Abstracts  |   November 2017
2017 Research Conference Abstracts and Poster Competition
Article Information
Abstracts   |   November 2017
2017 Research Conference Abstracts and Poster Competition
The Journal of the American Osteopathic Association, November 2017, Vol. 117, e27-e135. doi:10.7556/jaoa.2016.141
The Journal of the American Osteopathic Association, November 2017, Vol. 117, e27-e135. doi:10.7556/jaoa.2016.141
This issue of The Journal of the American Osteopathic Association (JAOA) features abstracts from the posters that were presented at the 60th Annual American Osteopathic Association (AOA) Research Conference. 
This year's abstracts were organized into the following categories: 
  • ▪ basic sciences (see page e27)
  • ▪ clinical (see page e69)
  • ▪ health services (see page e119)
This year's AOA Research Conference took place in Philadelphia, Pennsylvania, on Saturday, October 7, and Sunday, October 8, during the AOA's 2017 Osteopathic Medical Conference and Exposition (OMED 2017). Abstracts submitted by students into the poster competition (designated with “♦”) were judged, and first- and second-place winners were announced at OMED 2017 (designated with “★”). The JAOA did not receive copyright release forms from the authors of abstract H2; thus, that abstract is not included here. 
To enhance the readability of this special feature, abstracts have been edited for basic JAOA style only. The content has not been modified; information provided reflects information that was submitted by the primary author, including professional degrees and affiliations. Neither the AOA Research Council nor the JAOA assume responsibility for the abstracts’ content. 
Basic Sciences
♦B1—Chronic Diseases and Conditions
Blood-Brain Barrier Breakdown and Mechanisms of Alzheimer Disease Pathogenesis 
Eric Goldwaser, PhD, OMS IV1; Nimish Kumar Acharya, PhD2; Robert G Nagele, PhD3 
1Rowan School of Osteopathic Medicine (RowanSOM), Jersey City, New Jersey; 2Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA; 3New Jersey Institute for Successful Aging, RowanSOM, Stratford, New Jersey 
Age-related neurocognitive disorders such as Alzheimer disease (AD) are poorly understood from a pathogenic or mechanistic standpoint. However, current literature is directing more attention to the cerebrovasculature that nourishes the brain, as well as the cerebrospinal fluid (CSF) drainage system as paramount features that maintain normal neuronal functioning, especially in the regions related to memory and higher-order cognition otherwise affected in AD. Blood-brain barrier (BBB) breakdown allows plasma components, including amyloid-β42 (Aβ42) and brain-reactive autoantibodies (aAbs), to enter the brain interstitium and interact with cell surfaces, disturbing neuronal function and contributing to the progression of AD. Various cranial manipulative techniques may address these areas, and as such, may prove to be a highly fruitful research area that could provide beneficial advances in managing age-related dementias, like AD. The scope of this research poster is to present the pathogenic and cellular consequences that result from a dysfunctional BBB, which culminates in amyloid-burdened neurons, neuron death, and amyloid plaque formation, while also highlighting the potential value that cranial osteopathic manipulative treatments can offer. The presence of extravagated plasma components such as IgG and Aβ42 has been widely reported in the cerebral cortex of AD brains. We investigated the possible role of these plasma components, as well as IgM, IgA, and IgE, in mediating chronic endocytosis in neurons, their link to intraneuronal Aβ42 deposition, and the generation of amyloid plaques in AD brains. Immunohistochemistry (IHC) was used to monitor BBB breakdown in AD brains and age- and disease-matched controls, as well as the interactions of amyloid-β42 and autoantibodies with AD-vulnerable neurons. Appropriate experimental controls were accompanied with negative and positive controls where relevant to the chosen experiment and technique. A cell culture model was used to test the mechanistic role of autoantibodies in intraneuronal amyloid deposition. Treatment time points were chosen based on current literature used for cell culture model and treatment systems and most importantly, using physiologic concentrations of Aβ42 peptide of 100 nanomolar. Confocal microscopy with fluorescent-tagged targets and quantitative software analysis allowed for standardized and routine comparisons of assayed cell culture experiments. Each experiment was performed in biologic and experimental triplicates and conducted with blinded user data acquisition parameters to ensure nonbiased and reproducible results. Based on a tentative mechanism derived from observations of human AD brains described in detail previously, a cell culture model system was established to investigate cellular mechanisms associated with the phenomenon of aAb-mediated receptor endocytosis. Differentiated SH-SY5Y human neuroblastoma cells were used to test the possibility that IgG aAbs elicit intraneuronal Aβ42 accumulation through induction of chronic endocytosis. Immunofluorescence microscopy assessed the internalization of Aβ42 and surface proteins, and the subcellular trafficking of Aβ42. Cells were treated for up to 72 hours with specific antibodies against selected neuronal surface antigens, or with serum or purified-IgG from either AD or controls in conjunction with physiologically relevant concentrations of soluble, exogenous Aβ42. An array of inhibitors was used to test the requirement for specific types of endocytosis. Dynasore, a dynamin1/2 GTPase inhibitor of clathrin-mediated endocytosis, showed that Aβ42 accumulation is predominantly dependent on this pathway of entry into cells. We also demonstrated co-localization of IgG, α7 nicotinic acetylcholine receptor, and Aβ42 that was temporally related to the early endosomal marker, Rab11, and at later time points to the lysosomal marker, LAMP-1. Results using monovalent F(ab) antibody fragments generated from purified IgG of serum in patients with AD suggest that internalization of Aβ42 via endocytosis is triggered by the cross-linking capacity of neuron-binding aAbs. When tracked over time, these coupled events demonstrated aAb-mediated endocytosis and accumulation of serum IgG and Aβ42 within the lysosomal compartment of SH-SY5Y cells, consistent with the in vivo AD brain pathologic correlates. Accumulation of these serum components within neurons along with the associated depletion of key surface proteins and signaling receptors on their cell surfaces is thought to disrupt their homeostasis, leading to impaired neuronal function, neurotoxicity, progressive intracellular Aβ42 accumulation, and ultimately cell death and amyloid plaque development. IHC experiments of AD brains showed that brain-reactive aAbs bind selectively to pyramidal neurons in regions of BBB compromise and trigger pathological changes, including intraneuronal accumulation of Aβ42 and lysosomal compartment expansion. An array of serum aAbs from control and AD patients dramatically increased the rate and extent of intraneuronal amyloid-β42 deposition in the cell culture model. Preventing plasma extravasation by restoring the structural and functional integrity of the BBB may curtail initiation and progression of the pathologic changes in AD, and it is thus a promising therapeutic target that directly prevents assault from blood-borne factors that trigger and propagate this devastating disease. Results suggest that brain-reactive aAbs can gain access to the brain's interstitium via a defective BBB. This allows them to bind selectively to neuronal surfaces and enhance intraneuronal deposition of Aβ42 in AD brains, proposing that in the context of BBB compromise, brain-reactive aAbs may be an important risk factor for the initiation and progression of AD as well as other neurodegenerative diseases. 
Support: The Osteopathic Heritage Foundation and the Osteopathic Heritage Foundation Endowment Student Scholars program made funding for this project possible. 
♦B2—Chronic Diseases and Conditions
Cerebellar and Cerebral Cortical Responses to Cathodal Tdcs: An In Vivo Approach to Study Its Applicability to Cerebellar Ataxia Treatment 
Alexis Lynn De La Cruz, OMS II; Ramneek Manchanda, MS, MPH, OMS II; Andrew Keith, MS, OMS II; Huo Lu, MD, PhD 
Georgia Campus–Philadelphia College of Osteopathic Medicine (GA-PCOM), Suwanee 
Research Questions/Hypotheses: According to recent studies, the use of transcranial direct current stimulation (tDCS) has shown promise as a potential therapy for cerebellar movement disorders. Our previous studies explored the effects of anodal tDCS stimulation on Purkinje cell firing rates and local field potentials (LFPs) in the cerebellar cortex. The aim of our current study was to investigate the effects of cathodal tDCS stimulation on Purkinje cell firing rates and cerebellar cortical LFPs to answer the question if the physiological effects of tDCS are dependent on the polarity of the stimulation using an in vivo approach. Current treatment of patients with cerebellar ataxia using tDCS relies on a simplistic dosage approach in which cerebellar excitability is increased or decreased under anodal and cathodal stimulation, respectively. Recent studies have shown that this application of tDCS may be too simplistic, not accounting for the complexity of the cerebellar mechanics. Thus, further research must be performed to improve the application of tDCS for cerebellar movement disorders, including ataxia. We hypothesize that the cathodal transcranial direct current stimulation of the cerebellar cortex has variable effects on the cerebellar Purkinje cell activity and the LFPs of both the cerebellar and cerebral cortices because of the variability in the Purkinje cell dendritic trees. The significance of this research to the osteopathic community involves the elucidation of the cerebellar mechanics affected by tDCS stimulation. tDCS is used as a novel approach to cerebellar ataxia, a chronic condition affecting thousands of people worldwide. Exploring the effects of tDCS stimulation on the cerebellar and motor cortices can add to the understanding of the cellular mechanisms involved in tDCS therapy. Thus, this research will assist in the optimization of tDCS therapy for cerebellar ataxia. 
Methods: Surgery: All cranial surgical procedures were performed according to the Bower laboratory methods (Bower et al, 1981). Protocols had been approved by the IACUC of PCOM. Each rat was placed in an induction chamber with isoflurane (4% with oxygen at 1 L/min by calibrated vaporizer), allowing the rat to lose consciousness without distress. The animal was anesthetized with an injection of ketamine/xylazine/acepromazine cocktail into the intraperitoneal cavity. Supplemental doses were given throughout the experiment. The animal was then placed in head-mounting hardware on a custom-built surgical setup that included a heating pad with a vital sign monitor. An incision was made in the skin and the soft tissue was removed to expose the skull over the cerebellar and cerebral cortex. Two small holes were prepared, 1 over the cerebellum and 1 over the contralateral motor cortex. The dura was excised to expose the brain tissue. The skin posterior to the cerebellum was kept for the tDCS. To generate the tDCS, a metal wire (1-2 mm2 diameter) was placed on the skin immediately posterior to the hole prepared over the cerebellum. The current was delivered using a stimulus isolator (WPI A365, 100-200 μA) for 20 minutes. The ground electrode was placed on the contralateral cheek area. Neural recording: We used platinum/iridium monopolar electrodes (1 MΩ, UEPSEGSGXN4G, FHC). Neural signals were amplified (A-M Systems model 1700), digitized (Digidata 1300A, Axon Instruments), and recorded with Clampex 9 (Axon Instruments). An electrode was positioned into the motor cortex (1.6 mm anterior to the bregma, 3 mm lateral to the mid line, 1 mm depth). A second electrode was positioned into the cerebellar cortex and a single unit Purkinje cell activity was isolated. Then the filter was opened to be 1 Hz - 10 kHz. Recordings were conducted for 10 minutes before tDCS, 20 minutes during tDCS, and 10 minutes after tDCS. Data Analysis: Data were filtered with a band pass filtered between 0.3-10 kHz. Artifacts were removed manually, and spikes were detected using customized Matlab (R2016a) scripts that operate by detecting a threshold calculated by SD. A plot was generated for monitoring the frequency changes of Purkinje cell simple spike activities before, during, and after stimulation. LFPs (1-100 Hz) were examined for the general cerebellar and motor cortical cellular activities. A power spectrum analysis Welch-type was run on the original unfiltered data with a window of 100k samples (10 seconds) and a window of 100k for discrete Fourier transforms. A surface plot was generated using 1-minute time windows. For the cross-correlation and coherence analysis, nonfiltered signals were used to generate normalized plots using Matlab functions “xcorr” and “mscohere”. These methods have been widely used in the data analysis of brain activities (Adhikari et al, 2010; Brazhnik et al, 2012). Results from this analysis were illustrated using average trace and surface plots generated to show the changes before, during, and after tDCS in both frequency and time domains. 
Results: Six Purkinje cells were isolated from the cerebellar cortex of 5 Sprague-Dawley rats along with LFP recordings in the cerebellar and cerebral cortices. The intensity of cathodal stimulation was set at 100 μA and 200 μA. Power spectrum analysis was conducted to study the general cerebellar cortical activity changes by tDCS. The results revealed an increase in the amplitude at approximately 10 Hz in 2 of 6 cells. The remaining 4 cells did not show any significant changes in amplitude. Analysis of the mean frequency was conducted to study the individual Purkinje cell output. Three cells showed a decrease in firing rate after cathodal stimulation, while other 3 cells showed an increase in firing rate after the same stimulation. In general, cathodal stimulation resulted in an average decrease of 20% in the Purkinje cell firing rate. Our previous studies using anodal stimulation resulted in a 13% decrease in firing rate of Purkinje cells on average. Cross-correlation and coherence analyses were used to assess the relationship between the cerebellar and motor cortices. A cross-correlation level of 0.2-0.5 was observed in all recordings, which is consistent with results from anodal stimulation. Four of 6 cells showed coherence between the cerebellum and cerebral cortices at 10 Hz. Two of those 4 cells showed additional coherences at 75 and 80 Hz, respectively. These changes that occurred at the high frequency range are not consistent with either anodal or cathodal stimulation. 
Conclusion: Overall, an average decrease in the firing rate of the Purkinje cells was observed using cathodal tDCS. This decrease is greater than that observed using anodal tDCS. The limitations of our current study include the limited number of recordings, stimulation intensities, and the patterns of stimulation. Further data analysis using cross correlation and coherence with more cases will help us develop a more efficient stimulation protocol for tDCS. 
Acknowledgment: We thank John Duktig, April Wiles, and Shaunda Bell for their assistance at the GA-PCOM animal facility. 
Support: Support was supplied by the GA-PCOM research division. 
♦B3—Chronic Diseases and Conditions
Cerebellar Purkinje Cell Responses to DCS: An In Vitro Approach to Study Its Applicability to Cerebellar Ataxia Treatment 
Tracy Phan, OMS II; Cameron Moore, OMS II; Alex Wang, MPH, OMS II; Huo Lu, MD, PhD 
Georgia Campus–Philadelphia College of Osteopathic Medicine (GA-PCOM), Suwanee 
Research Questions/Hypotheses: The cerebellum is essential in movement coordination, and disorders, therefore, have a large impact on a patient's functionality. Currently, there is no cure for cerebellar ataxia, but novel treatments have been targeted at transcranial direct current stimulation (tDCS) and its effects on the sole output of the cerebellum, the Purkinje cell. tDCS has been shown to have an effect on Purkinje cell activity through in vivo studies, but the underlying mechanisms are not well understood. Further research is needed to properly characterize the effects of stimulation on the Purkinje cells. This knowledge will further aid in treatment application of tDCS with cerebellar ataxias. The aim of this study was to use the in vitro method to quantitatively measure the effects of tDCS on activities of Purkinje cells using a patch clamp technique under anodal and cathodal stimulation. We also analyzed the effect of graded intensity of stimulation on the firing rate of Purkinje cells. Additional efforts were made to study the relationship between the orientation of the Purkinje cell and the electrical field using a multicompartment model. A model with a single dendrite displays specific polarization along the soma-dendrite axis within an electric field (+0.5 to –0.5 mV) generated by DCS. To simulate the effect of DCS on a cell with branching dendrites, additional dendritic compartments were added to the model. We hypothesized that transmembrane potential change of Purkinje cells due to DCS would alter cell response under anodal and cathodal stimulation. The significance of this research to the osteopathic community involves the characterization of the effect of tDCS on cerebellar mechanics. tDCS is used as a novel treatment to cerebellar ataxia, a chronic condition affecting a large portion of the population. Exploring the effects of tDCS stimulation using in vitro technique on the Purkinje cell firing will further elucidate cellular mechanisms involved in tDCS therapy and therefore its potential efficacy in the management of cerebellar ataxia. 
Methods: Cerebellar tissue preparation: This study followed the protocol (#A14-007) approved by the PCOM IACUC. Male Sprague-Dawley rats were used for all experiments. The age of the rats was between 14 and 31 days. The purpose of using young pups was to have visible Purkinje cells before the cerebellar matrix was fully developed, which enhances the recording quality. Each rat was placed in an induction chamber with isoflurane (4% with oxygen at 1 L/min by calibrated vaporizer), allowing the rat to lose consciousness without distress. Rats were then removed from the chamber and weighed in grams before euthanasia. While unconscious, animals were decapitated using a guillotine. After removing the head, an incision was made using surgical scissors along the midline of the dermis from posterior to anterior exposing the skull. Two parallel incisions were then made along both sides of the ears to allow further access to the brain. The skull was lifted to expose the cerebrum and cerebellum. A scalpel was used to make a coronal cut midway of the forebrain. The forebrain and the cerebellum were then removed from the rest of the brain and immediately placed into ice-cold artificial cerebrospinal fluid (ACSF). A piece of agar block was cut into a “V” shape and glued to the center of the loading block of the vibratome. The cerebellum was sectioned to fit the “V” inlet and glued onto the block in a position to have parasagittal sections collected using a vibratome at 200-300 μm. Slices were transferred to a 37°C chamber that was constantly perfused with oxygenated ACSF. Recording: In vitro recordings from Purkinje cells were obtained using whole-cell patch clamp technique and visualized using a water immersion lens (×40) and an infrared filter. The ground electrode was placed in the recording chamber and aligned with the tip of recording electrode. The glass pipette was filled with internal solution for the recordings. The DCS was applied using parallel wires oriented on either side of the slice. Recordings for prestimulation, anodal, cathodal, and poststimulation were obtained. Once whole-cell patch clamp recording was established, we kept the membrane potential subthreshold between –60 mV and –75 mV using bias current. A series of current commands was given to test the basic property of the cell under the control condition. Then, the membrane potential was kept the same during DCS, and the same current commands were delivered. 
Data Analysis: Recordings in whole cell patch-clamp were obtained using Axoclamp-2B amplifier. Recordings were run through MATLAB R2016b, and the firing rate of Purkinje cells was determined. The frequency changes of Purkinje cell action potentials under anodal and cathodal stimulation were compared using a paired student t test. 
Results: Five Purkinje cells were isolated from the cerebellar cortex of 5 Sprague-Dawley rats and were recorded before, during, and after anodal and cathodal DCS to monitor average firing rate. No significant changes (P=.27, n=5) were observed in relationship with orientation of the Purkinje cell. A biphasic response to the changes in stimulation intensities was seen during anodal and cathodal stimulation. Compartment neuron models were used to determine firing rate change with all active properties. The 2 neuron models showed decreases in activity upon field activation. Single dendrite tree decreased by 30.8%, whereas the branched tree decreased by 36.2%. 
Conclusion: Overall, no significant changes were observed in relationship with Purkinje cell orientation. Limitations in this study included the number of recordings, viability of the cell throughout the multiple stimulations, and levels of stimulation intensities. Further research using both in vitro and in computo approaches will help understanding of the details of cellular and subcellular mechanisms of tDCS. 
Acknowledgment: We thank John Duktig, April Wiles, and Shaunda Bell for their excellent technique assistance at the GA-PCOM animal facility. 
Support: Support was supplied by the GA-PCOM research division. 
♦★B4—Chronic Diseases and Conditions
Creation of Ing3, Men1 and Rb1 Knockout in Mouse MC3T3-E1 Cells Using CRISPR System 
Andrew Tariao Mariano, OMS III1; Elisha Pendleton, MS2; Nalini Chandar, PhD2 
1Department of Biochemistry, Midwestern University Chicago College of Osteopathic Medicine (MWU/CCOM), Downers Grove, Illinois; 2MWU/CCOM 
Hypothesis: Bone tissue is a biological scaffold that is remodeled according to the stresses the body encounters. Dysregulation of physiological responses or genetic mutation can cause bone disorders ranging from osteoporosis to osteosarcoma. Menin, encoded by multiple endocrine neoplasia type 1 (Men1), is a protein involved in tumorigenesis and maintenance of bone mass. Unpublished knockdown studies within our laboratory suggest that knockdown of Men1 in osteoblast progenitor cells increase expression of Ing3. Ing3 encodes a type-2 tumor suppressor involved in cancers, cell cycle regulation and apoptosis. However, its role in the structure and function of bone tissue remains to be understood. To begin answering these questions, knockout models of Ing3 and Men1 were created in mouse osteoblast cell line, MC3T3-E1, using the clustered regularly interspaced short palindromic repeats (CRISPR) system. Knockout model of Rb1 was also created to evaluate Ing3's role in osteosarcoma, the most common primary tumor of the bone. The specific aims of this study were the following: (1) Design guide RNAs to target different regulators in osteoblast development: Rb1, Men1 (menin), and Ing3. (2) Demonstrate successful knockout of these genes at the genomic, transcript, and protein levels. 
Methods: Stable Ing3 knockout cell line was created using an all-in-one CRISPR plasmid system (pCRISPR), which contains: (1) Streptococcus pyogenes Cas9, (2) sgRNA targeting Ing3, and (3) selection marker (either EGFP or neomycin/G418 resistance cassette). pCRISPR was electroporated into MC3T3-E1 cells using Nucleofector. To determine gene-editing activity, CRISPR- targeting sites were amplified using Phusion High-Fidelity PCR kit, slowly re-annealed, and treated with T7E1 endonuclease, which measures formation of heteroduplexes. Additional Men1 and Rb1 knockout lines were also created using a similar method, and knockout lines were selected using G418. Real-time PCR, Western blots, and fluorescent staining were performed to verify the decrease in target gene transcripts and protein expression. 
Results: Using T7 endonuclease assay, we showed that gene editing occurred using pCRISPR-EGFP-ING3. To overcome the challenge of low gene editing efficiency, we electroporated MC3T3-E1 with pCRISPR-ING3-neomycin and selected for G418 resistant cells. Similar experiments were performed with Men1 and Rb1 CRISPR constructs. Fluorescent staining with anti-Men1 and anti-ING3 antibodies showed that expression of Men1 and Ing3 decreased when transfected with its respective CRISPR construct. qPCR showed that CRISPR-mediated gene editing decreased expression of target transcript. Surprisingly, knockout of Rb1 increased expression of Ing3, while knockout of Ing3 decreased Rb1 expression. Western blot further confirmed reduction of target gene expression but not their complete loss. 
Conclusions: We successfully created knockout cell lines of Men1, Rb1, and Ing3 using CRISPR technology. Loss of either Men1 or Rb1 affected the other's expression, suggesting a mutual regulation between the two. Elucidation of Ing3's involvement in osteoblast biology may result in novel strategies for targeting different cancers, like osteosarcoma, and management of chronic diseases that osteopathic physicians encounter every day, like osteoporosis. 
Support: This work was supported by a summer fellowship from Midwestern University to Andrew Mariano. 
♦★B5—Chronic Diseases and Conditions
Prolonged Fasting Attenuates Mitophagy and Impairs Cardiac Function in Mice 
Katrina Bantis, OMS II; J. Anthony Garcia, DO; Satoru Kobayashi, PhD; Qiangrong Liang, MD, PhD 
New York Institute of Technology College of Osteopathic Medicine, Old Westbury 
Excessive caloric intake poses an increased risk for age-related diseases, including cancer, diabetes, and cardiovascular disease. Conversely, intermittent fasting or caloric restriction can enhance human health by delaying the onset of such diseases. Autophagy is a tightly regulated, homeostatic process that involves the lysosomal degradation of excessive or damaged proteins and organelles to maintain cellular homeostasis. Mitophagy is a form of selective autophagy that specifically targets damaged mitochondria for degradation to ultimately reduce the cell's reactive oxygen species burden. Alternate-day fasting or starvation has been demonstrated to have cardioprotective effects in human and animal studies, but the underlying mechanism remains speculative. Autophagy is upregulated under nutrient-deprived conditions when the cell requires breakdown products to remain energetically viable. However, it is unclear whether mitophagy mediates cardioprotective effects during fasting. In this study, we investigated the functional status of mitophagy and cardiac function during fasting in adult mice. To measure mitophagy flux, we treated fed and fasted mitophagy reporter mice with vehicle or lysosomal inhibitors pepstatin A (PepA) and E64d. The novel reporter mice expressed mito-Rossela, a dual-emission biosensor comprising a pH-stable red fluorescent protein (RFP) linked to a pH-sensitive green fluorescent protein (GFP), allowing for the detection of mitophagy events using confocal microscopy. The confocal microscopic analysis of mitophagy events showed that mitophagy was upregulated after 24-hour but downregulated after 48-hour fasting. Western blotting results showed that fasting increased the expression levels of autophagy marker LC3-II in the mitochondrial fraction at 24-hr fasting compared with fed control, which was further elevated by PepA and E64d, suggesting increased mitochondrial degradation or mitophagy. 48-hour fasting continued to increase LC3-II-mitochondria association. However, LC3-II expression was not further increased by PepA and E64d compared with 24-hour fasting. These results suggest that mitochondria tend to be preserved under prolonged nutrient-deprived conditions. To complement the Western blot findings, we determined cardiac function using echocardiography and invasive left ventricular (LV) catheterization. The results showed that fasted mice exhibited reduced heart rate (238±61 vs 410±47 bpm, P<.01), fractional shortening (30.26±6.43 vs 40.10±1.09%, P<.01), and maximal left ventricular pressure (Pmax: 74.09±24.33 vs 99.88±3.27 mm Hg, P<.01), but it increased tau (18.01±4.81 vs 10.37±0.90, P<.01) compared with fed controls. These echocardiographic and hemodynamic data demonstrate lower cardiac contractility and elasticity under 48-hour fasting conditions, which is accompanied by the inhibited mitophagy flux. Collectively, it was suggested that cardiac function and exertion were impaired after a 2-day fast and that mitophagy may play an essential role in the maintenance of cardiac function during starvation. 
Support: This study was supported by NIH grant 1R15HL120027-01A1. 
♦B6—Chronic Diseases and Conditions
C Elegans as a Model Organism for Investigating Uric Acid Metabolism 
Trenton Carter Ferguson, OMS II; Jacob Wayne Helsel, BS; David Marble, BS; Shea Hatcher, BS; Predrag Krajacic, MD; Kristie Grove Bridges, PhD 
Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg 
Introduction: Obesity and metabolic syndrome are associated with elevated levels of uric acid (UA), and several studies have reported a correlation between UA levels and cardiometabolic risk factors, including triglyceride concentration. Many additional studies have reported a correlation between hyperuricemia and obesity. However, the relationship between UA and lipid metabolism is not well understood. A causative role for UA in the development of obesity and insulin resistance has been proposed. This line of research has been impeded by the fact that, unlike rodents and other commonly used model systems, humans lack uricase, which catabolizes UA into other products. The nematode Caenorhabditis elegans also lacks uricase but it does contain the gene for the UA-producing enzyme xanthine dehydrogenase/xanthine oxidase (XDH/XO) and has been shown to excrete UA. This organism has many advantages as a model system including ease of culture and the ability to visualize processes such as fat accumulation and may be a valuable tool for exploring the link between purine and lipid metabolism. 
Hypothesis: The nematode C elegans lacks uricase but it does contain the gene for the UA-producing enzyme xanthine dehydrogenase/xanthine oxidase (XDH/XO) and has been shown to excrete UA. The objective of this work was to for the first time detect and characterize XDH/XO activity in C elegans. We hypothesized that, as with the human enzyme, C elegans XDH/XO would have both dehydrogenase and oxidase activity that would be inhibited by allopurinol. Additionally, we hypothesized that the knockout mutant for the gene encoding XDH/XO would not have detectable enzyme activity, and subsequently no detectable levels of uric acid. The ultimate goal of this work is validating the use of C elegans as a model system for investigating the effects of uric acid production on lipid metabolism. 
Methods: Wild type and XDH/XO mutant worms were grown at 25°C under standard conditions, fed with Escherichia coli strain Na22. Young adult worms were collected by centrifugation. The pellet was resuspended in assay buffer containing a protease inhibitor cocktail and subjected to 5 freeze-thaw cycles using liquid nitrogen followed by sonication and dounce homogenization. These steps were needed to lyse the nematode cuticle in the absence of detergents or other denaturants that would inactivate the target enzyme. Lysates were clarified and contaminants removed by centrifugation. For enzyme assay, extracts were subjected to filtration through sephadex G-25 miditrap columns. This step was necessary to remove purines that could interfere with XDH/XO assays. Protein concentration of the extracts was determined using the ThermoScientific Coomassie Plus Protein Assay. For uric acid measurement, the lysates were instead deproteinized by ultrafiltration to remove peroxidases that could interfere with the enzymatic uric acid assay. All steps were done at 4° centigrade and enzyme assays were performed immediately following extract preparation. XDH/XO assays were performed using a fluorometric method that measures conversion of pterin to isoxanthopterin. When only the substrate pterin is present in the assay buffer, XO activity is measured. Addition of methylene blue, which substitutes for NAD+ as an electron acceptor, enables measurement of XO and XDH activity combined. Kinetic assays in 98-well black plates were done using a Biotek Synergy 2 plate reader. A time point in the linear range of the assay was used for subsequent end point analysis to determine XDH:XO ratio and to investigate the effects of allopurinol or disulfide bond reduction. All experiments were done at least 3 times with each data point done in triplicate within experiments. Purified bovine xanthine oxidase was used as a positive control. 
Data Analysis: XDH activity was calculated by subtracting activity in the absence of methylene blue from activity in the presence of methylene blue. Descriptive analysis was done using IBM SPSS statistics version 24. Concentration-response curves were generated and IC50 values calculated using GraphPad Prism 6 software. P value <.05 were considered significant. 
Results: Both XDH and XO activity were detected in wild-type nematode extracts. Addition of a disulfide bond reducing agent increased the XDH: XO ratio from 3.4 + 0.7 to 7.7 + 1.8 (P=.02). The IC50 of allopurinol for C elegans XDH/XO activity was 2.3 + 0.05 μM. These findings are very similar to those reported for the human enzyme. Uric acid concentration in wild-type nematode extracts was 424 μM. As expected, uric acid concentration in the mutant strain was below the detection limit for the assay and conversion of pterin to isoxanthopterin was barely detectable. 
Conclusion: Our results demonstrate that C elegans expresses XDH/XO, which has similar properties to the human enzyme. Furthermore, we were able to confirm that the knock-out mutants show only residual conversion of pterin to isoxanthopterine and consequently do not produce detectable amounts of uric acid. While additional studies are needed to characterize the mutant worms, this is an important step toward validating the use of C elegans as a model for investigating the relationship between the purine catabolic pathway and lipid metabolism as well as the correlation between hyperuricemia and obesity. 
Significance: Disease prevention is one of the core osteopathic principles. The goal of this project is to provide and validate a model organism that may lead to the development of novel approaches for the prevention and treatment of comorbidities associated with obesity. 
♦B7—Chronic Diseases and Conditions
Acne Bacterial Brain Infection Recapitulates Cellular Parkinson Pathogenesis 
Lauren M. Bellavia, OMS II1; Joyce M. Lee, MS1; Brendan J. Carney, BS1; Mervat Mourad, DO2; Joerg Leheste, PhD1 
1Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury; 2Department of Clinical Specialties, NYITCOM 
Research Questions/Hypotheses: Parkinson disease (PD) is the most common neurodegenerative movement disorder worldwide with a well-established pathology but poorly defined cause and pathogenesis. Aside from a relatively small percentage of early-onset cases with clear monogenetic or toxicant cause, circumstances of disease onset and progression are completely unknown in the vast majority of cases estimated in the 90th percentile. That is also the reason for the absence of preventive strategies or curing measures despite decades of PD research. One aspect common to all cases is the presence of some chronic inflammation affecting the central nervous system (CNS), which also seems to be the driving force behind disease progression, particularly in the dopamine (DA)-producing neurons in the substantia nigra pars compacta of the midbrain. In previous research by our group in collaboration with researchers at Massachusetts General Hospital (Harvard University), we discovered the anaerobic, gram-positive skin acne pathogen Propionibacterium acnes (P acnes) inside neurons of human cadaveric PD brains. Those bacteria were located inside midbrain neurons and cortical structures nearby, suggesting a link between P acnes and the well-known local bouts of inflammation seen in PD brains. One of the most immediate research questions that arises is how the bacteria are able to transition into the brain followed by their neural invasion. Weaknesses in an otherwise protective blood-brain barrier (BBB) appeared to be most likely, and we were able to show through previous research using an animal model that P acnes was actually able to move along the olfactory nerve from the nasal cavity into the olfactory bulb, demonstrating the olfactory system as a potential portal for dangerous, opportunistic pathogens into the CNS. The main question that remains, among many others, is whether P acnes, once inside the CNS, actually causes PD, or whether PD itself causes BBB disruption and the presence of P acnes in the brain. To answer this question, we devised a set of experiments in which we injected P acnes and control bacteria into striatum of the midbrain where the projection terminals of nigral DA neurons are located. We hypothesized that injection of P acnes but not controls would recapitulate the brain inflammation seen in PD and mirror the loss of DA neurons in the midbrain. 
Statement of Significance: With this work we are able to demonstrate a causal relationship between deliberate intracranial P acnes infection and the cellular and molecular processes that recapitulate the inflammatory pathogenic processes seen in human PD brains. If it is true that the pathogenesis of some or more PD cases involves P acnes, preventive measures or a cure in the form of antibiotic therapy could be within reach. Additionally, accepting a bacterial cause for the disease could lead to a targeted osteopathic approach manipulating the newly discovered brain glymphatic/lympathic continuum, facilitating lymphatic drainage of the pathogen and its metabolites from PD brains. 
Methods: All animal work was in compliance with the Animal Welfare Legislation and the Institutional Animal Care and Use Committee (IACUC) at NYITCOM (2015-JH-01). To test our hypothesis, we administered a single unilateral stereotaxic injection of either P acnes or Staphylococcus epidermidis as a control organism that is commensal to the skin flora into the striatum of wild-type mice of various ages. Each injection delivered a total of 1000 colony-forming units (CFU) per microliter. Animals were killed at several time points postinjection (12 hours to 60 days). Whole brains were extracted, and either 10 μm paraffin-treated tissue cross-sections or 30 μm frozen sections were prepared for standard and fluorescence immunohistochemistry analysis using antibodies indicating inflammation, necrosis, oxidative stress, microglial handling of pathogens, and cellular health and survival. Similar outcome measures were determined with independent techniques and based on brain biopsies and quantitative PCR (qPCR) or protein extraction followed by Western analysis. 
Data Analysis: Data analysis was performed using Microsoft Excel software. Quantifiable differences in study variables were compared using unpaired t test, analysis of variance, post-hoc analysis for continuous measures, as well as χ2 and Fisher exact tests for categorical variables with significance set at P<.05. 
Results: While the initial molecular response to either pathogen was similar, S epidermidis remained in the interstitial compartment invoking a stronger response but was effectively cleared after 48 hours, whereas P acnes persevered interstitially and intracellularly. The observed increased survival of P acnes was consistent with increased DA neuron loss in animals infected with P acnes. Additionally, P acnes produced a local oxidative stress response that was less robust than the one by S epidermidis but much longer lasting. Last, while microglial handling of S epidermidis indicated bacterial destruction, P acnes appeared to escape lysosomal breakdown surviving chronically. 
Conclusion: This work demonstrates how the chronic nature of a midbrain infection with P acnes can recapitulate well-studied cellular events associated with PD. This exemplifies a potential cause and effect relationship between intracranial P acnes infection and PD and suggests a role for antibiotic therapy in the management of PD. Further studies should explore extended pathophysiologic aspects of this novel PD pathogenic agent and focus on the development of preventive or treatment strategies. This work further highlights how the opportunity to invade a novel space can turn a commensal organism that receives little attention into the driving force behind a severe pathologic crisis. Studying our findings in the context of immunomodulatory osteopathic techniques, such as thoracic and/or pedal lymphatic pump, would be a recommended and interesting adjunct to this study. 
Support: NYITCOM intramural funding to J.R.L. 
♦B8—Chronic Diseases and Conditions
Methamphetamine-Induced Interleukin-6 Production Impairs Wound Healing in Mice 
Kishan Patel, OMS II; Hiu Ham Lee; J. Christian Belisario, OMS III; Arjun Vidyasagar, OMS I; Raddy L. Ramos, PhD; Luis R. Martinez 
Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Introduction: The prevalence of methamphetamine (METH) use is estimated at about 35 million people worldwide, with over 10 million users in the United States. Chronic METH abuse and dependence expose the user to a diverse range of adverse physical and cognitive health consequences. The administration of drugs such as METH via injection delivers almost immediate effects of euphoria due to the substantial accumulation of dopamine in the central nervous system. Significantly, heavy daily users of METH frequently develop neurologic manifestation of formication, a sensation akin to insects crawling on or under the skin. The result of formication is that users engage in constant skin “picking,” often causing the formation of ulcers that frequently scar. A marked lack of hygiene among users may also be correlated to higher rates of skin infections. Wounds associated with injection-drug users are the number 1 wound care problem at respite centers in US cities. In addition, the cost of treatment for patients with chronic wounds per year is a heavy economic burden to the health care system. Although there is substantial information on the behavioral and cognitive defects caused by METH in drug users, there is a dearth of knowledge regarding its impact on wound healing and inflammation. 
Hypothesis: Our data show that METH treated mice had decreased wound healing. Also, METH increased interleukin-6 (IL-6) production in skin tissue, and elevated levels of this cytokine may have a direct pathogenic role in inflammation. Therefore, we hypothesize that METH enhances IL-6 production via accumulation of leukocytes exacerbating the inflammatory response leading to delayed wound healing. We aimed to make major contributions in elucidating the mechanisms by which METH alters the inflammatory response and interferes with wound healing, which can become chronic and susceptible to microbial infections. 
Methods: All animal work was approved and monitored by the IACUC of NYITCOM. METH use was mimicked by daily intraperitoneal drug injection of 5 mg/kg/d to C57BL/6 mice for 7 days. After administration of the drug, ex vivofluorescent tagged neutrophils and macrophages were injected intravenously, and a circular full-thickness wound (5 mm in diameter) was made on the back skin of the mice using a skin biopsy punch. Then, cellular infiltration into the wound was documented using an in vivo imaging system, and pictures were taken every other day for 7 days. This technique allowed us to monitor leukocyte recruitment to the wounded site in real time. Also, we determined the gene expression and protein levels of IL-6 in excised wounds of untreated and METH-treated mice using RT-PCR and ELISA, respectively. IL-6-specific antibody was added directly into the wound of these animals to neutralize the effect of this cytokine and demonstrate its importance in wound healing and inflammation. 
Results: In vivo images showed massive and faster leukocyte infiltration into the wound site of METH-treated mice relative to the untreated animals. Neutralizing IL-6 antibody decreased white blood cell infiltration in METH-treated mice to similar levels to their control counterparts, indicating the importance of this cytokine in stimulating and prolonging the inflammatory response. Moreover, gene expression and protein levels of IL-6 in the wounds of METH-treated mice were elevated and reduced in rodents treated with IL-6 specific antibody. 
Conclusion: Our findings suggest that management of chronic wounds in METH users might be improved by regulating the levels of IL-6 and leukocyte infiltration. We believe this project is of considerable significance in the fields of drug abuse, dermatology, and immunity. It is anticipated that this interdisciplinary study may advance the future development of practical and translational therapeutic interventions for the management of chronic wounds in drug users. In this regard, it is possible that the application of osteopathic medicine (eg, lymph drainage techniques) may help to reduce inflammation and accelerate the wound healing rate in individuals who abuse this drug. 
Support: This study was supported by the National Institute of General Medical Sciences of the US NIH under award number R15GM117501. 
♦B9—Chronic Diseases and Conditions
A Drosophila Model for Understanding the Role of Autophagy in Diabetic Cardiomyopathies 
Derek De Mann, OMS III; JoBeth Bingham, BA; Lewis Josh Watson, PhD 
University of Pikeville Kentucky College of Osteopathic Medicine (UP-KYCOM) 
Research Question: We hope to answer the question as to whether or not the fibrosis that contributes to diabetic cardiomyopathy is altered as a result of inhibited autophagy and if this inhibition has an effect on lifespan. 
Hypothesis: (1) Inhibiting autophagy will increase survival and show decreased cardiomyocyte fibrosis in T1DM. Insulin inhibits autophagy, which could explain increased survival seen in patients with insulin-dependent diabetes mellitus who are compliant with their medications. (2) Inhibiting autophagy will decrease survival and increase cardiomyocyte fibrosis in T2DM. Because of the complex pathogenesis of insulin resistance, we predict that autophagy would be beneficial in T2DM due to theories of exercise-induced autophagy protecting against insulin resistance. Diabetic cardiomyopathy describes the structural and functional changes to the myocardium because of chronically elevated serum glucose independent of other cardiovascular comorbidities. Increases in interstitial fibrosis have been noted; however, its mechanism remains unclear. Osteopathic principles should be considered in managing patients with both T1DM and T2DM. The first tenet of osteopathic medicine states that “the person is a unit of body, mind, and spirit”; these components cannot be separated when considering a patient's illness or treatment. In T1DM, stress is associated with decreased self-care and altered serum glucose. Osteopathic physicians must consider a patient's spirit with respect to treatment in the hopes of establishing rapport and improving patient compliance that increases survival. The second tenet states that the body has self-healing mechanisms. First-line treatments for T2DM are lifestyle modifications in conjunction with pharmacologic therapy. With an established patient-provider relationship, osteopathic physicians must encourage self-care that aims to decrease dependence on medications and increase survival. Autophagy is a cellular process responsible for the structured removal of dysfunctional components. Alteration of autophagy is anticipated as a result of diabetes mellitus, but its function remains unclear. Recent studies investigating autophagy and its role in the progression of diabetic cardiomyopathy vary. There is conflicting literature regarding the suppression or induction of autophagy in both T1DM and T2DM and its effect as either being beneficial or maladaptive with respect to the heart. Drosophila melanogaster has been widely used to study diabetic complications and has also shown validity as a model organism for cardiovascular work. It is believed that 75% of the disease-causing genes in humans have a functional Drosophila homologue that could lead to identification of potential human therapeutics. Dilp is a series of Drosophila genes that code for insulinlike peptides and produce several T1DM phenotypes when ablated. Recent studies have also shown the development of a diabetic cardiomyopathic phenotype after flies developed insulin resistance from a high sugar diet (HSD). Atg7 and Ema are Drosophila genes that prevent the autophagic process when inhibited, but do not affect viability. By studying the interaction of these autophagic genes with respect to the restrictive cardiomyopathy seen in both T1DM and T2DM, we hope our research could develop or further support existing pharmacologic and lifestyle modification therapies that are encouraged by osteopathic physicians and provide them with an even greater understanding of diabetic pathophysiology. 
Objectives: Evaluate the cardiovascular phenotype of T1DM and T2DM Drosophila. Analyze 2 Drosophila groups, ones with knockout of Dilp1-5 to induce T1DM, and a wild-type (Wt118) group that will be given a HSD to induce T2DM. Using standard histologic and biochemical techniques, confirm the lifespan and metabolic and cardiovascular phenotype of each model. Evaluate the differing role autophagy plays in T1DM and T2DM phenotype. Using stocks with inhibited transcription of autophagic proteins, select for the desired progeny to analyze T1DM and T2DM flies with inhibited autophagy. Using the same methods of gathering data from the first aim of the project, compare whether the inhibition of Atg7 and Ema autophagic proteins, affects the lifespan and cardiovascular phenotype of diabetes mellitus. 
Methods: Fly stocks: flies heterozygous for a p-element disruption of Ema (P-ema) and Atg7 (P-Atg7) were used as a total body knockdown (roughly 50% reduced enzyme function) of autophagic flux. Dilp1-5 knockout flies were raised in standard conditions and produced a T1DM phenotype. T2DM flies were raised as Wt1118 embryos that were fed a normal 0.15M sucrose diet (ND) until eclosion, after which they were transferred to a 1M sucrose diet (HSD). Similarly, P-Atg7 and P-Ema were raised in both ND and HSD conditions. Cohorts of T1DM with inhibited autophagy were selected for by crossing Dilp1-5 and P-Atg7 (P-Atg7; Dilp1-5) as well as Dilp1-5 and P-ema (P-ema; Dilp1-5) both placed on ND. Lifespan: 100 flies compiled each cohort indicated by the graphs below. The first 50 males and 50 females to eclose were used in the lifespan study that occurred for 35 days, after which all further data were censored. All deceased flies were accounted for daily and removed so as not to repeat measurements. Biochemical assays: 25 flies from each cohort, independent of the lifespan study, were selected 3 weeks after eclosion and emulsified for histologic analysis. Phosphorylated Akt (P-Akt) levels served as an insulin sensitivity indicator to confirm the T2DM phenotype in HSD groups. Pericardin, a fibrous collagen-like protein, is upregulated in the hearts of diabetic Drosophila with cardiomyopathy. To quantify the extent of diabetic cardiomyopathy fibrosis and insulin insensitivity, P-Akt and pericardin were analyzed via Western blots. 
Data Analysis: Kaplan-Meier Survival Analysis, 1-way ANOVA followed by a Tukey post-hoc test or an unpaired t test where appropriate. A P value <.05 was considered significant in all analyses. 
Results: T1DM and T2DM flies showed diminished lifespan compared with ND controls. Increased survival and decreased pericardin levels were seen in T1DM flies with inhibited autophagy compared with T1DM flies. T2DM flies with inhibited autophagy showed varied levels of cardiac fibrosis and a complex lifespan splay depending on the autophagic protein that is inhibited when compared with T2DM flies. 
Conclusion: There appears to be a positive correlation between autophagic activity and cardiac fibrosis in T1DM, both negatively correlating with survival. Insulin inhibits autophagy, which supports osteopathic physicians to consider patient stress, ensure treatment compliance, and increase survival in T1DM. Inhibited autophagy in T2DM may be beneficial early in its pathogenesis, which was indicated by increased survival and varied fibrosis, but the rapid decline seen in lifespan may ultimately suggest positive correlation. Given the complex nature regarding the pathogenesis of T2DM, this requires further study but should still support osteopathic physicians to encourage self-care that increases autophagy and potentially survival. 
Support: Dr Watson's laboratory is supported by funding from UP-KYCOM. Mr De Mann was awarded a UP-KYCOM Summer Research Fellowship. 
♦B10—Chronic Diseases and Conditions
Muscarinic Cholinergic Receptors Regulate Oscillation of Intracellular Ca2+ in Steroid-Producing Adrenocortical Carcinoma Cells 
Nuntida Surachaicharn, OMS II1; Yara Shams, OMS II1; Mohammad Arshad, DO1; Harsh Sharthiya, MS2; Phillip G Kopf, PhD3; Latha M Malaiyandi, PhD2; Kirk E Dineley, PhD3 
1Midwestern University Chicago College of Osteopathic Medicine (MWU/CCOM), Downers Grove, Illinois; 2Department of Anatomy, MWU/CCOM; 3Department of Pharmacology, MWU/CCOM 
Research Questions: Elevated circulating aldosterone levels are associated with hypertension, thrombosis formation, cardiac hypertrophy, and congestive heart failure. Calcium (Ca2+) is required for aldosterone secretion that is triggered by steroidogenic stimuli, including angiotensin II (Ang II), potassium, and adrenocorticotropic hormone (ACTH). Despite this importance, the relationship between intracellular Ca2+ homeostasis and steroid production by the adrenal cortex remains incompletely understood. 
Methods: We used live-cell imaging with the Ca2+-sensitive fluorescent probe Fluo-4 in a human adrenocortical carcinoma cell line (HAC15) to show that activation of muscarinic cholinergic receptors cause oscillations in intracellular Ca2+. 
Data Analysis: Statistical analysis was performed and graphed using GraphPad Prism version 7.01. All experiments were repeated 5 to 7 times from at least 3 different culture preparations. Ca2+ oscillations were analyzed by taking the area under the curve, calculating total peak area, and comparing it to the number of peaks present. Comparisons were made using a t test, with P values <.05 regarded as significant. 
Results: The cholinergic agonists carbachol and bethanechol, but not nicotine, triggered Ca2+ oscillations of relatively rapid periodicity, often returning completely to baseline before spiking again. Carbachol-triggered Ca2+ oscillations were abolished by atropine and the M3-selective antagonists tiotropium and darifenacin, while preferential block of M1 or M2 receptors, with pirenzepine and methoctramine, respectively, was less effective. Carbachol-induced Ca2+ loads were essentially unaffected in the absence of extracellular Ca2+, indicating that Ca2+ originated from intracellular stores. Ca2+ oscillations were profoundly diminished by inhibition of the sarco/endoplasmic reticulum Ca2+ ATPase (SERCA) pump with thapsigargin, but only marginally affected by inhibitors of mitochondrial function. Furthermore, IP3 receptor inhibition with caffeine blocked Ca2+ oscillations nearly completely, while inhibition of ryanodine receptors with tetracaine and dantrolene had only a small effect. The physiologic importance of muscarinic-regulated Ca2+ oscillations is unclear, because muscarinic agonists and antagonists had little effect on aldosterone synthesis in HAC15 cells. 
Conclusion: In conclusion, the data show that muscarinic receptor activation leads to Ca2+ oscillations mediated by M3 subtypes that are tied to IP3 receptor activation, and repetitive Ca2+ release and recapture by the endoplasmic reticulum. 
Support: Supported by funds from Midwestern University. 
♦B11—Chronic Diseases and Conditions
Inhibition of TGFβ Signaling Elevates Expression of Laminin Binding Integrins in Doxorubicin-Treated Endothelial Cells 
Meera Raghavan, OMS I; Melissa Cobb, MA; Eugene Konorev, PhD, MD 
Kansas City University of Medicine and Biosciences College of Osteopathic Medicine, Missouri 
Background: Recent studies demonstrate that patients treated for early-stage cancers are more likely to die of complications of their chemotherapeutic regimen than from the cancer itself. Specifically, the chemotherapeutic doxorubicin (Dox), which is used to treat a variety of cancers, induces delayed cardiomyopathy that progresses to congestive heart failure. Currently, there are not any treatments in place to mitigate the cardiotoxic effects of Dox. Previous work by this laboratory demonstrated a decrease in microvascular density as well as an increase in TGFβ pathway–related transcripts in Dox-treated hearts. Further experimentation was conducted to ascertain whether or not these vascular defects were a result of increased TGFβ pathway signaling. In vitro co-culture of human umbilical vein endothelial cells (HUVEC) with human cardiac fibroblasts (HCF) demonstrated that Dox induces detachment of endothelial cells and decreased formation of vessel-like structures. When this co-culture was treated with a TGFβ receptor kinase inhibitor (SB431542), detachment of endothelial cells was prevented and increased vessel-like formations were observed. Additionally, monoculture of HUVEC revealed decreased adhesion of cells to laminin, an abundant endothelial basement membrane protein, in Dox-treated cells, and increased adhesion to laminin in SB431542-treated cells. Based on these experiments, it was conceivable that treatment with Dox disrupts endothelial cell adhesion to the basement membrane and that this process of vascular disruption is mediated by the TGFβ signaling pathway. 
Research Question: In healthy vasculature, endothelial cells are tethered to protein components of the endothelial basement membrane via alpha-beta heterodimeric proteins called integrins. It was hypothesized that Dox-induced disruption of endothelial cell adhesion to laminin was due to modulated expression of laminin-binding integrins. This study aimed to better elucidate the mechanism by which Dox causes vascular damage by assessing the effects of Dox on laminin-binding integrins. 
Significance: By better understanding the mechanism behind the cardiotoxic effects of Dox, physicians will be better able to predict patient outcomes and minimize long-term complications of anti-cancer treatment. From an osteopathic perspective, this will enable physicians to enhance patients' overall quality of life, treating the whole patient rather than only the disease state. 
Methods: The levels of integrin coding mRNA transcripts were assessed using TaqMan gene expression assays and quantitative polymerase chain reaction (qPCR). The levels of gene products for ITGB1, ITGB4, ITGA1, ITGA2, ITGA3, and ITGA6 were measured in untreated, Dox-treated, SB431542-treated, and combination Dox- and SB431542-treated HUVEC populations. Subsequently, surface expression of integrins was assessed using flow cytometry. HUVEC populations were untreated, Dox treated, SB431542 treated, and combination Dox and SB431542 treated and then stained with fluorophore conjugated antibodies specific to integrins beta1, beta4, alpha1, alpha2, alpha3, and alpha6, all of which tether endothelial cells to laminin. A subset of each population was stained with an isotype control to provide a baseline fluorescence level against which the antibody stained cells of the same population could be compared. 
Results: Dox was seen to significantly decrease the surface expression of alpha6 integrin in HUVECs. Alpha6 can dimerize with either beta1 or beta4 to form 2 different laminin binding heterodimers; however, surface expression of beta1 and beta4 did not appear to change significantly with Dox treatment when compared with untreated control HUVEC populations. Treatment with SB431542 prevented the effects of Dox on HUVEC surface expression of alpha6, increasing the level of expression compared with both the Dox-treated and untreated control populations. Additionally, SB431542-treated HUVEC demonstrated increased levels of ITGB4 mRNA and surface expression of beta4 integrin. HUVEC treated with combination Dox and SB431542 demonstrated drastic increases in ITGB4 mRNA and surface expression of beta4—22-fold and 14-fold, respectively, compared with untreated HUVEC populations. 
Conclusion: Dox clearly decreases alpha6 integrin expression, most likely contributing to decreased adhesion of endothelial cells to laminin, causing increased detachment of endothelial cells from the endothelial basement membrane and reduced microvascular density. Furthermore, endothelial cells treated with Dox are likely to express decreased surface levels of alpha6-beta1 and alpha6-beta4 integrins. SB435142 alleviated the effects of Dox on alpha6 integrin expression, as well as significantly increased the expression of beta4 integrin. Results of this study suggest that after treatment with SB425142, alpha6-beta4 integrin may play a role in the increased adhesion of endothelial cells to laminin and that observed effects of Dox on endothelial cells are mediated by the TGFβ pathway. Further evidence that increased expression of alpha6-beta4 integrin is responsible for improved cell adhesion by SB435142 may be obtained by knocking out or blocking the function of these proteins. Future experiments will focus on the expression of alpha6 and beta4 integrins in HUVEC co-cultured with HCF to account for the influences of cell-to-cell communication and environmental signaling on integrin expression and endothelial cell adhesion. This study lays the groundwork for elucidating mechanisms by which Dox reduces vascular density and induces cardiomyopathy. Understanding the mechanisms of cardiotoxicity open the doors to developing methods of decreasing the toxic effects of Dox and improving long-term patient outcomes. 
Support: This work was supported by grant R15HL133873 from the NIH National Heart, Lung, and Blood Institute. 
♦B12—Chronic Diseases and Conditions
Inhibition of HSPA9 Gene Disrupts Erythroid Maturation in Human Hematopoietic Progenitor Cells 
Raji Akileh, OMS II; Christopher Butler; Tuoen Liu, MD, PhD 
West Virginia School of Osteopathic Medicine, Lewisburg (WVSOM) 
Background: Myelodysplastic syndromes (MDS) is the most common form of adult myeloid blood cancers within the United States. A high fraction of patients with MDS can further progress to acute myeloid leukemia (AML) without intervention. MDS is a heterogeneous group of blood cancers characterized by abnormal hematopoietic cell maturation, increased apoptosis of bone marrow cells, and peripheral blood cytopenias. Patients with MDS normally present with symptoms including fatigue and weakness, easily bruise or bleed, fever, bone pain, and frequent infections. Low blood cell counts result in morbidity and mortality due to dysregulation of hemostasis and infection. Up to 25% of patients with MDS acquire an interstitial deletion on chromosome 5q, also known as Del(5q). Two distinct commonly deleted regions (CDR), distal CDR, and proximal CDR, located on the long arm (q arm) of chromosome 5 have been identified in patients with MDS and acute myeloid leukemia (AML). The proximal CDR contains 30 genes, including HSPA9, and is associated with progression from MDS to AML. 
Hypothesis: We hypothesize that inhibition of the Del(5q) candidate HSPA9 gene can disrupt the erythroid maturation, contributing to the peripheral blood cytopenia observed in patients with MDS. 
Statement of Significance: MDS is the most common myeloid malignancy of the elderly, with at least 10,000 new cases occurring in the United States annually. Patients with MDS present with low peripheral blood cell counts and anemia, which can manifest to infection and death. This is an important osteopathic consideration; because of a resulting pathogenesis, the body as a unit is unable to maintain homeostasis and the prevention of this disease. The full complement of gene mutations that contribute to MDS development and progression remains unclear. Our study reveals that one of the Del(5q) candidate genes, HSPA9, plays a role in regulating erythroid maturation. We observed that inhibition of HSPA9 disrupts erythroid maturation, which may contribute to anemia in patients with MDS. This is an important osteopathic consideration for osteopathic physicians: the structure and function of the cell, tissue, organ, and body have an intimate relationship. We also found that the erythroid maturation processes regulated by HSPA9 may be TP53-dependent, suggesting that inhibition of TP53 by HSPA9 may be necessary for HSPA9 to trigger its regulatory effects on erythroid maturation. Our study not only uncovers some of the underlying genetic and molecular mechanisms of Del(5q) MDS, but it also provides potential therapeutic indications through gene targeting in clinical MDS management. Thus, with a clear understanding of the mechanisms associated with MDS, osteopathic physicians are better able to fulfill osteopathic tenets in patients. In addition to directly managing the physical manifestations in patients, physicians are now better able to alleviate the associated burdens placed on the spirit and mind and allow for a more favorable recovery and clinical outcome. 
Methods and Data Analysis: (1) Cells and chemicals: human hematopoietic progenitor cells (CD34+ cells) were used in our study. The chemical MKT-077 was used to inhibit the HSPA9 expression of in human CD34+ cells. (2) Small interference RNA (siRNA): siRNA targeting HSPA9 was used to knockdown HSPA9 gene in human CD34+ cells. (3) Lentiviral short hairpin RNA (shRNA): lentiviral shRNA targeting HSPA9 (shHSPA9) and TP53 (shTP53) were produced and transduced into human CD34+ cells to knockdown HSPA9 and TP53 genes, respectively. (4) Western blotting assays were used to measure the expression of proteins, including HSPA9, TP53, and β-actin. (5) Flow cytometry was used to measure the cell apoptosis (Annexin V), erythroid maturation (CD71 and glycophorin A), and intracellular TP53 levels. (6) Statistics: Statistical significance was analyzed by the t test (2 groups) and 1-way ANOVA with a Tukey posttest (more than 2 groups), with a P value <.05 considered significant. 
Results: (1) Knockdown of HSPA9 inhibited cell growth, increased apoptosis, inhibited erythroid maturation, and increased TP53 levels in human CD34+ cells. To test the effects of HSPA9 knockdown in human CD34+, we first used the siRNA that specifically targets the HSPA9 gene. HSPA9-specific siRNA reduced the HSPA9 protein expression level to approximately 50% compared with control siRNA. Knockdown of HSPA9 by siRNA inhibited cell growth, increased apoptosis, inhibited erythroid maturation, and increased TP53 levels in human CD34+ cells. The authors also used shRNA to knockdown the HSPA9 gene in these cells, and similar phenotypes in cell growth, apoptosis, erythroid maturation, and TP53 expression were observed. (2) Pharmacologic inhibition of HSPA9-induced apoptosis, decreased erythroid maturation and increased TP53 levels in human CD34+ cells. MKT-077 is an HSPA9 inhibitor, and it reduced HSPA9 expression, inhibited cell growth, increased apoptosis, inhibited erythroid maturation, and induced TP53 expression in a dose-dependent manner in human CD34+ cells. (3) Reduction of TP53 reversed the inhibition of erythroid maturation caused by HSPA9 knockdown. We have observed that inhibition of HSPA9 by siRNA, shRNA and MKT-077 can inhibit erythroid maturation and increase TP53 levels in human CD34+ cells. Next, we tested whether reducing the levels of TP53 could reverse the erythroid maturation inhibition induced by HSPA9 knockdown in human CD34+ cells. We constructed 2 TP53 shRNAs which were able to decrease TP53 levels by about 80% and 50%, respectively, compared with control shRNA. We co-transduced lentiviruses containing shRNA targeting HSPA9 and TP53 into human CD34+ cells using double antibiotic selection. The erythroid inhibition following HSPA9 knockdown was significantly decreased and reversed after simultaneous knockdown of TP53 with shTP53. 
Conclusion: Previous studies showed that Del(5q) MDS bone marrow samples display an induction of TP53 in erythroid cells and upregulation of TP53 target gene expression. Our study focuses on the effects of HSPA9 on erythroid maturation, as well as cell growth and apoptosis in human CD34+ hematopoietic progenitor cells. We observed that inhibition of HSPA9 (by siRNA, shRNA, and MKT-077), a gene on the proximal CDR of chromosome 5, caused cell growth inhibition, apoptosis induction, and erythroid maturation inhibition in human CD34+ cells. These phenotypes were associated with increased TP53 levels. We also found that inhibition of TP53 in human CD34+ cells could reverse erythroid inhibition caused by HSPA9 inhibition. In conclusion, our study indicates that inhibition of HSPA9 gene can inhibit erythroid maturation, which may contribute to the peripheral blood cytopenia seen in patients with Del(5q) MDS. Our data also suggest that the inhibition of erythroid maturation via HSPA9 inhibition may be regulated through a TP53-dependent mechanism. 
Acknowledgment: We thank Dr Matthew J. Walter (Washington University in St. Louis) for his valuable guidance in our research. 
Support: This work was supported by WVSOM Faculty Startup (T.L.). 
♦B13—Chronic Diseases and Conditions
Overexpression of Tissue-Nonspecific Alkaline Phosphatase Promotes Calcification and Leads to Left Ventricular Hypertrophy in Mice With Atherosclerosis 
Varun Sindagi, OMS II; Param Dave, OMS II; Mitul Patel, BS; Ada Wong, BS; Konstantinos Damiris, OMS II; Olga Savinova, PhD 
New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Research Questions/Hypotheses: Our aim was to examine the effects of calcification on both the structure and function of the aortic root region. We engineered an approach to deliver tissue-nonspecific alkaline phosphatase (TNAP, a procalcifying enzyme) to sites of vascular inflammation in mice by overexpressing TNAP in myeloid cells. We hypothesize that under conditions of atherosclerosis, TNAP-positive myeloid cells will infiltrate aortic valves, leading to increased biomineralization, which subsequently mimics increased aortic valve stiffness associated with calcific aortic valve stenosis (CAVS). CAVS is the narrowing of the aortic valve due to atherosclerosis and calcium deposition. Narrowing of the valve decreases outflow of blood to the rest of the body. This leads to the heart compensating and working harder to pump out blood, eliciting hypertrophy, which eventually leads to heart failure. Standard lipid-lowering therapies for atherosclerosis have proven ineffective in CAVS. Therefore, patients with progressed CAVS have only invasive valve replacement and repair as their treatment options. It is the goal of osteopathic physicians to educate patients on lifestyle modification, as the body is a self-regulating and healing unit with the potential to prevent complications of atherosclerosis. 
Methods: Cre-recombinase technology in conjunction with a macrophage-specific lysozyme (LysM) promoter was used to overexpress TNAP on a background of hypercholesterolemia. Hypercholesterolemia was achieved by a combination of the genetic mutation (wicked high cholesterol, WHC) in the low-density lipoprotein receptor (ldlr) and an atherogenic diet (Paigen's type) fed to all mice for 15 weeks. Seven mice in the control group (WHC) and 7 mice in the experimental group (WHC-mTNAP) were used for physiologic and histologic analyses in the pilot experiment. To evaluate the extent of the stenosis in the aortic root, echo Doppler imaging was used to measure blood flow through the aortic valve. M-mode infrasound imaging was used to assess left ventricular geometry (diameter and wall thickness) and to calculate left ventricular mass index. TNAP transgenic and control animals were analyzed and compared at 8 weeks of age (baseline) and at 23 weeks of age. The specific echocardiographic measurements and calculations included: (1) AoV max, maximal aortic valve velocity (measure of stenosis); (2) EF, ejection fraction (cardiac contractility); (3) LVmass/BW, left ventricular mass index (cardiac hypertrophy); (4-5) LVID, left ventricular internal diameter; and LVPW, left ventricular posterior wall thickness (type and stage of cardiac remodeling). Plaque area, calcification, and collagen deposition were analyzed using oil red O, alizarin red, and picrosirius red stains, respectively. ImageJ was used to analyze histologic images. 
Data Analysis: Graphpad Prism Software was used to test statistical significance of data. Physiologic data of aortic root geometry and heart function, plaque area, lumen area, and % occlusion were analyzed using an unpaired t test. Plaque calcifications were analyzed using the Mann-Whitney test. Statistical significance was accepted at a P value <.05. Data were expressed as mean±SD. 
Results: Calcification was measured using alizarin red stain in the aortic root, and significant increase of calcium deposition was observed in plaques located at the base of left, right, and posterior aortic valve cusps (P<.0001, left cusp; P<.05, right cusp; P<. 01, posterior cusp) in WHC-mTNAP compared with WHC mice. Increased calcifications in TNAP-overexpressing mice did not increase plaque size in comparison with equally hypercholesterolemic WHC mice. Echocardiography was performed, and a significant increase in left ventricular ejection fraction and left ventricular mass in relation to body weight was observed in WHC-mTNAP mice compared with WHC mice (P<.05, EF%; P<.01, LVmass/BW). Overexpression of TNAP also showed a statistical trend toward an increase in left ventricular posterior wall thickness in diastole (P=.07472). 
Conclusion: TNAP plays a causative role in the calcification of plaques in the aortic root. Compensatory left ventricular hypertrophy detected in TNAP-overexpressing mice likely reflects the increased stiffening of the aortic root region due to calcification and requires further investigation. 
Support: This study was funded by NYITCOM Summer Research Program (V.S.); Academic Medicine Scholar Program (K.D.); and a faculty start up fund (O.V.S.). 
♦B14—Chronic Diseases and Conditions
Effect of Pregnancy on Abdominal Aorta Structure and Function 
Kimberly A. Klatt, OMS III1; Megan Zynda2; Johana Vallejo-Elias3; Jason D. Struthers4; Kimbal E. Cooper2; Delrae M. Eckman4 
1Midwestern University Arizona College of Osteopathic Medicine (MWU/AZCOM), Glendale; 2Biomedical Sciences, College of Health Sciences, MWU/AZCOM; 3Department of Physiology, MWU/AZCOM; 4College of Veterinary Medicine, Midwestern University, Arizona 
Introduction: Normal pregnancy is associated with significant cardiovascular changes to meet the metabolic demands of the placenta, growing fetus, and mother. These changes include an increase in uterine blood flow, plasma volume, elevated cardiac output, and a reduction in systemic vascular resistance. To meet this demand, the maternal aorta must undergo structural and functional changes. Most studies addressing the effect of normal and complicated pregnancies on aortic structure/function have focused on the ascending and descending aorta, and little attention has been given to the abdominal aorta (AA). Therefore, this study was designed to determine whether normal pregnancy alters the AA structure and function. 
Objective: Determine whether normal pregnancy alters (1) endothelial modulation of agonist-induced constriction and/or (2) the apparent contribution of elastin and collagen to the structure and function of rat AA. 
Methods: AA from nonpregnant (NP, n=5) and late-pregnant (P, gestational age 20±1 day, n=5) Sprague-Dawley rats were removed, cleaned of connective tissue, and cut into 3-mm long ring segments. Segments were mounted onto 2 triangular tungsten wires and suspended vertically in an isolated organ chamber containing calcium Krebs buffer solution. Smooth muscle function was assessed using 50-mM [K+]O and 1-μM phenylephrine (PE), in the absence/presence of L-NAME and indomethacin (INDO) to evaluate the contribution of NOS and COX, respectively. The contribution of elastin and collagen in mechanical distensibility in AA segments was assessed using stepwise increases (100 μm) in circumferential stretch, ranging from 0 to 3000 μm, in the absence/presence of elastase (0.5 mg/mL) and collagenase (0.5 mg/mL). 
Data analysis: Data from these experiments were analyzed using either a 1-way or 2-way ANOVA. P<.05 was considered significant. 
Results: AA segments from NP and P rats exhibited similar PE- and 50-mM [K+]O-induced constrictions. L-NAME significantly augmented PE-induced constrictions in arteries from NP and P rats. Whereas, L-NAME did not affect 50-mM [K+]O-induced constriction in arteries from NP or P rats. INDO attenuated PE-induced constrictions in both NP and P rats, but was without effect in vessels constricted to 50-mM [K+]O. Collagenase significantly attenuated the length-tension relationship AA from NP and P rats in a similar manner. In contrast, elastase attenuation of the length-tension relationship was greater in AA from P rats compared with those from NP. 
Conclusion: These preliminary data suggest that pregnancy does not alter PE- and 50-mM [K+]O- induced constrictions in AA. NOS-inhibition using L-NAME NOS augmented PE-induced constriction in AA from NP and P rats in a similar manner, while PE-induced constrictions were attenuated in the presence of INDO. Finally, the apparent contribution of collagen to vascular distensibility appears to be similar in NP and P rats, while elastin-attenuated AA distensibility was dependent on pregnancy status. Additional studies will be needed to assess whether AA structure/function is altered during the postpartum period. Finally, these studies serve as the foundation for future studies assessing aortic structure/function in animal models of complicated pregnancy. 
Support: MWU start-up funds (D.M.E.), Biomedical Sciences graduate student research support (M.Z., D.M.E.), Ken Suarez Summer Research Fellowship (K.K.). IACUC # 2821 
♦B15—Chronic Diseases and Conditions
Alterations of Glia and Vasculature in the Aging Mouse Brain 
Kelsey Full, OMS II; Aamir Mohiuddin, OMS II; Joyce Morris-Wiman, PhD 
Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine (WVSOM), Lewisburg 
Research Question: The blood-brain barrier (BBB) is critical for regulating exposure of harmful materials to the brain. It has been shown that as one ages, the integrity of the BBB can become compromised and is associated with cognitive decline. Various components are responsible for supporting the endothelial cells of the BBB, including astrocytes, oligodendrocytes, and microglia. Previous studies suggest that disruptions to the relationship between the BBB and supportive components can result in compromised vasculature and therefore white matter damage. Based on these findings, this study examines these relationships in regions of young and old mouse hippocampal regions and surrounding white matter. We hypothesize that with aging, the number/distribution of oligodendrocytes and astrocytes changes in association with the alteration of brain vasculature and increased BBB permeability. These findings will contribute to understanding the aging process and may be applied to future treatment. 
Methods and Data Analysis: Mouse brains were harvested from young (2-6 months, n=4) and aged (19-27 months, n=4) BalbC mice, snap-frozen in isopentane cooled in liquid nitrogen, and stored at -80°C until cryosectioned. 14-μm cryosections were mounted consecutively on a series of 10 slides to allow comparison of Kluver-Barrera staining and immunostaining for glial markers, GFAP, and CNPase, and markers of blood vessel integrity, IgG and laminin. Digital images of immunostained sections from the hippocampal region were acquired under epifluorescence with a Zeiss MRm digital camera and Axiovision software and assembled into collages using Adobe Photoshop. Collages of immunostained sections were thresholded to produce a binary image and analyzed using Image Pro plus software. Sections stained by the Kluver Barrera method were viewed under brightfield and the internal capsule, external capsule, and the corpus callosum assessed for flaws in normal morphology. Statistical differences in the distribution of immunomarkers and the incidence of white matter flaws were assessed using Statistica (StatSoft) with significance at P<.5 by ANOVA, LS test. 
Results: The aged brain showed significantly increased vessel permeability as indicated by the presence of IgG (P<.013), increased disruption within large myelin bundles (internal capsule, external capsule, and corpus callosum) assessed by Kluver-Barrera staining (P<.0278, by Kruskal-Wallis test), and increased density of GFAP-immunostained astrocytes (P<.038) in sections through the hippocampus in comparison with the young brain. No significant differences were observed in the density or distribution of CNPase-immunostained oligodendrocyte populations or in number of small vessels as detected by laminin immunostaining between the old and young mouse brain. 
Conclusion: Our results indicate that the aging in the mouse brain is associated with an increased astrocyte presence, disruption of the BBB, and increased prevalence of white matter disruptions. However, no differences were detected in oligodendrocyte numbers or distribution or in the number of small vessels between aged and young mouse brain. These findings suggest that a relationship exists between astrocyte populations and BBB integrity, but that aging in the hippocampal region may not be accompanied by changes in local vasculature and oligodendrocyte function. 
Support: This research was funded through WVSOM intramural grant and the WVSOM work-study program. 
♦B16—Chronic Diseases and Conditions
Requirement of Syk and PI3K for Epstein-Barr Virus LMP2A-Mediated Activation of NF-kB in B Cell Tumors 
Jason McAloon, OMS II1; Ryan Incrocci, MS2; Michael Montesano, OMS III1; Jonathan Bardahl, DO1; Michelle Swanson-Mungerson, PhD2 
1Midwestern University Chicago College of Osteopathic Medicine (MWU/CCOM), Downers Grove, Illinois; 2Department of Microbiology and Immunology, MWU/CCOM 
Introduction: Epstein-Barr virus (EBV) is a widespread human herpes virus, and is the causative agent of infectious mononucleosis, as well as a contributor to a number of cancers such as Hodgkin lymphoma (HL). EBV infection is carried in the latent form to evade detection by the immune system through the expression of latency genes, such as latent membrane protein 2A (LMP2A). Studies indicate that LMP2A mimics B cell receptor (BCR) signaling by activating the Syk/Ras/PI3K pathway, which contributes to the development of HL by both direct and indirect mechanisms. First, LMP2A mimics BCR signaling to directly promote HL development by protecting BCR-negative Hodgkin-Reed/Sternberg (HRS) cells from apoptosis. Second, our laboratory has identified that LMP2A indirectly promotes HL development by increasing macrophage inflammatory protein-1α (MIP-1α) levels. MIP-1α is a chemokine produced by HRS cells to create the EBV-associated HL tumor microenvironment, which is also critical for the long-term survival of the tumor. In an effort to understand the mechanism by which LMP2A increases MIP-1α production, experiments identified that the addition of inhibitors to Syk and PI3K blocked this LMP2A-mediated increase in MIP-1α levels. Additional studies identified that inhibiting NF-κB, which is a downstream target of PI3K, also blocked the LMP2A-mediated increase in MIP-1α. These findings are the first to suggest that LMP2A induces the activation and nuclear localization of NF-κB. A previous student used confocal microscopy to confirm that LMP2A induces constitutive NF-κB activation and nuclear localization. However, the mechanism by which LMP2A does this was unknown. Therefore, the goal of this study was to identify the signaling pathway required to induce NF-κB nuclear localization in LMP2A-expressing cells. We hypothesized that LMP2A activates Syk and subsequently PI3K to induce the nuclear localization of NF-κB in LMP2A-expressing B cells. Our aims tested whether the addition of either a Syk inhibitor and/or a PI3K inhibitor blocks the nuclear localization of NF-κB in LMP2A-expressing cells. 
Statement of Significance: The LMP2A-dependent activation of NF-κB is not only important for MIP-1α production, but also for B cell proliferation and survival. Therefore, identifying how LMP2A activates NF-κB in B cells may reveal novel inhibitors to disrupt this pathway in EBV-associated Hodgkin lymphoma. The loss of NF-κB activation in these cells has significant implications to disrupt the HL microenvironment, and correspondingly allow the human body to carry out its self-healing capabilities. 
Methods: All experiments were performed in accordance with Midwestern University Institutional Policies and Regulations. LMP2A-negative B cells (BJAB-Vector.1 and BJAB-Vector.2) and LMP2A-positive B cells (BJAB-LMP2A1.1 and BJAB-LMP2A1.2) were incubated in the absence or presence of the pharmacologic inhibitor for Syk (R788) or PI3K (Wortmannin) for 24 hours at 37°C with 5% CO2. To determine changes in NF-κB nuclear localization, cells were washed, fixed, and stained with an antihuman NF-κB p65 antibody (D14E12) before analysis using confocal microscopy. 
Results: Our data confirm that cells expressing LMP2A constitutively activate NF-κB and that inhibition of Syk and PI3K consistently decreased NF-κB nuclear localization, suggesting that LMP2A activates NF-κB via the Syk/PI3K pathway. 
Conclusion: Previous data from our laboratory suggest that LMP2A induces the nuclear localization of NF-κB, where it acts as a transcription factor promoting B cell MIP-1α production. Our findings suggest that Syk and PI3K mediate the activation of NF-κB in LMP2A-expressing B cell tumors, which may play an important role in the generation of a pro-survival tumor microenvironment. This finding may provide insight into guiding pharmacologic treatment and new approaches to disrupt EBV associated malignancies, and may subsequently allow the body to eradicate malignant cells. 
Support: This work was supported by the Midwestern University Kenneth A. Suarez Fellowship program. 
♦B17—Chronic Diseases and Conditions
Analysis of Systemic Hormone Exposure in a Rodent Model of Vulvovaginal Atrophy With Menopause 
Kelsi Erin Leigh Rogers, OMS II1; Alyssa M. Gates, OMS II2; Millie L. Mattox, BS2; Maureen E. Basha, PhD2 
1West Virginia School of Osteopathic Medicine (WVSOM), Lewisburg; 2Department of Biomedical Science, WVSOM 
Background: Over 2 million women enter menopause each year, and as the baby boomer generation ages, this number is expected to significantly increase. Decreasing estrogen levels associated with menopause can lead to vulvovaginal atrophy, which causes vaginal symptoms such as vaginal dryness, dyspareunia, burning, and increased pH. As urinary symptoms such as incontinency and urgency also have been documented to increase in menopausal women, nomenclature has recently evolved from “vulvovaginal atrophy of menopause” to “genitourinary syndrome of menopause” (GSM) to account for both genital and urinary symptoms associated with menopause. A current treatment recommendation for GSM includes vaginal estrogen delivery to minimize systemic hormone exposure. Many studies have been conducted that demonstrate the efficacy of low-dose vaginal estrogen in decreasing pH and improving dyspareunia and other atrophic symptoms, but the effects of these treatments on the urinary system and the safety of these treatments is not well understood. Particularly, concerns of the systemic effects of estrogen leave the safety of vaginal administration to women with hormone-dependent cancer and potential stimulatory effects on the endometrium to be ill-defined. Ovariectomized rodents are commonly used as a rodent model of vulvovaginal atrophy with menopause, and previous work in our laboratory using this model has demonstrated that local estrogen delivery not only stimulates growth of the vaginal epithelium, but also restores vaginal nonvascular smooth muscle (vaginal muscularis) structure and function. It is important that osteopathic management of vulvovaginal atrophy address not only structural changes resulting from menopause, but also symptoms related to female sexuality. This whole-person treatment promotes psychosocial health of postmenopausal women reiterating unity of the body, mind, and spirit. 
Objective: The goal of this follow-up study was to analyze indices of systemic hormone exposure following vaginal estrogen treatment in the rodent model of vulvovaginal atrophy with menopause. 
Methods: Three-month-old Sprague-Dawley ovariectomized (OVX) and sham-ovariectomized (SH) rats were ordered from a commercial supplier. Two weeks following surgery, animals were treated vaginally with either a vehicle cream (SH, OVX) or with a 0.002% 17-β estradiol cream (OVX). We performed experiments on 3 animals per group for a total of 9 animals: OVX and SH animals treated with vaginal vehicle (VV) and OVX animals treated with vaginal estrogen (VE). Animals were euthanized after 4 weeks of daily vaginal cream delivery, the urogenital tract was dissected, and uterine, bladder, urethral, clitoral, and vaginal weights were recorded. Sections of the uterine horn were paraffin embedded, and cross-sections were obtained for hematoxylin-eosin staining (HE staining) and immunohistochemical analysis of alpha-actin, a smooth muscle marker. Images of HE-stained uterine cross-sections were obtained using a Leica Versa microscope, and cross-sectional area was calculated using Image-J software. 
Data Analysis: Data were analyzed using 1-way analysis of variance (ANOVA) followed by Tukey post-hoc test for significant ANOVAs (P<.05). Data are presented as mean±SEM. Statistical analysis was performed using Graph Pad Software. 
Results: Our previous study demonstrated that the decrease in uterine weight following ovariectomy was partially reversed to SH values following local estrogen treatment. Expanding upon this finding, we reported that local estrogen treatment (OVXVE) increased the uterine cross-section area (4.06±0.97 mm2) compared with vehicle-treated animals (OVXVV, 1.42±0.97 mm 2), although this treatment did not restore cross-sectional area to that of SHVV animals (7.44±0.88 mm2). Bladder and urethral weights were not significantly affected by ovariectomy or vaginal estrogen replacement in the study. Although there was a trend of reduced clitoral weights of ovariectomized animals (OVXVV) compared with sham- (SHVV) and estrogen-treated (OVXVE) animals, this difference was not significant. An outer longitudinal and inner circular smooth muscle layer was visualized within uterine cross-sections from animals in all 3 groups, with no obvious effects of ovariectomy or local estrogen replacement on the abundance of uterine smooth muscle. 
Conclusion: Our study indicates that systemic hormone exposure with local estrogen treatment may result in stimulation of uterine growth and emphasizes the importance of determining the least effective dose of vaginal estrogen used when treating women with GSM. Unlike reproductive organs, the bladder and urethra did not undergo atrophy following ovariectomy. We did not determine whether estrogen loss and replacement affected functional changes of the urinary system in this study. Given the increase in urinary symptoms with menopause, further research is warranted to determine the effect of estrogen loss on bladder and urethral physiology. 
Support: This work was funded by a WVSOM intramural grant. 
♦B18—Chronic Diseases and Conditions
Analysis of Human Monocyte Activation by Cyanobacterium Oscillatoria Species Lipopolysaccharide 
Vijay Subramaniam, OMS II1; Ryan Incrocci, MS2; Philip Williams, PhD3; Mary L. Hall, BS4; Alejandro M.S. Mayer, PhD4; Michelle Swanson-Mungerson, PhD2 
1Midwestern University Chicago College of Osteopathic Medicine (MWU/CCOM), Downers Grove, Illinois; 2Department of Microbiology and Immunology; MWU/CCOM; 3Department of Chemistry, University of Hawaii-Manoa, Manoa, Hawaii; 4Pharmacology, MWU/CCOM 
Introduction: Within the gut-associated lymphoid tissue (GALT) reside cells of both the innate and adaptive immune system that respond to pathogen invasion by proliferating, serving to activate other cells of the immune system, and producing cytokines that communicate the invasion to other parts of the body. Lipopolysaccharides (LPS), widely recognized as toxins in gram-negative bacteria, are also implicated in the toxicity of cyanobacteria. Cyanobacteria exposure occurs after consumption of water or food that has accumulated dangerous levels of the bacteria and results in symptoms ranging from headache, fever, allergy, respiratory disease, and gastrointestinal illness. Ingestion of these gram-negative bacteria results in the exposure of cyanobacterium Oscillatoria species toxins, such as LPS, to monocytes in the GALT, which may result in the activation of monocytes to produce cytokines, phagocytose pathogens, and increase the expression of proteins that aid in the activation of T cells. Despite an understanding of LPS from other species of gram-negative bacteria, the ability of cyanobacterium Oscillatoria species LPS to affect human monocyte activation is currently unknown. Our past analysis of the effects of Oscillatoria species LPS on murine B cells indicate that Oscillatoria species LPS activates B cells to proliferate, upregulate activation markers and produce IgM to a lesser degree than Escherichia coli LPS. This difference in murine B cells is likely due to the inability of Oscillatoria species LPS to induce normal signaling through Toll-like receptor 4 (TLR4), which is the receptor for LPS. Because the ability of cyanobacteria LPS to activate monocytes in the GALT may profoundly contribute to cyanobacterial-induced human and animal disease, we hypothesized that cyanobacterium Oscillatoria species LPS would activate human monocytes. To test this hypothesis, our study determined the ability of Oscillatoria species LPS to induce proliferation and thromboxane B2 production, increase the expression of activation markers (HLA class II and CD86), and stimulate phagocytosis. By understanding the effects of cyanobacterium Oscillatoria species LPS on human monocytes, we will be better able to understand the mechanisms by which this bacterium misdirects normal immunologic processes to induce disease. 
Methods: For all experiments, human monocytes were isolated from human deidentified buffy coats purchased from Life Source using the EasySep Human monocyte isolation kit (Stemcell Technologies). (Because of the purchase of these deidentified human buffy coats, this study was considered exempt by the institutional review board at Midwestern University.) Purified monocytes were then incubated in the absence or presence of increasing concentrations of either Oscillatoria species or E coli LPS (as a positive control) for 48 hours. For the analysis of monocyte proliferation and thromboxane B2 production, cells were incubated in 96 well plates, supernatants were analyzed for thromboxane B2 production by ELISA, and proliferation was assessed using the MTT assay. For the analysis of HLA class II and CD86 expression, human monocytes were stained using either PE-conjugated anti-HLA class II antibody or APC-conjugated antihuman CD86 (Biolegend) and analyzed using a FACS Calibur followed by Cell Quest Software (BD Biosciences). To determine if Oscillatoria species LPS increased the ability of monocytes to phagocytose insoluble particles, human monocytes were incubated as described above for 48 hours, washed, and incubated with FITC-labeled latex beads for 1 hour before analysis using the Amnis flowsight flow cytometer. Additionally, we used confocal microscopy to analyze individual cells at a higher resolution to confirm the internalization of the FITC-dextran. 
Results: In our past studies, we analyzed B-cell activation induced by Oscillatoria species LPS and found that Oscillatoria species LPS activates B cells to proliferate, upregulate activation markers such as CD86 and MHCII, internalize antigen, and secrete IgM. However, despite being able to activate murine B cells, as predicted by our TLR4 signaling analysis, Oscillatoria species LPS did not activate murine B cells to the same levels of E coli LPS. Our results from the current study with human monocytes indicate that human monocytes do show a similar pattern of proliferation, in which human monocytes proliferate more with exposure to various concentration of E Coli LPS compared with Oscillatoria LPS. However, unlike murine B cells, human monocytes have shown increased activation and phagocytosis when exposed to Oscillatoria species LPS vs E Coli LPS. 
Conclusion: The Cyanobacterium Oscillatoria species LPS activates human monocytes, enhances phagocytosis, and induces proliferation. However, in contrast to murine B cells, Oscillatoria species LPS may be more efficient in activating certain aspects of human monocyte function than E coli LPS. Future studies plan to expand the concentrations of E coli and Oscillatoria species LPS that were used in these studies, to analyze the biochemical differences between E coli and Oscillatoria species LPS, and to investigate the differences in human monocyte TLR4 signaling after LPS exposure. As cyanobacteria continue to spread in freshwater sources, these findings are critical to understanding the mechanisms of toxicity of cyanobacteria in not only humans, but also animals. 
Support: This work was supported by the Midwestern University Kenneth A. Suarez Fellowship program (V.S.) and a One Health Intramural Grant from Midwestern University (M.S.M. and A.M.S.M). 
♦B19—Chronic Diseases and Conditions
Rotavirus Mediates Up-Regulation of Protein Kinase STK11IP in Mammalian Cells 
Patricia Wilt, OMS II; Madison Chase, OMS II; Michelle Vanoy-Warner, BS; Crystal Boudreaux, PhD 
West Virginia School of Osteopathic Medicine, Lewisburg 
Background/Research Question: Viruses subvert cellular factors and signaling pathways to take command of the environment for effective replication. All viruses do not have the same approach to subvert cellular factors, however, most viruses encode proteins that redirect cellular protein recruitment. Rotaviruses are important causes of acute gastroenteritis in the young of many animals and remain a leading cause of childhood diarrheal death worldwide. Rotaviruses are triple-layered, nonenveloped, 11-segmented, double-stranded (ds) RNA viruses with a life cycle that occurs entirely in the cytoplasm of infected cells. The rotavirus replication cycle undoubtedly requires the involvement of cellular proteins and signaling pathways. Yet, only a few cellular proteins/pathways that promote rotavirus replication have been described to date. Serine/threonine kinase-11 interacting protein (STK11IP) was identified using an RNAi approach that focused on cellular kinases. STK11IP was an intriguing candidate because it is known to control the subcellular localization of serine/threonine kinase 11 (STK11IP), the master regulator of 12 protein kinases. STK11IP and STK11 are both upstream components of the AMP-regulated protein kinase (AMPK) pathway, which also had been implicated in setting up a permissive environment for viral replication. Using protein analytical methods, the authors sought to answer the critical question of what is the mechanism of action of STK11IP during rotavirus infection through the following specific objectives. 
Objectives: (1) Identify which time point after infection gene and/or protein expression is up-regulated. (2) Determine what viral proteins associate with STK11IP. 
Significance: In the state of West Virginia, enteric illnesses are the second most common type of disease outbreak. Furthermore, rotavirus infections accounted for 3% of these outbreaks in reporting areas in 2015. Compared with the South as a region for CDC census reporting, the regional average for the same time frame was 6%. With half the regional average of rotavirus infections recorded in West Virginia, concerns arise questioning whether West Virginia residents without regular access to health care are less likely to be vaccinated. Additionally, identification of a mechanism for STK11IP as a cellular target may give rise to the possibility of natural compounds as treatment interventions that could mitigate the activity of the involved kinase. 
Methods: MA104 cells (African Green monkey kidney cell line) were maintained at 37°C in 5% CO2 in complete Medium 199 (M199) supplemented with 10% fetal bovine serum, penicillin-streptomycin, and amphotericin B. Rotavirus infections were performed with the simian strain SA11-4F at a multiplicity of infection (MOI) of 10 in serum-free M199. Infected and mock (cells treated in parallel without virus) cell lysates were collected 0 to 9 hours after infection. Lysates were then separated by SDS-PAGE gel electrophoresis, and probed by Western blotting using antibody-specific protein to STK11IP, viral structural protein 2 (VP2), and β-actin control. In parallel, total RNA was purified from infected and mock cell lysates for reverse-transcription assay and subsequent real-time PCR with purified cDNA. Co-immunoprecipitation assays were performed 9 hours after infecting using STK11IP, resolved by SDS-PAGE, and probed by Western blotting using specific antibodies to viral structural and nonstructural proteins. Western blots were quantified using Image J (NIH), and statistical analysis was performed using a t test (Excel). 
Results: Whole cell lysates were analyzed by Western blot using rabbit polyclonal antisera against STK11IP. The results show that a 121-kDa band consistent with the size of full-length STK11IP was detected in both mock and infected MA104 beginning 3 hours after infection. Several smaller molecular weight bands were also detected by the STK11IP antisera, consistent with the report of multiple isoforms for this protein. We observed that the levels of STK11IP were 50% higher following infection with SA11-4F at 9 hours after infection. Purified mRNA levels fluctuated throughout the time course of infection. STK11IP co-immunoprecipitated viral structural protein VP1 and VP2, and nonstructural proteins NSP2, NSP3, and NSP1. 
Conclusion: The data suggest STK11IP upregulation is induced during rotavirus infection. Increased protein levels are higher at later time points after infection, possibly indicating a role during genome replication and assembly. However, fluctuation in mRNA levels may suggest a manipulative role by the virus having a modulatory effect on the steps of replication. The structural and nonstructural proteins co-immuoprecipitated by STK11IP provide a new hypothesis of interactions with the viroplasm (a neo-organelle that serves as the site of viral replication in the cytoplasm) in which structural and nonstructural components observed in the pull down would be sequestered for genome replication and assembly before formation of a closed particle. Previous studies have shown that STK11IP regulates protein signaling by acting as a functional link between multiple proteins in a complex. Specifically, STK11IP can oligomerize with itself, facilitating the interaction between STK11 and Smad4 to negatively regulate TGFb signaling. Perhaps STK11IP has a similar function during rotavirus infection to functionally link viral proteins to each other or with other cellular factors. Future studies are being carried out to understand STK11IP function during rotavirus infection. 
♦B20—Chronic Diseases and Conditions
The Effect of Fasting on Mitochondrial Size and Mitophagy in Cardiomyocytes 
J. Anthony Garcia, OMS II; Usman Aslam, OMS IV; Katrina Bantis, OMS II; Satoru Kobayashi; Qiangrong Liang 
New York Institute of Technology College of Osteopathic Medicine, Old Westbury 
Short-term starvation or intermittent fasting has been shown to protect against stress or disease-induced cardiac injury. However, prolonged starvation or extreme calorie deficit itself may have severe physiologic consequences, such as arrhythmia and decreased cardiac output. Starvation activates general autophagy but promotes mitochondrial fusion and inhibits mitochondrial degradation or mitophagy in noncardiac cells. This observation has been proposed to preserve functional mitochondria contributing to cell survival under nutrient-restricted conditions. However, it remains largely unknown how fasting affects mitophagy and mitochondrial dynamics, including fusion and fission, in cardiomyocytes or in the heart. The goal of this study was to determine mitochondrial morphology and mitophagy in the heart during starvation. We used a novel mitophagy reporter transgenic mouse line expressing mito-Rosella, a dual-emission biosensor comprising a pH-stable red fluorescent protein (RFP) linked to a pH-sensitive green fluorescent protein (GFP). This novel reporter protein is tagged with a mitochondrial targeting sequence derived from the gene that encodes subunit VIII of human cytochrome C Oxidase. These mice were subjected to either 24-hours or 48-hours of fasting. Afterward, animals were killed, and cardiac tissues were harvested for confocal microscopic analysis of mitochondrial morphology and mitophagy events. To assess mitophagy flux, these animals were also treated with pepstatin A/E64d, membrane-permeable cathepsin inhibitors that lead to an accumulation of autolysosomes. Mitophagy events were seen as red puncta on the overlaid confocal images. Our results showed that fasting accelerated mitophagy in the heart during the first 24 hours as indicated by the appearance of red puncta with and without pepstatin A/E64d. Surprisingly, although the number of red puncta was increased by 48 hours of starvation, it was not further elevated by pepstatin A/E64d, suggesting that prolonged starvation inhibited mitophagy flux in the heart. In addition, we found that the reduced mitophagy flux was accompanied by a decreased mitochondrial length, width, and area in the heart after 48 hours fasting, suggesting an increased rate of mitochondrial fission. Future studies are warranted to determine whether mitochondrial number is also affected by fasting and whether the increased fission and reduced mitophagy are adaptive or maladaptive responses of the hearts during prolonged starvation. 
♦★B21—Chronic Diseases and Conditions
Evaluating Gap Junctional Intercellular Communication in Breast Cancer Cells: Potential for Increasing Chemotherapeutic Spread 
Prarthana Pradeep, OMS III1; Alexander Urban, OMS II2; Jennifer Jones, MS2; Thomas Bodenstine, PhD1 
1Department of Biochemistry, Midwestern University Chicago College of Osteopathic Medicine (MWU/CCOM), Downers Grove, Illinois; 2MWU/CCOM 
Introduction: Gap junctional intercellular communication is responsible for the transfer of ions, signaling molecules, and nutrients between adjacent cells. Gap junctions are made up of highly regulated channels that function in the plasma membrane and are composed of transmembrane proteins known as connexins. Cell-to-cell communication via gap junctions is a part of normal epithelial cell homeostasis, but dysregulation of this process is a common characteristic of neoplastic transformation and has been associated with the process of metastasis in breast cancer cells. In particular, downregulation of gap junctional activity in primary tumor cells has been shown to inhibit transfer of low molecular weight therapies between cells and may hinder delivery of therapy to regions of tumors more distant from a blood supply. 
Research Question: Previous data have demonstrated that activation of the protein kinase A (PKA) pathway in breast cancer cells is capable of restoring gap junction communication. Since the lack of this communication not only disrupts cellular homeostasis but also eliminates a natural mechanism for the transfer of therapies, we hypothesized that restoration of gap junction activity would serve as a potential mechanism to improve the effectiveness of chemotherapeutics in breast cancer cells. 
Statement of Significance: The experiments performed in this project aim to improve breast cancer treatment modalities, which will affect the overall multidisciplinary approach for the care and management of patients with breast cancer. 
Methods: To examine the functional effects of restoring gap junctional intercellular communication on the spread of chemotherapy, we used 2 human breast cancer cell lines with demonstrated low levels of intercellular communication: MDA-MB-231 and T47D. We examined how modulations to the protein kinase A (PKA) pathway affected communication and cell-to-cell spread of the chemotherapy doxorubicin. To assess gap junctional transfer activity between cells, the authors traced the spread of the gap junction permeable fluorescent dye, calcein, between cells and assessed gap junctional communication. DiI, a lipophilic dye that does not transfer between cells, was used to mark cells initially labeled with calcein. Cells were treated with and without LY294002, a compound shown to increase the activity of the PKA pathway and gap junctional activity. 
Data Analysis: Connexin 43 protein, a major connexin in normal breast tissue, was detected by Western blot analysis and immunofluorescence techniques for control and treated cells to determine overall protein levels and cellular localization. Results from dye transfer assays were recorded by fluorescence observation of live cells followed by quantitative analysis using flow cytometry. Treatment and spread of doxorubicin was documented by live and fixed cell fluorescence, and markers of late stage apoptosis were analyzed by immunofluorescence. 
Results: Western blot analysis demonstrated lower Cx43 levels in T47D when compared with MDA-MB-231. However, Cx43 protein in each case remained mislocalized with no apparent localization to the membrane and correlated with a lack of gap junctional activity as shown by minimal spread of calcein between cells. Treatment with LY294002 restored gap junction communication in both the MDA-MB-231 and T47D cell lines and induced changes in cellular localization of Cx43. We subsequently demonstrated the transfer of doxorubicin between cells under these conditions and are currently evaluating the effects of this transfer on functional activity and therapeutic efficacy. 
Conclusion: Treatment of breast cancer cell lines MDA-MB-231 and T47D with the compound LY294002 improved gap junction communication and altered Cx43 protein accumulation in cells. This effect led to improved transfer of doxorubicin from treated to untreated cells. Compounds that modulate the activity of PKA in cancer cells may have a potential role in future treatments aimed at increasing the penetrance of chemotherapeutic agents by increasing gap junctional activity. 
Support: This study was supported by the Midwestern University Office of Research and Sponsored Programs Kenneth A. Suarez Summer Research Fellowship. 
♦B22—Chronic Diseases and Conditions
Effect of High-Fructose Levels on Cellular Regulation of Energy 
Kyaw M. Tun, OMS II1; Miriam Gochin, PhD2; Alejandro Gugliucci, MD, PhD3 
1Touro University College of Osteopathic Medicine-CA (TUCOM), Vallejo; 2Department of Basic Sciences, TUCOM; 3Office of Sponsored Research, TUCOM 
Background, Hypotheses, and Objectives: 5' adenosine monophosphate-activated protein kinase (AMP-dependent kinase or AMPK) is an important cellular regulator of catabolic and anabolic pathways. The enzyme plays an important role in maintaining energy homeostasis as it senses the fluxes and availability of AMP and other metabolites and responds by inducing a cascade of events within cells. It is activated by metabolic stresses that inhibit ATP production and/or accelerate ATP consumption. Once activated, an AMPK-mediated phosphorylation cascade switches cells from active ATP consumption to active ATP production—stimulating glucose transport, glycolysis, and beta oxidation, while inhibiting lipogenesis and cholesterol biosynthesis. In this study, we examine (1) whether AMPK activity changes with varying levels of AMP and (2) whether the AMP binding site on AMPK can be modified by a glycation agent, resulting in diminished capacity for AMP-mediated regulation and energy sensing. Our hypothesis is based on the fact that the AMP-binding site contains 3 arginine residues that are prone to glycation by a compound called alpha-dicarbonyl methylglyoxal (MG). MG is produced when there is excessive and/or unregulated flux of trioses to the liver, which can be caused by increased levels of fructose in the body as seen in metabolic conditions such as hyperglycemia, insulin resistance, and diabetes. Therefore, we hypothesized that fructose load, via the increased flux of MG, could block the sensing of AMP by AMPK, and favor gluconeogenesis that leads to hepatic insulin resistance, hyperglycemia, and hepatic glucose output and lipogenesis, which can cause hepatic steatosis and high triglyceride levels. 
Significance: Due to being at a central control point in maintaining energy homeostasis, AMPK is projected to be a key regulatory target for therapeutics. Many therapeutic agents for metabolic conditions such as diabetes mellitus (DM), metabolic syndrome (MS), and non-alcoholic fatty liver disease (NAFLD) act in part by activating AMPK. The cause of the increasing prevalence of obesity, diabetes, and NAFLD worldwide has been associated by several studies with increased consumption of high-fructose corn syrup. Fructose is metabolized almost exclusively in the liver. If by-products of fructose metabolism affect AMPK function, they could exacerbate metabolic dysregulation. The tenets of osteopathic medicine dictate that the body is capable of self-healing, self-regulation, and health maintenance and that rational treatment is based on an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function. By interfering with the homeostatic function of AMPK, fructose would interfere with the body's self-regulation mechanism. To treat the conditions requires proper understanding of the effect of fructose on AMPK. 
Methods: The goals of the research were to (1) develop an effective enzyme assay to be used to measure AMPK activity in the laboratory by selecting various conditions for assay optimization, (2) establish the dependence of AMPK activity levels on different ATP:AMP ratios, (3) glycate the enzyme in vitro by MG, and (4) measure the effect of glycation on AMPK activity by using different ATP:AMP ratios. Determination of AMPK activity: AMPK activity was assessed by performing in vitro AMPKa1 kinase TR-FRET (time-resolved fluorescence energy transfer) assay protocol from PerkinElmer in the absence of AMP. The protocol was optimized by varying the levels of enzyme, ATP, buffer, temperature, and time of reaction. In summary, AMPK was allowed to phosphorylate ULight-acetyl-CoA carboxylase peptide, a fluorescently labeled synthetic peptide derived from rat acetyl-CoA carboxylase (SAM peptide). A europium-anti-phospho-acetyl-CoA carboxylase antibody selective for phosphorylated SAM peptide was added, resulting in TR-FRET signal between the europium chelate and the fluorophore on the peptide, enabling the amount of phosphorylated peptide to be determined. The data are reported as a ratio of the fluorescence readings at emission wavelengths 665 nm (TR-FRET) to 615 nm (auto-fluorescence of Eu-antibody). Sensitivity of AMPK to AMP: A series of measurements was made with constant concentration of ATP (50 μM) and varying concentrations of AMP, changing the ratio of AMP:ATP within 0-5. Glycation of AMPK (in progress): AMPK will be exposed to methyglyoxal for 15 minutes at 37°C, at a level that corresponds to that found typically in cells (approximately 2.9 mM per 106 cells as reported in literature), and the reaction will be quenched with aminoguanidine. A control reaction without MG will be carried out in parallel. Determination of glycation will be made using LC-MS spectroscopy (liquid chromatography-mass spectrometry). Measurement of glycated AMPK with and without AMP (planned): The TR-FRET protocol described above will be used to measure the effect of glycation on AMPK sensitivity to AMP. 
Results: The activity of AMPK, measured as the TR-FRET value, is reported as the ratio of fluorescence at 665 nm to that at 615 nm, relative to a negative control containing no enzyme, by subtracting the TR-FRET value of the negative control from the data. Since ATP concentration was kept constant at 50 mM in all samples, the variation reflects changes in AMP concentration. 
Data Analysis: It was seen that the activity of AMPK changes with varying levels of AMP. A slight increase in AMPK activity was seen with increasing ratio of AMP to ATP before the activity started declining. Therefore, it is believed that AMP activates AMPK only up to a certain concentration, after which it starts inhibiting AMPK. In other words, when AMP concentration is significantly greater than ATP concentration, it inhibits AMPK. This analysis agrees with the data reported in literature. ATP inhibits AMPK by binding to either allosteric g domain or catalytic a domain. On the other hand, AMP activates AMPK if bound to g domain, but at high concentrations, AMP binds to a domain and inhibits AMPK. 
Conclusion: Investigation of AMPK and its activators and inhibitors can open doors to therapeutic agents that can more effectively target metabolic conditions such as diabetes mellitus, NAFLD, and cancer. The next steps of this project will be glycating the enzyme using methylglyoxal and measuring its activity at varying levels of AMP:ATP. If we do not see glycation, alternate ways to inhibit AMPK will be explored. Further endeavors will be determining at what concentration AMP starts inhibiting AMPK, repeating the same experiments in vivo inside cells, and introducing AMPK activators such as AICAR (5-Aminoimidazole-4-carboxamide ribonucleotide), which is also an AMP analog and AMPK inhibitors such as Dorsomorphin. 
Support: Funds for this project were provided by the Office of Research at Touro University California. 
♦B23—Impact of OMM/OMT
Lymphatic Pump Treatment of Inflammation in Rat Adjuvant-Induced Arthritis 
Michael Volin, PhD1; Ryan McAuliffe, OMS I2; Brian Zanotti, BS1 
1Department of Microbiology and Immunology, Midwestern University Chicago College of Osteopathic Medicine (MWU/CCOM), Downers Grove, Illinois; 2Midwestern University/Arizona College of Osteopathic Medicine (MWU/AZCOM), Glendale 
Context: Rheumatoid arthritis (RA) is an immune-inflammatory disorder characterized by chronic inflammation. Rat adjuvant-induced arthritis (AIA) is a rodent model of RA that is well characterized to have many similarities with human RA, including dysfunctional lymphatics and aberrant cell mediated immunity. Lymphatic pump treatment (LPT) is an osteopathic manipulative treatment used with the intent to increase lymphatic flow and alleviate edema. We hypothesized that LPT for rats with AIA would enhance lymphatic function by increasing the number of synovial lymphatic vessels resulting in normalization of lymphatic flow and decreased clinical parameters of arthritis. We expected these outcomes when lymphatic pump treatment was used either as a preventive measure before arthritis developed or as a therapeutic modality. 
Methods: Rats were injected with an adjuvant at the base of their tail (day 0), which typically results in arthritis in their hind limbs starting around day 9, with inflammation peaking in severity around days 14 to 18. All animal experiments were performed with approval from the Midwestern University Animal Care and Use Committee. For the therapeutic study, 24 female Lewis rats were placed into 2 groups. Starting on day 14 through day 20, one group was treated 3 times per day for 30 seconds with LPT and the sham group was held for the same amount. For the preventive study, 24 female Lewis rats were placed into 2 groups. Starting on day 4 and continuing through day 10, 1 group was treated 3 times per day for 30 seconds with LPT and the sham group was held the same amount. LPT was performed by rhythmically pressing below the rib cage 30 times over a 30-second period, while the sham control group was held for 30 seconds. Articular index scoring and caliper measurements were taken on hind ankles through the course of the study. Hind ankles and peripheral blood were collected for study. Statistical significance was determined using ANOVA and a post-hoc t test. 
Results: In the therapeutic study, the animals treated with LPT started by day 15 to have smaller ankle circumferences and by day 16 to have lesser articular index scores, indicating reduced ankle swelling. This reduction in swelling with LPT persisted as the study continued, reducing ankle circumference increase as much as 24% and articular index score by a quarter point, but it did not reach statistical significance. In the preventive study, the animals treated with LPT by day 8 had smaller ankle circumferences and lesser articular index scores indicating reduced ankle swelling. This reduction in swelling with LPT became greater as the study continued until the final day of the study, day 11, when LPT-treated animals had significantly reduced swelling compared with the sham-treated group (average ankle circumference on day 11 for sham group 21.35 mm2 vs LPT group 20.48mm2, P<.05). Additionally, by day 11 the LPT group had a reduced articular index score of 0.2 vs the sham 0.5 (P=.08), indicating reduced signs of inflammation, such as redness and swelling. 
Conclusion: The results of these experiments suggest LPT given 3 times a day for 30 seconds starting on day 14, after the establishment of arthritis, can reduce swelling and signs of inflammation and that LPT given 3 times per day for 30 seconds starting on day 4, several days before the expected first signs of arthritis, can significantly reduce and delay the onset of arthritis as seen in the rat AIA model of rheumatoid arthritis. 
Support: This research was funded by American Osteopathic Association Research Grant 391601709. 
♦B24—Musculoskeletal Injuries and Prevention
Feedback Control During Reaching Involves Reflex Modulation to Perturbations in all Directions 
Puneet Cheema, OMS II; Tetsuro Muraoka, PhD; Isaac Kurtzer, PhD 
Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Research Question: Our daily activities involve behaving in an uncertain and disruptive world, like talking on a cellphone while walking in a crowd. The small collisions could cause the phone to fall, but rarely do since we predictively exert a strong grip and reactively stabilize our arm in space. Such corrective responses to limb displacement include the long-latency reflex (LLR). The LLR is mediated by the primary motor cortex, making it the fastest transcortical response, at least 50 milliseconds faster than voluntary reactions, though slower than the relatively simple spinal reflex. Previous studies have shown that the LLR is highly modulated during movement reflecting a time-varying change in the specified movement accuracy. While insightful, these studies studied single-joint movements, which necessarily ignores the complexities of multijoint movements used in everyday life. For example, single-joint paradigms cannot separately analyze the responses to load perturbations along the heading direction and to load perturbations at right angles to the heading direction. Movement amplitude and direction are independently controlled during movement planning, but this is unclear for movement corrections. The present study is the first to address how LLRs handle load perturbations in the same axis of the movement and off-axis to the movement. With further understanding of long-latency reflexes during multijoint action of the arm, this study may provide a basis in advancing the use of osteopathic medicine in upper limb injury prevention. 
Methods: This study was approved by the NYITCOM institutional review board (BHS-1141). 12 healthy individuals participated in a single 2-hour session. Participant characteristics: aged 22 years on average, 5 males/7 females, and 9 right-handed/3 left-handed. Their dominant arm was placed inside fitted cuffs, which were connected to a robot (BKIN Technologies). The “exo-skeleton” robot allows shoulder and elbow motion in the horizontal plane, measures arm motion, and can be programmed to apply physical loads to the arm. Direct vision of their arm was obscured by a metal partition while visual targets were presented through a projection system. Surface EMG (Bortec AMT-8) was obtained from several arm muscles, but the authors focus here on the shoulder extensor (posterior deltoid) and shoulder flexor (pectoralis major). The task involved point-to-point reaching to a single target. When the hand was at the start target, the shoulder and elbow angles were 60° and 90°, respectively. When the hand was at the goal target, the shoulder and elbow angles were 25° and 90°, respectively. Accordingly, the reaching movement only required shoulder extension, though participants were free to choose any movement path. On a random subset of trials, brief pulses of force (lasting 80 milliseconds) were applied to the arm. These perturbations occurred at 4 different distances to the end target: shoulder angle of 58°, 49°, 40°, and 31°. Moreover, perturbations were applied on-axis to the movement, which caused pure shoulder displacement toward or away from the target, and on off-axis to the movement, which moved the hand at right angles to the heading direction, ie, 4 perturbation directions in total. 
Data Analysis: Electromyographic (EMG) data were filtered (20-450 Hz), rectified, and zero adjusted. The authors focused on the long-latency reflex (50-100 milliseconds after perturbation) to the on-axis and on-axis condition resulted in the greatest increase in activity. A 2×4 ANOVA determined the impact of perturbations (unperturbed and perturbed), movement phase (4 locations of perturbation), and interaction between perturbation and phase on the long-latency reflex. 
Results: Shoulder muscles displayed the classic pattern of triphasic bursts: posterior deltoid accelerated the shoulder into flexion with an agonist burst, the pectoralis major decelerated the motion with an antagonist burst, and the posterior deltoid had a secondary burst to stabilize the arm. Accordingly, the perturbations were applied at different phases of this burst pattern. We observed robust long-latency reflexes to on-axis and off-axis perturbations throughout the movement in both muscles. This was confirmed with the main effort of perturbation: F1,11>22, P<.0001. A main effect of phase was also present for on-axis and off-axis perturbations in both muscles: F3,11>12, P<.0001. Lastly, a significant interaction between perturbation and phase was observed in all cases: F3,11>13. This was evident as substantial and steady increase in the long-latency reflex as the target was approached regardless of the changing background muscle activity. The long-latency reflex of the posterior deltoid increased about 150% in the on-axis direction and about 400% in the off-axis direction. The long-latency reflex of the pectoralis major increased about 300% in the on-axis direction and about 200% in the off-axis direction. 
Conclusion: Our novel results indicate that the long-latency reflexes of shoulder muscles are robustly modulated during multijoint action. Similar to previous studies, this modulation is independent of the waxing and waning of the burst sequence but rather steadily increases as the target is approached. Moreover, a similar increase in LLR magnitude occurs for load perturbations on-axis and off-axis to the movement, indicating that the time-varying specification of movement accuracy evolves in a similar manner for deviations in all directions. 
♦B25—Osteopathic Philosophy
Creation of a Student-Driven Mental Health Taskforce to Improve Mental Health and Wellness at Lake Erie College of Osteopathic Medicine 
Molly Johannessen, PhD1; Stephanie Mckenney-Groff, BA2; Christopher Kordick, BA2; Melanie Dunbar, PhD2 
1Department of Basic Sciences, Lake Erie College of Osteopathic Medicine-Erie (LECOM), Pennsylvania; 2LECOM 
The picture of mental health among medical students and physicians reveals incredible challenges, including high levels of anxiety, depression, and suicidality with lower mental and emotional quality of life.1–7 The Council of Osteopathic Student Government Presidents (COSGP) saw similar results in studies performed among osteopathic medical students.8 Overall, the mental well-being of current and future physicians across the country paints a grim picture of the future of patient health care. The status of mental well-being among the health care field is not without drive for improvement, however. Several institutions have demonstrated various tactics to create more nurturing environments while still meeting the rigorous demands of medical education.9–11 The identification of challenges regarding mental health and wellness as an integrated component of the medical education curriculum, as well as the inspiration for improvement, demonstrates the critical need to assess and improve the overall mental well-being among medical students at LECOM. 
Hypothesis: We hypothesize that a specifically student-driven mental health and wellness campaign will improve and enhance the mental health status and culture of the student body at LECOM. Therefore, the Student Government Association set out to assess the mental health and wellness of the students at LECOM, as well as develop, implement, and evaluate the effectiveness of a Mental Health Taskforce. 
Methods: Six assessments were used to evaluate the mental health and wellness of LECOM students throughout the first 2 years of their medical curriculum. The instruments used assess depression, anxiety, suicidality, unhealthy eating behavior, drug and alcohol abuse, and life event stressors. The measures are intended as screening indicators and selected based on assessments widely accepted for use in the field. Assessments were administered at 3 critical time points during the OMS I curriculum: (1) during new student orientation before the beginning of coursework, (2) at the completion of anatomy, histology, and embryology, approximately 2 months into courses, and (3) at the completion of their basic science core-curriculum, approximately 6 months into coursework. The fourth assessment will be administered at the completion of their systems-based science curriculum, denoting the end of preclinical medical education. Survey data were processed using a series of t tests, ANOVAs, and Pearson correlations assessing the survey responses across several different independent variables. 
Results: Not surprisingly, initial results paralleled those of the study performed by COSGP, which demonstrated a higher level of anxiety, depression, and suicidality among medical students compared with that of the general public.8 Follow-up data also showed significant increases in depression. In addition, these data supported that student perceptions of their own mental status and health correlated to their anxiety and depression indices. Similarly, their level of excitement and readiness for their education also correlated with mental health indices. Together, these data support the need for further self-awareness of mental health and wellness among LECOM students. To help improve these data and prevent any further decline, a taskforce of LECOM students was created to design a campaign focused on improving mental health outcomes campus-wide. Their activities were focused on providing stress mitigation techniques to students via health and wellness programs at the LECOM Medical Fitness and Wellness Center, providing student-driven support through events and activities focused on academics and mental well-being, and organizing workshops provided by guest lecturers focused on relaxation, meditation, nutrition, and time management. Working in conjunction with faculty to provide structure and feedback, the Mental Health Taskforce created a student-supported safe-network. Survey data furthermore supports student use of activities designed and organized by the Mental Health Taskforce as well as feedback regarding particular stress areas for which to continue focus. 
Conclusion: Overall, the work of the LECOM Mental Health Taskforce has been directed toward creating an environment where students can work together to improve the mental health and well-being of themselves and their fellow classmates. With an overall goal of improving the picture of mental health among future physicians, this group of students has created an avenue for improvement within LECOM. 
Support: LECOM IRB approval and through a LECOM Office of Institutional Planning, Assessment, Accreditation and Research internal research grant. 
1. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341. 
2. Givens JL, and Tjia J. Depressed medical students’ use of mental health services and barriers to use. Acad Med. 2002;77(9):918-921. 
3. Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians. JAMA. 2015;314(22):2373-2383. 
4. Almendrala A, Gregoire C. More than 1 in 4 medical students are depressed, analysis finds. Huffington Post. December 12, 2016. 
5. Karan A. Supervising physicians’ bad behavior adds to depression in medical students. STAT News. December 28, 2016. 
6. Kowalczyk L. Depression common among medical school students, study finds. Boston Globe. December 6, 2016. 
7. Scutti S. Study: more than a quarter of medical students are depressed, suicidal. CNN. December 7, 2016. 
8. Mcateer M, Krajcik D. A snapshot of mental well-being in osteopathic medical students. Presented at: COSGP AACOM Meeting, April 2016. 
9. Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular changes. Acad Med. 2014;89(4):573-577. 
10. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354-373. 
11. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15(2):88-92. 
♦★B26—Osteopathic Philosophy
Cannabinoid Signaling Mechanisms During Axon Development In Situ 
Sabrina Wedee, OMS I; Katherine Farley, OMS II; Tamira Elul, PhD 
Touro University College of Osteopathic Medicine-CA, Vallejo 
During fetal brain development, formation of neuronal connectivity is regulated by the concerted action of diverse molecular signaling systems. These signaling systems play a homeostatic role in the body and exemplify the key osteopathic concept of mind and body unity at the molecular level. Signaling molecules act as navigational guidance cues by attracting or repelling axons so that they can reach their appropriate target destinations in the brain. A particularly interesting molecular pathway whose mechanism is not well understood is the endocannabinoid signaling system. The endocannabinoid system is a neuromodulatory system involved in a wide range of physiologic processes, such as cognition, memory, appetite, and pain sensitivity. The main cannabinoid receptor, CB1R, is a G-protein coupled receptor that is present throughout the fetal brain. CB1R responds to endogenous endocannabinoid ligands as well as exogenous cannabinoids such as delta-9-tetrahydrocannabinol (THC) found in marijuana. Marijuana is the among the most commonly used illicit drugs among women of reproductive age; THC is known to enter maternal circulation, cross the placental membrane, and directly perturb the endogenous fetal cannabinoid signaling system by interacting with CB1R. 
Research Questions/Hypotheses: This study aims to elucidate the functions of the main cannabinoid receptor, CB1R, in the developing brain during formation of axonal connectivity. 
Osteopathic Significance: The endocannabinoid system has important physiologic functions and demonstrates the osteopathic principle that the body possesses self-regulatory mechanisms that are both self-healing and found in nature. By determining the molecular mechanism of cannabinoid signaling on axon growth and development, we can gain novel insight into how activation of this system might lead to potential detrimental or therapeutic effects. In particular, we aim to advance research on how prenatal cannabis exposure (PCE) through maternal marijuana use affects the developing fetal brain and rewires fetal neuronal circuitry. Our research would help future clinicians to better educate pregnant women about the effects of maternal cannabis abuse. 
Methods: To define the functions of cannabinoid signaling in developing axons, we studied the experimentally amenable retinotectal projection of tadpoles of the frog Xenopus laevis. To conduct the experiments, we applied AM251, a commercially available CB1R inhibitor, to X laevis embryos containing GFP expressing optic axons. We then captured images in intact brains of control and inhibited GFP optic axons and their terminal growth cones in whole brains. 
Data Analysis: We performed morphometric analyses of features of optic axons and growth cones (ImageJ). To compare parameters between control and inhibited axons (Excel), we used the t test. 
Results: Application of the CB1R inhibitor induced pathfinding errors in optic axons in the optic tract. The experimental optic axons were less numerous (P<.05) and less directed toward their final target in the brain than control optic axons (P<.05). CB1R inhibition also changed growth cone morphology, resulting in smaller growth cones (P<.05), with longer and thinner filopodial protrusions (P<.05). 
Conclusion: These data suggest that CB1R is involved in regulating growth cone filopodia which in turn control directional growth of optic axons in the optic tract. This experiment defines novel mechanisms for cannabinoid signaling during axon development in situ and provides insight into how prenatal cannabis exposure may act as a potential pathogenic switch that can affect CB1R activity. Future research could explore the impact of using cannabis by investigating CB1R agonists, which would directly mimic parental exposure. This research helps raise public health awareness and promotes the implementation of more patient educational programs aimed at educating pregnant women about the effects marijuana has on the developing fetal brain. Additionally, educating osteopathic physicians about the effects of maternal cannabis abuse can help them better inform their patients, which would lead to positive infant health outcomes. 
♦B27—Osteopathic Philosophy
Effects of Gender, Diet, and Exposure to Carcinogen 4-NQO on Histological Changes in Mouse Kidney 
Fasiha Syed, OMS III1; Lenore Pitstick, BS1; Alice Meyer, MS2; Matthew Pytinia, MS3; Joanna Goral, PhD2; Mae J. Ciancio, PhD3; Bruno Jham, DDS4; Jacalyn M. Green, PhD1 
1Department of Biochemistry, Midwestern University Chicago College of Osteopathic Medicine (MWU/CCOM), Downers Grove, Illinois; 2Department of Anatomy, MWU/CCOM; 3Biomedical Sciences Program, MWU/CCOM; 4CDMI, MWU/CCOM 
Introduction: A variety of factors, including use of tobacco, diet, sex, and genetics affect cancer risk. Smoking is a risk factor for about one-third of all human cancers. It is well established that administration of 4-nitroquinoline 1-oxide (4NQO) in drinking water mimics the effects of tobacco and leads to development of oral carcinoma in mice. The purpose of this study was to examine whether administration of 4NQO would result in pathologic changes in other organs beyond the oral cavity, including the kidney. In addition, we investigated the role of sex and dietary saturated fat on the histology of kidneys. 
Hypothesis: We hypothesized that 4NQO treatment would cause inflammation and development of renal cancer. We also hypothesized that the high fat diet would augment the effects of 4NQO. 
Methods: Male (n=36) and female (n=36) C57B1/6 mice, 5 weeks old, were divided into a low-fat (10 kcal% fat) and a high-fat (60 kcal% fat) group. After 1 week, the mice were given orally 50 μg/mL of 4NQO in 1.25% propylene glycol (PG) in water. Control groups received water or PG in water. After 17 weeks of treatment, mice from all groups were given only water for an additional 6 weeks and then euthanized. The kidneys were harvested, fixed in formalin, and processed for histologic evaluation. Hematoxylin-eosin–stained tissue sections were examined microscopically and evaluated for inflammation and possible presence of renal cancer. 
Results: No mice developed renal neoplasia or cancer. Lymphoid cells were present in a number of kidneys indicating possible inflammation; however, there were no differences among the treatment groups in the presence or degree of inflammation. 
Conclusion: In this established murine model of oral cancer, kidneys demonstrated resilience to the carcinogenic effects of 4NQO. Further characterization of lymphoid cell populations present in renal tissue may provide additional information on the inflammatory changes in the kidneys. Also, additional studies with longer exposure to 4NQO might be required for onset of renal dysplasia, since sporadic kidney tumors in humans tend to arise later on in life. 
Acknowledgments: We recognize the Office of Research and Sponsored Programs, and the Midwestern University Deans of CDMI and the Basic Science Division, for their support of this research. 
♦C1—Chronic Diseases and Conditions
Predicting Initiation and Sustenance to Exercise Therapy Among Low Back Pain Patients Using Multi-Theory Model (MTM) Approach 
Richard W. Kim, OMS I1; Falguni Patel, OMS II1; Rosa Chabok, MS1; Ronald S Dubin, MD2; Vinayak K Nahar, MD, MS, PhD, FRSPH3; Manoj Sharma, PhD4 
1Lincoln Memorial University DeBusk College of Osteopathic Medicine (LMU-DCOM), Harrogate, Tennessee; 2Kentucky Orthopedic Clinic, Middlesboro; 3Center for Animal and Human Health in Appalachia, LMU-DCOM; 4Behavioral and Environmental Health, School of Public Health-Jackson State University, Mississippi 
Background and Hypothesis: Low back pain (LBP) is one of the leading causes of disability worldwide, affecting nearly one-fifth of the global population. Exercise therapies, when adhered to, are an effective treatment for reducing pain and functional limitations among patients with LBP. Increasing initiation and adherence to exercise therapies for LBP could improve quality of life for millions of individuals. A newly proposed health behavior theory known as the multi-theory model (MTM) of health behavior change may prove a novel and effective framework for LBP exercise therapy interventions and counseling. According to MTM, individuals’ health behavior change is a function of 2 primary components: initiation of the behavior change and sustenance of the behavior change. Rooted in health promotion and most effectively actionable via holistic coordination between physician and patient, MTM based communication and counseling aligns with the osteopathic approach. It is an ideal vehicle for osteopathic physicians to improve the daily lives of their patients. Interventions using this patient-centered approach based on compassionate communication between patient and physician may improve patient satisfaction and reduce symptoms of LBP among patients of osteopathic physicians using this modality. The primary research question this study sought to answer is whether the MTM is a robust framework for predicting initiation and sustenance of exercise therapy among patients with LBP. Specifically, the aim of this study was to reveal the underlying constructs that drive initiation and sustenance of exercise behavior among patients with LBP. We hypothesized that MTM will significantly predict initiation and sustenance of exercise therapy behavior among LBP patients. 
Methods: For this cross-sectional study, a quota sample of 125 patients is envisaged based on G*Power analysis. Data collection is underway. This abstract presents the preliminary results based on 51 patients recruited from a large orthopedic clinic in Eastern Kentucky. Participants were included if aged 18 years or older, currently had low back pain, and had therapy exercises previously prescribed by their physician or physical therapist. Patients who performed prescribed exercises daily or had any medical condition other than LBP were excluded. Each participant meeting the aforementioned inclusion criteria completed a 44-item MTM based face and content validated questionnaire. 
Data Analysis: To summarize data, descriptive statistics were performed. With preliminary data, stepwise multiple regression analyses were completed to assess predictors of initiation and sustenance of LBP exercise behavior change among patients. A level of significance was set at 0.05. 
Results: In this preliminary data set, a total of 51 eligible patients completed the survey. The mean (SD) age of the participants was 48.72 (14.11) years. The majority of the participants were white (94%). Males represented 51% of the sample. Multivariable regression showed that initiation of exercise therapy behavior is explained by advantages (coefficient = 0.123, P=.001), adjusted R2=0.24. Moreover, sustenance of exercise therapy behavior is explained by practice for change (coefficient = 0.124, P=.006), adjusted R2=0.13. 
Conclusion: The analyses in this presentation are preliminary and thus caution must be exercised in interpreting the results. When data collection is completed, confirmatory factor analysis for construct validation and reliability testing by Cronbach alpha will be done. The larger dataset will also give greater confidence in computing multiple regression models. In the interim, the results seem promising, and MTM appears to be a useful model for designing and evaluating interventions promoting exercise therapy for patients with low back pain. 
♦C2—Chronic Diseases and Conditions
What's on Your Plate? The Relationship Between Eating Habits, Mood, and Portion Sizes 
Angela Carracino, OMS III; Adarsh Gupta, DO 
Department of Family Medicine, Rowan University School of Osteopathic Medicine (RowanSOM), Stratford, New Jersey 
Research Questions/Hypotheses: The purpose of this study was to examine the relationship between eating habits, perception of correct portion sizes, and mental health. Specific aims included determining whether portion control correlates to an individual's body mass index (BMI) and whether negative emotional states correlate to an individual's BMI. It was hypothesized that individuals with BMIs categorized as overweight (25.0-29.9) or obese (>30.0) would display significantly less knowledge of correct portion sizes than their normal-weight counterparts (BMI, 18.5-24.9). These individuals were also hypothesized to have a significantly higher degree of negative emotions. 
Methods: A survey tool was developed that incorporated the standardized Patient Health Questionnaire-9 (PHQ-9) to assess mood level, eating behavior questions, portion size assessment questions, and demographic information. Demographic information included height and weight to allow body mass index (BMI) for each participant to be assessed, as well as age, sex, educational level, and activity level. Participants were recruited both in person and online. Paper surveys were distributed to patients within all 4 Rowan Family Medicine clinical offices in New Jersey; surveys were completed in-person by participants and subsequently collected. The social media platform Facebook was used to recruit additional participants; public posts included a link to access the survey online via Qualtrics. Both methods of participant recruitment and data collection incorporated an informed consent and ensured complete anonymity to participants. A total of 131 complete responses were collected between June through August 2016. This study was approved by the Institutional Review Board before initiation of participant recruitment and data collection. 
Data Analysis: Data entry was accomplished using the online program Qualtrics. Body mass index was calculated manually using its associated formula (BMI=[weight in pounds/height in inches squared] ×703). All data were analyzed using IBM SPSS predictive analysis software. Using this program, analysis of variance (ANOVA) statistical tests were performed to assess the relationships among the various study variables. Results demonstrating a statistically significant correlation (P<.05) between any 2 variables suggested that a relationship between these variables existed. Further research must be conducted to determine if there is a causal effect of certain variables on other variables. 
Results: Results of the data analysis suggest that portion size knowledge does not correlate with negative emotional states or BMI; however, it is suggested that higher portion size knowledge is significantly correlated with eating out more often, female sex, and higher education levels. Higher BMI is also suggested to be significantly correlated with negative emotional states, male gender, lower activity levels, and older age. 
Conclusion: It is clear that multiple complex factors are involved in the development of obesity, and these factors must be addressed by physicians when dealing with weight management of patients with chronic obesity-related conditions. Future studies may incorporate analyzing individuals' diets to investigate how portion control plays a role in obesity. 
Support: This study was funded by the Summer Medical Research Fellowship (SMRF) Program at RowanSOM. 
♦C3—Chronic Diseases and Conditions
Are You a Food Addict? 
Shivani Patel, OMS III; Adarsh Gupta, DO 
Department of Family Medicine, Rowan School of Osteopathic Medicine (RowanSOM), Stratford, New Jersey 
Research Questions/Hypotheses: This study investigated the presence and role of food addiction in association with mental health disorders, obesity, and cardiometabolic diseases, as well as the risk of developing such diseases. Currently, the Diagnostic and Statistical Manual of Mental Disorders-V does not list food addiction as an existing mental health disorder, unlike gambling, alcoholism, and other substance abuse disorders. The overall objective of this study was to determine whether having an addiction to food is real and if so, how does it correlate to cardiometabolic health, obesity, and anxiety and depression. We hypothesized that food addiction is real and that it has a positive correlation with anxiety and depression, metabolic diseases, and obesity. If there is a link between the amount of addictive foods consumed and the concurrent presence of anxiety or depression in obese patients, then a new approach to treating these patients may be implemented in the future to lower both weight and overall cardiometabolic health risks. We believe that approaching certain obese populations with cognitive-behavior assessments and treatments could help reduce this growing endemic. 
Methods: An anonymous electronic and paper-copy survey was developed and distributed by the study team. The survey included the following standardized scales: Yale Food Addiction Scale (YFAS), Patient Health Questionnaire (PHQ-9), and the Generalized Anxiety Disorder (GAD-7) scale. In addition to these scales, a consent form, questions regarding one's belief in food addiction, age (must be 18 years or older), height, weight, and presence of hypertension and diabetes were also asked. The survey was distributed to patients within the 4 family medicine offices at RowanSOM, as well as through Facebook. Data were gathered through and analyzed for correlations. 
Data Analysis: At the conclusion of the study, 161 surveys were analyzed out of the 212 that were submitted. Seventeen responses were collected in person at the family medicine offices, and 195 were collected via online submissions through Two-sample t tests were run, and Pearson correlation coefficients were calculated. 
Results: In 11.80% of participants, a statistically significant positive correlation was found between the presence of food addiction and depression (M=10.42, SD=5.601, Pearson correlation=0.343, P<.01). In 12.34% of participants, a statistically significant positive correlation was found between the presence of food addiction and anxiety (M=11.11, SD=5.877, Pearson correlation=0.384, P<.01). In 11.84% of participants, a statistically significant positive correlation was found between the presence of food addiction and body mass index (M=30.37, SD=9.408, Pearson correlation=0.247, P<.01). The relationship between those who believed they had a food addiction and had a diagnosis of food addiction was statistically significant (P<.01). There were no statistically significant correlations between the presence of food addiction and sex, age, diabetes, or hypertension (P>.01). 
Conclusion: The study data provides evidence for the proposition that food addiction should be considered as a real eating and mental health disorder, and that it is a predictor of obesity, level of anxiety, and level of depression, as our hypotheses suggested. However, the diagnosis of a food addiction disorder is not a strong enough predictor of the development of diabetes or hypertension. In conclusion, based on the aforementioned findings, we believe approaching certain obese populations with psychological assessments and treatments (eg, cognitive behavioral therapy, psychotherapy) could assist in weight loss and decrease the overall prevalence of obesity and related health risks. Further research should be conducted to see if these therapies would provide patients with any potential health benefits. 
Acknowledgment: We thank Dr Robert Steer for his guidance in statistical analysis. 
Support: RowanSOM Summer Medical Research Fellowship provided funding to this project. 
♦C4—Chronic Diseases and Conditions
A Comparison of the Severity of Anaphylaxis in Patients With vs Without Concomitant Respiratory Diseases 
Johnny Nguyen, DO1; Suporn Sukpraprut-Braaten, PhD2; Jim Ingram, MD3; Greg Mock, MD2; Mindy Demarco, RN, BSN, CCRP3; Debbie Waggoner, PharmD2 
1Lake Erie College of Osteopathic Medicine, Searcy, AR; 2Unity Health, Searcy, Arkansas; 3Little Rock Allergy and Asthma Clinic, Arkansas 
Hypothesis: Anaphylaxis hospital admissions with a concomitant diagnosis of respiratory disease may result in prolonged hospital length of stay (LOS) and increased readmissions, as well as admissions to the critical care unit (CCU), compared with patients without respiratory diseases. 
Methods: The study design was a retrospective observational study with 105 patients who were admitted to Unity Health Medical Center with anaphylactic shock during the period of January 2012 to November 2016. Electronic medical records were reviewed. R i386 3.2.1 Statistical Software was used to compute descriptive statistics, t test, χ2 test, and multiple linear and logistic regression models. Comparison of the LOS between patients with anaphylaxis with respiratory diseases vs without respiratory diseases were analyzed. ORs were calculated to the likelihood of being either admitted or readmitted to the CCU. 
Results: The average age was 51.3 (±17.6) years. Of the 105 patients, 43 patients (41%) were men and 62 (59%) were women; 42 patients (40%) were current or former smokers; 12 (10.5%) had COPD or other chronic respiratory diseases; 8 (7.4%) had asthma; 11 (10.5%) were allergic to actifed, aspirin, cephalexin, codeine, demerol, iodine, NSAIDs, penicillin, or sulfa; and 3 (2.9%) were allergic to certain food, radiographic dye, and others allergens. Of the 105 patients, 10 (9.5%) were admitted to the CCU and 16 (13.3%) were readmitted with anaphylactic shock. The average LOS was 2.2 days. The LOS increased by 1.42 days for every 10 years of increase in age (P=.0057). Males were 3 times more likely to be admitted to the CCU than women (P=.206). Smokers had 1.21 times higher likelihood of being admitted to the CCU compared with nonsmokers (OR=1.21; 95% CI=0.224, 6.46; P=.819). Patients who had an allergic reaction to a medication stayed in the hospital 2.6 days longer (P=.231). The likelihood of being readmitted with anaphylactic shock was 1.57 times higher among patients with COPD, pneumonia, or other respiratory diseases than without these diseases (OR=1.57; 95% CI=0.249, 8.65; P=.608). Patients who were allergic to a medication had a 1.19 higher risk of being readmitted compared with patients with no known allergy (OR=1.19; 95% CI=0.137, 7.44; P=.861). 
Conclusions: Patients with COPD, pneumonia, other respiratory diseases are more likely to be readmitted with anaphylaxis. Furthermore, CCU admission rate increases among males and smokers. The LOS is significantly affected by age and allergy. 
♦C5—Chronic Diseases and Conditions
Identifying Trends in the Incidence of Delirium During Inpatient Hospitalizations to Determine Feasibility of Developing Prevention Strategy 
Elaine Leo, DO, MHA1,2; Suporn Sukpraprut-Braaten, PhD1; Andrew Powell, MD, FAPA2; Todd Brackins, PharmD, BCPP3 
1Department of Graduate Medical Education, Kansas City University of Medicine and Biosciences College of Osteopathic Medicine, Searcy, AR; 2Department of Psychiatry, Unity Health, Searcy, AR; 3Department of Pharmacy, Harding University, Searcy, AR 
Objectives: To determine whether there were patterns in the development of hospital-acquired delirium in patients treated at a community county hospital that could indicate an area of focus to develop and implement prevention strategies. Hospital-acquired delirium encounters were analyzed for predisposing factors of age and sex. Precipitating factors considered in this study were surgery and cardiac surgery, admission to critical care unit (CCU), sleep deprivation, and medical illnesses. Precipitating factors were analyzed by assessing encounters' discharge locations, patient room's window direction, and admission season. 
Methods: A cross-sectional study was designed to analyze for trends in hospital-acquired delirium. The study period was January 1, 2011, through October 13, 2016. Population of interest was patients admitted to the hospital. In this study, the term delirium encompassed different ICD-9 and ICD-10 codes, including altered mental status, metabolic encephalopathy, and disorientation unspecified. Hospital discharge encounters during the study period were queried for discharge diagnosis of delirium. Primary end point was development of delirium during hospitalization. 
Data Analysis: R v. 3.4.1 Statistical Software was used to perform descriptive statistics, χ2 test, and analysis of variance in this study. 
Results: A total of 36,165 patient encounters were evaluated. Of these encounters, 2266 were discharged with delirium. Two hundred twenty-four encounters developed delirium during their hospitalization. More than half of the encounters were older than 70 years, and 58% of them were females. Seventy-eight encounters (35%) were in the CCU before being discharged. Twenty-six encounters (12%) were discharged directly from the CCU. Surgical unit discharge location had the highest encounters (30%). Cardiac unit had the highest encounters related to surgery (8%). Ninety (40%) hospital-acquired delirium encounters occurred in the patient's room with the window facing west. Rooms with windows facing south had the second highest average of 1.6 encounters per room. Season had no impact on number of hospital-acquired delirium cases. On average, summer and winter 2016 had the highest number of encounters compared with other seasons and years. 
Conclusion: South-facing windows had 1.6 encounters per room and a statistically significant result (P<.05). Theory of season and window direction used as substitute for sleep quality was not statistically significant. Men and women had equal risk for developing delirium in the hospital. Health care providers should be aware of development of delirium among older patients in surgery and CCU. The study showed they had higher risk of acute fluctuating disorganized thoughts. Limitations to the study included lack of location where delirium occurred and information regarding the patient's quality of sleep. 
♦C6—Chronic Diseases and Conditions
Increased Frequency of White Matter Lesions With Artificial Sweetener Intake Without Functional Difference in Multiple Sclerosis 
Sarah Cottrell-Cumber, OMS III1; Jill Cramer, MD2 
1Edward Via College of Osteopathic Medicine (VCOM-Virginia), Waynesboro, Virginia; 2Department of Neurology, VCOM-Virginia, Blacksburg 
Background: Fatigue is a frequent and restricting symptom for patients with multiple sclerosis (MS). The mechanisms for fatigue in MS can be linked to autoimmune dysregulation, impaired neural functioning, and alterations in neuroendocrine feedback. Noncaloric artificial sweeteners, including saccharin, sucralose, and aspartame have been shown to alter glucose metabolism pathways. Patients with MS whose immune system is already poorly regulated, could be particularly sensitive to the effects of glucose metabolism on their damaged CNS. 
Objectives: This preliminary study aimed to identify a correlation between artificial sweetener intake and presence or degree of chronic fatigue in MS patients. We predicted that MS patients who consumed artificial sweeteners would have increased lesions in brain regions associated with fatigue, such as the premotor cortex, basal ganglia, and thalamus. 
Methods: IRB approval from VCOM-Virginia was obtained in 2016. A total of 30 patients with MS completed this preliminary prospective study. Exclusion criteria involved patients who were unable or declined to complete a fatigue questionnaire and patients with comorbid medical conditions causing fatigue. Participants completed 2 surveys: artificial sweetener survey and a fatigue questionnaire. T2/ FLAIR MRI data for each patient were analyzed for lesion location and quantity in 6 predetermined brain regions: cervical spine, brainstem, cerebellum, periventricular, subcortical white matter, and cerebral hemispheres. 
Results: Thirty participants completed the qualitative surveys. The artificial sweetener cohort regularly consumed artificial sweeteners with 45% of sweetener users consuming these products daily. Both sweetener users and non–sweetener users were clinically fatigued, with sums greater than 36 (sweetener users=47.11; non-sweetener users=46.71). MRI data from 16 patients demonstrated increased frequency of lesions, particularly in the cerebral hemispheres, deep subcortical white matter, and periventricular regions, in patients who consumed artificial sweeteners. There was a global increase in lesion frequency, instead of a concentrated increase in the subcortical white matter. 
Conclusions: This pilot study is novel because there is no literature on artificial sweetener use in MS patients, to the our knowledge. Correlating fatigue to artificial sweetener intake is promising because it signifies a lifestyle choice that is modifiable for these patients; however, there was not shown to be a functional difference for patients who consumed artificial sweeteners. 
♦C7—Chronic Diseases and Conditions
A Trend Toward Higher Systemic Recurrence in Rectal Cancer Patients With Wild-Type P53 Following Preoperative Chemoradiation 
Harkaran Rana, OMS IV1; Saahil Thukral, BS1; Kevin Lin-Hurtubise, MD2 
1New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury; 2Practicing Physician, Honolulu, Hawaii 
Research Questions/Hypotheses: P53 is a known tumor suppressor gene, and it is also responsible for recognizing apoptotic stimuli. A positive stain of overexpressed p53, characterized by the mutant-type, in solid epithelial tumors is associated with aggressive histologic features and poor prognosis. It is acknowledged that chemotherapy and radiation are not as effective on mutant p53 cells, as they are not as readily able to undergo apoptosis. The purpose of this study was to examine the outcomes of patients with rectal cancer in relation to the p53 status of their tumor. 
Methods: Fifty-two post-lower anterior resection cancer specimens were stained for p53. All patients preselected had undergone neoadjuvant chemoradiation, consisting of 30 fractions of radiation for a total of 5400 Gy with concurrent 5-Fu. Three patients' samples were excluded because of M1 staging. Eight other samples had no residual tumor, and 1 sample did not hold the stain. Data were gathered concerning pre-and post-op T staging and N-staging, recurrent, status, average follow-up, age, and sex. The Fisher exact test was used to find the significance between the positive and negative staining groups. Mean age of diagnosis was 59.5 years in the positive group with male to female ratio of 2.75 and a mean follow-up of 27.5 months vs 62.6 years, ratio of 1.0, and 31.6 months for the negative group, respectively. 
Data Analysis: p53 staining results: 33 positive (exclude 3 with M1 dz); 10 negative; 8 no residual tumor; 1 washout. 
Results: Of the 40 samples included in the study, 30 stained positive for p53 and 10 stained negative (Table C7). 30% of the positive patients downstaged after receiving the surgery, and 50% of the negative patients downstaged (P=.498). Additionally, 46.7% of mutant p53 patients had an N stage of N1 or greater, and only 20% of the wild type p53 patients had an N stage of N1 (0.475). Four patients from each group had a recurrence (P=.208), but only 1 of the mutant p53 patients had a systemic recurrence, whereas 3 of the 4 wild-type patients had a systemic recurrence (P=.071). 
Table C7.
A Trend Toward Higher Systemic Recurrence in Rectal Cancer Patients with Wild-Type P53 Following Preoperative Chemoradiation
Pre-op T-stage
 43 (30%)1 (10%)
 325 (83.3%)9 (90%)
 22 (6.7%)0
Pre-op N-stage
 22 (6.7%)0
 16 (20%)2 (20%)
 016 53.3%)4 (40%)
 X6 (20%)4 (40%)
 13 (9%)0
 030 (91%)10 (100%)
Post-op T-stage
 44 (13.3%)1 (10%)
 315 (50%)4 (40%).498
 211 (36.7%)3 (30%)
 102 (20%)
Post-op N-stage
 31 (3.3%)0
 25 (16.7%)0.475
 18 (26.7%)2 (20%)
 016 (53.3%)8 (80%)
 1st4 (13.3%)4 (40%).208
 Systemic3 (10%)3.071
 2nd03 (30%)
 Dod4 (13.3%)3 (30%)
 Awd3 (10%)1 (10%)
 Ned22 (73.3%)6 (60%)
 Doc1 (3.3%)0
Avg LN pos74/143/2.203
Table C7.
A Trend Toward Higher Systemic Recurrence in Rectal Cancer Patients with Wild-Type P53 Following Preoperative Chemoradiation
Pre-op T-stage
 43 (30%)1 (10%)
 325 (83.3%)9 (90%)
 22 (6.7%)0
Pre-op N-stage
 22 (6.7%)0
 16 (20%)2 (20%)
 016 53.3%)4 (40%)
 X6 (20%)4 (40%)
 13 (9%)0
 030 (91%)10 (100%)
Post-op T-stage
 44 (13.3%)1 (10%)
 315 (50%)4 (40%).498
 211 (36.7%)3 (30%)
 102 (20%)
Post-op N-stage
 31 (3.3%)0
 25 (16.7%)0.475
 18 (26.7%)2 (20%)
 016 (53.3%)8 (80%)
 1st4 (13.3%)4 (40%).208
 Systemic3 (10%)3.071
 2nd03 (30%)
 Dod4 (13.3%)3 (30%)
 Awd3 (10%)1 (10%)
 Ned22 (73.3%)6 (60%)
 Doc1 (3.3%)0
Avg LN pos74/143/2.203
Conclusion: While the downstaging results between the wild-type and mutant p53 patients were not significant, an increase in systemic recurrence was nearly statistically significant (P=.071) in those patients with the wild-type p53 gene than the mutant p53 patients. This finding is further supported by the small sample size used to obtain its near significance. This indicates some controversy surrounding the p53 status in response to neoadjuvant radiation-based therapy and tumor recurrence rate. Despite the downstaging results supporting the trend of p53's importance as a tumor suppressant, the normal wild-type p53 patients had more systemic recurrences than those patients with aberrant p53. This might suggest, in colorectal carcinomas at least, that some p53 mutations might be advantageous, especially when considering distant metastases. Additional clinical trials involving the use of newer neoadjuvant methods such as oxaliplatin-based chemotherapy should be the next step in isolating p53's diverse effects on colorectal tumors. These trials should focus on the response to neoadjuvant therapy and its correlation with the patient's p53 status. 
♦C8—Chronic Diseases and Conditions
Energy Balance and Body Composition in Individuals With Parkinson Disease 
Jared Feldman, OMS II1; Adena Leder, DO2; Sheldon Yao, DO2; Joanne DiFrancisco-Donoghue, PhD, RCEP2 
1New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury; 2Department of Osteopathic Manipulative Medicine, NYITCOM 
Introduction: Parkinson disease (PD) is the second most common neurodegenerative disease, and affects 1% of the population worldwide after age 65 years. Individuals with PD have several symptoms and characteristics that can influence dietary and lifestyle changes. These symptoms can modify factors such as body composition, energy intake, macronutrient intake, and metabolism. Increased body fat and decreased muscle mass can affect function, falls, and quality of life. It is important to be familiar with these changes to better understand PD progression and to help advance nutritional therapies for individuals with PD. Osteopathic physicians should understand the dietary factors that play a role in the disease course to provide health care specific to PD patients. 
Hypothesis: We hypothesized that participants with PD would exhibit slower than normal resting metabolic rate (RMR), a lower lean muscle mass to body fat ratio, and a reduced caloric intake compared with their resting metabolic rate. 
Methods: This study included 9 participants with PD, consisting of 8 men and 1 woman (aged 65.9±6.25 years). We conducted a case control study with participants at NYITCOM Adele Smithers Parkinson's Disease Treatment Center. This study was approved by the NYIT institutional review board (BHS-1280). All participants signed written consent before participating. Inclusion criteria for the study included (1) age between 45-85 years and (2) a diagnosis of PD. Exclusion criteria included (1) pregnancy, (2) any neurologic diagnoses other than PD, (3) any diagnoses of a digestive disorder that would affect diet, eg, colitis, Crohn disease, or irritable bowel syndrome. Each visit was approximately 60 minutes. 
Outcome Measures: Diet: A questionnaire was given to all participants to inquire about food intake and eating habits over a 3-day period. Participants recorded meal time, meal composition, and the amount of food consumed. Questionnaires were entered into a computer program to analyze energy intake and the breakdown of macronutrients. Resting metaboloc rate (RMR): RMR was recorded using a COSMED Quarkindirect calorimetry canopy unit. Participants arrived in the morning, having fasted before the RMR test. Body composition: A dual-energy x-ray absorptiometry (DEXA) scan was performed using a General Electric Lunar iDXA machine to analyze body composition. 
Data Analysis: Statistical analysis was performed using SPSS statistical software. Given the low power, descriptive statistics were used to analyze the pilot data. 
Results: DEXA and RMR: Participants had a mean BMI of 25.8±13.2, a lean to fat mass ratio of 0.46±0.16, and an A/G ratio of 1.29±1.33. Participants had a mean fat mass of 53.6±21.2 lb and a mean lean body mass of 117±22.3 lb. The average body fat percentage of 30.5±7.4 was high and may have resulted from the sedentary lifestyle characteristic of PD. The RMR test measured an average resting metabolic rate of 1457±326 kcal/d, which is classified as slow. Based on indirect calorimetry, participants reported an average total daily intake of 1585±635 kcal/d. Participants consumed on average 192 g of carbohydrates, 55.5 g of fat, 63.3 g of protein, 1858 mg of sodium, and 86.5 g of sugar. Questionnaire: 55% of participants reported GI problems. 22% noted dysphasia, 33% reported anosmia, 78% described a sweet food craving, 33% were embarrassed to eat in public, 11% reported difficulty standing from a seated position, and 11% noted nausea from medication. Participants reported a mean daily bowel movement frequency of 1.14±0.12, and a mean daily urination frequency of 7.67±0.85. On average, participants consumed 0.78±0.27 g of protein per kg of body weight. Only 1 participant in the study had adequate protein consumption according to the American Dietetic Association recommendation of 1.2 g/kg. This finding is consistent with other studies that examined protein intake in a PD population. A low protein intake is common in PD patients since protein can interfere with the absorption of levodopa. However, too little protein can decrease lean body mass and affect function. 
Conclusion: Seven of the 8 participants reporting dietary intake had inadequate caloric consumption. The low dietary intake in participants with PD could result from GI problems, dysphagia, or social anxiety disorder. The men had a total daily intake of 1569±684 kcal, which barely exceeded the RMR of 1502±318 kcal/d. More calories should be consumed to support processes such as the thermic effect of food digestion, daily activities, and exercise. Practitioners should try to increase protein intake in PD patients while carefully monitoring the effects of their medication. This study is ongoing and supports the need for further research examining dietary habits in a PD population. 
Support: NYITCOM Summer Research Program Grant. 
♦C9—Chronic Diseases and Conditions
Evaluation of a Simplified Insulin Dosing Algorithm in Patients Prescribed a Novel Wearable Insulin Delivery Device 
Sandip Mehta, DO1; Mara Vecchio, BS2; Carla Nikkel, BS3 
1Texas Star Adult Medicine, Bedford; 2Department of Research, Texas Health Research and Education Institute, Dallas; 3Department of Medical Affairs, Valeritas, Inc, Bridgewater, NJ 
Introduction: More than half of US adults with type 2 diabetes mellitus do not achieve glycemic targets. Evidence-based guidelines recommend continued advancement of therapy if A1C targets are not achieved after 3 to 6 months of therapeutic intervention. When insulin therapy is warranted, basal insulin is typically recommended first; however, given the progressive nature of type 2 diabetes, many patients will require the addition of prandial insulin (basal-bolus) over time to maintain or achieve glycemic control. Estimates suggest that up to 90% of patients with diabetes receive diabetes care from their primary care physician, yet primary care teams often report a lack of confidence regarding insulin management and a lack of time required to intensify insulin. The initiation and titration of basal-prandial insulin therapy is often viewed as complex and time consuming. Providing straightforward solutions to ease the complexities and perceived time constraints of initiating and dosing basal-bolus therapy can help physicians effectively treat patients with type 2 diabetes. Partnering with patients to empower self-management of their disease and insulin regimen has also shown to be beneficial. The aim of this study is to provide simplified insulin dosing guidance for physicians and patients to improve insulin management. Clinical trials comparing patient-driven insulin titration algorithms with physician-directed insulin titration algorithms suggest that blood glucose levels can be safely and effectively managed by patients. We have observed success with a simplified physician-directed weekly prandial insulin titration approach in patients prescribed V-Go, a novel 24-hour wearable basal-bolus insulin device. To our knowledge, no data exist evaluating the safety and efficacy of a specific dosing titration algorithm used with V-Go. 
Hypothesis: We hypothesized that the incorporation of a simplified insulin titration algorithm in patients with type 2 diabetes could be used effectively and safely, leading to improved glycemic control. 
Methods: This study incorporated 2 phases, first reported here, a proof-of-concept study conducted to evaluate the safety and efficacy of a simple physician-directed insulin dosing titration approach to aid in the formulation of the second phase of the study, a prospective patient-driven insulin titration trial. For the first phase, we conducted a retrospective review of patients initiated on V-Go for insulin delivery and titrated using a simplified physician-directed insulin titration algorithm. Electronic medical records from an adult internal medical clinic were queried and records reviewed to identify patients meeting predetermined criteria. Adjustments in insulin were captured for all visits between V-Go initiation and the first follow-up A1C after initiation. Primary end points were achievement of A1C targets (<7.5%) and prevalence of hypoglycemia in patients treated using this titration approach. Paired t tests were used to compare A1C and insulin outcomes with baseline. The study protocol was reviewed by the Texas Health Research and Education Institute Institutional Review Board, and a waiver of informed consent was approved. 
Insulin Titration Approach: The physician-driven titration approach evaluated in this study used daily 4-point (fasting and 2-hour postprandial breakfast, lunch, and dinner) self-monitored blood glucose profiles for weekly titration decisions. Based on the algorithm, bolus up-titration was recommended when 2-hour postprandial averages exceeded 170 mg/dL and down-titrated when 2-hour postprandial averages were below 100 mg/dL. Basal rates were adjusted if needed following the optimization of bolus dosing for all meals. 
Results: Of the 24 patients screened, 15 patients with type 2 diabetes met eligibility requirements and were evaluated with a mean±SD age of 60±9 years, weight of 258±76 pounds, and A1C of 8.7±1.4%. Thirteen of the 15 patients administered insulin at baseline (144±81 U/d, range 45 to 292 U/d). One week after initiation of V-Go, bolus up-titration occurred in 73% of patients (from 18 to 33 total bolus U/d). Adjustments in bolus dosing (up or down titration) occurred in 53% of patients at week 2 and 40% of patients at week 3. By week 4, most patients did not need further bolus titration. Basal rates increased in 5 patients and decreased in 1 patient during the first month. A1C target was achieved in 67% of patients and a significant A1C reduction of -1.6% (8.7%−7.1%; P<.001) was observed despite a significant decrease in the total daily dose of insulin (144 to 60 U/d; P=.002). Hypoglycemia prevalence decreased from 23% at baseline to 7% of patients by 4 months. 
Conclusion: With appropriate titration and management, insulin therapy is the most effective option to treat hyperglycemia. Practical and simple guidance to manage insulin therapy can positively affect outcomes. The adoption of a physician-directed titration algorithm to optimize insulin dosing in this proof-of-concept proved safe and resulted in clinically relevant glycemic improvement. We believe many patients could safely and effectively self-manage their insulin treatment with physician oversight. Applying these findings to a patient-directed approach needs further investigation. 
♦★C10Chronic Diseases and Conditions
Common Medications as a Risk Factor for Parkinson Disease: A Case Control Study 
Matthew S. Goldfinger, OMS III; Adam Grunseich, BS; Malwina M. Klusek, BS; Neil Modi, BS; Mahin Rehman, DO, MS; Adena Leder, DO; Jayme Mancini, DO, PhD; David Tegay, DO; Thomas Chan, DO; Bhuma Krishnamachari, PhD 
New York Institute of Technology College of Osteopathic Medicine, Old Westbury 
Research Questions/Hypotheses: Parkinson disease (PD), the second most common neurodegenerative disorder, has a complex and poorly understood cause. Recent work has shown that inflammation and microglial activation may play a role in PD. As a result, there is a great deal of interest in whether medications that lessen inflammation affect the likelihood of developing this disease. While research has been conducted on the association between nonsteroidal anti-inflammatory drug (NSAID) use and PD, variable results have been found across studies. Recent studies demonstrate that ibuprofen appears to confer a protective advantage. Other inflammation-reducing medications are not well studied. Specifically, there has not been much investigation into the effect of antihistamine medications on the subsequent risk of development of PD. The specific aim of this study was to investigate the effects of inflammation-reducing medications on the risk of PD. Specifically, we hypothesized that use of NSAIDs, aspirin, or antihistamines would be protective against PD. 
Osteopathic Significance: PD is a movement disorder with debilitating effects on the central motor system, thereby causing marked neuromusculoskeletal somatic dysfunctions. Treatments rely heavily on the biomechanical and neurologic osteopathic models. Some existing research suggests PD has an inflammatory component. Finding that specific inflammation-reducing medications are associated with PD risk may help better define an inflammatory component to the pathophysiology of the disease. Validation of an inflammatory component to PD may lend evidence for physicians to approach OMT in PD patients from an additional perspective adding immune/circulatory-focused interventions to the more conventional neuromuscular/skeletal approach. 
Methods: An IRB-approved survey was administered to individuals with PD (n=171) and controls over the age of 65 (n=112.) Participants provided information on their use of NSAIDs, aspirin and antihistamines pre- and post-PD diagnosis. These data were collected via a 5-point Likert scale of frequencies ranging from “not at all” to “all the time (daily).” For analysis, these scores were then recoded into “ever/never use” categories. 
Data Analysis: Sex-, age-, and race-adjusted ORs and their 95% CIs were calculated using binary logistic regression. Information on prediagnosis use in the cases was compared with the current/lifetime use in the control group, in addition to comparing current use of medications in both groups to ensure that cases weren't reporting medication use as a treatment for PD symptoms. 
Results: There was no significant difference between the Parkinson population as compared with the controls in NSAID use, regardless of whether pre- or postdiagnosis medication use was analyzed. When specifically investigating aspirin, however, we did find significant differences in use between the 2 groups. In the analysis using PD prediagnosis aspirin use, fewer of the cases responded that they used aspirin compared with controls (ever/never use OR=0.32, 95% CI=0.16-0.61, P<.05). This finding was also present in the analysis of current use (ever/never use OR= 0.28, 95% CI=0.15-0.54, P<.05). Antihistamine use also showed a protective effect both when analyzing prediagnosis medication use (ever/never use OR=0.42, 95% CI= 0.21-0.83, P<.05) and when analyzing by current usage (ever/never use OR=0.26 95%CI= 0.12-0.55, P<.05). 
Conclusion: This study found that both aspirin and antihistamines were protective against PD. Prior research has shown support for a protective effect of some NSAIDs. Therefore, the results of the present study largely support the findings in the prior literature on anti-inflammatory medications. This study also adds to existing literature in finding that antihistamine drugs may be protective. It is noteworthy that antihistamines and aspirin were found to be protective when looking at medication use before diagnosis in the participants with PD. Thus, the protective effects are not simply due to disease-related lifestyle changes but appear to describe a meaningful temporal relationship. Future research will benefit from further subdivision of the medication usage by chemical class, generation (first- vs second-generation antihistamines), or specific drug taken. Ultimately, prospective trials looking at medication use and PD risk may be warranted. 
♦★C11—Chronic Diseases and Conditions
Small Dense LDL Correlates With d-Lactate in Obese Adolescents: A Link Between Dyslipoproteinemia, Triose Flux, and Glycation? 
Yasmin Bains, OMS II1; Reyna Rodríguez-Mortera, MS, PhD2; Russell Caccavello, BS1; Claudia Luevano-Contreras, MD, PhD2; Eugenia Garay-Sevilla, MD, PhD2; Alejandro Gugliucci, MD, PhD1 
1Touro University College of Osteopathic Medicine-CA, Vallejo; 2University of Guanajuato, Mexico 
Background: The prevalence of obesity in both adults and children continues to increase nationally and is even higher in African American and Latino populations. Therefore, understanding the biochemical mechanisms that link obesity to various chronic diseases is essential in both management of care and the application of osteopathic manipulative therapy in obese patients. A key factor for CVD risk is the atherogenic dyslipidemia complex, characterized by high VLDL and small-dense LDL (sd-LDL). Sd-LDL stem from large VLDL1, which have been associated with increased de novo lipogenesis (DNL). DNL is increased in obese participants and is associated with increased triose flux in the liver. 
Hypothesis: We hypothesized that obese adolescents have both a higher incidence of sd-LDL as well as higher levels of D-lactate, and a correlation exists between both of them. 
Objectives: We explored the incidence of the atherogenic dyslipidemia complex, sd-LDL and D-lactate (as a marker of triose and methylglyoxal flux) in lean vs obese adolescents without MetS to uncover subclinical manifestations of CVR dyslipidemia and its possible association with methylglyoxal flux in the liver. 
Methods: A cross-sectional study of 30 obese adolescents and 30 controls (normal BMI) from Guanajuato, Mexico. Standard auto-analyzer methods were used for lipid panels. LDL subclasses were analyzed by gradient electrophoresis using the Lipoprint LDL method from Quantimetrix. D-lactate was measured spectrophotometrically. 
Results: The obesity group showed significantly higher levels of TG: 131 (101-149) vs 75 (56-93) mg/dL***; atherogenic index: 2.9±0.7 vs 2.4±0.4**; TG/HDL-C ratio: 2.2 (1.8-2.7) vs 1.1 (0.8-1.5)****; %LDL-3: 1.4±1.4 vs 0.6±0.8**; and lower LDL size 270.6±3 vs 272.2 ±1.1 Å**. D-lactate was higher in obese participants: 6.2±3 vs 4.5±2.5 μmol/L**. D-lactate correlated positively with TG/HDL-C ratio: r=0.36* and LDL-3 (sdLDL): r=0.45** and negatively with large LDL-1: r=−048** as well as LDL size: r=−0.46* (P<.05*; P<.01**; P<.001***; P<.0001****). 
Conclusion: Healthy, obese adolescents display early metabolic signs of insulin resistance (IR) and atherogenic dyslipidemia complex. Particularly noteworthy is the incidence of high small-dense LDL. Moreover, they displayed 63% higher D-lactate levels, indicating increased triose-MG flux (due to IR and/or increased fructose consumption). Sd-LDL and LDL size were strongly associated with D-lactate levels. Our study offers the first evidence of an association between atherogenic dyslipoproteinemia and triose-MG flux in a population at risk where intervention is warranted and feasible. 
Support: DAIP Universidad de Guanajuato (proyecto 011/2015), Intramural funds Touro University California (0069). 
♦C12—Chronic Diseases and Conditions
Resource Availability and Treatment Utilization for Post-Traumatic Stress Disorder for Active Military, Veterans, Law Enforcement, Physicians and Nurses: A Survey Study 
Kelsey Negherbon, OMS IV1; Jeffrey Zwerin, DO2 
1Touro University College of Osteopathic Medicine-CA (TUCOM), Vallejo; 2Primary Care Department, TUCOM 
Hypothesis: Clinically unmanaged symptoms of posttraumatic stress disorder (PTSD) in individuals with high-risk occupations can be attributed to lack of education regarding mental health, not seeking treatment when available, or limited patient care. 
Methods: We conducted a survey study from March 15, 2017, to April 12, 2017, that was distributed to individuals with jobs that are considered at high risk for developing PTSD, including active military members, veterans, law enforcement agents, firefighters, physicians, and nurses. Survey participants were recruited through phone calls to sheriff departments, veteran's associations, and online advertisements through social media. The study was electronically delivered and accessed through an online survey by 4776 participants. Of the 4776 views, 398 participants responded, with 208 complete and 190 partial answers. The online survey was composed of 3 core sections: section 1 contained questions pertaining to symptoms and management of PTSD; section 2 was devoted to respondents with military or veteran experience; and section 3 was applicable to all other high-risk occupations. Both partial and complete question responses were used in the study. The survey included multiplechoice, fill-in-the-blank, and Likert-scale items. 
Data Analysis: The responses were automatically uploaded through the ZohoSurvey statistical analysis of summary responses. Each question tracked the number of responses and those with no responses. The data analysis was calculated according to response rate of the individual question, and the applicable succeeding questions, not the total amount of survey participants (398). Both partial and completed responses were counted in the total survey participation count. Partial responses were included in the results analysis, as not all 3 section domains or questions applied to all survey participants (for example, not all individuals had military experience). 
Results: Of the 208 completed responses, 90.38% (188) of participants felt that they had PTSD. Of the participants that experienced symptoms described as PSTD based upon DSM-V criteria, only 62.19% sought professional help, 28.85% indicated that no treatment was offered, and 36.54% responded that they did not use any treatment. Of those that received treatment, the majority were unsatisfied with their treatment. Furthermore, 73.4% of responses indicated that they did not receive any training regarding PTSD symptom identification. 
Conclusion: Our findings indicate people in high-risk jobs experience symptoms of PTSD, and more vigilant and aggressive assessment, treatment, and follow-up is necessary. The study also demonstrated an increased need for employee/employer education on services and treatment available for mental health. 
Support: TroopsDirect provided significant support in the participant recruiting process, including a donated advertisement on social media. 
C13—Chronic Diseases and Conditions
Religious Delusions and Hallucinations: Etiology, Treatment, and Effect on the Length of Stay on the Inpatient Unit 
Sabina Bera, MD; Sara Abdijadid, DO 
Department of Psychiatry, Kern Medical Psychiatry Residency, Bakersfield, CA 
Research Question: The goal of medicine is to alleviate suffering. In psychiatry, accurately understanding and diagnosing a patient proves specially complicated when considering cultural factors, an important component of which is religion. The relationship between psychiatry and religion is an enthralling and lengthy one that may help us better treat patients. Religion is an important coping resource for those with a mental illness. Healthy populations report hearing the voice of God during religious experiences. Little is known about the frequency of religious delusions and hallucinations (RD/H) in mental disorders, although it appears to be relatively common. There is currently no consensus on criteria regarding the definition and classification of these symptoms and how to differentiate these symptoms from a religious experience. The mechanism producing these symptoms also remains unknown—several theories revolve around the temporolimbic region of the brain. Limited studies suggest these symptoms are not specific to any set of diagnostic criteria, and patients with RD/H have a worse prognosis. Most importantly, there is no standard of treatment for patients who specifically display these symptoms in conjunction with a mental illness. Our aim was to determine whether the presence of RD/H predicts the length of stay on the inpatient psychiatric unit. Follow-up investigations included considering the presence of a religious background and inpatient antipsychotic treatment for patients with RD/H. In addition, we sought to determine whether a neurologic workup could predict whether a patient would display RD/H. 
Methods: Data collection required access to the electronic medical records of 400 patients in the inpatient psychiatric unit from July to October 2016. IRB approval was obtained for this study. The first 100 patients were included in this study to report the initial findings. Initial psychiatric evaluations, daily progress notes, discharge summaries, neurologic evaluations, imaging results, and suicide and violence risk assessments were examined for each patient. Variables collected included the presence of RD/H, length of stay, discharge diagnosis, sex, race, age, antipsychotic treatment, urine toxicology results, ordering neuroimaging and EEG, and history of religious background. RD/H was recorded as listed in the mental status evaluation. Subject matter of RD/RHs were obtained from the daily subjective patient reports, which tended to be the most descriptive. No classification system was required for RD/RH, as the subject matter was consistent and easily identified. Reporting and detection bias was controlled for by incorporating the attending physicians. 
Data Analysis: Statistical analysis was performed using R statistical software. A P value of .0288 was found when comparing the presence of RD/H and length of stay. Difference in median length of stay was 3.5 days longer for the “Yes” group. 85% of patients with religious delusions identified as having a religious background compared with 75% of those without RD/H. 85% of patients with RD/H were treated with an atypical antipsychotic. 15% of patients with religious delusions were treated with a long-acting injectable antipsychotic. 12% of patients had neuroimaging performed, and 10% had an EEG. Both P values were >.28. 
Results: Statistical significance (P<.05) was found when comparing whether RD/H will predict the length of stay. The difference in median length of stay was 3.5 days longer for the “Yes” group. 26% presented with RD/H, and 77% identified as having a religious background. 85% of patients with religious delusions identified as having a religious background, compared with 75% of those without RD/H. 85% of patients with RD/H were treated with an atypical antipsychotic. 15% of patients with religious delusions were treated with a long-acting injectable antipsychotic. The content of RD/H was easily separated into 5 categories: 39% included God, 39% included the devil, 30% included scripture, 30% included demons, and 4% included black magic. Most patients with RD/H (85%) were treated with an atypical antipsychotic. When considering if a neurologic workup (neuroimaging and/or EEG) could predict whether a patient would have religious delusions, we found that 12% of patients had neuroimaging (head CT or MRI) performed, and 10% had an EEG. 53% did not have symptoms of RD/H and 47% did have symptoms of RD/H. There was no statistical significance when considering whether a neurologic workup would predict the presence of RD/H, complicating theories behind the mechanism of RD/H. Other interesting observations included that 0% of Asians reported RD/H (n=1), whereas 39% of blacks (n=13), 36% of Hispanics (n=28), and 100% of Native Americans reported RD/H (n=1). 19% of whites reported RD/H (n=54). 
Conclusion: Statistical significance (P<.05) was found when comparing whether RD/H would predict the length of stay, confirming that these patients required longer hospitalizations, and raising many questions as to the appropriate approach to treatment. A larger number of patients with RD/H identified as having a religious background compared with those without RD/H. Most patients with RD/H were treated with an atypical antipsychotic. Our study suggests that the presence of RD/RH is predictive of the length of stay. Patients with RD/RH therefore have a poorer prognosis and do not seem to improve quickly when treatment is started compared with those with other symptoms. These patients may require alternative treatment approaches, which should be investigated in future studies. Categorization of RD/H experienced by patients were clearly identified as 1 of 5 general categories. These findings may reflect the general beliefs of the community. There was no statistical significance when considering if a neurologic workup would predict the length of stay, complicating theories behind the mechanism of RD/H. The cause of RD/H remains unclear based on our study results. Neurologic abnormalities do not seem to have a significant impact on the severity of the patient's symptoms. Alternatively, this pathology was not connected to any disorder, such as temporal lobe epilepsy, in this study. A more comprehensive study is appropriate with advanced imaging techniques. In recent years, there has been a shift to simplify the classification of psychiatric disorders in the DSM-V. The research findings indicate significant value of the prior system of classification, which included subtypes for hallmark psychiatric disorders, currently absent from the DSM-V. This is especially important when taking into account patient prognosis and treatment plans for RD/H. The authors would encourage revisiting this topic in the next version of the DSM. 
♦C14—Chronic Diseases and Conditions
A Pilot Study: Examining the Inpatient Psychiatric Unit in Kern County: The Prognostic Value of Age, Gender, Race, Substance Abuse, Diagnosis, and Antipsychotic Treatment on the Length of Stay and Its Legal Ramifications 
Samantha Cassandra Madziarski, MD1; Sara Abdijadid, DO2 
1Psychiatry, American University of the Caribbean School of Medicine, Bakersfield, California; 2Psychiatry, Lake Erie College of Osteopathic Medicine-Bradenton, Florida 
Introduction: There has been a rise in recognition and treatment of mental health illness in both the state and country. With the advent of psychotropic medications, the history of mandatory admission has evolved from institutionalization of the mentally ill to shorter hospitalizations either on a voluntary or involuntary basis, now with legal protections, including right to a trial with an attorney.1 Underuse of community-based treatment or support can precipitate an involuntary admission.2 Some predictors of involuntary hospitalization predictors include male sex, substance abuse, contact with primary care provider, aggressive behavior, and low level of social functioning or lack of motivation.3 The legal hold in California applies to individuals deemed dangerous to themselves or others and/or gravely disabled (unable to use food, clothing, or shelter). The most common mental illnesses that are seen in the inpatient psychiatric units include major depression disorders, bipolar disorders, and schizophrenia, with some having substance abuse problems leading to dual diagnosis. 
Objective: There is sparse literature available regarding the prognostic factors surrounding inpatient variables, such as legal processes during admission, sex, diagnosis, substance abuse, and antipsychotic treatment in the United States and the effect of these variables on the length of stay. The objectives of this pilot study include finding how the length of stay is affected by each type of variable and how this can change clinical practice with psychiatric admissions. 
Methods: Data collection required access to the electronic medical records of 400 patients on the inpatient psychiatric unit from July to October 2016. The first 100 patients were included in this study to report the initial findings. Initial psychiatric evaluations, discharge summaries, and laboratory workup were examined for each patient. Variables collected included age, sex, legal hold status, substance abuse, LOS, and antipsychotic medications. Additional variables were collected for other studies but were not considered for this study. Reporting and detection bias was controlled for by incorporating the attending physicians. Statistical analysis was performed using R statistical software. 
Results: Females (n=44) are more likely than males (n=57) to have a legal hold (OR=2.43, P=.0319). Discharge diagnosis of bipolar, depressive, or psychotic disorder did not predict LOS (ANOVA P=.14). The type of antipsychotic treatment (atypicals, typicals, long-acting injectable, no antipsychotic) showed a weak suggestion of a lower LOS (<5 days) in the group that did not receive an antipsychotic as treatment (Kruskal-Wallis P=.08). A positive (vs negative) urine toxicologic result showed a longer LOS by 4.77 days (11.77 days vs 7.0). The group that did not have a urine toxicologic screen had a shorter LOS (<5days) than the negative result group using Turkeys HSD post-hoc comparison test. The P value for all 3 groups was .0353. 
Discussion: The data sample covered 101 patients at a specific time range and had equal representation of major mental illnesses seen in an acute psychiatric unit. Obtaining urine specimens from patients was not strictly enforced. Sex and legal hold had the strongest association with LOS as opposed to diagnosis, age, race, or substance abuse treatment. Male sex is considered a risk factor, which leads to concern for males not being placed on appropriate legal holds, to ensure safety. Therapeutic alliances may have played an unknown role and potentially influenced the LOS.4 Psychosis, female sex, and larger hospital size were associated with longer LOS, while discharge against medical advice, prospective payment, being married, being detained, and being younger or middle aged were associated with shorter LOS.5 
Conclusions: Overall LOS was higher in males and patients with legal holds. Positive urine toxicologic result also increased LOS. Not receiving an antipsychotic medication showed a weak suggestion for shorter LOS. It is not clear why females were more likely to have legal holds while males had increased LOS. Other disorders, such as anxiety, intellectual disability, and personality disorders, were not part of the diagnoses analyzed. 
Acknowledgment: Brian Jean, MS, statistical consultant, from Taft College. 
1. Testa M, West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010;7(10):30-40. 
2. McGarvey EL, Leon-Verdin M, Wanchek TN, Bonnie RJ. Decisions to initiate involuntary commitment: the role of intensive community services and other factors. Psychiatr Serv. 2013;64(2):120-126. doi:10.1176/ 
3. Hustoft K, Larsen TK, Auestad B, Joa I, Johannessen JO, Ruud T. Predictors of involuntary hospitalizations to acute psychiatry. Int J Law Psychiatry. 2013;36(2):136-43. doi:10.1016/j.ijlp.2013.01.006 
4. Hughes R, Hayward M, Finlay WML. Patients’ perceptions of the impact of involuntary inpatient care on self, relationships and recovery. J Mental Health. 2009;18(2):152-160. 
5. Tulloch AD1, Fearon P, David AS. Length of stay of general psychiatric inpatients in the United States: systematic review. Adm Policy Mental Health. 2011;38(3):155-68. doi:10.1007/s10488-010-0310-3. 
♦C15—Chronic Diseases and Conditions
Evaluation of the Nutrition and Health Awareness Program and Changes in Physical Activity on Health and Wellness Education 
Shovna Mishra, OMS III; Payush Chatta, OMS III; James du Pont, OMS III; Tanvi Devi, OMS III; Spencer Eberhard, OMS III; Angie Huynh, OMS III; Sameeha Khalid, OMS III; Josephine Kim, OMS III; Suneun Kim, OMS III; Muhammad Ulhaque, OMS III; Ray Wagner, MD, MS; Christopher Dixon, DO; Kate Whelihan, MPH, CPH; Joy H. Lewis, DO, PhD 
A.T. Still University School of Osteopathic Medicine in Arizona (ATSU-SOMA), Mesa 
Research Question/Hypotheses: To identify the overall improvement in physical activity, health, and wellness education, and health attitudes among 7 to 12-yearold children as a result of implementing the NHA (Nutrition and Health Awareness) program and the use of the Sqord brand accelerometers to combat rising pediatric obesity and related diseases. 
Methods: This pilot study recruited 28 participants, children of El Rio Community Health Center staff, ages 7 to 12 years, to attend an education health fair teaching physical activity, food groups, reading nutrition labels, diabetes, and cardiovascular disease. Sqords activity accelerometers were provided to participants to continually monitor their level of physical activity. Five weeks of activity data were collected (1 week before and 4 weeks after a health fair) and analyzed to evaluate physical activity continuity. Additionally, statistical analysis compared health attitudes and understanding of nutrition and health prevention by comparing pre- and postintervention health and wellness questionnaire results. 
Data Analysis: A paired t test compared scores of the pre- and postintervention health and wellness questionnaire (15 questions) on material taught in the health fair. A paired t test was also used to compare mean Sqord activity points per week from week 0 with mean Sqord activity points per week between weeks 1 through 4. Week 5 data were excluded from analysis, owing to participant drop off. To evaluate health attitudes, percent change in response to the question, "How many minutes a day do you plan to exercise after the course?" was measured on both questionnaires. 
Results: Questionnaire response rate was 100%. A significant difference (P=.0007) existed in questionnaire scores between the preintervention (M=9.857, SD=3.33, 95% CI=8.79, 10.93) and postintervention (M=11.786, SD=2.9, 95% CI=10.56, 13.02) results. Results suggest that the intervention was positively correlated to improvements in health knowledge (20% increase in questionnaire scores). 18% of children (71% of sedentary children) increased planned amount of exercise per day. Sqord activity data were not significant (P=.6). 
Conclusion: Preliminary analysis of the pre- and postintervention questionnaires suggests the NHA program is positively correlated with improvement in health knowledge. The increase in children's planned exercise amount indicates a correlation of the NHA program and positive change in health attitude. Sqord activity data were not significant. Future research can involve addressing parental involvement on childhood health and modifying the age range of participants and questionnaire. The project had a positive impact on the health center, bringing health awareness to early-aged children. The health center plans on continuing the intervention. 
Support: ATSU-SOMA, ASU Foundation Edson Startup Initiative. 
♦C16—Chronic Diseases and Conditions
Osteopathic Manipulative Treatment Reduces Oxidative Stress Levels and Improves Relative Stiffness and Quality of Life in Parkinson Disease 
Shannon A. Moriarty, OMS III1; Victoria Lu, OMS II1; Christi Oommen, OMS II1; Lauren M. Bellavia, OMS II2; Joyce M. Lee, OMS II2; Adena Leder, DO1; George Cheriyan, DO1; Joanne DiFrancisco-Donoghue, PhD1; Jayme D. Mancini, DO, PhD1; Joerg R. Leheste, PhD2; Sheldon Yao, DO1 
1Department of Osteopathic Manipulative Medicine, New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury; 2Department of Biomedical Sciences, NYITCOM 
Introduction: Parkinson disease (PD) is a neurodegenerative disorder involving the hallmark features of stiffness, bradykinesia, postural instability, and tremor caused by a decreased production of dopamine. Research demonstrates that neurodegeneration is commonly associated with an increase in inflammation and oxidative stress, demonstrated by higher systemic levels of reactive oxidative species (ROS) thought to originate from mitochondria in underused skeletal muscle tissue. High levels of oxidative stress, especially over a prolonged time, significantly exacerbate somatic and neuronal dysfunction. ROS are known to cause widespread damage to nucleic acids (DNA, RNA), lipids, and proteins. Specifically, damage to DNA can have severe consequences if not properly repaired, and there is evidence that this damage may contribute to the pathogenesis of PD, as well as certain cancers. Further, PD has a considerable effect on quality of life that progresses along with disease manifestation. The goal of osteopathic manipulative treatment (OMT) is to decrease musculoskeletal restrictions and improve circulation of fluids in an effort to decrease stiffness, reduce inflammation, and improve quality of life in individuals with PD. 
Hypothesis: We hypothesized that biweekly OMT over a 6-week period using a predefined protocol (PARK-OMM) will lead to decreased oxidative stress on DNA, reduced relative stiffness, and improved quality of life in PD compared with a 6-week controlled counseling period. 
Statement of Significance: By directly managing mechanical restrictions with OMT, symptoms of PD such as stiffness can be decreased, leading to an improved quality of life. Additionally, OMT can alleviate oxidative stress to DNA in PD. 
Methods: The study was approved by the NYIT institutional review board (BHS 975). Participants were recruited through flyer distribution and direct inquiry to patients of the NYITCOM Adele Smither's Parkinson's Center. Inclusion criteria included scores on the Movement Disorder Society's Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS) for motor function, sensory organization test (SOT) for balance, and/or the Balance Evaluation Systems Test (Mini-BESTest) for balance and gait analysis. Once included and consented, participants were randomly assigned in blocks of 2 to receive either the OMT or counseling intervention. Both groups received 6 weeks of biweekly interventions with either a 30-minute session of OMT protocol aimed to increase joint range of motion of the spine and extremities and decrease stiffness by a physician board certified in neuromusculoskeletal medicine/osteopathic manipulative medicine (NMM/OMM) or a 30-minute counseling session by a health care professional addressing a specific aspect of PD. Counseling topics included PD history and risk factors, trauma history, falls prevention, transfer and gait, balance and freezing, nutrition, exercise and stretching, depression and mental health, genetics, meditation and stress reduction, PD nonmotor symptoms, medication side effects, and sleep. Each session, both OMT and counseling, started with taking an updated history on self-reported stiffness using a 10-point scale. Additional outcome measures conducted at weeks 1, 3, and 6 included the PD Questionnaire-39 (PDQ-39) for quality of life and blood and urine samples. Additional blood and urine sample were obtained after the participants’ first intervention to assess for potential acute changes. Blood plasma and urine samples were stored at -80°C after collection until analysis. 
Data Analysis: Preclinical and clinical differences in study variables were compared using unpaired t test, analysis of variance, and post-hoc analysis for continuous measures, as well as χ2 tests and Fisher exact tests for categorical variables. To assess the relationship between continuous variables, correlation and linear regression analyses were used. 
Results: The average relative stiffness scores on the 10-point scale at week 1, week 3, and week 6 were calculated and graphed. Five of the 6 participants in the OMT group had a negative slope, with an average improvement of 3.25 points from week 1 to week 6, indicating a relative improvement in stiffness. One OMT participant had a 1-point increase in stiffness. Two of the counseling participants (n=4) had no change in stiffness from week 1 to week 6, and 1 participant showed an increase in stiffness by 2 points. One counseling participant (n=1) did not report any stiffness. PDQ-39 scores at week 1 and week 6 were analyzed for the OMT group (n=6) and the counseling group (n=4). The average change was -14 for the OMT group and 3 for the counseling group, with a lower score demonstrating an improvement in quality of life. One participant in the OMT group showed a slightly increased PDQ-39 score at week 6. Only 1 participant in the counseling group had decreased PDQ-39 scores, and the remaining 3 participants showed slightly increased PDQ-39 scores at week 6. A t test showed the trend was not statistically significant (P=.141). Blood and urine samples of the same participants were analyzed in duplicate for oxidative damage on an enzyme-linked immunosorbent assay (ELISA) platform for 8-hydroxy-2'-deoxyguanosine (8-OHdG), a critical DNA biomarker of oxidative stress and carcinogenesis. Creatinine levels were measured to determine relative kidney function to be considered with urinary measurements of 8-OHdG. Urinalysis of 8-OHdG indicated a statistically significant 37% (P=.03) reduction in oxidative damage to DNA in PD participants receiving OMT (n=6) vs counseling (n=4). 
Conclusion: Our pilot data demonstrating that OMT can be a useful modality in improving stiffness, a key manifestation of PD. By addressing the biomechanical restrictions of joints to improve range of motion and encouraging circulation of fluids by removing fascial restrictions, there was an improvement in participant-rated sensations of stiffness. Further, the majority of participants receiving OMT reported an improvement in quality of life compared with counseling, as measured by the PDQ-39. Decreased stiffness in PD can potentially allow for more independence and a better quality of life. Hand-in-hand with those behavioral findings, OMT-related alleviation of systemic oxidative stress levels likely affects morbidity and mortality associated with PD, which will need to be investigated further. We hope to strengthen these results as the study continues and our sample size increases. 
Support: American Osteopathic Association Research Grant to PI Sheldon Yao (grant #431607710). 
♦C17—Chronic Diseases and Conditions
Knowledge and Attitude of Young Taiwanese Women and Possible Effect on Breast Cancer Screening Rates in Taiwan 
Wing Ken Wong, OMS II1; Sara Tong, OMS II1; Athena W. Lin, PhD1; Annie Y-R Chen, MS2 
1Touro University College of Osteopathic Medicine-CA, Vallejo; 2Taipei Hospital, Ministry of Health and Welfare New Taipei City, Taiwan 
Hypothesis: The Taiwan Health and Welfare Report stated breast cancer was the leading cancer diagnosis for females, doubling that of the next most frequent diagnosis, colon cancer. However, of the 4 major types of cancer (oral, cervical, breast, and colon), breast cancer had by far the worst detection rate; only 1/179 people screened were detected to have breast cancer. Incidence rates in the female target population (aged 40-65 years) only had a screening rate of 39%, compared with a 66.8% rate in the United States.1 We hypothesized that the low breast cancer screening rate in Taiwan compared with America is associated with a low understanding of breast cancer risk and screening by the young female population. 
Statement of Significance: Breast cancer is one of the leading causes of cancer-related deaths in women worldwide. According to the American Cancer Society, breast cancer makes up 25% of all new cancer diagnoses in women globally. Historically, breast cancer rates of incidence and mortality have been relatively low in Taiwan compared with other countries but have increased at a steady rate within the past 15 years. Compared with the data in 2005, the mortality rate of breast cancer in 2015 had risen from 12.9% to 18.2%.1 While Taiwan has been increasing its efforts to increase breast cancer screening practices through full subsidization of mammograms, it still lags behind other countries with developed health care systems in terms of screening. The United States, for example, despite its lack of guaranteed health coverage, still managed a 66.8% screening rate among women in the at-risk age group in 2013, compared with Taiwan's 39%.2 The aim of this study was to identify a gap between the universal health care system and low breast cancer screening rate in Taiwan through assessing young (age 18-39 years) Taiwanese women's knowledge of and attitudes toward breast cancer and its relation to low screening rates in the at-risk (age >40 years) population. The ultimate goal was to educate and raise awareness in Taiwan to potentially raise breast cancer screening rates, leading to better outcomes. 
Methods: A survey based on a Likert scale was carried out to the female patients at Taipei Hospital. The population targeted for this study were 18- to 39-year-old females, on the basis that they were not yet in the at-risk age range for breast cancer. The female at-risk age group was used as a point of comparison. The data collected included participants’ age and their answers to various questions regarding breast cancer. The survey consisted of 18 questions concerning breast cancer and screening to determine the participants’ opinions and beliefs toward screening. Some basic facts related to breast cancer were also included to gauge the knowledge of the participants of this study. Questions that were not answered were considered to be nonresponses. 
Results: Of the responses (n=101) gathered for the young female population, only 4.9% were able to correctly identify the appropriate age for the first mammogram screen for breast cancer, compared with 45% of the responses (n=22) gathered for older females. 38% of the young female population correctly identified the frequency for self-breast examinations, compared with 68% in the older population. 57% of the younger group and 50% of the older population knew the risk factors of alcohol intake and smoking. Similarly, 62.9% of the young and 64% of the older respondents knew the benefits of exercise. 45% of the young female population knew the risk factor of increased weight or obesity, compared with 41% of the older population. While 59% of the older population was aware of early menstruation as a risk factor for breast cancer, only 30.6% of the young population understood the risk. 
Data Analysis: Although the level of concern for breast cancer among the young female population was considered low at 25% (compared with the at-risk age group at 32%), which matched the hypothesis, the data also indicated that the majority of young Taiwanese women felt that breast cancer screening was generally beneficial (n=82, 75%) and was important to them (n=79, 73%), similar to the at-risk group (n=18, 82%) and (n=19, 85%), respectively. However, this finding was not reflected in practical assessment of the questionnaire, in which less than 5% (n=5) of young female respondents knew when to get their first mammogram (compared with n=10, 45% in the at-risk group), and only 38% knew how often to perform a self-breast examination (compared with 68% in the at-risk group). With regard to the knowledge-based portion, the majority of young females performed well with questions relating to breast cancer's strong link to family history (n=96, 89%), importance of early detection/staging (n=100, 93%), and reasonably well with questions concerning common myths regarding breast cancer, such as breast size correlation with cancer risk (n=78, 72%) and the association of all lumps with breast cancer (n=88, 81%). However, young Taiwanese female respondents were markedly deficient in their evaluation of several breast cancer risk factors. Alcohol/smoking was identified as a risk factor by only 62 respondents (57%) as a breast cancer risk factor, while exercise and weight control were only identified by 68 (63%) and 49 (45%) respondents, respectively. This finding is reflected in the opinion portion of the survey, in which only 37% of respondents believed that reduction of the risk of breast cancer was possible. This result is in contrast to 63% of older females who believed in risk reduction. Additionally, only 30.5% of respondents were aware that early menstruation was a risk factor for breast cancer. In comparison with the young Taiwanese women, the at-risk group performed similarly for risk associated with alcohol (n=11, 50%), weight control (n=9, 41%), and exercise (n=14, 64%). These findings are significant, given similar studies3 that have linked deficiencies in knowledge of breast cancer risk with an adverse effect on early detection. The largest source of knowledge about breast cancer seemed to be from school (n=38, 35%) or the internet (n=35, 32%), and the greatest motivating factor in getting a future screening was the opinions of physicians (n=52, 48%), even though young female patients cited doctors as a source only 10% of the time. 
Conclusion: Our findings suggest that although young Taiwanese females were knowledgeable in certain aspects of breast cancer risks and have a positive opinion toward screening, relatively low concern level (compared with the at-risk group) and misinformation of other risk factors such as exercise and early menstruation could have an impact on cancer incidence, projecting into the future. Moving forward, it may be beneficial to begin raising breast cancer risk factor awareness for younger females in Taiwan, especially from primary care physicians. Further stratification and analysis of a wider population of young females may be beneficial, as only a small number of patients were surveyed. 
Acknowledgments: We thank Director Annie Chen and the TIHTC staff for their help and Taipei Hospital for its cooperation in allowing us to conduct our study. 
♦C18—Chronic Diseases and Conditions
Effects of Rock Steady Boxing on the Motor Symptoms of Parkinson Disease, a Pilot Study 
Kirtan Patel, OMS II; John Whalen, OMS II; Sunny Dharia, OMS II; Atif Ghaffar, OMS II; Adena Leder, DO 
New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Introduction: Parkinson disease (PD) is a progressively degenerative disorder of the nervous system that affects motor and non-motor function, and it has become an area of interest over recent years. The cause of PD is loss of dopamine-producing cells in the brain leading to noticeable impairment in motor function. Motor function impairment hinders individuals from performing simple daily tasks and activities, which can be highly debilitating. The major PD symptoms are akinesia/bradykinesia, postural instability, tremors, and rigidity. Currently, there is no cure for PD, but there are various treatments used to treat patients with PD, such as the combination of levodopa and carbidopa, DBS, and exercise. There is not much evidence to suggest whether there are any lifestyle modifications that can directly improve the quality of life of patients with PD. A powerful and productive treatment option is exercise, which has been shown to improve overall motor function. Therefore, this research project evaluated the potential positive effects of boxing through the Rock Steady program, when integrated into daily life, through the assessment of overall progression of motor function in each patient. 
Statement of Significance: The Rock Steady program is a nationally recognized affiliate targeted for patients with PD. Although this program has been present on the NYITCOM campus since October 2016, this potentially beneficial program has made major strides in getting patients with PD to join. In general, Rock Steady is a boxing program developed as a noninvasive alternative for patients with PD with the hope that the program improves the overall quality of life of patients without harmful side effects. As osteopathic physicians, we believe that the body should be treated as a whole, and the implementation of these lifestyle modifications should theoretically improve the motor symptoms that present with idiopathic PD. This observational study showed a correlation between the participation in boxing and the overall motor function of patients with PD. 
Hypothesis: If patients with PD attend more Rock Steady boxing sessions, then there will be a greater improvement in their motor function through the diminution of motor symptoms that they present with upon starting the program. 
Methods: The results are logged in compliance with the Health Insurance Portability and Accountability Act (HIPAA) to maintain confidentiality, and the study data are stored physically on site at NYITCOM and can only be accessed by personnel approved by the Institutional Review Board (IRB). The researchers performing the experiment were trained under HIPAA, the Collaborative Institutional Training Initiative (CITI), and the UPDRS certification program. These certifications enabled the researchers to acquire data and adequately assess the results of this observational study. At the same time the certifications also enabled the researchers to comply with necessary regulations for clinically based research with patients. For the purposes of maintaining confidentiality, each patient was assigned a random number. Two groups of participants, ages 45-85 years, were assessed for motor function before and after the Rock Steady Boxing program. One group was allowed to attend Rock Steady Boxing, and it was provided 3 days per week. The second group, control, were participants who decided not to attend Rock Steady Boxing program and attended 0 classes. Each participant had an initial assessment, which included the Unified Parkinson's Disease Rating Scale (UPDRS), the Fullerton Advanced Balance (FAB) scale, and the Mini Balance Evaluation Systems Test (Mini-BEST). Other tests used were 30-second Sit-to-Stand, which is the number of times a participant can arise from a chair within 30 seconds, and Timed Up and Go (TUG), which is how quickly a patient can rise from a chair to walk around an obstacle located 10 feet away and sit back down in the chair. There were 5 participants who completed UPDRS-II; 6 for UPDRS-III; 2 for Mini-BEST; 13 for FAB; 12 for Sit-to-Stand; and 12 for TUG. Rock Steady Boxing program had a warmup, 6 three-minute standard stations in a circuit and ended with a cool down. Each class had 6 standard stations: using punching bags, speed bags, focus mitts, fine motor, balance, and strength. At the end, there was a cool down, which included stretching and core exercises. Reassessments were completed after an average of 5 months of participation. 
Data Analysis: To analyze the data in this experiment, we used statistical analysis and biostatistics to determine whether there was a link between Rock Steady participation and improvement of symptoms recorded by the tests. Tests included mean, SD, SE, and t test. Data analysis was conducted using IBM SPSS version 22. 
Results: The average time between the first boxing class and the reassessment was approximately 5 months, with an average of 36 sessions attended by the participants. Participants showed a mean score increase of 0.6 points for UPDRS-II, from 9.8 initially to 10.4 at reevaluation (Table C18). For UPDRS-III, the mean score increased by 2.5 points, from 33.8 initially to 36.3 at reevaluation. For Mini-Best, the mean score increased by 4 points, from 19 initially to 23 at reevaluation. For the FAB test, the mean score increased by 1.7 points, from 34.5 initially to 36.2 at reevaluation. Sit-to-stand increased by 0.8 for participants, from 14.5 initially to 15.3 at reevaluation. Last, the TUG decreased by 1.2 seconds, from 9.2 seconds to 8 seconds at reevaluation. It is pertinent to mention that the results obtained were not statistically significant. 
Table C18.
Effects of Rock Steady Boxing on the Motor Symptoms of Parkinson Disease, a Pilot Study
Measure Mean Boxers
 Before 9.8 5
 After 10.4 5
 Before 33.8 6
 After 36.3 6
 Before 19 2
 After 23 2
 Before 34.5 13
 After 36.2 13
 Before 14.5 12
 After 15.3 12
 Before 9.2 12
 After 8.0 12
Table C18.
Effects of Rock Steady Boxing on the Motor Symptoms of Parkinson Disease, a Pilot Study
Measure Mean Boxers
 Before 9.8 5
 After 10.4 5
 Before 33.8 6
 After 36.3 6
 Before 19 2
 After 23 2
 Before 34.5 13
 After 36.2 13
 Before 14.5 12
 After 15.3 12
 Before 9.2 12
 After 8.0 12
Conclusion: The results of this study showed an improvement in balance for PD patients that participated in the program while showing a decline in other motor tests, but the results were not significant. Four of the 6 scales used for evaluation of motor function showed improvement. On average, the 12 participants who were evaluated for the TUG test showed an improvement in mobility as they were able to complete the test in about 8 seconds vs 9.2 seconds during their initial assessment. The 2 participants evaluated using Mini-Best showed improvement in balance, with an average increase of 4 points. Advanced balance was also improved according to the FAB, as patients on average scored 1.7 points higher. 12 participants were administered the Sit-to-Stand test and showed an improvement of 0.8, which means they were able to improve their motor function through the Rock Steady Boxing program. The results of the UPDRS Parts II and III showed an overall decrease in motor function, which led to the conclusion that a decline in motor function is still present. The results are inconclusive possibly due to several factors. The data used to derive these results came from a pilot project and thus there are possible quality issues as well as inconsistent standardization of data collection methods. In summary, it is difficult to determine whether the study shows that motor function improves or does not improve depending on the number of sessions attended. Based on the results it seems that the neurodegenerative effect of PD may be slowed or reversed through the Rock Steady boxing program; however, further evaluation is required. 
♦C19—Chronic Diseases and Conditions
Depression Among HIV/AIDS Patients in Shirati, Tanzania 
Omeed Atefi, OMS II; Rameen Atefi, OMS II; Yassmin Atefi, MS, OMS IV; Eiman Mahmoud, MD, MPH 
Touro University College of Osteopathic Medicine-CA, Vallejo 
Background and Objective: In 2014, Tanzania ranked 14th in the world in deaths due to complications of HIV/AIDS, with approximately 197 deaths per 100,000 population. Often, those with HIV in Sub-Saharan Africa are stigmatized within their communities. Despite this mental toll, there is very little literature on the prevalence of mental illness in Tanzania. We aimed to investigate and compare the prevalence of depression in Shirati, Tanzania, among HIV+ and HIV- groups. Understanding the depression rates in these groups could help provide insight in improving mental health care in the area. 
Hypothesis: We hypothesized that those who are HIV+ in Shirati, Tanzania, are more likely to screen positive for depression when compared with those who are HIV- or unaware of their HIV status. 
Methods: The primary component of this study was the Patient Health Questionnaire-9 (PHQ-9), a brief but powerful survey that has shown to be a good initial screen for depression. The PHQ-9 delineates the severity of depression based on the score of the participant. With a total score of 27, scores of 1-4, 5-9, 11-14, 15-19, and 20-27 represent minimal, mild, moderate, moderately severe, and severe depression, respectively. A score of ≥10 suggests that the participant would benefit from a treatment plan including therapy, pharmacology, and/or referral to a mental health specialist. Over the course of 3 weeks, the PHQ-9 depression screening survey was distributed to citizens of Shirati. A total of 269 surveys were completed by consenting adults, 147 of which were HIV+ individuals receiving treatment at an HIV clinic at Shirati KMT hospital. The remaining 122 surveys served as the control population as they were completed by individuals from the community who were HIV-/unaware of their HIV status. The surveys from each individual were totaled and tallied based on HIV status. 
Results: HIV+ participants were more likely to score higher on the PHQ-9 than the control participants, with the former group having a higher mean score (9.14±4.57 [SD] vs 6.93±4.59 respectively, P<.01). Although the HIV+ group reported fewer cases of moderately severe depression than that of the control population (2.7% vs 10.6%), they exhibited a far greater overall percentage of individuals who needed treatment or counseling (55.1% vs 18.9%), as suggested by the PHQ-9 guidelines stated above. 
Conclusion: These results suggest that there is a significantly higher prevalence of clinical depression in the HIV+ group in Shirati when compared with the control HIV-/unaware group. This significant finding shows that developments to mental health infrastructure in this region would benefit this group by curbing the comorbidities of depression while also improving quality of life. Simple interventions, such as appointing a member of the hospital staff to facilitate therapy or group meetings, could provide much-needed relief to those with mental health issues. In the future, we would like to continue this study by stratifying data based on sex, age, and socioeconomic status to properly assess the demographic within the HIV+ group who are most vulnerable to depression. A limitation to this study is the relatively small sample size (n=269) and the use of the PHQ-9, a screening tool to estimate prevalence. 
The study was approved by the Institutional Review Board of Touro College, Vallejo, CA (IRB Application # M-2217). 
♦C20—Chronic Diseases and Conditions
Adolescent Posttraumatic Stress Disorder: Adjunctive Buspirone Treatment Started During Acute Inpatient Psychiatric Hospitalization Randomized Controlled Trial 
Alexander Ghobadimanesh, DO1-3; Suporn Sukpraprut-Braaten, MSc, MA, PhD1-3; Herman Clements1-3; Ronald Wauters, MD1-3; Andrew J Powell, MD1-3 
1Graduate Medical Education, Kansas City University of Medicine and Biosciences College of Osteopathic Medicine (KCU-COM), Searcy, AR; 2Graduate Medical Education, Unity Health, Searcy, AR; 3Department of Psychiatry, Unity Health, Searcy, AR 
Background: The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) is more comprehensive in categorizing posttraumatic stress disorder (PTSD). PTSD is now classified under “trauma and stressor related disorders,” disassociating its DSM-IV recognition as solely an anxiety disorder. 
Objectives: The purpose of this study was to establish a diagnosis of PTSD based on DSM-5 diagnostic criteria in patients presenting to the adolescent inpatient psychiatric facility at the time of admission, measure the severity of their symptoms before treatment, and compare the buspirone-augmented selective serotonin reuptake inhibitor (SSRI) group to the SSRI-only group at the time of discharge to determine whether there was a significant reduction in PTSD symptoms. 
Methods: The study was designed as a randomized prospective single-blinded study aimed at determining if the adjunctive use of buspirone with an SSRI in adolescents with PTSD on an inpatient psychiatric setting would result in a greater response to treatment compared with using an SSRI alone. Inclusion criteria included age 12 to 18 years and PTSD that met the DSM-5 diagnostic criteria for PTSD. Exclusion criteria included pregnant patients, intellectually developmentally disabled patients, and patients who were taking a different SSRI from the SSRIs in the study on admission. The primary end point for the study was mean change in the Children's Revised Impact of Event Scale 8 (CRIES-8) assessment score before and after treatment. The CRIES-8 was a patient-administered scale ranging from 0-40 points. The CRIES-8 consisted of assessment of avoidance and intrusion symptoms, with 8 items that were scored on a 4-point Likert scale. The secondary end point is length of stay in the adolescent inpatient psychiatric facility. The study was approved by Harding University's Institutional Review Board. 
Data Analyses: Nonparametric method was used to analyze the data. R i386 3.4.0 Statistical Software was used to compute descriptive statistics, χ2 test, Mann-Whitney U test, and Wilcoxon signed-rank test. 
Results: The preliminary data were collected during the period of March 2017 to May 2017. Eighty-seven patients admitted to the adolescent inpatient psychiatric facility were screened to participate in the study. Seventeen patients had a diagnosis of PTSD based on DSM-5 diagnostic criteria. Six patients were not allowed by their guardians to participate in the study. Eleven patients participated in the study. Six patients were randomly assigned to a buspirone-augmented SSRI group, and 5 patients were randomly assigned to the SSRI-alone group. The age averages were 15 (±2.2) years for the buspirone-augmented SSRI group and 15 (±0.9) years for the SSRI-alone group (P=.923). Eight patients (73%) were females and 9 patients (82%) were white. All patients were emotionally, physically, and/or sexually abused. Six patients (55%) had a diagnosis of major depressive disorder. Five patients (44%) were illicit drug users. The difference in the CRIES-8 from baseline to discharge was greater in the buspirone-augmented SSRI group (–11.8 vs –5.6 points; P=.360) on average. The inpatient length of stay for the buspirone-augmented SSRI group was 2.9 days longer than the SSRI-alone group (P=.382). 
Conclusion: The preliminary data suggested that buspirone in addition to an SSRI may be more effective than an SSRI alone in reducing PTSD signs and symptoms, including avoidance and intrusive symptoms described in the CRIES-8. However, the inpatient hospital length of stay was longer in the buspirone-augmented SSRI group than the SSRI alone group. Limitations in the study include the small number of patients, single-blinded randomization, and initial index for onset of traumatic event. Future directions may include monitoring adolescent PTSD symptoms by using the National Stressful Events Survey PTSD Short Scale (NSESS) as well as integrating psychotherapy as another intervention. 
♦C21—Chronic Diseases and Conditions
Mental Illness in the Context of Multiple Chronic Conditions in Older Adults 
Rebecca Lopes, OMS III; Allison Heid, PhD; Rachel Pruchno, PhD 
Rowan University School of Osteopathic Medicine (RowanSOM), Stratford, New Jersey 
Research Questions/Hypotheses: (1) How does a mental health diagnosis affect individuals' engagement in self-management behaviors of exercise and medication adherence for individuals that have multiple chronic conditions (MCCs)? Hypothesis: If an individual has a mental health diagnosis as one of his or her chronic conditions, individuals will report less exercise and less medication adherence when compared with individuals who do not have a mental health condition as one of their comorbid conditions. (2) How do perceptions of cause regarding mental health conditions affect self-management behaviors of exercise and medication adherence? Hypothesis a: Individuals who report a higher level of psychological attribution for cause for their mental health condition will be more likely to report lower levels of exercise and medication adherence. Hypothesis b: Individuals who report a higher level of risk factors as cause for their mental health condition will report higher levels of exercise and medication adherence. (3) How do perceptions of cause for mental health conditions compare to perceptions of cause for physical health conditions? Hypothesis: Perceptions about the cause for mental health conditions will be more likely to be attributed to psychological factors compared with causal attributions made about physical conditions, whereas the perceptions about the cause for physical health conditions will be more likely attributed to risk factors compared with causal attributes of mental health conditions. 
Methods: Participants were aged 55 years or older and had 2 or more chronic health conditions (arthritis, hypertension, heart condition, cancer, diabetes, osteoporosis or osteopenia, stroke, lung or breathing problems, depression, anxiety, other mental health condition) were recruited through the New Jersey Institute for Successful Aging (NJISA) Rowan Medicine practice, had participated in a prior pilot study in the summer of 2015, and were required to speak English, not to have dementia, and be able and willing to participate in a 1-hour interview. Structured survey interviews were conducted. Health management behaviors: Exercise: A total score of vigorous exercise, moderate exercise, and walking [minutes per week; mean (SD) [M (SD) = 344.40 (382.36), range, 0-1470]. Medication adherence: Participants reported on whether they took prescription medications for each diagnosed condition using the 8-item Medication Adherence Scale [M (SD) = 7.24 (1.09), range, 4.38-8.00]. Perceptions of cause: Calculated for both mental health conditions and physical health conditions. Psychological causal attributions: stress and worry, rated 0 (strongly disagree) to 4 (strongly agree) [M (SD) = 2.29 (1.25), range 1-4 min]. Risk causal attributions: mean-item total score of 7-items, rated 0 (strongly disagree) to 4 (strongly agree), eg, hereditary, diet or eating habits, poor medical care in my past, my own behavior, aging, alcohol, and smoking [M (SD) = 12.14 (3.63), range 7-19, α=.54]. This study received approval from the Rowan University Institutional Review Board for 2016-2017. 
Data Analysis: Research question 1: We ran independent samples t tests to compare mean levels of exercise and medication adherence for individuals who had a mental health condition compared with individuals that did not have a mental health condition. Research question 2: We ran Pearson Product Moment correlations of psychological causal attributions and risk causal attributions for mental health conditions with levels of exercise and medication adherence. Research question 3: We used paired samples t tests to examine the mean difference in attribution of psychological cause and risk cause for mental health and physical health conditions. 
Results: Research question 1: We found that we are moving in the direction of more exercise for individuals without mental health conditions [M (SD) = 435.94 (437.13)] compared with individuals with mental health conditions [M (SD) = 186.88 (195.76)], but it was not significant (t22=1.52, P=.142). There was no mean difference for medication adherence (t22=–.26, P=.795). Research question 2: Individuals with mental health conditions who reported higher sores for their illness as being due to psychological causes reported more exercise. There was no association of psychological causal attributions with medication adherence. Individuals with mental health conditions who reported higher scores for their illness as being due to risk causes were trending toward reporting more exercise; there was no association of risk causal attributions with medication adherence. Research question 3: We found that the means were moving in the hypothesized direction, but there was no significance. The means showed that people with both mental health conditions and physical health conditions report more psychological causes of their mental health conditions than for their physical health conditions, and they report less risk cause for their mental health conditions than for their physical health conditions. 
Conclusion: From the data, we can infer that individuals who have mental health diagnoses may be less likely to exercise because of a lack of motivation and feelings of apathy. Our data demonstrate that attributing a tangible cause (either psychological or risk) to a mental health illness is associated with more exercise. Causal attributions for an illness that may lack concrete physical manifestations might allow individuals to perceive control of their symptoms, thus mediating the effects of their illness. Differences in perceptions of cause for mental health conditions compared with perception of cause for physical health conditions could be a result of patient-physician interactions, progression, timing, and order of MCCs, as well as onset and duration of personal life events. This work has important implications for the patient-physician relationship in terms of managing care and treatment plans for older patients with MCCs. Perceptions about the cause of an illness and its relationship to other concomitant chronic conditions can influence self-management, disease onset, progression, and duration, and ultimately the aging process. Further work should involve a larger sample size and a more diverse population. The data collected will serve as a platform for future investigation into the factors that affect the progression and timing of MCCs. 
Support: This research study was funded by the RowanSOM Summer Fellowship Program. 
♦C22—Chronic Diseases and Conditions
The Comparison of 2 Popular Activity Trackers in a Parkinson Disease Population 
Shaylyn Tuite, OMS II; Sana Hassan, OMS II; Alex Aksoanov, PT; Joel Pineda, PT; Veronica Southard, PT, DHSc, GCS; Joanne DiFrancisco-Donoghue, PhD, RCEP 
New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Introduction: Parkinson disease (PD) is a neurologic disorder that affects more than 1 million people in the United States each year. Cardinal symptoms include abnormal gait, decreased arm movements, bradykinesia, dyskinesia, and sleep abnormalities. In recent years, researchers and clinicians have been using activity trackers to gather data on activity and sleep for research. By using these trackers, clinicians are able to track disruptions in sleep and daily movement. Examination of these areas then allows researchers and clinicians to focus on managing the disruption, whether through medications or osteopathic manipulative medicine, to improve the patient's quality of life. Two of the most competitive trackers on the market are the Fitbit Flex and Jawbone UP3. Previous studies have compared the accuracy of these 2 trackers throughout normal populations and other similar devices throughout populations with neurologic disease. These trackers are worn on the wrists, and they calculate steps by arm swing and stride length. This calculation could be problematic in individuals with PD who exhibit abnormal gait, arm tremors, and smaller movements compared with the normal population. Many PD studies have already relied on these trackers for data. However, the accuracy of these trackers has never been tested specifically in a PD population, to the authors’ knowledge. 
Research Question: The goal of this study was to examine the reliability between 2 popular activity trackers in a PD population under laboratory conditions and in free living conditions. We hypothesized that there would be a statistical difference in the reliability between the 2 activity trackers in a PD population under both standardized and free living conditions. 
Methods: This study compared Fitbit Flex and the Jawbone UP3 accuracy in participants with PD. Twenty-six participants participated in this study. The study was approved by the NYIT Institutional Review Board, and all participants signed written consent forms. Participants were recruited at the New York Institute of Technology Academic Health Center. They ranged in age from 51 to 83 years. Each participant conducted a controlled 6-Minute Walk Test and wore the trackers for 3 nights to assess sleep data. The 6-Minute Walk Test compared both trackers with a manual step count conducted by a researcher and a pedometer attached to the hip. After assessing the patient's stride length and average speed using a 10-Meter Walk Test, the participant was instructed to walk up and down a premeasured hallway for 6 minutes total. Afterward, the number of steps on all 4 devices was recorded. The patient was then instructed to wear the Fitbit Flex and Jawbone UP3 over the course of a 3-night period. After each night they wrote down how many times they woke up and how many hours of sleep they got. Participants were instructed not to take off the trackers for those 3 days. 
Data Analysis: A repeated measures design was used to compare the Fitbit Flex and the Jawbone trackers with the manual step count and the pedometer step count under the controlled 6-Minute Walk Test. A 1-way ANOVA was used to compare the Fitbit Flex and the Jawbone UP3 under free living conditions. A repeated measures design was used to compare the 2 activity trackers’ sleep data with manual sleep data collection. α was set at .05. 
Results: Data analysis showed no significant difference between the activity trackers and the pedometer. This was shown specifically using laboratory conditions consisting of the 6-Minute Walk Test. There was also no significant difference between free living steps or 6-Minute Walk Test in the Fitbit Flex and Jawbone UP3. The difference between the manual counting and activity trackers was not significant, but it is worth noting that it was approaching significance at P values of .51 and .059. There was a significant difference between the pedometer and all 3, the 2 activity trackers and manual step count. However, there was no difference in step count or sleep between both activity trackers under both free living and laboratory conditions in patients with PD. It is important to note that sleep was not monitored in laboratory conditions. Sleep measured by Fitbit Flex in comparison to Jawbone UP3 and manual count had P values of .89 and .13, respectively. Sleep conditions measured by Jawbone UP3 to Fitbit Flex and manual count had P values of .890 and .113, respectively. Sleep conditions comparing manual count to Fitbit Flex and Jawbone UP3 had P values of .130 and .113, respectively. Cumulatively the significance of the Fitbit Flex between and within groups was .405, and the Jawbone UP3 between and within groups was .237. Therefore, none of these P values proved to be significant in the sleep study. 
Conclusion: In conclusion, both the Jawbone UP3 and Fitbit Flex devices proved to be comparably accurate in individuals with PD. This finding provides a positive outlook for future studies using these trackers and additional reassurance for clinicians using their data to help better their patients’ lives. This study also further validates previous studies’ results as the devices provided accurate data. 
♦★C23—Impact of OMM/OMT
Comparing the Effect of Osteopathic Manipulative Medicine Versus Concussion Education for the Acute Treatment of Mild Concussion Symptoms 
Nicole Angelo, OMS III; Hallie Zwibel, DO; Adena Leder, DO; Jayme Mancini, DO, PhD; Sheldon Yao, DO 
New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Introduction/Objectives: The prevalence of concussion, a form of mild traumatic brain injury, is continually rising in conjunction with increasing numbers of student athletes. Head injury leads to inflammation and the accumulation of toxic mediators, such as reactive oxygen species, postulated to be the source of concussion symptoms. Symptoms can be difficult to recognize, ranging from dizziness and imbalance to emotional changes and neurocognitive deficits. Treatment includes physical and cognitive rest until asymptomatic followed by a gradual return-to-play progression. While widely accepted, complete rest can lead to deconditioning in athletes. Studies have shown that reappearance of symptoms can also occur when activity is resumed. Osteopathic manipulative medicine (OMM) uses techniques addressing somatic dysfunctions (SDs) of the musculoskeletal system that can arise after injury. OMM could potentially aid in the clearance of toxic mediators present after concussion by removing musculoskeletal restrictions and thus improving glymphatic drainage. Past research found OMM to be effective in improving concussion symptoms, including tinnitus, dizziness, and nausea, in both adolescent and adult case studies. Small pilot studies have also demonstrated improvement of concussionlike symptoms, including dizziness and imbalance, in both the acute and subacute setting. OMM has the potential to address the causes of concussion symptoms and, through randomized controlled trial, could become a valuable alternative to rest in the management of concussion. 
Research Question/Hypotheses: To determine the effectiveness of OMM compared with a control group receiving concussion education in addressing acute concussion symptoms as measured by the Symptom Concussion Assessment Test – 3 (SCAT-3). 
Methods: This study is NYIT Institutional Review Board approved, BHS-1139, and is registered at (NCT02750566). This randomized controlled trial investigated the effectiveness of OMM in managing mild concussion symptoms over a 1-week period after diagnosis. Participants presenting at the NYITCOM Academic Health Care Center for concussion evaluation were recruited for this study. Participants aged 18-50 years with a diagnosis of concussion cleared of life-threatening injuries by a neurologist were included in the study. Exclusion criteria included participants with contraindications to OMM, history or current diagnosis of spinal cord injury, a neurodegenerative condition, pregnancy, inability to complete assessments, as well as loss of consciousness for greater than 2 minutes, witnessed seizures, or intractable vomiting following head injury. After informed consent, participants were randomized to an OMM or control group receiving concussion education. All participants received the intervention on the initial visit (visit 1) after enrollment and at follow-up 48-72 hours later during visit 2. Participants in the OMM group received physician-directed osteopathic manipulative treatment. Physicians were directed to assess and treat SD potentially contributing to concussion symptoms, with focus on the cranium, thoracic and lumbar spine, ribs, and pelvis/sacrum. The OMM group received key techniques to decrease craniocervical restriction and improve lymph drainage in the head and neck. Control participants received concussion education, standardizing 30 minutes of face-to-face time with a physician between groups. Data collected included pre- and postintervention SCAT-3 performed on the initial visit and follow-up visit. One week after the initial visit, SCAT-3 was repeated a final time during visit 3. SCAT-3 includes a symptom evaluation portion during which participants self-report 22 common concussion symptoms on a 0-6 severity scale, from which total symptom number and symptom severity can be summated. 
Data Analysis: Analysis included 22 participants, 11 who received OMM and 11 controls. One participant was not included in the analysis owing to inability to complete assessments during visit 2. Statistics were performed on IBM SPSS Statistics 24, and α was set at .05. Independent t tests were performed to determine any differences in initial concussion symptom number and severity values between groups. Mann Whitney U testing was performed to analyze mean differences between pre- and postintervention SCAT-3 symptom number and severity scores over visits 1, 2, and 3. 
Results: No significant differences in initial SCAT-3 symptom number and SCAT-3 symptom severity were found between the OMM and control groups. On visit 1, a statistically significant decrease in concussion symptom number (P=.005) and symptom severity (P=.003) was found from before the intervention to after the intervention in participants receiving OMM compared with controls receiving concussion education. Participants in the OMM group had a mean decrease of 3.64 in symptom number vs a 0.82 decrease in the control group. An average decrease of 12.36 in symptom severity was also seen in the OMM group vs a 4.09 decrease in the control group. On visit 2, no significant difference was found between pre and postintervention symptom number (P=.332) and severity (P=.652) for those receiving OMM vs control. Additionally, no significant difference was found between intervention groups in the change in symptom number and severity from preintervention visit 1 to preintervention visit 2 (P=.438 and P=.519, respectively) and from preintervention visit 1 to visit 3 (P=.546 and P=.436, respectively). 
Conclusion: The results of this study demonstrate the potential of OMM as acute treatment for mild concussion symptoms. OMM was shown to significantly decrease symptom number and severity when participants were treated at the time of their initial concussion diagnosis. Limitations of this study include a small participant population of student athletes with mild concussions, in whom symptoms usually resolved within 72 hours. OMM did not demonstrate a significant difference vs control between visit 1 and visit 2, as well as acutely from before to after the intervention during visit 2, because both groups’ symptoms resolved in the 48-72-hour follow-up period. Over the 1-week period between visit 1 and visit 3, a similar symptom resolution trend was again seen in both groups. Because of these results, further study with larger populations including moderate and severe concussions due to a variety of mechanisms is warranted. Standardization between time of concussion to treatment with OMM and the treatment techniques used by physicians should also be implemented. Through this process, OMM can be validated as an alternative treatment, supplementing the body's capacity to heal itself, to provide relief to concussion patients acutely, as well as decreasing recovery time overall. 
♦★C24—Impact of OMM/OMT
Effect of Pedal Pump Lymphatic Technique on Exercise Recovery After Maximal Exercise 
James Docherty, OMS III; Alexandra Schatz, OMS III; Rebecca Grohman, OMS III; Kristen de Vries, DO; Thomas Chan, DO; Sheldon Yao, DO; Joanne DiFrancisco-Donoghue, PhD 
New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Research Questions/Hypotheses: Pedal pump is an osteopathic manipulative medicine technique used by physicians to increase lymphatic drainage throughout the body. Pedal pump has been shown to increase lymphatic flow and improve immunity. This technique may improve circulation and improve clearance of metabolites after exercise. This study expands on prior research assessing the use of whole-body periodic acceleration (WBPA), a mechanical lymphatic technique, as an improved recovery method following intense exercise compared with active walking recovery. The research compares the pedal pump lymphatic technique with passive supine recovery after maximal exercise. 
Methods: Ten participants (aged 22-30 years, 6 male, 4 female), performed a maximal volume o2 test (Vo2 max) using a Bruce protocol followed by a recovery protocol using 1 minute of walking (2 mph) preceding either pedal pump or supine passive rest for 9 minutes, followed by sitting for 10 minutes. Participants returned on another day to repeat the Vo2 max test to perform the other recovery protocol. Outcome measures included blood lactate concentration (BL), heart rate (HR), blood pressure (BP), and oxygen consumption (Vo2). 
Data Analysis: These markers were measured at rest, exhaustion, and minutes 4, 7, 10, and 20 of the recovery protocols. A 2 ×6 repeated measures ANOVA was used to compare outcome measures. 
Results: No significant differences were found in Vo2 (P=.34), HR (P=.67), SBP (P=.55), or BL (P=.10) between recovery protocols. 
Conclusion: In this pilot project, we found no change in recovery between the pedal pump or passive recovery following maximal exercise. 
Acknowledgment: We thank the NYITCOM Sports Medicine Center, the Department of Osteopathic Medicine, and mentors Dr Joanne DiFrancisco-Donoghue and Dr Sheldon Yao for their guidance and support. 
♦C25—Musculoskeletal Injuries and Prevention
Hamstring Flexibility and Running Injuries in High School Cross-Country Runners 
C.J. Mehallo, DO1; Christopher J. Mehallo, DO1; Ryan Savitz, PhD2 
1Rothman Institute Orthopedics, Drexel Hill, PA; 2Department of Mathematics, Neumann University, Aston, PA 
Hypothesis: Hamstring flexibility is related to injuries in high school cross-country runners. 
Objective: To assess the change in hamstring flexibility and its relationship to lower extremity running related injuries in high school cross-country runners during the course of an 8-week cross-country season. 
Statement of Significance: Flexibility, particularly lack of flexibility, is commonly considered a risk for running-related injuries. There is, however, conflicting information from available studies regarding flexibility and overuse lower extremity injuries, particularly in female athletes. This study looks to increase the body of knowledge on these topics, particularly from the point of view of osteopathic and preventive medicine. 
Methods: Sixty athletes (40 female and 20 male) were enrolled from 2 high-schools in Northern Ohio. Of those, 47 athletes (29 female and 18 male) completed the study. 
Measurements: Hamstring flexibility was measured at the beginning and end of an 8-week cross-country season. Measurements were made by goniometer with the patient supine and the hip flexed to 90°. Injury data were derived from the training room logs of the school's athletic trainer and sports medicine physician. 
Results: Initially, female runners were found to have greater flexibility than male runners. However, male runners were able to significantly increase their hamstring flexibility, while female runners were not able increase their flexibility. For male runners, there was no link between hamstring flexibility and lower extremity running injuries, whereas for female runners, it was found that the more flexible runners were at increased risk of running-related injuries. 
Conclusions: Hamstring flexibility and change in hamstring flexibility does not appear to be a risk for running-related injury in male high school cross-country runners. Increased hamstring flexibility does appear to be a risk for running-related injuries in female high school cross-country runners. Direction for future research could include the use of complete osteopathic structural evaluation to identify other risks for running injuries or the use of osteopathic manipulative therapy to alter hamstring flexibility patterns to reduce the risk of running injuries. 
♦C26—Musculoskeletal Injuries and Prevention
Assessing Energy Intake and Its Effects on Body Composition in Female Endurance Athletes 
Mina Kumari Divan, OMS II; Courtney Baranek, OMS II; Ashley DeLuca, OMS II; Hallie Zwibel, DO; Joanne DiFrancisco-Donoghue, PhD, RCEP 
New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Introduction: Maintaining adequate energy balance during physical activity greatly benefits athletic performance. Energy expenditure is defined as the sum of the basal metabolic rate, thermic effect of food, and energy used during regular daily activity and exercise. High energy expenditure with low energy replenishment can lead to energy deficiency, or restricted energy deficit (RED). In female athletes, the risk of energy deficit is exacerbated by disordered eating, which can be largely affected by the miseducation and pressures of sports that focus on leanness and endurance. Disordered eating includes any eating habits that put the individual at greater risk for triggering energy imbalances. This energy imbalance has been shown to have a negative effect on body composition and leads to body image complications. This imbalance could ultimately affect the athlete's performance and can also lead to higher rates of injury, menstrual dysfunction, and lower bone density. Additionally, osteopathic medicine recognizes the importance of proper energy balance for the body's self-regulatory processes to restore and maintain optimal functioning. Addressing the nutritional status and body composition of female athletes can help osteopathic physicians prevent and treat negative health outcomes. 
Hypothesis: We hypothesized that female runners who are energy deficient would have a higher percentage of fat mass and a lower resting metabolic rate compared with female runners who were not energy deficient. 
Methods: This observational cohort study was conducted at the NYITCOM with the student population. The project was approved by the NYIT Internal Review Board (BHS-1281). All participants provided written consent before participating. Inclusion criteria included females aged 18-25 years, consistent middle distance (training for less than a half marathon) or long distance (marathon or half marathon) runners. Exclusion criteria included any diagnosed metabolic disorder (eg, Crohn disease, irritable bowel syndrome). 
Outcome Measures: Diet: A questionnaire was given to all participants to inquire about food intake over a 3-day period. Participants recorded meal time, meal composition, and the amount of food consumed. Participants were given a reference of standardized portion sizes. We entered the food log into MyFitnessPalto analyze energy intake and the breakdown of macronutrients. Resting metabolic rate (RMR): RMR was recorded by oxygen consumption (Vo2) at rest using a COSMED Quark indirect calorimetry canopy unit. Participants arrived in the morning after fasting and laid on a table wearing a mask that recorded Vo2 for 15 minutes. Body composition: A GE Lunar iDEXA scan was used to analyze body composition, including body weight, body mass index (BMI), lean body body mass (LBM), and percentage of body fat for all participants. Body image questionnaires: A self-assessment questionnaire was given to all participants. The 16-item Body Shape Questionnaire (BSQ-16A) was used to measure body shape–related feelings and eating behaviors over 4 weeks. 
Data Analysis: This pilot study was designed to examine preliminary efficacy. Five long-distance and 5 middle-distance female runners were included in the analysis. We ran a 2-way t test and descriptive statistics to compare body composition, RMR, caloric intake, and body image between long- and middle-distance runners. 
Results: There was a significant difference in body fat percentage between the long-distance and middle-distance runners, with long-distance runners being lower (P=.02). The mean body fat percentage for long-distance runners was 23.44%±3.24, and for middle-distance runners it was 31.34%±5.21. There were no significant differences in LBM, body weight, or BMI between long-distance runners (LBM, 93.68±17.76 lb; body weight, 128.52±21.49 lb; BMI, 21.48±1.40) and middle-distance runners (LBM, 90.64±15.33 lb; body weight, 140.60±24.68; BMI, 23.76±3.86). Based on indirect calorimetry, long-distance runners had a lower RMR (1250.40±224.54 kcal/d) compared with middle-distance runners (1534.60±173.83 kcal/d). Although the difference was not significant, only 1 long-distance runners had a normal RMR, 3 had a slow-normal RMR, and 1 had a slow RMR. Two participants who were middle-distance runners had a normal RMR, 2 had a fast-normal RMR, and 1 had a fast RMR. Interestingly, caloric intake was close between the 2 groups: 1600.40±286.69 kcal/day for long-distance runners and 1681.33±247.90 kcal/day for middle-distance runners. Middle-distance runners had a higher carbohydrate intake (195.87±10.11 g) compared with long-distance runners (153.00 g±34.3 g), while long-distance runners had a higher protein and fat intake (protein, 103.20±38.76 g; fat, 83.20±62.61 g) compared with middle-distance runners (protein, 72.38±8.78 g; fat, 58.99±7.83 g). Looking at average caloric intake, we found that 3 of the 5 participants in both the middle- and the long-distance groups were not consuming enough calories to balance their energy expenditure even before accounting for exercise. Middle-distance runners had a higher BSQ-16A score (42.00±8.89) compared with long-distance runners (34.80±15.02). The average for middle-distance runners was mild concern with shape, and the average for the long-distance runners was no concern with shape. 
Conclusion: In our pilot data, we were able to compile evidence of energy intake and its effect on the body composition of female runners. Our results indicate that long-distance runners had a significantly lower body fat percentage compared with middle-distance runners. Although there was a trend for middle-distance runners to be more on the normal to fast RMR scale and long-distance runners to be more on the slow to normal RMR scale, there was no significant difference between the average RMR for the 2 groups. This finding suggests that there is no energy deficiency difference between the 2 groups that would lead to a difference in RMR. The insignificant difference between the macronutrients consumption of middle- and long-distance female runners may have contributed to the insignificant difference between average RMR. However, the data suggest that female runners in this pilot study were only taking in approximately 200-300 calories above their RMR, which is not enough to maintain the amount of exercise they reported. The food log was a limitation of this study because of the inability to prove that the participants recorded accurately. With future research, we may also be able to identify whether differences in body fat percentage when comparing the groups of middle- and long-distance runners can be attributed to differences in caloric intake. 
♦C27—Osteopathic Philosophy
Attitudes Toward People Experiencing Homelessness Among ATSU-SOMA Students, Physicians, Faculty, And Staff 
Jacob Aaron Allgood, DO1; Kate Whelihan, MPH2; Susan Steffans, DO3; Joy H. Lewis, DO, PhD2 
1Clinical Science Medicine, A.T. Still University, School of Osteopathic Medicine in Arizona (ATSU-SOMA), Mesa; 2Department of Public Health, ATSU-SOMA; 3Department of Family Practice, ATSU-SOMA 
Research Questions/Hypotheses: When evaluating osteopathic medical student (OMS) and educator perceptions and attitudes toward people experiencing homelessness, we hypothesized that initial positive student attitudes would carry forward into clinical training. Furthermore, professional practice and positive trends would exist with the campus-based faculty, staff, and core community health center (CHC) preceptors. Additionally, we believed that osteopathic touch and the use of osteopathic manipulative treatment (OMT) would positively influence student perceptions of homeless patients. Specific research aims included the following: (1) Analyze ATSU-SOMA in Arizona student, faculty, staff, and preceptor perceptions and attitudes toward people experiencing homelessness. (2) Evaluate the perceived impact that participating in direct osteopathic patient care of people experiencing homelessness has on SOMA students. 
Background and Significance: The mission of ATSU-SOMA is to prepare community- and research-minded osteopathic physicians who serve the unmet health care needs of society through innovative, learner-centered undergraduate and graduate medical education. The selection of students, faculty, and staff, as well as curriculum, is geared toward this mission. SOMA is the only US medical school with a distributed, multistate model that embeds all students in CHCs at the onset of their second year. SOMA has a longitudinal curricular emphasis on addressing health disparities. Health care for people experiencing homelessness is a major challenge in the communities. It is important as medical educators to address the complexities and health disparities in delivering care to this population. Unfortunately, research suggests medical student attitudes toward people experiencing homelessness change negatively as they progress to graduation. Negative attitudes appear to progress and are more prominent among teachers than learners. This highlights the potential problem of physician/mentor attitudes affecting student development. Studies have shown improvements in these attitudes among trainees participating in specific education programs with direct care of people experiencing homelessness. Progress has been made in meeting medical student competencies addressing health care for the homeless, but more work is needed. This study assesses important information on the impact of SOMA's unique training model and opportunities to improve specific trainee outcomes. 
Methods: The validated Health Professional's Attitude Towards the Homeless Inventory (HPATHI) was used to obtain longitudinal data at the end of the 2016 and 2017 academic years. A pre- and postsurvey design was used to compare student progression of attitude through each year of medical school (approximately 108 students per class). Campus-based faculty, staff, and CHC core preceptors were also evaluated in May 2016. HPATHI surveys were distributed by email through Qualtrics with each respondent receiving a personalized link to complete the survey. To compare pre- and postsurvey results, respondent email addresses were linked to a randomly assigned identification number. To explore attitudes of OMS IV providing osteopathic care to patients experiencing homelessness, narrative case reports provided specific instances of how students believed their care affected the patient. Further, students explored how their experience providing osteopathic care affected their own attitudes toward this patient population. Informed patient consent was obtained to write each case report. This study was granted IRB exclusion by the ATSU IRB. 
Data Analysis: Repeated measures analysis of variance was used to compare SOMA student responses for each survey item on the HPATHI over time and to assess differences in these responses between students, faculty (clinical and non-clinical), staff, and CHC physicians. Student-perceived influential experiences were tabulated and associated with HPATHI responses using t tests. SOMA student responses were further compared with reports regarding other health profession students from published literature also using the HPATHI. Qualitative data obtained from narrative case reports that describe the OMS IV experience in the Healthcare for the Homeless rotation were reviewed by investigators to prepare a descriptive report on the perceptions of OMS IV providing direct osteopathic care. 
Results: No significant differences in reported attitudes between each OMS class were found for 25 of the 29 items included on the HPATHI. Only 4 items were found to be statistically different between classes. Overall, these results showed attitudes remained positive over all 4 years. When compared with faculty, staff, and clinical preceptors, students were found to mirror the attitudes of faculty and preceptors. SOMA clinical faculty differed when compared with Canadian emergency medicine faculty on 4/18 questions, where 3/4 questions showed SOMA clinical faculty reported more positive attitudes. When compared with Canadian medical students, SOMA students differed on 7/18 items for OMS I and II and 5/18 questions for OMS III and IV. All questions except 1 for OMS III and IV showed SOMA students had more positive attitudes. Report of positive experiences with homeless populations showed 83% to 89% agreement with positive attitudes for OMS I to III and 62% for OMS IV. Overall, students reported a positive experience when providing osteopathic care to patients experiencing homelessness. All students experienced the impact of hearing a patient's story and identifying social determinants of health. Several students found even a single OMT treatment effectively provided acute and chronic pain relief. Students also found a multifactorial benefit to osteopathic care and touch, and the improved rapport it created resulted in a true osteopathic experience treating mind, body, and spirit. 
Conclusion: The data are consistent with our hypothesis that SOMA's emphasis on service to the underserved and our unique curricular model of embedding students in CHC settings may help counter the progression of negative attitudes toward homelessness. Further, SOMA student attitudes consistently proved positive when compared with what has been observed in prior traditional medical education studies. The data also underscore the importance of faculty mentoring, for not only the clinicians but also nonphysician faculty, suggesting that all mentors can have a tremendous impact on the learners’ attitudes and perceptions. We plan to continue to track these attitudes as we follow the class of 2019 and 2020 through graduation. We will also include case report details from individual students providing osteopathic care to people experiencing homelessness. This will include specific student reflections on the effect of direct osteopathic manipulation of patients experiencing homelessness. The overall themes expressed by the students reflect a more complete and satisfying patient care outcome and improved osteopathic training experience. 
Support: We received a total of $5000 over the 18-month project period (07/01/16–12/31/17) as a grant from the American Association of Colleges of Osteopathic Medicine. We also had direct personnel support from A.T. Still University and Circle the City Medical Respite Center. 
♦C28—Osteopathic Philosophy
The Other 45 - Students Teaching Patients to Improve Student Confidence and Produce Better Patient-Centered Communication 
Deanna Marie Plewa, OMS I; Luke Johnson, DO; Margaret Claire Caudell, DO; Alexis Stoner, PhD, MPH; Matthew Cannon, DO 
Edward Via Virginia College of Osteopathic Medicine, Spartanburg, SC 
Background: A review of the literature illustrates the importance of educating medical students about teaching principles and then giving them opportunities to practice their skills by teaching a patient without a medical background. Teaching has been shown to be an effective strategy to help students better acquire and apply knowledge (Pasquale and Pugnaire, 2002). However, medical school curriculums do not typically include formal training on teaching principles, and most medical students enter residency without confidence in their teaching abilities (Dandavino et al, 2007). Additionally, having a high level of confidence as a student is essential to a future physician's ability to communicate with patients (McNair et al, 2016). Giving students the opportunity to teach patients about diseases has been shown to increase the medical student's confidence in his or her level of medical knowledge and ability to provide patient-centered communication (McNair et al, 2016). One study showed third-year medical students talking to their patients and discussing their disease states had a positive impact on the students’ views of patient-centered communication (Saba et al, 2014). To provide students with the opportunity to learn and apply these teaching principles within a primary care setting, The Other 45 was developed. Typically, a physician is scheduled 15 minutes for each patient encounter. This is often not enough time to ensure that patients have developed an adequate comprehension of their medical condition and how to best manage their health. The Other 45 allows a patient with a chronic medical condition to meet with a second-year osteopathic medical student (OMS II) for an additional 45 minutes to discuss his or her diagnosis, prescriptions, and other preventive health measures. This meeting will hopefully improve the patient's health outcomes and chronic disease self-management and allow both the patient and the student to gain a fuller understanding of that disease. This study was conducted to determine the benefits of this program for an OMS II and understand that teaching patients can improve the skillsets of future physicians. Specifically, this study sought to assess a student's ability to provide patient-centered care, confidence in a clinical setting, and basic knowledge of chronic disease processes. Osteopathic medical education is constantly evolving to produce well-rounded physicians who are capable of providing the highest standard of care. An integral part of providing that care is the ability of physicians to communicate effectively with their patients. To treat each patient as a whole, medical students must develop the ability to articulate complex disease states at an appropriate level with each patient. This project examines OMS II who are integrating their knowledge of certain disease states into a one-on-one dialogue with patients. This study provides data on how an early clinical experience program, The Other 45, positively affects students' confidence and its potential as a tool in further improving osteopathic medical education and patient-centered care. 
Hypothesis: After OMS II are formally instructed on basic teaching principles and then participate in The Other 45, the students will report increased confidence in a clinical setting, increased ability in providing better patient-centered communication, and improvement in their basic medical knowledge of chronic obstructive pulmonary disease, diabetes, or hypertension. 
Methods: All currently enrolled OMS II who were scheduled to participate in The Other 45 (120 students) were eligible and recruited to participate in the study. The project took place during an established Early Clinical Experience curriculum through the Edward Via College of Osteopathic Medicine. Before starting data collection, this project was approved by the Institutional Review Board. Each Friday, 2 students were sent to 1 of 3 underserved clinic sites participating in The Other 45. Before their assigned clinic day, students were given a formal presentation on proper teaching principles. At the clinic site, the students were allowed to meet one-on-one with a patient under the supervision of a faculty member. Using a provided script with simplified graphics, explanations, and their own medical knowledge, the students educated the patients on their chronic diseases for 45 minutes. The sessions consisted of discussing the cause of the patients’ chronic disease states, reviewing and understanding their medications, and ensuring the patient could comprehend the important information points. The students’ confidence in both patient-centered communication and knowledge of the disease processes were measured before and after participating in The Other 45 using a survey adapted from previously validated measures including the Patient-Practitioner Orientation Scale, the Harvard medical school Cambridge Integrated Clerkship evaluation, and the C3 instrument—Communication, Curriculum and Culture. The first 2 domains of the survey were obtained directly from these resources, and the third domain was adapted to fit this current study. 
Results: A total of 69 students participated in this study. The results of the pre- and postsurveys were analyzed using paired sample t tests. The survey was divided into 3 domains: patient-centered care, confidence in a clinical setting, and medical knowledge. Analysis of each of the 3 domains yielded statistically significant results. With P values of .023, <.001, and .004 respectively, the 3 domains showed significant increases in the students’ reported ability to provide patient-centered care, their confidence in the clinical setting, and their medical knowledge. All aspects of the confidence domain measured by this study provided statistically significant increases with P values ranging from <.001 to .007. 
Conclusion: The positive impact and benefit gained by the students that participated in The Other 45 is a direct example of why early clinical experiences must be included in all medical school curriculums. In addition, OMS II are an excellent resource to bridge the gap between the short time a physician has to spend with a patient and the patient's comprehension of their disease process. The wide focus of the primary care clinic provides OMS II with an excellent opportunity to become more comfortable talking to patients on their level of understanding and allows the students to better realize the importance of patient-centered care. While scheduling patients and students to be at the clinic at the same time was a limitation to this program, further studies should allow a more flexible model to ease the burden of scheduling. Future research should focus on measuring objective improvement in medical knowledge rather than subjective improvement in the student's confidence in their knowledge. As future physicians, OMS II should be allowed ample opportunity to improve their patient interactions, and programs like The Other 45 will fill this need. 
♦★C29—Osteopathic Philosophy
FIT-PHYSICIAN: The Use of Wearable Technology Combined With Physical Activity Education in Medical Students: A Randomized Clinical Trial 
Alexander M. Stangle, OMS IV; Jerry Balentine, DO; Min-Kyung Jung, PhD; William Werner, PT, EdD; Hallie Zwibel, DO; Patricia Happel, DO; Joanne Donoghue-DiFrancisco, PhD 
New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Introduction: Healthy People 2020 has called for an increase in the number of physician office visits that include counseling or education related to physical activity. The American College of Sports Medicine (ACSM) has also implemented a program, Exercise is Medicine, to encourage physicians globally to assess a patient's activity level at every visit. Although these trends are encouraging, there is a decline in the amount of education provided to medical students. Current literature supports the notion that medical schools should incorporate pilot programs that include physical education, nutrition, and well-being in medical schools. More than 1 in 10 adults now wear an activity tracker, and the ACSM consensus states that activity trackers are the hottest new trend for 2017. Activity trackers are widely used to track and promote physical activity in a variety of settings. These devices are currently used by employers, insurance companies, and researchers to help promote fitness. It has been reported that physical activity habits of medical students influence their counseling practices after graduation. However, there is a heavy demand of academic workload that makes it more difficult for these students to maintain a regular exercise program. Integrating wearable technology and fitness education into osteopathic medical training may provide opportunities for medical students to develop knowledge on healthy habits and maintenance of healthy behaviors. 
Hypothesis: Our primary hypotheses was that using an activity tracker plus education would improve step count more than using an activity tracker alone. Secondarily, we hypothesized that body composition would improve in the activity tracker plus education group rather than just the activity tracker alone group or the control group. 
Methods: FIT-Physician was a randomized clinical trial conducted at the NYITCOM from August 2016 through June 2017. This study was approved by the NYIT Internal Review Board and was registered on Identifier: NCT02778009. 120 first-year osteopathic medical students enrolled at NYITCOM provided written informed consent. Eligibility was assessed by a self-reported web-based questionnaire beginning in July 2016. Eligibility criteria included (1) age between 17-50 years and (2) incoming first-year medical student. Exclusion criteria included (1) pregnancy and (2) current use of an activity tracker. In this 39-week study, 120 first-year medical students were randomly assigned, with stratification by sex and age, to one of 3 groups. The first group (Fitbit-plus) (Fitbit Flex, Fitbit Inc,) wore activity trackers and were offered to participate in mentored weekly walk/runs that were conducted by faculty of the medical school. Weekly emails were sent offering small fitness challenges to try and increase step count. The second group (Fitbit only) received only activity trackers and were not able to attend these lectures and were not informed of the weekly walks/runs. The third group (Control) were asked not to purchase an activity tracker of any kind throughout the duration of the study. Step count was measured weekly for 39 weeks using a Fitbit Flex wrist-worn activity tracker for the Fitbit-plus group and the Fit-bit only group. A web-based dashboard designed for collecting mass data from this particular tracker (Fitabase, © 2015 Small Steps Laboratories LLC) was used to collect individual daily step counts. Fat mass, body fat percentage, weight, lean body mass, and body mass index (BMI) were assessed using dual-energy x-ray absorptiometry from a total body composition scan (Lunar I-Dexa scan General Electric). All groups had body composition analyzed in August before the start of the academic year using a GE Lunar DEXA scan (General Electric) and then had a final body composition scan in June at the end of their first academic year. Blood pressure was assessed using a Baumanometer (W.A. Baum Co Inc) upright mercury sphygmomanometer. 
Methods: We estimated that a sample size of 40 participants per group (120 participants overall) would provide 80% power to detect a mean (±SD) clinically importance difference in step count. A repeated measures design was used to determine significance (P=.05). 
Results: Baseline measurements were significantly different between males and females; therefore, baseline measurements were done by group. Step data were the primary outcome of this study. As a whole, the mean daily steps are significantly different between Fitbit plus and Fitbit only (6550 vs 5339, P<.001). For the duration of the 9 months (39 weeks), the mean daily steps are significantly different between males and females (5686 vs 6203, P<.001). An interaction between group and sex was significant (P<.001): In the Fitbit Plus, females (7296) showed more daily steps than males (5805). In Fitbit Only however, males (5568) showed more daily steps than females (5110). Without considering any covariates, the 3 groups were not significantly different with postmeasurements at α=.05. In females, however, with body fat percentage and systolic BP, groups differed noticeably (.05 < P<.10). However, considering the variability of the participants within this study, participants were separated by ACSM's classification of body fat percentage. When controlling for this, the number of days exercised was significantly higher in the overweight females in Fitbit Plus group compared with overweight females in Fitbit alone and controls. There was no difference between lean/average females between group or from before to after the study. When comparing BMI, overweight females in the Fitbit plus group had a significantly lower BMI compared with overweight females in Fitbit alone and control groups. Overweight females in Fitbit plus also had lower weight (kg) compared with overweight females in Fitbit alone and controls. The lean/average females in Fitbit plus had greater lean body mass than the lean/average females in Fitbit alone, and the lean/average females in Fitbit alone had higher lean body mass than the lean/average females in controls. There was no change or difference in % body fat, weight, or BMI in the lean/average females within group and between group. The overweight males in Fitbit plus and Fitbit alone showed significantly higher lean body mass when compared with control overweight males. There were no significant differences found in lean/average male for any outcome measures, and there was no change in body fat percentage, BMI, or weight within or between groups when comparing overweight males. 
Conclusions: our study showed that using activity trackers while incorporating education on physical activity and nutrition improved upon health outcome measures in overweight osteopathic medical students. Wearable technology in conjunction with education and fitness challenges may positively influence future physicians while helping them to provide informed recommendations on activity monitors and their expectations to their patients. This pilot program may serve as a guide for other osteopathic medical schools to implement education and physical activity into their curriculum. 
Support: In-house grant from NYITCOM. 
♦C30—Osteopathic Philosophy
Student Application of Osteopathic Manipulative Medicine (OMM) During Third-Year Rotations 
Lyudmila Burina Ganatra, OMS V; J. Christian Belisario, OMS III; Michael Terzella, DO; Wolfgang Gilliar, DO; Sheldon Yao, DO 
Department of Osteopathic Manipulative Medicine, New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Background: The osteopathic medical profession has evolved from a form of medical practice using exclusively osteopathic principles and practices (OPP) in the 19th century to a modern system that uses OPP in addition to all conventional methods of diagnosis and treatment. As classroom instruction and laboratory hours have been condensed to include coverage of the vastly expanding base of medical knowledge in the basic and clinical sciences, osteopathic manipulative medicine (OMM) training has shifted to the periphery of osteopathic medical education. Many premedical students now apply to osteopathic schools as an alternative to the MD route, without a sincere interest in osteopathic philosophy or the intention to incorporate OMM into their future practice. The loss of osteopathic focus in DO training is illustrated by a 2001 survey of osteopathic physicians, which reported that more than 50% of respondents used OMM on less than 5% of their patients, and most prescribed medications or surgery as first-line treatment. To maintain distinctiveness in osteopathic medical education, it is critical to implement a distinctive undergraduate curriculum in the first 2 years that will promote continued OMM use throughout clerkships, internships, and residency. An analysis of the OMM techniques used and the clinical context in which OMM is performed by osteopathic medical students during their third- and fourth-year clerkships can serve as a metric of efficacy of the existing osteopathic medical curriculum while offering critical insights into opportunities for curricular improvement and modification. 
Hypothesis: We hypothesized that third-year medical students at NYITCOM would choose to use OMM techniques most frequently in the adult primary care setting (family medicine) and would prefer to use techniques in which they received the greatest cumulative hours of instruction throughout the first 2 years: myofascial release (MFR), balanced ligamentous tension (BLT), and muscle energy (ME). 
Methods: This study was approved by NYITCOM Institutional Review Board (BHS-1253). All thirdyear medical students at NYITCOM were required to perform OMM during at least 10 supervised patient encounters throughout their third-year clerkships between August 1, 2016, and May 25, 2017. Each student could complete the encounters during 1 or more clerkships of their choice (internal medicine, family medicine, psychiatry, obstetrics-gynecology, pediatrics, surgery) and could use the technique of their choice on any patient they chose. Each student was required to submit an online log to document each patient encounter. Information collected included time, rotation, patient sex, patient age, chief complaint, regions treated, technique performed, osteopathic treatment model, patient ability to tolerate technique, student-perceived effect of OMT administered, pain level before treatment, pain level after treatment, and contact details and signature of supervising physician. All data were deidentified before analysis, and results were downloaded directly into an Excel spreadsheet. Any logs with incorrect or incomplete data fields were excluded from analysis. All data analyses were performed in the Matlab programming language. 
Data Analysis: All data were deidentified and uploaded into Matlab from Excel. All fourth-year students and academic medicine scholars were excluded from the analysis. The total logs and total techniques submitted by third-year students were calculated. The number of times each technique was used was calculated, as well as the percentage of time each technique was used. The total logs submitted by students during each clinical rotation were calculated. All data were graphed using the Chart plug-in tool in Matlab. 
Results: Data were collected and analyzed for 2980 logs and 5904 individual OMM techniques. Each self-reported OMM technique was used at the following frequency and percentage of time: myofascial release (n=1908, 32.3%); balanced ligamentous tension (n=749, 14.2%); muscle energy (n=812, 13.8%); articulatory (n=725, 12.3%); cranial (n=262, 4.4%); counterstrain (n=308, 5.2%); facilitated positional release (n=214, 3.6%); high-velocity, low-amplitude (n=137, 2.5%); Still technique (n=22, 0.38%); lymphatic (n=226, 5.1%); visceral (n=101, 1.7%); PINS (n=3, 0.20%); ganglionic inhibition (n=4, 0.1%); sinus drainage (n=8, 0.1%); thoracic outlet release (n=59, 0.69%); Spencer Technique (n=30, 0.51%); suboccipital release (n=79, 1.0%); paraspinal inhibition (n=24, 0.41%); Galbreath technique (n=14, 0.2%); and sacral rock (n=12, 0.2%). The number of logs submitted by rotation were as follows: family medicine (n=1877, 63%), internal medicine (n=566, 19%), pediatrics (n=178, 6%), surgery (n=119, 4%), and psychiatry (n=30, 1%). 
Conclusion: The 3 most common techniques used by osteopathic students on third-year clerkships were myofascial release (n=1908, 32.3%), balanced ligamentous tension (n=749, 14.2%), and muscle energy (n=812, 13.8%). These results correlated with the techniques that received the greatest number of hands-on instruction hours during the firstand second years of medical education and was consistent with our hypothesis. The most common rotation during which OMM was performed was family medicine and, also consistent with the hypothesis, OMM was most commonly performed in the adult primary care setting. These results indicate that hands-on instruction in specific techniques likely increases student comfort in independently using these maneuvers. Additional research into the most common techniques used by physicians in primary care settings can provide further insight into techniques that need additional hours of training or in which training is likely not as effective. For example, only 5.2% of the total techniques used were counterstrain techniques, although 20.1% of the total preclinical OMM hours are currently devoted to teaching counterstrain. This disproportionate relationship may indicate that the current methods used to teach counterstrain techniques are not effective, and this portion of the curriculum requires correction. 
Acknowledgment: We thank the Osteopathic Manipulative Medicine Department at NYITCOM for their assistance with log creation, distribution, and data collection. 
♦★C31—Osteopathic Philosophy
Pressure Variances in the Diagnosis of Lumbar Somatic Dysfunctions 
Elizabeth George, OMS IV; Nicole Angelo, OMS III; Navya Voleti, OMS II; Michael Gaspari, OMS II; George Cheriyan, DO; Sheldon Yao, DO 
New York Institute of Technology College of Osteopathic Medicine (NYITCOM), Old Westbury 
Research Questions: In the clinical practice of osteopathic medicine, palpatory skills are an essential diagnostic tool, often implemented in the physical examination to assess for somatic dysfunctions. During the first 2 years of osteopathic medical education programs, students are taught from experienced osteopathic physicians how to develop their palpatory skills and apply them for diagnostic and treatment purposes. Students further refine their skills during 2 years of clinical rotations and with their own patients as they continue to practice medicine. The use of pressure measurements has been used in similar fields of research to evaluate the pressure needed to reach pain at a trigger point and pain in various muscles. However, amount of pressure used during osteopathic palpation has not been well defined. Specifically, the authors wish to quantify the pressure applied in diagnosing somatic dysfunction. Identifying this pressure can contribute to osteopathic medical education and help identify potential differences between skill ranges of osteopathic examiners. The palpatory pressure used by examiners was measured objectively with the TekScan tool. The TekScan system has been used to gauge pressure in various areas of medical research but not to assess palpation forces. We hypothesized that the time taken to reach a diagnosis and the magnitude of pressure used during palpation while diagnosing will decrease as participants progress through clinical training. 
Methods: This study was approved by the NYITCOM institutional review board BHS-1120. The inclusion criteria required that participants be currently attending or have successfully graduated from an osteopathic medical school. All participants read and signed the consent form before participation. One person was recruited to be a “model” for the study and consented to serving as the model for the duration of the study. For data collection, the model laid prone on the examination table, and an investigator confirmed the location of the L5 lumbar segment with ultrasonography. TekScan pressure sensors were placed in the lumbar region and secured with velcro. Two physicians board certified in neuromusculoskeletal medicine/osteopathic manipulative medicine (NMM/OMM) confirmed an L5 somatic dysfunction diagnosis. Each participant was asked to approach the patient on their dominant side and diagnose L5 documenting the flexion/extension, side bending, and rotation. The TekScan sensors were used to record the pressure used by participants on the L5 transverse processes from the moment they began to palpate the patient. 
Data Analysis: Twenty-one participants were included in the analysis: 11 participants were students (OMS I, OMS II, and OMS III), and 10 participants were attending physicians in the OMM and family medicine department. Fischer exact tests were used to analyze differences in L5 diagnoses based on experience levels. Point biserial correlation tests were performed to analyze differences in peak and average pressure used during diagnosis. An independent samples t test was performed to analyze differences in time taken to reach a diagnosis based on experience levels. 
Results: Participants with an L5 diagnosis corresponding to the diagnosis made by the 2 attending physicians had less of a difference in peak force, mean difference 62.50 g/cm2, between their contact points (right vs left hands) vs those participants with a differing L5 diagnosis from the 2 physicians (mean difference, 319.38 g/cm2). The difference between the average force used between contact points resulted with the same finding. Participants with the corresponding L5 diagnosis had a smaller average difference (16.81 g/cm2) between the average pressure in their right and left contacts vs those who did not, an average difference of 123.92 g/cm2. There was no significant differences between attending physicians and students in the accuracy of the diagnosis of L5 (P=.387) or time taken to reach a diagnosis (P=.199). However, these values were trending toward significance as participant numbers increased. 
Conclusion: Our findings demonstrated no statistical significance in accuracy and pressure use and time to diagnosis with experience level. However, diagnosis accuracy corresponded with participants who used a more equal force in both contact points. These results suggest that accuracy of diagnosis can potentially be improved with the use of pressure sensors so students and physicians can learn to use a more equal pressure when palpating. Future studies should be conducted to further evaluate time to diagnosis, level of training, diagnostic accuracy, peak pressure used, and variance in pressure between hands with a greater sample size. 
♦★C32—Pain Management
Changes in Children and Parental Emotional Behavior Determine Long-Term Outcomes for Children With Chronic Pain Following Interdisciplinary Pain Management Program 
Cara Vernacchia, OMS III1; Marwan N Baliki, PhD2; Rami Jabakhanji, PhD2; Diane Amstutz, PhD2; Gadi Revivo, DO2 
1Touro University College of Osteopathic Medicine-CA, Upland; 2Northwestern University, Chicago, Illinois 
Research Question/Hypotheses: Chronic pain in children is a serious issue, affecting up to 25% of children at some point during childhood, and can lead to decreased social interactions, school absences, and impaired academic performance. In addition to physiologic, psychologic, social, and environmental factors, parental anxiety is believed to contribute to the development and maintenance of chronic pain in their children. Although parental behavior has been shown to influence a child's chronic pain experience, parents are generally only minimally involved in the child's treatment. More research is needed to elucidate which aspects of a parent's behavior contribute most negatively toward the child's pain to identify targets of treatment. We examined the role that parental functioning plays in children with various chronic pain conditions and the course of their recovery during an interdisciplinary pain management program. We assessed both child and parental functioning using the Bath Adolescent Pain Questionnaire (BAPQ) and the Bath Adolescent Pain-Parental Impact Questionnaire (BAP-PIQ). We hypothesized that (1) children with different pain diagnoses will show different baseline characteristics and responses to treatment, (2) all pain groups will positively respond to the comprehensive treatment program and display a decrease in pain and BAPQ scores, and (3) children who still show a positive response to treatment at long-term evaluation have parents with higher emotional functioning. 
Statement of Significance: Chronic pain can be debilitating for children physically, mentally, and socially. From an osteopathic perspective, treating the whole patient involves addressing the social, psychological, and environmental components of a patient's pain experience, in addition to prescribing pain medications. 
Methods: This was a retrospective chart review of children and adolescents (n=144, aged 8-18 years) with chronic pain who were treated in an interdisciplinary pain management program that included physical therapy, occupational therapy, cognitive-behavioral therapy, and physician visits. Demographic data, pain intensity, BAPQ, and BAP-PIQ scores were acquired from patient records at 3 time points: evaluation 1 (baseline), evaluation 2 (after treatment), and evaluation 3 (long-term follow-up). Patients were placed into 1 of 6 diagnostic groups: complex regional pain syndrome (CRPS), abdominal pain, back pain, hypermobility, headache, and fibromyalgia. We used 1-way ANOVA tests to evaluate differences between chronic pain groups at baseline and after treatment. Using 2-tailed t tests, we compared baseline pain intensity and functional scores to posttreatment outcomes. Associations between child and parental outcomes were determined using correlation analyses. We assessed the efficacy of treatment in determining successful long-term outcomes (defined as >30% improvement in pain and function 2 months after treatment) using logistic regression analysis in a subgroup of patients (n=25) and tested it on another group (n=26). The institutional review board reviewed and approved this study. 
Results: At baseline, children's function and parental behavior in all diagnostic groups had similar pain intensity and functional scores. Following treatment, all children showed significant improvements in pain and physical and emotional functioning. Parents also showed improvements in behavioral and emotional functioning. Interestingly, despite improved pain and function, changes in pain and function showed little correlation, indicating separate mechanisms. Future functional outcome was predicted by changes in parental self-blame and child emotion during treatment, with 84% success rate. On the other hand, only pain reduction during treatment was significantly related to pain outcome at long-term follow-up. 
Conclusions: Despite the varied pathophysiologic characteristics of chronic pain disorders in children, all have similar baseline pain intensity and functioning levels. Patients of varying chronic pain diagnoses can all benefit from an interdisciplinary pain management program. The biggest predictors of positive long-term outcomes are a child's emotions and parental self-blame. Treatment for chronic pain in children should address these components and involve the parents in therapy to decrease their levels of self-blame and improve long-term outcomes. 
Health Services
♦H1—Chronic Diseases and Conditions
Determining the Predictive Factors Leading to Intra-Hospital Transfer to Higher Level of Care or to Intensive Care Unit Among Rapid Response Activations at a Community Hospital Within a Consecutive 12-Month Period 
Jimmy Tam Huy, Pham, MA, MHS, OMS II1; Dong Dang, MD, PharmD2; Christopher Doig, DO3 
1Department of Internal Medicine, Michigan State University College of Osteopathic Medicine (MSUCOM), Livonia; 2Sleep Disorders Centers, University of Michigan, Ann Arbor; 3MSUCOM, Garden City 
Objective: To determine the predictive factors leading to higher level of care or intensive care unit admission among rapid response activations at a community hospital within a 12-month period. 
Methods: Retrospective data of patients aged 8 years or older who had an RRT intervention in a 12-month period in 2016 were examined. 
Data Analysis: Data were analyzed using the Pearson χ2 test and multinomial logistic regression model. 
Results: A total of 324 rapid responses were activated during the 12-month period in 2016. The mean age of RRT patients was 68.1 years (range, 18-101 years), 107 (32.8.%) were men and 219 (67.2%) were women. 
Conclusion: RRT activations with multiple reasons appear to be a strong predictive factor for likelihood of intrahospital higher-level care transfer or ICU admission. In the multinomial regression model, RRT activations with multiple reasons and duration of RRT were strong predictors of transferring to a higher level of care. Age, sex, primary reason, duration of RRT activation, and month do not appear to be predictive factors. 
♦H3—Chronic Diseases and Conditions
Extrinsic Factors in the Prevalence of Chronic Disease 
Mehar Ghei, OMS III; Adarsh Gupta, DO, MS 
Department of Family Medicine, Rowan School of Osteopathic Medicine (RowanSOM), Blackwood, New Jersey 
Hypotheses: This IRB-approved study evaluates the general health of the public by contrasting the diet and level of physical activity among civilians throughout the United States and compares the data with the prevalence of chronic disease specific to the region to determine where interventions may be required. The investigators hypothesize that regions lacking accessibility to healthy food and physical activity will illustrate a greater prevalence of chronic disease among civilians and may require statewide interventions. 
Methods: Data exemplifying physical activity, diet habits, and chronic disease prevalence was attained from the 2014 database. The data illustrate that the United States has a varying prevalence of obesity and chronic disease specific to the respective regions based on the extrinsic factors that shape the civilians’ lifestyle. According to CDC data, several aspects regarding one's environment may hinder an individual's opportunity for health-improvement resources: state regulations on food, crime rates, walkability of the region, and access to physical activity facilities and nutritious food. 
Data Analysis: The data were obtained from the database, categorized into geographical regions via Microsoft Excel, and then imported into SPSS for statistical analysis. Because many of the general health indicators were reported as percentages, post-hoc tests were applied to these variables to attain the mean values that represent univariate analysis of variance among states specific to the regions. The various regions’ health data were compared using 1-way analyses of variance with the continuous data, such as the prevalence of inactivity, diabetes mellitus, heart disease, and obesity per state. Spearman ϱ tests were performed to determine the correlations between the categorical data reflecting various aspects of fitness and chronic disease. Discriminant function and log-linear models were used to determine the significance of each health indicator and its relevance to the specific region. 
Results: The prevalence of obesity, heart disease, and diabetes mellitus illustrate the same statistical trends as prevalence of physical inactivity and inadequate nutrition in diet. According to CDC data, there is a higher population of adults not engaging in leisure time physical activity in the Southern and Midwestern US regions. The South and Midwest also have the lowest population of adults who are aerobically active 150 minutes daily. In contrast, the Western and Northeastern regions have a lower population of adults who do not engage in leisure time physical activity and a higher population of adults aerobically active 150 minutes daily. The Northeast and West also have the highest prevalence of adults meeting aerobic and muscle strengthening guidelines, whereas the Midwest and South have the lowest percentage. In regard to dietary habits of the civilians within the regions, it is apparent that Southern and Midwestern states have higher populations of citizens receiving inadequate nutrition. Adolescents in the South and Midwest regions drink a significantly greater amount of soda and higher populations of adults in the South and Midwest regions are consuming less than 1 fruit and vegetable per day. This pattern is similarly illustrated in chronic disease prevalence, as heart disease death rate, obesity, and diabetes mellitus are highest in the South and Midwest regions. The West and Northeast however, continuously display the lowest prevalence in chronic disease, which implies that the citizens within the region have adapted to a healthier lifestyle in comparison. Western and Northeastern regions display a higher prevalence of farmers’ markets, greater population of adults eating fruits and vegetables daily, and a lower prevalence of chronic disease. These data suggest that areas with a high prevalence of chronic disease, such as the South and Midwest, will most definitely benefit from an increased accessibility to farmers’ markets. Furthermore, a significant extrinsic factor which must be addressed is the violent crime rates within regions, as they greatly affect a civilian's ability to engage in an active lifestyle by limiting access to outdoor activities. Crime rates are highest in the South, as is prevalence of chronic disease. This finding exhibits the influence of neighboring and environmental factors on the general health of the public in a respective region. 
Conclusion: The data for adults who are generally active are indirectly proportional to chronic disease prevalence, which confirms the importance of physical activity in one's daily lifestyle. Similarly, the prevalence of adults who are inactive is significantly and directly correlated to the prevalence of obesity, heart disease death rates, and diabetes mellitus, suggesting that increasing accessibility to fitness centers in Southern and Midwestern regions would be beneficial. Last, the Southern United States would significantly benefit from investing in advancing their crime protection services, as it would allow their civilians to incorporate more physical activity into their daily lives and thereby decrease the prevalence of chronic disease. 
♦H4—Chronic Diseases and Conditions
Population and Needs Assessment of Migraineurs Treated by Reading Health System 
Lauren Chamberlain, OMS IV2; Haley Powell, OMS II1; Richard L Lukose, DO3 
1Alabama College of Osteopathic Medicine, Dothan; 2University of North Texas Health Science Center Texas College of Osteopathic Medicine, Reading, PA; 3Philadelphia College of Osteopathic Medicine, Pennsylvania. 
Introduction: Migraine headaches are a common chronic condition that contributes to a significant amount of disability and economic burden. Through this study, we aimed to identify the patient population that is using the emergency department (ED) for chronic migraine treatment within the Reading Health System (RHS). We propose that this portion of our population is relatively undertreated and undereducated regarding efficacious and low-cost preventive and rescue therapies, and therefore they tend to rely on higher-cost and less satisfying headache treatment. This is the first step in a multidimensional study to help the RHS design strategies and service-lines to reduce the need for recurrent ED visits for breakthrough migraine headaches. Our primary goals in this descriptive study were to identify the demographic pattern of patients with migraines at RHS who overuse the ED for management of headaches and to identify gaps in their migraine management so that we could deliver resources designed to bridge these gaps. We believe this will result in reduced disability and economic burden and increase patient satisfaction for this population. 
Methods: We conducted congruent and retrospective medical record reviews of men, women, and children of all ages presenting to the ED with a severe headache. Potential participants were selected based on a thorough review of their current visit and history by means of Epic electronic medical record software. If appropriate, once patients had been evaluated by a physician and the necessary testing to rule out life-threatening conditions had been completed, a research team member would review the patients’ record, visit them in the examination room, ask for their consent, and conduct a verbal interview. Questioning took approximately 10 minutes and involved their current headache, headache history, migraine medications, and medical history. Potential participants who were unable to be contacted in person were called within the following 3 days, and interviews were conducted via telephone. All interviewed participants were asked the same set of standard questions by a single interviewer. There were 2 research team members assigned to conduct interviews over the course of this study. Patient care during their visit was not affected by the interview, as the treating physicians and nursing staff were not involved in data collection. Data were collected manually and then sorted and evaluated electronically using programs such as Numbers, Microsoft Excel, and PowerPoint. We primarily used descriptive statistics and graphics to organize and analyze the data. Comparisons were made between the data, population demographic data, and peer-reviewed articles. The study was reviewed by RHS Research and Academic Affairs Department and it was determined that it did not require IRB review. 
Results: To date, we have surveyed 103 patients that were seen in the ED. We found that the patients presenting to RHS for a headache ranged from the ages of 10-80 years, with the majority (64%) being females aged 21-50 years. The patient population predominantly (52%) consisted of Hispanic descent. Thirty-nine percent of participants contacted a medical provider and were instructed to go to the ED, and 26% normally sought headache treatment by a neurologist. Only 34% were using prescription rescue medications, and nearly half reported using over-the-counter medications. Prophylactic prescription headache strategies were used by just 34% of those surveyed. Of the patients with migraines who met status for chronic migraine, 25% were treated by a neurologist, 28% were managed by their primary care physician, 19% were using appropriate prescription prophylactic treatments, and 25% were using appropriate prescription rescue medications. Of the 36 participants surveyed by interview, 24 met criteria diagnostic criteria for chronic migraine or considered their condition chronic. Of those 24 participants, 64% and 68% of these patients suffered from anxiety and depression, respectively. 56% reported sleeping issues such as insomnia and sleep apnea. Upon comparing the actual vs expected body mass index (BMI) values, it was evident that there was a trend toward a higher incidence of obesity and morbid obesity in patients presenting to the ED for a headache. Of the patients with chronic migraine, 36% classified as obese (BMI of 30-39.5) and 12% classified as morbidly obese (BMI >40); in total, well over half of the patients with chronic migraine were considered to have a BMI that was greater than normal. To evaluate general socioeconomic status, home zip codes were used to assess median income levels. The results demonstrated trends of greater numbers of ED visits associated with lower-income areas. 
Conclusions: This interview-style study explored why patients with headache go to the ED, which therapies are failing, and how the current system of headache treatment affects their daily life. Taking into account the behavioral, social, financial, and psychological factors of health and migraines, it can be challenging to treat an individual patient's needs. Based on the results of the needs within our community, there are particular services that could match RHS patients’ needs: diet and exercise programs for weight loss, biofeedback, medication maintenance, educational outreach, osteopathic manipulative treatment (suboccipital release, occipital decompression, myofascial unwinding), sleep studies and screenings, and referral to a neurologist for comprehensive management. An osteopathic approach, in which the patient is treated as a whole patient, psychological and social factors must be taken into account for a successful outcome. Delving into the psychosocial aspect behind medicine and neurologic and somatic functioning will allow us to focus affordable resources in that direction, ranging from biofeedback to osteopathic manipulative treatment techniques, and evidence-based treatments that tend to be effective with low cost and low risk. Possible limitations to this study include subjective responses, language barriers, and time of arrival for an interview in person. 
Support: The RHS Research and Academic Affairs Offices provided funding and logistical support through a research grant. 
♦H5—Chronic Diseases and Conditions
Physicians’ Beliefs and Their Perceptions of Patients’ Beliefs of the Causes, Controllability, and Concern of Type 2 Diabetes Mellitus 
Jeremy M. Mosher, OMS IV1; Veronica S. Derricks, MEd, MS2; Jay H. Shubrook, DO1 
1Touro University College of Osteopathic Medicine-CA, Vallejo; 2Department of Social Psychology, University of Michigan, Ann Arbor 
Research Questions/Hypotheses: Poor physician-patient communication facilitates negative consequences, such as worse interactions, reduced treatment adherence, and poorer health outcomes among patients. As such, it is essential to identify dimensions on which physicians and patients may disagree, particularly when these disagreements emerge for diseases such as type 2 diabetes mellitus (T2DM) that are continuing to increase in prevalence. Current research shows that physicians have inaccurate perceptions of patients’ health beliefs and overestimate the extent to which patients’ beliefs align with their own, resulting in miscommunication and poor understanding in the therapeutic alliance. Although studies have examined discrepancies between patient and physician beliefs, few studies have examined how physicians’ perceptions and beliefs about the causes, controllability, and level of concern about T2DM contrast with their perceptions of patients’ beliefs. Physicians’ perceptions of discrepancies between their own and their patients’ beliefs may influence how physicians engage their patients about preventive behaviors. Primary care providers, such as ACOFP family physicians, are often the front-line medical provider responsible for diabetes prevention and management. Therefore, it is important to understand physicians’ beliefs around communication efforts. This study investigated family physicians’ perceptions of their patients’ beliefs, relative to their own beliefs, regarding the causes, controllability, and concern about T2DM. We hypothesized that physicians would perceive significant differences between their own beliefs and patients’ beliefs for each dimension. 
Methods: Of 294 osteopathic family physicians who began the survey, 229 physicians completed it and were included in the final sample (90.0% European American, 52.8% male; age 29-82 years; mean [SD] age, 47.87 [14.07] years). 28.4% of physicians practiced in a single specialty group, 21.4% in a hospital setting, 14.0% in a multiple specialty group, 12.7% in a university/academic setting, 14% in a solo practice, 3.9% military or government, and 5.7% other. 75% of respondents reported directly managing the diabetes of at least 25 patients per month, with the patient population being 60.2% white, and 61.5% having either Medicare or Medicaid. A Qualtrics-based survey was disseminated to family physicians online through the American College of Osteopathic Family Physicians (ACOFP) e-mail listserv of 8368 physicians between December 2016 and January 2017. A reminder e-mail was sent to the listserv 2 weeks after the initial invitation. Requirements for eligibility were family physicians who treated patients with diabetes. The survey included 6 parts: (1) physicians’ perceptions about the causes of diabetes (4 items; 1, not at all, 5, all), (2) physicians perceptions of patients’ beliefs about the causes of diabetes (4 items; 1, not at all, 5, all) (3) physicians’ beliefs about the controllability of T2DM (3 items; 1, strongly disagree, 5, strongly agree), (4) physicians perceptions of patients’ beliefs about the controllability of T2DM (3 items; 1, would strongly disagree, 5, would strongly agree), (5) physicians’ concern about patients developing diabetes (2 items; 1, not at all, 5, very), and (6) physicians perceptions of patients’ concern about developing diabetes (2 items; 1, not at all, 5, very). Following the survey items, physicians answered questions about their personal demographic information (eg, age, practice setting, geographic location) and their current practice (eg, number of patients with diabetes, patient insurance, patient race). 
Data Analysis: Data from the physician survey were analyzed using SPSS (version 24.0, SPSS Inc). We used paired t tests to compare physicians’ responses with their expectations for patients’ responses. 
Results: Analyses showed that physicians perceived no convergence between their own and their patients’ beliefs. When asking about causes of T2DM, physicians reported perceptions that, compared with themselves, patients are more likely to believe that diabetes is caused by genetic make-up (t=3.26, P=.001). Moreover, physicians expected that patients would believe that diabetes is due more to genetics than lifestyle factors (t=10.83, P<.001). Finally, physicians reported beliefs that, compared with themselves, patients underestimate the role of diet and exercise in the development of diabetes (t=10.32, P<.001; t=10.49, P<.001). Regarding the perceived controllability of T2DM, physicians expected that, compared with themselves, patients would report more fatalistic beliefs about diabetes running in the family: thus, they would be more likely to agree that if diabetes runs in a person's family, there is not much they can do to avoid getting it (t=−22.14, P<.001). Moreover, physicians expected that patients would be more likely to believe that people with diabetes would have the illness for the rest of their life (t=−6.56, P<.001). Additionally, physicians expected that patients would underestimate how much control they had over the development of diabetes (t=12.32, P<.001). Finally, physicians reported perceiving that their patients were less concerned about developing T2DM than physicians were (t=16.71, P<.001). 
Conclusion: We found that osteopathic family physicians perceived significant differences between their own and their patients’ beliefs regarding the causes, controllability, and levels of concern about T2DM. Physicians believed that patients underestimated their role in the development of T2DM. Physicians also exhibited perceptions that patients overestimated the role of genetic factors and underestimated the controllability of developing T2DM. Finally, physicians reported being more concerned about their patients’ likelihood of developing T2DM than patients were. To engage patients effectively, build trust, and motivate behavioral change to prevent the development of diabetes, it is important that patient and provider beliefs align. While the perceived misalignment of understanding demonstrated in the study should be confirmed with patient data, the findings suggest that physicians’ assumptions may negatively affect patient communication. Future work will identify which factors are predictive of these discordant beliefs and whether physicians’ perceptions of patients’ beliefs diverge from patients’ actual beliefs. This comparison may indicate whether physicians underestimate their patients’ concern for T2DM or whether more interventions are needed to help physicians educate patients about T2DM. By correcting discordant beliefs about diabetes and building a mutual narrative from which to work, providers can best support patient adherence to lifestyle recommendations by addressing underlying fears, barriers, and misconceptions. 
Acknowledgment: We thank the ACOFP for allowing us to distribute this survey on their listserv; Dr Toby Jayaratne for allowing us to adapt her survey items and for her feedback on our study design; Dr Allison Earl for feedback and support; and the physicians who completed this survey. 
♦H6—Impact of OMM/OMT
Touro California Student-Run Free Clinic: An Investigation of Actual vs Target Patient Demographic and the Impact of Osteopathic Manipulative Medicine in the Vallejo, California, Community 
Selene Jamall, OMS II; Brandon Ang, OMS II; James Victor Kimpo, OMS II; Benfie Liu, MS; Eric Donn, MHA, OMS III; Henry Szeto, BS; James Devanney, OMS III; Melissa Pearce, DO 
Touro University College of Osteopathic Medicine-CA, Vallejo 
Hypotheses: (1) The student-run free clinic (SRFC) serves the medically underserved population (patients without primary care provider [PCP] access) of Vallejo. (2) The SRFC primarily provides osteopathic manipulative medicine (OMM) to the community compared with other clinic services. 
Methods: Data were analyzed based on registration forms in patient files from April 2010, the year of the clinic's founding, through July 2017. These data were transferred from hard copies of 424 consenting patients’ files into a spreadsheet using Microsoft Excel. Patients responded to a host of demographic questions, including age (categorized in this study as adults <65 years of age or >65 years of age as determined by the generally accepted age to distinguish elderly from nonelderly patients), ethnicity, and whether they currently saw a PCP. The service given during their clinic visit (history and physical examination [H&P] or OMM) was also recorded, and all collected responses were compared. 
Data Analysis: The majority of SRFC patients were found to be patients with access to a PCP and who were more likely to receive OMM as their clinic service. Patients without access to a PCP were more likely to receive H&P-based services. This finding suggests that these patients, often with existing treatment plans (for hypertension, diabetes, and/or obesity) through their current PCPs, may be seeking OMM services that they cannot otherwise access. The fact that patients without PCP access were not the majority of clinic visits suggests that SRFC's target population is not yet being adequately addressed. Therefore, we reject our first hypothesis that the SRFC primarily cares for the medically underserved, but we accept our second hypothesis that the SRFC primarily provides OMM to its community. 
Results: χ2 analysis was performed comparing the 2 age groups, adults <65 years old and >65 years old against PCP access (n=424, P<.0001). Patients with PCP access were also compared with their service provided (either H&P or OMM) at the clinic (n=400, P<.0001). The majority of patients seen by the student-run free clinic tended to be patients who already had PCP access (n=424, 60.1%). This was also suggested by the significant relationship found when comparing elderly vs non-elderly patients with PCP access. The relationship between PCP access and clinic service received was also found to be significant, such that patients with PCP access were more likely to receive OMM treatment during their visit (n=400, 59.8%) than patients without PCP access (37.3%). Patients with PCP access were further compared with a diagnosis of a single condition (hypertension, diabetes, or obesity) or a mixed condition including 2 or more of these diseases (n=232, P<.0448). 
Conclusion: The data suggest that the student-run free clinic currently sees more patients who have access to a PCP than those who do not. Additionally, patients with PCPs were more likely to receive or request an appointment to receive OMM than those without a PCP. The consistent presence of patients with access to a PCP at the clinic alongside their concurrent treatment plans managed elsewhere may indicate that they seek osteopathic manipulative medicine as an adjunctive or additional treatment modality that they are unable to access elsewhere. While this helps attest to the unique appeal and role of the clinic in the community, the data also suggest that the student-run free clinic should take steps toward more effectively reaching its intended target demographic, the medically underserved in Vallejo. We have chosen to examine these data as a foundation for both understanding our impact and refocusing the efforts of the student-run free clinic to more adequately evaluate the health needs of Vallejo's medically underserved and extending our relationships with local community organizations and leadership. By addressing the needs of these populations, the SRFC will be able to tailor its efforts more closely to the needs of its community, and in the long-term, better preventive care resources may result in patients being less reliant on costly emergency department and urgent care services. In finding ways to offer these services as a part of our clinic, we hope to continue integrating the basic needs of the community with student-driven health care to better serve our mission's target population. 
Acknowledgments: We thank Dr Melissa Pearce (SRFC Medical Director), Touro University California, the dedicated student and faculty volunteers, and of course, the patients, for making the endeavors in serving the community possible. 
♦H7—Impact of OMM/OMT
The Role of Osteopath Manipulative Treatment in Addressing Pain Back in a Global Context of Imbalanced Pain Medication Availability 
Marielle Sophia Newman, MPH 
Department of International Affairs, American Osteopathic Association, Chicago, Illinois 
Introduction: At present, the world faces complex difficulties in pain management. A rapid surge in opiate use in Australia, western Europe, and the United States has triggered an epidemic of addiction, with adverse outcomes, including lethal overdose. Meanwhile, an inappropriate lack of access to opiate drugs in eastern and southern Europe, Asia, Africa, and Latin America is a public health concern. Worldwide, the distribution of pain relief drugs is an extreme example of the inverse care law; approximately 90% of opioid analgesic consumption occurs in the United States, Canada, Australia, New Zealand, Japan, and a few European countries, while another 5 billion people have little or no access to essential analgesics. As a result, international public health entities are working to reduce inappropriate use of pain medication while also ensuring access to pain relief for patients worldwide who need it. Among these efforts are attempts to increase access to non–drug-based pain relief. Osteopathic manipulative treatment (OMT) and osteopathic manipulative therapy (OMTh) could contribute to this solution. OMT and OMTh involve physical manipulations of the musculoskeletal system to alleviate pain and disorder. Most randomized controlled trials of OMT or OMTh have examined treatment of back pain, neck pain, and headache. The evidence base for OMT and OMTh are strongest for treatment of low back and neck pain. Both conditions are common; back pain is one of the world's most common sources of disability, loss of quality of life, and reduced work capacity. In the context of imbalanced pain medication access, OMT and OMTh have the potential for significant public health impact. However, OMT and OMTh can only affect public health worldwide to the extent that patient need is aligned with treatment availability. Osteopathic physicians, who practice OMT within a full medical practice, and osteopaths, who practice OMTh only, are working in 35 countries. But no studies have appeared to address the correlation between pain epidemiology, pain drug access, and OMT or OMTh availability. This study assesses the question of how well access is aligned with patient need worldwide. 
Methods: This study relied solely on published data found in academic literature and published documents from osteopathic and public health organizations. A 2013 report by the Osteopathic International Alliance (OIA), Osteopathy and Osteopathic Medicine: A Global View of Practice, Patients, Education and the Contribution to Healthcare Delivery, was used to construct a list of countries in which OMT or OMTh is practiced and numbers of practitioners per country. Search terms incorporating each country name were used to retrieve published data from Medline (Pubmed) and Google Scholar on the prevalence of back pain in each country (eg, “prevalence of back pain in Spain”). When multiple studies were available, the most recent one concerning adults (persons over age 18 years) was chosen. Data on the statistically defined daily dose (S-DDD) of opioid drugs in use per country were abstracted from a study on worldwide opioid analgesic access (Bertarame et al, 2016). Data on country population size was retrieved from the CIA World Factbook (2017). All data were abstracted into a table in MS Excel. Analysis was then completed without the use of additional statistical software. Simple descriptive statistics were completed, followed by use of the Pearson product moment to calculate correlations between osteopaths available and S-DDD. 
Results: Osteopathic professionals are known to be practicing in 35 countries. Data on practitioners in the UAE, Korea, and Argentina was not found. Data on the remaining 32 countries were recorded in 2 streams: osteopathic physicians and manipulation-only osteopaths. The United States and Russia have osteopathic physicians only (n=82,500 [US]; 1300 [Russia]). Germany and France have substantial numbers of osteopathic physicians (n=2300 and 1600, respectively) and osteopaths (n=5000-7000; n=17,460). Another 28 countries have only osteopaths, with few or no osteopathic physicians. These professional pools range from 11 practitioners (Cyprus) to 5000-6000 (Italy), with an average of 1433 and a median of 263. Osteopathic physicians worldwide number 87,854, and osteopaths worldwide are 55,733. Epidemiologic data on back pain and opiate access varies widely. Most data were self-reports of low back pain collected via survey; high heterogeneity was observed between studies. Prevalence ranged from 3.9% in a US population (Friburger, 2009) to 83% in Japan (Fujii and Matsudaira, 2012). A global review (Meucci, Fassa, and Faria, 2015) noted a chronic low back pain prevalence of 19.6% in people aged 20-59 years. Statistical daily doses per million population of opiate analgesics were likewise wide-ranging, with Egypt having 75 daily doses per million people and the United States having 43,879, with a global mean of 8151 and a median of 5277. The correlation between osteopath availability and drug availability was calculated as r=0.71. 
Discussion: There has been little attention to orienting the global osteopathic profession to address the public health issue of pain. These data show that countries with very high access to opiate drugs are also countries where OMT or OMTh tends to be readily available. This finding suggests that OMT and OMTh are currently underused to prevent opioid misuse in these countries, and that it may be underused to manage untreated pain elsewhere. Right-sizing OMT and OMTh availability is hindered by the paucity, heterogeneity, and poor quality of the data, suggesting that additional research is important. 
♦H8—Osteopathic Philosophy
Empathy in Residency Years 
Ann J. Impens, PhD1; Kyle Henderson, PhD2; Mireille Rizkalla, PhD2; Katarina Ivlovic, MA2 
1IHI, Midwestern University Chicago College of Osteopathic Medicine (MWU/CCOM), Downers Grove, Illinois; 2MWU/CCOM 
Research Question: To measure empathy in osteopathic medical residents. Aims of the study are to study differences/similarities in empathy level across program years and specialty type and to assess whether degree of the use of touch and interest/use of OMM was related to self-reported empathy levels. We report on 1 year of data collection and present cross-sectional data only. 
Statement of Significance: Physician empathy is correlated to better patient compliance, medical outcomes, and reduced physician burnout. It is widely accepted that empathy is a vital component in the professional development of physicians and affects quality of care and patient outcomes. Knowing if and when empathy changes from osteopathic medical student to resident to practicing physician can help pinpoint opportune times to enhance/maintain empathy levels and could be informative for medical education efforts. The 2011 systematic review by Neuman et al concluded there is a decline in empathy during medical school and residency, which is especially evident in longitudinal studies. Most studies, however, have been conducted on allopathic students and residents. To our knowledge, there is only 1 study that followed a group of medical students into their residency years (Hojat et al, 2005). In this study, however, empathy during medical school was a self-reported measure while empathy during the residency years was measured by evaluation by program directors. Furthermore, the authors were unable to locate any studies on empathy levels in osteopathic residency programs, demonstrating a gap in this field. 
Methods: The Jefferson Scale of Empathy (JSE) and questions regarding the residents’ current use of touch and frequency of OMM were administered to residents of the Illinois MWU-OPTI. JSE consists of 20 items that are answered on a 7-point Likert scale, with total possible scores ranging from 20-140 (higher score indicates more empathy). In addition to demographic information, we assessed experience with OMM, level of interest in OMM, frequency of use of OMM, and degree of the use of touch through 7-point Likert scales (1 = strongly disagree, 7 = strongly degree). This study was approved by MWU-IRB. 
Data Analyses: Differences between residents on empathy scores according to specialty type, year in program, type of program (MD, DO, or combined), and other variables of interests were analyzed using t tests, χ2, ANOVAs, or correlations as appropriate for the types of variables. Significance levels were assessed with 2-tailed tests and P≤.05. 
Results: 95 (85 DO) residents completed the survey. Average empathy score for MDs was 118.8 (SD, 11.61; range 100-134) compared with 115.41 (SD, 12.5; range 83-140) for DOs. 70% of MD residents were male compared with 48.9% of DO residents. The majority of residents were in PGY 2 and PGY 3 (70% of the MD residents; 77.6% of DO residents). All MD residents and 69% of DO residents were in family medicine residency programs. Nineteen percent of DOs were in an emergency medicine and 11% in an OB/GYN program. No statistically significant differences were found between MDs or DO residents, year in program, or program type. A statistically significant difference was found in specialty type, with emergency medicine residents scoring lower compared with family medicine or OB/GYN residents. The average empathy scores for EM residents was 106.93 (SD, 9.93) compared with 117.89 (SD, 12.4) for family medicine and 115.2 (SD, 10.12) for OB/GYN. Several questions assessed attitudes with respect to volunteering, type of patients deserving health care, comfort with diversity, and decisions to enter chosen profession. Statistically significant correlations were found for the emergency medicine residents between empathy and volunteering (–.6; I do not volunteer because it hinders my ability to get ahead), medical authoritarianism (–.58; Conscientious patients deserve better health care than those with self-inflicted problems) and medical egalitarianism (.5; We should do what we can to equalize health care for different groups). Statistically significant correlations were found for the family medicine residents between total empathy score and volunteering (–.34), openness (.26; Even after I made up my mind about something, I am willing to consider other opinions), medical authoritarianism (–.36), medical egalitarianism (.48), and conflict with diversity (.47; I am comfortable helping others who are different from me culturally). DOs also completed several questions related to osteopathic philosophy and their current use of OMM. Moderate significant correlations were found for the total sample between empathy score and role of osteopathic philosophy in attending medical school (.3) and choosing to take OMM as an elective if it had not been required (.37). When dividing the sample by subspecialty, no significant correlations were found between these variables and total empathy scores for the EM and OB/GYN residents. 
Conclusion: We are reporting results of a small, cross-sectional study conducted in a limited number of specialty programs and limited to 1 geographic area, thus hindering the generalizability of the results. We were unable to conduct subanalyses based on sex/training given the small sample size of MDs. Sex differences, specifically higher empathy scores for female participants, has been reported elsewhere. Residents in this sample scored fairly high in empathy (118 for MDs and 115 for DOs). For comparison, Hojat and Gonnella (2015) reported an average empathy score of 114 (SD, 10.4) for US medical students. We did find a statistically significant difference in empathy score between medical specialties, with emergency medicine residents scoring much lower. Such a difference (although not of the same magnitude) has been reported elsewhere. Hojat (2000) reported that those in people-oriented specialties scored significantly higher (115; SD 9.9) compared with those in more technology-oriented specialties (112.34; SD 11.02). There is some ambiguity, however, as to how to classify emergency medicine. It is sometimes included in the people-oriented specialties or included in the “other medical subspecialty” category. Although we did not find a statistically significant difference in empathy levels between DOs reporting current use of OMM in their clinical encounters and those who did not, a trend can be reported. Of the 85 DOs in the sample, 15 did not use OMM in their clinical encounters. Their average empathy score was 111 (SD, 10.8) compared with 116 (SD, 12.35) for those who did use OMM in their clinical encounters. We are planning continued data collection to enable us to conduct subanalyses (eg, sex differences) and also to follow individuals longitudinally through their residency years. 
Support: American Association of Colleges of Osteopathic Medicine, MWU/CCOM, and Center for Research in Medical Education and Health Care, Thomas Jefferson University. 
♦H9—Osteopathic Philosophy
Evolving Practice Settings for Osteopathic Graduates: How Debt Influences Anticipated Career Path 
Matthew Kunz, OMS II1; Jesse Richards, DO2; Caleb Scheckel, DO3; Jessica Newman, DO2; Kenneth Poole, MD, MBA3; Lanyu Mi, MS4 
1Midwestern University Arizona College of Osteopathic Medicine, Glendale; 2Internal Medicine, University of Kansas Medical Center, Kansas City; 3Department of Internal Medicine, Mayo Clinic Arizona, Phoenix; 4Mayo Clinic, Phoenix, Arizona 
Research Question/Hypothesis: How has anticipated practice type of osteopathic graduates changed over the past decade and does debt affect anticipated career choices? 
Introduction: Over the past decade, the health care landscape in the United States has evolved. Changes in patient population, reimbursement, and insurance coverage have triggered variations in practice types chosen by early-career physicians in the United States. Similarly, it has been shown that debt has a significant influence on career decisions of graduating medical students. Each year, the average medical student debt continues to rise, with an average debt of nearly $200,000. To understand the future of the osteopathic medical profession, it is important to recognize the current motives and preferences of graduating osteopathic physicians. In this study we sought to analyze trends in graduating osteopathic medical students’ anticipated practice types and how debt may affect their chosen career. 
Methods: The American Association of Colleges of Osteopathic Medicine (AACOM) annually invites all accredited COMs to administer a voluntary survey to graduating classes. The survey examines trends in medical graduates in terms of demographics, satisfaction, career choice, and other metrics. The total response rate has remained between 72% and 77% of all graduates in the years evaluated (2007, 2010, 2013, and 2016). Total responses increased from 2403 in 2007 to 4191 in 2016. With permission, we received deidentified responses from the AACOM for analysis. We evaluated global trends in anticipated practice type and differences in high vs low debt respondents stratified into quartiles (25th percentile=Q<25, 75th percentile=Q>75). For analysis, χ2 and analysis of variance tests were used with standard statistical methods with a P value of .05. 
Results: From 2007 to 2016, there was a significant decrease in students anticipating entering self-employment, from 20.99% in 2007 to 9.87% in 2016, and inversely there was a significant increase in students anticipating working for health maintenance organizations (HMOs), from 1.95% in 2007 to 13.83% in 2016 (P<.0001). In 2007, 2010, 2013, and 2016, the students with the least amount of debt were more likely to anticipate government service (average QP75 of 61.92%) or group/private practice (average Q>P75 of 8.55%). 
Conclusion: The anticipated practice types of students evolved significantly from 2007 to 2016, with a shift away from solo practice and toward employee positions. Graduating osteopathic physicians demonstrated a significant shift away from private practice and toward HMOs during this time span. Our findings also suggest that debt has a significant impact on the anticipated future practice type of graduating students. Students with less debt were much more likely to participate in government service, and students with the most debt were more likely to work for HMOs or in private groups. As average medical student debt continues to rise, understanding its implications for physician practice patterns is imperative as we consider possible physician shortages in areas of geography or by specialty. This analysis demonstrates a significant shift in medical school graduates’ expected practice settings and demonstrates that debt can change expected career trajectory. 
♦H10—Osteopathic Philosophy
Meditation, Empathy, and Stress in Osteopathic Medical Students: An Interventional Pilot Study 
Jerry Balentine, DO; Matthew Goldfinger, BS; William Blazey, DO; Min-Kyung Jung, PhD; Bhuma Krishnamachari, PhD 
New York Institute of Technology College of Osteopathic Medicine, Old Westbury 
Research Questions/Hypotheses: Physician and medical student burnout is a major problem that negatively affects both patient and physician well-being. High stress levels may be one of the most important factors that contribute to burnout. Additionally, higher levels of burnout may be associated with lower empathy. Empathy is a major factor in attaining positive clinical outcomes for patients. Thus, solutions to lessen empathy drain and decrease stress are crucial. Meditation may be one such avenue to promote positive student attitudes, though very few studies have examined this idea through empirical research. The specific aim of this study was to use validated measures to investigate whether use of a guided meditation app would be associated with higher levels of self-rated empathy and lower stress levels. We hypothesized that osteopathic medical students who participated in a program using a meditation app would have higher levels of empathy and lower stress levels than those who did not participate. 
Osteopathic Significance: Fostering empathy and decreasing stress in osteopathic medical students is particularly important, as they are the future of the health care workforce, and a trend of declining empathy and increasing stress during medical education may lead to decreased health care quality outcomes. 
Methods: This pilot study was IRB approved. First-, second-, and third-year osteopathic medical students were recruited into the study. The study was initiated in January 2017, at the beginning of the semester. Students were randomly assigned to an intervention group (use of the Headspace meditation app) or control group (no use of the app). The study included 19 students in the intervention group and 21 controls. Students in the intervention groups used the app 3 days a week, 10 minutes each session. Empathy and stress were measured before study initiation and after 3 months. The Jefferson Scale of Empathy (JSPE) was used to measure empathy. Higher scores on this scale indicate higher empathy. The perceived stress scale (PSS) was used to measure stress levels. Higher scores on this scale indicate higher stress. 
Data Analysis: t tests were used to compare the intervention group and control groups on age. χ2 tests were used to compare the 2 groups on sex. Generalized linear regression was run to estimate the mean difference in empathy and stress scores between those who did and did not receive the intervention. 
Results: The mean (SD) age was 24.6 (3.3) years in the intervention group and 24.4 (3.7) years in the control group. 68.4% (n=13) of the intervention group and 47.6% (n=10) of the control group were female. Age and sex were not significantly different between the intervention and control groups. The mean empathy score in the total study population differed between males and females (P=.04). Specifically, the mean (SD) JSPE score in males was 110.9 (12.4) and in females was 118.6 (10.1). Because the scores were significantly different, all analyses were stratified by sex. In males, there was no statistically significant difference in empathy scores between the intervention and control groups before the study initiation or after 3 months. Similarly, in females, there was no statistically significant difference in empathy scores between the intervention and control groups before the study initiation or after 3 months. In males, there was also no statistically significant difference in stress scores between the intervention and control groups before the study initiation or after 3 months. However, in females, there was a statistically significant difference in stress scores between the intervention and control groups after 3 months (P=.01). Specifically, before study initiation, the intervention group had a mean (SD) score of 19.33 (5.03), and the control group had a score of 18.5 (4.79). After 3 months of meditation, the intervention group has a score of 16.09 (5.30) and the control group had a score of 24.20 (2.86). 
Conclusion: This pilot study found that meditation is effective for reducing stress in females. It is unclear why the same effect was not seen in males. It is possible that the study sample size was too small to detect a difference in this group. Repeating the study on a larger scale might detect a difference in males as well. Conversely, males and females may process stress differently and may need different tools to assist in decreasing stress. In the JSPE scale analysis, meditation was not associated with an increase in the empathy score. A lack of detected effect could be due to small sample size. We did find that males and females had a significantly different baseline empathy score. This is consistent with previous research that found a difference in baseline performance on the JSPE scale between males and females. An additional factor to consider when interpreting the results is the timing of the project. Students were first assessed at the beginning of the spring semester. As classes would not yet have started, this may be associated with lower stress. The second measurement was taken at 3 months, in the middle of the academic semester, when we would expect higher stress levels. Given the expected rise in stress levels over the course of the study, the decreased stress seen in females who used meditation is promising. A larger study will be conducted that can look at the effects of meditation on stress and empathy over a longer period. Future studies should consider the impact of timing in the school year. Additionally, it will be important to analyze the effects separately in students based on school year. If future research shows that student empathy increases and stress decreases with use of a meditation app, osteopathic medical schools may choose to incorporate this feature in their curricular programs. 
♦H11—Osteopathic Philosophy
Engaging in “Mind, Body, Spirit”—A Student Perspective on Incorporating Mindfulness in Osteopathic Medical Education Through the Wellness, Academic, Resilience and Mindfulness (WARM) Curriculum 
Hiroe Hu, OMS III; Mohammad Khorsand, OMS III; Rachit Anand, OMS II; Tami Hendriksz, DO; H. Eduardo Velasco, MD, PhD, MSc 
Touro University College of Osteopathic Medicine-CA (TUCOM), Vallejo 
Background: At osteopathic medical schools, the medical education should emphasize the unity of mind, body, and spirit. While the medical curriculum does apply this concept to patient care, the wellness of medical students is often overlooked. Today, 14 medical schools offer formal mindfulness training courses to their students. However, none of these schools are osteopathic medical schools. This past academic year, TUCOM piloted the Wellness, Academic, Resilience, and Mindfulness (WARM) curriculum. One of the core goals of the WARM curriculum is to provide means for the students to learn and practice the principle of mind, body, and spirit interrelationship in their personal and professional development. The curriculum integrates and streamlines school-sponsored curricular and student-directed extracurricular activities that incrementally and sequentially teach the importance of mindfulness and resilience in medical training and in the medical profession. 
Hypothesis and Research Question: We proposed that osteopathic medical students’ personal and professional development in wellness, academics, and resiliency training may center around their understanding of mindfulness. We aimed to establish baseline values of students’ mindfulness and other WARM parameters using validated instruments to establish future directions of the WARM curriculum. 
Methods: An element paramount to the WARM curriculum is student involvement. Through a student-directed survey at the beginning of the academic year, the WARM curriculum student representatives gathered data on the specific needs of first- and second-year medical students. The survey (response rate=53.5%, n=266) showed that over 90% of respondents were interested in learning about mindfulness during their medical education, and over half of the respondents saw the need for school-sponsored mindfulness workshops, meditation retreats, and an on-campus meditation garden, among other means. After establishing that the WARM curriculum met the student needs, over the academic year faculty members of TUCOM integrated mindfulness and resiliency principles into the curriculum, and WARM student representatives delivered mindfulness-related activities on campus, including the building of a new meditation garden on campus. Through an IRB-approved, voluntary, and anonymous survey at the end of the academic year (response rate=53.4%, n=266), we administered the Five-Facet Mindfulness Questionnaire (short-form) (FFMQ-SF) to establish baseline values of preclinical students. We also administered Health Promoting Lifestyle Profile II (HPLP-II), John Hopkins Learning Environment Scale (JHLES), and Perceived Stress Scale (PSS) to measure performance in the Wellness, Academics, and Resilience components, respectively. Finally, we administered a student-directed qualitative survey where preclinical students commented on their perceived impact of the WARM curriculum on their understanding of the first osteopathic tenet. 
Data Analysis: Two-sample t tests performed between OMS I and OMS II baseline values showed that there was no significant difference between the 2 classes in their composite scores in the 4 WARM parameters. Linear regression analysis was performed to demonstrate possible relationships between the students’ scores on FFMQ-SF and their scores in HPLP-II, JHLES, and PSS. 
Results: Analysis suggested that there is a significant relationship between students’ mindfulness and their self-care behaviors, thus suggesting that the more mindful medical students tend to have better wellness habits. We also found that there is a plausible protective factor of mindfulness to perceived stress, as demonstrated by the inverse correlation between the students’ scores in the FFMQ-SF and the PSS. There was no significant relationship observed between mindfulness and students’ satisfaction with their learning environment, as scored by the JHLES. The qualitative data suggest that a number of students found mindfulness to be a useful additional tool in understanding the unity of mind, body, and spirit. Potential limitations of this study are voluntary participation. 
Conclusion: We established baseline data of the preclinical students’ behavior in the WARM parameters. Future longitudinal research will observe the progressive impact of the WARM curriculum. According to our data analysis, mindfulness may be the mediating factor for achieving better wellness habits and resilience to stress in medical school. This factor is particularly important for osteopathic medical students, who are expected to embody the osteopathic tenets in their personal lives. Future projects of the WARM curriculum will be informed by and tailored accordingly to these data. Our immediate aim is to further strengthen and integrate mindfulness and resilience into our preclinical curriculum. 
Acknowledgment: We acknowledge the efforts and contributions provided by TUCOM Student Promotions Committee (SPC) members, including Drs Tami Hendriksz, Athena Lin, Teresita Menini, Victor Nuno, Natalia Garcia-Russell, Ted Wong, and James Binkerd. We also thank the members of Touro University Office of University Advancement for their contributions in fundraising and executing the building of the on-campus meditation garden. 
Table C7.
A Trend Toward Higher Systemic Recurrence in Rectal Cancer Patients with Wild-Type P53 Following Preoperative Chemoradiation
Pre-op T-stage
 43 (30%)1 (10%)
 325 (83.3%)9 (90%)
 22 (6.7%)0
Pre-op N-stage
 22 (6.7%)0
 16 (20%)2 (20%)
 016 53.3%)4 (40%)
 X6 (20%)4 (40%)
 13 (9%)0
 030 (91%)10 (100%)
Post-op T-stage
 44 (13.3%)1 (10%)
 315 (50%)4 (40%).498
 211 (36.7%)3 (30%)
 102 (20%)
Post-op N-stage
 31 (3.3%)0
 25 (16.7%)0.475
 18 (26.7%)2 (20%)
 016 (53.3%)8 (80%)
 1st4 (13.3%)4 (40%).208
 Systemic3 (10%)3.071
 2nd03 (30%)
 Dod4 (13.3%)3 (30%)
 Awd3 (10%)1 (10%)
 Ned22 (73.3%)6 (60%)
 Doc1 (3.3%)0
Avg LN pos74/143/2.203
Table C7.
A Trend Toward Higher Systemic Recurrence in Rectal Cancer Patients with Wild-Type P53 Following Preoperative Chemoradiation
Pre-op T-stage
 43 (30%)1 (10%)
 325 (83.3%)9 (90%)
 22 (6.7%)0
Pre-op N-stage
 22 (6.7%)0
 16 (20%)2 (20%)
 016 53.3%)4 (40%)
 X6 (20%)4 (40%)
 13 (9%)0
 030 (91%)10 (100%)
Post-op T-stage
 44 (13.3%)1 (10%)
 315 (50%)4 (40%).498
 211 (36.7%)3 (30%)
 102 (20%)
Post-op N-stage
 31 (3.3%)0
 25 (16.7%)0.475
 18 (26.7%)2 (20%)
 016 (53.3%)8 (80%)
 1st4 (13.3%)4 (40%).208
 Systemic3 (10%)3.071
 2nd03 (30%)
 Dod4 (13.3%)3 (30%)
 Awd3 (10%)1 (10%)
 Ned22 (73.3%)6 (60%)
 Doc1 (3.3%)0
Avg LN pos74/143/2.203
Table C18.
Effects of Rock Steady Boxing on the Motor Symptoms of Parkinson Disease, a Pilot Study
Measure Mean Boxers
 Before 9.8 5
 After 10.4 5
 Before 33.8 6
 After 36.3 6
 Before 19 2
 After 23 2
 Before 34.5 13
 After 36.2 13
 Before 14.5 12
 After 15.3 12
 Before 9.2 12
 After 8.0 12
Table C18.
Effects of Rock Steady Boxing on the Motor Symptoms of Parkinson Disease, a Pilot Study
Measure Mean Boxers
 Before 9.8 5
 After 10.4 5
 Before 33.8 6
 After 36.3 6
 Before 19 2
 After 23 2
 Before 34.5 13
 After 36.2 13
 Before 14.5 12
 After 15.3 12
 Before 9.2 12
 After 8.0 12