MSPAS Research Book

The University of Dubuque Master of Science in Physician Assistant Studies

Fifth Annual Capstone Research Symposium 2023

November 2023

University of Dubuque Linda Chlapaty Hall

Letter of Recognition

Dear Friends and Colleagues,

The University of Dubuque Master of Science in Physician Assistant Studies Program is pleased to honor the talentand dedicationof our students,faculty,and staffthrough the Class of 2023’s Capstone Research Symposium. This researchsymposiumis the culminationof each student’syearlong effort to pursue a relevant inquiryof their choosing,basedon a clinicalcase encountered during their final year of the PA program. In addition to this presentation, each student authored a publication-ready, scholarlyarticle that underwent extensive peer, faculty, and external review to refine their knowledge as evidence-based clinicians and develop inter-professional relationships fundamental to their role as future Physician Assistants.

The pursuit of clinical research is integral to each student’s development, and we take pride in their achievements. We believe their ambition and commitment will shape the future of not only the PA profession but also the trajectory of medicine overall. We hope this symposium will contribute to the dissemination of research findings into everyday clinical practice.

The success of our students would not be possible without dedicated faculty, staff, and external reviewers and evaluators who prepare our students for evidence-based decision making which integrates clinical expertise, patient values, and clinical research in the process of patient-centered, clinical decision making.

We appreciate your attendance and look forward to the interprofessional discussion and engagement.

Sincerely,

PA-C Capstone Director MSPAS Program

Advisor MSPAS Program

Ms. Rachel Rokser,

Ms. Addy First, MS Capstone

Table of Contents

1. Abigail Sutter

Effects of Platelet Rich Plasma on Clinical Pregnancy Rate in Women with Repeated Implantation Failure

2. Allissa Stallman

Efficacy of Hydrocortisone, Thiamine, and Ascorbic Acid to reduce End Organ Damage in Patients with Sepsis

3. Carlie Knutson

Efficacy of Human Amnion/Chorion Allografts vs Standard of Care for Healing Diabetic Foot Ulcers in Adults

4. Courtney Schroeder

Prostatic Artery Embolization versus Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia Symptoms

5. Derek Salow

Roux-en-Y versus Sleeve Gastrectomy for Remission of Type 2 Diabetes Mellitus in Obese Adults

6. Elizabeth Leonard

The Use of Prazosin for Treatment of Post-Traumatic Stress Disorder (PTSD) Sleep Disturbances

7. Emily Onken

Impact of Early vs Late Hartmann’s Reversal on Mortality in Acute Diverticulitis

8. Erin Steffenson

Examination of Oral Dydrogesterone vs Micronized Vaginal Progesterone for Luteal Phase Support in IVF Patients

9. Joe Recker

Comparing Globus Pallidus Internus vs Subthalamic Nucleus Deep Brain Stimulation for Motor Symptoms in Parkinson’s Disease

10. Keaton Lawson Wolf

Glucagon-Like Peptide-1 Receptor Agonist as Adjunct to Bariatric Surgery for Post-Surgical Weight Regain/Insufficient Weight Loss

11. Kendall Koenen

A Systematic Review of PRP vs. Topical Minoxidil for Hair Growth in Adults with Androgenetic Alopecia

12. Kylee Casper

Fecal Microbiota Transplantation for Relief of Irritable Bowel Syndrome Symptoms as Evaluated by the IBS -Symptom Severity

Score

13. Lauren Hoyne

Letrozole vs. Clomiphene Citrate for Live Birth Rates in Women with Anovulatory Polycystic Ovarian Syndrome

14. Logan Slack

Blood Flow Restriction Therapy Effects on Quadricep Strength Post-ACL Reconstruction Surgery

15. Madigan Arend

The Role of Systemic Chemotherapy in the Management of Granulosa Cell Ovarian Tumors

16. Megan Cibulka

Efficacy of Once-Weekly Semaglutide vs SGLT-2 Inhibitors in Type 2 Diabetics Uncontrolled on Metformin

17. Megan Lee

The Efficacy of Teriparatide for Inducing Union in Nonunion Fractures

18. Michael McDonald

The Role of Cryoanalgesia in Post-Thoracotomy Pain Reduction

19. Molly Norman

Efficacy of Mirabegron as Add-on Therapy for Benign Prostatic Hyperplasia

20. Samantha Redmond

Progression Free Survival with Maintenance PARP Inhibitors in BRCA-mutated Pancreatic Cancer

21. Sarah Human

Efficacy of Pimecrolimus for Flare Prevention of Atopic Dermatitis in Pediatric Patients

22. Yvonne Heller

Meconium-Stained Amniotic Fluid: Can Routine Suctioning Decrease Incidence of Meconium Aspiration Syndrome in Non-Vigorous Neonates?

23. Zoe Weber

Creatine Monohydrate: Is it a Potential Solution for Elderly Females Adversely Affected by Sarcopenia?

Abstracts

1. Abigail Sutter

Effects of Platelet Rich Plasma on Clinical Pregnancy Rate in Women with Repeated Implantation Failure

Background: Many women struggle with infertility and seek infertility counseling. Some women turn to in-vitro fertilization (IVF)to help conceive.Repeated implantation failure (RIF) is poorly defined, but most agree that it is three ormore failed embryotransfers.There iscurrently no guidelineasto whattherapiesshould be offered to women with RIF. The use of platelet rich plasma (PRP) has been used in other medical fields and is believed that it may increase clinicalpregnancywhen usedin combination with IVF.

Objective: The objective of this review is to investigate whether the use of intrauterine infusion (IUI) of PRP increases clinical pregnancies in women with RIF.

Methods: PubMedand Cochrane Database of Systematic Reviews were searched from February to April 2023. Inclusioncriteriawere systematic reviews, meta-analysis, orrandomized controltrials(RCTs),femalesaged 19-44,at least2 implantation failures, clinical pregnancy outcome, published within last 10 years, PRP volume 0.5 mL and infused 48 hours prior to embryo transfer, PRP concentration fourto seven times more concentrated than peripheralblood.Studieswere excludedifincluded patients had known hematologic comorbidities, uterine abnormalities, or hormonal disorders. Three RCTs were utilizedin the research and given ratings based on critical appraisalworksheetsfrom the Center for Evidence-Based Medicine.

Results: Two RCTsofmoderatequality andone RCT with low-moderate quality found the use of IUIPRP 48 hours prior to embryo transfer showed an increase in clinical pregnancies.

Conclusion: The use of PRP with IVF increases clinical pregnancy rates. More high-quality studies with larger populations are needed to create any decisive clinical guidelines.

2. Allissa Stallman

Efficacy of Hydrocortisone, Thiamine, and Ascorbic Acid to Reduce End Organ Damage in Patients with Sepsis

Background: Despite continued advancements in medical therapeutics, sepsis globally affects close to 50 million people a yearandremains a leading cause of death in ICU patients. Additionally, the high cost of sepsis care is a burden to the healthcare system. While current treatment guidelinesfocus on broad spectrum antibiotics, IV fluids, and pressors,high levelsofmorbidity andmortality persist with a mortality rate around 25% in the US. Evaluation to find additionaleffectivetreatmentsthatfocuson metabolic deficiencies would be beneficial in sepsis management.

Objective: This systemic review aimed to determine the efficacy of the addition of hydrocortisone, thiamine, and ascorbic acid to theconventionalsepsistreatmentin adults.

Methods: PubMedand Tripdatabaseswere searched from March 2023 to April 2023. Inclusion criteria were adults overthe age of 18 diagnosed with sepsis and treated with hydrocortisone,ascorbic acid,andthiamine (HVTtherapy), systemic reviews, meta-analysis, and RCTs. Studies were notincluded iftheycontained pregnant participants, were alreadybeingtreated with one ormoreof the HVT therapy at the time of admission, and animal studies. Two RCTs and one meta-analysiswere chosenforthissystemicreview and were all given a quality rating based on the critical appraisal worksheets from Center for Evidence-Based Medicine.

Results: Two RCTs,one beingofmoderate qualityand one beingoflowquality,showedno significantimprovementin 72-sequentialorganfailure assessment(SOFA) score. One lowquality meta-analysisshowedresults trending towards improvementin SOFAscores,butoverall results were not significant enough to show efficacy.

Conclusion: HVTtherapy in combination with fluids and broad-spectrum antibiotics is not shown to improve end organ damage in the treatmentofsepsis.The inconsistency in dosingofHVTand othercompounding variable make it hard to drawdefinitiveconclusions,but some studies have showed promising results so higher quality research is recommended.

3. Carlie Knutson

Efficacy of Human Amnion/Chorion

Allografts vs Standard of Care for Healing

Diabetic Foot Ulcers in Adults

Background: Diabetic foot ulcers (DFU) are common complications of diabetes due to dysregulation of blood sugar,atherosclerosis,neuropathy,andpoorwoundhealing. Standardofcare(SOC)aloneincludeswetto dry dressings, off-loading, and debridement. However, the addition of human amnion/chorion allografts may improve healing times.

Objective: The objectiveofthis review was to investigate the efficacy of human amnion/chorion allografts in the setting of DFU.

Methods: Literature was searched through PubMed and Cochrane from February 2023 to March 2023. The inclusion criteria consisted of systematic reviews, metaanalysis, randomized control trials (RCTs), and cohort studieswherethe participants were over the age of 18 and had diabeticulcers.Studieswere excludedfrom the review ifthey were notdone in thelast10yearsornotpublishedin English.Two RCTs and one meta-analysis and systematic reviewwere chosen.The qualityofeach trialwasanalyzed using the Center for Evidence-Based Medicine’s Critical Appraisal Worksheets (CEBM).

Results: The trials varied from moderate to moderatelyhigh qualitystudies.These all showed that the addition of human amnion/chorion allografts improved healing time.

Conclusion: The combination of the current SOC plus human amnion/chorion allografts increased healing rates. However, larger trials with more diverse patient populationsshould bedone before implementation of this into protocol.

4. Courtney Schroeder

Prostatic Artery Embolization versus Transurethral

Resection of the Prostate for Benign Prostatic Hyperplasia Symptoms

Background: Benign prostatic hyperplasia (BPH) is a common condition in adultmen, that can cause disruption in everydayactivities.The currentgold standard treatment is transurethral resection of the prostate (TURP), an intensivesurgicalprocedure.Prostatic artery embolization (PAE) is a new minimally invasive technique gaining tractionasitcan reduceanesthesia use,time in the hospital, and recovery time.ItisunclearifPAEor TURP is superior in reducinglowerurinary tract symptoms (LUTS) in those with BPH.

Objective: This systematic review aimed to determine if PAE is superior to TURP in reducing LUTS from BPH.

Methods: Aliteraturesearch within PubMedand Cochrane wasconducted April9th,2023to April 14th, 2023. Search terms included “Transurethral Resection of Prostate" [Mesh] AND prostatic artery embolization AND "Lower Urinary Tract Symptoms" [Mesh]. Of the 32 resulting articles, 22 articles were screened and, of those, nine assessed foreligibility.Afterimplementation of eligibility criteria, two randomized control trials (RCTs) and one retrospectiveanalysiswere selected and analyzed through the Center for Evidence-Based Medicine’s Critical Appraisal Worksheets.

Results: This systematic reviewincluded threearticleswith 272 total patients assessed via the International Prostate Symptom Score (IPSS) after either PAE or TURP to determine reduction in LUTS from BPH. The quality of publications range from low-moderate to moderate and none found significant data to suggest PAE is superior to TURP in the reduction of LUTS in BPH. Two articles, Abt etal. and Insaustiet al., found PAE to have lower adverse effects compared to the TURP procedure.

Conclusion: The data illustrated PAE is not superior to TURP in reducing LUTS from BPH, though the articles lacked quality that decreased the validity of the results.

5. Derek Salow

Roux-en-Y versus Sleeve Gastrectomy for Remission of Type 2 Diabetes Mellitus in Obese Adults

Background: Type 2 Diabetes Mellitus (T2DM) has long been a worldwide healthconcernwith significantcosts and complications. However, it has the capability to be cured with weight loss surgery, the two most common being sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

Objective: The goal of this research was to determine if there is a difference in the remission rate of T2DM in the first five years after bariatric surgery in adults with presurgicalBMI≥ 25 and pre-existing T2DM who underwent SG versusRYGBby measuringHemoglobinA1c (HbA1c).

Methods: PubMedand Cochrane databases were searched in March 2023.Inclusion criteria included adults aged 1865 with BMI≥ 25 and T2DM undergoing SG or RYGB, studies with more than 12 months follow-up, and T2DM remission measured by HbA1c.Exclusioncriteria included articles where T2DM remission was not the primary outcome,a third type ofsurgery wasinvolved,orfollow-up beyondfiveyears.Three systematicreviewswere included. The quality ofeachstudywasanalyzed usingthe Centerfor Evidence Based Medicine worksheets.

Results: The moderate quality studies by Guraya and Yip etal. showed that T2DM remission rates between SG and RYGB were similar with no significant differences. The moderate to high quality study by Castellana et. al found that T2DM remission rates between SG and RYGB were similar with no significant differences.

Conclusion: In adults with BMI≥ 25 and T2DM undergoing weight loss surgery, there is no significant difference in T2DM remission between SG and RYGB in the firstfive years.The decision shouldbe basedon factors like complications,cost,invasiveness,orpatientpreference.

6. Elizabeth Leonard

The Use of Prazosin for Treatment of Post-Traumatic Stress Disorder (PTSD) Sleep Disturbances

Background: Nightmares and sleep disturbances are common and distressing symptoms of PTSD that can be difficult to alleviate. Prazosin has been researched previously as a treatment option, with some recent trials showing no significant benefit.

Objective: Thisreviewexamined the efficacy of prazosin versus placebo for treating nightmares and sleep disturbances in patients with PTSD.

Methods: PubMed and Cochrane Review databases were searchedforarticlescomparing prazosin to placebo in the treatment of PTSD sleep disturbances from 2008 up to April 2023. Inclusion criteria were studies must be RCT, meta-analyses,orsystematicreviews,participants were 18 years and older, and had a PTSD diagnosis. Studies were excluded if they were not in the English language. Two RCTs and one meta-analysis were included in this paper. Criticalappraisal of these studies was accomplished with use of Center for Evidence-Based Medicine’s Critical Appraisal (CEBM) worksheets.

Results: The includedstudiesvariedfromlow-moderate to moderatequality.Two of the studies showed a significant benefitofprazosin compared to placebo, while one study showed no benefitofprazosin overplacebo forPTSD sleep disturbances.

Conclusion: From the results of this study the current research indicates prazosin should be used as either an augmentation medicationorafterfirst-line PTSD treatment failure. However, more recent RCTs with larger populationsshould becompleted before confirming this as protocol.

7. Emily Onken

Impact of Early vs Late Hartmann’s Reversal on Mortality in Acute Diverticulitis

Background: Acute diverticulitis requiring surgical management with colostomy creation has increased in incidence,with casesfeaturing a younger population than previously seen. Determining optimal reversal timing would minimize post-operativecomplications and provide patients with timing expectations for bowel continuity restoration.

Objective: This study aims to determine the impact of early colostomy reversal (≤ 6 months) compared to late reversal(>6 months),on post-operative mortality in adults who underwent a Hartmann’s procedure for acute diverticulitis treatment.

Methods: PubMed & Trip databases were searched from March 5 to April 14, 2023. Inclusion criteria involved participants who underwent Hartmann’s reversal for diverticulitis, assessment of multiple reversal timepoints, and outcomes including mortality. Three retrospective cohort studies were critically appraised via objective criteria outlined by the Centre for Evidence-Based Medicine.

Results: Resio et al., a moderate-to-high quality study, determinedmortalitywasnotsignificantlydifferent among the early (45-110 days),middle (111-169 days), and late (≥ 170 days) reversal timing groups. Comparatively, a moderatequality study by Salemetal.foundthe lowestrisk for in-hospital death in patients who underwent reversal within the first 6 months. Mortality was unable to be assessed acrossreversaltimepoints in Fleming & Gillen, a moderatequality study,asthere was no mortality reported in the reversal group.

Conclusion: Asonly one ofthe three retrospective studies found decreased mortality risk when colostomy reversal was completed within 6 months, the question of optimal Hartmann’s reversal timing after acute diverticulitis treatmentremainsunresolveduntilprospective studies are completed.

8. Erin Steffenson

Examination of Oral Dydrogesterone vs Micronized Vaginal Progesterone for Luteal Phase Support in IVF Patients

Background: Progesterone provides luteal phase support in women undergoing in vitro fertilization (IVF) by supporting early pregnancy and helping differentiate the endometrial lining for implantation. While micronized vaginal progesterone (MVP) is the gold standard, oral dydrogesterone is an alternative being examined.

Objective: The objectiveofthisresearchisto compare the ongoingpregnancyrateofMVPgelvsoraldydrogesterone for luteal phase support in IVF patients.

Methods: A systematic search of PubMed, CINAHL Complete, and Cochrane databases was conducted from March 29-April6,2023.Inclusion criteria included females of reproductive age and studies looking at ongoing pregnancy rate thatcompared oraldydrogesterone to MVP gel. Exclusion criteria included studies not utilizing IVF and those using oral micronized progesterone. One evaluatorinspectedarticlesto exclude those that did not fit additional criteria such as English language, full text published,andpublicationwithinten years, while utilizing the CenterforEvidence-BasedMedicine’scriticalappraisal worksheet. The search resulted in one randomized noninferiority trial, one randomized controlled trial, and one randomized, single-blinded clinical trial.

Results: Each study was of moderate quality. The first study showednon-inferiority betweenoral dydrogesterone and micronizedvaginalprogesterone.The secondand third studies each found that the two treatment arms, oral dydrogesterone and MVP gel, were comparable with no significant difference in ongoing pregnancy rate.

Conclusion: Overall,resultsshowed oral dydrogesterone had comparable outcomes to MVP gel, although further research with dosing/duration, birth rate outcomes, and adverse effectswillbe needed in order to change the gold standard.

9. Joe Recker

Comparing Globus Pallidus Internus vs Subthalamic Nucleus Deep Brain Stimulation for Motor Symptoms in Parkinson’s Disease

Background: Parkinson’s Disease (PD) is a neurodegenerative disease caused by a decrease of dopamine in the basal ganglia. The first line treatment is dopamine replacement with either levodopa or Sinement. An alternative treatment option is Deep Brain Stimulation (DBS) to stimulate the Subthalamic Nucleus (STN) or GlobusPallidus internus (GPI) areas of the basal ganglia. While both the STN and GPIdecrease PD motor symptoms,themore efficaciousarea forstimulation hasnot been determined

Objective: GPIand STN are two anatomical locations within the basalganglia forDBSto improve motorfunction and decrease medication dependence.The objective of this research isto determine which DBS is more efficacious in decreasing motor symptoms in patient with PD.

Methods: A randomized control trial (RCT), systematic review (SR) (without meta-analysis) and meta-analysis (WithoutSR),were obtained from Cochrane and PubMed through searches between March and April 2023. The articlesmetthe inclusioncriteria ofadults18yearsorolder with advanced PD that compared the efficacy of bilateral GPI vs STN DBS and the improvement of motor function in PD using the United Parkinson’s Disease Rating Scale (UPDRS) motorscore.Each article wascriticallyappraised using the Center of Evidence-Based Medicine’s Critical Appraisal Worksheets.

Results: All three studies were moderate quality. There were, in total, 1565 patients included in these studies, which resulted in no significant difference in on-phase between STN and GPIDBS, but found significant improvement in motor function during the off-phase for STN DBS.

Conclusion: Both STN-DBS and GPI-DBS with medical therapyare viable treatment options for improving motor symptomsand qualityoflife in patients with PD. STN may be the preferred target in DBS for off-phase treatment of PD and improvement in motor function.

10. Keaton Lawson Wolf

Glucagon-Like Peptide-1 Receptor Agonist as Adjunct to Bariatric Surgery for PostSurgical Weight

Regain/Insufficient Weight Loss

Background: While bariatricsurgeryhasbeenan effective method forweightlossformanyyears, many patients may experiencesignificant weight regain or inadequate weight lossaftersurgery.The use ofGLP-1 RAsforweight loss is well-established in the general population, however, efficacy has not been established when utilized as an adjuncttreatment to bariatric surgery for weight regain or insufficient weight loss.

Objective: The goal of this study is to determine if the addition of Glucagon-Like Peptide-1 Receptor Agonist would improve weight loss compared to bariatric surgery alone in those withinsufficientweightlossorweightregain postoperatively.

Methods: Medical databases (PubMed, Trip) were accessedon April10th,2023.Studiesthat included weight regain, GLP-1 RA, adults >18 years, and sleeve gastrectomy/roux-en-y gastricbypasswere included.Those with patients taking weight loss medications other than GLP-1 RAs or those who were unable to use them were excluded. Three retrospective analysis studies were evaluated andcritically appraised usingCEBMworksheets.

Results: The use ofsemaglutide and liraglutide iseffective for the use of weight regain or insufficient weight loss when starting therapy at a variety of time points after bariatric surgery. Semaglutide appears to be significantly more effective for weight loss compared to liraglutide. Women tend to have an increased amount of weight loss when taking semaglutide.

Conclusion: Weightregainorinsufficientweightlossafter bariatric surgery can potentially be treated using a GLP-1 RA such as semaglutide or liraglutide. This provides an option for clinicians to treat this common challenge and opensthe doorforfuture research to be done on the topic.

11. Kendall Koenen

A Systematic Review of PRP vs. Topical Minoxidil for Hair Growth in Adults with Androgenetic Alopecia

Background: Androgenetic alopecia is the most common hair disorder worldwide with only two FDA approved therapies: minoxidil and finasteride. Platelet rich plasma therapy is an emerging treatment showing promise in current literature for hair growth.

Objective: We sought to compare the efficacy of PRP intradermal injections to topical minoxidil in adult men with AGA for hair growth.

Methods: Study protocol followed the PRISMA guidelines involving a multistep search of PubMed and Trip fromJanuary31st,2023 through April 15th, 2023 for studiesinvolvingpredetermined criteriain accordance with the PICO criteria.Inclusioncriteria includedadults of male gender and AGA grade I-IV classified by the NorwoodHamilton Scale. Exclusion criteria included previous/currentuse ofsystemictreatmentsforAGA, other types of alopecia, platelet disorders, thrombocytopenia, sepsis or cancer. This yielded 32 studies for review and three RCTsoflow-moderate,moderate,and moderate-high qualitythatwereselected foranalyzation using the Center forEvidence Based Medicine criticalappraisalworksheets.

Results: The studiesby Balasundaram et al. and Singh et al. both showed no statistical difference in hair growth between the PRP and minoxidil treatment arms. Verma et al. showed a comparatively better outcome for PRP than minoxidilon globalphotography, however, no data points orp-valuewere provided.Interestingly,Singh etal.showed the highest increase in hair density in the combination group using PRP and minoxidil.

Conclusion: :Overall,monotherapy ofPRP did not prove to be superior to topical minoxidil, but rather equal in efficacy.However, there is promise regarding efficacy of combinationtherapy and further research should be done.

12. Kylee Casper

Fecal Microbiota

Transplantation for Relief of Irritable Bowel Syndrome

Symptoms as Evaluated by the IBS-Symptom Severity Score

Background: Irritable bowel syndrome (IBS) is a common gastrointestinal disorder in which the only treatment is symptom management. While the gut microbiome is not totally understood, implementing changes to the microbiota with a fecal microbiota transplantation (FMT) may provide improvement to IBS symptoms that patients frequently endure.

Objective: The objective of this research is to identify if an FMT may be efficacious in patients with IBS for improvement of symptom severity as defined by the IBSSSS questionnaire.

Methods: PubMed and Cochrane were searched between March and Aprilof2023 to provide studies with inclusion criteriaofadultsdiagnosed with IBS and utilization of the IBS-SymptomSeverityScore(IBS-SSS).Studiesexcluded were those with dominant IBS symptoms, use of medicationswiththe FMT,FMT administeredorally, postinfectious or antibiotic induced IBS, longer duration, and studiesnotin full-textpublication.Three moderate quality studieswere chosenand werecritically appraised using the CenterforEvidence-Based Medicine’s Critical Appraisal Worksheets.

Results: Allthreestudiesconcluded thatan FMT provided a beneficialchange in the symptoms of IBS as defined by the IBS-SSS atthree months.However,the two longerterm studiesdetermined thatthechange ofscoresin the IBS-SSS did notcontinuallydecrease or remain static,indicatingthat the FMT only provided transient relief.

Conclusion: FMTisnotan effective treatment for IBS and doesnotcure the long-termsymptomsthatIBSentails. The amount of time and resources that go into the process outweighs the possible transient relief that IBS patients may endure after an FMT.

13. Lauren Hoyne

Letrozole vs. Clomiphene

Citrate for Live Birth Rates in Women with Anovulatory Polycystic Ovarian Syndrome

Background: The most common sequelae of polycystic ovariansyndrome (PCOS) is anovulatory infertility, most often requiringovulation induction with pharmacotherapy. Clomiphene citrate (CC) has remained the first line, approvedtreatmentfordecades despite its low efficacy of conception (30-40%). Recent studies have shown that letrozole (LE) may be a better option for anovulatory infertility in women with PCOS.

Objective: The purpose of this investigation is to determine the efficacy of ovulation induction with Letrozole compared to CCby examining live birth rates in women with PCOS.

Methods: PubMed and Cochrane databasesweresearched from March 27-April 13, 2023. Studies were screen to includewomen of childbearing age diagnosed with PCOS (Rotterdamcriteria), LE vs CC alone as interventions and excludedothercausesforinfertility, were not taking other infertilitymedicationsorutilizingfertility methods.Twenty articles were screened resulting in two randomized controlled trials (RCT) and one systematic review/metaanalysis that met the required criteria. All studies were critically appraised with the Cener for Evidence Based Medicine (CEBM) worksheet and were deemed to be of high, moderate-to high, and moderate quality.

Results: Participantswhoreceived LE had higher rates of live birth compared to those with CC. Legro et al., a highquality RCT and Liu et al., a moderate quality metaanalysisandsystematic review found significantly higher rates with LE (LE 27.5% vs CC 19.1%, p = 0.007 and LE 32.8%vsCC 22.2%,p <0.001,respectively).Ameretal.,a moderate-to-high quality RCT found higher rates of live birth (LE 48.8% vs CC 35.4%, p = 0.089), although were not statistically significant.

Conclusion: LE was associated with higher rates of live birth compared to CC and may serve as a better first line choice forwomen with anovulatory infertility and PCOS.

14. Logan Slack

Blood Flow Restriction Therapy Effects on Quadricep Strength Post-ACL Reconstruction Surgery

Background: Blood flowrestriction therapy is a low-risk therapymodality that induces muscle hypoxia and can be used forpost-ACLreconstruction surgery. It can promote expedited muscle hypertrophy and lead to an accelerated recoverycomparedto standardphysicaltherapy which can accelerate recovery and prevent quadricep atrophy.

Objective: The purpose of this review is to investigate in patients 14-59 with ACL reconstruction surgery, does blood flowrestriction therapy,compared to non-blood flow restriction therapy or standard PT, increases quadricep strength post-surgery in patients 14-59 with ACL reconstruction.

Methods: A literature review was conducted between February 27th and March 27th of 2023 which included a systematicreview,RCTs,and a cohortstudy.The databases search encompassed PubMed, Cochrane, and Applied Sciences all as free text without MeSH terms. A total of 104 articleswere identified andthree were included in this review. Inclusion criteria included English language, studies published within the past five years, RCTs, systematic reviews, cohort studies, ages 14-59, BFR therapy, and ACLR surgery. Exclusion criteria included elite athletes, additional procedures besides ACLR, thromboembolic events, and studies without a control group. This systematic review is comprised of an RCT, a systematicreviewincludingfourRCTs,and a retrospective cohort study. A CEBM worksheet was utilized to ensure validity, clinical relevance, and applicability during the appraisal process.

Results: In this review, three studies of low-moderate quality showed a statistical difference in increased quadricep strength withBFRtherapyafteratleast12 weeks of rehabilitation compared to standard PT.

Conclusion: BFR therapy shows efficacy in increasing quadricep strength post-ACLR surgery compared to standard PT, but more research needs completed before strong recommendations are made.

15. Madigan Arend

The Role of Systemic Chemotherapy in the Management of Granulosa Cell Ovarian Tumors

Background: Granulosa cell ovarian tumors are rare occurringmalignancies with high incidence of recurrence years after initial diagnosis. Due to the rarity of disease, treatment options are highly variable and have not been standardized across treatment centers.

Objective: The effect of adjuvant chemotherapy in conjunction with first line surgical treatment is variably used but has not been established as an option for longer periods of disease free recurrence.

Methods: Randomized controlled studies, retrospective cohortstudies,and systematic reviewswere searched from PubMed and Cochrane between February 1st and April 15th , 2023. Inclusion criteria included adult patients, primary diagnosis of granulosa cell ovarian cancer, and studies conducted within the last 10 years. Exclusion criteriaincluded children,concurrentcancerdiagnoses, and adjuvant radiation therapy. This review includes three retrospectivecohortstudieseachofmoderatequality based on CEBM worksheet that was utilized.

Results: Allthree retrospective cohortstudiesdid not find a correlation in adjuvant chemotherapy to surgical treatmentin prolongingthe period ofdisease-free survival.

Conclusion: Granulosa cell ovarian tumors should be treatedwith radical or fertility sparing treatment alone as there isno benefitofadjuvantchemotherapyto diseasefree survival.

16. Megan Cibulka

Efficacy of Once-Weekly Semaglutide vs SGLT-2

Inhibitors in Type 2 Diabetics Uncontrolled on Metformin

Background: T2DM is a common metabolic disorder of adultsin the US. While metformin is still considered first line pharmacotherapy, many do not achieve glycemic controlon it alone. Current add-on therapy is determined based on patient comorbidities, safety profile, cost, and insurance coverage.Evaluation ofsuperior add-on glucose lowering therapies for patients failing metformin monotherapy would be beneficial for adult T2DM management.

Objective: This SR aimed to examine the glycemic efficacy ofOWSIcomparedto SGLT-2iasadd-on therapy for T2DM adults uncontrolled on metformin.

Methods: Aliteraturesearch within Pubmedand Cochrane wasconducted fromMarch 14th,2023to April14th, 2023. Search terms included semaglutide, canagliflozin, empagliflozin, and HbA1C. Publications including adults (≥18 years) with T2DM inadequately controlled on metforminmonotherapy were included. Studies that were nota meta-analysis,SRor RCT or were published prior to 2013 were excluded. Two meta-analyses and one RCT were analyzed utilizing the Center for Evidence-Based Medicine’s Critical Appraisal Worksheets.

Results: Within the selected publications, 18,048 T2DM patients were included for review. Publication quality ranged from moderate to high quality. Patients failing metforminmonotherapy sawa significant improvement in hemoglobin A1C (HbA1C) lowering effectiveness when taking OWSIversus daily SGLT-2i.

Conclusion: This SR demonstrated that OWSIshowed superior efficacy compared to three SGLT-2i in lowering HbA1C in T2DM patients uncontrolled on metformin monotherapy.

17. Megan Lee

The Efficacy of Teriparatide for Inducing

Union in Nonunion Fractures

Background: The economic burdenplaced on patients and hospitalsfortreatingnonunionfracturesisoneof the many impacts nonunion fractures have. Nonunion fractures requireincreased healthcare utilization, increased risk of chronicpain,mental health problems, physical disability, and increased duration of opioid use.

Objective: Thissystematicreview aimed to determine the efficacy and risks of using teriparatide, a PTH analog to induce union in nonunion fractures of any bone in adults and adolescents.

Methods: A database search of Cochrane Library and PubMed was conducted on April 13, 2023. Inclusion criteria consisted of studies with nonunion fractures, age 13+, PTH analog for treatment and studies in the English language.Exclusioncriteria consisted ofstudies published over10 yearsago,singlecasestudies,PTHused in primary fracture healingandanimalstudies.Within thissearch there were 3 studiesthatweredeemedappropriate,howeverlowqualitystudies.Critical appraisal was performed utilizing the Center for Evidence-Based Medicine’s Critical Appraisal.

Results: Each ofthesestudy resultsshowed teriparatide is over90%effective in inducingunion in nonunion fractures with no side effects reported. However, these studies had many limitations includinglack ofcontrol groups and lack of randomization that makes the conclusions unreliable.

Conclusion: Teriparatide as a nonsurgical option for nonunionfracturescould be utilized offlabelafterfirst line managementsforpatientswho are poorsurgicalcandidates orprefera nonsurgicaloptionwith little to no side effects. However,atthistime theevidenceto supportan indication for use is low. Higher quality studies utilizing randomization, control groups as well as more specific inclusion and exclusion criteria to better analyze which patient population this medication is best for are needed before efficacy conclusions can be determined.

18. Michael McDonald

The Role of Cryoanalgesia in Post-Thoracotomy Pain Reduction

Background: Due to the extensivenerve involvement and inevitably invasivenatureofthoracic surgical procedures, the aim to reduce post-thoracotomy pain proves to be a complex issue.Pain haslongbeen a hindering obstacle for patientsduringrecoveryandistraditionallyaddressed with an opioid based regimen. With recent knowledge highlighting the dangers of opioid use dependency, the pursuitofreducingpostoperative pain in thoracic surgeries through alternativemethods such as cryoanalgesia, stands to be a formidable challenge.

Objective: This systematic review aims to examine the efficacy of cryoanalgesia in reducing post-thoracotomy pain.

Methods: Aliteraturesearch within PubMedand Cochrane wasconducted fromMarch 6th,2023to March 15th, 2023. Search terms included intercostal [free text] AND cryo* [free text] AND pain [free text]. Publications including patients18 years or older receiving thoracotomy surgical procedureswith use of intraoperative cryoanalgesia were included.Studiesthatwere nota meta-analysis, systematic review, RCT, or published prior to 2010 were excluded. Two RCTs and one retrospective cohort study were analyzed through utilization of the Center for EvidenceBased Medicine’s Critical Appraisal Worksheets.

Results: Within the selected publications, there were 247 adult patients (control=112; cryoanalgesia=135).

Publicationquality ranged from low to high. Patients who received cryoanalgesia reported significantly reduced postoperative pain and opioid consumption compared to the control groups

Conclusion: The data among these articles unanimously demonstrated the efficacy of cryoanalgesia in reducing post-thoracotomy pain. However, the small sample sizes, notablemissingdatapoints,and lack of uniformity among procedural techniques requires further investigation and decreases validity of this study.

19. Molly Norman

Efficacy of Mirabegron as Addon Therapy for Benign Prostatic Hyperplasia

Background: In the United States,BPH is one of the most prevalenturologic disorders in adult male patients. While the conventionaltreatmentofalpha-adrenergic blockers is suitable and safe for many patients, those with comorbidities such as hypotension from autonomic dysfunction arenotgoodcandidatesforthistreatment. This leavesa gap in treatmentoptions for the often bothersome and frustrating urinary symptoms in these patients.

Objective: Thissystematic reviewsoughtto determine ifa newer medication, mirabegron, may be safe as an adjunctive treatment to the conventional alpha-blocker therapy currently recommended.

Methods: A database search of PubMed and Cochrane Library was performed between March 15th, 2023, and April12th, 2023. Included were studies published within the last 10 years on males age 40 and older with symptomatic BPH not due to neurogenic overactive bladder.Excludedwere studiesinvolvingparticipants with prostate cancerorcurrenturinarytractinfection.The search yielded three studies that met these criteria: a moderate quality RCT by Kaplan et al., a low-to-moderate quality RCT by Singh etal.,and a low-to-moderatequality RCTby Ichihara etal.The Center for Evidence Based Medicine’s critical appraisal tools were utilized to determine quality and reliability of each study.

Results: Each ofthese studies found evidence to suggest that addition of mirabegron to tamsulosin therapy yields increased efficacy for control of lower urinary tract symptoms (LUTS) due to BPH.

Conclusion: There is still a need for more research regardingspecific dosing and potential use of mirabegron as monotherapy.

20. Samantha Redmond

Progression Free Survival with Maintenance PARP Inhibitors in BRCA-mutated Pancreatic Cancer

Background: Currently, guidelines for those diagnosed with pancreaticcancer are recommended various regimen combinationsofchemotherapeutic agents for maintenance therapy,butthosediagnosed with BRCA-germline mutated pancreatic cancer have another option to use PARP inhibitors.Maintenancetherapy can be difficultforpatients as they question their prognosis and the quality of life in their remaining time, emphasizing the importance of researchingprogression free survival(PFS)time to provide realistic expectations and informed decision-making.

Objective: The objectiveofthisresearchis to determine if PFS is prolonged with PARP-inhibitors as maintenance therapy in BRCA-mutated, advanced pancreatic cancer treated with first-line platinum-based therapy.

Methods: Pubmed, Cochrane, and the Journal of clinical oncology were searched from 03/03/2023 to 03/14/2023 with 101 articlesanalyzed. Inclusion required age of 18+, diagnosed with advanced, germline-mutated pancreatic cancer,and receiptofplatinum-based chemotherapy. Two single-arm studies and one double-blinded, placebocontrolled study were included in this systemic review. Criticalappraisal was guided by the Centre for evidencebased medicine (CEBM) worksheets.

Results: Three trials were included in our review of literature. Kindler et al. provided a high-quality doubleblinded,placebo-controlled study that resulted PFS at 7.4 months compared to placebo at 3.8 months. This trial demonstrated the benefits of PARP-inhibitors for those with BRCA-mutations and was the influence for multiple otherstudies.Two single-armtrialswerealsoincluded,one being moderate quality from Reiss et al., and one low qualityfromLowery etal.with PFSat13.1 monthsand 1.7 months, respectively.

Conclusion: Asingle trial(POLOtrial)showed prolonged PFS with PARP inhibitor use versus placebo. Unfortunately, this is the only trial that has compared PARP inhibitorsto placebo.Furtherresearch is required to validate these findings and begin comparing PARPinhibitors against continued chemotherapy.

21. Sarah Human

Efficacy of Pimecrolimus for Flare Prevention of Atopic Dermatitis in Pediatric Patients

Background: Atopic dermatitis (AD) is a common inflammatory skin disease, most prevalent in childhood. While daily topical emollients and intermittent use of corticosteroids are first line treatment, there are several concerns about side effects including skin thinning and hypothalamic-pituitary-adrenal axis suppression. Evaluationto findeffective alternativetreatmentswould be beneficial in pediatric AD management to reduce flares requiring the need for topical corticosteroid use.

Objective: This systematic review aimed to examine the efficacy ofpimecrolimus cream 1% for flare reduction in the treatment of atopic dermatitis in pediatric patients.

Methods: A literature search within PubMed and Cochrane was conducted from February 2023 to April 2023.Searchtermsincluded topical calcineurin inhibitor, topicalvehicle cream, and atopic dermatitis. Publications including patients 17 years of age and younger with a formaldiagnosisofatopic dermatitiswere included.Studies thatwere nota meta-analysis, systematic review, RCT, or cohortstudy published priorto 1998were excluded. Three RCTs were analyzed through utilization of the Center for Evidence-BasedMedicine’sCriticalAppraisalWorksheets.

Results: Withinthe selectedpublications,there were1,485 pediatricpatients(placebo=549; pimecrolimus=936). The quality of all publications was moderate. Patients had significant improvement in reduction of flares through measured outcomes when using pimecrolimus cream 1% compared to standard vehicle creams.

Conclusion: The dataillustrated that pimecrolimus cream 1% demonstrated significant reduction in AD flares. However,furtherhigher-qualitystudies comparing topical calcineurin inhibitors (TCIs) to topical corticosteroids (TCS) and TCIsafety profilesare needed to guide specific treatment regimen.

22. Yvonne Heller

Meconium-Stained Amniotic Fluid: Can Routine Suctioning Decrease Incidence of Meconium Aspiration Syndrome in Non-Vigorous Neonates?

Background: In 2015, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA)altered theNeonatal Resuscitation Program (NRP) guidelinesto indicate routine suctioning of non-vigorous neonates born through meconium-stained amniotic fluid (MSAF) is no longer required. These changes were made without evidence suggesting decreased outcomes of meconium aspiration syndrome (MAS).

Objective: The goal of this systematic review is to determine if routine endotracheal suctioning decreases incidence ofMASin non-vigorous neonates born through MSAF.

Methods: PubMed and Cochrane were searched from January 1, 2013 to March 29, 2023. Inclusion criteria consisted of non-vigorous neonates born through MSAF, studies comparing endotracheal suctioning (ETS) versus no-ETS,gestationalage >34 weeks,randomized controlled trials (RCTs), meta-analyses, and systematic reviews. Exclusion criteriawere simulation trials, pilot studies, and duplication of data. Two RCTs and one combined systematic review and meta-analysis (SR+MA) were utilized. RCTs and systemic review were appraised using the Center for Evidence-Based Medicine’s Critical Appraisal Worksheets to evaluate the quality of studies.

Results: All three studies were of moderate quality. The findings between all three studies indicate insignificant improvement of MAS with or without routine ETS.

Conclusion: The decision to suction a non-vigorous neonate born through MSAF should be based on provider experienceand clinicaljudgmentuntil definitive evidence can be explored.

Creatine Monohydrate: Is it a Potential Solution for Elderly Females Adversely Affected by Sarcopenia?

Background: The elderly population is expected to increase in coming years which will cause an increase in sarcopenia. Elderly females will be at higher risk for complicationsfromsarcopenia compared to males as they are disproportionately affected by osteopenia and osteoporosis.Efficacioustreatmentisneededforsarcopenia in this population to avoid poor quality of life.

Objective: Investigation of whether creatine supplementation combined with resistance training better treatssarcopenia in elderlyfemalesthanresistance training alone as measured by one rep maximum of bench press.

Methods: Databases searched: PubMed and Cochrane Date ofsearch:April21st,2023 Inclusioncriteria included genderand age range andothercriteriathatensuredstudies included in the review could be compared properly. Exclusion criteria ensured there were no confounding variables. Type of studies included: Three randomized controlled trials The Center for Evidence-Based Medicine’sCriticalAppraisalWorksheetwascompletedby the lead author for each trial included.

Results: The trials by Aguiar et al. and Gualano et al. found significant differences in the one rep maximum of bench pressin the creatine group compared to the placebo group, while the trial by Roschel et al. did not. These studieswere foundto be moderate quality after analyzing their strengths and limitations.

Conclusion: Based on our findings, creatine combined with resistance training should not be recommended as a treatment option for sarcopenia in elderly females due to inconclusive efficacy and clinicians should instead recommend resistance training alone.

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