Effect of Spinal Manipulation on Corticospinal and Stretch Reflex Excitability in Patients With Chronic Low Back Pain  

David Albert Goss, Jr, OMS II¹; Stevan A. Walkowski, DO²; Andrew J. Ross, BS³; James S. Thomas, PhD³; Richard L. Hoffman, MS⁴; Brian C. Clark, PhD⁴ 

¹Ohio University College of Osteopathic Medicine (OUCOM), Athens; ²Department of Family Medicine, OUCOM; ³School of Rehabilitation and Communication Sciences, Ohio University, Athens; ⁴Department of Biomedical Sciences, OUCOM 

Objective: The purpose of this pilot study was to examine the effects of a high-velocity, low-amplitude (HVLA) spinal manipulation on corticospinal and stretch reflex excitability of the lumbar paraspinal muscles in adults with and without chronic low back pain (LBP). 

Methods: Ten adults with chronic LBP (>12 weeks) and 10 healthy adults without LBP participated in this study. All subjects received HVLA spinal manipulation. Before and immediately after the manipulation, we used transcranial magnetic stimulation to assess corticospinal excitability by quantifying the motor evoked potential (MEP) amplitude of the erector spinae (ES) muscles. We also used an electromechanical tapping device to elicit short-latency stretch reflexes from the ES. 

Results: Spinal manipulation did not alter the mean (standard deviation [SD]) MEP amplitude of the ES in patients with chronic LBP (0.80 [0.33] uV vs 0.80 [0.30] uV) or in healthy individuals without LBP (0.56 [0.09] uV vs 0.57 [0.06] uV). Likewise, spinal manipulation did not alter the short-latency stretch reflex amplitude of the ES in patients with chronic LBP (0.66 [0.12] uV vs 0.66 [0.15] uV) or in healthy individuals without LBP (0.60 [0.09] uV vs 0.55 [0.08] uV). Interestingly, we observed that subjects who exhibited an audible response to spinal manipulation had a 25.7% decrease in the stretch reflex whereas subjects who did not exhibit an audible response had a nominal 3.9% increase. 

Conclusions: These preliminary findings suggest that a single spinal manipulative treatment does not systematically alter corticospinal or stretch reflex excitability of the ES muscles in asymptomatic controls or individuals with chronic LBP. However, these findings suggest that the stretch reflex is attenuated when spinal manipulation results in an audible response. This study was approved by the Ohio University Institutional Review Board (#09F064). This work was supported by a research grant from the Osteopathic Heritage Foundations. 

Salivary α-Amylase as a Biomarker of the Response to Rib Raising: A Crossover Study  

Rafal Kopanczyk, OMS III; Jacqueline Lickliter, OMS III; Aaron T. Henderson, OMS IV; Jason F. Fisher, OMS IV; To Shan Li, DO; Kristie Grove Bridges, PhD 

West Virginia School of Osteopathic Medicine, Parkersburg 

Background: Our previous work suggested that salivary α-amylase may be a useful biomarker of the response to rib raising, a technique believed to alter sympathetic nervous system (SNS) activity. However, that study had a small number of subjects and did not address the possibility that not all patients will respond to rib raising. The goals of this follow-up study were to further examine the feasibility of using α-amylase to monitor the response to rib raising and to determine if the amount of pressure applied has any impact on the response. 

Hypothesis: Salivary α-amylase will decrease significantly in response to rib raising but not in response to a light touch control procedure. 

Methods: After institutional review board approval, 40 healthy adults were enrolled in this crossover study. Participants received both OMT and control procedures in random order at 2 different visits at least 1 week apart. Saliva samples were collected before and after each procedure and salivary α-amylase activity was measured. Fingertip pressure sensors were used to measure the amount of pressure applied during the procedures. 

Results: A total of 35 subjects completed the study and 3 different practitioners performed the procedures. No significant difference in the amount of pressure applied was seen between practitioners. Baseline α-amylase levels varied widely and the mean change from baseline after OMT was -38.7 U/mL. The mean change from baseline after the control procedure was -28.6 U/mL. This difference was not statistically significant (P=.804). However, a statistically significant difference was seen in the response to OMT between those who received the control first (mean change from baseline, -56.6 U/mL) and those who received rib raising first (mean change from baseline, -24.7 U/mL; P=.02). Analyses investigating the impact of other factors including which practitioner performed the manipulation, the amount of pressure applied, baseline amylase levels, subject perception, and salivary flow rate are ongoing. 

Conclusion: These preliminary results suggest that changes in SNS activity in response to rib raising vary greatly between individuals and that previous experience may affect this response. Additional analysis is needed to investigate practitioner differences and the impact of baseline sympathetic activity or pressure applied. This study was supported by a grant from the American Osteopathic Association. 

Objective Measure of Effect of Osteopathic Manipulative Treatment on Balance  

 

Ashlynn N. Gordon, OMS III¹; Victoria Graham, DPT²; Eric Hurwitz, PhD³; Marcel P. Fraix, DO⁴; Michael A. Seffinger, DO⁴ 

¹NMM/OMM Department, Western University of Health Sciences College of Osteopathic Medicine of the Pacific (WesternU/COMP), Pomona, California; ²Physical Therapy and Physical Medicine and Rehabilitation, WesternU/COMP, Pomona; ³WesternU/COMP, Honolulu, Hawaii; ⁴Department of Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine, WesternU/COMP, Pomona 

Background: Dizziness is the third most common complaint among all outpatient visits and the single most common complaint among patients older than 75 years. It is often a symptom of benign paroxysmal positional vertigo, which typically improves within 2 months time. This study evaluated the effect of osteopathic manipulation treatment (OMT) for spinal somatic dysfunction in patients with greater than 3 months duration of dizziness symptoms using the SMART Balance Master (SBM), a validated instrument that measures balance. 

Null Hypothesis: Osteopathic manipulative treatment for spinal somatic dysfunction in patients with at least 3 months of dizziness will not have a measurable effect on improving balance using the SBM. 

Methods: This was a prospective clinical cohort study. The SBM provides graphic and quantitative analysis of sway and balance while the protocol systematically eliminates sight, spatial orientation and platform levelness, challenging the participants to remain balanced in the standing position while sway and posture are measured via the platform upon which the participant stands. Power analysis yielded the need for 16 patients to obtain 99% power at α=.05 level (2-sided). Sixteen participants (2 males, 14 females; age range, 13-75 y; mean age, 49 y; average duration of symptoms, 84 months) with dizziness of at least 3 months duration and somatic dysfunction, but no history of stroke or brain disease, were recruited from the local university community by flyer and e-mail and evaluated for postural balance before and after OMT and 1 week later using the SBM. Two experienced (>20 years) faculty, board certified in neuromusculoskeletal medicine and osteopathic manipulative medicine, provided OMT. 

Results: Paired t tests of the changes in means of the composite scores of all challenge tests revealed that balance improved immediately after OMT (P=.0002); this improvement was apparent 1 week later (P<.0001). There was no change between immediately post-OMT and 1 week later scores (P=.1971). 

Conclusion: The null hypothesis was rejected. Osteopathic manipulative treatment for spinal somatic dysfunction improved balance in patients with at least 3 months of dizziness. Treatment effect was clinically significant immediately after OMT intervention and was sustained 1 week later. The study was approved by the Western University institutional review board and was sponsored by the departments of neuromusculoskeletal medicine/osteopathic manipulative medicine, physical therapy, and physical medicine and rehabilitation at Western University of Health Sciences in Pomona, California. 

Salivary Biomarkers of Metabolic Syndrome and Prediabetes  

Benmichael O. Idowu, OMS II¹; Derek G. Rodeback, OMS II²; Jacqueline Lickliter, OMS III²; Daniel Opris, OMS III²; Rafal Kopanczyk, OMS III²; Aaron T. Henderson, OMS IV²; Andrea M. Nazar, DO²; Edward Bridges, PhD²; Kristie Grove Bridges, PhD² 

¹Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine (WVSOM), Lewisburg; ²WVSOM 

Background: Metabolic syndrome (MBS) is a combination of risk factors including hypertension, central adiposity, dyslipidemia, and elevated blood glucose that results in an increased risk of developing cardiovascular disease and type 2 diabetes mellitus. The development of noninvasive biomarkers of MBS would facilitate participation in screening and treatment programs aimed at reducing these modifiable risk factors. The purpose of this study was to identify salivary biomarkers that may be useful for early detection of MBS and prediabetes. 

Hypothesis: Salivary homocysteine and alpha₁-antitrypsin (A1AT) will be elevated in patients with metabolic syndrome, prediabetes (impaired fasting glucose), or both. 

Methods: Twenty-six adults were enrolled in this cross-sectional study after institutional review board approval. Participants were asked to fast for at least 10 hours before their appointment. A medical history was taken and participants provided a saliva sample using the passive drool method. Blood samples were collected through finger stick. Lipid panels and fasting blood glucose were measured using a Cholestech LDX instrument. Blood pressure, height, weight, and waist circumference were also measured. The presence of metabolic syndrome was determined using criteria established by the American Heart Association and the National Heart, Lung, and Blood Institute. 

Results: Of the 25 volunteers who completed the study, 5 had MBS but none had impaired fasting glucose. Salivary homocysteine was detected in only 2 of the participants, 1 of whom had MBS. There was no significant difference between salivary A1AT levels in healthy participants and in those with MBS. However, statistically significant correlations between salivary A1AT and fasting blood glucose (P=.049) and between A1AT and total cholesterol (P=.011) were seen. 

Conclusions: Additional studies are needed to determine if salivary A1AT may be a useful biomarker of prediabetes or MBS. The use of salivary homocsteine as a noninvasive biomarker will require the development of more sensitive detection methods. 

Testicular Torsion: Does Climate Play a Role?  

Ronak A. Gor, MD, OMS IV¹; Jason B. Loflen, DO²; Justine Schober, MD² 

¹Lake Erie College of Osteopathic Medicine, Lansdale, Pennsylvania; ²Hamot Hospital Department of Emergency Medicine, Erie, Pennsylvania 

Hypothesis: Risk factors associated with testicular torsion (TT) are poorly understood. Several prior studies assessing the climatic conditions associated with TT provide varying results. Considering the diversity of climatic conditions in northwestern Pennsylvania, we sought to assess whether climate may play a role in the development of TT. 

Methods: We retrospectively reviewed all patients from our institution over 18 years with a charted diagnosis of TT. Onset of symptoms was recorded with respect to date, month, and season. Atmospheric temperature, dew point, and atmospheric pressure at the time of onset, 24 hours before onset, and 48 hours before onset were recorded. Two stratification methods were used for analysis. We first stratified patients into groups based on onset temperature. We also stratified patients based on sexual maturity (prepubertal, pubertal, and postpubertal). P value <.05 was considered statistically significant. 

Results: Eighty-one patients had the diagnosis of TT. Mean age was 10.6 years (range, 0.25-38 y). There were no statistical differences seen between atmospheric variables before or at onset of TT. With respect to the group stratified by temperature, there was a statistically significant difference in the incidence of TT with a higher incidence occurring with atmospheric temperatures 59°F or lower. There were no statistical differences among months (P=.49) or seasons (P=.274). It is, however, worth noting that 59.3% of the cases occurred during the winter and spring when compared as a group against the summer and fall (P=.059). There was no statistical difference among the mean onset temperatures of patients stratified by age; however, a trend was seen with lower mean temperature for the pubertal age group (P=.15). Spearman's rank correlation revealed no significant correlation between the incidence of TT and increasing temperature (r=-0.2, P=.8), increasing dew point (r=0.37, P=.36), or increasing atmospheric pressure (r=-0.37, P=.47). 

Conclusion: This is the largest study assessing the effects of climate on TT. It appears that TT may be associated with atmospheric temperatures below 60°F. These data suggest that cooler temperatures may be associated with incidence of TT. We did not find any correlation between TT and dewpoint or atmospheric pressure. We found a previously unreported trend where pubertal males with TT exhibited lower onset temperatures. 

Health and Longevity: Getting a Grip on DNA  

Emily Forbes, OMS II; Brian H. Hallas, PhD; German Torres, PhD; Joerg Leheste, PhD 

Department of Neuroscience, New York College of Osteopathic Medicine of New York Institute of Technology, Old Westbury 

Hypothesis: In the United States, the proportion of the population older than 65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. This will cause a shift in the pattern of disease and treatment toward chronic illness and age-related degeneration. Recent work in nonhuman primates suggests a comprehensive role of caloric restriction (CR) in humans promoting an increase in lifespan and a decrease in age-related disease. The molecular mechanisms responsible for such benefits are strongly interconnected with the function of the protein modifying enzyme sirtuin1 (SIRT1). An increase in SIRT1 function has been shown to attenuate physical and cognitive signs of aging, including neurodegeneration and cancer. This makes SIRT1 a promising target for pharmaceutical intervention. To uncover the molecular basis for the benefits of SIRT1 activation, we previously studied its indirect association with DNA via nuclear core histone proteins H3 and H4. A genome-wide analysis revealed more than 80 specific gene targets which SIRT1 binds and transcriptionally regulates. This diverse group of DNA targets includes genes involved not only in neurodegeneration (psen1) and cancer (dlec1) but also clinical depression (gpr50) and epilepsy (nova-2). The inability of SIRT1 to directly bind DNA but yet associate with a very diverse set of specific DNA targets leads us to hypothesize the existence of 1 or several DNA-binding proteins that join together with SIRT1. 

Methods: For the identification of DNA-binding proteins that associate with SIRT1, nuclear protein fractions from human embryonic kidney (HEK-293) cells were used in a SIRT1-specific protein pull-down. Peptides from a tryptic digest were analyzed by a mass-spectrophotometer and statistically validated (P≤.05). Select SIRT1-protein interactions were further evaluated via intein-mediated reporter gene assay. 

Results: FBXL10, 1 of the proteins identified, is a DNA-binding histone demethylase abundant at ribosomal DNA (rDNA) loci inside nucleoli. There, FBXL10 is known to restrict rDNA expression limiting cell size and proliferation. 

Conclusion: These experiments support our hypothesis that SIRT1 forms gene regulatory complexes with DNA-binding proteins to interact and regulate specific DNA targets. The reported involvement of FBXL10 in cell size determination and proliferation provides a novel link between SIRT1 and cancer. 

Histological Characteristics of the Tracheobronchial Tree of the Least Shrew ( Cryptotis parva )  

Fadi Arodaki, MA, OMS II¹; Mohammed Al-Tikriti, PhD²; Wael Khamas, PhD²; Nissar A. Darmani, PhD³ 

¹Department of Anatomy and Basic Medical Sciences, Western University of Health Sciences College of Osteopathic Medicine of the Pacific (WesternUCOMP), Pomona, California; ²Department of Anatomy, WesternUCOMP; ³Department of Basic Medical Science, WesternUCOMP 

Background and Hypothesis: Being a vomit-competent species, the least shrew is becoming an important animal model for the study of emesis and other behaviors. Since Cryptotis parva has recently been introduced in the laboratory, a full understanding of their normal anatomical structures is a crucial step for further characterization of this species. In this project we studied the respiratory system of the least shrew relative to the well-established, laboratory-used species. 

Methods: Five least shrews (weight, 4-5 g; age, 45-60 days) were used in this study. The animals were killed after deep anesthesia via inhalation of isoflurane. The lung and trachea were quickly removed and submersed in 8% neutral buffered formalin solution for 72 hours. Standard histological procedures were followed to stain histological sections for light microscopic examination. 

Results: The lining epithelium of the trachea was found to be pseudostratified ciliated columnar. Two types of cells were easily identified: basal and ciliated. Few goblet cells were interspersed among the ciliated cells, and they were not instantly recognizable. The submucosa contains a thin, highly vascular connective tissue layer that lies immediately underneath the basement membrane. A few tracheal seromucous glands were located at the free end of the c-shaped cartilaginous rings. Their ducts were lined by simple cuboidal epithelium, which was open to the surface. The expected cartilaginous rings are replaced by spirally run smooth muscle before entering the lung. Consequently, the bronchial trees were divided and reduced in their luminal diameter as they proceed distally. The lining epithelium of tracheobronchial tree gradually changes into simple cuboidal epithelium that lacks goblet cells. 

Conclusion: The division of tracheobronchial tree is similar to other mammalian species. However, the principal bronchus lacks cartilaginous plaques even before it becomes intrapulmonary bronchus. Moreover, the wall of the bronchi is supported by thick layers of spirally arranged smooth muscles. Two types of cells—basal and ciliated—were readily recognized. However, goblet cells were rarely observed. The pseudostratified ciliated columnar epithelium changes into simple cuboidal much earlier in the bronchial division relative to other species. 

The Role of P-cadherin as a Protective Protein Against Tumor Aggressiveness and Invasiveness Within Oral Epithelium  

Christopher Wade Fowler, OMS II; Kathryn Lawson, PhD; Andrew Walker, PSM 

Department of Biochemistry, Midwestern University/Arizona College of Osteopathic Medicine, Glendale 

Background: Cadherins are cell adhesion molecules that are present in normal epithelial tissue. In oral tumor cells, the epithelial cadherin, P-cadherin, undergoes altered expression. In human tumor specimens, loss of P-cadherin correlates with more aggressive tumors and a poorer prognosis in patients. P-cadherin is present in healthy epithelium and expression increases in early tumorigenesis and then substantially decreases in late stage carcinomas. This decrease may have a causative role to the increased invasive and aggressive nature of late stage oral carcinomas. To investigate this observation, we manipulated P-cadherin expression in 2 human oral tumor lines. 

Hypothesis: That P-cadherin expression is protective against progression of oral cancer and that decreased levels of P-cadherin contribute to tumor invasiveness, aggressiveness, and metastasis. 

Methods: Using 2 human oral carcinoma cell lines, we knocked down expression of P-cadherin. We have stably introduced a vector that produces a small hairpin RNA (shRNA), which efficiently silences P-cadherin expression in oral tumor cells. Using these cells, we then observed the effects that decreased levels of P-cadherin have on the aggressive characteristics of the cell, including morphology, motility, and expression of matrix metalloproteinases, specifically MMP-9 and MT-1. 

Results: A knockdown of nearly 50% in P-cadherin was confirmed using Western blots and immunofluorescence indicated that knockdown was homogeneous. Levels of E- and N-cadherin were unchanged with decreased levels of P-cadherin. Of particular interest were the morphology changes of these cells. Cells appeared less adherent to neighboring cells and are more rounded and isolated than the unaltered cell lines. In P-cadherin depleted cells, real-time polymerase chain reaction showed an increase of 80% in MT1 expression and a decrease of 70% in expression of MMP-9. 

Conclusions: The loss of P-cadherin appears linked with the expression of different MMPs and this change would support the observation that loss of P-cadherin within the cell leads to a more invasive tumors with an increased ability to metastasize. Morphology changes also indicate that P-cadherin depleted cells are less able to maintain stable cell-to-cell junctions, increasing chances of unregulated growth. Investigation of P-cadherin's effect on signaling pathways within the cell can identify possible targets for decreasing invasiveness and aggressiveness of tumors. 

Effects of Flavonoids on the Plasma Membrane Calcium ATPase  

Jennifer R. Callison, OMS II; Paul Ramlow, BS; Asma Zaidi, PhD Kansas City University of Medicine and Biosciences College of Osteopathic Medicine, Missouri 

Hypothesis: The plasma membrane Ca²⁺-ATPase (PMCA) is an integral membrane protein that plays an important role in maintaining Ca²⁺ homeostasis and is crucial for neuronal survival. Disruption in the 10,000-fold Ca²⁺ gradient across the plasma membrane maintained by the PMCA can lead to altered Ca²⁺ signaling and subsequent development of neurodegenerative disorders, such as Parkinson disease (PD). Studies have shown that dietary flavonoids such as resveratrol and epigallocatechin gallate (EGCG) offer neuroprotection, but the precise mechanisms are unknown. This study hypothesizes that resveratrol and EGCG exhibit neuroprotection through the preservation of the PMCA and the lipid raft membrane environment in which it is embedded. 

Methods: Cultured SH-SY5Y dopaminergic neurons were plated on 6 well plates in a media containing DMEM and 10% FBS. Cells were pretreated for 1 hour with various concentrations of resveratrol or EGCG (1-100 μM) and then exposed for 24 hours to 50 μM 6-hydroxydopamine (OHDA), a neurotoxin used in cell models of PD. Resveratrol or EGCG alone was added to cells to assess the effects of the flavonoids by themselves. Cell morphology was assessed using light microscopy. PMCA protein levels were assessed by immunoblots using pan-PMCA antibody as well as by immunofluorescence by confocal microscopy. Lipid rafts were visualized by confocal microscopy following labeling with a cholera toxin-Alexafluor 488 conjugate. 

Results: Exposure of SH-SY5Y cells to OHDA led to a dose-dependent shrinking of the neuritic processes consistent with previous studies. There was a dose-dependent decrease in PMCA protein levels. Pretreatment of cells with resveratrol and EGCG prior to the addition of OHDA preserved cell morphology and prevented OHDA-mediated PMCA loss. Exposure of cells to flavonoids by themselves also showed upregulation of the PMCA protein. The flavonoids also preserved the integrity of lipid rafts as evidenced by fluorescence microscopy. 

Conclusions: Based on our results, resveratrol and EGCG exhibit neuroprotective effects, and this appears to be through preservation of PMCA and its lipid raft environment. Our data support the use of dietary flavonoids as an interventional therapy for the prevention and treatment of neurodegenerative diseases such as Parkinson disease. 

The Relationship of Pelvic Anatomy to Energy Use During Walking: Implications for OMT to Increase Pelvic Mobility  

Stephanie L. D'Agostino, OMS III; Lisa K. DeNardi, OMS II; Cody C. Honl, OMS II; Robert Lee, BS; Brinkman A. Murray, OMS IV; Jandy Hanna, PhD 

West Virginia School of Osteopathic Medicine, Lewisburg 

Osteopathy teaches that structure and function are interrelated and a historical examination of this relationship may help us better understand lower limb morphology. For example, early fossil bipeds like “Lucy” (Australopithecus afarensis) have provided a wealth of information regarding the specific anatomic features of bipedalism. Lucy has relatively short lower limbs, and short lower limbs may increase the energy cost of walking, thereby causing reduced efficiency during ambulation (Kram and Taylor, 1991). Lucy also had an exaggerated pelvic breadth, which may have allowed her to increase pelvic rotation and therefore stride length during walking. This increase in stride length, due to greater pelvic rotation, may have allowed early hominids to overcome the energetic cost of having such short lower limbs (Rak, 1991). In modern humans, recent work supports the idea that a wide pelvis allows short-legged people to achieve greater stride lengths and higher walking speeds (Gruss, 2006), but the energy cost of such anatomy and function has not been examined. To determine if limb length and pelvic breadth are correlated with energy use during walking, each subject walked at a steady rate on the treadmill as we evaluated stride length and pelvic rotation using 4 motion-capturing cameras while the gas analysis system collected oxygen consumption (a proxy for metabolic rate). Limb length and bi-trochanteric breadth (as a proxy for pelvic breadth) were also measured on each subject. The data were analyzed using motion analysis software (Innovision Systems Inc, Columbiaville, Michigan) and custom-written Microsoft Office Excel (Microsoft Corporation, Redmond, Washington) macros. Stride length as a percentage of lower limb length was significantly correlated with pelvic rotation (R²=0.3348, P=.04). In addition, metabolic rate was significantly and negatively correlated with pelvic rotation (R²=-0.507, P=.03). Thus, subjects who exhibited longer strides and greater pelvic rotation used less energy during walking. These data show a direct relationship between structure and function, which can be applied to osteopathic medicine and treatment. We suggest that treatment of patients with somatic dysfunction in the lower limb and pelvis may help decrease patient energy use and increase efficiency during walking. The procedures used in this study were reviewed and approved by the West Virginia School of Osteopathic Medicine (WVSOM) institutional review board (protocol #JH10262009). Funding for this study was through a WVSOM intramural grant. 

Ischemia and Reperfusion Injury of Cardiac Myocytes Treated With Pravastatin and Niacin  

Derrick Durell Wagoner, OMS II; Richard S. Shinn, OMS II; Brian Griffith, PhD; Bethany Hampton, BS; Judith Maloney, PhD 

Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg 

Background: Reperfusion therapy following myocardial infarction is crucial for reducing morbidity and mortality. However, this can paradoxically cause additional myocardial cell death and thereby negate some of the beneficial effects of reperfusion. One component of reperfusion injury is oxidative stress. This depletes cellular adenosine triphosphate and oxidized nicotinamide adenine dinucleotide (NAD+) levels, thereby altering metabolic and energy homeostasis. This, in turn, activates both apoptosis and necrosis pathways. Another aspect of reperfusion injury is the reduction in myocardial cell survival pathways involving PI3K-Akt. Agents that might target these 2 pathways are niacin and pravastatin, drugs that are commonly used to treat dyslipidemia. 

Hypothesis: Therefore our hypothesis is that niacin, a precursor for NAD+, will reduce cellular damage and death by restoring NAD+ levels, while pravastatin, because it activates Akt, will enhance cell survival. Moreover, these 2 mechanisms may converge to decrease myocardial apoptosis and thereby prevent myocardial ischemia-reperfusion injury. 

Methods: Mouse HL-1 cardiomyocytes were used in this study. They received 2 hours of simulated ischemia followed by 6 hours of reperfusion. Pravastatin, niacin, or vehicle controls were administered with reperfusion. At the completion of reperfusion, apoptosis was determined by measuring caspase 3 activity. 

Results: Simulated ischemia-reperfusion elevated caspase 3 activity in HL-1 cells. Compared to HL-1 cells undergoing 2 hours of simulated ischemia followed by 6 hours of reperfusion with vehicle control, treating with pravastatin decreased caspase 3 activity. Similarly, treating with niacin under the same conditions also decreased caspase 3 activity. 

Conclusion: In HL-1 cells, both niacin and pravastatin decreased simulated ischemia-reperfusion-induced apoptosis. Reperfusion therapy is a critical factor in managing a myocardial infarction. However, a certain amount of cell death inevitably occurs by apoptosis. By targeting 2 distinct pathways involved in reperfusion injury, we might be able to prevent much of this damage and hence prevent or slow the progression to cardiac hypertrophy, failure, and death following myocardial infarction. 

The Efficacy of Using a Small Molecule Inhibitor of Bcl-2 in the Treatment of Breast Cancer  

Maryna Popp, OMS II; Amanda L. Whaley, OMS II; Bethany Hampton, BS; Joshua P. Smith, OMS II; Brian Griffith, PhD 

Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg 

Background: According to the American Cancer Society, in 2010, nearly 210,000 women and men will be diagnosed with invasive breast cancer in the United States, and nearly 41,000 patients are expected to die this year. One obstacle responsible for the high mortality rate is the development of drug resistance. Therefore, it is important to identify and characterize new chemicals that effectively target cancer cells, particularly drug-resistant cancer cells. One possible drug target for breast cancer is the anti-apoptotic protein, BCL-2, which is overexpressed in more than 70% of all breast cancer cells. This protein is responsible for inhibiting apoptosis by binding and inactivating proapoptotic proteins BAK and BAX, allowing for further destructive cancer cell proliferation. Thus, our research is interested in investigating the efficacy of a Bcl-2 inhibitor, 4-(3-methoxy-phenylsulfannyl)-7-nitro-benzofurazan-3-oxide (MNB), in the treatment of patients with breast cancer. 

Hypothesis: MNB will act as a small molecule inhibitor of Bcl-2. We expect MNB to work in a dose-dependent manner to induce apoptosis in Mcf-7 and SK-BR-3 cancer cell lines (Bcl-2 positive cell lines). We anticipate that MNB will selectively inhibit the heterodimerization of BCL-2 with BAK and BAX thereby resulting in apoptosis. The long-term goal of our research is to identify a new chemotherapeutic drug that can be used to target drug-resistant breast cancer. 

Methods: The cytotoxic effects of MNB were determined by MTT assays, and TD50 values were calculated using SigmaPlot software. Apoptosis was measured via fluorescent microscopy using Fas-CALIBUR and Annexin V staining, and using tunnel assays with fluorescein-12-dUTP and VECTASHIELD+DAPI staining. The effect of MNB to inhibit the heterodimerization of BCL-2 was investigated using Western analysis. 

Results: The TD50 dose of MNB in Bcl-2 positive cells was determined to be 1.8uM ±0.25, whereas the TD50 dose for Bcl-2 negative cells was 13.4uM ±5. The cytotoxic effect of a 10uM dose was determined to be 80% in BCL-2 positive cells and 50% in BCL-2 negative cells. Preliminary data suggest that MNB selectively inhibits the heterodimerization of Bcl-2 and BAX. 

Conclusion: MNB, a small molecule inhibitor of BCL-2, selectively induces apoptosis in breast cancer cells that express the protein BCL-2. This new chemotherapeutic agent has the potential to treat both non–drug-resistant and multiple drug-resistant breast cancers. 

Investigation of the Impacts of Temporomandibular Joint Pathology and Antemortem Tooth Loss on Three-Dimensional Craniofacial Shape  

Laura A. Barket, OMS II¹; Heather F. Smith, PhD² 

¹Midwestern University/Arizona College of Osteopathic Medicine (MWU/AZCOM), Glendale; ²Anatomy, MWU/AZCOM 

Hypothesis: There has been little investigation into the effects of temporomandibular joint (TMJ) disorder and alveolar resorption from tooth loss on the overall structure of the skull. This study was designed to look at the manifestations of both pathologies on the 3-dimensional morphology of the facial skeleton and basicranium. 

Methods: The initial phase of the study was 3-dimensional data collection on skull shape from individuals exhibiting TMJ disorder or alveolar resorption secondary to tooth loss, and nonpathologic specimens from each of the same populations as the pathological specimens. The raw data from these specimens was divided into different anatomic subsets, including the basicranium, palate, upper face, and temporal bone, screened using a Generalized Procrustes Analysis, a superimposition technique, before running a series of statistical analyses. Procrustes ANOVA was performed, Procrustes and Mahalanobis distances calculated and compared, Discriminate Function Analysis run, and a Principle Components Analysis conducted to help determine whether there was a statistically significant difference in the cranial morphology between the pathologic and nonpathologic data sets. In the data sets where a statistically significant difference was noted, a wire frame was used to visualize the morphological difference between the 2 groups. 

Results: Both alveolar resorption and TMJ pathology were found to significantly affect facial structure. The shape of the mid and upper face, including the zygomatic and nasal regions, was substantially altered in individuals with alveolar resorption. Individuals with TMJ pathology exhibited significant changes in palatal morphology, suggesting remodeling of alveolar bone likely due to the alternating masticatory patterns observed in individuals with this condition. 

Conclusion: Implications of this research are far reaching for both medical practitioners and dentists. Alveolar resorption caused by tooth loss begs a strong case for dental implants to ward off inevitable changes in facial structure. Similarly, patients with TMJ disorder also need preventative and palliative care to prevent further damage to facial bones and for obvious pain management. 

Interactions of Extracellular Potassium, Calcium, and Hydrogen With the Cardiac Potassium Channel HERG  

Attilio Macrito, OMS II¹; Vikram Makhijani, OMS II²; Kristeen Pareja, BS²; Eddie Thara, DO²; Nicholas Logemann, DO²; A. Miller, PhD² 

¹Touro University College of Osteopathic Medicine—California (TUCOM-CA), American Canyon; ²TUCOM-CA, Vallejo 

Background: The human ether a-go-go related gene (HERG) encodes a cardiac potassium channel that is important in the repolarization of the action potential. A reduction in the number of HERG channels has been implicated in long QT syndrome, which in some cases can degenerate into the lethal arrhythmia Torsades de Pointes. Many patients present with abnormal serum electrolyte levels due to a variety of conditions including gastrointestinal dysfunction, renal and endocrine disorders, diuretic use, alcoholism, and aging. Changes in extracellular electrolytes and extracellular pH have been shown to reduce HERG channel function. 

Hypotheses: The hypotheses of this project are that extracellular H⁺ and extracellular calcium block the HERG channel and that this block will be dependent on the permeant ion, potassium. 

Methods: Experiments were performed using 2-electrode voltage clamping of Xenopus oocytes expressing wild-type HERG. cRNA of wild-type HERG was injected into enzymatically defolliculated oocytes and currents were recorded 1 to 5 days after injection. 

Results: Increasing extracellular calcium from 0.1 mM to 10 mM as well as decreasing extracellular pH from 7.0 to 6.0 resulted in a greater decrease in HERG current when extracellular potassium was reduced from 20 mM to 0 mM. Additional experiments showed that the decrease in current due to increasing calcium was different at different extracellular pH. The Drosophila voltage-gated potassium channel, Shaker, showed a smaller decrease in current by extracellular calcium, which was not dependent on extracellular potassium. 

Conclusion: Although the mechanism by which both extracellular calcium and extracellular pH reduce current through HERG channels is not clear, one plausible explanation is pore block by these cations. The results presented here suggest that potassium, calcium, and hydrogen may interact at the outer mouth of HERG such that block of HERG by calcium and hydrogen depends on the concentration of other extracellular actions. There is evidence that the outer mouth of the HERG channel is different than other voltage-gated potassium channels, and thus, these interactions may be unique to the HERG channel. This study has implications for an increased risk of cardiac arrhythmias in patients with hypokalemia. 

Neuronal Ischemic Sensitivity in a Transgenic Mouse Model of Alzheimer Disease  

Rung-Chi Li, OMS II; Jennifer O. Mytar, OMS I; Gloria J. Klapstein, PhD 

Touro University College of Osteopathic Medicine—California, Vallejo 

Background: Alzheimer disease (AD) shares many risk factors with vascular disease. Cerebral macrovascular pathology is a major cause of disability, dementia, and death. Accumulating evidence has linked stroke and AD and has shown that each exacerbates the severity of the other. This disease is generally believed to be a neurologically driven disorder. However, this concept has been questioned based on the strong connection between AD and stroke. 

Objective: We investigated whether ischemic neuronal damage in a triple transgenic mouse model of AD is due to intrinsic neuronal sensitivity to ischemia or has contributions from vascular dysfunction. 

Methods: Ischemic damage was modeled using oxygen-glucose deprivation (OGD; an in vitro global cerebral ischemia model) in brain slices from mice with an APP/PS1/tau triple gene mutation, a model of aggressive AD. These mice develop amyloid plaques at about age 2 to 3 months, and behavioral memory deficits are well established by age 6 months. The technique of acute brain slice preparation we used allows direct examination of neuronal synaptic properties under controlled conditions, removing the need for the vascular system for delivery of oxygen and glucose. By taking the vasculature out of the equation, this method avoids the variable and confounding effects of amyloid on vascular dysfunction. 

Results: Our results have demonstrated a significantly higher maximum recovery rate after OGD for 7.5 minutes in 3.5-month-old AD mice compared to the wild-type cohorts. The AD neurons show much less sensitivity to OGD, indicating that the sensitivity seen in models employing vascular occlusion may be primarily due to differences in vascular properties, not because AD neurons inherently have an increased propensity for ischemic damage. 

Conclusion: We believe this is an example of “preconditioning,” a physiological protective mechanism where early, mild insults can prepare and protect the brain from later insults. In this instance, the early exposure of amyloid plaques in the brain is the pre-existing condition. Though this pathology in the brain does kill neurons, the surviving neurons are better able to sustain an insult such as OGD. The current findings provide a platform to let us understand the close relationship between neuronal and vascular contributions to AD. It may also provide the potential for targeting therapies to neuronal or vascular targets in the future. 

Biochemical Characterization of the Ferric Uptake Regulator From Klebsiella oxytoca 

William Spencer Ellis, OMS I¹; Allison,Galbraith, BS¹; Jose Hernandez, PhD² 

¹Midwestern University/Arizona College of Osteopathic Medicine (MWU/AZCOM), Glendale; ²Department of Biochemistry, MWU/AZCOM 

Iron is a scarce micronutrient that has been recognized as a determinant of virulence for multiple pathogens. Iron acquisition, storage, and utilization are vital functions performed by nearly all living beings. Many bacterial species regulate their iron-related genes, as well as a variety of other functions, by a master protein called Fur (ferric uptake regulator). Our hypothesis was to determine the existence and nature of a Fur protein homologue in Klebsiella oxytoca, a microorganism related with increasing cases of nosocomial infections and neonatal bacteremia. In this work, several molecular biology and protein biochemistry methods were used for the purification and characterization of K. oxytoca Fur protein. The protein was isolated by affinity chromatography, and homogeneity of the preparation was confirmed by native gel analysis. Protein activity was studied through electrophoretic mobility shift assays. K. oxytoca Fur showed high affinity for the flavodoxin B (fldB) gene promoter (KD∼1 uM) and weaker affinity for its own promoter region. DNA binding activity required the presence of Zn²⁺, and to a lesser extent, Mn²⁺. Other metals (Co²⁺, Ni²⁺) and reducing conditions did not appear critical for protein activity. Moreover, we demonstrated that the DNA binding site is located within the 200 bp region upstream of the fldB start codon, and several putative binding sequences were identified. K. oxytoca cell cultures grown at different iron concentrations demonstrate iron-dependence. K. oxytoca Fur antibodies were obtained to test in vivo production of Fur protein in different growth conditions. Western blot analyses indicated similar Fur content at different iron concentrations tested and slightly increased production of Fur protein in response to the presence of H₂O₂-induced oxidative stress. Moreover, a recombinant strain of K. oxytoca overproducing the Fur protein was generated and tested for siderophore production and H₂O₂ sensitivity. The mutant strain displayed largely increased susceptibility to H₂O₂. In conclusion, this work reports a new Fur regulator in a microorganism with increasing clinical relevance. In the presence of specific metals the protein showed physiologically relevant affinity for its target DNA. Minor autoregulation was observed. Presence of H₂O₂ slightly increased production of Fur and largely inhibited growth of cells overproducing Fur, establishing a link with regulation of oxidative stress responses. 

Water, Soil, and Blood Lead Toxicity in Peruvian Children  

Devone T. Mansour, OMS II¹; Shane R. Sergent, OMS II²; Gary Z. White, OMS II³; Gary L. Willyerd, DO³; Mary Jo Voelpel, DO² 

¹Michigan State University College of Osteopathic Medicine (MSUCOM), Rochester Hills; ²MSUCOM, East Lansing; ³MSUCOM Detroit Medical Center 

Background: During medical missions to Peru, it was found through a simple test that Peruvian children exhibited elevated blood lead levels in the range of 5 to 10 μg/dL. It was from this discovery our pursuit for the heavy metal contamination directed us to analyze the water supplies and soil in Peru. 

Objective: We investigated the extent to which the water supplies and soil in the towns of Humachuco, Cajabamba, and Maracbalito were contaminated with heavy metals and compared its levels to the abnormal elevated blood lead data gathered from Peruvian children. 

Methods: Water samples were collected from 8 sites in 3 towns based on the percent of population using those sites as their source of water. Water sample collection vials contained Nitric Oxide to stabilize the heavy metals. The soil was collected along the river's edge in Humachuco and at the road side in 2 separate containers made of glass and plastic. A comprehensive analysis of heavy metals was evaluated using Inductively Coupled Plasma Atomic Emission Spectroscopy (ICP-AES), which produces excited atoms and ions that emit electromagnetic radiation at wavelengths characteristic of a particular element. Blood lead levels in children were obtained via a finger stick and transferred to blood lead sensors and analyzed by a LeadCare System utilizing Anodic Stripping Voltammetry (ASV). This analysis consists of 2 components—sensing and electronics. The sensing unit includes a test electrode, a stirring assembly, and 2 electrodes that carry current and regulate potential. The electronics unit controls the analysis cycle, sorts the electronic signals, and calculates the results. 

Results: The Peruvian water supplies presented with trace or negligible levels of heavy metals. However, we found an elevation in the concentration of lead within the soil that was reflective of the abnormal elevated blood lead levels gathered in Peruvian children. 

Conclusion: We see evidence for heavy metal exposure in Peruvian children. The elevation of lead in the soil samples obtained reflects the musculoskeletal and cognitive defects noted within the Peruvian children unacceptable by CDC standards. Symptomatically, many individuals presented with bouts of nausea, gastrointestinal complications, severe headaches, hyperhidrosis, aphasia, and amnesia. However, the heavy metal toxicity cannot be directly linked to disease severity. 

Tumor-Derived Expression of the Transcription Regulator FOXP3 Controls the Generation of Immune-Related Cytokines by Melanoma Cells  

Cynthia Chen, OMS IV¹; Samuel Olson, BS²; Hermes Garban, MD, PhD² 

¹Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Yorba Linda, California; ²LA Biomedical Research Institute at Harbor-UCLA, Torrance, California 

FOXP3 is a pivotal transcription regulator that controls the tolerogenic function of Regulatory T cells (Tregs) in the immune system. The role of FOXP3 is important for the development and function of Tregs and immune tolerance. It has also been shown that FOXP3 is expressed in numerous cancer cells such as in malignant melanoma. Ectopic expression of FOXP3 by cancer cells has been suggested to play an active role in down-regulating local antitumor responses, however, its mechanism of control remains elusive. Thus, we hypothesize that FOXP3 will control the expression of endogenous immune-related cytokines by melanoma cells inducing immunotolerance in the tumor microenvironment. To test this hypothesis, we have compared the expression and suppression of the transcription factor FOXP3 in the cultured B16 mouse melanoma cells model by using the lentivirus-mediated/shRNA-based knocking down of FOXP3 gene expression. We have monitored specific gene expression using the polymerase chain reaction (PCR) and immunoblotting (Western blot) for specific protein generation. Immune-related cytokines released to the culture media were determined by multiplex immunofluorescent assay (Luminex) and reported as relative amount of cytokines compared with positive control (FOXP3-expressing B16 melanoma cells). Our results demonstrated that the suppression of expression of FOXP3 in melanoma cells showed an overall downregulation of a selected group of cytokines, in particular TNF-α, IL-12, IL-6, and IL-4. FOXP3 did not seem to have an appreciable effect, however, on the expression of IL-5, IL-2, and IFN-γ. Altogether, our data suggest the specific role of tumor-derived expression of FOXP3 in the control of the expression of tolerogenic cytokines secreted to the tumor microenvironment. Furthermore, selective suppression of FOXP3 expression or activity in cancerous cells may help to develop better and more effective targeted therapies as treatment for patients with malignant melanoma. 

Global Health Simulations: The Missing Link to Prepare Participants for Fieldwork in Rural Ghana  

Vanessa Parisi, OMS IV¹; Edward S. Cho, DO, MPH²; Anthony M. Errichetti, PhD³; Deborah A. Lardner, DO, DTM&H²; Zehra Ahmed, PA, MBBS² 

¹New York College of Osteopathic Medicine of New York Institute of Technology (NYCOM), Glen Cove; ²Center for Global Health, NYCOM, Old Westbury; ³Institute for Clinical Competence, NYCOM, Old Westbury 

Context: As global health studies become incorporated into medical education through didactics, lecture series, and discussion, fieldwork opportunities are becoming a critical part of this curriculum. However, there is little evidence of preparatory training occurring before departure. Because simulations have proven to be an effective tool for training medical professionals, a program that incorporates simulation on fieldwork scenarios would be instrumental in linking theoretical knowledge to practical experience. 

Methods: Our global health simulation program prepares participants for cultural encounters, focusing on leadership, team building, and resource management. Surveys addressing ethnicity, culture, and resource management in health care were administered prior to the simulations, directly following the simulations, and upon returning from fieldwork. Prior to the simulation, 53% of participants that traveled to developing countries were “undecided” about the utility of simulations in global health. Following the simulation and fieldwork, 88% and 65%, respectively, decided that simulations would be “very useful” to their future fieldwork. The impact of simulation on ethical and cultural notions was statistically insignificant. However, the postfieldwork survey demonstrated significant impact on participant views on ethnic and cultural difference compared to the presimulation surveys (Friedman, P<.028-.034). 

Conclusion: Although simulation does not replace actual experience, we believe that it has substantial utility in preparing participants for global health fieldwork. Furthermore, simulation has limited impact on deep-rooted views concerning ethical and cultural norms, possibly because of the limited simulation exposure to affect change. This simulation program, when used in combination with global health coursework, can better prepare participants for their fieldwork experience. 

S1 Exploring Preferred Incentive Strategies for Community-Based Health Workers Providing Antenatal Care Services in Rural Ghana  

Cheryl A. Dinglas, OMS III; Edward S. Cho, DO; Michael Ignat, OMS II New York College of Osteopathic Medicine of New York Institute of Technology, Bayside 

Background: Performance-based pay has been a compensation option for skilled healthcare workers to improve health outcomes. Nongovernmental organizations have traditionally recruited nonskilled community-based health workers (CBHWs) either through a voluntary or salary basis. However, no studies have shown that performance-based pay could be used for CBHWs. The same benefits of performance-based pay used for skilled healthcare workers could similarly be applied to CBHWs to improve health outcomes. 

Hypothesis: Performance-based pay is a preferred incentive strategy for CBHWs over traditional salary-based pay or volunteering. 

Design: A cross-sectional study was done to determine the appropriate incentives of CBHWs in implementing an antenatal care program in rural Ghana. 

Methods: Surveys were administered to female community members of the Kwahu South, Eastern Region of Ghana, interested in providing antenatal care. We focused on the following incentive strategies: (1) community recognition of volunteering, (2) salary-based pay, (3) performance-based pay, and (4) a low base salary with additional performance-based pay. In addition, we assessed the factors, which were valued if their outreach work were voluntary or if their compensation was in the form of in-kind payments. 

Results: Among 208 surveyed participants, 47.6% valued training experience when volunteering, whereas 34.6% valued family benefits (food and housing) as in-kind payments. When different forms of payment were offered as compensation, 39.1% preferred a low base salary with additional performance-based pay regardless of their educational background or prior healthcare training. 

Conclusion: The results suggest that a low base salary with additional performance-based pay is not only desirable for CBHWs of diverse educational backgrounds, but suggests that CBHWs are willing to take responsibility for the quality of their outreach work. If the payment structures for CBHWs were redesigned to directly link with the quality of outreach interventions, nongovernmental organizations would maximize their financial investment and effectiveness. Understanding the motivation of CBHWs can ensure that their services will be sustainable and effective. 

Bringing Healthcare to the Haitians: A Medical Mission to Port-au-Prince, Haiti  

Victoria Ridgeway, BS 

Georgia Campus-Philadelphia College of Osteopathic Medicine, Suwanee 

Although months have passed since the devastating earthquake that shook Haiti, its people are still in need of medical attention. This was the goal of a medical mission team that traveled to Port-au-Prince, Haiti. It was an ideal opportunity for medical students to put into practice the knowledge and skills obtained during their training. The importance of primary and preventative care was emphasized with each patient. Medical students rotated with physicians specializing in family practice, obstetrics/gynecology, internal medicine, ID, dermatology, GI, surgery, and orthopedics. Students were assigned tasks such as obtaining histories, performing physical examinations, assisting in procedures, and developing a diagnosis and treatment plan for each patient. When the treatment plan included osteopathic manipulative treatment, students performed it as well. Excellent clinical skills were essential due to the limited amount of ancillary testing. Efforts were directed to Haiti not only because it is the poorest country in the western hemisphere, but also because of the shortage of healthcare evidenced by a life expectancy of 60.78 years, infant mortality rate of 59.69/1000, and a 2.2% HIV prevalence rate. Infectious diseases are also widespread with a high incidence of hepatitis, typhoid fever, malaria, and infectious diarrheas. Patients presented with a variety of common and unique illnesses. As a result of the limited primary care, chronic conditions such as diabetes, hypertension, and musculoskeletal complaints were often seen. Many patients presented with ophthalmologic conditions such as dry eye, cataracts, and ptergiums. More rare illnesses included Pott disease and elephantiasis. Communicating the importance of preventative health measures to clinic patients was essential. Although only 50% of the population has access to clean drinking water, simple hygiene practices and the necessity of clean water were emphasized. Patients were instructed to wear sunglasses and a hat to protect their eyes and prevent further damage. Everyone received multivitamins, a toothbrush, and toothpaste as supplies allowed. Educating patients is a tool that should be used at every opportunity and is the cornerstone of preventative medicine. Medical missions provide the opportunity for osteopathic medical students to practice skills, preventative healthcare techniques, and osteopathic manipulative medicine while gaining knowledge about the sequellae of untreated medical conditions and how to adapt treatment plans in a country with limited options. 

Medicinal Plant Use and Traditional Medicinal Practices in Rural Mexico: A Case Study in Tamaula, Guanajuato, MX  

Emilie Y. Prot, OMS I 

Ohio University College of Osteopathic Medicine, Athens 

Context: Tamaula is an isolated rural ranching town located in the mountains near the city of Irapuato, Mexico. Tamaula is a community of 220 people made up by 37 nuclear families. 

Objectives: To study the traditional health practices in a small and poor village in Mexico. To better understand the extent of knowledge the people of Tamaula have in herbal medicines, each male and female of a household was interviewed individually to determine how prevalent the use of medicinal plants is, if there existed a gendered difference in the knowledge and use of herbal remedies, if there was a correlation between herbal remedy knowledge and education and finally if the people that used herbal remedies were satisfied with their herbal treatments. 

Methods: Data were collected from in-person household surveys that asked how the inhabitants used specific herbs. All participants in the study (n=48) use or have used herbal remedies to cure illnesses. A list of 24 commonly used plants with their therapeutic uses was prepared for the survey. A total of 19 of the plants were used to treat gastrointestinal problems, 6 plants were used to treat cough and cold symptoms, 5 plants were used for external wound care, and 2 for urinary infections. 

Results: During the interviews 18 additional plants with medicinal purposes local to the area were identified by the interviewees along with 5 animal parts. For instance, cow hoof, the rattlesnake, and skunk liver were cited for their therapeutic use. Women participants knew slightly more plants than their male counterparts. Most of the men knew 16 to 20 of the plants (n=7) whereas most women knew on average 21 or more plants (n=14). Two women who attended high school showed lower plant knowledge than the other participants. The participants in the personal interviews shared stories of how plants and animal parts were used and cured their ill children. 

Conclusions: The use of medicinal plants in Tamaula is widespread. Both male and female participants displayed a wide knowledge of the plants, but the women are in charge of the health of the family members. A physician appointed by the government visits Tamaula every month. Therefore the people of Tamaula use herbs and animal parts to cure their family members from common illnesses and save severe cases for allopathic treatments. 

Accuracy of the Clinical Assessment of Anemia in El Salvador  

Laura K. Romstedt, OMS II, RD; David S. Drozek, DO; Gillian H. Ice, PhD, MPH; Godwin Dogbey, PhD 

Ohio University College of Osteopathic Medicine, Athens 

Background: Anemia has been known to cause physical symptoms such as decreased quality of life and, in extreme cases, increased mortality. The prevalence of anemia in many populations may warrant their screening. One of the most reliable ways to screen for anemia is by examining hemoglobin values using a HemoCue machine. There is substantial cost associated with this method, however, and many populations go without. Because a history and physical examination may be more affordable and accessible than attaining hemoglobin levels in certain populations, clinical assessments and alternative techniques become important in screening. 

Objectives: To determine the prevalence of anemia in a subpopulation of El Salvador. The second objective was to determine the sensitivity and specificity of the clinical diagnosis of anemia in this subpopulation and to determine if experienced physicians make more accurate diagnoses than residents and students. 

Methods: The subjects were selected through a convenience sample taken from patients who presented at medical brigades set up in El Salvador in association with the Center for the Complete Development of Children and Their Families and with Ohio University College of Osteopathic Medicine. Each subject was first sent for hemoglobin testing and then assessed by a physician or supervised student. The hemoglobin levels were kept hidden from the provider. On the form, the provider was asked, “Based on your clinical assessment, is this person anemic: yes or no?” Following the assessment, all subjects were sent to the pharmacy where hemoglobin values were read and anemic patients received treatment. After data collection, patients were categorized as anemic based on hemoglobin values less than 12 mg/dL for women and less than 13 mg/dL for men. The incidence of anemia and the sensitivity and specificity of the clinical assessment was calculated. 

Results: Of 483 tested subjects, the prevalence of anemia was 24%. Although this is much higher than the 10% to 18% expected prevalence based on the reviewed literature, almost 90% of the cases were found to be mildly anemic, with hemoglobin values greater than 9.5 mg/dL. The sensitivity and specificity of the clinical diagnosis of anemia for all physicians and students was 28% and 79% respectively. Highly statistically significant differences were found between the diagnostic accuracy—sensitivity and specificity—between Canadian residents, US residents, and Salvadorian physicians. Canadian and US residents had the highest sensitivity and specificity of 44% and 94%, respectively. 

Conclusion: The prevalence of anemia in this study is higher than for other studies conducted in Latin America, indicating that El Salvador may benefit from further investigations as to the cause of anemia in this population. The low sensitivity found suggests that physicians may require further training in order to more accurately diagnose anemia without laboratory values. It may also suggest that a physical and history examination alone may not be sufficiently sensitive to diagnose anemia, particularly mild anemia. Further research investigating cost effective techniques for diagnosing anemia may benefit many low income areas, including El Salvador. 

A Qualitative Study Describing the Perceptions of Healthcare Providers in Rural Underserved Nicaragua  

Laura Fluke, OMS III; Jessica Cox, OMS II; Stanley E. Grogg, DO; Matt Vassar, PhD 

Oklahoma State University College of Osteopathic Medicine, Tulsa 

Background: Nicaragua is the poorest country in Central America. Forty-eight percent of the population lives in poverty, which affects access to healthcare (UNWFP). Healthcare workers recently traveled to rural Nicaragua to provide medical service. 

Objective: To understand the perceptions of the providers related to cultural understanding and working with the medically underserved. 

Hypothesis: Due to the descriptive and qualitative nature of this study, formal hypothesis testing was not performed. Rather, we posed the following research questions: (1) What are the experiences of US healthcare providers during a short-term international healthcare experience? (2) How did this experience affect their cultural understanding? and (3) How did the experience affect their perceptions of working with medically underserved populations? 

Methods: The sample included 6 medical students, 2 residents, 4 physicians, and 5 healthcare support personnel aged between 24 and 71 years. Men (41%) and women (59%) participated. All subjects participated in mobile clinics in Chacraseca, Nicaragua, for 4 days. At the end of their experience, each subject was given an open-ended survey and a second survey, in which they ranked their level of agreement or disagreement with provided statements from 1 to 5. Responses to the open-ended questions were used to qualitatively measure the subjects' perceptions of their experiences. Responses to the second survey were used for descriptive statistical analysis. 

Results: Results indicated that this experience increased willingness to participate in international medical work, with 87.5% of participants reporting an increased interest in the international component of their career. One-hundred percent of the participants felt that this experience was influential in increasing their cultural understanding. Over 87% reported increase in awareness of the need to understand cultural differences existing between healthcare provider and patient. Although not included here, qualitative analysis of participant comments will be provided in the final poster presentation. 

Conclusions: This study indicates that clinical experience in rural under-served Nicaragua increased participants' interest in the international component of their careers. Further research is needed to determine whether the increase in cultural understanding influenced the increased interest in international medical work. 

Observed Differences in Patient Care and Medical Practice in Israel  

Michael Dick, OMS II; David Issever, MHS, OMS II; Robin Rosenblatt, MS, OMS II; David Tatum, OMS IV; Sarah Zitsman, OMS II; Audra Lehman, MD; Tamira Elul, PhD 

Touro University College of Osteopathic Medicine–California, Vallejo 

Hypothesis: Israel is a small, highly technological country with a socialized healthcare system. We hypothesized that patient care and medical practice in Israel would differ in some substantial ways from that in the United States. To investigate such differences, we participated in the Touro University-California-Global Health Program 2010 Summer Internship in Israel. The overall goal of this program was to enhance our perspective about medical practices in different global settings, to improve our cultural competency, and to participate in service and scholarship in a global setting. 

Methods: During the summer of 2010, we participated in a month-long Global Health Program based at Bikur Holim Hopsital in Jerusalem, Israel. This program entailed 1-week rotations in different departments, shadowing physicians, observing patients, and when possible, taking physicals and histories, and occasionally doing hands on procedures such as suturing. 

Results: We observed several substantial differences between patient care and the healthcare system in Israel compared to the United States. First, the patient information in Israel was highly interconnected with patient charts being immediately accessible (through a patient ID) between different hospitals throughout the country. Second, in several departments, a social worker accompanied the physicians on rounds, providing followup advice and explaining things more clearly to patients, often assuring them that the necessary paper work would not be their headache. Third, in 1 case, an indigent, transient patient without insurance or paperwork was allowed to remain in the hospital for an unexpectedly lengthy time (several days) for observation following an allergic reaction. Finally, in several outpatient clinics, the physical infrastructure allowed for much greater and ongoing accessibility between doctors and patients, with informal consultations regularly observed. 

Conclusions: Several aspects of patient care and the healthcare system in Israel are substantially different than in the United States, which may reflect the small size, the advanced technological state, and the socialized medical system in Israel. These findings will help us understand the medical system in the United States in the context of its unique national characteristics, and improve our ability to practice medicine as osteopathic physicians in the United States and elsewhere in the world. 

Leprosy: Rehabilitation Through Community-Sustainable Income Generation  

Alison Noelle Hench, OMS II¹; Josia Magatti, KMT²; Eiman Mahmoud, MD, MPH³; Michael James Sullivan, BA⁴; Jolie Marie Olmstead Hoppe, OMS II¹ 

¹Touro University College of Osteopathic Medicine–California (TUCOM-CA), Vallejo; ²Shirati Hospital Research Center, Shirati, Tarime, Tanzania; ³Basic Sciences, Research, TUCOM-CA, Vallejo; ⁴Chemistry and Biochemistry, TUCOM-CA, Vallejo 

Incidence of leprosy has declined in Tanzania; however, the physical and psychosocial manifestations of the disease have long-term effects on a patient's quality of living, social status, and family life. While it is commonly acknowledged that poverty increases the risk of contracting the bacterial infection, it is seldom recognized how the disease perpetuates poverty. The implementation of community-rehabilitation has been shown to decrease the perpetuation of leprosy-associated disabilities. Phase I concluded that long-term facilities relying on charity resources are insufficient without a form of supplemental income generation. Phase I established a clean water supply, resources for food self-sufficiency, and the beginnings of income generation. These actions have been a positive force in the community's health and well-being. Based on the questionnaire findings from phase I, phase II supplied materials to address the physical needs of the lepers. The goal of phase II of the Leprosy Project was to implement and apply the primary needs assessed in phase I and to devise and solidify a method of generating a steadier and more reliable income. A focus group was held with the patients residing in the leprosy camp to evaluate how to increase their group income. The able-bodied residents maintain maize and millet crops near Lake Victoria, whose harvest is a major source of revenue for the camp. Unanimously, the 9 leprosy camp residents agreed that a gasoline-powered water pump would allow year-round farming and therefore establish steady income generation. The camp generated 100,000 Tanzanian Shillings from the past season's maize and millet harvest and hope to double that by growing throughout the year. Phase II evaluated the findings of phase I and provided the items that addressed the physical needs of affected individuals. During phase II a water pump was provided, which will allow water access to crops during the dry season and increase income generated from the camp's millet and maize crops. Phase III of this study will continue the efforts of phase I and II in working to improve the self-sustainability of the camp, focusing on income generation. Phase III will include evaluating the efficacy of provision of support to income generation project in decreasing the perpetuation of leprosy-associated disabilities. 

The Effect of Community-Based Student-Initiated Projects in Reducing Incidence of Schistosomiasis Through Treatment and Health Education in Rural Tanzania  

Jason Duong, OMS II; Robin Rosenblatt, MS, OMS II; Brandon Bireley, OMS II; Attilio Macrito, OMS II; Vanna Rocchi, OMS II; Eiman Mahmoud, MD, PhD 

Touro University College of Osteopathic Medicine–California, Vallejo 

Hypothesis: Schistosomiasis is a chronic parasitic infection affecting approximately 176 million Africans. This tropical disease deserves attention not only because of the multitude of people it affects, but also because it leads to abdominal symptoms in the short term and hepatosplenomegaly and portal hypertension upon advancement (World Health Organization, Schistosomiasis Fact Sheet, February 2010). Due to limited access to hospital care and education, lakeside villagers are not only untreated, but also simply unaware of precautions against schistosomiasis. By providing yearly on-site screening, education and treatment, the incidence of schistosomiasis in rural Tanzania can be reduced. 

Methods: As a response to the need to decrease rates of schistosomiasis in villages along Lake Victoria, Tanzania, a longitudinal study was carried out. Minigo, a village along Lake Victoria with a population of 3635, visited yearly since 2006, was provided with educational sessions on the basics of Schistosomiasis, including how it's contracted as well as how to modify daily activities to minimize their exposure. On location screening for S. haematobium and S. mansoni was provided through physical examination and fecal and urine sample testing. Praziquantel 40 mg/kg of body weight was prescribed for those who tested positive and prophylactically for those in prolonged contact with the waters. Those who tested positive with complications were provided with an ultrasound and peripheral blood smear to determine the morbidity of the disease in order to inform the patient if additional treatment is needed. A second village, Masonga (population 2000), was also educated, screened, and treated starting in 2010. 

Results: The incidence rate was 30% in 2007, 14% in 2009, and 10% in 2010 in Minigo. Masonga, providing a basis for comparison, had an incidence of 20%. 

Conclusion: This study demonstrates the effectiveness of providing access to treatment at the community level and preventative education in the reduction of disease prevalence, yielding a 67% decrease of schistosomiasis in Minigo. Additionally, the incidence of schistosomiasis in Masonga reiterates the value of intervention and education by providing a baseline rate two times higher than that of Minigo. Further follow-up in both villages will include continual screening, treatment, and education in hopes to observe a similar decline of Schistosomiasis infection in Masonga to confirm the efficacy of this intervention. 

Osteopathic Manipulative Medicine in the Andes Mountains of Peru  

Serennah E. Harding, OMS II; Jonathan S. Morse, OMS II; Murray R. Berkowitz, DO; Crystal Tidwell, OMS; Karly Bishop, OMS III; Brett Tidewell, OMS; Martha L. Cruz, OMS II; Meghan Morris-Mitchell, OMS III 

Georgia Campus–Philadelphia College of Osteopathic Medicine, Suwanee 

Hypothesis: Osteopathic manipulative medicine (OMM) will be well received by local healthcare providers in the Andes region of Peru. 

Methods: Seven osteopathic medical students partnered with the Foundation for International Medical Relief of Children to serve the people of Agallpampa, Peru. Our purpose was to shadow Peruvian allopathic physicians, participate in healthcare promotion and delivery, and conduct advocacy for OMM. Our research team demonstrated the following OMM techniques for local physicians and nurses in Peruvian health posts: thoracic pump, pedal pump, sacral rock, trigeminal stimulation, rib raising, colonic stimulation, lumbar soft tissue, and principles of muscle energy. Demonstration sessions for OMM were recorded. Local medical personnel practiced performing the techniques. No previous knowledge of OMM on the part of local physicians or nurses was anticipated. The willingness of the Peruvian healthcare providers to learn and apply OMM was measured by qualitative interviews and discussions. 

Results: The heightened awareness of OMM by Peruvian physicians and nurses in the area of Agallpampa, Peru, demonstrated that these techniques improved the treatment and care provided to the indigenous population, as reported by the Peruvian healthcare providers who were trained by the osteopathic medical students 

Discussion: The town of Agallpampa sits 10,000 feet above sea level and is the regional center for many Andean villages. Unfortunately, amongst the beautiful Andes Mountains, Agallpampa's people live in extreme poverty. The people perform jobs requiring intense physical labor and live mainly on carbohydrate diets. Malnutrition and respiratory infections are the main health problems afflicting this region. We sought to raise awareness of the role OMM can play as adjuvant treatment for these main health issues. 

Conclusion: The positive effects of OMM were demonstrated in this region of Peru. Our team hopes to further study and quantify the usefulness of techniques for the Andean medical personnel. Our team suggests that further research be done to monitor the effectiveness of OMM in alleviating health problems in the Andean population. More qualitative research should be performed to measure the effectiveness of applying OMM to improving the healthcare of all people everywhere, especially in remote regions of the world that have historically been without access to modern medicines and healthcare technology. 

Assessing Pediatric Anthropometry of Peru  

Shane R. Sergent, OMS II; Melissa Kay Hart, OMS I; Danelle R. Graves, OMS II; Kerry B. Melenovsky, OMS II; Gary L. Willyerd, DO; Christina Dokter, PhD 

Michigan State University College of Osteopathic Medicine, East Lansing 

Background: The goal of this poster is to examine the deviation of simple anthropometry in pediatric patients from 2 regions in Peru: La Libertad and Cajamarca. In August 2010, Michigan State University College of Osteopathic Medicine participated in a medical service elective providing free medical care and supplies to the regions, which are located 11,000 feet above sea level and are devastated by many stressors, eg, open pit mining, infections, poor water quality, malnutrition, and underdevelopment. According to 2004-2005 data (ENDES continua) it is commonly accepted that children of such regions are plagued with stunted growth, learning difficulties, behavioral problems, mental retardation, and even death. 

Hypothesis: At either 1 or all of the sites examined, there may be findings that indicate children's development levels that are below the standard normal. 

Methods: This observational cross-sectional study observed children between the ages of 2 years and 19 years for body composition using the following biometrics: height, weight, predicted body mass index, circumferences of waist, arm, and head. Protocols followed standards set forth by Malina (1995) for physiological assessment of human fitness. The data collected will be used to construct growth charts and compared to accepted standards set forth by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Levels below accepted norms will indicate a need for interventions in areas of the stressors listed above including community education. At either one or all of the sites examined, there may be findings that indicate children's development levels that are below the standard normal. Method of sampling included all children aged between 2 and 19 years presenting to a clinic site unless they chose not to participate. Sample population was obtained from 1 of the 3 defined sites with the primary site was Huamachuco within the region La Libertad, Peru. 

Results and Conclusion: Preliminary results from the sites show significant deviations at all 3 sites from CDC and WHO standards. The data collected will serve as a baseline for future research projects and the delivery of healthcare services to these regions. 

Is There a Link Between Body Composition and Cardiovascular Fitness in El Salvador?  

Janell Dawn Ison, OMS II; Gillian Ice, PhD; David S. Drozek, DO 

Ohio University College of Osteopathic Medicine, Athens 

Introduction: Physical fitness is an important predictor of disease morbidity and mortality. As training increases, physical and cardiovascular fitness as well as body composition improve. Although the link between fitness and body composition has been well established in developed countries where much of the population is sedentary and overweight, less is known about body composition and fitness in these areas. As many developing countries such as those in Latin America undergo the nutrition transition and become increasingly sedentary, it is important to gain a better understanding of the relationship between body composition and fitness. 

Hypothesis: There is a link between cardiovascular fitness and body composition in a sample of subjects in El Salvador. 

Methods: Subjects were recruited during medical brigades in villages of El Salvador. Resting heart rate was measured with a Polar heart rate monitor. Participants completed a 3-minute step aerobic exercise to the beat of a metronome with a block 6 inches high. Next, a postexercise heart rate was acquired. Skin fold measurements were taken using skin fold calipers at the biceps, triceps, suprailiac, and subscapular regions. Body fat percentage was estimated using the Durnin equation. Data were analyzed using person correlation and regression in SPSS. 

Results: Cardiovascular fitness, as measured by a change in heart rate, was not correlated with estimated body fat percentage (P >.05). Age was significantly associated with change in heart rate (r=-0.28, P=.001). Body fat percentage was associated with systolic blood pressure at rest (r=0.28, P=.007) and after exercise (r=0.23, P=.03) and diastolic blood pressure at rest (r=0.30, P=<.001). After adjusting for age, body fat did not predict change in heart rate. Forty-two participants experienced a decline in heart rate after exercise, suggesting that they were not performing the exercise task correctly. After eliminating those individuals, body fat and heart rate were negatively correlated (-0.24, P=.01).Body composition was predictive of change in heart rate after controlling for age (β=-1.0, P=.06). 

Conclusion: After controlling for individuals thought to not adequately perform the exercise, there was a link between change in heart rate and body composition, opposite that expected based on other literature. This finding suggests that there were some cultural challenges associated with this task such as language interpretation, thereby not resulting in the heart rate change as expected. 

First Responder Emergency Preparedness Training Model Assessment  

Brian F. Goodhue, OMS II; Farrah Munir, OMS II; Omar A. Rokayak, OMS II; Bailey C. Runkles, OMS II; Hebah Y. Sadek, OMS II 

Edward Via Virginia College of Osteopathic Medicine, Blacksburg 

Abstract: Given the effects of man-made and natural disasters on developing countries, and as a part of their global health initiative, the faculty and students of the Edward Via Virgina College of Osteopathic Medicine (VCOM) conducted first responder training to improve the emergency response preparedness in Punta Cana, Dominican Republic. Currently, this region lacks a emergency service system and trained personnel. Recognizing the limitations that this places on effective transient, life-sustaining care to patients involved in an emergency, the organizers, using current public health standards set forth by Health People 2010, implemented a practical, educational agenda to combat this problem. 

Hypothesis: Implementation of an assessment and training workshop will enhance knowledge level in emergency response care among first responders in the Punta Cana region. 

Methods: Through a 21-hour, intensive training program including classroom, didactic, and lab participation, attendees obtained concrete knowledge and skills to respond to and treat individuals with acute life threatening injuries. Workshop participants included teachers, law enforcement officers, and hotel personnel who are often the first on the scene of an emergency. To accurately establish the efficacy of the program, initial knowledge, attitudes, and skills of the participants were assessed objectively based on professional standards set forth by the National Registry of First Responders (NRFR). Trainers assessed participant knowledge gains by performance testing, reflections, and case study of participants. 

Results: Professional assessment by attending physicians, headed by VCOM's Department of Emergency Medicine, demonstrated that participants were deficient in all of the above 3 parameters of emergency patient assessment, evaluation of trauma and triage, fracture management, spinal immobilization, and cardiopulmonary rehabilitation. At the conclusion of the program, an additional assessment was conducted, during which previously deficient skills were performed at or above the passing standards set forth by the NRFR. 

Conclusions: First responder training was a successful model to increase knowledge and performance to save lives in the Punta Cana region. VCOM should replicate the program with additional Dominicans and in developing countries who wish to improve their level of emergency preparedness and test the training model. 

Disaster Response in Dominican Schools Through VCOM Mini Med School  

Samuel W. Adams, II, OMS II; Christopher G. Cline, OMS II; Geneva L. Gehring, OMS II; Brittany S. Peacock, OMS II 

Edward Via Virginia College of Osteopathic Medicine, Blacksburg 

Abstract: A medical assistance mission team of 36 Edward Via Virginia College of Osteopathic Medicine (VCOM) students, faculty, and physicians participated in a comprehensive medical assistance mission trip to the Dominican Republic from April 17, 2010, to April 24, 2010—2 months after the massive Haiti earthquake. The trip focus was emergency medicine ACLS training, disaster preparedness, village medical mission, and preventative healthcare and education. A US-based VCOM “Mini Med School” was tested with students at Punta Cana International School (private), Ted Kheel Polytechnic School (public), and Dominica Orphanage and School. 

Hypothesis: The VCOM Mini Med School adapted for Dominican audiences will result in educational gains among school students and positive changes in experience, skill development, and attitudes among medical students. 

Methods: Educational materials, training methods, and related experiences were adapted from the VCOM Mini Med School model. Five teams of 3 VCOM medical students with assistance from translators taught a 5-topic rotation in healthcare/disaster response: (1) earthquakes and tsunamis; (2) first aid for fractures, sprains, lacerations, and abrasions; (3) first aid for heat stroke and sunburn; (4) alcohol, fainting, and seizures; and (5) smoking/breathing problems. Assessment tools included interaction with Dominican students during each session, VCOM student journals and guided reflection each day, VCOM student-developed case studies, and response to an evaluation instrument. 

Results: Dominican student response to questions at the beginning and end of each session and engagement demonstrated gains. Student from VCOM responses to evaluation instruments, daily debriefing, student journals, and case studies showed positive gains in experience, skill development, and attitudes toward medical assistance missions. The research hypothesis was accepted. 

Conclusions: The educational gains of medical students and outcomes of Dominican students demonstrate the US-based Mini Med School is transportable across language and culture and in the Dominican setting. Plans for future trips should consider outcomes and suggestions from this initial pilot. Future research on Mini Med School is needed to probe Dominican student engagement and change in behaviors and to test the model in other settings. Additional research is also needed on the contribution of the Mini Med School to VCOM medical student training effectiveness and medical school experience. 

Culturally Competent Overseas Clinical Training for Osteopathic Medical Students  

Jason S. Samona, OMS III; Reza Nassiri, DSc Institute of International Health, Michigan State University College of Osteopathic Medicine, East Lansing What images stream to mind when someone utters the word “culture”? For many, visions of foreigners in colorful garb, exotic foods, and tongue-twisting languages rush through our consciousness. As physicians in training, medical students are instructed to look past these initial thoughts. On a recent medical mission to the Dominican Republic, students saw beyond the stereotypes to discover what it truly means to be culturally competent. Understanding and accepting the cultural roots of a people allows one to better derive the true significance of how certain beliefs become institutions in a society. The Dominican people have suffered 300 years of foreign rule, warfare, and political turmoil, which persists to this day. Enduring these burdens has indisputably hardened the Dominican sense of national pride. This is on full display with the flag proudly flown, locals crying out the names of Dominican players in the National Baseball League to passing tourists, and the sounds and sights of the native meringue music and dance on the street corners of Santo Domingo. An individual can only truly appreciate this culture when they are fully aware of the deep seeded emotions and traditions that have created it. Cultural competency comes with a genuine feeling of respect that translates across any language barrier. Just outside the city of Saint Cristobel and hidden between the thick brush of the jungle, a winding dirt road leads to a modern day community of Lepers. Severe public discrimination and ridicule have cast the disfigured inhabitants of this colony into solitude. By conversing and placing a caring hand on their back, the patients' spirits soared. Respect can break down the most hardened of cultural barriers when delivered in a legitimate, heartfelt manner. Visions of song and dance, the Dominican flag, and the joyful face of a leprosy patient will never leave my mind. Although these were vital elements of my encounters, these sights do not define the overall experience. My time spent as a naïve medical student in a foreign land shed light on my dim understanding of ethnic sensitivity. Understanding, acceptance, and genuine respect emerged as irrefutable components of culturally competency. The pillars of proper medical care are forged from these simple yet undisputable truths. This medical mission proved to be an ideal mechanism for osteopathic medical students to develop a true understanding of culture's role in proper medical care. 

Mission to Haiti: Importance of Global Health in Medical Education and Student Development  

Amy R. Borden, OMS II; Devin K. Higgins, OMS II; Terri L. Plundo, DO, RN 

Des Moines University—College of Osteopathic Medicine, Iowa 

Background: On Tuesday, January 12, 2010, a 7.0 magnitude earthquake changed Haiti forever. Within minutes, thousands were dead, others were trapped beneath the rubble, and thousands more were thrown into confusion. The country's already fragile infrastructure, economy, and beloved Presidential Palace were destroyed. Five months later, our team from Des Moines University in Iowa landed in Port-au-Prince, and we saw where the rebuilding had begun, along with the great need that still existed. Our team consisted of 6 medical students, 2 physicians, and a physician assistant. Working alongside Compassion for Haiti, which provided a local support team, we were able to set up a self-sustained clinic to provide care for the Haitian people. 

Objectives: Provide medical care, relief, and hope for the people of Haiti; develop leadership and cultural competency within the student team; allow students to practice and gain confidence in their diagnostic abilities; promote the osteopathic philosophy and Des Moines University; and pave the way for future short-term medical trips. 

Methods: A student-led team selected participants through applications and interviews open to all programs within the university. Once participants were chosen, committees were established to arrange travel, logistics, medicine, and supplies. In country, from June 11, 2010, to June 20, 2010, we worked in a make-shift clinic in a church building in Cité Soleil, 1 of the most impoverished areas neighboring Port-au-Prince. Each morning patients would be lined up when we arrived and we would work until everyone had been seen. 

Results: As a result of the primitive conditions, we were forced to develop and rely on our personal diagnostic skills. In addition, all medicine and supplies had to be transported with us. Nearly 850 patients were seen during the 6 days we held the clinic, with medical conditions ranging from acute to chronic. 

Outcomes: While serving the local population, the mission provided medical students with hands-on patient experience, helping to develop confidence and competency in medical skills. Furthermore, experiencing a different culture and working closely as a team presented the opportunity for personal growth and discovery. Providing care and seeing the needs of those around us brought a recommitment to the altruistic goals of medicine. Finally, the trip helped in the development of leadership skills, increased our knowledge base, and established the necessary connections for future medical trips. 

A Template for Conducting Medical Mobile Clinics in Petite Rivière de Nippes, Haiti  

Sean Weaver, MPH, OMS II; Christina R. Ellis, MPH, OMS II; Mana Pirnia, MPH, OMS II 

Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California 

Hypothesis: In July 2010, a team of 13 second-year osteopathic medical students, a pharmacist, and 2 osteopathic physicians travelled to rural Petite Rivière de Nippes, Haiti, partnered with Visitation Hospital (VH), and conducted 4 mobile clinics in remote areas surrounding the VH clinic with the goal of providing ambulatory medical care to rural indigent communities. 

Methods: The medical team scouted the sites prior to each clinic and worked with community leaders on site preparation. On the day of the clinic, the community leader made a list of names of people waiting to be seen. This list was used to call patients to triage to obtain vitals and elicit chief complaint. The station was staffed by 3 second-year osteopathic medical students and 1 translator. Another second-year osteopathic medical student and translator performed a focused examination. The physicians alternated between patients, asked follow-up questions and provided additional assessment. The physician provided the diagnosis, developed a treatment plan, and answered patients' questions. Medications were then dispensed at the mobile clinic pharmacy, and patients were counseled on proper usage. The pharmacy was staffed by a pharmacist, translator, and 2 second-year osteopathic medical students. Because of a lack of translators, a large-scale patient education program was not implemented. 

Results: Because of the remote nature of the mobile clinic sites, diagnoses were made based on clinical signs and symptoms. Of the 426 patients seen, the 10 most common clinical diagnoses were intestinal parasites (183 cases), anemia (106 cases), pain due to somatic dysfunction (69 cases), gastroesophageal reflux disease (33 cases), upper respiratory tract infection (25 cases), malaria (24 cases), urinary tract infection (23 cases), fungal infection (21 cases), hypertension (21 cases), and vaginal candidiasis (20 cases). 

Conclusion: Mobile clinics can be successfully deployed in rural Haiti if several criteria are met. First, a partnership must be made with an established organization that is well connected to the community. Second, adequate human capital, including physicians, pharmacists, osteopathic medical students, and medical translators are essential. Third, medical personnel should come prepared with the background to diagnose and with medications to treat patients with the conditions previously identified. Future expansion of the mobile clinic framework should address rapid testing to confirm clinical diagnoses and patient education regarding disease prevention and management. 

OMM and TCM: Comparisons of Manipulative Treatment  

Angela Zhang, OMS II¹; Sophia Chen, MPH, OMS II¹; Hung-Rong Yen, MD, PhD² 

¹Touro University College of Osteopathic Medicine–California, Vallejo; ²Chang-Gung Memorial Hospital, Gueishan Township, Taoyuan County 333, Taiwan (R.O.C.) 

Background: With the exception of acupuncture, little literature is available that compares osteopathic manipulative treatment (OMT) to traditional Chinese medicine (TCM). In a search of comparative research of OMT and TCM, we found most to be introductory. Thus, we sought to further our understanding of OMT and TCM while participating in Touro University's Global Health Program (GHP) at Chang-Gung Memorial Hospital (CGMH) in Taiwan. OMT aims to facilitate the body's ability to heal itself by targeting somatic dysfunction through techniques that manipulate soft tissue and bone. In TCM, there is a modality of treatment that also utilizes the hands: the 4000-year-old practice of Tui-Na, which means “push” and “grab.” TCM emphasizes Qi-flow and balance. 

Hypothesis: We hypothesize that the practices of OMT and TCM share similarities in their respective techniques. 

Methods: Through the GHP, we shadowed physicians of various sub-specialties in TCM at GCMH for 1 week followed by extensive literature review. In the acupuncture and orthopedic outpatient departments, we observed several Tui-Na techniques being applied to a mostly elderly population and to an experimental pediatric asthma clinic. The selection criteria in our review of the literature was broad. Results of searches for “osteopathy” and “chinese medicine” from PubMed and Google Scholar were included. We evaluated treatments on lower back pain, clavicle fracture, and asthma. For lower back pain, we observed a technique in which the backs of the hands are utilized in a rolling fashion along the muscles from medial to lateral. For clavicle fracture, the treatment included grasping of the patient's arm while palpating the clavicle and performing a winding motion with the arm, loose packing the joint, abducting/adducting and internally rotating the arm, and giving a strong traction tug. For asthma, pinching along the paravertebral muscles was used. 

Results: We found that TCM Tui-Na and OMT share similar techniques, and differences lay in their specific clinical applications. For example, OMT uses lymphatic pump, diaphragmatic re-doming, and rib raising, while TCM utilizes acupuncture, paravertebral stretching, and inhibition to treat asthma. Through this GHP clerkship, we introduced OMT to physicians and gained knowledge about TCM. We hope this stimulates interest in future research that compares the 2 practices and enables osteopathic physicians to integrate concepts in approaching patient care. 

Deworming Protocols for Medical Clinics in Rural Haiti  

Yang Li, OMS II; Artem Ryazantsev, OMS II 

Western University College of Osteopathic Medicine of the Pacific, Pomona, California 

Context: A team consisting of osteopathic medical students, osteopathic physicians, and a pharmacist traveled to the rural area of Petite Rivière de Nippes, Haiti. The team was joined by Haitian medical staff from Visitation Hospital. 

Objectives: To provide medical care for rural populations and to establish a comprehensive deworming protocol for each rural community. 

Methods: Due to the endemic nature of gastrointestinal parasitic infections, a protocol for identification and treatment was instituted. A working diagnosis was established by 1 of 2 conditions: (1) anemia as evidenced by pale conjunctiva or (2) bloating, constipation, or lower quadrant abdominal pain. Initially, patients with parasitic infections were identified within the scope of the medical clinics and treated on a case-specific basis. A diagnosis of parasitic infection was present in 15 of 50 patients (30%) and 58 of 114 patients (51%) at the first 2 mobile clinic sites, respectively. Given the high prevalence of parasitic infections encountered, a separate staging area was established specifically for the deworming protocol and a “blanketing” approach was taken. A standard dose of albendazole 400 mg (200 mg pediatric) was given to adult patients fitting the above criteria and to all pediatric patients. 

Results: A total of approximately 400 pediatric and adult patients were treated for parasitic infections in each of the subsequent mobile clinics. The rapid protocol allowed for nearly complete treatment of children in each rural community. 

Conclusions: Comprehensive deworming protocols should be an integral part of medical missions to rural Haiti. The high prevalence of parasitic infections makes the “blanketing” approach an effective method of treatment. While the treatment is only expected to last 3 to 6 months because of the lack of sanitation and clean drinking water, the low cost of treatment (approximately $3 per 100 patients) ensures this protocol remains feasible. Future teams should address a long-term approach to preventing parasitic infections via infrastructure improvements (eg, clean water). 

Profiling Medical and Cultural Practices in Taiwan  

Naomi Chiang, OMS II¹; Shao-Yu Wang, MD²; Athena Lin, PhD¹ 

¹Touro University College of Osteopathic Medicine–California, Vallejo; ²Linkou Chang Gung Memorial Hospital, Linkou, Taipei, Taiwan 

During Touro University's Global Health Program (GHP) Summer Clerkship at Linkou Chang-Gung Memorial Hospital, opportunities were given to experience the differences between medical and cultural practices in Taiwan and the United States. Glimpses into Taiwan's healthcare system through interactions with patients revealed that Taiwan's healthcare system allowed patients to gain direct access to specialized physicians. Free care and unlimited hospital stay in shared rooms allowed patients to more freely seek physician help, possibly contributing to better preventative care. In 1 particular case study, a 72-year-old man with a history of asthma, coronary artery disease, diabetes mellitus, hypertension, hepatitis C virus as a carrier, and prostate and tongue cancer was admitted to the Internal Medicine Department at Linkou Chang Gung Memorial Hospital complaining of progressive dyspnea for a month and orthopnea, wheezing, and pitting edema for a week. He complained also of lumbar back pain and left shoulder pain that radiated to the head and that manifested as chronic headaches. The multiple problems reflect common issues inhabitants of Taiwan face as a result of cultural, genetic, and geographic differences as well as the patient's own history and life experience. Taking the history for this patient proved to be valuable and key to understanding how cultural practices and genetic factors in the Taiwanese population could contribute to the prevalence of certain diseases. Exposure to cultural, medical, and genetic differences in Taiwan turned out to be an enriching experience. Engagement with the patient and his family through history taking and physical examination allowed for a better understanding of the patient's background and Taiwan's healthcare system. As an osteopathic medical student, I gained valuable knowledge and tools for holistic treatment and preventative care, which could be furthered and applied to Taiwanese patients in America. In turn, the patient's family and physicians in Taiwan were exposed to osteopathic medicine. This intercultural exchange can prove to be valuable to physicians in both Taiwan and the United States.