A student-led research publication of the George Washington University School of Medicine and Health Sciences | Spring 2019, Volume XII Table of Contents:

ON THE COVER On the cover is a photograph of a section of A student-led research publication of the George Washington University School of Medicine and Health Sciences | Spring 2019, Volume XII healthy mouse hippocampus tissue (near the dentate gyrus) at 30 days of age. The tissue is stained for nuclei (blue), astrocytes (green), and glucose transporter GLUT8 (red). The image was produced during research conducted by Madhuri Rao, MSII. Photos like Rao’s, capturing the beauty and intricacy of science, are featured annually in the George Washington University (GW) School of Medicine and Health Sciences (SMHS) Art of Science Contest. The competition began in 2018 as a means of highlighting the research that SMHS medical students, graduate students, and postdoctoral fellows are conducting. This year, more than 17 images were submitted, an increase from last year’s competition, and fve entries were chosen as winners. A grand prize of $250 was awarded to Brett Eaton, a PhD student who submitted an image of Samantha Dow, Naemeh Pourshafe, and Jessica the Marburg virus budding from infected dendritic Schenck. cells. Prizes of $100 were awarded to four other The winning images will be displayed in Ross entrants, all GW PhD students — Rachel Burga, Hall, alongside the winners from last year.

WILLIAM H. BEAUMONT BASIC SCIENCE Juan Nogues, The Effect of TET Mutations RESEARCH PRIZE WINNERS on DNA Methyltransferase Cytotoxicity and ERV Arjun Panda, A Machine Learning Approach Induction in B- and T-Cell Malignancies to Mapping Co-regulated Variant Loci and p 20–21 Maria Abigail Cerezo, Expression over Time p 12–13 Evaluation of Longitudinal Madhuri Rao, A Developmental Profle of Antibody Responses in Caitlin Ward, Association of SREBF1 and Glucose Transport and Utilization in Mice Zika-Infected Individuals TOM1L2 Polymorphisms with Bone and Muscle p 22–23 from Colombia . . . . . p. 6–7 Phenotypes p 14–15 Mohamed Al-Amoodi, The Association Sharjeel Chaudhry, Daniel Bestourous, FAM210A and of Polymorphism rs3736228 Within the LRP5 Prevention of SOST Polymorphisms Are Associated with Gene with Bone Mineral Density in a Cohort of Cardiovascular Thrombosis Musculoskeletal Phenotypes in Healthy Young Caucasian Young Adults p 24–25 through Inhibition of Adults p 15–16 Coagulation Factor Ryan Lee, Association of GREB1 XII ...... p. 8–10 Gifty Dominah, Programmed Death Polymorphisms with Bone and Muscle Health Ligand 1 Is a Negative Prognostic Marker in Phenotypes p 25–26 Recurrent Isocitrate Dehydrogenase-Wildtype Neil Almeida, CyTOF Glioblastoma p 16–18 analysis provides insight into immune response Jeffrey Roberson, Molecular Examination CLINICAL RESEARCH to H3.327M neoantigen of Hidradenitis Suppurativa in Clinical Samples: Abigail Pepin, Evaluating Racial Disparities peptide vaccine in glioma Towards Understanding Mechanisms and in Breast Cancer Referrals for Hereditary Risk patients ...... p. 10 –11 Exploring Therapeutic Targets p 18–19 Assessment p 27–28

Fusion ♦ 2018 THE GEORGE Table of Contents: WASHINGTON UNIVERSITY Ari Mandler, Utilization of Ancillary Services Natalie Pudalov, Cortical Thickness THOMAS LEBLANC, PhD for Voice and Swallowing Outcomes Following Asymmetries in MRI-Abnormal Pediatric George Washington University (GW) Cardiothoracic Surgery p 29 Epilepsy Patients: A Potential Metric for Surgery President Outcome p 44 JEFFREY S. AKMAN, MD ’81, RESD ’85 Chantal Nguyen, Depth-Camera Measured Vice President for Health Afairs Biomechanics of the Lower Extremity Reveal Nikhil Gowda, Perioperative Complications Walter A. Bloedorn Professor of Movement Abnormalities and Targets for Associated with Congestive Heart Failure Administrative Medicine Prevention in ACL Reconstructed Patients in Elderly Patients Following Primary Hip Dean of the School of Medicine p 29–30 Hemiarthroplasty p 45–46 and Health Sciences (SMHS) ROBERT MILLER, PhD, Christina Darwish, Trends in Treatment Nisha Kapani, Impact of Mesenchymal Vice President for Research at GW, and Strategies and Comparison of Outcomes Stem/Stromal Cell Intra-Arterial Delivery During Senior Associate Dean for Research, in Lymph Node Positive Bladder Cancer Pediatric Cardiac Surgery on Neurogenesis in Vivian Gill Distinguished Research p 31–32 the Porcine Subventricular Zone p 47–48 Professor, Professor of Anatomy and Regenerative Biology at SMHS ALISON K. HALL, PhD Dana Perim, Impact of Smoking on Sowmya Mangipudi, Long-term Changes Outcomes Following Knee and Shoulder in Flow-Mediated Dilation Among Post- Associate Dean for Research Workforce Development, Professor of Neurology Arthroscopy p 32–33 Operative Abdominal Aortic Aneurysm Patients p 48–49

William H. Beaumont Medical David Daniel, Comparison Between Research Society Executive Board Medical Therapy and Endovascular Treatment of Stephanie Rodriguez, Racial disparities the Extracranial Atherosclerotic Vertebral Artery in Late-Stage Prostate Cancer: A SEER Database Abigail Pepin, Co-President Alva Powell, Outreach Ofcer Disease: A Systematic Review p 33–34 Analysis 2005–15 p 50–52 Neil Almeida, Co-President Nikhil Gowda, Fusion Ofcer Harleen Marwah, The Impact of Insulin Tess Whiteside, Developing a Method Dependence on Post-Operative Complications to Objectively Assess Sensory Nerve Fiber in Diabetic Patients Undergoing Anatomic Sensitivity: A Pilot Study p 52–53 Student Editorial Board: Pulmonary Resections p 35–37 Abby Pepin Andrea Klein Thomas Zaikos, Laparoscopic Hand- Armon Panahi Ishaan Dharia, Intubation Related Vocal Assisted Resection of a Rare Intra-Adrenal Dhanusha Subramani Cord Paresis: Outcomes from a Patient Cohort Schwannoma p 53–55 Diego Zegarra p 38 George Thomas Vikas Kotha, Risk Factors for Amputation Hira Mohyuddi Leora Aizman, Provider Differences Following Lower Extremity Free Tissue Transfer Murwarit Rahimi in Management of Normal Second Stage in a Chronic Wound Population p 55–56 Neil Almeida Nikhil Gowda p 39–40 Puneet Gupta Samantha Terhaar Melissa Peace, Screening for Vocal Cord MEDICAL EDUCATION Paralysis in High-Risk Premature Infants After Patent Ductus Arteriosus Ligation p 41 Tirsit Makonnen, Sustainable Project Management Team: Development Goals and Mental Health Thomas Kohout Knowledge Among First-Year Medical Students Michelle Peng, Rectus Fascia vs Fascial Katherine Dvorak p 56–57 Ashley Rizzardo Lata for Autologous Fascial Pubvaginal Sling: A Single-Center Comparison of Perioperative and Functional Outcomes p 42–43 Fusion is a publication of the George Washington University School of Medicine and Health Sciences William H. Beaumont Medical Research Honor Society. This research journal is published by students in collaboration with the Ofce of the Dean and the Ofce of Communications and Marketing.

TABLE OF CONTENTS 1 Letters:

From the Editors: As part of the George amongst our students, faulty, and staf. We Washington University aim to support GW’s goal to expand and (GW) School of Medicine enhance research experiences for its students and Health Sciences’ (SMHS) as an opportunity to learn and become future mission to educate, research, leaders in medicine and health sciences felds. and heal, GW medical stu- We would like to ofer our congratulations dents have the opportunity to to this year’s William H. Beaumont Medical conduct research in a multi- Honor Society Student Research Award win- tude of felds. The William H. ners. These individuals and their research Beaumont Medical Research projects stood out as exceptional in quality Honor Society aims to pro- among their peers. mote inquiry-based research This year’s edition would not have been pos- to train physician-scientists for sible without the support of many individuals. the future. This journal, run We would like to thank former presidents, Neil Almeida, MSII by the William H. Beaumont Janine Amirault and Sarah McCormack, for Society, is an entirely student- their continued involvement and support of run publication including this organization. We would like to thank research conducted by GW our faculty adviser, Dean Alison Hall, for her medical students while in wisdom and support. We would also like to medical school. This year’s thank the SMHS Ofce of Communications collection of abstracts refects and Marking for the design and produc- a sample of the diverse student tion of this year’s edition. Finally, we would research being conducted at like to thank our classmates and peers who SHMS from basic science to volunteered their time to edit the abstracts clinical research to public submitted, without whom this journal could health initiatives. not exist. As co-presidents of the On behalf of the William H. Beaumont William H. Beaumont Medical Medical Research Honor Society’s executive Research Honor Society, we board and members, we hope you enjoy the aim to provide a forum to learn 2019 edition of Fusion! Abby Pepin, MSII about peer research, inspire future and matriculating med- ical students, and serve as an outlet to share research experiences of GW Neil Almeida, MSII medical students. We hope that this journal Abby Pepin, MSII inspires a dialogue to continue the sharing Co-Presidents of the William H Beaumont of new knowledge and passion for research Medical Research Honor Society

2 Fusion ♦ 2019 Letters:

From the Faculty Adviser: It’s an honor to assist with this edition of of each class joins the clinical Fusion magazine that highlights research done and translational research by medical students at the George Washington scholarly concentration, that University (GW) School of Medicine and includes longitudinal lec- Health Sciences. tures, summer research with You will fnd examples of the broad range of an abstract and poster, and research pursued by students, from basic bio- additional elective clerkships medical discovery to clinical and translational in research. But you don’t have research with patients to initial translation to to be in the scholarly concen- practice and communities, on every page of tration to do research! Many Fusion. In their submissions, medical students students compete for external described numerous sophisticated approaches, research fellowships as well as including chart review, data collection, molec- internal WT Gill and Health ular biology techniques, feld studies, study Services Research summer fel- design, assisting in IRB applications, and sta- lowships. Students are encour- Alison K Hall, PhD tistical analyses to name just a few. It is always aged to present — and to learn a challenge to select the abstract winners from — at GW’s Research Days in a collection of such excellent projects. April each year. I would also like to thank the research Fusion magazine is just one efort by the mentors who host students in their programs William H. Beaumont Research Honor here at GW and in our partner institution Society to engage GW medical students in the Children’s National Health Center, and in excitement and impact of research. I welcome researchprogramsatthe nearbyNIHcampus you to explore p. 4–5 and for additional ways to and other institutions around the nation. join this community of clinician-investigators. Mentorship is key in engaging students and encouraging research careers in academic health centers. Alison K. Hall, PhD Medical students have rich opportunities Associate Dean for Research Workforce for involvement in research. About 20 percent Development, Professor of Neurology

LETTERS 3 Numerous Opportunities for Medical Students to Engage in Research + Scholarship

RESEARCH SCHOLARLY CONCENTRATION Last year, 32 MD students elected to join the Clinical and Translational Research Scholarly Concentration. In this program, students conduct mentored research over the summer between frst and second year, attend research lectures, and continue with research scholarships. For details, see https://tinyurl.com/ 32ybpn74cl. YEAR-OUT Taniya Walker, MSII, won a 2018 Gill Fellowship to conduct cardiology research on the effects of computed Stephen Langerman is taking the 2018–19 tomography scan fndings on the outcomes of year off to conduct research as part of the transcatheter aortic valve replacement National Institutes of Health (NIH)-Medical Research Scholars Program. He will study GW RESEARCH FELLOWSHIPS the infuence of social factors, such as crime, A number of competitive scholarship GW MEDICAL STUDENT RESEARCH STUDENT MEDICAL GW poverty, and dis- programs are available to assist in crimination on health funding exceptional projects in health outcomes with Tiffany care and medicine. In 2018, 31 students M. Powell-Wiley, MD, won a Gill Summer Research Fellowship MPH, who heads the and 57 students won a Health Services Social Determinants Scholarship. For details,see of Obesity and https://tinyurl.com/ybu4z3w5 and Cardiovascular Risk https://tinyurl.com/y8ltewa9. Laboratory at NIH.

RESEARCH DAYS AT GW FUSION GW Research Days is an April annual event that celebrates research Fu s io n i s GW ’s across GW. Students and postdoctoral fellows present posters and oral annual me dic al presentations and compete for cash prizes. student research See https://researchdays.gwu.edu/. journal. It is a forum to share research done by GW medical students with the l arge r res ea rc h c o mmuni t y. I n 2019, 35 student research abstracts were published. The Beaumont Society seeks Fusion editors At Research Day 2018, Nicole Casasanta, Sarit Toltzis, Dara Baker, and Christina Pugliese accepted the each year. William Beaumont Research Award from former Fusion editors, Sarah McCormack and Janine Amirault

4 Fusion ♦ 2019 EXTERNAL FELLOWSHIPS Medical students may elect to take a year off from the MD program to conduct research full-time at GW, NIH, or other institutions. This can be a great way to fully immerse yourself in a research project and form connections at other institutions. External fellowship opportunities are listed at https://tinyurl.com/y9vj54gj.

Third-year SMHS MD student Maggie Beatson, at left, is a Brown University Dermatoepidemiology Research Fellow, studying predictors of skin cancer

METEOR PROGRAM WILLIAM H. BEAUMONT The Mentored Experience to Expand Opportunities in RESEARCH HONOR Research (METEOR) program is a competitive fellowship SOCIETY for underrepresented-in-medicine The Beaumont Research Honor students. Students Society was established to are supported educate and inform medical for a pre- students about research. Any matriculation GW medical student interested research in research is welcome to summer and join. 2018-2019 Co-Presidents enroll in the are Neil Almeida and Abby research track. Pepin. See https://tinyurl.com/ https://tinyurl. com/y86oxwmb y7yuwr6w METEOR students Guido Pelaez, MS1, and Juan Nogues, MSII CTSA ...... The Clinical and Translational Science ART OF SCIENCE IMAGE CONTEST Award (CTSA) is a joint Students submit artistic images done at GW. Aslam Akhtar, NIH award between GW of their research for cash prizes. MSII, was last year’s grand prize and Children’s National The award highlights the winner. See https://tinyurl.com/ Health System to conduct breadth and beauty of research ybr8l26g “bench to bedside” research. TRAVEL AWARDS Medical students are encouraged to apply for outside funding for summer or year- out research, or for travel to meetings. Visit the Scholarly Concentration website to see a list of oppor- RESEARCH PRIZES The 2018 Doris DeFord Speck tunities for summer The 2018 Walter Freeman Research and George Speck Endowed research, travel, and Award for best research paper Prize was awarded to Laura yearlong fellowships. was presented to (from left) Jason Tiedemann (at right) for her Chien and Peter Mullins by Lorenzo research on neonatal intensive See tinyurl.com/ Norris, MD. care management. y9vj54gj

To learn more, please contact the Office of Student Professional Enrichment smhs.gwu.edu/ospe. 5 William H. Beaumont Research Prize Winners:

Evaluation of Longitudinal Antibody Responses in Zika- Infected Individuals from Colombia Maria Abigail Cerezo, MSII CO-AUTHORS: • EC50 1yr Grace Mantus 1 100,000 • EC50 2yr Liliana Encinales 2 Andres Angelo 10,000 Cadena Bonfanti 3,4 Nelly Pacheco 2 1,000 Aileen Chang, MD, MPH 5 ADVISER: Rebecca Lynch, DPT 5 100

1 Emory University 10

2 Allied Research Society LLC Serum Dilution) EC50 (Reciprocal 3 Universidad Simn Bolívar 1 4 La Clinica de La Costa Ltda 5 The George Washington University School EC50 1yr EC50 2yr of Medicine and Health Sciences Time Point

Since the Zika epidemic in 2015, FIGURE 1: Comparison of antibody titers from patients in Colombia, South America, at there have been striking associations one and two years post-Zika infection Titers were evaluated through indirect ELISA assays between Zika virus (ZIKV) infec- The reciprocal plasma dilution at which binding was at 50% is graphed (EC50) This plot tion and neurological complications, depicts a gradual waning of the memory antibody response found within the plasma sequelae which are most devastat- ingly seen in fetal development.1,2 As Dengue and Zika neutralizing anti- post-Zika infection and were tested a result, there is an urgent need for bodies than those who did not develop against the ZIKV E (envelope) pro- a vaccine against Zika. However, in GBS during Zika infection.3 This tein. As expected, all serum samples order to elicit protective, neutral- study hypothesizes that in regions bound highly to ZIKV E monomer endemic for flavivirus with detectable waning in infection, individuals titer over one year (Figure 1). In order We found that FL responses were signifcantly who developed GBS and to map the targeted viral epitopes, had high neutralizing we ran competition ELISAs using stronger in people who did not develop GBS, antibody titers will have known monoclonal antibodies, 4G2 antibodies that target and ZK67. These antibodies target and that DIII responses were undetectable diferent viral epitopes the fusion loop (FL) and Domain from those who do not. III (DIII) of the E protein respec- in all patients. To conduct this study, tively. Interestingly, we found that clinically diagnosed the majority of sera contained anti- plasma samples taken bodies targeting the FL but not DIII. izing antibodies there is a critical from Zika-infected persons living Therefore, we investigated whether need-to-know of how pre-existing in Colombia, South America, were there were clinical differences in immunity to Dengue virus afects the tested for the presence and strength people who did or did not develop antibody response to Zika infection. of memory antibodies at two diferent Guillain-Barre syndrome (GBS). We We have previously observed that time points after virus clearance. Sera found that FL responses were signif- people who developed Guillain-Barre were collected at one year (mean 1.3 cantly stronger in people who did not syndrome (GBS) had higher titers of years) and two years (mean 2.3 years) develop GBS, and that DIII responses

6 Fusion ♦ 2019 were undetectable in all patients (Figure 2). Our future direction is to A Competition with FL Antibody 4G2 expand this dataset to map epitopes 100 found on the ZIKV E dimer, which **p = 0 0012 will better refect the natural confor- • mation of ZIKV E protein. 80 • • REFERENCES 60 • I 1. Parra B, Lizarazo J, Jiménez-Arango JA, I I Zea-Vera AF, González-Manrique G, • Vargas J, et al. Guillain-Barré Syndrome 40 I Associated with Zika Virus Infection in Colombia. N Engl J Med. 2016 Oct 20 20;375(16):1513–23. •

2. da Silva IRF, Frontera JA, Bispo de % competition at 1:20 plasma dilution 0 Filippis AM, Nascimento OJMD, RIO- GBS-ZIKV Research Group. Neurologic GBS Zika Complications Associated with the Zika Virus in Brazilian Adults. JAMA Neurol. Disease Status 2017 Aug 14.

3. Lynch RM, Mantus G, Encinales L, Competition with DIII Antibody ZK67 Pacheco N, Li G, Porras A, et al. Aug- B mented Zika and Dengue Neutralizing 100 Antibodies Are Associated with Guillain- Barré Syndrome. The Journal of infectious diseases. 2018 Aug 3. 75

50

25 • •

% competition at 1:20 plasma dilution I 0 GBS Zika

Disease Status FIGURE 2: Graphs of Plasma Binding Competition to Zika E Monomer Protein with Two Known Antibidies The percent binding competition to E protein at a plasma dilution of 1:20 is graphed to (A) anti-fusion loop antibody 4G2 and (B) anti-DIII antibody ZK67 Each dot represents an individual plasma and is graphed by disease status of having a diagnosis of GBS or Zika infection alone There is signifcantly less competition (fusion loop antibodies) in the plasma from patients diagnosed with GBS by Mann-Whitney

BEAUMONT RESEARCH PRIZE WINNERS 7 Prevention of Cardiovascular Thrombosis Through Inhibition of Coagulation Factor XII

Sharjeel A B

Chaudhry, MSIII 6 0✖106 ADVISER: Robert 1 5✖107 Flaumenhaft, MD p = ns PhD 4 5✖106 1 0✖107 Beth Israel 3 0✖106 Deaconess, Harvard Medical School 5 0✖106 ✖ 6

Thrombin (RFU/m in) Thrombin 1 5 10 Thrombin (RFU/m in) Thrombin Discovery of an antithrombotic ** 0 0 therapy that does not cause bleeding 1 would be a transformative advance in 30 300 10 30 50 No SF Ctrl lgG the management of conditions such No SFLLRN SF + Ctrl lgG anti-FXIIa anti-TF as myocardial infarction, stroke, and (μg/M l) (μg/M l) venous thromboembolic disease.1 One promising approach is inhibition C of factor XII (FXII/FXIIa), which FIGURE 1: Platelet-based thrombin 8 0✖106 p = ns has been demonstrated to be throm- generation is FXXII-dependant Platelet- boprotective in preclinical models.2 rich plasma was stimulated with 50 μM ✖ 6 Importantly, severe congenital FXII 6 0 10 of the PAR-1 agonist peptide SFLLRN deficiency is not associated with (SF), and thrombin generation at 60 6 bleeding and FXII inhibition does 4 0✖10 minutes was measured by cleavage of not augment bleeding in animal a furogenic substrate in the presence 3-4 6 of (A) X210-C01, (B) anti-TF antibody, models. Despite its potential as a (RFU/m in) Thrombin 2 0✖10 therapeutic target, the physiological and (C) anti-FVIIa antibody These mechanisms of FXII recruitment to 0 results demonstrate that stimulated platelets can actively support thrombin sites of injury and its activation by 3 5 30 100 generation via a FXII-dependant platelets remains poorly understood. Ctrl lgG No SFLLRN pathway ** p <0 05 compared to To explore the binding and activation anti-FVIIa control by Kruskal-Wallis with Dunn’s of FXII by platelets during thrombus ( g/M l) μ post-test formation, we stimulated platelet rich plasma with PAR-1 agonist peptide SFLLRN and measured the thrombin generating capacity of platelets by platelet-dependent FXIIa genera- containing increasing concentrations cleavage of a fuorogenic substrate in tion in the presence of CaEDTA, a of 80% phosphatidylcholine and 20% the presence of anti-FXIIa antibody, specifc zinc chelator, to test whether phosphatidylserine (PC/PS). We used anti-TF antibody, and anti-FVIIa zinc was required for FXII binding platelet fow cytometry with FITC- antibody. We also stimulated washed and activation. We next interrogated labeled FXII, bead-immobilized platelets with SFLLRN and tested whether phosphatidylserine (PS), immunoprecipitation, and mass spec- the ability of the various platelet a negatively-charged phospholipid trometry to investigate a potential fractions, including from a patient expressed on the surface of stimulated platelet binding partner for FXII. We with Hermansky Pudlak Syndrome platelets, was responsible for FXII found that stimulated, but not resting (HPS), to generate thrombin and activation using lactadherin, a phos- platelets, are able to support thrombin FXIIa. Similarly, we measured phatidylserine blocker, and liposomes generation via a FXII-dependent

8 Fusion ♦ 2019 A WT PLATELETS B HPS PLATELETS -5 8 0✖106 pathway (Figure 1). We demonstrated 4✖10 ** that the FXIIa-generating capacity of ✖ -5 6 0✖106 platelets is contained in the insoluble 3 10 fraction, not the releasate (Figure 2). ✖ -5 4 0✖106 ** Evaluation of the interaction between 2 10 p = ns ** FXII and the platelet surface by fow -5 6 FXIIa Generation (RU) FXIIa Generation 1✖10 ✖ Fluorescence (RFU/m in) Fluorescence 2 0 10 cytometry showed that FXII-FITC I', ** binds to stimulated platelets in a spe- 0 0 cifc manner requiring cationic zinc. 3 Platelet-dependent FXIIa genera- 30 300 Vehicle No SF tion was inhibited by the presence of ReleasateInsoluble SF + Ctrl lgG anti-FXIIa CaEDTA (Figure 3). We found that (μg/M l) PS blockade with lactadherin prevents platelet-dependent FXIIa generation, FIGURE 2: The FXIIa and thrombin-generating activity of platelets is not contained while the addition of PS-containing in releasate (A) Washed platelets (2 7 x 109) were stimulated with 100 μM SFLLRN, and liposomes to plasma did not trigger the ability of the indicated fractions to generate FXIIa was measured by a FXIIa-specifc FXIIa production (Figure 3). These chromogenic substrate **p<0 05 Mann-Whitney U test (B) Platelet-rich plasma (PRP) results suggest that PS is necessary from a patient with Hermansky Pudlak Syndrome (HPS) was stimulated with 50 μM but not sufcient for FXII activation SF and thrombin generation at 60 minutes with measured by cleavage of furogenic substrate in the presence of increasing concentrations of X210-C01 **p<0 05 compared to control by Kruskal-Wallis with Dunn’s post-test Continued on p. 10

A B Zinc C 500 ···•··--­ No Zinc 3✖10-2 400 5✖10-2 300 2✖10-2 4✖10-2 2✖10-2 200 3✖10-2 -2 100 ········••' -2 1✖10 FXII-FITC Binding (g/MFI) FXII-FITC . 2✖10 .~ ...... 0 1✖10-2 5✖10-3 10 30 100 300 1,000 * *

FXIIa Generation ▲ OD 40g/m in FXIIa Generation 0 0 ( ▲ OD/m in) FXIIa Generation FXII-FITC (nM) D 10 20 30 40 10 30 100 V ehicle VehicleSFLLRN SFLLRN CaEDTA (mM) Lactadherin (nM) 8✖10-5 6✖10-5 FIGURE 3: FXII binding to activated platelets in zinc- and phosphatidylserine- dependent (A) Washed platelets were stimulated with 50μM SFLLRN and 4✖10-5 binding to increasing concentrations of FITC-labeled FXII was assessed by 2✖10-5 fow cytometry (B) Platelets were stimulated with 50μM SFLLRN and platelet- dependent FXIIa generation was measured using a chromogenic substrate in the 0

FXIIa Generation ( ▲ OD/m in) FXIIa Generation presence of increasing concentrations of (B) CaEDTA, a specifc zinc chelator, (C) lactadherin, and (D) liposomes containing 80% phosphatidylcholine and 20% Vehicle PC/PSPC/PS 1 3 PC 100 phosphatidylserine (PC/PS) PC/PSPC/PS 10PC/PS 30 100 Activated Platelets Phospholipid Liposomes (μM)

BEAUMONT RESEARCH PRIZE WINNERS 9 Continued fom p. 9 crucial for arterial thrombosis but T. Targeting Coagulation Factor XII relatively less important in venous Provides Protection from Patholog- ical Thrombosis in Cerebral Ischemia and that another platelet surface clotting. Greater insight into this Without Interfering with Hemostasis. J constituent is required. Using co- mechanism would help address an Exp Med 2006;203: 513-8. immunoprecipitation of FXII with important scientific question and 3. Renne T, Pozgajova M, Gruner S, Schuh aid in the much-needed development binding partners from platelet lysate K, Pauer HU, Burfeind P, Gailani D, followed by mass spectrometry, we of antithrombotic medications that Nieswandt B. Defective Thrombus For- identifed candidate platelet surface carry minimal risk of hemorrhage. mation in Mice Lacking Coagulation Factor XII. J Exp Med 2005;202: 271-81. that bind with FXII in the REFERENCES presence of zinc. Factor XII binds 4. Muller F, Gailani D, Renne T. Factor XI the platelet surface in a specific, 1. Leading Causes of Death. CDC National and XII as Antithrombotic Targets. Curr Center for Health Statistics; 2016. Avail- zinc-dependent manner, which is Opin Hematol 2011;18: 349-55. able from: www.cdc.gov/nchs/fastats/ followed by its activation in a process leading-causes-of-death.htm 5. Key NS. Epidemiologic and Clinical Data that requires PS. Together, these Linking Factors XI and XII to Throm- 2. Kleinschnitz C, Stoll G, Bendszus M, results may explain the longstanding bosis. Hematology Am Soc Hematol Educ Schuh K, Pauer HU, Burfeind P, Renne Program 2014;2014: 66-70. clinical observation that platelets are C, Gailani D, Nieswandt B, Renne CyTOF Analysis Provides Insight into Immune Response to H3 327M Neoantigen Peptide Vaccine in Glioma Patients Neil D. Almeida, MSII, Control T cells + H3.3 dextramer PE KIND T cells + H3.3 dextramer PE and Jared Taitt, 4 4 1 10 Q I Q2 10 Q I Q2 BS 0 0.04 9 7.19E-3 20.5 103 103 Dextramer ADVISERS: Payal 102 102 was detected Watchmaker, 1 1 usinganti-PE PhD, and Hideho 10 10 1 monoclonal Okada, MD, PhD 0 Q 4 0 Q4 0.35 0.2 4 1 2 3 4 1 2 3 4 1 University of California, San Francisco 0 10 10 10 10 0 10 10 10 10 YB173DI :: 173YB_TETRAMER–PE YB173DI :: 173YB_TETRAMER–PE Pr141Di :: 141Pr_CD3 Pr141Di :: 141Pr_CD3

4 10 Ql Q2 4 Gliomas are the most common brain 10 Q2 0 0.1 5 Qt 0 3.33 tumor found in children and comprise 103 103 Dextramer half of all pediatric central nervous was detected 102 102 system (CNS) tumors.1 Difuse mid- using anti-PE 1 line glioma, H3 K27M-mutant is a 10 101 polyclonal

novel entity describing a classifcation 0 Q4 '- _, Q3 0 Q4 -- of tumors of the CNS, predominantly 0.59 99 .3 0.30 1 2 3 4 arising in pediatric patients, located 0 10 10 10 10 0 101 102 103 104 within midline structures, and car- Pr141Di :: 141Pr_CD3 Pr141Di :: 141Pr_CD3 YB173DI :: 173YB_TETRAMER–PE YB173DI :: 173YB_TETRAMER–PE rying a poor prognosis. K27M muta- FIGURE: tions in H3F3A or HIST1H3B/C, encoding the histone variants H3.1 and H3.3, have been shown to be critical midline glioma who are positive for vaccine, combined with the tetanus for gliomagenesis.2 The Okada lab HLA-A2 and the H3.3K27M mutation toxoid (TT) peptide, emulsified in recently implemented a trial in which that underwent radiation therapy, Montanide. Poly-ICLC, which is a newly diagnosed children with difuse received a specifc H3.3K27M peptide Toll-like receptor 3 agonist, was given

10 Fusion ♦ 2019 concurrently to improve the thera- from small tumor samples, making it monoclonal antibody with minimal peutic efects of the vaccine. Vaccine ideal for this clinical trial. Dextramer non-specifc staining. Furthermore, was administered every three weeks technology involves utilizing heterog- this validated the efcacy of utilizing for the first 24 weeks. If there was enous polymers conjugated to MHC dasatinib as a method of increasing stable or improved disease, vaccine molecules that bind to T-cells and TCR cell surface expression. This will was administered every 6 weeks for a can subsequently be detected using serve as a powerful tool to learn about total treatment period of 96 weeks. My CyTOF. how the anti-tumor immune response objective was to develop an immune Control T-cells and K27M TCR could be activated and the impact evaluation system to gain insight into transduced T-cells were treated with of tumor microenvironment on the immune response to H3.327 peptide dasatinib to reduce TCR internaliza- functional status of vaccine-induced vaccine. Peripheral blood mono- tion and subsequently stained with cis- T-cells both systemically and locally. nuclear cells were obtained at each platin. This was followed with staining REFERENCES: of these time points and analyzed with H3.3 dextramer with conjugated utilizing mass cytometry (CyTOF). PE fuorophore and metal conjugated 1. Minturn, Jane E. Gliomas in Children. CyTOF is an emerging single-cell CD3 (141Pr). H3.3 dextramer-PE was Current Treatment Options in Neurology June 2013; 15 (3); 316. analysis platform that uses atomic detected on CyTOF using anti-PE mass spectrometric analysis to quan- monoclonal or polyclonal antibody 2. Karremann, Michael. Difuse High-Grade tify up to 42 metal-tagged antibodies conjugated 173Yb. These preliminary Gliomas with H3 K27M Mutations Carry a Dismal Prognosis Independent of Tumor per cell. The large number of analytes results indicate that TCR-specifc T Location. Neuro Oncology. Jan. 2018; per cell allows the simultaneous moni- cells can be detected using dextramer- 20 (1); 123. toring of multiple immune subsets PE and metal conjugated anti-PE

-- BEAUMONT RESEARCH PRIZE WINNERS 11 Basic Science:

A Machine Learning Approach to Mapping Co-regulated Variant Loci and Gene Expression over Time Arjun Panda, MSII ADVISER: Anelia Horvath, PhD, MSc

The George Washington II -r'j ~ :f: Vl ~ Vl University School ----­

of Medicine and Health Sciences RNA Variant Allele Freq.

We developed a machine learning analysis pipeline to discover func- tional gene variants by examining the efect of RNA containing single nucleotide variants (SNVs) on gene expression at cis- and trans- genomic Gene Expression locations over time. This refects a hypothesis of genetic co-regulation '

where, as the relative presence of a >-i § 0 particular variant allele seen in RNA FIGURE 1: transcription changes over time (due to changing cellular require- ments), gene expression elsewhere the Horvath lab has tackled using a gene expression trends elsewhere in in the genome is afected as a result novel metric called the Variant Allele the genome, elucidating functional (Figure 1). We believe this analysis Frequency (VAF).2 The variant allele relationships between gene variants pipeline can give novel mechanistic frequency (VAF) measures the RNA and gene expression. insights into a wide range of basic and expression of SNV-containing loci Our pipeline starts with clustering

translational cell biology questions, ( VA F RNA = nvar / ( n var + n ref )), where in Graphia Professional, which uses particularly on the evolution of drug nvar and nref are read counts con- a graph-based approach to build resistance in cancer cells. taining the variant and reference SNV relationships between .3,4 Each In order to measure changing (Figure 1). Whereas a DNA allele VAF or gene expression “time-course” cellular requirements in cancer cell count can model the efect of a dis- groups with another if it meets a lines, we conducted paired-end RNA crete dose of variant harboring alleles minimum Pearson correlation of sequencing on human melanoma cell (N ∈ {0,1,2} for diploid genomes) on a 0.96. As a result, genes with similar line WM164 under four experimental phenotype such as transcription, the expression trends and VAF trends conditions: with and without histone VAF is a continuous measurement are connected to each other in a deacytelase (HDAC) inhibition, and with a support of N ∈ [0,1]. Thus the structured graph (Figure 2). We then with and without IFN-gamma treat- VAF accounts for the true allelic prev- used a machine learning method ment. This was done over eight time alence at multi-allelic loci and refects called the Markov Cluster algorithm points each, for a total of 32 samples. molecular regulation events such (MCL) to partition the graph into We then aligned the RNA-sequencing as imprinting, post-transcriptional formal clusters by looking for packs reads to the and called regulation by RNA binding mol- of highly interconnected genes.5 We variants.1 ecules, as well as RNA editing. From then built custom R modules to scan Measuring the regulation of here, we needed to see if temporal through the clusters to fnd pairs of variant containing RNA is a problem VAF regulation mirrored absolute VAF and gene expression profles that

12 Fusion ♦ 2019 cluster together in two samples or more. Once found, each pair was cat- egorized as a cis- relationship if they were less than one million base-pairs apart, and trans- otherwise. All 60,963 VAF and gene expres- sion profles were clustered into 3,730 clusters, where each cluster represents a certain pattern of RNA regulation through time. Using custom R scripts, we discovered 440 co-regulated VAF containing positions and gene expression profles. Further work will include Protein-Protein Interaction (PPI) analyses to validate fndings, especially in a larger data set.

REFERENCES FIGURE 2: 1. Li, H., Handsaker, B., Wysoker, A., Fennell, T., Ruan, J., Homer, N., Marth, G., Abecasis, G., Durbin, R., and 1000 Quantitative Assessment of RNA and 4. Theocharidis, A., van Dongen, S., Genome Project Data Processing Sub- DNA Paired Sequencing Data. Nucleic Enright, A.J., and Freeman, T.C. (2009). group (2009). The Sequence Alignment/ Acids Res. 44, e161. Network Visualization and Analysis of Map format and SAMtools. Bioinforma. Gene Expression Data Using BioLayout Oxf. Engl. 25, 2078–2079. 3. Freeman, T.C., Goldovsky, L., Brosch, M., Express(3D). Nat. Protoc. 4, 1535–1550. van Dongen, S., Mazière, P., Grocock, R.J., 2. Movassagh, M., Alomran, N., Mudvari, Freilich, S., Thornton, J., and Enright, A.J. 5. Van Dongen, S. (2008). Graph Clustering P., Dede, M., Dede, C., Kowsari, K., (2007). Construction, Visualisation, and Via a Discrete Uncoupling Process. SIAM Restrepo, P., Cauley, E., Bahl, S., Li, M., Clustering of Transcription Networks J. Matrix Anal. Appl. 30, 121–141. et al. (2016). RNA2DNAlign: Nucleotide from Microarray Expression Data. PLoS Resolution Allele Asymmetries Through Comput. Biol. 3.

BASIC SCIENCE 13 Association of SREBF1 and TOM1L2 Polymorphisms with Bone and Muscle Phenotypes Caitlin M. well described, the genetic variants to be signifcantly associated with the Ward MSII, that infuence these relationships are muscular phenotypes in each cohort. ADVISERS: not fully understood. In this study, This expectation was confirmed Austin Gillies,2 we focused on two single nucleotide using an additive model in Caucasian Susan Knoblach, polymorphisms (SNPs) (rs1889018 and females from the AIMMY cohort for PhD,1,2 Heather rs7501812) found in genes SREBF1 and right hand grip strength; however, this Gordish- TOM1L2, respectively. Our goal was fnding was not extended to the other Dressman, PhD,1,2 to explore their individual and possible cohorts. TOM1L2 is often studied Dustin Hittel, Phd,3 Laura L Tosi, MD,1,2 pleiotropic efects on bone and muscle in conjunction with SREBF1 as they phenotypes in one cohort of African share a locus. Our data confrm the 1 The George Washington University School American children (Bone Health) and impact that TOM1L2 rs7501812 has on of Medicine and Health Sciences two cohorts of young adults (FAMuSS a variety of phenotypes including total 2 Center of Genetic Medicine, Children’s and AIMMY). body BMD, grip strength, VO2 max National Health System All cohorts were genotyped using and baseline 1-repetition maximum 3 Department of Biochemistry and Molecular the Applied Biosystems Taqman strength in more than one cohort Biology, Cumming School of Medicine, allelic discrimination assays and the and in both Caucasians and African University of Calgary, Alberta QuantStudio 7 Flex Real-Time PCR Americans, thus meeting our expecta- System. After testing for Hardy- tions based on the existing literature. It is well established that muscle and Weinberg equilibrium (HWE), data The pleiotropic features of TOM1L2/ bone have a rich and complex biome- was stratified by chanical relationship. In particular, sex and cohort and The role of SREBF1 has been well described in according to the mechanostat hypoth- analyzed using esis, bone growth and bone loss are analysis of covari- recent literature as a regulator of myogenic regu- stimulated by the local mechanical a nce (A NCOVA) elastic deformation of bone. Thus, applying both an latory factors (MRFs) and causes muscle atrophy bone mineral density (BMD) increases additive and domi- in response to muscle use and strength- nant model. Where when overexpressed both in vivo and in vitro. ening due to increased load-bearing of appropriate, post the afected bone.1 Originally, it was hoc pair-wise com- thought that the strain of the muscle parisons were performed and the SREBF1 have been explored in con- on the bone was the primary impetus resulting p-values adjusted for multiple junction with other loci affecting 5 causing the increased BMD, how- comparisons using the Sidak method. BMD and lean mass. In this study, ever, more recently, researchers have For the SNP-SNP interaction anal- we found that the two SNPs had a concluded that a paracrine/endocrine ysis, linear regression models were statistically significant pleiotropic relationship between muscle and used and included gender, appropriate relationship with the phenotypes bone is the more likely explanation. covariates, and an interaction term VO2 max and bone volume of the non- From the onset of life, muscle and quantifying the number of minor dominant arm in the FAMuSS cohort, bone cells are highly similar due to alleles present for each SNP pair. while the relationship in the dominant their common mesodermal origin.2 The role of SREBF1 has been well arm approached signifcance. described in recent literature as a regu- At the height of their development, REFERENCES: these tissues make up the majority of lator of myogenic regulatory factors 1. Sugiyama T, Yamaguchi A, Kawai S. Efects our body mass and exhibit complex (MRFs) and causes muscle atrophy of Skeletal Loading on Bone Mass and endocrine relationships with the rest when overexpressed both in vivo and 4 Compensation Mechanism in Bone: A New of the body.3 While the proteins that in vitro. Based on this finding, we Insight into The “Mechanostat” Theory. J are secreted from muscle and bone are expected the SREBF1 SNP rs1889018 Bone Miner Metab. 2002;20(4):196-200.

14 Fusion ♦ 2019 2. Brotto M, Bonewald L. Bone and Muscle: 4. Dessalle K, Euthine V, Chanon S, Delar- 5. Medina-Gomez C, Kemp JP, Dimou Interactions Beyond Mechanical. Bone. ichaudy J, Fujii I, Rome S, et al. SREBP-1 NL, Kreiner E, Chesi A, Zemel BS, et 2015 Nov;80:109-114. Transcription Factors Regulate Skeletal al. Bivariate Genome-Wide Association Muscle Cell Size By Controlling Protein Meta-Analysis of Pediatric Musculoskel- 3. Cianferotti L, Brandi ML. Muscle-bone Synthesis Through Myogenic Regulatory etal Traits Reveals Pleiotropic Effects Interactions: Basic and Clinical Aspects. Factors. PLoS One. 2012;7(11). at the SREBF1/TOM1L2 Locus. Nat Endocrine. 2014 Mar;45(2): 165-77. Commun. 2017 Jul 25;8(1):121. FAM210A and SOST Polymorphisms are Associated with Musculoskeletal Phenotypes in Healthy Young Adults Daniel Cohorts: AIMMY: 153 Caucasian alleles present for each SNP pair. IRB: Bestourous, young adults aged 18-35 (82 M, 71 F; avg. This project was approved by the IRB MSII, age 23.2 yrs) and 75 African American of the Children’s National Health ADVISERS: Austin young adults aged 19-25 (21 M, 54 F; System and the University of Calgary. Gillies,2 Christina avg. age 19.2); FAMuSS: 368 young SOST was found to be out of Hardy- Dollar,2 Susan adults (135 M, 233 F, avg age 23); Bone Weinberg equilibrium in the FAMuSS Knoblach, PhD,1,2 Health:73healthyAfrican-American (p=0.034), Bone-Health (p=0.006), Heather Gordish- children, (38 male, 35 female; ages 5-9) and AIMMY cohorts (p<0.001). 1,2 3 Dressman, PhD, Dustin Hittel, Phd, Laura Phenotypes: AIMMY: right and left Among men of FAMuSS, statistically 1,2 L Tosi, MD, arm grip strength, maximal oxygen signifcant associations were found consumption (VO2 max), and body between variants of FAM210A and 1 The George Washington University School mass index (BMI). FAMuSS: base- D arm baseline bone+marrow volume of Medicine and Health Sciences line isometric strength and 1-RM (p=0.006), D arm baseline cortical 2 Center of Genetic Medicine, Children’s strength in the non-dominant (ND) bone volume (p=0.001), and ND National Health System and dominant (D) arms, and total arm baseline cortical bone volume 3 Department of Biochemistry and Molecular bone and cortical humeral bone vol- (p=0.009) using an additive model. Biology, Cumming School of Medicine, umes. Bone Health: height-adjusted Statistically signifcant associations University of Calgary, Alberta total BMD minus head z-score. were found between FAM210A and Genotyping: Applied Biosystems the right (p=0.022) and left (p=0.007) Genetic variants in the muscle-spe- Taqman allelic discrimination assays grip strengths of African-American cific gene FAM210A (rs4796995), and the QuantStudio 7 Flex Real- women of AIMMY. Caucasian males and the bone-specific gene SOST Time PCR System were used to per- of AIMMY were found to have a (rs4792909), which codes for the osteo- form genotyping. Statistical Analysis: statistically significant association kine sclerostin, have been shown to be Hardy-Weinberg equilibrium was between VO2 max and FAM210A associated with total BMD and frac- assessed. Phenotypes were tested in both the additive (p=0.037) and ture risk. FAM210A knockout mice in gender specific cohorts using dominant (p=0.002) models. No have low grip strength, as well as high ANCOVA, where phenotype was significant association was found levels of matrix metalloproteinase-12 the independent variable, genotype between FAM210A the Bone- (MMP-12), a bone-resorption related was the dependent variable, and Health phenotypes. SNP-SNP peptide. Sclerostin suppresses the weight and/or age were covariates. interaction analysis between SOST Wnt/b-catenin signaling pathway in Post hoc pair-wise comparisons were and FAM210 showed statistically osteoblasts and osteocytes by binding performed and the resulting p-values signifcant interactions in FAMuSS to LRP5/6 coreceptors, thereby inhib- adjusted using the Sidak method. For on ND arm baseline 1-RM strength iting osteoblast development. The the SNP-SNP interaction analysis, (coefficient=0.567, p=0.046) and purpose of this study is to explore the linear regression models were used ND arm baseline cortical bone infuence of these genetic variants on and included gender, appropriate volume (coefcient=352, p=0.040). A musculoskeletal phenotypes in three covariates, and an interaction term previously developed cohorts. quantifying the number of minor Continued on p. 16

BASIC SCIENCE 15 Continued fom p. 15 Early identifcation of individuals interventions designed to reduce at risk for developing lower peak bone long term fracture risk by helping statistically significant interaction mass and possibly increased fracture these individuals maximize the use was also found in the Caucasian risk as seniors has the potential to of appropriate ftness, nutrition, and subgroup of AIMMY in VO2 max set the stage for the development of other health maintenance strategies. (coefcient=1.529, p=0.037). personalized medicine protocols/ Programmed Death Ligand 1 Is a Negative Prognostic Marker in Recurrent Isocitrate Dehydrogenase-Wildtype Glioblastoma Gifty A. NIH Cohort Recurrent Glioblastoma Dominah, MSII A NIH Cohort Glioblastoma B (WHO 2007) IDH-wildtype (WHO 2016) ADVISER: Edjah 100 100 Nduom, MD3 PD-L1 (CD274) high PD-L1 (CD274) high 80 PD-L1 (CD274) low 80 PD-L1 (CD274) low CONTIBUTORS: 60 60 Drew Pratt,1,2 Gifty p=0 0005 p=0 015 Dominah,3 Graham 40 40 Lobel,3 Arnold 20 20 Survival Probability Survival Probability Survival Probability Survival Probability Obungu,3 John Lynes,3 Victoria Sanchez,3 0 0 20 40 60 80 100 120 140 20 40 60 80 100 120 140 Nicholas Adamstein,3 Xiang Wang,3 Nancy Overall Survival (months) Overall Survival (months) A Edwards,3 Tianxia Wu,4 Dragan Maric,5 PD-L1 PD-L1 low Amber J Giles,6 Mark R Gilbert,1,6 Martha 83 53 20 11 4 2 1 1 low 38 22 6 3 2 2 1 1 PD-L1 Quezado1 42 16 2 1 0 PD-L1 22 9 0 high high

1 University of Michigan TCGA (Agilent 4502-A) 2 National Cancer Institute (NCI), National TCGA (Agilent 4502-A) D C Recurrent Glioblastoma, Non G-CIMP Institutes of Health (NIH) Glioblastoma 100 100 PD-L1 (CD274) high 3 National Institute of Neurological PD-L1 (CD274) high 80 80 PD-L1 (CD274) low Disorders and Stroke, NIH PD-L1 (CD274) low 60 p=0 135 4 Clinical Trials Unit, National Institute of p=0 135 60 Neurological Disorders and Stroke, NIH 40 40 5 Flow and Imaging Cytometry Core Facility, 20 20 Survival Probability Survival Probability National Institute of Neurological Diseases Survival Probability 0 0 20 40 60 80 100 and Stroke, NIH 20 40 60 80 120100 140 Overall Survival (months) PD-L1 Overall Survival (months) 6 Neuro-Oncology Branch, NCI, NIH PD-L1 low 255 76 28 12 4 1 low 6 5 4 2 1 0 PD-L1 PD-L1 The glioblastoma microenviron- 233 55 14 7 4 2 1 6 1 0 high high ment is particularly immunosup- '------'II.______pressive, including many secreted Figure: Kaplan–Meier survival estimates comparing high and low PD-L1 expression and cell-based immune suppres- in glioblastoma (A) Differences in survival curves from tumors meeting the 2007 WHO 1 sive mechanisms. Programmed histologic criteria for glioblastoma (5% PD-L1 cut-off) (B) Differences in survival curves from death ligand-1 (PD-L1) is a labile, recurrent IDH-wildtype glioblastoma reclassifed according to the 2016 WHO nomenclature inducible transmembrane receptor (5% PD-L1 cut-off) (C) TCGA survival curves, classifed only as glioblastoma, stratifed by ligand that facilitates immune system median PD-L1 mRNA expression (D) Survival curves from TCGA patients after fltering for evasion through co-ligation of its recurrent, non–G-CIMP (IDH-wildtype) tumors (median PD-L1 mRNA cut-off) receptor, PD-1, on activated T-cells.2

16 Fusion ♦ 2019 Upregulation of PD-L1 on tumor cells has been proposed as a mechanism of PD-L1 IHC (SP263) N(%) 3 immune escape in gliomas, and its Total ≥1% n = 54 ≥5% n = 43 ≥25% n = 28 detection at the protein level has been n = 183a (29 5) (23 4) (15 3) previously demonstrated.4,5 However, Age (yr) studycharacteristics(grading,sample size) and technical considerations Median (range) 48 (4-75) 52 (4-74) 53 (18-74) 53 (23-74) (assays, cut-offs) have resulted in Sex highly variable rates of expression — Female 57 (31) 16 (30) 14 (33) 6 (21) ranging from 6.1% to 88% in larger Male 124 (69) 38 (70) 29 (67) 22 (79) studies.4 Furthermore, the role of Presentation PD-L1 as a prognostic marker in gliomas, independent of predicting Primaryb 46 (25) 13 (24) 11 (26) 9 (3) Recurrent/post- treatment response, remains conten- 137 (75) 41 (76) 32 (74) 19 (68) tious. A specific cut-off for PD-L1 therapy expression has not been established Diagnosis (WHO 2016) in glioblastoma, and it remains to LGG 6 (3 3) 0 (0) 0 (0) 0 (0) be seen what role PD-L1 expression AA, IDHmut 21 (11 6) 1 (1 8) 0 (0) 0 (0) has in patient selection in future AO, IDH-mut/1p19q clinical trials which include PD-1/ 5 (2 7) 2 (3 7) 1 (2 3) 1 (3 6) codeleted PD-L1 blockade — as either a predic- tive or prognostic marker. Here, we Glioblastoma, IDHwt 81 (44 2) 37 (68 5) 30 (69 7) 20 (71 4) sought to address the prognostic role Glioblastoma, IDHmut 13 (7 1) 2 (3 7) 1 (2 3) 0 (0) of PD-L1 in recurrent glioblastoma Glioblastoma, NOS 31 (16 9) 12 (22 2) 11 (25 6) 7 (25) in a large tumor cohort according DMG, H3K27Mmut 16 (8 8) 0 (0) 0 (0) 0 (0) to the updated 2016 World Health Organization (WHO) classifcation TABLE: LGG, low-grade (diffuse) glioma (WHO grade II); AA, anaplastic astrocytoma; AO, of difuse gliomas. Additionally, we anaplastic oligodendroglioma; DMG, diffuse midline glioma sought to localize cellular expression of PD-L1 in the tumor microenviron- an = 5 cases did not have available clinical information ment using multiplex immunofuores- bPrior to chemotherapy or radiotherapy cence in post-treatment glioblastoma. Glioblastoma, NOS: WHO grade IV diffuse gliomas with negative IDH R132H staining Checkpoint inhibition has demon- and an alternative IDH1 or IDH2 mutation probability between 11 and 89% strated clinical efcacy in a variety Not shown: AANOS (not otherwise specifed, n = 2); AAIDHwt (n = 1); AOANOS of solid tumors. Reports of PD-L1 (anaplastic oligoastrocytoma, n = 1); AONOS (n = 1); DMG non-H3K27M (n = 5) expression in glioblastoma are highly variable (ranging from 6% to 88%) and its role as a prognostic marker has The Cancer Genome Atlas (TCGA) log-rank P = .015). PD-L1 remained a yielded conficting results. To validate and published studies were compared signifcant negative prognosticator in the prevalence and prognostic role of with clinical outcome. Multiplexed Cox regression analysis (hazard ratio: PD-L1 expression in a large cohort of immunophenotyping was used to 1.96, P = .021). Analysis of TCGA data difuse gliomas according to the 2016 identify PD-L1+ cell populations in confrmed decreased overall survival revised WHO classifcation. Using post-treatment glioblastoma. Using in recurrent non–glioma CpG island tissue microarrays, we compared 5 a 5% cut-of, PD-L1 expression was methylator phenotype (G-CIMP) PD-L1 monoclonal antibodies (n = 56) signifcantly associated with a poor glioblastoma (n = 12, log-rank P = .023), and validated expression (n = 183) using prognosis in both histologically but not in glioblastoma as a group (n = quantitative immunohistochemistry defned (n = 125, log-rank P < .001) and 444, log-rank P = .135). PD-L1 RISH (IHC) and RNA in situ hybridiza- recurrent isocitrate dehydrogenase tion (RISH). Expression data from (IDH)-wildtype glioblastoma (n = 60, Continued on p. 18

BASIC SCIENCE 17 Continued fom p. 17 in future clinical trials of PD-1/PD-L1 Molecule B7-H1 by Glioma Cells: A Poten- blockade. tial Mechanism of Immune Paralysis. Cancer Res. 2003;63(21):7462-7467. showed a signifcant correlation with REFERENCES: IHC (P < .0001). PD-L1 was observed 4. Berghoff AS, Kiesel B, Widhalm G et 1. Nduom EK, Weller M, Heimberger AB. in the proliferating perivascular al. Programmed Death Ligand 1 Expres- Immunosuppressive Mechanisms in sion and Tumor-Infiltrating Lympho- stem cell and immune niche of post- Glioblastoma. Neuro Oncol. 2015;17(suppl cytes in Glioblastoma. Neuro Oncol. treatment glioblastoma. A 5% PD-L1 7):vii9-vii14. 2015;17(8):1064-1075. expression cut-of identifed a subset 2. Dong H, Strome SE, Salomao DR et 5. Nduom EK, Wei J, Yaghi NK et al. of glioblastoma that is associated with al. Erratum: Tumor-associated B7-H1 PD -L1 Expression and Prognostic a worse clinical outcome. This asso- Promotes T-cell Apoptosis: A Potential Impact in Glioblastoma. Neuro Oncol . ciation remained signifcant within Mechanism of Immune Evasion. Nat Med. 2016;18(2):195-205. 2002;8(8):793-800. the newly defned IDH-wildtype clas- sifcation. These fndings could have 3. Wintterle S, Schreiner B, Mitsdoerffer implications for patient stratifcation M et al. Expression of the B7-Related Molecular Examination of Hidradenitis Suppurativa in Clinical Samples: Towards Understanding Mechanisms and Exploring Therapeutic Targets Jeffrey L. is estimated between 0.05% and Anti-CD3, a T-cell marker, and Roberson,1,2 4.10% of the population; however, its anti-CD31, a PECAM and vascular MSIV morbidity can be signifcant due to T-cell specifc marker, were used for ADVISERS: Bonnie the debilitating nature of the lesions immunohistochemical (IHC) analysis. C Carney,1,3,4 BS; and the social stigma associated with IHC was conducted in four HS and Lauren Moffatt,1,3,4 purulent and malodorous discharge.1 four healthy skin specimens with six PhD; Saira Nisar,1,3 While the exact pathophysiology of regions of interest (three epidermal MBBS, MS; HS is not known, the NOTCH sig- and three dermal) per sample. Cellular and Jeffrey W naling pathway involved in embryo- quantifcation was performed at 40x Shupp,1,3,4 MD logic development, cell diferentiation, magnification and compared with and molecular signaling has previously Student’s t-test. 1Firefghters’ Burn and Surgical Research beenimplicatedwithoutidentifcation Finally, RNA was extracted and Laboratory, MedStar Health Research of exact genes.2,3 This study aims to quantifed, and cDNA was generated Institute evaluate the cytoarchitecture, cell sur- via reverse transcriptase PCR from 2The George Washington University School face markers, and molecular signaling 3 NS and 4 HS biopsies. A NOTCH of Medicine and Health Sciences pathways present in HS patients to signaling PCR array was used to 3The Burn Center, MedStar Washington further understand the disease and identify the degree of gene regulation. Hospital Center identify potential therapeutic targets Candidate genes were identified if 4 Georgetown University School of Medicine to ultimately provide an alternative to their fold change was greater than or surgical excision. less than 2.5 when compared to normal Samples were obtained from 11 skin in at least three of the HS samples. Hidradenitis suppurativa (HS) is patients with HS who underwent Histopathologic examination a chronic inflammatory disease of surgical excision and compared showed that HS skin had wider epi- the skin which classically presents to 11 samples of normal skin (NS). dermal layers, extending into and as recurrent painful and exudative Histopathology of HS and NS samples engulfng the dermis, as well as exten- lesions most often found in inter- were compared via hematoxylin and sive dermal cellular infltration and triginous areas with high densities eosin (H&E) staining and imaging at aggregation. IHC analysis revealed of apocrine glands. HS prevalence 10x magnifcation. that, at the dermal level, HS lesions

18 Fusion ♦ 2019 had a signifcantly greater quantity of CD3+ (324.29±139.28 vs. 14.93±16.32, Immunohistochemical Identifcation and Quantifcation of p<0.0001), and CD31+ (322.15±155.46 Cells in Hidradenitis Suppurativa vs. Normal Skin vs. 2.84±5.56, p<0.0001) cells/mm2 Skin Type CD3 CD31 than healthy skin samples (Table). Epidermis Epidermis NOTCH array analysis identi- Dermis (n=12) Dermis (n=12) (n=12) (n=12) fed three genes in HS with a 2.5-fold upregulation compared to NS: KRT1 “Hidradenitis (keratin family), UbD (ubiquitin Suppurativa 2 28±5 46 324 29±139 28 4 27±7 72 322 15±155 46 D), and CCNE1 (cyclin-dependent (cells/mm2±SD)” kinase). Ten genes were down-regu- “Normal 6 40±10 37 14 93±16 32 2 84±4 20 2 84±5 56 lated in HS more than 2.5-fold com- (cells/mm2±SD)” pared to NS: CCND1 (cyclin D1 p-Value 0 2123 <0 0001 0 5806 <0 0001 regulator of G1/S transition), Hey1 (involved in somite development), TABLE: MFNG (demarcates boundaries during embryological development), demonstrating a signifcantly greater REFERENCES MMP7 (metalloproteinase involved dermal lymphocytic infltrate com- 1. Saunte DML, Jemec GBE. Hidradenitis in tissue remodeling), Notch 4 (cell pared to healthy skin. Additionally, Suppurativa: Advances in Diagnosis and proliferation and differentiation), genes involved in embryological devel- Treatment. JAMA 2017;318(20):2019–2032. DLL4 (encodes for NOTCH ligand), opment as well as skin and adipocyte 2. Hofman L, Ghias M, Lowes, M. Patho- LFNG (defines boundaries during differentiation are dysregulated in Physiology of Hidradenitis Suppurativa. embryological development), PPAR-g HS. Work is ongoing to correlate the Seminars in Cutaneous Medicine and (adipocyte diferentiation), and LMO2 identifed candidate genes with their Surgery 2017;36:46-54. (yolk sac erythropoiesis). respective protein levels by IHC with 3. Blok JL, Li K, Brodmerkel C, Jonkman MF, Epidermal and dermal cytoarchi- the goal of identifying molecular tar- Horváth B. Gene Expression Profling of tecture of HS lesions difer in com- gets for treatment of HS. Skin and Blood in Hidradenitis Suppura- parison to healthy skin with HS lesions tiva. Br J Dermatol 2015;174(6):1392-1394.

BASIC SCIENCE 19 The Effect of TET Mutations on DNA Methyltransferase Cytotoxicity and ERV Induction in B- and T-cell Malignancies Juan Carlos Nogues, MSII Mino % Live Day 6 Maver% Live at Day 6

CO-AUTHORS: 100 100

Zi Michael Wang, BS; 50 ~ . ] 50 • Sarah Chisholm, MA ;JI. ~ "' 250 500 1000 2000 4000 ~ Advisers: Katherine 250 500 1000 2000 4000 3 DayTx -e-5DayTx -..-3X3Tx Chiappinelli, PhD 3 DayTx -e- SDayTx -..-3X3Tx Mitcell Smith, MD, Mino% Live Day 9 Maver % Live at Day 9 100 PhD; Eduardo Sotomayor, MD 100 ~ .... .:, 50 ~ 50 .. ;JI. ;JI. ~- ~ GW Cancer Center, George Washington 250 500 1000 2000 4000 250 500 1000 2000 4000 3 DayTx -e-SDayTx -..-3X3Tx University School of Medicine and Health 3 DayTx -e-5DayTx -..-3X3Tx Sciences CCRF% Live Day 6 Karpas % Live Day 6 100 100 .. ~ 50 Cancers exhibit altered DNA meth- ::; 50 ~ ~ ;JI. - ;JI. ylation compared to normal cells, 250 500 1000 2000 4000 250 500 1000 2000 4000 including decreased methylation at 3 DayTx ,-.-3X3Tx 3 DayTx -.- S DayTx -..-3X3Tx --- 5 DayTx Karpas % Live Day 9 regions normally silenced for genome CCRF% Live Day 9 100 stability and increased methylation 100 > ~ ::; 50 ::; 50 ---~ at promoter regions of tumor sup- ;JI. ;JI. pressors. 5-azacytidine (Aza) is a 250 500 1000 2000 4000 250 500 1000 2000 4000 DNA methyltransferase inhibitor 3 DayTx -e- SDayTx -..-3X3Tx 3Daylx -e-SDay -..-3X3Tx (DNMTi) that removes DNA meth- Jeko % Live Day 6 Jeko % Live Day 9

ylation and is FDA approved for the 100 100 treatment of myelodysplastic syn- 80 .... 80 60 ~ 60 ::; .... ] 40 drome. We have shown that DNMTi ;JI. 40 ~ ;JI. ~ 20 upregulate the interferon response, 20 250 500 1000 2000 4000 250 500 1000 2000 4000

tumor antigens, and antigen presenta- 3 DayTx -.- SDayTx -..-3X3Tx 3 OayTx --- SDayTx -..-3X3Tx tion in solid tumors, contributing to an overall upregulation in immune sig- FIGURE 1: Dose response curve for AZA treatment naling.1 DNMTi activate a canonical interferon signaling pathway through upregulated expression of dsRNA, specifcally hypermethylated endog- further hypothesized that mutations dividing cells. Since Aza is only stable enous retroviruses (ERVs) that acti- in ten-eleven translocation methylcy- in the body for <30 minutes and MCL vate dsRNA sensors. The interferon tosine dioxygenases (TET), enzymes cells have slow doubling times, only a response activated by ERV signaling that normally demethylate DNA, fraction of cells divide during that 30 recruits immune cells, promoting might lead to a hypermethylated minute window. To improve response tumor clearance and sensitization to state making cells more resistant to in these cancers, extended drug avail- immune therapy.2 direct cytotoxicity from DNMTis. ability is necessary. We sought to determine whether We also sought to test the efects of We used three different treat- DNMTis cause a similar ERV acti- TET mutation on ERV induction ment regimens to demonstrate that vation and cell killing in B- and and immunogenicity. For 5-Aza to extending the availability of active T-cell malignancies, focusing frst on inactivate DNMTis it must be incor- drug shows a better response, sig- mantle cell lymphoma (MCL). We porated into the DNA of actively nificantly more so than increasing

20 Fusion ♦ 2019 the drug dose or treating for a longer period of time. The treatments ERV Expression included: one dose a day for 3 days (3 Day Tx; blue), one dose a day for 5 days 500 (5 Day Tx; red), and three doses a day 450 0 for three days (3X3 Tx; green). This 400 1 ● Syncytin was done for a dose response curve 15 - of 250, 500, 1000, 2000, and 4000 ● 0 ▼ envW2 ηg/mL, compared to PBS control (0). ● 10 0 ervFC2 Figure 1 shows the percentage of live - 0 cells at two time points, day 6 and 9 ● 0 0 after starting treatment. In the TET 5 - ▼ ● wild type MCL cells (Maver, Mino, ▼ ▼ ▼ ▼0 ▼ ▼ Jeko) the 3X3 group showed better normalization to control expression Relative ●▼ ●▼ ●▼ 0 ● ●▼ 0 ● ('\ 0 killing when compared to 3- and 0 I I I I I I I I I I I I 5-day Tx. The differences between the 3X3 treatment and the single CCRF 3DCCRF 250 3DCCRF 500 5D CCRF 250 5DCCRF 500 3X3CCRF 250 3X3Maver 500Maver 3D 250 3DMaver 500 5DMaver 250 5D 500 dose per day was more pronounced in Maver 3X3Maver 250 3X3 500 the slowest growing cell lines. Mino, which showed the largest diference Cell Lines in killing, doubles between 50-72hrs, whereas Jeko (doubling time 26-33hrs) FIGURE 2: ERV expression of CCRF and Maver Cell Line shows a less drastic diference between the 3 dose versus 1 dose per day groups. This supports the hypothesis that TET2, whereas CCRF only has TET3 REFERECES slower growing tumors beneft from mutated. In vivo responses by these 1. Chiappinelli, K. B., Strissel, P. L., Des- sustained drug delivery over increased tumors to DNMTi is likely due to richard, A., Li, H., Henke, C., Akman, B., drug dose. TET mutated leukemia increased immunogenicity, rather ... & Makarov, V. (2015). Inhibiting DNA cells (Karpas299, CCRF-CEM), were than just direct cytotoxicity, which methylation causes an interferon response less Aza sensitive. This supports our is supported by the increase in ERV in cancer via dsRNA including endog- enous retroviruses. Cell, 162(5), 974-986. hypothesis that TET mutations lead expression shown in Figure 2 (ERVs to a hypermethylated state more profiled: Syncytin-1, ervFC2, and 2. Stone, M. L., Chiappinelli, K. B., Li, H., resistant to DNMTi. The resistance envW2). CCRF showed increased Murphy, L. M., Travers, M. E., Topper, correlates with the extent of TET M. J., ... & Hung, C. F. (2017). Epigenetic ERV expression in both the fve-day therapy activates type I interferon sig- mutations. Karpas, the most resis- treatment and the 3X3 treatment. naling in murine ovarian cancer to reduce tant, has mutations in TET1 and immunosuppression and tumor burden. Proceedings of the National Academy of Sciences, 114(51), E10981-E10990.

BASIC SCIENCE 21 A Developmental Profle of Glucose Transport and Utilization in Mice Madhuri P. Rao, P11 P15 P30 MSII ADVISER: FC H WM FC H WM FC H WM Joseph Scafdi, DO GLUT2 Actin Center for Neuroscience, GLUT2 Frontal Cortex GLUT2 Hippocampus GLUT2 White Matter Children’s National 0 3 ** 0 3 * 0 20 Health System 0 2 0 2 0 15 0 10 0 1 0 1 0 05

The brain uses glucose and related Actin (AU) to Ratio Ratio to Actin (AU) Actin (AU) to Ratio Ratio to Actin (AU) to Ratio 0 0 0 substrates for energy (Berg et al., 2002) P11 P15 P30 P11 P15 P30 P11 P15 P30 but how the brain transports and uses glucose during development has not FIGURE 1: Western Blot of GLUT2 levels in the frontal cortex (FC), hippocampus been completely characterized. The (H), and white matter (WM) of P11, P15, and P30 mouse brains (top) Western aim of this project is to compile an Blot quantifcation of GLUT2 levels, expressed as ratio to actin in the frontal cortex, age, region- and cell-specifc profle hippocampus, and white matter of P11, P15, and P30 mouse brains (N = 3) (bottom) of glucose transport and utilization during development using a mouse model. This profile can be used to between ages in the frontal cortex was we analyzed and was not detected. better understand metabolic changes seen (Figure 1). GLUT4 and GLUT8 are both in pediatric diseases such as perinatal GLUT2 is preferentially expressed insulin-dependent glucose trans- hypoxia, epilepsy, hyperglycemia, and in astrocytes (Qutub and Hunt, 2005). porters (Sankar et al., 2002). An mitochondrial disease. As the number of astrocytes increases upward trend in GLUT4 expression Brains of C57Bl/6 mice were with age (Reemst et al., 2016), we by P30 was seen, but no signifcance harvested and dissected at ages expected an increase in GLUT2 in the frontal cortex, hippocampus, or P11, P15, and P30, corresponding expression during development, espe- white matter was seen. There was very to neonates, young children, and cially in the hippocampus (Oberheim high variability among individuals. adolescents respectively. The frontal et al., 2012). GLUT2 expression was GLUT 8 expression, however, showed cortex, hippocampus, and white signifcantly increased by P30 in the an extremely signifcant increase in matter were isolated by micro- frontal cortex and (Figure 2) and P30 mice in the frontal cortex, hip- dissection, each having diferent cell there was no signifcant diference in pocampus, and white matter, which populations important in learning, GLUT2 expression in white matter. can be explained by the feeding pat- memory, and cognition during early GLUT3 is the main glucose trans- tern of mice. From birth until P15, development. Glucose transporters porter in neurons (Gomez et al., the mice are in their suckling phase (GLUT) 1, 2, 3, 4, and 8 were selected 2010), but there is little temporal and and receive mostly proteins and fatty as measures of brain glucose transport no region-specific data for GLUT3 acids through their mothers’ milk (Gomez et al., 2010) and quantifed via expression. Results showed no statis- (McKenna et al., 2015) but by P30 Western Blotting. tically signifcant changes in GLUT3 mice feed on their own and have a GLUT1 is in the blood-brain bar- expression in the hippocampus and diet rich in carbohydrates, which rier endothelium (Sankar et al., 2002). white matter and a mild statistically stimulates insulin release. Since As vascularization is established early, insignificant upward trend in the GLUT8 is an insulin-dependent we did not expect signifcant changes frontal cortex. The lack of statistical glucose transporter, the increase in in GLUT1 expression during develop- significance may be that the peak insulin should cause an increase in ment, and no signifcant diference expression occurs between the ages expression of GLUT8 in the brain.

22 Fusion ♦ 2019 Although GLUT4 should have shown similar patterns in expression, it is P11 P15 P30 only weakly expressed in the brain. I FC H WM 11 FC H WM FC H WM Therefore, GLUT8 may be the key GLUT8 insulin-dependent glucose trans- Actin -- porter in the brain. Links to metabolic changes in diabetic pediatric patients GLUT8 Frontal Cortex GLUT8 Hippocampus GLUT8 White Matter should be further explored. 1 5 ** 1 5 1 0 *** Future studies include immunos- *** 0 8 1 0 1 0 0 6 taining human brain from a neonate, 0 5 0 5 0 4 a young child, and an adolescent. Mice 0 2 Ratio to Actin (AU) to Ratio Ratio to Actin (AU) to Ratio subjected to perinatal hypoxia will Actin (AU) to Ratio 0 Ob0 0 □ be compared to this profle to better P11 P15 P30 P11 P15 P30 P11 P15 P30 understand the metabolic changes FIGURE 2: Western Blot of GLUT8 levels in the frontal cortex (FC), hippocampus that occur in this common pediatric (H), and white matter (WM) of P11, P15, and P30 mouse brains (top) Western form of brain injury. Blot quantifcation of GLUT8 levels, expressed as ratio to actin in the frontal cortex, REFERENCES: hippocampus, and white matter of P11, P15, and P30 mouse brains (N = 3) (bottom)

1. Berg, J. M., Tymoczko, J. L., & Stryer, L. (2002). Each Organ Has a Unique Developing Brain After Injury: Knowns 6. Reemst, K., Noctor, S. C., Lucassen, P. J., Metabolic Profle. Biochemistry. 5th Edi- and Unknowns. Neurochemical Research, & Hol, E. M. (2016). The Indispensable tion. Retrieved from https://www-ncbi- 40(12), 2527–2543. https://doi.org/10.1007/ Roles of Microglia and Astrocytes during nlm-nih-gov.proxygw.wrlc.org/books/ s11064-015-1600-7 Brain Development. Frontiers in Human NBK22436/ Neuroscience, 10. https://doi.org/10.3389/ 4. Oberheim, N. A., Goldman, S. A., fnhum.2016.00566 2. Gmez, O., Ballester-Lurbe, B., Poch, & Nedergaard, M. (2012). Heteroge- E., Mesonero, J. E., & Terrado, J. (2010). neity of Astrocytic Form and Func- 7. Sankar, R., Thamotharan, S., Shin, D., Developmental Regulation of Glucose tion. Methods in Molecular Biology Moley, K. H., & Devaskar, S. U. (2002). Transporters GLUT3, GLUT4 and (Clifton, N.J.), 814, 23–45. https://doi. Insulin-Responsive Glucose Transporters GLUT8 in the Mouse Cerebellar Cortex: org/10.1007/978-1-61779-452-0_3 — GLUT8 and GLUT4 Are Expressed GLUTs in the Cerebellum. Journal of in the Developing Mammalian Brain. Anatomy, 217(5), 616–623. https://doi. 5. Qutub, A. A., & Hunt, C. A. (2005). Molecular Brain Research, 107(2), 157–165. org/10.1111/j.1469-7580.2010.01291.x Glucose Transport to the Brain: A Sys- tems Model. Brain Research Reviews, 3. McKenna, M. C., Scafdi, S., & Robertson, 49(3), 595–617. https://doi.org/10.1016/j. C. L. (2015). Metabolic Alterations in brainresrev.2005.03.002

BASIC SCIENCE 23 The Association of Polymorphism rs3736228 Within the LRP5 Gene with Bone Mineral Density in a Cohort of Caucasian Young Adults Mohamed Al- Females Males Amoodi, MSIII Characteristic CO-AUTHORS: N Mean ± SD N Mean ± SD Whitney Jones,2 Age (years) 96 22 3 ± 4 4 93 23 7 ± 4 2 1 Danny Lee, MSIII, Weight (kg) 96 62 4 ± 9 2 93 78 0 ± 12 3 Steven McKenzie, Height (cm) 96 165 9 ± 5 8 93 178 8 ± 7 7 MSIII,1 Helen C Miller, MSIII,1 BMI 96 22 7 ± 2 9 93 24 3 ± 3 1 1 Zachary Zeller, MSIII, TABLE: AIMMY Demographics ADVISERS: Seth Stubblefeld, MSII,3 Susan Knoblach, PhD,1,2 Heather Gordish- Dressman, PhD,1,2 Dustin Hittel, Phd,3 Laura is to expand existing knowledge of rs3736228 in the AIMMY cohort was L Tosi, MD,1,2 LRP5 and explore the association of found to be in HWE. Using a domi- rs3736228 polymorphisms and BMD nant model, we found that females 1 The George Washington University School to replicate the fndings of previous with one or more copies of the risk of Medicine and Health Sciences studies regarding the association of T allele had a signifcant lower mean 2 Center of Genetic Medicine, Children’s SNP rs3736228 with BMD in a cohort total BMD (CC: n=69, 1.129 ± 0.010; National Health System of healthy young adults. CT/TT n=29, 1.089 ± 0.016; p = 0.0347). 3 Department of Biochemistry and Molecular Participants from the University However, a similar association was Biology, Cumming School of Medicine, of Calgary cohort from the Assessing not seen in males. No signifcant asso- University of Calgary, Alberta Inherited Metabolic Syndrome ciations were observed with height, Markers in the Young (UC AIMMY) weight, or BMI. Osteoporosis is a signifcant burden study included 209 healthy young The rs3736228 polymorphism for our aging population. Developing adults and mixed ethnicity, pre- within the LRP5 gene was found to a better understanding of the genetic dominantly Caucasian (81%) young be negatively associated with BMD underpinnings of poor bone quality adults (male n=102, female n =107, in females in the UC AIMMY cohort. may assist in the future development average age=23 years). Phenotypes It is known that the polymorphism of prevention strategies. A study by were height, weight, body mass index rs3736228 alters the codon in posi- Correa-Rodriguez (2016) identifed a (BMI), and total BMD. Genotyping: tion 1330. The more common C allele group of single nucleotide polymor- Allelic discrimination was deter- encodes alanine, while the minor T phisms (SNPs) that were associated mined using Applied Biosystems allele encodes valine. This mutation with both body composition and bone Taqman and Applied Biosystems downregulates the LRP5 cell surface mineral density (BMD) in a popula- 7900HT Realtime PCR. Statistical receptor function, which plays a tion of Caucasian young adults.1 In Analysis, after being tested for Hardy- pivotal role in bone formation. The particular, they found rs3736228 in Weinberg equilibrium (HWE), the LRP5 gene has now been shown in the low-density lipoprotein receptor data was stratified by sex and ana- multiple studies to be associated with related protein 5 (LRP5) gene par- lyzed using analysis of covariance bone quality measures like calcaneal ticularly influenced BMD. SNP (ANCOVA) and a dominant model. Quantitative Ultrasound (QUS) and rs3736228 has been demonstrated to Where the f-tests were signifcant, BMD. Our study has expanded these have a pleiotropic efect on pheno- post hoc pairwise comparisons were fndings and suggests that rs3736228 types, demonstrating associations performed and the resulting p-values also infuences BMD in healthy young in other studies with body composi- were adjusted for multiple comparison females. This supports the work tion, circulating nutrient levels, and using the Sidak method. of a recent study which found that 2,3,4 obesity. The aim of this study The genotype distribution for when stratifying by sex, females only

24 Fusion ♦ 2019 showed a trend towards signifcance in calcaneal QUS measures.1 While Total Bone Mineral Density in Males the development of BMD is polygenic, • p=0 0327 our work suggests that focus on LRP5 1 16 • polymorphisms may be particularly helpful in defining genetic risk for 1 14 low BMD. In addition, given that this polymorphism has shown to have 1 12 pleiotropic efects, we plan to investi- gate the associations of rs3736228 with BMD Total 1 10 I other anthropomorphic phenotypes. I 1 08 • REFERENCES: 1. Correa-Rodriguez M, Schmidt-RioValle 1 06 J, & Rueda-Medina, B. The rs3736228 polymorphism in the LRP5 gene is associ- CC CT/TT ated with calcaneal ultrasound parameter re3736228 Genotype but not with body composition in a cohort of young caucasian adults. Journal of Bone FIGURE: Plot of SNP Variations vs Total BMD and Mineral Metabolism 2016:1-7.

2. Falcon-Ramirez E, Casas-Avila L, Cerda- 3. Funakoshi Y, Omori H, Yada H, & Katoh 4. Jiang XY, Chen HH, Cao FF, Li L, Lin Flores RM, Castro-Hernandez C, Rubio- T. A1330V polymorphism of the low-den- RY, Wen H, et al. A polymorphism near Lightbourn J, Velazquez-Cruz R, et al. sity lipoprotein receptor-related protein 5 osteoprotegerin gene confer risk of obesity Association of LRP5 haplotypes with gene and bone mineral density in japanese in Uyghurs. Endocrine 2010:37(3):383-388. osteoporosis in mexican women. Molecular male workers. Environmental Health and Biology Reports 2013:40(3):2705-2710. Preventive Medicine 2011:16(2):106-112. Association of GREB1 Polymorphisms with Bone and Muscle Health Phenotypes Ryan Lee, MSII Previous studies have identified genetic variation in GREB1, specif- CO-AUTHORS: specifc genetic loci associated with cally polymorphisms rs5020877 and Daniel Bestourous, variation in bone mineral density rs10929757, on BMD measures in a MSII,1 Stephen (BMD) in genome-wide association cohort of African American children Richards, MSII,1 analyses.1,2 One region in as well as two cohorts of Caucasian Caitlin M Ward, 2p22-25 was found to have signifcant young adults. MSII,1 association with BMD variations in The relationship between GREB1 ADVISERS: Austin the lumbar spine.3 Growth Regulation polymorphisms and phenotype were 2 1,2 Gillies, Susan Knoblach, PhD, Heather by Estrogen in Breast Cancer 1 gene assessed in three distinct cohorts: Bone 1,2 Gordish-Dressman, PhD, Dustin Hittel, (GREB1), a gene within this loci, was Health, 73 healthy African American 3 1,2 Phd, Laura L Tosi, MD, recently shown to be upregulated children previously recruited to assess

during osteoblast and chondroblast fracture risk factors; Functional 1 The George Washington University School diferentiation.4 In one study, genetic Single Nucleotide Polymorphism of Medicine and Health Sciences variants of GREB1 were found to be Associated with Human Muscle 2 Center of Genetic Medicine, Children’s associated with BMD variations at Size and Strength (FAMuSS), 368 National Health System the lumbar spine and femoral neck healthy Caucasian young adults 3 Department of Biochemistry and Molecular in Caucasian adults, establishing previously recruited as part of a Biology, Cumming School of Medicine, University of Calgary, Alberta GREB1 as a target gene for future 3-month long program to evaluate BMD genetic studies.5 The current study sought to elucidate the role of Continued on p. 26

BASIC SCIENCE 25 Continued fom p. 25 Covariates Sex rs5020877 rs10929757 used genetic infuences on strengthening Baseline isometric strength — F 0 14 0 13 muscles in the non-dominant arm; Age, weight and Assessing Inherited Markers of Non-dominant arm M 0 35 0 41 Metabolic Syndrome in the Young Baseline isometric strength — F 0 15 0 3 Age, weight (AIMMY), 153 health Caucasian Dominant arm M 0 32 0 33 young adults and 75 healthy African Baseline 1-RM strength — F 0 021 0 43 Age, weight American young adults previously Non-dominant arm M 0 19 0 61 recruited to identify signifcant risk Baseline 1-RM strength — F 0 11 0 48 factors for metabolic syndrome. Age, weight Dominant arm M 0 29 0 42 The Applied Biosystems Taqman Baseline bone (+ marrow) F 0 32 0 48 Allelic Discrimination Assays and Age, weight Real-Time PCR system were used volume — Dominant arm M 0 66 0 7 to genotype the DNA samples from Baseline bone (+ marrow) F 0 11 0 44 Age, weight the cohorts. All statistical analyses volume — Non-dominant arm M 0 71 0 87 were performed separately by gender, Baseline cortical bone volume F 0 44 0 26 and Hardy-Weinberg Equilibrium Age, weight — Dominant arm M 0 61 0 94 (HWE) was assessed for each SNP Baseline cortical bone volume F 0 051 0 33 in race-specifc cohorts. Analysis of Age, weight — Non-dominant arm covariance (ANCOVA) tests were M 0 69 0 53 utilized, where the respective covari- TABLE: Phenotype Analysis for GREB1 Polymorphisms in the FAMuSS Cohort ates were entered into the model. Post hoc pair-wise comparisons were showed a signifcant association with REFERENCES: performed, and the resulting p-values any phenotype. There were no signif- adjusted for multiple comparisons 1. Richards JB, Kavvoura FK, Rivadeneira cant SNP-SNP interactions between F, et al. Collaborative meta-analysis: using the Sidak method. rs5020877 and rs10929757 for any of associations of 150 candidate genes with Both SNPs were found to be in the phenotypes analyzed. osteoporosis and osteoporotic fracture. HWE in the FAMuSS and AIMMY Ann Intern Med. 2009;151:528-537. The results from this study dem- cohorts, but neither was in HWE onstrate that variations in the GREB1 2. Rivadeneira F, Styrkarsdottir U, Estrada in the Bone-Health cohort. In the gene, originally known for its role in K, et al. Twenty bone-mineral density loci Bone Health cohort, rs5020877 was tumor progression and more recently identifed by large-scale meta-analysis of significantly correlated with Dual genome-wide association studies. Nat for its role in osteoblast/chondroblast Genet. 2009;41:1199-1206. X-Ray Absorptiometry (DEXA) diferentiation, may contribute to dif- bone mineral content (BMC) in the ferences in baseline 1-RM strength of 3. Wynne F, Drummond FJ, Daly M, et al. lumbar spine in males (p=0.036) as Suggestive linkage of 2p22-25 and 11q12-13 dominant and non-dominant arms, with low bone mineral density at the well as left hip (p=0.036); whereas, lumbar spine BMC as well as total lumbar spine in the Irish population. Calci in females, rs10929757 was signifi- body, left hip, and lumbar spine BMD. Tissue Int. 2003;72:651-658. cantly associated with total body These fndings suggest independent 4. Liu T, Gao Y, Sakamoto K, et al. BMP-2 BMD (p=0.016), as well as BMD for effects of these two loci and that promotes differentiation of osteoblasts the left hip (p<0.001), lumbar spine patients with rare allele for rs5020877 and chondroblasts in Runx2-defcient cell (p=0.036), and total body (p=0.035). are stronger but have decreased bone lines. J Cell Physiol. 2007;211:728-735. In the FAMuSS cohort, rs5020877 quality while those with the rare allele 5. Hegarty KG, Drummond FJ, Daly M, et genotype was significantly associ- for rs10929757 have an increased bone al. GREB1 genetic variants are associated ated with baseline one-rep maximum quality. However, given the small with bone mineral density in Caucasians. (1-RM) strength in the non-dominant number of patients having the rare J Bone Miner Metab. 2018;36(2):189-199. (ND) arms of females (p=0.021). In allele for either SNP, further study is the AIMMY cohort, neither SNP needed to verify these fndings.

26 Fusion ♦ 2019 Clinical Research:

Evaluating Racial Disparities in Breast Cancer Referrals for Hereditary Risk Assessment

Abigail Pepin,1 * MSII; Rehema Thomas,1 MSI Not ~,.27 CO-AUTHORS: Referred Jennifer 10 Peterson,3 * Kerry 2 Johnson, Elizabeth 88 Stark,MS, CGC,2 Tara Referred Biagi, MS, CGC2 ■ 127 ADVISER: Rebecca Kaltman,2 MD 0 20 40 60 80 100 120 140 * denotes co-frst Numer of Individuals author ■ non-Hispanic African Americans ■ non-Hispanic Caucasians 1 The George Washington University School of Medicine FIGURE 1: Physician referral rates for breast cancer patients treated at GW Cancer and Health Sciences Center between 2014 and 2018 meeting NCCN criteria differed signifcantly by race 2 GW Medical Faculty Associates Ruth Paul (BNH 76 5%, N = 88 and WNH 92 7%, N=127; χ2=13 0642, p-value=0 00030 Hereditary Cancer Clinic, (p-value signifcance <0 05) 3 Des Moines University

There is a pronounced onco-racial American women contributes to this N= 81, WNH N= 116), whether at disparity in Washington, D.C., which disparity. our Ruth Paul Cancer Genetics and had the highest national incidence of A total of 1,180 patients (non- Prevention Service (RPCGPS) or breast cancer in African American Hispanic African Americans (BNH) elsewhere, by reviewing GW Cancer patients between 2010 and 2015 and N=502; non-Hispanic whites (WNH) Center records, RPCGPS records, the worst outcomes.1 Recent data N=435) were treated at the George and patient clinic records for genetic indicates a higher incidence of delete- Washington Cancer Center (GW screening results from outside insti- rious BRCA1 [and BRCA2] mutations Cancer Center) for breast cancer tutions. Patient charts were used to and variants of uncertain signifcance (both in situ and invasive carcinoma), identify individuals who received a (VUS) in African American patients between 2014 and 2018. Utilizing GW physician referral during the course compared to Caucasian patients when Cancer Center’s Cancer Registry, we of their cancer care. controlling for patients of Ashkenazi identifed women by race (BNH N Twenty-one percent of breast Jewish (AJ) descent.2 Despite this, =115; WNH N =137) who met select cancer patients seen in GW Cancer African American women meeting NCCN criteria for referral for genetic Center between 2014–18 met study National Comprehensive Cancer evaluation including breast cancer criteria for referral for genetic evalu- Network (NCCN) criteria for genetic diagnosis under age 50, triple nega- ation (n = 252; BNH N=115, WNH testing are less likely to complete tive breast cancer (TNBC) under age N=137), including breast cancer diag- such testing compared to Caucasian 60, and two primary breast cancers. nosis under age 50 (BNH N = 76; women nationally.3 Studies have Excluded patients were those who WNH N = 108), TNBC under age investigated psycho-social drivers of were not BNH or WNH or who did 60 (BNH N =14; WNH N =5), and minority patient aversion to genetic not meet the select NCCN criteria two primary breast cancers (BNH N testing. We hypothesize that lack of listed above. Patients were then = 18, WNH N = 16). Several patients physician referral for cancer genetic stratifed by race according to who counseling and testing for African underwent genetic evaluation (BNH Continued on p. 28

CLINICAL RESEARCH 27 Continued fom p. 27

32 identifed met two or more criteria Not Evaluated for referral (BNH N = 7, WNH N = -~-14 8). Physician referral rates differed significantly by race (BNH 76.5%, 83 N = 88 and WNH 92.7%; N= 127; χ2 Evaluated 123 =13.0642, p-value=0.00030) (Figure 1). There was no significant differ- - ence in adherence by race for patients 0 20 40 60 80 100 120 140 referred to genetic counseling (BNH Numer of Individuals 92%, N=83; WNH= 91%, N=123, χ2 ■ non-Hispanic African Americans ■ non-Hispanic Caucasians =0.00178, p-value=0.894) (Figure 2). Low genetic testing rates for FIGURE 2: Individual patients treated for breast cancer at GW Cancer Center between African American breast cancer 2014 and 2018 who met NCCN criteria for referral and were referred by their physician patients are an impediment to for genetic counseling stratifed by race and referral adherence resolving the prominent onco-racial breast cancer disparities, particularly in order to increase the identifica- 2. Hall MJ, Reid JE, Burbidge LA, et al. in young, TNBC, and patients with tion of at-risk women in the African BRCA1 and BRCA2 mutations in women multiple primary tumors. This study American community. of diferent ethnicities undergoing testing identifed a race-based phenomenon for hereditary breast-ovarian cancer. Cancer 2009; 115(10):2222-23. in physician referral rates. Possible REFERENCES: reasons for this discrepancy may 1. Cancer Facts and Figures: 2018. Atlanta, 3. Jones T, McCarthy AM, Kim Y, et al. include lag in physician education on GA: The American Cancer Society, 2018. Predictors of BRCA1/2 genetic testing among black women with breast cancer: the topic of hereditary risk, barriers (Accessed July 4, 2018, at https://www. cancer.org/content/dam/cancer-org/ a population study. Cancer Med. 2017; in physician-patient communication research/cancer-facts-and-statistics/ 6(7):1787-1789. and/or implicit bias. Future work annual-cancer-facts-and-fgures/2018/ is needed to clarify the root cause cancer-facts-and-fgures-2018.pdf.)

28 Fusion ♦ 2019 Utilization of Ancillary Services for Voice and Swallowing Outcomes Following Cardiothoracic Surgery long-term swallowing and speech post-operative feeding difficulties, Ari G. Mandler, complications. and 13 had documented aspiration. MSII A fourteen-month retrospective Of the 13 with aspiration, fve under- CO-AUTHOR: review of the Society of Thoracic went a modifed barium swallow with 1 Melissa A Peace, Surgeons database at a single tertiary speech-language pathology, and fve ADVISERS: Can children’s hospital was performed to had otolaryngology consultations. Yerebakan, MD, 1,3 include all infants undergoing open On discharge, 13/67 patients (19%) Pamela Mudd, MD, cardiothoracic surgery. Demographic, necessitated gastrostomy tube place- MBA1,2 operative, and outcome variables were ment, and 8/67 patients (12%) required

1 The George Washington University School identifed. supplemental oxygen or continued of Medicine and Health Sciences Our results showed, 67 patients ventilation. Following discharge, 8/67 2 Children’s National Health System were identifed (36M/31F; mean [SD] patients (12%) were followed by oto- (Children’s National) gestational age 36.5 [4.5] weeks) whose laryngology for vocal cord paralysis 3 Children’s National Heart Institute surgeries included patent ductus (n=7), persistent dysphagia (n=3), or arteriosus ligation (n=20), aortic stridor (n=2). We sought to determine the utiliza- operation (n=10), Tetralogy of Fallot Open cardiothoracic surgery in tion of otolaryngology and speech- repair (n=8), and Norwood proce- infancy is associated with high rates language pathology services among dure (n=6). Post-operatively, 20/67 of voice and swallowing dysfunction. infants following open cardiothoracic patients (30%) had documented weak Inpatient ancillary services are under- procedures. Given their susceptibility cry or weak cough; of these, 10 were utilized in managing this population, to iatrogenic-induced vocal cord evaluated by otolaryngology, and and outpatient follow-up is poor, dysfunction, the proper use of ancil- seven were found to have vocal cord suggesting the need for prospective lary services is critical in limiting paralysis. 30/67 patients (45%) had protocols to ensure adequate care. Depth-Camera Measured Biomechanics of the Lower Extremity Reveal Movement Abnormalities and Targets for Prevention in ACL Reconstructed Patients Chantal The anterior cruciate ligament (ACL) the development of ACL injury- Nguyen, MSII is one of the most commonly injured prevention programs utilizing biome- CO-AUTHORS: knee ligaments which requires exten- chanical interventions, which correct Alex Ngan,2 Patrick sive rehabilitation. Athletes who hazardous movement abnormalities Curran, MD2 injure their ACL risk long-term and reduce rates of injury.2 Studies ADVISERS: Drew disability compromising general have identifed specifc movements, Lansdown, MD2 function, including increased rates such as excessive internal rotation Brian Feeley, MD2 of osteoarthritis. Roughly 80% of angles at the hip and knee, as placing ACL injuries have a noncontact individuals at greater risks for ACL 1 The George Washington University School origin, suggesting that ACL injury injury. To detect these abnormali- of Medicine and Health Sciences risk is greatly infuenced by patterns ties, motion capture technologies are 2 University of California, San Francisco of motion.1 The potential beneft of prospectively identifying diferences Continued on p. 30 in landing strategies has prompted

CLINICAL RESEARCH 29 Continued fom p. 29 120 10 * * * employed, but they are often expen- 100 8 sive, labor-intensive, and impractical 6 3 80 screening tools in clinic. The depth 85 5 4 camera in the Microsoft Kinect 2 60 2 system has emerged to be a promising 55 4 64 7 40 low-cost assessment system that uti- 0 lizes surface mapping technology to 20 -2 generate high-quality human kine- -4 0 Hip IR Hip Abduction matic profiles. It maps surfaces by Reconstructed Control Contralateral sending out bursts of infrared light, ■ Reconstructed ■ Contralateral Bar graph comparing which provide real-time tracking FIGURE 1: ■ Control of human limbs.4 This study seeks knee fexion across all groups to evaluate knee kinematics in the FIGURE 2: Bar graph comparing controls, ipsilateral, and contralateral signifcant diference in hip adduc- hip IR, hip abduction across all leg of ACL reconstructed patients to tion among all groups. Comparing groups Negative values for hip IR assess ACL injury risk. knee fexion, controls (85.5) had sig- correspond to external rotation A cross-sectional study of ACL nifcantly higher degrees of fexion reconstructed patients at 6 months compared to reconstructed (55.4; extremity biomechanics with great post-operation (n=15) and controls p<0.01) knees. research and clinical utility. (n=12) was performed. Participants At the greatest point of fexion, performed three single leg squats for the contralateral leg in the ACL group REFERENCES each leg with arms spread out and demonstrated significantly more 1. Renstrom P, Ljungqvist A, Arendt E, et opposite leg forward, with move- internal rotation during a single leg al. Non-contact ACL injuries in female ment captured via the Microsoft squat, thereby indicating that the athletes: an International Olympic Com- mittee current concepts statement. British Kinect 2 camera placed 1-2 meters knee control in the contralateral J Sports Med 2008;42(6):394-412. in front of the participant. Custom leg is abnormal. Rehabilitation may MATLAB software was utilized to have improved deficiencies in the 2. Padua DA, DiStefano LJ, Hewett TE, et al. National Athletic Trainers' Association analyze raw data, which included hip reconstructed knee while abnormal Position Statement: Prevention of Ante- internal rotation (IR), adduction, and mechanics on the contralateral side rior Cruciate Ligament Injury. J of Athl knee fexion at the highest point of may further predispose patients to Training 2018;53(1):5. flexion. Negative values for hip IR injury on that side. While not signif- 3. Carlson VR, Sheehan FT, and Boden corresponded to hip external rota- cant, ipsilateral knees had higher hip BP. Video Analysis of Anterior Cruciate tion. Statistics comparing control, adduction than that of contralateral Ligament (ACL) Injuries: A Systematic contralateral, and ipsilateral legs were and control knees. This could also Review. J of Bone and Joint Surgery Rev conducted using one-way analysis be used as a motion analysis marker 2016;4(11):e5. of variance and student T-test, with for abnormal reinjury biomechanics. 4. Gray AD, Willis BW, Skubic M, et al. signifcance set at p < 0.05. The depth camera accurately quanti- Development and validation of a portable The mean age in years was 27.7 and fed that ACL patients cannot reach and inexpensive tool to measure the drop vertical jump using the Microsoft Kinect 31.2 for the control and ACL recon- the same knee fexion as controls in V2. Sports Health 2017;9(6):537-544. structed groups, respectively. The per- both the ipsilateral and contralateral centage of females was 17% and 51% leg; instead, ACL patients performed for control and ACL reconstructed abnormal compensatory behaviors groups, respectively. For degree of hip that further increased risk of re- IR, the contralateral group (7.74) was injury. Therefore, this prevention- signifcantly higher than those of the focused motion analysis system has ipsilateral (-2.06; p<0.05) and control emerged as a fast, low-cost, and group (-1.94; p<0.05). There was no non-invasive method to assess lower

30 Fusion ♦ 2019 Trends in Treatment Strategies and Comparison of Outcomes in Lymph Node Positive Bladder Cancer Christina Darwish, MSII +Censored ADVISERS: Treatment Group Median Survival (95% CI) Andrew Sparks,2 Surgery Alone (SA) 11 93 (10 48–13 90) MS; Richard Amdur, Neoadjuvent Chemotherapy (NAC) 28 06 (24 48–31 54) 1 0 PhD; 1,2 and Michael Adjuvent Chemotherapy (AC) 25 56 (22 74–28 68) Whalen, MD 1,2 Chemotherapy + Radiation (C+R) 13 93 (12 00–17 94) 0 8 Chemotherapy Only (C) 13 01 (11 37–14 85) 1 The George Washington University (GW) No Treatment/Palliative Care (NT) 2 96 (2 27–4 70) School of Medicine and Health Sciences 0 6 2 GW Medical Faculty Associates

While extensive research has assessed 0 4 Survival Probability Survival Probability treatment outcomes in muscle invasive bladder cancer, lymph node positive 0 2 AC disease (LN+) has been excluded from randomized studies or grouped with metastatic disease.1-3 Although node 0 0 positivity confers reduced 5-year 0 20 40 60 80 100 120 cancer specifc and overall survival, it is potentially curable if treated before Last Contact or Death, Months from Dx systemic metastasis.4 Treatment is not standardized, however, especially with lack of radiographic response regression models. A univariable (aOR=6.88) was higher for NAC. 5 to induction chemotherapy. This logistic regression model of treatment Overall, utilization of NAC and no study seeks to compare outcomes and by year was used to identify treat- treatment has increased, use of AC demonstrate trends in treatment for ment trends over time. Multivariable and RC alone has declined, and use of LN+ bladder cancer. models were adjusted for confounding chemotherapy and radiation without We performed a retrospective demographic, facility-level, and clini- surgery has not changed signifcantly. cohort study using the National copathologic variables. Combined chemotherapy and RC Cancer Database (2006-2014) and Among 1869 patients (cN1, 48%; is associated with improved outcomes identifed 1869 cT2-4N1-3M0 bladder cN2, 44%; cN3 8%), 567 underwent for LN+ bladder cancer compared to cancer patients treated with (1) radical RC, 418 underwent NAC, 591 RC or chemotherapy alone, although cystectomy (RC), (2) neoadjuvant che- underwent AC, 61 underwent there is no significant difference motherapy (NAC) + RC, (3) adjuvant radiation + chemotherapy, 136 between NAC and AC. Use of radia- chemotherapy (AC) + RC, (4) radiation underwent chemotherapy alone, tion and chemotherapy without RC + chemotherapy, (5) chemotherapy and 96 had no defnitive treatment. has stayed consistent and is associ- alone, or (6) no treatment/palliative Overall survival did not difer between ated with worse oncologic outcomes care only. The primary outcome was NAC and AC, but both had improved compared to RC with perioperative survival by treatment, analyzed using survival compared to RC alone. All chemotherapy, but there is no signif- Kaplan-Meier and multivariable other treatment groups had worse cant diference when compared to RC Cox-proportional hazards regression. survival outcomes in comparison to or chemotherapy alone. Secondary outcomes included patho- NAC. When comparing NAC to RC logic down-staging, analyzed using alone, down-staging to pT0 (adjusted univariable/multivariable logistic odds ratio [aOR]=26.39) and pN0 Continued on p. 32

CLINICAL RESEARCH 31 Continued fom p. 31 of Invasive Bladder Cancer : Long-Term Node Dissection and Radical Results in 1,054 Patients. J Clin Oncol. Cystectomy. J Urol. 2001;165(1):62-64. 2011;19(3):666-675. doi:10.1097/00005392-200101000-00015. REFERENCES 3. Vale CL. Neoadjuvant Chemotherapy 5. Milowsky MI, Bryan Rumble R, Booth 1. Grossman HB, Natale RB, Tangen CM, in Invasive Bladder Cancer: Update CM, et al. Guideline on Muscle-Invasive et al. Neoadjuvant Chemotherapy plus of a Systematic Review and Meta- and Metastatic Bladder Cancer (European Cystectomy Compared with Cystectomy Analysis of Individual Patient Data. Eur Association of Urology guideline): Alone for Locally Advanced Bladder Urol. 2005;48(2):202-205. doi:10.1016/j. American Society of Clinical Oncology Cancer. N Engl J Med. 2003;349(9):859- eururo.2005.04.006. clinical practice guideline endorsement. 866. doi:10.1056/NEJMoa022148 J Clin Oncol. 2016;34(16):1945-1952. 4. Herr HW, Donat SM. Outcome of doi:10.1200/JCO.2015.65.9797. 2. Stein BJP, Lieskovsky G, Cote R, et al. Patients With Grossly Node Positive Radical Cystectomy in the Treatment Bladder Cancer After Pelvic Lymph Impact of Smoking on Outcomes Following Knee and Shoulder Arthroscopy Dana Perim, MSIII Procedure aOR for smokers Lower 95% CI Upper 95% CI p ADVISERS: Jessica vs non-smokers Hyer, MD, PGY3, KAM 1 228 0 979 1 541 0 08 Richard Amdur,PhD, and Rajeev SHADEC 1 462 1 03 2 075 0 033 Pandarinath, MD KAC 1 058 0 703 1 592 0 79 KAA 1 213 0 859 1 713 0 27 The George Washington University School of KAB 1 969 1 407 2 757 < 0001 Medicine and Health Sciences DCSA 1 137 0 686 1 883 0 62 SHADEB 1 933 1 211 3 084 0 006 With well over a million procedures performed annually,1 arthroscopy SHACUR 1 297 0 874 1 925 0 2 of the knee and shoulder are two aOR: adjusted odds ratio; CI: confdence interval. KAM: Knee arthroscopy with of the most commonly performed meniscectomy (medial or lateral); SHADEC: shoulder arthroscopy with decompression; orthopaedic surgeries. Optimization KAC: knee arthroscopy of patient outcomes by minimizing TABLE: Adjusted odds of reaching the composite outcome* for smokers, by modifable risk factors is crucial, and procedure one well-established modifable risk *Composite outcome: Any cardiac, renal, wound (including all surgical site infections), factor is smoking. Approximately sepsis, thromboembolic, or pulmonary complication as recorded in the NSQIP database. 15.5% of Americans smoke,2 and the prevalence of smoking is highest in males ages 25-64,3 a group which also shoulder and knee arthroscopic sur- an invaluable source of data on a encompasses the majority of patients gery for sports injury. large sample of patients collected in a undergoing arthroscopic procedures.1 The National Surgical Quality reliable, systematic way from centers The frst step towards mitigating Improvement Program (NSQIP) across the country. the risk associated with smoking is to database was queried retrospectively Deaths and complications defne its impact on postoperative out- for patients who underwent knee or recorded in the frst 30 days postoper- comes. The purpose of this study was shoulder arthroscopic surgery for atively were included and categorized to evaluate any association between sports injury between 2010-2016. as cardiac, renal, wound (including preoperative smoking and periopera- These patients were identifed using all surgical site infections), sepsis, tive and early postoperative complica- the current procedural terminology thromboembolic, or pulmonary. A tions in a large population following (CPT) codes. This database provides composite outcome was formed and

32 Fusion ♦ 2019 defned as positive if a patient experi- with medial and lateral meniscectomy increase the risk of potentially serious enced any of the above complications. (OR=1.97, 95% CI:1.407-2.757). perioperative and early-postoperative Univariate and multivariate analyses Preoperative smoking was found complications. Our work adds to the were performed to determine whether to be an independent risk factor for breadth of literature demonstrating preoperative smoking was an indepen- complications for several arthroscopic that smoking is detrimental to patient dent risk factor for any of these post- procedures, though with variability outcomes in orthopaedic surgery in operative complications individually between types of procedure. In our both the short- and long-term. or for the composite outcome. study, patients who smoked were REFERENCES: The study included 134,822 cases. signifcantly younger, and, presum- In univariate analysis, smoking was ably, healthier. This is a potential 1. Shah N V., Solow M, Kelly JJ, et al. Demo- associated with increased rates of com- confounder, which may account for graphics and rates of surgical arthroscopy and postoperative rehabilitative prefer- plication in knee arthroscopy with some of the variability in the impact ences of arthroscopists from the Arthros- the following: ACL reconstruction smoking had on outcomes between copy Association of North America or medial and lateral meniscectomy, different procedures. Strengths of (AANA). J Orthop. 2018;15(2):591-595. doi:10.1016/j.jor.2018.05.033. and shoulder arthroscopy with the this study include the use of a nation- following: debridement, decompres- ally validated database, with a large 2. National Center for Chronic Disease sion, or rotator cuf repair. Signifcant sample size and robust clinical char- Prevention and Health Promotion (US), Health O on S and H. The Health Conse- associations then underwent mul- acteristics. Limitations include the quences of Smoking—50 Years of Progress. tivariate analysis, which found that retrospective nature of the study, Centers for Disease Control and Preven- smoking was an independent risk lack of data on surgical technique tion (US); 2014. Retrieved from http:// factor for any complication/mortality and simultaneous procedures, 30-day www.ncbi.nlm.nih.gov/pubmed/24455788. Accessed June 28, 2018. event in shoulder arthroscopy with follow up window, and reliance of self- decompression (OR=1.46; 95% CI: reporting of smoking status. 3. Jamal A, Phillips E, Gentzke AS, et al. 1.030-2.075), shoulder arthroscopy Overall, our data highlights that Current Cigarette Smoking Among Adults — United States, 2016. MMWR with debridement (OR=1.933; 95% even in generally low-risk arthroscopic Morb Mortal Wkly Rep. 2018;67(2):53-59. CI: 1.211-3.084) and knee arthroscopy procedures, preoperative smoking may doi:10.15585/mmwr.mm6702a1. Comparison Between Medical Therapy and Endovascular Treatment of the Extracranial Atherosclerotic Vertebral Artery Disease: A Systematic Review David Daniel, strokes occur in the vertebrobasilar present with TIAs.2 For decades, the MSIII circulation.1 Vertebrobasilar circula- primary treatment in these patients ADVISERS: tion perfuses the medulla, cerebellum, has consisted of antiplatelet and Muhammad pons, midbrain, thalamus, and occip- anticoagulation drugs such as aspirin Zeeshan Memon, ital cortex. Therefore, atherosclerotic and warfarin. However, advances MD, and Shahram disease in these vessels can result in in endovascular technology with Majidi, MD significant multisystem disability balloon angioplasty or angioplasty and death. There are two portions with stent placement have become The George Washington University School of of the vertebral artery, extracra- efective alternatives. Recent trials Medicine and Health Sciences nial (V1 – V3) and intracranial (V4). such as the VIST trial have shown Though the extracranial vertebral that interventional techniques are Atherosclerosis is a common cause artery disease is generally regarded to feasible, safe, and efective.3 However, of vertebral artery stenosis leading to have more benign outcomes as com- more evidence is required to reach vertebrobasilar or posterior circula- pared to intracranial, 50% of these a consensus. The aim of the present tion strokes and transient ischemic patients may have a stroke at initial attacks (TIA). About 20 % of ischemic presentation while another 26% may Continued on p. 34

CLINICAL RESEARCH 33 Continued fom p. 33 Medical Endovascular study is to compare best medical treat- No of Studies 8 49 ment and the endovascular approach No of Subjects 362 2142 in terms of stroke and death rates at 1 Mean Age 65 6 64 1 month and at last follow-up. Females 84 580 We identifed ECVA studies pub- lished between January 1966 and TABLE 1: Baseline Characteristics December 2017 using a search on PubMed. The rates of stroke and stroke and/or death were estimated versus endovascular group 12 (4.5 %) to better understand the safety and for best medical treatment and endo- vs 1 (0.04%) (p-value =0.001). There efcacy of the endovascular treatment vascular treatment at 1 month and was no statistically signifcant difer- compared to the standard medical at last follow-up. A random effects ence in rates of TIA or death to other therapy. model was used to calculate pooled causes between the two groups. proportions (PP) across studies and Our analysis demonstrated that REFERENCES 95% confdence intervals. A total of 57 endovascular treatment signifcantly 1. Merwick A, Werring D. Posterior circula- reports were included in the analysis, reduced the risk of stroke and death tion ischaemic stroke. BMJ 2014;348:3175 eight studies reported outcomes in when compared to best medical treat- 2. Caplan L, Wityk R, et al. New Eng- patients receiving medical treatment ment alone at 30 days and at follow-up. land medical center posterior circu- (362 patients) and forty-nine studies However, because of the paucity of lation registry. Annals of Neurology reported upon patients treated with long-term outcomes of patients on 2004;56:389-398 endovascular approach (2142 patients). standard medical therapy and large 3. Markus HS, Larsson SC, et al. Stenting for The mean age of patients in the variability observed between endo- symptomatic vertebralartery stenosis: The medical group was 65.6 years (range vascular case series, a prospective Vertebral Artery Ischaemia Stenting Trial. Neurology 2017;89:1229-1236 61.3 - 69.0 years) and 64.1 years (range randomized trial is warranted in order 53.5 - 72 years) in the endovascular group. The 30-day incidence of stroke was 26 (7.2%) in the medical treat- Medical Endovascular Signifcance ment group compared to 18 (0.84%) in the endovascular group, resulting # of Peri-Op Strokes 26 (7 2%) 18 (0 84%) p = <0 0001 in a higher risk for patients in the best medical treatment when compared # of Strokes at Follow-Up 33 (12 3%) 51 (2 4%) p = <0 0001 to endovascular treatment (p-value = 0.0001). Similarly, at follow-up, 33 # of Stroke Related Deaths at 12 (4 5%) 1 (0 04%) p = 0 001 (12.3%) strokes were observed in the Follow-Up medical group compared to 51(2.4%) in the endovascular group (p-value **Peri-Op = within 30 days = 0.0001). There was also statisti- cally signifcant diference in stroke TABLE 2: Outcomes related death in the medical group

34 Fusion ♦ 2019 The Impact of Insulin Dependence on Post-Operative Complications in Diabetic Patients Undergoing Anatomic Pulmonary Resections Harleen the impact of insulin dependence on categorical variables. Multivariate Marwah, MSII DM patients undergoing anatomic logistic regression models were gen- CO-AUTHORS: pulmonary resections. erated with NIDDM and IDDM as Ryan Lee, MBA, MS The National Surgical Quality independent risk factors to establish II, and Ishwarya S Improvement Program surgical reg- risk associations between diabetes Mamidi, MS II istry maintained by the American mellitus and specifc adverse events ADVISER: Anna College of Surgeons was queried to in these patients. McLean, MD identify patients who underwent Upon analyzing the preoperative pulmonary resections from 2005 comorbidities between the three The George Washington University School of to 2016 by Current Terminology cohorts, NIDDM and IDDM patients Medicine and Health Sciences Procedure (CPT) codes. Ultimately, had significantly higher rates of 18,246 patients were included in the dyspnea (p<0.001), chronic obstruc- The prevalence of diabetes mellitus analyses after excluding patients with tive pulmonary disease (p=0.014), (DM) has been rapidly increasing, missing data. Patients were stratifed congestive heart failure (p=0.001), contributing greatly to the burden into three cohorts by their diabetes hypertension requiring medication of disease in patients and increasing mellitus status — non-diabetics (Non- management (p<0.001), acute renal economic costs for the healthcare DM), non-insulin dependent diabetes failure (p=0.048), dialysis depen- system in the United States.1,2,3 Impact mellitus (NIDDM), and insulin- dence (p<0.001), open wound/wound on quality of life after surgical treat- dependent diabetes mellitus (IDDM). infections (p<0.001), hematologic ment is a signifcant concern for many These cohorts were compared for disorders (p<0.001), and functional diabetic patients.4 While the impact differences in their demographics, dependence (p<0.001) compared to of DM on various surgical procedures preoperative comorbidities, and non-diabetic patients. The non-dia- has been studied, its impact on patient complication rates using one-way betic cohort had a signifcantly larger outcomes following anatomic pulmo- analysis of variance (ANOVA) for proportion of smokers (35.51%) than nary resections remains to be estab- continuous variables and Pearson’s the NIDDM (30.34%) patients and lished. Therefore, we conducted this Chi-squared tests or Fischer’s exact retrospective analysis to investigate tests (expected cell count < 5) for Continued on p. 37

DEMOGRAPHICS Non-DM % NIDDM % IDDM % P-value 15,433 2,017 796 Sex <0 001 Female 8447 54 73% 897 44 47% 340 42 71% Male 6986 45 27% 1120 55 53% 456 57 29% Race <0 001 American Indian/Alaska Native 101 0 65% 14 0 69% 4 0 50% Asian or Pacifc Islander 576 3 73% 104 5 16% 20 2 51% Black or African American 1007 6 52% 173 8 58% 95 11 93% Hispanic 21 0 14% 1 0 05% 1 0 13% White 13728 88 95% 1725 85 52% 676 84 92%

TABLE 1A:

CLINICAL RESEARCH 35 PRE-OPERATIVE COMORBIDITIES Smoke 5480 35 51% 612 30 34% 245 30 78% <0 001 Dyspnea <0 001 No Dyspnea 11934 77 33% 1487 73 72% 567 71 23% At Rest 265 1 72% 35 1 74% 21 2 64% Moderate Exertion 3234 20 96% 495 24 54% 208 26 13% Ventilator Dependence 29 0 19% 0 0 00% 5 0 63% 0 002 COPD 3756 24 34% 541 26 82% 216 27 14% 0 014 Ascites 10 0 06% 1 0 05% 4 0 50% <0 001 Congestive Heart Failure 75 0 49% 16 0 79% 11 1 38% 0 001 Hypertension 8291 53 72% 1675 83 04% 672 84 42% <0 001 Acute Renal Failure 15 0 10% 4 0 20% 3 0 38% 0 048 Dialysis Dependent 44 0 29% 14 0 69% 16 2 01% <0 001 Disseminated Cancer 1130 7 32% 111 5 50% 55 6 91% 0 011 Wound Infection 93 0 60% 23 1 14% 15 1 88% <0 001 Steroid Use 709 4 59% 82 4 07% 59 7 41% <0 001 Weight Loss 453 2 94% 57 2 83% 26 3 27% 0 823 Bleeding Disorder 431 2 79% 83 4 12% 51 6 41% <0 001 Blood Transfusions 46 0 30% 2 0 10% 5 0 63% 0 057 Functional Status <0 001 Independent 15293 99 09% 1981 98 22% 781 98 12% Partially Dependent 123 0 80% 33 1 64% 14 1 76% Totally Dependent 17 0 11% 3 0 15% 1 0 13% OPERATIVE VARIABLES ASA Classifcation <0 001 1-No Disturb 58 0 38% 0 0 00% 1 0 13% 2-Mild Disturb 3146 20 38% 174 8 63% 32 4 02% 3-Severe Disturb 10942 70 90% 1575 78 09% 604 75 88% 4-Life Threat 1284 8 32% 268 13 29% 159 19 97% 5- Moribund 3 0 02% 0 0 00% 0 0 00% Anesthesia Administered 0 065 Epidural 20 0 13% 3 0 15% 0 0 00% General 15385 99 69% 2014 99 85% 793 99 62% MAC/IV Sedation 5 0 03% 0 0 00% 2 0 25% Other 5 0 03% 0 0 00% 1 0 13% Regional 9 0 06% 0 0 00% 0 0 00% Spinal 9 0 06% 0 0 00% 0 0 00% aValues expressed as Mean ± Standard Deviation All other values expressed as (%) and N

TABLE 1B:

36 Fusion ♦ 2019 Continued fom p. 35 IDDM NIDDM Complication Odds Ratio (95% CI) P- Value Odds Ratio (95% CI) P- Value IDDM patients (30.78%; p<0.001), Superfcial Incisional SSI 0 699 (0 361-1 354) 0 288 0 835 (0 513-1 360) 0 47 as well as a history of disseminated cancer (7.32%) compared to either Deep Incisional SSI 1 338 (0 294-6 093) 0 707 0 868 (0 251-2 996) 0 822 diabetic cohort (p=0.011; Table 1a-b). Organ/Space SSI 0 615 (0 305-1 240) 0 174 0 90 (0 516-1 570) 0 711 From the multivariate regression Wound Dehiscence 1 137 (0 140-9 222) 0 905 - - models, NIDDM patients were found Pneumonia 1 342 (1 033-1 748) 0 027 0 965 (0 797-1 168) 0 712 to be at a significantly higher risk Unplanned Intubation 1 449 (1 063-1 976) 0 019 1 005 (0 791-1 277) 0 966 for reoperation (OR 1.349, 95% CI Pulmonary Embolism 1 004 (0 461-2 184) 0 993 0 825 (0 516-1 321) 0 424 1.063-1.712, p=0.014) following pul- Ventilator Dependence 1 792 (1 281-2 507) 0 001 0 824 (0 632-1 075) 0 154 monary resections when compared (48 hours) to non-diabetics (Table 2). IDDM Progressive Renal 0 485 (0 233-1 01) 0 053 0 741 (0 399-1 376) 0 342 patients were at a signifcantly higher Insuffciency risk for experiencing pneumonia (OR Acute Renal Failure 2 888 (1 548-5 389) 0 001 1 219 (0 666-2 229) 0 521 1.342, 95% CI 1.033-1.748, p=0.027), Urinary Tract Infection 0 788 (0 481-1 291) 0 343 0 968 (0 675-1 388) 0 86 unplanned intubation (OR 1.449, CVA/Stroke 2 353 (1 184-4 675) 0 015 1 141 (0 561-2 319) 0 716 95% CI 1.063-1.976, p=0.019), venti- Cardiac Arrest 1 94 (1 086-3 465) 0 025 1 148 (0 696-1 894) 0 588 lator dependence for greater than 48 Deep Venous 1 532 (0 879-2 671) 0 132 0 964 (0 609-1 526) 0 875 hours (OR 1.792, 95% CI 1.281-2.507, Thromboembolism p=0.001), acute renal failure (OR Myocardial Infarction 1 949 (0 961-3 952) 0 064 1 467 (0 867-2 483) 0 153 2.888, 95% CI 1.548-5.389, p=0.001), Post-Operative Blood 0 974 (0 733-1 296) 0 859 0 966 (0 797-1 171) 0 725 strokes (OR 2.353, 95% CI 1.184-4.675, Transfusions p=0.015), cardiac arrest (OR 1.94, Systemic Sepsis 1 353 (0 729-2 513) 0 338 0 977 (0 684-1 394) 0 897 95% CI 1.086-3.465, p=0.025), and an Septic Shock 0 697 (0 410-1 184) 0 182 1 111 (0 717-1 721) 0 639 extended length of hospital day of at Return to OR 0 809 (0 602-1 086) 0 158 1 349 (1 063-1 712) 0 014 least 10 days (OR 1.357, 95% CI 1.120- Extended Length of Stay 1 357 (1 120-1 644) 0 002 1 089 (0 944-1 258) 0 243 1.644, p=0.002; Table 2). (≥ 10 days) Discussion: Diabetes mellitus patients had greater risk for numerous TABLE 2: complications than non-diabetics. By establishing risk associations between diabetes mellitus and these adverse REFERENCES: 3. Boyle JP, Thompson TJ, Gregg EW, et outcomes, surgeons are better pre- al. Projection of the Year 2050 Burden of 1. NCD Risk Factor Collaboration (NCD- Diabetes in the U.S. Adult Population: pared to handle these potential com- RisC). Worldwide Trends in Diabetes Dynamic Modeling of Incidence, Mor- plications. Targeting glucose levels to Since 1980: A Pooled Analysis of 751 Popu- tality, and Prediabetes Prevalence. Popul <200 mg/dL in diabetics may lower the lation-Based Studies with 4.4 Million Par- Health Metr. 2010;8:29. risk for these serious complications. ticipants. Lancet. 2016;387(10027):1513-30. 4. Cykert S. Risk Acceptance and Risk Aver- IDDM patients were at an increased 2. Gregg EW, Zhuo X, Cheng YJ, et al. sion: Patients’ Perspectives on Lung Sur- risk for pneumonia, intubation, ven- Trends in Lifetime Risk and Years of Life gery. Thorac. Surg. Clin. 2004;14:287-293. tilator dependence, renal failure, Lost Due to Diabetes in the USA, 1985- 2011: A Modelling Study. Lancet Diabetes cardiac arrest, and extended length Endocrinol. 2014;2(11):867-74. of stay, demonstrating the impact of insulin dependence on surgical com- plications. Thus, surgeons can better preoperatively plan for these adverse events in diabetic patients undergoing pulmonary resections.

CLINICAL RESEARCH 37 Intubation Related Vocal Cord Paresis: Outcomes from a Patient Cohort Ishaan Dharia, No Complete MSII Complete Resolution Resolution T-test ADVISER: Steven Bielamowicz, MD Average Glottal Function 2 89 7 66 p= 6 30E-4 Index (GFI) The George Average Physical Exam Score 0 1 52 p= 5 16E-09 Washington University School of TABLE: Differences in Average Post-Treatment GFI and Physical Exam Scores for Medicine and Health Sciences Patients With and Without Complete Resolution of Vocal Cord Weakness

Vocal cord paresis and paralysis are and EMG date, were combined to at intubation and outcomes showed recognized complications of endo- create a new defnition of prognosis no statistically signifcant diferences tracheal intubation; the effects of of each subject’s vocal cord paresis/ (p = 0.05). We also found that patients such complications can range from paralysis. Using these criteria, a score with complete resolution of their vocal quality of life changes such as efortful was determined for each patient—a cord dysfunction had a post-treatment speaking, vocal fatigue, and loss of score closer to 2 indicated a good prog- average GFI of 2.89, which was 4.77 high register, to more severe outcomes nosis while a score closer to 0 indicated points lower than the average GFI like aspiration pneumonia and com- a poor prognosis. Data analysis was for patients without complete resolu- plete voice loss.1 conducted on 3 tiers of patients. tion. This diference was statistically We conducted a retrospective Our analyses of all patients showed signifcant at p < 0.05. study, approved by the institu- that subjects less than or equal to 60 This study is one of the first to tional review board of The George years of age had an average prognosis use a larger sample of these patients Washington University Medical score of 1.21 while subjects above to analyze trends—using the com- Faculty Associates. The charts of 62 the age of 60 had a score of 0.79; the piled data we were able to show how patients were reviewed for this study. difference between these prognosis various cofactors can be used to Each of these subjects was diagnosed values were statistically significant determine both the initial prognosis with vocal fold paresis/paralysis based at p < 0.05. Our results found that and outcomes of these patients. Our on fve assessments: patient history, hypertension was the most common results should help guide physicians subjective rating scales, laryngeal comorbidity seen in patients who to better prevent, diagnose, and treat examination, laryngeal electromyog- were diagnosed with a post-intu- patients with vocal cord injury due to raphy (EMG), and acoustic/aerody- bation vocal cord paresis/paralysis. intubation. namic measures. Results from the second tier of analysis Subjects were classifed into four showed that of all 38 patients from REFERENCES groups based on EMG interpreta- whom we had post-treatment data 1. Nazal CH, et al. Vocal Cord Paralysis After tions of reinnervation or denervation: for, only 9 patients (24%) achieved Endotracheal Intubation: An Uncommon Complication of General Anesthesia. mixed, reinnervation, denervation, complete resolution of their vocal cord Brazilian J of Anesthesiology (English and none. Multiple studies have shown paresis/paralysis (defned as a Glottal Edition) 2018;68(6):637-640. that signs of reinnervation/denerva- Function Index (GFI) of 7 or below 2. Parnes SM and Satya-Murti S. Predictive tion on EMG are indicative of patient and a physical exam score of 0). The Value of Laryngeal Electromyography prognosis; however, the duration of average age of subjects that achieved in Patients with Vocal Cord Paralysis time between the symptom onset and complete resolution was 54.44 years of Neurogenic Origin. Laryngoscope EMG test date has also been shown to and the average age of those that did 1985;95(11):1323-1326. be correlated with prognosis.2,3 Thus, not completely recover had an average 3. Munin MC, Murry T, and Rosen CA. the above groupings, plus the duration age of 59.94. A chi-squared analysis Laryngeal Electromyography: Diagnostic and Prognostic Applications. Otolaryngol of time between the intubation date assessing the relationship between age Clin of North Am 2000;33(4):759-770.

38 Fusion ♦ 2019 Provider Differences in Management of Normal Second Stage Leora Aizman, MSIII ADVISERS: Alexis Delivery Methods C Gimovsky, MD,1 aOR 11 94 Andrew Sparks, MS2 (95% CI 1 61-87 62 99 2% 100% 90 9% 1The George 80% Washington 60% University (GW) School of Medicine and aOR 0 25 Health Sciences 40% aOR NA (95% CI 0 03-1 97 aOR NA 2 GW Medical Faculty Associates 20% 2 9% 3 3% 2 9% 0 0% 0% 0 0% 0 8% Cesarean NSVD FAVD VAVD This study evaluates whether delivery delivery provider affects maternal and neo- ■ MD ■ CNM natal outcomes in nulliparous women Delivery Methods aOR- adjusted Odds Ratio, CI-confdence interval, NSVD- with singleton gestation and a normal FIGURE: normal spontaneous vaginal delivery, FAVD- forceps assisted vaginal delivery, VAVD- second stage of labor. vacuum assisted vaginal delivery We performed a retrospective cohort study of term, nulliparous women with singleton gestations BMI, epidural use, induction, and of cesarean delivery but signifcantly and cephalic presentation, who had a gestational age at delivery. There was afected the incidence of normal spon- second stage of labor <3 hours in dura- a significant difference in rates of taneous vaginal delivery. Most women tion at a single institution. Exclusion normal spontaneous vaginal deliveries delivered vaginally, with 97.07% criteria were intrauterine fetal (NSVD): 99.2% in CNM patients and of women in the MD group and demise, planned cesarean delivery 90.9% in MD patients. Incidence 100% in the CNM group. Maternal or suspected major fetal anomaly. of cesarean delivery was 0% in the demographics signifcantly difered Outcomes were compared by delivery CNM group and 2.93% in the MD between the two groups, with older provider: obstetrician (MD) and certi- group. The CNM group had a lower patients and decreased epidural use fed nurse midwife (CNM). Primary incidence of composite maternal in the CNM group. MD patients outcome was incidence of cesarean morbidity: 9.17% vs 19.54% in the had higher rates of hypertension delivery, with maternal and neonatal MD group. There were no signifcant and induction, as well as higher BMI outcomes compared secondarily. diferences in maternal or neonatal scores. MD and CNM groups had sim- We evaluated 427 women: 120 with outcomes. ilar maternal and neonatal outcomes CNM providers and 307 with MD In term nulliparous women with when controlling for confounders. providers. Maternal demographics singleton gestations who had a normal significantly differed by maternal second stage, delivery provider did age at delivery, race, hypertension, not signifcantly afect the incidence Continued on p. 39

CLINICAL RESEARCH 39 Continued fom p. 40

IMD (n=307) ICNM (n=120) Ip-value IOR (95% CI) Ip-value IaOR (95% CI) Ip-value Delivery Subtype 9 (2 93%) 0 (0%) 0 0668 (*) CD 279 119 (99 17%) 0 0022* NA - NA - NSVD (90 88%) 1 (0 83%) 0 3049 11 94 (1 61 – 88 79) 0 0154* 11 94 (1 61 – 87 62) 0 0154* FAVD 10 (3 26%) 0 (0%) 0 0668 (*) 0 25 (0 03 – 1 97) 0 1881 0 25 (0 03 – 1 97) 0 1881 VAVD 9 (2 93%) NA - NA - Chorioamnionitis 20 (6 51%) 3 (2 50%) 0 0986 (*) 0 37 (0 11 – 1 26) 0 1119 0 31 (0 07 – 1 38) 0 1247 Endometritis 1 (0 33%) 0 (0%) 0 9999 NA - - - Postpartum 20 (6 51%) 6 (5 00%) 0 5563 0 76 (0 30 – 1 93) 0 5576 0 63 (0 23 – 1 73) 0 3715 hemorrhage Transfusion 0 (0%) 0 (0%) NA NA - - - 3rd degree lac 12 (3 91%) 2 (1 67%) 0 3669 0 42 (0 09 – 1 89) 0 2565 0 42 (0 09 – 1 92) 0 2641 4th degree lac 1 (0 33%) 0 (0%) 0 9999 NA - - - At least 1 negative 60 (19 54%) 11 (9 17%) 0 0096* 0 42 (0 21 – 0 82) 0 0155* 0 38 (0 19 – 0 77) 0 0072* maternal outcome NICU admission 10 (3 26%) 7 (5 83%) 0 2697 1 84 (0 68 – 4 95) 0 2274 1 87 (0 69 – 5 03) 0 2167 CPAP 13 (4 23%) 8 (6 67%) 0 2962 1 62 (0 65 – 4 00) 0 3002 1 64 (0 66 – 4 06) 0 2859 Sepsis 2 (0 65%) 1 (0 83%) 0 9999 1 28 (0 12 – 14 27) 0 8400 1 30 (0 12 – 14 46) 0 8314 Seizure 0 (0%) 1 (0 83%) 0 2810 NA - - - HIE 0 (0%) 2 (1 67%) 0 0785(*) NA - - - Shoulder dystocia 6 (1 95%) 1 (0 83%) 0 6787 0 42 (0 05 – 3 54) 0 4262 0 43 (0 05 – 3 59) 0 4336 Death 0 (0%) 1 (0 83%) 0 2810 NA - - - At least 1 negative 21 (6 84%) 10 (8 33%) 0 5930 1 24 (0 57 – 2 71) 0 5936 1 26 (0 57 – 2 76) 0 5683 neonatal outcome MD- medical doctor, CNM- certifed nurse midwife, OR- odds ratio, aOR- adjusted odds ratio, NA: not enough occurrence for accurate result; CD- cesarean delivery, NSVD- normal spontaneous vaginal delivery; FAVD- forceps assisted vaginal delivery; VAVD- vacuum assisted vaginal delivery; CPAP- continuous positive airway pressure; NICU- neonatal intensive care unit; HIE- hypoxic ischemic encephalopathy Data are in mean (%)

TABLE: Perinatal Outcomes

40 Fusion ♦ 2019 Screening For Vocal Cord Paralysis In High Risk Premature Infants After Patent Ductus Arteriosus (PDA) Ligation Melissa A. postoperative consultations, and vs. 0.09%, p=0.0013) compared to Peace, MSII comorbidities (voice abnormalities, those who did not. COAUTHOR: Ari G feeding difculties, gastrostomy tube It’s important to note, not all Mandler, MSII1 placement, and supplemental oxygen patients who post-operatively pre- ADVISER: Pamela at discharge) were extracted from the sented with symptoms concerning for Mudd, MD1,2 charts. Standard statistical method- vocal cord paralysis were sufciently ology was applied. evaluated. Additionally, the reported 1 The George Seventy-four patients were iden- prevalence of vocal cord paralysis Washington University School of Medicine tified (33M/41F; mean [SD] gesta- may be underestimated due to the and Health Sciences tional age 25.6 2 Children’s National Health System [3.5] weeks). Of these patients, [T]he reported prevalence of vocal cord paralysis Patent Ductus Arteriosus (PDA) 17 infants (23%) is a congenital heart abnormality, were diagnosed may be underestimated due to the lack of otolaryn- afecting up to 80% of all Extremely with vocal cord Low Birth Weight (ELBW) infants.1 paralysis; 14 gology evaluation after PDA ligation, highlighting Surgical repair of this cardiac anomaly patients (19%) renders the Recurrent Laryngeal experienced the need for a better screening protocol. Nerve vulnerable to iatrogenic left-sided vocal damage, ultimately inducing vocal cord paralysis, 2 cord paralysis.2 Our objectives were patients experienced bilateral vocal lack of otolaryngology evaluation to determine the clinical compliance cord paralysis, and 1 patient experi- after PDA ligation, highlighting the with postoperative screening for vocal enced right-sided vocal cord paralysis. need for a better screening protocol. cord paralysis and associated comor- Despite 33 patients (45%) suffering Premature infants with known vocal bidities in premature infants fol- from post-operative voice abnor- cord paralysis after PDA ligation lowing PDA ligation. Given that vocal malities, defned as a hoarse or weak have greater feeding and respiratory cord paralysis is a known complication cry, and 48 patients (55%) with docu- comorbidities. Therefore, timely diag- of PDA ligation, an understanding of mented feeding difculties, only 27 nosis may improve discharge planning the current screening methodology is patients (36%) were evaluated by and patient/parent counseling. needed for improvement of care. otolaryngology for possible vocal cord REFERENCES: A three-year retrospective chart paralysis. Patients with known vocal review was performed for all prema- cord paralysis had a higher rate of 1 Evans N. Diagnosis of patent ductus arte- ture infants who underwent PDA gastrostomy tube placement (53% vs. riosus in the preterm newborn. Arch Dis Child. 1993; 68: 58–61. ligation at the Children’s National 12%, p= 0.0003), supplemental oxygen Health System pediatric hospital. (64% vs. 36%, p= 0.0417), and need for 2 Lee K. Essential Otolaryngology: Head and Vocal cord palsy, otolaryngology chronic ventilation at discharge (18% Neck Surgery, 8th edn. San Francisco, CA: McGraw Hill, 2003.

CLINICAL RESEARCH 41 Rectus Fascia vs Fascial Lata for Autologous Fascial Pubovaginal Sling: A Single-Center Comparison of Perioperative And Functional Outcomes Michelle Peng, MSII ADVISERS: Fascia lata Rectus fascia Rachael D pubovaginal sling pubovaginal sling p-value Sussman,1 Benoit Peyronnet,1 Nirit N=21 N=84 Rosenblum, MD,1 Operative time (min) 84 (±29 1) 81 9 (±28 9) 0 68 Benjamin M Length of stay (hours) 25 (±9 8) 33 7 (±24 3) 0 15 Brucker, MD,1 Victor W Nitti, MD1 Estimated blood loss (ml) 91 7 (±90 3) 141 6 (±104 2) 0 04

1New York University Postoperative complications 11 (52 4%) 41 (48 9%) 0 81 Clavien grade 1 11 25 Clavien grade 2 1 14 Our objective in this study was com- Clavien grade 3 0 3 paring perioperative and functional Clavien grade 4 or 5 0 0 outcomes of autologous fascia lata Readmission 1 (4 8%) 3 (3 6%) 0 99 vs. rectus fascia pubovaginal sling in female patients with stress urinary Wound complications 0 (0%) 12 (14 3%) 0 12 Seroma 0 9* incontinence (SUI). Wound infections 0 4* Autologous fascial pubovaginal slings (AFPVS) are the most widely used surgical treatment in patients *: one patient had both a seroma and a wound infection with complex SUI.1,2 The majority TABLE 1: Perioperative Outcomes of series have reported the use of rectus fascia grafts.3,4 Despite this convention, the use of fascia lata with rectus fascial slings. The aim of Results: Between 2012 and 2017, has been described as an alterna- the present series is to compare peri- 105 women underwent pubovaginal tive with the benefts of minimizing operative and functional outcomes of slings: 21 using FL and 84 using RF. postoperative pain and theoretically autologous fascia lata vs. rectus fascia Operative time did not differ sig- lowering the risk of abdominal com- pubovaginal sling in female patients nificantly between the FL and RF plications such as wound infections. with SUI. groups (84 vs. 81.9 min; p=0.68). There Furthermore, fascia lata harvest been Materials and methods: Charts were more wound complications in used in patients with signifcant cen- of all female patients who underwent the RF group, but this difference tral obesity, poor quality abdominal AFPVS for SUI from 2012 to 2017 at did not reach statistical signifcance fascia or with an extensive history of a single academic center were retro- (0% vs. 14.3%; p=0.12). The overall abdominal surgery.5 Despite potential spectively reviewed. Patients were complications rates were comparable benefts, fascial lata sling harvest is divided into two groups: those with in the FL and RF groups (52.4% associated with its own set of com- the autologous sling harvested from vs. 48.9%; p=0.81), but the propor- plication related to morbidity from a the fascia lata (FL group) and those tion of postoperative complications second incision site and concerns with with the autologous sling harvested Clavien grade ≥ 2 tended to be higher long term durability.3 To our knowl- from the rectus fascia (RF group). in the RF group (4.8% vs. 20.2%; edge, fascia lata slings have never Peri-operative and functional out- p=0.11). Overall, wound complications been assessed in direct comparison comes were compared. accounted for 29.3% of post-operative

42 Fusion ♦ 2019 complications in the RF group (12/41). The functional outcomes were com- Fascia lata Rectus fascia pubovaginal pubovaginal parable between FL and RF group, p-value with similar rates of patients cured sling sling of SUI symptoms at 1 month (82.4% N=21 N=84 vs. 76.4%; p=0.74), 1 year (55.6% vs. 1-month SUI outcomes 0 74 63.8%; p=0.76), and the latest follow- Cured 14 (82 4%) 55 (76 4%) up (66.7% vs. 65.8%; p=0.87). Improved 1 (5 9%) 9 (12 5%) When compared to rectus fascia Unchanged 2 (11 8%) 6 (8 3%) harvest for pubovaginal sling, fascia Worsened 0 2 (2 8%) lata harvest may decrease periop- Lost to follow-up 4 12 erative morbidity, especially wound 1-month de novo self- 3 (17 7%) 21 (28 8%) 0 54 complications, without compromising catheterization functional outcomes. Change in post-void residual at 1 + 50 9 (±51 5) + 20 5 (±104 8) 0 06 REFERENCES month (ml) 1-year SUI outcomes 0 76 1. AUA/SUFU Guideline. Surgical Treat- Cured ment of Female Stress Urinary Inconti- 5 (55 6%) 30 (63 8%) nence (SUI): AUA/SUFU Guideline. 2017 Improved 3 (33 3%) 9 (19 2%) Unchanged 1 (11 1%) 6 (12 8%) 2. Syan R, Brucker BM. Guideline of guide- Worsened 0 2 (4 3%) lines: urinary incontinence. BJU Int. 2016 Lost to follow-up 117(1):20-33. 13 37 1-year de novo self- 1 (11 1%) 3 (6 4%) 0 51 3. Zoorob D, Karram M. Role of autolo- gous bladder-neck slings: a urogyne- catheterization cology perspective. Urol Clin North Am. Change in post-void residual at 1 + 43 6 (±66 5) - 7 (±77 8) 0 18 2012;39(3):311-6. year (ml)

4. Bayrak Ö, Osborn D, Reynolds WS, Last follow-up SUI outcomes 0 87 Dmochowski RR. Pubovaginal sling Cured 12 (66 7%) 48 (65 8%) materials and their outcomes. Turk J Urol. Improved 5 (27 8%) 17 (23 3%) 2014;40(4):233-9. Unchanged 1 (14 3%) 6 (8 2%) 5. Flynn BJ, Yap WT. Pubovaginal sling Worsened 0 2 (2 7%) using allograft fascia lata versus autograft NA 3 11 fascia for all types of stress urinary incon- tinence: 2-year minimum followup. J Urol. Last follow-up de novo self- 3 (16 7%) 7 (9 6%) 0 41 2002;167(2 Pt 1):608-12. catheterization Last follow-up change in post- + 46 (±55 4) +27 4 (±113 5) 0 10 void residual at 1 year (ml) Mean follow-up (months) 8 5 (±9 5) 14 1 (±15 4) 0 11 SUI: stress urinary incontinence

TABLE 2: Functional Outcomes

CLINICAL RESEARCH 43 Cortical Thickness Asymmetries in MRI-Abnormal Pediatric Epilepsy Patients: A Potential Metric for Surgery Outcome Natalie Pudalov, CT. There was also a trend towards suggesting that thicker ipsilateral CT MSII significance for the side of focus is associated with a good surgery out- ADVISERS: (ipsilateral vs. contralateral) and a sig- come. Here, we observed thinner CT Emanuel nifcant interaction between side and on the contralateral side in patients Boutzoukas,1 Maria lobe (repeated measures ANOVA, that largely experienced surgical 1 Z Chroneos, p=.055; p<.05), indicating that CT by success. Future research with larger 1 Xiaozhen You, PhD, lobe varied according to whether the sample sizes could investigate the 1 Leigh Sepeta, PhD, patient had a temporal or extratem- relationship between CT and dif- William D Gaillard, MD,1 Madison M Berl, poral epilepsy focus. On the ipsilateral ferent types of MRI abnormality and PhD1 side, the order of greatest CT by lobe surgery outcomes.

was: Temporal> Frontal> Parietal> 1Children’s National Health System REFERENCES: Occipital. On the contralateral side, the occipital lobe was thickest but 1. Widjaja, E., Mahmoodabadi, S. Z., Snead, O. C., Almehdar, A., & Smith, M. L. Neuroanatomical morphometric the other lobes were consistent in (2011). Widespread Cortical Thinning analysis in childhood temporal and their order. There were no signifcant in Children with Frontal Lobe Epilepsy. extratemporal epilepsy reveals pat- CT differences related to having a Epilepsia, 52(9), 1685-1691. terns of widespread cortical thin- temporal versus extratemporal focus. ning.1,2 The degree of neocortical 2. Mueller, S. G., Laxer, K. D., Barakos, J., Across both temporal and extra- Cheong, I., Garcia, P., & Weiner, M. W. thinning both ipsilateral and contra- temporal epilepsy groups, we found (2009). Widespread Neocortical Abnor- lateral to the focus in epilepsy is asso- that the temporal lobe was thickest malities in Temporal Lobe Epilepsy with ciated with poor epilepsy surgery out- and Without Mesial Sclerosis. Neuro- on the ipsilateral side. This may be come for MRI-normal adult epilepsy image, 46(2), 353-359. because the MRI abnormality which as well as MRI-abnormal childhood was la rgely epilepsy.3,4 This project extends upon dysplasia con- previous investigations by looking at Seizure onset and duration was associated with thin- tributed to a cortical thickness (CT) differences thicker CT. in a pre-surgical pediatric epilepsy ning of the ipsilateral parietal lobe suggesting that Seizure onset population with MRI abnormalities. and duration Sagittal T1-weighted MPRAGE perhaps the parietal lobe is vulnerable to long-term was associ- structural MRI scans were performed on 25 pediatric epilepsy patients (age a t e d w i t h effects of ongoing seizure activity. 7–17 years) with abnormalities on thinning of MRI. All surface-based morpho- the ipsilateral metric processing and analyses were parietal lobe conducted using FreeSurfer (FS) 6.0. suggesting that perhaps the parietal 3. Bernhardt, B. C., Bernasconi, N., Concha, L., & Bernasconi, A. (2010). Cortical A repeated measures ANOVA was lobe is vulnerable to long-term efects Thickness Analysis in Temporal Lobe of ongoing seizure activity. used to examine the efects of focus Epilepsy. Reproducibility and Relation to (temporal or extratemporal), side Additionally, the majority of this Outcome. Neurology, 74(22), 1776-1784. (ipsilateral or contralateral), and lobe sample (84%) were noted to have suc- 4. Kamson, D. O., Pilli, V. K., Asano, E., cessful surgery outcomes, as quanti- (frontal, temporal, parietal, occipital) Jeong, J. W., Sood, S., Juhász, C., & on cortical thickness. fed by an Engel Class 1 or 2 designa- Chugani, H. T. (2016). Cortical Thick- Repeated measures ANOVA tion post-surgery, a standard metric ness Asymmetries and Surgical Outcome revealed a signifcant efect of lobe indicating seizure freedom or signif- in Neocortical Epilepsy. Journal of the Neurological Sciences, 368, 97-103. (p<.01) such that Temporal CT> cant reduction. Thus, our results are Frontal CT> Occipital CT> Parietal in accordance with previous research,

44 Fusion ♦ 2019 Perioperative Complications Associated with Congestive Heart Failure in Elderly Patients Following Primary Hip Hemiarthroplasty Nikhil Gowda, MSII Operative Variables Control % CHF % P-value CO-AUTHORS: I I I I I 14095 600 Ryan Lee, MSII, Danny Lee, MSII, Days to Operation from 1 607 2 998 <0 001 ADVISER: Rajeev Admission ± 7 256 ± 4 676 Pandarinath, MD Total Operating Time 79 96 79 00 0 594 (Minutes) ± 43 440 ± 40 680 The George Washington University School of Total Hospital Stay 7 66 11 21 Medicine and Health Sciences <0 001 Length (Days) ± 7 912 ± 11 560 Although there are reports of the Days from Operation to 13 57 10 74 0 004 impact of congestive heart failure Death ± 8 879 ± 8 848 (CHF) on total knee arthroplasty Days from Operation to 6 22 8 24 (TKA) and total hip arthroplasty <0 001 Discharge ± 7 026 ± 9 621 (THA), there is a lack of literature analyzing CHF in hip hemiarthro- Discharge Destination <0 001 plasty (HHA) procedures. The main Home 2821 20 01% 103 17 17% objective of this study was to evaluate the efect of CHF on risks for compli- Other than Home 7803 55 36% 391 65 17% cations following HHA. Not Reported 3471 24 63% 106 17 67% The American College of Surgeons National Surgery Quality Care Type 0 561 Improvement Program (ACS - Inpatient 14024 99 50% 598 99 67% NSQIP) is a multi-institutional national database tracking 30-day Outpatient 71 0 50% 2 0 33% patient outcomes and complica- tions for surgical procedures. The TABLE 1: Surgery Related Variables of HHA in Control vs CHF ACS-NSQIP database was queried patients for all patients who had undergone HHA from 2005 to 2016. Pearson’s independent risk factor for pneu- This data illustrates that a known chi-squared tests and Fischer’s exact monia (OR 1.55, 95% CI 1.146-2.097, diagnosis of CHF in patients under- tests were utilized to compare difer- p=0.004), progressive renal insuffi- going hip hemiarthroplasty puts ences in demographics, comorbidities, ciency (OR 3.277, 95% CI 1.681-6.387, patients at a signifcantly higher risk and complication rates. Multivariate p<0.001), pulmonary embolisms (OR of longer hospital stays following logistic regression analyses were used 2.728, 95% CI 1.256-5.926, p=0.011), their procedures. Increased length of to assess the impact of CHF as an cardiac arrest (OR 3.582, 95% CI stay (LOS) in orthopedic procedures independent risk factor for postopera- 2.128-6.031, p<0.001), extended length is associated with increased post- tive complications following HHA. of stay (≥5 days) (OR 1.447, 95% CI operative morbidity (i.e. deep venous Six hundred HHA patients 1.218-1.720, p<0.001), readmission (OR thromboembolisms1) and increases (4.08%) had CHF, and this patient 1.294, 95% CI 1.004-1.669, p=0.047), the cost burden to the health care cohort was older (p<0.001) and had a and mortality (OR 2.189, 95% CI system.2 larger proportion of males (p<0.001). 1.688-2.839, p<0.001). (See Tables 1 CHF was found to be a significant and 2.) Continued on p. 46

CLINICAL RESEARCH 45 Continued fom p. 45 95% Beyond LOS, this study found that Postoperative Complications Odds Ratio Confdence P- Value CHF is an independent risk factor I IInterval I I for developing pneumonia following Superfcial Incisional SSI 1 725 0 625 4 758 0 292 HHA. A lower threshold of suspicion Deep Incisional SSI 1 014 0 358 2 873 0 979 for pneumonia development in the Organ/Space SSI 1 091 0 258 4 608 0 905 postoperative period should be main- Wound Disruption 4 205 0 874 20 234 0 073 tained for these patients; more aggres- sive antibiotic prophylaxis may be Pneumonia 1 55 1 146 2 097 0 004 considered for CHF patients in HHA. Unplanned Intubation 1 305 0 751 2 267 0 346 Additionally, this study found Pulmonary Embolism 2 728 1 256 5 926 0 011 CHF to be an independent risk factor Ventilator Dependence 1 032 0 451 2 364 0 94 for cardiac arrest. The compensatory (>48 hours) beta-adrenoreceptor stimulation of Progressive Renal Insuffciency 3 277 1 681 6 387 <0 001 the heart to increase stroke volume in the setting of CHF is associated with Acute Renal Failure 1 653 0 705 3 877 0 248 increased risk of arrhythmias and Urinary Tract Infection 1 064 0 756 1 498 0 722 sudden cardiac death (SCD).3 Heart CVA/Stroke 1 004 0 397 2 539 0 994 failure was also found, unsurprisingly, Cardiac Arrest 3 582 2 128 6 031 <0 001 in this study to be a signifcant risk Myocardial Infarction 1 622 0 977 2 695 0 062 factor for post-surgical mortality in Blood Transfusions 1 175 0 964 1 431 0 11 HHA. In the setting of HHA, we recommend monitoring patients with Deep Venous 1 305 0 591 2 883 0 511 a history of CHF with telemetry/EKG Thromboembolism (DVT) for evidence of ventricular arrhyth- Systemic Sepsis 1 353 0 798 2 295 0 262 mias or other risk factors for SCD Septic Shock 1 584 0 817 3 071 0 173 prior to discharge and in follow-up Death 2 189 1 688 2 839 <0 001 visits. Cardiac function testing prior to Return to Operating Room 1 087 0 722 1 637 0 69 orthopedic procedures such as HHA Extended Length of Stay 1 447 1 218 1 72 <0 001 may also be warranted. (≥ 5 days) The current study also found an increased risk of progressive renal Readmission 1 294 1 004 1 669 0 047 insufficiency due to CHF prior to TABLE 2: Multivariate Analyses Assessing Congestive Heart Failure as an HHA. CHF and kidney disease are Independent Risk Factor for Postoperative Complications tightly associated.4 Furthermore, there is evidence to suggest that arthroplasty 3. Goyal V, Jassal DS, Dhalla NS. Patho- is associated with decreased kidney complications in order to optimize physiology and Prevention of Sudden 5 favorable outcomes. function. Therefore, this finding Cardiac Death. Can J Physiol Pharmacol raises the concern for the need for REFERENCES 2016;94:237-244. careful review of the use of periop- 1. Lewis TC, Cortes J, Altshuler D, Papa- 4. Silverberg D, Wexler D, Blum M, Schwartz erative and postoperative medication dopoulos J. Venous Thromboembolism D, Iaina A. The Association Between Con- usage in HHA patients with history Prophylaxis: A Narrative Review with gestive Heart Failure and Chronic Renal of CHF. a Focus on the High-Risk Critically Ill Disease. Curr Opin Nephrol Hypertens Further studies evaluating the Patient. J Intensive Care Med 20. 2004;13:163-170. timing of medical optimization of 2. Missios S, Bekelis K. Hospitalization 5. Kimmel LA, Wilson S, Janardan JD, CHF before undergoing HHA is Cost After Spine Surgery in the United Liew SM, Walker RG. Incidence of warranted. More specific precau- States of America. J Clin Neurosci Acute Kidney Injury Following Total 2015;22:1632-1637. Joint Arthroplasty: A Retrospective tionary measures must be taken Review by RIFLE Criteria. Clin Kidney to preemptively address potential J 2014;7:546-551.

46 Fusion ♦ 2019 Impact of Mesenchymal Stem/Stromal Cell Intra-Arterial Delivery during Pediatric Cardiac Surgery on Neurogenesis in the Porcine Subventricular Zone Nisha Kapani, MSI1,2,3 _,---- ... ------... ADVISERS: Takuya Maeda, MD,1,2 - ..::, -- Zaenab Dhari, MD,1,2 ------Camille Leonetti, DL SVZ PhD,1,2 Nobuyuki Ishibashi, MD,1,2,3

1 Children’s National Heart Institute, Children’s National Health System (CNHS) 2 Center for Neuroscience Research, CNHS 3 The George Washington UniversitySchool V-SVZ of Medicine and Health Sciences

Congenital heart disease is the leading birth defect, afecting almost 1% of FIGURE 1: DCX+ Staining, scale bar: 200 μm births each year.1 Moreover, children who undergo cardiac surgery with cardiopulmonary bypass (CPB) show served as the animal model for this proliferation of NSPCs. However, signifcant cognitive and behavioral study. Two-week old piglets (n=12) MSC delivery reduced the length of impairments.2 The subventricular were randomly assigned to one of GFAP+ processes of radial-glia like zone (SVZ) in the postnatal/adult three groups: (1) Control, (2) Deep cells and the amount of DCX+ neuro- brain is a very crucial region for hypothermic circulatory arrest blasts in tier 1 and increased the den- neurogenesis and it plays an impor- (CPB/DHCA), and (3) CPB/DHCA sity of DCX+ cells in tiers 2 and 3 where tant role in neocortical growth of followed by MSC administration. neuroblasts migrate tangentially the gyrencephalic front lobe during MSCs (10x10 6 per kg) were delivered toward the frontal lobe. These fndings postnatal life. Our preclinical studies intra-arterially through CPB. The suggest that MSC delivery changes have shown that CPB insults can piglet brains were fxed three hours neuroblast distribution within the cause a reduction in the neural stem post-CPB. NSPC proliferation was SVZ and promotes neuronal migration progenitor cell (NSPC) pool.1 Others determined by SOX2+ and Ki67+ toward the frontal lobe. have shown that MSCs promote antibodies.Neuroblastandradial-glia Our data shows that CPB insults neurogenesis from SVZ NSPCs in like cells were identifed by DCX+ and cause proliferation of SVZ neural early and late rodent models.2 The GFAP+ antibodies. The anterior-SVZ stem/progenitor cells. Moreover, our aim of this study was to observe the was divided into three tiers which preliminary results suggest that MSC impact of mesenchymal stem/stromal were then subdivided into ventral delivery has the potential to affect cell (MSC) intra-arterial delivery and dorsolateral SVZ. Quantifcation migratory stream of young neurons through cardiopulmonary bypass of the NSPC and neuroblasts in in SVZ in the acute phase. To deter- (CPB) on the proliferation of neural each tier/region was performed, as mine the ameliorative efect of MSC stem/progenitor cells (NSPC) and these parameters refect neurogenic delivery on neurogenesis, we will need neuroblast migration in the porcine activity. to further investigate the SVZ in long subventricular zone (SVZ). CPB/DHCA increased early pro- term studies. The porcine SVZ resembles its liferation of NSPCs. MSC delivery did human counterpart and therefore not alter CPB-induced increased early Continued on p. 48

CLINICAL RESEARCH 47 Continued fom p. 47

REFERENCES

1. Nobuyuki I, Scafidi J, Murada A, et al. White matter projection in congenital heart disease. American Heart Associa- tion Circulation 2012; 125:859-871.

2. Morton PD, Korotcova L, Lewis BK, et al. Abnormal neurogenesis and cortical growth in congenital heart disease. Sci Transl Med. 2017 January 25; 9(374). FIGURE 2: DCX+ Dorsolateral Zone Tier 2+3, scale bar 50 μm

Long-Term Changes in Flow-Mediated Dilation Among Post-Operative Abdominal Aortic Aneurysm Patients Sowmya Mangipudi, Pre-Surgical vs. Long-Term Follow-Up FMD Percent MSII 15 - ADVISERS: Regent n=43 Lee, MBBS,1 Ashok Handa, MBBS 10 - The University of n=43 Oxford -5 - FMD % I Ruptured abdominal aortic aneu- rysms (AAA) cause around 175,000 I I I I deaths globally per year.1 In the U.K., 0 - I AAA rupture comprises 1% of causes of death for men over 65 years.2 Several Wilcoxon matched-pairs signed rant test studies have explored fow-mediated P value 0 0051

dilation (FMD) as a biomarker for -5 I I endothelial dysfunction, which plays TP-3 TP-F1/F2 a key role in the pathophysiology of FIGURE 1: Pre-surgical FMD values (TP3) vs Post-surgical long-term follow up FMD aneurysm development. A previous values (1 year and 2–4 year follow up combined, TP-F1/F2) Analyzed using Wilcoxon study from this group (OxAAA), in Sign Rank Test fact, found that decreased FMD of the right brachial artery was corre- lated with AAA progression; in addi- participants in the previous study. were included in the study (N=43). tion, soon after surgical repair of the The study was conducted using the Participants were recalled to the aneurysm, FMD among participants OxAAA database of participants who hospital from May-August 2018 for improved.3 No previous study has had received either an endovascular follow-up collection of blood samples, explored whether this improvement (EVAR) or an open AAA repair at The and FMD measurement using high- persists long-term, however. The John Radclife Hospital in Oxford, frequency ultrasound of the brachial purpose of this study, therefore, was U.K. since 2013. Participants who artery. Arterial diameter was mea- to evaluate the long-term changes in had received at least a preoperative suredatbaseline,duringfourminutes endothelial function of a subset of and postoperative FMD evaluation of artery occlusion, and immediately

48 Fusion ♦ 2019 after release of occlusion to measure FMD. The data were analyzed using Pre-Surgical, Post-Surgical, 10Year, and 2–4 Year Follow-Up FMD Percent the software “Brachial Analyzer,” n=13 and results were compared against 15 participants’ previous FMD values. The Wilcoxon Sign Rank Test was used to compare patients’ FMD values 10 at two time points (pre-surgical and n=43 1–4-year follow up), while ANOVA

was used to analyze patients’ changes FMD % -5 in FMD over multiple points of follow up (pre-surgical, post-surgical, 1-year, and 2–4-year follow up). 0 Demographic information about this cohort and FMD protocol has Friedman test previously been published;3 this sub- P value 0 0079 group, however, was 97% male and -5 TP-3 TP-5 TP-F1 TP-F2 100% white, consistent with the UK epidemiology of AAAs. The average FIGURE 2: Pre-surgical FMD values (TP-3), Post-surgical (TP-5), 1-Year Follow-Up (TP- number of days from surgery to follow F1), and 2–4 Year Follow-Up (TP-F2) FMD % ANOVA Analysis up for participants was 996.7. Analysis showed a statistically significant increase in FMD among all 43 patients or stroke among patients.4 If AAA is 2. Thompson SG, Brown LC, Sweeting between 1–4 years after AAA repair indeed a systemic disease, perhaps the MJ, et al.; the RESCAN collaborators. Systematic Review and Meta-Analysis of risk of rupture is not the only consid- (p=0.0061) (Figure 1). The following the Growth and Rupture Rates of Small figure (Figure 2) demonstrates an eration for timing of surgical interven- Abdominal Aortic Aneurysms: Implica- increase in FMD at each point of tion. FMD could therefore not only be tions for Surveillance Intervals and Their follow up after surgery for the 13 used as a cost-efective, reproducible, Cost-Efectiveness. Southampton (U.K.): NIHR Journals Library; 2013 Sep. (Health participants for which all data points and non-invasive biomarker to aid in Technology Assessment, No. 17.41.) were available; however, the small determinations of surgical interven- Chapter 1, Background. Available from: sample size limits any interpretation tions, but may serve as a biomarker https://www.ncbi.nlm.nih.gov/books/ of statistical signifcance . for increased cardiovascular disease NBK261036/

This study demonstrated risk. Though the power of this study is 3. Lee, R., Bellamkonda, K., Jones, A., improved FMD several years after limited, it provides the frst evidence Killough, N., Woodgate, F., Williams, AAA repair among patients. These for long-term improvement in endo- M., ... & Channon, K. M. Flow Mediated fndings support the hypothesis that thelial function after AAA surgery; Dilatation and Progression of Abdominal Aortic Aneurysms. European Journal of further research should build on these AAAs are systemic vascular diseases, Vascular and Endovascular Surgery 2017; and not simply local, abdominal fndings. 53(6), 820-829. pathology. The exact mechanism is REFERENCES 4. Bath, M. F., Saratzis, A., Saedon, M., unknown at this time. Current vas- Sidlof, D., Sayers, R., Bown, M. J., ... & 1. Howard, D. P., Banerjee, A., Fairhead, J. cular research findings present the Quarmby, J. Patients with Small Abdom- F., Handa, A., Silver, L. E., Rothwell, P. aortic thrombus as a possible source inal Aortic Aneurysm Are at Signifcant M., Oxford Vascular Study. Age-Specifc Risk of Cardiovascular Events and This of systemic inflammation; another Incidence, Risk Factors and outcome of Risk Is Not Addressed Sufciently. Euro- U.K. cohort study of AAAs that found Acute Abdominal Aortic Aneurysms in a pean Journal of Vascular and Endovascular Defned Population. The British Journal that even small, sub-surgical AAAs Surgery 2017; 53(2), 255-260. substantially increase the risk of MI of Surgery 2015; 102(8);907-15.

CLINICAL RESEARCH 49 Racial Disparities in Late-Stage Prostate Cancer: A Seer Database Analysis 2005–15 Stephanie Rodriguez, MSII A ADVISERS: 2 5 ,, Andrew D Sparks, ':-i.. '. ' MS, Hanbing ' ▲ ' I 2 I Zhou, MS, Richard M ▲ L Amdur, PhD, ▲I Jianqing Lin, MD 1 5 I ▲ ▲ I ▲ The George Washington University' School of 1 I

Medicine and Health Sciences Age-Adjusted OR

Incidence of metastatic prostate 0 5 cancer in the United States has increased over the past ten years, but it is unknown how this trend varies 0 I I I I I I I 2009–12 2013–15 2009–12 2013–15 2009–12 2013–15 over time in diferent racial and ethnic White Men Black Men AAPI Men populations.1 Racial and ethnic dis- parities in prostate cancer incidence Race x Year and mortality are well documented.2,3 B 2 5 Further examination of diferences in initial rates of prostate cancer diagnosis by race/ethnicity is needed 2 to distinguish factors precipitating disparity. 1 5 We identified all men first ■ ■ ■ ■ diagnosed with prostate cancer I I ■ ■I I I from 2005–15 in the Surveillance, Age-Adjusted OR 1 Epidemiology, and End Results (SEER) program of the National 0 5 Cancer Institute, which monitors 18 population-based cancer registries. Yearly cancer diagnosis frequency 0 from 2005 to 2015 was categorized 2009–12 2013–15 2009–12 2013–15 2009–12 2013–15 and analyzed by stage (in situ/local- White Men Black Men AAPI Men ized, regional, and distant), race/ Race x Year ethnicity [White, Asian American/ Pacific Islander (AAPI), Black], FIGURE 1: Adjusted OR (with 95% confdence interval) for prostate cancer in 2009- and age group (45–54, 55–69, 70-75). 12 and 2013–15 versus 2005–08, stratifed by race Adjusted for age A Distant vs in Chi-squared tests and multivariable situ/localized B Regional vs in situ/localized Horizontal black line shows the odds for the reference group White, Asian, and Black men’s odds of having an initial diagnosis logistic regression models were used of distant prostate cancer, versus in situ/localized cancer, increased by 106%, 84%, and for data analysis with p<0.05 consid- 62%, respectively (p= 001), between the early and late years of the study Their odds ered signifcant. of having an initial diagnosis of regional prostate cancer versus in situ/localized cancer, In the 10-year study period, the increased by 24%, 30%, and 31%, respectively (p= 001) proportion of regional-stage prostate

50 Fusion ♦ 2019 cancer increased from 14.2% to 16.6% of cases (p<.0001) and distant-stage A increased from 3.3% to 5.8% (p<.0001). 2 5 The odds of being diagnosed with regional-stage prostate cancer in 2013–2015 compared to 2005–08 2 were 1.3 times higher for Black men ■ I ■ (95% CI: 1.2-1.5), 1.3 times higher for 1 5 I ■ ■ AAPI men (95% CI: 1.1-1.5), and 1.2 ■I ■ times higher for White men (95%

Age-Adjusted OR 1 CI.2-1.3) (Figure 1a). The odds of being diagnosed with distant-stage prostate cancer in 2013–15 compared 0 5 to 2005–08 were 1.6 times higher for Black men (95% CI: 1.4-1.9), 1.8 times 0 higher for AAPI men (95% CI: 1.5- 2009–12 2013–15 2009–12 2013–15 2.3), and 2.1 times higher for White men (95% CI: 1.9-2.2) (Figure 1b). Black Men AAPI Men In 2005-2008, 2009-2012, and 2013- Year x Race 2015 respectively, the odds of being B diagnosed with distant-stage prostate 2 5 cancer were 1.8 times higher, 1.7 times higher, and 1.4 times higher for Black men compared to White men (all 2 respective p<.0001) (Figure 2a), and 1.5 times higher, 1.5 times higher, and 1.4 1 5 times higher for AAPI men compared to White men (all respective p<.001) ▲ ▲I I ▲ I (Figure 2b). 1 Age-Adjusted OR The incidence of late-stage pros- ▲ ▲ I ▲I tate cancer has increased signifcantly I 0 5 in all U.S. males despite race and ethnicity. Men from minority groups experienced higher rates of newly- 0 diagnosed distant-stage prostate 2009–12 2013–15 2009–12 2013–15 cancer within each year group when Black Men AAPI Men compared to White men, with rates Year x Race declining over time. Regional-stage prostate cancer increased the most FIGURE 2: Adjusted OR (with 95% confdence interval) for prostate cancer in Black over time in AAPI and Black men, and AAPI men when compared to White men, stratifed by year Adjusted for age A while newly diagnosed distant-stage Distant vs in situ/localized B Regional vs in situ/localized Horizontal black line shows prostate cancer increased the most the odds for the reference group In 2005–08, 2009–12, and 2013–15, respectively, the over time in White men. Genetic odds of having an initial diagnosis of distant prostate cancer, versus in situ/localized, variation in disease progression, dif- were 76%, 68%, and 40% higher for Blacks than Whites, and 53%, 52%, and 37% higher ferences in socioeconomic status, and for AAPI than Whites (p< 001) The odds of initial diagnosis of regional prostate cancer, versus in situ/localized, were 36%, 28%, and 30% lower for Blacks than Whites (p< 001), healthcare access have been posited for the respective year groups, while 2009-2012 showed the only signifcantly higher as theories for disparities in prostate odds of regional diagnosis in AAPI compared to whites to be 11% higher (p< 05)

Continued on p. 52

CLINICAL RESEARCH 51 Continued fom p. 51 REFERENCES nationwide population-based analysis.” Urol Oncol 2016 May; 34(5): 233.e7-15. 1. Jemal A, Fedewa SA, Ma J, et al. “Prostate 4. Kelly SP, Anderson WF, Rosenberg PS, et 2,4,5 Cancer Incidence and PSA Testing Pat- cancer care. Changes in guidelines al. “Past, Current, and Future Incidence for PSA-based screening may be terns in Relation to USPSTF Screening Rates and Burden of Metastatic Prostate Recommendations.” JAMA 2015 Nov 17; responsible for this increase, although Cancer in the United States.” Eur Urol 314(19): 2054-61. Focus 2018 Jan; 4(1): 121-127. this was not directly investigated. Based on our fndings and previous 2. Shenoy D, Packianathan S, Chen AM, et al. 5. Powell IJ, Bock CH, Ruterbusch JJ, et al. studies, we suggest considering racial “Do African-American men need separate “Evidence supports a faster growth rate prostate cancer screening guidelines?” and/or earlier transformation to clinically and ethnic disparities when devel- BMC Urol 2016 May 10; 16(1): 19. signifcant prostate cancer in black than in oping PSA-based screening guidelines white American men, and infuences racial in an efort to reduce them.2,3 3. Chao GF, Krishna N, Aizer AA, et al. progression and mortality disparity.” J Urol “Asian Americans and prostate cancer: A 2010 May; 183(5): 1792-6. Developing a Method to Objectively Assess Sensory Nerve Fiber Sensitivity: A Pilot Study Tess Whiteside, A. • MSII FIGURE: n-PRDs from an ADVISER: Julia individual with tourniquet-induced Finkel,MD 1,2 ischemia The tourniquet was RESEARCH removed at 20 min and effects of COORDINATORS: reperfusion were noted at 22 min Kevin Jackson,1 A) 5 Hz (at 1 5mA) n-PRDs; nPRD Luka Vujaskovic,1 AUCs were 0 690, 1 900, and 1 04 Christina Shincovich1 for baseline, 12 min, and 22 min, respectively B) n-PRDs from the 2000 1 Sheikh Zayed Institute for Pediatric Surgical Hz (at 1 5mA) stimulus; nPRD AUC Innovation, Children’s National Health values were 0 505, 0 699, and 0 824 System for baseline, 12 min, and 22 min, 2 The George Washington University, School respectively of Medicine and Health Sciences

The rate of chronic pain in the United data indicates that a unique PRD In this pilot study of healthy States is greater than the combined (nPRD) can be produced by depolar- adult subjects, infrared pupillometry rates of diabetes, heart disease, and izing sensory nerves (Aβ, Aδ, and C was used to evaluate whether the cancer, with associated healthcare fbers) via non-noxious neurospecifc nPRD was refective of known dif- costs ranging from $560-$635 billion electrical stimuli at particular fre- ferences in nerve fiber physiology per year.1,2 It is imperative that an quencies. The amplitude of the nPRD under tourniquet-induced ischemic objective assessment tool be devel- correlates with pain self-report and conditions. Changes in sensory nerve oped to ensure adequate pain eval- the area under the curve (AUC) of the fber activity occur in ischemic envi- uation and appropriate analgesic nPRD refects nerve fber sensitivity. ronments due to factors such as degree intervention is provided to patients These fndings suggest that the AUC of myelination.3 At a baseline state, experiencing chronic pain. could function as a metric of nerve activated, myelinated Aβ touch fbers Pupillary reflex dilation (PRD) fber sensitivity and that the nPRD inhibit transmission of presynaptic occurs when an alerting stimulus acti- has potential utility in objective pain signals by unmyelinated, noci- vates peripheral nociceptive fbers and assessment of pain characteristics, ceptive C-fibers to diminish pain elicits pupillary dilation. Preliminary including type and intensity. sensation.5 However, in an ischemic

52 Fusion ♦ 2019 environment, Aβ fbers are not acti- vated. Thus, there is no suppression Time point ΔAUC of C-fber (5Hz) ΔAUC of Aβ fber (2000Hz) of C-fibers, resulting in stable or Baseline - - increased pain. It was hypothesized Before Tourniquet Removal   that this phenomenon could be quan- After Tourniquet Removal   tifed by the nPRD AUC for each fber type and that tourniquet application TABLE: Expected Change in nPRD AUC for Each Nerve Fiber Type at Different Time would cause decreased Aβ sensitivity Point and increased C-fber sensitivity (see Table). A baseline electrical stimulus for ischemia resulted in removal of Aβ REFERENCES each subject was determined by their regulation and disinhibition of the 1. AAPM Facts and Figures on Pain. Chi- perception threshold. For baseline C-fiber. During the reperfusion cago, IL: American Association of Pain nPRD measurement, each fber type period, the C-fiber nPRD AUC Medicine. (Accessed November 4, 2018, was assessed using perception inten- decreased towards baseline indicating at http://www.painmed.org/patientcenter/ facts_on_pain.aspx#incidence) sity at a specifc activating stimulation a return of Aβ suppression. During frequency (C fber at 5 Hz, Aδ at 250 this reperfusion period, the Aβ nPRD 2. Institute of Medicine Report Hz, and Aβ at 2000 Hz). A tourniquet AUC increased to refect heightened from the Committee on Advancing was then placed on the subject’s upper sensitivity. For all fve subjects, there Pain Research, Care, and Education: Relieving Pain in America: A Blueprint arm to induce ischemia, and the same was a signifcant diference between for Transforming Prevention, Care, nPRD measurements were repeated the Aβ nPRD AUC values (p=0.024) Education, and Research. Mil Med. May at 5-minute intervals for each fiber and a diference trending towards sig- 2016;181(5):397-399. type. The tourniquet was removed at nifcance between the C-fber nPRD 3. Kumar K, Railton C, Tawfc Q. Tourniquet 20 minutes, and fnal measurements AUC values (p=0.091) at the three Application During Anesthesia: “What were taken during reperfusion. time points. We Need to Know?” J Anaesthesiol Clin In this pilot study, five subjects These results indicate that the Pharmacol 2016;32(4):424-430. demonstrated the hypothesized nPRD has potential to detect modu- 4. MacIver MB, Tanelian DL. Activation outcome. As demonstrated in the lation of nerve fber sensitivity. The of C Fibers by Metabolic Perturbations Figure, at 12 minutes after tourniquet data from subsequent trials will help Associated with Tourniquet Ischemia. Anesthesiology 1992;76(4):617-623. placement the Aβ nPRD AUC was determine whether infrared pupil- diminished while the C-fber nPRD lometry in conjunction with selec- 5. Melzack R, Wall PD. Pain Mecha- AUC was significantly increased tive neurostimulation can be used to nisms: A New Theory. Science from baseline. This suggests that objectively measure and monitor pain. 1965;150(3699):971-979.

CLINICAL RESEARCH 53 Laparoscopic Hand-Assisted Resection of a Rare Intra-Adrenal Schwannoma Thomas D. his primary care physician with new Kocher maneuver was performed Zaikos, MSIII onset mild abdominal discomfort to refect and retract the duodenum and Peter for which he used omeprazole with and gain access into the retroperito- Shahid, MSIII only modest relief. An abdominal neal space. The mass was dissected ADVISERS: Jeremy ultrasound was obtained and dem- free and removed, which required Holzmacher, MD, onstrated a mass in the right-upper dividing a portion of the right adrenal PGYIV, and Lynt B quadrant. A subsequent abdominal/ gland. Hemostasis was achieved, inci- Johnson, MD, MBA pelvis CT study demonstrated a sions were repaired, and the patient heterogenous 4.3 cm mass adjacent recovered well and was discharged The George to the right kidney and abutting the home two days later without any Washington inferior vena cava and porta hepatis complications. University School with no evidence of invasion into any Gross examination of the resected of Medicine and structures. An ultrasound-guided specimen demonstrated an encapsu- Health Sciences transabdominal biopsy was obtained lated 48 g mass with a heterogenous and demonstrated Schwannomas are benign tumors of a spindle cell neo- the peripheral nerve sheath. They fre- plasm that was con- While biochemically and hormonally inert, quently occur in the head, neck, and sistent with schwan- extremities.1 Schwannomas within noma. During his these adrenal tumors cannot be defnitively adrenal glands are extremely rare, with pre-surgical evalu- only 42 reports. The majority of cases have been discovered incidentally ation, the patient diagnosed or differentiated from other adrenal and do not demonstrate increased denied headaches, incidence in any age group or gender.2 palpitations, or his- masses without surgical resection and histo- Importantly, despite their association tory of hypertension. with the adrenal medulla all previous He had no surgical pathologic studies. cases except for one report no clinical history; he was only or biochemical evidence of hormonal taking intermittent activity.3 Diferentiation of schwan- omeprazole; he was a former smoker; tan-white-orange and partially-cystic nomas from other nonfunctional and his family history was remarkable interior. Histopathologic examina- adrenal masses (adrenal adenoma, for leukemia, diabetes mellitus, and tion demonstrated a spindle cell adrenocortical carcinoma, adrenal hypertension. His physical exam was neoplasm with neural diferentiation metastasis, adrenal myolipoma, and benign, with only a mildly elevated and areas of high density (Antoni A) neuroblastomas) is challenging and systolic blood pressure and no signif- and low density (Antoni B) cellularity imaging alone is insufcient.4 Current cant fndings on the abdominal exam. surroundedbyadrenalmedullatissue. guidelines state that the management Pre-surgical labs were within normal Immunohistochemical staining of adrenal incidentalomas should limits. Therefore, surgical resection demonstrated a mass that was dif- consider the tumor size and associated was discussed for defnitive diagnosis fusely positive for S-100 and SOX10; symptoms, where masses larger than 6 and treatment. and negative for CD117/c-kit and cm or those causing symptoms should The patient was consented for HMB-45. Together, these data sup- be resected while masses smaller than a laparoscopic hand-assisted resec- port the diagnosis of intra-adrenal 4 cm should be closely followed with tion of the retroperitoneal mass. schwannoma. imaging.5 Upon entering the abdominal cavity, Adrenal schwannomas are a rare A previously healthy 37-year- the mass was easily identified as it entity that have only been reported 42 old male with no significant past protruded anteriorly adjacent to times in the medical literature. While medical history initially presented to the hepatoduodenal ligament. A biochemically and hormonally inert,

54 Fusion ♦ 2019 these adrenal tumors cannot be defn- REFERENCES: Population of Six Patients. J Endocrinol itively diagnosed or differentiated Invest 2011;34(6):417-21. 1. Goh BK, Tan YM, Chung YF, et al. from other adrenal masses without Retroperitoneal Schwannoma. Am J Surg 4. Strauss DC, Qureshi YA, Hayes AJ, et al. surgical resection and histopathologic 2006;192(1):14-8. Management of Benign Retroperitoneal studies. Therefore, adrenal inciden- Schwannomas: A Single-Center Experi- 2. Mohiuddin Y, Gilliland MG. Adrenal ence. Am J Surg 2011;202(2):194-8. talomas pose a clinical challenge as Schwannoma: A Rare Type of Adrenal their discovery requires maintaining Incidentaloma. Arch Pathol Lab Med 5. NIH State-of-the-Science Statement on a broad diferential diagnosis which 2013;137(7):1009-14. Management of the Clinically Inapparent Adrenal Mass “Incidentaloma.” NIH Con- includes benign schwannomas and 3. Xiao C, Xu B, Ye H, et al. Experience sens State Sci Statements 2002;19(2):1-25. malignant adrenal neoplasms. with Adrenal Schwannoma in a Chinese Risk Factors for Amputation Following Lower Extremity Free Tissue Transfer in a Chronic Wound Population following LE FTT for closure in a clinicians foreshadow the trajectory Vikas Kotha, chronic wound population. of wound closure and limb salvage. MSIV Between April 2011 and January Furthermore, these results are a CORRESPONDING 2018, 135 LE FTT procedures were first-step to creating protocolized AUTHOR: Karen K Evans, MD1 performed by the corresponding risk-stratifcation recommendations ADVISERS: Elliot author for soft tissue coverage of for patients undergoing LE FTT for Walters, MD1,2 nonhealing wounds. We studied the complex, nonhealing wounds. To Christopher E relationship of patient demographics, this end, future work will include risk Attinger, MD1 wound characteristics, and periop- analysis for individual risk factors. erative traits with limb-salvage and REFERENCES: 1MedStar Georgetown University Hospital ambulation rates. 2George Washington University Hospital Overall microsurgical success was 1. Falola RA, Lakhiani C, Green J, et 96.3% (130/135) and limb salvage rate al. Assessment of Function After Free Tissue Transfer to the Lower Extremity Microsurgical reconstruction via was 86.7% (117/135). Comorbidities sig- for Chronic Wounds Using the free tissue transfer (FTT) is the last nifcant for amputation were diabetes Lower Extremity Functional Scale. J option for closure of nonhealing, (p=0.009), COPD (p=0.002), ESRD Reconstr Microsurg. 2018;34(5):327-333. lower extremity (LE) wounds.1–3 (p=0.007), and PVD (0.02). Only hind- doi:10.1055/s-0037-1621736 Unfortunately, amputation may be foot wound-location was signifcant 2. Lu J, DeFazio M, Lakhiani C, et al. required even if FTT is successful. for amputation (p=0.006). Signifcant Limb Salvage and Functional Outcomes Thus, assessing amputation risk perioperative traits included elevated Following Free Tissue Transfer for the Treatment of Recalcitrant Diabetic Foot before reconstruction would help sur- platelet count on day of closure (332.8 Ulcers. J Reconstr Microsurg. 2018;1(212). geons profle patient risk and direct vs 257.8, p=0.01) gracilis flap-type doi:10.1055/s-0038-1667363 salvage eforts with outcome-expec- (p=0.03). Infectious complication was 3. Evans KK, Attinger CE, Al-Attar A, et tations. However, there is a paucity the only postoperative complication al. The Importance of Limb Preserva- of literature regarding microsurgical predictive of amputation (p=0.007). tion in the Diabetic Population. J Dia- outcomes in chronic wound patients. By highlighting patient and betes Complications. 2011. doi:10.1016/j. The purpose of this study was to eval- perioperative traits that increase jdiacomp.2011.02.001 uate risk factors for major amputation risk of amputation, these data help

CLINICAL RESEARCH 55 medical education:

Sustainable Development Goals and Mental Health Knowledge Among First Year Medical Students

Most people with mental health problems want to have paid employment - I IX If a friend has a mental health problem, I know what advice to give them to professional help Medication can be an effective treatment for people with mental health problems Psychotherapy can be an effective treatment for people with mental health problems People with severe mental health II IX problems can fully recover Most people with mental health problems go to a health care II IX professional to get help 0% 25% 50% 75% 100%

Respondent Percentage ■ Strongly Agree ■ Agree Slightly ■ Disagree Strongly ■ Disagree Slightly ■ Neither Agrre Nor Disagree ■x Don’t Know

FIGURE 1: MAKS Results of First-Year MD Student Baseline Knowledge of Mental Health Biopsychosocial Factors

Tirsit students (MS1s) to determine their factors of mental illness, as well as Makonnen, mental health knowledge, as well as the ability to identify terms that are MHS, MSIII their attitudes towards mental health defned as mental illnesses under the ADVISER: biopsychosocial factors. Diagnostic and Statistical Manual of Lorenzo Norris, MD Fifty-nine frst-year medical stu- Mental Disorders, 5th Edition (DSM- dents at the George Washington 5).2 ATSPPH assesses perceptions The George University School of Medicine and towards mental health biopsychoso- Washington Helath Sciences were selected to par- cial factors, also making it ideal as a University School of Medicine and Health ticipant in this study prior to the onset post intervention assessment.3 The Sciences of the behavioral sciences section of program intervention itself aimed to the curriculum, allowing the assess- introduce students to negative mental The United Nations Sustainable ment of baseline knowledge. The frst- health outcomes such as demoraliza- Development Goals for 2030 high- years underwent a baseline assess- tion, burnout, depression, and depen- lights the impact of mental health ment, an intervention to introduce dency; as well as the diferent strate- illnesses by including goals for the negative mental health outcomes, as gies that can be applied to address prevention and treatment of behav- well as a post intervention assessment. the diferent negative mental health ioral, developmental, and neurological The baseline assessments included the outcomes. disorders.1 One way to measure the Mental Health Knowledge Schedule While this investigation looks at progress of these goals is to monitor (MAKS) and the Attitudes Towards many factors, there are three main a foundational indicator such as Seeking Professional Psychological fndings that merit the greatest atten- mental health literacy among medical Help Scale (ATSPPH). MAKS is tion. The frst is that there is great students. This study aims to look designed to assess confdence of one’s discordance to the statement “Most specifically at first year medical knowledge of the biopsychosocial people with mental health problems

56 Fusion ♦ 2019 positive statements positive mental about towards students’ attitudes shifting in results mixed showed intervention the that is fnding third hold. The may students that of biases possibility the to points which defnitions, DSM-5 classic are these because concerning is This illness. amental as identifed to be agreement unanimous the lack depression and addiction responses drug that is second finding The services. care health of mental ology epidemi the about misinformation or knowledge in either is agap there MS1s among that help.” implies This go to a healthcare professional to get professional togo ahealthcare FIGURE 2: FIGURE

Terms Surveyed to Respondents MAKS Results of First-Year MAKSResults of MentalHealth Disorders MDStudent BaselineIdentifcationof Manic Depression Bipolar Disorder Drug Addiction Schizophrenia Depression Stress Stress Grief ■ 0%

Yes - -

-

■ ■

demiology of mental health services. services. health of mental demiology epi the as well as DSM-5, the under aboutparticularly which disorders fall curriculums, health mental in flled be should that gaps knowledge the tify iden results These MS1s. among edge knowl health mental in attitudes and knowledge baseline in amix onstrates dem intervention program the and ATSPPH survey, survey, MAKS the negative. the towards shifted attitudes their had students some why order to address in modifed must be intervention the that implies health biopsychosocial factors. This This factors. biopsychosocial health Strongly Agree Disagree Slightly - In conclusion, of combination In the

25% ~--

Respondent Percentage ■ ■ ■

Agree Slightly - Neither Agrre NorDisagree 50%

- - - -

■ No 3. 3. 2. 2. 1. REFERENCES

Elhai, J. D. (2008). Reliability and validity validity and Reliability J. D. (2008). Elhai, Evans-Lacko, S. (2010). Development and and (2010). S. Development Evans-Lacko, United Nations. (2015). Transforming (2015). Transforming Nations. United 329. 320 159(3), Research, Psychiatry Form. Scale-Short Help Psychological sional Profes Toward Seeking Attitudes of the doi:10.1177/070674371005500707 55(7), 440-448. of Psychiatry, Journal dian Cana The Schedule. Knowledge Health Mental of the Properties Psychometric transformingourworld/publication transformingourworld/publication sustainabledevelopment.un.org/post2015/ https:// from 2018, 1, March Retrieved Platform. Knowledge Development .:. Sustainable Development tainable Sus for Agenda World: 2030 our The 75% doi:10.1016/j.psychres.2007.04.02 doi:10.1016/j.psychres.2007.04.02 ■ Don’tKnow ■ x ■ ]

Disagree Strongly l>

100% - - - -

USIONI• ----

Fusion is the annual, student-run scien- A student-led research publication of the George Washington University School of

Medicine and Health Sciences | Spring 2019, Volume XII tifc journal of The George Washington University School of Medicine and Health Sciences William H. Beaumont Medical Research Honor Society.

Fusion was created to showcase medical student achievements in basic science and clinical research, clinical public health, medical education, and global health research. Submissions are requested from medical students annually in the fall.

[?US •ON F i THE STUDENT-RUN SCIENTIFIC JOURNAL OF THE GEORGE WASHINGTON UNIVERSITY SCHOOL OF MEDICINE AND HEALTH SCIENCES TheTheTThe heWilliam WilliamW illiam h . h hBeaumon.. BeaumonB eaumonT mTT edical m medicaledical Resea ReseaRe seaRchRRchch h ono hh onoonoR sRRocie s soocieciTy eTyTy v.v. iii iiiiii,, , spRi spRingnging 2 20092009 009 TILLIAUEDICAESRCHE W M H. BEA MONT M L R EA H HONOR SOCIETY V. IV, SPRING 2010

RNA Interference in Virus Induced Hepatitis C and the Silencing Mechanism of Tumor Suppressing Genes, p.6 v. iii, spRing 2009 Dynamic Stabilization for the Treatment of Degenerative Spinal Disorders, p.11

Variables Associated with the Acceptance of Acupuncture among Children with Cancer: Interim Analysis of a Prospective Study, p. 16

A STUDENT-RUN SCIENTIFIC JOURNAL SERVING THE GEORGE WASHINGTON UNIVERSITY MEDICAL CENTER a student-run scieieie ntifc Journ alalal servingngheheng T he ggg eorge W ashi ngngng ton universisisi ty medededical center A Student-run Scientifc Journal Serving The George Washington University Medical Center THE WILLIAM H. BEAUMONT MEDICAL RESEARCH HONOR SOCIETY, VOL. V, SPRING 2011 Fusion • 2007 1 . Fusi.oN FUSION ,: A student-led research publication of the George Washington University School of Medicine and Health Sciences | Spring 2016,Volume IX THE STUDENT-RUN SCIENTIFIC JOURNAL OF THE GEORGE WASHINGTON UNIVERSITY SCHOOL OF MEDICINE AND HEALTH SCIENCES

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