of microangiopathichemolysis. She was diagnosed with idiopathic TTP with anADAMTS-13 activity level < 5%. On the first hospital day,plasmapheresis and prednisone 60 mg/day were begun. After7 days, there was no clinical response to daily plasmapheresisand prednisone. On the eighth hospital day, the patient wasless responsive and developed seizure activity. She underwentendotracheal intubation for airway control and receivedintravenous phenytoin for seizure control. Because of her non-response to plasmapheresis, she received rituximab (hospitalday 8), vincristine (hospital day 9), and cyclosporine (hospitalday 11). On the thirteenth hospital day, her platelet countbegan to rise and her mental status improved. She waseventually extubated and remained seizure-free. Her neurologicstatus returned to normal. She was discharged home witha platelet count of 290,000/mm3 on daily prednisone andcyclosporine and twice weekly plasmapheresis.

CONCLUSION:Many patients with idiopathic TTP have measurableautoantibodies directed against ADAMTS-13. Immune systemdysregulation is thought to play a role in the pathogenesis ofTTP in these patients. A few case reports and small prospectivestudies suggest a potential role for immunosuppressive agentsas adjuncts to plasmapheresis in these refractory cases. Thiscase report adds support for the role of immunosuppressivetherapy in the successful management of plasmapheresis-refractory TTP.

P26. Interbody Fusion Through a DirectLateral, Mini-Open TranspsoasApproach Can Provide ExcellentIndirect Decompression and Reductionof a Degenerative, Unstable LumbarSpondylolisthesis: A Case ReportMatthew Dilisio, M.D., Richard Brower, M.D.Orthopaedic Surgery, SummaHealth System

PURPOSE/OBJECTIVE:The gold standard procedure for the treatment of adegenerative lumbar spondylolisthesis is a direct decompressionand fusion requiring extensive exposure of the posterior spineand entry into the spinal canal. The advantages of minimallyinvasive lumbar spine surgery are well described. There is noevidence in the literature of an interbody fusion through adirect lateral, mini-open transpsoas approach to treat adegenerative, unstable lumbar spondylolisthesis. We present apatient with a degenerative L4-L5 spondylolisthesis thatwas treated with this less invasive technique to indirectlydecompress the spinal canal with less operative morbidity thana traditional posterior decompression and fusion.

CASE STUDY:A 54-year-old woman with a history of chronic low back painwith radicular symptoms presented to our clinic with evidenceof spinal stenosis due to a degenerative, unstable L4-L5spondylolisthesis as documented on radiographs andMRI. Shewas an otherwise healthy, active female that was becomingincreasingly limited in her daily activities. A posterior lumbardecompression and fusion was associated with more morbiditythan our patient was willing to assume. Because of this, weplanned to utilize a less invasive technique in order to indirectlydecompress her canal, stabilize her unstable listhesis, and allowquicker return to her activities. The patient was taken tothe operating room for an L4-L5 interbody fusion through amini-open lateral transpsoas approach from the left withparaspinal placement of pedicle screws posteriorly. Excellentreduction of the listhesis and decompression of the canalwhere confirmed on post-operative radiographs. Thepatient’s pain and disability quickly improved during the earlypostoperative period.

CONCLUSION:This case demonstrates that lumbar interbody fusion througha direct lateral, mini-open transpsoas approach is an adequatelyinvasive surgical option that can achieve excellent restorationof intervertebral height, restoration of foraminal height, anddecompression of the spinal canal in a patient with an unstable,degenerative spondylolisthesis. This approach allows aminimally disruptive solution to pathology that would havehistorically required an extensive anterior and/or posteriorapproach that resulted in higher morbidity and recovery time.



P27. Stent Fracture: A Case In Two PartsJennifer Dy, D.O., William Bauman, M.D.Internal Medicine, SummaHealth System

INTRODUCTION:Stent fracture is a rare complication in the placement of bothdrug eluting and bare metal stents; and can be noticed eitherincidentally on angiography or under more rare circumstancesas the cause of unstable angina or an acute myocardialinfarction. Herein, we present the case of a patient withST-elevation myocardial infarction secondary to complete,displaced stent fracture.

CASE STUDY:A 67-year-old Caucasian male with a past medical history ofcoronary artery disease (CAD) status post myocardial infarction(MI) in 2006 with Cypher drug eluting stents (DES) tothe right coronary artery (RCA) and circumflex artery,hyperlipidemia and ongoing tobacco abuse presented to ourED complaining of a one day history of chest pain. Initialworkup was suggestive of a non-ST elevation MI, includingEKG demonstrating T-wave inversion in the inferolateral leads.The patient underwent a catheterization the following day withpercutaneous coronary intervention (PCI) and stent to hiscircumflex artery, which had a 90% restenosis. Additionally, theRCA and stent were noted to be anerysmal in appearance, andthe patient was scheduled for outpatient elective angiogram.He returned to the ED 1 day later complaining of similar chestpains, and EKG demonstrated ST elevation in the inferior leadswith reciprocal change. A code STEMI was called andemergent catheterization demonstrated fracture of the RCAstent with complete thrombosis. Retrospectively, the patient’sstent was likely fractured on the first admission but the RCAwas not the suspected culprit lesion.

CONCLUSION:This case demonstrates a rare cause of acute myocardialinfarction due to PCI with stenting, a very commonlyperformed procedure. The mechanism of stent fracture is notwell understood, but can occur in 1-8% of patients, particularlythose with DES. One study demonstrated the incidence ofsome degree of stent fracture in up to 29% of patient at autopsy,suggesting that most cases of stent fracture are minorand asymptomatic. When stent fractures are recognized insymptomatic patients, they should be treated on an urgentbasis.

P28. Unilateral Live Twin EctopicPregnancy in a Patient withLimited Risk FactorsBrad Gable, M.D., Asad Javed, M.D.Emergency Medicine, SummaHealth System

INTRODUCTION:Unilateral live twin ectopic pregnancies represent a rarecomplication in pregnancy with approximately 8 case reportsin the literature. Here we present a case of live twin ectopicpregnancy in a patient with minimal risk factors.

CASE STUDY:A previously healthy 27-year-old G2P1 female presented to ourED within one hour of sudden onset of severe right lowerquadrant abdominal pain and associated lightheadedness. Thepatient’s last menstrual period was approximately seven weeksearlier with no prenatal care. Her past medical history wasonly remarkable for prior cesarean section. Physical examdemonstrated normal vital signs except a pulse of 104, andsuprapubic tenderness. Pelvic examwas normal except for rightadnexal fullness. The patient was tilt positive. A transvaginalultrasound examination demonstrated no evidence of anintrauterine pregnancy, a prominent endometrium, two fetalpoles and two separate heartbeats in the right adnexa withestimated gestational age of 6 weeks, 6 days and free fluid in thepelvis. Laboratory studies revealed a quantitative beta-HCG of26,690 and hemoglobin of 10.4. Obstetrics was emergentlyconsulted, the patient was taken to the operating room wherelaparoscopy revealed an ectopic pregnancy at the junction ofthe cornua and right fallopian tube.

CONCLUSION:Unilateral twin ectopic pregnancies are a rare complicationwith an incidence of only 1:125,000 pregnancies. Ectopicpregnancies occur in approximately 2% of all pregnancies. Only1 out of 200 ectopic pregnancies will be unilateral twin tubalgestations. There have been approximately 100 cases of theserare cases in the medical literature to date. There are only8 reported prior cases of documented live twin ectopicpregnancies in the literature. Risk factors for twin ectopicinclude a history of sexually transmitted infections, endometriosis,pelvic inflammatory disease, and use of fertility agents. Theemergency department management of ectopic pregnanciesremains an important topic, especially given the increasingincidence of ectopic pregnancies over the last several decades.A rise in incidence is mainly due to the increase in chlamydiainfections and the rise in use of assisted reproductivetechniques. Risk factors for ectopic include but are not limitedto prior ectopic pregnancies, history of pelvic inflammatorydisease, IUD use, prior surgeries, use of assisted reproductiontechniques, increased age and smoking. Our patient only hada single minor risk factor of prior surgery (caesarean section)making this incidence of unilateral live twin ectopic pregnancyquite unique.



P29. Atypical Peters’ Plus Syndromewith New AssociationsNancy Hanna, M.D.1, Deepak P. Edward, M.D.,FACS1, Kimberly Eickholt, M.D.2,Robert Burnstine, M.D.3, Dimitri Agamanolis,M.D.2, Haynes Robinson, M.D21Ophthalmology, SummaHealth System, 2Pathology andLaboratory Medicine, Akron Children’s Hospital,3Ophthalmology, Akron Children's Hospital

INTRODUCTION:Peters’ plus syndrome is a rare condition that includes ocularand systemic malformations. We describe a case of unilateralPeters’ anomaly with previously unreported systemic findingsassociated with this syndrome.

CASE STUDY:The patient described in this case report was a newborn girlreferred to the neonatal intensive care unit for workup of severalcongenital anomalies. She was born at 34 weeks gestation to aG1P0 17-year-old Caucasian female via normal spontaneousvaginal delivery weighing 1803 g. After birth, multipleanomalies were noted including hypertelorism, low set ears,agenesis of the right lung, patent ductus arteriosus, atrial septaldefect, imperforate anus, clinodactyly, type IV intestinal atresiaand malrotation that eventually required surgery. An eyeexamination revealed left microphthalmia with no view to theposterior segment. The neonate had a complicated course anddied four days later from respiratory distress and cardiac failure.An autopsy was performed and revealed in addition to the aboveanomalies, an absent right pulmonary artery, pulmonary veinand uterus. Microscopic examination of the left eye showedkeratolenticular adhesion with absence of central Descemet’smembrane and corneal endothelium consistent with Peters’anomaly. The anterior chamber angle demonstrated anteriorlocation of the iris root and ciliary processes, poorly developedscleral spur, incompletely cleaved anterior chamber angle andabsent Schlemm’s canal. The remaining ocular tissues appearedunremarkable. Genetic analysis revealed a 326kb heterozygousdeletion involving the ROR2 gene on chromosome 9p22.31.

CONCLUSION:The findings of this case are typical of Peters’ plus syndrome.Although the true prevalence is unknown some authors reportthat there are fewer than 70 known cases described in theliterature. The case is unusual because to our knowledge theassociation of agenesis of the right lung, absent right pulmonaryartery and vein, and uterus have not been reported in connectionwith Peters’ plus syndrome. Also, the pathologic findings ofthe angle structures in this case were consistent with thatreported in severe developmental glaucoma, illustrating thatangle malformation may be the cause of glaucoma in some ofthese patients. The absence of Schlemm's canal, not reportedpreviously in association with Peters’ anomaly, may suggest thatangle procedures such as goniotomy or trabeculotomymay notbe effective in treating glaucoma in these patients. Also thisneonate had a uniquemutuation never linked to this syndromebefore.

P31. Plasmablastic Lymphoma in anHIV-Negative Patient Presenting as aPost-Transplant LymphoproliferativeDisorderSudy Jahangiri, M.D., Linda Ha, D.O.Internal Medicine, SummaHealth System

INTRODUCTION:Plasmablastic lymphoma (PBL) is an uncommon andaggressive subtype of non-Hodgkin lymphoma mostcommonly seen in patients with human immunodeficiencyvirus/acquired immunodeficiency syndrome (HIV/AIDS). Ithas been observed in chronically immunosuppressed patients asa post-transplant lymphoproliferative disorder (PTLD). PTLDoccurs in 0.5-1.2% of renal transplants. Themajority of PTLDsare seen in the first post-transplant year as this year is associatedwith the highest degree of immunosuppression. With theincreased use of chronic and potent immunosuppression, therehas been a rise in late-onset PTLD. We present a case ofPBL, an uncommon lymphoma, presenting 13 years post-renaltransplant.

CASE STUDY:This is a 47-year-old Caucasian male with a renal transplant in1997, on multiple immunosuppressive agents, and whopresented with a 3 week history of an enlarging right-sided neckmass, 20 pound weight loss, and chills. He denied difficultyswallowing or breathing, fever, or night sweats. Significantphysical examination findings included bilateral anterior cervicaland supraclavicular lymphadenopathy, most notably a 6 x 4 x3cm anterior cervical lymph node. There was a 2.5cm areaof right palatal edema and right maxillary sinus tenderness.Computed tomography scan of the head and neck revealedbilateral cervical lymphadenopathy and a soft tissue massinvolving the right maxillary and sphenoid sinus with sinus wallerosion. A biopsy of the neckmass diagnosed PBL. The patientwas started on chemotherapy, prophylactic intrathecalmethotrexate, and antibiotics. All immunosuppressive agentswere discontinued. Although the PBL responded well tochemotherapy with dramatically decreased lymphadenopathy,after one chemotherapy cycle, the patient developedneutropenia, bilateral pneumonias and clostridium difficilecolitis. Despite aggressive care, his respiratory statusdeteriorated and he died shortly afterwards.

CONCLUSION:With the increased success of solid organ transplants, there area growing number of patients on chronic and potent immuno-suppressive therapy. This case provides an opportunity to reviewcharacteristics of PTLDs, reminding clinicians to remainvigilant of the increased risk of late-PTLDs in chronicallyimmunosuppressed patients. This case also provides us anopportunity to explore PBL as a PTLD. Although PBL hasbeen studied predominantly in HIV/AIDS patients, there hasbeen limited literature on PBL in post-renal transplant patients.We hope this case can add to the literature to improveunderstanding of PBL as a PTLD.



P32. Fourteen Year Old with ProximalTibial and Distal Femoral LesionsElizabeth Knazek, M.D., Scott Weiner, M.D.Orthopaedic Surgery, SummaHealth System

BACKGROUND:Neurofibromatosis is a genetic disorder affecting the nervoussystem. There is a known link between neurofibromatosis andskeletal lesions. Non-ossifying fibromas (NOFs) are one of themost commonmanifestations of neurofibromatosis. NOFs arepediatric benign bone lesions, usually found in long bones. Adiagnosis of neurofibromatosis type I requires 2 or more of thefollowing symptoms: >6 café au lait spots, >2 neurofibromas,freckling in the axillary or inguinal region, optic glioma,>2 Lisch nodules, distinctive osseous lesions such as sphenoiddysplasia, thinning of long bone cortices, pseudoarthrosis, andfamilial diagnosis of neurofibromatosis. Histology usually showsthe typical storiform pattern of spindle cells andmultinucleatedgiant cells seenwithNOFs in patient without neurofibromatosis.

CASE STUDY:A 14-year-old male presented after several weeks pain in hisright proximal tibia. The patient was initially seen 15 monthsprior with asymptomatic benign lesions in his distal femur andproximal tibia bilaterally (neurofibromas). Conservativetreatment was recommended unless symptoms worsened.Follow-up 6 months later revealed no progression ofsymptoms. Nine months later the patient developed rightproximal tibial pain. X-rays of the patient’s knees showednon-ossifying fibromas of the distal femur and proximal tibiabilaterally. The patient was at high risk for fracture given thesubchondral location of the right-sided lesions. Therefore,we proceeded with surgical treatment of the right tibia whichincluded curettage and biopsy of the tibial lesion followed byallograft reconstruction. Histology confirmed the typicalnon-ossifying fibroma pattern of storiform spindle cells andmultinucleated giant cells. The patient was placed post-operatively in a knee immobilizer and allowed to progress tofull range of motion over a 6-week period. By 4-month post-operative x-rays, the allograft was completely consolidated withno signs of fracture or progression of lesions.

DISCUSSION:Fractures throughNOFs account for 10% of fractures throughbenign lesions. Location, size, and medical history dictatetreatment. The patient in our case had subchondral lesions,which, if fractured, would produce significant morbidity.Therefore, surgical curettage and bone grafting wererecommended. At 4-months post-op, the defect hadconsolidated. The patient was able to return to an activelifestyle.

P33. Muscular Dystrophy:More than a Pediatric ProblemMorgan Koepke, M.D.Internal Medicine, SummaHealth System

INTRODUCTION:Myotonic muscular dystrophy (DM) consists of subtypes 1 and2. It is the most common form of adult muscular dystrophy.Patients suffer from myotonia, muscle weakness, muscleatrophy as well as multisystem problems including but notlimited to respiratory failure, cardiac arrhythmias, and CNSdefects. Gold standard of diagnosis is DNA testing, however,a clinical diagnosis is often possible.

CASE STUDY:This case involves a 50-year-old male whose presentingsymptoms were consistent with a diagnosis of uncomplicatedcommunity acquired pneumonia. Over the course of sixmonths’ time the patient continued to have chronic dyspneaon exertion as well as the gradual development of ptosisand generalized muscle weakness. Diagnosis was pursued withlaboratory testing for connective tissue disease, pulmonaryfunction testing, arterial blood gas, high-resolution computedtomography of the chest and electromyography. Work upultimately revealed chronic respiratory failure and EMG resultsconsistent with myotonic muscular dystrophy. His clinicalcourse appears to be more consistent with DM1, however, atthis time DNA analysis has not been pursued.

CONCLUSION:Studies are being conducted to help find a treatment formyotonic muscular dystrophy, but current therapy issupportive. Myotonic muscular dystrophy type 1 shows astrong level of anticipation, a phenomenon wherebysubsequent generations display a more severe phenotype anddevelop symptoms earlier in life. It is believed that anticipationis caused by progressive lengthening of aberrant tri-nucleotiderepeats as the gene is passed from parents to offspring, thereforegenetic counseling is key for these families. Therapy withBiPAP/CPAP and chest physiotherapy may help prolongsurvival. Regular monitoring of electrocardiography isrecommended as fatal cardiac arrhythmias may develop overtime, however, pacemaker implantation is not universallyprotective or recommended. These patients have high peri-operative mortality with small amounts of anesthesiaprecipitating respiratory failure so knowledge of this conditionis important prior to even simple procedures. A high index ofclinical suspicion is often necessary in order to avoid delayeddiagnosis and increased premature mortality for these patients.



P34. A Dramatic Presentation ofInfective EndocarditisJill Miracle, M.D., Michael Tan, M.D.Internal Medicine, SummaHealth System

INTRODUCTION:Infective endocarditis (IE) is associated with a high risk ofmorbidity andmortality, especially when complicated by centralnervous system embolism. The most common cause of IE isStaphylococcus aureus, which has surpassed the Viridans GroupStreptococci as the most common etiologic agent. Risk factorsfor embolization include S. aureus as the etiologic organism,mitral valve involvement, and large vegetation size.

CASE STUDY:M.F. is a 76-year-old female with history of Crohn’s diseaseand Clostridium dificile colitis transferred to our hospital forfurther management of a gastrointestinal bleed. Upon transfer,the patient was afebrile, normotensive, and physical examwas unremarkable. Upper endoscopy revealed a non-bleedingduodenal ulcer. The patient did not experience further bleedingand remained stable until hospital day five when she becamehypotensive, febrile, confused, and further bleeding ensued.The patient was transferred to the intensive care unit andintubated for declining mental status. Blood cultures wereobtained and due to patient’s penicillin intolerance aztreonam,metronidazole, and vancomycin were initiated. The patient’sblood cultures grewmethicillin-resistant staphylococcus aureus.Transthoracic echocardiogram revealed no vegetations. Thepatient’s hypotension persisted, requiring vasopressors. TheMRSA isolate had a minimum inhibitory concentration of1.5 for vancomycin, thus vancomycin was changed todaptomycin (6 mg/kg). The patient’s mental status alsoshowed no improvement leading to unsuccessful attempts towean the patient from the ventilator. Computed Tomographyof the brain was unremarkable and Magnetic ResonanceImaging revealed innumerable intraparenchymal lesionsthroughout the bilateral cerebral hemispheres and cerebellum.Transesophageal echocardiogram revealed a 2 cm x 2 cmmobile mass on the posterior leaflet of the mitral valve andquestionable vegetation on the pulmonic valve. The patientpassed away three days later.

CONCLUSION:The diagnosis of endocarditis was delayed in this patient astransthoracic echocardiogram (TTE) did not reveal vegetations.The overall sensitivity of TTE for vegetations may be lessthan 60 to 70 percent as compared to transesophagealechocardiography (TEE), which has a sensitivity of 75 to95 percent. Additionally, the negative predictive value for IEof a negative TEE is over 92 percent. It has been shown thatTEE is low yield in those with low pretest probability of IE,but is helpful in diagnosis and changing management in thosewith high pretest probability of endocarditis.

P35. Colo-anal Intussusception:A Case ReportLisa Mohrman, M.D., Frederick Slezak, M.D.General Surgery, SummaHealth System

INTRODUCTION:Colo-anal intussusception is a rare but serious condition.To date only a few cases have been described in the literature,primarily outside of the United States and prior to 1980. Inpreviously reported cases, there has always been an identifiablecause of the intussusception, such as colon mass or diverticulardisease. This case is unique in that no pathologic etiology couldbe identified.

CASE STUDY:We report the case of a 95-year-old chronically ill, bed boundmale nursing home patient, presenting to the emergency roomwith a three day history of abdominal pain and a two dayhistory of rectal bleeding. On initial exam, he was found tohave a non-reducible rectal prolapse; abdominal films wereconsistent with a bowel obstruction. He was taken to theoperating room to undergo rectal exam under anesthesia andAltmeier procedure. On further exam, we found a sulcusaround the prolapse and the dentate line could not beidentified. It was determined that the patient had a colo-analintussusception and the procedure was converted to anexploratory laparotomy with a sigmoid colectomy. The patienthad a very redundant sigmoid colon and on examination nomasses or other abnormalities were identified.

CONCLUSION:Several approaches to surgically address this condition havebeen described in the literature. In this case, doing anexploration allowed the best exposure to resect the diseasedbowel. Although extremely rare, surgeons should considerthis condition in the differential diagnosis of patients with anon-reducible rectal prolapse.



P36. A Case Report: MetastaticOsteosarcoma Presenting28 Years LaterOlaronke Oshilaja, M.D.1, Steven Thompson, M.D.1,Nibha Saxena, M.D.1, Eric Espinal, M.D.21Pathology and Laboratory Medicine, SummaHealth System,2General Surgery, SummaHealth System

INTRODUCTION:The lung is themost common site for metastatic osteosarcoma.Metastasis after treatment is usually 2- 3 years later, with 5 yearspost treatment being uncommon. In the literature however,the latest recurrence of osteosarcoma is 14.3 years after treatment.

CASE STUDY:We report an unusual case of metastatic osteosarcomapresenting in the lungs, 28 years after the primary diagnosis.To our knowledge this is the first case reported in the Englishliterature. The patient is a 45-year-old female, who presentedwith a persistent cough for 3 months and has a past medicalhistory of osteosarcoma in the right proximal tibia in 1980.Computed tomography scan revealed a 16x12 cm large,multiseptated predominately solid mass in the right lower lung.The patient underwent a right pneumonectomy. The histologyof the mass was that of a highly cellular pleomorphic sarcomawith focal osteoid production. The diagnosis is most consistentwith metastatic osteosarcoma. Recently, the patient haspresented with multiple metastatic lesions, which include thebrain, the left thigh and the soft tissue of the upper and lowerextremities.

CONCLUSION:Low grade osteosarcoma is an indolent disease, it is highlyunusual for metastasis to occur 28 years later with good localcontrol, but such metastasis can and do occur, underscoringthe importance of good clinical history and surveillance evendecades after treatment.

P30. Latisse Induced PeriocularSkin HyperpigmentationJoshua Chaim Priluck, M.D., Selena Fu, M.D.Ophthalmology, SummaHealth System

INTRODUCTION:Bimatoprost solution (0.3% ) (LatisseTM; Allergan, Irvine, CA)is a synthetic prostaglandin analogue indicated for thetreatment of hypotrichosis and dispensed separately to lowerintraocular pressure (0.3% LumiganTM; Allergan, Irvine, CA).For the treatment of hypotrichosis, LatisseTM is used as a singledrop on a sterile applicator and applied to the patient’s uppereyelid skin at the eyelashmargin daily at night. LatisseTM’s FDAapproval is based mostly on studies done on LumiganTM, sinceit is technically an identical drug with a different applicationtechnique. However, the side effects for LatisseTM have notbeen well studied or documented. Only one unpublished studyhas been performed, and is referenced on the product insert.

CASE STUDY:We report four cases of LatisseTM induced hyperpigmentationof the eyelid skin using the eyelid delivery method and discussthe findings of these cases in comparison with previouslyreported data with LumiganTM. The intensity and color of skinchange seen in this case series has similarities to the skinhyperpigmentation reported with LumiganTM and otherprostaglandin analogues for the treatment of glaucoma.Theapplication of LatisseTM to the upper eyelids appears to causehyperpigmentation beyond the region of application. Thishyperpigmentation extends onto the preseptal upper eyelidskin, and three of the four cases had hyperpigmentation of thelower eyelids.

CONCLUSION:It is possible that in patients using LatisseTM, lower eyelid skinpigmentation may occur due to drug spread following uppereyelid contact with the lower eyelid. In patients usingLumiganTM, pigmentary changes were usually first noted onthe lower eyelids followed by changes in the upper eyelids.åThe continuation of LatisseTM by the reported patientssuggests the periocular hyperpigmentation was cosmeticallyacceptable.


P37. Chronic Mesenteric Ischemia: ACurable Cause of Failure to ThriveSara Snyder, D.O., Elizabeth Baum, M.D.Geriatric Medicine, SummaHealth System

INTRODUCTION:Chronic mesenteric ischemia is a rare occurrence in medicalliterature and accounts for only 5% of all intestinal ischemicevents. This diagnosis is often missed or diagnosed very late inthe course of the illness after it has affected patients’ function.

CASE STUDY:An 82-year-old female with type 2 diabetes mellitus, peripheralartery disease and hypertension presented with 2month historyof postprandial bloating and vomiting. She restricted eatingto small meals with some relief of symptoms. Over a 5 monthperiod she lost 30 lbs and became depressed. Prior to this,patient was in good health, swimming 5 days per week. EGDand multiple abdominal CT scans were all normal. Aftermultiple ER visits/physician visits, a duplex ultrasonographywas performed, revealing superior and inferior mesentericartery occlusion. Stenting of the superior mesenteric artery wascompleted. Within 6 hours of the procedure, patient resumedeating. Within 3 weeks she resumed swimming and usualactivities. A second case presented with similar symptoms ofnausea, pain and weight loss, but due to her Failure To Thrive(FTT) was sent to a SNF for hyperalimentation. Awaitingsurgery she had a stroke.

DISCUSSION:Themain presenting symptoms of chronic mesenteric ischemiaare weight loss, postprandial nausea/pain, and sitophobia.Ninty-five percent of patients also have comorbid vasculardisease. This diagnosis is missed entirely or not made until thepatient has lost significant weight and may be diagnosed withFTT. Surgeons are hesitant to attempt interventions in frailelderly patients. It is important to realize frailty with thisdiagnosis is usually caused by the disease process, so surgicalintervention/stenting should improve the cause of the frailty.Success rates have been reported as high as 90% for the surgicalprocedure, with a 5 year survival rate reported as high as 80%.Without surgery or intervention, both of these patients wouldhave been appropriate hospice/palliative care candidates. Inconclusion, chronic mesenteric ischemia needs to be includedin the differential diagnosis for FTT patients with vasculardisease. More outcome data needs to be gathered on thesuccess rate in frail elderly of stenting versus surgicalintervention for chronic mesenteric ischemia.




ORAL PRESENTATIONSBASIC SCIENCE CATEGORY

8:15 a.m. The Effect of Endometriosis onthe DNA Integrity of Different Stagesof Embryos’ Development and theRole of L-Carnitine in PreventingDamage to Early StagesGihan Mansour, M.D.1, Ashok Agarwal, Ph.D.2,Tomasso Falcone, M.D.2, Bradford Fenton, M.D., Ph.D.1

1Obstetrics and Gynecology, SummaHealth System,2Obstetrics and Gynecology, Cleveland Clinic

INTRODUCTION:The association between a finding of endometriosis implants in theperitoneal cavity and decreased fertility is well described, but the actualmechanism is not well known. One hypothesis is that endometriosisimplants producemetabolic byproducts such as oxidative stress that aretoxic to themigrating embryo and decrease the likelihood of successfuldevelopment and implantation of the embryos as it makes its way intothe uterine cavity. Antioxidants such as L-Carnitine (LC) may be ableto prevent this damage.

The goal of this study was to assess the effect of incubation withperitoneal fluid from endometriosis patients on cellular damage of theembryos (measured by apoptosis counts) and to evaluate theeffectiveness of LC in preventing this damage.

METHODS:Experimentally controlled study. A total of 120 (2 cell stage) and120 (8 cell stage) frozen mouse embryos were divided randomly into3 subgroups: Group I: incubated in the peritoneal fluid (PF) of patientswith endometriosis; Group II: incubated in control media; Group III:incubated in PF of endometriosis supplementedwith LC (0.6mg/ml).Cells were incubated for 48-72 hours at 37oC in 5%CO2.Morula andblastocysts were fixed using3 % formaldehyde. Apoptosis was analyzedby terminal deoxynucleotidyl transferase-mediated dUTP nick-endlabeling (TUNEL) assay. The number of apoptotic blastomeres werecounted in each group using confocal microscopy and groups werecompared using Wilcoxon rank sum tests.

RESULTS:In the 8 cell stage, the apoptosis index in endometriosis (Group I:36.9%) was significantly (p < 0.001) elevated compared to the control(Group II: 9.3%). LC supplementation in Group III produced anapoptosis index of 12%, which was significantly lower (p < 0.001) thanthe unsupplemented Group I (36.9%). In the 2 cell stage group,significant improvement was also seen when adding LC to peritonealfluid of endometriosis patients (Group III) as only 6% of blastomereswere apoptotic, compared to 41% in Group I (p < 0.001).

CONCLUSION:Incubation ofmouse embryos with peritoneal fluid from endometriosispatients decreases embryo quality at both the 2 and 8 cell stage asmeasured using apoptosis index, with more damage to 2 cell stageembryos. This indicates that endometriosis patients have decreasedfertility due to cytotoxic factors as well as oxidative stress in theperitoneal cavity. LC supplementation prevents apoptosis of early stagesof embryonic development, and this may become a novel approach forimproving fertility in endometriosis patients.

8:27 a.m. TMPRSS2-ERG Gene Fusion isPresent an a Subset of Transition ZoneProstatic TumorsMaria E. Navas, M.D.2, SaraM. Falzarano, M.D.1,5,Kelly Simmerman1, Mark A. Rubin, M.D.3,Eric A. Klein, M.D.4, Ming Zhou, M.D., Ph.D.1,4, andCristina Magi-Galluzzi, M.D., Ph.D.1,4

1Pathology and Laboratory Medicine Institute, Cleveland Clinic,2Department of Pathology, SummaHealth System,3Department of Pathology, Cornell University,4Glickman Urological and Kidney Institute, Cleveland Clinic,5Department of Pathology and Human Oncology, Universityof Siena, Siena, Italy

INTRODUCTION:Most prostate cancers (PCA) exhibit a unique chromosomalaberration in chromosome 21. The rearrangement is characterized bythe fusion of the protein TMPRSS2with the oncogene ERG. A recentstudy has shown that the TMPRSS2-ERG gene fusion is lacking inPCA arising from the transition zone (TZ) of the prostate.

METHOD:A tissue microarray of TZ-predominant PCA from 62 patients whounderwent radical prostatectomies (RP) at our institution between2004 and 2009 was constructed. Two separate tumor foci, one in theTZ (n=62) and, when available, one in the peripheral zone (PZ)(n=35) were selected for gene fusion analysis. The TMPRSS2-ERGfusion status was determined using a multicolor interphasefluorescence in situ hybridization assay.

RESULTS:The patients median age was 59 years (range 42-81). PCA Gleasonscore (GS) was 6 (34%), 7 (55%); 7 with pattern 5 (5%) and 9 (6%).Themean tumor volumewas 294mm2 (>2.0 cc). Fifty-nine/62 caseswere informative. TMPRSS2-ERG gene fusion was present in 11.9%(7/59) of TZ tumors, and in 34.3% (12/35) of PZ tumors. Genefusion through deletion occurred in 4 TZ (57.1%) and 6 PZ (50%)cases. In three patients, the TMPRSS2-ERG gene fusion was presentin both TZ and PZ tumors: in one case the rearrangement wasassociated with a deletion in both tumors; in the other two cases, adeletion was present either in the TZ or in the PZ tumor.

CONCLUSIONS:PCA arising from TZ is biologically and genetically different from PZtumors. Although the TMPRSS2-ERG gene fusion is prevalent in PZtumors, it is also present in a subset of TZ PCA. The lower frequencyof gene fusion in TZ PCA may suggest a different carcinogenicpathway. Further studies are needed to address whether suchdifference may account for the clinical and biological differences.


ORAL PRESENTATIONS8:39 a.m. The Effects of Hypothyroidismon the Proximal Femoral Physis inMiniature SwineJason Tank, M.D.1, Robin Jacquet, M.S.2, ElizabethLowder, B.S.2, Dylan Childs, B.S.2, William Landis,Ph.D.2, Walter Horne, D.V.M.2, Melanie Morscher,B.S.3, Weiner Dennis, M.D.3, Todd Ritzman, M.D.31Orthopaedic Surgery, SummaHealth System,2Orthopaedic Surgery, NEOUCOM,3Orthopaedic Surgery, Akron Children’s Hospital

INTRODUCTION:Hypothyroidism has been implicated as a potential etiology in growthplate disorders such as slipped capital femoral epiphysis (SCFE). Thepurpose of the present pilot study is to establish a protocol to obtaina defined hypothyroid state in immature miniature swine anddetermine if the growth plate is altered. The authors hypothesize thathypothyroid miniature swine physes exhibit structural changes in cellsand extracellular matrices that reflect changes in gene expression ofmajor components that lead to growth plate development (Sox-9)and give growth plate resilience and strength (aggrecan and type IIcollagen) and hypertrophic character (type X collagen and matrixmetalloprotease-13 [MMP-13]).

METHODS:Two male, 10-week-old Sinclair miniature swine, were given6-propyl-2-thiouracil (PTU) in their drinking water and two otherlike animals, serving as controls, were provided water without PTU.Animal blood levels of thyroid stimulating hormone (TSH),triiodothyronine (T3), and thyroxine (T4) were monitored weekly.After 15 weeks, proximal femoral physes were harvested and dividedinto portions for histology and quantitative reverse transcription-polymerase chain reaction (QRT-PCR) analysis using laser capturemicrodissection. An independent sample t-test was performed forstatistical analysis of gene expression data.

RESULTS:Compared to controls, swine provided PTU had increased TSHand decreased T3 and T4 serum levels, features consistent with ahypothyroid state. Compared to controls, hypothyroid swine exhibitedstructurally altered physes, including losses in chondrocyte columns,cells within columns, and extracellular matrix between columns as wellas expanded cartilage resting zones. QRT-PCR analyses of growthplate chondrocytes demonstrated statistically significant decreasedgene expression of aggrecan (p < 0.05) and type X collagen (p < 0.1)as well as trends toward decreased expression of type II collagen andSox-9 in hypothyroid animals compared to controls. There wasno change in hypothyroid animals forMMP-13 expression comparedto controls.

CONCLUSION:This is the first time a model of hypothyroidism in miniature swinehas been established. In comparison to controls, hypothyroid swinephyses generated significant differences in the biochemical character ofproteoglycans and type X collagen in addition to marked changes incellular and extracellular matrix architecture. Such changes potentiallyweaken overall physeal strength and may provide insight into SCFEand other human orthopedic pathologies.

CLINICAL SCIENCE CATEGORYG

8:51 a.m. Hallway Versus Bed EmergencyDepartment Patient Satisfaction StudyNathan Billings, M.D., Kirk Stiffler, M.D.,Scott Wilber, M.D.Emergency Medicine, SummaHealth System

OBJECTIVE:Emergency department (ED) overcrowding affects satisfaction and isa national problem that many ED’s address by using hallway treatmentareas. Our objective was to compare the satisfaction of EDpatients assigned to hallway beds (HW)with those assigned treatmentrooms (TR).

METHODS:We performed a cross-sectional cohort study at a 72,500 annual visiturban, community teaching hospital ED. During peak ED volumehours, patients completed a confidential self-administered surveyassessing satisfaction withmedical care, treatment location, and overallsatisfaction on a 100mm visual analog scale. Those unable to completethe survey, with severe psychiatric illness, alcohol/drug intoxication,or language barrier were excluded. We recorded willingness to returnto or recommend the ED, age, gender, insurance status, andemergency severity index (ESI). The difference between meansatisfaction in mm was compared using 95% confidence intervals(95% CI) for the difference between means; exclusion of 0 wasconsidered significant. Linear regression controlled for demographicand severity differences. A pilot study found mean HW satisfaction tobe 52.77+/-29.29sd mm. Detecting a clinically important differenceof 7-11mmwith alpha of 0.05 and beta of 0.20 required 135 patientsper group.

RESULTS:We enrolled 135 patients per group; the mean age was 46.3 years and58.1% were female. Overall satisfaction was 8mm lower (95% CI3.19-12.88) for HW compared to TR. A similar 8mm decrease forHWwas seen inmedical care and willingness to recommend or returnto the ED. Satisfaction with treatment location alone was 20mm lower(95% CI 14.55-26.29) for HW. Controlling for differences in race,ESI, and insurance, HW still reduced overall satisfaction by 8mm(95% CI 3-14mm).

CONCLUSION:Satisfaction is significantly lower in HW patients for all aspects ofED care. Stakeholders should be aware of this and considereliminating HW or adjusting patient satisfaction scores based ontreatment location.


9:03 a.m. Pelvic Floor Tension MyalgiaMeasurement in Chronic Pelvic PainClara Chae, M.D., Bradford Fenton, M.D.Obstetrics and Gynecology, SummaHealth System

BACKGROUND:Chronic pelvic pain (CPP) in women constitutes a syndrome ofpain arising from one or more pelvic structures including themuscles of the pelvic floor. There is no standard, agreed uponresearch definition for this type of pain, termed pelvic floortension myalgia (PFTM). Measuring pain in pelvic floormuscles can be done using several different approaches, butone of themost straightforward is single digit constant pressurepalpation of individual muscles producing a patient assessedvisual analog scale (VAS) pain rating for each muscle. Theobjective of this study was to evaluate the distribution of painscores in pelvic floor muscles among women with CPP, and toevaluate potential research definitions of PFTM.

METHODS:In a referral center for CPP, women underwent 1 kg/cm2constant force single digit palpation of individual pelvic floormuscles and were asked to rate the presence of pain from 0(no pain) to 10 (worst pain). Muscles evaluated includedpuborectalis, iliococcycgeous, obdurator internus withprovocation, and the anal sphincter.

RESULTS:A total of 235 underwent evaluation, and for each muscle themost common pain rating was 0 (no pain). When pain waspresent, scores tended to follow a normal distribution. Withinpatients, there was no significant trend toward laterality, butpain ratings were worse (p=0.02) for deeper muscle groups.Comparing three potential definitions for PFTM: 80% ofpatients had some degree of muscle pain, 36% had 3 sites witha VAS of 4 or more, and 9% had 4 sites with a VAS of 7 ormore. Patients with more restrictive definitions had more painat other sites.

DISCUSSION:Pelvic floor muscle pain is common in CPP, affecting both sidesequally withmore pain in deeper muscles. Single digit palpationprovided a straightforward methodology for detecting pain,and a patient rated pain scale produced scores with normaldistributions. This method permits comparison betweendifferent potential definitions of PFTM, which can then be usedto better understand the impact of pelvic floor pain, and toconstruct studies using standardized definitions.

9:15 a.m. Sleep Duration or Quality andObesity in Primary CareAndrew Chema, M.D.1, Everett Logue, Ph.D.1,Claire Bourguet, Ph.D.2, Demond Scott, M.D.1,Patrick Palmieri, M.D.3, William Smucker, M.D.1,Patricia Dudley, B.A.1, Heather Datsko, B.A.11Family Medicine, SummaHealth System, 2Family Medicine,NEOUCOM, 3Psychiatry, SummaHealth System

INTRODUCTION:Human experimental studies in laboratory settings andobservational data from general population samples suggestphysiologically plausible bi-directional relationships betweensleep duration or quality and obesity. There is an expectationthat similar associations can be detected in primary care samplesin spite of some sampling bias and measurement error. In twopreviously published studies of the relationship between sleepduration and obesity, the authors did not use validated sleepmeasures, measure sleep quality, or document the degree ofselection bias. Our goal was to examine the relationshipbetween sleep duration or sleep quality, and obesity in a primarycare sample, using more rigorous survey methods.

METHODS:The sample included 225 adult patients from a family medicineresidency program. We used a pseudo-random samplingprocess based on waiting room clock times to produce arepresentative study group. Sleep characteristics weremeasuredwith theMonk sleep timing questionnaire, the Pittsburgh SleepQuality Index, and the Berlin apnea questionnaire. BMI’s andmedical history data were available from the electronic medicalrecord. Stratification and regression were used to control forpotential confounders.

RESULTS:The prevalence of overweight and obesity (85.6%), and Berlinpositive apnea (59.1%) were high. The prevalence of diagnosedapnea by patient-report was lower (9.3%). As expected, therewere significant associations between sleep quality and obesity(odds ratio (OR) = 2.4; p=0.003). The association betweensleep duration and obesity was U-shaped, that is obesity wasmost prevalent among respondents who had the shortest andlongest sleep duration (74%, 53%, 53%, 62%; linear termp=0.002 and quadratic term p=0.03). The association betweensleep quality and obesity was negative and linear (69%, 72%,56%, 43%). Less stable bedtimes during the week (OR =2.3;p=0.008) or on the weekend (OR = 1.8; p=0.04) were also as-sociated with obesity. The association between sleep qualityand obesity was not explained by patient demographics or snor-ing [OR adj = 2.2; 95% CI= (1.2, 4.1)].

DISCUSSION:The deleterious impact of an elevated BMI on the geometry ofnasopharnyx, snoring risk, and apnea risk is well known. Less isknown about the hypothesized physiological impact of snoringor poor quality sleep on metabolism, appetite, and obesity.Clinical trials incorporating the experimental manipulation ofsleep and sleep hygiene among overweight and obese primarycare patients are needed to address the relevant issues.

ORAL PRESENTATIONS


9:27 a.m. Use of RFID Technology toEstablish EMS ED Turnaround TimesMatthew Frey, M.D., Sheila H. Steer, M.D., FACEP,Francis Mencl, M.D.,FACEP, Jonathan Zalewski,NREMT-PEmergency Medicine, SummaHealth System

PURPOSE/OBJECTIVE:EMS personnel sometimes wait for Emergency Department (ED)beds to become available for their patients, depriving communitiesof EMS resources and delaying patient care. Currently there isno benchmark for EMS offload times in the ED. This studydemonstrates a novel method for monitoring times, determiningdelays and establishing a benchmark, which will be helpful indeveloping and monitoring interventions to reduce EMS waittimes in the ED.

METHODS:This is a descriptive observational study done at a high volume,urban community hospital with an emergency medicine residency.Radio frequency identification (RFID) tags were affixed to 65 cotsfrom 19 EMS agencies. An RFID reader detected the cots as theyentered and exited the ED through the ambulance bay. Duringthe 12 weeks from December 1, 2009 to February 28, 2010 datawas collected on 1865 consecutive patient cots with complete datafor 1417 cots. Offload times were calculated and analyzed to showvariations in times based on time of day and day of week. Times arereported as medians and interquartile ranges (IR).

RESULTS:Average overall offload time was 13 minutes 18 seconds (range1'12" to 80'39"). The median time was 10'49"(IR 8'10" to15'20"). Forty-two percent (596/1417, 95% CI 39-45%)drop-offs were less than 10minutes. However, twenty-six percent(371/1417, 95% CI 21-29%) were greater than 15 minutes. Thecumulative time spent by all squads waiting beyond 15 minutestotaled 54.5 hours. Median times were longest on Mondays(11'52"), shortest on Wednesdays (10'19"). During the day theshortest wait time by hour was 0900-1000 (median 9'39")and 1000-1100 (median 9'33") with the longest waits between1500-1600 (median 13'42") and 1600-1700 (median 13'50").

CONCLUSIONS:RFID is a simple, passive and reliable means of monitoring EMSoffload times in the ED. Most squads are able to transfer care oftheir patients and exit within 15 minutes suggesting this may be areasonable benchmark in our community. We also identified dailyand hourly variation in offload times, which represent areas foradditional investigation and systems improvement.

9:54 a.m. Ability of PrehospitalElectrocardiogram Computer Interpretationto Accurately Identify Patients with STElevation Myocardial InfarctionAmber Gist, M.D., M.H.A., Colleen Bhalla, M.D.,Francis Mencl, M.D., Scott Wilber, M.D., M.P.H.,Jon Zalewski, NREMT-PEmergency Medicine, SummaHealth System

PURPOSE/OBJECTIVE:The American Heart Association recommends that prehospitalproviders obtain electrocardiograms (ECGs) on patients suspectedof having a myocardial infarction. They recommend this ECGbe used to activate the cardiac catheterization lab (cath lab) forpatients with ST elevation myocardial infarction (STEMI) priorto the patient’s arrival in the emergency department (ED). Ourobjective is to evaluate the computer interpretation of prehospitalECGs in diagnosing STEMI for accuracy, sensitivity and specificity.In doing so, we would like to predict the number of missed cathlab activations and inappropriate activations if this reading was theonly determining factor.

METHODS:This study is a retrospective review of 100 prehospital ECGs frompatients transported by EMS to Akron City Hospital, diagnosedwith STEMI, and taken to the cath lab from the ED beginningJanuary 2007 and ending February 2009. An additional100 ECGs from the same time period were randomly selectedfrom our prehospital ECG database using random numbergenerator. The study included all available ECGs that weretransmitted using LifePack 12 monitors in the prehospital settingto Akron City and stored in our Medtronic database. An accuratecomputer interpretation was a reading of “Acute MI Suspected,”other interpretations were documented as misses. The primaryoutcomes were to determine the sensitivity and specificity ofthe computer for identifying STEMI accurately. This sample sizeprovided a confidence interval of +/- 10%.We utilized this data toextrapolate the number of false positive activations if computerinterpretation of ECG was used to activate the cath lab, and todetermine how many STEMIs would be missed if computerinterpretation was used for activation.

RESULTS:The computer correctly labeled 58/100 ECGs from patients witha STEMI as “acute MI suspected.” None of the ECGs frompatients without a STEMI were labeled as “acute MI suspected”.Sensitivity was 58% (58/100; 95% CI 0.48-0.67) while thespecificity was 100% (100/100; 95%CI 0.96-1.0). If this had beenthe only data used to activate the cath lab we would havehad 42 missed activations, but we would not have had anyinappropriate activations.

CONCLUSION:Prehospital ECG computer interpretation is highly specific but notsensitive for determiningwhich patients are having ST elevationMI.The utility of this mechanism for activating the cath lab is limited. Itmay be efficient, given a specificity of 100%, to activate the cath labbefore a patient arrives based on positive reading, howeveradditional resources are needed to interpret negative ECGs.

ORAL PRESENTATIONS


10:06 a.m. Urine Drug Testing for LongTerm Opioid TherapyLeslie McKinley, D.O., William Smucker, M.D.,Everett Logue, Ph.D., Dee Fierman, RN,Patricia Dudley, B.A., Adarsh Krishen, M.D.Family Medicine, SummaHealth System

INTRODUCTION:Urine drug testing (UDT) is an important part of safe opioidprescribing recommended by the Federation of State MedicalBoards as a method to confirm adherence to treatment, anddetect substance misuse and drug diversion. In September2009, the Family Medicine Center of Akron (FMC) instituteda policy of universal UDT when patients received refills foropioids. This study describes the outcomes of universal UDT.

METHODS:A registry of chronic pain patients requesting opioid refills andthe electronic medical record were used to collectdemographic, UDT results, and management decisions basedon UDT. UDT results were determined to be Concordant ifthey contained only the prescribed medication(s). DiscordantUDTs were free of prescribed opioids, adulterated, orcontained either illicit drugs or controlled substances notprescribed by the FMC.

RESULTS:Fifty-nine percent of chronic pain patients (139/234) had atleast one UDTwithin six months. Fifty-one percent (71) wereConcordant and 49% (68) were Discordant. Forty-nine of thediscordant urines were free of prescribed medication, 1 wasadulterated, 35 contained an illicit substance, 2 containedcontrolled substance not prescribed by FMC, and theremaining were some combination of these reasons.Management of discordant urines included; no further opioids(37), continuation of opioids (31), and frequent testing (26).

CONCLUSIONS:A universal UDT program is feasible but the UDT order rateseemed to be low if the benchmark is one test per month perpatient. Themoderate percentage of discordant results suggeststhat more work is needed to reduce the probability ofdrug abuse. No adverse events occurred when physiciansdiscontinued opioid. UDT improved compliance withrecommended opioid prescribing practices.

10:18 a.m. Endoscopic Ultrasound-GuidedFine Needle Aspiration: ClinicopathologicFindings at Akron City HospitalMarkW.Nelson, D.O.1, Cherie R.Hart-Spicer, M.D.1,William F. Shaheen, M.D.2, Amy H. Deeken, M.D.1,William A. Henthorne, M.D.1,Pars Ravichandran, M.D.11Pathology and Laboratory Medicine, SummaHealth System,2Internal Medicine, SummaHealth System

PURPOSE/OBJECTIVE:Endoscopic ultrasound with guided fine needle aspiration(EUS-FNA) is a safe, minimally-invasive procedure used insampling intra-abdominal and intrathoracic lesions for primarydiagnosis or staging of known malignancies. In many cases,EUS-FNA can yield diagnostic information that is helpfulin further patient management (operative vs. non-operativetherapy). We would like to share our experience with thistechnique, and our overall clinicopathologic findings duringthe brief time we were performing EUS-FNAs at Akron CityHospital.

METHODS:A retrospective review was done on all the single-provider EUScases performed at Akron City Hospital from May 1, 2008 toJuly 31, 2009. Specimens were obtained during the procedureand processed with the cooperation of endoscopy nurses andcytopathology residents working with an on-site pathologist.All EUS cases that had cytologic and histologic material weresystematically reviewed. Surgical follow-up and diagnosis wasdocumented and compared with the previous EUS diagnosis.

RESULTS:During the 15-month study period, 163 EUS procedures wereperformed. Cytologic material was procured from 91 aspiratesfrom 82 patients. These included aspirations of the pancreas,lymph nodes, retroperitoneum, and submucosal masses fromthe stomach, duodenum, and esophagus. The cytologicdiagnoses included 17 non-diagnostic cases, 30 benign lesions,13 malignant neoplasms, 11 atypical/suspicious lesions,8 endocrine tumors, and 12 lesions with uncertain malignantpotential. Twenty-eight (31%) of these aspirations had surgicalfollow-up. Of these, 75% (21/28) of the EUS diagnoses wereconfirmed surgically.

CONCLUSION:In the reviewed timeframe, EUS-FNA was able to provideaccurate cytologic diagnoses for a broad spectrum ofconditions, ranging from benign pancreatic cysts toadenocarcinoma and rarer lesions like pancreatic endocrinetumors. These findings are consistent with other, larger studieswhich show EUS-FNA as an important diagnostic and stagingtool.We found that this advanced endoscopic procedure can besuccessfully implemented even in the community setting withthe cooperation of cytopathology and endoscopy teams.

ORAL PRESENTATIONS


10:30 a.m. Quality of Life in ChronicPelvic Pain PatientsThida Nunthirapakorn, M.D.,Bradford Fenton, M.D., Ph.D.Obstetrics and Gynecology, SummaHealth System

PURPOSE/OBJECTIVE:Chronic pelvic pain (CPP) is a syndrome that includes a variablenumber of organ specific diagnoses: gynecologic pain, interstitialcystitis (IC), irritable bowel syndrome (IBS), pelvic floor tensionmyalgia (PFTM), and pelvic abdominal wall myofascial pain syndrome(MFPS). The NIH has promulgated a standardized method formeasuring quality of life (QoL) across a wide range of medical diseasesknown as the patient reported outcomemeasures system (PROMIS).The extent to which the presence of one or more of these CPPdiagnoses impacts a patient’s PROMIS domain scores is unknown,nor is how any interaction between these diagnoses changesQoL measures.

METHODS:A total of 133 patients referred to a specialty center for theevaluation and management of chronic pelvic pain underwent ahistory and physical examination including the 96 item PROMISshort form and assignment of individual pain diagnoses usingstandardized criteria. In accordance with an IRB approved protocol,PROMIS scores were calculated for all of the functional domains andscaled for comparison to the reference population. Twoway correctedt-tests were performed between adjusted domain scores of patientswith different pain diagnoses.

RESULTS:Patients with CPP scored significantly (p<0.05) worse in all PROMISdomains except anger compared to the reference PROMISpopulation. Diagnoses associated with several significantly (p<0.05)worse PROMIS domain scores included IBS, PFTM, and MFPS.Analysis of variance did not reveal a difference in scores with greaternumber of CPP diagnoses in any PROMIS domain.

CONCLUSION:This is the first study to apply the new PROMIS scoring system topatients with CPP. Compared to the reference population, CPPpatients do have a lower quality of life. Although it could be assumedthat pain involving multiple organ systems would lead to a worseningof QoL, such was not the case in this population. This implies thatmanagement of only one pain generator will be inadequate to improvepatient function and that multidisciplinary management of each andevery individual pain will be required to improveQoL outcome scores.

10:42 a.m. Three-Dimensional ComputerImage Analysis in Foot and AnkleSurgery: Computer Modeling in theDetermination of At-Risk Structuresfor Calcaneal OsteotomiesErin Prewitt, M.D., David Kay, M.D.,Timothy Marks, B.S., Leann Speering, M.S.,CCRP,Michael Askew, Ph.D.Orthopaedic Surgery, SummaHealth System

BACKGROUND:Improvements in radiographic computer imaging have providedmeans to obtain three-dimensional (3D) anatomical visualizations ofbone and soft tissue anatomy, pathology, and injuries. OsiriX softwareis an open-source, Mac-based, DICOM viewer that provides suchopportunities for surgical planning and post-surgical evaluation. Thissoftware has been applied to many fields of medicine, but to ourknowledge it has not been studied in orthopaedics.

PURPOSE:The purpose of this study is to evaluate the accuracy of the OsiriXsoftware for application to foot and ankle surgery, andmore generally,to orthopaedic surgery. We present 3D computer imaging ofinanimate objects and the anatomy placed at-risk in common foot andankle osteotomies.

METHODS:The accuracy of OsiriX was evaluated by two separate methods. First,a 3D model was created with radiopaque objects of various sizes,shapes, and angles. Measurements were taken with calipers and aprotractor. A CT scan of themodel was then imported into theOsiriXsoftware and the correspondingmeasurements were obtained. Second,to determine the applicability of the OsiriX software in the clinicalsetting, CT scans of two cadaver feet were obtained. These feet wherethen dissected medially to identify structures at-risk in the medialdisplacement and Evan’s calcaneal osteotomies. Both osteotomieswere then performed and physical measurements were obtained. TheOsiriX software was then used to obtain correspondingmeasurementsderived from the CT scans of the two feet.

RESULTS:OsiriX-derived measurements of the 3D model were found to be onaverage within 0.039cm of the physical caliper measurements. Theangular measurements obtained from the model where within0.68 degrees, on average, between the goniometer and OsiriXmeasurements. Physical measurements in the cadaver feet were foundto be on average within 0.060cm of the OsiriX values.

DISCUSSION:We have shown that the measurements obtained through the OsiriXsoftware are valid and can be used in the clinical or research setting.Virtual surgery and computer imaging opens new possibilities fordeveloping novel surgical procedures and better understanding of the3D nature of the involved anatomy. Ease of use and accessibility makethe OsiriX software a valuable tool for orthopaedic surgeons. Ourfindings support the use of the Osirix software for use in orthopaedicimaging. This open source software allows universal access to a toolwhich can be helpful in surgical planning, outcomes measures inpost-surgical situations, and virtual training and research.

ORAL PRESENTATIONS


10:54 a.m. Effectiveness of an AdvancedDirectives Communication Protocolduring Hospital TransfersSara S. Snyder, D.O., Bill Zafirau, M.D.,Sue Hazelett, M.S., BSN, RN, Ankit Bansal,Susan McMahonGeriatric Medicine, SummaHealth System

BACKGROUND:As developments in medical technology improve our ability toprolong life, it is increasingly important that patients,physicians, and families make proactive decisions regardingCPR and life sustaining treatment. Although AdvancedDirectives play a more prominent role in long term carefacilities (LTCFs), this information often does not reach theacute care setting. Studies have shown that only 4-8% ofemergency department patients transferred from LTCFs areaccompanied by AdvancedDirectives. Not only does this wastevaluable resources, but it can also lead to a contradiction ofpatient’s formally expressed wishes. The purpose of this studywas to test the efficacy of implementing a new transferform between LTCF’s and the acute care setting to ensureappropriate care and to help narrow the gap of information thatoccurs in transitions. This form records the presence ofAdvanced Directives, as well as important health/backgroundinformation.

METHODS:The intervention involved development and implementationof the transfer form, as well as education at each facility aboutthe transfer form and its use. The transfer form wasimplemented in 26 of 36 LTCFs who comprised the CareCoordination Network affiliated with Summa Health Systemin Akron, Ohio. The study design involved consecutiveretrospective chart reviews in the nursing home as well as thehospital. Patients’ charts were reviewed at both 1 and 6monthsprior to the initiation of the transfer form in 2007, and then1 and 6months after the initiation of the transfer form in 2008.

RESULTS:In 2007, 210 patient charts were reviewed, while in 2008172 patient charts were included. With the implementation ofthe transfer form in 2008, there was a 79% concordancebetween the documented LTCFs AdvancedDirectives, and thehospital Advanced Directives, whereas in 2007 thisconcordance was 66.6% (p=0.038). Also, inpatienthospice/palliative care admissions rose significantly, from only1.5% of patients having a palliative care admit in 2007 (n=2) to7.7% of patients in 2009 (n=9, p=0.015).

CONCLUSION:The use of a transfer form improved the documentation intransitions of care by increasing the concordance of theAdvanced Directives communication between the long termcare facility and the hospital. There is also a suggestionfrom our outcomes that this form has served its secondarypurpose, such as increasing admissions onto the acute palliativecare unit. Further studies will need to look at increasing thiscommunicative effort.

11:06 a.m. Multiple Chronic Pelvic PainDiagnoses in a General GynecologySettingEileen Witten, M.D., Bradford Fenton, M.D.Obstetrics and Gynecology, SummaHealth System

PURPOSE/OBJECTIVE:Chronic pelvic pain (CPP) has several definitions and multiplerelated conditions of other organ systems, such as interstitialcystitis (IC), irritable bowel syndrome (IBS), and vulvodynia(VVD). Although it is known that multiple pelvic pain relateddiagnoses coexist in referral populations, it is unclear howfrequently these conditions occur in an outpatient setting.Failure to adequately diagnose andmanage these other chronicpain syndromes may decrease patient response to treatment.

METHODS:While waiting to be seen in an outpatient gynecology residentclinic, 498women completed the survey instrument. Questionsrelated to the American College of Obstetricians andGynecologists definitions of cyclic and constant chronic pelvicpain were included, as well as standardized questions designedto detect IC, IBS, and VVD.

RESULTS:Cyclic CPP was present in 20%, constant CPP was present in9%, and CPP by any definition was presnt in 24%. IC wasdetected in 6%, IBS in 15%, and VVD in 5% of all respondents.Of patients with any definition of CPP, 8% had IC, 16% hadIBS, 11% had VVD, and 31% had at least one other pelvic paindiagnosis; this was significantly related to both cyclic CPP(p=0.039) and constant CPP (p<0.001).

CONCLUSION:CPP is a common condition amongwomen presenting for careat a general gynecology clinic. Pain dianoses in other pelvicorgan systems are not as common as gynecologic pain on anindividual basis, but frequently coexist with CPP, and wouldrequire separate evaluation and management to optimizeresponse to treatment.

ORAL PRESENTATIONS



11:18 a.m. The Utility of Web-Based Educationin a Community-Based Residency ProgramShruti Malik, M.D.Obstetrics and Gynecology, SummaHealth System

BACKGROUND:Themost effective tools formedical education and administrativecommunication at the residency level are widely debated.Withthe increasing use of the Internet and computer-basededucational tools, the current generation of resident physiciansmay benefit from web-based educational methods. A smallamount of literature is available regarding Internet-basedresidency applications; most of it pertaining to administrativefunctions or web-based modules and surveys. Our objectivewas to design a central web-based site for the residents tocoordinate lectures, call schedules, common documents andeducational resources.

METHODS:This is a descriptive analysis of an individual sign-on, passwordprotected website that was constructed using GoogleTM sitesone year ago. Individual GMailTM accounts were obtained orgiven to 22 residents and 8 faculty members. The websiteconsists of a Homepage and 10 other web pages for weeklylectures, morning reports, call schedules, important documents,OR schedule assignments and contact information. Allpre-reading assignments and available lectures are posted onthe website to allow easy access. All important administrativeforms and rotation objectives are also available. Of note, thereis a page to allow for automated anonymous submission ofresident concerns to the program coordinator. Manyindividuals are also able to synchronize the lecture and callschedules with their mobile devices to allow quick access at alltimes. Individual counters have been recently placed on eachpage to monitor the number of hits. However, these countersare unable to track document access through GoogleTMDocuments or calendar access through mobile devices.

RESULTS:There are an average of 11.8 hits per day on our Homepage,hyperlinks to 9 commonly used websites and over 300 shareddocuments currently on the website including lectures,pre-readings and journal articles. There are also 53 documentscomprising of common forms, schedules, guidelines androtation objectives.

CONCLUSIONS:Our residency website is accessed daily and provides residentswith easy access to a large amount of educational materials,calendar schedules, commonly used administrative forms and ameans for confidential submission of comment or concerns.Further study is needed to compare paper and web-basededucational and organizational tools, the effect on assessmentexams, and the effect on office time and cost. This free,web-based, paperless educational tool may benefit the currentgeneration of residents and potentially decrease administrativecosts and energy in the future.

ORAL PRESENTATIONS


FAMILY MEDICINEGolden ShovelAdarsh E. Krishen, M.D., FAAFPShiny AppleHugh A. Schuckman, M.D.Teaching ServiceObstetrics and Gynecology Teaching Staff

OBSTETRICS AND GYNECOLOGYJames Fanning, D.O.

PATHOLOGYPars Ravichandran, M.D.

UROLOGYDennis Bentley, M.D.ResidentEric Massanyi, M.D.

OPHTHALMOLOGYJeffrey Lamkin, M.D.

ORTHOPAEDICCurtis Noel, M.D.AttendingsRaymond Acus, III, M.D.TimMyer, M.D.ResidentJovan Laskovski, M.D.

INTERNAL MEDICINEAttendingDon Albainy, M.D.IMCRon Jones, M.D.SubspecialtyStephen Verbeck, M.D.



2009 TEACHER OF THE YEAR AWARDS


AWARD WINNERS

WALTER A. HOYT, SR., M.D. AWARD FOR BASIC SCIENCEStephanie A. Valente, D.O. (General Surgery) andCherie Hart-Spicer, M.D. (Pathology and Laboratory Medicine)New Biomaterial as a Promising Alternative toSilicone Breast Implants

WILLIAM H. FALOR,M.D. AWARD FOR CLINICAL SCIENCESushma Kandula, M.D. (Ophthalmology)Patients’ Knowledge and Perspectives on Wet Age-RelatedMacular Degeneration and its Treatment

ANDREWKERR,JR.,M.D.AWARD FORCLINICAL SCIENCELisa Mohrman, M.D. (General Surgery)Changes in the Lipid Profile and Differences in Weight-lossOutcomes Between Laparoscopic Roux-en-Y GastricBypass (LRYGB) Patients and Laparoscopic AdjustableGastric Banding (LAGB) Patients

ROBERT A. LIEBELT,M.D. POSTER AWARD FORCASE REPORT/LITERATURE REVIEWErin M. Prewitt, M.D. (Orthopaedic Surgery)Transmalleolar Osteotomy for the Treatment of Talar BodyFractures: Case Report of a Bimalleolar Approach

WALTER A. KEITZER,M.D. AWARD FOR BEST POSTERMonica Verma, M.D. (Ophthalmology)Cataract Surgery in Patients on Warfarin Therapy:Hemorrhagic Complications and Effect on PostoperativeVisual Acuity

ROBERT FLORA,M.D./LINDA UPP,M.D. AWARDFOR MEDICAL EDUCATION RESEARCHMark W. Nelson, D.O. (Pathology and Laboratory Medicine)Utilization of Telepathology Technology in CT GuidedBiopsy Specimen Evaluation

ROBERT FLORA,M.D./LINDA UPP,M.D. AWARDFOR WOMEN’S HEALTH RESEARCHJil M. Johnson, D.O. (Obstetrics and Gynecology)Comparison of Teenage Video Gamers versus PGY IOb/Gyn Residents on a Laparoscopic Simulator

ROBERT FLORA,M.D./LINDA UPP,M.D. AWARDFOR PUBLIC HEALTH RESEARCH:Trisha Imhoff, M.D. (Family Medicine)Influenza Vaccination Opt-Out Policy Study



POSTGRADUATE DAY 2009RESEARCH AWARD WINNERS


CYTOPATHOLOGYCheri Hart-Spicer, M.D.Staff PathologistSumma Health SystemAkron, OH

GENERAL PRACTICE DENTISTRYMatthew Croston, DDSPrivate PracticeAkron, OH

Leslie Do, DDSPrivate PracticeAkron, OH

Stephen McKee, DDSPrivate PracticeElmira, NY

Pamela Susai, DDSPrivate PracticeAkron, OH

EMERGENCY MEDICINENathan Billings, M.D.Locum Tenens

Timothy Dake, M.D.Private Practice: Qualified Emergency Specialist, Inc.Cincinnati, OH

Gwendolyn Fletcher, M.D.Private Practice: Summa Emergency AssociatesAkron, OH

Matthew Frey, M.D.Locum Tenens

Michael Glueckert, M.D.Private Practice: Mount Carmel Hospital(Emergency Services, Inc.)Columbus, OH

Laurie James, D.O.Harbor - UCLAMedical Center Specialty: Sports MedicineLos Angeles, CA

Amy Niertit, M.D.Private Practice: Summa Emergency AssociatesAkron, OH

Erin Roskos, M.D.Private Practice: Alliance Medical AssociatesAlliance, OH

Nicholas Shundry, M.D.Private Practice: Summa Emergency AssociatesAkron, OH



2009 RESIDENTS’ FUTURE PLANS


FAMILY MEDICINEMariquita Belen, M.D.Private Practice: Family MedicinePeace Health Medical GroupEugene, OR

Andrew Chema, M.D.Private Practice Family Medicine Associatesof Medina, Summa Physicians Inc.Medina, OH

Kerwyn Flowers, D.O.Sacred Heart Medical GroupPanama City Beach, FL

Leslie McKinley, D.O.Private Practice: Family Medicine,Summa Physicians Inc.Akron, OH

Manasi Revankar, D.O.Private Practice: Primary Care PracticeFamily MedicineNY

Christopher Taggart, M.D.Fellowship: Hospice and Palliative MedicineSumma Health SystemAkron, OH

GENERAL SURGERYRaman Kumar, M.D.Academic: Colorectal FellowshipSt. Mark’s HospitalSalt Lake City, UT

Michael Valente, D.O.Fellowship: Colon and Rectal Surgery FellowshipGrant Medical Center/The Ohio State University Medical CenterColumbus, OH

Stephanie Valente, D.O.Fellowship: Surgical Breast OncologyUniversity of Southern CaliforniaLos Angeles, CA

GERIATRIC MEDICINEPreeti Betkerur, M.D.Geriatritian: Geriatric Medicine Summa Health SystemAkron, OH

Sara Snyder, D.O.Fellowship: Hospice and Palliative CareSumma Health SystemAkron, OH

HOSPICE AND PALLIATIVE CAREChizor Eruchalu, M.D.Hospitalist: Internal Medicine andHospice andPalliative MedicineHeartland Regional Medical CenterMarion, IL

Jodi Hannan, M.D.Wayne County HospiceWooster, OH

Shorin Nemeth, D.O.Unknown at this time

INTERNAL MEDICINEMark Arredondo, M.D.Private Practice Group PracticeGrove Hill, AL

Michelle Caldwell, D.O.HospitalistStanley HospitalAlbemarle, NC

Carrie Caruso, M.D.Hospitalist: Salem Community HospitalSalem, OH

Ronald Conner, M.D.Chief Resident: Summa Health SystemAkron, OH

Aaron Haynes, M.D.Hospitalist: Alaska Native Medical CenterAnchorage, AK

Jonathan Hlivko, M.D.Fellowship: GastroenterologyWest Virginia University HospitalMorgantown, WV

Kathy Ligon, M.D.Fellowship: Palliative MedicineSan Diego Hospice and Palliative MedicineSan Diego, CA

Marc McKinley, D.O.Fellowship: NephrologyThe Ohio State University HospitalsColumbus, OH

Christina Peters, D.O.Private Practice: Summa Physicians Inc.Wadsworth, OH

continued on next page


INTERNAL MEDICINE (cont)

Lili Poon, D.O.Fellowship: Sleep MedicineUniversity Hospitals, Case Medical CenterCleveland, OH

Debbie Anne Qua, M.D.Fellowship: Pulmonary/Critical Care MedicineBeth Israel HospitalNew York, NY

Christopher Shaw, M.D.HospitalistOH

Alyssa Shon, M.D.Fellowship: Infectious DiseaseUniversity at BuffaloBuffalo, NY

Erica Stovsky, M.D.Fellowship: Palliative MedicineSumma Health SystemAkron, OH

Hope Torregosa, M.D.Fellowship: GeriatricsCleveland Clinic FoundationCleveland, OH

George Trimble, M.D.Hospitalist: Community HospitalPainesville, OH

Nicole Williams, M.D.Fellowship: GeriatricsSumma Health SystemAkron, OH

OBSTETRICS AND GYNECOLOGYClara Chae, M.D.Private Practice

Andrea Crane, M.D.Academic: UNC at Chapel Hill School of MedicineUROGYN: Fellowship in Female Pelvic Medicineand Reconstructive SurgeryChapel Hill, NC

Paul Kidder, D.O.Private Practice: Primrose OB/GYN, Cox Medical Ctr.Springfield, MO

continued on next page

OBSTETRICS AND GYNECOLOGY (cont)

Thida Nunthirapakorn, M.D.Military Service: National Naval Medical CenterBethesda, MD

Eileen Witten, M.D.Private Practice

OPHTHALMOLOGYScott Steiner, M.D.Private Practice: General OphthalmologyCleveland ClinicWooster, OH

MatthewWillett, M.D.Fellowship: GlaucomaCleveland ClinicCleveland, OH

ORTHOPAEDIC SURGERYAndrew Bries, M.D.Fellowship: Sports MedicineSteadman-Hawkins ClinicGreenville, SC

Elizabeth Knazek, M.D.Military Service: US Army

Kyle Nelman, M.D.Fellowship: Sports MedicineLaguana Hills, CA

PATHOLOGYMark Nelson, D.O.Fellowship: CytopathologySumma Health SystemAkron, OH

PLASTIC SURGERYMark Burke, M.D.Private Practice: Roswell Park Memorial Cancer CenterBuffalo, NY

Nima Patel, M.D.Fellowship: Breast and Microvascular Surgery FellowshipMemorial Sloan-Kettering Cancer CenterNew York, NY


PRELIMINARY MEDICINEAnthony Baraga, M.D.Residency: Physical Medicine and RehabUniversity of CaliforniaOrange, CA

Mohammad Khan, D.O.Residency: Internal MedicineSumma Health SystemAkron, OH

Dale Kimbrough, M.D.Residency: RadiologyUniversity HospitalsCincinnati, OH

Jennifer Montgomery, M.D., PhDResidency: RadiologyCase Medical Center, University HospitalsCleveland, OH

Ryan Unger, M.D.Residency: Physical Medicine and RehabLoyola UniversityMaywood, IL

PSYCHIATRYAnastasia Beklemisheva, M.D.Private Practice: PsychiatrySumma Barberton HospitalBarberton, OH

Camille Stephenson, M.D.Private Practice: PsychiatrySumma Health SystemAkron, OH

TRANSITIONAL MEDICINEMolly Fuller, M.D., Ph.D.Residency: OphthalmologyUniversity of Michigan/WK Kellogg Eye CenterAnn Arbor, MI

Cyle Goodman, M.D.Residency: RadiologyMetroHealth Medical CenterCleveland, OH

Venu Kudithipudi, M.D.Residency: RadiologyMichigan State UniversityFlint, MI

TRANSITIONAL MEDICINE (cont)

Evan Lagouros, M.D.Residency: OphthalmologySumma Health SystemAkron, OH

Tony Le, D.O.Residency: Emergency MedicineSumma Western Reserve HospitalCuyahoga Falls, OH

AndrewMahoney, M.D.Residency: RadiologyMetroHealth Medical CenterCleveland, OH

Emily Myers, M.D.Residency: Internal MedicineSumma Health SystemAkron, OH

Umar Osman, M.D.Residency: Internal MedicineSumma Health SystemAkron, OH

Marwan Shaikh, M.D.Residency: Internal MedicineUniversity of Florida Shands HospitalJacksonville, FL

Anil Tumu, M.D.Residency: RadiologyWheaton Franciscan Health CareMilwaukee, WI

UROLOGYCerone Jeffrey, M.D.Private Practice: Canton Urology Associates Inc.Canton, OH

Daniel Mulligan, M.D.Fellowship: Robotic Urologic SurgeryThe Ohio State University Medical CenterColumbus, OH


Walter A. Hoyt, Sr., M.D. Award for Basic Science – $1,000

James S. Tan, M.D. Award for Basic Science – $1,000

WilliamH. Falor, M.D. Award for Clinical Science – $1,000

Andrew Kerr, Jr., M.D. Award for Clinical Science – $750

Robert A. Liebelt, M.D. Poster Award for Case Report/Literature Review – $500

Walter A. Keitzer, M.D. Award for Best Poster – $500

Flora /Upp Award for Medical Education Research – $1,000

Flora/Upp Award for Women’s Health Research – $500

Flora/Upp Award for Public Health Research – $500

SummaHealth System gratefully acknowledges the time,dedication and critical insight

of the Postgraduate Day Judging Committee.



POSTGRADUATE DAY AWARDS

Summa Heal th Sy s t emSumma Akron Ci t y and St . Thomas Ho sp i ta l s

Eighteenth Annual

Postgraduate DayJune 7, 2010

MED-10-10586/CPS/EH/5-10/250

Postgraduate Day - Summa Health

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