SCRIP: Scholarly Research In Progress 2017 by GeisingerCollege

SCRIP SCHOLARLY RESEARCH IN PROGRESS VOLUME 1

OCTOBER 2017

SCRIP

SCHOLARLY RESEARCH IN PROGRESS

VOLUME 1 OCTOBER 2017 2

Can routine pre-reduction radiographs be safely omitted in the setting of anterior shoulder dislocations? A case report and a review of the literature

Mark Dunleavy, Michael Tracy

An unusual case of giant colonic diverticulum

Benjamin Rutta, Jeffery M. Costanzo, Christopher A. Barbarevech

Models of Epilepsy: A literature review

Gabrielle Prezkop

Trochlear nerve schwannoma in a 57-year-old male presenting with vertical diplopia

Robert V. Decker, Michael D. Kim, Leonard T. Walsh

Association of limited activity and the onset of arthritis among medicare recipients

Nadia Maqsood, Michael Pheasant, Chris Kropiewnicki, David Jeffs, Alexis Payne, Kim Carrette, Elizabeth Kuchinski, and Mushfiqur Tarafder

Actin filament associated protein 1 (AFAP1) is an essential regulator of bone formation

Holly Corkill, Albena Gesheva, Kier Blevins, Broc Wenrich, Evan Frigoletto, Jess M. Cunnick, John A. Arnott and Youngjin Cho

Noninvasive plasma biomarkers show increased accuracy for detection of Alzheimer’s disease

Matthew Weirich

Evolution of multiple movement disorders as complications of anoxic brain injury: A case report

Jee Moon, Thomas Watanabe

Mefloquine discontinuation: Proposed solution for adverse drug-induced neuropsychiatric side effects

Lindsay Falgoust

Assessment of patient transportation as a determinant of appointment attendance at the Susquehanna Community Health and Dental Center

Branson Allen, Katherine Chung, Jason Gu, Brianne Handal, Marco Najar, Chloe Swanger, Leanne Woiewodski, Elizabeth Kuchinski, Janet Townsend and Mark White

Association of education level and influenza/ pneumococcal vaccine adherence in adults over the age of 65

Kaitlyn Sternat, Stephanie Tilberry, Patrick Roman, John Wroblewski, Ashley Slack, Christopher Karnicki, Elizabeth Kuchinski and Mushfiqur Tarafder

Call for SCRIP Student Editors We are looking for students with experience in research and/or a strong scientific background who want to learn more about editorial processing and the publication process. The role of the student editor is to assist in the writing, peer review, publication, and editing of content for the SCRIP journal. It is a great way to build your academic scholarship portfolio and to develop skills on the critical evaluation of manuscripts. Candidates may send their updated CV (that includes all relevant research and/or creative scholarship experience; all relevant writing, editing, or peer critique experience) to scrip@som.geisinger.edu with the subject ‘Application for Student Editor’.

A MESSAGE from the

EDITOR-IN-CHIEF

ACKNOWLEGMENTS The SCRIP would not be possible without the contributions of faculty volunteers. We gratefully acknowledge their support in providing peer review.

Welcome to the inaugural edition of the Journal of Scholarly Research in Progress (SCRIP). It is both a honor and a great responsibility to serve as the Editor-in-Chief for the SCRIP—a Geisinger Commonwealth School of Medicine journal devoted to publication of student-generated research in the areas of biomedical sciences, educational, clinical, and community-based research. Launching a new journal is no small feat, and we achieved a good measure of success with high-quality content from our students. Our peer-review turnaround time averaged two weeks and our faculty reviewers were committed to this vital component of our assessment of submitted articles. I wish to express my gratitude to the students for their valuable submissions and to the faculty who showed interest and volunteered their time serving as peer reviewers. Those submitting authors who have had their work accepted should be proud of their achievement.

We would also like to thank Dr. William Iobst, Vice President for Academic and Clinical Affairs and Vice Dean, for his encouragement and support in promoting the scholarship of our students.

As the Editor-in-Chief, there are a few things I would like to share with you. First, it is my pleasure to let our authors and readers know that the aim of this journal is to highlight and disseminate student scholarly activity at Geisinger Commonwealth School of Medicine. While many of our students participate in meaningful scholarly research, they do not always have an opportunity to disseminate their work. This journal will provide a venue for Geisinger Commonwealth students to contribute their original articles, reviews, short communications, letters, editorials, literature review, and case reports. Second, I take the responsibility of sustaining and building upon the SCRIP’s quality and success very seriously. Suggestions from our contributors and readers to further develop and/or improve the journal would be more than welcome; if you would like to share your thoughts, please email me at scrip@som.geisinger.edu.

Director, Office of Sponsored Programs

Lastly, I would like to take this opportunity to invite students who have an interest in being involved in the editorial work of the journal. The role of the student editor is to assist in the writing, peer review, publication, and editing of content for the journal. It is a great way to build your academic scholarship portfolio, and I believe that this would help to ensure the journal’s growth and sustainability. Potential candidates may send their updated CV (that includes all relevant research and/or creative scholarship experience; all relevant writing, editing, or peer critique experience) to scrip@som.geisinger.edu with the subject ‘Application for Student Editor’. Sincerely,

Sonia Lobo Planey, PhD Editor-in-Chief

OFFICE OF RESEARCH & ECONOMIC DEVELOPMENT Phone: 570-504-9662 Sonia Lobo Planey, PhD Associate Dean for Research Associate Professor of Biochemistry Michele Lemoncelli Administrative Assistant to the Associate Dean for Research & Office of Research and Economic Development Karen Baker, CRA Katie Pasqualichio Grants Specialist Laura E. Mayeski MT(ASCP), MHA Director of Research Compliance Victor T. Mallory Manager, Laboratory Animal Resources Thomas Majernick, MS Laboratory Animal Technician

ON THE COVER:

SCRIP SCHOLARLY RESEARCH IN PROGRESS VOLUME 1

OCTOBER 2017

The image shows an immunofluorescent stain of T24 bladder carcinoma cells treated with small interfering RNA targeting the protein DHHC2. Cytoskeleton-Associated Protein 4 (CKAP4) was stained with anit-CKAP4 rabbit antibody (green). Microtubules were stained with anti-alpha-tubulin mouse antibody (red). Nuclei were stained with DAPI (Blue). Image acquired by Thomas Majernick.

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Can routine pre-reduction radiographs be safely omitted in the setting of anterior shoulder dislocations? A case report and a review of the literature Mark Dunleavy 1*; Michael Tracy 2

Geisinger Commonwealth School of Medicine, Scranton, PA, 18509 Scranton Orthopedic Specialists, Scranton, PA, 18519 *Correspondence: MDunleavy@som.geisinger.edu 1

ABSTRACT Historically, obtaining both a prereduction and postreduction radiograph was the standard of care for managing acute anterior shoulder dislocations. Here we present two cases where Emergency Department (ED) physicians performed a closed reduction of anterior shoulder dislocations without first obtaining the prereduction radiograph. After reviewing the literature, we conclude that there is not enough evidence that this is a safe practice, and until a clinical decision rule is constructed that can pass independent validation, we recommend obtaining the prereduction radiograph in all cases of suspected anterior shoulder dislocation.

INTRODUCTION

Case 1

The glenohumeral joint is the most mobile joint in the human body but also the most frequently dislocated. According to recent epidemiologic studies, shoulder dislocations have an estimated incidence of 11.2-23.9/100,000 person-years (1-3) and account for over half of the dislocated joints reduced in emergency departments (4). Despite the frequent occurrence of this type of injury, there seems to be little agreement regarding the best way to manage it radiographically. Historically, obtaining a prereduction X-ray was considered commonplace in any case of a suspected anterior shoulder dislocation (5). For example, in a survey of trauma surgeons in the UK conducted in 2006, 100% of the respondents advocated the use of X-rays before making any attempt at reduction (6), This practice allowed clinicians to ensure diagnostic accuracy, recognize associated fractures, and eliminate the suspicion that any fractures noted on the post-reduction films were caused by the reduction procedure itself.

Our first patient is a 16-year-old left hand dominant gentleman with no significant past medical history who presented to our clinic after being treated in the emergency department (ED) for an acute traumatic anterior shoulder dislocation. He had sustained a tackle while playing football the previous day and immediately felt significant pain in his right shoulder. Per report from the patient and his family, the treating physician at the ED diagnosed him with an anterior shoulder dislocation based on clinical criteria alone, and reduced the shoulder without a pre-reduction X-ray. On physical exam in our clinic the following day, he exhibited pain with the arm in the abducted externally rotated position, but there was no true apprehension. An MR arthrogram was obtained and exhibited an anterior labral tear. After a trial of non-operative management, the patient remained symptomatic and approximately three months after the initial injury underwent a right arthroscopic anterior labral repair. At five-month follow-up of surgery, the patient is doing well and has had no recurrent dislocations.

Recently, however, the necessity of the prereduction film has been called into question by some researchers. Citing cost, length of ER stay, patient discomfort, and unnecessary X-ray exposure, it has been suggested that the pre-re-

duction film is actually much more of a hindrance than a help. The trend of forgoing the prereduction X-ray has even extended into some clinics. In a recent study, Kahn and Mehta were surprised to discover that 20.5% of patients were reduced without a prereduction film, noting that some of the attending emergency physicians at their institution instead preferred to reduce shoulder dislocations immediately to avoid any delay in treatment and the ensuing muscle spasm (7). Clearly, there is a discrepancy on how best to manage this very common injury. In this paper, we present two illustrative cases of patients with anterior shoulder dislocations that were managed without prereduction radiographs. We then review the literature to see if this practice can be safely recommended.

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Case 2 Our second patient is a 31-year-old, right hand dominant gentleman with a past medical history of depression/anx-

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iety who presented to our clinic after a fall several days prior. He was diagnosed with a right anterior shoulder dislocation in the ED after receiving a prereduction radiograph confirming the diagnosis and excluding fracture. On physical examination, he had decrease range of motion and strength, but intact motor and sensory function of the axillary nerve. An MR arthrogram was obtained and exhibited an anterior Bankart tear and a Hill-Sachs lesion. Per patient preference, he was treated non-operatively with physical therapy for shoulder stabilization and strengthening. Approximately five months later, he presented to our clinic again after another fall and, per the ED, another right shoulder dislocation. A closed reduction maneuver was performed in the ED without obtaining a prereduction radiograph. Following a long discussion with the patient, he elected again to treat the injury non-operatively and, to our knowledge, has not experienced any recurrent dislocations.

MATERIALS AND METHODS A comprehensive search of the Pubmed database was done using the search terms “anterior shoulder dislocation” and “pre reduction.” The subsequent articles were assessed for inclusion into our study and stratified based on relevance, resulting in nine studies.

RESULTS After a systematic review of the literature, we found three proposed clinical decision guidelines constructed to reduce the number of pre-reduction radiographs: the Banff Shoulder Dislocation Guideline (8), the Hendey clinical decision rule (9), and the Quebec clinical decision rule (10). Each was developed following independent retrospective and prospective studies conducted by their respective research groups. We also found two studies that aimed to stratify the need for prereduction radiographs based solely on age (11,12). The diagnostic skill of the emergency physician is the focal point of many of the studies arguing against the prereduction films. In a study by Shuster et al. emergency physicians were asked to rate their level of confidence that the shoulder was dislocated on a ten-point scale in each case of suspected dislocation. When the physicians rated themselves “certain” of dislocation (10/10 on the scale), their diagnostic accuracy on clinical examination alone was 100% (69/69). Shuster and colleagues also found that the mean time of reduction was 26 minutes shorter when emergency physicians decided against a prereduction radiograph and thus concluded that they were not necessary in the management of anterior shoulder dislocation when the

clinician was certain of the diagnosis (13). In a later study, they constructed the Banff Shoulder Dislocation treatment guideline that directed physicians to forgo the prereduction X-ray when clinically certain (10/10 on the scale) and to obtain one whenever there was any doubt (9/10 or less on the scale). Of the 63 patients enrolled in this prospective cohort study, physicians were certain of the diagnosis of anterior dislocation in 59 patients and were able to successfully reduce them without an X-ray. By using this guideline, the researchers found an overall reduction of 88.9% in the use of prereduction radiographs and again recommended bypassing them in the management of shoulder dislocations (8). In an update published seven years later, Shuster et al. states that they successfully and safely reduced over 300 shoulder dislocations using their treatment guideline (14). Similar rates of clinician accuracy were seen in a prospective observational study done by Hendey with more concern placed on identifying associated fractures. One hundred and four patients with suspected shoulder dislocations were divided into two groups based on the mechanism of their injury. Group 1 consisted of 28 patients sustaining a recurrent dislocation with atraumatic mechanism and group 2 consisted of 76 patients with no prior dislocation or a blunt mechanism of injury. When physicians were clinically certain of dislocation, they were 100% accurate in diagnosing group 1 patients (21/21) and 98% accurate in diagnosing group 2 patients (60/61). The one patient inaccurately diagnosed as dislocated instead had a humeral head fracture. There were 10 patients with dislocation/ fractures and 6 patients with fractures/no dislocation, all of which were in group 2. Thus, the researchers concluded that prereduction X-rays can be avoided when there is a recurrent, atraumatic mechanism of injury and the clinician is certain of joint position, but are indicated when a patient sustains a suspected dislocation that is either a first time occurrence or from blunt trauma (15). In a later study, Hendey et al. attempted to validate their findings by employing an algorithm for selective radiography based on mechanism of injury (atraumatic vs. blunt trauma), previous dislocations, and the physician’s clinical certainty of joint position. The investigators instructed clinicians to omit prereduction X-rays in any case of a recurrent dislocation with an atraumatic mechanism when the physician was clinically certain of the diagnosis and to obtain one in all other cases. Clinicians were also instructed to forgo the postreduction radiograph whenever they were clinically certain of a successful reduction. They managed to reduce all of the dislocations without missing any fractures, with a 46% overall reduction in x-ray usage. The mean ED times were also calculated for those receiving both pre-and postreduction films (288 min), either pre- or postreduction

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films (245 min), and no films (155 min) (9).

Figure 1. The Banff Shoulder Dislocation Guideline

Figure 2. The Hendey clinical decision rule for the management of patients with suspected shoulder dislocation

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Emond et al. continued this trend of investigating potential clinical factors associated with fracture dislocations. They sought to construct a predictive model to supplement physician judgment when determining which patients should receive prereduction X-rays based on those cohorts that were at the highest risk. In their retrospective chart review study, they found 334 patients suffered from an anterior shoulder dislocation at their institution, and that 85 (25.5%) also sustained a clinically significant fracture. After a thorough statistical analysis of the data, the investigators identified three variables strongly associated with clinically important fracture dislocations: age 40 years or older, first episode of dislocation, and traumatic mechanism of injury (fall of more than one flight of stairs, fight/ assault, motor vehicle crash). They then used this predictive model to cross-validate their sample and found that it was 97.7% sensitive in identifying fracture-dislocations (83 of 85 patients identified). Interestingly, 106 patients (31.7%) that had anterior dislocations did not receive prereduction X-rays, and 19 of those 106 (22.6%) had sustained a clinically significant fracture that was ultimately identified on postreduction radiography. There were no specific clinical criteria that could be identified to support their decision, but researchers noted that fewer initial radiographs were ordered in younger patients, women, and patients with a history of shoulder dislocation (16). The Emond group then conducted a prospective study to refine the factors associated with fracture-dislocations. They found that three combinations of factors correctly accounted for all of the clinically significant fracture-dislocations in the study: if the patient was aged 40 or older and had humeral ecchymosis, aged 40 or older and it was their first episode of dislocation, and if they were younger than 40

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years and the mechanism of injury was anything other than a fall from standing height or an atraumatic mechanism. Using these criteria, the investigators then created the Quebec decision rule, which would theoretically instruct physicians to not obtain a prereduction film unless the patient presented with any of the previously stated characteristics. Postreduction films would only be obtained if a prereduction film indicated a fracture or if the physician was uncertain if the reduction was successful. By using this rule, no clinically significant fractures would have been missed, with a sensitivity of 100%, specificity of 34.2%, a negative predictive value of 99.2%, and a negative likelihood ratio of 0.04. The number of prereduction X-rays would have been reduced by 27.9% (62/222) and postreduction radiographs by 81.9% (182/222), while reducing the ED stay by 26.5 minutes Figure 3. The Quebec shoulder dislocation rule (10). Unfortunately, however, in a later retrospective study conducted on an Australian patient population DISCUSSION by independent investigators, the Quebec decision rule Despite being such a common injury, there is still no unifailed validation. With regard to the under 40 cohort speversally accepted method of radiographically managing cifically, the rule achieved a sensitivity of only 0.42, specianterior shoulder dislocations. The historically accepted ficity of 0.40, and a negative predictive value of 0.91. Some treatment algorithm of obtaining both pre- and postrereasons for the difference postulated by the investigators duction X-rays has been challenged in a number of recent were that they used a larger, more diverse, and more inclustudies in the emergency medicine literature. The primary sive sample size than Emond et al. (17). objectives of the researchers in eliminating these films are In more recent studies, it has been suggested that prere- noble: reducing cost, X-ray exposure, and the amount of duction radiographs can be omitted simply based on age. time spent in the ED. Unfortunately, however, there are a Orloski et al. performed a large retrospective cohort study number of pitfalls to recommending the selective eliminaconsisting of over 7000 patients with anterior shoulder tion of prereduction X-rays. Despite the elegance of the dislocations and found that less than 1% of those patients clinical decision rules constructed by the various research in the second and third decade of life had an associated groups, none have achieved validation by independent fracture. Using this finding alone, the researchers suggest- studies conducted on different populations. ed it was safe to omit the prereduction film in this patient The reasons for this vary with regard to the specific study, population. It is important to note that they did not differbut some possible explanations can be inferred by examentiate between clinically significant and insignificant fracining the demographics of the respective study groups. tures (11). Likewise, Reid et al. retrospectively examined a For example, the subjects in Shuster et al. studies were cohort of 119 pediatric patients with a low-energy injury mainly young, healthy individuals (mean age 33.5 years) mechanism and found that only 3% had a fracture identiand thus the diagnostic accuracy of emergency physicians fied. Except for one patient who was transferred without a might not be as impressive in older patients in whom the reduction attempt, all were safely reduced in the ED and clinical presentation can be significantly less conspicuous. thus led the researchers to conclude that prereduction raPhysicians in this study were also highly trained in the diographs were unnecessary in the pediatric population. management of shoulder dislocations (the study was conBoth studies again stated the primary motivation for forgoducted near a ski area) and so the findings may not necing the radiographs was quicker relief for the patients, lowessarily be extrapolated to other areas where physicians er cost and radiation, and decreased length of ED stay (12). are less experienced. Furthermore, the sample size of the

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studies was quite small and thus some more complex and deceptive injuries might not have presented. Similar issues with the demographic characteristics of the study population were encountered in the Hendey study. Despite the fact that no missed fractures were found, the sample size was too small to effectively exclude rare events (the upper limit of the 95% confidence interval was 4%, which is far too high). Also, 24% of the patients were lost to follow up, any of which could have suffered from a missed fracture or persistent dislocation (9). Finally, the Quebec decision rule, presented by Emond et al. was refuted outright when applied to an Australian population (17). Regardless of the reason for failing validation, without independent confirmation of the safety and efficacy of these treatment algorithms, they cannot be recommended (18). In the first case we presented, the patient was a 16-yearold with a traumatic mechanism of injury. Although the Orloski et al. and Reid et al. studies would argue that a prereduction X-ray is unnecessary based on his young age alone, the mechanism of injury and the fact that he was a first-time dislocator would likely have prompted the Emond et al. and Hendey et al. study groups to obtain a radiograph to rule out concomitant fracture. Due to the discord between the research groups and the lack of an independently verified clinical decision rule, the ideal plan of care in this situation is actually quite ambiguous. If the clinician were certain of the diagnosis and the absence of fracture, Shuster et al. would argue that a closed reduction procedure could be safely performed without a prereduction radiograph. Despite the diagnostic accuracy of nearly 100% observed in the Shuster study (8), however, Emond et al. found that when left to rely on their own clinical acumen, emergency physicians omitted the prereduction films in nearly one patient out of five who harbored a clinically important fracture-dislocation identified on the postreduction radiograph (16). With that degree of inaccuracy, it is unsafe to trust the general emergency physician’s intuition alone, especially when considering the ease and relative quickness of obtaining the prereduction film. It is also quite imperative to not ignore the significant impact of a missed fracture-dislocation simply based upon the relatively rare nature of the injury. In fact, the possibility and consequences of associated clinically important fractures was not a major focus in some of these studies (8,13). It was mentioned in the first study by Shuster et al. that in one case, a physician rated his confidence level high (79/10) and attempted reduction, but the patient instead had a displaced fracture of the surgical neck of the humerus (13). Obviously, it is ill-advised to attempt a closed reduction in a patient with an associated humeral neck fracture, due to the possibility of further displacement and avascular necrosis of the humeral head (19). The only other associated fractures seen in the study were greater tuberosity fractures, Hills-Sachs deformities, and Bankart deformities

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which, the researchers argued, did not affect the need for immediate reduction as the initial management of the injury. They did not take into consideration the importance of identifying any greater tuberosity fractures prior to reduction, as it has been shown that attempting this reduction without general anesthesia can iatrogenically cause a humeral neck fracture (20). Also, since Hendey et al. advocated selectively eliminating postreduction radiographs in certain patients, little consideration was given to the ramifications of missed Hill-Sachs and Bankart lesions, both of which are associated with an increased rate of recurrent dislocations (21-24), which can complicate long-term care. The second case presented illustrated a situation of a young (31-year-old) patient experiencing a recurrent dislocation after a minor fall from less than standing height. Admittedly, the risk of a fracture dislocation in this case is significantly low. Since the ED physician elected to reduce the shoulder without a radiograph, however, the question arises: was the shoulder actually dislocated? The purpose of the prereduction film is to not only exclude fracture, but to also prove that the shoulder was indeed dislocated in the first place. This question can be extended to the studies using a retrospective design or those that prospectively reduced the dislocation without the radiograph (8,12,21). Without proof of initial dislocation, it is theoretically possible that the diagnostic accuracy and the efficacy of emergency physicians’ reduction procedures exhibited in these studies could have been overestimated by counting successful reductions when there was no dislocation in the first place. Lacking proof of dislocation also complicates the orthopedic follow-up of these patients. Recurrence rates are very high for males and those of younger age, often necessitating further imaging studies and arthroscopic stabilization procedures for these patients (25). If the shoulder was never dislocated to begin with, this extensive follow-up could expose patients to a high amount of unnecessary morbidity. Finally, detecting fractures on a postreduction radiograph without first obtaining the prereduction film can expose the clinician to a certain degree of medicolegal liability, because it can be argued that the fracture was caused by the reduction procedure itself, as described in a recent case study by Möhler et al. (25). Although this is a highly unlikely complication using modern reduction techniques that do not involve traction (13), legal trouble is still readily avoidable by simply obtaining the prereduction film.

CONCLUSION It is very clearly proven in the literature that forgoing the prereduction radiograph in cases of anterior shoulder dislocation leads to a faster reduction, shorter ED stay, and reduced ED costs. It is less clear whether or not this is a safe practice. Since the adverse effects of a missed frac-

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ture-dislocation are so significant and none of the proposed clinical decision tools have been independently validated, we conclude that there is not enough evidence to recommend forgoing the prereduction radiograph in cases of suspected anterior shoulder dislocation.

REFERENCES 1. Kroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg. 1989;108:288–90. 2. Simonet WT, Melton LJ III, Cofield RH, et al. Incidence of anterior shoulder dislocation in Olmsted County, Minnesota. Clin Orthop Relat Res. 1984:186–191. 3. Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010;92:542–549. 4. Mohamud D. Shoulder. In: Marx J, ed. Rosens's Emergency Medicine: Concepts and Clinical Practice. St Louis, MO: Mosby; 2002:576–606. 5. Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, ed 3. Philadelphia, Saunders, 1998, 820-29. 6. Chomg M, Karatagalis D, Learmonth D. Survey of the management of acute traumatic first-time anterior shoulder dislocation among trauma physicians in the UK. Ann R Surg Engl. 2006;88:45458 7. Kahn JH, Mehta SD. The role of post-reduction radiographs after shoulder dislocation. J Emerg Med. 2007;33:169-73. 8. Shuster M, Abu-Laban RB, Boyd J, Gauthier C, Shepherd L, Turner C. Prospective evaluation of a guideline for the selective elimination of pre-reduction radiographs in clinically obvious anterior shoulder dislocation. CJEM 2002:4:257-62. 9. Hendey GW, Chally MK, Stewart VB. Selective radiography in 100 patients with suspected shoulder dislocation. J Emerg Med 2006;31:23-8. 10. Emond M, Le Sage N, Lavoie A, Moore L. Refinement of the Quebec decision rule for radiography in shoulder dislocation. CJEM 2009;11(1):36-43. 11. Orloski J, Eskin B, Allegra PC, Allegra JR. Do all patients with shoulder dislocations need prereduction x-rays? Am J Emerg Med 2011;29(6):609-12. 12. Reid S, Liu M, Ortega H. Anterior shoulder dislocations in pediatric patients: are routine prereduction radiographs necessary? Pediatr Emerg Care 2013;29(1):39-42. 13. Shuster M, Abu-Laban RB, Boyd J. Prereduction radiographs in clinically evident anterior shoulder dislocation. Am J Emerg Med 1999;17:653-8 14. Shuster M, Abu-Laban RB, Boyd J. The Role of Radiographs in Anterior Shoulder Dislocation. J Emerg Med 2009;36(2):190 15. Hendey GW. Necessity of radiographs in the emergency department management of shoulder dislocations. Ann Emerg Med 2000; 31:23-8. 16. Émond M, Le Sage N, Lavoie A, Rochette L. Clinical factors predicting fractures associated with an anterior shoulder dislocation. Acad Emerg Med 2004;11:853-8. 17. Ong S, Kelly AM, Gunn B. Failed validation of the Quebec shoul-

der dislocation rule for young adult patients in an Australian emergency department. CJEM 2011;13(3):150-4. 18. Still IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med. 1999;33:437-47. 19. Hershe O, Gerber C. Iatrogenic displacement of fracture-dislocations of the shoulder: a report of seven cases. J Bone Joint Surg Br 1994;76:30-33. 20. Atoun E, Narvani A, Even T, Dabasia H, Van Tongel A, Sforza G, Levy O. Management of first-time dislocations of the shoulder in patients older than 40 years: the prevalence of iatrogenic fracture. J Orthop Trauma 2013; 27(4):190-3. 21. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg 1956;38A:957-77. 22. Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Orthop Clin North Am 1980;11:253-70. 23. Wen D. Current concepts in the treatment of anterior shoulder dislocations. Am J Emerg Med 1999;17:401-7. 24. Yu J. Anerior shoulder dislocations. J Fam Pract 1992;35:567-76. 25. Wasserstein DN, Sheth U, Colbenson K, Henry PD, Chahal J, Dwyer T, Kuhn JE. The True Recurrence Rate and Factors Predicting Recurrent Instability After Nonsurgical Management of Traumatic Primary Anterior Shoulder Dislocation: A Systematic Review. Arthroscopy 2016;32(12):2616-25. 26. Möhler A, Arikan H, Gris M. Pre-hospital treatment of an anterior shoulder dislocation: medico-legal concerns. Rev Med Brux. 2015;36(5):433-5.

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An unusual case of giant colonic diverticulum Benjamin Rutta1*, Jeffery M. Costanzo2, Christopher A. Barbarevech2 Geisinger Commonwealth School of Medicine, Scranton PA, 18509 GI Consultants of NEPA, Scranton PA, 18510 *Correspondence: BRutta@som.geisinger.edu 1

ABSTRACT

This is an unusual case of giant colonic diverticulum presenting with chronic GI symptoms of abdominal pain and diarrhea. The clinical presentation and putative causes of Giant colonic diverticulum are discussed.

CASE REPORT We describe an unusual case of 66-year-old male diagnosed with giant colonic diverticulum presenting as diverticulitis. The patient was admitted to the hospital for a history of persistent diarrhea lasting 2 months, abdominal pain, nausea and weight loss. CT scans of the abdomen and pelvis demonstrated a giant colonic diverticulum at the superior aspect of the sigmoid colon. The patient was treated successfully with bowel rest and intravenous antibiotics (500 mg of levofloxacin IV q24 hours, Metronidazole 500mg IV q8 hours) with resolution of symptoms. Two months post hospital discharge the patient underwent colonoscopy which confirmed the presence of mild left diverticulosis with a solitary giant diverticulum in the sigmoid colon at 30 cm from the anal verge (Figure 1A & 1B). Subsequently a sigmoid colectomy and diverticulectomy was done to excise the outpouching. The patient had complete resolution of his diarrhea, abdominal pain, and returned to his prior weight. Giant colonic diverticular disease (GCD) is a rare finding, with less than 200 cases published to date (1). It is defined as a diverticulum equal to or greater than 4 cm in size (2). In a recent systematic review of 166 cases, the most common clinical presentation was found to be abdominal pain followed by a combination of generalized symptoms such as constipation, diarrhea, and nausea (2). An X-ray or CT will, typically, correctly assess the diagnoses. There are three possible classifications for GCD. Type I can be considered a pseudodiverticulum, originating from a prior pulsion diverticula. The walls are composed of granulation and fibrous tissue with inflammatory cells and discontinuous remnants of the muscularis mucosa. Type II, inflammatory type, arises due to colonic communication with an abscess. The wall is composed of scar tissue. Type

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Figure 1. A) Axial view of giant diverticulum from the sigmoid colon B) Coronal view of giant diverticulum arising from the sigmoid colon

Figure 2. Gross specimen of GCD

III, true diverticulum, contains all the layers of the bowel and suggest a congenital original (3). After the sigmoid colectomy, the specimen was dissected and analyzed. It consisted of the neck connecting to the lumen of the large intestine, measuring 2.7 cm in diameter, leading to a cavity measuring 9.5 cm by 7.2 cm. The wall thickness was measured to be ranging from 0.7 cm to 2.1 cm. The absence of muscular tissue is suggestive of a type I, pseudo diverticulum (Figure 2). There are no definitive etiologies to explain the development of GCD, but a prominent theory suggests that the continuous inflammation of the opening of the diverticu-

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lum creates a one-way valve, allowing air from the lumen to enter but not escape the outpouching. Another related theory suggests that it is gas-producing bacteria trapped within the diverticular lumen in combination with valve mechanism that explains the driving force behind GCD (2). The patient had no notable risk factors.

DISCLOSURES Author contributions: B. Rutta wrote the manuscript and reviewed the literature. J. Costanzo and C. Barbarevech contributed the case and edited and reviewed the manuscript. Financial Disclosure: None Informed consent was obtained for this case report.

REFERENCES 1. Petrucciani, N., Giannini, G., Aurello, P., Magistri, P., Gasparrini, M., & Ramacciato, G. (2015). Giant colonic diverticulum: clinical presentation, diagnosis and treatment: systematic review of 166 cases. World J Gastroenterol, 21(1), 360-368. 2. Abdelrazeq, A. S., Owais, A. E., Aldoori, M. I., & Botterill, I. D. (2009). A giant colonic diverticulum presenting as a 'phantom mass': a case report. Journal of Medical Case Reports, 3, 29. 3. Grover, H., Nair, S., & Hertan, H. (1998). Giant true diverticulum of sigmoid colon. The American journal of gastroenterology, 93(11), 2267-2268.

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Models of Epilepsy: A literature review Gabrielle Prezkop*

Geisinger Commonwealth School of Medicine, Scranton PA, 18509 *Correspondence: GPrezkop@som.geisinger.edu

ABSTRACT With a multitude of models for epilepsy currently available to researchers, the viral induced model of epilepsy, specifically the Theilerâ&#x20AC;&#x2122;s murine encephalomyelitis virus, is the most realistic and accurate model that can be used.

INTRODUCTION Epilepsy is a disease that affects approximately 5.6 people per 1,000 in the United States each year (1). It is characterized by recurrent and unpredictable seizures due to hyperexcitability of the brain (2). There are two types of epilepsy, congenital and acquired. Congenital occurs at birth, while acquired epilepsy arises from events such as traumatic brain injury or after infection of the CNS. Epilepsy, whether acquired or congenital, can seriously impact quality of life and the ability to accomplish activities of daily living for the patient that suffers from this disease. Although there are treatments such as anti-epileptic drugs that can curb the onset of the seizures, many people are pharmacoresistant to treatment. This resistance proves the need for the development of new treatments and therapies for these patients. Various models of epilepsy, mostly in animals, provide researchers with an insight into the brains of those with epilepsy. Several models exist that can accurately display and mimic epilepsy, but each model works through a different mechanism. A few of these models will be discussed in this review: the kindling model of epilepsy via the use of pentylenetetrazole (PTZ), maximal electrical shock (MES), a chemoconvulsant model that uses kainate, viral induced models of epilepsy, and a brief discussion on the future genetic models of epilepsy. Each model has its advantages and disadvantages. Through this review, the model that best depicts epilepsy accurately and realistically will be decided upon. Kindling model The kindling model of epilepsy is the oldest known method for inducing epileptogenesis in animal models. Kindling involves repeated sub-convulsive stimulation, usually chemical induction via subcutaneous injections of pentylenetetrazole (PTZ), to induce partial and then later generalized seizures in animals. The induced seizures increase

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in duration, strength, and severity, just as seizures in progressive epilepsy do. Kindling can take weeks of inducing full motor seizures in order to produce an adequate model of epilepsy (3). It has been found that the kindling model of epilepsy can lead to rewiring of the neural circuitry and synaptic connections within the brain, particularly the hippocampal mossy fibers. Restructuring, inhibition, and density changes of the GABA and glutamate receptors within the brain have also been found to develop from the continual seizure activity (4). Advantages to using the kindling model of epilepsy are that it is a reliable and well established method for inducing epileptogenesis. Through established doses of electrical stimulation, a reliable and precise amount of damage can be induced in order to create epilepsy in a desired area of the brain, such as Temporal Lobe Epilepsy. The seizure activity generated is considered to be permanent. As Sato et al. have previously demonstrated in a study, the pattern of seizures along with the interictal, ictal, and postictal periods can be monitored and manipulated. The disadvantage to using the kindling model of epilepsy is that kindling is often time consuming and requires consistent and long term stimulations in order to produce the desired effect. The stimulations given must be very large and consistent in order to produce the desired epileptic model. This disadvantage can mean long term studies that may not be feasible under funding and time constraints. The neuronal loss with this model is also significant. Another disadvantage to the PTZ kindling model is that it mainly displays efficacy with petit mal seizures and the drugs that would help to prevent those seizures (i.e., GABAergic neurotransmission effectors and T-type Ca2+ channel effectors) (5). Other models have since been developed that are less time consuming to induce epilepsy. MES model Almost as well established as the kindling model of epilepsy is the MES model of epilepsy. This model, as well as the PTZ kindling model, are completed in neurologically normal mice. In the MES test, mice or rats receive an electrical stimulus of sufficient intensity to induce maximal seizures of their hind limbs, with tonic extension as the endpoint of the test (6). The MES test is inexpensive, well accept-

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ed, and requires minimal equipment to perform on large quantities of test subjects. However, the model only induces tonic-clonic seizures and only tests drugs that would be designed to prevent the spread this type of seizure. Epilepsy is not limited to tonic-clonic seizure presentation; it can include other types such as petit mal. Therefore, the MES test is limited to testing Na+ channel blocker drugs, which introduces a limitation for expanding the development of novel antiepileptic drugs. The main disadvantage of the MES test with supramaximal stimulation is that it does not detect anticonvulsant drugs, which increase the seizure threshold, but are not potent enough to raise the threshold above 50 mA (mice) or 150 mA (rats), although such drugs (e.g., ethosuximide) could be of clinical value. In addition, the MES test fails to identify drugs that are clinically effective in treating partial seizures; it does not distinguish between efficacies in the treatment of primarily and secondarily generalized tonic–clonic seizures, and it is not a good model for the identification of drugs for pharmacoresistant epilepsies (6). Chemoconvulsant model The next model of epilepsy is the chemoconvulsant model of epilepsy, in particular the kainate-induced model. In this case, animals are injected with a kainate solution, and seizures are monitored for an established number of hours post-injection. Seizures from this model are rated on a scale from one to five with five being the most severe— often including tonic, clonic motions. The kainate model induces epilepsy by mitochondrial superoxide production (7). The superoxide production causes damage to DNA and can lead mostly to hippocampal cell death. This neuronal loss is largely localized to the hippocampus because the CA3 neurons of the hippocampus are the most responsive to the kainate injection (8). The advantages to the kainate chemoconvulsant model include the singular injection that, within hours, can create seizures for epileptogenesis that become more severe and longer in duration for the extent of the experiment. Thus, there is less effort exuded to produce the same effects as the kindling model. There is also an accurate localization of the seizures that can be induced by a simple injection into the area of interest, usually the dentate gyrus or other localizations of the hippocampus (9). Another advantage to this model is that the oxidative damage and free radicals that are seen to cause the epilepsy can be somewhat reversed or subdued through the use of antioxidant agents (7). When the antioxidant agents are introduced into the system, the superoxides disappear and can no longer induce the DNA damage and hippocampal neuronal loss seen at the beginning of the experiment. This model could provide antioxidant therapies for alleviation of the oxida-

tive stress caused by the epileptic seizures. Disadvantages involve the risk of overdosing the kainate and therefore the possibility of a high mortality rate in the animals. The toxicity and restrictive use of specific chemoconvulsants such as kainate can be a greater problem than solution. Viral-induced models Lastly are the viral induced models of epilepsy. To date, there have been no reports of an animal model that displays overt long-term defects such as spontaneous recurrent seizures—the defining feature of epilepsy (10). Two viruses are known that have been proved to induce seizures. The first is the Theiler’s murine encephalomyelitis virus (TMEV) and the second uses human herpes virus 6B to induce the seizures. The TMEV model uses the virus, typically generated in rats and mice, and injects it into the region of interest. This particular virus causes inflammation, hence the encephalomyelitis, as well as oxidative stress, both of which lead to the induction of epilepsy. The oxidative stress is measured in reduced glutathione to oxidized glutathione ratios; the lower the ratio, the more oxidative stress is occurring. The paper by Bhuyan et al. discusses that the possible mechanism for this particular model of epilepsy is the role inflammation has in inducing the initial seizures. The repetitive induction of these seizures causes the oxidative stress, which leads to the neuronal damage and loss consistent with that seen in epilepsy (11). The inflammation is similar to the inflammation that occurs with an event such as traumatic brain injury, which has been seen to be a cause of acquired epilepsy. The oxidative stress produced is comparable to that seen in the kainate model. The human herpes virus 6B (HHV6B) is a very common childhood virus that could lead to central nervous system invasion. The virus can lay dormant until it becomes reactivated later in life in a situation involving immunocompromisation. The reactivation can lead to meningitis and encephalitis. The virus can also cause febrile seizures when first acquired. These febrile seizures, if they occur often enough, may eventually lead to status epilepticus and epilepsy because of the damage caused. (12). Although this is a new model and it is not well known, it appears to be realistic concerning human epilepsy. Advantages of using these two viruses to induce epilepsy is that they can model more realistic and relatable versions of epilepsy. Children and adults become infected with viruses every day. The latent and acute effects of the virus can model the onset of epilepsy as well as long term effects of epilepsy. The TMEV model provides a rapid onset of epileptic symptoms and seizures, and more importantly, the animals can clear the virus out of their systems within

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two weeks. Clearing the virus means no long term or third party effects from the virus and an extremely low animal mortality rate, while the epilepsy remains so that it can be observed for long term effects (11). The HHV6B model shows the latent effects of a virus that humans have been known to acquire. Unlike the TMEV model, the HHV6B stays in the animal's system for long periods of time and is difficult to clear on its own. This could potentially lead to a high mortality rate; however, it models a realistic situation of acquired epilepsy. Genetic models With frequent advances in research, there is the possibility that models for epilepsy will lead to genetically modified mice and rats that can most closely mimic the innate epilepsy that occurs in humans. Currently, there is little literature on genetic models in mice and rats for epilepsy. One of the prominent models so far is the Genetic Absence Epilepsy Rats from Strasbourg (GAERS). This model began with 30 percent of the Wistar rats from the initial breeding colony in the laboratory in Strasbourg that presented spontaneous spike and wave discharges (SWDs), which were bilateral and synchronous over the cerebral cortex. A strain in which all animals displayed SWDs was selected after several generations by selecting breeders with SWDs. This strain of rats has now been bred through 37 generations (13). However, this model is limited in that researchers have only been able to demonstrate absence seizure epilepsy and thus only have the ability to test GABAergic medications for treating epilepsy with this model. The second model of genetic absence epilepsy in mice is the WAG/Rij model. This model is similar to the GAERS rats in terms of the type of epilepsy these mice model. However, there are limitations with this model. In rats, absences appear after puberty and are maintained during life, while in humans seizures occur before puberty and then disappear or convert to more serious forms of epilepsy. There is also a large frequency difference of the spikes and waves in the discharge train: 8–10 Hz in the rat and 3 Hz in the human (14). Although there are still imperfections with these models, they show promise in developments for more accurate models of epilepsy that can be used for pharmacological research in the future.

CONCLUSION Overall, the literature supports the TMEV viral induced model of epilepsy. The extremely low mortality rate, accurate and localized effects within the brain, and the ability to show realistic and easily observable inflammation and oxidative stress, allows the virus to provide a way for researchers to grasp what exactly occurs in epilepsy in the both the acute and long term phases. Although it does have its disadvantages, the TMEV model appears to be the most feasible and most easily supported model of epilep-

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sy. The virus induced model can provide the means to develop new anticonvulsant drugs as well. With the pharmacoresistant population of people suffering from epilepsy, perhaps the oxidative effects of the virus and inflammation could provide insight into antioxidant and anti-inflammatory therapies for those who suffer from epilepsy.

REFERENCES 1. Gaitatzis A, Carroll K, Majeed A, Sander JW. The epidemiology of the comorbidity of epilepsy in the general population. Epilepsia. 2004 Dec 1;45(12):1613-22. 2. Morimoto K, Fahnestock M, Racine RJ. Kindling and status epilepticus models of epilepsy: rewiring the brain. Progress in neurobiology. 2004 May 31;73(1):1-60. 3. Mazarati A, Shin D, Auvin S, Sankar R. Age-dependent Effects of Topiramate on the Acquisition and the Retention of Rapid Kindling. Epilepsia. 2007 Apr 1;48(4):765-73. 4. Sato M, Racine RJ, McIntyre DC. Kindling: basic mechanisms and clinical validity. Electroencephalography and clinical neurophysiology. 1990 Nov 30;76(5):459-72. 5. Mandhane SN, Aavula K, Rajamannar T. Timed pentylenetetrazol infusion test: a comparative analysis with sc PTZ and MES models of anticonvulsant screening in mice. Seizure. 2007 Oct 31;16(7):636-44. 6. Castel-Branco MM, Alves GL, Figueiredo IV, Falcão A, Caramona MM. The maximal electroshock seizure (MES) model in the preclinical assessment of potential new antiepileptic drugs. 7. Liang LP, Ho YS, Patel M. Mitochondrial superoxide production in kainate-induced hippocampal damage. Neuroscience. 2000 Nov 15;101(3):563-70. 8. Ben-Ari Y, Cossart R. Kainate, a double agent that generates seizures: two decades of progress. Trends in neurosciences. 2000 Nov 1;23(11):580-7. 9. Williams PA, White AM, Clark S, Ferraro DJ, Swiercz W, Staley KJ, Dudek FE. Development of spontaneous recurrent seizures after kainate-induced status epilepticus. Journal of Neuroscience. 2009 Feb 18;29(7):2103-12. 10. Stewart KA, Wilcox KS, Fujinami RS, White HS. Development of postinfection epilepsy after Theiler's virus infection of C57BL/6 mice. Journal of Neuropathology & Experimental Neurology. 2010 Dec 1;69(12):1210-9. 11. Bhuyan P, Patel DC, Wilcox KS, Patel M. Oxidative stress in murine Theiler's virus-induced temporal lobe epilepsy. Experimental neurology. 2015 Sep 30;271:329-34. 12. Theodore WH, Epstein L, Gaillard WD, Shinnar S, Wainwright MS, Jacobson S. Human herpes virus 6B: a possible role in epilepsy? Epilepsia. 2008 Nov 1;49(11):1828-37. 13. Danober L, Deransart C, Depaulis A, Vergnes M, Marescaux C. Pathophysiological mechanisms of genetic absence epilepsy in the rat. Progress in neurobiology. 1998 May 1;55(1):27-57. 14. Coenen AM, van Luijtelaar EL. Genetic Animal Models for Absence Epilepsy: A Review of the WAG/Rij Strain of Rats. Behavior Genetics. 2003;6(33):635-55.

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Trochlear nerve schwannoma in a 57-year-old male presenting with vertical diplopia Leonard T. Walsh1, Robert V. Decker1, Michael D. Kim2

Geisinger Commonwealth School of Medicine, Scranton, PA 18509 Scranton Neurological Associates, PC, Scranton, PA 18510 *Correspondence: LWalsh@som.geisinger.edu 1

ABSTRACT

CASE PRESENTATION

Schwannoma of a cranial nerve is a rare condition accounting for 6-8% of intracranial neoplasms, with vestibular schwannomas being the most common. They are generally isolated lesions except in Neurofibromatosis Type 2, which can often present with bilateral vestibular schwannomas. Trochlear nerve schwannoma is an exceedingly rare benign tumor of the fourth cranial nerve of which there have only been 36 documented cases according to current literature. Lesion of the trochlear nerve will affect the superior oblique muscle on the side opposite its origin and may lead to vertical diplopia and/or torsional diplopia. We present a case of trochlear schwannoma identified on MRI following development of vertical gaze diplopia that resolved without intervention.

A 57-year-old male without a remarkable medical history presented with persistent diplopia for two weeks duration without eye pain, headache, or focal weakness. Two years prior, he experienced progressively worsening diplopia for two weeks, upon which he consulted ophthalmology. He reportedly had a negative workup, and his symptoms gradually resolved with no intervention. Upon his presentation to our office, he complained of vertical double vision, but this time the objects were slightly skewed and his symptoms improved with right head tilt. Neurologic examination revealed left-sided trochlear nerve palsy.

INTRODUCTION Schwannomas are encapsulated tumors composed of benign neoplastic spindle cells and arise from peripheral, cranial, and spinal nerves (1, 2). Intracranial schwannomas account for 8% of all primary brain tumors, and most arise from the sensory distribution of cranial nerves, particularly the vestibulocochlear nerve (CNVIII) (3). The next most commonly involved nerves are the trigeminal (CN V), and facial (CN VII) nerves, followed by the lower cranial nerves, which include the glossopharyngeal (CNIX), vagus (CN X), accessory (CNXI), and hypoglossal (CN XII) nerves. However, a rare subset of tumors can arise from the trochlear nerve (CN IV), a pure motor nerve. To our knowledge, only 36 cases of trochlear nerve schwannoma have been reported (4). In the majority of these cases, patients present with a history of diverse symptoms including hemiplegia, slurring of speech, headache, and vertical diplopia. We present a rare case of trochlear nerve schwannoma manifesting as vertical gaze diplopia that was identified by magnetic resonance imaging (MRI).

MRI studies of the entire brain were performed with a 1.2 Tesla Hitachi Oasis system and included sagittal T1-weighted, axial T1-weighted, T2-weighted, diffusion-weighted, fluid-attenuated inversion-recovery (FLAIR), and gadolinium-enhanced axial and sagittal T1-weighted images. Dedicated imaging through the level of the cavernous sinuses and orbits included unenhanced and fat-saturated enhanced axial T1-weighted images, axial T2-weighted images, coronal short-tau inversion-recovery (STIR) images, and gadolinium-enhanced fat-saturated coronal T1-weighted images. Studies disclosed an asymmetric focus of abnormal enhancement measuring 0.5 cm x 0.3 cm lateral to the brainstem along the expected course of the left fourth nerve (Figure 1). These findings are consistent with trochlear nerve schwannoma. CT angiography of the head was subsequently performed and multi-planar/3-D images were created to optimize visualization of vascular anatomy and exclude a vascular abnormality. This study disclosed no enhancing aneurysm lateral to the brainstem in the area of abnormal signal intensity on MRI. The remainder of the study was unremarkable. After discussion with the patient, the decision was made to proceed with observation alone due to the high incidence of permanent side effects associated with surgical intervention. The patientâ&#x20AC;&#x2122;s symptoms did come to a full resolution with observation alone, with no residual effects.

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ranged cells (Antoni Type A) mixed with regions of loosely arranged cells (Antoni Type B) (2). The T1-weighted image in our patient (Figure 1) demonstrates avid enhancement after contrast administration as expected for cranial nerve schwannoma. In the present case, an MRI of the brain without and with 20 mL of gadolinium was performed which demonstrated a 0.5 x 0.3 cm asymmetric focus of abnormal enhancement along the expected course of the left trochlear nerve immediately lateral to the brainstem, which was suggestive of a trochlear nerve schwannoma. This study was submitted for additional interpretation, which elaborated further upon the suspected lesion. This interpretation described a 0.4 x 0.2 x 0.3 mm avidly enhancing structure to the left of the pons/midbrain junction. There was no evidence of midline shift, herniation, or mass effect.

Figure 1. Axial T1-weighted brain MRI with gadolinium reveals an asymmetric focus of abnormal enhancement (arrow) lateral to the brainstem along the expected course of the left fourth nerve.

DISCUSSION Trochlear nerve schwannoma is a very rare intracranial tumor that has been reported in only 36 cases, according to our literature search. The first case of trochlear schwannoma was reported in 1976 by Kings and associates (5). According to a report published by Elmalem et al., patients typically present with initial symptoms of vertical diplopia (60%), hemiplegia (43%), headache (40%), and cerebellar signs (37%), such as ataxia, dysmetria, and nystagmus (6). Trochlear nerve palsy was detected in less than 50% of cases, and absence of diplopia in several cases could be due to gradual compensation by other extraocular muscles for the loss of superior oblique innervation (7).

A CT angiogram of the head with contrast and post-procession was also performed to exclude vascular abnormality. This test was negative for significant stenosis, enhancing aneurysm, acute intracranial hemorrhage, and acute territorial type infarct. Patients with benign cranial nerve IV lesions generally have good prognosis and should be followed with serial MRI scans without neurosurgical intervention unless they develop brainstem compression. Surgical intervention will nearly always cause permanent fourth nerve palsy. According to the literature review of Inoue et al., there have only been 32 cases of surgical excision of trochlear nerve schwannoma from 1976 to 2014, and only one patient showed improvement of diplopia after subtotal excision. Most patients developed permanent and complete fourth cranial nerve palsy postoperatively, highlighting the difficulty in removing these tumors without compromising cranial nerve function (10). Conservative treatment options typically include prism spectacles or observation (11). In our case, the patient’s symptoms resolved with observation.

Diplopia is a manifestation of extraocular muscle dysfunction, which may be the result of an abnormality of the muscle itself or a motor nerve lesion supplying the muscle. Vertical diplopia is the expected manifestation of a trochlear (CN IV) nerve lesion, due to dysfunction of the superior oblique (8, 9). In addition, our patient’s vision improvement upon head tilt is characteristic of fourth nerve palsy (6).

Conflict of Interest

Cranial nerve schwannomas have characteristic appearance on magnetic resonance (MR) imaging. On T1-weighted images, these lesions have low or intermediate signal intensity and demonstrate avid enhancement after contrast material administration, with or without nonenhancing cystic spaces. Larger lesions commonly have heterogeneous enhancement, cystic spaces, and foci of hemosiderin due to internal hemorrhage. On T2-weighted images, schwannomas appear heterogeneously hyperintense. This heterogeneity is attributed to regions of compactly ar-

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All authors certify that they have no affiliations with or involvement in any entity or organization with any financial interest or non-financial interest in the materials discussed in this manuscript. There are no financial disclosures. There is no conflict of interest.

1. Samadian, M., Farzin, N., Bakhtevari, M.H., Hallajnejad, M., Rezaei, O. Isolated trochlear nerve schwannoma presenting with diplopia: A case report and literature review. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 2015; 2:111. 2. Skolnik, A.D., Loevner, L.A., Sampathu, D.M., Newman, J.G., Lee, J.Y., Bagley, L.J., et al. Cranial nerve schwannomas: diagnostic imaging approach. Radiographics 2016; 36:2-3. 3. Pilavaki, M., Chourmouzi, D., Kiziridou, A., Skordalaki, A., Zaram-

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poukas, T., Drevelengas, A. Imaging of peripheral nerve sheath tumors with pathologic correlation: pictorial review. European Journal of Radiology 2004; 52:229-30. 4. Liu, P., Bao, Y., Zhang, W. Trochlear nerve schwannoma with repeated intratumoral hemorrhage. Journal of Craniofacial Surgery. 2016; 27:528. 5. King, J.S. Trochlear nerve sheath tumor: case report. Journal of Neurosurgery 1976; 44:245-47 6. Brazis, P.W. Palsies of the trochlear nerve: diagnosis and localizationâ&#x20AC;&#x201D;recent concepts. Mayo Clinic Proceedings 1993; 68:501. 7. Du R, Dhoot J, McDermott MW, Gupa N., Cystic schwannoma of anterior tentorial hiatus case report and review of the literature. Pediatric Neurosurgery 2003; 38:167-73 8. Brazis, P.W., Lee, A.G. Acquired binocular horizontal diplopia. Mayo Clinic Proceedings 1999; 74:907. 9. Brazis, P.W., Lee, A.G. Binocular vertical diplopia. Mayo Clinic Proceedings 1998; 73:55. 10. Inoue, T., Shima, A., Hirai, H., Suzuki, F., Matsuda, M. Trochlear nerve schwannoma treated with gamma knife after excision: a case report and review of the literature. Journal of Neurological Surgery Reports 2015; 76: 248-52 11. Elmalem, V.I., Younge, B.R., Biousse, V., Leavitt, J.A., Moster, M.L., Warner, J., et al. Clinical course and prognosis of trochlear nerve schwannomas. Ophthalmology 2009; 116:2015.

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Association of limited activity and the onset of arthritis among medicare recipients Nadia Maqsood1*, Michael Pheasant1, Chris Kropiewnicki1, David Jeffs1, Alexis Payne1, Kim Carrette1, Elizabeth Kuchinski1, and Mushfiq Tarafder1 Geisinger Commonwealth School of Medicine, Scranton, PA 18509 *Correspondence: NMaqsood@som.geisinger.edu 1

ABSTRACT Background: Arthritis is defined as joint pain or joint disease with symptoms including pain or inflammation of the joints, stiffness, and reduced motion (1). Arthritis is most prevalent in the aging population and approximately half of the US population over the age of 65 has arthritis. The disease affects 22.7% of all adults living in the United States and is the most common cause of disability in adults living in the United States. This number is projected to increase to 26% by the year 2040 (2). Other research studies have confirmed that arthritis leads to limited activity and that activity can reduce the severity of arthritis (3). The majority of prior research has examined how activity is affected or can affect arthritis after the onset of the disease (4). There is a lack of literature relating limited activity to the onset of arthritis. Methods: The Medicare Health Outcome Survey (MHOS) used a prospective cohort study design for data collection. The baseline survey was administered in 2011 and the follow up was conducted in 2013. The parent study sample included: Medicare beneficiaries over the age of 18 who were English speaking and/or Spanish and Chinese speaking in cases where translation was available. The secondary study sample exposure was defined as limited activity. This was derived by participants responding â&#x20AC;&#x153;yesâ&#x20AC;? to their health limiting their activity and having difficulty with the following: walking or climbing stairs or getting in and out of chairs. Participants that had arthritis at the baseline were excluded. The outcome was defined as reported arthritis in the follow up survey. Microsoft Excel and Epi Info 7 were used to analyze data. Proportions were calculated for categorical variables. For limited activity, odds ratio and relative risk were calculated. Odds ratio of limited activity stratified by gender was examined to identify potential effect modification. A multiple logistic regression was performed to examine the association between incidence of arthritis and limited activity after controlling for gender, age, race, marital status, and obesity.

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Results: Limited activity, gender, age, race and obesity were all determined to be risk factors. The risk of arthritis for individuals with limited activity is 1.59 times higher than the risk of arthritis for individuals without limited activity. The odds of arthritis for individuals with limited activity is 1.68 times higher than the odds of arthritis for individuals without limited activity. Gender was determined not to be an effect modifier or a confounder. However, it is a risk factor for arthritis. The risk of arthritis for female participants is 1.26 times higher than the risk of arthritis for males. The odds of arthritis for female participants is 1.31 times higher than the odds of arthritis for males. The risk of arthritis for individuals over the age of 75 is 1.06 times higher than the risk of arthritis in those who are under the age of 65. The odds of developing arthritis for individuals over the age of 75 is 1.39 times higher than for those who are under the age of 65. Therefore, being over the age of 75 years is a risk factor for arthritis and is also a confounding variable compared to participants under the age of 65 years. The risk of arthritis for Black/African American participants is 1.3 times greater than the risk of arthritis for White participants. The odds of arthritis for Black/African American participants is 1.32 times higher than the odds of arthritis for White participants. The risk of arthritis for those who identified as Other is 1.14 times greater than the risk of arthritis for White participants. The odds of arthritis for those who identified as Other is 1.23 times higher than the odds of arthritis for White participants. The risk of arthritis for obese participants is 1.45 times greater than the risk of arthritis for non-obese patients. The odds of arthritis for obese participants is 1.61 times higher than the risk of arthritis for non-obese patients. These risks and odds are all statistically significant based on the 95% confidence interval. The following factors were determined as not significant: marital status of participants and participants in the age category of 65 years old-74 years old. Conclusion: The exposure of limited activity is a risk factor for developing arthritis. This research informs prac-

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titioners of the risk of developing arthritis among individuals experiencing limited activity and could help lead to the development of prevention measures to ameliorate the onset of arthritis.

activities such as walking, gardening, bicycling, and using stairs. The only correlation the researchers found was that there was a statistically significant trend of higher leisure time physical activity associated with reduced risk of hip replacement in women (1).

INTRODUCTION

The majority of previous research has examined how activity is affected or can affect arthritis after the onset of the disease. During our review, however, we found that literature relating limited activity to the onset of arthritis was absent. Therefore, in this study we examined this gap to determine whether limited activity can be a risk factor for the onset of arthritis.

According to the National Arthritis Foundation, arthritis is defined as any type of joint pain or joint disease. There are numerous forms of the disease, the most common form being osteoarthritis. Other forms include rheumatoid arthritis and psoriatic arthritis. The symptoms of arthritis include pain or inflammation of the joints, stiffness, and reduced motion (2). Arthritis is most prevalent in the aging population with approximately half of the population over the age of 65 having arthritis (2). Thus, this field of study is becoming more important as the percentage of the US population over this age is projected to increase to 21.7% by the year 2040 (5). Arthritis is the most common cause of disability in adults living in the United States, where it affects 22.7% of all adults, although the percentage of affected adults is projected to increase to 26% by the year 2040 (6,7). 42.3% of the affected individuals have arthritis-attributable activity limitations (AAAL) (7). Therefore the importance of addressing arthritis treatment and prevention is evident. In the United States, arthritis affects more females than males, with 26% of females having arthritis compared to 18% of males having arthritis (2). In a study of 1,021 patients with osteoarthritis, those with arthritis of the knee had the most limited activity (4). Of those who participated, 546 patients were “insufficiently active” as compared to only 86 who were “highly active”. Furthermore, the data from this study indicated that of the participants, 674 were female as compared to 347 who were male. During our literature review, we assessed the correlation between activity and arthritis. Previous studies demonstrate that arthritis leads to limited activity (4). Some activities that are limited by arthritis include walking, stair climbing, rising from a chair, and other movements (3). In one study, the authors found that participants with osteoarthritis in the knee were significantly less active when compared to those with osteoarthritis of the hip (4). Studies also provide evidence that activity can reduce the severity of arthritis. In the study carried out by Ageberg et al. the effect of leisure time physical activity on severe hip or knee osteoarthritis was studied. Severe hip or knee osteoarthritis was defined as a knee or hip replacement due to osteoarthritic difficulties. This was a population-based, prospective cohort study with a baseline and follow-up survey assessing leisure time physical activity which included

Due to the significance of arthritis in the current US population, we sought to determine if limited activity is a potential risk factor for the onset of arthritis. The goal of this study was to determine if a correlation exists between limitations in activity due to health status and the onset of arthritis in either the hip or knee among Medicare recipients who participated in the Medicare Health Outcomes Survey (MHOS). We investigated the following specific aims as we were interested in the association between limited activity (our exposure for analysis) and outcome, and how it differs by gender. Our first specific aim was to determine whether there is a correlation between limited activity due to health status and the onset of arthritis in the hip or knee among Medicare recipients. Our hypothesis was that limited activity due to health status will have a positive correlation with the onset of arthritis. Our second specific aim was to determine whether the correlation mentioned in Aim 1, if it exists, varies by gender. We hypothesized that when compared with males, females will have a higher incidence of arthritis following limited activity.

MATERIALS AND METHODS Study design and description of human subjects The MHOS used a prospective cohort study design for the data collection. The baseline survey was administered in 2011 and a follow up survey was conducted in 2013. The survey was available to all Medicare recipients over the age of 18. The source population for the survey was all Medicare recipients, and the study population for the survey was all Medicare recipients over the age of 18 who willingly responded to the survey by completing it and returning it (8). Recruitment of participants and eligibility The MHOS selected participants through their Medicare Advantage Organizations (MAO). All MAOs that had at least 500 beneficiaries and had Medicare contracts before

Limited Activity and the Onset of Arthritis

January 1, 2010 were required by the Centers for Medicare and Medicaid Services to administer the baseline survey to all of their Medicare recipients. All MAOs that administered the baseline survey in 2011 were also required to administer the follow-up survey in 2013 (9). Beneficiaries under the age of 18 were excluded from the survey as well as Medicare recipients who did not speak English or for whom translation was not available. In some cases, translation was available for Spanish or Chinese speaking participants. If an MAO had under 500 beneficiaries, it was not required to administer the baseline. If an MAO had between 500 and 1,200 beneficiaries, all beneficiaries were given the survey. If an MAO had more than 1,200 beneficiaries, a simple random sample of 1,200 beneficiaries was given the survey. If an MAO had more than 3,000 beneficiaries, then the beneficiaries who responded to the previous year’s baseline survey were omitted before the simple random sample was chosen. Any participants who filled out the baseline survey and disenrolled from their MAO or were deceased before the follow-up survey was administered were excluded from the follow-up. The National Center for Quality Assurance (NCQA) notified each MAO that is required to participate and gave the MAO guidelines for administering the survey and handling the data according to the predetermined Quality Assurance Guidelines (QAG). Our study eligibility criteria included those participants who did not have arthritis at baseline and also met our exposure criteria outlined in the data analysis section below. Collection of data An NCQA certified survey vendor provided the participating MAOs with surveys that were administered according to the protocol specified in the Healthcare Effectiveness Data and Information Set (HEDIS) 2011 manual. The surveys were mailed to the participants. Surveys could have been completed in English, Chinese, or Spanish, provided that translation was available. The baseline MHOS contained 84 questions while the follow up survey contained 69 questions. MHOS questions included those that addressed demographics, activities of daily living and health status. For example, a question asked the participant to answer, “during the past four weeks, how much did pain interfere with your normal work?” on a Likert scale from 1-5 (9). After the surveys were mailed to the participants, the survey vendors would call participants who did not respond to the survey in order to obtain more responses. Vendors called up to six times if a survey was not sent back or was sent back incomplete. When calling participants, the vendors had a standardized computer-assisted telephone interviewing (CATI) script to collect the missing information. For the follow-up survey, once again the surveys were mailed to the participants. Those who did not respond

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were called to obtain more responses at a maximum of up to six calls (9). Costs, compensations, risks and confidentiality In the parent survey study participants were not compensated. Participant costs included the time it took to complete the study as well as the potential for psychological stress while answering sensitive survey questions. There was no further interaction with the study participants on this secondary study. As such, there was no further compensation or costs to participants. The risks of the parent study included possible violation of privacy due to the use and handling of respondent data. There were no additional risks to the human subject participants in our secondary study. Informed consent in the parent study was implicit when the study participant submitted a completed survey. The informed consent was made available in a letter that accompanied the survey. A survey was considered complete when the participant answered at least 79.5% of the survey and all six Activities of Daily Living questions (ADLs). Further consent was not required as no additional data was collected. In the parent study, participants were protected through modification of the public use file. There are 303,425 beneficiary records available in the file. In order to assure confidentiality, certain demographic and plan-level fields have been eliminated or modified for public view. These fields include social security number, name, and health insurance claim number, which were all removed from the public file and replaced with a randomly assigned nine digit identifier. This unique alphanumeric identifier was assigned to every beneficiary field and used to organize the data. This data was handled and stored in accordance with their predetermined quality assurance guidelines. In the secondary study, we maintained confidentiality by storing the de-identified data on password protected computers that was exclusively accessed by members of our research team. Data analysis plan The data for this study was obtained from the MHOS. Relevant fields of data were inserted into a Microsoft Excel spreadsheet. The two variables that we analyzed were limited activity and arthritis. From the MHOS baseline survey we extracted the exposure variable, limited activity, by including respondents who responded positively to having “limited activity due to health status”, and who also responded affirmatively to having difficulty in at least one of the following categories: walking, sitting down and standing up, and climbing stairs. Moreover, the respondents must not have been diagnosed with arthritis of the hip or knee at baseline. This was our eligibility criteria for exposed individuals.

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Nonexposed individuals were defined as those who responded with a “no” to having all of the above listed criteria. Respondents who reported having only moderate, and not significant limitations to activity or ability to walk, sit and stand up, or climb stairs were not included in either the exposed or nonexposed group. While these individuals experience some restrictions in lifestyle, we were only interested in study participants who were significantly exposed to limited activity. This was our eligibility criteria for nonexposed individuals. Once the exposure data was obtained, eligible participants were dichotomized into exposed and nonexposed groups as defined by our exposure criteria. Information was also extracted to exclude exposed and nonexposed individuals who had the outcome of interest at the baseline. This was done by excluding anyone who answered “yes” to having a physician-diagnosed arthritis of the hip or knee in the initial questionnaire. Individuals who exhibit the outcome variable of interest, arthritis, were defined as respondents among our study sample who indicated in the follow up survey that they have physician-diagnosed arthritis of the hip and or knee. According to this criterion, subjects were dichotomized into groups of outcome present or outcome absent groups. We also extracted information about the following potential confounding variables for each subject of our study: gender, age, race, marital status, and obesity (Figure 1).

Figure 1. Study demographics. After eliminating participants who did not fit our aforementioned inclusion criteria, the study population consisted of 72,088 participants who filled out the relevant portion of the survey. The study population consisted of 34,164 males (48.0%); 36,974 females (52.0%); 8,440 participants under the age of 65 (11.7%); 41,610 participants between the ages of 65-74 (57.7%); 22,038 participants over the age of 75 (30.6%); 53,751 participants who were not obese (76.3%); 16,703 participants who were obese(23.7%); 40,877 participants who were not married (57.7%); 29,953 participants who were married (42.3%); 59,247 participants who identified their race as White (85.8%); 5,397 participants who identified as Black/African American (7.8%); and 4,392 participants who identified their race as Other (6.4%). In addition, 12,965 participants reported having arthritis of the hip/knee in the follow-up survey (18.0%), and 59,123 participants reported not having arthritis of the hip/knee (82.0%). After applying our criteria for having limited activity, 8,948 participants met the criteria and were therefore categorized as having limited activity (12.4%) and 63,140 participants did not meet the criteria and were categorized as not having limited activity (87.6%).

Once this data was properly identified and all exclusions were applied, we calculated the incidence of arthritis in both the exposed and nonexposed populations. Once this calculation was performed, we obtained the relative risk of arthritis among individuals with limited activity by dividing the incidence of arthritis among exposed individuals by the incidence of arthritis among nonexposed individuals. We organized data using Microsoft Excel and performed data analysis using Epi info 7. Statistical significance of these measures was assessed by calculating the 95% confidence interval. In addition, we determined whether gender plays a role as an effect modifier of the incidence of arthritis by calculating stratified odds ratios. This was done by calculating the odds ratio for arthritis among male subjects and female subjects separately, then calculating a men versus women ratio.

The descriptive analyses that we conducted included univariate, bivariate, and multivariate analyses. For our univariate analysis we calculated the proportions of participants with arthritis in the follow up study (hereafter labelled as ‘arthritis after’), limited activity, gender, age, race, obesity, and marital status. For our bivariate analysis we analyzed the variables of limited activity and incidence of arthritis to obtain a relative risk, odds ratio, and confidence interval. We also conducted a bivariate analysis of the variables of gender, race, age, marital status, and obesity by arthritis to obtain crude odds ratio, relative risk, and 95% confidence interval where applicable. For our multivariate analysis we conducted a multiple logistic regression to find possible confounding variables in our study, which included gender, age, race, marital status, and obesity. The results obtained from our multivariate analysis were the crude odds ratio,

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arthritis in Medicare recipients. Limited activity was found to be a risk factor because the risk of arthritis for individuals with limited activity is 1.6 times higher than the risk of acquiring arthritis for individuals without limited activity (Figure 2). The odds of arthritis for individuals with limited activity is 1.68 times higher than the odds of arthritis for individuals without limited activity (Table 1). Therefore, limited activity is a risk factor for the onset of arthritis, and there is a significant association between limited activity and the onset of arthritis based on the 95% confidence interval.

Figure 2. Incidence of arthritis stratified by limited activity. Figure 2 shows the incidence of arthritis between the study population of participants with limited activity and the participants who did not have limited activity. Out of the 8,948 participants who had limited activity, 2,386 participants developed arthritis (27%) and 6,562 did not develop arthritis (73%). Out of the 63,140 participants who did not have limited activity, 10,579 participants developed arthritis (17%) and 52,561 did not develop arthritis (83%).

Figure 3. Incidence of arthritis stratified by limited activity and gender. A stratified bivariate analysis was done on the relationship between limited activity and incidence of arthritis stratified by gender in order to determine effect modification. The incidence of arthritis was 24% for males with limited activity and 29% for females with limited activity. The incidence of arthritis was 15% for males without limited activity and 19% for females without limited activity.

Gender was determined not to be an effect modifier or a confounder for the relationship between limited activity and arthritis, however, it is a risk factor (Figure 3). The adjusted odds ratio shows that the odds of acquiring arthritis for participants who identify as female are 1.31 times higher than the odds of a male acquiring arthritis. In addition, the risk of arthritis for female participants is 1.26 times higher than the risk of arthritis for males (Table 1). Based on the 95% confidence interval, these associations are statistically significant. Therefore, being a female is a risk factor for the onset of arthritis but does not significantly affect the relationship between limited activity and arthritis in this study. The risk of arthritis for individuals over the age of 75 is 1.06 times higher than those who are under the age of 65. For participants over the age of 75, the odds of acquiring arthritis is 1.39 times higher than the odds of participants under the age of 65 (Table 1). This relationship was found to be significant based on the 95% confidence interval values, and being over the age of 75 was also identified as a confounder based on the difference between our crude and adjusted odds ratio which was found to be 30.23%. Therefore, being over the age of 75 is a risk factor for arthritis and is also a significant confounding variable for the onset of arthritis.

RESULTS AND DISCUSSION

The risk of arthritis for individuals in the 65-74 age group was reduced by a factor of 0.82 of that used for participants in other age groups (Table 1). The 65-74 age group was also identified as a confounder for being less likely to acquire arthritis with the difference between the crude and adjusted odds ratios being 27.64%. However, based on the 95% confidence interval, the association between this age group and the onset of arthritis was not significant.

In our research, we found that limited activity, gender, age, race, and obesity are risk factors for the development of

The risk of arthritis for Black/African American participants is 1.30 times greater than the risk of arthritis for White par-

adjusted odds ratio, and 95% confidence interval.

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Table 1. Factors associated with incidence of arthritis. Our logistic regression analysis, Table 1, examined the outcome of arthritis in light of limited activity, gender, age, race, obesity, and marital status adjusting for all remaining variables as potential confounders. The adjusted odds ratio for limited activity was 1.68 (95% CI: 1.59, 1.78) and the relative risk was 1.59 (95% CI: 1.51, 1.65). The adjusted odds ratio for gender was 1.32 (95% CI: 1.2744, 1.3768) and the relative risk was 1.26 (95% CI: 1.22, 1.30). When examining the age ranges, 65 to 74 years old and 75 and older, the adjusted odds ratios were 1.00 (95% CI: 0.93, 1.07) and 1.39 (95% CI: 1.29, 1.49) respectively. The relative risk for the age range 65 to 74 years old was 0.82 (95% CI: 0.78, 0.86) and the relative risk for the age range of 75 years and older was 1.06 (95% CI: 1.00, 1.11). When examining the race categories, Black/ African American participants and those who classified themselves as Other, the adjusted odds ratios were 1.32 (95% CI: 1.23, 1.41) and 1.23 (95% CI: 1.13, 1.33) respectively. The relative risk for Black/ African American participants was 1.30 (95% CI: 1.24, 1.37) and the relative risk for those who classified themselves as Other, the relative risk was 1.14 (95% CI: 1.07, 1.21). The adjusted odds ratio for obesity was 1.61 (95% CI: 1.54, 1.69) and the relative risk was 1.45 (95% CI: 1.41, 1.50). The adjusted odds ratio for marital status was 1.03 (95% CI: 0.99, 1.07) and the relative risk was 0.90 (95% CI: 0.87, 0.92).

ticipants. The odds of arthritis onset for participants that identified as Black/African American were 1.32 times higher than the odds for participants who identified as White, while participants who identified as Other had a 1.23 higher odds of getting arthritis than White participants. The risk of arthritis for those who identified as Other is 1.14 times greater than the risk of arthritis for White participants (Table 1). Therefore Black/African American participants have a higher risk of developing arthritis compared to participants of other races. This finding was statistically significant based on our 95% confidence interval values but was not determined to be a confounding variable for the onset of arthritis.

The risk of arthritis for obese participants is 1.45 times greater than the risk of arthritis for non-obese patients. For participants who are in the obese category, the odds of arthritis onset are 1.61 times higher than the odds of arthritis onset in non-obese participants (Table 1). Based on the values of our 95% confidence interval, this finding is significant, but is not a confounder for the onset of arthritis. Therefore, being obese is a risk factor for arthritis compared to participants who are not obese but is not a confounder for the relationship between limited activity and the onset of arthritis. Marital status was determined not to be a confounder, but married participants had higher odds of getting arthritis

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than nonmarried participants. The odds of acquiring arthritis among married participants was 1.03 times higher than nonmarried participants, but based on the 95% confidence interval values, marital status was not statistically significant in the association between limited activity and the onset of arthritis. The risk of arthritis for married participants is reduced by a factor of 0.90 of that used for non-married patients (Table 1). However, based on the 95% confidence interval it is not significant.

study, additional research can be conducted to determine whether the outcome of arthritis incidence upon exposure to limited activity varies between osteoarthritis and rheumatoid arthritis. Research can also be conducted to study these variables in alternate populations and locations to enhance external validity.

These results support our first hypothesis of limited activity having a positive correlation with the onset of arthritis. However, our results for gender do not support our second hypothesis, because gender was determined not to be an effect modifier or confounder and did not significantly affect the relationship between limited activity and arthritis in this study. Our results for age are expected and align with the literature which indicates a higher prevalence of arthritis in the aging population compared to the younger population (2).

1. Ageberg E, Engström G, Verdier MGD, Rollof J, Roos EM, Lohmander LS. Effect of leisure time physical activity on severe knee or hip osteoarthritis leading to total joint replacement: a population-based prospective cohort study. BMC Musculoskelet Disord. 2012;13(73). 2. Arthritis Foundation [Internet]. (2011) [cited 2017 Apr 10] What is Arthritis? Available from: http://www.arthritis.org/about-arthritis/understanding-arthritis/what-is-arthritis.php 3. Pisters M, Veenhof C, Dijk GV, Heymans M, Twisk J, Dekker J. The course of limitations in activities over 5 years in patients with knee and hip osteoarthritis with moderate functional limitations: risk factors for future functional decline. Osteoarthritis and Cartilage. 2012;20(6):503-510. 4. Rosemann T, Kuehlein T, Laux G, Szecsenyi J. Osteoarthritis of the knee and hip: a comparison of factors associated with physical activity. Clinical Rheumatology. 2007;26(11):1811-1817. 5. CDC [Internet]. (2016) [cited 2017 Apr 10] Improving the quality of life for people with arthritis at glance 2016. Available from: http:// www.cdc.gov/chronicdisease/resources/publications/aag/arthritis. htm 6. U.S. Cancer Statistics Working Group [Internet]. (2013) [cited 2017 April 10] United States cancer statistics: 1999–2010 incidence and mortality web-based report. Atlanta, GA: US Department of Health and Human Services, National Cancer Institute. Available from: http://www.cdc.gov/uscs. 7. Barbour KE, Helmick CG, Theis KA, et al. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation-United States, 2010–2012. MMWR Morb Mort Wkly Rep. 2013; 62(44):869873. 8. Health Services Advisory Group. Medicare Health Outcomes Survey. Cohort 14 Analytic Public Use File Data User’s Guide. 20112013:2-50. 9. Healthcare Effectiveness Data and Information Set. Specifications for the Medicare Health Outcomes Survey. 2015:15-85.

The results of our study are limited according to the limitations of the MHOS study. The survey statistics are likely to be affected by many biases, including reporting bias, volunteer bias, and loss to follow up. Moreover, there is an inherent limitation of the study associated with defining the exposure variable of interest—limited activity. We used many variables to derive one possible interpretation of limited activity, but other interpretations are possible. Therefore, this data may not be reflective of all individuals with relevant limitations in activity. The findings of this study are significant in that they provide evidence to demonstrate that limited activity can lead to the onset of arthritis. Specifically, we found that exposure of limited activity is a risk factor for developing arthritis. However, despite being a risk factor for arthritis, gender was not found to be an effect modifier of limited activity’s effect on the incidence of arthritis. While there are limitations to this study, the results provide important implications in the realms of science and healthcare. This research informs practitioners of the risk of developing arthritis among individuals experiencing limited activity, such as hospitalized patients or disabled individuals. Furthermore, our findings may contribute to the informed development of prevention measures to ameliorate the onset of arthritis. The outcome of our research could potentially contribute to the knowledge surrounding potential arthritis risk factors which can impact future health care practices in the aging population. Based on the correlation between limited activity and the onset of arthritis, we can now recommend more activity in order to prevent arthritis and potentially impact the practices surrounding the aging population. Public health programs can be employed which increase activity in patients who might be at risk of developing arthritis and therefore can improve the patient’s health. In order to expand the impact of this

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REFERENCES

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Actin filament associated protein 1 (AFAP1) is an essential regulator of bone formation Holly Corkill1, Albena Gesheva2, Kier Blevins1, Broc Wenrich1, Evan Frigoletto1, Jess M. Cunnick1, John A. Arnott1* and Youngjin Cho1 Geisinger Commonwealth School of Medicine, Scranton, PA, 18509 University of Scranton, Scranton, PA, 18510 *Correspondence: JArnott@som.geisinger.edu 1

ABSTRACT

INTRODUCTION

Actin Filament Associated Protein 1 (AFAP1) is an actin filament crosslinking protein and an adaptor protein that can integrate signal inputs to specific cellular compartments or regulate actin cytoskeletal integrity. Although knowledge of the normal developmental role for AFAP1 and upstream and downstream signaling components/target genes involved in AFAP1 signaling has been limited, we recently investigated AFAP1 as a novel regulator of bone growth. We made the novel finding that AFAP1 is expressed in differentiating osteoblasts, is induced by TGF-Î˛1 and regulates expression of CCN2, an anabolic matricellular protein that regulates osteoblast differentiation and function. Using AFAP1 null mice (AFAP-/-) we demonstrated that these mice have low body weight, shortened limbs, reduced bone mineralization and impaired osteoblast growth, differentiation and function. Here, we report the micro CT analysis of AFAP1 null mice displaying a significant reduction in trabecular bone volume (BV/TV) in distal femurs of 4 week and 8-week-old female AFAP1-/- mice and a significant reduction in trabecular bone volume in lumbar vertebrate (L5) compared to wild type and heterozygote. Similarly, osteoblast specific null AFAP1 mice (Conditional knockout; CKO) display shortened limbs and reduction in body weight, and skeletal preparation of newborn CKO mice show defects in both intramembranous and endochondral ossification; hypo-mineralization in the frontal, parietal and occipital bones, widened fontanels and reduced ossification in several other bones including the mandible. Micro-CT analysis of CKO mice show delayed mineralization in calvarias with the presence of irregularly shaped gaps in calvarial sutures. Micro-CT analysis of 5-week-old tibia shows a reduction in trabecular bone volume and architecture in CKO mice compared to controls while the cortical thickness was relatively unaffected. Taken together, these results demonstrate that AFAP1 is important for normal skeletogenesis probably through control of osteoblast differentiation and function.

Actin filament-associated protein 1 (AFAP1, AFAP-110) is the prototypical member of a family of three structurally related proteins: AFAP1, AFAP1 like 1 (AFAP1L1), and AFAP1 like 2 (AFAP1L2, XB-130). AFAP1 was discovered over two decades ago as a binding partner for oncogenic Src (1). AFAP1 is a substrate of cSrc as well as Protein Kinase C (PKC) and harbors a binding site for PKC family members (2) and SH2 and SH3 binding motifs for cSrc (3, 4). AFAP1 regulates actin filament cross-linking (5), invadosome formation/stability (2, 6-8) and cell contractility (9). Thus one proposed role for AFAP1 is that it acts as an adaptor protein that directs the localization of kinases that regulate actin cytoskeletal organization (5, 10). AFAP1 is up-regulated in certain cancers and AFAP1 expression is associated with higher grades of prostate cancer (11). However the role of AFAP1 in development and normal physiology has remained as an area of active investigation. Genetic change of AFAP1 is linked to collagen degenerative disease in the eyes (12), systematic capillary leak syndrome (13) and thoracic aneurysms and dissections (14). However, knowledge of AFAP1â&#x20AC;&#x2122;s normal physiological or developmental function and its interacting signaling components is limited. Using AFAP1-/- null mice, we were the first to demonstrate a novel physiological role for AFAP1 in lactation (15). These studies demonstrated that AFAP1 is required for the spatial and temporal regulation of cSrc activity in the normal breast during lactation to establish copious milk production at parturition and specifically required for milk fat production (15). Although we are beginning to understand a physiological role of AFAP1 and its role in directing cSrc activity in the normal breast, potential roles for AFAP1 in other tissues and cells with abundant expression of AFAP1 have yet to be characterized. We have recently demonstrated that AFAP1 is highly expressed in osteoblasts and that this expression is up-regulated during specific times during bone formation (16), suggesting that AFAP1 may be important for osteogenesis.

AFAP1 and Bone Formation

Src is the founding molecule of a family of non-receptor tyrosine kinases that, when activated, are involved in numerous physiological and pathological processes including cell proliferation and matrix secretion (17-19), and Src can be activated downstream of the bone growth factor TGF-β1 (20, 21). We have previously demonstrated that TGF-β1 activates Src in osteoblasts and that Src and AFAP1 are required for TGF-β1 signaling (16). Further we found

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that AFAP1 expression is induced by TGF-β1 in osteoblasts and that the expression of the bone matricellular protein connective tissue growth factor (CCN2) was impaired using AFAP1 siRNA, indicating the requirement of AFAP1 for CCN2 induction by TGF-β1. Taken together this suggests that AFAP1 may play a role in bone formation or maintenance. Thus this study characterizes the potential role of AFAP1 in bone using AFAP1 knockout mouse models.

Figure 1. AFAP1-/- global null mice have low bone mass. The data show reduced bone observed in AFAP1 global null mice compared to the wild type control. (A) Micro-CT images of distal femurs from 4-week-old AFAP1-/- mice compared to AFAP1+/+ mice show decreased trabecular bone volume. Table 2: Percent bone volume (BV/TV) show 53% reduction in BV/TV of 4-week-old AFAP1 null compared to WT and 69% reduction from 8-week-old null mice compared to WT Note the significant reduction in BV/TV (highlighted row) (B) Representative Micro-CT images of lumbar vertebrate (L5) from 8-week-old female AFAP1+/+ and AFAP1-/- showing the reduction in bone mass and tissue mass in AFAP1 global null. (C) The percent bone volume (BV/TV %) were significantly lower in L5 vertebrate of AFAP1-/- compared to that of wild type (Box and whisker graph to show min, max, and average; n=6; p<0.05 with two-tailed t test).

Figure 2. Osteoblast specific AFAP1 conditional knockout mice (CKO) showed delayed ossification in calvaria. (A) Whole skeletal preparation of newborn pups revealed defects in intramembranous ossification in CKO and CHe compared to CWT. (B) Quantitation of the percentage of alizarin red stained area of fontanelle confirms the reduced ossification in CKO (C) Mandible length was also reduced in CKO compared to CWT mice (n=10 for each genotype, box and whisker graph to show max, min, and mean, * and ** mark p<0.05, one way ANOVA with Bon-Ferroni adjustment of multiple comparison) (D) Micro CT analysis of 8-week-old female skull showed delayed ossification in CKO and CHe leading to irregular suture closure of calvaria (marked as black arrowhead).

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Figure 3. Loss of AFAP1 in osteoblast lineage leads to reduced bone mass. (A) Representative Micro-CT images of proximal tibias from 5-week-old CKO showed reduction in trabecular bone when compared to that of CWT and CHe. (n=4, each genotype). The proximal end (starting at 1.5 mm distally from the most proximal part of the growth plate and continuing distally for 1.5 mm, marked upper red in the far left panel) were visualized and reconstructed in 3D. Anterior to posterior view and proximal-distal view of the same region is shown. Mid-shaft cortical bones (marked lower red in the left panel) were analyzed. (B) Percent BV/TV, calculated from micro-CT analysis, was lower in the bones of CKO (n=4, each genotype).

Table 1. AFAP1 mouse models

MATERIALS AND METHODS Generation of osteoblast specific AFAP1 conditional knockout (CKO; AFAP1fl/fl:osx-cre) mice The generation of AFAP1-/- global knockout animals and AFAP1 floxed animals (AFAP1fl/fl) in B6 background were reported by us (15). To selectively delete AFAP1 expression in osteoblasts, we mated AFAP1 fl/fl mice with Osterix-EGFP Cre mice (Osx Cre, Jackson Laboratory) in which the expression of EGFP Cre fusion protein is restricted to the osteoblast lineage (22). Both AFAP1fl/fl and Osx Cre were backcrossed to B6 background for 5 generations (15) prior to mating. Resulting AFAP1fl/+:OsxCre mice (Conditional Heterozygote; CHe) were then bred with AFAP1fl/fl mice to obtain AFAP1fl/fl: OsxCre (Osteoblast specific Conditional Knockout; CKO) mice at 25% frequency. AFAP1+/+ mice were mated with OsxCre mice to generate control AFAP1+/+:OsxCre (Conditional wild type; CWT). To discern influence of OsxCre expression on bone homeostasis (23-

25), either CWT or CHe mice were included in the analysis of skeletogenesis of CKO mice. All mice discussed in this manuscript are summarized in Table I. All mice utilized for analysis were matched for age and sex and were mostly littermates. Whole skeletal preparation Newborn pups were treated as described (26). Skeletal elements were visualized using a digital dissecting microscope (Zeiss) and total area staining positive for alizarin red was normalized to the area of whole skull using Image J. From images acquired, length and width of mandible is measured using Image J and expressed in an arbitrary unit (n=10, one way ANOVA with Bon-Ferroni adjustment of multiple comparison). For micro CT analysis, whole skull of 8-week-old female CWT, CHe, and CKO were prepared, fixed, and scanned with the following setting (60 kV, 167 uA, 0.5 mm aluminum filter, 0.7Â° rotation step, 4 frame averaging 2000 x 1336 CCD, 1200 msec exposure and 12 mi-

AFAP1 and Bone Formation

cron voxel size). Scans were reconstructed to optimize the visualization of bone tissue and depicted as a color-coded image based off the density distribution of sample. Micro-CT analysis Tibiae and lumbar vertebrate were prepared from age and sex matched, all female, littermates of AFAP1+/+ and AFAP1-/- mice. Micro-CT image acquisition and 3D constructions were performed at University of Texas Health Science Center San Antonio micro-CT facility as described (27, 28). For micro CT analysis of whole skull of 8-weekold female CWT, CHe, and CKO mice were prepared, fixed, and scanned with the following setting (60 kV, 167 uA, 0.5 mm aluminum filter, 0.7° rotation step, 4 frame averaging 2000 x 1336 CCD, 1200 msec exposure and 12 micron voxel size). Scans were reconstructed to optimize the visualization of bone tissue and depicted as a color-coded image based off the density distribution of the sample.

RESULTS AND DISCUSSION Impaired osteogenesis in AFAP1-/- and CKO mice AFAP1-/- mice have reduced weight gain and shorter tibia length at 8 weeks of age compared to the wild type (data not shown). Using micro-CT, we found a significant reduction in trabecular bone volume (BV/TV) in distal femurs of 4 week and 8-week-old female AFAP1-/- mice compared to wild type and heterozygote (Figure 1A, 53% reduction in 4 weeks and 69% reduction in 8 week old AFAP1-/- compared to the wild type). Significant reduction in trabecular bone volume was also observed in AFAP1-/- from lumbar vertebrate (L5) with micro-CT (Figure 1B). Similar reductions were seen from histological section of tibia and femur from neonate mice (unpublished data). Consistent with the global null mice, AFAP1 osteoblast specific null mice (CKO) displayed shortened limbs and reduction in body weight compared to wild type control mice expressing Osx EGFP Cre (CWT) (data not shown). The weight reduction in CKO was not due to dental malocclusion observed in the Osx EGFP Cre mice (23) as both CWT and CKO mice were supplemented with doxycycline to prevent the malocclusion (23) and fed a soft gel type diet. Further, the diet intake was comparable between CWT and CKO. Whole skeletal preparation of CKO newborn mice revealed defects in both intramembranous and endochondral ossification; hypo-mineralization in the frontal, parietal and occipital bones, widened fontanels (Figure 2A and 2B) and reduced ossification in several other bones including the mandible (Figure 2C) when compared to CWT and CHe. Delayed mineralization in calvarias of CKO was confirmed in micro-CT analysis of 5-weeks-old skull (not shown) and 8-weeks-old skull, with the presence of irregular shaped gaps in calvarial sutures (Figure 2D, marked with arrows). Micro-CT analysis of 5 weeks old tibia shows a reduc-

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tion in trabecular bone volume and architecture in CKO mice compared CWT and CHe mice (Figure 3A and 3B), while the cortical thickness was relatively unaffected (not shown). Taken together, this data provides evidence for the novel finding that AFAP1 is involved in bone formation. Bone homeostasis is maintained by the balanced activities of osteoblasts, osteocytes and osteoclasts. The function of AFAP1 in regulating any of these cell types has not been explored in detail except for its requirement in relaying TGF-β1 signals to induce CCN2 expression in osteoblasts, reported by us (29). Reduced bone mass in AFAP1-/- and CKO, paired with substantially higher expression of AFAP1 in osteoblast rather than osteoclasts, highly suggests that there is an inherent defect in osteoblast differentiation and function rather than in osteoclasts or osteocytes in these mice. Furthermore, delayed ossification in calvaria of CKO mice (Figure 2) suggests defects in MSC growth and differentiation in the absence of AFAP1, as intramembranous bone formation requires proliferation and osteogenic differentiation of MSC. This finding is of particular interest, because MSCs are an attractive candidate for clinical applications such as fracture repair and treatment of metabolic bone disease due to their ability to differentiate into bone and other multiple tissues and their availability from autologous adult tissue (30). Further detailed studies of the role of AFAP1 in MSCs, osteoblasts, osteocytes and osteoclasts are warranted to determine the precise contribution of AFAP1 to bone formation and/or maintenance.

REFERENCES 1. Flynn DC, Leu TH, Reynolds AB, Parsons JT. Identification and sequence analysis of cDNAs encoding a 110-kilodalton actin filament-associated pp60src substrate. Molecular and cellular biology. 1993;13(12):7892-900. 2. Qian Y, Baisden JM, Cherezova L, Summy JM, Guappone-Koay A, Shi X, et al. PC phosphorylation increases the ability of AFAP-110 to cross-link actin filaments. Mol Biol Cell. 2002;13(7):2311-22. 3. Guappone AC, Flynn DC. The integrity of the SH3 binding motif of AFAP-110 is required to facilitate tyrosine phosphorylation by, and stable complex formation with, Src. Mol Cell Biochem. 1997;175(12):243-52. 4. Guappone AC, Weimer T, Flynn DC. Formation of a stable src-AFAP-110 complex through either an amino-terminal or a carboxy-terminal SH2-binding motif. Mol Carcinog. 1998;22(2):110-9. 5. Qian Y, Gatesman AS, Baisden JM, Zot HG, Cherezova L, Qazi I, et al. Analysis of the role of the leucine zipper motif in regulating the ability of AFAP-110 to alter actin filament integrity. J Cell Biochem. 2004;91(3):602-20. 6. Baisden JM, Qian Y, Zot HM, Flynn DC. The actin filament-associated protein AFAP-110 is an adaptor protein that modulates changes in actin filament integrity. Oncogene. 2001;20(44):6435-47. 7. Gatesman A, Walker VG, Baisden JM, Weed SA, Flynn DC. Protein kinase Calpha activates c-Src and induces podosome formation via AFAP-110. Molecular and cellular biology. 2004;24(17):7578-97.

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8. Dorfleutner A, Cho Y, Vincent D, Cunnick J, Lin H, Weed SA, et al. Phosphorylation of AFAP-110 affects podosome lifespan in A7r5 cells. J Cell Sci. 2008;121(Pt 14):2394-405. 9. Lener T, Burgstaller G, Crimaldi L, Lach S, Gimona M. Matrix-degrading podosomes in smooth muscle cells. Eur J Cell Biol. 2006;85(3-4):183-9. 10. Qian Y, Baisden JM, Zot HG, Van Winkle WB, Flynn DC. The carboxy terminus of AFAP-110 modulates direct interactions with actin filaments and regulates its ability to alter actin filament integrity and induce lamellipodia formation. Exp Cell Res. 2000;255(1):102-13. 11. Zhang J, Park SI, Artime MC, Summy JM, Shah AN, Bomser JA, et al. AFAP-110 is overexpressed in prostate cancer and contributes to tumorigenic growth by regulating focal contacts. J Clin Invest. 2007;117(10):2962-73. 12. Takigawa M. CCN2: a master regulator of the genesis of bone and cartilage. Journal of cell communication and signaling. 2013;7(3):191-201. 13. Xie Z, Nagarajan V, Sturdevant DE, Iwaki S, Chan E, Wisch L, et al. Genome-wide SNP analysis of the Systemic Capillary Leak Syndrome (Clarkson disease). Rare diseases. 2013;1(1). 14. Prakash SK, LeMaire SA, Guo DC, Russell L, Regalado ES, Golabbakhsh H, et al. Rare copy number variants disrupt genes regulating vascular smooth muscle cell adhesion and contractility in sporadic thoracic aortic aneurysms and dissections. American journal of human genetics. 2010;87(6):743-56. 15. Cunnick JM, Kim S, Hadsell J, Collins S, Cerra C, Reiser P, et al. Actin filament-associated protein 1 is required for cSrc activity and secretory activation in the lactating mammary gland. Oncogene. 2014;0. 16. Arnott JA, Zhang X, Sanjay A, Owen TA, Smock SL, Rehman S, et al. Molecular requirements for induction of CTGF expression by TGF-beta1 in primary osteoblasts. Bone. 2008. 17. Aleshin A, Finn RS. SRC: a century of science brought to the clinic. Neoplasia.12(8):599-607. 18. Tang CH, Yang RS, Chen YF, Fu WM. Basic fibroblast growth factor stimulates fibronectin expression through phospholipase C gamma, protein kinase C alpha, c-Src, NF-kappaB, and p300 pathway in osteoblasts. J Cell Physiol. 2007;211(1):45-55. 19. Parsons SJ, Parsons JT. Src family kinases, key regulators of signal transduction. Oncogene. 2004;23(48):7906-9. 20. Sato M, Kawai-Kowase K, Sato H, Oyama Y, Kanai H, Ohyama Y, et al. c-Src and hydrogen peroxide mediate transforming growth factor-beta1-induced smooth muscle cell-gene expression in 10T1/2 cells. Arteriosclerosis, thrombosis, and vascular biology. 2005;25(2):341-7. 21. Tanaka Y, Kobayashi H, Suzuki M, Kanayama N, Terao T. Transforming growth factor-beta1-dependent urokinase up-regulation and promotion of invasion are involved in Src-MAPK-dependent signaling in human ovarian cancer cells. J Biol Chem. 2004;279(10):8567-76. 22. Rodda SJ, McMahon AP. Distinct roles for Hedgehog and canonical Wnt signaling in specification, differentiation and maintenance of osteoblast progenitors. Development. 2006;133(16):3231-44. 23. Wang L, Mishina Y, Liu F. Osterix-cre transgene causes craniofacial bone development defect. Calcified tissue international.

2015;96(2):129-37. 24. Huang W, Olsen BR. Skeletal defects in Osterix-Cre transgenic mice. Transgenic research. 2015;24(1):167-72. 25. Davey RA, Clarke MV, Sastra S, Skinner JP, Chiang C, Anderson PH, et al. Decreased body weight in young Osterix-Cre transgenic mice results in delayed cortical bone expansion and accrual. Transgenic research. 2012;21(4):885-93. 26. Ivkovic S, Yoon BS, Popoff SN, Safadi FF, Libuda DE, Stephenson RC, et al. Connective tissue growth factor coordinates chondrogenesis and angiogenesis during skeletal development. Development. 2003;130(12):2779-91. 27. Harris SE, MacDougall M, Horn D, Woodruff K, Zimmer SN, Rebel VI, et al. Meox2Cre-mediated disruption of CSF-1 leads to osteopetrosis and osteocyte defects. Bone. 2012;50(1):42-53. 28. Bouxsein ML, Boyd SK, Christiansen BA, Guldberg RE, Jepsen KJ, Muller R. Guidelines for assessment of bone microstructure in rodents using micro-computed tomography. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2010;25(7):1468-86. 29. Cho Y, Silverstein R, Geisinger MT, Martinkovich S, Corkill H, Cunnick JM, et al. AFAP1 Is a Novel Downstream Mediator of TGF-beta1 for CCN2 Induction in Osteoblasts. PLoS One. 2015;10(9):e0136712. 30. Augello A, De Bari C. The regulation of differentiation in mesenchymal stem cells. Human gene therapy. 2010;21(10):1226-38.

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Noninvasive plasma biomarkers show increased accuracy for detection of Alzheimer’s disease Matthew Weirich1*

Geisinger Commonwealth School of Medicine, Scranton, PA, 18509 *Correspondence: MWeirich@som.geisinger.edu 1

ABSTRACT Alzheimer’s disease is a neurodegenerative disorder that causes severe dementia and deterioration of the brain. Since there is currently no treatment to halt the progression of Alzheimer’s Disease, it is crucial to detect Alzheimer’s in its earliest stages in order to begin treatments immediately and maximize the potential for desired patient outcome. Literature published regarding this topic suggests that rather than performing a spinal tap to retrieve cerebral spinal fluid to conclude an Alzheimer’s diagnosis, new plasma biomarkers should be used instead. Different proteins, microRNAs, and gene expression markers have recently been described as the agents for these novel detection methods. By utilizing blood analyses of Alzhimer’s patients and comparing their plasma to that of control patients who are cognitively healthy, it is possible to determine whether plasma biomarkers are present to help with determining a diagnosis. Published literature has shown that due to cost and accuracy, testing a patient that is showing early signs of cognitive impairment for presence of the protein biomarkers should be the first step. Due to the recency of these discovieries, some current studies are reporting contradicting results. For this reason, protein biomarkers should be tested alongside other markers as well. There should be subsequent testing for microRNAs and gene expression markers if indicated, and if there is still inconclusive evidence, a spinal tap could be performed for diagnosis. This review examines the utility of these biomarkers as possible detection methods for Alzheimer’s Disease.

INTRODUCTION Alzheimer’s disease (AD) is the most common form of dementia that exhibits deterioration of the brain and is caused by the improper misfolding of Amyloid beta (Aβ) and tau (1). Improper folding of Aβ and tau leads to changes in the three-dimensional conformations of the proteins, which results in protein aggregations and the formation of clusters (1). Once these clusters begin to develop in regions of the brain, they recruit other proteins to misfold as well, creat-

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ing plaques of Aβ and tangles from twisted tau proteins (2). As more plaques and tangles are produced, they begin to occupy specific areas in the brain, consequently blocking communication between neurons and resulting in brain degeneration and the onset of dementia. Currently, the only true diagnostic procedure for AD is done by performing a spinal tap in order to retrieve cerebrospinal fluid (CSF) to measure the levels of Aβ and phosphorylated-tau (p-tau) (3). The problem with conducting a spinal tap for suspected symptoms of AD is its highly invasive nature due to the retrieval of CSF via a large needle inserted into the lower lumbar region of the patient. A spinal tap may yield pain and discomfort around the area for a few days and is not done as a preclinical screening for AD due to the invasive nature (4). Recent studies have shown that measuring the levels of certain proteins, gene expression markers, and microRNAs (miRNAs) in the circulating plasma has the potential to reveal whether or not an individual has AD or is at risk to develop it in the near future. This review will examine the potential of early AD detection methods by way of noninvasive screening using plasma rather than CSF. Plasma biomarkers Biomarkers for diseases, particularly AD, have been shown to include protein, miRNAs, and gene expression levels in the circulating blood plasma. By utilizing quantitative analysis techniques, even low levels of these circulating biomarkers can be evaluated. The results can then conclude a possible diagnosis or predict that a patient may be diagnosed in the future. In recent years, the most commonly studied biomarker has been protein, with a focus on Aβ40 and Aβ42, to conclude an AD diagnosis. Since these are the markers for the Aβ plaques in the brain and their concentrations change significantly in CSF, it was believed that they would also show trace concentration changes in the blood (5). Studies, however, have returned inconsistent results regarding this theory, resulting in an increase of Aβ studies and the search for novel protein biomarkers in recent years (6).

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Aβ40/42 Kim et al. looked into determining whether the Aβ42 and Aβ40 concentrations could be considered a possible diagnostic plasma biomarker for AD (5). The study analyzed plasma from 100 early-onset AD (EOAD) without familial AD genetic markers and 46 age-matched control individuals that displayed normal cognitive function. Their research findings concluded that Aβ42 concentrations in the plasma were decreased significantly and the ratio of Aβ40/Aβ42 was higher for EOAD patients compared to the normal controls (5). The results from this study indicated that these two biomarkers and their ratios have the ability to predict AD with 70% sensitivity and 68% specificity (5). In order to test the variability of Aβ40 and Aβ42 over the progression of AD, Seppälä et al. conducted a longitudinal study of 52 congnitively impaired subjects and 217 control subjects (7). Baseline measurements were taken for all individuals, and plasma protein samples were taken at 3 and 6 years after the initial plasma collection for a sub-

set (N=70; 59 Cognitive Healthy, 11 Cognitive Impaired) of the total individuals. Out of all the subjects, those that declined cognitively during subsequent follow-ups showed decreased levels of Aβ42 in their plasma compared to individuals that remained at stable cognitive function (Table 1) (7). The conclusion that decreased Aβ42 correlates to an increase in cognitive impairment over time correlated with the findings from Kim et al. which indicate that monitoring Aβ concentrations in the plasma overtime may result in a potential preclinical AD biomarker (5). Other novel protein biomarkers Agarwal et al. took a different investigatory approach by narrowing down 120 proteins discovered to have concentration changes within AD patients compared to control individuals to a subset of just nine proteins (8). Looking at 47 AD subjects and 11 control individuals, they predicted AD by the concentrations of nine specific proteins (FAS, IL-11, GCSF, IL-3, IL-1a, TNF-a, RANTES, PDGF-BB, TGF-b) with 90.25% validation accuracy (8).

Table 1. Cognition and changes of Aβ between baseline and follow-ups in subjects (Reprinted with permission [7]).

Noninvasive Plasma Biomarkers for Alzheimer’s Disease

Alternatively, Sattlecker et al. quantified over a thousand proteins in blood plasma in order to check for up- or downregulation of proteins in response to 90 AD patients, 76 mild cognitive impairment (MCI) subjects, and 69 healthy individuals (9). The study used an assay called a SOMAscan to quantify low concentrations of proteins in the blood. This allowed for an effective analysis of the levels of proteins thought to have slight modification changes. The researchers concluded that proteins belonging to the complement cascade, a component of the innate immune response, increased significantly in patients who declined rapidly from MCI to AD over a year long period (9). Based on this data, Sattlecker et al. believe that monitoring complement cascade proteins may serve as a biomarker not only for the progression of AD, but also for possible early detection of AD, which may lead to modifications of drugs used to treat AD. While numerous protein plasma biomarkers have been discovered, the possibility that thousands of others have not yet been detected or that the biomarkers already studied are altered differently in patients at varying levels of cognitive decline still remains. In order to better understand the diagnostic possibilities of protein plasma biomarkers, more research in the field is needed. Gene expression markers As genomic technology and research has advanced in the last decade, cheaper mapping of individual genomes has become possible. This has led to investigating gene expression alteration as a possible AD diagnostic biomarker. Fehlbaum-Beurdeley et al. performed a genome-wide association study (GWAS) on 150 total individuals (80 AD, 70 controls) and found 133 novel genes that distinguished AD from control patients (10). The genes discovered were found to be a part of macrophage and lymphocyte interactions, similar in nature to the proteins that Sattlecker et al. found interacted with the complement cascade of the immune system (9-10). However, with the Fehlbaum-Beurdeley study, the 133 genes associated with AD showed a sensitivity of 100% and a specificity of 96% when comparing AD patients to healthy control patients (10). Booji et al. also conducted a GWAS on 94 AD and 94 control patients and was able to develop an algorithm that can be used to classify individuals as AD (positive test result) or not having AD (negative test result) (11). The algorithm was designed using 1,239 probes in the genome and was run on healthy controls, as well as patients with known AD and associations between specific genes and their expression levels were aquired. The results were shown to be 87% accurate, with a sensitivity of 84% and a specificity of 91% when comparing AD patients to healthy control individuals simply based on gene expression markers from the GWAS (11). The modern day ease in sequencing a genome has

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opened up a whole new area of study regarding the identification of the pathology behind diseases and how they progress in the human body. While there has not been a substantial amount of published literature focusing on gene expression, it is an area of future research. MicroRNA (miRNA) An up-and-coming approach to possibly detecting AD in blood at earlier time points in the course of the disease is by utilization of miRNAs and detecting whether they are up- or down- regulated. Tan et al. conducted a study on 105 potential AD patients and 150 controls and found dysregulation of 3 miRNAs in their serum (miR-125b, miR-181c, and miR-9) (12). Using real-time reverse transcriptase polymerase chain reaction (qRT-PCR), it was found that miR125b and miR-181c were down-regulated while miR-9 was up-regulated in AD patients when compared to control patients. The results also showed that they were able to predict AD patients from controls using only miR-125b with 68.3% specificity and 80.8% sensitivity (12). Geekiyanage et al. also concluded that miR-181c was down-regulated in AD patients compared to control patients, but also found significant down-regulation in miR137, miR-9, miR-29a, and miR-29b (both P<0.05, student’s t test and Mann-Whitney test) (13). Their result showing down-regulation of miR-9 differed from the results of Tan et al. which reported an up-regulation of miR-9 (12). The differences in these findings is a source of error related to the use of miRNAs as biomarkers for potential disease diagnoses. Other sources of error surface because levels can fluctuate based on individuals or because of error in collection and processing of the RNA (6). Other studies also reported dysregulated miRNAs when comparing AD patients’ plasma to controls. Bekris et al. used qRT-PCR to conclude that miR-370, miR-328, miR138, miR-132, and miR-15 had altered concentrations levels in AD patients’ plasma. An increase in miR-15 levels was associated with greater concentrations of neurotic plaques in the brain post-mortem, signifying that plasma components were indicative of disease progression in the brain (6). Leidinger et al. found 12 miRNAs (miR-1285, miR-107, miR-103a, miR-26a, miR-26b, miR-let-7f, miR-let7d, miR-532, miR-151a, miR-161, miR-112, and miR-5010) concentrations in the blood samples of 48 AD patients and 22 controls that were able to distinguish between diseased and healthy individuals (14). These 12 miRNAs differentiated between AD and control samples with 93% accuracy, 95% specificity, and 92% sensitivity (14). Hodges et al. conducted a smaller study on 48 individuals (24 AD, 24 controls) and found that miR-186 exhibited a two-fold significant decrease (p=0.03) in AD patients’ plasma compared to the controls (15). While this was a smaller sample size, the data suggested that alterations in concentrations of specific miRNAs could be indicative of an AD diagnosis.

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DISCUSSION

REFERENCES

Recent research studies have shown that there is potential for noninvasive plasma biomarkers to predict whether an individual has AD or is at risk for AD. The varying concentrations of Aβ40 and Aβ42, along with other proteins involved in the innate immune response, have shown strong accuracy and specificity when comparing AD patients to control patients (5, 7-9). Other studies have looked into potential gene expression biomarkers that could be utilized as diagnostic components using GWAS (10-11). Along with protein and gene expression, miRNAs have been researched and correlations between dysregulated specific miRNA have been discovered (6, 12-13, 14-15). These novel approaches for AD diagnosis point in the direction that a noninvasive test, such as measuring plasma contents, may be possible in the near future to eliminate the need for spinal taps to retrieve CSF in order to diagnose AD.

1. Ashraf GM, Greig NH, Khan TA, Hassan I, Tabrez S, Shakil S, et al. Protein misfolding and aggregation in Alzheimer's disease and type 2 diabetes mellitus. CNS Neurol Disord Drug Targets. 2014;13(7):1280-93. 2. Alzheimer’s Association [Internet]. Chicago: Alzheimer’s Association; c2016 [cited 2016]. Available from: http://www.alz.org. 3. Zafari S, Backes C, Meese E, Keller A. Circulating Biomarker Panels in Alzheimer's Disease. Gerontology. 2015;61(6):497-503.   4. Fu Y, Zhao D, Yang L. Protein-based biomarkers in cerebrospinal fluid and blood for Alzheimer's disease. J Mol Neurosci. 2014 Dec;54(4):739-47. 5. Kim HJ, Park KW, Kim TE, Im JY, Shin HS, Kim S, et al. Elevation of the Plasma Aβ40/Aβ42 Ratio as a Diagnostic Marker of Sporadic Early-Onset Alzheimer's Disease. J Alzheimers Dis. 2015;48(4):104350 6. Bekris LM, Lutz F, Montine TJ, Yu CE, Tsuang D, Peskind ER, et al. MicroRNA in Alzheimer's disease: an exploratory study in brain, cerebrospinal fluid and plasma. Biomarkers. 2013 Aug;18(5):455-66. 7. Seppälä TT, Herukka SK, Hänninen T, Tervo S, Hallikainen M, Soininen H, et al. Plasma Abeta42 and Abeta40 as markers of cognitive change in follow-up: a prospective, longitudinal, population-based cohort study. J Neurol Neurosurg Psychiatry. 2010 Oct;81(10):1123-7. 8. Agarwal S, Ghanty P, Pal NR. Identification of a small set of plasma signalling proteins using neural network for prediction of Alzheimer's disease. Bioinformatics. 2015 Aug 1;31(15):2505-13. 9. Sattlecker M, Khondoker M, Proitsi P, Williams S, Soininen H, Kłoszewska I, et al. Longitudinal Protein Changes in Blood Plasma Associated with the Rate of Cognitive Decline in Alzheimer's Disease. J Alzheimers Dis. 2016;49(4):1105-14. 10. Fehlbaum-Beurdeley P, Jarrige-Le Prado AC, Pallares D, Carrière J, Guihal C, Soucaille C, et al. Toward an Alzheimer's disease diagnosis via high-resolution blood gene expression. Alzheimers Dement. 2010 Jan;6(1):25-38. 11. Booij BB, Lindahl T, Wetterberg P, Skaane NV, Sæbø S, Feten G, et al. A gene expression pattern in blood for the early detection of Alzheimer's disease. J Alzheimers Dis. 2011;23(1):109-19. 12. Tan L, Yu JT, Liu QY, Tan MS, Zhang W, Hu N, et al. Circulating miR-125b as a biomarker of Alzheimer's disease. J Neurol Sci. 2014 Jan 15;336(1-2):52-6. 13. Geekiyanage H, Jicha GA, Nelson PT, Chan C. Blood serum miRNA: noninvasive biomarkers for Alzheimer's disease. Exp Neurol. 2012 Jun;235(2):491-6. 14. Leidinger P, Backes C, Deutscher S, Schmitt K, Mueller SC, Frese K, Haas J, Ruprecht K, Paul F, Stähler C, Lang CJ, Meder B, Bartfai T, Meese E, Keller A. A blood based 12-miRNA signature of Alzheimer disease patients. Genome Biol. 2013 Jul 29;14(7):R78. 15. Hodges AK. Wong G, Lunnon K, Lovestone S. Plasma microRNA: A new source of biomarker for Alzheimer's disease. Alzheimer's & Dementia: The Journal of the Alzheimer's Association, Volume 6 , Issue 4 , S510

The current literature has potential to eliminate CSF collection to conclude an AD diagnosis, or at least limit spinal taps for only verification purposes if biomarkers prove inconsistent. However, one biomarker alone may not be sufficient or accurate enough to be the sole diagnostic component due to the possibility of false positives and negatives. The primary reason for this uncertainty lies in the fact that results tend to be inconsistent, even when comparing the results from one study to another for the same target (5). This inconsistency arises due to the fact that the concentrations of these specific novel plasma biomarkers are sometimes present in trace amounts and difficult to detect (9), or there are other factors also influencing the concentrations that are not being addressed (12). Relying on one specific biomarker target, whether it be a protein, gene expression regulator, or miRNA would not be sufficient. However, combining a few of the aforementioned biomarkers, and reaching a theoretical threshold in concentrations or percent of variation from baseline results over a period of time could have the ability to confirm a diagnosis and account for false positive and false negative results (7). A type of tiered system should be established wherein once a patient begins to show signs of cognitive decline, these types of biomarker studies would be conducted. Initially starting with protein levels seems to be the most convienent, and so far has proven to be the most reliable since Aβ40/42 levels are what CSF analyses are utilizing for AD diagnosis. If levels show signs of possible AD, then a panel of miRNAs or gene expression markers could be tested. If there are still discrepancies, then a spinal tap should be performed to collect CSF for a diagnosis.

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Evolution of multiple movement disorders as complications of anoxic brain injury: A case report Jee Moon1* and Thomas Watanabe2

Geisinger Commonwealth School of Medicine, Scranton PA, 18509 Moss Rehab, Elkins Park, PA 19027 *Correspondence: JMoon@som.geisinger.edu 1

ABSTRACT

Case Description

Acute brain injury (ABIs) is a type of acquired brain injury that has varied clinical presentations. We present a patient who developed complications of an ABI from respiratory arrest. Imaging revealed bilateral basal ganglia lesions, and he was admitted to acute inpatient rehabilitation after a four-week, acute hospital stay to address deficits in cognitive and physical functions. He was subsequently discharged to a skilled nursing facility. Over several months, his clinical course was complicated by evolving movement disorders, leading to severe contractures involving all extremities as well as oro-motor difficulties, leading to a subsequent acute inpatient rehabilitation stay. Interventions included bilateral lower extremity (LE) tendon releases and serial casting of upper and lower extremities, tracheostomy due to tongue dystonia, which compromised his airway, and temporomandibular joint (TMJ) surgery to address chronic jaw dislocation. Rehabilitation addressed deficits in communication and dysphagia due to dystonia of jaw, oropharyngeal muscles and tongue. With improved LE range of motion, training progressed to transfers and ambulation. Due to severe limitations in upper extremity (UE) motor control, rehabilitation focused on preventing skin breakdown and pain. Severe dystonia prevented use of high tech eye gaze communication devices, but he was able to use an alphabet and communication board with eye gazing.

P.H. is a 24-year-old Caucasian male who was admitted to an acute care hospital with a chief complaint of shortness of breath/respiratory arrest secondary to Asthma. He sustained a cardiac arrest, leading to a severe anoxic brain injury. Imaging demonstrated bilateral basal ganglia lesions (Figure 1). He was sent to therapy for further evaluation. Early physical assessments showed abilities to turn his head, mouth words, some upper extremity (UE) (elevate right shoulder, flex right digits) and lower extremity (LE) movement (moved toe wiggling and heel slides). He quickly developed UE contractures. Initially, he was able to eat pureed foods and drink thin liquids. Cognitively, he demonstrated evidence of responsiveness and command following through eye movements such as raising upper eyelids and blinking to answer simple “yes” or “no” questions. After movement to a skilled nursing facility and continued physical, occupational, and speech therapies as well as an intrathecal baclofen trial in the 8 months follow-

INTRODUCTION Traumatic brain injury (TBI) is something that impacts 1.7 million Americans annually, with a majority of them going untreated due to their lack of external symptoms. Even so, TBIs estimate about $76.5 billion per year, ranging from $85,000 to $3 million in average lifetime costs (1). The causes of TBIs range from a variety of factors that differ by age group. Many TBIs occurring between ages 5 to 64 involve motor vehicle accidents or self-inflicted wounds, while after age 65, 54% are caused by falls (2). Figure 1. CT of bilateral basal ganglia

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Anoxic Brain Injury

ing the injury, he was admitted to acute inpatient rehabilitation for further evaluation and treatment. He presented there with severe bilateral upper and lower extremity contractures of his legs including severe hip and knee flexion and hip adduction (Figure 2A and 2B), so he was referred early on to orthopedic surgery for post-operative casting and bracing to further improve LE range of motion (ROM). It was clear that he had lost significant mobility compared with his level of function at the end of his acute hospital stay. UE function was also severely compromised, and he was initially treated with botulinum toxin injections and serial casting with modest improvement. He later underwent UE orthopedic procedures to further improve ROM and function (Table 1).

Figure 2. (A) Initial presentation; (B) X-ray at presentation Procedure

Time Span

Left Hip Adductor Tenotomy

8 Months pi

Right Gluteus Maximus Tenotomy Right Tensor Fascia Latae Fasciotomy

Due to the extent of his physical deficits (aphonia and minimal use of extremities), it was very difficult to assess his level of cognition. From a motor standpoint, he was essentially “locked in” although not by the usual neurological lesion (bilateral pontine injury). He was most effective at using eye movement. A low-tech board consisting of “yes”, “no”, and certain letters on each corner to spell out words was used as a basic method of communication, showing moderate levels of success depending on the patient’s alertness. Furthermore, muscle contractures of his face, including his jaw and tongue, caused chronic TMJ dislocation with complications with his airway, necessitating a tracheostomy. He has continuously required a percutaneous endoscopic gastrostomy (PEG) for nutrition, medications, and hydration. He eventually underwent reconstructive surgery of his TMJ joint to allow some jaw movement and mouth closure. The LE procedures allowed him to improve significantly regarding mobility, from dependence for transfers and no ambulatory ability to minimal assistance for sit to stand and ambulation with moderate assistance. He is able to close his mouth and work on verbalization. He can now sit in a wheelchair without discomfort and is expected to being UE strengthening and functional use in the near future.

Bilateral SPLATT Bilateral Plantar Release

DISCUSSION

Bilateral Tendon Achilles Lengthening Coronoidotomy (failed)*

11 months

Temporomandibular Joint Reconstruction*

13 months

Arthrodesis Wrist Limited Without Bone Graft

14 months

Left Flexor Plasty Elbow Flexor Origin Slide Forearm/Wrist Shoulder Tenotomy Intrinsic Hand Muscle Release

Table 1. List of all surgical interventions (*represents TMJ interventions)

Neurological deficits after a hypoxic-ischemic injury are unpredictable and often quite debilitating. Additionally, hypoxic brain injuries may lead to delayed-onset features after months or even years (3). The basal ganglia is often a significant location for damage after cerebral hypoxia, vulnerable as a result of hypoperfusion or high oxidative metabolism (4). Basal ganglia damage has been linked to two major types of movement disorders: dystonia and akinetic-rigid syn-

Anoxic Brain Injury

drome (3). Dystonia presents with uncontrolled, asymmetric muscle contractions primarily in distal limbs, while the akinetic-rigid syndrome presents as Parkinsonian, identified with bradykinesia, micrographia, and tremors (5). These two syndromes can be found independently of each other or mixed, dependent on age and location of injury. Patients who developed akinetic-rigid syndrome only had an average age of 41 years, while those with dystonia only had an average age of 13.5, leading to the belief that age was a key component in determination of clinical outcomes after a basal ganglia lesion (3). Alternatively, the location of the damage has been noted to be of consequence, with the globus pallidus connected to akinetic-rigid syndrome and the putamen for dystonic syndromes (3). Even with statistical evidence that suggest certain patterns with brain injuries, there is still an enormous spectrum of symptoms that make prognosis extremely difficult (3, 5). Functional outcomes after hypoxic-ischemic injury have been quite varied as well, with a majority of patients remaining in a vegetative coma (9%) or passing away (64%). The most important factor for function and ability is the duration of global ischemia, with most survivors having minimal neurological dysfunction if the duration is short. For those with longer episodes of hypoxia, 60% of people demonstrated cognitive deficits after 3 months and 48% after a year (4). While memory and speech were the most difficult functions to recover, it was noticed that some patients with hypoxic-ischemic amnesia demonstrated fairly intact, functional short-term memory, further adding to the discrepancies of hypoxic injuries (3).

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not mean lack of function. This patient’s history and progress proves that every patient deserves the fullest of everyone’s attention for the sake of the patient’s well being.

REFERENCES 1. Facts about Traumatic Brain injury [Internet]. Investment in research saves live and money. Research America; [cited 2017Jun23]. Available from: http://www.researchamerica.org/sites/default/files/ uploads/TBI.pdf 2. Traumatic Brain Injury & Concussion [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2016 [cited 2017Jun23]. Available from: https://www.cdc. gov/traumaticbraininjury/data/dist_death.html 3. Venkatesan A, Frucht S. Movement Disorders after Resuscitation from Cardiac Arrest. Neurologic Clinics. 2006;24(1):123-132. 4. Khot S, Tirschwell D. Long-Term Neurological Complications after Hypoxic-Ischemic Encephalopathy. Seminars in Neurology. 2006;26(4):422-431. 5. Lu-Emerson C, Khot S. Neurological Sequelae of Hypoxic Ischemic Brain Injury. NeuroRehabilitation. 2010;26:35-45.

PH was selected because of the “typically untypical” nature of his condition’s progress, which made it a good case for learning. The severity of his spasticity and contractures, although common problems in TBIs, presented to a much greater degree compared to other TBI patients. Furthermore, not only did he undergo a very extensive number of interventions, he also presented with a positive response to these interventions—a factor that varies from patient to patient. His recovery and intervention scheme made PH an extremely interesting case to view and study as a student.

CONCLUSION Hypoxic ischemic brain injuries often produce a varied course of complications, including hypertonia and dystonia, leading to decreased function, which is often very difficult to rehabilitate. The severity of motor deficits may make it difficult to assess cognitive function, which, surprisingly, may be relatively well preserved. Due to the number of problems that can result as a consequence of these brain injuries, effective rehabilitation usually requires a transdisciplinary approach that incorporates many different types of interventions that may change as the patient goes through different phases of recovery. In this approach, it is always important to remember that lack of movement does

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SCHOLARLY RESEARCH IN PROGRESS

Mefloquine discontinuation: Proposed solution for adverse drug-induced neuropsychiatric side effects Lindsay Falgoust1*

Geisinger Commonwealth School of Medicine, Scranton, PA, 18509 *Correspondence: LFalgoust@som.geisinger.edu 1

ABSTRACT Malaria is a parasitic infection of the blood known to have devastating impacts on the human population worldwide. Among the many antimalarial drugs developed in attempts to combat this global infectious disease is mefloquine. Valued in the past as a cost effective, convenient, and efficacious method for reducing malarial infectivity rates, mefloquine became a drug of choice and standard of prevention. However, increased dosage of mefloquine used to treat malarial infection induced unfavorable neurotoxic side effects in recipients. Recent case study reports among military and nonmilitary subpopulations have exposed this controversial neurotoxic property of the drug, making its continued administration a debatable issue. With statistical analyses that provide evidence of mefloquine-induced neuropsychiatric side effects not seen among other antimalarial drugs, the clinical utility of mefloquine has begun to diminish. Among popular debate now is if mefloquine’s neuropsychiatric risks, including death, outweigh the long-withstanding benefits of cost and convenience enough to discontinue mefloquine’s use entirely. After reviewing mechanistic explanations of how mefloquine is capable of stimulating neurological effects, the correlation between the drug and clinical observation becomes apparent. By altering neuronal anatomy and interfering with synaptic calcium homeostasis, mefloquine exposes recipients to neurotoxic events not observed among alternative antimalarial drugs. This review seeks to justify the discontinuation of mefloquine on the basis of tangible mechanistic discoveries that support various clinical case study reports. With the availability of additional drugs like doxycycline and atovaquone-proguanil, which display fewer side effects and comparable efficacy to mefloquine, discontinuation of mefloquine appears to have no negative impact on the future of malaria prevention.

BACKGROUND Malaria is a parasitic blood infection transmitted via the bite of female mosquitos. Several strains of the parasite currently exist throughout the world, some of which are

more fatal than others if contracted. As an infectious disease endemic in 109 countries and responsible for 1.7 to 2.5 million deaths annually, malaria has become known as one of the most important and potentially life-threatening diseases encountered by western travelers (1). If not diagnosed and treated in a timely fashion, malaria infections can ultimately lead to death (2). For this reason, extensive research efforts have sought not only to understand the blood parasite’s deadly effect on the body, but also to develop drugs that could decrease the rate of infectivity. Among the first compounds used in malaria prevention was quinine, a compound originally obtained from the bark of the South American quina-quina tree (3). With the future of scientific advancements came the determination to develop synthetic drugs capable of reproducing the effective antimalarial characteristics of quinine. The synthetic drug chloroquine soon replaced quinine as the mainstay for malaria prevention and treatment after exhibiting comparable efficacy (2,3). However, with the rapid and extensive use of chloroquine came the emergence of chloroquine-resistant malarial strains, forcing drug developers to construct novel compounds (4). In the process of manipulating chemical properties to avoid mutations that conferred resistance, drug developers produced several new compounds that exhibited unique chemical structures and functions. Although some of these new drugs were accompanied by success and tolerability, others exhibited unintentional adverse effects. Among these chloroquine-derived drugs now known to induce unfavorable effects on individuals is mefloquine (5).

INTRODUCTION Mefloquine is revered for its superiority in efficacy of malaria prevention and treatment, with a 96% cure rate against Plasmodium falciparum malaria and 99.6% cure rate against Plasmodium vivax malaria compared to chloroquine’s 26% cure rate and 82% cure rate against P. falciparum and P. vivax, respectively (5). Although mefloquine is valued for its convenience, affordability, and aforementioned longstanding superior efficacy in malarial preven-

Mefloquine Discontinuation

tion since the Vietnam War, controversial properties of the drug have recently been exposed after extensive clinical observations (6). Due to the correlation between mefloquine administration and serious neuropsychiatric reactions including acute psychoses, seizures, vivid dreams, depression, hallucinations, and suicide, some believe mefloquine should be discontinued as an antimalarial drug in order to prevent irreversible neurological damage and death (7). Others believe that mefloquine, when prescribed to the right individuals without a history of neuropsychiatric disorders, provides a cheap, suitable, and effective route for malarial resistance that has proven its value to society throughout history (8). Although military case study data has been criticized for

Battalion

Term (season)

No. members deployed

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low generalizability to the general public, the reported neurological events and suicidal thoughts experienced among military personnel is enough to justify mefloquine discontinuation for the worldwide population. With the existence of mechanistic explanations for how mefloquine induces severe neuropsychiatric side effects, including synaptic degeneration and altered neuronal homeostatic mechanisms, counterarguments from skeptics who refute causal relationship between mefloquine and adverse effects comes into question (4,9). Such mechanistic discoveries show that mefloquine-induced neuropsychiatric side effects are not restricted to one subpopulation of individuals. Thus, both military and nonmilitary personnel can be exposed to the neurotoxic properties of the drug.

Age

Returned questionnaires

Adherence to mefloquine prophylaxis

No.

No. of doses taken

No. (%) adherent

1st

April to September 2002

684

31.5 ± 7.4

653

95.5

28.8 ± 5.1

624 (95.6)

2nd

October 2002 to March 2003

669

32.2 ± 7.8

657

98.2

28.7 ± 5.3

619 (94.2)

3rd

April to September 2003

523

33.2 ± 7.3

521

99.6

35.1 ± 9.2

475 (91.2)

Table 1. Statistical data on adherence to mefloquine prophylaxis among Japanese Ground Self-Defense Force personnel (adapted from [1])

No. of Cases

Mefloquine

US service members who resided in Europe/Japan in 2002 with no prescription for mefloquine, chloroquine, or more than 14 tablets of doxycycline

US service members who were deployed for one or more months in 2002 with no prescription for mefloquine, chloroquine, or more than 14 tablets of doxycycline

Mental disorders

1280

Nervous system

Any cause (excludes complications of pregnancy, childbirth, and the puerperium, congenital anomolies and certain conditions originating in the prenatal period)

135

Outcome

Hazard ratio (95% CI) for mefloquine prescribed group vs. Europe/Japan reference group

Hazard ratio (95% CI) for mefloquine prescribed group vs. deployed reference group

1314

0.76 (0.55 - 1.07)

1.23 (0.87 - 1.72)

312

292

0.58 (0.26 - 1.32)

0.76 (0.34 - 1.73)

7308

5868

0.47 (0.39 - 0.56)

0.94 (0.79 - 1.12)

Table 2. Hazard ratios for hospitalizations due to various disorders experienced among deployed and non-deployed individuals (adapted from [7])

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Mefloquine Discontinuation

With the availability of other antimalarial drugs, like atovaquone-proguanil and doxycycline, both proven effective in malaria prevention, it seems imprudent to put individuals at risk of neurological deficit when this is not necessary. Moving forward, it is imperative to offer these alternative forms of prevention. Although these alternative drugs may be more expensive or inconvenient, when compared to mefloquine they exhibit fewer reported deleterious side effects and are proven just as tolerable (10). Unlike mefloquine, the benefits of atovaquone-proguanil and doxycycline outweigh their risks and for this reason should become the sole front-runners for malaria prevention.

Another study exposed additional neuropsychiatric side effects experienced by military personnel post-mefloquine use, including nightmares, sleep disturbance, anxiety, headache, dizziness, and amnesia (Table 3) (1). One study used incidence to show the frequency of neuropsychiatric phenomena among the 1,831 individuals studied. With incidence rates of 2.7% and 2.2% respectively, sleep disturbances and nightmares occurred more frequently in individuals than headache (1.3%) and anxiety (.5%) (Table 3) (1). Although these incidence rates seem rare, it is important to note that even though these reported effects only happened in a small portion of the population, they are still

Clinical reports of mefloquine-induced neuropsychiatric side effects Military personnel case studies The relatively long half-life of mefloquine allows for weekly drug administration—an appealing property of the drug among military personnel (8). Adherence percentages ranging from 91.2% to 95.6% suggest that a large majority of military personnel will be protected from malaria infection during their time abroad (Table 1) (1). With military members being deployed for time periods that can exceed five months at a time, compliance towards taking mefloquine appears to be an advantageous property of the drug among military personnel (11). However, in a study that focused on US Service Member hospitalizations from 20022004, observational findings and randomized clinical trials supported an increased risk of neuropsychiatric events – including depression, panic attacks, headache, and vivid dreams – for individuals prescribed mefloquine (7). Additionally, the hazard ratio (1.23) for mefloquine-prescribed individuals versus a deployed group of US service members was higher than the hazard ratio (0.76) for mefloquine prescribed individuals versus US service members not deployed but stationed overseas in Japan and Europe. The hazard ratio for other nervous system effects (0.76) also increased in the mefloquine prescribed group vs. deployed reference group compared to the hazard ratio (0.58) for the mefloquine-prescribed group vs. Europe/Japan stationed reference group (Table 2) (7). Although mefloquine still appears effective in prevention, these adverse side effects have caused the US military to adapt its policies on malaria prevention, no longer recommending mefloquine utilization among service personnel.

Study 1*

Incidence rates for adverse events reported after mefloquine use Incidence ≥ 2.0%

2.0% > incidence ≥ 1.0%

1.0% > incidence ≥ 0.3%

Symptom

No. (%)

Symptom

No. (%)

Symptom

No. (%)

Dizziness/vertigo

130 (7.1)

Sleepiness

29 (1.6)

Anxiety

10 (0.5)

Fatigue/lassitude

68 (3.7)

Weakness

28 (1.5)

Sleep disturbance

49 (2.7)

23 (1.3)

5 (0.3)

41 (2.2)

Headache

Amnesia

Nightmares

Study 2**

Deaths associated with mefloquine usage Patient Nationality

Patient Age

Clinical Details

American (USA)

Not stated

After 1 mefloquine tablet, patient experienced cardiopulmonary arrest, death.

Thai

Malaria recrudesced 21 days after mefloquine treatment. Given halofantrine over 3 days. Experienced sudden cardiac arrest, death.

British

Developed blistering of lips and oral mucosae. Generalized erythema and blistering, then exfoliation of the mucosae. Ulceration of the mucosae, hair and nail loss. Cardiac asystole, death.

British

After taking Lariam for overseas trip, became acutely depressed. Committed suicide by jumping to his death from the roof of a mansion block.

German

Took 2 Lariam tablets for suspected malaria. After 4 hours, experienced headaches, ‘burning in bones,’ deafness, dizziness. Confused, panic, depression. Hospitalized. Committed suicide.

American (USA)

Early during mefloquine prophylaxis, experienced fever (102 degrees), chills, headache, cough. Initially treated as malaria. Then, during a 2-hour car ride, experienced a ‘head rush.’ Collapsed, died.

British

Not stated

8 fatal reactions to mefloquine, reported to the UK Medicines Control Agency.

Not stated

4 fatal reactions to Lariam, recorded on the manufacturer’s database of adverse drug reactions.

French

Treated with Lariam for 48 hours. Committed suicide 6 weeks later (self-inflicted knife wounds).

Table 3. Adverse events and deaths reported after mefloquine use (adapted from *[1] and **[6]). *Data collected from 1,831 Japanese Ground Self-Defense Force members who completed the questionnaire regarding mefloquine usage.

Mefloquine Discontinuation

impacting people’s lives and will continue to do so. These particular effects of mefloquine should not be ignored. Recently, the US military has agreed that rarity should not be ignored. The U.S military policy disagrees with the Center for Disease Control’s suggestions for malaria-prevention agents (Table 4) (12). Military policy promotes the use of doxycycline and supports the removal of mefloquine (12). Therefore, although mefloquine may exhibit desirable effectiveness, it appears to promote unappealing adverse effects that render its utility impracticable. By taking action and making policy changes, the military shows that they are not taking the controversial issues surrounding mefloquine lightly. Nonmilitary personnel applicability of reports and observations Due to the unique characteristics military populations exhibit including unique environmental exposure, job duties, stress levels, demographics, and overall health, the applicability of military case study results to the general public has been questioned (7,13). Some criticize military case studies because of biases in data collection. For example, several of these military case studies focus on subjects who exhibit similar traits that collectively vary from the typical US citizen. One study observed contraindications to mefloquine among US military personnel but primarily

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sampled young adults in good health, with 93.8% of participants under the age of 40 (11). Other critics reject military case study conclusions because they refute drug causality for neuropsychiatric side effects and instead attribute observed mental phenomena to exposure to personal trauma (13). However, a case study that followed a twenty-seven-yearold male active in the United States Air Force provides a counter to this theory (13). While taking mefloquine on duty, this Staff Sergeant experienced extreme neuropsychiatric side effects that started as simple sleep disturbances but quickly escalated to depression, disorientation, and suicidal thoughts (13). However, the key factor in this study is that this individual was not exposed to the stressful environment typical of military personnel (13). This study provides support that the neuropsychiatric side effects experienced by military personnel are not restricted to unique trauma or lifestyle believed to be uniform throughout this subpopulation. Further, other studies have reported adverse neuropsychiatric side effects in other nonimmune travelers, providing insight into the applicability of military case study findings. For example, in an eight trial study that examined 4240 individuals, mefloquine reported more neuropsychiatric adverse events compared to other available drugs, with a risk ratio of .49 for atovaquone-proguanil users and a .84 risk

CDC Recommendation

US Military Policy

Choice of malaria chemoprophylaxis agent

Chemophylaxis guidelines do not recommend one drug versus another, but rather emphasize the goal of individualizing the recommendation for the individual traveler on the basis of past experience, itinerary, possible drug interaction, potential side effects, costs, and medical contraindications such as drug allergies.

Individualizing advice and recommendations for large military deployments is rarely logistically possible or feasible. Recognizing this reality, in September 2009, the US military adopted a new policy on the use of malaria chemoprophylaxis in the US military. Doxycycline is now the drug of choice to prevent malaria in deployed US military forces in all areas other than sub-Saharan Africa. In September 2011, AFRICOM policy changed to recommending atovaquone-proguanil for sub-Saharan Africa.

Doxycycline

An option for chemoprophylaxis in all areas

Recommended first-line chemoprophylaxis in all areas other than sub-Saharan Africa.

Atovaquone-proguanil

An option for chemoprophylaxis in all areas

Atovaquone-proguanil is the drug of choice for sub-Saharan Africa. Atovaquone-proguanil is recommended for those who are intolerant of or who have contraindications to doxycycline in other areas.

Mefloquine

An option for chemoprophylaxis in all areas

Mefloquine is not recommended as a primary option. It should be used only in those whose travel requires malaria chemoprophylaxis, who cannot take either doxycycline or atovaquone-proguanil, and who meet all requirements of the current FDA-approved product label.

Table 4. CDC vs. military policy for malaria prevention (adapted from [12])

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Mefloquine Discontinuation

1,118 malaria cases among US civilians in 2012 Purpose of travel at the time of malaria acquisition

No.

(%) of Total No.

603

(53.9)

Tourist

(2.9)

Missionary or dependent

(7.2)

Business representative

(8.2)

Student or teacher

(4.2)

Air crew or sailor

(0.4)

Peace Corps

(0.5)

Other

(3.9)

Unknown

210

(18.8)

Visiting friends/relatives

Table 5. Frequency of malaria acquisition among US citizens organized by purpose of travel (adapted from [14]).

ratio for mefloquine users (10). This study also discussed 22 reports of individuals who took Mefloquine at normal dosages and then died afterwards (10). Among these 22 individuals, 5 committed suicide, further providing evidence of the neurotoxic effects and lower clinical utility of mefloquine (10). Another review of recent literature suggested that mefloquine would soon be abandoned due to 19 deaths, including 3 suicides, attributed to the drug’s neurotoxicity (Table 3) (6). This study reported a threefold increase in neuropsychiatric occurrences with mefloquine usage (OR 47.1, 95% CI 1.4 to 8.7) among 564 nonmilitary Dutch travellers compared to those taking other preventative agents (6). Additionally, this study explained that mefloquine was the 15th most common cause of post-travel illness among 4524 travelers returning from Sub-Saharan Africa (6). Collectively, these statistical analyses show the adverse effects mefloquine has among nonmilitary personnel. A broad variety of subpopulations are exposed to malaria acquisition outside of the armed forces, proving the need to address mefloquine usage among both military and nonmilitary subpopulations (Table 5) (14). While mefloquine may assist in ensuring malaria prevention to both military and nonmilitary personnel, it simultaneously compromises mental health. Thus, US citizens, whether they are active travellers or active military personnel, should not succumb to the devices of a drug proven to have connections to adverse neurological effects and even death.

Mechanistic explanations for mefloquineinduced neurotoxicity Altered neuronal properties and function The neuropsychiatric side effects discussed within case studies have promoted extensive research efforts that seek to explain the mechanism by which mefloquine induces neurological harm. Among the competing hypotheses, researchers have described mefloquine as an agent capable of altering neurotransmitter and ion release and triggering neurodegeneration, both of which could explain the neurotoxic properties of the drug (4). Mefloquine is believed to alter neurotransmitter release by inhibiting acetylcholinesterases (4). Due to the integral role cholinesterases have on breakdown of acetylcholine, inhibition of these enzymes could impact the ability of neurons to alter and release neurotransmitters. Such inhibition can subsequently intervene with communication between adjacent neurons and negatively impact synaptic transmission. Further, when Protein-Tyrosine Kinase 2 (PKY2) – a protein tyrosine kinase that plays a role in calcium-induced regu-

Various 5-HT receptors Drug

h5-HT1A [3H]8OH-DPAT

h5-HT2A [125I]DOI

h5-HT2C [125I]DOI

Ki (nM) ± SEM (+)-Mefloquine (Active against the plasmodium parasite)

>9,100

341 ± 67

5,730 ± 770

(–)-Mefloquine

>10 µM

1.510 ± 260

3,870 ± 620

5-HT (serotonin)

2.67 ± 0.33

9.1 ± 1

4.31 ± 0.93

LSD (Psychedelic compound)

2.78 ± 0.51

0.71 ± 0.17

2.91 ± 0.75

DMT (psychedelic tryptamine compound)

450 ± 150

210 ± 43

166 ± 50

DOM (Psychoactive chemical; substituted amphetamine)

14,200 ± 4,600

4.3 ± 1.2

25.7 ± 4.2

Ketanserin (H5-HT2 receptor antagonist; antihypertensive)

6,510 ± 320

7.6 ± 1.9

117 ± 34

Ro60-0175 (5HT2C receptor agonist)

6,680 ± 430

13.1 ± 2.1

7.3 ± 1.6

SB242087 (h5-HT2 receptor antagonist)

>9,300

120 ± 32

11.4 ± 4.0

WAY 100635 (5HT-1A receptor antagonist; dopaminergic activity)

1.21 ± 0.16

331 ± 54

3,000 ± 1,100

Table 6. Mefloquine enantiomers, (+) and (-), affinity for H5-HT receptor subtypes compared to LSD, DMT, DOI, and other compounds (adapted from [17])

Mefloquine Discontinuation

lation of ion channels â&#x20AC;&#x201C; is experimentally suppressed, the overall cytotoxic effects of mefloquine are altered (4). Mefloquine impacted the number of viable PKY2-transfected cells, with 100% viability at 1 uM mefloquine concentration but only about 20% viability at 50 uM mefloquine concentration (4). By decreasing the number of PKY-2 viable cells, mefloquine impacts the ability of these cells to regulate calcium homeostasis and thus impacts cellular communication. This led to the belief that mefloquine plays a role

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in calcium homeostasis of the nervous system. The flow of calcium into neurons is a critical component of neurotransmission and when it is interrupted the ability of our body to transmit signals becomes compromised. With the reported effects of mefloquine in altering calcium homeostasis, it becomes possible to see how this drug can promote adverse neurological effects, particularly on synaptic transmission.

Comparative risks between mefloquine and doxycycline

Patient/Population: Non-immune child and adult travelers (international travel) Comparative Risks* (95% CI) Study 1

Outcomes

Neuropsychiatric adverse event

Assumed Risk Mefloquine (Comparison)

Corresponding Risk Doxycycline (Intervention)

688/1000

578/1000 (502 to 660)

Relative effect (95% CI)

No. of Participants

Relative Risk 0.84 (0.73 to 0.96)

441 (2 studies)

Comparative risks between mefloquine and atovaquone-proguanil Patient/Population: Non-immune child and adult travelers (international travel) Comparative Risks* (95% CI) Relative effect (95% CI)

No. of Participants

304/1000 (253 to 359)

Relative Risk 0.72 (0.6 to 0.85)

976 (1 study)

771/1000

663/1000 (578 to 763)

Relative Risk 0.86 (0.75 to 0.99)

317 (1 study)

288/1000

141/1000 (109 to 181)

Relative Risk 0.49 (0.38 to 0.63)

976 (1 study)

Outcomes

Assumed Risk Mefloquine (Comparison)

Corresponding Risk Atovaquone-proguanil (Intervention)

Any adverse effect

422/1000

Neuropsychiatric adverse event Neuropsychiatric adverse event

Study 2

Adverse side effects after mefloquine and atovaquone-proguanil (Malarone)

Outcomes

Atovaquone-proguanil (Malarone) n=493 28 days

Mefloquine n=483 53 days

% of subjects with adverse experiences

% of subjects with adverse experiences attributable to therapy

% of subjects with adverse experiences

% of subjects with adverse experiences attributable to therapy

Any neuropsychiatric event

Anxiety

Depression

Dreams

Headache

Dizziness

Visual difficulties

Any adverse experience

Study 3

Table 7. Adverse effects and comparative risks between mefloquine vs. doxycycline and mefloquine vs. atovaquone-proguanil (adapted from [18]). *The basis for the assumed risk is provided in the footnotes of the publication. The corresponding risk (and 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and 95% CI).

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SCHOLARLY RESEARCH IN PROGRESS, Vol. 1, October, 2017 ÂŠ2017 Geisinger Commonwealth School of Medicine

SCRIP Drug Atovaquone/Proguanil

Doxycycline

Mefloquine

Mefloquine Discontinuation

Reasons for taking this drug

Reasons against taking this drug

• Good for last-minute travelers because the drug is started 1-2 days before traveling • Some people prefer a daily medicine • Good choice for shorter trips because you only have to take the medicine for 7 days after traveling • Very well tolerated medicine — side effects uncommon • Pediatric tablets available that may be more convenient

• Cannot be used by pregnant women or women breastfeeding a child less than 5 kilograms • Cannot be taken by people with severe renal impairment • Tends to be more expensive than other options • Some people, including children, would rather not take a daily medication

• Some people prefer a daily medicine • Good for last-minute travelers because the drug is started 1-2 days before traveling. • Tends to be the least expensive • Some people are already taking doxycycline chronically for prevention of acne so they would not have to take additional medication • Can also prevent additional infections

• Cannot be used by pregnant women and children younger than 8 years old • Some people would rather not take a daily medication • Must be taken 4 weeks after travel • Women prone to getting vaginal yeast infections when taking antibiotics may prefer a different medication • Increased risk of sun sensitivity • Some are concerned about the potential for getting an upset stomach.

• Some people prefer a weekly medication • Good choice for long trips because of dosage • Can be used during pregnancy

• Cannot be used in areas with mefloquine resistance • Cannot be used in patients with certain psychiatric conditions • Cannot be used in patients with a seizure disorder • Not recommended for persons with cardiac conduction abnormalities • Not a good choice for last-minute travelers because it needs to be taken at least 2 weeks prior to travel. • Some people would prefer to not take a weekly medication • Must be taken for 4 weeks after travel

Table 8. Pros and cons for several antimalarial drugs (adapted from [8])

Additionally, increased mefloquine concentration caused a decrease in neuronal dendritic length (4). In order to study this, GSH (glutathione), a compound important in preventing cellular damage, was quantified to see the effects mefloquine had on oxidative stress of cells (15). With an increase in mefloquine concentration came a subsequent decrease in GSH levels. With decreased GSH, cells are more susceptible to oxidative damage, which can result in neurodegenerative events like decrease in dendritic length (15). This study showed that oxidative stress is promoted by mefloquine, which can subsequently impact neuronal communication and synaptic transmission. Appropriate dendrite lengths are key in allowing for proper signaling pathways and synaptic transmission between adjacent neurons. By promoting neurodegeneration, specifically among dendritic length, mefloquine interferes with signal With a unique chemical structure that allows mefloquine to cross the blood brain barrier and accumulate in the brain, the drug has been proven capable of altering normal brain function (16). Normal blood serum levels of mefloquine range from 1.5-3.3 uM whereas postmortem levels of mefloquine in the brain were shown in one study to be of significantly higher concentrations at around 21-34 uM (9). This 10-30-fold increase supports the hypothesis that mefloquine can accumulate in the brain (9). Accumulation can interfere with normal brain function by further promoting the aforementioned neurotoxic effects to a greater extent.

Mimicry of hallucinogenic episodes Additional studies have shown that mefloquine may induce neurological events like hallucinations, dream disturbances and vivid dreams, which are common to hallucinogens like Lysergic Acid Diethylamide (LSD), Dimethyltryptamine (DMT), and 2,5-Dimethoxy-4-Iodophenyl (DOI). These compounds exhibit comparable hallucinogenic effects because they share a common neurotransmitter receptor and transporter (13,17). Both the (+) and (-) enantiomers of mefloquine interact with neurotransmitter receptors and transporters like h5-HT receptors, which are acted upon by LSD, DMT, and DOI when introduced into the brain (Table 6) (17). Additionally, the (+) mefloquine enantiomer exhibits higher affinity for the H5-HT2A receptor than DMT, and the (+) and (-) mefloquine enantiomers show equal affinity for other subtypes of the h5-HT receptor (17). Binding curves for mefloquine, LSD, DMT, and DOI, providing insight into the ability of mefloquine to bind to h5-HT receptors in similar ways to the common hallucinogens. Thus, it is plausible that the novel chemical structure of mefloquine not only promotes neurological harm via altered calcium homeostasis and neuronal morphology, but also is capable of mimicking hallucinogenic episodes. These mechanistic explanations prove the capacity of mefloquine to induce adverse neurological effects on individuals that spans the entire population. Any US citizen is susceptible to the effects of mefloquine once administered the drug.

SCRIP Neurologically safe antimalarial drugs available Aside from mefloquine, there are alternative drugs available for malaria prevention that vary in cost, dose number, and dose frequency. Various research studies have been conducted in attempts to determine the best option for malaria prevention in terms of tolerability, safety, and efficacy (10). Atovaquone-proguanil is highly tolerable and exhibits little side effects but is a drug that needs to be taken every day (8). Although the most expensive antimalarial drug available, the high cost appears justified when considering the adverse neuropsychiatric side effects and events avoided when taking atovaquone-proguanil instead of mefloquine (8). Compared to mefloquine, atovaquone-proguanil drug therapy showed a decrease in risk for both neuropsychiatric adverse effects and neuropsychiatric adverse events, with relative risk values of .49 and .86, respectively (18). Further, atovaquone-proguanil showed a decrease in risk for any adverse effect compared to mefloquine, with a relative risk of .72 (Table 7). Another comparison of studies investigated adverse side effects of mefloquine and Malarone (atovaquone-proguanil), and their results provide insight into the decreased occurrence of neuropsychiatric events as well as other adverse events like anxiety, depression, dreams, headache, dizziness, and visual difficulties among those taking atovaquone-proguanil compared to mefloquine (Table 7). Doxycycline is a daily, highly tolerable drug proven valuable not only as a preventative agent for malaria, but as an agent capable of fighting additional infections including Lyme disease, leptospirosis, scrub typhus, travellers’ diarrhea and lymphatic filariasis (10,18). Doxycycline has decreased risk of neuropsychiatric harm compared to mefloquine, with 578 per 1000 cases compared to 688 per 1000 cases, respectively (Table 7) (18). Additionally, doxycycline’s efficacy is very similar to that of mefloquine. Three randomized placebo-controlled trials report a 92%96% efficacy for prevention of P. falciparum infection and 98% P. vivax compared to mefloquine’s 100% efficacy (19). With the presence of many cons and reported deaths attributed to mefloquine usage, mefloquine’s status as a viable option for malarial prevention does not seem justified (Table 8) (8). Those that support its continued use appear to do so only for its long-standing efficacy and history with malarial prevention instead of the basis of recently exposed scientific facts and observational data.

DISCUSSION Throughout the decades, preventing malaria has become increasingly more complex, especially for non-native individuals travelling to foreign malaria-stricken areas. An in-depth understanding of the risks that accompany mefloquine usage in comparison to alternatives like atova-

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quone-proguanil and doxycycline shows that continued support for mefloquine as an antimalarial agent is unadvised. Statistical analyses show that mefloquine has a higher risk ratio for neuropsychiatric adverse events (.84 compared to .49 for atovaquone-proguanil), increased frequency of neuropsychiatric harm (688 cases per 1000 cases compared to 578 cases per 1000 cases for doxycycline), and higher risk for any adverse effect (422 cases per 1000 cases compared to 304 cases per 1000 cases for atovaquone-proguanil) compared to other antimalarial drugs available (10). With mechanistic explanations and clinical observations that provide evidence and support for mefloquine discontinuation, continued administration of this drug will do more harm than good in the fight against malaria. By acting on hallucinogenic receptors, inhibiting ion channels, and promoting dendritic degeneration, mefloquine interferes with integral aspects of synaptic function and neuronal communication. Thus, discontinuing the use of mefloquine and promoting the use of alternative agents will ensure the neurological safety of not only our military personnel, but also our nonmilitary citizens who travel to foreign countries. Although certain case studies only report about 20 deaths causally associated with mefloquine use, these extremes of neuropsychiatric disorder cannot be ignored. Instead, these occurrences should be seen as a warning sign that supports discontinuation of the drug. With mefloquine still on the market, it is urgent that mechanistic explanations, statistical analysis, and case study reports reach the level of the general public. With malarial strains conferring resistance to mefloquine at this moment in time, new drugs will eventually have to be produced. Research is currently being conducted at the Walter Reed Army Institute of Research with the focus of maintaining the efficacy of mefloquine but manipulating its unique chemical characteristics in order to prevent its ability to cross the blood brain barrier (20). In this manner, instead of promoting neuropsychiatric harm around the world, mefloquine can provide insight into the side effects drug developers hope to avoid, ultimately leading to novel combinations of preventative agents that will help in the continued fight against malaria in the future.

REFERENCES 1. Fujii T, Kaku K, Jelinek T, Kimura M. Malaria and mefloquine prophylaxis use among Japan Ground Self-Defense Force personnel deployed in East Timor. J Travel Med. 2007 Jul-Aug;14(4):226-32. 2. Baird JK. Effectiveness of antimalarial drugs. N Engl J Med. 2005 Apr 14;352(15):1565-77. 3. Achan J, Talisuna AO, Erhart A, et al. Quinine, an old antimalarial drug in a modern world: role in the treatment of malaria. Malar J. 2011 May 24;10:144.

SCRIP 4. Milatovic D, Jenkins JW, Hood JE, Yu Y, Rongzhu L, Aschner M. Mefloquine neurotoxicity is mediated by non-receptor tyrosine kinase. Neurotoxicology. 2011 Oct;32(5):578-85. 5. Maguire JD, Krisin, Marwoto H, Richie TL, Fryauff DJ, Baird JK. Mefloquine is highly efficacious against chloroquine-resistant Plasmodium vivax malaria and Plasmodium falciparum malaria in Papua, Indonesia. Clin Infect Dis. 2006 Apr 15;42(8):1067-72. 6. Croft AM. Developing safe antimalarial drugs: Key lessons form Mefloquine and halofantrine. Int J Risk Saf Med. 2007;(19):153-161. 7. Wells TS, Smith TC, Smith B, et al. Mefloquine use and hospitalizations among US service members, 2002-2004. Am J Trop Med Hyg. 2006 May;74(5):744-9. 8. Centers for Disease Control. cNov2012 [cited Mar 2015]. “Choosing a Drug to Prevent Malaria.” Malaria. Available from: http://www. cdc.gov/malaria/travelers/drugs.html 9. Nevin RL. Epileptogenic potential of mefloquine chemoprophylaxis: a pathogenic hypothesis. Malar J. 2009 Aug 5;8:188. 10. Jacquerioz FA, Croft AM. Drugs for preventing malaria in travellers. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD006491. Update in: Cochrane Database Syst Rev. 2015;10:CD006491. 11. Nevin RL. Mefloquine prescriptions in the presence of contraindications: prevalence among US military personnel deployed to Afghanistan, 2007. Pharmacoepidemiol Drug Saf. 2010 Feb;19(2):20610.   12. Magill AJ, Forgione MA, Maguire JD, Fukuda MM. Special considerations of US military deployments. c2013 [cited Feb 2015]. Available from: http://wwwnc.cdc.gov/travel/yellowbook/20 14/ chapter-8-advising-travelers-with-specific-needs/special-considerations-for-us-military-deployments. 13. Peterson AL, Seegmiller RA, Schindler LS. Severe neuropsychiatric reaction in a deployed military member after prophylactic mefloquine. Case Rep Psychiatry. 2011;2011:350417. 14. Cullen K, Arguin P. Malaria Surveillance – United States 2012. MMWR. 2014; 63(SS12):1-22. 15. Hood JE, Jenkins JW, Milatovic D, Rongzhu L, Aschner M. Mefloquine induces oxidative stress and neurodegeneration in primary rat cortical neurons. Neurotoxicology. 2010 Sep;31(5):518-23. 16. Nevin RL. Re: McGuire JM. The incidence of and risk factors for emergence delirium in U.S. military combat veterans. Journal of Perianesthesia Nursing. 2012;27(4):236-45. J Perianesth Nurs. 2013 Dec;28(6):334-5.   17. Janowsky A, Eshleman AJ, Johnson RA, et al. Mefloquine and psychotomimetics share neurotransmitter receptor and transporter interactions in vitro. Psychopharmacology (Berl). 2014 Jul;231(14):2771-83. 18. Croft AM. “Drugs for preventing malaria in travellers (review). The Cochrane Collaboration. 2010;(4): 1-79. 19. Tan KR, Magill AJ, Parise ME, Arguin PM; Centers for Disease Control and Prevention. Doxycycline for malaria chemoprophylaxis and treatment: report from the CDC expert meeting on malaria chemoprophylaxis. Am J Trop Med Hyg. 2011 Apr;84(4):517-31. 20. Sousa JC, Milner E, Carroll D, et al. The use of a prodrug approach to minimize potential CNS exposure of next generation quinoline methanols while maintaining efficacy in in vivo animal models. Eur J Drug Metab Pharmacokinet. 2014 Dec;39(4):231-6.

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Assessment of patient transportation as a determinant of appointment attendance at the Susquehanna Community Health and Dental Center Branson Allen1, Katherine Chung1*, Jason Gu1, Brianne Handal1, Marco Najar1, Chloe Swanger1, Leanne Woiewodski1, Elizabeth Kuchinski1, Janet Townsend1 and Mark White1 Geisinger Commonwealth School of Medicine, Scranton, PA 18509 *Correspondence: KChung@som.geisinger.edu 1

ABSTRACT Forty-five million Americans either live in underserved areas or are uninsured and thus have poor access to healthcare in their communities. This study focuses on transportation in the uninsured population of Williamsport, PA, at the Susquehanna Community Health and Dental Center. A total of 162 patients were interviewed and survey data were collected; these include information on mode of transportation, access to a personal vehicle, distance traveled from home to the clinic, and the difficulty in coming to the health center. We found that the mode of transportation played a key role in determining the likelihood of missing an appointment due to transportation problem. We found that 71.3% of patients who use STEP, a community-based transportation, have had a missed appointment due to transportation issues. This is the highest rate of missed appointments in any other mode of transportation. Additionally, interviews with survey respondents mentioned unreliability and inconsistency in pick-up times with STEP. This study concluded that despite continuing efforts to provide public transportation for the underserved patients, the need to implement a new transportation system that can be personalized and efficient is a major task to ensure their health and wellbeing.

INTRODUCTION Forty-five million Americans either live in underserved areas or are uninsured and thus have poor access to healthcare in their communities (1). Bindman et al. concluded that access to healthcare was inversely associated with preventable hospitalization rates for asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes (2). One way that uninsured patients gain access to primary care is through Federally Qualified Health Centers, formerly called “Community Health Centers.” It was found by Evans et al. that, as the density of Federally Qualified Health Centers increased, the number

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of preventable hospitalizations among the uninsured decreased (3). Furthermore, results of a study of Medicare claims showed that, of patients that are eligible for both Medicare and Medicaid, those who used Federally Qualified Health Centers had a decreased hospitalization rate for ambulatory care-sensitive conditions compared to those of this group who did not use the health centers (4). This same study also demonstrated a relationship between proximity to a Federally Qualified Health Center and use: those that utilized the health center for its primary care resources tended to live closer to it (4). This relationship is, then, of particular concern to Federally Qualified Health Centers in rural areas where patients may have to travel long distances to receive care. Therefore, in these rural areas, transportation may play a role in uninsured patients’ access to primary and preventative care through Federally Qualified Health Centers. While barriers to healthcare access in the United States are well studied, the barriers that have most often been delineated in the literature are socioeconomic in nature (1). Transportation as a barrier to healthcare access is also not as well studied. One striking conclusion from a 2013 review of research on transportation and healthcare access was that “lack of transportation was associated with less health care utilization, lack of regular medical care, and missed medical appointments …” (5). However, the significance of these barriers with regards to transportation were uncertain due to wide variability in study populations and measurement of transportation barrier (5). This study focuses on transportation in the uninsured population of Williamsport, PA, at the Susquehanna Community Health and Dental Center. This study aims to determine whether or not transportation is a barrier to appointment attendance and to determine the effectiveness of community-based transportation STEP by assessing the effect of no-show rate in patients using STEP.

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MATERIALS AND METHODS This study examines transportation as a barrier to health care access in uninsured patients on several different metrics. Self-reported data from surveys administered in the waiting room or from those administered over the phone was gathered on race, sex, age, usage of public transportation, and access to a personal vehicle. The participants were also asked to rank their perceived quality of health. From this data, we determined whether or not transportation plays a prominent role in gaining access to care in this area and those like it. Our main objectives focus on the Health Center and therefore no data was collected from the Dental Center next door. A total of 139 surveys were administered in print to patients before their scheduled appointments and were completed by patients in the Susquehanna Community Health Center waiting room. The research team also telephoned about 120 patients who did not show up for their scheduled appointments at the center within the same time frame that the paper surveys had been administered. This was to ensure that all data is collected from January to April, including those that did not show up at the Health Center to take the paper survey. The team was able to verbally administer surveys to 23 of the patients contacted. Statistical tests were used for bivariate and multivariate data analysis using Microsoft Excel. General patient demographic information was obtained from the center for comparison with collected data to determine if survey sample results accurately represented the centerâ&#x20AC;&#x2122;s patient population.

RESULTS There were 139 patients surveyed on site through paper surveys and 23 patients surveyed on the phone using a scripted phone survey. Of the total surveyed patients (n= 162), 64% were White, 25% were Black, and 2% were Latino/Hispanics (Figure 1). The data collected is comparable to the actual total patient population (n=10,030) in the Susquehanna Community Health Center, 71% are White, 21% are Black, and 2% are Latino/Hispanics (Figure 2). There are 5804 women (58%) and 4226 men (42%) registered as patients of the Community Health Center and 69% of the patients live below poverty level (Table 1). Two of the most common modes of transportation were patients who drive themselves in their own vehicle (73 patients; 40% of total surveyed patients) and patients who have someone else drive them to the Health Center (40 patients; 22% of total surveyed patients) (Figure 3). In the survey, some patients selected more than one type of transportation that they usually use to get to the Health Center, therefore the total data points used for this figure

Figure 1. Patient demographics of surveyed patients. There were 139 patients surveyed on site through paper surveys, and 23 patients surveyed on the phone using a scripted phone survey. Of the total surveyed patients (n=162), 64% were White, 25% were Black, and 2% were Latino/Hispanics.

Figure 2. Total patient population (n=10,030) in the Susquehanna Community Health Center. The patient population consists of 71% White, 21% Black, and 2% Latino/Hispanics. These are comparable to the surveyed patients from Figure 1, which demonstrates that the surveys collected are representative of the total population of the Health Center.

Table 1. Other patient demographics provided by the Susquehanna Community Health Center. There are 5804 women (58%) and 4226 men (42%) registered as patients of the Health Center, and 69% of the patients live below poverty level. About 68% of the patients are on Medicaid and 11% are uninsured.

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Figure 3. How patients usually get to the Health Center by a mode of transportation, and the percent of patients who missed their appointments due to transportation difficulties. Two most common mode of transportation were patients who usually drive themselves in their own private vehicle (73 patients; 40% of total surveyed patients) and patients who have someone else drive them to the Health Center (40 patients; 22% of total surveyed patients). There were 183 total patient input in this figure. This number is more than the total patient surveyed (n=158) because there were some patients who checked more than one type of transportation usually used to get to the Health Center. Other types of transportation include public transit (14%), STEP or other medical transport (4%), walk or bike (19%), and others (1.6%). Of the 40% of patients who drove themselves to the Health Center, 23.3% missed an appointment due to transportation difficulties. Only 4% of patients use STEP or other medical transport, yet 71% of these patients have missed their appointments due to transportation difficulties.

Figure 4. Relationship between distance patient live away from clinic and the total number of patients. The numbers of patients who have missed an appointment due to transportantion difficulties are shown. Patients, on average, live less than five miles away from the Health Center. Despite the proximity to the Health Center, patients are still missing their appointments.

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SCHOLARLY RESEARCH IN PROGRESS, Vol. 1, October, 2017 ÂŠ2017 Geisinger Commonwealth School of Medicine

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found that individuals who relied on public transportation such as a bus, taxi, or a community-based transportation system (STEP) exhibited the highest rates of missed appointments associated with transportation issues (Figure 3). Remarkably, those who relied on STEP to get to their Table 2. Missed appointments due to transportation usually taken to the Health Center. appointments exhibited much higher This table format shows the relationship between patient transportation and percentage rates of missed appointments due to of the patient missed appointments due to transportation difficulties. transportation than any other mode of transportation. During interviews with respondents and individuals within the Williamsport community, the unreliability of STEP and inconsistency of pick-up times given by STEP were mentioned several times. These individuals in the Williamsport community are individuals who work at the Table 3. The percentage of missed appointments in relation to distance away from the Health Center (nurses, receptionists, Health Center. Patients who live the farthest (more than 10 miles away) are less likely and administrators). While STEP proto miss an appointment (25% of the patients versus 37.5% of the patients who live less vides transportation services to those than one mile away from the Center). Patients who live 2-5 miles and 5-10 miles have a who otherwise would have no form of similar rate of missed appointments, 32.6% and 33.3% respectively. transportation to the Health Center, this study has shown that it is an unis higher than the total number of patients surveyed. For reliable source of transportation, and individuals who use example, a patient can select both STEP and private veSTEP are much more likely to miss their appointments due hicle as his or her main mode of transportation to get to to problems associated with transportation than patients the Health Center. When assessing the number of patients who do not use STEP. who use STEP and the number of patients who use private vehicle, this patient will be in both categories. Therefore Over two thirds of the patient population of this Health 183 total patients were input in this data compared to the Center is on Medicaid, which mandates transportation be total patients surveyed (n=158). Other types of transpor- provided for eligible individuals. Therefore, it is reasonable tation that patients use are public transportation such as to conduct more research to determine how to best enbuses or taxis (14%), STEP or other medical specific trans- sure patients have access to transportation. Improving the port (4%), walk or bike (19%), and others (1.6%). Of the 40% reliability of STEP may be the most logical area to pursue of patients who drove themselves to the Health Center, a reduction in the transportation barrier that exists among 23.3% missed an appointment due to transportation diffi- the patients of the Health Center. culties (Table 2). Only 4% of patients use STEP or other medical transport, yet 71% of these patients have missed CONCLUSIONS their appointments due to transportation difficulties. The main objective of this study was to determine whethOne of the most interesting findings of this study was that er or not transportation is a barrier to appointment attenindividuals who lived ten or more miles away from the dance and to analyze the effectiveness of STEP in proHealth Center missed fewer appointments due to transviding transportation to the underserved population who portation than individuals living less than a mile away from could not otherwise get to a doctorâ&#x20AC;&#x2122;s appointment. In this the Health Center (Figure 4 and Table 3). In fact, those who study, we found that patients who do not have or do not lived furthest away from the Health Center exhibited the use their private vehicle to get to the Health Center are lowest rates of transportation-related missed appointment more likely to have missed an appointment due to transand those who lived closest to the Health Center had the portation difficulties (Figure 3). Other forms of transpormost difficulty with transportation. While the cause of this tation are less reliable in that the percentage of missed finding is unclear, it is possible the individuals who live appointments is higher than patients driving themselves more than ten miles away from the Heath Center have to the Health Center in their private vehicle. Other forms more reliable forms of transportation. of transportation include walking/biking, public transit (taxThe relationship between mode of transportation and is and buses), STEP or other medical transport, and relynumber of missed appointments was also examined. It was ing on another person to drive them to the Health Center.

Patient Transportation and Appointment Attendance

Of these types of transportation, STEP was found to be most unreliable, with more than 71.4% of patients using STEP having missed an appointment in the past because of transportation difficulties (Figure 3). Surveyed patients who use STEP often noted that it has inconsistencies and that it was inconvenient, as they were being picked up too early or dropped off too late. In one instance, a patient had a morning appointment but she had to wait until late afternoon to get dropped off because there were no STEP buses that were scheduled at a more convenient time.

DISCUSSION This study had several limitations. The sample size was achieved with only 162 respondents, which represents a small portion of the entire patient population at the Health Center, which has over 10,000 patients. Furthermore, the response rate from surveys conducted over the phone was low. Of the 120 patients telephoned, only 23 were available and willing to participate in the survey. Despite a small sample size, the demographics of the sample in this study did closely mirror the demographics of the Health Center’s population (Figure 1 and Figure 2). Additionally, survey data was collected during the winter months of 2016, which may have resulted in higher rates of transportation-related missed appointments by individuals who live close to the Health Center and typically walk. For future research, results may be more conclusive if data is taken throughout the year. Such a study could address possible distortion that seasonal weather could play in transportation such as road conditions. Access to health care service is imperative for ensuring the general health and wellbeing of a population of people. Cost of health care and lack of health insurance are factors that have proven to be clear barriers that impede the access individuals have to health care services. Previous studies have attempted to determine if the lack of transportation presents a substantial barrier to health care access. The results of this study support these previous findings, yet are different with regard to the population that was studied. Rather than a strictly metropolitan environment, the Community Health Center in Williamsport, PA, represents a modality of health care stationed in the urban center of a rural county. Due to the unique placement of the Health Center, individuals living in both urban and rural areas are served in this location. Many of the patients utilizing the health center are from rural areas that necessitate longer travel times to gain access to the services that the healthcare center offers. Therefore transportation barriers may impact patients in rural areas more than patients living in urban settings. Collectively, these studies have found certain factors such as car ownership, distance away from health care, and reliance on public transportation such as buses and taxis are all correlated with decreased utilization of health service

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due to missed appointments and thus possible worse health outcomes. In a recent study, Keating et al. looked at the challenge of completing pulmonary rehabilitation in patients with COPD. It was concluded that poor access to transport and lack of perceived benefit are two major factors that affect uptake and completion of pulmonary rehabilitation (6). Two reviewers also independently extracted data and found that travel and transport were consistently identified as barriers to both uptake and completion of pulmonary rehabilitation. Pulmonary rehabilitation relieves dyspnea and fatigue, improves emotional function and enhances the sense of control that individuals have over their condition (7). Rehabilitation is an important component of the management of COPD, however barriers such as transportation can deny patients its benefits such as improving quality of life and exercise capacity.

ACKNOWLEDGMENTS We would like to acknowledge the River Valley Health & Dental Center (formerly Susquehanna Health & Dental Center) for providing patient demographics for Figure 2, as well as providing the location for the research. We would also like to acknowledge The Geisinger Commonwealth School of Medicine for providing the opportunity to do the Community Health Research Project as part of the curriculum.

REFERENCES 1. Shook M. Transportation Barriers and Health Access for Patients Attending a Community Health Center 2005. 2. Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. Jama 1995;274:305-11. 3. Evans CS, Smith S, Kobayashi L, Chang DC. The Effect of Community Health Center (CHC) Density on Preventable Hospital Admissions in Medicaid and Uninsured Patients. Journal of health care for the poor and underserved 2015;26:839-51. 4. Wright B, Potter AJ, Trivedi A. Federally Qualified Health Center Use Among Dual Eligibles: Rates Of Hospitalizations And Emergency Department Visits. Health affairs (Project Hope) 2015;34:1147-55. 5. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. Journal of community health 2013;38:976-93. 6. Keating A, Lee A, Holland AE. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chronic Respiratory Disease 2011;8(2):89–99. 7. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic 2006;(4):CD003793.

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Association of education level and influenza/ pneumococcal vaccine adherence in adults over the age of 65 Kaitlyn Sternat1†, Stephanie Tilberry1†, Patrick Roman1, John Wroblewski1, Ashley Slack1, Christopher Karnicki1, Elizabeth Kuchinski1 and Mushfiqur Tarafder1* Geisinger Commonwealth School of Medicine, Scranton, PA 18509 †Joint first authors *Correspondence: MTarafder@som.geisinger.edu 1

ABSTRACT Objectives: To determine if there is a relationship between highest education level and influenza and pneumococcal vaccine adherence among individuals 65 years and older and if that relationship differs by biological sex, while adjusting for reported income, race, and healthcare coverage. Methods: A comprehensive literature review was completed to acknowledge existing data on vaccination adherence among the elderly population in relation to education level. Data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS) Codebook was collected on the following variables: highest education level, pneumonia and influenza vaccination status, biological sex, income, race, and healthcare coverage. EpiInfo 7 and Microsoft Excel were utilized to complete secondary data analysis and identify significant associations based on odds ratio values and 95% confidence intervals. Results: When compared to those with less than a high school education, members of every other education category had significantly higher odds of being vaccinated for pneumonia. Influenza vaccination status, however, did not vary in each educational category and only those with a bachelor’s degree or more had significantly higher odds of vaccination adherence. These relationships did not differ by sex, although women were more likely to have reported receiving both vaccines as compared to men. Conclusion: The hypothesis was supported that those with more education have higher vaccination adherence compared to those with less education. These results may be related to education about both vaccines and public health strategies, as well as the inherent demands of a one-time vaccine versus a yearly vaccine. By investing the relationship between education level and vaccination

adherence, this research holds potential to inform public health officials of potential barriers to these vaccines, ultimately improving adherence rates and health outcomes.

INTRODUCTION Influenza and pneumonia affect millions of people throughout the United States (US) annually. Influenza is a viral respiratory illness that causes symptoms including fever, sore throat, headaches, etc. (1). Incidence rates of influenza consistently impact millions in the United States resulting in thousands of hospitalizations and deaths (2). Pneumonia is a lung infection with symptoms including, fever, shortness of breath, nausea, vomiting, and diarrhea (3). The incidence of pneumonia in the US is approximately 175,000 cases yearly, with a 5-7% fatality rate (3). Adults over the age of 65 (i.e. elderly population) are considered high risk because they often have chronic conditions and overall weaker immune systems, making pneumonia and influenza combined the fifth leading cause of death in this age cohort (4,5). The CDC reports that the yearly influenza vaccine (i.e. flu shot) is the best preventative option, as it reduces the risk of flu by 50-60% (6). There are currently two pneumonia vaccines, PCV13 and PPSV, which are recommended based on age and past medical history (4). Studies aimed at evaluating the efficacy of these pneumonia vaccines offer mixed results, but are still highly recommended by health professionals (4). It has been predicted that the number of people over the age of 65 will double by the year 2050 (7), thus it becomes evident why their vaccine adherences are significant issues. According to the CDC, the current rates for influenza and pneumonia vaccine coverage for this population are 69.1% and 63.5%, respectively (8,9). This 65 and older group is responsible for a majority of the hospitalizations and mortalities secondary to influenza infection and have the highest case-fatality rate for pneumococcal diagno-

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ses (10,11). With such effective and accessible vaccinations available, identifying contributing factors towards low vaccine adherence is a primary step towards implementing effective public health programs to reduce the number of influenza and pneumonia cases among the elderly population. One such factor that has been considered with vaccination adherence is level of education. A review of literature to examine factors associated with flu shot reception discovered a wide range of results on this topic (12). Twenty-three articles discussing studies from eighteen countries were critically appraised, and education level was concluded to have an inconsistent association with flu shots (12). Other studies aimed at exploring pneumococcal and influenza vaccinations in an older population and health care personnel found that misinformation, misconception, and lack of education about the vaccines were significant barriers to coverage (5,13). In contrast, other research studies displayed an association between highest level of education and pneumonia and influenza vaccination coverage among those aged over 65, respectively (10,11,13). This same relationship investigated and compared the 2009 H1N1 influenza vaccine to the annual flu shot and found that college graduates were more likely to have received both vaccinations than less educated participants (14). Literature on this topic suggests that the association between education level and vaccination adherence for pneumonia and influenza has not been definitively established with gaps that this study aims to address. Previous research focused on education about vaccines and education level with other potential contributing factors, but this study prioritizes highest level of education in association with vaccinations. Furthermore, frequently either flu shot or pneumonia vaccine adherence was studied, but rarely evaluated in conjunction. By exploring an association between both vaccines simultaneously, this analysis allows for consideration of the significance of how differing requirements between the one-time pneumonia vaccine and the annual influenza vaccine may impact their particular coverage rates. The final gap was a lack of biological sex consideration. Some studies included analysis of the association between sex and vaccine coverage (6,7,11) but none in reference to education level. Stratification by sex may add clarity to the unclear relationship between education and vaccination adherence. The lack of a comprehensive study evaluating level of education and vaccine adherence has resulted in a gap of knowledge that public health officials may need to increase vaccination adherence. The intent of this analysis was to investigate whether there is an association between highest level of education and adherence with the annual influenza and one-time pneumonia vaccine in adults 65 years and older. We tested the hypothesis that there will be a positive association between education level and

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pneumonia and influenza vaccine adherence among the elderly population.

MATERIALS AND METHODS The parent study, the 2013 Behavioral Risk Factor Surveillance System (BRFSS), was a cross-sectional telephone survey conducted by state health departments in collaboration with the Centers for Disease Control and Prevention (CDC) (15,16). Survey questions were comprised and distributed to health department professionals, who then trained in-house or contracted interviewers to make phone calls. The source population was the entire eligible adult population of each state, and the study population was composed of each state’s residents who answered the phone and completed the survey. Samples of phone numbers were obtained through the CDC, and participants were contacted through random digit dialing. Eligibility criteria for the parent study included noninstitutionalized state residents with access to a telephone who were over the age of 18 years. Our study added an additional eligibility criteria of adults who are 65 years of age or older only. Sampling methodology differed from state to state as the CDC gave states freedom to select a sample representative of the source population. To accomplish this, states worked with the CDC and a state statistician to design samples within certain geographical boundaries or counties. BRFSS created two general sample categories: landlines and cellular phones. Landline numbers were subjected to household sampling, which required interviewers to collect data on the total number of eligible adults living in that household. A random selection from the collected data was then made for one adult per household. Furthermore, landlines were also subjected to disproportionate stratified sampling, a method superior to simple random sampling. This type of sampling split the total list into two strata, a high and medium density block, based on the apparent density of household numbers. Landline numbers in the high-density block were sampled at higher rate than medium-density blocks. Cellular phones were instead counted as a single adult household. BRFSS defined a household as “a housing unit with a separate entrance, where occupants eat separately from other persons on the property, and that is occupied by its member as their principle or secondary place of residence” (16). Finally, the parent study used Design and Raking Weighting to help ensure the study population adequately reflected the source population on demographic characteristics including sex, age, and race. The data were collected using a standardized questionnaire developed in collaboration with the CDC. The questionnaire contained a standard core of questions that was asked immediately following the confidentiality agree-

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Association of Education and Vaccine Adherence

ment. By discretion of the state health departments, questionnaires could have included optional modules designed by the CDC to collect data on issues relevant to those particular states. The questionnaire also incorporated a rotating core as part of the standard core every other year and was offered as an optional module otherwise. Finally, states had options to include their own state-added questions, but the CDC did not evaluate those questions or collect data on their responses. Questions aimed to identify certain behavioral risk factors in the community and therefore cover a wide range of information, including health care access, chronic diseases, demographics, alcohol and tobacco use, diet, exercise, and immunization history. The CDC utilized the Computer-Assisted Telephone Interview System for aspects such as data collection programming and scripts for interviewers. An interview was considered complete if participants completed roughly half of the survey questions. To ensure validity of the data, a random 5% of the sample were called back to verify their information. As a secondary research study, we examined existing data collected by the BRFSS 2013 survey. Once the required data set was collected, it was compiled into an Excel spreadsheet and analyzed in concordance with our objectives. Our study analyzed two central variables: highest level of education and vaccine adherence in U.S. population aged 65 years and older. The exposure of interest, highest level of education, was defined through the BRFSS survey question: “What is the highest grade or year of school you completed?” The response categories offered were: “Never attended school or only attended kindergarten, grades 1 through 8 (elementary), grades 9 through 11 (some high school), grade 12 or GED (high school graduate), college 1 to 3 years (some college or technical school), college 4 years or more (college graduate), refused”. However, our data analysis plan combined these options into four categories: Less than a high school education, high school diploma (or GED equivalent), some college or technical school, and bachelor’s degree or more. Our study examined two outcome variables: influenza vaccination adherence and pneumonia vaccination adherence. BRFSS explores annual influenza vaccination by asking participants to report if they have received a flu shot or nasal spray flu vaccine over the last 12 months. Response categories included: “Yes, no, don’t know/not sure, refused”. Pneumonia vaccination in BRFSS was addressed by prompting, “Have you ever had a pneumonia shot?” The same answer choices of “Yes, no, don’t know/ not sure, and refused” were given. We maintained both these questions and the response options to define influenza vaccine adherence and pneumonia vaccination adherence, respectively. Responses in the “don’t know/not sure” and “refused” categories were excluded, making

each outcome variable dichotomous. A positive outcome was defined as answering “yes” and a negative outcome of answering “no.” When considering sex of the participant on the relationship between education and vaccination, we used the gender variable as defined by BRFSS, which asked participants to self-identify as male or female during initial questions. The two categories were male and female. Based on the literature review, we predicted the following variables might have an effect on the relationship of interest because they have been examined frequently in previous studies: socioeconomic class, race, and healthcare coverage (7,10,17). The BRFSS survey identified income by asking participants “Is your annual income from all sources:” with response categories: “less than $10,000, less than $15,000 ($10,000 to less than $15,000), less than $20,000 ($15,000 to less than $20,000), less than $25,000 ($20,000 to less than $25,000), less than $35,000 ($25,000 to less than $35,000), less than $50,000 ($35,000 to less than $50,000), less than $75,000 ($50,000 to less than $75,000), $75,000 or more, don’t know/not sure, refused.” For purposes of this study, we excluded responses in the “don’t know/not sure” and “refused” categories and combined the others into the following: lower class ($0 to less than $35,000), middle class ($35,000 to less than $75,000), and upper class ($75,000 or more). This income variable served as a proxy for socioeconomic status, and employment status was not considered. The BRFSS imputed values for race/ ethnicity were: “White, Non-Hispanic, Black, Non-Hispanic, Asian, Non-Hispanic, American Indian or Alaska Native, Hispanic, and other race, Non-Hispanic.” We did not make any changes to these variable groups. Our last potential confounder, healthcare coverage, was assessed in BRFSS through the question “Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?” Response categories were “yes, no, don’t know/not sure, refused.” Our healthcare variable categories kept the “yes” and “no” options, while eliminating all “don’t know/not sure” and “refused” answers. Descriptive statistics were completed in Microsoft Excel. They included univariate proportions for the dichotomous and categorical variables of education level, pneumonia vaccine status, influenza vaccine status, biological sex, income category, race, and healthcare coverage. Bivariate descriptive statistics included pneumonia vaccine proportions stratified by education level, influenza vaccine proportions stratified by education level, pneumonia vaccine proportions stratified by sex, influenza vaccine proportions stratified by sex, and education level proportions stratified by sex. To determine whether an association exists between education level and influenza and pneumonia vaccination,

Association of Education and Vaccine Adherence

we used logistic regressions in EpiInfo 7 to calculate odds ratios. 95% confidence intervals were used to determine statistical significance. Bivariate analyses were completed to determine measure of association of educational level, sex, income category, race, and healthcare coverage on pneumonia and influenza vaccine adherence. Crude and adjusted odds ratios and 95% confidence intervals were computed and reported for each factor. In order to meet the second specific aim, we analyzed the effect of one’s sex on the relationship between education level and pneumonia and influenza vaccination using multivariate analyses. Specifically, multiple logistic regressions through EpiInfo 7 were utilized to compute odds ratios with 95% confidence intervals.

11%

30%

Bachelor's Degree or More Some college or technical school

34%

High school diploma or GED Less than high school 25%

Figure 1. Proportion of participants by highest level of education

38%

Among participants with a bachelor’s degree or more, 70.01% received the pneumonia vaccine and 65.87% received the influenza vaccine. Among the participants who attended some college or technical school, 70.94% received the pneumonia vaccine and 61.15% received the influenza vaccine. Of those who obtained their high school diploma or GED, 69.54% reported pneumonia vaccination adherence compared to 60.16% who reported influenza vaccination adherence. Respondents with less than a high school education had the lowest vaccination rates with only 63.74% reporting pneumonia vaccination and 56.71% reporting influenza vaccination (Figure 8 and 9). Of all participants who were female, 71.06% received a pneumonia vaccine and 61.65% received a yearly flu shot (Figure 10). Among male participants, 66.49% reported pneumonia vaccine adherence and 62.02% reported influenza vaccine adherence (Figure 10). It was determined that there is a statistically significant association between one’s highest education level and pneumonia vaccine adherence. Those in any other edu-

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38%

Yes

RESULTS Of the total number of eligible (age 65 years or older) participants (n=160,882), 30% had a bachelor’s degree or more, 25% attended some college or technical school, 34% had a high school diploma or GED, and 11% had less than a high school education (Figure 1). 69% of respondents received their pneumonia vaccine, while 31% did not (Figure 2). 62% of participants received their influenza vaccine, and 38% did not (Figure 3). Of all participants, 63% identified as female and 37% identified as male (Figure 4). 54% of participants fell in the lower class income group, 30% were middle class, and 16% were upper class (Figure 5). Racial proportions were as follows: 86% White, Non-Hispanic, 6% Black, Non-Hispanic, 4% Hispanic, 2% other race, Non-Hispanic, 1% American Indian or Alaska Native, and 1% Asian, Non-Hispanic (Figure 6). 99% of participants responded that they had healthcare coverage and 1% did not (Figure 7).

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62%

Yes 62%

38%

31%

No Yes

Yes 69%

62%

Figure 2. Proportion of participants by pneumonia vaccination status

Figure 3. Proportion of participants by influenza vaccine 16%

Upper Class

Female

37%

Middle Class

16%

Male 63%

54%

30% Female

37%

Upper Class

Male 63%

Middle Class 30%

Figure 4. Proportion of participants by reported sex

54%

2% American Indian or Alaska Native

86%

Lower Class

Figure 5. Proportion of participants by reported income

1% 6%

Lower Class

Asian, Non-Hispanic Black, Non-Hispanic Hispanic Other race, Non-Hispanic White, Non-Hispanic

Figure 6. Proportion of participants by reported race

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Association of Education and Vaccine Adherence

No Yes

62%

No Yes 99%

Percentage of Participants

38%

80% 70% 60%

70.01%

70.94% 69.54%

63.74%

50% 40% 30% 20% 10% 0%

Figure 7. Proportion of participants by reported healthcare coverage

Bachelor’s degree or more

80%

65.87% 61.15%

50%

60.16%

56.71%

40% 30% 20% 10%

Percentage of Participants

Less than high school

Highest Education Level

70%

High school diploma or GED

Figure 8. Proportion of participants who received a pneumonia vaccine by highest education level

80% 60%

Some college or technical school

70% 60%

71.06% 66.49% 61.65%

50%

62.02%

40% 30% 20% 10%

Bachelor’s degree or more

Some college or technical school

High school diploma or GED

Less than high school

Highest Education Level

Figure 9. Proportion of participants who received an influenza vaccine by education level

cation category had statistically higher odds of having received their pneumonia vaccine when compared to those with less than a high school education: high school diploma or GED odds ratio (OR) 1.30 (1.25-1.35 (95% confidence interval), some college or technical school OR 1.39 (1.351.45), bachelor’s degree or more OR 1.33 (1.28-1.38) (Table 1). A statistically significant association between education and influenza vaccination existed as well when comparing higher education levels to those with less than a high school education: high school diploma or GED OR 1.15 (1.111.19), some college or technical school OR 1.20 (1.16-1.25), bachelor’s degree or more OR 1.47 (1.42-1.53) (Table 2). Females were more likely to be in the vaccinated group regarding pneumonia and influenza vaccines with OR values of 1.24 (1.21-1.27) and 1.07 (1.04-1.09), respectively, when compared to males (Table 1 and 2). Those in the middle class category had significantly higher odds of pneumonia vaccination when compared to lower class respondents, however the upper class category did not: middle class OR 1.05 (1.02-1.08), upper class OR 1.00 (0.97-1.04) (Table 1).

Pneumonia Vaccine

Influenza Vaccine

Positive Pneumonia and Influenza Vaccine Status

Figure 10. Proportion of participants who received pneumonia and influenza vaccines by sex

Both income categories had significantly higher odds of influenza vaccination compared to the lower class group: middle class OR 1.25 (1.22-1.28), upper class OR 1.46 (1.411.51) (Table 2). When compared to White participants, race had a significant association with pneumonia vaccination except for American Indian or Alaskan Native participants: Black, Non-Hispanic OR 0.60 (0.58-0.63), Asian, Non-Hispanic OR 0.81 (0.73-0.91), American Indian or Alaskan Native OR 1.04 (0.93-1.16), Hispanic OR 0.37 (0.35-0.40), other race, Non-Hispanic OR 0.81 (0.75-0.88) (Table 1). All racial categories had significant association with influenza vaccine adherence when compared to Whites: Black, Non-Hispanic OR 0.63 (0.61-0.66), Asian, Non-Hispanic OR 1.23 (1.09-1.36), American Indian or Alaskan Native OR 0.82 (0.74-0.91), Hispanic OR 0.57 (0.54-0.60), other race, Non-Hispanic OR 0.74 (0.69-0.80) (Table 2). Participants with healthcare coverage had significantly higher odds of pneumonia and influenza vaccine adherence compared to those without healthcare with OR values of 2.29 (2.092.50) and 2.15 (1.97-2.34), respectively (Table 1 and 2).

Association of Education and Vaccine Adherence

Factor

Education Level

Sex

Healthcare Coverage

Income Category

Race

Crude OR

Adjusted OR

(95% Confidence Interval)

Less than a High School education

1.00

High School Diploma or GED

1.30 (1.25 - 1.35)

1.07 (1.02 - 1.12)

Some College or Technical School

1.39 (1.35 - 1.45)

1.12 (1.07 - 1.18)

Bachelor’s Degree or More

1.33 (1.28 - 1.38)

1.11 (1.05 - 1.16)

Male

1.00

Female

1.24 (1.21 - 1.27)

1.26 (1.23 - 1.30)

1.00

Yes

2.29 (2.09 - 2.50)

2.08 (1.87 - 2.32)

Lower Class: Less than $35,000

1.00

Middle Class: $35,001 - $75,000

1.05 (1.02 - 1.08)

0.99 (0.96 - 1.02)

Upper Class: $75,000 +

1.00 (0.97 - 1.04)

0.95 (0.91 - 0.99)

White, Non-Hispanic

1.00

Black

0.60

0.61

Table 1. Factors associated with pneumonia vaccine adherence based on regression analysis

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and healthcare coverage: middle class OR 0.99 (0.96-1.02), UC OR 0.95 (0.91-0.99) (Table 1). Both income categories were significantly more likely to be in the influenza vaccine adherence category compared to the lower class group after adjustment: middle class OR 1.14 (1.14-1.18), upper class OR 1.27 (1.23-1.32) (Table 2). Adjusted OR values for race and pneumonia vaccination indicated that only American Indian or Alaska Natives were not significantly different than Whites: Black, Non-Hispanic OR 0.61 (0.58-0.64), Asian, Non-Hispanic OR 0.84 (0.74-0.95), American Indian or Alaskan Native OR 1.07 (0.94-1.21), Hispanic OR 0.39 (0.370.43), other race, Non-Hispanic OR 0.82 (0.750.89) (Table 1). Adjusted OR (adjusted for education, sex, income, and healthcare coverage) values for race and influenza vaccine showed significant differences between each racial category compared to Whites: Black, Non-Hispanic OR 0.67 (0.64-0.71), Asian, Non-Hispanic OR 1.20 (1.10-1.39), American Indian or Alaskan Native OR 0.89 (0.79-0.99), Hispanic OR 0.60 (0.57-0.64), other race, Non-Hispanic OR 0.77 (0.71-0.84) (Table 2). Healthcare coverage remained significant after adjustment for education, sex, income, and race in reference to both pneumonia vaccine adherences, OR 2.08 (1.87-2.23) (Table 1), and influenza vaccine adherence, OR 2.00 (1.80-2.21) (Table 2).

DISCUSSION

Each factor was analyzed for association with pneumonia and influenza vaccinations again after adjusting for all other potential confounding factors discussed. Every category, other than less than a high school education, still had significantly higher odds of receiving a pneumonia vaccine after adjusting for sex, income, race, and healthcare coverage: high school diploma or GED OR 1.07 (1.02-1.12), some college or technical school OR 1.12 (1.07-1.18), bachelor’s degree or more 1.11 (1.05-1.16) (Table 1). Only the bachelor’s degree or more group had significantly higher odds of influenza vaccine adherence compared to those in the less than high school education group: high school diploma or GED OR 1.01 (0.97-1.05), some college or technical school OR 1.02 (0.97-1.06), bachelor’s degree or more OR 1.16 (1.11-1.22) (Table 2). Females had higher odds of vaccination compared to males with an adjusted OR (adjusted for education, income, race, and healthcare coverage) of 1.26 (1.23-1.30) for pneumonia vaccine (Table 1) and adjusted OR of 1.08 (1.06-1.11) for influenza vaccine (Table 2). The upper class group had significantly lower odds of pneumonia vaccination compared to the lower class group, but the middle class group was not statistically different than the lower class group after adjusting for education level, sex, race,

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The results of the statistical analyses support the hypothesis that those with more education would have higher vaccination adherence compared to those with less education. Because our findings indicate a positive association between education and vaccination, we have contributed to decrease the existing disagreement regarding this topic. Of the participants aged 65 and older, those with higher education were significantly more likely to report receiving their pneumonia vaccine compared to those with less than a high school education before and after adjusting for sex, income, race, and healthcare coverage, indicating they were not confounding variables. These results were expected and in agreement with Lu and Nutori’s (11) findings based on the fact that those with more education may better understand the severe health consequences of pneumonia. The association between highest level of education and flu shot adherence, while significant, showed that only those with a bachelor’s degree or more had higher odds of receiving their influenza vaccine when compared to those with less than a high school education. Because the origi-

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Association of Education and Vaccine Adherence

Factor

Education Level

Crude OR

Adjusted OR

(95% Confidence Interval)

Less than a High School education

1.00

High School Diploma or GED

1.15 (1.11 - 1.19)

1.01 (0.97 - 1.05)

Some College or Technical School

1.20 (1.16 - 1.25)

1.02 (0.97 - 1.06)

patterns of our results as less educated individuals may remain misinformed as a consequence of public health outreach methods and therefore have lower odds of influenza vaccine adherence.

An unclear relationship between education level and flu shot coverage among the elderly population is a significant gap in existing literature. Previous review of related articles Bachelorâ&#x20AC;&#x2122;s Degree 1.47 1.16 or More (1.42 - 1.53) (1.11 - 1.22) determined that education level and flu shot coverage have an inconsistent association Sex Male 1.00 1.00 (12). Some researchers have argued that there is an association between these two variables, Female 1.07 1.08 (1.04 - 1.09) (1.06 - 1.11) while others have postulated that an association does not exist (10,13). Our results contribHealthNo 1.00 1.00 care ute to this gap by supporting the claim that an Coverage association between level of education and flu Yes 2.15 2.00 shot adherence does exist and is statistically (1.97 - 2.34) (1.80 - 2.21) significant. Furthermore, because minimal literIncome Lower Class: Less 1.00 1.00 ature exists on this relationship in reference to Category than $35,000 the pneumonia vaccine, we have also added Middle Class: 1.25 1.14 to public health knowledge by distinguishing $35,001 - $75,000 (1.22 - 1.28) (1.14 - 1.18) differences between influenza and pneumonia Upper Class: 1.46 1.27 vaccine adherence. Because we considered $75,000 + (1.41 - 1.51) (1.23 - 1.32) both vaccines simultaneously, we have also Race White, Non-His1.00 1.00 considered the inherent differences of vaccine panic administration. The fact that the flu shot is a Table 2. Factors associated with influenza vaccine adherence based on yearly recommendation may have contributed regression analysis to the result that only those with a bachelorâ&#x20AC;&#x2122;s degree or more had higher odds of adherence. The pneumonia vaccine is only required once nal crude odds ratios showed significance for each educain a lifetime, which may also have an influence on differtion category, the factors of sex, income, race, and healthcare coverage may have confounding effects. Those with a ent coverage rates as well. BRFSS did not include survey high school diploma or GED and those who attended some questions regarding opinions on the differences of vaccine college or technical school did not have statistically higher administration, but it is a future consideration. odds of flu shot adherence versus those with less than a high school education. Although we predicted a positive relationship, these results are somewhat unexpected in that only the highest education category displayed a significant association with vaccination. However, these results are similar to the study which investigated the H1N1 influenza vaccine and showed that college graduates were more likely to receive the pneumonia vaccine and the annual flu shot compared to those with less education (14). The 65 and older population is a major target for flu shot campaigns due to their high-risk status, but many of those materials come in forms such as reading materials, online resources, and educational seminars (18). These materials may only be reaching the most highly educated people, because those with less education may face barriers such as low reading levels, lack of computer skills, or discomfort with attending professional events. In past literature, misinformation and lack of knowledge about diseases and vaccines have been identified as barriers and reasons for refusing flu shot administration (13,14). This aligns with the

Women displayed significantly higher odds of receiving both vaccines before and after adjustment, which aligns with some previous literature on this topic (7,11). In regard to healthcare coverage, there were significantly higher odds of receiving each vaccine if the individual had healthcare coverage before and after adjustment. Lack of healthcare coverage has been identified as a risk factor for vaccination non-adherence in previous studies (10,11). When considering income, those in the middle and upper class had significantly higher odds before and after adjustment for receiving each vaccine, similarly to existing literature (10,14). Whether adjusted for other variables or not, all races other than American Indian/Alaskan Native group members had significantly lower odds of reporting pneumonia vaccine adherence, while American Indian/Alaskan Native group members did not have significantly different odds when compared to White, Non-Hispanics. All races other than Asian, Non-Hispanic had significantly lower odds of flu shot adherence whether adjusted or not, while Asian, Non-Hispanic groups members did not have significantly

Association of Education and Vaccine Adherence

different odds compared to White, Non-Hispanics. Racial disparities among vaccination status for both pneumonia and influenza vaccines have also been identified in the past (14,17). Although several beneficial conclusions emerged based on this research, there were limitations. Due to the way the BRFSS age variable was designed, participants had to be categorized as “65 or older” or “younger than 65”. However, it would be worthwhile to classify older Americans further, perhaps by increments of 10 years (i.e. 65-74, 75-84, 85 and older, etc.). This could provide further insight into vaccination barriers and allow public health professionals to develop more efficient and unique vaccine promotion techniques. Additionally, because BRFSS was a telephone survey, self-reported responses are a limitation as well. All results presented in this study assume that answers reported by participants were completely accurate, which may not be the case, especially regarding the pneumonia vaccine question if they had ever received one. Elderly people may be unaware or forget the details of their childhood medical history. Lastly, the confounding variables we chose to analyze were sex, income category, race, and healthcare coverage. We selected these variables based on common factors considered in our literature review. However, there are surely other variables that influence the relationship between education level and pneumonia and influenza vaccine coverage. Therefore, factors such as family situation, marital status, physical mobility level, and employment status are potential factors that should be considered in future studies. Based on the results of our study, we conclude that a statistically significant, positive association exists between highest education level and pneumonia vaccination adherence among elderly citizens aged 65 and older. Within this same population, bachelor’s degree or more is significantly associated with influenza vaccine adherence. These findings contribute to public health knowledge by identifying education level as one potential influence on the low vaccination rates among this elderly population. Also, because biological sex was not significant, men and women with similar education levels do not require distinctive approaches. Epidemiological researchers must work cohesively with public health and policy professionals to ensure that the most up-to-date and reliable data is understood and extensively considered when designing future plans to increase pneumonia and influenza vaccination coverage among the older population.

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c2004-2017. Pneumonia: Causes, Symptoms, and Treatment; 2017 May 17. 4. Ventola CL. Immunization in the United States: Recommendations, Barriers, and Measures to Improve Compliance: Part 2: Adult Vaccinations. P T. 2016 Aug;41(8):502-6. 5. Santibanez TA, Nowalk MP, Zimmerman RK, Jewell IK, Bardella IJ, Wilson SA, Terry MA. Knowledge and beliefs about influenza, pneumococcal disease, and immunizations among older people. J Am Geriatr Soc. 2002 Oct;50(10):1711-6. 6. Centers for Disease Control and Prevention. Vaccine Effectiveness – How Well Does the Flu Vaccine Work?; 2017 Feb 15. 7. Kim ES, Strecher VS, Ryff CD. Purpose in life and use of preventive health care services. Proc Natl Acad Sci U S A. 2014 Nov;111(46):16331-6. 8. Center for Disease Control and Prevention. Atlanta, GA USA; c2016. Influenza; 2016 Oct 6. 9. Center for Disease Control and Prevention. Atlanta, GA USA; c2017. Pneumonia; 2017 Jan 20. 10. Lochner KA, Wynne M. Flu shots and the characteristics of unvaccinated elderly Medicare beneficiaries. Medicare Medicaid Res Rev. 2011 Nov;1(4). 11. Lu PJ. & Nuorti JP. Pneumococcal Polysaccharide Vaccination Among Adults Aged 65 Years and Older, U.S. 1989-2008. Am J Prev Med. 2010 Oct;39(4):287-95. 12. Yeung MP, Lam FL, Coker R. Factors associated with the uptake of the seasonal influenza vaccination in adults: a systematic review. J Public Health (Oxf). 2016 Jan;38(3):746-53. 13. Millner VS, Eichold BH, Franks RD, & Johnson GD. Influenza vaccination acceptance and refusal rates among health care personnel. South Med J. 2010 Oct;103(10):993-8. 14. Santibanez TA, Singleton JA, Santibanez SS, Wortley P, Bell BP. Socio-demographic differences in opinions about 2009 pandemic influenza A (H1N1) and seasonal influenza vaccination and disease among adults during the 2009-2010 influenza season. Influenza Other Respir Viruses. 2013 May;7(3):383-92. 15. Centers for Disease Control and Prevention. Atlanta, GA USA; c2014. Behavioral Risk Factor Surveillance System 2013 Codebook Report Landline and Cell-Phone Data; 2014 Oct 24. 16. Centers for Disease Control and Prevention. Atlanta, GA USA; c2015. Behavioral Risk Factor Surveillance System Overview: BRFSS 2014; 2015 Sept. 17. Centers for Disease Control and Prevention (CDC). Influenza and pneumococcal vaccination levels among persons > or = 65 years--United States, 1999. MMWR Morb Mortal Wkly Rep. 2001 Jun;51(45):1019-24. 18. National Council on Aging. Arlington, VA USA: NCOA;c2017. Share Flu Resources.

REFERENCES 1. Centers for Disease Control and Prevention. Atlanta, GA USA; c2016. Key Facts About Influenza (Flu); 2016 Aug 25. 2. Centers for Disease Control and Prevention. Atlanta, GA USA; c2016. Seasonal Influenza, More Information; 2016 May 4. 3. Medical News Today. Brighton UK: Healthline Media UK, ltd;

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FINDING

YOUR WAY Opportunities for Student Funding You can find assistance in looking for funding opportunities specifically designed for students at the Office of Sponsored Programs (OSP). Funding opportunities can include fellowships, internships, research, programming, and collaboration. OSP can help you locate and qualify funding opportunities as well as assist in application prep, budgeting, and editing. We are here to help you every step of the way! School policy requires that applications are submitted by OSP so please call or stop by early so that we can meet your deadline. OSP’s subscription to Grantscoop provides access to all faculty, staff and students using a GCSoM computer. This searchable database will provide you with details on a wide range of funding opportunities and can be filtered to show you only student-eligible entries. Go to www.grantscoop.com and create your profile/password. The profile will allow you to access from home and save your searches. Stay tuned for a new publication designed just for students featuring new and upcoming funding opportunities from both government and private foundations. The newsletter will be broadcast to students monthly. We’d love to hear your feedback so please stay connected and let us know how we can improve to meet your needs. Contact Information: Karen Baker, Director Office of Sponsored Programs Phone: (570) 955-1323 Internal Ext: 5157 Email: KBaker03@som.geisinger.edu Katie Pasqualichio Grants Specialist Phone: (570) 558-3955 Internal Ext: 5335 Email: KPasqualichio@som.geisinger.edu

2018 SUMMER RESEARCH IMMERSION PROGRAM Each summer the Geisinger Commonwealth School of Medicine Summer Research Immersion Program (SRIP) brings together first year medical students for an opportunity to gain research experience in basic science, clinical science, public/ community health, behavioral health, or medical education under the guidance of a research mentor. The summer research experience includes a $2,500 educational stipend. At the end of the program, students present their research in a poster session. In addition to research, SRIP students participate in a variety of complementary enrichment activities: GCSoM and Geisinger faculty research seminars GCSoM Grand Rounds and clinical seminars at our hospital partners Special events or conferences related to your research topic Clinical exposure Scientific writing & communication workshops SRIP Program Goals: To provide GCSoM medical students with an in-depth experience in research To enhance participants’ knowledge of the scope and types of research relevant to improving health in the region, nationally and globally To offer opportunities to participate in research across the translational continuum from laboratory based biomedical studies to clinical and public health research conducted with community partners To learn from colleagues about their research experiences To enhance GCSoM students’ skills in oral and written scholarship Program Dates: SRIP 2018 will be an eight-week program held June 4 – July 27, 2018. Program Deadlines: Application release date: December 1, 2017 Application submission deadline: February 1, 2018 For more information please contact the SRIP Director, Elizabeth Kuchinski, MPH (ekuchinski@som.geisinger.edu) or Dr. Sonia Lobo Planey, Associate Dean for Research, (splaney@som.geisinger.edu).